Block 2 - URTI/LRTI Flashcards
Bugs in ear?
SMH
S. pneumoniae
M. catarrhalis
H. influenzae
Bugs in oral?
Prevotella
Peptococcus
Peptostreptococcus
Corynebacterium
S. aureus
Strep
Eikenella
Bugs in lungs
SMH YMC
S. pneumoniae
M. catarrhalis
H. influenza
Yeast
M. pneumoniae
C. pneumoniae
Acute otitis media (AOM) risk factors?
Most common in <5yo
Age of first episode
Daycare
Not breastfed in first 3 months
Genetic bias
Tobacco exposure
AOM pathophysiology?
Negative middle ear pressure
Eustachian tube inflammation
Movement of secretions w/ URI flora into middle ear cleft
AOM common bugs?
S. pneumoniae
Moraxella catarrhalis
H. influenza
Viral
Common s/sx of AOM?
Acute onset otalgia
Tugging on ear
Otorrhea
Redness of tympanic membrane
Diagnosis of AOM?
Middle ear effusion (MEE) + one of the following:
Moderate/Severe bulging of TM or New onset otorrhea not due to otitis externa
Mild bulge TM AND recent (48hr) onset ear pain or intense erythema of TM
AOM pain management?
APAP/ibuprofen
Abx dont provide pain relief in first 24hrs
S. pneumoniae AOM, Tx?
Amoxicillin
RF for resistance, use augmentin or ceftriaxone
M. catarrhalis AOM, Tx?
Amoxicillin
H. influenza AOM, Tx?
Amoxicillin
RF for resistance, use augmentin or ceftriaxone
What are the RF for resistance to amoxicillin?
Received amoxicillin within 30 days
Concurrent purulent conjunctivitis
History of recurrent AOM unresponsive to amoxicillin
Amoxicillin dose for AOM?
90mg/kg/day in 2 divided doses
Same goes for augmentin
How long do you give Abx for AOM?
<2yo or severe = 10 days
2-5yo with mild/moderate = 7 days
≥6yo with mild/moderate = 5-7 days
Tx algorithm for AOM?
First check to see if they have bilateral sx,
Yes = give pain med + abx
No? Then check to see if they’re severe
Yes = give pain med + abx
No? Then give just pain med and “wait + see” with Abx
Sinusitis RF?
Allergic rhinitis + asthma
Structural defects
Daycare
Sinusitis s/sx?
Purulent discharge
Dental pain
Facial pain/pressure
Fever
How do you differentiate viral and bacterial sinusitis?
Viral improves in 5-10 days
Bacterial has persistent symptoms + >10days long, severe sx in the beginning
Diagnosis of sinusitis?
Persistent illness (>10 days)
Worsening conditions
Severe (temp >39 and purulent discharge for at least 3 days)
If orbital/CNS complications are present, CT or MRI should be considered
Sinusitis Tx?
Abx or observational period
Augmentin 45mg/kg/day BID
x5-7 days in adults
x10 for kids or in adults who dont improve by day 3
Sinusitis complications?
Periorbital and intra-orbital inflammation and infection
Brain abscess
Bacterial meningitis
Pharyngitis RF?
Children 5-15 yo
Parents of school-aged children
Occupations that work w/ children
Pharyngitis pathophysiology?
Direct contact w/ droplets
Mechanism not clearly defined (has asymptomatic carriers)
Pharyngitis common bugs?
Viruses account for majority
Bacterial cause = S. pyogenes
Which URTI condition should you NOT rely on symptoms to distinguish viral from bacterial?
Pharyngitis
Pharyngitis diagnosis?
Raid GAS antigen test (RADT?)
Positive? no need for culture
Negative? back up culture in kids
**culture is still gold standard
Pharyngitis Tx?
PCN or amoxicillin x 10 days
Must give within 9 days on onset
May also give supportive care (APAP, NSAIDs, topical anesthetics, NO corticosteroids)
Complications of GAS pharyngitis?
Rheumatic fever
Glomerulonephritis
Mastoiditis
What are the atypical species found in the lungs?
M. + C. pneumoniae
Clinical pearls of Abx and lungs?
Dapto is inactivated by surfactants in the lungs
Aminoglycosides have poor penetration
How is pneumonia (PNA) diagnosed?
New infiltrate + one of the following:
New onset fever
Purulent sputum
Leukocytosis
Decline in oxygenation
Which PNA is classified as “walking PNA”?
CAP
What is CURB 65?
Assesses site of treatment for CAP
Confusion
Uremia (BUN>20mg or 7mmol)
RR≥30
BP≤90/60
65+ age
0-1 = outpaitnet 2 = hospital 3 = hospital or ICU 4+ = ICU
How do you tell if CAP is severe?
3+ minor or 1+ major
Minor = RR≥30, Uremia, WBC<4, PLT<100, <36 degrees, hypotensive and needs fluids
Major = invasive mech ventilation or septic shock w/ vasopressors
CAP outpatient “healthy” pt Tx?
Amox
or
Doxy
CAP outpatient “with comorbidities” pt Tx?
Beta lactam + anti-atypical
CAP inpatient nonsevere Tx?
Beta lactam + anti-atypical
or
Resp. FQ (Levo, Moxi, Dela)
CAP inpatient severe Tx?
Beta lactam + (macrolide or resp FQ)
What are the anti-atypical abx?
Fluro (levo, moxi, dela)
Tetra
Pleuromutilin (lefamulin)
Macrolides
How long is CAP treated?
5 days unless afebrile, then its 2-3 days
IV to PO 1:1 Anti-MRSA?
Doxy
Zyvox
Bactrim
IV to PO 1:1 Anti-Atypicals?
Azithr
Doxy
Fluoro (levo and moxi)
What is HAP?
Occurs 48hrs+ after admission that was not incubating at time of admission
Early = within 4 days
Late = 5+ days
HAP RF for MRSA?
Abx within 90 days
Ventilation**
Septic shock**
Local prevalence >20%
**RF for mortality
No RF for MRSA nor mortality
HAP Tx?
Monotherapy that covers both MSSA + P. aeruginosa
No aminoglycosides nor colistin
x7days
RF for MRSA only not mortality
HAP Tx?
Anti MRSA + monotherapy for P. aeruginosa
No aminoglycosides nor colistin
x7days
RF for mortality or Abx IV within 90 days
HAP Tx?
Anti MRSA + double P. aeruginosa coverage
What is VAP?
Occurs 48-72 hrs after endotracheal intubation
Compare HAP and VAP double P. aeruginosa coverage
They share prior IV abx within 90 days and septic shock
VAP has extra stuff like: 5+ hospitliazation days, RRT prior to VAP, >10% GN are resistant to monotherapy
HAP only has ventilation as an extra item
RF for aspiration pneumonia?
Intoxicants
Loss of consciousness
Supine (instead of 45 degrees)
Dysphagia
When do you give Abx for aspiration pneumonia?
If symptoms persist >48hrs and no abscess or empyema
When do you give Abx for chemical pneumonitis?
You dont
Do you give abx for empyema?
Yes + drainage
Aspiration PNA diagnosis?
Aspiration event
PNA s/sx
Chest X-ray (RLL is most common)
Sx dont resolve in 1-2 days)
Empyema diagnosis?
Need pleural fluid samples
Suspect w/ failure of pneumonia to respond clinically within a few days
What are some ways to prevent/control infection of aspiration PNA?
Head above bed (45 degrees)
Oral chlorhexidine
How do you treat empyema?
Community acquired?
*2nd/3rd gen Ceph + Flagyl
or
*Amino-PCNw/BLI
Hospital acquired?
*MRSA+P.aeruginosa (noAG) + anaerobe
x2-6wks
Viral PNA diagnosis?
Influenza RADT
Oropharyngeal sample (influenza type A and B)
Viral PNA Tx?
1st line: Neuraminidase inhibitors
Tamiflu or Zanamivir (inhaled) or peramivir (IV)
Others: Baloxavir (PO)
Monitoring parameters and viral PNA Rx Tx?
Tamiflu = confusion Zanamivir = behavior changes Peramivir = rash, behavior changes Baloxavir = dont take w/ cations
Viral PNA shots?
Trivalent = 2 A + 1 B
Quad = 2 of each
High dose >65yo
FluBlok for anyone allergic to flu vaccines
