Bronchitis, pneumonia, pharyngitis, tonsillitis, otitis media, sinusitis Flashcards
Penicillin V - Dose and route (Otitis media)
Adults: 1g x 4 for 5-7 days orally
Children: 15mg/kg x 4 for 5-7 days
Penicillin V - MoA
Inhibits bacterial cell wall synthesis
Penicillin V - Adverse effects
Hypersensitivity
Urticaria (hives)
Interstitial nephritis
Penicillin V - Contraindications
Hypersensitivity
Penicillin V - Interactions
Probenecid: inhibits renal secretion – increased serum concentration
Penicillin V - Dose and route (Sinusitis)
1g x 4 for 7-10 days orally
Penicillin V - Dose and rouse (Pharyngitis)
500mg x 2 for 10 days orally
Penicillin V - Dose and route (Acute tonsillitis)
650mg x 4 for 10 days orally
Clindamycin - Dose and route
150 mg x 4 orally
Clindamycin - MoA
Protein synthesis inhibitor
Clindamycin - Adverse effects
Nausea
Vomiting
Diarrhea that can lead to pseudomembranous colitis
Clindamycin - Contraindications
Porphyria
Premature or newborn (can lead to gasping syndrome)
Liver and kidney dysfunction
CURB-65 score
Confusion Urea >7mmol/L (19mg/dL) Respiration rate >30/min Blood pressure <90/60mm Hg Age >65 years Score: 0: Treat home 2: Hospitalized > or equal 3: management in ICU
Pneumococcal pneumonia first line treatment
Penicillin V: 1,3g x 4 for 7-10 days orally
Staphylococcal pneumonia first line treatment
Dicloxacillin: 0,5 - 2g x 4 orally or IV
Haemophilus influenzae pneumonia first line treatment
Ampicillin: 500 mg X 4 IV
Amoxicillin - 250-500 mg PO
Mycoplasma-, Chlamydia- Legionella- and B. Pertussis -first line treatment
Erythromycin: 500 x 4 orally
Pneumonia - Diagnosis based on physical exam
- Tachypnea (RR>30/min), Use of accessory muscles
- Fever, Cough, pleuritic chest pain, Dyspnea
- Oxygen saturation < 90% in adults, <95% in children
- SBP:<90 DBP<60
- Increased/decreased tactile fremitus
- Percussion: Dull –> consolidation, Flat –> pleural fluid
- Auscultation: Crackles, bronchial breath sounds, pleural friction rub
Pneumonia - Diagnosis
Imaging:
- CXR: identify the inflammation, Lobar/multilobar infiltrates, cavitation, pleural effusion. Differentiate CAP from other conditions. Pneumatoceles or abscess –> S. aureus. Upper-lobe cavitating lesion –> tuberculosis
- CT: pts suspected postobstructive pneumonia caused by a tumor/foreign body or suspected cavitary diseases
Etiologic:
- Gram’s staining of sputum sample: Sputum sample must have > 25 neutrophils, < 10 squamous epithelial cells per low-power field.
- Blood cultures: Leukocytosis > 10*10^9/L
- Urinary antigen test: S. pneumonia and L. pneumophila.
- PCR of nasopharyngeal swabs
- Serology: Rise in titer of IgM antibody
- Biomarkers: CRP>50-100 mg/L, Procalcitonin; distinguish bacterial from viral infection.
Pneumonia - Empirical treatment
Penicillin V- 1,3 g x 4 PO
Hospitalized pts: Penicillin G 3g X4 IV (CURB 2-3)
Penicillin- Allergy: Erythromycin - 500 mg X 4 IV
CURB65:
0-2: Penicillin V or Penicillin G
3-4: Penicillin G + Gentamycin
Dicloxacillin - MoA
Inhibits bacterial cell wall synthesis, beta lactam antibiotic.
Dicloxacillin - Adverse effects
Hypersensitivity
Urticaria (hives)
Interstitial nephritis
Dicloxacillin - Interaction
Probenecid: inhibits renal secretion – increased serum concentration
Dicloxacillin - Contraindication
Hypersensitivity
Amoxicillin - MoA
Inhibits bacterial cell wall synthesis, beta lactam antibiotic.
Amoxicillin - Adverse effects
Superinfection
Hypersensitivity
Interstitial nephritis
Amoxicillin - Interactions
Probenecid: inhibits renal secretion – increased serum concentration
Amoxicillin - Contraindication
Decreases effect of contraceptives
Hypersensitivity
Erythromycin - MoA
Protein synthesis inhibitor. Macrolide antibiotic
Erythromycin - Adverse effects
Stomatitis
Heart burn
Uncoordinated peristalsis
Erythromycin - Interactions
Inhibits Cyt P-450 and increases levels of statins
Erythromycin - Contraindications
Hypersensitivity
Pneumonia - Prevention
Vaccination: influenza and pneumococcal polysaccharide vaccine
Stop smoking
Bronchitis - Diagnosis
Physical exam:
- Auscultation: wheezing & whistling
- Symptoms: cough, mucus production, dyspnea, chest congestion, sore ribs, runny nose, low fever
- Oxygen saturation: severity of the disease
- CXR: rule out pneumonia
- CRP, CBC
- Lung function tests (spirometry): rule out emphysema and asthma
- Culture of sputum: rule out diseases caused by bacteria f.ex. whooping cough (B. pertussis)
Ask pt about recent colds or viruses, time period of cough, and SOB.
Bronchitis - Treatment
Empirical: Rest, stop smoking, drink plenty of water Acetaminophen if fever/pain Codeine: 25 mg max 3 X daily for adults Ephedrine: 1mg/ml for children If bacterial: Penicillin V If caused by Influenza virus you may give: Zanamivir If caused Whooping Cough (B. pertussis): Erythromycin: 500mg x 4 orally
Zanamivir - Dose and MoA
Neuraminidase inhibitor
2 inhalations, each containing 5 mg, twice daily for 5 days
Zanamivir - Adverse effects
Respiratory and GI- irritations
Zanamivir - Interactions
Do not the flu vaccine within 48 h –> decreases its effectiveness
Zanamivir - Contraindication
Asthma and Emphysema
Grading of symptoms in sinusitis
Visual analogue scale
0-30: Mild
30-70: Moderate
70-100: Severe
Sinusitis - Diagnosis
Acute:
Based on clinical features and illness duration.
Moderare symptoms for > 10 days or Severe symptoms of any duration, incl unilateral/focal facial swelling or tooth pain.
Acute fungal sinusitis: take cultures and biopsy from involved areas
Acute hospital-acquired sinusitis: Confirm with CT; not otherwise used
Nasal Endoscopy and Skin-test for allergy can also be used to confirm diagnosis or rule out other disease.
Chronic:
Bases on clinical symptoms and history
CT: extent of disease, underlying anatomic defect or obstruction (polyp)
Endoscopy-derived tissue samples for histology and culture: guide treatment, visualization for abnormal anatomy
Acute Sinusitis - Treatment
Symptoms < 5 days –> VAS<30 –> Symptomatic treatment: Pain killer, Oxymetazoline, Nasal saline lavage, sinus drainage
Symptoms >5 days –> VAS 30-70 –> Symptomatic treatment + Budesonide
Symptoms >5 days –> VAS >70 –> Penicillin V and Budesonide
Antibiotics should be given to pts with severe symptoms and for pts without improvement after 10-14 days.
Fungal sinusitis: Amphotericin B
Intracranial complications (assess, orbital involvement): surgical interventions and IV antibiotics
Chronic: Sinus surgery, surgical removal of impacted mucus.
Exacerbation of chronic sinusitis: Doxycycline 200 mg PO first day, 100 mgx1 next 7-10 days.
Oxymetazoline - Dose
0,5 mg/mL 1 spray in each nostril 2-3 X daily
Oxymetazoline - MoA
Alpha 1 adrenoceptor agonist
Oxymetazoline - Adverse effects
Increases BP
Cardiovascular and CNS deprression
Oxymetazoline - Interaction
MAO- inhibitors; increases hypertensive effects
Oxymetazoline - Contraindication
Children < 6 years and elderly
Heart disease’
Budesonide - Dose
32 mcg / dose –> 2 spray in each nostril; morning and evening
Budesonide - MoA
Long- acting glucocorticoid
Budesonide - Adverse effects
Dry nose
nose bleed
itching
Budesonide - Interactions
Itraconazola and cyclosporine increases the conc of budesonide
Budesonide - Contraindication
Hypertension, PUD, heart disease, allergy
Amphotericin B - Dose
1 mg/kg IV infusion
Amphotericin B - MoA
Binds to ergosterol in cell membrane and increases cell membrane permeability and leakage of cell contents
Amphotericin B - Adverse effects
Renal toxicity –> hypokalemia, hypomagnesemia
Azotemia
Liver failure
Amphotericin B - Interactions
Cyclosprine, thiazides and corticosteroids increases hypokalemia
Amphotericin B - Contraindication
Renal failure/ renal disease
Otitis media - Diagnosis
Clinical manifestations
Pneumoatic otoscopy: fluid in middle ear and immobile TM
TM: erythematous, bulging or retracted
CT/MRI
Acute Otitis media - Treatment
spontaneous resolution in 80% pts –> wait 2-3 days be roe initiating antibiotics
Symptomatic treatment: Decongestants and pain killers
Penicillin V: if high fever, secretions for several days, suspicion of or proved complications
Position the head elevated
Tympanocentesis
Chronic otitis media - Treatment
Surgery: prevent complications, remove/decrease secretions, improve hearing
Removal of pus, detritus and cholesteatoma
Inactive disease: Topical antibiotic drops - Ciprofloxacin
Tympanocentesis
Ciprofloxacin - dose
3mg/mL. Apply the content of one single-dose container in the infected ear.
Pharyngitis - Diagnosis
If symptoms is consistent with viral URI –> no strep testing
If not:
Throat swab culture
Rapid antigen-detection tests for gr a strep infection
Samples for specific cultures for other bacterial/viral causes should be obtained if suspected
HIV considered –> test for HIV RNA
Pharyngitis - Treatment
Most cases: no treatment, symptomatic; acetaminophen, throat lozenge
S. pyogenes confirmed: Penicillin V, if allergy –> Clindamycin 300 mg TID
Influenza: Zanamivir
HSV: Acyclovir - 200 mg X5 po
Tonsillitis - Diagnosis
Physical exam: high fever, red tonsils with pus, swollen and painful submandibular lymph nodes
Rapid antigen detecting test: for hemolytic strep
Throat culture: identify pathogen
CBC, CRP
Tonsillitis - Treatment
Mild- Moderate: rest, paracetamol, drink plenty of water, throat lozenges/spray Severe: Penicillin V Chronic Tonsillitis: Clindamycin Tonsillectomy
Pneumonia - Differential diagnosis
Acute bronchitis, acute exacerbation of chronic bronchitis, HF, PE, hypersensitivity pneumonitis, Whooping cough
Gentamicin - Dose
5 mg/kg IV x1
Erythromycin - Dose in Acute otitis media
500 mg X3 PO
Gentamicin - MoA
Protein synthesis inhibitor
Gentamicin - Adverse effects
Nephrotoxicity
Ototoxicity (vestibular and cochlear)
Drug-induced renal failure (acute tubular necrosis, when they accumulate in proximal tubule cells)
Gentamicin - Contraindications
Decreased kidney function
Pregnancy
Gentamicin - Interactions
Neuromuscular blocking agents: potentiated effect of these drugs.
Similar drugs: additive nephrotoxicity
Loop diuretics: increased ototoxicity
