Clinical Case Studies Week 3 (CAP/HAP, Urinary Tract Infections, Croup and Otitis Media) Flashcards

Question

How manage severe HAP disease? \> Collect blood and sputum for cultures before starting antibiotic therapy

Answer 1

* Piperacillin + tazobactam IV * Cefepime (in immediate nonsevere or delayed nonsevere penicillin hypersensitivity) IV \> Switch to oral therapy as per mild to moderate severity HAP once the patient has improved significantly

Answer 2

Aspiration pneumonia is a bacterial infection that occurs in the days following ‘macroaspiration’ of organisms from the oropharynx * Food * Saliva * Liquids * Vomit

Answer 3

* Conditions associated with altered or reduced consciousness * Any condition that reduces gag reflex, coughing, ciliary movement and immune mechanism \> Alcoholism \> Seizures \> Drug overdose \> Stroke \> Head Trauma * People with poor dentition, severe periodontal disease - aspiration of anaerobes

Answer 4

* Asses need for antibiotic (aspiration pneumonia vs aspiration pneumonitis) * Treat as per CAP in patients from the community or who have been in hospital for \<48 hours * Treat as per HAP in patients who have been in hospital for \> 48 hours **aspiration pneumonia:** symptom onset delayed, tachycardia, fever, hypoxaemia **aspiration pneumonitis:** acute chemical injury to the lung, symptom onset rapid within hours of aspiration. Symptoms improve quickly within 24-48 hours.

Answer 5

A) * Amoxicillin oral + * Metronidazole oral B) * Benzylpenicillin IV + * Metronidazole IV * alternative: amoxicillin+clavulanateIV

Answer 6

* Paracetamol for antipyretic action **Moderate to severe pneumonia** * Oxygen therapy * Supportive nursing care and monitoring

Answer 7

A) * Fever, cough, sputum, SOB, chills B) * Tx failure * Sepsis * End-organ failure C) * Decrease WCC * Decrease in CRP and ESR (markers of inflammation) * Clearing of X-ray changes D) * Monitor for adverse effects of antibiotic treatment

Answer 8

* Pneumonia can be categorised by place or means of acquisition * Streptococcus pneumoniae is the most common cause of CAP * HAP is defined as pneumonia where onset occurs in patient who are hospitalised for \> 48 hours * Aspiration pneumonia is due to aspiration of organisms from the oropharynx * Empirical treatment is often given before culture results are available – obtain blood and sputum for culture before empirical tx * Treatment of pneumonia is mostly with antibiotics and choice of therapy depends on the severity of the disease, pathogens involved and institution guidelines based on local sensitivity pattern as well as patient comorbidities and allergy

Answer 9

Uncomplicated urinary tract infections (UTIs) mainly occur in nonpregnant women who do not have a functional or anatomical abnormality of the urinary tract. Acute uncomplicated cystitis and pyelonephritis are most commonly caused by Escherichia coli (70 to 95% of cases) and Staphylococcus saprophyticus (5 to 10% of cases). \> Symptomatic candidal UTIs are uncommon

Answer 10

At the time of writing, approximately 20% of E. coli urine isolates from adults in the community are resistant to trimethoprim. Trimethoprim continues to be recommended as empirical therapy for acute cystitis because the risk of adverse outcomes from treatment failure is low.

Answer 11

Clinical features of cystitis include acute dysuria, frequency, urgency and, occasionally, suprapubic tenderness \> Cystitis in men is uncommon; its prevalence increases with age and is often related to abnormalities of the urinary tract

Answer 12

obtain a urine sample for culture and susceptibility testing from \> pregnant women \> men \> patients who have recently taken antbiotics \> patients with recrurrent infections Also obtain a urine sample for culture and susceptibility testing from patients who do not respond to empirical antibiotic therapy.

Answer 13

Cranberry products, ascorbic acid and methenamine hippurate are not effective for the treatment of acute UTI.

Answer 14

**When bladder is infected --\> lower UTI (cystitis)** Bladder’s defence mechanism: \> Urination and the composition of urine [low pH and high osmolality (urea) of urine] \> Prevention of bacterial adherence to the bladder wall **When kidneys are infected --\> upper UTI (pyelonephritis)** Spread of bacteria upstream via the ureters Facilitated by vesicoureteral reflux

Answer 15

**Women** * Female anatomy * Pregnancy * Sexual activity * Certain types of birth control * Menopause **Men** * Prostate problems * Uncircumcised penis * Anal intercourse * Unprotected sex with a woman who has a vaginal infection

Answer 16

Urinary tract abnormalities * e.g. In babies leading to urinary (vesicoureteral) reflux * e.g. Affecting bladder innervation (MS, Parkinson’s) Blockages in the urinary tract * e.g. kidney stones, BPH A suppressed immune system --\> diabetics Catheter use A recent urinary procedure

Answer 17

**In symptomatic patients** Treatment should be started empirically Modify empirical treatment based on results of cultures and susceptibility Only treat asymptomatic patients who are at high risk of complications e.g. pregnant women Use short courses antibiotics (3-5 days) for uncomplicated cystitis in all women including elderly Reserve fluoroquinolones for non-pregnant women and men with culture proven resistant organisms \> dont have to do cultures for non-pregnant women who have uncomplicated UTI

Answer 18

Acute Cystitis Acute Pyelonephritis Asymptomatic Bacteriuria

Answer 19

Symptomatic UTI is much less common in men than in women * Acute uncomplicated cystitis occurs in a small proportion of men between 15 and 50 years of age * Most frequently in elderly men, who may have an anatomical or functional abnormality of the urinary tract. \> Prostatitis should be considered in men presenting with cystitis symptoms that are recurrent or are accompanied by pelvic or perineal pain or fever

Answer 20

* Most women \< 65 who are treated symptomatically (without antibiotic therapy) for acute uncomplicated cystitis become symptom free within 1 week. * If antibiotic therapy is not given, the risk of acute pyelonephritis or sepsis following uncomplicated cystitis is low, but may be reduced by antibiotic therapy * In Australia, the majority of acute, uncomplicated UTIs can still be successfully treated with oral trimethoprim, nitrofurantoin or cefalexin

Answer 21

* Trimethoprim 300mg daily for 3 days * Nitrofurantoin 100mg q6h for 5 days \> If trimethoprim and nitrofurantoin cannot be used --\> used cefalexin

Answer 22

the narrowest spectrum antibiotic to which the pathogen is susceptible should be used * Amoxicillin 500mg q8h for 5 days * Trimethoprim + sulfamethoxazole bd for 3 days * Amoxicillin + clavulanic acid bd for 5 days

Answer 23

* Fosfomycin 3g as a single dose * Norfloxacin 400mg bd for 3 days * Ciprofloxacin bd for 3 days

Answer 24

Urinary alkalinisers should not be used with * Fluoroquinolones → crystalluria * Nitrofurantoin, methenamine hippurate, lithium → less effective Use with caution or avoid * In patients who need sodium restriction e.g. heart failure patients

Answer 25

**Bacterial infection of the kidney parenchyma (upper UTI)** Signs and symptoms: * Sx of lower UTI plus fever (not always present but when present body temp can rise up to 39.50C) * Chills * Flank pain - unilateral over involved kidney * Nausea and vomiting * Gross haematuria (30-40%) \> SX of acute pyelonephritis usually develop over hours or over the course of a day but may not occur at the same time

Answer 26

A) * Amoxicillin + clavulanic acid 875/125 bd for 14 days B) * Ciprofloxacin 500mg bd for 7 days C) * Fever (38°C or higher) + Systemic Sx eg tachycardia, N, V, sepsis, septic shock D) * Gentamicin IV PLUS + Amoxicllin OR ampicillin (2g IV q6h) E) * Ceftriaxone 1g IV daily OR cefotaxime 1g q8h

Answer 27

D**efinition of recurrent UTI** * Women: ≥2 infections in six months or ≥3 infections in one year * Men: \> 1 episode **Reccurent infection can be** * Relapsing infection with the same organism * Re-infection by a different organism (~80%) **Treatment** * Obtain urine samples for cultures and susceptibility testing for all patients with recurrent UTI * Treat an acute episode of recurrent UTI as for cystitis or pyelonephritis * Consider prophylaxis in patients with frequent re-infection

Answer 28

Antibiotic prophylaxis Oestrogen therapy Cranberry Methenamine Hippurate Self care advicce

Answer 29

1. Trimethoprim 150mg at night 2. Cefalexin 250mg at night 3. Nitrofurantoin 50mg at night Can be continued for 3 to 6 months and in some cases longer \> Nitrofurantoin – avoid long term use because of peripheral neuropathy & pulmonary toxicity

Answer 30

Small clinical trials have found that the use of intravaginal oestrogen in postmenopausal women ↓ recurrent UTI Normalises the vaginal flora \> Oestriol vaginal cream or pessaries – use intra-vaginally daily at bedtime for 2 to 3 weeks then once or twice weekly

Answer 31

Offers no benefit in treatment of UTI Not recommended for the prevention of UTI Available as tablets, capsules, juice and foods Few harmful effects but: \> Juice may ↑ calorie and glucose intake \> May cause GI side-effects e.g. heartburn \> Interaction with warfarin - ↑ bleeding risk \> Cost may be an issue

Answer 32

Antiseptics (Methenamine Hippurate) * Are converted to ammonia & formaldehyde in acidified urine → general antibacterial activity against G-ve and G+ve bacteria and fungi in vivo \> Require a urinary pH of \<5.5 for activity * Not effective at treating UTIs * Evidence for preventing UTIs is poor * Dose 1g twice baily * Consider contraindications

Answer 33

* Drink enough water every day to satisfy your thirst and to keep your urine ‘lightcoloured’ (unless a doctor advises you not to) * Urinate when you feel the urge, rather than holding on * Empty your bladder completely when urinating * Reduce the risk of vaginal/urethral colonisation with uropathogens \> Empty bladder immediately after sexual intercourse \> Avoid the use of intrauterine devices and spermicides for contraception \> Maintain good perineal hygiene \> Wiping front to back after a bowel movement

Answer 34

* Larger than normal numbers of bacteria present in urine \>108 colony-forming units/ml of urine * BUT there are no symptoms * More common in the elderly, women with diabetes, people who have recurrent UTIs, and in people with urinary catheters

Answer 35

Screening for and treating asymptomatic bacteriuria is NOT generally recommended * 76% of cases of ABU resolve spontaneously * Prophylactic antibiotic treatment does not ↓ frequency of symptomatic UTI * Adverse effects & resistance from antibiotics Who to treat for ABU? \> pregnant women \> patients undergoing elective urological procedures

Answer 36

20-30% of untreated cases of ABU progress to acute pyelonephritis Acute pyelonephritis in pregnancy is associated with premature labour ABU also associated with intrauterine growth retardation and neonatal death Routine screening in first trimester of pregnancy as part of pre-natal care

Answer 37

A UTI typically starts when uropathogens that reside in the gut contaminate the periurethral area and are able to colonise the urethra. ## Footnote **Migration to the bladder (cystitis) and kidneys (pyelonephritis) via the ureter can result**

Answer 38

Very common bacterial infection in humans * Occur frequently in community & hospital environments * Females \>\> males (30 x) = ≈ 50% of all women will have one UTI during their lifetime = Anatomic and physiological differences * Children --\> Up to 40% of children who get UTIs have anatomical or functional abnormalities of the urinary tract \> Elderly living at home: 5-20% \> Elderly in care facilities and hospitals: 20-50%

Answer 39

* Urinary tract infections are more common in women but it is more serious when it occurs in men * UTIs are categorised as lower or upper urinary tract infection and they can be complicated or uncomplicated * Short term therapy with antibiotics is required for acute uncomplicated UTI * Antibiotic treatment is of longer duration in men and in complicated UTI * Screening for and treating ABU is not recommended except in pregnant women and patients undergoing elective urological procedure * There are pharmacological and non-pharmacological measures for the prevention of UTI

Answer 40

Inflammation of the middle ear Peaks between 6 months and 3 years \>Eustachian drainage tube dysfunction **1. Acute Otitis Media (OM)** Infected effusion and inflammation **2. Otitis Media with effusion** Effusion but not infected **3. Chronic Suppurative Otitis Media (CSOM)** infection of the middle ear with a perforated eardrum and discharge for \>6 weeks Can cause hearing impairment and disability Occasionally serious complications can occur

Answer 41

**Commonly viral infection** \> antibiotics often (inappropriately) prescribed \> can also be bacterial or mixed infection **regardless of cause is usually self limiting** \> Spontaneous resolution in 80% cases in 2-3 days \> Symptoms may persist up to 8 days in some children

Answer 42

yessir true

Answer 43

**Middle ear inflammation AND middle ear effusion** \> Bulging tympanic membrane \> Otorrhoea (tympanic membrane perforation and effusion) --\> discharge from the ear **PAIN ALONE IS NOT SUFFICIENT FOR DIAGNOSIS OF ACUTE OTITIS MEDIA**

Answer 44

Acute onset ear pain (tugging, holding, rubbing ear) Fever, irritability, poor feeding Bulging tympanic membrane

Answer 45

Adequate and regular analgesia with paracetamol +/- NSAID \> Antihistamines, decongestants and steroids are NOT beneficial for AOM \> Pain is a poor indicator of response to antibiotic For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days due to the antibiotics Antibiotic therapy does not improve pain at 24 hours Antibiotic therapy can cause harm through allergy, adverse effects and reistance

Answer 46

Infants \<6months \<2 years with bilateral infection Systemically unwell (lethargic, pale, irritable +fever) Children with otorrhoea (perforated eardrum) Aboriginal and Torres Strait islander (ATSI) children Children at high risk of complications (eg immunocompromised)

Answer 47

Return to Dr if symptoms worsen, or don’t improve in 48-72 hours - antibiotics may be required A delayed prescription for antibiotic therapy can be provided Rare complications of AOM (without without antibiotics) * \> mastoiditis and facial palsy --\> urgent referral

Answer 48

1. Adverse effects of antibiotics Diarrhoea, rash or more serious hypersensitivity reactions 2. Effect on microbiome Full consequences not fully understood Yeast infections (eg thrush) to more serious infections (eg Clostridium difficile infection) 3. Antibiotic Resistance Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting your family and the community

Answer 49

A) Amoxicillin \> do not use lower doses B) Amoxicillin/clavulanate \> B-lactamase producing H influenzae of M cattarhalis C) Ciporofloxacin ear drops until middle ear has been free of discharge for at least 3 days D) Urgent clinical review/hospital referral (may require IVABs)

Answer 50

A) * cefuroxime for 5 days * trimethoprim + sulfamethoxazole for 5 days B) * trimethoprim + sulfamethoxazole as above

Answer 51

group child care allergic rhinitis adenoid disease various structural anomalies, such as cleft palate and those associated with Down syndrome exposure to smoke (eg cigarettes, wood fires) socioeconomic disadvantage (eg crowded housing)

Answer 52

Streptococcus pneumoniae vaccination

Answer 53

Manage as for acute otitis media and consider referral to an otolaryngologist \> frequent recurrences may require myringotomy and insertion of tympanostomy tubes (grommets)

Answer 54

Middle ear effusion can persist for weeks after resolution of AOM * By 3 months 90% will have resolved spontaneously = wathcful waiting * May be appropriate to watch and wait 1st 3 months \> Watchful waiting would be appropriate in a child that is not experiencing persistent otitis media with effusion \> A child that is of a non-risk factor category would be indicated for observation (watchful waiting) and would be expected to completely resolve of their symptoms after 3 months (90% of cases)

Answer 55

Grey-white fluid behind an immobile tympanic membrane without signs of inflammation

Answer 56

Middle effusion for \> 3 months * Usually asymptomatic * May have hearing loss or balance/behavioural problems * Problem if affecting hearing and speech development * May need ENT referral and ?grommets * Some children (eg ATSI children (see guidelines – link in eTG) or children with risk factors for recurrent OM) are at high risk of developing chronic suppurative OM

Answer 57

Restore hearing (if affected) Resolve and prevent recurrent infections Address risk factors for recurrent OM

Answer 58

Is an infection of the middle ear with a perforated eardrum and discharge for \>6 weeks Non-painful, copious discharge from ear Can cause hearing impairment and disability Occasionally serious complications can occur \> Intracranial infection and acute mastoiditis \> Increased risk in Aboriginal children

Answer 59

Dry aural toilet Topical antibiotic drops * Ciprofloxacin 0.3% ear drops – 5 drops 12hourly until the middle ear has been free of discharge for \>3 days **Persistent discharge may require prolonged treatment --\> ENT referral**

Answer 60

Common presentation in primary care Middle ear inflammation AND middle ear effusion Often viral infection but antibiotics often prescribed REGARDLESS OF CAUSE IS USUALLY SELF LIMITING **_Management_** Adequate and regular analgesia \> For most children antibiotics are NOT required * Shared decision making * Review or delayed prescription at 24-48 hours * Risk of adverse effects and increased resistance from antibiotic use \> If antibiotics required: * Amoxicillin (or if no response or concerns re resistance  amoxicillin/clavulanate) * Penicillin allergy (cefuroxime or sulfamethoxazole/trimethoprim)

Answer 61

Reduce risk factors (smoke exposure, day care) Pneumococcal vaccination Consideration of ENT referral and grommets

Answer 62

**Not infected** **Persistent OM with effusion if \>3mths (Glue ear)** \> May present with hearing or behavioural/balance problems \> Restore hearing, resolve and prevent infections, address risk factors \> Consider ENT referral +/- grommets **Risk of chronic suppurative OM (especially in Aboriginal and Torres Strait Islander children)**

Answer 63

**Infection of the middle ear with perforated eardrum and discharge for \>6wks** \> Can cause hearing impairment and disability \> Occasionally serious complications can occur **Treatment** \> aural toilet and ciprofloxacin ear drops

Answer 64

Acute laryngotracheobronchitis Inflammation of upper airway, larynx and trachea

Answer 65

* Coryzal (URTI) prodrome \> corzyal: acute inflammatory contagious disease involving the upper respiratory tract; especially. \> prodrome: an early symptom indicating the onset of a disease or illness. * Hoarseness/husky voice * Inspiratory stridor * Barking (brassy) cough (barking seal cough!) * Variable airway obstruction due to inflammatory oedema within the subglottis

Answer 66

Most common 1-3 years (6mths-6 years) Duration 2-5 days (post-viral cough may last weeks) * Most commonly parainfluenza viruses * Antibiotics

Answer 67

**Typical croup symptoms that occur without acute viral infection** Usually in the early hours of the morning Shorter course than acute laryngotracheobronchitis Often recurrent Occurs in older children \> have co-existing asthma Treatment is the same as for acute croup

Answer 68

stridor = harsh vibrating noise when breathing A) Mild chest wall retractions and tachycardia, but no stridor at rest B) Stridor at rest, chest wall retractions, use of accessory respiratory muscles, and tachycardia C) Persisting stridor at rest, increasing fatigue, markedly decreased air entry and marked tachycardia D) Restlessness, LOC↓, hypotonia, cyanosis and pallor \> LOC: level of consciousness \> hypotonia: medical term for decreased muscle tone \> cyanosis: bluish-purple hue to the skin \> pallor: unhealthy pale appearance Minimise distress to the child as this can worsen symptoms

Answer 69

Inhaled foreign body, anaphylaxis, bacterial tracheitis, epiglottitis

Answer 70

Good evidence to support the routine use of a single dose of corticosteroids in all children with croup \> Regardless whether mild, moderate or severe \> Reduces hospital admission and prevents re-presentation \> No evidence for use of humidifier or cough suppressants

Answer 71

Budesonide inhalation single dose Dexamethasone single dose Prednisolone single dose

Answer 72

Adrenaline by inhalation via nebuliser, repeated after 30 minutes if no improvement PLUS EITHER budesonide by inhalation via nebuliser as a single dose OR dexamethasone orally or IM/IV if vomiting as a single dose OR prednisolone as a single dose

Answer 73

**Acute laryngotracheobronchitis** **Triggered by virus** * Antibiotics are NOT indicated **URTI sx, inspiratory stridor, barking cough** **Most common 1-3 years** **Treatment** * Single dose of corticosteroids in ALL children with croup * Plus nebulised adrenaline in severe croup Spasmodic croup – sx without viral trigger (often in asthmatics)