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Bal (PPP2) > Clinical Case Studies Week 3 (CAP/HAP, Urinary Tract Infections, Croup and Otitis Media) > Flashcards

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

1
Q

What are the risk factors for pneumonia?

A
  • Age >65 „
  • Children < 2 „
  • Chronic disease „

>heart failure and seizure disorders „

  • Alcoholism „
  • Asthma, COPD „
  • Cigarette smoking „
  • Dysphagia due to stroke, dementia, Parkinson’s disease „
  • Institutionalisation (RACF) „
  • Immunosuppression „
  • > HIV/AIDS, organ transplant, chemotherapy, long term steroids, PPI „ Indigenous background
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2
Q

How to prevent pneumonia?

A
  • Annual influenza vaccination „
  • Pneumococcal vaccination (>65 years of age every 5 years)„
  • Smoking cessation „
  • Treatment of comorbidities „
  • Medication review (e.g. proton pump inhibitors, benzodiazepines and other sedatives) „
  • Good oral hygiene and early mobilisation during the hospital stay (for HAP)
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3
Q

What are some signs and symptoms of pneumonia? What is significant about sputum production?

A
  • Fever (often > 380C) „
  • Dyspnoea „
  • Rigors or night sweats „
  • New onset cough „
  • Chest discomfort /pain „
  • Pleuritic chest pain „
  • Elevated Respiratory Rate
  • Sputum production

> Colour may suggest a particular pathogen:

  • S. pneumoniae: rust coloured sputum
  • Klebsiella species: red currant jelly sputum
  • Pseudomonas: green sputum

> Elderly persons may present with less specific symptoms such as reduced mobility, falls and mental confusion, incontinence (new onset), alteration in sleep-wake cycles, loss of appetite

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4
Q

What are some other investigations used in pneumonia?

A
  • Chest X-ray „
  • Pulse oximetry „
  • Respiratory Rate „
  • Full blood count (FBC) – elevated WCC „
  • BP „
  • Urine testing „
  • Sputum Gram stain and cultures „
  • Nucleic acid amplification testing (NAAT) „
  • Blood culture
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5
Q

What is used to diagnose pneumonia?

A

A chest X-ray is crucial to making a diagnosis of pneumonia

  • Alveoli are filled with a mixture of inflammatory exudate, bacteria and white cells
  • It appears on a chest X- ray as an opaque area in the normally clear lung fields
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6
Q

The following ways are used to classified pneumonia, provide further detail to the types of pneumonia

A) By pathogen

B) By place of acquisition –> focus of lecture

C) By means of acquisition

D) By chest X-Ray appearance

E) By Severity

A

A)

  • Typical/Atypical
  • Bacterial/Viral/Fungal

B)

  • Community-acquired pneumonia (CAP)
  • Hospital-acquired pneumonia (HAP / nosocomial infection)
  • Nursing home-acquired (NHAP)

C)

  • Aspiration pneumonia

D)

  • Lobar pneumonia
  • Bronchopneumonia

E)

  • Mild/moderate/severe
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7
Q

What is community-acquired pneumonia (CAP)? Which patients are excluded?

A

Pneumonia in individuals who are not hospitalised, or have been hospitalised for <48 hours not including patients who are:

  • Immunocompromised „
  • Has chronic suppurative lung diseases „
  • Residents of aged care facilities (high level care)
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8
Q

What are the common and uncommon pathogens assoicated with CAP

A

Common Pathogen

  • Streptococcus pneumoniae (50%)
  • Atypical Pathogens (20%)
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Legionella pneumophilia
  • Respiratory viruses (10%)
  • Haemophilus influenzae (5%)

Uncommon Pathogen

  • Staphylococcus aureus
  • Pseudomonas aeruginosa
  • Burkholderia pseudomallei
  • Acinobacter baumannii (in tropical region)
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9
Q

Once CAP confirmed, what are considerations that guide management?

A
  • How severe is the disease? (CORB, SMARTCOP score – mild, moderate vs severe)
  • Where should the person be treated? (inpatient vs outpatient)
  • Which antibiotics to use? – microbiology investigation, local treatment guideline, patient allergy
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10
Q

What are red flags for hospital admission in adults with CAP

A
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11
Q

What are red flags for intensive care support in adults with community-acquired pneumonia?

A
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12
Q

Compare empirical treatment to directed treatment

A

empirical treatment

  • Empirical use of antibiotics „
  • Treat an established infection when the causative organism has not been identified „
  • Guided by clinical presentation „
  • Used when there is likely to be a clear benefit

directed treatment

  • Directed use of antibiotics treats an established infection taking into account antimicrobial susceptibility
  • Use the most effective, least toxic and narrowest spectrum drug available in accordance with clinical guidelines
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13
Q

How to manage mild CAP? What to do if no improvement within 48 hours?

A
  • Amoxycillin (Amoxicillin)
  • OR Doxycycline*

*Reserved for atypical pathogens e.g. mycoplasma pneumoniae –> possess no cell wall, beta-lactam AB not effective against it thats why doxycycline is used

*C/I in pregnancy; Clarithromycin 500mg orally 12 hrly for 5-7 days can be used instead of doxycycline

If no improvement within 48 hours

  • Amoxycillin (amoxicillin) + doxycycline
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14
Q

How to manage moderate CAP in all regions (except tropical regions)

>Collect blood and sputum samples for culture BEFORE starting antibiotics

A
  • Benzylpenicillin (IV)

+

  • Doxycycline (replace with clarithromycin 500 mg orally, 12 hourly if doxycycline not appropriate) –> (ORAL)
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15
Q

If a patient with a moderate-severity CAP improves within 2 to 3 days –> what to do?

A
  • Treat for 5 days (intravenous + oral).
  • Treat for 7 days (intravenous + oral) if clinical response is slow

IV: benzylpenicillin

ORAL: doxycycline or clarithromycin

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16
Q

What to do for moderate CAP as the patient’s condition improves?

A

Consider switching to oral therapy as per mild CAP

  • Amoxicillin orally
  • Doxycycline orally
  • If doxycycline poorly tolerated –> clarithromycin orally
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17
Q

How to manage severe CAP in all regions (except for tropical regions)

> Collect blood and sputum samples for culture BEFORE starting antibiotics

A
  • Ceftriaxone IV

OR

  • Cefotaxime IV

+ (in all cases)

  • Azithromycin IV

> Modify therapy based on the result of susceptibility testing

> Switch to oral therapy as per moderate CAP once patient has improved significantly

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18
Q

What is hospital-acquired pneumonia?
> nosocomial infection

A
  • Develop in a patient who has been hospitalised for longer than 48 hours
  • Mostly occur by ‘micro-aspiration’ of bacteria that colonise the oropharynx or upper gastrointestinal tract
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19
Q

What are some risk factors for HAP?

A
  • Endotracheal intubation
  • Multiple organ failure
  • Decreased mental status
  • Reduction in gastric acidity
  • Thoraco-abdominal surgery
  • Recent broad-spectrum antibiotic exposure
  • Chronic lung disease
  • Age
  • Duration of hospitalisation (5 days or more)
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20
Q

What is the risk for a intubated patient?

A

Presence of endotracheal tube provides a direct pathway into the lower normally sterile respiratory tract

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21
Q

What are the common and uncommon pathogens associated with HAP?

A

Common Pathogens

  • Streptococcus pneumoniae
  • Aerobic Gram-negative bacilli
  • MRSA, multidrug-resistant Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter species (recent exposure to broad spectrum antibiotic tx)

Uncommon Pathogens

  • Legionella (see Legionella pneumonia)
  • Respiratory viruses (including influenza, parainfluenza, respiratory syncytial virus and adenovirus)
  • Candida species
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22
Q

What does the empirical treatment of HAP depend on? Provide THREE different reasons.

A
  1. Disease severity (Features of patients with high-severity HAP)
  • septic shock „
  • respiratory failure, particularly if requiring mechanical ventilation „
  • rapid progression of infiltrates on chest X-ray.
  1. Risk of acquiring multidrug-resistant (MDR) organisms
  2. Antibiotic susceptibility patterns – refer to local treatment guideline
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23
Q

For the management of HAP, when is there a high risk of multidrug-resistant infection (MDR)?

A
  • Staying in high risk ward (Intensive care unit, high dependency unit, area with a high rate of MDR infection) „
  • Recent treatment with antibiotics „
  • Recurrent or prolonged hospitalisation „
  • Resident of a high level care nursing home „
  • Immunocompromised
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24
Q

How manage mild to moderate HAP disease?

> Collect blood and sputum for cultures before starting antibiotic therapy

A
  • Amoxycillin + Clavulanate –> oral or enteral

OR

  • Cefuroxime (in immediate nonsevere or delayed nonsevere penicillin hypersensitivity) –> oral or enteral
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25
Q

How manage severe HAP disease?

> Collect blood and sputum for cultures before starting antibiotic therapy

A
  • 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

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26
Q

What is aspiration pneumonia? What may contribute towards it?

A

Aspiration pneumonia is a bacterial infection that occurs in the days following ‘macroaspiration’ of organisms from the oropharynx

  • Food „
  • Saliva „
  • Liquids „
  • Vomit
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27
Q

What are some risk factors for aspiration pneumonia? Provide THREE answers.

A
  • 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
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28
Q

How to manage pneumonia? What is the difference between pneumonia and pneumonitis?

A
  • 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.

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29
Q

For Aspiration pneumonia

If no improvement within 48 hours:

> Reassess diagnosis ƒ

>If anaerobe is likely, then consider the following therapy

A) What drugs to use if not responding to tx of CAP or HAP

B) What drugs to use if not responding to tx of CAP or HAP and cannot tolerate oral therapy

A

A)

  • Amoxicillin oral

+

  • Metronidazole oral

B)

  • Benzylpenicillin IV

+

  • Metronidazole IV
  • alternative: amoxicillin+clavulanateIV
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30
Q

What is some other supportive management for Pneumonia? For moderate to severe pneumonia?

A
  • Paracetamol for antipyretic action

Moderate to severe pneumonia

  • Oxygen therapy „
  • Supportive nursing care and monitoring
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31
Q

Monitoring for outcomes, efficacy and toxicity is ahcieved through the following headings, briefly explain further

A) Resolution of symptoms

B) Complications

C) Resolution of signs

D) Adverse effect of antibiotic tx

A

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
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32
Q

Summary of Pneumonia

A
  • 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
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33
Q

UTI from this card onwards…

A
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34
Q

Aetiology of UTI in adults?

A

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

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35
Q

What to use for empirical oral antibiotic therapy for UTI?

A

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.

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36
Q

What are features of cystitis?

A

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

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37
Q

What to do before starting antibiotics to treat cystitis?

A

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.

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38
Q

true or false

For nonpregnant women with a first episode of acute uncomplicated cystitis, urine culture and susceptibility testing may not be necessary; empirical therapy can be started based on symptoms alone.

A

true

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39
Q

If pyuria is absent on microscopy, the diagnosis of acute cystitis is unlikely.

true or false

A

true

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40
Q

What is not effective for the treatment of UTI?

A

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

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41
Q

Difference between cystitis and pyelonephritis?

A

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

42
Q

What are some risk factors for UTI? Compare it between females and males.

A

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
43
Q

What are some risk factors for UTI which is shared between both women and men?

A

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​

44
Q

What are the principles of treatment in UTIs?

A

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

45
Q

What are the three types of UTI

A

Acute Cystitis

Acute Pyelonephritis

Asymptomatic Bacteriuria

46
Q

How/why is acute cystitis different in men?

A

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

47
Q

What antibiotics are used for the treatment of acute cystitis?

A
  • 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
48
Q

What to use for the empirical treatment of acute uncomplicated cystitis in non-pregnant women?

A
  • Trimethoprim 300mg daily for 3 days
  • Nitrofurantoin 100mg q6h for 5 days

> If trimethoprim and nitrofurantoin cannot be used –> used cefalexin

49
Q

What to do if the pathogen is resistant to empirical therapy and symptoms of cystitis are not improving?

A

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
50
Q

If resistance to all the drugs mentioned beforehand, what is used (acute cystitis)

A
  • Fosfomycin 3g as a single dose
  • Norfloxacin 400mg bd for 3 days
  • Ciprofloxacin bd for 3 days
51
Q

What is some other treatment for cystitis?

A

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
52
Q

What is acute pyelonephritis? What are some signs and symptoms?

A

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

53
Q

For treatment of acute pyelonephritis;

A) Empirical therapy of nonsevere pyelonephritis

B) penciillin hypersensitivity

C) If pathogen is suscpetible to a narrower spectrum antibiotic?

D) In severe pyelonepthritis Sx include?

E) Empirical tx while awaiting results

F) If gentamicin is CI

G) Sepsis caused by multidrug-resistant G-ve mo those who recently travelled to south and east asia

H) What is the total duration of therapy

A

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
54
Q

What is the definition of recurrent UTI? How to treat?

A

Definition 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
55
Q

How to prevent UTIs

A

Antibiotic prophylaxis

Oestrogen therapy

Cranberry

Methenamine Hippurate

Self care advicce

56
Q

What drugs are used for antibiotic prophylaxis of UTIs?

A
  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

57
Q

How is oestrogen therapy used in the prevention of UTIs?

A

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

58
Q

How is cranberry used in the prevention of UTIs?

A

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

59
Q

What is methenamine hippurate (antiseptic) used for in preventing UTIs?

A

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
60
Q

What is some self care advice for UTIs

A
  • 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

61
Q

What is asymptomatic bacteriuria (ABU)?

A
  • 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
62
Q

Is treatment required for ABU?

A

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

63
Q

Why must ABU in pregnant woman be treated?

A

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

64
Q

When does a UTI typically start?

A

A UTI typically starts when uropathogens that reside in the gut contaminate the periurethral area and are able to colonise the urethra.

Migration to the bladder (cystitis) and kidneys (pyelonephritis) via the ureter can result

65
Q

What is the incidence, prevalence and epidemiology of UTIs

A

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%

66
Q

Summary of UTI

A
  • 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
67
Q

Croup and OM in kidz from here…

A
68
Q

What is otitis media? When does it peak? What are the 3 different types?

A

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

69
Q

What type of infection if AOM? Is it self-limiting?

A

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

70
Q

True or false

for AOM: pull on ear and will feel better

for otitis externa: pull on ear and will hurt more

A

yessir true

71
Q

How to diagnose acute otitis media?

A

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

72
Q

Acute otitis media where effusion is infected, what other symptoms will there be?

A

Acute onset ear pain (tugging, holding, rubbing ear)

Fever, irritability, poor feeding

Bulging tympanic membrane

73
Q

How to manage otitis media? What medications are not used? Why antibiotics not helpful?

A

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

74
Q

For most children antibiotics are not required for AOM, who are the exceptions?

A

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)

75
Q

For normal patients, what does shared decision making with parent or carer mean for AOM?

A

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
76
Q

Harms of antibiotic therapy?

A
  1. Adverse effects of antibiotics

Diarrhoea, rash or more serious hypersensitivity reactions

  1. Effect on microbiome

Full consequences not fully understood Yeast infections (eg thrush) to more serious infections (eg Clostridium difficile infection)

  1. Antibiotic Resistance

Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting your family and the community

77
Q

If antibiotics are indicated for AOM:

A) what to use?

B) if no response to 48-72 hours, what to change to

C) for children with chronic otorrhea, add what?

D) if child very unwell or not responding to therapy?

A

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)

78
Q

If allergic to pencillins, what to use in place of amoxicillin or amoxicillin + clavulanate?

A) delayed non-severe hypersensitivity to penicillins

B) immediate (non severe or severe) or delayed severe hypersensitivity to pencillins

A

A)

  • cefuroxime for 5 days
  • trimethoprim + sulfamethoxazole for 5 days

B)

  • trimethoprim + sulfamethoxazole as above
79
Q

What are risk factors for recurrent bacterial OM?

A

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)

80
Q

What vaccination should child have to prevent bacterial OM?

A

Streptococcus pneumoniae vaccination

81
Q

What to do if recurrent infection of OM occurs?

A

Manage as for acute otitis media and consider referral to an otolaryngologist

> frequent recurrences may require myringotomy and insertion of tympanostomy tubes (grommets)

82
Q

How long does effusion last after resolution of AOM? Does it go away? When would it not be appropriate to wait?

A

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)

83
Q

What are the clinical signs of middle ear effusion?

A

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

84
Q

What is persistent OM with effusion (glue ear) –> how long does it last for? What is the solution?

A

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
85
Q

What are the aims of management of OM with effusion?

A

Restore hearing (if affected)

Resolve and prevent recurrent infections

Address risk factors for recurrent OM

86
Q

What is chronic suppurative otitis media (CSOM)? Symptoms?

A

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

87
Q

What is the treatment for CSOM?

A

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

88
Q

Summary for AOM

A

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)
89
Q

Summary for preventing and managing recurrent bacterial OM

A

Reduce risk factors (smoke exposure, day care)

Pneumococcal vaccination

Consideration of ENT referral and grommets

90
Q

Summary for otitis media with effusion

A

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)

91
Q

Summary for chronic suppurative otitis media

A

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

92
Q

What is croup?

A

Acute laryngotracheobronchitis

Inflammation of upper airway, larynx and trachea

93
Q

How does croup present itself?

A
  • 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
94
Q

What age does croup occur in, how long does it last for?

A

Most common 1-3 years (6mths-6 years)

Duration 2-5 days (post-viral cough may last weeks)

  • Most commonly parainfluenza viruses
  • Antibiotics
95
Q

What is spasmodic croup? When and who does it occur in?

A

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

96
Q

Outline the severity of coup through the following

A) Mild airway obstruction

B) Moderate airway obstruction

C) Severe airway obstruction

D) Life-threatening airway obstruction

A

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

97
Q

Differential diagnosis for croup?

A

Inhaled foreign body, anaphylaxis, bacterial tracheitis, epiglottitis

98
Q

What to use in croup? Why use these medications?

A

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

99
Q

What corticosteroid to use in mild-moderate croup?

A

Budesonide inhalation single dose

Dexamethasone single dose

Prednisolone single dose

100
Q

What corticosteroid to use in severe croup?

A

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

101
Q

Croup summary

A

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)

Bal (PPP2) (14 decks)

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