respiratory tract infections Flashcards
for a RTI to develop, the pathogen must…
gain access to the lungs
host defense mechanisms
nasopharynx - nasal hair, anatomy of airway
oropharynx - saliva, epithelial cell sloughing
trachea, bronchi - cough, epiglottic reflexes, sharp angled branching airways,
terminal airways, alveoli - alveolar lining fluid, cytokines, macrophages, PMNs, cell-mediated immunity
factors known to interfere with host defenses
altered level of consciousness - compromise epiglottic exposure - aspiration
smoking*** (and second hand smoke) - disrupts mococilliary function and macrophage activity
viruses (flu) - impairs alveolar macrophage fxn and mocociliary clearance - inc risk of secondary bacterial infection
alcohol - impairs cough and epiglottic reflexes - aspiration, increases oropharyngeal colonization with gram negative organisms, decreased mobilization of neutrophils
endotracheal tubes, NG tubes, respiratory therapy machinery (ventilators)
immunosuppression - malnutrition, immunosuppressive therapy, HIV
Elderly - increased number and severity of underlying diseases, increased hospitalizations, decreased mucociliary clearance, decreased immune function
pathogenesis of CAP
aspiration** - most common for bacteria pneumonia
specific pathogens in CAP
Strep Pneumoniae*** (25-70% of cases) - most common in outpatient, inpatient (ICU and non-ICU) Mycoplasma pneumoniae Haemophilis influenzae Legionella pneumophila Chlamydophila pneumoniae
Strep pneumoniae
CAP
2/3 of bacteremic pneumonia cases
more prevalent and severe in patients with splenic dysfunction, DM, chronic cardiopulmonary or renal disease and HIV
Risk factors for drug-resistant S. pneumoniae (DRSP)
-extremes of age (less than 6, over 65 years old)
-prior antibiotic therapy*
-underlying illnesses, co-morbid conditions
-day care attendance or family member of child in day care
-recent or current hospitalization
- immunocompromised, HIV, nursing home, prison
susceptibilty of streptococcus pneumoniae
azithromycin - resistance up to 48.4%
tetracycline - 24.1% resistance
mycoplasma pneumoniae
CAP
“walking pneumoniae”
atypical pathogen
spread by close contact
gradual onset of fever, HA, and malaise; development of persistent, hacking, nonproductive cough* after 3-5 days
radiographic findings usually more impressive than physical findings - patchy, interstitial infiltrates (not consolidation*)
no predominant organism on sputum gram stain
can be cultured using specialized media; slow growth
usually benign and self-limiting; symptoms may persist up to 4 weeks (treat to decrease)
Legionella pneumophila
CAP
likely to end up in ICU
atypical pathogen
transmitted by inhalation of aerosols containing organism
infection characterized by multisystem involvement: high fevers (over 40 C), rapid progression on CXR and multilobar involvement
Chlamydophilia pneumoniae
CAP
atypical, typicall occurs in young adults, mild sxs
CAP and staph aureus
2,259 patients - 1% MSSA, 0.7% MRSA
30% received anti-MRSA agents
more likely in patients post-influenza
2-14 days post-infuenza*** - sudden onset of shaking chills, pleuritic chest pain, productive cough, inc WBC with left shift, consolidation
high index of suspicion for MRSA (CA-MRSA) - bactrim
conditions and risk factors related to specific pathogens in CAP
alcoholism, COPD/smoker, aspiration, lung abscess, exposure to bat or bird droppings, birds, rabbits, or farm animals, HIV infection, hotel or cruise ship stay in previous 2 weeks (legionella), inj drug use, nursing home,
clinical presentation and evaluation of CAP - general
Classic presentation: sudden onset of fever, chills, pleuritic chest pain (pain on inspiration), dyspnea, productive cough (thick, may be rust colored**)
in elderly - classic symptoms may be absent (esp fever, mild increase in WBC), may present with decline in functional status
clinical presentation and evaluation of CAP - physical exam
heart rate, blood pressure
-pulse: increased 10 bpm for every 1 C elevation
-relative bradycardia: viral, atypical pathogens - inc temp, no inc HR
-record postural changes to assess hydration status
tachypnea, cyanosis, use of accessory muscles of respiration, sternal retration, nasal flaring - suggests serious respiratory compromise
evidence of consolidation - suggestion og bacterial etiology
-dullness to percussion, decreased breath sounds over affected area, inspiratory crackles, increased tactile fremitus, whisper pectoriloquy, egophony (E to A changes)
clinical presentation and assessment of CAP - chest radiography
only way to differentiate acute bronchitis from CAP
should be performed on ALL outpatients and inpatients with suspected CAP
clinical presentation and evaluation of CAP - sputum exam
observe color, amount, consistency, odor
-rust colored - S. pneumoniae
-dark red, mucoid sputum - K. pneumoniae
-foul-smelling sputum - mixed anaerobic infection
microscopic exam - gram stain
-sample containing over 25 PMNs and less than 10 epithelial cells/LPF should be evaluated
-gram positive, lancet shaped diplococcu - S. pneumoniae
-small, gram-negative coccobacilli - H. influenzae
clinical presentation and assessment of CAP - additional tests
WBC, differential SCR, BUN, electrolytes, LFTs pulse ox, O2 saturation urinary antigen tests - in severe CAP -L. pneumophilia serogroup 1 -S. pneumoniae - 71% sensitive, 96% specific
criteria for severe CAP
Direct admission to ICU for patients with either major criteria or 3 minor criteria
Major criteria: need for mechanical ventilation, septic shock with need for vasopressors
minor criteria: RR over 30, hypotension requiring fluids, BUN over 20, WBC under 4000, PLTs under 100,000, core temp under 36 C, other
scoring systems to evaluate severity of illness and predict mortality of CAP
CURB-65
- Confusion
- Uremia (BUN over 20)
- Respiratory rate (over 30 bpm)
- low Blood pressure (systolic under 90 or diastolic under 60)
- age over 65
treatment of CAP - general
humidified oxygen if hypoxemic
bronchodilators (albuterol) if bronchospasm present
fluids for rehydration
chest physiotherapy for marked accumulation of retained respiratory secretions
appropriate antimicrobial therapy
empiric treatment of CAP - IDSA outpatient therapy
previously healthy patient and no prior antibiotic use within the previous 3 months:
-macrolide: clarithromycin or azithromycin
-doxycycline
presences of comorbidities (heart, lung, liver or renal disease, DM, alcoholism, malignancy, asplenia, immunosuppression) OR antimicrobial use within the previous 3 months*
-respiratory FQs: moxifloxacin, levofloxacin
-B-lactam PLUS macrolide: high dose amoxicillin (1g q8h) or amox-clav (2g q12h) preferred, OR ceftiaxone, cefpodoxime, cefuroxime, doxycycline may be used as an alternative to macrolides
in regions with a high rate (over 25%) of infections caused by high-level (MIC over 16) macrolide-resistant S. pneumoniae, consider alternative agents (even in patients without comorbidities): resp FQs (levo, moxi), B-lactam PLUS** macrolide
Empiric treatment of CAP - IDSA inpatient therapy - general medical ward
non-ICU
respiratory FW (moxi or levo - usually IV initially) esp in pen allergic
B-lactam PLUS macrolide (usually azith)
-preferred B-lactams: ceftriaxone* or cefotaxime
-ceftaroline: FDA approved 600 mg q12h
-doxycycline may be used as alternative to macrolides
Empiric treatment of CAP - IDSA inpatient therapy - ICU
ALWAYS combo!
-B-lactam PLUS azithromycin: ceftriaxone, cefotaxime, amp/sulbactam
—macrolides have anti-inflammatory properties
-B-lactam PLUS resp FQ:
—ceftriaxone, cefotaxime, ampicillin/sulbactam
—moxifloxacin, levofloxacin
in ICU patients with severe CAP, mortality lower with B-lactam/macrolide*** vs. B-lactam/FQ
-penicillin-allergic: respiratory FQs plus aztreonam
empiric treatment of CAP - ISDA inpatient therapy - special concerns
If P. aeruginosa is a consideration:
-antipneumococcal, antipseudomonal B-lactam (pipercillin/tazobactam, cefepime, imipenem, meropenem, doripenem) PLUS** ciprofloxacin or levofloxacin
-antipneumococcal, antipseudomonal B-lactam PLUS* aminoglycoside PLUS* azithromycin
-antipneumococcal, antipseudomonal B-lactam PLUS aminoglycoside PLUS antipneumococcal FQ
-substitute aztreonam in penicillin-allergic patient
if CA-MRSA is a consideration - add vancomycin or linezolid
anitpneumococcal, antipseudomonal B-lactams
pipercillin/tazobactam, cefepime, imipenem, meropenem, doripenem
antipneumococcal FQ
levo, moxi
duration of therapy in CAP
treat for a minimum of 5 days***
patients should be afebrile for 48-72 hours and no more than 1 CAP-associated sign of clinical instability
criteria for clinical stability: temp under 37.8 C. HR under 100, RR under 24, SBP over 90, O2 over 90, or pO2 over 60 mmHg on RA, ability to take oral medications, normal mental status
pathogen-directed therapy - CAP ** S. pneumo
PSSP (MIC under 2):
-preferred: Pen G (IV) or amoxicillin (PO)
-alternative: macrolide, cephalosporin, resp FQ, doxycycline
PRSP (MIC over 2):
-preferred: resp FQ, ceftrixone, cefotaxime
-alternative therapy: vancomycin, linezolid, high-dose amoxicillin (3 g/day) (NOT** amox-clav)
Pathogen-directed therapy - CAP *** H. influenzae
non B-lactamase producing:
-preferred: amoxicillin
-alternative: FQ, doxycycline, azithromycin, clarithromycin
B-lactamase producing:
-preferred: 2nd or 3rd generation cephalosporin, amox-clav
-alternative: FQ, doxycycline, azithromycin, clarithromycin
Pathogen-directed therapy - CAP *** mycoplasma pneumoniae, chlamydophila pneumoniae
preferred: macrolide, doxycycline
alternative: FQ
Pathogen-directed therapy - CAP *** Legionella pneumophila
preferred: FQ, azithromycin
alternative: doxycycline
Pathogen-directed therapy - CAP *** staph aureus
MSSA: -preferred: nafcillin, oxacillin -alternative: cefazolin, clindamycin MRSA: -preferred: vanc, linezolid -alt: SMX/TMP
Pathogen-directed therapy - CAP *** anaerobes
aspiration
preferred: B-lactam/B-lactamase-inhibitor, clindamycin
alt: carbapenem
Pathogen-directed therapy - CAP *** enterobacteriaceae
preferred: 3rd or 4th generation cephalosporin, carbapenem
alt: B-lactam/B-lactamase inhibitor, FQ
enterobacteriaceae***
Citrobacter enterobacter E. coli klebsiella morganella proteus providencia salmonella serratia shigella
HCAP, HAP, VAP
HCAP: health-care associated pneumonia (removed from guidelines in 2016 - low probability of MDROs) - any patient who was hospitalized in an acute care hopsital for 2+ days within 90 days of infection; resides in nursing home or LTC facility, received recent IV antibiotics, chemo or wound care in past 30 days of infection, attended a hospital or hemodialysis clinic
HAP: Hospital-acquired pneumonia - pneumonia occurring 48+ hours after hospital admission
VAP: ventilator-associated pneumonia pneumonia occurring over 48-72 hours after endotracheal intubation
managing HCAP
most patients with HCAP can be appropriately treated with CAP therapy
**broad-spectrum antibiotic may be warranted in: IV antibiotics within previous 90 days, history of MDR pneumonia, critically-ill, post-influenzae infection, structural lung disease (bronchiectasis, CF)
pathogenesis of HAP and VAP
microaspiration of oropharyngeal secretions colonized with pathogenic bacteria: normally, oropharynx is colonized with aerobic gram-positive organisms and anaerobes; become colonized with gram-negatives after 3-5 days of hospitalization
risk factors for HAP and VAP
advanced age, severity of underlying disease, duration of hospitalization, endotracheal intubation, mechanical ventilation, presence of NG tubes, altered mental status, surgery, previous antimicrobial therapy
diagnosis of HAP/VAP
no gold standard
timing* in relation to hospitalization and endotracheal intubation
microbiology of HAP/VAP
identification of bacterial pathogen is difficult d/t colonization of respiratory tract
aerobic gram-negative bacilli = about 70%***
-P. aeruginosa - 10-20%
-enteric gram-negative bacilli - 20-40%
-acinetobacter baumannii - 5-10%
S. aureus (esp MRSA) - 20-30%
-more common in DM, head trauma and ICU residence
factors associated with increased risk of MDR VAP vs. non-MDR VAP
prior IV antibiotics use within 90 days, 5+ days of hospitalization prior to occurance of VAP, septic shock at the time of VAP, acute respiratory distress syndrome (ARDS) before VAP, acture renal replacement therapy prior to VAP
lower risk of MDR VAP associated with coma at time of ICU admission
risk factors for antibiotic resistance in HAP and VAP
risk factors for MDR HAP - prior IV antibiotics use within 90 days
risk factors for MRSA HAP/VAP - prior IV antibiotics use within 90 days, more likely in late onset HAP/VAP, insufficient data for positive MRSA screen as a risk
risk factors for MDR P. aeruginosa HAP/VAP: prior IV antibiotics use within 90 days (carbapenems, broad-spectrum cephalosporins, FQs)
initial empiric treatment of HAP and VAP
all hospitals should regularly generate and disseminate a local antibiogram - include susceptibility data specific to patients with VAP, if possible or the the ICU populations
empiric regimens should be based on local distribution of pathogens associated with HAP and VAP and their susceptibility profiles
empiric therapy of clinically suspected VAP
ALL empiric regimens should provide coverage for: S. aureus, P. aeruginosa, other gram-negative bacilli
include agent active against MRSA (vanc, linezolid): risk factors for MRSA, patients treated in ICU where over 10-20% of S. aureus are MRSA, patients treated in ICUs where prevalence of MRSA unkown
**Prescribe 2 antipseudomonal antibiotics from different classes only in the following patient: risk factors for antimicrobial resistance, patients in ICU where over 10% of gram-negative isolates are resistant to monotherapy agent, patients in ICUs where local resistance rates unknown
***Prescribe empiric monotherapy for P. aeruginosa: patients without risk factors for antimicrobial resistance, patients in ICU where less than 10% of gram-negative isolates are resistant to monotherapy agent
suggested empiric treatment options for clinically suspected VAP - gram-positive antibiotics with MRSA activity
Vanc 15 mg/kg IV q8-12h
OR
linezolid 600 mg IV q12h
suggested empiric treatment options for clinically suspected VAP - B-lactam antibiotics with antipseudomonal activity
Pip/tazo 4.5 g IV q6h OR cefepime 2 g IV q8h ceftazidime 2 g IV q8h OR imipenem 500 mg IV q6h meropenem 1 g q8h OR aztreonam 2 g IV q8h
suggested empiric treatment options for clinically suspected VAP - non-B-lactam antibiotics with antipseudomonal activity
Ciprofloxacin 400 mg IV q8h Levofloxacin 750 mg IV q25h OR amikacin 15-20 mg/kg IV q24h gentamicin 5-7 mg/kg IV q24h tobramycin 5-7 mg/kg IV q24h OR (ONLY if MDRO) colistin* polymyxin B 1.5 mg/kg IV q12h
recommended empiric therapy for HAP - not at a high risk of mortality* and no factors increasing likelihood for MRSA
provide coverage for MSSA - pip/tazo 4.5 q6h, cefepime 2 g q8h, imipenem 500 mg q6h, meropenem 1g q8h, levofloxacin 750 q24h
high risk of mortality = need for ventilatory support for HAP and septic shock
recommended empiric therapy for HAP - Not at high risk of mortality but with factors increasing likelihood of MRSA
ONE of the following: pip/tazo 4.5 q6h OR cefepime 2 g q8h OR ceftazidime 2 g q8h OR imipenem 500 mg q6h OR meropenem 1 g q8h OR levoflox 750 q24 OR cipro 400 q8h OR aztreonam 2 g q8h
PLUS*** vencomycin 15 mg/kg q8-12h (target through 15-20) OR linezolid 600 mg q12h
recommended empiric therapy for HAP - high risk of mortality* or recipient of IV antibiotics during the prior 90 days
TWO* of the following: pip/taxo 4.5 q6h OR cefepime 2 g q6h OR ceftazidime 2 g q8h OR imipenem 500 mg q6h OR meropenem 1 g q8h OR levoflox 750 mg q24h OR cipro 400 mg q8h OR aminoglycoside OR aztreonam
PLUS* vancomycin 15 mg/kg q8-12h (target trough 15-20) OR linezolid 600 mg q12h
PK/PD optimization of antibiotic therapy
guidelines suggest dosing using PK/PD data rather than manufacturer’s prescribing information
B-lactams: continuous or prolonged infusion
treatment options with restricted recommendations
Aminoglycosides: NOT recommended as a monotherapy agent, avoid empiric use if alternatives available, why? poor lung toxicity, nephrotoxicity, ototoxicity
polymyxins: avoid empiric use if alt available, reserve for MDROs
tigecycline: don’t use
pathogen specific treatment for HAP and VAP
based on susceptibilty
if MSSA - nafcillin, oxacillin, cefazolin
if MRSA - vancomycin, linezolid
if enterobacteriaceae - numerous options
if ESBL-producer - carbapenem or pip/tazo (CTX-M)
if P. aeruginosa:
-not in septic shock or at high risk of monotherapy - monotherapy
-patient in septic shock or at high risk of death - combination therapy with 2 agents to which the isolate is susceptible
if acinetobacter - carbapenem or ampicillin/sulbactam - if susceptible
polymyxin IV inhaled colisitin if MDR
Duration of treatment for HAP and VAP
7 days
PCT to guide d/c of antibiotic therapy
suggested to utilize procaclitonin plus clinical criteria* to guide d/c of antibiotic therapy in HAP/VAP
acute bronchitis overview
etiology - respiratory viruses
clinical presentation - cough (2-3 weeks), coryza, sore throat, malaise, headache, fever, normal CXR
treatment
-symptomatic: antitussives, antipyretics, adequate hydration
-NO ANTIBACTERIAL THERAPY WARRANTED
acute exacerbation of chronic bronchitis - clinical presentation
definition of chronic bronchitis - any patient who reports coughing up sputum on most days for at least 3 consecutuive months each year for 2 consecutive years
3 cardinal symptoms of ABECB (acute bacterial exacerbation of chronic bronchitis) - must have all 3 for ABE
-increased cough or dyspnea
-increased sputum production
-increased sputum purulence
acute exacerbation of chronic bronchitis - clinical presentation
definition of chronic bronchitis - any patient who reports coughing up sputum on most days for at least 3 consecutuive months each year for 2 consecutive years
3 cardinal symptoms of ABECB (acute bacterial exacerbation of chronic bronchitis) - must have all 3 for ABE
-increased cough or dyspnea
-increased sputum production
-increased sputum purulence
chest auscultation - inspiratory and expiratory rales, rhonchi, mild wheezing; expiratory phase is prolonged
acute exacerbation of chronic bronchitis microscopy and laboratory assessment
obtain sputum early in the morning
increased PNMs - suggests continued bronchial irritation
gram stain often reveals a mixture of GPC and GNB
role of sputum culture - controversial (colonization)
bacteria involved:
-H. influenzae - 45% (30-40% B-lactamase positive)
-S. pneumoniea - 20% (20% PRSP; 30-40% macrolide-resistant)
-M. catarrhalis - 30% (95% B-lactamase positive)
-enterobacteriaceae, P. aeruginosa - seen in patients with end-stage COPD
acute exacerbation of chronic bronchitis - treatment overview
reduce or eliminate exposure to irritants, especially cigarette smoking and occupational exposure
promote clearance of pulmonary secretions
antimicrobial therapy:
-primary goal: propmt resolution of symptoms and positively influence the duration of the patient’s symptom-free post-treatment period
-assess “infection-free perios” when patients off antibiotics - time between infections
-infection-free interval significantly longer with FQs, amox/clav, azithromycin***
select antibiotics that are effective against common respiratory pathogens
consider drug interactions, compliance
assess presence of risk factors: age, severity of illness, over 4 exacerbations/year, cardiac disease, home O2 use, antibiotic use in previous 3 months, recent costicosteroid use
acute exacerbations of chronic bronchitis therapeutic options - uncomplicated ***
Criteria or risk factors: age under 65, FEV over 50% predicted, less than 4 exacerbations/year, no comorbid conditions, no risk factors
initial treatment options:
-2nd generation macrolide (clarith, azith)
-2nd or 3rd generation cephalosporin (cefuroxime)
-doxycycline
-amoxicillin
-SMX/TMP
acute exacerbations of chronic bronchitis therapeutic options - complicated ***
Criteria or risk factors: age over 65, FEV under 50% predicted, 4+ exacerbations/year, 2+ risk factors
initial treatment options:
-respiratory FQ (levo (renal adjust), moxifloxacin)
-amox/clav
acute exacerbations of chronic bronchitis therapeutic options - complicated with risk for infection with P. aeruginosa ***
Criteria or risk factors: severe symtoms, constant purulent sputum, FEV under 35% predicted, 2+ risk factors (esp. prior antibiotics or steroids)
Initial treatment options:
-FQ with antipseudomonal activity (cipro, levo)
-pip/tazo
-if hospitalized, emiric IV antibiotics to cover P. aeruginosa
pharyngitic - microbial etiology
viruses - most common*** streptococcs pyogenes (group A, B hemolytic) - most common bacterial pathogen (10-30% of cases)
pharyngitis - clinical presentation
sudden onset of sore throat with dysphagia and fever
pharyngeal hyperemia and tonsillar swelling (with or wtihout tonsillar exudates)
cannot differentiate bacterial vs viral etiology based on clinical symptoms - unless overt viral features are present (rhinorrhea, cough, oral ulcers, hoarseness)
pharyngitis - diagnosis
throat culture for GAS (group A strep) - takes 24-48 hours; diagnostic standard in the past
rapid antigen detection tests (RADT)
-detect GAS antigen
-sensitive 70-90%
-specific over 95%
-positive? treat; negative? do a culture
-in children and adolescents, back-up negative RADT with culture
-throat culture unnecessary if RADT positive
pharyngitis treatment overview
Goals of treatment: resolution of symptoms, limit spread of infection, prevent complications
symptomatic care for all patients (including viral): antipyretics, non-Rx lozenges and sprays containing menthol and topical anesthetic for pain relief
pharyngitis treatment
Group A strep -
- Pen VK 250 mg TID or QID or 500 mg BID for 10 days - drug of choice - need 40% above the MIC; never been resistant - only drug known to prevent rheumatic fever; penicillin resistance has never been reported
- amoxicillin 500 mg TID or 875 mg BID for 10 days - second drug of choice - sometimes fails d/t normal flora (so does pen VK) - could also use amox/clav
- second generation oral cephalosporins - may be more effective than penicillin; option if penicillin or amox failure
- penicillin-allergic patients: 1st gen cephalosporin x 10 days, macrolide (azithromycin 5 days or clarithromycin 10 days; concern for resistance esp. if they fail), clindamycin for 10 days
- short course regimens (5 days) may be equally effective - cefdinir, cefpodoxime
acute rhinosinusitis
up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness or both
viral rhinosinusitis
acute rhinosinusitic caused by or presumed to be caused by a viral pathogen
-diagnosed when signs and symptoms of acute rhinosinusitis are present less than 10 days and symptoms are not worsening
acute bacterial rhinosinusitis
(ABRS) - acute rhinosinusitis that is caused by, or presumed to be caused by, a bacterial pathogen
-diagnosed based on clinical presentation
recurrent acute rhinosinusitis
4 or more episodes of ABRS per year without signs and symptoms between episodes
chronic rhinosinusitis
presence of 2+ signs and symptoms of rhinosinusitis for 12 weeks or longer and presence of inflammation
etiologic agents in ABRS
most cases of acute rhinosinusitis begin when a viral** URI extends into the paranasal sinuses - mucosal inflammation - obstruction of sinus ostia (decreased sinus drainage) - mucosal secretions trapped and local defenses impaired - bacteria from adjacent surfaces proliferate - bacterial infection
bacterial pathogens - H. influenzae, Strep pneumo, moraxella catarrhalis
major symptoms of acute rhinosinusitis
purulent anterior nasal discharge, purulent of discolored posterior nasal discharge, nasal congestion and obstruction, facial congestion and fullness, facial pain and pressure, hyposmia or anosmia, fever (acute sinusitis only)
minor symptoms of acute rhinosinusitis
headache, ear pain, pressure or fullness, halitosis, dental pain, cough, fever, fatigue
diagnosis of ABRS
TREAT
onset with persistent** symptoms or signs compatible with acute rhinosinusitis, lasting for 10+ days without any evidence of clinical improvement (if on day 10 it is not better or worse, likely bacterial = treat)
onset with severe* symptoms or signs of high fever (39+ degrees C) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of the illness
onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral URI that lasted 5-6 days and was initially improving (“double sickening”)
sinus radiograph or CT - does not differentiate viral from bacterial rhinosinusitis
culture of secretions from nasal cavity - poorly correlates with sinus cultures
sinus puncture and culture - definitive diagnosis, not usually performed clinically (painful)
treatment of ABRS - initial empiric therapy***
first line: amox/clav 500/125 TID or 875/125 BID
second line:
-amox/clav 2g/125 BID
-doxycycline 100 mg BID; 200 mg QD
(otolaryngology guidelines recommend amoxicillin, with or without clavulanate)
treatment of ABRS - B-lactam allergy ***
no first line second line: -doxycycline 100 mg PO BID; 200 mg QD -levofloxacin 500 mg QD -moxifloxacin 400 mg QD
treatment of ABRS - risk for antibiotic resistance or failed initial therapy ***
no first line second line: -amox/clav 2g/125 BID -levofloxacin 500 mg QD -moxifloxacin 400 mg QD
treatment of ABRS - severe infection requiring hospitalization ***
no first line second line: -amp/sulbactam 1.5-3g IV q6h -levofloxacin 500 mg IV or PO QD -maxifloxacin 400 mg IV or PO QD -ceftriaxone 1-2 g IV q12-24h
treatment of ABRS - amov/clav
first-line therapy for children and adults due to increasing prevalence of B-lactamase-producing H. influenzae
high dose therapy recommended in patients at risk for resistance
decreased susceptibilty in S. pneumoniae is USA - monitor patients to ensure effective treatment
treatment of ABRS overview
resp FQs (moxi, levo) - second line
doxycycline - alt to amox/clav in adults
oral 2nd or 3rd gen cephalosporins - not recommended due to high prevalence of PRSP
ceftriaxone - decreasing susceptibilty of S. pneumoniae
macrolides - option ONLY is pen-allergic patients; high prevalence of resistance in S. pneumoniae
SMX/TMP - high resistance in S. pneumoniae
duration - adults 5-7 days
supportive therapy: ***AVOID topical and oral decongestants and antihistamines
