Upper Respiratory Infection - Block 2 Flashcards
Most URTIs derive from?
Viral etiologies
What is the most common infection for pediatric patients receiving antibiotics in the US?
Acute otitis media: 6-24 months olds
What are the subtypes of otitis media?
- Aucte otitis media
- Otitis media with effusion
- Chronic otitis media
What are the common pathogens of AOM? MOA?
- Strep pneumoniae: alteration of PBP
- H. flu: production of b-lactamases
- Moraxella catarrhalis: production of b-lactamases
Describe the appearances of a non-infected vs otitis media?
Non-infected: thin, clear tympanic membrane
Otitis media: bulging, erythematous tympanic membrane from fluid build up
Why are children more susceptible to ear infections?
Shorter, more horizontal ETs -> increased bacteria entry
What are the s/s of AOM?
Otalgia: moderate to severs if pain is ≥48H
Fever: Severe if ≥39C or 102.2F
What is the diagnostic criteria for AOM?
Middle ear effusion and 1 of the following:
1. Moderate-severe bulging of tympanic membrane or new onset otorrhea
2. Mild bulging of tympanic membrane AND onset of ear pain within last 48H OR intense erythema of tympanic membrane
What is the screening tool for middle ear effusion?
pneumatoscopy and/or tympanometry
What is the difference between AOM and otitis media with effusion?
Otitis media with effusion: has the fluid without s/s of acute ear infection
Pharm tx for OM with effusion?
ABX is not necessary
First line treatment for AOM?
Amoxicillin
Consider change to current treatment plan, if complications develop or symptoms worsen within ___ days?
3
What is initial observation?
Only initiate ABX if sx worsen/decline within 48-72H of sx onset
Who qualifies for initial ABX?
- Children ≥ 6 months with AOM who present with severe symptoms (i.e., toxic-appearing, persistent ear pain ≥ 48 hours , or temperature ≥ 39°C or 102.2°F)
- Children ≥ 6 months with AOM and otorrhea
- Children aged 6 – 23 months with bilateral AOM
Who qualifies for initial observation?
- Children ≥ 6 months with non-severe unilateral AOM without otorrhea
- Children ≥ 2 years with bilateral AOM without otorrhea
Pharm tx of initial diagnosis of AOM?
- Amoxicillion
- Augmentin
- Azithromycin or Clindamycin
- Cefdinir, Cefuroxime, Cefpodoxime
- Ceftriaxone
Pharm tx for AOM tx failure at 48-72H?
Augmentin or Ceftriaxone
How long do you need to reconsider tx plan?
symptoms worsen or decline with 48 - 72 hours of onset
How is excluded from amoxicillin tx?
- Recieved amoxicillin in the past 30 days
- Have concurrent purulent conjunctivitis
- Have a hx of recurrent infections unresponsive to amoxicillin
These patients get Augmentin
Why is amoxicillin considered the first line?
Efficacious for S. pneumoniae
* More spontaneous resolution with H flu and Morexella
What are the advantages of using Augmentin in AOM?
Patients with concurrent purulent conjuntivitis and AOM are likely infected by non-typeable H. flu -> requiring b-lactamase inhibitor
AOM tx for non severe penicillin allergies?
Second gen: Ceftin (cefuroxime)
Third gen:
* Omnicef (cefdinir)
* Vantin (Cefpodoxime)
* Rocephin (Ceftriaxone)
Apart from amoxicillin what are the advantages of using ceftriaxone over other cephalosporins for AOM?
Ceftriaxone is the only ceph option that achieve a drug concnetration above MIC for >40% of the dosing interval
Types of IgE mediated rx?
anaphylaxis, angioedema, wheezing, laryngeal edema, hypotension, hives
Types of serious delayed rx?
SJS, TEN, cytopenia
Tx for AOM with severe penicillin allergy? SOA?
- Azithromycin (has activity for all 3)
- Clindamycin (NO activity against H flu or M. cat)
When would you consider adjunct therapy for AOM?
- ABX doesn’t reduce pain in initial 24H of tx
- Pain continues for 3-7 days while on ABX
What are the recommended adjuct meds for AOM? Dosing?
Tylenol:
* WBD: 10-15 mg/kg Q4-6H, don’t exceed 5 dose/24H
* Max DD: 75 mg/kg/d Don’t exceed 4g/d
Motrin:
* WBD: 4-10 mg/kg Q6-8H
* Max: 600 mg/dose
* Max DD: 2.4 g/d
Duration of AOM therapy?
Penicillin and cephalosporin (except Rocephin):
* <2YO, with perforation or recurrent AOM: 10 days
* ≥ 2YO, no perforation or hx of recurrent AOM: 5-7 days
Azithromycin: 5 days
Ceftriaxone: 1-3 days
When do you follow up with AOM tx?
Within 48-72H
If sx worsen:
* Initial observation occurred: initiate ABX
* Initiated ABX: change therapy due to Hflu and Mcat risk
Common pathogens of ABRS?
- S. pneumoniae
- H. influenzae
- M. catarrhalis
ABRS commonly affect what?
Maxillary and ethmoid sinuses
What are the presentations of ABRS?
- Onset with persistent signs or sx, lasting for ≥10 days
- Onset with severe sx for 3-4 consecutive days
- Onset with worsening sx lasting 5-6 dyas (double sickening)
Improvement of viral rhinosinusitis should be seen in ___ days?
7-10
What is first line for ABRS?
Child: Augmenten 45 mg/kg/day (OR) 90 mg/kg/day, PO divided in 2 doses
Adults: Augmenten 500/125mg PO TID (OR) 875/125mg PO BID (OR) 2,000/125mg PO BID
RF for pneumococcal resistance?
- Living in geographic regions with rates of penicillin-non-susceptible S. pneumoniae
- Age ≤2YO or ≥65YO
- Attendance at daycare
- Recent hospitalization within the past 5 days
- ABX within the past month
- Immunocompromised px
- Multiple comorbidities
- Severe infection
Identify medications for symptomatic management of ABRs?
- OTC analgesics for pain and fever
- OTC products for nasal drainage and inflammation
- Don’t use products that excessively dry nasal mucosa or clear secretions (sudafed, afrine, antihistamines)
What is the initial empiric tx for ABRS in children first line?
Augmentin
What do you give for ABRS if child presents with b-lactam allergy?
Non-type 1 allergy: Clindamycin + cefixime or cefpodoxime
Type 1 allergy: Levofloxacin
Dose of Augmenin for ABRS?
45 mg/kg/day (OR) 90 mg/kg/day, PO divided in 2 doses
If a child has failed ABRS tx or show resistnce, what do you use?
Augmentin: 90 mg/kg/day, PO divided in 2 doses
Clindamycin + 3rd generation cephalosporin (i.e., cefixime or cefpodoxime)
Levofloxacin
If a child has severe ABRS requiring hospitalization, what do you use?
Augmntin
Ceftriaxone
Cefotaxime
Levofloxacin
What do you give for ABRS if an adult presents with b-lactam allergy?
Non type 1 allergy: Doxycycline
* Clindamycin + 3rd generation cephalosporin (i.e., cefixime or cefpodoxime)
Type 1 allergy: Doxycycline, Levofloxacin, Moxifloxacin
If an adult has failed ABRS tx or show resistnce, what do you use?
Augmentin
Clindamycin + 3rd generation cephalosporin (i.e., cefixime or cefpodoxime)
Levofloxacin
Moxifloxacin
Doxycycline
If an adult has severe ABRS requiring hospitalization, what do you use?
- Ampicillin-sulbactam
- Ceftriaxone
- Cefotaxime
- Levofloxacin
- Moxifloxacin
Duration of therapy for ABRS? Evaluation?
Adults: 5-7 days
Children: 10-14 days
Reassess in 48-72 hrs
What is most common sx of acute pharyngitis?
Sore throat primarily derived from viral etiology
What is the pathogen causing acute pharyngitis?
S. pyogenes (Group A b-hemolytic Strep. pyogenes)
Who are more susceptible to acute pharyngitis?
- Children 5-15 YO
- Parents of school aged children
- Individuals who work with children
How long is the incubation period of GAS?
2-5 days
Untreated GAS patients are infectious for how long? Treated patients?
Untreated: During acute illness and 7 days after
Treated: 24H after starting ABX
most common bacterial cause of acute pharyngitis
GAS
Presentation of viral pharyngitis?
- Conjunctivitis
- Cough
- Coryza: inflammation of mucous membrane in the nose
What are the presentations of bacterial pharyngitis?
- SOre throat
- Painful swallowing
- Fever
- HA
- N/V
- Erythema/inflammation
- Red swollen uvula, petchiae on soft palate
Lab tests for GAS?
- Throat swab and culture (gold standard)
- Rapid antigen detection test (more practical)
Describe the Centor criteria?
≥ 3 Centor criteria -> test for GAS
< 3 Centor criteria -> GAS unlikely; no testing necessary
* DOESN’T replace GAS testing
Can’t cough, exudate, nodes, temp >38C, Young or old
* <15YO: +1 point
* >44YO: -1 point
If RADT produces positive (+) result for the patient:
Pateint has GAS pharyngitis
If RADT produces negative (-) result in children or adolescents:
Recommend a throat swab to confirm
If RADT produces negative (-) result in adult patient:
NOT necessary to confirm results with throat culture -> patient is not likely to have GAS
What is the preferred ABX for GAS?
- penicillin VK
- Penicillin G benzathine
- Amoxicillin
What is the preferred ABX for GAS with non-type 1 allergy?
- Cephalexin
- Cefadroxil
- Cefuroxime
- Cefpodoxime
- Cefdinir
- Cefixime
What is the preferred ABX for GAS with type 1 allergy?
- Clindamycin
- Azithromycin
What is the duration of therapy for GAS?
Penicillin V, cephalosporin, clindamycin, clarithromycin: 10 days
Azithromycin: 5 days
Penicillin G benzathine: 1 day
Evaluation and follow up with GAS tx?
Without ABX: resolution 3-4 days
With ABX: resolution is earlier
Follow-up testing generally is NOT necessary, unless patients remains symptomatic 2-7 days after finishing initial antibiotic therapy.
