Upper Respiratory Tract

Question 1

What are the predominant bacterial etiology for URI in pediatric patients?

Answer 1

Strep pneumoniae, H. influenzae, Moraxella catarrhalis

Question 2

Most common viral etiologies for URI in pediatric patients?

Answer 2

Influenza, RSV, adenovirus, rhinovirus, human metapneumovirus (60% of all cases)

Question 3

What are some diagnostic considerations for AOM to define severity?

Answer 3

• T > 39C
• Otalgia > 48 hrs
• Bilateral involvement
• Age of patient: 6 mo - 2 years

Question 4

When should abx be initiated for AOM?

Answer 4

• Otorrhea regardless of age
• Severe symptoms
• 6 mo to 2 years with bilateral AOM (lower NNT for b/l presentation with otorrhea)

Question 5

When should watchful waiting management be used for AOM?

Answer 5

• 6 mo to 2 years with unilateral AOM and mild symptoms

- >2 years old with b/l or unilateral AOM and mild symptoms

Question 6

What is 1st line therapy for initial AOM management?

Answer 6

• HD oral amoxicillin 90 mg/kg/day to overcome strep pneumoniae resistance

Question 7

What is the 2nd line therapy for AOM?

Answer 7

• Amoxicillin/clavulanate 90 mg/kg/day based on amoxicillin component
• Useful in patients at high risk for H. influenzae who had beta lactamase producer
• Lower rates of vaccination

Question 8

When are alternative therapies considered in AOM?

Answer 8

• Can be considered if treatment failure 48-72 hr after receipt of amox/clav
• CTX 50 mg/kg/dose IM daily x 1-3 doses (duration dependent on initial vs recurrent infection)
• Cefpodoxime 10 mg/kg/day PO in 2 divided doses
• Cefuroxime 25 mg/kg/day PO in 2 divided dose
• Cefdinir 14 mg/kg/day PO in 2 divided doses

Question 9

What is the first line therapy for penicillin resistant strep pneumoniae AOM?

Answer 9

Clindamycin + 3rd generation cephalosporin

Question 10

What is the recommended duration of antibiotic therapy for AOM?

Answer 10

• 6 mo - 23 mo OR with severe symptoms: 10 days (increased treatment failures, persistence of severe symptoms, no decrease in nasopharyngeal colonization in 5 day treatment group)
• 2-5 years with mild to moderate presentation: 7 days
• > 6 years with mild to moderate: 5-7 days

Question 11

When should antibiotic ppx be considered in AOM?

Answer 11

> 6 episodes/year

Must have received first line therapy with completed duration of treatment for age

Question 12

What is the current recommendation on PCV13 vaccination to confer protection against strep pneumoniae in AOM?

Answer 12

Complete 4 doses of PCV13 prior to 18 mo of age

Question 13

What is the current ACIP recommendation in all patients > 6 months of age for the influenza vaccination?

Answer 13

• 2 vaccine doses in first season for patients 6 mo - 8 years

Question 14

What high risk factors should be considered to give PPSV23?

Answer 14

• Chronic heart disease, chronic lung disease (asthma), DM, sickle cell anemia, asplenia, CSF leak

Question 15

What diagnostic considerations are there for acute bacterial rhinosinusitis?

Answer 15

Purulent nasal discharge
Longer duration of symptoms (double sickening) *at least 7-10 days without improvement
Fever for 72-96 hours

Question 16

What risk factors for resistance are there for acute bacterial rhinosinusitis?

Answer 16

• <2 years or >65 years
• Abx within the last month
• Hospitalization within the last 5 days
• Comorbidities: smoking, DM, chronic cardiac disease, chronic hepatic/renal disease
• Immunocompromised

*For risk factors, should use HD amox/clav or 2nd line agents

Question 17

What are the primary pathogen considerations for acute bacterial rhinosinusitis?

Answer 17

• Strep pneumoniae
• H. influenzae
• Moraxella catarrhalis (often beta lactamase positive)
• Staphylococcus aureus (routine MRSA coverage is NOT warranted)
• Strep pyogenes

Question 18

What is first line therapy for ABRS management?

Answer 18

Amox/clav 500 mg PO TID or 875 mg PO BID (increased amox resistance for H. influenzae in adults vs AOM)

Alternative first line agent: Doxycycline 100 mg PO BID

Question 19

When should HD therapy (amox 2 g PO BID) be used for ABRS?

Answer 19

• Severe disease (fever > 39C, systemic toxicity)
• High endemic areas of Strep pneumo not susceptible to PCN
• MDR pathogens

Question 20

What alternative cephalosporin therapy is best for ABRS?

Answer 20

• Cefixime or cefopodoxime in addition to clindamycin (do not use cephalosporin monotherapy)

Question 21

What duration of therapy is recommended for ABRS?

Answer 21

• Adults: 5-7 days

- Pediatrics: 10-14 days

Question 22

How should chronic sinusitis be managed?

Answer 22

Recommends saline irrigation +/- intranasal corticosteroids (no antibiotics)

Question 23

What are the common pathogens for AECOPD?

Answer 23

• H. influenzae
• Strep pneumoniae
• PSA (risk factor for GNR is bronchiectasis)

Question 24

What initiation considerations are there for AECOPD?

Answer 24

• Exacerbation severity
• > 65 yo
• Low FEV1
• Presence of co-morbidities (cardiovascular dx or endocrine disorder)
• History of exacerbations
• Prior antibiotic use and local antibiogram

Question 25

What low risk and high risk antimicrobial management are used for AECOPD? How long of a treatment duration?

Answer 25

Low risk for PSA: Amox/clav, tetracycline, macrolide

High risk for PSA (recent antimicrobial therapy, recent hospitalization, bronchiectasis): ciprofloxacin/levofloxacin

Duration: 5-7 days (REDUCE trial)

Question 26

What antimicrobial prophylaxis regimens are used for AECOPD prevention?

Answer 26

• Azithromycin 250 mg TIW

- Moxifloxacin 400 mg PO QD x 8 weeks

Question 27

What is a contraindication for PCV13?

Answer 27

Severe allergic reaction to any vaccine containing diptheria toxoid