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Antibiotic > URTI > Flashcards

URTI Flashcards

1
Q

Acute otitis media (AOM) pathophysiology

A

Preceded by a viral URTI → dysfunction of eustachian tube and mucosal swelling of middle ear Reflux of bacteria/viruses and fluid from nasopharynx into middle ear → not cleared properly by mucociliary system
Children more susceptible due to anatomy of eustachian tube (shorter and more horizontal)

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2
Q

AOM Risk factor

A

Winter season outbreaks of viral infections
Episode of acute otitis media in first 6 months of life Sibling with a history of recurrent otitis media Exposure to tobacco smoke in home
Attendance at a daycare centre
Pacifier use

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3
Q

MIrcobiology AOM

A 
Viruses (40-45%) 
Respiratory syncytial virus (RSV) 
Rhinovirus 
Adenovirus 
Parainfluenza virus 
Bacteria 
Streptococcus pneumoniae 
Haemophilus influenzae 
Moraxella catarrhalis 
Staphylococcus aureus 
Streptococcus pyogenes
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4
Q

CLinical presentation of AOM

A 
Fever , 
Natural history  --- Resolves over ~ 1 week
Tugging at Ear   
Acute onset
Runny nose, nasal congestion, cough
earpain (otalgia)
Difficulty sleeping
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5
Q

Diagnosis of AOM

Diagnostic criteria

A

Children who present with moderate to severe bulging of tympanic membrane (TM), or new onset otorrhea not due to acute otitis externa
OR
Children who present with mild bulging of TM and recent (< 48hrs) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or intense erythema of TM)

Physical examination
- Otoscope
Discolored or reddened tympanic membrane Thickened tympanic membrane
Bulging tympanic membrane

Culture of middle ear fluid (natural or drain)

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6
Q

Diagnosis of AOM
No gold standard for diagnosis
Signs and symptoms very non-specific
Young children cannot verbalize symptoms

A

Diagnosis of AOM
No gold standard for diagnosis
Signs and symptoms very non-specific
Young children cannot verbalize symptoms

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7
Q

Types of Treatment for AOM

A

Non-antibiotic/Supportive treatment
Paracetamol or NSAID’s for pain and fever
Decongestants and antihistamines not shown to affect outcome
Topical analgesics not recommended

Surgical insertion of tympanostomy tubes (Ttubes)

  • Allows drainage of middle ear fluid
  • Only for children with recurrent episodes
    - 3 episodes in 6 months, or
    - 4 episodes in 1 year, with 1 episode in the preceding 6 month
  • Observation Period (Delayed Treatment)
  • Wait and See Prescription (WASP)
  • Immediate Treatment
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8
Q

AOM controversy

Use of antibiotic ear drops not recommended

  • Local adverse effects
  • Contribute to development of resistance

~ 80% of cases will resolve within 3 -4 days without antibiotics
Over-prescribing of antibiotics may contribute to development of resistance and risk of adverse effects Immediate antibiotic treatment results in ~ 1 day faster resolution of illness

A

AOM controversy

Use of antibiotic ear drops not recommended

  • Local adverse effects
  • Contribute to development of resistance

~ 80% of cases will resolve within 3 -4 days without antibiotics
Over-prescribing of antibiotics may contribute to development of resistance and risk of adverse effects Immediate antibiotic treatment results in ~ 1 day faster resolution of illness

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9
Q

Observation Period (Delayed Treatment) AOM

A

No antibiotics
Symptomatic treatment for initial period of 48- 72 hours
If child improves → do not give antibiotics
If no improvement, or worsening → start antibiotics Must ensure appropriate follow-up and have reliable parents
Disadvantage –may need a second physician visit

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10
Q

Wait and See Prescription (WASP) AOM

A

Initial physician visit → give parents prescription for antibiotic
But, fill prescription only if no improvement in 48 hours
Reduces antibiotic use (~ ⅔ of prescriptions not filled) Parents satisfied with this approach
More convenient than second physician visit

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11
Q

Immediate Treatment AOM

A

Immediate Treatment
At the time of diagnosis → start antibiotic
More convenient
Expected by parents?

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12
Q

types of AOM

A

Otorrhea with AOM
Unilateral or Bilateral AOM with Severe Symptoms
Bilateral AOM without Otorrhea
Unilateral AOM without Otorrhea

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13
Q

Tx principle for types of AOM

A

Otorrhea with AOM
Unilateral or Bilateral AOM with Severe Symptoms
- ABX therapy

Bilateral AOM without Otorrhea

  • 6 months to 2 years = ABX therapy
  • > = 2years = Antibiotic therapy, OR Observation period

Unilateral AOM without Otorrhea
= Antibiotic therapy, OR Observation period

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14
Q

Definition of severe and non severe illness in AOM

A

Severe illness

  • Moderate to severe otalgia OR
  • otalgia for ≥48 hours OR
  • temperature ≥ 39°C in the past 48 hours

Non-severe illness
- Mild otalgia for < 48 hours AND temperature < 39°C

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15
Q

Infants < 6 months of age
Specifically excluded from 2013 guidelines
2004 guidelines →immediate antibiotic therapy Observation period not recommended in this age group

AOM

A

Infants < 6 months of age
Specifically excluded from 2013 guidelines
2004 guidelines →immediate antibiotic therapy Observation period not recommended in this age group

AOM

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16
Q

Abx for AOM first choice

A

Amoxicillin
Drug of first choice
Patient has not received amoxicillin in past 30 days,

AND
Does not have concurrent purulent conjunctivitis, AND
Not allergic to penicillin

Dose

  • Children = 80-90mg/kg/day divided every 12 hours
  • Adults = 500mg –1g tds
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17
Q

AOM alternative first line therapy

A

Amoxicillin-clavulanate
Alternative first-line therapy

Patient has received amoxicillin in past 30 days, OR Has concurrent purulent conjunctivitis, OR

Has a history of recurrent AOM unresponsive to amoxicillin

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18
Q

Abx for AOM if patient have taken ABX in previous month

A

Taken antibiotics in the previous month
High dose amoxicillin
Cefuroxime = 30mg/kg/day divided every 12 hours Bad taste may affect compliance

Second or third generation oral cephalosporins Need to cover more resistant β-lactamase producing organisms

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19
Q

duration of therapy for AOM

A

Depends on age of child and severity of infection
< 2 years of age = 10 days
Severe symptoms = 10 days
2 –5 years of age with mild to moderate AOM = 7 days
≥6 years of age with mild to moderate AOM = 5 –7 days

20
Q

tx failure for AOM alternative

A

No response after 48 –72 hours → treatment failure → change antibiotics

Amoxicillin-clavulanate
Ceftriaxone IM or IV 50mg/kg daily (maximum 1g) x 3 days

Other second or third generation oral cephalosporins

21
Q

Penicillin-allergic patients AOM

A

Second or third generation oral cephalosporin, OR ceftriaxone (IM/IV)

22
Q

Severe, immediate hypersensitivity reaction in AOM what tx

less severe rxn then?

A

Azithromycin, clarithromycin
Clindamycin –only for documented Strep. pneumoniae

Less severe reaction
- Cephalosporins

23
Q

Prevention of Acute Otitis Media

A

Recommended strategies

  • Eliminating exposure to tobacco smoke
  • Breastfeeding for first 6 months of life
  • Eliminating pacifier use in second 6 months of life

Vaccinations
- Influenza vaccine (Decreases incidence by ~30%)
- Pneumococcal vaccine
(6% reduction in incidence AND Decreases need for T-tubes, number of office visits and decreased antibiotic prescriptions)

24
Q

Sinusitis

A

Inflammation and/or infection of the paranasal sinus mucosa (and usually also involves nasal mucosa)

25
Q

CLassification of sinusitis

A

Acute –symptoms last < 4 weeks
Subacute –symptoms last 4 –12 weeks
Chronic –symptoms persist > 12 weeks

26
Q

pathophysiology of acute bacterial sinusitis

A

Usually preceded by a viral upper respiratory tract infection that causes mucosal inflammation Inflammation results in obstruction of sinus ostia Mucosal secretions are trapped, local defenses impaired, and bacteria trapped and can multiply and set up infection

27
Q

Risk factor for sinusitis

A

Dental infection or extraction
Allergic rhinitis

Swimming 
Prior URTI 
Asthma
Cigarette smoking 
Environmental pollution 
Mechanical ventilation
Anatomic abnormalities –adenoids, deviated nasal septum, nasal polyps
Nasogastric (NG) tubes
28
Q

microbiology

A

virus and bacterial

Usually a single organism
With increasing use of pneumococcal vaccine → increase in prevalence of H. influenzae and Moraxella

29
Q

Clinical presentation of acute sinusitis

acute bacterial sinusitis

A 
Acute sinusitis 
Nasal congestion 
Facial/sinus pain or pressure 
Nasal discharge 
Fever
Tooth pain 
Reduced sense of smell (hyposmia) 
Malaise

Viral infection –usually resolves within 7 –10 days

Acute bacterial rhinosinusitis
Persistent signs and symptoms of acute rhinosinusitis for ≥ 10 days without evidence of clinical improvement, OR
Symptoms or signs of acute rhinosinusitis worsen within 10 days after initial improvement (double worsening)

30
Q

Diagnosis for acute bacterial sinusitis

A

Primarily a clinical diagnosis

Other investigations
Aspiration and culture of fluid from sinuses
- Gold standard
- Requires skill and experience

X-ray of sinuses
Ultrasound of sinuses
CT or MRI of sinuses
- Only if suspecting complications

31
Q

Course of disease ABS

A

40-60% recover spontaneously within 7 –10 days (likely viral)
If persists longer than 7 –10 days → more likely bacterial
- Primary bacterial
- Secondary bacterial –after a viral infection

32
Q

Tx for ABS

A

Symptomatic/adjunctive
- Analgesics
- Antihistamines and decongestants
A) Not recommended in guidelines (vs. practice)
B) No objective evidence of benefit vs. risk of adverse effects
- Irrigation of nasal sinuses with saline
A) Recommended as adjunctive therapy for both adults and children

33
Q

ICS for ABS

A

mometasone
budesonide
flunisolide
fluticasone

Steroids may reduce nasal and sinus mucosal inflammation and facilitate drainage of sinuses

Steroid plus antibiotic more effective than antibiotic alone
Some evidence of a dose-response relationship

  • recommended for symptomatic relief of acute bacterial rhinosinusitis (ADULT)
34
Q

Abx therapy for ABS

A

May be a small benefit with faster resolution of symptoms
May prevent progression to chronic sinusitis and complications

Amoxicillin alone OR amoxicillin/clavulanate
Dosing
Low dose = 45mg/kg/day in 2 divided doses
High dose = 80 –90mg/kg/day in 2 divided doses (high dose for Areas with high prevalence of non-susceptible Strep pneumoniae isolates)

Second-line antibiotics
- If suspect that patient is at risk for having a resistant organism
EG Recent course of antibiotics, recent hospitalization, local resistance patterns, etc., OR
- Failure to improve within 72 hours with amoxicillin

Amoxicillin/clavulanate
Second or third generation oral cephalosporins Fluoroquinolones –levofloxacin (adults only) Doxycycline (adults only)

Penicillin-allergic patients 
- Immediate-type hypersensitivity 
A) Clarithromycin, azithromycin 
B) Cotrimoxazole 
C) Fluoroquinolone 
D) Doxycycline

Minor reaction
A) Oral cephalosporins

35
Q

Abx therapy principle ABS

A

Watchful waiting (without antibiotic), OR
Immediate antibiotic therapy

Watchful waiting
Start antibiotic if no improvement by 7 days, OR
if condition worsens at any time
Amoxicillin alone OR amoxicillin/clavulanate Recommend high dose amoxicillin over standard dose

36
Q

Duration of therpy for ABS

A

adults: 5 –10 days
Lower incidence of adverse effects with shorter duration

Children
10 –14 days

37
Q

Pharyngitis bacteria

A

Group A β-hemolytic Streptococcus (Streptococcus pyogenes)

80% is virus caused

38
Q

pharyngitis epidemiology

A

Children 5 –15 years of age at greatest risk
Rare in adults > 30 years of age
Seasonal outbreaks

39
Q

clinical presentation of pharyngitis

A 
Sore throat 
Headache
Abdominal pain
Red, swollen uvula
Pain on swallowing
Enlarged, tender cervical lymph nodes  
Nausea and vomiting  Erythema/inflammation of tonsils and pharynx (with or without patchy exudates)
Runny nose 
Fever 
Cough
40
Q

diagnosis of pharyngitis

A 
Difficult to distinguish viral from bacterial cause based on clinical presentation 
Age of patient 
Contact history or outbreaks in area 
Throat swab/culture 
     - Gold standard for diagnosis 
     - 24 –48 hours for results
Rapid antigen detection testing 
   - Based on immunoassay 
   - Results within minutes 
   - Can be done in GP office setting

IDSA guidelines (2012)

  • Rapid antigen detection test and/or culture should be done to confirm diagnosis
  • Cannot rely on clinical features to distinguish bacterial from viral infection
41
Q

Clinical scoring systems (Centor criteria)

A

for pharyngitis

1 point each for 
Fever 
Tonsillar exudates 
Swollen, tender anterior cervical lymph nodes 
Lack of cough

MOH guidelines (2006)

- Score < 3 → no antibiotics 
- Score 3 or 4 → treat with antibiotic

US-based guidelines

- Score 0 or 1 → no further diagnostic testing, no antibiotics 
 - Score 2, 3 or 4 → rapid antigen test → antibiotic if positive
42
Q

complication of pharyngitis

A

Viral infection –self-limited
Group A Streptococcus infection
- Acute rheumatic fever (rheumatic heart disease)
(Rare in developed countries)
- Acute glomerulonephritis
- Develop 1 –3 weeks after infection
- Antibiotic treatment will prevent acute rheumatic fever, but does not prevent glomerulonephritis

43
Q

symptomatic tx for pharyngitis

A 
Paracetamol 
NSAID’s 
Corticosteroids 
Lozenges 
Adequate fluid intake
Adequate rest
44
Q

abx tx forpharyngitis

A

Amoxicillin or Penicillin x 10 days

Other treatment options (low / standard dose)
First or second generation oral cephalosporins Azithromycin/clarithromycin –penicillin allergic Clindamycin –penicillin allergic
Recommend 10 day course of therapy except azithromycin

Amoxicillin dosing 
- Standard dosing = 25mg/kg bd 
- Once daily dosing 
   50mg/kg (maximum 1g) 
   10 days duration 
As effective as penicillin and divided dose amoxicillin
45
Q

pharyngitis

Use of antibiotics shortens symptoms by ~1 – 2 days Considered significant enough to warrant treatment Prevents transmission to others and development of complications
No longer contagious after 24 hours of treatment

A

pharyngitis

Use of antibiotics shortens symptoms by ~1 – 2 days Considered significant enough to warrant treatment Prevents transmission to others and development of complications
No longer contagious after 24 hours of treatment

Antibiotic (21 decks)

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