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PR3124 > URTI l (pharyngitis, sinusitis & AOM) > Flashcards

URTI l (pharyngitis, sinusitis & AOM) Flashcards

1
Q

What is used to diagnose bacterial pharyngitis?

A

Modified Centor Criteria
0-1 = likely viral
2-3 = moderate risk, can initiate empirical therapy or culture
4-5 = high risk, initiate empirical therapy

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2
Q

Treatment for bacterial pharyngitis

A 
1st line : Penicillin VK (PO)
Alternatives : 
- amoxicillin
- cephalexin
- clarithromycin
- clindamycin
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3
Q

Pathogens of bacterial pharyngitis

A

Group A beta-hemolytic Streptococcus pyogenes

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4
Q

Complications of bacterial pharyngitis

A

1-3 weeks

  1. Acute rheumatic fever (can be prevented from using antibiotics early)
  2. Acute glomerulonephritis (cannot be prevented even with antibiotics)
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5
Q

Pediatric doses for bacterial pharyngitis

A
  1. Penicillin VK (250mg BD/TDS)
  2. Amoxicillin (40-50mg/kg/day divided BD)
  3. Cephalexin
  4. Clindamycin (7mg/kg/dose TDS)

Duration = 10 days

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6
Q

Adult doses for bacterial pharyngitis

A
  1. Penicillin VK (250mg QDS or 500mg BD)
  2. Amoxicillin (1g OD or 500mg BD)
  3. Cephalexin
  4. Clindamycin (300mg TDS)

Duration = 10 days

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7
Q

Presence of sinusitis

A

Major (7)

  1. Purulent anterior nasal discharge
  2. Purulent or discolored posterior nasal discharge
  3. Facial congestion/fullness
  4. Nasal congestion/obstruction
  5. Facial pain/pressure
  6. Hyposmia/anosmia
  7. Fever

Minor (6)

  1. Fatigue
  2. Dental pain
  3. Halitosis
  4. Headache
  5. Ear pain/pressure/fullness
  6. Cough

Sinusitis only if :

  1. At least 2 majors
  2. 1 major & at least 2 minors
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8
Q

Bacterial sinusitis diagnosis

A

Presence of sinusitis only :
At least 2 majors
1 major & at least 2 minors

Bacterial if (any) :

  1. Persists for >10days
  2. Severe symptoms onset (purulent discharge x3-4 days or high fever >39)
  3. Worsening symptoms (appear 5-6 days after improvement)
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9
Q

Treatment for bacterial sinusitis

A

1st line : Amoxicillin or Amoxicillin/clavulanate

  • amox/clav only if :
    1. recent antibiotics use
    2. recent hospitalisation
    3. non-responsive to amoxicillin after 72h

Alternatives :

  • respiratory fluoroquinolones (levofloxacin/moxifloxacin)
  • co-trimoxazole (trimethoprim & sulfamethoxazole)
  • 2nd gen cephalosporin (cefuroxime)

Duration :
5-10 days (adult)
10-14 days (children)

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10
Q

Pathogens of bacterial sinusitis

A
  1. Streptococcus pneumoniae

2. Haemophilus influenzae

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11
Q

Why is ciprofloxacin not considered a respiratory fluoroquinolone?

A

Ciprofloxacin has poor activity against Streptococcus pneumoniae

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12
Q

Do we use normal doses of amoxicillin for bacterial sinusitis?

A

No because Streptococcus pneumoniae have resistance to penicillins through a multistep penicillin-binding protein(PBP) mutations, increasing MIC value.

  • amoxicillin > penicillin due to better PK profile (higher F)
  • use high dose amoxicillin

adult dose = 1g TDS
pediatric dose = 80-90mg/kg/day divided BD

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13
Q

Haemophilus influenzae resistance

A

Due to beta-lactamase production, thus require beta-lactamase inhibitor (clavulanate)
Hence, use amoxicillin-clavulanate
1. recent antibiotic use
2. recent hospitalisation
3. failure to improve 72h after initiation of amoxicillin

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14
Q

Risk factors for AOM (7)

A
  1. Siblings
  2. Attending daycare
  3. Supine position during feeding
  4. Tobacco smoke exposure at home
  5. Pacifier use
  6. Winter season
  7. Age <5y/o
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15
Q

Prevention of AOM

A
  1. Avoid tobacco smoke exposure at home
  2. Exclusive breastfeeding for first 6months (pass maternal antibodies to infants to prevent viral URTI)
  3. Vaccinations (influenza, haemophilus influenzae type B & pneumococcal)
  4. Minimise pacifier use
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16
Q

Pathogens of AOM

A

Bacteria > Viral

  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Moraxella catarrhalis
17
Q

Why are children <5y/o more prone to AOM?

A

They have shorter and straighter eustachian tube.
Eustachian tube connects the nasopharynx and middle ear to regulate middle ear pressure.
Viral URTI leads to backflow and accumulation of nasal discharge into middle ear, providing medium for the growth and multiplication of bacterial, leading to AOM

18
Q

Diagnosis of AOM

A

Use tympanic otoscope to look for :

  • erythema of tympanic membrane
  • bulging of tympanic membrane

AOM

  • acute onset (<48h)
  • otalgia (pain in the ears)
19
Q

When to initiate empirical treatment or observe?

A

Observatory period can if :

  • at least 6months
  • non-severe illness (severe if moderate-severe otalgia, otalgia for 48h, high fever >39 in last 48h)
  • no otorrhea
  • close monitoring possible
  • shared decision making w the parent/caregiver
20
Q

Treatment criteria for AOM

A

<6months : no observatory period, have to initiate empiric treatment

6months-2y/o :
observatory period only if unilateral AOM w/o otorrhea

> =2y/o :
observatory period for unilateral/bilateral AOM w/o otorrhea

ALL AGES :
initiate empiric treatment if otorrhea or severe symptoms

21
Q

Treatment for AOM

A 
1st line : Amoxicillin or Amoxicillin/clavulanate
amoxicillin if : 
- no amoxicillin within 30 days
- no concurrent purulent conjunctivitis
- no penicillin allergies

amox/clav only if :

  • recent amoxicllin use within 30days
  • concurrent purulent conjunctivitis
  • history of AOM non-responsive to amoxicillin

Alternatives :

  1. Cefuroxime PO or Ceftriaxone IM (mild penicillin allergies)
  2. Clindamycin (severe penicillin allergies)
22
Q

When do we consider high dose of amoxicillin?

A

Sinusitis and AOM
This is because Streptococcus develop resistance against penicillins through a multistep penicillin-binding protein mutations, increasing MIC for penicillins.
Pediatric higher dose = 80-90mg/kg divided BD
Adult higher dose = 1g TDS

23
Q

Duration of treatment for AOM

A 
<2y/o = 10 days
Severe symptoms (high fever >39 within 48h, otalgia for at least 48h, moderate-severe otalgia) = 10 days
2-5y/o = 7 days
>6y/o = 5-7 days
24
Q

Pediatric dose for AOM

A
  1. Amoxicillin (80-90mg/kg divided BD)
  2. Amoxicillin/clavulanate (80-90mg/kg divided BD)
  3. Cefuroxime (30mg/kg/day divided BD)
  4. Ceftriaxone
  5. Clindamycin
25
Q

Pediatric dose for bacterial sinusitis

A
  1. Amoxicillin (80-90mg/kg divided BD)
  2. Amoxicillin/clavulanate (80-90mg/kg divided BD)

cannot levofloxacin or moxifloxacin

26
Q

Adult dose for bacterial sinusitis

A
  1. Amoxicillin (1g TDS)
  2. Amoxicillin/clavulanate (625mg TDS or 1g BD)
  3. Levofloxacin 500mg OD
  4. Moxifloxacin
  5. Co-trimoaxazole
  6. Cefuroxime
27
Q

What antibiotics cannot be used for Streptococcus pneumoniae?

A

Tetracyclines and macrolides due to resistance.

Mainly clarithromycin & azithromycin, and doxycyclines.

28
Q

Period for Acute Sinusitis

A

Within 4 weeks

29
Q

How long should observatory period for AOM be?

A

48-72h. Start antibiotics if condition worsens or fails to improve.

PR3124 (6 decks)

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