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ID Exam 3 E
Beck's Exam 3 portion: Upper and lower respiratory infections and tx
| Question | Answer |
|---|---|
| Common bacteria associated with upper respiratory infections include: | Streptococcus pyogenes, pneumoniae (+) Hemophilus Influenzae, Maraxella catarrhalis (-) |
| What do we look at when approaching a pt with an URI? | What pathogen caused it? How to treat? (Confirm infection; Obtain specimen to identify pathogen (IF NEEDED); select antimicrobial therapy (IF NEEDED); monitor response and optimize therapy |
| Who are the most susceptible age group for acute pharyngitis? Who should not get acute pharyngitis? | 5-15 year old; parents of school age children or work with children; rare for <3 yo unless transmitted from older sibling |
| What is the MOST COMMON cause of pharyngitis? | VIRUSES |
| List out the most common viruses that can cause pharyngitis: | Rhinovirus, Coronavirus, Adenovirus, HSV, Influenza, Parainfluenza, Epstein-Barr virus |
| What is the MOST COMMON BACTERIA that can cause pharyngitis? | Streptococcus pyogenes--> Group A B-hemolytic Streptococcus (GAS)--> AKA Strep Throat |
| S/sx of Viral pharyngitis? | cough, rhinorrhea, hoarseness, oral ulcers, conjunctiivitis (pink eye) |
| S/sx of Bacterial pharyngiits? | Fever, Headache, N/V/ abdominal pain, Patchy tonsilopharyngeal exudates, palatal petechiae (red), tender lymph nodes, sudden onset of sore throat |
| How does Group-A Strep (GAS) spread? | Direct contact with secretions (nasal or saliva); more likely in winter and early spring; incubation period (2-5 days); untreated pts are contagious during acute phase and 1 week after (even after symptoms resolve) |
| Diagnosis of Acute pharyngitis--> what are the 2 diagnosis tools to confirm infection and obtain specimen to identify pathogen? | 1. Throat culture is the gold standard, highly sensitive (90-95% sensitive) pro--> fewer false (+) but con--> 24-48 hours for results. This can be used as a back-up to RADT in certain populations 2. Rapid antigen detection test (RADT) (95% specific; 70-90% sensitivity): use if suspicious of GAS, pro--> results w/in 20 min, con--> false (-) |
| Flow chart: 1. use RADT if you suspect gas: if negative--> | Low risk for GAS seen in adults--> no throat culture; no antibiotic if (-) and are high risk for GAS (5-15 yo, <3 yo and adults w/risk factors--> obtain a throat culture--> (-)--> no abx; if throat culture (+)--> start appropriate abx |
| Flow chart: 1. use RADT if you suspect gas: if positive--> | Start appropriate abx |
| RADT testing is not recommended if symptoms indicative of viral etiology or if <3yo. What is the exception? what are the risk factors? | <3 yo w/ risk factors; RF: have household members w/GAS or enrolled in daycare or in setting of high rate of cases of GAS infection |
| What are your goals of tx for acute pharyngitis/GAS? | improve s/sx; minimize ADR and the overuse of abx; prevent transmission to close contacts; prevent complications of GAS pharyngitis |
| What are your first-line Tx options for GAS? | PCN VK (Drug of choice); Amoxicillin; Benzathine PCN G |
| Pediatric dose and duration of PCN VK (DOC) for GAS? | 250 mg PO BID or TID for 10 days |
| Adult dose and duration of PCN VK (DOC) for GAS? | 250 mg PO QID or 500 mg PO BID for 10 days |
| Pediatric dose and duration of Amoxicillin for GAS? *suspension tastes better than DOC which is why its seen more in practice | 50 mg/kg PO daily (max 1000 mg) for 10 days OR 25 mg/kg PO BID (max 500 mg) for 10 days |
| Adult dose and duration of Amoxicillin for GAS? | 1000 mg PO daily or 500 mg PO BID for 10 days |
| Pediatric dose and duration of Benzathine PCN G for GAS? | <27 kg: 600,000 units IM (one dose) >27 kg: 1.2 million units IM (one dose) *remember about with syphilis drug shortage problem, still applies to this point of one and done dose compared to 10 days of therapy with other options; but remember, super painful dose |
| Adult dose and duration of Benzathine PCN G for GAS? | 1.2 million units IM (one dose) *remember about with syphilis drug shortage problem, still applies to this point of one and done dose compared to 10 days of therapy with other options; but remember, super painfu |
| What are your alternative therapy for GAS tx options? such as for pts with PCN allergies | Cephalexin and Cepfadroxil: (10 days); avoid in PCN anaphylaxis; Azithromycin: 5 days; resistance observed 5-8% Clarithromycin: 10 days; resistance observed 5-8% watch DDI; Clindamycin: 10 days; resustance observed 1%; risk for C. Diff associated diarrhea; (**good luck getting a child to drink clinda for 10 days) |
| Steptococcus Pyogenes has ____ _________ _________ to PCN; We avoid using Cephalosporins or B-lactams in pts with what allergy? | NO KNOWN RESISTANCE TYPE-1 PCN allergy |
| What are we monitoring while treating a pt with GAS? | improvement of symptoms and no need for test of cure |
| Remember Strep Pyogenes is not known to be ______ to PCN; what is our drug of choice for GAS? | resistant; DOC--> PEN VK |
| What do we need to know about GAS carriers? | -1/3 of acute GAS infections are colonized with GAS in upper respiratory tract; -routine testing for carriers or treating asymptomatic contacts is NOT RECOMMENDED (risk of transmitting to someone is LOW unless that pt has an acute infection that reactivates the GAS) -Carrier has symptomatic pharyngitis? This is where it gets grey on tx options... |
| What are the Tx options for GAS carriers? | Clindamycin; PEN VK + Rifampin; Amox-Clav; Pen G + Rifampin *remember to check for DDI's with Rifampin combos |
| What Adjunctive care in children and adults with GAS can we use? | Analgesics/antipyretic agents: (acetaminophen and NSAIDS) |
| Acetaminophen dosing in infants, children and adolescents as adjunctive therapy is? | 10-15 mg/kg/dose every 4-6 hours as needed for pain relief; Max: do not exceed 5 doses in 24 hours; Max 2,600 mg/day *no age restriction |
| NSAID dosing in infants, children and adolescents as adjunctive therapy for GAS? Age cut-off for Ibuprofen is?? | 4-10 mg/kg/dose (max 400 mg/dose) every 6 to 8 hours as needed for pain and fever; Max dose: 1200 mg/day; age cut-off: greater than or equal to 6 months old; Avoid aspirin due to risk of REYE'S syndrome (children < 18yo) |
| Acetaminophen Adult dosing as adjunctive therapy for GAS is: | 650 or 1000 mg PO every 4-6 hours as needed for fever/pain; Max: 4000 mg/day (for most adults) |
| NSAID Adult dosing is as adjunctive therapy for GAS is: | Ibuprofen 200-400 mg every 6-8 hours as needed for fever/pain; Max dose: 1,200 mg/day (OTC) |
| Another adjuctive therapy in adults with GAS is? | Non-rx lozenges/sprays with menthol and topical anesthetics |
| Acute Otitis Media (AOM) is also known as an? Beck note: Based on MOR--> change the drugs and remember: PCN is for ________; Amoxicillin is for _______ | ear infection; throat; ears |
| What are the subtypes of Otitis media? | -Acute otitis Media ⭐️; -Otitis meda w/effusion--> middle ear is inflammed, fluid behind ear drum, does not mean the fluid is infection, may not need abx; -Chronic otitis media--> chronically inflammed, not meaning chronic infection and many not need abx |
| Acute otitis media (AOM) is generally a _______ infection and is the leading cause of abx prescriptions in children. Which age group is this seen in most? | pediatric; 6 months old to 2 yo; rare for adults |
| AOM is usually _______ by upper respiratory VIRAL infection | preceded; before the children got to AOM, they probably had a viral infection and then converted to a bacterial infection |
| Why are children more susceptible to AOM? | The Eustachian tubes are not angled making it easier for the pathogens to get to their middle ear; pathogens don't have to fight gravity as much as with the angled tubes in adults |
| What are the main pathogens responsible for AOM? | Streptococcus Pneumoniae ⭐️ and Haemophilus influenzae (both of these cause 60% of cases); other pathogen responisble is Moraxella catarrhalis |
| MRSA is emerging as a pathogen that can cause AOM in ____ | adults |
| Haemophius Influenzae (non-typeable) what does this mean? | Non-typeable--> vaccines are not hitting this influenza (vaccines are only for TYPABLE) |
| Remember your Resistance mechanisms: | alteration to the PCN binding protein--> that is why s. pneumoina is becoming smarter, but easier to overcome for ear infection when you GIVE MORE DRUG. |
| H. Influenzae and M. Catarrhalis develop resistance via? how do we counter? | produce B-lactamase; give B-lactamase inhibitors |
| Is there a vaccine for M. Catarrhalis? | No, so you can't prevent M. Catarrhalis (only with B-lacatamse inhibtor); Remember your H. Influenza vaccine--> is only for type-able, so if the pathogen is H. Influenza---> your vaccine didn't have an effect and its the non-typeable pathogen. |
| What s/sx of AOM do I look for in children? | Irritability, Ear ache, Ear rubbing/tugging, fever, decreased appetite |
| What s/sx of AOM do I look for in adults? | Unilateral ear pain (adults tend to get in one ear at a time), muffled hearing, ruptured tympanic membrane (ear drum)--> when it pops, should get relief of pain and purulent discharge |
| When confirming infection, what do I look for in diagnosis of AOM? | Middle ear effusion (fluid behind the ear drum) AND MODERATE or SEVERE bulging of tympanic membrane OR new onset of otorrhea not related to acute otits externa *otorrhea--> drainage not related to otitis media (swimmer's ear) |
| When confirming infection, what do I look for in diagnosis of AOM (2nd slide)--> | Middle ear effusion (fluid behind the ear drum) AND MILD bulging of tympanic membrane AND onset of ear pain w/in 48h OR intense erythema of tympanic (VERY RED ear drum) |
| Are cultures necessary for AOM? | Skip collection cultures and know pathogen and use target therapy |
| Goals of care in AOM? | Pain management and Prudent use of abx |
| To treat or not to treat: Otitis media with EFFUSION OR chronic otitis media--> (1) | 1. generally DO NOT require abx tx |
| To treat or not to treat in AOM: what does it depend on? | Age of child with AOM; Unilateral vs Bilateral; Severity of AOM |
| Determine severity of AOM: Mild to Moderate is classified as: | Mild otalgia (ear pain) for <48h; temperature <39 C (102.2 F) |
| Determine severity of AOM: Severe is classified as: | Moderate to severe otalgia (ear pain); Otalgia: >/= 48h Temperature: > 39 C (102.2 F) *Must cross over 102 to be severe |
| Otorrhea is defined by Dr. Beck as: | drainage of the ear "not swimmer's ear" |
| For a pt that has Otorrhea w/ AOM regardless of age gets? | Rx |
| For a pt that has unilateral or Bilateral AOM w/ Severe symptoms regardless of age? | Rx |
| For a pt w/ Bilateral AOM w/o Otorrhea that is 6-23 months old gets? | Rx |
| For a pt w/ Bilateral AOM w/o Otorrhea that is >/= 2yo gets either? | Rx or watchful waiting |
| For a pt w/ unilateral AOM w/o Otorrhea regardless of age gets either? | Rx or watchful waiting |
| If the option of watchful waiting for the tx of AOM, how long should one wait to see symptoms improve or worsen? | 2-3 days |
| If the parent(s)/ guardian choose watchful waiting, there ____ be a clear plan for follow up in ____-____ hours to assess worsening or improvement of symptoms. What kind of plan? | MUST; 48-72h; have the dr write a rx but wait to fill it (*idea is to give them a plan to follow, don't leave them with no plan |
| What should we consider when deciding the Abx selection for AOM? | -Previous abx use (what did they take before); -Concurrent purulent conjunctivitis (Do they have pink eye at the same time as ear infection?; -Drug allergies |
| What are my first line options for AOM? | Amoxicillin (DOC ⭐️ ) and Amox-Clav |
| What is the Pediatric dosing for Amoxicillin in AOM? | HIGH DOSE: 90 mg/kg/day PO divided BID ⭐️ *this is to overcome resistance that S. pneumo develops *alteration of PCN binding protein) GIVE MORE DRUG |
| What is the Pediatric dosing for Amoxicillin-Clavulanate in AOM? *remember Amox-Clav is first-line if pt meets critera | HIGH DOSE: Amoxicillin 90 mg/kg/day PO divided BID Clavulanate: 6.4 mg/kg/day |
| What is the criteria for a pt to be on amox-clav as first-line for AOM? | Preferred option IF (only needs to meet 1 creitera) -amox in last 30 days -history of recurrent AOM that was not responsive to Amoxicillin -has concurent purulent conjunctivitis (pink eye) |
| Side effects of Amox-Clav include: | more diarrhea than amoxicillin; suspension 14:1 amox-clav (this ratio is ideal (less diarrhea) ratio--> (amox 600 mg/clav 42.9 mg/5 mL |
| What alternative therapies for AOM can be used for pts that have a PCN allergy? (*not the Type 1 allergy) | 3rd gen cephalosporins: Cefdinir, Cefuroxime, Cefpodoxime, Ceftriaxone |
| My child is allergic to PCN and *has a Type 1 allergy, what options for AOM treatment are there? | Azithromycin, Clarithromycin, and Cindamycin |
| What should i be monitoring after giving abx for the treatment of AOM? | Improvement of symptoms; Hypersensitivity rxn |
| remember for adults who are allergic to PCN, if its not type 1, give? | cephalosporins |
| If adults for the treatment of AOM are type 1, we give them: | Z-pac or clarithromycin (watch for DDI) and monitor and watch for/if there is an allergic response |
| When determining Duration of tx of AOM with abx what should i consider? | **if they are younger--> give more drug ⭐️ -10 days--> if pt is <2 yo and have severe symptoms; -7 days--> 2-5 yo w/ mild/moderate AOM; -5-7days--> >/=6yo w/ mild/moderate AOM |
| Tx failure options for AOM? | What was the initial abx?; think about resistance mechanisms -First tried Amox 90--> after 2-3 days (consider tx failure)--> move to amox/clav combo for resistance could also swtch from amox to ceftriaxone (3 injections, painful for kids) |
| Tx failure options for AOM? alternatives if allergic to PCN (non-type 1) | give cetriaxone (3 divided doses)with or w/o clindamycin Last option would be Clinda with Ceftriaxone---> if tx failure--> Consult specialist. This is when you get a culture (Tympanocentesis) culture what's behind the ear (but have to have failed with many abx prior) |
| Adjunctive care of AOM for children--> | remember Acetaminophen and NSAID dosing and max; it takes 2-3 days for the ear pain to go away or to feel better; so until the abx works, give these as supportive care |
| Give the example from class of FDA intervention for pain management of AOM: | 2015 FDA intervened against ear drops that were not FDA approved that claimed to relieve ear pain, inflammation, and infection: Benzocaine-containing products; chloroxylenol containing drugs (*not recommended and not much better than NSAIDS or Tyleonol) |
| Are there tx options for otitis media w/ effusion? | -Recommend against INS or systemic steroids for OME -recommend against using systemic antibiotics for OME -recommend against using antihistamines, decongestants, or both for treating OME |
| When can Tympanostomy tubes be considered for pts? | -may consider for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year w/ 1 episode in the previous 6 months; -can be considered if there is middle ear effusion present in at least 1 ear -2021 study: rate of AOM episodes during a 2 year period was not significantly lower w/ tubes compared to medical management (antibiotics) |
| Prevention is key--> remember ear infections are PRECEDED by viral infections--> as pharmacists recommend appropriate vaccines such as: | Flu, covid, RSV, H. Influenzae, Pneumococcal |
| What are the common pathogens for Rhinosinusitis? | Viruses; Bacteria (S. Pneumo, H. Influenzae (nontypable), M. Catarrhalis (these bacteria cause about 50-70% of cases |
| What other pathogens have a more minor role in causing Rhinosinusitis? | S. aureus, G (-) bacilli, Atypical pathogens, Anaerobes |
| Viruses vs Bacterial in terms of s/sx: | Viruses: symptom duration (5-7 days), early onset fever; Bacterial: symptom duration (persistent) |
| What s/sx do viruses and bacteria share? | Cough and runny nose |
| Other S/sx of Rhinosinusitis that can be seen: | Purulent anterior nasal discharge; purulent or discolored posterior nasal discharge; nasal congestion or obstruction; facial congestion or fullness; facial pressure or pain; fever; HA; ear pain/pressure/fullness; Halitosis; dental pain; cough; fatigue |
| Diagnosis of Rhinosinusitis criteria: | More consistent with Bacterial rhinosinusitis (only needs to meet 1 criteria: -persistent s/sx >10 days w/o improvement -Severe symptoms at onset of illness (Fever >39 (102.2) AND Purulent nasal discharge or facial pain lasting 3-4 consecutive days; -Worsening s/sx after initial improvement (new onset of fever, HA, or increase in nasal discharge following viral URI that lasted 5-6 days and was initially improving aka (double-sickening) |
| Do we collect cultures for Rhinosinusitis? | only obtain specimen if NEEDED otherwise Skip |
| What are the goals of tx for Rhinosinusitis? | -improve s/sx -Minimize ADR and the overuse of abx -recommend appropriate abx when necessary -prevent complications and progression form acute to chronic rhinosinusitis |
| what are the risk factors for antibiotic resistance for S. Pneumo when determining tx options for Rhinosinusitis? | -Age <2 or >65 -Exposure to child in daycare -prior abx w/in past month (30 days) -recent hospitalization -Multiple medical comorbidities (chronic heart, lung, liver, renal disease, diabetes -Immunocompromised |
| What is my first-line therapy as stated by the IDSA guidelines for the tx of Rhinosinusitis? | Amox/clav |
| If the pediatric pt has no risk for drug resistance and non-severe infection, what is the amox/clav dosing for Rhinosinusitis as stated by the IDSA? | 45 mg/kg/day PO in divided BID for 10-14 days |
| If the pediatric pt is AT RISK for drug resistance and non-severe infection, what is the amox/clav dosing for Rhinosinusitis as stated by the IDSA? | HIGH DOSE: 90 mg/kg/day PO in divided BID for 10-14 days |
| If the adult pt has no risk for drug resistance and non-severe infection, what is the amox/clav dosing for Rhinosinusitis as stated by the IDSA? | 500/125 mg PO TID OR 875/125 mg PO BID for 5-7 days |
| If the adult pt is AT RISK for drug resistance and non-severe infection, what is the amox/clav dosing for Rhinosinusitis as stated by the IDSA? | HIGH DOSE: 2000/125 mg PO BID for 5-7 days |
| FYI: Amoxicillin can be considered in children as an option for children w/ for Rhinosinusitis? | -uncomplicated, mild-moderate infection; -do not attend daycare -did not receive abx in the last month ->10% resistance of S. Pneumo to PCN No risk dose: 45 mg/kg/day PO divided BID At risk: 90 mg/kg/day PO divided BID |
| My child is allergic to PCN (Type 1 allergy) what is my option for Rhinosinusitis? | Levofloxacin 10-20 mg/kg/day PO every 12-24 hours (Max dose: 500 mg/day |
| My child is allergic to PCN (Non-type 1 allergy) what are my options for Rhinosinusitis? | Clindamycin 30-40 mg/kg/day PO TID PLUS (either one) Cefixime 8 mg/kg/day PO BID or Cefpodoxime 10mg/kg/day PO BID |
| Adult is allergic to PCN, what are their tx options for Rhinosinusitis? | -Doxycycline 100 mg PO BID or 200 mg PO daily -Levofloxacin 500 mg PO daily -Moxifloxacin 400 mg PO daily *why not cipro? we are seeing resistance problem with strep pneumo (YELLOW) |
| FDA safety for FQ use as options for acute bacterial sinusistis--> (*just need to know why the FDA is mvoing us away from FQ's) | FQ's should be reserved for use in pts who have no other tx option for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated UTI b/c the risk of serious SE's outweighs the beneifts in these pts. -tendon rupture; peripheral neuropathy; aortic anerurism and dissection. mental health and dysglycemias |
| Monitoring and follow up for pts with Rhinosinusitis or acute bacterial sinusitis--> | clinicians should follow up in 48-72h from initial tx decision (abx or observation) to assess for worsening of symptoms or lack of improvement *really to check for improvement of symptoms (**watchful waiting does exist for Rhinosinusitis) |
| Tx failure in children for Rhinosinusitis-->so if observation was chosen first--> | Worse in 72h?--> initiate amox w/ or w/o clavulanate--> lack of improvement in 72h?--> additional observation or initiate abx based on shared decision making w/ the parent(s)/ guardian |
| Tx failure in children for Rhinosinusitis-->so if Amox was chosen first--> | Worse in 72h?--> initiate to HIGH DOSE amox/clav--> lack of improvement in 72h?--> additional observation or initiate high dose amox/clav based on shared decision making w/ the parent(s)/ guardian |
| Tx failure in children for Rhinosinusitis-->so if amox/clav was chosen first--> | Worse in 72h?--> initiate Clindamycin + Cefixime OR Linezolid + cefixime OR Levofloxacin--> lack of improvement in 72h--> continued high dose amox/clav OR Clinda + cefixime OR Linezolid + Cefixime OR Levofloxacin |
| What are my adjunctive care options for Rhinosinusitis? | If viral--> APAP/NSAID; intranasal saline irrigation w/ physiologic or hypertonic saline If Bacterial: APAP/NSAID/Intranasal saline irrigation w/ physiologic or Hypertonic saline; Do not Recommend: Antihistamine/decongestants/INS (**only use INS if PMH of allergic rhinitis) |
| Bronchitis (Lower respiratory infection) can be either: | Acute (sudden) or Chronic bronchitis (months and related to COPD) |
| Viruses responsible for acute bronchitis are? | Flu, RSV, and Parainfluenza |
| Bacteria responsible for acute bronchitis are? | Mycoplasma pneumoniae; Streptococcus pneumoniae; H. Influenzae (non-typeable); M. Catarrhalis |
| For Chronic Bronchitis pathogens, what bacteria responsible for infections? | H. Influenzae, Moraxella Catarrhalis, S. Pneumoniae, Gram (-) |
| What are the clinical presentations of Acute bronchitis? | Initially common cold symptoms (COUGH--> non-productive--> mucopurulent and up to 3+ weeks); pt may have dyspnea (shortness of breath) and may have fever |
| What are the clinical presentations of Chronic Bronchitis? | Cough--> Productive purulent sputum (largest in morning, white to yellow-green with bad taste/breath; >/= 3 consecutive months each year for 2 consecutive years (other causes excluded) |
| B/w the 2 types of bronchitis, who should get sputum cultures? | In acute--> Sputum culture is NOT routine Chronic--> Sputum culture MORE routine |
| For pts with acute bronchitis in immunocompetent adult outpatients (based on ungrounded consensus of Chest expert panel) reports--> | Immunocompetent adult outpatients w/ cough due to acute bronchitis, we suggest NO routine rx of: abx/antiviral/antitussive/inhaled B agonists/Inhaled anticholinergics/inhaled Corticosteroids/ oral NSAIDS *until such tx have been shown to be safe and effective at making cough less severe or resolve sooner |
| Based on the suggestion of the expert pannel--> we're telling our pts who have acute bronchitis--> | "You have to deal with your cough and let it run its course" |
| What are the HALLMARK symptoms of Chronic Bronchitis? | -Increased dyspnea -Increased sputum volume -Increased sputum purulence **We either meet all 3 or meet at least 2 (with one of those being the increaed sputum purulence) |
| For pts suffering from Chronic bronchitis and if abx is indicated--> | Follow outpatient CAP regimen |
| Chest expert panel report on non-pharm and pharm tx for acute cough associated with the Common Cold (CACC) states--> | 1. Adult and pediatric pts w/ CACC suggest AGAINST OTC cough/cold meds 2. Adults w. CACC suggest AGAINST NSAIDS (to reduce cough) 3. Pediatric pts (1-18) suggest HONEY may offer more relief of cough more than no tx (diphenhydramine or Placebo) but it is not better than dextromethorphan 4. Pediatric pts <18 suggest avoiding codeine-containing products |
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