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URI (Acute Otitis Media (Pathophysiology (Usually follow viral URI that…
URI
Acute Otitis Media
Epidemiology
Most common cause of PCP and ED visits
Most common in kids <5 yo
Changes is transmission reduce with flu and pneumo vaccine
Etiology
Bacteria causes 90% of cases
S. pneumo, H. flu, M. catt
B-lactam resistance for most pathogens ( h flu and M catt)
Pathophysiology
Usually follow viral URI that impairs mucocilliary apparatus and causes Eustachian tube dysfunction
middle ear becomes blovked with fluid, bulging erythematous tympanic membrane
bacteria that colonize the nasopharynx enter middle eat and not cleared by mucociliary system - proliferate and cause infection
Children more susceptible due to horizontal Eustachian tube
Complications in clude hearing loss, mastoiditis, bacteremia, meningitis, speech and langauge sequelae
S/Sx
bulging tympanic membrane
typically post-viral URI
Rubbing, tugging or ear. crying, irritable, difficulty sleeping
otorrhea, otalgia, fever
Treatment
Non-Pharm
Eardrops with local anesthetics and Ibu/APA
Pharm
Decide need for ABX based on age, severity, laterality, and joint decision making - Children 6mo-12y w/ moderte to severe symptoms, temp>39 should receive ABX - children 6m-23m w. non-severe bilateral AOM should receive ABX - children 2y or older w/ nonsevere AOM may recive watchful waiting
Diarrhea, diaper rash risk for children on ABX
If ABX indicated - amoxicillin for most cases - excpet if amox given in past 30 days, concurrent conjunctivities, hx of recurrent infection - then do amox/clav
typically high-dose amox (80-90mg/kg/day) typically for 10 days (can be shorter for children >6yo)
Reassess after 48-72 hours - should be clinical improvement in s/sx, pain, fever, tympanic membrane. most asymptomatic after 7 ays
Goals
pain management, prudent ABX use. consider primary prevention via bacterial and viral vaccines
Diagnosis
First need to differentiate AOM as acute with effusion or chronic
AOM w/o effusion may not need ABX
Acute Pharyngitis
Epidemiology
Viral causes most common but GABH strep is primary bacterial cause
Associated with rare but serious sequelae if not treated - acute rheumatic fever acute glomerulonephritis, reactive arthritis, peritonsillar abscess, mastioditis, otitis media, rhinosinusitis, necrotizing fasciitis
Children 5-15 yo are most susceptible, parents of school aged children, adults who work with children
seasonal outbreaks in winter and early spring each year
incubation period of 2-5 days - spread occurs via direct contanct with droplets of saliva or nasal secretions - untreated pts are infectious during illness and for 1 week after - effective ABX therapy reduces infectious window to 24 hours
Etiology
Viruses cause teh majority of cases - rhinovirus, coronavirus, adenovirus, HSV, flu
Bacterial less likely - GABH strep most common bacterial pathogen - also can be caused by group C ang G strep, corynebacterium, n. gonorrhea
Pathophysiology
alteration in host immunity allows bacterial of oropharynx to migrate and cause infection
pathogenic factors include pyrogenic toxins, hemolysins, streptokinase, proteinase
Diagnosis
throat swab and culture, rapid antigen-detection test (RADT)
microbiologic testing recommended for symptomatic pts unless they have symptoms suggestive of viral etiology or are younger than 3yo
Clinical Presentation
sore throat of sudden onset, fever and constitutional symptoms resolving in 3-5 days, sore throat, pain on swallowing, fever, HA, N/V, abdominal pain, erythema/inflammation of tonsils, enlarged tender lymph nodes
Viral cause more likely to have conjunctivitis, coryza, cough
Goals
improve clinical s/sc, minimize ADRs, prevent transmission, prevent acute rheumatic fever and suppurative complications
treatment decisions include supportive care, ABX when appropraite, chose right ABX and duration - selection of ABX depends on cost, safet, efficacy, adherence, bacterial resistance per local patterns
Treatment
Non-pharm
supportive care should be offered to all pts with acute pharyngitis
Antipyretics, analgesics, non-prescription lozenges and sprays with menthol and topical anesthetics
APAP and NSAIDs
Pharm
Pen-V
Children - 250 mg BID or TID x10 days
Adults - 250 mg QID or 500 mg BID x10 days
Pen-G
<27 kg - 0.6million units; >27kg - 1.2 million units IM x1 dose
Amox
50mg/kg QD; 25 mg/kg BID x10 days
Penicillin Allergy
Cephalexin
20 mg/kg PO BID x10
CLindamycin
7 mg/kg/day TID x10 days
Azithromycin
12 mg/kg/day for 1 dose then 6 mg/kg qd x4
Clarithromycin
15 mg/kg/day divided PO BID x10 days
Expect resolution of fever and s/sx in 3-4 days without ABX therapy 0.5-2.5 days with ABX therapy. F/u testing not necessary but f/u cultures warranted 2-7 days after ABX completion if not clinically resolved
Acute Bacterial Rhinosinusitis
Etiology
typically viral in nature - very important to differentaite b/t viral and bacterial for ABX stewardship
S. pneumo and H. flu are most common bacterial cuases. M. catt can also occur but less common. . pyogenes, S. aureus, gram - bacilli, anaerboes can cause ABR but very uncommon
Epidemiology
Overdiagnosed and ABX are over-prescribed
Most commonly viral pathogen not bacterial
Clinical Presentation
onset with persistent s/sx lasting for >10 days without improvement. onset with severe s/sx of high fever, purulent nasal discharge, or facial pain for 3-4 days. onset with worsening s/sx with new onset headache, fever, nasal discharge sollowing viral URI
Purulent anterior nasal discharge, nasal congestion/obstruction, facial congestion, facial pain or pressure, fever, HA, ear pain, halitosis, dental pain, cough, fatigue
Goals
Reduce s/sx, achieve and maintain patency of ostia, limit ABX treatment, eradicate infection, minimize duration of illness, prevent complications, prevent progression from acute to chronic disease
Diagnosis
Gold standard is sinus puncture but it si invasive so not typically done
typically based on clinical presentation for diagnosis and empiric treatment
Treatment
Pharm
Amox-Clav is first line for ABR
45 mg/kg/day for kids - 500/125 TID or 875/125 BID for adults
Levo, doxy, moxi or clinda+3rd gen cephcan be used in B-lactam allergy
Need to consider fi pt should be referred to specialist if mental status change, visual disturbances, immunosuppressed, nosocomial, anatomic defects, unusually severe symptoms, multiple recurrences, unilateral findings, hx of ABX failure
Typically s/sx begin to resolve in 48-72 hours
Non-Pharm
For VIRAL ONLY - nasal decongestant sprays reduce inflammation via vasoconstriction - no more than 3 days use. oral decongestants may be used as well
For bacterial infection - irrigation of nasal cavity with saline, steam inhalation to increase mucosal moisture, mucolytics may be used
First step is to differentaite b/t viral and bacterial - based on duration, initial severity, worsening symptoms
Viral typically improves in 7-10 days - bacterial diagnosed after 10 days, worsening after 10 days, or worsening after inital improvement. bacterial may also be suspected if severe symptomsa t beginning of illness
Pathophysiology
inflammation and/or infection of paranasal sinuses
Often preceeded by viral respiratory infection that causes mucosal inflammation and obstruction of sinus ostia (paathways that drain the sinuses)
Mucosal secretion becomes trapped, local defenses ipaired, bacterial from adjacent surfaces proliferate
Chronic symptoms can develop due to persistent pathogens or defect in host immune system