bacterial ENT/Sinus infections

acute pharyngitis

• inflammation of the pharnyx which includes strep through

• caused by streptococcus pyogenes (also knwon as group A streptococcus or GAS) begins with asymptomatic pharyngeal colonization of GAS until infection occurs due to alteration in host immunity

streptococcus pyogenes

• bacteria that causes acute pharnygitis

Group A Streptococcus (GAS) symptoms

• sudden onset of sore throat

• pain with swallowing

• fever

• anterior cervical lyphadenopathy

• palatal petechiae

• pharyngeal and tonsillar erythema

• tonsilar hypertorphy with/without exudates

• scarlatinofrom rash

viral pharyngitis symptoms

• conjunctivitis

• cough due to drainage

• hoarseness

• diarrhea

• discrete ulcerative stomatitis

• viral exanthema

centor score assessment

• tool used to assess if a patient needs to be tested for strep throat

• includes age, exudate or swellong of tonsils, tender/swollen anterior cervical lypmph nodes, temepratur >100.4, cough absent

2

• those who meet __ or more center criteria should receive an RADT

first line therapy for acute pharyngititis without penicillin allergy (strep)

• pencillin V, oral for 10 days

• amoxicillin, oral for 10 days

• benzathine penicillin G IM once

therapy for acute pharyngititis with penicillin allergy (strep)

• cephalexin, oral for 10 days

• cefadroxil, oral for 10 days

• clindamycin, oral for 10 days

• azithromycin oral for 5 days

• clarithromycin oral for 10 days

amoxicillin/clavulanate

• what penicllin antibiotic do you NOT use for acute pharyngitis

10 days

• duration of therapy for acute pharyngitis unless using IM penicillin or azithromycin

acute rhinosinusitis

• inflammation of the mucosal lining of nasal passage and paranasal sinuses

• fluid builds up in sinuses allowing virus or bacteria to grow

• usually viral often occuring after a previous upper repsiratory tract infection but may also be bacterial

s pneumoniae, H influenza, M catarrhalis

• top 3 pathogens for acute bactierl rhinosinusistis

acute rhinosinusistis symptoms

• runny or stuffy nose

• facial pain or pressure

• headache

• post-nasal drip

• sore throat

• cough

• bad breath

severe acute rhinosinusistis

• ≥ 3-4 days

• fever of 102F AND purulent nasal discharge or facial pain

persistent acute rhinosinusistis

• ≥ 10 days without improvement

• nasal discharge, daytime cough

worsening acute rhinosinusistis

• 3-4 days

• worsening or new onset fever, headache, datime cough, or nasal discharge after inital iprovement of a viral upper respiratory infection

bacteiral acute rhinosinusistis management

• watchful waiting is encourages for uncomplicated cases for which reliable follow up is available

• amoxicillin or amoxicillin/clavulanate is the recommended first line therapy

• macrolides such as azithromycin are not recommended due to high levels of strep pneumoniae resistance

• for penicillin allergic patients: docycline or a repsiratory fluoroquinolone (levofloxacin or moxifloxacin) are recommended alternative agents

5-7

• duration of therapy for acute bacterial rhinosinusistis with no risk of resistance with improvement on antibiotic is __ days

amoxicillin/clavulanate (500/125mg PO TID or 875/125 PO BID)

• initial empirical first line therapy for acute bacterial rhinosinusistis

doxycycline

• preferred agent for acute bacterial rhinosinusistis with b lactam allergy

amoxicillin

• not everyone needs an antibiotic for sinusitis, but when they need an antibitoic and have risk factors for resistance (without abx allergies) they should received amoxicillin/clavulanate and NOT ___

rhinosinusitis summary

• if symptoms applicable, determine if likely viral vs bacterial

  • must meet one of following to be bacterial

    • severe: ≥ 3-4 days of 102.2F + either purulent nasal dischare or facial pain

    • persistent: ≥ 10 days without improvement

    • worsening: double sickening, initial improvement and then worsening for 3-4 days

• if bacterial pathogen likely, treat with appropriate antibiotic and treat with OTC non pharm for symptomatic relief but wirgh benefit risk of topical/PO decongestants and antihistamines

  • no allergies: amoxicillin/clavulanate (resistance risk factors)

  • allergies: doxycycline or respiratory fluoroquinolone (levofloxacin or moxifoloxacin)

• duration of antibiotic therapy: 5-7 days unless not improving

acute otitis media

• rapid onset of signs and symptoms of inflammation in the middle ear

AOM bacterial etiology

• streptococcus pneumoniae (up to 50% ccaused by this)

• non-typeable haemophilus influenza

• morexella cararrhalis

• others: strep pyogenes, sterp agalactiae, gram nefative enteric bacilli, staph aureus

acute otitis media clinical presentation

• the younger the child, the more likely the symptoms with be absent or nonspecific

• otalgia- denoted by pulling of the ear

• irritability

• fever

• otorrhea

• hearing loss

• upper respiratory infection present (rhinitis, cough)

antimicrobial therapy

• AOM

• < 6 months

• certain diagnosis

antimicrobial therapy

• AOM

• < 6 months

• uncertain diagnosis

antimicrobial therapy

• AOM

• 6 months-23 months

• certain diagnosis

observation (48-72 hours)

• AOM

• 6 months-23 months

• uncertain diagnosis

• non-severe

antimicrobial therapy

• AOM

• 6 months-23 months

• uncertain diagnosis

• severe

observation (48-72 horus)

• AOM

• ≥ 2 years

• certain diagnosis

• non-severe

antimicrobial therapy

• AOM

• ≥ 2 years

• certain diagnosis

• non-severe

non-severe AOM

• mild otaliga and fever < 39C or 102.2F

severe AOM

• moderate to severe otalgia or fever ≥ 39 C or 102.2 F

high dose amoxicillin

• at diagnosis for patients being treated initially with antimicrobial agents for AOM

• recommend this for non-severe

• and no allergies

non type 1 (cefini

ceftriaxone IM x 1 for 3 days

• at diagnosis for patients being treated initially with antimicrobial angents

• use this for severe AOM with penicillin allergy

high dose amoxicillin

• clinically defined treatment failure after initial management with observation option

• use this for non-severe AOM

high dose amoxicillin/clavulanate

• clinically defined treatment failure after initial management with observation option

• use this for severe AOM

high dose amoxillin/clavulanate

• clinically defined treatment failure after inital management with antimicrobial agents

• use this for non-severe AOM

ceftriaxone IM x 3 days

• clinically defined treatment failure after inital management with antimicrobial agents

• use this for severe AOM

when should amoxicillin/clavulanate be considered 1st line besides severe AOM and failure to amoxicillin after 48-72 hours

• if received amoxicillin in last 30 days

• concominant purulent conjunctivitis

• history of recurrent AOM unresponsive to amoxicillin (≥3 episodes in 6 months or ≥ 4 episodes in 12 months with at least 1 episode int he last 6 months)

80-90 mg/kg/day (usually BID)

• high dose amoxicillin dosage

6.4-10

• when the combination product amoxicillin/clavulanate is used, ensure clavulante dose is ≤ __- mg/kg/day (or 125mg/dose) to lessen side effects

10 days

• AOM duration of therapy for < 2 years of age

7 days

• AOM duration of therapy for ≥ 2 years o