Respiratory INFECTIONS (URIs: Sinusitis, Pharyngitis, LRIs -CAP)

Sign that most strongly suggests that pharyngitis = viral and not bacterial

Absence of fever!!

which is more common, viral or bacterial sinusitis

viral

when to treat Adults with Penicillin VK or Amoxicillin x 10 days for GAS pharyngitis

+RADT or +Throat culture ONLY; 90% of cases in adults are viral (no antibiotics without positive test)

Saline nasal irrigations are recommended for symptomatic relief in _________________?

- Viral sinusitis - Allergic rhinitis - Bacterial sinusitis

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. 1) What are the most common pathogens to cause an acute sinusitis infection? 2) What pathogens are most likely to be the etiology of HH's infection?

1) Viruses are the most common, particularly rhinovirus, coronavirus, parainfluenza. 2) However, in this case we have a high suspicion for acute bacterial rhinosinusitis (symptoms>10 days, double sickening, refractory to adjuvants) so the most common pathogens for that are going to be Streptococcus pneumoniae, Haemophilus influenzae, and less commonly Moraxella catarrhalis.

Pharyngitis symptoms that strongly suggest viral infection (4)

1. Absence of Fever 2. Cough 3. Rhinorrhea (runny nose) 4. Hoarseness 5. Oral ulcers

12 Risk factors for CAP (hint: SCANDAL)

1. Age ≥65 2. Immunocompromised (malignancy, neutropenia, chronic steroid use, myelosuppressive agents, HIV) 3. Smoking 4. Alcoholism 5. Asthma 6. Cardiovascular disease (CVD) 7. COPD 8. Chronic renal failure 9. Congestive heart failure 10. Diabetes 11. Liver disease 12. Neoplastic disease

2 primary risk factors for GAS Pharyngitis

1. Ages 5-15 2. Seasonal (Winter and Early Spring disease)

All of the following can cause inflammation to your sinus ostia, leading to narrow sinus ostia & a ripened environment for infection (6)

1. Allergic inflammation 2. Asthma 3. Swimming 4. Facial Trauma 5. Tobacco 6. Viral infection

which ABRS treatment options must be taken with food to reduce the risk of GI intolerance/diarrhea

1. Amoxicillin/Clav (!!!!!) 2. Doxycycline (some diarrhea, nausea more common)

Serious ADE of fluoroquinolones (3)

1. Arthralgias (musculoskeletal toxicity) 2. Achilles tendon rupture (BBW) 3. CNS: dizziness, confusion, hallucinations - elderly and epilepsy must be closely monitored

Treatment options for GAS pharyngitis in patients with a severe PCN allergy (3)

1. Azithromycin 2. Clarithromycin 3. Clindamycin

4 things you can do if symptoms worsen following initiation of antibiotic therapy for Acute bacterial rhinosinusitis

1. Broaden antibiotic coverage 2. Switch classes of antibiotics (amox/clav->doxy or fluoro) 3. Sinus Aspiration/Culture to determine susceptibilities/better tailor therapy 4. Evaluate for other causes of treatment failure: original etiology was non-infectious (allergic, kartenger syndrome, tobacco, asthma), structural abnormality causing persistent symptoms (i.e. deviated septum)

Monitoring for Toxicities of Cephalosporins used in CAP treatment (outpatients with co/m, inpatients) (2) Cefpoxodime (PO) Ceftaroline (IV) Ceftriaxone (IV) Cefuroxime (IV, PO)

1. C.difficile infections 2. Diarrhea

Treatment of GAS pharyngitis in patients with a mild PCN allergy (2)

1. Cephalexin 2. Cefadroxil 1st gen cephs, narrow spectrum

Typical Inpatient CAP diagnosis modalities (3) additional tests that are done for severe disease (2)?

1. Chest Xray - nearly always shows an infiltrate 2. Blood culture (high WBC) 3. Sputum Gram stain (s.pneumoniae = gram positive) Severe Disease 4. Culture 5. Pneumococcal and Legionella urinary antigen testing not routinely recommended except in patients with severe disease

2 indications for Levofloxacin or Moxifloxacin in acute bacterial sinusitis

1. Concerns of resistance and Failure of initial 1st line therapy 3. Severe PCN allergy + CI to doxycycline

A Chest-xray (to look for infiltrates), blood culture and sputum gram stain are routinely done for Inpatient CAP diagnosis. In very severe disease (septic shock, respiratory failure requiring ventilation), 2 additional tests may be done, what are they

1. Culture 2. Pneumococcal and Legionella urinary antigen testing

Monitoring for toxicities for Amoxicillin-Clavulanate (ABRS) (2)

1. DIARRHEA: take with food 2. Hypersensitivity reaction (PCN)

When should high-dose amoxicillin/clav be given for acute bacterial rhinosinusitis? (high risk populations for resistant s.pneumoniae or poor outcome) (6)

1. If there is ≥10% rate of invasive Penicillin-Resistant S.pneumoniae in the community 2. Very severe infection 3. Patients <2 years old 4. Patients >65 years old 5. Antibiotic use within the past month 6. Immunocompromised

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. What in the case above describes a sinusitis infection versus the common cold? (4)

1. Double sickening: initial improvement in symptoms but then a return of symptoms, often worsening 2. Symptoms that have persisted >10 days (MOST IMPORTANT INDICATOR!) 3. Purulent nasal discharge 4. Focal facial pain

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. State all the antibiotics (classes are ok with exceptions) that cover the most common pathogen that causes bacterial sinusitis infections? (3)

1. Drug of choice: Amoxicillin/Clavulanate (Augmentin) - good coverage of strep and the addition of the beta-lactamase inhibitor (clav) broadens the gram-negative coverage (H.influenzae, Moraxella catarrhalis) and anaerobes (but we aren't really worried about anaerobes in this case) 2. Tetracyclines - specifically doxycycline increasing resistance w/ S.pneumoniae in the community with this drug, but would be 2nd line driven by a patient with a true PCN allergy that is unable to take Amox/Clav 3. Levofloxacin/Moxifloxacin (not ciprofloxacin!)- 3rd line - unnecessarily broad, reserved for concerns for concerns of resistance/failure of initial 1st line therapy or severe penicillin allergy

who is at higher risk for experiencing dizziness / hallucinations / confusion on Levofloxacin therapy (CNS effects) (2)

1. Elderly 2. Epilepsy (pre-existing CNS disorders)

3 signs on physical exam indicative of pneumonia

1. Elevated Respiratory Rate >24-30 breaths/min 2. Rales (78%) (crackling/bubbling heard due to pulmonary edema/ fluid accumulation within in alveoli) 3. Consolidation: dullness on percussion with a stethoscope, E-A changes; -> audible signs of inflammation/edema in the lungs

8 signs/symptoms of Pneumonia

1. Fever 2. Pleuritic Chest Pain 3. Productive Cough 4. Fatigue 5. Anorexia 6. Sweats 7. Nausea 8. Dyspnea (fluid accumulation in alveoli/inflammation in lungs impairs gas exchange/respiration ability)

3 most common symptoms of Pneumonia

1. Fever (65-90%) 2. Pleuritic Chest Pain (30-46%) 3. Productive Cough (80-90%)

Monitoring for toxicity macrolides (CAP) (3) clarithromycin, azithromycin

1. GI Upset 2. Metallic taste (clarithro only) 3. DDIs, CYP3A (clarithro only) theophylline, caffeine, histamines, cyclosporine, triazolam, etc.

Monitoring for toxicities: Azithromycin (CAP, macrolides)

1. GI Upset (least of all macrolides) 2. Avoid QT prolonging agents Note: unlike other macrolides which are metabolized hepatically by CYP3A, azithromycin is excreted unchanged in the urine. Therefore, it has less DDIs and many less side effects aside from GI sx due to hemiketal (even has the least GI side effects in azithro due to structure/acid stbility). Additionally, it has an extended half-life which allows for once daily dosing which is more favorable. hence, azithromycin is the preferred macrolide b/w Azithro/clarithro

Monitoring for toxicities: Clarithromycin (CAP, macrolide) (3)

1. GI upset 2. Metallic taste 2. DDI (CYP3A substrate/inhbitor): histamines, cyclosporine, caffeine, theophylline, triazolam

Monitoring for toxicities for Fluoroquinolones used in CAP (levofloxacin, moxifloxacin)

1. GI, headache rare and dose dependent - more likely to occur when underlying condition is present 2. Hyper/hypoglycemia 3. QT prolongation 4. Seizures Uncommon but serious 5. Arthralgias 6. Achilles tendon rupture (BBW) 7. Dizziness/confusion/hallucinations (CNS)especially in elderly

6 Minor Symptoms of Sinusitis

1. Headache 2. Ear pain/pressure/fullness 3. Halitosis (bad breathe) 4. Dental Pain (related to pressure of the inflamed sinuses pushing up against some of your dental nerves) 5. Cough 6. Fatigue

2 severe symptoms seen more with bacterial sinusitis in contrast to viral sinusitis

1. High fever >102ºF 2. Purulent nasal discharge

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. what pathogens are likely causing his infection? would they be considered extracellular or intracellular pathogens, why?

1. High suspicion for acute bacterial rhinosinusitis (symptoms>10 days, double sickening, refractory to adjuvants): therefore the most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and less commonly Moraxella catarrhalis. 2. Extracellular pathogens: all secrete toxins and use capsule to evade the immune system (pneumo = pneumolysins/capsule, influenzae = IgA protease, capsule, M.catarrhalis: block phagocytosis with surface proteins/LOS endotoxin -> no capsule)

which side effects of fluoroquinolones are rare, dose-dependent and are more likely to occur in patients with an underlying condition that is already present (3)

1. Hyper/Hypoglycemia 2. Seizures 3. QT prolongation

2 important ADE of Corticosteroids to consider, especially when as an immunosuppressive in a highly inflammatory infection include: (2)

1. Hyperglycemia (avoid in patients with uncontrolled diabetes) 2. Higher rates of secondary infection

2 reasons why levofloxacin and moxifloxacin are last line options for ABRS?

1. Increasing rates of resistance of bacteria to Fluoroquinolones in the community 2. More toxicities associated with fluoroquinlones in comparison with other antibiotic agents

What creates a ripe environment for infection in the sinuses (sinusitis)

1. Inflammation of sinus tissue lining 2. Blockage with excess mucous or Ciliary Dysfunction (creating excess mucous accumulation)

2 disease states that can cause dysfunction of the ciliary apparatus lining the sinus ostia cavity, increasing the risk for mucus build-up, and infection

1. Kartagener syndrome 2. Cystic fibrosis

Only if in the presence of a lung abscess or emphysema suspected would you provide specific coverage of anaerobic organisms for CAP, even in the setting of potential aspiration. More simply put, it is rare that you need to worry about providing/broadening antibiotic coverage for CAP to anaerobic organisms, why? (2) Context: aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs

1. Most pulmonary infections do not involve anaerobes (lungs are a very aerobic environment; bacterial infections are overall rare in respiratory infections but if they do occur the most common are S.pneumoniae and Atypicals.) 2. Most CAP antibiotics have adequate coverage of mouth anaerobes (upper airway anaerobes), capable of causing pneumonia after an aspiration event (mouth contents enter lungs, Peptostreptococcus - most 2nd-5th gen Cephs cover): → pretty well covered by your Beta-Lactams, so you wouldn't need to add on any specific anaerobic coverage

You do not routinely need to add additional anaerobic coverage to standard CAP therapy in patients with suspected aspiration pneumonia, (unless there is a lung abscess or emphysema suspected) , Why not? (2) Context: Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs, hence anaerobe concern

1. Most pulmonary infections do not involve anaerobes: - The Lungs are a very aerobic environment - Bacterial infections are overall rare in respiratory infections but if they do occur the most common are S.pneumoniae and Atypicals (remember most respiratory infections are usually viral in nature) 2. Most CAP antibiotics have adequate upper airway anaerobe coverage: Beta-lactams (the oral anaerobes that live in your mouth and could potentially cause pneumonia after an aspiration event → pretty well covered by your Beta-Lactams, so you wouldn't need to add on any specific anaerobic coverage)

2 Supportive Care measures that can be used to relieve pain and fever associted with GAS pharyngitis infection? (2)

1. NSAIDs 2. APAP

Clinical presentation of viral sinusitis Initial symptoms: 4 Clinical signs/sx: Duration: Peak respiratory symptoms:

1. Nasal discharge (clear<-->thick/mucoid/green) 2. Congestion/obstruction 3. Daytime cough (gets worse at night) 4. Sore throat (from post-nasal drip) Duration of infection: 5-10 days; peak respiratory symptoms at 3-6 days

When to consider empiric antibiotic treatment for bacterial rhinosinusitis (3)

1. Persistent symptoms >10days 2. Severe sx: High fever>102, purulent nasal discharge over 3-4 days 3. Double sickening: Worsening symptoms, Initially get better but then worsen after 5-6 days, potentially followed with New onset of fever at day ~ 5 even then: Most patients even with documented acute bacterial sinusitis have self-limiting infections/symptoms --> must have a discussion with the patient to decide whether or not antibiotic therapy is appropriate

Monitoring for toxicities for Doxycyline therapy (4)

1. Photosensitivity (wear sunscreen, cover up) 2. Esophageal ulceration (take with water, remain upright for 30mins post-dose) 3. Permanent discoloration of teeth in children <8yo (CI) 4. Nausea (more common), Diarrhea (take with food)

All of the following can cause nasal obstruction and lead to a narrowing of your sinus ostia (5)

1. Polyps 2. Foreign bodies 3. Tumors 4. Deviated septum 5. Nasal intubation (having been in the hospital nasally intubated)

Doxycycline patient counseling (3)

1. Take with water and remain upright for 30 minutes after each dose to avoid esophageal ulceration 2. Wear sunscreen/cover-up to prevent sunburn (photosensitivity) 3. Take with food: to reduce N/V

Guidelines recommend to: Add empiric coverage of MRSA or P. aeruginosa in adults presenting with CAP if they have locally validated risk factors for either pathogen are present, however many institutions may not have locally validated risk factors available. Therefore, strong individual risk factors for MRSA or P.aeruginosa infeciton can be used to determine whether or not a patient is at high risk for CAP being secondary to these drug-resistant pathogens, and therefore would require broader empiric CAP treatment. What are these risk factors? (2)

1. Prior isolation of these organisms (MRSA or P. aeruginosa ), especially from the respiratory tract Ex: a patient has a history of MRSA pneumonia within the last year → if they present again with pneumonia even if they are coming from the community we would want to broaden our coverage to include coverage of MRSA! 2. Recent hospitalization and exposure to parenteral antibiotics within the last 90 days Ex: if a patient is presenting to the hospital with CAP but they had been hospitalized and received broad spectrum IV antibiotics within the last 90 days, we might want to broaden our empiric coverage to include MRSA or P. aeruginosa which are more-hospital acquired pathogens; these organisms are NOT covered by our current CAP treatment which is why this is important

2 strong individual risk factors for infection with drug-resistant pathogens, MRSA or P.aeruginosa

1. Prior isolation of these organisms from the patient especially from the respiratory tract (prior culture with MRSA/pseudomonas) 2. Recent hospitalization and exposure to parenteral antibiotics in the last 90 days if either are present --> add empiric coverage due the fact that MRSA and P.aeruginosa are more hospital-acquired pathogens and are not covered by the current CAP treatment regimen, and these patients with would be at a high risk for having CAP secondary to these more drug-resistant organisms)

6 Major Symptoms of Sinusitis

1. Purulent nasal discharge (nasty/yellow discolored) (anterior/posterior) 2. Nasal congestion/obstruction 3. Facial congestion/fullness 4. Facial pain, pressure (anterior ethmoid, maxillary) 5. Loss of sense of smell/taste (hyposmia/anosmia) 6. Fever

Monitoring for Efficacy for CAP treatment

1. Resolution of signs/sx 2-3 days after therapy initiation; should feel almost completely better by day 3 (defervescence) 2. If symptoms do not resolve: may need to obtain a sputum culture to get more diagnostic info to determine if pt is on the appropriate antibiotics 3. If patient is getting better - no need to do a sputum culture (&no need to repeat one if a culture was already done prior) DO NOT DO A CHEST X-RAY! CXR may still be positive for pneumonia despite appropriate therapy and resolution of symptoms. (infiltrates, etc) may persist beyond when the pt is symptomatic. CXR≠ TEST OF CURE for CAP

Allergic Rhinitis OTC symptomatic treatment (2)

1. Saline nasal irrigations (helps mobilize secretions and provide symptomatic relief) 2. Intranasal Corticosteroids (relieve congestion)

When to treat patients for CAP in the Intensive Care Unit (ICU) (3)

1. Septic shock requiring vasopressors 2. Acute respiratory failure requiring mechanical intubation or ventilation 3. PSI Class V or ≥3 minor criteria of PSI (pneumonia severity index)

Monitoring for efficacy of empiric treatment of bacterial sinusitis

1. Should begin to respond in 3-5 days after treatment initiation 2. If symptoms worsen in 2-3 days: - Broaden coverage or switch classes of antibiotics (amox/clav to doxy or fluoroquinolone) - Sinus aspiration: cultures would be helpful in determining susceptibilities for better tx selection - evaluate for other causes of failure (non-infectious-allergic/swimming/tobacco, structural abnormality - deviated septum)

4 most common symptoms of GAS pharyngitis

1. Sore throat (sudden onset) 2. Pain on swallowing 3. Fever! 4. Red throat+/- purulent exudate

Describe the Nasal discharge of viral sinusitis

1. Starts out Clear/Watery 2. Becomes Thick/Mucoid 3. Eventually becomes nasty colored (green) and opaque 4. Then infection resolves

Top 3 most common bacterial pathogens of ABRS

1. Streptococcus pneumoniae (+) 20-43% 2. H.influenzae (-) 22-35% 3. Moraxella catarrhalis (-) 2-10%

7 pathogens that can cause CAP; despite the fact that S.pneumoniae remains the most important bacterial cause of CAP.

1. Streptococcus pneumoniae (+, diplococci) 2. Haemophilus influenza (-, coccobacilli) 3. Mycoplasma pneumoniae (atypical, acid-fast, mild walking pneumonia) 4. Staphylococcus aureus (+) 5.Chlamydia pneumoniae (- atypical pneumonia) 6. Moraxella catarrhalis (- diplococci) 7. Legionella spp. (atypical, -structure, silver stain)

If symptoms worsen 2-3 days after initiating Amoxicillin/Clav 2g PO BID for Bacterial sinusitis, what should you do?

1. Switch to Doxycycline or Fluoroquinolone 2. Culture (sinus aspiration) to better tailor therapy to susceptible pathogen of interest 3. Evaluate for other causes of treatment failure: non-infectious cause of sinusitis, structural abnormality

3 most commons signs/sx indicative of bacterial sinusitis

1. Symptoms present for >10 days (AT LEAST) 2. Double-sickening (sx Symptoms Initially get better but then worsen after 5-6 days, potentially with a new onset of fever after day 5 3. Severe Symptoms: HIGH FEVER>102ºF Purulent nasal discharge over 3-4 days

2 primary signs of acute bacterial rhinosinusitis

1. Symptoms present for >10days 2. Double-sickening (sx that initially improve followed by clinical worsening)

Patients with Community-Acquired pneumonia should be treated for a minimum of 5 days. Treatment can be discontinued at 5-days or beyond if the patient is afebrile x 48 hours with no more than 1 sign of clinical instability. What are 6 general signs of clinical instability?

1. Tachycardia (elevated HR) 2. Hypotension SBP<90 (or <90/60) 3. O2 saturation <90% on room air 4. Altered mental status (confusion, delirium) 5. RR>24 breaths/min 6. Fever

6 Criteria for clinical stability to look for while on antibiotic therapy for CAP (to determine if tx should be continued following 5-day course in the absence of >1 of these)

1. Temperature ≤ 37.8ºC (defervescence) 2. HR ≤100bpm (absence of tachycardia) 3. RR ≤24 breaths/min (no hyperventilation) 4. SBP ≥90 mmHg (absence of hypotension) 5. Arterial O2 saturation ≥90% on room air 6. Normal mental status Note: Ability to maintain oral intake is also a sign of clinical stability to factor in when discharging a patient on a course of PO antibiotics for CAP.

2 common causes of rhinitis (inflammation of the nasal mucosa)

1. Viral infections 2. Allergies

2 patient groups at an increased risk for achilles tendon rupture with use of Fluoroquinolones

1. elderly 2. patients on steroids

6 populations that are high risk for drug-resistant S.pneumoniae infection

1. ≥10% rate of invasive PCN resistant S.pneumo in the communoty 2. Very Severe infection 3. Patients <2 years old 4. Patients >65 years old 5. Recent hospitalizations 6. Antibiotic use within the past month 7. Immunocompromised (HIV, immunosuppressant meds)

Outpatient treatment of community acquired pneumonia for patients with CHD, COPD, chronic liver disease, CKD, DM, Malignancy 1st Line (S.pneumo coverage +Atypical coverage) 2nd line:

1st Line: Oral Beta-Lactam + Macrolide or Doxycycline Amox/Clav + Doxycycline Amox/Clav + Azithro/Clarithro Cefpodoxime + Doxycycline Cefpodoxime + Azithro/Clarithro 2nd Line Respiratory Fluoroquinolone monotherapy: Moxifloxacin or Levofloxacin monotherapy (Respiratory fluroquinolone, NOT cipro)

Acute bacterial rhinosinusitis treatment 1st line: If severe/high risk for resistant-infection: 2nd line for PCN allergy: Last line if all else are CI: Duration:

1st line: Amoxicillin/Clav (standard-dose) If severe/high risk for resistant-infection: High-dose Amoxicillin/Clav 2nd line for PCN allergy: Doxycycline Last line if all else are CI: Levofloxacin or Moxifloxacin Duration: 5-7 days in adults 10-14 days in children

Treatment of community-acquired pneumonia in Healthy Outpatients without comorbidities

1st line: High-Dose Amoxicillin or Doxycycline 2nd line Azithromycin NO longer recommended for healthy outpatients due to ↑ rates of resistance to S.pneumoniae in the community

Treatment of patients with Severe CAP being treated inpatient without risk factors for MRSA or P.aeruginosa infection 1st line: 2nd line:

1st line: IV β-lactam + Macrolide Ampicillin/Sulbactam + Azithromycin Ampicillin/Sulbactam + Clarithromycin 2nd line: IV β-lactam + Respiratory Fluoroquinolone Ampicillin/sulbactam + Levofloxacin Ampicillin/sulbactam + Moxifloxacin

Treatment of patients with Non-Severe CAP being treated inpatient without risk factors for drug-resistant MRSA or P.aeruginosa infection 1st Line: 2nd Line if Severe PCN allergy or cannot tolerate first line regimen:

1st line: IV β-lactam + Macrolide Ampicillin/sulbactam (IV) + Azithro/Clarithro Ceftaroline (IV) + Azithro/Clarithro Ceftriaxone (IV) + Azithro/Clarithro 2nd Line: Respiratory Fluoroquinolones as monotherapy Levofloxacin or Moxifloxacin

Resolution of signs/symptoms following CAP treatment is expected to occur

2-3 days after initiation of therapy; defervescence at day 2-3 patient should feel almost completely better by day 3

Problem with use of Negative RADT + and Positive Throat culture for Group A streptococci (looking for beta-hemolysis and bacitracin sensitivity) purely as a diagnostic in GAS Pharyngitis in children?

20% of school aged-children ages 5-15yo are colonized with Group A streptococci, so if you have a child with a viral pharyngitis infection that is also colonized with GAS, a PCP may see a Negative RADT, but a positive throat culture and treat them with antibiotics; therefore they may not be treating an actual infection they may be treating simply a colonization Note: despite this, strep throat is treated aggressively in children ages 5-15 due to high risk for ARF. In adults, negative RADT and +Throat culture + antibiotic administration could lead to poor antibiotic stewardship, antibiotic resistance, unnecessary side effects without efficacy.

After treatment initiation, patients with ABRS should begin to respond in ______ days

3-5 days

Symptoms should begin to resolve __________ days after treatment initiation for bacterial sinusitis

3-5 days

Antibiotics decrease time to symptomatic improvement by ~16h vs placebo if started within __________of symptom onset in patients with GAS

48 hours

Highest efficacy with antibiotics in GAS pharyngitis is seen if started within ____________ of symptom onset

48 hours

Turnaround time for throat culture looking for Streptococcus pyogenes in suspected GAS pharyngitis

48 hours

Empiric antibiotic treatment for community acquired pneumonia should be given for NO LESS THAN ____________ days

5 days If patient is stable at <5days: finish out the 5-day course If patient is stil clinically unstable on day 5: continue treatment for 2-3 more days.

JR is a 68-year-old female with a past medial history of COPD (Stage I), uncontrolled Type 2 diabetes (last A1c 10%) and hypertension (controlled on lisinopril). She resides in a long-term care facility but has had no recent hospitalizations or received antibiotic therapy. She is not known to be colonized with any drug-resistant organisms. She presents to the emergency department with complaints of worsening fatigue, shortness of breath and productive cough. Community acquired pneumonia is suspected. She is febrile (39.4°C) and her O2 saturation is 94% on room air, but her vital signs are otherwise stable. Her CURB-65 score is 2. On her second hospitalization day, JR has defervesced, is satting 99% on room air and has no signs of clinical instability. The team is ready to discharge her home. How long should she be treated for her pneumonia? A. 3 days B. 5 days C. 7 days D. 10 days

5 days Patients should be treated for a minimum of 5 days and treatment can be discontinued if afebrile x 48 hours and no more than 1 sign of clinical instability (elevated heart rate, respiratory rate, SBP <90, O2 sat <90% on room air, altered mental status).

RADT turnaround time

5-7 minutes variable sensitivity (rule out), and specificity (rule in), would have to confirm with throat culture if negative in children 5-15yo

Acute bacterial rhinosinusitis (ABRS) should not be considered unless symptoms persist for

>10 days

Acute, Subacute and Chronic rhinosinusitis definition based on duration

Acute: sx for <1 month Subacute: sx for 1-3 months Chronic: sx for >3 months

Patient presents to clinic with a sore throat, pain with swallowing, 102ºF temperature, tender cervical lymphadenopathy and tonsillar exudates on PE, and denies any history of cough. Due to their presenting symptoms (meeting all centor criteria) the PCP recommends testing for GAS pharyngitis. What tests are recommended? Adults: Children:

Adults: 1. Rapid antigen detection test (RADT) 2. If negative- no need for throat culture Children: 1. RADT IF NEGATIVE 2. Confirm with Throat Culture (48 hr turnaround time but very accurate): looks for beta-hemolysis and bacitracin sensitivity

Duration of therapy for ARBS Adults: Children: Amoxicillin/Clav, Doxycyline (PCN allergy), Levofloxacin/Moxifloxacin (PCN allergy + Doxy CI)

Adults: 5-7 days Children: 10-14 days

-Penicillin VK 250 mg QID or 500 mg PO BID x 10d -Amoxicillin 500 mg BID x 10d preferred treatment for _________ with ___________ and __________, started within ______ of symptom onset.

Adults; GAS Pharyngitis; no PCN allergy; 48 hours

ABRS Medication Patient Counseling: "take with food, be aware that diarrhea is very commonly associated with this medication (antibiotic-associated diarrhea), may decrease the effectiveness of birth control"

Amoxicillin/Clav

Drug of choice for ABRS (excellent coverage of S.pneumoniae, H.influenzae and Moraxella catarrhalis which are the top 3 pathogens that cause bacterial sinusitis)

Amoxicillin/clavulanate adults = 5-7 days children = 10-14 days

Which OTC products are NOT recommended routinely for symptomatic relief of sinusitis

Antihistamines and Decongestants

Fluoroquinolones have particularly excellent coverage of

Atypical organisms

Which organisms cause Walking Pneumonia? A much less severe form where patients are not as ill and typically do not require hospitalization as often.

Atypicals: Mycoplasma pneumoniae Chlamydia pneumoniae Legionella spp.

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. The team recommends giving him Augmentin 875mg PO BID x 7 days. How quickly should symptoms begin to resolve? A. 5-7 days B. 3-5 days C. 10-14 days D. 2 days

B. 3-5 days monitoring for efficacy: symptoms should begin to resolve in 3-5 days after treatment initiation

Which Cephalosporin agents could be used in the treatment of a patient with Congestive heart failure being treated as an outpatient for community acquired pneumonia in combination with doxycycline? A. Cefazolin B. Cefpodoxime C. Ceftriaxone D. Ceftaroline

B. Cefpodoxime is the only PO agent on this list (3rd gen ceph, PO)

RQ has been on moxifloxacin for community acquired pneumonia treatment for 3 days. She has been afebrile for 48 hours, and her breathing has improved significantly. The treatment team feels she is ready for discharge and asks how much longer should her moxifloxacin be initiated? A. Stop today if she's feeling better B. Continue Moxifloxacin for 2 more days C. Continue Moxifloxacin for 5 more days D. Switch to azithromycin to complete a 14 day course

B. Continue Moxifloxacin for 2 more days A- False, The minimum recommended treatment duration for CAP is at least 5 days or until clinically stable. Regardless that this patient is clinically stable prior to the end of 5-day therapy, she should complete a full 5-day course. C - False there is no need to extend her duration of therapy past 5 days if she is clinically stable. D - Azithromycin would not be used as monotherapy for CAP and these is no advantage seen with 10, or 30 day duration of therapy. This would only be less efficacious than the Respiratory fluoroquinolone monotherapy, and increase rates of resistance.

TP is a 26-year-old male with a PMH of seasonal allergies and presents to his local pharmacy with complaints of congestion, facial pain and green nasal discharge. His symptoms have persisted for 5 days and he is inquiring about any OTC products he could use to help relief his symptoms. You suspect he has sinusitis with concomitant allergic rhinitis. All of the following adjuncts would be good recommendation to make EXCEPT: A. Saline nasal irrigations B. Diphenhydramine C. Intranasal Corticosteroids D. Tylenol D. Decongestants

B. Diphenhydramine; D. Decongestants Antihistamines & Decongestants are NOT typically suggested for sinusitis. Saline nasal irrigations are 1st line for all forms of sinusitis to help mobilize secretions and relieve symptoms. Intranasal CCS are a great option for patients with concomitant allergic rhinitis. APAP = good option for any aches/pain/fever

MP is a 62 year old woman with a history of diabetes and CHF. She presents to the emergency department with shortness of breath and is diagnosed with community acquired pneumonia. Her CURB-65 score is 1. What is the best management strategy for the patient? A. Discharge home on moxifloxacin 400 mg PO daily for 10 days B. Discharge home on amoxicillin/clavulanate 875 mg PO q12h and doxycycline 100 mg PO q12h x 5 days C. Admit to the hospital and start ceftriaxone 1g IV q24h and azithromycin 500 mg IV daily D. Admit to the hospital and start piperacillin/tazobactam 4.5g IV q6h

B. Discharge home on amoxicillin/clavulanate 875 mg PO q12h and doxycycline 100 mg PO q12h x 5 days due to her CURB 65 of 1, she does not need to be admitted to the hospital and can be treated as an outpatient (answers C & D are incorrect). Moxifloxacin would be an option but given her diabetes she is at higher risk of adverse effects (particularly hypoglycemia) and the treatment duration of 10 days is too long.

Which is most likely to be the cause of community-acquired pneumonia? A. Legionella pneumophila B. Influenza A C. Streptococcus pneumoniae D. Moraxella catarrhalis

B. Influenza A: viruses are the most common cause of CAP; (influenza, human rhinovirus, etc). S.pneumoniae is the most common BACTERIAL cause of pathogen overall.

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. What would be the best treatment option for HH's infection?

Bacterial Sinusitis: Augmentin 875mg PO BID (standard-dose amox/clav) x 5-7 days

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. The team recommends giving him Augmentin 875mg PO BID. What would be the appropriate duration of treatment? A. 3 days B. 10 days C. 7 days D. 14 days

C. 7 days ideal duration of treatment of acute bacterial sinusitis in adults is 5-7 days.

by what ROA are the following cephalosporins given in the treatment of community acquired pneumonia? Cefuroxime Cefpodoxime Ceftriaxone Ceftaroline

Cefuroxime (IV, PO) Cefpodoxime (PO) Ceftriaxone (IV) Ceftaroline (IV)

Which of the following represents an appropriate treatment regimen for a patient with no co-morbid conditions being treated as an outpatient for community acquired pneumonia? A. Azithromycin B. Levofloxacin C. Amoxicillin D. Ceftriaxone

C. Amoxicillin amoxicillin or doxycycline PO are the 1st line DOCs for outpatient w/o co-morbid conditions for CAP A. Azithromycin aka Z-paks are really no longer recommended as monotherapy for healthy outpatients without comorbidities for CAP due to high rates of S.pneumo macrolide resistance. B. Respiratory fluoroquinolone monotherapy not recommended in healthy outpatients, risks >>benefits D. Ceftriaxone = IV, therefore not used outpatient.

Streptococcus pneumoniae is the #1 causative pathogen of acute bacterial sinusitis. Staphylococcus aureus plays a more minor role in sinusitis infections, however can still be a potential pathogen of concern. How could you differentiate which of these pathogens are present in culture following sinus aspiration/obtaining of a sample of infected fluid from a patient with suspected ABRS?

CATALASE TEST: strep = Catalase-negative staph = Catalase-positive

When to treat patients for CAP Outpatient

CURB-65 = 0-1 confusion BUN>19 RR>30 BP<90/60mmHg Age≥65

If a patient comes into a pharmacy or urgent care clinic and is experiencing symptoms of pneumonia, the decision must be made as to whether or not they should be given antibiotics and sent home (treated as outpatient) or to admit them to the hospital (inpatient). This decision is guided by the _________

CURB-65 Score

What guides whether or not to treat patients for Community acquired pneumonia?

CURB-65 Score

When to treat patients for CAP Inpatient, in the Hospital

CURB-65 ≥ 2 confusion BUN>19 RR>30 BP<90/60mmHg Age≥65

Clarithromycin DDIs (Macrolide) (5 examples)

CYP3A substrate and inhibitor: - Histamines - Theophylline - Cyclosporine - Caffeine - Triazolam - many others

IV cephalosporins that can be used to treat community acquired pneumonia inpatient (3)

Ceftaroline (IV) Cefuroxime (IV) Ceftriaxone (IV)

LM is a 46 y/o AAF who presents to her PCP with a 3 day history of fever, chest pain, and cough. She has no PMH but does have an allergy to penicillins. She said her mother told her she had a rash as a child. She denies any recent antibiotic use or hospitalization. Though her vital signs were all within normal limits, her lung exam did show signs of pneumonia. Her PCP believes that she could be infected with community acquired pneumonia. If LM had a history of COPD and diabetes, how would that change the treatment recommendation for her pneumonia?

Cepodoxime (PO) + Azithromycin (avoiding PCN but use PO ceph + macrolide to cover atypicals b/c of comorbidities) If she had a history of COPD and DM, she would move to the second column (outpatient with co/m), where we really want to make sure that we have great coverage of S.pneumoniae AND ATYPICALS; In this case we would consider something like: Cefpodoxime + Azithromycin. Patients with low-risk PCN allergies such as a childhood rash would have a very low risk of cross-reactivity to Cephalosporins, therefore it would probably be very safe for the patient to receive in combination with azithromycin

Tool that is very important for CAP diagnosis inpatient

Chest Radiograph (CXR): w/ infiltrates, typically seen in the lower fields of the lung

A _______________ is NOT a test of cure for community acquired pneumonia and should not be repeated or done to assess efficacy of antibiotic therapy and patient recovery.

Chest X-ray (CXR) CXRs still may be positive for pneumonia despite appropriate therapy and resolution of symptoms

-Penicillin VK 250 mg 2-3x/day x 10d -Amoxicillin (50 mg/kg) qday x 10d preferred treatment for _________ with ___________ and __________

Children; GAS pharyngitis (s.pyogenes); no PCN allergy

CURB-65 Score

Confusion Uremia (BUN>19) Respiratory rate >30 BP <90/60mmHg (low BP) 65 -> Age ≥65 1 point for each criteria If score is ≤1 = treat as OUTPATIENT If score is ≥2 = treat as INPATIENT

Most common way of diagnosing acute bacterial rhinosinusitis?

Clinical Diagnosis based on signs/symptoms (high fever, purulent nasal discharge, double sickening), duration of illness (>10days)

Outpatient CAP diagnosis

Clinical/symptom based; since we don't have access to radiology/chest x-rays, not typically doing cultures, we typically treat CAP outpatient empirically based on the patients symptoms

Fluoroquinolones Toxicities Common (2): Rare and Dose-dependent (3): Uncommon but serious (5):

Common (2): 1) GI side effects 2) headache Rare and Dose-dependent (3): 3) Hyper/hypoglycemia (↑ risk in elderly and DM) 4) Seizures (lowers seizure threshold) 5) QT prolongation Uncommon but serious (5): 6) Arthralgias/myalgias 7) Achilles tendon rupture (BBW↑ risk in elderly or use of CCS) CNS effects: 8) Dizziness 9) Confusion 10) Halluncinations

pneumonia that starts in the community

Community acquired pneumonia (CAP)

CAP definition

Community acquired pneumonia (CAP): pneumonia that starts in the community --> when the patient is out and about in the community at home, NOT associated with the healthcare setting)

JR is a 68-year-old female with a past medical history of COPD (Stage I), uncontrolled Type 2 diabetes (last A1c 10%) and hypertension (controlled on lisinopril). She resides in a long-term care facility but has had no recent hospitalizations or received antibiotic therapy. She is not known to be colonized with any drug-resistant organisms. She presents to the emergency department with complaints of worsening fatigue, shortness of breath and productive cough. Community acquired pneumonia is suspected. She is febrile (39.4°C) and her O2 saturation is 94% on room air, but her vital signs are otherwise stable. Her CURB-65 score is 2. Which of the following statements regarding antibiotic spectrum for treatment selection in JR is true? A. Fluoroquinolones should only be used for JR in combination with a macrolide as they do not provide coverage of atypical organisms. B. Vancomycin should always be used in combination with a beta lactam due to increasing rates of S. pneumoniae resistance in the community C. P. aeruginosa coverage with a fluoroquinolone would be appropriate for JR since all patients with COPD are at high risk of P. aeruginosa. D. Beta-lactams are not appropriate for monotherapy for empiric inpatient treatment for community acquired pneumonia since they do not provide coverage of atypical organisms.

D. Beta-lactams are not appropriate for monotherapy for empiric inpatient treatment for community acquired pneumonia since they do not provide coverage of atypical organisms. Atypical coverage is still an important component of CAP treatment regimens and should be included for empiric treatment of hospitalized patients per the 2019 CAP guidelines. P. aeruginosa coverage is not needed for all patients with COPD, but patients with severe COPD are at higher risk than the general population. (answer C incorrect). Fluoroquinolones have excellent coverage of atypical organisms (answer A incorrect). Prevalence of drug-resistant S. pneumoniae is increasing in the community but the current prevalence does not necessitate use of vancomycin empirically (answer B incorrect).

Which of the following CANNOT be used as empiric treatment of ABRS? A. Amoxicillin/Clav B. Moxifloxacin C. Doxycycline D. Ciprofloxacin E. Levofloxacin

D. Ciprofloxacin: does not have any coverage of S.pneumoniae (or any streptococcal spp.), and S.pneumo is the #1 causative pathogen of ABRS

JR is a 68-year-old female with a past medical history of COPD (Stage I), uncontrolled Type 2 diabetes (last A1c 10%) and hypertension (controlled on lisinopril). She resides in a long-term care facility but has had no recent hospitalizations or received antibiotic therapy. She is not known to be colonized with any drug-resistant organisms. She presents to the emergency department with complaints of worsening fatigue, shortness of breath and productive cough. Community acquired pneumonia is suspected. She is febrile (39.4°C) and her O2 saturation is 94% on room air, but her vital signs are otherwise stable. Her CURB-65 score is 2. JR is admitted to an internal medicine ward for a 24 hour observation on antibiotics. Should she receive adjunct corticosteroids as part of her treatment regimen? A. Yes, corticosteroids decrease mortality in severe CAP and the benefits outweigh the risks for her B. Yes, corticosteroids are a standard of care per the CAP treatment guidelines for all inpatients being treated for CAP C. No, there is no data that corticosteroids improve clinical outcomes in patients with CAP D. No, the risks of corticosteroids given her uncontrolled diabetes outweigh the potential benefits for JR

D. No, the risks of corticosteroids given her uncontrolled diabetes outweigh the potential benefits for JR A- meta-analyses has shown CCS may have some mortality benefit in severe CAP but still pose a risk for hyperglycemia and higher rates of secondary infection; given her uncontrolled DM, the risks>benefits. therefore this is false. B -False, guidelines only recommend use of adjunct CCS in severe CAP for patients with refractory septic shock. they are not routinely recommended otherwise or a standard of care in CAP. C- False, Meta-analyses have demonstrated that corticosteroids may have a mortality benefit in severe CAP.

ABRS Medication Patient Counseling: wear adequate sunscreen especially in summer months, or hat/long-sleeve when out and about. Take with water and remain upright for 30 minutes after each dose (avoid esophageal ulcerations). Take with food to avoid GI upset (Nausea, potential diarrhea)

Doxycycline

What agent should be used as empiric therapy for acute bacterial rhinosinusitis if a patient has a PCN allergy? (and is unable to take amox/clav DOC)

Doxycycline

LM is a 46 y/o AAF who presents to her PCP with a 3 day history of fever, chest pain, and cough. She has no PMH but does have an allergy to penicillins. She said her mother told her she had a rash as a child. She denies any recent antibiotic use or hospitalization. Though her vital signs were all within normal limits, her lung exam did show signs of pneumonia. Her PCP believes that she could be infected with community acquired pneumonia. What would be the best treatment option for LM's pneumonia?

Doxycycline 100mg QD x 5 days We do not have enough information to calculate her CURB-65 but based on her symptoms and lack of comorbid conditions it is likely that she can be treated as an outpatient. Outpatient without comorbidities drugs of choice: Amoxicillin Doxycycline--> Doxycycline likely the better option here as LM has a history of rash with PCN; due to the fact that it is a minor allergy or could have resolved as it was present when she was a child → in all likelihood she could receive amoxicillin, but to be cautious without a better allergy history for the patient, since we are treating her outpatient where she won't be closely observed the best option for LM is probably: Doxycycline 100mg QD x 5 days

Patient complains of congestion and constantly having to blow their nose. Their brother told them that their snot was very green and therefore it must be a bacterial infection. What do you tell them?

During infection, WBCs release an enzyme known as myeloperoxidase to attack both viruses and/or bacteria. This myeloperoxidase enzyme is what turns your mucous green, the color of the snot does NOT differentiate between a viral and bacterial etiology.

Laboratory marker that supports Pneumonia

Elevated WBC count w/Left Shift ( ↑ %Bands)

Do any of the antibiotic agents used for CAP without risk factors for MRSA or P.aeruginosa provide any coverage for these drug-resistant pathogens?

Fluoroquinolones provide coverage for P.aeruginosa only. Ceftriaxone, Azithromycin, Levofloxacin do NOT cover MRSA. Our typical regimens that we are using for CAP may not cover either of these organisms (MRSA or P.aer) therefore in patients that are at high risk for developing Pneumonia secondary to these more resistant organisms we would need to broaden/empirically cover these organisms in this case.

have a black box warning for achilles tendon rupture

Fluoroquinolones: Levofloxacin, Moxifloxacin, Ciprofloxacin

which antibiotic agents may cause blood sugar derangement, an increased risk for seizures, dizziness, confusion, hallucinations, QT prolongation all of which are more problematic in elderly patients

Fluoroquinolones: Levofloxacin, Moxifloxacin, Ciprofloxacin

purulent exudates around the tonsils are a sign of

GAS pharyngitis (S.pyogenes)

Antiphagocytic capsule - protective antigen in certain encapsulated serotypes IgA protease - cleaves human IgA LOS (lipooligosaccharide) - endotoxin, shed from outer membrane of bacteria that undergo autolysis - highly immunogenic and toxic, problematic during invasive disease by encapsulated strains.

Haemophilus influenzae virulence factors

Pneumonia occurring at least 48 hours after hospitalization that was not incubating at the time of admission

HAP, Hospital Acquired Pneumonia

Hospital Acquired Pneumonia (HAP) vs. Ventilator Associated Pneumonia (VAP)

HAP: pneumonia that is not incubating at the time of hospital admission and starts in patients that have been hospitalized for at least 48 hours (≥48hrs after hospitalization) VAP: Pneumonia occurring at least 48 hours after intubation (≥48 hours after intubation)

why is HCAP (Healthcare Associated Pneumonia) no longer used as a classification for patients at risk for drug-resistant pathogens (who would require broader spectrum antibiotic therapy)?

HCAP risk factors were things like: Nursing home residence, LTC facility, patients hospitalized for ≥2+ days in the last 90 days, receiving home infusion therapy, chronic dialysis, family members with known resistant pathogen . . .These risk factors: 1. Were NOT shown to predict high prevalence of antibiotic-resistant pathogens in most settings (failed to accurately represent the population at risk for drug-resistant pathogens) 2. Lead to an ↑ in the use of broad-spectrum antibiotics without improving patient outcomes

treatment of ABRS in patients with recent antibiotic use in the past month

High-dose amoxicillin/clavulanate (to ensure coverage of drug-resistant S.pneumoniae)

When can Ampicillin/Sulbactam be used in the treatment of community acquired pneumonia

INPATIENTS! It is an IV Beta-lactam so is the drug of choice to supply S.pneumoniae coverage for both non-severe and severe CAP being treated inpatient. Despite this it must be combined with a Macrolide (non-severe or severe) or Respiratory fluoroquinolone (severe) to provide atypical coverage as well (mycoplasma pneumoniae, legionella, chlamydia pneumoniae)

When is it NOT recommended to test for Group A streptococci (pyogenes) in suspected pharyngitis infection

If symptoms strongly suggest viral infection 1. Absence of fever 2. Cough 3. Runny nose 4. Hoarseness 5. Oral ulcers

Chest X-ray findings for CAP

Infiltrates, can be in one or both lungs (multi lobe vs. single lobe), usually in the lower fields of the lungs

rhinosinusitis definition

Inflammation of the nasal and paranasal sinuses, that is often secondary nasal inflammation (rhinitis) caused by viral infection or allergies (most commonly: maxillary, anterior ethmoid)

why is PSI not used as often for CAP prognosis / treatment designation vs. CURB-65 if it is a better prognostic indicator

It is more complicated (more extensive criteria); do not always have the information available (PaO2/FiO2, blood count, hypotension requiring fluid resuscitation, CXR/multilobar infiltrates, etc)

When are Levofloxacin or Moxifloxacin be used in the treatment of ABRS?

LAST LINE, and only used in patients with a: SEVERE PCN allergy AND Contraindication to Doxycycline (<8yo). (b/c of ↑rates of resistance to fluoroquinolones in the community, and many toxicities) (blood sugar derrangement, QT prolongation, seizures, arthalgias,tendonitis/reupture, CNS effects)

Which is why Azithromycin often preferred over Clarithromycin (in choice of macrolide agent )

Less toxicities! (Only GI, least GI tox due to acid stability) Less DDIs! (excreted unchanged in the urine vs. other macrolides = hepatic CYP3A metabolism)

What agent(s) can be used for empiric treatment of severe ABRS in a patient that is 7 years old with a severe penicillin allergy

Levofloxacin or Moxifloxacin (Cannot use Amox/Clav due to severe PCN allergy, cannot use Doxycycline b/c CI in children<8yo due to permanent teeth discoloration; only used in severe instances where there is no other option. high musculoskeletal toxicity risk.)

agents that provide unnecessarily broad coverage for ABRS (given that the most common pathogens are S.pneumoniae, H.influenzae and to a lesser extent Moraxella catarrhalis) and therefore are reserved last line when there are concerns of resistance/failure of initial first line therapy or severe PCN allergy

Levofloxacin, Moxifloxacin

Used for acute bacterial rhinosinusitis only if the patient has a severe PCN allergy that completely precludes the use of amox/clav, and some other contraindication to doxycycline

Levofloxacin, Moxifloxacin (Fluoroquinolones) but NOT ciprofloxacin because it does not have any coverage of S.pneumoniae which is the most common etiologic pathogen of ARBS

Treatment of pharyngitis caused by Neisseria gonorrhea or Chlamydia pneumoniae

Likely does not require antibiotic treatment. Pharyngitis caused by anything other than GAS (s.pyogenes), likely does not require anti-infectives

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. The PCP believes this could be a sinusitis infection. How did HH likely acquire the agent that is causing the sinusitis infection?

Likely due to his asthma and seasonal allergies which cause inflammation leading to narrowing of the sinus ostia which is the opening that connects a sinus to the nasal cavity - the narrowing leads to mucous stasis and ciliary dysfunction which makes for a ripe environment for bacterial proliferation/growth

Why is either doxycycline or a macrolide added to Amox/Clav or Cefpodoxime (PO) for treatment of CAP in outpatients with comorbidities?

Macrolides (azithro/clarithro) and Doxycycline still cover S.pneumoniae to a degree but serve to provide coverage of the atypical pathogens like Mycoplasma pneumoniae, Legionella and Chlamydia pneumoniae

Amoxicillin/Clav DDIs

May decrease the effectiveness of Oral Contraceptives

Guideline recommendations for the use of Corticosteroids in Community Acquired Pneumonia

Meta-analyses have demonstrated that corticosteroids may have a mortality benefit in severe CAP, however risk of hyperglycemia and higher secondary infection rates remain a concern. The guidelines do not routinely recommend adjunct steroids unless patients have refractory septic shock

Duration of therapy for CAP treatment

Minimum of 5 days and continued until the patient achieves clinical stability. If patient is stable at <5days: finish out the 5-day course If patient is stil clinically unstable on day 5: continue treatment for 2-3 more days.

Block phagocytosis: no capsule, but surface proteins bind to complement components and plasminogen to disguise the bacteria to providing similar protection. Biofilm formation: has been observed in the middle ears of children with recurrent otitis media LOS (lipooligosaccharide) - endotoxin shed from bacteria, contribute to inflammation and may promote spread of bacteria

Moraxella catarrhalis virulence factors

regardless of clinical presentation, why must there be a patient discussion prior to initiating empiric antibiotic therapy for acute bacterial sinusitis?

Most patients even with documented acute bacterial sinusitis have self-limiting infections/symptoms; when bacterial sinusitis is uncomplicated, it is likely that the patient may receive more harm from the side effects of antibiotics than the benefits of symptom relief/infection eradication

which atypical pathogens can cause CAP

Mycoplasma pneumoniae Legionella spp. Chlamydia pneumoniae

Could Ceftriaxone + Azithromycin, Levofloxacin be used to broaden coverage in a patient that was hospitalized 3 months ago and received IV metronidazole therapy? (note: recent hospitalization and exposure to parenteral antibiotics = strong individual risk factor for MRSA or P.aeruginosa infection therefore broader coverage is required).

NO: Ceftriaxone, Azithromycin and Levofloxacin DO NOT COVER MRSA. Levofloxacin covers P.aeruginosa but this is not sufficient to provide MRSA coverage as well. The only Cephalosporin that covers MRSA is Ceftaroline.

5 risk factors for sinusitis (all forms)

Narrowing of Sinus ostia (2) 1. Inflammation of the sinus ostia: allergies, asthma, swimming, facial trauma, tobacco, viral infection 2. Nasal Obstructions: polyps, foreign bodies, tumors, deviated septum, nasal intubation 3. Dysfunction of ciliary apparatus (comorbid disease states) Kartagener syndrome, Cystic Fibrosis 4. ↑ Viscosity of sinus secretions: ripened environment for bacterial growth 5. Immune disorders

Clinical stable O2 saturation on room air = _______

O2 sat ≥ 90% on room air

Patients with SEVERE community acquired pneumonia can experience a very excessive inflammatory response, in what patients is the use of Corticosteroids recommended, if at all, to help control this inflammatory response seen secondary to severe infection?

Only if the patient has Refractory Septic Shock: even in patients with severe CAP, UNLESS THEY ARE IN SEPTIC SHOCK we do not recommend concomitant steroids as part of our therapy for patients. Corticosteroids pose risk of hyperglycemia (dangerous for those with uncontrolled diabetes), and higher rates of secondary infection (due to immunosuppressive effects), therefore the risks outweigh the benefits for many patients with SEVERE CAP or severe influenza pneumonia

Scoring system that is a better CAP prognostic indicator than the CURB-65 score

PSI (Pneumonia Severity Index) Risk Class I-II: outpatient Risk Class III-V: inpatient

Treatment of GAS Pharyngitis in Children w/o PCN allergy (2)

Penicillin VK 250mg BID-TID x 10 days or Amoxicillin (50 mg/kg) QD x 10 days

Treatment of GAS Pharyngitis in Adults w/o a PCN allergy

Penicillin VK BID-QID x 10 days or Amoxicillin QD x 10 days Most likely avoid antibiotic tx in adults presenting >48hrs of symptom onset

Drug of choice for Streptococcus pyogenes infections

Penicillins! (Penicillin VK or Amoxicillin) Group A Strep while it can cause both mild (pharyngitis) and pretty severe infections (skin and soft tissue, scarlet fever), it still remains very very susceptible to very narrow spectrum agents like penicillins, 1st gen cephalosporins

Clinically stable RR

RR ≤ 24

Why is a definitive diagnosis (culture) not used often in practice to diagnose ABRS?

Requires painful/invasive sinus aspiration: aspiration of the patients sinuses to collect a sample of infected fluid and send it for culture; therefore not commonly done in practice (dx is more based off of clinical signs/sx and duration of sx >10days)

Most symptoms of sinusitis are caused by viral infections, what are some of the viral pathogens that could be at play?

Rhinovirus Coronavirus → not COVID-19, but avg. run of the mill coronaviruses that cause typical cold/flu-like symptoms Parainfluenza Adenovirus

Patients with a PSI score that falls into Risk Class __________ should be treated for CAP inpatient.

Risk Class III-V

The top 3 most common pathogens of acute bacterial rhinosinusitis are all oropharyngeal flora. How then do they cause infection of the sinus ostia?

S.pneumoniae, H.influenzae, M.catarrhalis are normal flora of the respiratory tract; when there is inflammation causing narrowing of the sinus ostia (allergies, asthma, swimming, tobacco, facial trauma, viral infection, polyps, foreign bodies, CF, etc) movement of mucus and secretions is slowed, which ripens the environement for these organisms to grow to higher levels than normally allowed and cause infection

1st line therapy for symptomatic relief to recommend for viral, allergic and/or bacterial sinusitis

Saline nasal irrigations

Fever Pleuritic Chest Pain Productive Cough Fatigue Anorexia Sweats Nausea Dyspnea

Signs/sx of Pneumonia

Asthma, CF, Kartagener syndrome, Deviated septum, Nasal intubation, facial trauma, swimming, allergic inflammation, tobacco, viral infection, polyps, tumors and immune disorders are all risk factors for

Sinusitis

Most common pathogen of bacterial pharyngitis

Streptococcus pyogenes (Group A streptococci) (GAS) more common in children (20-30% in children vs. <10% of sore throats in adults are caused by GAS)

Most common causative bacterial pathogen of CAP

Streptococcus pneumoniae

Antiphagocytic capsule - protective antigen, 90 serotypes identified Toxins: IgA protease - cleaves immunoglobulin A (to evade the immune response) Pneumolysin - cholesterol-binding cytolysins that kill immune cells

Streptococcus pneumoniae virulence factors

HR is a 26-year-old male with a past medical history of asthma presents to his local pharmacy with complaints of congestion and green nasal discharge. His symptoms have persisted for 5 days and he is inquiring about potential antibiotics because he thinks this could be bacterial sinusitis. What do you recommend?

Symptomatic relief with saline nasal irrigations: HR's symptoms have persisted for <10 days so it is unlikely that he has bacterial sinusitis. Symptomatic relief with saline nasal irrigations is recommended. Color of nasal discharge does not distinguish bacterial vs viral sinusitis. Asthma can increase risk for sinusitis in general, but not necessarily bacterial sinusitis. He likely has viral sinusitis or sinusitis secondary to allergies/inflammation, which are not indications for antibiotics!

Double-sickening (sign of bacterial sinusitis)

Symptoms initially get better but then worsen after 5-6 days, potentially with a new onset of fever after day 5

Clinically stable body temperature (sign of defervesence)

Temp ≤ 37.8ºC

Downside to Centor Criteria in the diagnosis of GAS pharyngitis Fever Tonsillar exudates → visualized on PE Absence of cough Tender cervical lymphadenopathy

Tends to over-diagnose GAS pharyngitis vs microbial diagnostics (RADT, Throat culture)

LM is a 46 y/o AAF who presents to her PCP with a 3 day history of fever, chest pain, and cough. She has no PMH but does have an allergy to penicillins. She said her mother told her she had a rash as a child. She denies any recent antibiotic use or hospitalization. Though her vital signs were all within normal limits, her lung exam did show signs of pneumonia. Her PCP believes that she could be infected with community acquired pneumonia. What are the most likely pathogens causing LM's pneumonia?

The etiology of CAP is not very well defined but a lot of times it is caused by viruses (secondary to the rhinovirus (H.rhinovirus), secondary to the flu depending on the season (influenza) → but when worried about potential bacteria the most common pathogen we want to cover is S.pneumoniae. We also want to cover the atypical organisms as these can cause more of a walking pneumonia picture where patients are not as ill, and not necessarily needing hospitalization which is what we think about for LM Mycoplasma pneumoniae Chlamydia pneumoniae

HH is a 18 y/o CM who presents to his PCP with congestion, purulent nasal discharge, and facial fullness x 14 days . He stated that he tried OTC decongestants which seemed to work initially but his symptoms returned a couple of days later. His PMH is significant for asthma and seasonal allergies. His PCP recommends giving him Augmentin 875mg PO BID x 7 days. How would you counsel HH on this medication drug-drug interactions and toxicities?

Tox: Diarrhea (take w/ food), hypersensitivity reactions DDI: Can decrease the effectiveness of oral contraceptives (but he's a male), no other DDIs

Can be used for any aches, pain or fever associated with sinusitis

Tylenol (Acetaminophen)

sinusitis, otitis media, pharyngitis, tonsilitis, laryngitis are all _______________ whereas bronchitis, pneumonia and bronchiolitis are ___________

Upper respiratory tract infections; lower respiratory tract infections

Pneumonia occurring at least 48 hours after intubation

VAP, Ventilator Associated Pneumonia

___________ PATHOGENS ARE THE MOST COMMON CAUSES OF RHINOSINUSITIS

VIRAL

Why are URIs probably the most common cause of inappropriate antibiotic utilization

We do not want to be using antibiotics to treat viruses and viruses are by far the most common cause of both sinusitis and pharyngitis; additionally, URIs like bacterial sinusitis and GAS pharyngitis (in adults at least) are often self-limiting and risks vs benefits must always be weighed prior to initiation of antibiotic therapy

Why can we use a respiratory fluoroquinolone as monotherapy in non-severe CAP being treated inpatient, but we must use a respiratory fluoroquinolone in combination with an IV Beta-Lactam for severe CAP being treated inpatient?

We would not use a Respiratory Fluoroquinolone as monotherapy in Inpatients with SEVERE CAP because there is increasing S.pneumoniae resistance to Fluoroquinolones in the community, and in Severe CAP we want to make sure we have EXCELLENT coverage of S.pneumoniae as these patients are are severely ill → Beta-Lactams = DOC for S.pneumoniae

LM is a 46 y/o AAF who presents to her PCP with a 3 day history of fever, chest pain, and cough. She has a PMH of COPD and an allergy to penicillins. She said her mother told her she had a rash as a child. Though her vital signs were all within normal limits, her lung exam did show signs of pneumonia. Her PCP believes that she could be infected with community acquired pneumonia. Can LM be put on Cepodoxime + Azithromycin for outpatient treatment of her community acquired pneumonia?

Yes: Patients with low-risk PCN allergies such as a childhood rash would have a very low risk of cross-reactivity to Cephalosporins, therefore it would probably be very safe for the patient to receive in combination with azithromycin. (Note this patient has COPD which is a CAP co-morbid condition which is why she requires PO Beta-Lactam + Macrolide as 1st line therapy). If the patient's allergy history was more concerning and we didn't want to give her a beta-lactam we could also consider a Respiratory Fluoroquinolone such as Levofloxacin or Moxifloxacin to treat her in that case

ABRS

acute bacterial rhinosinusitis should not even be considered in the diagnosis unless symptoms are present for >10 days

Common viral pathogens that cause pharyngitis

adenovirus rhinovirus coronavirus influenza parainfluenza coxsackie virus

CAP treatment can be discontinued once the patient is

afebrile x 48 hours with no more than 1 sign of clinical instability (at day 5 of tx or beyond)

Average Duration of viral sinusitis symptoms? Peak symptoms usually occur at _______days

avg duration 5-10 days; peak respiratory symptoms occur at 3-6 days (congestion, daytime cough, sore throat from post-nasal drip, nasal discharge)

most prescribed of all of the macrolides; most likely due to extended-half life allowing for once daily dosing and less DDIs due to the fact that it is its not metabolized by CYP3A4 but is excreted in the urine unchanged.

azithromycin

Why is ciprofloxacin not considered a respiratory fluoroquinolone?

because it lacks coverage of S.pneumoniae which is the most important pathogen of interest in respiratory infections (ABRS, CAP)

Pathogens that secrete toxins and use capsule to evade immune system are _______________ pathogens

extracellular pathogens

Why is amoxicillin/clav the drug of choice in ABRS

has excellent coverage of S.pneumo, H.influenzae, and M.catarrhalis, the top 3 most common pathogens of bacterial sinusitis

Initial signs/sx of viral sinusitis within the first 24-48 hours of infection

headache, myalgias, fever (mild sickening) Followed by: congestion, daytime cough, sore throat from post-nasal drip, nasal discharge

rhinitis

inflammation of the nasal mucosa

You should add empiric coverage of MRSA or P. aeruginosa in adults with CAP if

locally validated risk factors for either pathogen are present --> however not all institutions have this information available. In the absence of known locally validated risk factors for MRSA or P.aeruginosa, used individually validated risk factors 1. Prior culture with MRSA/pseudomonas, 2. Recent hospitalization, and exposure to parenteral antibiotics in the last 90 days.

-RR ³ 30 beaths/min -Pa02/Fi02 ratio £ 250 -Multilobar infiltrates -New onset Confusion/delirium -Uremia (BUN ³ 20mg/dL) -Leukopenia •WBC < 4000 cells/mm3 -Thrombocytopenia •Platelet < 100,000 cells/mm3 -Hypothermia < 36◦ C (96.8 F) -Hypotension requiring fluid resuscitation

minor criteria of Pneumonia Severity Index (PSI)

when to use the centor criteria in GAS pharyngitis diagnosis

only in the absence of access to testing; just because it tends to overdiagnose bacterial infection

The top 3 most common pathogens of acute bacterial rhinosinusitis are all ___________________ flora.

oropharyngeal

Patients with low-risk PCN allergies such as a childhood rash would have a ___________ risk of cross-reactivity to Cephalosporins

very low

The vast majority of sinusitis cases are due to

viruses or allergies

Like sinusitis, pharyngitis is more commonly caused by

viruses: Adenovirus Coxsackie virus Rhinovirus Coronavirus Influenza Parainfluenza

If the patient's CURB-65 Score is _______, then treat them as an outpatient

≤ 1

If the patient's CURB-65 Score is _______, then treat them as an inpatient (must at least receive their initial treatment in an inpatient setting where they can be closely monitored for symptomatic improvement before being sent home)

≥ 2 confusion, BUN>19 (uremia), RR>20, BP <90/60mmHg, Age≥65 1 point for each criteria