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Flashcards in ENT pharm Deck (69)
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1

Distinguishing b/t viral and bacterial infection?

- sinus infection is likely to be caused by bacteria rather than virus if any of the 3 following conditions is present:
1. sxs last for 10 days w/o any evidence of improvement
2. sxs are severe, including fever of 102 or higher,and nasal d/c and facial pain enduring for at least 3-4 consecutive days at beginning of illness, maxillary tooth pain, unilateral maxillary sinus tenderness
3. sxs or signs worsen, as characterized by new fever or HA developing or nasal d/c increasing, typically after viral URI that lasted 5-6 days and initially seemed to improve
- guidelines suggest that 5-7 day course of abx is long enough to tx infection in adults w/o encouragng abx resistance. Children should be on abx tx for 10-14 days

2

Sx therapy for rhinitis/sinusitis?

- if you think its viral tell pt to take:
analgesics - ibuprofen over tylenol
saline irrigation
topical steroids (esp if allergic rhinitis)
topical decongestants
oral decongestants

3

Tx considerations for bacterial infection?

- abx needed
- tx initiated empirically
- cultures only for complicated cases, done by ENT

4

Common bacteria that cause sinusitis?

strep pneumo
H flu
pseudomonas
staph aureus
M cat
anaerobic - dental infections

5

Abxs used for acute sinusitis?

- amoxicillin - approp sinus penetration
- AM/CL - augmentin (SE diarrhea)
- doxy - bones and teeth
- clarithro or zithro: QT prolong
- levo - tendon rupture
- bactrim ds 160/800 po bid (sulfa - SJS) - used in PCN allergic pts, bigger guns

6

Amoxicillin use in acute sinusitis? Adverse reactions?

- amoxicillin 500 mg po tid x 7-10 days
- used first line agent in past
- but emergence of antimicrobial resistance (vary regionally)
- warnings: monitor blood, renal, hepatic fxn in long term use
- adverse rxn: GI upset, hypersensitivity rxns eg urticaria, rash, SJS, yeast infections

7

Augmentin use in acute sinusitis? CI?
Adverse reactions?

- recommended as initial empiric therapy in non PCN allergic pts
- comes in 2 strengths:
500/125 mg 1 po tid x 7 days
875/125 mg 1 po bid x 7 days
- CI: severe renal impairment
- adverse rx: diarrhea, nausea, abdominal pain, rash, urticaria, vomiting, vaginitis, anaphylaxis
- preg: class B so can be used unless allergic to PCN

8

Doxy use in acute sinusitis?
Warnings?

- 100 mg, 1 po bid x 7 days
warnings:
-hepatoxicity
-hypersensitivity: drug rash, urticaria, edema, anaphylaxis
-photosensitivity
-tissue hyperpig
-peds: teeth enamel hypoplasia or perm tooth discoloration
- don't use during preg as TCN has been a/w reduced bone growth

-* overall don't use!

9

Zpack use in acute sinusitis?
adverse rxns?
use in what pop?

- generally not recommended for empiric therapy b/c of high rates of resistance
- indicated for preg pts who are PCN allergic
- dosing:
500 mg qd x 3 days
- special alerts:
potentially fatal cardiac arrhythmias: elderly, QT prolong, elect disturbances

adverse rxns:
diarrhea, abdominal pain, cramping, vomiting, anorexia
- vaginitis, acute renal failure

10

Tx for acute sinusitis that is uncomplicated with mild sxs?

- pseudoephedrine (sudafed) 30 mg
- OTC pack
- 1-2 tabs po q 4-6 hrs (max 4 doses/ 24 hrs)
- warnings: HTN, CVD, DM, thyroid
- adverse rxns: nervousness, dizziness, insomnia
- oxymetazoline 0.05% 2 sprays each nostril q 8 hrs for 3 days only
- normal saline nasal spray (ocean)

11

80% of pts with viral URI will show what on CT?

- will have inflamed sinus mucosa
- look for fluid level

12

Tx decisions for acute sinusitis?

- has pt been exposed to abx in last 30 days? if yes go to empiric 2nd line tx
- has pt improved in 3-5 days? no
- empiric 2nd line tx:
augmentin
levoflox: 500 mg 1 po qd
- moxifloxacin 400 mg po qd

13

Duration of tx for acute sinusitis?

- abx should be rx for 5-7 days
- no difference was noted in response rates or relapse rates comparing short courses and longer courses of abx
- rates of adverse events were lower for 5 day than 10 day courses

14

Chronic sinusitis tx decisions? are abx effective?

- abx usually not effective
- consult ENT
- reasons for tx failure: resistant pathogens, inadequate dosing, structural abnormalities, or noninfectious etiology
- empiric 2nd line after tx failure:
augmentin, levofloxacin, or moxifloxacin

15

When should you refer pt with sinusitis to ENT?

- mult episodes of ABRS (3-4 episodes/year)
- chronic rhinosinusitis with exacerbations of ABRS
- pts with allergic rhinitis who may be candidates for immunotherapy
- urgent referral: severe infection (high persistent fever, orbital edema, HA, visual disturbance, alt mental status, or meningeal signs)

16

Key to dx otitis media?

- pneumoscopy - does TM move

17

Tx for babies and children with otitis media?

- tx 0-6 months and admit
- 6 mo - 2 yrs abx no matter what
- once 2 - hold off on abx unless severe

18

How common is AOM?

- most frequent dx in kids b/t 1 - 3
- lasts 24-72 hrs
- middle ear effusion
- we are overusing abx on AOM!

19

Sx tx for AOM?

- ibuprofen/motrin
- auralgan (combo of benzocaine and glycerin) never use in children under 2
- topical aqueous lidocaine (lignocaine)

20

Deciding to use abx vs. observation in AOM?

- abx should be admin to any child younger than 6 mo, regardless of dx certainty
- abx recommended for kids 6 mo- 2 years when dx is certain or dx is uncertain but illness is severe: observation is an option for children whom dx is not certain and illness isn't severe
- abx recommended for children older tahn 2 yrs if dx is certain and illness is severe: observation is an option when dx is certain but illness isn't severe and in pts with uncertain dx

21

Decide on antimicrobial therapy for AOM?

based on decision on:
-clinical and microbiologic efficacy
-acceptability
-side effects and toxicity
-convenience of dosing schedule
-cost

22

AOM tx in peds?

- amoxicillin: first line if low risk for amox resistance (haven't had b-lactam abx in previous 30 days)
- 90 mg/kg/d in divided doses bid x 10 days (max 3 g/day)

-augmentin: 90 mg/kg/day of amox and 6.4 mg/kg/day of clavulanate (max 3 g/day)
- in divided doses q 8 hrsx 10 days

23

AOM tx in peds who are allergic to PCN?

- azithro:
10 mg/kg/d (max 500 mg/day as day one dose, and max 150 mg/day for days 2-5)
- clarithro:
15 mg/kg/d divided into 2 doses, 1 g/day is max dose
- erythromycin/sulfisoxazole (pediazole): 50 mg/kg/d in divided doses q 6 hrs x 10 dayas, max 2 g/day erythro and 6 g/day sulfisoxazole

24

Other AOM tx alternatives?

- cephalosporins:
cefdinir (omnicef): 6 months to 13 yrs - 7 mg/kg PO q 12 hrs or 15 mg/kg PO qd, not to exceed 600 mg/day , if older than 13 admin as adults

cefuroxime (ceftin): 30 mg/kg/d in 2 divided doses

25

Recommended duration of tx for AOM in peds?

- recommended:
10 day course: more effective in pts younger than 2
- 5-7day course for children 6 and older with mild-mod AOM
- single dose zpack has FSA approval: 30 mg/kg

26

Prophylaxis for kids with AOM

- for kids who have had 3 infections/3 months,
4 episodes/6 months, 6 episodes in 12 months - amoxicillin 20 mg/kg/d for 3-6 months
- tubes

27

Pain control for kids with AOM?

- auralgan (antipyrine) drops:
indications - reduce pain and swelling, to remove or soften cerumen, fill ear canal, repeat q 1-2 hrs, don't use with perforation!!!!
- use ibuprofen (tylenol not recommended)

28

DOC for initial therapy for AOM in adults?

- amoxicillin 500 mg po bid for 5-7 days for mild to moderate, if severe 500 mg PO TID for 10 days
adverse rxns: GI, hypersensitivity, blood dyscrasias, yeast infections
- if severe otalagia or elevated temp: consider augmentin 500-875 mg q bid for 5-7 days
adverse rxn: GI, N/V/D, abdnominal pain, rash, urticaria, vaginitis, anaphylaxis

29

Tx for pts that report PCN allergy but who don't experience a type 1 hypersensitivity rxn (urticaria or anaphylaxis)?

Tx for pts with severe rxn to PCN?

- cefdinir (ceph 3rd gen): 300 mg po bid or 600 qd
- cefpodoxime (ceph 3rd): 200 bid
- cefuroxime (2nd gen): 500 mg po q 12 hrs
- ceftriaxone (3rd gen - aka rocephin) - 2 g IM or IV once

- for pts with known or severe allergies to b-lactam abx - macrolide: erythro with sulfisoxazole or azithro or clarithro is preferred drug
- Bactrim may be used in regions wehere pneumococcal resistance to this combo isn't a concern

30

What is malignant otitis externa? How does it affect usually?
Tx?

- necrotizing external otitis, invasive infection of canal and skull base
- affect elderly pts with DM and HIV pts
- antipseudomonal abx:
cipro 750 mg po BID
levo 750 po or IV qd
if resistant:
hospital stay with IV antipseudomonal b lactam agent with or without aminoglycoside