respiratory tract infections

Question 1

for a RTI to develop, the pathogen must…

Answer 1

gain access to the lungs

Question 2

host defense mechanisms

Answer 2

nasopharynx - nasal hair, anatomy of airway
oropharynx - saliva, epithelial cell sloughing
trachea, bronchi - cough, epiglottic reflexes, sharp angled branching airways,
terminal airways, alveoli - alveolar lining fluid, cytokines, macrophages, PMNs, cell-mediated immunity

Question 3

factors known to interfere with host defenses

Answer 3

altered level of consciousness - compromise epiglottic exposure - aspiration
smoking*** (and second hand smoke) - disrupts mococilliary function and macrophage activity
viruses (flu) - impairs alveolar macrophage fxn and mocociliary clearance - inc risk of secondary bacterial infection
alcohol - impairs cough and epiglottic reflexes - aspiration, increases oropharyngeal colonization with gram negative organisms, decreased mobilization of neutrophils
endotracheal tubes, NG tubes, respiratory therapy machinery (ventilators)
immunosuppression - malnutrition, immunosuppressive therapy, HIV
Elderly - increased number and severity of underlying diseases, increased hospitalizations, decreased mucociliary clearance, decreased immune function

Question 4

pathogenesis of CAP

Answer 4

aspiration** - most common for bacteria pneumonia

Question 5

specific pathogens in CAP

Answer 5

Strep Pneumoniae*** (25-70% of cases) - most common in outpatient, inpatient (ICU and non-ICU)
Mycoplasma pneumoniae
Haemophilis influenzae
Legionella pneumophila
Chlamydophila pneumoniae

Question 6

Strep pneumoniae

Answer 6

CAP
2/3 of bacteremic pneumonia cases
more prevalent and severe in patients with splenic dysfunction, DM, chronic cardiopulmonary or renal disease and HIV
Risk factors for drug-resistant S. pneumoniae (DRSP)
-extremes of age (less than 6, over 65 years old)
-prior antibiotic therapy*
-underlying illnesses, co-morbid conditions
-day care attendance or family member of child in day care
-recent or current hospitalization
- immunocompromised, HIV, nursing home, prison

Question 7

susceptibilty of streptococcus pneumoniae

Answer 7

azithromycin - resistance up to 48.4%

tetracycline - 24.1% resistance

Question 8

mycoplasma pneumoniae

Answer 8

CAP
“walking pneumoniae”
atypical pathogen
spread by close contact
gradual onset of fever, HA, and malaise; development of persistent, hacking, nonproductive cough* after 3-5 days
radiographic findings usually more impressive than physical findings - patchy, interstitial infiltrates (not consolidation*)
no predominant organism on sputum gram stain
can be cultured using specialized media; slow growth
usually benign and self-limiting; symptoms may persist up to 4 weeks (treat to decrease)

Question 9

Legionella pneumophila

Answer 9

CAP
likely to end up in ICU
atypical pathogen
transmitted by inhalation of aerosols containing organism
infection characterized by multisystem involvement: high fevers (over 40 C), rapid progression on CXR and multilobar involvement

Question 10

Chlamydophilia pneumoniae

Answer 10

CAP

atypical, typicall occurs in young adults, mild sxs

Question 11

CAP and staph aureus

Answer 11

2,259 patients - 1% MSSA, 0.7% MRSA
30% received anti-MRSA agents
more likely in patients post-influenza
2-14 days post-infuenza*** - sudden onset of shaking chills, pleuritic chest pain, productive cough, inc WBC with left shift, consolidation
high index of suspicion for MRSA (CA-MRSA) - bactrim

Question 12

conditions and risk factors related to specific pathogens in CAP

Answer 12

alcoholism, COPD/smoker, aspiration, lung abscess, exposure to bat or bird droppings, birds, rabbits, or farm animals, HIV infection, hotel or cruise ship stay in previous 2 weeks (legionella), inj drug use, nursing home,

Question 13

clinical presentation and evaluation of CAP - general

Answer 13

Classic presentation: sudden onset of fever, chills, pleuritic chest pain (pain on inspiration), dyspnea, productive cough (thick, may be rust colored**)
in elderly - classic symptoms may be absent (esp fever, mild increase in WBC), may present with decline in functional status

Question 14

clinical presentation and evaluation of CAP - physical exam

Answer 14

heart rate, blood pressure
-pulse: increased 10 bpm for every 1 C elevation
-relative bradycardia: viral, atypical pathogens - inc temp, no inc HR
-record postural changes to assess hydration status
tachypnea, cyanosis, use of accessory muscles of respiration, sternal retration, nasal flaring - suggests serious respiratory compromise
evidence of consolidation - suggestion og bacterial etiology
-dullness to percussion, decreased breath sounds over affected area, inspiratory crackles, increased tactile fremitus, whisper pectoriloquy, egophony (E to A changes)

Question 15

clinical presentation and assessment of CAP - chest radiography

Answer 15

only way to differentiate acute bronchitis from CAP

should be performed on ALL outpatients and inpatients with suspected CAP

Question 16

clinical presentation and evaluation of CAP - sputum exam

Answer 16

observe color, amount, consistency, odor
-rust colored - S. pneumoniae
-dark red, mucoid sputum - K. pneumoniae
-foul-smelling sputum - mixed anaerobic infection
microscopic exam - gram stain
-sample containing over 25 PMNs and less than 10 epithelial cells/LPF should be evaluated
-gram positive, lancet shaped diplococcu - S. pneumoniae
-small, gram-negative coccobacilli - H. influenzae

Question 17

clinical presentation and assessment of CAP - additional tests

Answer 17

WBC, differential
SCR, BUN, electrolytes, LFTs
pulse ox, O2 saturation
urinary antigen tests - in severe CAP
-L. pneumophilia serogroup 1
-S. pneumoniae - 71% sensitive, 96% specific

Question 18

criteria for severe CAP

Answer 18

Direct admission to ICU for patients with either major criteria or 3 minor criteria
Major criteria: need for mechanical ventilation, septic shock with need for vasopressors
minor criteria: RR over 30, hypotension requiring fluids, BUN over 20, WBC under 4000, PLTs under 100,000, core temp under 36 C, other

Question 19

scoring systems to evaluate severity of illness and predict mortality of CAP

Answer 19

CURB-65

• Confusion
• Uremia (BUN over 20)
• Respiratory rate (over 30 bpm)
• low Blood pressure (systolic under 90 or diastolic under 60)
• age over 65

Question 20

treatment of CAP - general

Answer 20

humidified oxygen if hypoxemic
bronchodilators (albuterol) if bronchospasm present
fluids for rehydration
chest physiotherapy for marked accumulation of retained respiratory secretions
appropriate antimicrobial therapy

Question 21

empiric treatment of CAP - IDSA outpatient therapy

Answer 21

previously healthy patient and no prior antibiotic use within the previous 3 months:
-macrolide: clarithromycin or azithromycin
-doxycycline
presences of comorbidities (heart, lung, liver or renal disease, DM, alcoholism, malignancy, asplenia, immunosuppression) OR antimicrobial use within the previous 3 months*
-respiratory FQs: moxifloxacin, levofloxacin
-B-lactam PLUS macrolide: high dose amoxicillin (1g q8h) or amox-clav (2g q12h) preferred, OR ceftiaxone, cefpodoxime, cefuroxime, doxycycline may be used as an alternative to macrolides
in regions with a high rate (over 25%) of infections caused by high-level (MIC over 16) macrolide-resistant S. pneumoniae, consider alternative agents (even in patients without comorbidities): resp FQs (levo, moxi), B-lactam PLUS** macrolide

Question 22

Empiric treatment of CAP - IDSA inpatient therapy - general medical ward

Answer 22

non-ICU
respiratory FW (moxi or levo - usually IV initially) esp in pen allergic
B-lactam PLUS macrolide (usually azith)
-preferred B-lactams: ceftriaxone* or cefotaxime
-ceftaroline: FDA approved 600 mg q12h
-doxycycline may be used as alternative to macrolides

Question 23

Empiric treatment of CAP - IDSA inpatient therapy - ICU

Answer 23

ALWAYS combo!
-B-lactam PLUS azithromycin: ceftriaxone, cefotaxime, amp/sulbactam
—macrolides have anti-inflammatory properties
-B-lactam PLUS resp FQ:
—ceftriaxone, cefotaxime, ampicillin/sulbactam
—moxifloxacin, levofloxacin
in ICU patients with severe CAP, mortality lower with B-lactam/macrolide*** vs. B-lactam/FQ
-penicillin-allergic: respiratory FQs plus aztreonam

Question 24

empiric treatment of CAP - ISDA inpatient therapy - special concerns

Answer 24

If P. aeruginosa is a consideration:
-antipneumococcal, antipseudomonal B-lactam (pipercillin/tazobactam, cefepime, imipenem, meropenem, doripenem) PLUS** ciprofloxacin or levofloxacin
-antipneumococcal, antipseudomonal B-lactam PLUS* aminoglycoside PLUS* azithromycin
-antipneumococcal, antipseudomonal B-lactam PLUS aminoglycoside PLUS antipneumococcal FQ
-substitute aztreonam in penicillin-allergic patient
if CA-MRSA is a consideration - add vancomycin or linezolid

Question 25

anitpneumococcal, antipseudomonal B-lactams

Answer 25

pipercillin/tazobactam, cefepime, imipenem, meropenem, doripenem

Question 26

antipneumococcal FQ

Answer 26

levo, moxi

Question 27

duration of therapy in CAP

Answer 27

treat for a minimum of 5 days*** patients should be afebrile for 48-72 hours and no more than 1 CAP-associated sign of clinical instability criteria for clinical stability: temp under 37.8 C. HR under 100, RR under 24, SBP over 90, O2 over 90, or pO2 over 60 mmHg on RA, ability to take oral medications, normal mental status

Question 28

pathogen-directed therapy - CAP **** S. pneumo

Answer 28

PSSP (MIC under 2): -preferred: Pen G (IV) or amoxicillin (PO) -alternative: macrolide, cephalosporin, resp FQ, doxycycline PRSP (MIC over 2): -preferred: resp FQ, ceftrixone, cefotaxime -alternative therapy: vancomycin, linezolid, high-dose amoxicillin (3 g/day) (NOT** amox-clav)

Question 29

Pathogen-directed therapy - CAP *** H. influenzae

Answer 29

non B-lactamase producing: -preferred: amoxicillin -alternative: FQ, doxycycline, azithromycin, clarithromycin B-lactamase producing: -preferred: 2nd or 3rd generation cephalosporin, amox-clav -alternative: FQ, doxycycline, azithromycin, clarithromycin

Question 30

Pathogen-directed therapy - CAP *** mycoplasma pneumoniae, chlamydophila pneumoniae

Answer 30

preferred: macrolide, doxycycline alternative: FQ

Question 31

Pathogen-directed therapy - CAP *** Legionella pneumophila

Answer 31

preferred: FQ, azithromycin alternative: doxycycline

Question 32

Pathogen-directed therapy - CAP *** staph aureus

Answer 32

``` MSSA: -preferred: nafcillin, oxacillin -alternative: cefazolin, clindamycin MRSA: -preferred: vanc, linezolid -alt: SMX/TMP ```

Question 33

Pathogen-directed therapy - CAP *** anaerobes

Answer 33

aspiration preferred: B-lactam/B-lactamase-inhibitor, clindamycin alt: carbapenem

Question 34

Pathogen-directed therapy - CAP *** enterobacteriaceae

Answer 34

preferred: 3rd or 4th generation cephalosporin, carbapenem alt: B-lactam/B-lactamase inhibitor, FQ

Question 35

enterobacteriaceae***

Answer 35

``` Citrobacter enterobacter E. coli klebsiella morganella proteus providencia salmonella serratia shigella ```

Question 36

HCAP, HAP, VAP

Answer 36

HCAP: health-care associated pneumonia (removed from guidelines in 2016 - low probability of MDROs) - any patient who was hospitalized in an acute care hopsital for 2+ days within 90 days of infection; resides in nursing home or LTC facility, received recent IV antibiotics, chemo or wound care in past 30 days of infection, attended a hospital or hemodialysis clinic HAP: Hospital-acquired pneumonia - pneumonia occurring 48+ hours after hospital admission VAP: ventilator-associated pneumonia pneumonia occurring over 48-72 hours after endotracheal intubation

Question 37

managing HCAP

Answer 37

most patients with HCAP can be appropriately treated with CAP therapy **broad-spectrum antibiotic may be warranted in: IV antibiotics within previous 90 days, history of MDR pneumonia, critically-ill, post-influenzae infection, structural lung disease (bronchiectasis, CF)

Question 38

pathogenesis of HAP and VAP

Answer 38

microaspiration of oropharyngeal secretions colonized with pathogenic bacteria: normally, oropharynx is colonized with aerobic gram-positive organisms and anaerobes; become colonized with gram-negatives after 3-5 days of hospitalization

Question 39

risk factors for HAP and VAP

Answer 39

advanced age, severity of underlying disease, duration of hospitalization, endotracheal intubation, mechanical ventilation, presence of NG tubes, altered mental status, surgery, previous antimicrobial therapy

Question 40

diagnosis of HAP/VAP

Answer 40

no gold standard | timing* in relation to hospitalization and endotracheal intubation

Question 41

microbiology of HAP/VAP

Answer 41

identification of bacterial pathogen is difficult d/t colonization of respiratory tract aerobic gram-negative bacilli = about 70%*** -P. aeruginosa - 10-20% -enteric gram-negative bacilli - 20-40% -acinetobacter baumannii - 5-10% S. aureus (esp MRSA) - 20-30% -more common in DM, head trauma and ICU residence

Question 42

factors associated with increased risk of MDR VAP vs. non-MDR VAP

Answer 42

prior IV antibiotics use within 90 days, 5+ days of hospitalization prior to occurance of VAP, septic shock at the time of VAP, acute respiratory distress syndrome (ARDS) before VAP, acture renal replacement therapy prior to VAP lower risk of MDR VAP associated with coma at time of ICU admission

Question 43

risk factors for antibiotic resistance in HAP and VAP

Answer 43

risk factors for MDR HAP - prior IV antibiotics use within 90 days risk factors for MRSA HAP/VAP - prior IV antibiotics use within 90 days, more likely in late onset HAP/VAP, insufficient data for positive MRSA screen as a risk risk factors for MDR P. aeruginosa HAP/VAP: prior IV antibiotics use within 90 days (carbapenems, broad-spectrum cephalosporins, FQs)

Question 44

initial empiric treatment of HAP and VAP

Answer 44

all hospitals should regularly generate and disseminate a local antibiogram - include susceptibility data specific to patients with VAP, if possible or the the ICU populations empiric regimens should be based on local distribution of pathogens associated with HAP and VAP and their susceptibility profiles

Question 45

empiric therapy of clinically suspected VAP

Answer 45

ALL empiric regimens should provide coverage for*: S. aureus, P. aeruginosa, other gram-negative bacilli include agent active against MRSA (vanc, linezolid): risk factors for MRSA, patients treated in ICU where over 10-20% of S. aureus are MRSA, patients treated in ICUs where prevalence of MRSA unkown ***Prescribe 2 antipseudomonal antibiotics from different classes only in the following patient: risk factors for antimicrobial resistance, patients in ICU where over 10% of gram-negative isolates are resistant to monotherapy agent, patients in ICUs where local resistance rates unknown ***Prescribe empiric monotherapy for P. aeruginosa: patients without risk factors for antimicrobial resistance, patients in ICU where less than 10% of gram-negative isolates are resistant to monotherapy agent

Question 46

suggested empiric treatment options for clinically suspected VAP - gram-positive antibiotics with MRSA activity

Answer 46

Vanc 15 mg/kg IV q8-12h OR linezolid 600 mg IV q12h

Question 47

suggested empiric treatment options for clinically suspected VAP - B-lactam antibiotics with antipseudomonal activity

Answer 47

``` Pip/tazo 4.5 g IV q6h OR cefepime 2 g IV q8h ceftazidime 2 g IV q8h OR imipenem 500 mg IV q6h meropenem 1 g q8h OR aztreonam 2 g IV q8h ```

Question 48

suggested empiric treatment options for clinically suspected VAP - non-B-lactam antibiotics with antipseudomonal activity

Answer 48

``` Ciprofloxacin 400 mg IV q8h Levofloxacin 750 mg IV q25h OR amikacin 15-20 mg/kg IV q24h gentamicin 5-7 mg/kg IV q24h tobramycin 5-7 mg/kg IV q24h OR (ONLY if MDRO) colistin* polymyxin B 1.5 mg/kg IV q12h ```

Question 49

recommended empiric therapy for HAP - not at a high risk of mortality* and no factors increasing likelihood for MRSA

Answer 49

provide coverage for MSSA - pip/tazo 4.5 q6h, cefepime 2 g q8h, imipenem 500 mg q6h, meropenem 1g q8h, levofloxacin 750 q24h high risk of mortality = need for ventilatory support for HAP and septic shock

Question 50

recommended empiric therapy for HAP - Not at high risk of mortality but with factors increasing likelihood of MRSA

Answer 50

ONE of the following: pip/tazo 4.5 q6h OR cefepime 2 g q8h OR ceftazidime 2 g q8h OR imipenem 500 mg q6h OR meropenem 1 g q8h OR levoflox 750 q24 OR cipro 400 q8h OR aztreonam 2 g q8h PLUS*** vencomycin 15 mg/kg q8-12h (target through 15-20) OR linezolid 600 mg q12h

Question 51

recommended empiric therapy for HAP - high risk of mortality* or recipient of IV antibiotics during the prior 90 days

Answer 51

TWO* of the following: pip/taxo 4.5 q6h OR cefepime 2 g q6h OR ceftazidime 2 g q8h OR imipenem 500 mg q6h OR meropenem 1 g q8h OR levoflox 750 mg q24h OR cipro 400 mg q8h OR aminoglycoside OR aztreonam PLUS* vancomycin 15 mg/kg q8-12h (target trough 15-20) OR linezolid 600 mg q12h

Question 52

PK/PD optimization of antibiotic therapy

Answer 52

guidelines suggest dosing using PK/PD data rather than manufacturer's prescribing information B-lactams: continuous or prolonged infusion

Question 53

treatment options with restricted recommendations

Answer 53

Aminoglycosides: NOT recommended as a monotherapy agent, avoid empiric use if alternatives available, why? poor lung toxicity, nephrotoxicity, ototoxicity polymyxins: avoid empiric use if alt available, reserve for MDROs tigecycline: don't use

Question 54

pathogen specific treatment for HAP and VAP

Answer 54

based on susceptibilty if MSSA - nafcillin, oxacillin, cefazolin if MRSA - vancomycin, linezolid if enterobacteriaceae - numerous options if ESBL-producer - carbapenem or pip/tazo (CTX-M) if P. aeruginosa: -not in septic shock or at high risk of monotherapy - monotherapy -patient in septic shock or at high risk of death - combination therapy with 2 agents to which the isolate is susceptible if acinetobacter - carbapenem or ampicillin/sulbactam - if susceptible polymyxin IV inhaled colisitin if MDR

Question 55

Duration of treatment for HAP and VAP

Answer 55

7 days

Question 56

PCT to guide d/c of antibiotic therapy

Answer 56

suggested to utilize procaclitonin plus clinical criteria* to guide d/c of antibiotic therapy in HAP/VAP

Question 57

acute bronchitis overview

Answer 57

etiology - respiratory viruses clinical presentation - cough (2-3 weeks), coryza, sore throat, malaise, headache, fever, normal CXR treatment -symptomatic: antitussives, antipyretics, adequate hydration -NO ANTIBACTERIAL THERAPY WARRANTED

Question 58

acute exacerbation of chronic bronchitis - clinical presentation

Answer 58

definition of chronic bronchitis - any patient who reports coughing up sputum on most days for at least 3 consecutuive months each year for 2 consecutive years 3 cardinal symptoms of ABECB (acute bacterial exacerbation of chronic bronchitis) - must have all 3 for ABE -increased cough or dyspnea -increased sputum production -increased sputum purulence

Question 59

acute exacerbation of chronic bronchitis - clinical presentation

Answer 59

definition of chronic bronchitis - any patient who reports coughing up sputum on most days for at least 3 consecutuive months each year for 2 consecutive years 3 cardinal symptoms of ABECB (acute bacterial exacerbation of chronic bronchitis) - must have all 3 for ABE -increased cough or dyspnea -increased sputum production -increased sputum purulence chest auscultation - inspiratory and expiratory rales, rhonchi, mild wheezing; expiratory phase is prolonged

Question 60

acute exacerbation of chronic bronchitis microscopy and laboratory assessment

Answer 60

obtain sputum early in the morning increased PNMs - suggests continued bronchial irritation gram stain often reveals a mixture of GPC and GNB role of sputum culture - controversial (colonization***) bacteria involved: -H. influenzae - 45% (30-40% B-lactamase positive) -S. pneumoniea - 20% (20% PRSP; 30-40% macrolide-resistant) -M. catarrhalis - 30% (95% B-lactamase positive) -enterobacteriaceae, P. aeruginosa - seen in patients with end-stage COPD***

Question 61

acute exacerbation of chronic bronchitis - treatment overview

Answer 61

reduce or eliminate exposure to irritants, especially cigarette smoking and occupational exposure promote clearance of pulmonary secretions antimicrobial therapy: -primary goal: propmt resolution of symptoms and positively influence the duration of the patient's symptom-free post-treatment period -assess "infection-free perios" when patients off antibiotics - time between infections -infection-free interval significantly longer with FQs, amox/clav, azithromycin*** select antibiotics that are effective against common respiratory pathogens consider drug interactions, compliance assess presence of risk factors: age, severity of illness, over 4 exacerbations/year, cardiac disease, home O2 use, antibiotic use in previous 3 months, recent costicosteroid use

Question 62

acute exacerbations of chronic bronchitis therapeutic options - uncomplicated ***

Answer 62

Criteria or risk factors: age under 65, FEV over 50% predicted, less than 4 exacerbations/year, no comorbid conditions, no risk factors initial treatment options: -2nd generation macrolide (clarith, azith) -2nd or 3rd generation cephalosporin (cefuroxime) -doxycycline -amoxicillin -SMX/TMP

Question 63

acute exacerbations of chronic bronchitis therapeutic options - complicated ***

Answer 63

Criteria or risk factors: age over 65, FEV under 50% predicted, 4+ exacerbations/year, 2+ risk factors initial treatment options: -respiratory FQ (levo (renal adjust), moxifloxacin) -amox/clav

Question 64

acute exacerbations of chronic bronchitis therapeutic options - complicated with risk for infection with P. aeruginosa ***

Answer 64

Criteria or risk factors: severe symtoms, constant purulent sputum, FEV under 35% predicted, 2+ risk factors (esp. prior antibiotics or steroids) Initial treatment options: -FQ with antipseudomonal activity (cipro, levo) -pip/tazo -if hospitalized, emiric IV antibiotics to cover P. aeruginosa

Question 65

pharyngitic - microbial etiology

Answer 65

``` viruses - most common*** streptococcs pyogenes (group A, B hemolytic) - most common bacterial pathogen (10-30% of cases) ```

Question 66

pharyngitis - clinical presentation

Answer 66

sudden onset of sore throat with dysphagia and fever pharyngeal hyperemia and tonsillar swelling (with or wtihout tonsillar exudates) cannot differentiate bacterial vs viral etiology based on clinical symptoms - unless overt viral features are present (rhinorrhea, cough, oral ulcers, hoarseness)

Question 67

pharyngitis - diagnosis

Answer 67

throat culture for GAS (group A strep) - takes 24-48 hours; diagnostic standard in the past rapid antigen detection tests (RADT) -detect GAS antigen -sensitive 70-90% -specific over 95% -positive? treat; negative? do a culture -in children and adolescents, back-up negative RADT with culture -throat culture unnecessary if RADT positive

Question 68

pharyngitis treatment overview

Answer 68

Goals of treatment: resolution of symptoms, limit spread of infection, prevent complications symptomatic care for all patients (including viral): antipyretics, non-Rx lozenges and sprays containing menthol and topical anesthetic for pain relief

Question 69

pharyngitis treatment

Answer 69

Group A strep - - Pen VK 250 mg TID or QID or 500 mg BID for 10 days - drug of choice - need 40% above the MIC; never been resistant - only drug known to prevent rheumatic fever; penicillin resistance has never been reported - amoxicillin 500 mg TID or 875 mg BID for 10 days - second drug of choice - sometimes fails d/t normal flora (so does pen VK) - could also use amox/clav - second generation oral cephalosporins - may be more effective than penicillin; option if penicillin or amox failure - penicillin-allergic patients: 1st gen cephalosporin x 10 days, macrolide (azithromycin 5 days or clarithromycin 10 days; concern for resistance esp. if they fail), clindamycin for 10 days - short course regimens (5 days) may be equally effective - cefdinir, cefpodoxime

Question 70

acute rhinosinusitis

Answer 70

up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness or both

Question 71

viral rhinosinusitis

Answer 71

acute rhinosinusitic caused by or presumed to be caused by a viral pathogen -diagnosed when signs and symptoms of acute rhinosinusitis are present less than 10 days and symptoms are not worsening

Question 72

acute bacterial rhinosinusitis

Answer 72

(ABRS) - acute rhinosinusitis that is caused by, or presumed to be caused by, a bacterial pathogen -diagnosed based on clinical presentation

Question 73

recurrent acute rhinosinusitis

Answer 73

4 or more episodes of ABRS per year without signs and symptoms between episodes

Question 74

chronic rhinosinusitis

Answer 74

presence of 2+ signs and symptoms of rhinosinusitis for 12 weeks or longer and presence of inflammation

Question 75

etiologic agents in ABRS

Answer 75

most cases of acute rhinosinusitis begin when a viral** URI extends into the paranasal sinuses - mucosal inflammation - obstruction of sinus ostia (decreased sinus drainage) - mucosal secretions trapped and local defenses impaired - bacteria from adjacent surfaces proliferate - bacterial infection bacterial pathogens - H. influenzae, Strep pneumo, moraxella catarrhalis

Question 76

major symptoms of acute rhinosinusitis

Answer 76

purulent anterior nasal discharge, purulent of discolored posterior nasal discharge, nasal congestion and obstruction, facial congestion and fullness, facial pain and pressure, hyposmia or anosmia, fever (acute sinusitis only)

Question 77

minor symptoms of acute rhinosinusitis

Answer 77

headache, ear pain, pressure or fullness, halitosis, dental pain, cough, fever, fatigue

Question 78

diagnosis of ABRS

Answer 78

TREAT onset with persistent** symptoms or signs compatible with acute rhinosinusitis, lasting for 10+ days without any evidence of clinical improvement (if on day 10 it is not better or worse, likely bacterial = treat) onset with severe*** symptoms or signs of high fever (39+ degrees C) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of the illness onset with worsening** symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral URI that lasted 5-6 days and was initially improving ("double sickening") sinus radiograph or CT - does not differentiate viral from bacterial rhinosinusitis culture of secretions from nasal cavity - poorly correlates with sinus cultures sinus puncture and culture - definitive diagnosis, not usually performed clinically (painful)

Question 79

treatment of ABRS - initial empiric therapy***

Answer 79

first line: amox/clav 500/125 TID or 875/125 BID second line: -amox/clav 2g/125 BID -doxycycline 100 mg BID; 200 mg QD (otolaryngology guidelines recommend amoxicillin, with or without clavulanate)

Question 80

treatment of ABRS - B-lactam allergy ***

Answer 80

``` no first line second line: -doxycycline 100 mg PO BID; 200 mg QD -levofloxacin 500 mg QD -moxifloxacin 400 mg QD ```

Question 81

treatment of ABRS - risk for antibiotic resistance or failed initial therapy ***

Answer 81

``` no first line second line: -amox/clav 2g/125 BID -levofloxacin 500 mg QD -moxifloxacin 400 mg QD ```

Question 82

treatment of ABRS - severe infection requiring hospitalization ***

Answer 82

``` no first line second line: -amp/sulbactam 1.5-3g IV q6h -levofloxacin 500 mg IV or PO QD -maxifloxacin 400 mg IV or PO QD -ceftriaxone 1-2 g IV q12-24h ```

Question 83

treatment of ABRS - amov/clav

Answer 83

***first-line therapy for children and adults due to increasing prevalence of B-lactamase-producing H. influenzae*** high dose therapy recommended in patients at risk for resistance decreased susceptibilty in S. pneumoniae is USA - monitor patients to ensure effective treatment

Question 84

treatment of ABRS overview

Answer 84

resp FQs (moxi, levo) - second line doxycycline - alt to amox/clav in adults oral 2nd or 3rd gen cephalosporins - not recommended due to high prevalence of PRSP ceftriaxone - decreasing susceptibilty of S. pneumoniae macrolides - option ONLY is pen-allergic patients; high prevalence of resistance in S. pneumoniae SMX/TMP - high resistance in S. pneumoniae duration - adults 5-7 days supportive therapy: ***AVOID topical and oral decongestants and antihistamines