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From Flashcardlet > Sinusitis > Flashcards

Sinusitis Flashcards

1
Q

Are URTI’s commonly viral or bacterial?

A

Majority of cases are viral, therefore ABX have not been effective, however viral URTI’s can result in secondary bacterial inf. and then must be treated with antibiotics. What 7 days and if symptoms do not get better, start ABX.

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2
Q

Pt has purulent secretions. should they be given ABX?

A

Purulent secretions in the nares and throat neither predict bact. inf. nor benefit from ABX treatment.

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3
Q

Sinusitis/Rhinosinusitis (ABRS- Acute bacterial rhinosinusitis/AVRS- Acute Viral rhinosinusitis)

A
  1. Symptomatic inflamm. of the nasal cavity and paranasal sinuses for < 4 weeks.
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4
Q

Anatomy of the sinus

A

four air filled cavities.

  1. Frontal
  2. Ethmoid - most common site of sinusitis
  3. Maxillary
  4. Spehnoids
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5
Q

Overview of Sinusitis

A 
blockage from your sinus openings or keeping the cilia from moving efficiently can result in a sinus inf.
-Failure of normal mucus transport
-Decreased sinus ventilation
-Risk Factors:
  colds or upper resp.
  allergies...etc
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6
Q

What do cilia in the sinus do?

A

the cilia move the mucus toward the naturally occurring ostium (hole or orifice to allow proper draining)
-works as immune defense of the URT

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7
Q

Which are the most common bacteria pathogen in sinusitis?

A
  1. Strep. Pneumo. (30-40%)
  2. H. Influenza (20-36%)
  3. Moraxella Catarrhalis (12-20%)

less common:

  • Strep. Pyogenes
  • Staph. Aureus (colonizer in nose. do not give empiric coverage for S. Aureus even though of the colonization within the nose. Do not want to increase resistance)
  • Anaerobic bacteria
    • Peptostreptococcus
    • Bacteroides
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8
Q

Are Fungi common in sinusitis?

A

generally not common in immunocompetant pts.
- are normal flora in upper airways
(Pneumo. Jirovici is a fungi that causes pneumonia in HIV pts)

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9
Q

Acute sinusitis classifications

A

Inf. of the sinus lasts up to 4 weeks

– Manifests as cough, rhinorrhea and or nasal obstruction

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10
Q

Chronic sinusitis classifications

A
  • Progression for 3 months (12 wks)
  • Pts. experiencing 3 or 4 episodes annually or fail to respond to medical therapy
  • Manifests as cough, rhinorrhea and or nasal obstruction
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11
Q

Risk Factors for Sinusitis

A

-Viral URTI
-Age 50
-Nasal dryness (easy solution is saline)
-anatomical abnormalities
deviated septum
nasal polyps
cleft palate
-Dental infections and procedures
-Tobacco use and CF
-Trauma
Nasogastric tube
-Immunocompromised pts

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12
Q

In ABRS, what signs should pt see Doctor for immediately?

A 
Visual changes
-Diplopia (double vision)
-Extraocular movements
Periorbital edema or erythema
Facial swelling
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13
Q

How do you definitively diagnose pt with sinusitis?

A

Aspiration of the sinuses and culture (not routinely done)
- >10^5 organisms/mL

may consider CT or MRI in complicated cases (unknown/unsolvable chronic cases)

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14
Q

What will you see in an ADULT with ABRS?

A
  • Sinus symptoms > 7 days
  • Purulent nasal discharge
  • Maxillary facial or dental pain
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15
Q

difference between sinusitis and allergic rhinitis?

A

Allergic rhinitis is an inflamm. of the mucous membrane in the nose, not the sinusitis

allergic rhinitis is caused by allergies –> runny nose, sneezing, congestion

Poorly controlled chronic or recurring allergic rhinitis can lead to sinusitis.

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16
Q

Sinusitis: What is first line therapy for an ADULT?

A

Amoxicillin/Clavulanate (Augmentin)

875/125 mg Q12

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17
Q

Sinusitis: What is second line therapy for an ADULT?

A 
Augmentin HD (worries about drug resistant sterp. pneumo)
1000/62.5 mg - 2 tab. Q12
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18
Q

Sinusitis: What is third line therapy for an ADULT?

A

Cephalosporins

  • Cefpodoxime
  • Cefuroxime
  • Cefdinir
19
Q

Sinusitis: Therapy if and ADULT has a B-lactam allergy?

A

TMP/SMX
Doxycycline (tetracycline)
Macrolide (don’t want to use erythromycin)

20
Q

Sinusitis:Why don’t you want to use erythromycin for therapy of an ADULT with a B-lactam agent?

A

erythromycin is completely resistant to H. Influenza which is one the common causes of sinusitis. use Clarithromycin or azithromycin instead.

21
Q

Sinusitis: Therapy for an ADULT if ABX resistance or ABX failure?

A

HD Augmentin (1000/62.5 mg 2 tab. Q12)
or respiratory Fluoroquinolones (want to use last to prevent resistance)
-Moxi, Levo, Gemifloxacin

22
Q

Sinusitis: First line therapy for a CHILD?

A

Amoxicillin/ Clavulanate (Augmentin) 875/125 mg Q12

23
Q

Sinusitis: Second line therapy for a CHILD?

A

Augmentin HD 1000/62.5 mg 2 tab. Q12

24
Q

Sinusitis: “Third Line” therapy for a CHILD

A

Cephalosporins

  • Cefpodoxime
  • Cefuroxime
  • Cefdinir
25
Q

Sinusitis:therapy for B-lactam allergy in CHILD?

A

TMP/SMX
Macrolide (not erythromycin)

type 1: Levofloxacin (FQ) -may need to use even though has AE- concerns of cartilage or joint damage
“type 2”: Clindamycin -safe to give to pts with penicillin allergies
PLUS Cefixime or Cefpodoxime
(Don’t want to give Tetracyclines to children- AE’s)

26
Q

Sinusitis:CHILD therapy is ABX resistance or ABX failure

A

Augmentin HD

  1. Cefpodoxime (1,2,3 same as “third line” therapy)
  2. Cefuroxime
  3. Cefdinir
  4. Ceftriaxone
27
Q

When would you give a patient HD ABX right away as opposed to second line?

A

Considerations:

  • Documented resistance and high endemic rates of invasive S. Pneumo. (DRSP)
  • Sever Inf.
  • Fever >102F
  • Suppurative (pus) complications
  • Consistent attendance (daycare)
  • Age 65
  • Recent ABX within 1 month
  • Recent Hospitalization
  • Immunocompromised
28
Q

Sinusitis: Macrolides aren’t preferred for therapy because?

A

Macrolides are not preferred due to high rates of DRSP

-can be used in uncomplicated cases

29
Q

Sinusitis:TMP/SMX is not preferred for therapy because?

A

TMP/SMX is not recommended due to high rate of DRSP and H. Influenza.
-can be used in uncomplicated cases

30
Q

Sinusitis: Monotherapy of 2nd or 3rd gen. cehalosporins are…

A

not recommended due to variable rates of resistant S. Pneumo.

  • Combo therapy is recommended
  • can be used in uncomplicated cases
31
Q

Sinusitis:what is the recommended duration of therapy for ADULTS with uncomplicated ABRS?

A

5-7 days (ADULTS)

32
Q

Sinusitis: What is the rec. duration of therapy for CHILDREN with uncomplicated ABRS?

A

10-14 days

may predispose to SE and issues in adults, but want to give longer therapy to children

33
Q

What is antibiotic failure?

A

If patient has persistent or worsening symptoms 72 hours after initiating therapy

34
Q

Sinusitis: What non-pharmacological therapy are available?

A

Nasal Topical Decongestants

  • Phenylephrine, Oxymetazoline
  • 3 days max to prevent rebound -Currently only in severe cases

Oral Decongestants

  • Pseudoephedrine (avoid in CV disease) -currently in severe cases
  • Intranasal corticosteroids - primarily in patients with allergic rhinitis

Saline

Antihistamines should NOT be used in acute sinusitis–> can dry mucosa and disturb clearance of mucosal secretions

35
Q

Sinusitis: General Recommendations

A
  • Get plenty of rest. Try lying on the side that is least congested
    • laying down increases nasal congestion
  • Drink hot liquids and plenty of fluids
  • Apply moist heat by holding a hot, wet towel against your face or breathe in steam
  • Vaporizer or steam from boiling water
  • Humidifers (de-humidify the air) should be used when a clean filter is in place to prevent bacteria and fungal spores into the air.
  • Consult before using OTC cold remedies
36
Q

Sinusitis: How many days into ABX therapy should the pt see improvement?

A

Should see improvement after 3-5 days, if so continue therapy until completion.
If symptoms do not improve after 3-5 days consider broader coverage/switch ABX

37
Q

How many organisms does it take to definitively say that the pt has ABRS?

A

> 10^5 bacteria via aspiration of sinuses

38
Q

How many days into showing symptoms should a pt be given antibiotics because of suspected bacterial infection?

A

7 days

39
Q

Should antihistamines be given as therapy for sinusitis?

A

No, because antihistamines may dry out the mucosa making it difficult to drain and clear the sinuses

40
Q

If patient is hospitalized what is appropriate therapy in ADULTS?

A

-Amopxicillin/clavulanate (oral)
-FQs
-Ceftriaxone (3rd gen.)
most commonly used because is eliminated 1/2 kidney 1/2 liver –> doesn’t need renal adjustment. NOT used in infants because it may cause biliary sludging (Kernicterous)
-Cefotaxime (3rd gen.)
“Gotta pay the extra TAX for H.influenza coverage”

41
Q

When hospitalized, what is appropriate therapy for a CHILD with sinusitis ?

A
  • Ampicillin/sulbactam (IV only)
  • Levofloxacin (very broad spectrum +/-)

same as adult therapy…
- Ceftriaxone (3rd gen.)
most commonly used because is eliminated 1/2 kidney 1/2 liver –> doesn’t need renal adjustment. NOT used in infants because it may cause biliary sludging (Kernicterous)
- Cefotaxime (3rd gen.)
“Gotta pay the extra TAX for H.influenza coverage”

42
Q

When bacterial inf. are likely, what is the DOC for Sinusitis?

A

Amoxicillin (Amox/clauv - Augementin)

43
Q

What OTC nasal products do you recommend to a pt with severe Sinusitis?

A

Nasal Topical Decongestants
: -Phenylephrine, Oxymetazoline
-3 days MAX to prevent rebound
-Currently only in severe cases

Oral Decongestants
- Pseudoephedrine (avoid in CV disease) -currently in severe cases

Saline

44
Q

pt is severely congested and asks for a recommendation for an OTC product to help.
-Pt has Sinusitis and CV problems

A

can recommend Saline

Nasal Topical Decongestants
: -Phenylephrine, Oxymetazoline
-3 days MAX to prevent rebound
-Currently only in severe cases

cannot rec. Pseudoephedrine - may exacerbate CV disease

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