1
Q
Distinguishing b/t viral and bacterial infection?
A
- 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
Q
Sx therapy for rhinitis/sinusitis?
A
- 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
Q
Tx considerations for bacterial infection?
A
- abx needed
- tx initiated empirically
- cultures only for complicated cases, done by ENT
4
Q
Common bacteria that cause sinusitis?
A
strep pneumo H flu pseudomonas staph aureus M cat anaerobic - dental infections
5
Q
Abxs used for acute sinusitis?
A
- 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
Q
Amoxicillin use in acute sinusitis? Adverse reactions?
A
- 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
Q
Augmentin use in acute sinusitis? CI?
Adverse reactions?
A
- 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
Q
Doxy use in acute sinusitis?
Warnings?
A
- 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
Q
Zpack use in acute sinusitis?
adverse rxns?
use in what pop?
A
- 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
Q
Tx for acute sinusitis that is uncomplicated with mild sxs?
A
- 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
Q
80% of pts with viral URI will show what on CT?
A
- will have inflamed sinus mucosa
- look for fluid level
12
Q
Tx decisions for acute sinusitis?
A
- 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
Q
Duration of tx for acute sinusitis?
A
- 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
Q
Chronic sinusitis tx decisions? are abx effective?
A
- 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
Q
When should you refer pt with sinusitis to ENT?
A
- 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
Q
Key to dx otitis media?
A
- pneumoscopy - does TM move
17
Q
Tx for babies and children with otitis media?
A
- tx 0-6 months and admit
- 6 mo - 2 yrs abx no matter what
- once 2 - hold off on abx unless severe
18
Q
How common is AOM?
A
- most frequent dx in kids b/t 1 - 3
- lasts 24-72 hrs
- middle ear effusion
- we are overusing abx on AOM!
19
Q
Sx tx for AOM?
A
- ibuprofen/motrin
- auralgan (combo of benzocaine and glycerin) never use in children under 2
- topical aqueous lidocaine (lignocaine)
20
Q
Deciding to use abx vs. observation in AOM?
A
- 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
Q
Decide on antimicrobial therapy for AOM?
A
based on decision on:
- clinical and microbiologic efficacy
- acceptability
- side effects and toxicity
- convenience of dosing schedule
- cost
22
Q
AOM tx in peds?
A
- 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
Q
AOM tx in peds who are allergic to PCN?
A
- 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
Q
Other AOM tx alternatives?
A
- 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
31
pH and administration of otics?
- otics differ in pH
- drops designed for use are often buffered slightly to acidic pH b/c normal enviro of EAC is acidic, such drops can be extremely painful if they penetrate into middle ear, normal pH of middle ear is neutral
- most oto-topic abx steroid combos are at least somewhat acidic b/c almost impossible to keep either quinolones or aminoglycosided in soln at neutral or basic pH
- acidity of polymyxin, neomycin, and hydrocortisone varies from 3.5-4.5
- cipro and hydrocortisone combos have pH of 4.5-5 as well as tobra and dexamethasone combos
- low pH is an advantage in tx EAC, but this is advantage is lost in middle ear
- within middle ear space potential for low pH solns to cause pain can make them a disadvantage
- use steroids in drops if a lot of inflammation!
32
What is otitis externa? commonly called?
- represents an acute bacterial infection of skin of ear canal, but can be caused by fungal infection
- rarely causes prolonged problems or serious complications, infection is responsible for sig pain and acute morbidity
- occurs during summer months
- swimmers ear
33
PP of OE?
- 2 common initiating events:
1 -moisture trapped in ear canal can cause maceration of skin and provide good breeding ground for bacteria
- this may occur after swimming (esp in contaminated water) or bathing
- also may occur in hot humid weather
2- trauma to ear canal is sig factor - invasion of bacteria into damaged skin
- occurs after attempts at cleaning ear with cotton swab, paper clip
34
Causative agents of OE? signs and sxs?
- pseudomonas
- staph
- enterobacter aerogenes
- proteus mirabilis
- fungi
signs and sxs:
ear pain with movement of pinna, erythematous auditory canal
35
First step in tx of OE?
- clean ear canal
- remove cerumen, desquamated skin, and purulent material from ear canal
- facilitates healing
- enhances penetration of ear drops
36
types of otics used in tx OE -
| cortisporin-otic suspension?
- rx only
- dispensed in soln or suspension
- cortisporin-otic suspension:
polymyxin B sulfate 10000 units
neomycin 3.5 mg
hydrocortisone
- instilled directly into ear canal:
4 gtts to affected ear TID-QID adult
3 gtts TID-QID for peds
- do this for 5-7 days, don't exceed 10 days
37
Cortisporin-otic suspension adverse rxns?
- local rxns
- extended use can lead to resistant infections and thinning or atrophy of skin
- use with caution in pts with perforated TMs b/c of possible ototoxicity from neomycin
susp, soln: 10 ml with dropper
38
What should be considered b/f using cortisporin-otic suspension?
- allergies
- any other ear infection - viral, fungal
- punctured TM (ototoxicity)
- preg (cat C): hasn't been studied in preg women, birth defects in animals
- breastfeeding: no reported problems
39
Cipro HC otic suspension, ciloxan? Adverse effects?
- cipro 0.2%/hydrocortisone 1%
- fluoroquinolone with activity against pseudomonas, strep, MRSA, staph epidermidis, and most gram - organisms but with no activity against anaerobes
- 3 gtts to affected ear BIDx 7 days (adults and peds)
- dont use in kids younger than 1
- adverse effects:
HA, pruritus
- suspension: 10 ml with dropper
40
Before using cipro HC otic suspension what should be considered?
- any allergies
- any other ear infection: viral, fungal
- punctured TM
- preg C
- breastfeeding: not recommended
41
Ciprodex otic suspension? Adverse reactions
| don't use in what age?
```
- cipro 0.3%/dexamethasone .1%
more potent drop
- adverse rxns:
ear discomfort/pain
pruritis
dysgeusia: changes taste
erythema
```
- suspension: 5 ml, 7.5 ml
4 gtts to affected ear BID x 7 days (adults and peds)
- don't use in babies under 6 mo
42
Ofloxin 0.3% soln? amt used?
- floxin otic soln
- 10 gtts to ear qd for 7 days in adults
- 5 gtts to affected ear qd for 7 days for 6m mo-13 yr
- not recommended in less than 6 mo
- soln: 5 ml or 10 ml, dropper bottles
43
What should be considered b/f admin ofloxin 0.3% soln?
- allergies
- any other viral or fungal ear infection
- preg C
- breastfeeding: not recommended
44
Ofloxacin is DOC in what situation?
| adverse reactions?
- when perforated TM can't be ruled out
- SAFE in TM perforation!
- adverse reactions:
pruritus, local reaction, taste changes if TM not intact, dizziness, ear pain
45
Tobradex? amt used? CIs, interactions? Preg? precautions?
- tobramycin and dexamethasone
- actually ophthalmic used off label as otic prep
- adult dose: 5 gtt bid
- ped: 5 gtt bid
- CIs: doc hypersensitivity
- interactions: effects decreased when used concurrently with gentamycin
- preg: cat B
- precautions: shouldn't be used when eardrum perforation is present
46
Acetic acid in aluminum acetate (domeboro) indication? amt to use?
- 2% soln propolylene glycol diacetate
- acidifies ear canal, exerts astringent, bactericidal, and fungicidial effects
- good use as alt to abx soln primarily b/c it isn't assoc with allergic or toxic effects, has no cross reactivity with other meds and is affordable
- 3-5 gtts q 4-8 hrs x 5-7 days (adults and peds older than 3)
- preg B - alt for PG women with OE
- breastfeeding safety unknown
47
Adverse reactions of domeboro (acetic acid in aluminum acetate)?
- burning
- stinging
- irritation
48
Use of 5% aluminum acetate (burow's soln)?
- effective against both bacterial and fungal OE
- buffered mix of aluminum sulfate and acetic acid, available w/o rx in US
- useful in tx and prevention of OE
49
Alcohol vinegar otic mix?
- 50% rubbing alcohol
- 25% white vinegar
- 25% distill water
- adult and pedi dose: 4-6 gtt in affected ear BID/QID
- preg: A
- avoid use when TM perf. or Eustachian tube is present
- useful for prevention of OE and can be used as flushing soln for fungal infections
50
Indications for auralgan (antipyrine and benzocaine)? dosage?
- analgesic-anesthetic - relieve pain, swelling and congestion of some ear infections (OE and AOM)
- cerumen removal adjunct - softens earwax so it can be washed away more easily
- dosage:
adults and children -
-for ear pain caused by infection:
use enough to fill entire ear canal q 1-2 hrs until pain is relieved
- for softening earwax before removal: use enough to fill entire ear canal 3x a day for 2-3 days
51
Allergies, preg for aualgan use?
| SEs?
- allergies:
antipyrine, benzocaine, other local anesthetics
- preg: havent been done, but hasn't reported to cause problems in humans
- SEs:
itching, burning, redness
- if using for earwax removal, ear should be flushed with warm water after using for 2-3 days, this is usually done by provider, or pt is educated on use
52
Debrox (OTC) use? Dose, CIs?
- carbamide peroxide 6.5% otic soln - 15 ml, 30 ml
- indications: cerumen removal
- dose: 5-10 gtts in ear, keep drops in ear for several minutes, use BID for up to 4 days, may irrigate with warm water
- CIs:
perforated TM, ear drainage or d/c, ear pain or irritation, dizziness
53
Pt education on using otics
- wash hands first!
- to avoid contamination be careful not to touch dropper or let it touch ear
- if med has to be refrigerated, hold bottle in hand to warm it up
- if drops are suspension (not soln) shake well for 10 sec b/f using
- if edema is evident and prevents application of drops:
use cotton gauze sat with abx drops, med should be applied to cotton wick as often as possible, after 24-28 hrs cotton can be removed and med applied directly into canal
- impt to keep water away from ear until infection clears (5-7 days) and 4-6 weeks afterward
- wash hair in sink, use shower cap or ear plugs
54
Prevention of otitis externa?
- wear ear plugs when swimming or showering
- drying ear with hair dryer
- avoid removing ear wax mechanically
55
Use of ear wicks?
- helps topical med penetrate a very swollen ear canal
- wick can be commercially prepared from hard sponge material (merocel) or cut from bigger sponge by provider or made from narrow packing gauze
- wick is placed in ear canal (causes brief but sig discomfort) and moistened with topical abx eardrops
- ear wick removed after 2-3 days
56
Tx for mild OE?
- clean ear
| - non abx topical prep containing an acidifying agent and glucocorticoid (acetic acid/hydrocortisone)
57
Tx for mod to severe OE?
- need a prep that contains abx, antiseptic, and glucorticoid (cipro HC, cortisporin)
- also use wick, protect from water, and can use NSAIDs
58
What is vertigo?
- subtype of dizziness in which pt inappropriately experiences perception of motion due to dysfxn of vestibular system (inner ear)
- sx tx until cause is determined
59
Tx of labrynthitis (compazine)? dosing, Adverse rxns?
- prochlorperazine (compazine):
5 and 10 mg tabs, 25 mg supp if vomiting
- indications: severe vomiting, and nausea
- dose: oral 5-10 mg po tid-qid prn nausea
- supp: 25 mg rectally bid prn nausea
- adverse rxns: drowsiness, dizziness, blurred vision, anticholinergic effects, lowered seizure threshold
60
Meclizine (antivert) in tx of labrynthitis?
- indications:
N/V
vertigo of vestibular origin
- dosage: 25-100 mg/day in divided dosages
- adverse rxns:
drowsiness, sedation (take before bed), dry mouth, blurred vision
61
Diazepam use in tx labrynthitis?
- suppres vestibular system
- dose 2-10 mg 2-4x a day prn
- interactions: ETOH, opioids
- adverse rxns:
CNS depression, ataxia, memory impairment
62
Meds for meniere's?
- diuretics (consider if diet doesn't control)
- antiemetics
- anxiolytics
- antihistamines
- scopolamine
- * this pt needs to see ENT
63
Diuretics used for menieres? HCTZ?
- HCTZ: 25 mg qd
CI: sulfonamide allergy
- warnigns: renal or hepatic impairment, gout, DM
- adverse reactions: hypokalemia, hyperglycemia
64
Hydrocholorthiazide and triamterene (maxzide) use for menieres?
- K+ sparing
- 25 mg qd starting dose
- CI: sulfonamide allergy
65
Acetazolamide (diamox) use in menieres?
rarely used
66
Antiemetics used in menieres?
- prochlorperazine (compazine): 5-10 mg po tid-qid
25 mg supp
- meclizine (antivert):
for N/V
dose: 25-100 mg/day in divided doses
adverse rxns: drowsiness, sedation, dry mouth, blurred vision
67
Anxiolytics used in menieres?
- valium/diazepam
- atarax (hydroxyzine) - anticholinergic (antihistamine and mild antianxiolytic)
- 10 and 25 mg tabs, start at 10 mg q 4-6 hrs prn and work up if needed to 25-50 mg q 4-6 hrs
- drowsiness, dry mouth
- interactions: anti anxiety drugs: diazepam, alprazolam
antihypertensives: clonidine, propranolol
68
Meds for allergic rhinitis?
- intranasal glucocortiocids (topical)
-MOA: inhibit allergic inflammation
- considered first line tx:
first gen:
beclomethasone 1 spray PN qd
flunisolide: 1 spray PN BID
budenoside (rhinocort aqua)
second gen:
fluticasone (flonase): 2 sprays PN qd or 1 spray bid
mometasone (nasonex): 2 sprays (100 mcg) PN once daily
- "use": rinse the nose with saline spray if crusting is evidence
69
Adverse effects of topical intranasal glucocorticoids?
| warnings?
- HA
- pharyngitis
- epistaxis (don't shoot at septum)
```
warnings:
adrenal suppression (rare - topical)
delayed wound healing
immunosuppression
risk vs benefit:
smallest dose for shortest duration of time
```
