Student ENT Infections Jan 27 PDF

ENT Infections Pharmacotherapy II: Augsburg PA Program, 2025 Ryane Lester, PA-C, MPAS  Learning Objectives Chapters 89, UpToDate articles posted to Moodle (Summary and Recommendations: “Complications, diagnosis, and treatment of odontogenic infections” and “Un...

ENT Infections Pharmacotherapy II: Augsburg PA Program, 2025 Ryane Lester, PA-C, MPAS  Learning Objectives Chapters 89, UpToDate articles posted to Moodle (Summary and Recommendations: “Complications, diagnosis, and treatment of odontogenic infections” and “Uncomplicated acute sinusitis and rhinosinusitis in adults”) 1. Identify the common pathogens that cause otitis media, otitis externa, bacterial pharyngitis, acute bacterial sinusitis and dental infection. 2. Apply the algorithm for the management of acute otitis media based on age and duration of symptoms to make a treatment decision. 3. Summarize key prescribing considerations for high risk patients presenting with ear infections. 4. Apply the algorithm for the management of acute otitis externa based on severity and duration of symptoms to make a treatment decision. 5. Identify the first and second-line (PCN allergy) treatment for a patient presenting with acute otitis media otitis externa, bacterial pharyngitis, acute bacterial sinusitis and dental infection. 6. Provide patient education and other clinical interventions regarding the prevention and treatment of acute otitis media and otitis externa. 7. Calculate dosages based on body weight for a pediatric patient. For the following representative medications (included on the Unit Representative Medication List), know the medication class, mechanism of action, indications, adverse effects, contraindications, interactions (common), monitoring (if needed), and patient education. Amoxicillin Augmentin Azithromycin Ciprofloxacin  Case A 35-year-old female presents to the ER with 5 day history of sore throat, malaise, sinus congestion, ear pain, headache. She has been taking ibuprofen 600mg every 6hrs as needed for pain. Also c/o associated headache, difficulty swallowing and ear pain. She denies shortness of breath. She thinks its viral and has been putting off coming in until the work week was over. Vitals: Temp: 99.0, HR: 99, BP: 100/52, Resp: 16, O2 98% on room air HEENT: posterior oropharynx with significant erythema, symmetrical swelling of tonsils and uvula, airway remains patent, no trismus, scant tonsillar exudates, no uvular deviation Case Otitis Media  Otitis Media Otitis Media: inflammation of the inner ear Bacterial or viral Even when bacterial, it can often resolve spontaneously – which is why we have guidelines for abx For Acute Otitis Media → inflammation, infection and fluid What other signs and symptoms? Fluid in the inner ear → bulging of the TM, possibly perforation Most often after viral URI Pathogens: Haemophilus influenzae M. cat Strep pneumo*  Otitis Media Diagnosis: What do we need? Three elements Acute onset Middle ear effusion (causes bulging and decreases mobility), or perforation → otorrhea Middle ear inflammation (pain, erythema) Otitis Media Treatment ALL SHOULD GET PAIN RELIEF Antibiotics vs observation Observation: symptomatic relief only for 2-3 days* Do you recall? Important things to consider: Under 6 months get abx regardless of certainty or symptoms  Otitis Media Antibacterial therapy Initial treatment: High dose amoxicillin 40-45mg/kg BID (90mg/kg/day divided BID) PCN allergy (NON type I) → cephalosporin Cefdinir 14 mg/kg/day divided BID PCN allergy (Type I) → cephalosporins should be avoided Azithromycin 10mg/kg day 1, 5 mg/kg/day days 2-5 If you did observations and symptoms persist – start same as you would for initial treatment  Otitis Media What happens if symptoms worsen or persist → antibiotic resistant If non-severe illness → change to amoxicillin plus clavulanate 3.2 mg/kg BID If severe → change to ceftriaxone 50mg/kg IM x 3 days If PCN allergy, change to ceftriaxone IM x 3 days or clindamycin 30-40mg/kg/day divided TID If you had PCN allergy, what were you started with initially? An alternative first line would be right to amox-clavulanate  Otitis Media Treatment of Subsequent OM: Most otic preparations are contraindicated for patients who do not have intact TMs. Goes directly to the source of infection in the middle ear; Decreased systemic absorption = less adverse effects and resistance. Otic preparations approved for AOM with T-tubes: ciprofloxacin/dexamethasone (Ciprodex) ciprofloxacin/fluocinolone acetonide (Otovel)  Otitis Media 3 y.o 35 lbs – no penicillin allergy 4 y.o 46 lbs – pcn allergy, rash 2 y.o 28 lbs - pcn allergy, angioedema Otitis Externa  Otitis Externa Inflammation of the external ear canal Swimmer’s ear Usually due to bacteria Pathogen: MC = Pseudomonas and Staphylococcus aureus S/s: Rapid onset pain Pruritis, some fullness PE: _______ motion tenderness and _________ motion tenderness Edema, erythema of the EAC Discharge  Otitis Externa How do we get the infection: Excessive moisture or abrasion This will facilitate bacterial colonization and growth Tx: Topical abx usually suffice, sometimes oral added for severe Topical: If uncomplicated: Acetic acid 2% and alcohol combo (book says can treat – most always abx) Fluroquinolone: Ciprofloxacin or ciprofloxacin and glucocorticoid combination Three drug combo: hydrocortisone, neomycin, polymyxin B (older) Ear wick  Otitis Externa Pt. education: Keep ear dry as possible, usually heals in 10 days, will have continued pain for a few days Apply drops correctly, warm the drop before administration, wiggle the ear lobe Prevent: don’t put anything in the ear, dry after swimming, avoid earplugs unless swimming  Otitis Externa Oral: THINK HIGH RISK Diabetics, immunocompromised, unable to instill Or if the infection has spread beyond EAC and involves the pinna Ciprofloxacin – adults Cephalexin – children Complications  Otitis Externa Therapeutic Goal: Reduce inflammation, eliminate infection, and prevent complications due to AOM and AOE High-Risk Patients: PCN Allergy- cefdinir, cefuroxime, or cefpodoxime; azithromycin Amoxicillin in last 30 days = amoxicillin/clavulanate >3 episodes of AOM in the past 6 months or 4 episodes in the past year = refer Can’t see TM in OE- avoid ototoxic drops such as aminoglycoside DM or immunocompromise with OE = systemic treatment +/- otic Evaluating Therapeutic Effects: OM & OE should improve in 48-72hrs Minimizing Adverse Effects: Middle ear effusion (MEE) resolution in 27kg = 500mg 2/3 times a cheap day for 10 days o Adults: o Amoxicillin: 50 mg/kg/day orally (can be once daily or 2 divided doses; max o Oral Penicillin V, 500mg BID/TID 1000mg/day) x 10 days o Amoxicillin is also reasonable 500mg orally BID x 10days; 1000mg once daily x 10 days Adults Children & Adolescents Children & Adolescents  Bacterial Pharyngitis What about PCN allergy: If mild allergy → cephalosporins If severe allergy → macrolide (anaphylaxis, severe delayed reaction) Adults: Azithromycin: 12mg/kg/day – max 500m per dose x 3 days* Children: Azithromycin: 12mg/kg/day – max 500mg per dose X 5 days*  Bacterial Pharyngitis 15 y.o with positive strep 120lbs Bacterial Sinusitis  Bacterial Sinusitis (Rhinosinusitis) Inflammation of the nasal cavity and paranasal sinuses Acute = less than 4 weeks Most common is viral Uncomplicated acute bacterial rhinosinusitis is what we are focusing on No extension outside of the sinuses or nasal cavity MUSH less common than viral Bacteria secondarily infect an inflamed sinus Complication of a viral infection Pathogen: Streptococcus pneumoniae, H. influenzae, M. catarrhalis  Bacterial Sinusitis S/s: Nasal congestion, discharge, tooth pain, facial pain/pressure, worse bending over Fever, fatigue, cough, loss of smell, ear pain/pressure IF BACTERIAL = symptoms longer than 10 days Worsening symptoms after an initial improvement PE: Erythema or edema to the periorbital area, tenderness to sinuses or teeth, nasal drainage and PND Diffuse mucosal edema, narrowing meatus, turbinate hypertrophy  Bacterial Sinusitis (Rhinosinusitis) - adults Treatment: Supportive care – part of patient education* Analgesics, saline irrigation, intranasal glucocorticoids, saline spray, decongestants etc. Antibiotics: adults  Bacterial Sinusitis (Rhinosinusitis) - adults Treatment: Antibiotics: Adults Penicillin allergy Bacterial Sinusitis (Rhinosinusitis) - children Treatment: Antibiotics: children, for 10 days Bacterial Sinusitis (Rhinosinusitis) - children Treatment: Antibiotics: children Penicillin allergy  Clinical Decision making If you ever start an initial antibiotic and symptoms are not improving or getting worse – seek other sources, other reasons, consult, change antibiotics, move to high dose  Dental Infections Tooth infection: From what? Why do we worry? How do we prevent – patient education: Oral hygiene, dental visits How: Originate in the tooth or supporting structures → spreads Pulp, periodontal pocket, ,or pericoronitis → facial structures Making the diagnosis: Lots of mouth flora – needle aspiration is best if possible  Dental Infections We want to ensure no red flag symptoms before initiating treatment for dental infection: Trismus, 'hot potato' voice Swallowing difficulty, drooling Restricted tongue mobility, firm or swollen floor of the mouth Truly – they need to see a dentist, even if we initiate treatment, root canal/surgery, etc often indicated Abx → if signs of local or systemic spread of infection Fever, cellulitis, LAD  Dental Infections Abx: recommended for necrotizing periodontal disease, severe gingivitis, periodontitis, suppurative infections Augmentin (amox-clavulanate) Adults: 875 mg every 12 hours or 500 mg every 8 hours (during depends 10-14 days) Children: Augmentin,metronidazole* Metronidazole – first line if PCN allergy Macrolide = second line (clarithromycin), clindamycin They should also get analgesics Specific Drugs  Back to the case What do we want to do?  Amoxicillin A penicillin; beta-lactam abx (who else) Contraindications: What does that mean? Serious hypersensitivity reaction (what would this be) MOI: Interactions: Inhibit the bacterial cell wall synthesis – how? Birth control pills or hormone-based birth control, abx may decrease effectiveness – alters hormone levels Indications: Allopurinol – increase risk of reaction ENT infections (pharyngitis, tonsillitis, AOM Blood thinners – CYP system/flora H. pylori Probenecid – increases abx concentration LRTI (PNA) Acute sinusitis Monitoring: only if prolonged use Skin and soft tissue infections Hx of renal or liver disease UTI Patient education: Adverse effects: Discuss abx in regards to breastfeeding or if pregnant C. difficile Diarrhea, nausea, vomiting Hypersensitivity reactions  Augmentin Amoxicillin and Clavulanate Indications: A beta lactam; PCN Similar activity against g pos and g negative MOI: bacteria Amoxicillin: Inhibit the bacterial cell wall The clavulanic acid extends the coverage to synthesis B lactamase producing bacteria and MSSA Clavulanic acid: binds and inhibits the PNA, acute bacterial rhinosinusitis, UTI, beta-lactamases that inactivate amoxicillin AOM, skin or soft tissue infection → expands the spectrum of activity Adverse effects: B lactamases (enzymes made by Diarrhea, nausea, vomiting bacteria) break the B lactam ring C. difficile Hypersensitivity reaction  Augmentin Contraindications: Monitoring: Only if prolonged therapy Serious hypersensitivity reaction to amoxicillin Hx of liver or renal disease or clavulanic acid or other beta lactams Patient education: Adverse effects: Birth control pills or hormone-based birth C. difficile control, abx may decrease effectiveness Diarrhea, nausea, vomiting Discuss abx in regards to breastfeeding or if pregnant Interactions: Birth control pills or hormone-based birth control, abx may decrease effectiveness – alters hormone levels Allopurinol – increase risk of reaction Blood thinners – CYP system/flora Probenecid – increases abx concentration  Azithromycin Macrolide Indications: Derivative of erythromycin Gram negative, atypical, mycobacterial, and gram positive organisms MOI: CAP Bind to bacterial ribosomes to inhibit protein URTI – AOM, COBD exacerbations, synthesis pharyngitis, sinusitis Skin infections MAC tx and prophylaxis STI  Azithromycin Adverse effects: Interactions: Hepatic effects Meds involved with CYP (P450) 3A enzymes GI side effects, C. difficile Inhibits this system QT prolongation Simvastatin Severe hypersensitivity reaction Anticoagulants – risk of hemorrhage (DOAC) Contraindications: Monitoring: Severe hypersensitivity reaction D/c if hepatotoxicity Hx of hepatic dysfunction Monitor if long term use Patient education: Generally safe in pregnancy, question in 1st trimester Minimally concentrated in breast milk  Ciprofloxacin Fluoroquinolone Adverse effects: Targets mostly gram negative Tendon rupture - Achilles peripheral neuropathy MOI: CNS affects Inhibits DNA replications of the bacterial DNA MG patients – prohibit cell division and replication C. diff QT prolongation Indications: AAA UTI (E. coli, Klebsiella) Some below the diaphragm infections (enteric infections) Topical eye treatment, ear treatment (pseudomonal coverage) Anthrax  Ciprofloxacin Contraindications: Monitoring Generally avoid in pregnancy Only if prolonged – CBC, renal, hepatic Children – MSK toxicity Monitor for adverse reactions Interactions: Patient education: QT prolongation meds: amio, procainamide, Education on common GI side effects sotalol Go over medication Cytochrome: tizanidine, clozapine, Signs of adverse effects theophylline Thank You Questions?