UPPER RESPIRATORY TRACT INFECTION MOST 5.pdf

UPPER RESPIRATORY TRACT INFECTION a There are three types of otitis media, involving inflammation of the middle ear which include Acute otitis media, Otitis media with effusion, Chronic Otitis media Common infections in children are acute otitis media which happen aft...

UPPER RESPIRATORY TRACT INFECTION a There are three types of otitis media, involving inflammation of the middle ear which include Acute otitis media, Otitis media with effusion, Chronic Otitis media Common infections in children are acute otitis media which happen after the initial viral respiratory illness common cold which is due to the bacterias streptococcus pneumoniae, H.influenzae, and Moraxella Catarhalis This starts with the symptom of an acute ear pain with an acute onset of otalgia/ ear pain One diagnosis is If there is moderate to severe bulging of the tympanic membrane or new onset otorrhea (ear drainage) which it is NOT due to acute otitis external (inflammation/ irritation of external ear canal) Second diagnosis is if there is a mild bulging of the tympanic membrane and onset of ear pain within the last 48 hours or an intense erythema of tympanic membrane. You must differentiate acute otitis media from otitis media with effusion or chronic otitis media because the latter two do Not require antibiotic therapy. High dose of amoxicillin can help overcome penicillin allergy If there is a contraindication or the symptoms do not get solved within 3 days then the patient needs to be switched to another antibiotics You can observe and Not give any antibiotics if the patient is a child who is 6 months and older with non severe unilateral acute otitis media without otorrhea Can also observe and Not give med if the patient is 24 months and older with bilateral acute otitis media without otorrhea For initial observation, you must make joint decision with the parents If the child's symptom declines within 48-72 hrs (2- 3 days), then Must Initiate Antibiotics Antibiotics must be initiated if: - the child is 6 months and older with acute otitis media showing severe symptoms like toxic appearing, persistent ear pain lasting more than 48 hours and temperature of 39 C or higher - The children is 6 months and older with acute otitis media with otorrhea - The children is 6 to 23 months with bilateral acute otitis media - The First Line treatment for otitis media in children is Amoxicillin High dose which is 80-90 MG /KG/DAY ORALLY DIVIDED TWICE DAILY - If certain criteria are present then you would give Amoxicillin Clavulanate which is 90 mg per kg per day with 6.4mg per kg per day orally of clavulanate twice a day - However, if the Child received Amoxicillin in the last 30 days or have concurrent purulent conjunctivitis or have history of recurrent infection unresponsive to Amoxicillin Clavulanate then you would try other Antibiotic besides Amoxicillin - If there is a Non Severe penicillin allergy or second line then you would give either Cefdinir, Cefuroxime, or Cefpodoxime - Cefdinir is 14mg/kg/day in 1-2 doses - Cefuroxime is 30mg/kg/day orally divided into two daily doses - Cefpodoxime is given 10mg/kg/day divided into two daily doses - If the antibiotics above dont work then you give Ceftriaxone which is 50 mg/kg/day Im or IV once daily for 3 days also for second line or non severe penicillin allergy - If there is failure of the antibiotic and no Improvement in symptoms at 48-72 hours then you would give first line Amoxicillin-Clauvanate again which will be 90mg/kg/day orally of amoxicillin plus 6.4mg/kg/day orally of clavulanate divided twice daily - If the child has non severe penicillin allergy you would give ceftriaxone 50mg/kg/ day IM or IV once daily for 3 days Olivia Funk Lecture on Skin and Soft Tissue Infection Abbreviations - BPM, Beat per minute - CMP, Comprehensive Metabolic Panel - CBC, Complete Blood Count - CRP, C- Reactive Protein - CT- Computed Tomography - HR- Heart Rate IV- Intravenous - IVDU- Intravenous Drug User - I&D - Incision & Drainage - MRSA- Methicillin Resistant Staphylococcus Aureus - MSSA- Methicillin Susceptible Staphylococcus Aureus - PK- Pharmacokinetics - SSTI- Skin and Soft Tissue Infection Skin and Soft tissue Infection (SSTI) are categorized based on site, depth, presentations, and clinical setting SSTI caused by initial local trauma Primary - Involve areas of prev healthy skin Monomicrobial Secondary - Involve areas of prev damaged skin Polymicrobial Physical findings of SSTI - Appearance of site: Erthema, Induration, Swelling, Discharge, warmth - There is pain at site - The vitals include Fever, Increased Respiratory rate, Increased Heart Rate Lab Findings of SSTI - CMP, CBC:WBC, CRP, Imaging- CT/MRI shows soft issue, edema, fascial thickening, fluid collection, soft tissue air - Culture and sensitivities - Gram stain - Skin Organism & Pathogen - Normal Skin Flora (Coag Neg Staphlococcus , Cutibacaterium spp. ,Micrococcus spp., Corynebacterium spp. ) - Gram Positive Cocci*** ( Staphylococcus aureus, Streptococcus Pyogenes) - Rare (Enterobacterales, Pseudomonas aeruginosa, Vibrio spp, Clostridiodes spp.) Purulent (abcess or pus present) Nonpurulent - streptococcus coverage Purent - staphylococcus coverage MRSA Risk - Nasal colonization, prior MRSA infection, recent hospitalization, recent IV antibiotics P.aeruginosa Risk: Warm climate, Exposure to water, High local Prevalence There are different types of SSTIs 1) Supeficial - impetigo, furuncle, carbuncle 2) Nonsuperficial - Non-purulent - Erysipelas, Cellulitis, Necrotizing Fascilitis - Purulent - Abscess Impetigo (Superficial) - Presentation of superficial thick golden yellow also known as Honey colored crusts dried discharge - Fluid filled lesions can rupture - Around the mouth but can be anywhere on the skin - Culters are recommended but not required - Covers for S.aureus (MSSA) and Group A Streptococcus - It is preferred topically for 5 days - Oral therapy is used for 7 days if Numerous lesions present also if - MRSA Coverage if suspected or confirmed - Penicillin is preferred if Only Streptococci confirmed Folliculitis Furuncle (Hair follicle in(painful & pus filled) or Carbuncle (severe abscess, boil by staphylococcus bacteria) Furuncle - boil developing in hair follicle, firm tender red nodule with spontaneous drainage Carbuncle - multiple furuncle coalesce , swollen erythematous deep follcular masses - Cover for Staph aureus including MRSA - Treatment include - Furuncle is warm compress - Carbuncle is I & D - Antibiotics to cover MSSA if systemic signs and symptoms - If non-responsive, MRSA Coverage - The duration is 5-7 days - Cephalexein, Dicloxacillin, Clindamycin, (MSSA) - SMX-TMP, Doxycycline these are for MRSA Coverage Non-superficial Infections - Nonpurelent ( Erysipelas, Cellulitis, Necrotizing Fascilitis) - Purulent (Abscess) - Mild has local signs and symptoms of infection - Moderate has systemic signs and symptoms of infection  - Severe is when oral antibiotics have failed & i/d purulent or when systemic signs/symptoms of infections or patient is immunocompromised or there is deeper infections NON-PURULENT INFECTIONS - Erysipelas - Cellulitis - Necrotizing Fascitis Erysipelas - Bright red x-demarcated area - Has Lymphatic involvement Cellulitis - Starts superficially, spreads deeper - May be accompanied with abscess Necrotizing Infection - Rapid spreading causing tissue death - Causes skin discoloration Symptoms of Nonpurulent Infections Include Malaise,fever, chills, local tenderness, pain, erthema CT: Thickening of superficial fascia and skin Blood and wound cultures only if on chemotherapy for malignancy, neutropenia, severe cell mediated immunodeficiency, immersion injuries, severe infections(if able) and animal bites -> Group A Streptoccocus which is S.Pyogenes Treatment depends on if its mild, moderate or severe - Outpatient is mild infection you cover for group A Streptococcus - Inpatient is moderate to severe infection based on systemic therapy - For moderate infection you cover for group A streptococcus - For severe infections there is broad spectrum coverage which includes MRSA + Gram Negative Anareobic coverage - Vancomycin + piperacillin/tazobactam , imipenem, meropenem - The duration of the treatment is 5 days but if there are no improvements you can extend up to 14 days As you can see above the Mild has oral medications which include Penicilin VK, Cephalexin, Dicloxacillin, Clindamycin The moderate has IVs which are IV penicillin, ceftriazone, cefazolin, and clindamycin The severe has MRSA coverage which is Vancomycin with one of the following gram Neg Coverage which include Ivs of Piperacillin-tazobactam, Meropenem, or Imipenem-Cilastatin. - Necrotizing Fasciitis is when there is death of cells due to bacterial infection causing the skin color to become bluish gray color with intense pain causing skin discoloration - There are different types of of Necrotizing Fascitis including Type 1,2,3 - Type 1 includes Polymicrobial which is mixed aerobic anaerobic microbes, monomicrobial - Type 2 group A streptococci - Type 3 Clostridiodies perfringens - First line is surgical intervention for Necrotizing Fascitis  - The duration is 1-2 weeks which is dependent on clinical presentation Emiric therapy general is - Vancomycin / linezolid with Piperacilin/tazobactam - Carbapanem - Ceftriaxone + Metronidazole Targeted therapy - Group A strep : Penicillin +Clindamycin - Vibrio vulnificus : Doxycycline + Ceftazidime - Aermonas Hydrophilia: Doxycycline + Ciprofloxacin - Clostridium spp: Penicillin + Clindamycin - Gas pockets formed on superficial skin and deeper within the skin - Gas Gangrene is really smelly  - Common pathogens are C.perfringens, Group A streptococcus, Bacteroides, Peptostreptococcus, Klebsiell, E.coli - Gas gangrene can be seen on the CT scan - Linezolid and Clindamycin are given to reduce exotoxin release which causes tissue damage due to cytokine release Purulent Infection (Abscess) - Presentation of this skin has Abscess and cyst formation with localized fluid collection - Can be accompanied with pain, fever, malaise - The CT scan is well defined fibrous capsule, fat stranding, abcess - It is recommended to get gram stain and culture from Pus In moderate to severe infections - Polymorphonucleocytes may be present on the gram stain - THINK STAPH AUREUS WHEN PURULENT - - For Mild treatment, it is just Incision and Drainage - For Moderate treatment, it is Incision & Drainage with Oral therapies - For Severe treatment, it is Incision & Drainage with IV Therapies - The duration is 5 to 14 days - For Source Control we do Incision and Drainage which is used in the presence of Abcess. - Antibiotics alone cannot treat purulent infections. - Therefore, invasive surgical procedure with incision is made and then the abcess is drained and irrigated - The imaging is used to detect abscess.  - Here for the moderate there are oral meds (SMX-TMP, Doxycycline, Minocycline, Clindamycin), if confirmed MSSA then (Dicloxacillin and Cephalexein) - For severe there are IVs : empiric or confirmed MRSA include (Vancomycin, Linezolid, Daptomycin, Telavancin, Tedizolid, Ceftaroline)’ - For severe confirmed MSSA include (Naficillin-Oxacillin, Cefazolin, Clindamycin) Other SSTIs Animal Bite wounds - Polymicrobial in nature - Common organisms in nature are Pasturella, Streptococcus, Staphylococcus - Premptive therapy in immunocompromised, advanced liver disease,edema, moderate-severe injuries (esp hand or face) - Covers both aerobic and anerobic bacteria - Give Amoxicillin-Clauvanate , Alternatives are Doxycycline or Moxifloxacin - Metronidazole / Clindamycin + Ciprofloxacin / Levofloxacin/ Cefuroxime - The duration is 3-5 days - Vaccinations include Rabies for Post exposure prophylaxis and Tdap if not received in prev 10 years - Vaccinations - Given for post exposure prophylaxis for rabies - If not exceed in prev 10 years then Tdap Human Bites (Fist Fight) - Commonly clenched fist injuries - Common bacterias are Viridians Streptococci, S.aureus (MSSA), Fusobacterium - Obtain cultures - Give Amoxiciilin Clauvanate, Alternatives are Doxycycline, or Clindamycin + Ciprofloxacin - The iv options are ampicillin-sulbactam, cefoxitin, ertapanem, moxifloxacin Surgical Site Infections - Comes from exogenous source like healthcare providers, environment or instruments - Common pathogens include S.aureus, coagulase neg staphylococcus, enterococci - Cefazolin is used for MSSA Coverage - If risk factors present then you do MRSA Coverage - If the Surgery Involves Axilla, Gastrointestinal tract, Perineum, or Femal Genital tract then give Cephalasporin or Fluoroquinolone + Metronidazole - Cefazolin is used as Surgical Prophylaxis Treatment Considerations - Not all SSTIs require antimicrobial treatment - Source control is crucial if achievable - One source control and clinical stability obtained then consider Iv to PO conversion if applicable - Select emperic antimicrobials based on infection site, risk factors, local susceptibility patterns, history and likely pathogens Overall most causative pathogens are Group A Streptococcus (Non-purulent) and S.Aureus (Purulent)