Download - Let me clear my throat - Swedish
Let me clear my throat: empiric antibiotics in respiratory tract infections
Alexander John Langley, MD MS MPH
Goals of this talk
Overuse of antibiotics is a major issue, as a result many specialist medical groups have developed guidelines over the past 20 years to curb unnecessary empiric antibiotics
Many talks focus on when not to prescribe antibiotics, particularly in the outpatient setting
This talk is aimed at helping providers feel more comfortable in choosing antibiotics in the outpatient setting when data collection and follow up are more difficult than the inpatient setting, but where appropriate treatment may help to avoid expensive ED and inpatient care
Outline
There are many potential topics, we shall cover three outpatient topics
Cough – and the clinical diagnosis of pneumonia
Nasal congestion – and the clinical diagnosis of bacterial sinusitis
Sore throat – and the clinical diagnosis of strept throat
What we will not cover
Special populations – kids, pregnant women, diabetics, immunocompromised, geriatric
Other settings – ED, inpatient, ICU, nursing home
Cough and Pneumonia
Why do we want to treat: dual goals of symptom relief, and preventing serious invasive disease including possible death
Why is it hard to treat: most where a pathogen can be isolated are viral, most commonly rhinovirus. Followed by influenza (not topic of today’s topic), and third is Strep Pneumo – representing 5% of cases (and 37% of bacterial cases)
Making the diagnosis
There are two roles for the MD – does someone have pneumonia and need antibiotics, does someone need hospitalization Diagnosis – Heckerling decision tool on the previous page can help, IDSA
guidelines say diagnosis should include CXR (2 view) as part of standard part of assessment
CURB 65 and CRB 65 – used for triaging – 0 or 1 can be safely managed outpatient, >=3 should be hospitalized
Treatment
Mild with no recent antibiotics – choose a macrolide or doxycycline. 5 day treatment is as effective as longer courses
If recent antibiotics or comorbidities – use a different class than previously used, preferred for either is respiratory fluoroquinolone – either levofloxacin or moxifloxacin
Resistance to azithromycin in mycoplasma varies from 7% in Seattle to 50% in New Jersey
Resistance to azithromycin in Strep Pneumoniae can reach 60% (currently 9% in all Swedish inpatients)
Nasal Congestion and bacterial sinusitis
Why do we treat – mostly symptom relief, although invasive disease can occur
Why is it hard to treat – Cannot initially differentiate from viral processFortunately can usually delay treatment without significant risk of
severe complications
Making the diagnosis
After 10 days of symptoms without improvement the probability of bacterial infection rises to 60%
There is also the concept of double sickening – primary viral infection starts getting better, than a secondary bacterial infection causes distinct worsening of symptoms after this improvement
Diagnosis –IDSA 2 major, or 1 major and 2 minor with symptoms Major - purulent nasal discharge, nasal congestion or obstruction, facial congestion or fullness,
facial pain or pressure, decreased sense of smell, fever
Minor - headache, ear pain, pressure, fullness; halitosis, dental pain; cough, fatigue
Treatment
70% of patients with bacterial rhinosinusitis resolved their infection within 2 weeks without antibiotics. Antibiotics do shorten symptoms – but main benefit is only seen in patients with symptoms persisting beyond 15 days
As a result watchful waiting is recommended for those presenting within 7 days regardless of severity (according to the 2015 AAO-HNS)
Antibiotic choice is amoxicillin or amoxicillin-clavunate (if risk of resistance) for 5-10 days
Intranasal steroids provide modest benefit in combination with antibiotics
Sore throat – group A strep
Why do we treat: primarily to prevent rheumatic heart disease, some mild relief of symptoms
Does not prevent PANDAs or post streptococcal glomerulonephritis
Why its hard to diagnosis– even at it’s most prevalent (in November) it only represents 5-15% of pharyngitis, with mononucleosis a common culprit
Diagnosis
Modified Centor score1 Point for each of the following- Age (ranges from +1 to -1)- tender anterior cervical lymphadenopathy- Tonsillar exudates- Fever- No cough
Get a rapid strep for scores of 3-4Culture no longer recommended routinely in adults,Unless patient is re-presenting after an initial evaluation
Treatment
Penicillin or amoxicillin
If penicillin allergic -> cephalosporins, clindamycin, macrolide
Only 66% of group A strep is sensitive to clindamycin at uw
If there is a recurrence broaden amoxicillin to augmentin, Keflex to Cefdinir. If due to non-compliance than give penicillin G benzathine
Take home points
Antibiotic usage is difficult to determine because of symptomatic overlap with viral infections
Using constellations of symptoms can help you determine patients with reasonably high likelihood of bacterial infections – but getting this likelihood to 100% is difficult or even impossible with even the most robust work up
Delayed treatment in selected patients is an effective way to safely manage a variety of infections while reducing antibiotic use