Antibiotics: When & What to Use - College of Nursing€¦ · Acute Otitis Externa: Diagnosis Symptoms of inflammation of the ear canal Pain (often incapacitating) Itching Fullness

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Antibiotics:When & What to Use

Nancy Bonthius, Pharm.D.Clinical Associate Professor

Stead Family Department of PediatricsUniversity of Iowa Stead Family Children’s Hospital

Author Disclosures

I have nothing to disclose that would create a conflict of interest.

Educational Objectives

Recall the most appropriate antibiotics used to treat the most common types of infections:

Acute Otitis Media Acute Otitis Externa Streptococcal Pharyngitis Acute Bacterial Sinusitis Bacterial Conjunctivitis Pneumonia Urinary Tract Infection Bacterial Gastroenteritis Bacterial Skin & Soft Tissue Infections

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Bacteria by Site of Infection

Why This Is Important

Primary care clinicians treat children with infectious diseases on a daily basis. Viral Bacterial Fungal

With increasing rates of antibiotic resistance, accurate diagnosis & effective treatment is critical. Right Drug Right Dose Right Duration

Acute Otitis Media (AOM)

Most common childhood infectious disease treated with antibiotics in the U.S.

Infection of the middle ear associated with rapid onset of S&S (pain, fever) and concurrent findings of middle ear fluid

Must differentiate from otitis media w/ effusion (OME) Defined as fluid in the middle ear w/o S&S of infection

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Acute Otitis Media:Other Risk Factors

Other Risk Factors: Age Family history of AOM/Siblings Child care outside home Bottle Fed Pacifier use Angle of feeding

Acute Otitis Media:Diagnosis

A definitive or “certain” diagnosis requires 3 findings:

Rapid onset of S&S of middle ear fluid (effusion)

Middle ear effusion must be accompanied with 1 of these: Bulging TM Limited or absent mobility of TM Air-fluid level behind the TM Presence of otorrhea

S&S of middle ear inflammation: Distinct TM erythema &/or otalgia (pain interfering with normal

activity & sleep)

Acute Otitis Media:Pathogens

Multipathogenic Disease Viruses only= 20% Virus + Bacterial= 65% Bacterial only (or no organisms detected)= 15%

Bacterial Pathogens Streptococcus pneumoniae: 25-50%

~8% decrease in overall incidence of AOM since use of heptavalent pneumococcal vaccine (Prevnar)

Haemophilis influenza: 15-30% Moraxella catarrhalis 3-20%

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Acute Otitis Media:Treatments

Treatment Based on Age & Certainty of Diagnosis

Acute Otitis Media:Treatment*

Temp. >39o &/or severe otalgia

At Diagnosis: Treatment initially with antibiotics

Recommended PCN allergy alternative

NO Amoxicillin Non-type (I): Cefdinir,80-90mg/kg/day Cefuroxime,

Cefpodoxime

Type I: Azithromycin,Clarithromycin

YES Amoxicillin-Clavulanate Ceftriaxone, 1 or 3 days90mg/kg/day (amoxicillin),with 6.4mg/kg/day clavulanate

*Antibiotic dose: azithromycin 10 mg/kg PO on day 1, then 5 mg/kg for days 2-5; cefdinir 14 mg/kg/day PO q day or ÷ BID; cefpodoxime 10 mg/kg/day PO q day or ÷ BID; ceftriaxone 50 mg/kg IM; cefuroxime 30 mg/kg/day PO ÷ BID; clarithromycin 15 mg/kg/day PO ÷ BID; clindamycin 30-40 mg/kg/day PO ÷ TID.



Recommended PCN allergy alternative


Cefpodoxime



Clinical Treatment Failure: 48-72h after initial observation


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Clinical Treatment Failure: 48-72h after initial observationRecommended PCN allergy alternative


Cefpodoxime




Chemical Structure: Predict Allergenicity

Acute Otitis Media:Duration of Therapy

10-day Course <6 years of age Any age if moderate to

severe disease

5-7 Day Course >6 years of age if..

Mild disease Do not have ruptured TMs Have not received

antibiotics in the past 30 days

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Acute Otitis Media:Treatment for PE Tubes

Ofloxacin Otic q day or BID Can use optic – less pain

Ciprofloxacin Otic q day or BID Can use optic- less pain

Functional PE Tubes: Use Ear Drops Benefits

Highly active G(+) & G(-) coverage

No systemic side effects

Less frequent dosing Administer 5-7 days Can also be used if

perforated TM

Acute Otitis Media:Complications of PE Tubes

Keep water out of ears!

Molded ear plugs

Head rap to hold plugs

Prevention of PE Tubes Complications

Acute Otitis Media:Complications

Suppurative Complications in Children with AOM Mastoiditis Labyrinthitis Intracranial extension of infection

Meningitis Brain Abscess Septic Thrombophlebitis of the venous sinuses

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Acute Otitis Media:Complications

Chronic suppurative otitis media Presents as a discharge through perforated TM or PE

tubes for >6 weeks despite antibiotics Pseudomonas aeruginosa- most likely cause Gram (-) bacilli- less common Staphylococcus aureus

Acute Otitis Media:Follow-Up

Follow-up is recommended 8-12 weeks after AOM to verify resolution of OME In all kids <2 years old In older kids if language or learning problems Do hearing evaluation when OME lasts >3 months,

especially with hearing loss, speech delay, or learning problems.

Acute Otitis Externa (AOE) Generalized inflammation of the external ear canal

Extremely painful, usually unilateral Cellulitis of canal skin (pinna or TM maybe involved) Sometimes referred to as “swimmer’s ear”

~10% will have AOE during their lifetime. Median age = 9 years of age (Uncommon < age 2)

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Acute Otitis Externa:Barriers & Causes

Cerumen= important barrier to moisture & infection Secreted by local sebaceous & apocrine glands Contain lysozyme Slightly acidic pH- helps inhibit infection (esp. P aeruginosa)

Infection may occur if the ear environment is altered. Prolonged water exposure

swimming most common cause Local trauma or aggressive irrigation Alkaline ear drops Soapy deposits, debris from eczema

Acute Otitis Externa:Pathogens

Most cases are bacterial infections (98%) Pseudomonas aeruginosa: 20-60% Staphylococcus aureus: 10-70% Rarely, Candida species may cause AOE, but it

complicates an underlying bacterial infection.

Acute Otitis Externa:Diagnosis

AOE usually has a rapid onset (within 48 hrs)

Requires complete history & thorough ear exam

Visualization of the TM (difficult due to swelling & material in canal) should be attempted, because treatment will vary.

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Acute Otitis Externa:Diagnosis

Symptoms of inflammation of the ear canal Pain (often incapacitating) Itching Fullness +/- hearing loss or pain

with movement of jaw

Signs of inflammation of the ear canal Tenderness of the tragus,

pinna, or both Diffuse ear canal edema,

erythema, or both +/- otorrhea, lymphadenitis,

TM erythema, or cellulitis of pinna & adjacent skin

Acute Otitis Externa:Differential Diagnosis

Differential Diagnosis Localized furuncle or infected sebaceous gland in ear canal

Chronic or recurrent otorrhea may be 2O to: Foreign object inside canal Infected branchial cleft remnant Benign or malignant tumor (rare)

Malignant (or necrotizing) otitis external Extremely severe, life-threatening- caused by Pseudomonas Immunocompromised & elderly with diabetes- may invade

posterior cranial bone

Acute Otitis Externa:Treatments

Most cases of AOE treated with appropriate topical antibiotics resolve within 5 days. Topical agents come into direct contact with pathogens

at concentrations well above MIC. Minimize resistance & limit side effects If ear canal is very swollen, meds won’t get deep enough

Use an ear wick that permits drug to remain in contact with wall

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Topical antibiotics are highly effective for AOE Neomycin/Polymyxin B/Hydrocortisone drops given QID x

5-7 days Neomycin can cause contact dermatitis Aminoglycoside resistance in S aureus & P aeruginosa Polymyxin is not active against S aureus Generally safe, but aminoglycoside might cause vestibular toxicity Do not use if perforated TM

Ofloxacin or Ciprofloxacin otic drops q day-BID x 5-7 days Both are highly active against G(+) & G(-) Not ototoxic Can be used in perforated TM


Other Treatments for AOE Antiseptic therapy- Might be effective if mild & early

Acetic Acid (w/ or w/o hydrocortisone) or Aluminum Acetate

Oral antibiotics treatment if the following: Concomitant AOM Antibiotics that treat S aureus & P aeruginosa for:

Cellulitis of the pinna or contiguous skin Lymphadenitis

Pain: Acetaminophen 15mg/kg q4-6

(+ ibuprofen 15mg/kg q 8h if needed) No benzocaine ear drops! Duration too short & potentially toxic.

Streptococcal Pharyngitis Tonsillopharyngitis is diagnosed in

~11 million patients/year in the U.S.

In temperate climates, it tends to occur in winter & early spring.

Treatment of Group A β-hemolytic streptococci (GAS) Shortens the clinical course- return to normal activity sooner Can minimize transmission Decreases risk of complications

Rheumatic Fever Post-streptococcal Glomerulonephritis Pediatric autoimmune neuropsychiatric disorders associated with

streptococcus (PANDAS)

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Streptococcal Pharyngitis:Pathogens

Viruses: account for the majority Group A β-hemolytic streptococci

(GAS) 37% of all age kids presenting with

a sore throat have a GAS infection. Primarily a disease seen in 5-15

year olds Relatively uncommon in preschool

children After ~48hrs of antibiotics, change

toothbrush

Other Pharyngitis:Pathogens

Less common causes of bacterial pharyngitis: Arcanobacterium haemolyticum Mycoplasma pneumoniae Chlamydia pneumoniae Neisseria gonorrhoea Groups C & G streptococci

Streptococcal Pharyngitis:Accurate Diagnosis Crucial

Clinical Findings Suggestive of GAS Sudden onset: odynophagia, variable degrees of fever,

& headache (frequently frontal lobe- age dependent) Abdominal pain- N/V/D (esp. in younger kids) Erythema of tonsils & pharynx w/ or w/o exudates Anterior cervical lymphadenitis Beefy-red, swollen uvula Palatal petechiae Scarlatiniform rash

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Streptococcal Pharyngitis:Accurate Diagnosis Crucial

Clinical Findings Suggestive of Viral Pharyngitis Coryza & Cough Hoarseness Conjunctivitis Diarrhea Exudate (possible with adenovirus)

Diagnostic Testing Rapid Antigen Detection Test (RADT)- “Rapid Strep”

Very specific, but sensitivity = 85-95% If negative, do culture ~12% of all kids with NO symptoms carry GAS in throat

Streptococcal Pharyngitis:Treatments

Penicillin V <27 kg: 250mg PO BID-TID x10 days>27 kg: 500mg PO BID-TID x10 days

Amoxicillin 50mg/kg q day (max=1 g) x10 daysBenzathine Pen G <27 kg: 600,000 U IM x1 day

>27 kg: 1,2000,000 U IM x1 dayFor patients allergic to PCN:Cephalexin* 25-50 mg/kg/day PO ÷ TID-QID x10 days

Cefadroxil* 30 mg/kg/day PO ÷ BID x10 daysClindamycin 20 mg/kg/day ÷ TID (max=1.8 g/day) x10 daysAzithromycin 12 mg/kg PO q day (max=500 mg) x5 daysClarithromycin 15 mg/kg/day ÷ BID (max 250 BID) x10days

Do not use these to treat GAS infection: sulfonamides, trimethoprim-sulfamethoxazole, tetracyclines, & fluoroquinolones.*Do not administer in those with immediate (type I) hypersensitivity to a penicillin.

Acute Bacterial Sinusitis (ABS)

~20 million cases of ABS occur yearly in the U.S. & cause substantial clinical & financial burden.

ABS is a bacterial infection of the paranasal sinuses. Almost always preceded by a viral URI 6-13% of viral URIs in kids are

complicated by 2O bacterial sinus infection

Differentiating viral vs. bacterial sinusitis =challenging clinical task Viral infection from common cold =

~95% of all sinusitis

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Acute Bacterial Sinusitis:Sinus Development

Paranasal sinus development is age-dependent Maxillary & ethmoid sinuses- present at birth, but small Sphenoid sinuses- usually fully pneumatized by 5 years Frontal sinuses- development varies, usually teen years

Acute Bacterial Sinusitis:Diagnosis

Acute Bacterial Sinusitis:Diagnosis

Typical Viral URI Findings

Symptoms tend to resolve in 5-10 days Cough Scratchy throat Afebrile (typically) Fever early (sometimes) Headache Myalgias Purulent discharge (possible)

Typical ABS Findings Symptoms persist >10 days

w/o improvement Similar symptoms as viral with

continued nasal congestion+

Anterior or posterior nasal discharge- often purulent

Facial pressure or pain Hyposmia or anosmia Maxillary dental pain Sinus tenderness (older kids) Some w/ ABS get acutely sick

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Acute Bacterial Sinusitis:Pathogens

The middle ear and sinuses are related parts of a single system, so the pathogens are the same.

Most Common Pathogens: Streptococcus pneumoniae (increased PCN resistance) Haemophilis influenza (30-50% produce β-lactamase) Moraxella catarrhalis (55-100% produce β-lactamase)

Less Common Pathogens: Group A β-hemolytic streptococci (GAS) Staphylococcus aureus (including MRSA) & anaerobes

Acute Bacterial Sinusitis:Treatments

Uncomplicated ABS of mild-to-moderate severity in children without risk factors for infection with antibiotic-resistant pathogens:* Amoxicillin 45-90 mg/kg/day PO divided BID Amoxicillin-clavulanate 45-90 mg/kg/day PO (amoxicillin

component) divided BID Amoxicillin-clavulanate 80-90 mg/kg/day PO (amoxicillin)

and 6.4 mg/kg/day (clavulanate) divided BID Cefdinir 14 mg/kg/day given q day or divided BID Cefuroxime 30 mg/kg/day divided BID Cefpodoxime 10 mg/kg/day given q day or BID

*Daycare attendance, antibiotic therapy in the preceding 90 days.


Uncomplicated ABS of moderate severity and/or in children with risk factors for infection with antibiotic-resistant pathogens: Alternative agent: Ceftriaxone 50 mg/kg IM x 1 in children with vomiting†

ABS in kids with type I hypersensitivity to PCNs Clarithromycin 15 mg/kg/day PO divided BID‡ Azithromycin 10 mg/kg PO on day 1, then 5 mg/kg daily

for days 2-5‡ Clindamycin 30-40 mg/kg/day PO divided TID§

†If vomiting has ceased, begin PO, 24 h later. ‡Not standard therapy due to poor efficacy & increasing resistance among S. pneumoniae. §Use as single agent only if S. pneumoniae is identified as a pathogen. May also consider use in combination with Gram-negative coverage (like cefixime 8 mg/kg/day q day or divided BID).

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ABS in kids with non-type I hypersensitivity to PCNs Cefdinir, cefuroxime, or cefpodoxime (in doses above).

Antibiotic management of treatment failure in children with ABS:ii

For children initially receiving amoxicillin, antibiotic should be changed to either high-dose amoxicillin-clavulanate or cefdinir, cefuroxime, or cefpodoxime (in doses above).

For ABS of mild-to-moderate severity who failed to improve with one of these regimens, consider parenteral ceftriaxone

ii Worsening of S&S after 48-72 h of treatment suggests either an ineffective initial antibiotic choice or an alternative diagnosis. Consider sinus imaging &/or aspiration.

Acute Bacterial Sinusitis:Complications

Complications from spreading to adjacent areas. Orbital complications- most common

Frequently arise from ethmoid sinuses Begin as preseptal cellulitis → postseptal cellulitis or orbital abscess Eyelid edema, ↓ extraocular muscle movement, diplopia & vision loss

Osteitis of frontal bone (Pott’s puffy tumor)-most common complication of frontal sinusitis

Intracranial extension → brain abscess, meningitis, or septic cavernous sinus thrombosis

Streptococcus anginosus (milleri) = especially virulent pathogen associated with complications of ABS

Bacterial Conjunctivitis

Inflammation of the conjunctiva is common Account for 1-4% of clinic visits >5 million clinic visits yearly in U.S.

Etiologies include: Bacteria Viruses Trauma (including chemicals) Allergic

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Bacterial Conjunctivitis:Diagnosis

Suggest Bacterial Glued/sticky eyelids Mucoid, purulent discharge Conjunctivitis-otitis syndrome-

H influenzae main cause

Suggest Viral > 6 years old No watery discharge No or mild glued eyes in

morning Presents from April-

November Unilateral

“Red Eye” =main finding in bacterial & viral conjunctivitis

Bacterial Conjunctivitis:Pathogens by Age

Staphylococcus aureus

Chlamydia trachomatis

Neisseria gonorrhoeae

Haemophilusinfluenzae

Streptococcuspneumoniae

MoraxellaCatarrhalis

StaphylococcalSpecies

PseudomonasSpecies

Neisseria gonorrhoeae (in sexually active)

Newborn Toddlers/Children Adolescents/Adults

Bacterial Conjunctivitis:Treatment

Antibiotic Treatment: ↓duration & spread of infection Need rapid bactericidal killing & concentration dependent Broad spectrum to cover G(+) & G (-) Greatest effect if started within 2-5 days of onset

Topical Treatment: Polymycin B combinations Macrolides Aminoglycosides Fluoroquinolones

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Topical Treatment: Polymycin B combinations with:

Neomycin, trimethoprim, bacitracin or erythromycin ointments-widely used

All S pneumoniae & MSSA are resistant to Polymyxin B! ~75% of S pneumoniae is resistant to trimethoprin-

sulfamethoxazole (which also causes localized allergic rxn) Follow pts carefully on these regimens

Macrolide: Erythromycin or Azithromycin ointment Azithromycin resistance rates: S pneumoniae (20%), S aureus

(30%), and H influenzae (76%) Neonatal Chlamydia (Use Oral): Erythromycin

50mg/kg/day PO ÷ QID x10-14 days


Topical Treatment: Aminoglycoside Topicals:

Gentamicin, tobramycin & neomycin

Effective against G(-), but limited G(+) -esp. S aureus (particularly MRSA) & streptococci.

Allergic & toxic reactions (superficial punctate lesions)

Fluoroquinolone Topicals: Provide broad spectrum, are bactericidal, & are well tolerated 2nd Gen: ciprofloxacin, ofloxacin & norfloxacin; 3rd Gen:

levofloxacin 4th Gen: moxifloxacin, gatifloxacin, & besifloxacin- all have activity

against S pneumoniae & H influenzae (but costly)


Topical Treatment: Never use steroids in the eye- ONLY an ophthalmologist

should prescribe! Can cause blindness in the presence of some pathogens

If conjunctivitis continues to progress, refer to ophthalmology.

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Pneumonia

Pneumonia= one of the world’s most common peds infections.

Viral = 95% of infant cases (& most common of all ages) <5 years old: ~40/1,000 >5 years old: ~20/1,000

Pneumonia is sporadic & occurs anytime of the year Peak in winter: RSV & influenza viruses can be

complicated by bacterial superinfections, esp. S aureus (including MRSA)

Complications: ↑ morbidity & mortality

Symptoms/findings of pneumonia are sometimes nonspecific, esp. in infants & young children. Fever & tachypnea = highly sensitive, but lack specificity Retractions & crackles = high specificity, but low sensitivity

High suspicion of bacterial pneumonia: Rapid onset of high fever (>39oC) Cough Tachypnea without a viral prodrome

Pneumonia:Diagnosis

S pneumoniae or H influenzaeoften present acutely with: High fever, chills, tachypnea,

tachycardia, & productive cough Auscultatory finding are localized to specific zones:

Crackles, rhonchi, bronchial breath sounds, dullness & egophony

Viruses, mycoplasma & chlamydiae often present subacutely with: Low-grade fever, nonproductive cough, absent or diffuse

lung sounds (except mycoplasma, which causes wheezing)

Pneumonia:Diagnosis

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Pneumonia:Pathogens by Age

Birth-3 weeks Group B streptococci (S agalactiae) Escherichia coli Listeria monocytogenes

4 months-5 years Streptococcus pneumoniae Lower respiratory tract viruses* Mycoplasma pneumoniae Chlamydia pneumoniae Staphylococcus aureus†

3 weeks-3 months Lower respiratory tract viruses* Chlamydia trachomatis Streptococcus pneumoniae Bordetella pertussis

5 years-15 years Mycoplasma pneumoniae Chlamydia pneumoniae Streptococcus pneumoniae Staphylococcus aureus† Lower respiratory tract viruses*

Pneumonia:Treatment by Age/Pathogen

0-20 days

3 wk-3mo

4 mo-5 yr

>5 yr

Admit

Admit if febrile or hypoxic.If patient is afebrile: azithromycin 10 mg/kg PO on day 1, then 5 mg/kg/day on days 2-5 or erythromycin 30-40mg/kg/day PO in divided doses q 6h

Amoxicillin 90 mg/kg/day PO divided q 8h x 10 days. If penicillin allergy or atypical organism, consider azithromycin, clarithromycin, or erythromycin

Azithromycin 10 mg/kg PO on day 1, then5 mg/kg/day on days 2-5 or clarithromycin15 mg/kg/day PO divided q 12h.For S. pneumoniae infection: amoxicillin alone, 90mg/kg/day PO divided q 8h

Ampicillin IV + gentamicin IV with or without cefotaxime Erythromycin 40 mg/kg/day IV divided q 6h. If patient is febrile, add 1 of these agents: cefotaxime 200 mg/kg/day IV divided q 8h orcefuroxime 150 mg/kg/day IV divided q 8hCefotaxime 150 mg/kg/day IVdivided q 6h or cefuroxime 150 mg/kg/day IV divided q 8h orampicillin alone, 200 mg/kg/day IVdivided q 8h for S. pneumoniaeCefuroxime 150 mg/kg/day IVdivided q 8h + erythromycin 40 mg/ kg/day IV (or PO) divided q 6h. For S. pneumoniae: ampicillin alone, 200 mg/kg/day IV divided q 8h

Age Outpatient Inpatient

Pneumonia:Complications

Treatment courses are 7-14 days.

Persistent fever >48 h after starting antibiotics: Inappropriate antibiotic Complicated pneumonia

Parapneumonic effusion Empyema- should be

admitted (can be deadly)

Empyema presentation: Fever, dyspnea, pleuritic chest pain, pleura rub (before

fluid accumulates), dullness to percussion, tachypnea, rales & ↓ breath sounds

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Urinary Tract Infection

Most peds UTIs are treated as outpatients But, it is one of the most common hospital admission

Prevalence rates vary: Age Gender Race Circumcision status-

circumcision has been shown to protect from UTIs

Highest childhood prevalence Uncircumcized males < 3 mo Females < 12 mo

Urinary Tract Infection:Diagnosis

Clinical presentations of UTI depends on age: Neonate:

poor feeding, jaundice, temperature instability & irritability Infants:

high-grade fever, irritability, N/V Older Ages:

dysuria, urgency, frequency, new onset day or night enuresis Obtain a urine analysis (UA) and culture:

Limitations: UA dipsticks can be false + or false- (bacteria must split nitrite)

+ Culture = Gold Standard Likely UTI if these present:

leukocyte esterase, nitrites on dipstick, or >5 leukocytes per high-powered-field indicating pyuria

Urinary Tract Infection:Diagnosis

Pyelonephritis: abdominal discomfort, N/V, localized back or flank pain usually accompanied with fever, chills, or rigors. Older

In the very young: high index of suspicion is always required for early detection

Predisposing conditions associated with UTIs, (esp. recurrent cases): constipation, voiding dysfunction, hypercalciuria,

vesicoureteral reflux, & sexual activity in adolescent females.

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Urinary Tract Infection:Pathogens

Most common are G(-) that inhabit the GI tract: E coli = most common Others = Klebsiella, Proteus, Pseudomonas, &

Haemophilus species The true incidence of H influenzae & Haemophilus parainfluenzae

UTIs is unknown because they do not grow on standard culture media. They require enriched media for isolation.

Less common are G(+): Enterococcus faecalis & Staphylococcus saprophyticus

Urinary Tract Infection:Pathogens

Predisposing factors in the occurrence of UTIs Previous antibiotic use; prior urological surgery &

instrumentation are well-described risks Causes: P aeruginosa, enterococci,

& Haemophilus species

Decrease risk of recurrent UTIs Ingestion of cranberries/cranberry juice

a recent meta-analysis showed evidence of efficacy in those with recurrent UTIs

Avoidance of “bubble baths” & hot tube use

Urinary Tract Infection:Treatment Based on Age

Management depends on: age, clinical signs & symptoms at presentation

Treatment duration: 5-10 days depending on age/diagnosis/severity

Indications for inpatient: < 1 month of age failed oral therapy need for intravenous rehydration isolated bacteria sensitivity only to IV antibiotics

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Trimethoprim/sulfamethoxazole* 6-10 mg/kg/day PO ÷ BID (Max.= 320 mg trimethoprim dose)

Nitrofurantoin* 5-7 mg/kg/day PO ÷ QID

Cephalexin 25-100 mg/kg/day PO ÷ QID

Ciprofloxacinɸ 20-30 mg/kg/day PO ÷ BID(Max.=1.5 g/day)

Cefixime 8 mg/kg/d PO ÷ BID or q day

Ceftriaxone 50-100 mg/kg/d IM or IV ÷ BID or q day

*Not to used in infants with jaundice or <2 months old.ɸOnly teens and older

Outpatient UTI Treatment

Urinary Tract Infection:Treatment

Trimethoprim/sulfamethoxazole* 1-2 mg/kg/day PO

Nitrofurantoin* 1-2 mg/kg/day PO

Amoxicillin 10mg/kg/day PO

*Not to used in infants with jaundice or <2 months old.

Outpatient UTI Prophylaxis

Urinary Tract Infection:Treatment

Bacterial Skin & Soft Tissue Infections

Bacterial skin & soft tissue infections (SSTIs) are frequent causes of clinic & ER visits. Impetigo Purulent Cellulitis Non-purulent Cellulitis Animal/Human Bites

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Bacterial Skin Infections:Impetigo

Topical Treatment: Appropriate for small, isolated

areas only Best Choice:

Mupirocin (Bactroban) 2% Ointment TID x 8 days

Active against MSSA and MRSA

Second Choice: Retapamulin (Altabax) 1% Ointment BID x 5 days Not approved for MRSA Brand name cost = $88 (15 gm tube)

Bacterial Skin Infections:Impetigo

Oral Treatment: If larger area is involved or if spreading, use oral treatment. Select treatment active against both Strep. & Staph.

aureus!! No amoxicillin (by itself)!! My Choice: Augmentin Other Choices:

1nd and 2nd generation Cephalosporins (no 3rd gen)

If Community-acquired MRSA (CA-MRSA) Oral: TMP-SMX (DS); Tetracyclines, Clindamycin, or

Linezolid

Bacterial Skin/Tissue Infections: Non-purulent Cellulitis

Non-purulent Cellulitis:

Coverage For:

Antibiotics Oral: Amoxicillin/Clavulanate; Cephalexin; Dicloxillin;

Clindamycin; Amoxicillin + TMP-SMX; Doxycycline; Minocycline; Linezolid

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Bacterial Skin/Tissue Infections: Purulent Cellulitis

Purulent Cellulitis:

Coverage For: β-hemolytic streptococci Community-acquired MRSA (CA-MRSA)

Antibiotics Oral: TMP-SMX (DS); Doxycycline; Minocycline;

Clindamycin, or Linezolid

Bacterial Skin/Tissue Infections: Animal/Human Bites

Animal/Human Bites:

Coverage For: Anaerobes

Antibiotics Oral: Amoxicillin/Clavulanate 40-90 mg/kg/day (amoxicillin)

PO ÷ BID x 7-10 days. (Max = 875 mg/125 mg/dose)

Antibiotic Side Effects

Most Common: GI Complaints

Take with food. Avoid fruit and fruit juices while taking

antibiotics if diarrhea is a problem. Cut down on dairy products if diarrhea is a

problem. Take Lactaid enzymes while on antibiotics.

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Antibiotic Side Effects

Most Common: GI Complaints

Follow BRAT diet (bananas, rice, applesauce, toast) if diarrhea is a problem.

Be proactive against diaper rashes (use Desitin).

-Lactams:Adverse Effects

Hypersensitivity – 0.4% to 10 % Mild to severe: rash to anaphylaxis & death Cross-reactivity exists among all penicillins

and even other -lactams (5 to 10%) Desensitization is possible Aztreonam does not display cross-

reactivity with penicillins and can be used in penicillin-allergic patients

Bactrim:Adverse Effects

• Gastrointestinal: Nausea, vomiting, diarrhea• Hematologic

Leukopenia, thrombocytopenia, eosinophilia

Hemolysis (with G-6-PD deficiency) • Dermatologic: ALLERGY: Rash,

urticaria, epidermal necrolysis, Steven’s-Johnson, drug fever

CNS: Headache, seizures, KENICTERUSin neonates

Other: phlebitis

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Macrolides: Adverse Effects

• Gastrointestinal: up to 33 % Nausea, vomiting, diarrhea, dyspepsia Erythro > > clarithro, azithro

• Thrombophelebitis: IV Erythro & Azithro

• QTc prolongation, ventricular arrhythmias

• Other: ototoxicity (high dose erythro in patients with renal insufficiency)

Macrolides:Drug Interactions

• Erythromycin and Clarithromycin are STRONG INHIBITORS of cytochrome p450 system (3A4):

Digoxin SSRIsCarbamazepine Valproic acidBenzodiazepines MethylprednisolonePhenytoin WarfarinErgot alkaloids Azole antifungalsTacrolimus CyclosporineSirolimus Calcium Channel Blockers

Fluoroquinolones:Adverse Effects

• Gastrointestinal: nausea, vomiting, diarrhea• CNS: headache, agitation, insomnia,

dizziness, rarely, hallucinations • Cardiac: prolongation QTc interval

• Assumed to be class effect • Led to withdrawal of grepafloxacin, sparfloxacin

• Articular Damage: cartilage damage, arthralgia• Dysglycemias

• Led to withdrawal of gatifloxacin• Hepatotoxicity

• Led to withdrawal of trovafloxacin

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Fluoroquinolones:Drug Interactions

• Divalent and trivalent cations• Zinc, Iron, Calcium, Aluminum, Magnesium• Antacids, Sucralfate, enteral feeds • Administer doses 2 to 4 hours apart; FQ first

Clindamycin:Adverse Effects

• Gastrointestinal: >10% Nausea, vomiting, diarrhea, dyspepsia Esophagitis Pseudomembranous colitis

Mild to severe diarrhea Requires treatment with metronidazole

• Hepatotoxicity: rare Elevated transaminases

• Allergy: rare

Aminoglycosides:Adverse Effects

• Nephrotoxicity Direct proximal tubular damage –

reversible if caught early Risk factors: High troughs, prolonged

duration of therapy, underlying renal dysfunction, concomitant nephrotoxins

Ototoxicity 8th cranial nerve damage –

irreversible vestibular & auditory toxicity Vestibular: dizziness, vertigo, ataxia Auditory: tinnitus, decreased hearing

Risk factors: same as for nephrotoxicity

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Linezolid: Adverse Effects

• Gastrointestinal: nausea, vomiting, diarrhea (11%)

• Headache: 10%

• Thrombocytopenia: 3 to 10% Overall myelosuppression often with treatment durations

of >2 weeks Therapy should be discontinued and hematologic counts

will return to normal

Linezolid:Drug & Food Interactions

Linezolid is a reversible, nonselective monoamine oxidase inhibitor

Serotonin syndrome possible with concomitant use of: Tyramine rich foods Serotonergic medications (SSRIs, MAOIs)

Foods high in tyramine: Aged, fermented, pickled, smoked

Cheese, pepperoni, soy sauce, red wines, beer, sauerkraut

Serotonin Syndrome

Presence of three or more of the following: Agitation (34%) Abdominal pain (4%) Ataxia/incoordination (40%) Hypertension/hypotension (35%) Diaphoresis (45%) Diarrhea (8%) Hyperpyrexia (45%) Hyperthermia Hyper-reflexia (52%) Mental status change

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Antibiotics: When & What to Use - College of Nursing€¦ · Acute Otitis Externa: Diagnosis Symptoms of inflammation of the ear canal Pain (often incapacitating) Itching Fullness