URGENT CARE ANTIBIOTICS AND ANTIVIRALS

NICHOLEE LANGE, DNP, CNP

DISCLOSURES

• None

URGENT CARE

TOPICS COVERED TODAY:

• HEENT

• Respiratory Tract Infections

• Skin Infections

• GU/GI infections

• STDs

• Viral Infections

ANTIBIOTIC STEWARDSHIP

• At least 30% of antibiotic courses prescribed in the outpatient setting are unnecessary

• Total inappropriate antibiotic use (which includes unnecessary antibiotic use plus inappropriate antibiotic selection, dosing, and duration) is close to 50% of outpatient antibiotics

• Antibiotics cause 1 out of 5 emergency department visits for adverse drug events

• 1 in 3 abx given for children is unnecessary

CDC, 2018: https://www.cdc.gov/antibiotic-use/healthcare

ANTIBIOTIC IMPROVEMENTS

• 14 new classes of antibiotics (approx. 130 different types) were introduced between 1935 and 2003

• In the US, since 1998 only 14 new abx have been approved, but only 2 of which (linezolid and daptomycin) actually had new targets of action

• Solithromycin recently rejected by FDA for CAP- liver toxicity

CHANGING MINDSET

• Adherence to abx stewardship may improve mindset or patients and clinicians

• Decrease adverse drug reactions

• Decrease antimicrobial resistance

SOURCE:FISHER B, HARVEY RP, CHAMPE PC (2007). "CHAPTER 33". LIPPINCOTT'S ILLUSTRATED REVIEWS: MICROBIOLOGY (LIPPINCOTT'S ILLUSTRATED REVIEWS SERIES). HAGERSTWON, MD: LIPPINCOTT WILLIAMS & WILKINS. PP. 367–92. ISBN 978-0-7817-8215-9.

EYE INFECTIONS

Serous Mucoid Mucopurulent Purulent

Viral + - - -

Chlamydial - + + -

Bacterial - - + +

Allergic + + - -

Toxic - + + -

Allergy Symptoms Viral Symptoms Bacterial Symptoms

• Itching

• Tearing

• Redness

• mild eyelid swelling

• Allergy hx

• acutely red eye

• watery discharge,

conjunctival swelling

• In some cases:

photophobia and a

foreign-body

sensation.

• Associated URI

• Burning

• Irritation

• Tearing

• Mucopurulent or

purulent discharge

• Conjunctival swelling

mild eyelid edema

• Less severe, less

rapid in onset, and

progress at a much

slower rate Image from Grant County Health2018 Grant County Health District, Moses Lake, Washingtonhttp://granthealth.org/pink-eye-conjunctivitis/

CONJUNCTIVITIS

• First line empiric therapy: [4x a day for 5-7 days]

• Erythromycin ointment (infants)

• (Tobramycin drops)- adults and peds

• Trimethoprim-polymyxin (polytrim)- adults and peds

• Ofloxacin- preferred in contact wearers

• Ciprofloxacin- preferred in contact wearers

Alternative therapies: include bacitracin ointment, sulfacetamine ointment, bacitracin polymyxin, fluoroquinolone drops, azithromycin drops

CLINICAL PEARLS: OPHTHALMOLOGICAL EMERGENCIES• Red eye, eye pain, vision changes (document Snellen chart)

• Hypopyon

• Globe penetrating FB

• Red swollen lid (most likely unilateral): other signs, such as pain with EOMs, ophthalmoplegia, optic nerve involvement, fever and leukocytosis

• Don’t use steroids on eyes unless you’re certain what you’re treating.

• Topical antihistamines should be used 1st line if questioning inflammatory response

AOM

Medscape articleMuhammad Waseem, MBBS, MS, FAAP, FACEP, FAHA Professor of Emergency Medicine in Clinical Pediatrics, Weill Cornell Medical College; Attending Physician, Departments of Emergency Medicine and Pediatrics, Lincoln Medical and Mental Health Center; Adjunct Professor of Emergency Medicine, Adjunct Professor of Pediatrics, St George's University School of Medicine, Grenada

AOM- TREATMENT GUIDELINES

• <6 months with AOM be treated with antibiotic.

• Infants less than 2 months with a fever need very close monitoring and follow up

• 6mo-2yr with unilateral moderate-severe symptoms or bilateral AOM be treated with an appropriate antibiotic.

• 6mo-2yr with unilateral AOM and mild symptoms (ie, mild ear pain for <48 hours and temperature <102.2°F) may treat or close observation with parent approval

• ≥2 yr who appear toxic, symptoms >48 hours, have temperature in the past 48 hours, have bilateral AOM or otorrhea, may be treated

• ≥2 yr who are immunocompetent (and without craniofacial abnormalities) initial observation may be appropriate if the caretakers understand the risks and benefits

AOM ABX SELECTIONFirst line: ADULTAmoxicillin 500mg BID, TID x 5-10 day- Cephalosporin if PCN Allergy

Second Line: Augmentin 875-125mg BID x 5-14 days (if initially treated with Amoxicillin)cephalosporin or macrolide is reasonable second line)

Third Line for failure or PCN, cephalosporin allergy:macrolide

Failure on 1st and 2nd like with severe symptoms:Ceftriaxone x 3 days or Levaquin

AOM TREATMENT DURATION

• Children: < 2 year, perforation, or recurrent AOM: 10 days.

• Recurrence may require additional 10-14 days duration for second dose

• Children > 2 years, without perforation, or recurrent AOM: 5-7 days

Effusion

• 60% of middle ear effusions resolve by approx. 2-4 weeks, but can take nearly 12 weeks in approx 10% of patients- Doesn’t require additional abx.

SINUSITIS

Treating Sinusitis:

• acute rhinosinusitis lasting for ≥10 days without clinical improvement

• Onset with severe symptoms or signs of high fever (102F) and purulent nasal discharge or facial pain lasting for at least three to four days

• Worsening symptoms or signs for three to four days characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral URI with duration of 3-5 days

SINUSITIS ABX CHOICE

Higher resistance rates of H influenza and Strep pneumonia. However, the percentage of ABRS due to S. pneumonia has decreased while the proportion due to H. influenza has increased. Prevalence of H. influenzae resistance ranging from 27 to 43 percent in the United States

1st choice: Augmentin BID x 5-10 days

• Cephalosporin or Doxycycline if PCN allergy (caution: pregnant women and children)

• 2nd choice: 3rd generation cephalosporin (cefiximine 400mg daily or cefpodoximine 200mg BID) +/- clindamycin 300mg every 6hrs x 5-10 days

• 3rd choice: levaquin 500mg daily x 7 days or moxifloxacin 400mg daily

Macrolides (clarithromycin, Zithromax), Bactrim, or 1st gen cephalosporin are not recommended for empiric therapy due to high resistance rates of Strep pneumonia

SINUSITIS TREATMENT DURATION

• Shorter courses (five to seven days) are reasonable as the available evidence suggests that response rates are similar to longer courses of antibiotics, and longer courses are associated with more adverse events

• Relapse:

• mild symptoms: can use same abx just longer duration.

• Severe symptoms: likely to indicate resistance, and therefore, should use 2nd line abx option.

• Recommendation is not to use systemic glucocorticoids. When given in addition to antibiotics, oral glucocorticoids may minimally shorten the time to symptom resolution or improvement, but increase adverse effects.

• ***Caution using steroids with fluoroquinolones

ABRS PHARMACOLOGICAL SUPPORTIVE CARES

• Analgesia: temporary relief of discomfort

• Oral decongestants: recommended

• are useful for ETD

• Intranasal decongestants: recommended, though generally only improve symptoms and doesn’t improve course of sinusitis (3-5 days max duration)

• Mucolytic: serve to thin secretions and may promote ease of mucus drainage and clearance

• Saline Rinses: irrigation with buffered, physiologic, or hypertonic saline may reduce pain and improve comfort, particularly for those with recurrent sinusitis

CASE STUDY

• 7 yo boy, with dad, for 2 day onset of fevers of up to 101F, abdominal pain, vomiting. Poor appetite, irritable with parents, sleeping more often, but not lethargic. OTC analgesia somewhat improves symptoms, but returns after 4-6 hours. Goes to school, though no known exposures.

• PMH is normal vaginal delivery at gestation, intermittent allergic atopic dermatitis (dad says this is to nickel specifically).

• Surgical hx none.

• Family hx mom and dad healthy, siblings healthy, grandparents with some heart disease, but parents don’t remember which kinds. They’re alive and well otherwise. Aunts and uncles are healthy as far as dad knows.

PH: • VS: HR 115, temp: 100.6F, Resp: 18, O2: 98

• HEENT: normocephalic, atraumatic. Conjunctiva clear, sclera nonicteric, EOMs intact. There is pain without deformity, rhinorrhea noted. Oral mucosa moist and intact, mild erythema to oropharynx, no exudate, no lesions noted, palate rises symmetrically.

• Neck: Supple, trachea midline. Anterior lymphadenopathy noted, no posterior cervical about the or supraclavicular lymphadenopathy noted

• CV: Regular rate and rhythm, no murmurs

• Respiratory: Clear to auscultation, no wheezes or rhonchi noted

• Abdomen: Soft, flat, nondistended, no guarding, +tender to palpation throughout, potentially more tender facial grimaces in right mid-quadrant, BS normoactive, no organomegaly, no CVA tenderness

• Skin: warm, pink, no rashes noted.

LABS:

• CBC: Leukocytosis of 19.6, increase in bands to 16.2, remaining unremarkable

• BMP: Unremarkable

• CRP elevated: 90

• UA: Trace leukocyte esterase otherwise unremarkable

X-RAY ABDOMEN

• Non-obstructive bowel gas pattern, small amount of stool noted in sigmoid otherwise unremarkable (radiology agreed)

ULTRASOUND RIGHT LOWER QUADRANT/APPENDIX

• Unable to visualize appendix region due to bowel gas, no evidence of stranding or peritonitis noted, “but cannot definitively rule out appendicitis”

PLAN

• Several treatment options were discussed with patient and parent. Due to leukocytosis and right abdominal pain I can send him to the ER for further workup of the abdomen, call surgery, or do some watchful waiting over the next 12 hours and follow up tomorrow AM.

• Parents opted for follow up tomorrow

NEW PROVIDER SEE’S PATIENT THE NEXT DAY…

• Patient now has a very fine mildly erythematous rash on the back and abdomen, non-tender, does not hurt or itch, has not spread, no household contacts, no changes in topical products, no exposures

• Labs:

• White blood cell count is up to 17 otherwise remaining labs are stable from the day before, no changes or improvement on exam.

WHAT NEXT?!?!

• Ran a strep…….Positive!

• Rechecked in 48 hours, leukocytosis has resolved, symptoms resolving

PHARYNGITIS• Viral 25-45% of the time: Adenovirus, rhinovirus, and

coronaviruses are among the leading causes of viral pharyngitis, RSV, influenza.

• Epstein Barr virus

• GAS is most common bacteria that causes pharyngitis, though others include: Arcanobacterium haemolyticum, Fusobacteriumnecrophorum, Mycoplasma and Chlamydia species, Corynebacterium diphtheriae

PHARYNGITIS

Figure 1 App: https://app.figure1.com/rd/images/56d3c17a1f34ff617f05c2c6

• Overtreatment of pharyngitis continues to represent a major cause of inappropriate antibiotic use

• Glucocorticoids should be limited to severe pain and/or inability to swallow due to inflammation

Supportive cares:• NSAIDs• Acetaminophen• throat lozenges & throat sprays (benzocaine, lidocaine)• small study used herbal tea containing licorice root, elm inner bark,

marshmallow root, and licorice root aqueous dry extract (Throat Coat), which had higher efficacy than placebo. Honey may also be beneficial

STREP PHARYNGITIS TREATMENT• 1st line: Pen VK, Amoxicillin, penicillin G benzathine (IM)

• Pen VK: 500 BID, TID x 10 days

• Amox: can be 1g daily or 500mg BID x 10days (25mg/kg/day in peds)

• Penicillin g benzathine: 1.2 million units in a single IM dose

• 2nd line or if PCN allergy

• Cephalexin 500mg BID x 10 days (more broad spectrum and covers higher resistance rate of strep)

• Peds: 25 to 50 mg/kg/day divided every 12 hours

• Cefuroximine: 250mg BID x 10days

• Cefdinir 300mg BID x 10days

• Macrolides:

• Zithromax: 5 days

• Clarithromycin 250mg BID x 10 days

ACUTE BRONCHITIS• Antibiotics are not recommended

• Viral Etiology:

• Influenza A and B

• Parainfluenza

• Coronavirus types 1 to 3

• Rhinoviruses

• Respiratory syncytial virus

• Human metapneumovirus

• Bacteria is an uncommon causes of acute bronchitis, accounting for only 6 percent of cases

• Pertussis, c pneumo, m pneumo

ACUTE BRONCHITIS

• Median cough is approx. 18 days (5-21 days)

• +/- purulent sputum

• URI symptoms precede cough

• +/- wheezing and rhonchi on PE

• Bronchial hyperresponsiveness: (post viral cough syndrome) transient, resolving in six weeks, and is believed to be underlying cause of the lingering cough

• +/- chest wall pain and chest tightness with cough

ACUTE BRONCHITIS

• Supportive cares:

• Guaifenesin

• Dextromethorphan

• NSAIDs/acetaminophen

• Nasal congestion treatment (previously discussed)

• Benzonatate (Tessalon) 200mg TID prn.

• Time… may try substitutes to buy patient time

WHEN TO USE ABX IN BRONCHITIS

• Antibiotics recommended in patients

• Unimproved cough after 14 days (differentiate between pneumonia)

• Older than 65 years with acute cough (if they have had a hospitalization in the past year)

• Diabetes mellitus

• Congestive heart failure

• Steroids/immunosuppression

• In patients with acute exacerbations of chronic bronchitis, the use of antibiotics is recommended as it reduces morbidity

ACUTE BRONCHITIS = “CHEST COLD”

• Studies have found using the term “bronchitis” instills a fear or a perceived bacterial infection with high expectations to receive an antibiotic.

• Try changing terms to “chest cold” where expectation is lower

PNEUMONIA

• #1 bacteria: strep pneumonia

• Other microbial to consider:

• Haemophilus influenza

• Moraxella catarrhalis

• Mycoplasma

• Staph aureus

• MRSA

PNEUMONIA TREATMENT

• Complicating factors to consider before ordering abx

• Risk factors for drug-resistant S. pneumoniae in adults include:

• Age >65 years

• Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months

• Alcoholism

• Medical comorbidities

• Immunosuppressive illness or therapy

• Exposure to a child in a daycare center

PNEUMONIA TREATMENT• 1st line: Macrolide (5 day course) OR doxycycline 100mg BID x 7 days

• 1st line pediatrics: amoxicillin 90-100mg/kg/day.

• Augmentin reasonable choice, cefdinir 14 mg/kg/day if PCN allergy, macrolides or fluoroquinolones if severe sx or allergies

• 1st line with comorbidities or hospitalization (non ICU): fluroquinolone (levofloxacin, moxifloxacin, gemifloxin) OR beta lactam (high dose amoxicillin, amoxicillin with clavulanatepotassium; ceftriaxone, cefuroxime, or cefpodoxime PLUS macrolide)

• macrolide over doxycycline because more data shows efficacy of macrolides for uncomplicated CAP

• CA-MRSA: add vancomycin or linezolid

• ICU:

• beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin

• beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone

• penicillin-allergic patients, a respiratory fluoroquinolone PLUS aztreonam

CASE STUDY

• 72 year old lady with a hx of HTN, hyperlipidemia, OA, comes into the office with a 3 day hxof dysuria, frequency, and urgency, odor to urine. Denies any recent UTI in last 3 months. Denies flank pain, fevers, chills, abdominal pain, vaginal symptoms, nausea or vomiting. “states feels like my usual UTIs”

• Meds: Lisinopril 20mg daily, simvastatin 10mg, ASA 81mg daily, vit d and calcium, Tylenol prn for pain

• PE: VSS, afebrile. Heart RRR, lungs CTA, no abdominal pain to palpation and BS normoactive, no CVA tenderness

CASE STUDY

• UA: >50 WBCs, 6-10 RBCs, nitrate positive, leukocyte esterase and WBC clumps

• Best choice Abx for this patient?

• A. fosfomycin 3g single dose

• B. Cipro 250mg BID x 3 days

• C. Macrobid 100mg BID x 5 days

• D. Augmentin BID x 7 days

CASE STUDY

• Answer is C.

• Recently Macrobid has become highly recommended for uncomplicated UTIs in young and old

UTI TREATMENT

• An adult with early onset of 3 cardinal symptoms: dysuria, frequency, urgency, hematuria, in absence of vaginal symptoms, fevers, flank pain, or STD risk; OK to treat for UTI with a normal UA

• Pseudomonas, enterococcus and klebsiella do not show positive with WBCs right away.

UTI TREATMENT

• Adults:

• 1st line

• nitrofurantoin 100mg BID x 5 days

• TMP-SMX DS BID x 3 days

• Fosfomycin 3 g single dose (expensive)- good for poor compliance, facility may accrue cost

• 2nd line: (or drug resistance)

• Augmentin 500mg BID x 5-7 days

• Cefpodoxime 100mg BID x 5-7 days

• Cephalexin 500mg BID x 5-7 days

• 3rd line:

• Cipro 250mg BID x 3 days

• Levoquin 250mg daily x 3 days

PEDIATRIC UTI TREATMENT• Early and aggressive therapy should be initiated within 72 hours from onset to prevent renal

involvement and damage

• 1st line: cephalosporin's or nitrofurantoin (in a nonfebrile patient)

• Nitrofurantoin 7 to <12 kg: 12.5 mg every 6 hours

• 12 to < 22 kg: 25 mg every 6 hours

• 22 to <31 kg: 37.5 mg every 6 hours

• 31 to <42 kg: 50 mg every 6 hours

• ≥42 kg: 50 to 100 mg every 6 hours

• Cefixime 16 mg/kg by mouth on the first day, followed by 8 mg/kg once daily to complete therapy

• Cefdinir 14 mg/kg by mouth once daily

• Cephalexin: 50 to 100 mg/kg per day in three divided doses

• 2nd line: TMP-SMX; increasing resistance rates

• 3rd line: fluoroquinolones

ACUTE VAGINITIS

VAGINITISAlways rule out PID or cervicitis (chandeliers sign)

• BV

• 1st line metronidazole 500mg BID x 7d or clindamycin 300mg BID x 7d

• Clindamycin (vaginal suppository) 100 mg intravaginally once daily for three days or metronidazole 0.75% daily x 5 days (higher recurrence)

• Chlamydia

• Recommendation is still 1 g Zithromax single dose

• Recently some emerging evidence that doxycycline has been more efficacious-

• Doxy 100 mg twice daily for 7 days or 200mg daily x 7

• Ofloxacin and Levaquin high effective- use for 1 week

• Gonorrhea

• 1g Zithromax PLUS 250mg ceftriaxone IM (due to increased resistance rates)

• Doxy is not recommended for uncomplicated gonococcal infections due to N. gonorrhoeae resistance

• Trichomonas

• Treatment consists of metronidazole or tinidazole as a single dose (2 gram, 4 tabs)

HERPES SIMPLEX• Valacyclovir (Valtrex):

• Orolabialis: 2G BID x 1 day

• Genital: initial episode 1g BID x 10 days; recurrence- 500 mg twice daily for 3 days or 1,000 mg once daily for 5 days

• Acyclovir:

• Orolabialis: 200 to 400 mg 5 times daily for 5 days

• Genitalis: Initial episode: 200 mg 5 times daily for 7 to 10 days or 400 mg 3 times daily for 7 to 10 days

• Recurrence: 400 mg 3 times daily for 5 days or 800 mg twice daily for 5 days or 800 mg 3 times daily for 2 days

• Note: Initiate within 1 day of lesion onset or during the preceding prodromal sx

• Famacyclovir:

• Orolabialis: 1,500 mg as a single dose; initiate therapy at first sign

• Gential: 250 mg 3 times daily for 7 to 10 days

HERPES ZOSTER (SHINGLES)

• Patches of linear lesions, “dew drops on rose petals,” unilaterally

• Red Flags:

• Face: watch for ocular involvement, lesion on nose- immediate opthomologyconsult

• Ear: Ramsey Hunt syndrome: ear pain, paralysis, canal, Lesions on: hard palate and/or tongue lesion, tinnitus. Neuropathy of V, IX, X

• Antivirals and steroids

https://jnnp.bmj.com/content/71/2/149

https://www.reviewofophthalmology.com/article/herpes-zoster-virus-vaccinate--treat-early

ANTIVIRAL THERAPY

• Antiviral therapy — The goals of antiviral therapy are to:

• Lessen the severity and duration of pain associated with acute neuritis

• Promote more rapid healing of skin lesions

• Prevent new lesion formation

• Decrease viral shedding to reduce the risk of transmission

• Prevent PHN

• < 72 hr: Start meds

• >72 hours: administer antiviral therapy after 72 hours if new lesions are appearing (indicates ongoing viral replication)

TREATMENT OF ZOSTER

• Acyclovir:

• 800 mg every 4 hours (5 doses per day) for 5 to 7 days

• Valacyclovir:

• 1g TID x 7 days

• Famciclovir

• 500 mg every 8 hours for 7 days

CELLULITIS

• Nonpurulent vs purulent.

• Abscess (surrounding cellulitis?) or multiple abscess

• Fever

• Comorbidities

• Risk factors- MRSA?

ABX THERAPY• Abscess

• I&D

• Cellulitis: 5-10 days duration

• Amoxicillin 500 TID or 875mg BID

• Penicillin 500mg QID

• Cephalexin 500mg QID

• Clindamycin 300mg TID

• Bactrim DS BID

• Erysipelas — Patients with erysipelas should be managed with empiric therapy for infection due to beta-hemolytic streptococci.

• MRSA

• Bactrim DS BID

• Clindamycin 300mg TID

• tetracyclines

• Combo therapies

• “The art of medicine consists of amusing the patient while nature cures the disease.” - Voltaire