Therapeutics ID Nelson Flashcard

Common Cold: Treatments

  1. Analgesics (APAP, ASA, IBU, Naproxen)
  2. Antihistamines
  3. Decongestants

Topical (oxymetazoline, xylometazoline)

-short term use only to prevent rebound congestion

Systemic (pseudoephedrine)

-can raise blood pressure

 

4. Other Treatments

-Cromolyn Sodium (duration of cold shortened, symptoms decreased final 3 days)

-interferon nasal spray

-zinc gluconate lozenges

-high dose Vit C

 

Etiology for Rhinosinusitis

  1. Viral
  2. Strep. pneumoniae
  3. H. influenzae
  4. Moraxella catarrhalis

Classification and Duration of Rhinosinusitis

Acute: < 4 weeks

Subacute: 4 – 12 weeks

Chronic: > 12 weeks

Signs and Symptoms of Rhinosinusitis

Common:

 

sinus tenderness, cough, sinus pressure, nasal obstruction, headache, postnasal drainage, discolored nasal discharge, sore throat

 

Possible:

 

halitosis, malaise, fever/chills, maxillary toothache, periorbital swelling

Risk Factors for Rhinosinusitis

  • Allergies
  • GERD
  • Structural abnormalities
  • Immunodeficiency

Differential Diagnosis for Rhinosinusitis

Perennial Rhinitis (seasonal allergies)

Viral sinusitis (7-10 days)

Acute bacterial sinusitis (Sx > 10 days)

High Dose Amoxicillin for Bacterial Rhinosinusitis
90 mg/kg/day, 2 divided doses
Low Dose Amoxicillin for Bacterial Rhinosinusitis
45 mg/kg/day, 2 divided doses
Symptomatic Treatment for Rhinosinusitis

1. Topical and Systemic Decongestants

-relieves nasal congestion

-may not promote sinus drainage

2. Antihistamines

-useful in patients with allergic rhinitis

3. Intranasal Corticosteroids

-provides relief of facial pain and tenderness, turbinate swelling

-not for first sinus infection, but for repeated episodes

Etiologies for Pharyngitis

1. Bacterial (more severe, see PCP)

-Strep. pyogenes (Group A Beta Hemolytic)

-Group C and G Strep.

-Arcanobacterium hemolyticum

-Mycoplasma pneumoniae

-Chlamydia pneumoniae

 

2. Viral (monitor at home)

-Rhinovirus

-Coronavirus

-Adenovirus

-Parainfluenza virus

-HSV

-Influenza

-Coxsackievirus

-Epstein Barr Virus

-CMV

 

Signs and Symptoms of Pharyngitis

  1. Acute onset sore throat
  2. Fever
  3. Tonsilar Exudate
  4. Swollen, tender anterior cervical lymph nodes
  5. Group A Streptococci

-erythematous throat with patches of purulent exudate (white to gray) on tonsils and posterior pharynx

-erythema of uvula and tongue

-fever > 38 degrees C

Diagnosis of Pharyngitis

1. Throat Culture

-swab posterior pharynx and plate

-lengthy (requires 18-24 hrs incubation)

– >90% sensitive and highly specific

 

2. Rapid Antigen Test

-throat swab testing requiring 5 minutes

– 60-90% sensitive and very specific

Pharyngitis Treatment: DOC, alternatives to allergies, and alt. drugs

DOC: PCN

 

PCN allergy type 1: Erythromycin

PCN allergy (non-type 1): 1st gen Cephalosporins

 

Alternatives:

 

Ampicillin/Amoxicillin

1st gen. cephalosporins

Macrolides

Pharyngitis Complications

1. Suppurative

-peritonsilar abscess

-retropharyngeal abscess

-cervical lymphadenitis

-otitis media

-sinusitis

-mastoiditis

 

2. Toxin-Mediated

-scarlet fever

-streptococcal toxic shock-like syndrome

 

3. Non-Suppurative

-rheumatic fever

-acute glomerulonephritis

Definition of Acute Laryngotracheobronchitis

AKA Viral Croup

 

Viral illness that causes inflammation and edema of the tracheal wall, narrowing of the lumen, and restriction of airflow

Etiologies of Acute Laryngotracheobronchitis

  1. Parainfluenza virus
  2. Adenovirus
  3. RSV
  4. Influenza A virus

Signs and Symptoms of Acute Laryngotracheobronchitis

  1. Rhinorrhea
  2. Mild pharyngitis
  3. Cough (sounds like a seal)
  4. Low grade fever
  5. Inspiratory stridor (sounds like dog whining)
  6. Hoarseness

Duration of Acute Laryngotracheobronchitis

Improvement after 1-2 days

Resolution by 3-7 days

Diagnosis of Acute Laryngotracheobronchitis

X-Ray

CT scan

Laryngoscopy

Symptomatic Treatment of Acute Laryngotracheobronchitis

  • Analgesics (APAP, IBU)
  • Adequate hydration
  • Cool mist therapy

Treatment for Severe Airway Narrowing as a result of Acute Laryngotracheobronchitis

  • Nebulized epinephrine
  • Corticosteroids

Dexamethasone 0.6 mg/kg PO/IM x 1 dose (max: 10 mg)

Nebulized Budesonide

Etiologies of Acute Epiglottitis

  • H. influenzae type B
  • B-Hemolytic Strep.
  • S. pneumoniae
  • S. aureus
  • Aerobic G- Bacteria

Signs and Symptoms of Acute Epiglottitis

  • Fever
  • Irritability
  • Sore throat
  • Rapidly progressive stridor with resp. distress

Treatment of Acute Epiglottitis

Endotracheal intubation/Emergency tracheostomy

 

IV antibiotics: cefotaxime, ceftriaxone, or ampicillin/sulbactam

 

Postexposure prophylaxisRifampin for household if:

  •  child < 4 yo
  • child < 12 months and has not received Hib vaccine series
  • immunosuppressed child

Risk Factors for Bronchiolitis

  • Season
  • Age (premature infant)
  • Underlying lung disease
  • Congenital heart disease
  • Immunocompromised
  • Tobacco smoke exposure

Etiology for Bronchiolitis

  • RSV
  • Metapneumovirus
  • Parainfluenza viruses (Type 1, 2, 3)
  • Secondary bacterial infection

 

Signs and Symptoms of Bronchiolitis

  • Irritability/Restlessness
  • Mild fever
  • Cough
  • Rhinitis
  • Vomiting/Diarrhea
  • Abnormal Breathing

-inspiration crackles

-labored with retractions

-tachypnea

-nasal flaring

-grunting

Diagnosis and Duration of Bronchiolitis

Diagnosis

  • Clinical examination
  • Chest X-Ray (to rule out pneumonia)
  • Pulse oximetry (severity of resp. distress)
  • Nasopharyngeal aspirate

Duration

  • Normal/Healthy Child: symptoms improve in 3-4 days but airways may remain sensitive for weeks

Outpatient Management of Bronchiolitis

  • nasal saline with bulb suctioning
  • antipyretics
  • rehydration if needed
  • infection control
  • avoid tobacco smoke exposure
  • education of disease progression

Inpatient Management of Bronchiolitis

Standard Measures:

  • Supplemental O2
  • nasal saline with deep suctioning
  • antipyretics
  • rehydration
  • infection control

Questionable Measures:

  • Bronchodilators (only effective in patients with asthma)
  • Corticosteroids (no proven efficacy)
  • Ribavirin (RSV) – not routinely recommended, questionable efficacy, potential toxic effects for exposed HCP (pregnant nurses), expensive, black box warnings

Bronchiolitis Prevention

Palivizumab

  • Humanized Mouse Monoclonal Antibody
  • Exhibits neutralizing and fusion-inhibitory activity against RSV
  • Only recommended for select infants

Patients that Qualify for Palivizumab Therapy

Patients < 2 yo with:

  • chronic lung disease requiring medical therapy within 6 months of RSV season
  • hemodynamically significant congenital heart disease

Premature Infants:

  • < 1 yo born at < 28 weeks gestation
  • < 6 months of age born at 29-32 weeks of gestation
  • Consider if < 6 months of age born at 32-35 weeks of gestation with risk factors

Otitis Media Pathophysiology

  • Allergy or URI causes congestion and swelling of nasal mucosa, nasopharynx, and eustachian tube
  • Obstruction of eustachian tube isthmus results in accumulation of middle ear secretions
  • Secondary bacterial or viral infection of effusion causes suppuration and features of Acute Otitis Media

Risk Factors for Otitis Media

  • Age
  • Daycare Attendance
  • Environmental Factors
  • More than 1 sibling living at home
  • Pacifier use
  • Previous antibiotic use
  • Previous otitis media
  • Season (winter and fall)
  • Gender (Male > Female)
  • Ethnicity
  • Underlying pathology

Clinical Presentation of Otitis Media

  • Otalgia (denoted by pulling of ear)
  • Irritability
  • Fever
  • Otorrhea
  • Hearing loss
  • URI present
  • Symptoms of URI
  • Nonspecific symptoms

Diagnosis of Acute Otitis Media

All 3 Criteria Must Be Met:

  1. History of acute onset signs and symptoms
  2. Presence of middle ear effusion
  3. Signs and symptoms of middle ear inflammation

Acute Otitis Media Etiology

Bacterial

Strep. pneumoniae

H. influenzae

Moraxella catarrhalis

Group A Strep

Staph. aureus

Anaerobic organisms

G- Enteric bacilli

 

Viral

RSV

Rhinovirus

Adenovirus

Influenza virus

Parainfluenza virus

Enterovirus

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