1. heater raining Center for Excellence Theater Training Center for Excellence Remote Duty Medic Antimicrobial Therapy DELETE THIS TEXT BOX BEFORE USE: Use this slide for the FIRST SLIDE of any module AFTER the first module of your course

2. 2 Theater Training Center CASE STUDY: 1 49 year old male, non-smoker S: 3 day HX cough, fever, pleuritic chest pain, exertional dyspnea O: rales right lower lobe, 39.0, 138/98, 98 regular, 16, 94% room air A: P:

3. 3 Theater Training Center Community Acquired Pneumonia (CAP) EPIDEMIOLOGY –More common in winter months –Influenza and pneumonia the 7 th most common cause of death –The most common cause of death from infectious disease

4. 4 Theater Training Center Community Acquired Pneumonia (CAP) PATHOGENESIS Modes of acquisition –Microaspiration –Aerosolized organisms inhaled Contributors –Defect in host mechanisms –Virulence of organism

5. 5 Theater Training Center Community Acquired Pneumonia (CAP) HOST DEFENSES Mechanical factors –Nasal hair –Turbinates –Mucocilliary apparatus –Cough –Airway branching

6. 6 Theater Training Center Community Acquired Pneumonia (CAP) CLINICAL FEATURES Cough, fever, pleuritic chest pain Dyspnea, rigors, rales, fatigue Sputum –Mucopurulent = bacterial –Scant / Watery = atypical pathogen

7. 7 Theater Training Center Community Acquired Pneumonia (CAP) MICROBIOLOGY 1.Streptococcus pneumoniae 20-60% –Gram Positive Aerobic Cocci 2.Haemophilus influenza –Gram Negative Coccobacilli 3.Mycoplasma pneumoniae –Defective Cell Wall Bacteria

8. 8 Theater Training Center Community Acquired Pneumonia (CAP) INITIAL TREATMENT PLAN No cardiovascular history 1.Macrolide (first choice) 2. Doxycycline

9. 9 Theater Training Center Community Acquired Pneumonia (CAP) INITIAL TREATMENT cont. With preexisting cardiovascular history or other comorbidities 1.Augmentin + Macrolide or Doxycycline 2.Ceftriaxone + Macrolide or Doxycycline 3.Levofloxacin as monotherapy ( top cover )

10. 10 Theater Training Center Community Acquired Pneumonia (CAP) SUPPORTIVE TREATMENT 1.Antipyretics 2.Hydration 3.Antihistamine / Decongestants 4.Mucolytics 5.Steroids 6.Bronchodilators 7.Antitussives

11. 11 Theater Training Center CASE STUDY: 2 27 year old female, non-smoker S: 6 day HX “head cold” with worsening of symptoms + headache O: T: 39.5, Rhinorrhea, purulent nasal secretions, maxillary tooth pain A: P:

12. 12 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) PATHOPHYSIOLOGY A pyogenic complication of a viral URI Estimated that only 0.2 – 2.0 % of all viral URI’s are complicated by ARBS Syndrome: –Viral URI > mucocilliary dysfunction > bacteria from nasopharynx colonize the sinuses = bacterial invasion

13. 13 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) VIRAL URI NATURAL HISTORY Most are well or nearly well at 10 days Question: How do we distinguish bacterial infection from viral URI

14. 14 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) CLINICAL FEATURES Purulent nasal discharge Maxillary tooth or facial pain Maxillary sinus tenderness Fever / Headache Symptoms worsening after 5-7 days

15. 15 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) CLINICAL DIAGNOSIS Best way to diagnose ABRS is: –Sxs of URI not improved in 10 days –Sxs worsen after 5-7 days –Unlikely is Sxs present for < 7 days

16. 16 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) MICROBIOLOGY 1.Streptococcus pneumoniae 30-35% –Gram Positive Aerobic Cocci 2.H. influenzae 15-25% –Gram Negative Coccobacilli 3.Moraxella catarrhalis –Gram Negative Coccobacilli

17. 17 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) INITIAL TREATMENT 1.Amoxicillin / Clavulanic Acid 2.Azithromycin 3.Levofloxacin: if first line TX fails, ( top cover )

18. 18 Theater Training Center Acute Bacterial Rhinosinusitis (ABRS) SUPPORTIVE TREATMENT 1.Antipyretics 2.Hydration 3.Decongestants / Antihistamines

19. 19 Theater Training Center CASE STUDY: 4 25 year old male, labor foreman S: “Muffled” hearing R ear x 4 days O: Swelling, pus in external canal, pain upon tugging of tragus A: P:

20. 20 Theater Training Center Otitis Externa (Swimmer’s ear)

21. 21 Theater Training Center Otitis Externa (Swimmer’s ear) CLINICAL FEATURES Pain with tragal pressure Erythema Pruritis Hearing impairment

22. 22 Theater Training Center Otitis Externa (Swimmer’s ear) MICROBIOLOGY 1.Pseudomonas aeruginosa –Gram Negative Aerobic Bacilli 2.Staphylococcus aureus –Gram Positive Aerobic Cocci 3.Fungal infections 2-10% (Otomycosis) –Candida

23. 23 Theater Training Center Otitis Externa (Swimmer’s ear) INITIAL TREATMENT 1.Thoroughly clean the ear canal 2.Treat inflammation and infection 3.Control pain 4.Consider alternative diagnosis if Abx failure

24. 24 Theater Training Center Otitis Externa (Swimmer’s ear) OUTPATIENT TREATMENT cont.. 1.Topical agent –Cortisporin Otic 4gtts/tid x 10 days –Ciprofloxacin drops 2.Systemic antibiotic –Ciprofloxacin 3.Antifungal agent –Fluconazole

25. 25 Theater Training Center Otitis Externa (? Etiology)

26. 26 Theater Training Center CASE STUDY: 4 31 year old male, S: L ear pain since last night, “couldn’t sleep”; HX of recent URI O: Erythema / swelling and bulging of tympanic membrane A: P:

27. 27 Theater Training Center CASE STUDY: 4

28. 28 Theater Training Center Otitis Media DIAGNOSIS ( all three ) 1.Acute onset of symptoms / typically following a URI 2.Presence of middle ear effusion (bulging TM, air / fluid level, otorrhea) 3.Middle ear inflammation, (distinct erythema of TM, distinct otalgia which interferes with normal activity or sleep)

29. 29 Theater Training Center Otitis Media MICROBIOLOGY 1.Streptococcus pneumoniae Gram Positive Aerobic Cocci 2.H. influenzae Gram Negative Coccobacilli 3.Moraxella catarrhalis Gram Negative Coccobacilli

30. 30 Theater Training Center Otitis Media INITIAL TREATMENT (mild cases) 1.Antipyretics / pain control 2.Hydration 3.Antihistamines / Decongestants 4.Observe for changes

31. 31 Theater Training Center Otitis Media INITIAL TREATMENT ( moderate cases ) Add the following treatment 1.Amoxicillin / Clavulanic Acid 2.Azithromycin: if PCN allergy 3.Levofloxacin: if first line TX fails ( top cover ) 4.Ceftriaxone IM / IV ( severe cases )

32. 32 Theater Training Center CASE STUDY: 5 34 year old male S: “Sore throat x 2 days”; denies coughing / runny nose / tearing O: Temp = 39. C, TM’s unremarkable, throat reveals > A: P:

33. 33 Theater Training Center

34. 34 Theater Training Center Streptococcal Pharyngitis CLINICAL PREDICTORS Acute onset Tonsillar exudate Tender anterior cervical adenopathy Absence of cough History of fever

35. 35 Theater Training Center Streptococcal Pharyngitis MICROBIOLOGY 1.Gp A Streptococcal Pharyngitis –Gram Positive Aerobic Cocci 15% 2.Viral –Rhinovirus, Influenza, Parainfluenza 3.Other ( not to miss ) –Para/retropharyngeal abscess, Diptheria, Ludwig's Angina, Epiglottitis

36. 36 Theater Training Center Streptococcal Pharyngitis INITIAL TREATMENT 1.Amoxicillin / Clavulanic Acid 2.Azithromycin: if PCN allergy 3.Cephalexin Role may be with recurring infections

37. 37 Theater Training Center Streptococcal Pharyngitis SUPPORTIVE TREATMENT 1.Antipyretics 2.Saline gargles 3.Cepacol lozenges 4.Hydration 5.Other ?

38. 38 Theater Training Center CASE STUDY: 6 53 year old male, office worker S: “Itchy, gritty” sensation to L eye with crust in the mornings O: Redness about affected sclera with discharge A: P:

39. 39 Theater Training Center Conjunctivitis

40. 40 Theater Training Center Conjunctivitis CLINICAL FEATURES Highly contagious Redness / discharge one or both eyes Morning crust / eyes stuck shut Purulent discharge, thick / yellow Multiple symptoms consider viral

41. 41 Theater Training Center Conjunctivitis MICROBIOLOGY 1.Viral etiology Adenovirus 2.Staphylococcus aureus Gram Positive Aerobic Cocci 3. Allergic Conjunctivitis

42. 42 Theater Training Center Conjunctivitis OUTPATIENT TREATMENT 1.Erythromycin ointment Half inch ointment qid x 5-7 days 2.Fluoroquinolone drops Ciprolox 1-2 gtts qid x 5-7 days

43. 43 Theater Training Center CASE STUDY: 7 30 year old sexually active female S: Acute onset of dysuria, urgency and frequency O: Temp 37.1C, Suprapubic pain / tenderness; UA reveals……. A: P:

44. 44 Theater Training Center Urinary Tract Infection CLINICAL FEATURES Cystitis –Dysuria –Urgency –Frequency –Suprapubic Pain –Suprapubic Tenderness

45. 45 Theater Training Center Urinary Tract Infection CLINICAL FEATURES Pyelonephritis –Fevers –Chills –Flank pain

46. 46 Theater Training Center Urinary Tract Infection CLINICAL FEATURES Signs and SX not very specific for UTI –Cystitis / Pyelonephritis –Vaginitis - Candida, Trichomonas, Bacterial Vaginosis –STD’s – Herpes, Chlamydia, Gonorrhea

47. 47 Theater Training Center Urinary Tract Infection CLINICAL FEATURES Combinations of symptoms very suggestive: Dysuria and frequency without vaginal discharge or irritation = 90% probability of cystitis

48. 48 Theater Training Center Urinary Tract Infection MICROBIOLOGY 1.E coli 75-90% 2.Staphylococcus Saprophyticus 5-15%

49. 49 Theater Training Center Urinary Tract Infection INITIAL TREATMENT 1.Sulphamethoxazole/Trimethoprim DS 2.Ciprofloxacin

50. 50 Theater Training Center Urinary Tract Infection DURATION of THERAPY TMP/SMX – 3 days –For uncomplicated UTI in otherwise healthy, non-pregnant women TMP/SMX – 7 days –For older women, those with recurrence, immunocompromise Men – Should not receive short course therapy

51. 51 Theater Training Center Urinary Tract Infection SUPPORTIVE TREATMENT 1.Hydration 2.Phenazopyridine 3.Cranberry Juice

52. 52 Theater Training Center Urinary Tract Infection PREVENTION 1.Regular bladder emptying 2.Abstention 3.Cranberry juice 4.Discontinuation of diaphragm use