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DELETE THIS TEXT BOX BEFORE USE: Use this slide for the FIRST SLIDE of any module AFTER the first module of your course Theater Training Center for Excellence Remote Duty Medic Antimicrobial Therapy heater raining Center for Excellence
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: Theater Training Center 2
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 Theater Training Center 3
Community Acquired Pneumonia (CAP) PATHOGENESIS Modes of acquisition – Microaspiration – Aerosolized organisms inhaled Contributors – Defect in host mechanisms – Virulence of organism Theater Training Center 4
Community Acquired Pneumonia (CAP) HOST DEFENSES Mechanical factors – Nasal hair – Turbinates – Mucocilliary apparatus – Cough – Airway branching Theater Training Center 5
Community Acquired Pneumonia (CAP) CLINICAL FEATURES • Cough, fever, pleuritic chest pain • Dyspnea, rigors, rales, fatigue • Sputum – Mucopurulent = bacterial – Scant / Watery = atypical pathogen Theater Training Center 6
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 Theater Training Center 7
Community Acquired Pneumonia (CAP) INITIAL TREATMENT PLAN No cardiovascular history 1. Macrolide (first choice) 2. Doxycycline Theater Training Center 8
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) Theater Training Center 9
Community Acquired Pneumonia (CAP) SUPPORTIVE TREATMENT 1. Antipyretics 2. Hydration 3. Antihistamine / Decongestants 4. Mucolytics 5. Steroids 6. Bronchodilators 7. Antitussives Theater Training Center 10
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: Theater Training Center 11
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 Theater Training Center 12
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 Theater Training Center 13
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 Theater Training Center 14
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 Theater Training Center 15
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 Theater Training Center 16
Acute Bacterial Rhinosinusitis (ABRS) INITIAL TREATMENT 1. Amoxicillin / Clavulanic Acid 2. Azithromycin 3. Levofloxacin: if first line TX fails, (top cover) Theater Training Center 17
Acute Bacterial Rhinosinusitis (ABRS) SUPPORTIVE TREATMENT 1. Antipyretics 2. Hydration 3. Decongestants / Antihistamines Theater Training Center 18
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: Theater Training Center 19
Otitis Externa (Swimmer’s ear) Theater Training Center 20
Otitis Externa (Swimmer’s ear) CLINICAL FEATURES • Pain with tragal pressure • Erythema • Pruritis • Hearing impairment Theater Training Center 21
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 Theater Training Center 22
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 Theater Training Center 23
Otitis Externa (Swimmer’s ear) OUTPATIENT TREATMENT cont. . 1. Topical agent – Cortisporin Otic 4 gtts/tid x 10 days – Ciprofloxacin drops 2. Systemic antibiotic – Ciprofloxacin 3. Antifungal agent – Fluconazole Theater Training Center 24
Otitis Externa (? Etiology) Theater Training Center 25
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: Theater Training Center 26
CASE STUDY: 4 Theater Training Center 27
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) Theater Training Center 28
Otitis Media MICROBIOLOGY 1. Streptococcus pneumoniae • Gram Positive Aerobic Cocci 2. H. influenzae • Gram Negative Coccobacilli 3. Moraxella catarrhalis • Gram Negative Coccobacilli Theater Training Center 29
Otitis Media INITIAL TREATMENT (mild cases) 1. Antipyretics / pain control 2. Hydration 3. Antihistamines / Decongestants 4. Observe for changes Theater Training Center 30
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) Theater Training Center 31
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: Theater Training Center 32
Theater Training Center 33
Streptococcal Pharyngitis CLINICAL PREDICTORS • Acute onset • Tonsillar exudate • Tender anterior cervical adenopathy • Absence of cough • History of fever Theater Training Center 34
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 Theater Training Center 35
Streptococcal Pharyngitis INITIAL TREATMENT 1. Amoxicillin / Clavulanic Acid 2. Azithromycin: if PCN allergy 3. Cephalexin • Role may be with recurring infections Theater Training Center 36
Streptococcal Pharyngitis SUPPORTIVE TREATMENT 1. Antipyretics 2. Saline gargles 3. Cepacol lozenges 4. Hydration 5. Other ? Theater Training Center 37
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: Theater Training Center 38
Conjunctivitis Theater Training Center 39
Conjunctivitis CLINICAL FEATURES • Highly contagious • Redness / discharge one or both eyes • Morning crust / eyes stuck shut • Purulent discharge, thick / yellow • Multiple symptoms consider viral Theater Training Center 40
Conjunctivitis MICROBIOLOGY 1. Viral etiology • Adenovirus 2. Staphylococcus aureus • Gram Positive Aerobic Cocci 3. Allergic Conjunctivitis Theater Training Center 41
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 Theater Training Center 42
CASE STUDY: 7 30 year old sexually active female S: Acute onset of dysuria, urgency and frequency O: Temp 37. 1 C, Suprapubic pain / tenderness; UA reveals……. A: P: Theater Training Center 43
Urinary Tract Infection CLINICAL FEATURES Cystitis – Dysuria – Urgency – Frequency – Suprapubic Pain – Suprapubic Tenderness Theater Training Center 44
Urinary Tract Infection CLINICAL FEATURES Pyelonephritis – Fevers – Chills – Flank pain Theater Training Center 45
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 Theater Training Center 46
Urinary Tract Infection CLINICAL FEATURES • Combinations of symptoms very suggestive: • Dysuria and frequency without vaginal discharge or irritation = 90% probability of cystitis Theater Training Center 47
Urinary Tract Infection MICROBIOLOGY 1. E coli 75 -90% 2. Staphylococcus Saprophyticus 5 -15% Theater Training Center 48
Urinary Tract Infection INITIAL TREATMENT 1. Sulphamethoxazole/Trimethoprim DS 2. Ciprofloxacin Theater Training Center 49
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 Theater Training Center 50
Urinary Tract Infection SUPPORTIVE TREATMENT 1. Hydration 2. Phenazopyridine 3. Cranberry Juice Theater Training Center 51
Urinary Tract Infection PREVENTION 1. Regular bladder emptying 2. Abstention 3. Cranberry juice 4. Discontinuation of diaphragm use Theater Training Center 52
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