Nonpharmacologic Management Essay Examples

Nonpharmacologic Management Essay Examples

Nonpharmacologic Management Essay Examples
Know presentation, DX and Management
Diagnoses List
 

Acute bronchitis-

DESCRIPTION
Acute cough due to inflammation of the bronchioles, bronchi, and trachea; usually follows an upper respiratory infection or exposure to a chemical irritant.
ETIOLOGY

Adenovirus
Rhinovirus
Influenza A and B
Parainfluenza

RISK FACTORS

Upper respiratory infection
Air pollutants
Smoking and/or secondary exposure
Reflux esophagitis
Allergy
Chronic obstructive pulmonary disease
Acute and chronic sinusitis
Infants
Older adults
Immunosuppression

ASSESSMENT FINDINGS

Cough: dry and nonproductive, then productive; may be purulent
URI symptoms
Fatigue
Fever due to bacterial infection; more common in smokers and patients with COPD
Fever due to viral cause (unusual after first few days)
Burning sensation in chest
Crackles, wheezes
Chest wall pain
Nonpharmacologic Management Essay Examples

DIFFERENTIAL DIAGNOSIS

Pneumonia
Tuberculosis
Asthma

DIAGNOSTIC STUDIES

Decision criteria for chest radiographs: tachypnea, hypoxia, fever, abnormal lung exam
Only consider chest X-ray if high index of suspicion for pneumonia or superimposed heart failure
Consider PPD: expect negative results
PREVENTION

Smoking cessation
Avoid known respiratory irritants
Treat underlying conditions that contribute to risk (asthma, gastroesophageal reflux disease, etc.)
Influenza immunization for high-risk populations

NONPHARMACOLOGIC MANAGEMENT

Increase fluid intake
Use humidifier
Rest
Smoking cessation
Consider honey in children older than 1 year
Patient education about disease, treatment, expected cause of cough, and emergency actions

PHARMACOLOGIC MANAGEMENT

Cough suppressants for nighttime relief
Avoid antihistamines
Antibiotics if organism is bacterial
Antivirals if influenza diagnosed
Decongestants and antihistamines are ineffective unless sinusitis or allergy is underlying
Bronchodilators if wheezing or prior history of asthma

Although antibiotics are commonly prescribed, they are NOT recommended.

ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT

Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments

Cough Suppressants
Suppress cough in the medullary center of the brain
dextromethorphan/guaifenesin
Adult: 10 mL q 4 hr
Max: 4 doses in 24 hours
Children 6-12 years: 5 mL q 4-6 hr;
Max: 4 doses in 24 hr
Children <6 years: not recommended Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug interaction with some SSRIs Avoid in patients who are having difficulty clearing secretions Robitussin DM various generics Dextromethorphan 10 mg/5 mL  Guaifenesin 100 mg/5 mL dextromethorphan Adult and ≥12 years: 10 mL q 6-8 hr prn for cough Max: 4 doses in 24 hr Children 6-12 years: 5 mL every 6-8 hr prn for cough Max: 4 doses in 24 hr 4-6 years: 2.5 mL every 6-8 hr prn for cough Max: 4 doses in 24 hr Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug intervention with some SSRIs Avoid in patients who are having difficulty clearing secretions Do not use if on a sodium restricted diet Delsym Dextromethorphan 15 mg/5 mL (alcohol free/orange or grape flavor) Adult: 10 mL q 12 hr Children 6-12 years: 5 mL q 12 hr Children 4-6 years: 2.5 mL q 12 hr codeine/guaifenesin Adults and children ≥ 12 years: 10 mL q 4 hr prn cough Max: 6 doses in 24 hrChildren 6-12 years: 5 mL q 4 hr prn cough Max: 6 doses in 24 hr Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug interaction with some SSRIs Schedule V medication Avoid in patients who are having difficulty clearing secretions Avoid narcotic cough suppressants in patient with COPD or asthma May be habit forming May aggravate constipation Robitussin AC Each 5 mL contains  100 mg guaifenesin and  10 mg codeine Antitussives Topical anesthetic effect on the respiratory stretch receptors benzonatate Adults and children > 10 years:
100-200 mg TID prn cough
Max: 600 mg daily

Do not break or chew capsule – can produce local anesthesia and may reduce patient’s gag reflex
Monitor for dizziness, drowsiness and visual changes
Begins to act in 15-20 minutes and lasts for 3-8 hours
Avoid use in patients sensitive to or taking agents with PABA – possible adverse CNS effects

Tessalon
Caps: 100 mg, 200 mg

Expectorants
guaifenesin
Adult: 200-400 mg PO q 4 hr prn
Max: 2400 mg/day
Children 2-5 years: 50-100 mg. PO q 4 hr prn
Max: 600mg/ day
Children 6-11 years: 100-200 mg PO q 4 hr prn
Max: 1200 mg/day
Children ≥12 years: 200-400 mg PO q 4 hr prn;
Max: 2400 mg/day.

Caution if nephrolithiasis
Caution in patients under 6 years
Take with plenty of water; do not cut/crush/chew ER tab

Short-Acting Bronchodilators
albuterol
Inhalation:
Adult Dose: metered-dose inhaler (MDI) or dry powder inhaler (90 mcg/actuation): 2 inhalations q 4 to 6 hr as needed
Metered-dose inhaler (100 mcg/actuation):
Acute treatment: 1 to 2 inhalations; additional inhalations may be necessary if inadequate relief however patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment
Maintenance (in combination with corticosteroid therapy): 1 to 2 inhalations TID-QID
Max: 8 inhalations daily
Dry powder inhaler (200 mcg/inhalation):
Acute treatment: 1 inhalation (200 mcg) as needed; Max: 4 inhalations (800 mcg)/day; patient should be advised to promptly consult health care provider or seek medical attention if prior dose fails to provide adequate relief or if control of symptoms lasts <3 hr Maintenance (in combination with corticosteroid therapy): 1 inhalation (200 mcg) q 4-6 hr; Max: 4 inhalations (800 mcg)/day Nebulization solution: 2.5 mg TID-QID as needed; Quick relief: 1.25 to 5 mg q 4-8 hr as needed (NAEPP 2007) Pediatric: Inhalation: Metered-dose inhaler or dry powder inhaler (90 mcg/actuation) quick relief: refer to adult dosing for all ages Metered-dose inhaler (100 mcg/actuation): Children 6 to 11 years: Acute treatment: 1 inhalation; additional inhalations may be necessary if inadequate relief; however, patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment Maintenance (in combination with corticosteroid therapy): 1 inhalation; may increase to maximum of 1 inhalation QID Children ≥12 years and adolescents: refer to adult dosing Inhalation: Metered-dose inhalers: Shake well before use; prime prior to first use, and whenever inhaler has not been used for >2 weeks or when it has been dropped, by releasing 3 to 4 test sprays into the air (away from face). HFA inhalers should be cleaned with warm water at least once per week; allow to air dry completely prior to use. A spacer device or valved holding chamber is recommended for use with metered-dose inhalers.

Storage

Metered-dose inhalers (HFA aerosols): Store at 15°C to 25°C (59°F to 77°F). Do not store at temperature >120°F. Do not puncture. Do not use or store near heat or open flame.

Ventolin HFA: Discard when counter reads 000 or 12 months after removal from protective pouch, whichever comes first. Store with mouthpiece down.
Use with caution in patients with impaired renal disease, hyperthyroidism, diabetes, glaucoma

CONSULTATION/REFERRAL

Refer to pulmonologist if symptoms not improved after 4 weeks

FOLLOW-UP

7 days if not improved or if condition worsens
High-risk groups (i.e., those with co-existing disease) warrant quicker follow-up

EXPECTED COURSE

Shorter symptom duration if causative agent is rhinovirus or coronavirus
Symptoms may persist 3-4 weeks

POSSIBLE COMPLICATIONS

Pneumonia
Chronic cough

 

Acute laryngopharyngitis

DESCRIPTION
An acute inflammation of the pharynx/tonsils. The most common cause of acute pharyngitis is viruses. Accurate diagnosis and treatment of Strep pharyngitis is important to prevent rheumatic fever, poststreptococcal glomerulonephritis, to reduce transmission, and to limit complications, such as peritonsillar abscess, lymphadenitis, and mastoiditis
ETIOLOGY

Causes

Viral*
Bacterial

Rhinovirus
Adenovirus
Parainfluenza
Epstein-Barr virus (mononucleosis)
Respiratory syncytial virus

Group A beta-hemolytic
Streptococcus**
Haemophilus influenzae
Mycoplasma pneumonia
Chlamydia pneumoniae
Neisseria gonorrhoeae
No pathogen can be isolated in many cases

* Most common etiology
** Common depending on time of year
INCIDENCE

Prevalent in school age population, but occurs in all age groups (5-18 years most common)
Occurs in 5-15% of adults and 20-30% of children
More common during winter months

RISK FACTORS

Age
Exposure during Group A beta-hemolytic Streptococcus (GABHS) infection outbreaks
Family history of rheumatic fever places higher risk if GABHS is untreated

ASSESSMENT FINDINGS

Sore throat and pharyngeal edema
Tonsillar exudate and/or enlarged tonsils
Malaise
Clinical findings are not specific for diagnosis of bacterial or viral illness. The signs and symptoms of strep pharyngitis and other etiologies overlap, and an accurate diagnosis based on clinical findings alone is difficult
Suggestive of Strep:

Cervical adenopathy
Fever >102° F (38.8° C)
Absence of other upper respiratory findings (cough, nasal congestion, etc.)
Petechiae on soft palate
“Beefy red” tonsils
“Sandpaper” rash (bridge of nose, neck, and/or torso)
Abdominal pain, headache
Streptococcal tonsillitis has a distinct odor

Suggestive of viral infection:

Concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash

Modified Centor Clinical Prediction Rule for Group A Strep infection

Tonsillar exudates
+1 point

Tender anterior chain cervical adenopathy
+1 point

Fever by history
+1 point

Age <15 years +1 point Age 15-45 0 points Age >45
-1 point

Cough (almost always excludes Streptococcus)
-1 point

3-4 points: treat empirically for Strep infection
2 points: rapid Strep test, treat if positive
1 point: unlikely Strep
0 or -1 points: do not test or treat

DIFFERENTIAL DIAGNOSIS

Upper respiratory illness
Tonsillitis
Mononucleosis

DIAGNOSTIC STUDIES

Rapid antigen strep test (95-99% specific).
The swab should be taken from the tonsils, tonsillar fossa, and the posterior pharyngeal wall. Good specimen is essential
In children and adolescents, negative rapid antigen test should be confirmed with a throat culture. Confirmation not necessary in adults due to lower risk for the development of acute rheumatic fever

10% of patients with mononucleosis have concomitant Strep infection

 

Antistreptolysin (ASO) titer should not be ordered to diagnose acute infection (ASO detects past infection)

 
PREVENTION

Avoid contact with infected people during outbreaks
Good hand washing, especially during cold weather months
Teach patients not to share drinking glasses, eating utensils, etc.
Prompt treatment of patients with family history of rheumatic fever

NONPHARMACOLOGIC MANAGEMENT

Gargling with warm salt water
Increased fluid intake
Patient education about disease, course and treatment
Change toothbrush after treatment

PHARMACOLOGIC MANAGEMENT

Antipyretics/analgesics (acetaminophen, ibuprofen) are adjunctive treatment for fever and throat pain
Empiric treatment of asymptomatic household contacts of strep pharyngitis patients is not routinely recommended
For Strep pharyngitis, amoxicillin and penicillin V (10 days) are drugs of choice. For penicillin-allergic children, cephalexin/cefadroxil/clindamycin (10 days) or macrolides (5 days) are recommended
Antibiotics no benefit in treatment of nonstrep pharyngitis infections. Exceptions are Corynebacterium diphtheriae, Neisseria gonorrhoeae, and others

 

Medication (based on patient’s age or weight)
Treatment

Penicillin G
One IM injection

Penicillin V
Amoxicillin
Requires 10 days of treatment

First-generation
cephalosporins
Requires 10 days of treatment

Second-generation
cephalosporins
5 days of treatment

Azithromycin (for PCN allergy); limited efficacy against Streptococcal infection and should only be used for patients with documented history of PCN anaphylaxis or hives
12 mg/kg dose daily x 5 days

Clindamycin 7 mg/kg TID x 10 days for resistant/chronic recurrent Streptococcal infection
Mupirocin BID-TID to nasal mucosa for carrier

STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT

Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments

Penicillin Bacterial;
Bactericidal: inhibits cell wall mucopeptide synthesis; inhibits beta-lactamaseGeneral comments
Indicated for infections caused by penicillinase-sensitive microorganisms
Generally well tolerated; watch for hypersensitivity reactions
Clavulanate broadens spectrum of coverage
Consider amoxicillin/clavulanate if failure after 72 hours
Give in divided doses
Amoxicillin and Penicillin V are considered first-line agents in most cases, unless other antibiotic exposure in the last 90 days
The course of treatment is 10 days for all beta-lactam antibiotics, but FDA has approved 5-day course of cefdinir and cefpodoxime
penicillin V potassium
Adult: 500 mg 2-3 times daily for 10 days
Children: 250 mg PO BID-TID  for 10 days
Adolescents: 500 mg PO BID for 10 days

Lactation: Safe
Give 1 hour before and 2 hours after meals

Pen V K
Tablet: 250 mg, 500 mg
Oral Solution: 125 mg/5 mL, 250 mg/5 mL

penicillin G benzathine
Adult: 1.2 million units IM for 1 dose
<27 kg: 0.6 million units IM for 1 dose ≥27 kg: 1.2 million units IM for 1 dose Lactation: Safe Do not confuse Bicillin L-A with Bicillin C-R Do not confuse penicillin G benzathine with penicillamine or penicillin G procaine. They are NOT interchangeable Very painful injection if not combined with Penicillin G procaine (Ex. 900,000 units of Penicillin G benzathine + 300,000 units of Penicillin G procaine = 1.2 million units) Bicillin L-A Injection: 600,000 units/mL, 1.2 million units/2 mL NOT FOR IV USE amoxicillin Adult: 500-875 mg PO q 12 hr for 10-14 days (higher dosing for severe infections) Children:  >40 kg: dose for 10 days
50 mg/kg once daily for 10 days
Max: 1 g/day
Alternate: 25 mg/kg BID for 10 days
Max: 500 mg/dose

GI side effects
Amoxicillin is not stable in the presence of beta lactamase producing organisms
DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN
Decrease dose for renal impairment
Children’s dose of amoxicillin should never exceed maximum adult dose

Amoxil
Caps: 250 mg, 500 mg
Tabs: 500 mg, 875 mg
Suspension: 250 mg/5 mL;
400 mg/5 mL
Pediatric drops: 50 mg/mL

Moxatag
775 mg ER Tab daily for 10 days

continued

STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT

Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments

Macrolides
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrestGeneral comments
Effective treatment for S. pyogenes in the presence of penicillin allergy
Associated with higher rates of GI side effects
Age, weight and severity of infection determine dose in children
Local antibiotic resistant rates should be considered prior to prescribing.
azithromycin
Adult: 
Usual: 500 mg daily for 3 days
Alternative: 2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5Children >6 months old:
Usual: 10 mg/kg once daily for 3 days or 10 mg/kg on day 1 and 5 mg/kg days 2-5
Max: 500 mg daily

Lactation: Safety Unknown
First-line for penicillin allergic (Type I allergic reaction)
Consider clindamycin, if failure after 48-72 hours
Avoid concomitant use of aluminum or magnesium containing antacids
Cautious use if renal or hepatic impairment
Hypersensitivity reactions may recur after initial successful symptomatic treatment

Zithromax
Tabs: 500 mg, 250 mg
Powder: 2 g/bottle
Suspension: 100 mg/5 mL,
200 mg/5 mL

clarithromycin
Adult: 250 mg PO q 12 hr for 10 days
Children 6 months and older:
15 mg/kg/day PO divided q 12 hr for 10 days
Max: 250 mg/dose

Cautious use in patients with either renal or hepatic dysfunction
Clarithromycin may be involved in drug reactions involving CYP 450 system; special care when prescribing concurrently with 3A4 substrate medications
Common side effect is an abnormal taste in mouth while taking tablet or suspension

Biaxin
Coated tabs: 250 mg, 500 mg

Biaxin XL
Coated tabs extended release: 500 mg

Other Antibacterials
Bacteriostatic or bactericidal, inhibits protein synthesisGeneral comments
Half-life is 2.4-3 hours
Carries a black box warning for C. difficile associated diarrhea
clindamycin
Adult: 300 mg PO q 8 hr for 10 days
Children: 7 mg/kg/day PO divided q 8 hr for 10 days
Max: 300 mg/dose
Adolescents: 150-300 mg PO q 6 hr
Max 300 mg per dose

Lactation: Probably Unsafe
May cause exfoliative dermatitis
Caution in hepatic dysfunction
Only use if other antibiotics have been unsuccessful
Use in patients with initial bacterial failure who are penicillin/cephalosporin allergic with Type I reaction; consider use in patients who failed therapy with ceftriaxone (used in conjunction with tympanocentesis)

continued

STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT

Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments

 
Cleocin
Injection: 150 mg/mL
Tabs: 75 mg, 150 mg, 300 mg
Capsule: 150 mg, 300 mg
Solution: 75 mg/5 mL
Granules for solution: 75 mg/5 mL

Cautious use in patients with hepatic, renal impairments, colitis
Side effects include pseudo-membranous colitis, C. difficile diarrhea
Take with a full glass of water

First Generation Cephalosporins
Arrests bacterial growth by inhibiting bacterial cell wall synthesisGeneral comments
Caution if recent antibiotic associated colitis
cephalexin
Adult: 500 mg PO q 12 hr for 10 days
Children >1 year of age: 
25-50 mg/kg/d in 2-4 divided doses for 10 days
Max: 500 mg q 12 hr

Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
Give without regard to meals
PT should be monitored in patients at risk: renal or hepatic impairment, poor nutritional state
After mixing suspension, store in refrigerator for up to 14 days

Keflex
Caps: 250 mg, 500 mg, 750 mg
Tablets: 250 mg, 500 mg
Suspension: 125 mg/5 mL, 
500 mg/5 mL

cefadroxil
Adult: 1 g PO daily in divided doses q 12 hr for 10 days
Children: 30 mg/kg PO divided q 12 hr for 10 days

Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
No dosage reduction needed for geriatric patients

Duricef
Caps: 500 mg, 1000 mg,
Tabs: 1000 mg
Suspension: 250 mg/5 mL,
500 mg/5 mL

CONSULTATION/REFERRAL

Evidence of acute renal failure and reddish, tea-colored urine (2-3 weeks post infection) may indicate acute poststreptococcal glomerulonephritis
Tonsillar edema and upper airway obstruction
Peritonsillar abscess

Tonsillectomy is not recommended to reduce the frequency of Strep pharyngitis

 
FOLLOW-UP

None usually needed
Patient no longer considered contagious after 24 hours on antibiotic
Follow-up culture not recommended, may be done to assure compliance

EXPECTED COURSE

Peak fever and pain on days 2 and 3
Lasts 4-10 days

POSSIBLE COMPLICATIONS

Upper airway obstruction
Acute post-Strep glomerulonephritis after Streptococcal infection
May develop sloughing of skin on fingertips and toes in weeks following Strep infection

 

Acute maxillary sinusitis

DESCRIPTION
Also known as: (Acute Rhinosinusitis, Recurrent Acute Rhinosinusitis, Chronic Rhinosinusitis)
Inflammation of at least one paranasal sinus due to bacterial, viral, or fungal infection; or allergic reaction. Annually, acute bacterial rhinosinusitis costs more than $3 billion and accounts for more outpatient antibiotic prescriptions than any other diagnosis. The terms sinusitis and rhinosinusitis are used interchangeably because inflammation of the sinus cavities and nasal cavities are usually concurrent.

Classification

Acute rhinosinusitis (ARS): symptoms <12 weeks Recurrent ARS (RARS): at least three episodes of acute bacterial rhinosinusitis in a year Chronic rhinosinusitis (CRS): symptoms of varying severity >12 weeks. Further classified with or without nasal polyps; abnormal findings on CT scan or nasal endoscopy

ETIOLOGY

Bacterial

Acute 
sinusitis

Streptococcus pneumoniae species (most common)
Haemophilus influenza (common in smokers)
Moraxella catarrhalis

Viral

Rhinovirus
Coronavirus
Influenza A and B
Parainfluenza virus
Respiratory syncytial virus

Chronic
sinusitis

Gram-negative more likely
Staphylococcus aureus
Pseudomonas aeruginosa
Anaerobic organisms

 

Vast majority of rhinosinusitis cases are due to viruses, NOT bacteria. Viral URIs usually precede bacterial infections of the sinuses. It is the persistence of symptoms that suggests sinusitis.

INCIDENCE

Common in all ages
Men = Women
Common in early fall and early spring
13% of adults annually
A majority of patients with rhinosinusitis seek care from their PCPs

RISK FACTORS

Allergies, asthma
Tooth abscess (25% of chronic sinusitis is due to tooth abscess)
Cigarette smoking
URIs, cystic fibrosis, immune deficiencies
Swimming in contaminated water
Any condition that results in swollen nasal mucous membranes, such as common cold and allergic rhinitis
Anatomical abnormalities that prevent normal mucosal drainage, such as ciliary dyskinesia, nasal polyps and deviated septum
Asthma, GERD, and otitis media are often comorbid with CRS

ASSESSMENT FINDINGS

Fever (may or may not be present)
Persistent symptoms of URI (>10-14 days)
Nasal congestion and/or discharge (may be purulent and/or bloody)
Headache
Sore throat from persistent postnasal discharge
Pain/pressure over cheeks and upper teeth (suggests maxillary sinus involvement)
Pain/pressure and tenderness over eyebrows (suggests frontal sinus involvement)
Pain/pressure and tenderness behind and between eyes (suggests ethmoid sinus involvement)
Cough
Anosmia
Halitosis
Postnasal discharge, throat clearing
Periorbital edema

Bacterial infection more likely if: symptoms >10 days, worsening of symptoms after initial improvement, persistent purulent nasal discharge, fever, unilateral face or tooth pain.

DIFFERENTIAL DIAGNOSIS

Viral URI
Allergic rhinitis
Nonallergic rhinitis (triggered by strong odors or change in temperatures)
Dental abscess
Headaches
Nasal foreign body
Wegener’s granulomatosis

DIAGNOSTIC STUDIES

CBC: elevated WBC count if bacterial infection
Sinus X-rays: opaque areas on radiographs; air-fluid levels
CT scan: most useful tool to evaluate recurrent sinusitis but unable to differentiate viral from bacterial infection. Required before surgery or when complications of sinusitis are suspected
Imaging recommended with unilateral CRS to exclude tumor, anatomical defect, or foreign body. MRI is superior to CT for soft tissue imaging
Transillumination: opacification with air-fluid levels if sinus cavity is infected
Allergen-specific IgE testing for respiratory allergens for RARS or CRS
Evaluate for immune deficiency if CRS is resistant to treatment: quantitative IgG, IgA, IgM; pneumococcal antibody; complement function and T-cell number and function
Consider culture and sensitivity for treatment resistant infections
Consider evaluating for cystic fibrosis in a child with CRS with nasal polyps, especially if Pseudomonas aeruginosa is cultured from the sinuses

PREVENTION

Promote drainage by avoiding irritants that increase swelling in mucous membranes and cause retention of sinus exudate
Blowing, rather than “sniffing” nose
Good hand washing to prevent URIs
Management of allergic rhinitis

NONPHARMACOLOGIC MANAGEMENT

Avoid environmental irritants (cigarette smoke)
Manage allergic rhinitis appropriately
Humidified air can improve mucus clearance
Look for the presence of otitis media when evaluating a patient with rhinosinusitis (and vice versa)
Increase fluid intake
Sleep with head of bed elevated to aid with drainage
Patient education regarding disease, treatment options, etc.

PHARMACOLOGIC MANAGEMENT

Current data support watchful waiting of acute infections for 10 days; start antibiotic therapy if symptoms extend beyond 10 days.

Antibiotics: for acute infections and patients with moderate to severe infection
Amoxicillin-clavulanate is first-line antibiotic
Doxycycline, levaquin, or moxifloxacin if PCN allergy
Macrolides no longer recommended due to high rate of resistance
Amoxicillin not recommended; M. catarrhalis and H. influenzae can produce ß-lactamase and are resistant to amoxicillin
If no improvement occurs within 3-5 days, consider an alternate antibiotic that broadens coverage or covers resistant bacteria.
If partial response, consider additional 10-14 days with same or different antibiotic. If no substantial improvement or resolution in 21-28 days, refer to specialist
Decongestants: oral route preferred over topical, however, may use oxymetazoline q 12 hours for 1-3 days for ARS. Neither oral nor topical are beneficial for CRS
Analgesics for headache, antipyretics for fever
Topical intranasal steroids as monotherapy or in conjunction with antibiotics, especially in children and/or adults with underlying allergies. May consider a 3- to 6-week course of topical antibiotics for CRS (mupirocin, gentamicin, tobramycin nebulized or irrigations). Low systemic absorption. Studies demonstrate 82% improvement
CRS: oral antibiotic plus short course of oral steroids. Antibiotics of greater benefit for patients without nasal polyposis. Antibiotic therapy beyond 10-14 days is recommended. Oral steroids should be prescribed for patients with nasal polyps to decrease polyp size. Nasal steroids should be prescribed for patients with and without polyps; CRS is an inflammatory condition
Patients with asthma who develop rhinosinusitis should be treated aggressively, since successful treatment will improve asthma
Saline irrigation may be used as adjunctive therapy, using distilled or boiled tap water only. Patients should be instructed to clean the delivery device to avoid contamination. Squeeze bottles are superior to saline sprays, nebulizers, or devices (Neti pot)
In children, ARS is self-limiting, and antibiotic treatment facilitates improvement and resolution. Nasal steroids are a useful adjunct, however, nasal irrigation, antihistamines, decongestants, and mucolytics have not been proven beneficial for ARS in children.
In children with CRS, the mainstay of treatment is medical; surgery less frequently needed

Limited data support antibiotic therapy
Intranasal steroids should be prescribed, and antibiotics should be used for acute exacerbations
Surgery is an infrequent treatment for CRS in children; when needed, adenoidectomy with or without antral maxillary irrigation is used

Risk for resistance should be evaluated prior to determining antibiotic therapy. Risk factors for resistance include: age <2 years or >65 years, recent antibiotic use, hospitalization within the past 5 days, presence of co-morbid conditions, immunocompromised state.

 

ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT
Reserve antibiotics for persistent, unimproved symptoms >10 days or severe symptoms for >3-4 days

Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments

Penicillin
Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most effective against organisms with rapidly dividing cell wallsGeneral comments
Indicated for infections caused by penicillinase-sensitive microorganisms
Generally well tolerated; watch for hypersensitivity reactions
May have high rates of resistance depending on geographic region
amoxicillin
Adult: 500 mg-875 mg PO q 12 hr for 5-7 days
 
Children:
>40 kg: dose as adult
<3 months: 20-30 mg/kg/day PO divided q 12 hr for 48-72 hr >3 months: 25-45 mg/kg/day PO divided q 12 hr
>2 years old: 80-90 mg/kg/day PO divided q 12 hr for 5-7 days; do not exceed max adult dose

DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN
Ineffective against beta lactamase-producing organisms
Decrease dose for renal impairment
Children’s dose of amoxicillin should never exceed maximum adult dose
Consider high-dose amoxicillin for severe sinusitis or likelihood of drug-resistant Streptococcus pneumoniae

Amoxil
Caps: 250 mg, 500 mg
Tabs: 500 mg, 875 mg
Suspension: 250 mg/5 mL;
400 mg/5 mL
Pediatric drops: 50 mg/mL

Moxatag
Extended-release tabs: 775mg

Extended-Spectrum
Penicillin
Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most
effective against organisms with rapidly dividing cell walls
 
General comments
 
Addition of clavulanic acid (as potassium) extends antimicrobial spectrum (covers many gram-negative organisms) and protects PCN molecule if the organism produces beta lactamase
 
Clavulanic acid is known to cause diarrhea
amoxicillin/clavulanic acid 
(as potassium)
Adult: 500/125 mg PO TID or 875/125 mg PO q 12 hr for 5-7 days
 
Alternative: 2000 mg or 90 mg/kg PO q 12 hr for 10 days for S. pneumoniae or at risk for resistance
 
Children:
>40 kg: dose as adult
<3 months: 30 mg/kg/day PO q 12 hr for 7-10 days >3 months and older and <40 kg: 25-45 mg/kg/day PO q 12 hr DO NOT USE IN PATIENTS WHO HAD HIVES OR ANAPHYLAXIS TO PENICILLIN Children: base dose on amoxicillin component Monitor for PCN hypersensitivity Take with meals to minimize gastrointestinal side effects Contraindicated in severe renal impairment (CrCl <30 mL/min), dialysis, or history of Augmentin-associated cholestatic jaundice, hepatic dysfunction Chew tabs contain phenylalanine   Augmentin Tabs: 250/125 mg, 500/125 mg, 875/125 mg Elixir: 125/31.25/5 mL; 250/62.5/5 mL XR: 1000/62.5 mg Tetracycline Bacteriostatic, inhibits bacterial protein synthesis by disruption of RNA at ribosomal sites  General comments May alter GI flora doxycycline Adult: 100 mg PO q 12 hr or 200 mg PO daily for 5-7 daysChildren: not recommended Caution in hepatic impairment and recent colitis associated with antibiotic use Associated with diarrhea continued ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT Reserve antibiotics for a) Persistent and not improving symptoms > 10 days or b) Severe symptoms for > 3-4 days

Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments

May lead to permanent yellowing or graying of the teeth in children <8 years old. Vibramycin Tabs: 100 mg Elixir: 25 mg/5 mL, 50 mg/5 mL Cephalosporins Third generationProvides broader coverage of gram-negative organisms; beta-lactamase-producing organisms General comments Recommended in combination with clindamycin for children with penicillin allergy. Not indicated as monotherapy for treatment of sinusitis For patients who had skin rash to penicillin, OK to use third-generation cephalosporin Generally well tolerated cefpodoxime Adult ≥12 years: Sinusitis: Usual: 200 mg q 12 hr for 10 days Children (2 months to 12 years):  Usual: 5 mg/kg q 12 hr for 10 days Max: 200 mg/dose NOT likely to cause an adverse reaction in patients with history of IgE response to penicillins; use caution Decrease dose for renal impairment Children’s dose should not exceed adult dose Cefpodoxime: take tabs with food; suspension may be given without regard to food Vantin Tabs: 100 mg and 200 mg Suspension: 50 mg/5 mL, 100 mg/5 mL Various generics cefdinir Adult > 13 years:
Usual: 300 mg q 12 hr (or 600 mg q 24 hr) for 10 days
Children 6 months-12 years: 
Usual: 7 mg/kg q 12 hr or 14 mg/kg daily for 10 days
Max: 300 mg per dose

Separate medication by at least 2 hours when giving with iron supplements (except iron fortified cereals)

Omnicef
Tabs: 300 mg
Suspension: 125 mg/5 mL,
250 mg/5 mL

Various generics

Cefixime
Children 6 months to 11 years:
Usual: 8 mg/kg/day for 10 days
Max: 400 mg/day

Suprax

Other Antibacterials
Bacteriostatic or bactericidal, inhibits protein synthesisGeneral comments
Half-life is 2.4-3 hours
Carries a black box warning for C. difficile associated diarrhea
Clindamycin
Adult: 300 mg PO q 8 hr x 10 days
Children: 10-25 mg/kg/day PO q 6-8 hr
Max: 1.8 g/day
Adolescents: 150-300 mg PO q 6 hr
Max: 1.8 g/day PO
 

May cause exfoliative dermatitis
Caution in hepatic dysfunction

Cleocin
Tabs: 75 mg, 150 mg, 300 mg
Elixir: 75 mg/5 mL

Macrolides
Inhibit protein synthesis by binding to the 50S ribosomal subunitGeneral comments
Macrolides are not recommended for empiric treatment due to high rates of resistance. May consider as alternative to PCN in pregnancy, if

Is this the question you were looking for? If so, place your order here to get started!