common infections in primary care · 2021. 2. 16. · uncomplicated uti ¡no structural or...

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COMMON INFECTIONS IN PRIMARY CARE

Brandon Dionne, PharmD, BCPS-AQ ID, BCIDP, AAHIVP

Assistant Clinical Professor

Northeastern University School of Pharmacy

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OBJECTIVES

¡ Identify the most common pathogens causing urinary tract infections (UTIs), skin and soft tissue infections (SSTIs), and respiratory tract infections (RTIs)

¡ Develop an appropriate empiric treatment plan for a patient’s infection based on risk factors

¡ Modify an empiric regimen or start a definitive therapy based on culture data and/or patient progress

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INTERPRETING SUSCEPTIBILITIES

¡ Susceptibility results often include minimum inhibitory concentrations (MICs)

¡ MICs cannot be compared between antibiotics

¡ Use the interpretations (S, I, or R) to guide therapy

¡ S is susceptible/sensitive – safe to use

¡ I is intermediate – may be OK if higher dose can be used or drug concentrates at site of infection

¡ R is resistant – antibiotic should not be used

¡ Breakpoints are set by the Clinical Laboratory Standards Institute (CLSI) in the M100

¡ Freely available online - https://clsi.org/standards/products/free-resources/access-our-free-resources/

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URINARY TRACT INFECTIONS

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https://clsi.org/standards/products/free-resources/access-our-free-resources/

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EPIDEMIOLOGY

¡ UTIs are one of the most common bacterial infections, affecting 150 million people each year worldwide

¡ 10.5 million office visits and 2–3 million emergency department visits in the United States in 2007

¡ Female >> male

¡ ~50% of women will suffer ≥ 1 episode of UTI in their lifetime

¡ Prevalence increases with age

¡ Age > 65: female ≈ male

Flores-Mireles AL, et al. Nat Rev Microbiol. 2015;13(5):269–284.Walsh C, et al. Surgery (Oxford). 2017: 35:6; 293-298.

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ETIOLOGY

Flores-Mireles AL, et al. Nat Rev Microbiol. 2015;13(5):269–284.

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UTI CLASSIFICATIONS

Uncomplicated UTI

¡ No structural or functional abnormality of the urinary tract

¡ Healthy, non-pregnant, pre-menopausal adult women

Complicated UTI¡ Structural or functional abnormality of urinary tract

¡ Neurogenic bladder ¡ Kidney stones ¡ Catheter or stent or instrumentation

¡ Underlying conditions ¡ Pregnancy¡ Men; children; elderly¡ Immunocompromised¡ Hospital acquired infection

Flores-Mireles AL, et al. Nat Rev Microbiol. 2015;13(5):269–284.Walsh C, et al. Surgery (Oxford). 2017: 35:6; 293-298.

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URINE DIPSTICK

¡ Reagent strip testing of urine sample

¡ Advantages: rapid, inexpensive, and easy to use

¡ Disadvantages: less sensitive and specific than urine culture

¡ Used to detect leukocyte esterase and nitrites

https://www.alibaba.com/product-detail/rapid-response-urine-dipstick-10-parameter_60062233181.html

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URINALYSIS

¡ Bacteria

¡ Usually semi-quantitative

¡ Nitrite

¡ (+) bacteria that reduce nitrate¡ Enteric gram negative rods (i.e., Enterobacterales)

¡ (-) bacteria that do not reduce nitrate

¡ S. saprophyticus

¡ Enterococcus spp.

¡ Pseudomonas aeruginosa

¡ Pyuria

¡ WBC >10 cells/hpf

¡ Leukocyte esterase – semi quantitative

¡ WBC casts

¡ Indicative of pyelonephritis

¡ Squamous epithelial cells

¡ >5-10 cells/hpf suggests contamination

¡ Hematuria

¡ Proteinuria

Simerville, et al. Am Fam Physician. 2005;71(6):1153-1162.

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URINALYSIS SUMMARY

Characteristic (-) UTI (+) UTI Appearance Clear Cloudy/hazy

Bacteria (-) (+)Nitrite (-) (+/-)

Leukocyte esterase (-) < small < moderate < large WBC 0-5 cells/mm3 >5-10 cells/mm3

WBC casts (-) (+/-)

Squamous epithelial cells None or few = good sampleMany = contamination (recollect)

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URINE CULTURE

¡ Urine culture generally NOT necessary for acute uncomplicated cystitis

¡ Pathogens usually predictable

¡ Therapy may be completed before culture results are known

¡ When to culture:

¡ Recurrent UTI

¡ Pyelonephritis

¡ Male

¡ Pregnancy

¡ Typically 103 cfu/mL for catheterized and 105 cfu/mL for clean catch considered significant bacteriuria

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ASYMPTOMATIC BACTERIURIA

¡ Bacteriuria without genitourinary signs or symptoms

¡ Common in healthy young women

¡ Common in elderly (> 65 years)

¡ Treatment of asymptomatic bacteriuria increases risk of UTI with MDROs

¡ Should only be treated in select populations:

¡ Pregnant women – 4-7 days

¡ Patients undergoing a urologic procedure with anticipated mucosal trauma – 1-2 doses

¡ Kidney transplant in past month??

¡ Neutropenia??

Nicolle LE, et al. Clin Infect Dis. 2019;68(10):1611-1615.Cai T, et al. Clin Infect Dis. 2012;55(6):771.

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UTI TREATMENT

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GOALS OF THERAPY

¡ Eradicate invading organism(s)

¡ Treat or prevent systemic manifestations

¡ Prevent recurrence

¡ Minimize potential for collateral damage

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COLLATERAL DAMAGE

¡ Ecological adverse effects of antimicrobial therapy

¡ Leads to the selection of drug resistant organisms & colonization/infection with multidrug resistant organisms

¡ Associated with broad spectrum cephalosporins and fluoroquinolones

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PK OF UTI ANTIBIOTICS

Antibiotic Oral Dose (mg) Peak Cserum (mg/L ) Peak Curine (mg/L )Amoxicillin 250

5003.5-5.05.5-11.0

305-865772

Cephalexin 250500

915-18

830110

TMP/SMX 160/800 1-2/40-60 74/190

Ciprofloxacin 250500

0.8-1.91.6-2.9

>200350

Levofloxacin 500 5.7 521-771

Nitrofurantoin 100 <2 50-150

Fosfomycin 3000 26 1053-4415Gupta K, et al. Ann Intern Med. 2001;135(1):41-50.

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CYSTITIS

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UNCOMPLICATED CYSTITIS

¡ Most common type of UTI in non-pregnant, pre-menopausal women with no systemic disease ¡ Diagnosed based on urinary symptoms and urinalysis

¡ Urine culture is not necessary¡ Most likely organism is E. coli

¡ Short-course therapy preferred ¡ Improved adherence

¡ Fewer adverse effects ¡ Lower cost ¡ Less “collateral damage”

¡ Duration of therapy is dependent on antimicrobial agent

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Antibiotic (oral) Duration NotesNitrofurantoin monohydrate/ macrocyrstals 100mg po BID

5 days Drug of choice (DOC)Minimal resistance and low risk of collateral damage – avoid when CrCl <30 mL/minADRs: GI, peripheral neuropathy, pulmonary fibrosis

TMP/SMX 160/800mg (DS) po BID 3 days Avoid if local E. coli resistance rates >20%ADRs: Hyperkalemia, rash, thrombocytopenia

Fosfomycin 3g po x1 Single dose Minimal resistance and low risk of collateral damageActivity against ESBL- and KPC-producers vancomycin resistant Enterococcus spp. (VRE)ADRs: diarrhea, headache

Fluoroquinolones -Ciprofloxacin 250 mg po BID-Levofloxacin 250 mg or 500 mg po QD

3 days Rising prevalence of FQ resistanceReserved for patients without other antibiotic options due to severe disabling side effectsADRs: QTc prolongation, risk for C. difficile diarrhea

β-Lactam agents- Amoxicillin-clavulanate 500 mg/125 mg PO TID- Cefpodoxime 100 mg PO BID- Cefdinir 300 mg PO BID x3-7d

3-7 days Inferior efficacy High in vitro resistance rate ADRs: GI effects

Gupta K, et al. Clin Infect Dis. 2011; 52(5): e103-20.

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COMPLICATED CYSTITIS

¡ Infection of the lower urinary tract, plus presence of one of the following:¡ Pregnancy¡ Urinary catheter

¡ Male¡ Anatomic abnormality ¡ Functional abnormality

¡ Urinalysis and urine culture should be obtained ¡ Pathogens are not easily predicted ¡ Increased risk of resistance

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CYSTITIS IN PREGNANCY

¡ Increased risk of UTI during pregnancy

¡ Bacteriuria can progress to pyelonephritis

¡ Premature delivery or low birth weight infants

¡ Guidelines recommend screening pregnant women for bacteriuria by urine culture at least once in early pregnancy and intermittently throughout

¡ Pregnant women should be treated for both asymptomatic and symptomatic bacteriuria

¡ Follow up culture after treatment completion

Nicolle LE, et al. Clin Infect Dis. 2005; 40(5): 643-54.Matuszkiewicz-Rowińska J, et al. Arch Med Sci. 2015;11(1):67-77.

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ANTIBIOTIC OPTIONS IN PREGNANCY

Antibiotic (oral) Duration of Treatment

Notes

β-Lactam agents- Amox/clav 500 mg/125 mg PO TID- Cephalexin 500 mg po BID- Cefpodoxime 100 mg PO BID- Cefuroxime 250 mg PO BID

5-7 days Pregnancy category B

Nitrofurantoin monohydrate 100mg po BID 5-7 days Pregnancy category B (avoid after 38th week of gestation due to risk of hemolytic anemia)

TMP/SMX 160/800mg (DS) po BID 5-7 days Pregnancy category D (avoid in 1st trimester due to risk for neural tube defects and after 38th

week due to risk of kernicterus)

Matuszkiewicz-Rowińska J, et al. Arch Med Sci. 2015;11(1):67-77.

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ANTIBIOTICS TO AVOID IN PREGNANCY

AVOID:

¡ Fluoroquinolones

¡ Pregnancy category C

¡ Fetal cartilage development disorders

¡ Tetracyclines

¡ Pregnancy category D

¡ Embryotoxicity and retardation of skeletal development

Matuszkiewicz-Rowińska J, et al. Arch Med Sci. 2015;11(1):67-77.

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OUTPATIENT PYELONEPHRITIS TREATMENT

Antibiotic (oral) Duration NotesFluoroquinolones -Ciprofloxacin 500 mg po BID-Levofloxacin 750 mg po QD (+/-)IV FQ+ or IV ceftriaxone or IV aminoglycoside$

7 days 5 days

1 dose 1 dose

+ If local FQ resistance is <10%$ If local FQ resistance is > 10%

TMP/SMX 160/800mg (DS) po BID (+/-)IV ceftriaxone or IV aminoglycoside#

14 days 1 dose

If causative bacteria is susceptible #TMP/SMX susceptibility is unknownHigh-dose extended-interval dosing of aminoglycoside

β-Lactam agents (po)*

IV ceftriaxone or IV aminoglycoside10-14 days 1 dose

*Inferior efficacy and need combinationwith parenteral antibiotic therapy

Gupta K, et al. Clin Infect Dis. 2011; 52(5): e103-20.

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RECURRENT UTIs: ≥ 2 WITHIN 6 MONTHS OR ≥ 3 WITHIN 1 YEAR

Relapse/Persistence: occurs ≤ 2 weeks of UTI,

§ Involves the same organism

§ Usually due to:

§ Functional abnormalities

§ Structural abnormalities

§ Chronic bacterial prostatitis

Reinfection: occurs > 2 weeks after last UTI

¡ Typically involves a different organism

¡ More common than relapse

¡ May be due to:

¡ Sexual intercourse

¡ Diaphragm/spermicide use

Dason S, et al. Can Urol Assoc J. 2011; 5(5):316-322.

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TREATMENT OF RELAPSE UTI

¡ Repeat culture and susceptibility testing

¡ Imaging and specialist referral

¡ Remove obstruction if any

¡ Rule out chronic bacterial prostatitis in male

¡ Prolonged treatment duration

Dason S, et al. Can Urol Assoc J. 2011; 5(5):316-322.

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PROPHYLAXIS OF REINFECTION UTI

Associated with sexual activity à Post-coital prophylaxis

¡ TMP/SMX 80/400 mg (SS tab) PO x1

¡ Nitrofurantoin 50-100 mg PO x1

¡ Cephalexin 250 mg PO x1

¡ Ciprofloxacin 125 mg PO x1

Unknown etiology with symptoms àLong-term prophylaxis ~6 mo

¡ TMP/SMX SS ½ tab (40/200 mg) PO QD or TIW

¡ Nitrofurantoin 50 mg or 100 mg PO QD

¡ Cephalexin 125 mg or 250 mg PO QD

¡ Fosfomycin 3 g q10days

¡ If infection occurs, switch to conventional treatment regimen, then resume prophylaxis

Albert X, et al. Cochrane Database Syst Rev. 2004;(3):CD001209.

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SELF-CARE

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URINARY ANALGESICS

¡ Phenazopyridine [Pyridium (RX); AZO (OTC)] 200 mg TID

¡ Indication: Provides symptomatic relief of dysuria, urgency and frequency for MAX of 2 days

¡ Common ADRs: red/orange discoloration of body fluids, headache, GI

¡ Serious ADRs: rash, anaphylaxis, hemolytic anemia

¡ Disadvantages:

¡ May mask symptoms of untreated UTI

¡ Contraindicated if CrCl <50 mL/min, hepatic insufficiency

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PREVENTATIVE STRATEGIES

¡ Fluids/hydration – 2-3 L/day

¡ Dilute urine/bacterial inoculum

¡ Promote increased voiding

¡ Cranberry juice, capsules, or tablets

¡ Thought to disrupt bacterial adherence to bladder epithelial cells

¡ Design flaws and heterogeneity in data and products

¡ Many show no benefit

¡ Limit use of spermicides

¡ Lactobacillus probiotics

¡ Normalize vaginal pH, regulating genitourinary flora

¡ Topical estrogen replacement for postmenopausal women with recurrent UTI

¡ Promote lactobacilli growth in vaginal flora

¡ Methenamine (Cystex, AZO UT Defense)

¡ D-mannose – not much data

Hooton TM, et al. JAMA Intern Med. 2018;178(11):1509-1515.

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SKIN AND SOFT TISSUE INFECTIONS

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EPIDEMIOLOGY

¡ Cause 48.5 infections per 1,000 patient-years

¡ Staphylococcus aureus SSTIs doubled from 57 to 117 cases per 100,000 patient-years between 2001-2009

¡ From 2005-2009, community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections increased by 34%

Kaye KS, et al. Clin Infect Dis. 2019;68(suppl 3): S193–S199.

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SSTI CLASSIFICATIONS

Non-Purulent SSTI

¡ Impetigo

¡ Erysipelas

¡ Cellulitis

Purulent SSTI

¡ Furuncle

¡ Carbuncle

¡ Abscess

Stevens DL, et al. Clin Infect Dis. 2014;59(2):E10-E52.

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ETIOLOGY

Non-purulent

¡ Beta-hemolytic Streptococcus spp. (especially Streptococcus pyogenes) are the most common causes of cellulitis

¡ Staphyloccus aureus can cause impetigo

¡ Capnocytophaga canimorsus and Pasteurella multocida can be involved in dog and cat bites

Purulent

¡ Staphylococcus aureus is the most common cause

¡ Risk factors for methicillin-resistance (MRSA)

¡ Nasal colonization

¡ Prior MRSA infection

¡ Recent hospitalization

¡ Recent antibiotics

Kaye KS, et al. Clin Infect Dis. 2019;68(suppl 3): S193–S199.

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NON-PURULENT CELLULITIS TREATMENT

¡ Mild – no evidence of systemic symptoms

¡ Penicillin 500 mg PO q6h

¡ Dicloxacillin 500 mg PO q6h

¡ Cephalexin 500 mg PO q6h (or cefadroxil 1 g PO q12-24h)

¡ Clindamycin 300 mg PO q6-8h if severe beta-lactam allergy

¡ Moderate – one sign of systemic symptoms

¡ Requires intravenous antibiotics


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PURULENT SSTI TREATMENT

¡ Incision and drainage is the most important step – send for culture and susceptibility

¡ Mild – area of purulence <5 cm

¡ Guidelines recommend against antibiotics

¡ Clinical trials of antibiotics improve cure by about 10% vs I+D alone (70% vs 80%)

¡ Moderate – area of purulence >5 cm, failure of I+D alone, or one sign of systemic infection

¡ Trimethoprim/sulfamethoxazole 1 or 2 DS PO q12h for at least 5 days

¡ Doxycycline 100 mg PO q12h for at least 5 days


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ANIMAL BITE TREATMENT

¡ Irrigation of wound

¡ Target gram-positive and anaerobic bacteria

¡ Amoxicillin/clavulanate 875/125 mg PO q12h

¡ Give tetanus vaccine if >10 years since last vaccination

¡ Generally should not be closed unless near face


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RESPIRATORY TRACT INFECTIONS

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CLASSIFICATIONS

Upper Respiratory Tract Infections

¡ Acute otitis media

¡ Rhinosinusitis

¡ Pharyngitis

Lower Respiratory Tract Infections

¡ Bronchitis

¡ Community-acquired pneumonia

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ACUTE OTITIS MEDIA

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EPIDEMIOLOGY

¡ 11th most common reason for an emergency department visit

¡ 15th most common reason for an office visit

¡ 75% of children <1 yo will have ≥1 episode

¡ Costs almost $3 billion annually in the US

Hing E, et al. Adv Data. 2006(374):1-33.McCaig LF, Nawar EW. Adv Data. 2006(372):1-29.Faden H, et al. Pediatr Infect Dis J. 1998;17(12):1105-12.Soni A. Agency for Healthcare Research and Quality, 2008.

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ETIOLOGY

¡ 40-75% of cases are caused by viruses

¡ Most common bacterial pathogens

¡ Streptococcus pneumoniae (35-40%)

¡ Haemophilus influenzae (30-35%)

¡ Moraxella catarrhalis (15-18%)

AAP Subcommittee on Management of AOM. Pediatrics. 2004; 113(5):1451–1465.Wald ER. Clin Infect Dis. 2011;52(Suppl 4):S277–S283.

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SEVERITY OF AOM

¡ Severe

¡ Moderate or severe otalgia for ≥48 h

-OR-

¡ Temperature ≥39°C

¡ Non-severe¡ Mild otalgia for <48 h

-AND-

¡ Temperature <39°C

¡ Bilateral vs. Unilateral

Lieberthal AS, et al. Pediatrics. 2013;131(3):e964-99.

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TREATMENT DURATION

Age Otorrhea Severe Non-severe bilateral

Non-severe unilateral

<6 months 10 days ABX 10 days ABX 10 days ABX 10 days ABX

6-23 months 10 days ABX 10 days ABX 10 days ABX Observe or 10 days ABX

2-5 years 10 days ABX 10 days ABX Observe or 7 days ABX

Observe or 7 days ABX

≥6 years 10 days ABX 10 days ABX Observe or 5-7 days ABX

Observe or 5-7 days ABX

• Observe for 48-72 h with follow-up and access to clinician/antibiotics if the symptoms do not improve within 2-3 days or worsen at any time


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TREATMENT

Initial immediate or delayed therapy Antibiotic treatment after failure

First-line therapy Alternative (PCN allergy) First-line therapy Alternative

Amoxicillin 80-90mg/kg/day PO bid

OR

Amoxicillin/clavulanate 90mg/kg/day of amoxicillin and 6.4 mg/kg/day of clavulanate PO bid

Cefdinir 14 mg/kg/day POonce daily-bid

Cefuroxime 30 mg/kg/day PO bid

Cefpodoxime 10 mg/kg/day PO bid

Ceftriaxone 50 mg/kg/dayIM or IV for 1 to 3 days

Amoxicillin/clavulanate 90mg/kg/day of amoxicillin and 6.4 mg/kg/day of clavulanate PO bid

OR

Ceftriaxone 50 mg/kg/dayIM or IV for 3 days

Clindamycin 30-40 mg/kg/day PO tid with or without a 3rd generation cephalosporin

Failure of second ABXClindamycin 30-40 mg/kg/day PO tid plus a 3rd

generation cephalosporin

Tympanocentesis

Consult specialistLieberthal AS, et al. Pediatrics. 2013;131(3):e964-99.

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TREATMENT FAILURE

¡ Clinical improvement should be noted within 48-72 hours¡ Resolution of fever¡ Improvement in irritability or fussiness

¡ Symptoms may initially worsen after diagnosis of AOM¡ Should begin to improve 24 hours after diagnosis

¡ If symptoms do not improve, can consider switching antibiotics¡ Amoxicillin à amox/clav¡ Amox/clav à ceftriaxone

¡ Consider tympanocentesis if still no improvement¡ Gram stain, culture, and susceptibilities


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PREVENTION

¡ Immunizations

¡ Prevnar 13

¡ Hib

¡ Annual influenza

¡ Breastfeeding

¡ At least 6 months

¡ Avoid tobacco smoke


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RHINOSINUSITIS

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EPIDEMIOLOGY

¡ ~30 million cases are diagnosed annually in the US

¡ ~1 in 5 antibiotics prescribed in the US is for sinusitis

¡ Adults with sinusitis miss ~6 workdays/year

¡ Patients with sinusitis are more likely to

¡ Use the emergency room

¡ Spend more than $500/year on care

¡ See a medical specialist

Schiller JS, et al. Vital Health Stat. 10 2012;(252):1–207.Gill JM, et al. Fam Med. 2006;38(5):349–354.Bhattacharyya N.. Am J Rhinol Allergy. 2009;23(4): 392–395.

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ETIOLOGY

¡ Viruses are responsible for most cases of acute sinusitis

¡ ~90-98% of cases

¡ Antibiotics prescribed for 81% of adults with sinusitis

¡ In RCTs, ~70% of patients improve spontaneously

¡ Acute bacterial rhinosinusitis (ABRS) causes

¡ Streptococcus pneumoniae

¡ Haemophilus influenzae

¡ Moraxella catarrhalis

Gwaltney JM Jr, et al.. Clin Infect Dis. 2004;38:227–33.Young J, et al. Lancet. 2008;371:908–14.Chow AW, et al. Clin Infect Dis. 2012;54(8):e72-112.

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WHEN TO TREAT WITH ANTIBIOTICS

¡ Persistent signs and symptoms¡ ≥10 days without any evidence of improvement

¡ Severe signs and symptoms¡ High fever ≥39°C-AND-¡ Purulent nasal discharge or facial pain≥3-4 consecutive days at beginning of illness

¡ Worsening (or “double-sickening”) signs or symptoms ¡ New onset of fever, headache, or increase in nasal drainage¡ After 5-6 days of typical viral URI with improving symptoms

Chow AW, et al. Clin Infect Dis. 2012;54(8):e72-112.

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COLDS

https://xkcd.com/1612/

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TREATMENT OF CHILDREN (10-14 DAYS)

Indication First Line Second Line

Initial empiric therapy Amoxicillin/clavulanate45 mg/kg/day PO bid

Amoxicillin/clavulanate 90 mg/kg/day PO bid

β-lactam allergy

Type I hypersensitivity Levofloxacin 10-20 mg/kg/day PO q 12-24 h

Non-type I hypersensitivity

Clindamycin 30-40 mg/kg/day PO tid PLUS cefixime (8 mg/kg/day PO bid) or cefpodoxime (10 mg/kg/day PO bid)

Severe infection requiring hospitalization

Ampicillin/sulbactam 200-400 mg/kg/day IV q6h

Ceftriaxone 50 mg/kg/day IV q12h

Cefotaxime 100-200 mg/kg/day IV q6h

Levofloxacin 10-20 mg/kg/day IV q 12-24 h


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TREATMENT OF ADULTS (5-7 DAYS)

Indication First Line Second Line

Initial empiric therapy Amoxicillin/clavulanate 500/125 mg PO tid or 875/125 mg PO bid

Amoxicillin/clavulanate 2000/125 mg PO bid

Doxycycline 100 mg PO bidβ-lactam allergy Doxycycline 100 mg PO bid

Levofloxacin 500 mg PO daily

Moxifloxacin 400 mg PO daily

Severe infection requiring hospitalization

Ampicillin/sulbactam 1.5-3 g IV q6h

Levofloxacin 500 mg PO or IV daily

Moxifloxacin 400 mg PO or IV daily

Ceftriaxone 1-2 g IV q 12-24 h

Cefotaxime 2 g IV q 4-6 hChow AW, et al. Clin Infect Dis. 2012;54(8):e72-112.

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WHEN TO USE HIGH-DOSE AMOXICILLIN/CLAVULANATE

¡ High endemic rates (≥10%) of penicillin non-susceptible S. pneumoniae¡ Severe infection

¡ Evidence of systemic toxicity¡ Fever ≥39°C¡ Threat of suppurative complications

¡ Attendance at daycare¡ Age <2 or >65 years¡ Recent hospitalization within past 5 days¡ Antibiotic use within past month¡ Immunocompromised or comorbid conditions


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PHARYNGITIS

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EPIDEMIOLOGY

¡ Cause of ~2 million ED and office visits annually

¡ Costs about $1.2 billion annually

¡ Children 5-15 yo are the most affected age group

¡ Highest incidence in winter and early spring

Hing E, et al. Natl Health Stat Report. 2010; (28):1–32.Salkind AR, Wright JM. Value Health. 2008;11(4):621–627.Shulman ST, et al. Clin Infect Dis. 2012;55(10):e86-102.

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ETIOLOGY

¡ Viruses cause the majority of cases

¡ Rhinovirus (20%)

¡ Coronavirus (5%)

¡ Adenovirus (5%)

¡ HSV (4%)

¡ Group A β-hemolytic streptococci (GABHS, a.k.a. GAS or S. pyogenes)

¡ Causes 5-15% of cases in adults and 20-30% in children

Wessels MR. N Engl J Med. 2011;364(7):648–655.Shulman ST, et al. Clin Infect Dis. 2012;55(10):e86-102.

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PRESENTATION

Viral

¡ Conjunctivitis

¡ Coryza¡ Rhinorrhea

¡ Cough

¡ Oral Ulcers

¡ Hoarseness

¡ Diarrhea

¡ Rash

Bacterial

¡ Abrupt onset of sore throat

¡ Fever

¡ Headache

¡ GI upset

¡ Patchy exudates

¡ Palatal petichiae

¡ Scarlatiniform rash

¡ Anterior cervical adenitis

¡ Exposure to GAS pharyngitisShulman ST, et al. Clin Infect Dis. 2012;55(10):e86-102.

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TREATMENT

Drug Dose Duration

No penicillin allergy

Penicillin V Children: 250 mg PO bid-tidAdolescents and adults: 250 mg qid or 500 mg bid

10 days

Amoxicillin Children: 50 mg/kg/day PO once daily-bid (max = 1000 mg/day) 10 days

Benzathine penicillin <27 kg: 600,000 units IM once; ≥27 kg: 1,200,000 units IM once 1 dose

Penicillin allergy

Cephalexin 20 mg/kg/dose PO bid (max = 500 mg/dose) 10 days

Cefadroxil 30 mg/kg once PO once daily (max = 1000 mg) 10 days

Clindamycin 7 mg/kg/dose PO tid (max = 300 mg/dose) 10 days

Azithromycin 12 mg/kg PO once (max = 500 mg), then 6 mg/kg PO daily (max=250 mg)

5 days

Clarithromycin 7.5 mg/kg/dose PO bid (max = 250 mg/dose) 10 daysShulman ST, et al. Clin Infect Dis. 2012;55(10):e86-102.

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BRONCHITIS

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ETIOLOGY

Viral

¡ Influenza

¡ Parainfluenza

¡ Coronavirus types 1 to 3

¡ Rhinoviruses

¡ Respiratory syncytial virus

¡ Human metapneumovirus

Bacterial (<6% of cases)

¡ Mycoplasma pneumoniae

¡ Bordetella pertussis

¡ Chlamydophila pneumoniae

Harris AM , et al. Ann Intern M ed. 2016;164(6):425-34.

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COMMUNITY-ACQUIRED PNEUMONIA

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EPIDEMIOLOGY

¡ Most common cause of severe sepsis and infectious cause of death

¡ Eighth most common cause of death in the US

¡ 60,000 deaths in 2005

¡ 20-40% mortality rate (depending on severity)

¡ Incidence rate of 5.16 to 6.11 cases per 1000 persons per year

¡ Higher in men vs women

¡ Seasonal variation

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ETIOLOGY

¡ In most cases, no pathogens are detected¡ Viral pathogens cause ~1/4 of cases

¡ Human rhinovirus¡ Influenza A or B

¡ Bacterial pathogens cause ~1/7 of cases¡ Streptococcus pneumoniae¡ Staphyloccocus aureus¡ Haemophilus influenzae¡ Atypicals

¡ Mycoplasma pneumoniae

¡ Legionella pneumophila

¡ Chlamydophila pneumoniae

Jain S, et al. N Engl J Med. 2015;373:415-427.

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Jain S, et al. N Engl J Med. 2015;373:415-427.

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CURB-65

¡ Confusion – disorientation to person, place, or time

¡ Uremia – BUN ≥ 20 mg/dL

¡ Respiratory rate – tachypnea ≥ 30 breaths/min

¡ Blood pressure – SBP < 90 mmHg or DBP ≤ 60 mmHg

¡ Age ≥ 65 years

¡ Score can be used to determine setting of treatment

¡ ≤1 – Outpatient treatment

¡ 2 – Inpatient vs observation

¡ ≥ 3 – Admission (possibly to ICU)

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OUTPATIENT TREATMENT – TYPICALLY 5 DAYS

Previously healthy and no use of antimicrobials within the previous 3 months

¡ Macrolide¡ Azithromycin 500 mg PO x1, then 250 mg PO daily¡ Clarithromycin 500 mg PO BID or 1000 mg ER

daily¡ Consider alternative if >25% of Streptococcus

pneumoniae is macrolide-resistant

¡ Doxycycline 100 mg PO BID

¡ Amoxicillin 1000 mg PO TID

Presence of comorbidities or antimicrobial use within the previous 3 months

¡ Respiratory fluoroquinolone¡ Levofloxacin 750 mg PO daily¡ Moxifloxacin 400 mg PO daily

¡ β-lactam plus a macrolide (or doxycycline)¡ Amoxicillin 1000 mg PO TID¡ Amoxicillin/clavulanate 875/125 or 2000/125 mg PO

BID

¡ Cefpodoxime 200 mg PO BID¡ Cefuroxime 500 mg PO BID

Metlay JP, et al. Am J Respir Crit Care Med. 2019;200(7):e45-e67.

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NEW ANTIBIOTICS FOR CAP

Lefamulin (Xenleta)

¡ Pleuromutilin – protein synthesis inhibitor

¡ 600 mg PO q12h

¡ Non-inferior to moxifloxacin in LEAP 2

¡ Has not been studied in moderate or severe hepatic impairment

¡ Potentially lower risk of Clostridoides difficile

Omadacycline (Nuzyra)

¡ Aminomethylcycline – protein synthesis inhibitor

¡ 300 mg PO q24h on an empty stomach

¡ Non-inferior to moxifloxacin

¡ No renal or hepatic adjustments

¡ Low risk of Clostridoides difficile

Alexander E, et al. JAMA. 2019;322(17):1661-1671.Stets R, et al. N Engl J Med. 2019;380(6):517-527.

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INFLUENZA

Treatment

¡ Influenza A or B¡ Neuraminidase inhibitors preferably started within

48 hours of start of symptoms¡ Oseltamivir 75 mg PO BID x 5 days

¡ Zanamivir 10 mg (2 inhalations) BID x 5 days

¡ Peramivir 600 mg IV x 1 dose

¡ Cap-dependent endonuclease inhibitor¡ Baloxavir marboxil 40 mg (40-79 kg) or 80 mg (≥80 kg)

x 1 dose

Prophylaxis

¡ Influenza A or B¡ Neuraminidase inhibitors if initiated within 48 hours

of start of symptoms¡ Oseltamivir 75 mg PO daily x 7 days after exposure

¡ Zanamivir 10 mg (2 inhalations) daily x 7 days after exposure

Metlay JP, et al. Am J Respir Crit Care Med. 2019;200(7):e45-e67.Uyeki TM, et al. Clin Infect Dis 2018;68:e1–e47

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PREVENTION

¡ Modifiable risk factors

¡ Tobacco smoking

¡ Alcohol use disorder - treatment

¡ Acid-suppressant use

¡ Antipsychotic medications

¡ Immunization

¡ Influenza vaccination annually for everyone!

¡ Age ≥ 65 years

¡ Pneumovax (PPSV23)

¡ Prevnar (PCV13) is optional

¡ Age 2-64 years

¡ Pneumovax and/or Prevnar for high-risk groups

¡ Hib for high-risk groups

Mandell LA, et al. Clin Infect Dis. 2007;44(Suppl 2):S27–72

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CONCLUSION

¡ Antibiotics should generally start as narrow as possible and broadened in the case of resistance or non-response

¡ Treatment duration should be as short as possible

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QUESTIONS?

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common infections in primary care · 2021. 2. 16. · uncomplicated uti ¡no structural or...

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