Antibiotics & Common Infections Stewardship, Effectiveness, Safety & Clinical Pearls OTH aA0 Le 1 Viral Prescription Pad for respiratory infections (download or order for free) ‘provides information about symptomatic tele for viral infections and indicates when patients should consider a return visit ‘2. Talking with Patients about When to Use Antibiotics provides communication tips to effectively address requests for antibiotics for viral infections. Enhanced communication skills reduce antibiotic prescribing (27% absolute risk reduction - ARR) ‘8. Posters for office A poster displayed in the practice waiting room stating a commitment to reducing antibiotic use ‘reduces inappropriate antibiotic use (205 ARR) ‘http://www.dobugsneeddrugs org/wp- To the Patient + Lin 5 emergency room visits for adverse drug events (ADEs) are from antibiotics + Antibiotics are the most common cause of ADEs in children, accounting for 7 of the top 15 drugs leading to ADE-related ER visits. + Antibiotic associated diarthea, including Clostridium difficile diarthea + Cardiac - QT interactions with clarithromycin & fluoroquinolones + Central nervous system (CNS) adverse effects (eg, dizziness, headache, sleep disturbance, seizure, encephalopathy) + Hyperkalemia (cotrimoxazole) + Skint minot/major (eg. cotrimoxazole) + Tendon rupture (fluoroquinolones) + Risk of drug interactions (warfarin, statins/ macrolides, .) +f risk of secondary fungal infections +t risk of an untreatable infection in the patient due to bacterial resistance > To Society +financial costs of treating adverse reactions (USA’ $20 billion in excess healthcare costs) + antimicrobial resistance: more difficult to treat infections over time, leading eventually to no adequate optionsAntibiotics & Common Infe Dealing with Pa ns — Part 1 Table of Contents Common Infections — Part 1 Stewardship, Effectiveness, Safety & Clinical Pearls Bronchitis, Acute Community Acquired Pneumonia (CAP) Pharyngitis Sinusitis, Acute Oral Antibiotics - General Overview Pregnancy/Lactation (Oral Antibiotics — Drug Comparison Charts, Penicilins Cephalosporins Macrolides Tetracyclines Fluoroquinolones Antifolates: Sulfamethoxazole, Trimethoprim Other Clindamycin Metronidazole Nitrofurantoin Fosfomycin Linezolid Probenecid (wed. pote etectie ek ofecol) Vancomy int’s Expectations & Demands Non-antibiotic Rx for Predominantly Viral infections We asked some clinicians... Getting patient buy-in. 10 10 el el 12 12 13 13 oa ‘Acknowledgements (nove dente ore) rales & very pleased to acknowledge those who comtibuted to Part topic development & review Overall ABK topie/project guidance: tynette rosa act, aes lorenregier Pharmacist, ties Tessa uscher Family Phystian,saslatoon ‘Wome Shevchuk Uo, colge of Pharmacy Fam omonoski RN (NP) Uofs student Health Linda Sue Pharmacist, QAR sastin ora Pharmac, SHR Stevaniship ‘Casey Philips Pharmact, ROMP Stewardship ‘Content development ~ABX Part ‘Pharmac, RFs Topi ead Pharmac, ares Pharmacy Reset, SHR Pharmacy Resim, SHR Pharmacist, ties Co Lead ‘andrew Pla rachel atin, laren regi Topic input and review: ‘anne nguyen Pharmac, 8 frentuensen mac, aes e5ska Minion ROHR Microbiology Si Bkser Farrukh Family phystian,sasatoon dea SHR erebioby ‘ohn alport, Family Physica, gina ‘omathan ey family Phyrkin,salatoon Nears tess Pharmacét, ties Nore tices Family Physica saskatoon Feil tccongle Family Physica, northern sk Roger srstol Emergency Hed, SHR ShaqilPeermotamed 10, SHR infectious Dsease Tomsmth Windsor Family Phystian, Prince Abert ‘The pele academic detalng team [2ck Dum, ‘Vaughn ohnson, Tana Nistom, Lisa Rutherford, Brenda Schuster, Pam rarbon) Debbi Bunla,cobtte Molly Mestenmolloy com) ‘Coming up next, Spring 2017 ‘ABX — Part 2: Skin Infections, Acute Cys! www.RxFiles.ca Sometimes no prescription isthe right prescription, Prometing SEE Cam annse SP a P92ACUTE BRONCHITIS: Management Considerations vay faFilesca © Oc 2016 eR eS fe Antibiotics are NOT recommended, as bronchitis is predominantly vial. J» Advise on treatments that wl provide symptomatic rele: maintaining hydration humidity. Cough suppressants may be considered for managing cough & inhaled bronchodilators wheezing is present. Haney may help children Js Patents should se their prescriber f:3) symptoms worsen, 2) new symptoms develop (eg. dyspnea fever, vomiting, 3) cough >4manth, or 4) 3 episodesiye lnopprepate aria uels rngrestane Gleningte ws, ene ‘tonne yur own prescrbig races Refer te nenlter cover, «The major osc uncompleted bones oes rie (90K in ads 8 sooo ndien «hats ae NOT recommended frase uncomplcsed recht Seer Pers ssening theese af ambit ferthsindesionove eles Sema benef hawever upto 80vef ons nthe US, sleecveen mbt « hate ncompheved bona seeinging Cou wea pease 103 creat othoug upto 3% fracas ve cough boone 3 wel. ‘way precy moy st upto Sweets Recommend Sper mnogement « Aaaecomplested bones (eg histor sneing mparesngtuncon Cronchean dare mmunecamprombedl my reuetunhervesgaton (ce mgtnctontexn chemeron + Rule ut noua eae gem preset M0049, AR >28 breana/nin ealtempertres3B or tings ofc consoaten « Coteured sputum ceesnot ety feremine between beer era gn 1 Fevers uncommon & may beinleve of nec or peumeia {ite pun hes cnfmed pers se ees pe 78 ter ambit reEmens. Uncommon bu hee ne ecaionaleutbrea Erenageecanton 2 Viale. Influenza &, influenza B,Parenfuenza, RSV, & Adenovirus SES aoe SST "Antibiotics are not recommended for acute uncomplicated bronchitis ‘+ Multiple studies & meta-analyses assessing anbiaticsforthe treatment of acute uncomplicated bronchi have showin no banat or modes improvement, alongwith an) isk of adverse events ‘+ For example, 8 2016 Cochrane review (17 RCTs, 3,936) evaluating antibiotics (etaactams, donyoycine, macrolides, TMP-SI6X vs placsba found no difference in clinical improvement. Antibiotics W cough (NNT=6), night cough (WNT=?) & mean duration of cough by 0.5 days, but risk of adverse events (Wwe, primaciy gatraintestinl related = maintain hyaraton + humid Pm i hmiititointain Mio evilence froraganet tydration:cautin in HF & CKD patent ‘Mumditr-clean frequent to rskot tacteriaturgigrovah 3050% hurd) Wo stong evience ororaganst. ‘Cochrane review (3 ACT, res): betterthan ‘pacebo, but infer to dextomethorphan i cough frequency Cough duration not assessed. Hay J numberof coughing epsodes but does not duration of ess, 3 | honey 25 som pos eerie Desaromethorphan 084) 1030mg poae-thr PRN Tied erence stay wh note wa, tay J duzatonat cough in patents with whering/aiefow obstucton when wed 20k ‘sabuamot ‘ones 2 puts ina a [WE MAHER eo toe enou e Uinited evidence sto, = 24 fr veel ‘pratropum "2" post infectious cough ome 4 puts 10 ay improve daytime & ngheine cough, & Ayepnes sociated with coughing + Encourage prevention eg smoking cessation, U exposure to second: fand smoke Not routinely recommended for symptom management: 2 oralorinhaled corticosteroids ae not recommended in patients with acute bronchitis without asthma x Expectorant (e.g. guaifenesin}: most evidence failed to show a benefit Should p= 65ysbe rested with an ABKto the rok of developing preumonia? sie ber paespresetng ah se prcumeniashulsundergsvesgien (eg. chest x-ray). + Rprevousrevospeive cohort dy (194 t 280) suggested that nde wr nae bonchts whe ere ssyen may ene om snes (Mo prevrteséional eet peumerain the ment olewng act ences ‘was 39 for those 265 years, & 198 for those between 16-64 years of age). + However 201581 oc 103 companng ames 200m 90 D7 ote proce showed ne sferencem duration or svetyet symptoms up emer feqrlss of ag Thee wos on fake ave eves frauen tah dae stave omosthin grup NEED Pa‘COMMUNITY ACQUIRED PNEUMONIA: Management Considerations vay faFiles.ca © Oc 2016 See ee Js & chest xray is recommendedto confirm suspectaé pneumonia Js The CRB-65; andiac, pulmonary, Ta recent uea Favalobl, nay we CURE «5 where SUN>7mNMOVL=a pom ‘See fates page 90 for information on Cand peda patent reralorhepit fale; smoking; akoholsm; malgran; OM; malntrion oracle ‘eh bss 05%); mmunosuppresive tx iculingcorcosteou we (high-dose >30 ay]; hxpaaleation or broad spectrum ABx in past 2 month, H/immunsuppreseed “cite sven oueaaeras me Lo Ta BODES os TERETE napus Paarane DTS RY reoteuurs pope ngs cusone rath gon sO Dene Covel amo Sesnrweon ea Mpc Sesmowen teeter PeCOMMUNITY AQUIRED PNEUMONIA: Management Considerations ‘Duration of therapy in adults ‘+ Teatfora minimum’ days & untiatebrie for 4-7 2h. 1 Meta-anahees 15 ACs 2796; 5 RCTem,303 comparing teste durations of 12 days to>? days shoved no dfierence ncinkalsucces rates nambubtny Pe ‘uithromycin v5 days: ited data avaible comparing the to regimen, but there does notappearto be aditference meticacyorsaety. Due tothe ong 0 ("62 hous inaduts), 2 34ay couse ofaztvomycin s nessence proving therapy ejond 3 aye. Patients may stil felunvellat Cay 3; reassure AB stil orig POSS "Gicomplcated= ie CAP healhy Fomunted Chdren without under ng Pulmonary yathooy aise fom mil eave ava deease uration of Therapy in Pediatrics: The standan duration rain 7-10 days fsception: ‘rthvomycn) One srallstuy (140, ages 6 months ts yeas) in Sraelconlaled ‘hats days vas pot inferior 1020 days, but 34ays was asocated with 7 falure rates. sy Ragiesce @ Oct 2016 Ru DDonyeyeine as 22" ine agent 1 Lmtd evidence withdoxycjtne for CAP- However, ithas 5 preumonice, > influnaoe, 5 oureus& aypkalcoverage; achieves hghserum& lung dr comentations;and hs comentation dependent ling + Monotherapysufelent for mast athough some caradian erences suggest the ‘optonot combining doxycycline witha bets actamdue to concems wth doxyyeine resbtance to pneuonce.cument, 5 pneumoniae bas good susceptbltyto Aoxycjetne insaslathewan, & therefore the combination 6 not necessary ‘+ Most guidelines suggest 810 (200me Day 1, then 100m 810) regimen; however 100mg po B10 Ga 3 flowed by 100mg dally maybe sugested duet ts og tat lie aahraher fist dose, 2ahr wah multiple doses). Data comparing the etfeacy ofthe ‘wo regimens mite. anecdotal, tte day generally tokrable ‘Vaccinations: + Recommend an annua influenza vacing, sth can J the rebate rékot preumonia 153%, hospaleation by 50% & moray by Upto 68% onenatoreloem,snorege 65 + nacommend a PHEUNOVAK 23 vacie for thor 265 yea fag, orate rk regatdesofage (eg. D4, CKO, honk candor pulmonary dase, LTC sient, Immunecomproméed) ‘Overa 2 year period, PMEUMOVAX-2 prevents cas of preumoniaforevery312 immunced Ee resents DPREVNAR-13 stuties showed 2 in nase preumococeald ease, but rot overall preumona res Neither vaccine type has beenshownto pneumoniespecteoralkcause moray | PEUMOVAX 2 booster [5 yeas} may be consiered i hgh sk nda, although ited and based onthe theortal in iit overtime. ‘when coverage for typical pathogens needed? + -ypiabsare thought to be esporsbk for"15% of CAP, & maybe more common ia ‘the folowing popubtins "veaneumonie in yung, healthy aduRs (CAP uruallyresohes without ABs) preumonioe in Cresent, immunacompromied patents, orthore with ‘maple comorbaites. acute oncet of symptom unbley +The ok of 8x withatypealcoverage nother aduhs & uncertain. CaS wasa non inter sty compariag a bets-bctam #2 macrolide foratypcal athogen Coverage, or2furoquinobe, i 213 patents inthe Metherands Median: age 70 eas, CURE 65 sores1. "40% cOPO/astna, "20% CVO, “15% DM. Bet-beTam ‘monotherapy vas nr inferorto the other 2 eatment ame forthe pray endpoint [aleaure moray) + asx vahanypialcoverage ot nated erpircaly, consider aig atypeal coverage leg adda macoke to arora amos ortho done lin the patient doesnot improve in 35 das orsymptons worsen‘Management Considerations vo fafa. ca © 0 2016 [ReneS fe the mary of plarngn cases do NOT require amber as they ae Vial infects (200% nad, 705 ince). J. Phares typical se bting ohen 37 days; upto <0 days). | avalistedclinealdecsion ule eg mastescemorcon can bel ent bv ekytins \whodo not equi gnostic testing (ee below oramtbites | Forconfimed Group Steptococcs (G45) ary, penelinfor30 ays 8 the dug, lofchoke. Them tno documented GAS ean to peniclin, | advice on treatments that wllrviesymptomatirebt SAID, acetaminophen, medicated throat kzengs,topkalanesthetes, warm quis | rates shoul se their presciter 3) symptoms worsen, 2/symptons tale bnger ‘han 3105 das to msobe, £/or 3 unisteratnacks eli develops ath fadue Ohochae do HO musics a cio eh a 1 fateh waa sive st subshoul meee onambot wth het Compton See nolfedConbsconcon Eton Sabet abe eb = Thetuwarou! ine bribeat nb eusan oleae Povee omens ‘Sane whiny tempat nconimed CoS wile erate Re « taubinis an fared empha eae sts drconned¥thent sea epi Groups steplococtis 685) pursterrceupcee Sreepsoroeque sme) EMPIRIC DRUG REGIMENS OF CHOICE & SUSCEPTIBILTY CONCERNS Tapa Tare ae TAT ———— lvoanebitc |-onyuantmerts mcontimed | cemre mee fecter phan. as ie TERY HOOT TW oe ow «+ Avalifated clincaldecion rue, lle the modiied Centorscore,can be wed to help peicainy | yg aDuaisnmcimum7soneéay | seecrumotactiy, tac, env eekyates who do nt equ dagnete esti orem sare To Aay, | sy wc cts i Soe = OST ear pT “eg COE Ts nS 7 lamosctn "10das (nau sc00me/day|-boder spectrum han Tiana H dure 3006 8x30 imeure ar etctve Sts Sa eeTET t Inu more pi eee ace t ‘ciuinn Teitee 7 ena ae RRRERS ERY a ether o Pee OTe efiay = HOCTOIO | vo docoaned IRE ao i cepatxn ‘Goda (earmmum c00melny | woes Sere | Ravcioopecmc econ aw ut 0 3044, Tmo Teas eave mst Soong 0304015 . tem Serertcrermert || lameanaranzncr res pean ar SRT z sae Joona ste loving soGOUcr ane ontined GU contrat Type TIONS 2 were 1abTer sat enbr cote enti due wcomene wih Pastas to martoMer fodvene sete. y ao vibe read see Pets 2ong/ig/iay= Todays) Marah carsieraonr Se a aeRO RN aa ls Soong DEO Saqemorosetuormeiss eTymnttiente Sooner weattow arnchien Feit ingiiglin Tied BOAO] én orbacerteraeston «+ Dagrort wstg ot commended esremomycn| (ncn sone da) tres aus, bot Cmodied Cenbrscor of dune ong a1 3095 qubaborcatcon {pons of al sect meng eno, ae SH a ‘seins one aah = Eby, unks other rekfacion eg suing wines imcton mone noe erythromycin ‘dO days (maximum 2000me/day) | erythromycin, _cinomi ct i ihe page aduteas0ng a0 10 ay sathronmcn 355 dys no + tsceptanthe oid cen som muy eot ccm pred ro A dig asus soi ee aoe chm in con my nc aeieg ema ie “tlubrhear deesse orimmunosupprssbn Use cinealjugmem Scomsertetie | [athromyein Lean i rocerthe come ot (Panr/hoatsuab) move badly. ‘Adus:500ng 0ay 2, 50mg Days 25, ‘orsoomg dai 3days therapy ie Cong 5 patPHARYNGITIS: Management Considerations ‘Duration of Antibiotic Therapy + Confirmed bacteral pharyngis should be tated with 20 days of anions (excepto: fazthvomycin sued in enciin allege patients; other options aval) + Pains il hy have lincaimprovement within the ist few ays af therapy, but20 days oftherapy i recommended fr preventing acute rheunat fever, 6 shor courses fate note efectnveforteating the incon, 1g 2 mete-aa}sés comparing vs 10a of penkilin (2 CTS, m=308) concluded Short couses vere inferior in achieving facta cure, ORO29 (195301306) SEM ee. tbupofen pon v asocated pan nore & | peds:5-10 mete po. ‘than acetaminophen & placebo. § | 'naxmomsoneay pede fees 2 | sauroone poqeane ren 3 [acctmopien™= TE eR Tan TERN BT E | reasaossng/gpoqwehrrrn) | msocatedpanbut move efctve 6 | Pcsumnts monet ‘tan peceto | ® | adune:sooome poceehrenn | - peducs fe ; var en pa FAT 2S penccane toncosine | eu Bf sores err =a + concerns vith methemogbinemia No evidence, but anecdotally may ere! Sepmye@20 PR) rte velit fromassocated pain > Gaiglng or drinking ware ius |" eg varmsahvaterrime,tea | Uttkeviteme, butanecdotahy E | semydamie "asm | prove relat tomassociated pain aig or tne g2 53h PR Nat recommanded Tor symptam management + Routine we ofcontkorerils induration of pin not considered clink Signiicam and nsAlbs/aetaminophen have bss adverse events * Chinese herials:nsuffcentevience to support se. patie iss, encourage 2 product wha Natural roduc Humber (WP Peniclin vs cephalosporins vs Macrlidespencila remains the ano of choke «There no clinically rekvantdierence nsymgtom resoluton between the various anes + Penkila hs the most evilence for preventing complications; has 2 namow spectrum; ‘etfcaious sate, expensive; there & no documented resstance 10 GAS. yaw failesce © Oct 2016 ‘Whats the rik of acute rheumatic fever? + Incomada, the current prevalence of acute rheumatic fever 60. 10 235s per 300,000. “The incence in some remote, Caradian aboriginal communities maybe higher (ie Norther ontario 833/100 000) ‘The kay abo be higherin imangrat romendemi 235, <5 Phipps, Chin. + Reditfcuk to estate the rekot acute rheurati fever due to Unteated pharynge: 35 the mojo ofstulles comparing ambotis versus pcebo were conducted Prior to the 1960: (higher ae face rheumatic fever, adn young mas fom fhe US armed Forces). bacteria versus vialetbbey vas often not confirmed reverstalies lave ether no documented cates ofacite rheumat fever or did tastes the outcome + Imanefto to bance unecessary antibiotic use vth preventing rheuratifver we the modified centorscore to ently patents who equi a throat svab/RADT waitto prescribe amtibetis unilthe suf ofthe that swab are avaible + Stang amibots withing days of symptom onset prevents acute rheurati fever + Hamibites are stated empirically, dcomtinue if throat sab &megatie + dhldenare ata geaterrskof complications feg.otts media, pertorsilar abscess, rheumatic fever}; may inate amtbiots soone + fula0day couse of penn recommended forconfimed GAS plaryngi Pharyngitis caused by chlamydia trachomatis + Mirae that chlamydia rochomaticausespharyngte, bt rates appear to be 4 nek acts include: age 15-28 eas, sexually active, engagement inorlses 1 insaslatchevan, chlamydia trachomatiesemening requies a daferent Bb equrkion ‘+ "Testment: doxycjtine 100m po Dx 74a), orartromycing x3 dose Managementof Recurrent Pharyngitis + Potemlcauses recurent pharyrgté duet inadequate eradication, new nection, Vial infection nanasymptonate caierc ote spuntonne case + Contovesialas to whether or aot asymptomatic carries with recurrent pharyngitis ‘eed tobe Mente * Mlentiiaton may telpavol abiotic in those with ecuret vial pharyngitis + vol ienttying asympomat cares without recurrent pharygis 1+ Ako conier age, season, srs &symptons to ru outa valet bee mod ed ‘cemorscor ‘+ Avod wing continuous long-term antbitk therapy (le repeated couses oF ropha), Ganong cngmitnumerenea otmttabiapeontpnartaag eeACUTE SINUSITIS: Management Considerations SN CTS fe Mas cases do NOT require antibiotce ax 98-99% of infections are viral | Vial & bacterial sinusitis hve similar symptoms, but symptoms that ‘worsen or ae prolonged (210 days) suggest bacterial involvement Js Advise on treatments that provide symptomatic elie: analgesics, saline nasal dops/rinses, decongestants, warm facial packs, & corticosteroids. J. Amoxiilin ithe antibiotic of chaie for bacterial sinus Reserve macrolides for patients with true pencilin allergies. |. Patients shoul se their healthcare provider symptoms worsen or take| longerthan 10 daysto resolve [RRS ‘Inappropriate antbitic uses driving resistance & leadingto 3 eis Please amine your ow presebing practices Relertomevskter Cover, cure smwusrris Acute stwustris Sate mac TacRIAL (EE Vic! sinus: antboties NOT equied DE vctort snus: ameiones no! requves [ toctorl sists moy require antbotes + Prediion rules have been developed to help distinguish bacterialtrom Vial sinustis However, ue to limitations with these the guidelines instead focus on the prerance& duration ofthe above 3 symptom. Acute vial siustis symptoms tend to improve within wk" siorE on «The colour of mucus should nt be used to diagnasis a bacterial snustie infection (indicative of inftarmmaion, but nat of bacteria) « Snustis is set-simting “85% of bacterial cass wilimprave within 2 ‘weeks without antibiotics. n other words, au of 2000 patients presenting wth snusti, Sto 20 patients would have bacterial sinus, ‘nd ta 17 of these bacterial cases would recalve without antibiotic, + Compared t placebo, antibotes (beta lactams, macrolides, FQ) have not been shown te Wauration of pain or illness. The NNT far cca, improvement is high (NNT=7 te 48), a sstematicreview including patents with symptoms fr 27 days failed to show a benefit with antbioties. Antibiotic AE prem liehted were common (NNH=BEG32) sy fagiesce @ Ot 2016 «Sinus complesions are verre ef eral racial or sof tissue nfeians See fla smptoms annex page. incdence's sr among thesetrented wih ambos ers plaesbo (0) + Sinus very rain cre (3 yea di to underdeveloped snus cave. To bcetaranophen No guatyevsence but shout |" Sosinerceaionuearsamal|vresnatecset 4) Scie penn nese 8). ones" 3] s-ome/le qo-ahe (max 40mg/ke/ day) saamgpogethe rt 7) tema aa Daas TT 4B] Bepapnrageaon om tn tive egson 8 pomotsbur 8), beameriarne = sale 8) -e2ay1s: 30mg po.gs- hr PRN imax s20mgis} | - Topical preparations: less systemic 8) “Btwecctuscsoneoaearent | sttmpbnlontat cy cro, to 8] Srl neue 3sanrie pment own sjgsore TNTRANASAL: modest effective for pain & rasal congestion (MUF35/2 3), {5 placebo. ay kssensymptons by 35 days AE (eg epitass, nasal hig). CORAL: may prove benefit fr severe Sinsaé, a combination vithanamboti (wnt? orsymptor improvement oF resolution Wo benefit with monotherapy Tio quality evience butanecdotaly may promote mucus dairage ‘Anecdotally, nasal drops pays may el {imted confiting evidence with rasa ligation; may Vaymptoms, quality of lie, Pmucoclarycharance & Vase of TRTRAWASAL [ot ommended RSTAT Je Fteazone "50 meg 2spray 0 ach nortilonce di = Mometarone "50 meg 2%0¢spra¢ each ort tie day ona (nly forsevere sinus) + Prednzone 4010 cong po da 7 days [> warm bcel cls > saline sal drop rses/evigation| 350m hypertonk saline fasairgation Sect nee saline spray spray TaD PRM other sine medications. 's watchful waiting an appropriate option for patients with acute sinusitis? “+ Most sinusitis cases improve without antibiotics. Watehul wating should be considered in patients who: = present with symptoms that have not worsened, or = have had symptoms or less than 10 days, and = youteel confident in their abilty for fllow-up (/e.antibeticwillbe started ithe 2aeatesinusis symptoms fist improve after 7 days or warsen at anytime) “+ Write a prescription that is pat-dated for when therapy may be inated, & instruct the patient o call and inform the clinic they flthe prescription,ACUTE SINUSITIS: Management Considerations sy fagiesce @ Ot 2016 5 preumonie.Hinfercae M. carrots (nen) oueus fa to MODERATE pnp cider ne werenng symtoms) Ineantwone_proe swotrerram Ta eo io MODERATE mom si dp or wow 7 OT TeeLaSSOnETeans err | preteoneesare *s0 dap (rmimom fay) | 1 dore src, ‘Amoxiin trem tobtes wth ‘dts: Soong te 1000 po TD vt ws aode intermediate urceptbily. SEVERE ever S35°C AND purulent nasa aScharge or acl pana as] or TREATMENT FALURE WITH AMONICLLIN Symptoms nt reslved after day) nonin’ | Suita vn wD aOuNS ven Hol tecomnon Ctowtonate_| (85me/i/tay amore: #10) teralptteger .caeaanae, | smelter amenciins | sadnonotcaraoae F dussd0me po 10 (ork?smg po, | SSKOLGIAE ies? min Dota eS aks iokgae | Srmarena tossing tt) pen ALLERGY: ew HERSENSTTNTY (og a] es: 3-0 gay = Bi (ras 1000ng day TaOaa Jaduts: 30mg 0500me po BID s5-10¢a)5" ERTS LENG: TE HVPERSERSTITY (apy) ceturoxime Doweydine 200mg po Day 3, then 100mg po BID 5-20a)5* artery [Seb oo oom youn 2T0Gms™ [Pease ay, henge dally Uns 5 asiromycint |" (manimamsoome bay 3, 250m Daye 25) |,cuns:s00mg po bay, then 250mg po dail ays 25 uration of therapy, i neding to eat with an antbiotc ‘+ nbealthy adults Sufering fomsinusit, shor couse eg-5 day) have the same beneftas ager couses of therapy (eg 10days), wah ess harm. «+ Armetaamijre (12 nes, m-4430] found nodterence ncinealsucess (cue oF Improvement ofsymptone) with short couses (3107 day) versus bngercouses (6 to 0days) ofthe same amon Asenstnyaraist (7 ATS, e275) comparing 5 vets 30 daye Ul not da dfernce inchnkalsuccets eter Overal, there ‘nas nodlerence madvere event However, inthe sefetwtyanalse (5210 days) shor courses had fewer adver events (ORO, 95% C10.62 080). ‘+ OWler gat ith comorblaiee wave escluled fromthe to, and therefore we do rothave evidence to suppor a sorter couse of therapy nthe popubtion ‘+ Alonger course of therapy e310 days) stl ecommended force based on the aatible evince, fanowclinweanonetin/cantanate Pinon conte the amb of choke de ose say ow cot taro spectrum &.qanty of ese erste abe forthe ton + hnoulin cos ¢ pneu testhe ms of hose smoxtln [2000 pT, rvomeleay inchion erent sobs wth intermediate suse + Anon dovate posits boner cong, spc ftalytovars bt bcamase pduing inter eg nfree cate) novever te oon ot ‘Mobis tthe ekafctodene sven The igeraness inc ierat a SThhe nb donne (5) Vth het medertelserer darian 1a D3. {21039 MBE, maybe mow coment, «ter highdose amon oromoncii vuanat my be prefered inte fovig pate utente nthe pst moat Xow yon ver mir icon ee aeenemcywtnigense ‘rent espaaton inmunccompomse «moi oanste maybe peered inthe folowing at Teathcam pone (CEretombet whch inde orteaed nia pire symptom orate otsnute {entmet te wih amos Comores eg dabetes ocho cad, hep or nme) Soterorespsd secon nf sre nthe ane hose «+ bonyeytnesacres aloft potential pathogens ‘When should patients with sinusitis be refered toa spacial? ‘+ Recutent Sinusitis: nt epodes of acute haceralsinsts/year ‘Nelterantibotes nor nranaralsteros have hovn' eduction athe recurrent sinus epbodes Conder assessment forages, immunologk deficiency, orsugery. + Chvonic sinusitis 212 veels of nfbmmation pls 22. the follwing: mucopuruent Acharge,nasalcongeston, fac pan pressure fulles, or V sense of sme ‘Conder invarasalcortcoserols saline irgationfrsymplom maragement repeated couse ofantbotks are sot recommended Consider referalto an a5/Mose/ Throat spelt above measures fil ‘+ Alarm symptoms for urgent feral to Emergency Room: Systemic tov abered mentalstatus; severe headache; sueling ofthe oni or Charge invoualacuity; back, necro tasue or dchage E=advere rents CV=andvascb Etceeaded ease Fforoqinah ae lst Paoral Antibiotics: Overview wu mtience oc20ie +aimun inion Concnoaton (Ge erent stained wt tem ‘Mime Common opndar ig inept ns Spee ee nections, 2d dabete fot ake Antic oi wh god city inlade mevonicee hada ml amc ‘itp becerieg jeopeme, Chamydophis,lagonela There nce bck eval A eh the paste viewed sadersgamebinsedare rata ereutto bes bee Satincoba wit good tty mcade mace otouiobnes ted eee. eg Eended Speci Blea maze (EBL on ts an) Onan podaig EBL ten to be mrstant 2 fertile aeeplabsporinr, rely sltra-acum/bethcmnasebasorcombuastone sed ray sho mubidag estuace othr chase eg meeps fates cee) the Aegis Gu pate Heb Pegs n 1435 of col xed D994 of ebro praumonayeabte vere EBL porte NISRA Mo oh arenas anceps Hover any Sephever alae patil, ose. a}ampil veh ns hse pac rd ychy ie it meth ila ear tne Singh ures SS _aibotes During Pregnandy/iacaton ‘ephalarparn GeneTions eR Wo Tae on DSROAUOTONE eaten cle efuosie 0/8) ete po) ete V4 Ethene sor aT etpetpe) ceemove Ethene abe aT fet go) caine (1) Teton / Chitin conte Wa) ebie (N/0) Trey 7p Tnpeniclinalerpcprtents, how ili cepaleporin coarser? ‘ovinonet eauonamaee ‘Which anirbilare most sociated with tid df cle? tla nettoaze ys withortsathoteexerve Mostantbeter ca Zoe he wih cme OR W 2 stot expe). Daan Which antimicrobials re most eocted with QT prolongation? ferpuenatsehef OT pobapninn tectoppent penestwrth maces kb, Sinker nthe] 8 fre testo‘al Antibiot Fr enc rag poe onc civ ell neous caren emorene Pi ge eg uh reer oming sara meng fre BRIBES cfopear acon rel eee Aopen macs ef bce 42 a enen0 ter) an si wcsaatay ous outorncrpe nave Bug clrapee Tw pnclnamaryecsegy 050 rsopaton ] Ana clin wnaienvie meena © wrow.etiesce Oc2016 Peas s0scone/eay ave oh [57 Tau Soong reqevonenptstomsas[s8 tae Dooney ss Eo «El “xpi Tana TSR ST SN MANGA Pood NSE & * pitinten earinnoue ere sacon os weeuiayaren Vermanan Tana ag | ene a eR en aT AT ls ‘Adu: $00 100076 lsz232 ‘Max: 4000 so00m/48) a0 ‘amox/Cawlanate CAVUNE & Soegseamoulincngorere Cava conyret "iver mepmey merimcorengheetsicors | aptueen cre snznicyauguaeecinere manson ue soorglny | «tow oossong Tieimaean 3 Tina fimeswinaaneaigectn Ltetegunoore songs Sieedacim nang Goraaiing a ishowar a Sra einai me cua ln tos pebumepe ome el Sep en NEA own bog etc aaein a sesacinapon coves ue ect meses mse eginet pe cml ‘Adulte Soong poqshon emptystomach 572 sas Penilin Vrs PENG amg ones oe 3 F 5 a = a] ‘Adult 300-600mg pogsh on empty stomach [519 Gcorggoasinertn noenrgte (a2 ax: So0org ida) Ta PS ng STE SRT TT ATG aT SUE RETEST We See teats ctcoap fate ripen Mh A eres BAM] Gover mtu: woctine "2h mart aromas mre er ene darn? fg seers wh vate aren re cyorae | eoeacpie iu ge ctempne Aekotley es cemented pn ee tet Oe gE ‘Cephalexin were, BD {erage toupee Nek trot ca east 8) Mite sina comsue macaw sep coun pono erm ent RD TSENG av Deine enn ‘eiprout are B [eee A Se oie sence, SK Mar eerie Prot Rest. AES) rte nec atcoro-commann equa euro ny oPh eng ne) ati neers ‘eds: 2-100mg/ig ay po died gah] baut:stone weathers [23050 [Pade sone ieinyedvaedash == | Aaut:Soomg orton mein) [S30 ee: 18 someday pode aah | Iaui-Soone oath ne neon, |S Peis wa orelelny pode aah [2 Iaut:stome poveth food ws) [ee2 angimusepeoemery Soran w TERRE ER EST adeno tet eal seat PANES) tet grcen Bong pou sae pecregne comple UT en EHCP comm sas sas SSS icteemeon nr TE RESTS SE SVS SR SE US SPREE STATE codon igen meine stanonomtemceg et mete PERE gS He le z{[coreromenunsenewomencimnta gyapen mater etenomc om ~ nmned wat te hacrin symone amet “ete pecumoneupererpntayter ict ec atcroveny armas cae ‘ug camjooens pres Moc prophase nye ctecnehcse Seer spn foe remarm nance iy ein ecco COPD, opt terse tod ‘Adu: Soomg day 3; 250mg days 25 Siongnysscop nanceiinate Bote ‘wax: so0mgiday ‘whine tng rater a Poon vege Seetccs: one renophs aren Tas Fa PT “ice: petmonepererpntay onic seats rope NAVE et wane arb) sizes rans woe ny, eu [Adulte 500mg po 2h ering stony ‘wax: 2000%g/43y Envoy sete 206 9c EnetvomeyaExaiate rgmincs senarone: PI] | «tec Smentn cteacrasin cn (mee coceatl 2 Ste ee ercemanega Sint mow amreayares yun ones nas yo) ss pearona tie gen RE ‘enprat aesw-erm tte eaeaton “nga someon aeermwnesstotpon nt otormee biog wenn Geman ot erwomen eee nga nye: 333mg poah ‘ase: 250ng poash Stearate: 2507 po 46h ‘wax 2000m@/63) sm pie setap, eerie, savsane seine abe foram ac) arecain Sirus rain Eos eer gems spn ca ornare ey) THicoungect ick Kies peretson ences penis tae Sk 2030h ican 28" vents ee toione Sapte cuneate Tathrompein—ZTHROWAK | «crepe Soar goarnonsy i oomph agama pee a sso sae je] s.s0 isa ss 25 \s20 sa30 Tp ecmeon se aeman Aca ta pepen een 2h ttn tay Volare eect [pbc alrg armour eurencearmcoreweite gman a ey a Se en eee eaten cue soit tye ate seein eon MN: reremon anf Skane hs eion scone nepetne pene ri petite ceca bomen {roe [as mpow npn nw aan ypestioyeacon Parner See (ase wmv ene opr 2 proerepe pare aceon mce wie) ype tm seein fennel perenne marmge) ‘Donyeyine= BOX DOWN g |» cover eas peru = SepVCERE GENRE, Tap FOROS TTT sonar stcsoe man sypenr mnjermcons nave peer tren pecan re batcorspureinatotara mee rata: ye see ‘eterno on expe (Sa) nt my ne in ne tomgrove turin ey {Sulu itiegounaipou ces onuse peg Adult 200mg stat, then 00mg g12 Gramps en aon ey ax: 200mg/ Gay ‘Adulte 200M; then 2000 po 4224, ‘wax: 2000@/¢3y Tana Toa tend pecvunoge = Saphcap eenoaT TOTS RET Dimers Stosypene anyone msgs Du tseceton within wv A oe ggestlng mii bocce erate) Tange a fone ansypenmnjareeer nuance eee cnempay omen atopton Ua oe =] s25 sar sae sae [Adulte 250mg posh on empty stomach ‘Max: 2000mg/63y iss a3 sa ar Pe Evo SR ae OUD mon‘oral antibiotics (continued) Treat withadeguat dose appropriate duration nies Dthgyme cry Peeowna col DA. ee cel Con rewton depen Hig far igh econo reomerocneer fens yen ga aang insanely, "anne, tntwannrvin a longten ater enn oe {Tesorpuonvectenson inc’ AM (eye aun ron mune, igs hue Tsint, rel dun of hromaoe they So rerio eto (Stow teas “tion inn te} nye kreuortah nro anes fcqunoere oe eyasoes mee sanctum sete hota en poe ssreesnne tee Sty eaten pie putcporioonn jeanrcten cea] [ft poree my cc ser rh Bf eetaatinwfeacn none ules ‘heitnacnanwetrcn~areene apn stescc,fameprbe cafe st wat atopy he Jere eee poaoons md AECOPD, bare we while apace See Peary pin epee en eae are aT Soe ‘Sete net pa ect mvarenenn ‘ait: 500mq 9028 ng) Sonatas Stor min mscoroioaioy enptad Ur, nator ere Soom ph Pemrunn res: momgringe® | Uetitmy inte moma Sear rene peravnpowtemrammanaermeste | ype Tereloaah ACH Z z Peds Si0mere noma | zescrommey Bl : ‘Adult 500-7300 po q2ahseae ancy onmunnioe sa mer weston Peds notated ae : aut 00m po 24h ney ‘ax: 200mg/a Peds: notindiated Adult 400mg po q42h:epum nn28iy ax: s00ng/day a cara pet Su RESORT ALDOpIm NURI TnG ATSEAEG RO Ewa GFE Ton Citra CT SOARES Eh ren neoenne canes mac oerg. unmasks ARIA RIDLEY wen, ncn ato caron ppacen taonecfoptiemoarely Meuse heme neat epieerey, Mem warivernee bene meanece men (eee Nees TD ery te = neon ten ees ure Syonenyopea tonsovemae ortnetapen nepocertateme tn tne etcetera; pe tom cuore ‘hae: ere win cPoeetceeyharheneetl pte nth pm Esc mater tuerarens pes ctareeo\sgann penn $e nan. Anpepceme wt mpg emia gee, ipettenaace tithe re eramntee pens penfon hen Weta oaereae Hore fr ateconetoel Sulemthoraole/Timethoprin |» Greage pho [SC 1S SR pa 7 APN NTT Rea 6g ay Ta po Tie AN ET ACT SEPTHSCovimomceg_ | Seanamat fur Rance ga ts ano Hal Pome r ‘Adult 200/140 poqa2h sas pier esac, steesinUnceeseres pephareninaneztena cto ow tvAtcors ne popnyece. | Max: 320me/tay ofTMPcomponent [233 por gee niberrumeecrant oe tmebopin silanes eacor mamumepegetcctea (le, nae sw? oss an en] fog Howe eee [Ghuirapembnnestcomenyestse tetentsceetiy ‘ha Beco tanger ny op ag a SSE SPORTER BETTS Peds: aome/le/tay podvided aan ea? —] ‘ete uneuesner ony same esses #uconperel Uh poghye ‘Adult: S00me po 2h x7 Abie sgn coe ‘Max: 2000@/¢ay 7 Dionne PrducesGemfbiaciFACIVE br Ofiaci ORN mb; TesafbiacaTROVAN Bbc sno ato TRU a Ben Giga ROAR Bbcnbn (continued) ‘indamyan| Bagimcsncen ‘ALAC eeateresceieity Bieces seen nena) 1.7% fan: euopara, momboeyepne REESE Tipciatancberaene pote ps ces ste ela rib Dv] mt Oe. eyacemre recroermen con Ser ctcoreaum afl meton amy sen reach eer e purge Dene Wtoneaale FR Siri Dinara See Ce Coe PTH ‘eetiin om sos omctoneaiely new ngeee tenement ‘ee seus norm ntact fash oN rant ong hms hg veel CO Tara WRRORTS acnoDavrn see eptcmesore grins msc oypumoray toe hee ae og: Seraomimin snr weermsco nent Gerben fketenoh [pfu tesa noeraemeenctarpronnctre may Lemar, SB eectecnor tac rgm cmon oengingotm eee meer‘cxc um, sertenoncue | se opin tbat enconpuntie Tat cecwes ue tm setum etl ey te). ‘eatery [pe vpunun, rome opel eitemlope meant, cies faneansyeane rts, oe ne Rangers ee ac net pram anor ep Arte mcg. ai area twee com mr ee Probenecid SeNURTE ‘eectpan- orth curr lrg Prelim angen i ew con SSO Per pean ‘camry eettnnenivocnpynesedinenowateteetrgt temener/¢farecmvet_ | Agu 500mg po ID30 13 mia porto ‘ert 2p chert cold due toa virus Would youlie tif Tgave you "OTS Lica asta something to help with the cough? uel T’ve been coughing You do look quite unwell. It could just bea chest PETC en MELLIN > | cold but we should send you for an x-ray torule out cm feel like dying. Pneumonia and anything else See gc Deets ‘Actually, antibiotics cause a lot more side effects than _Antibiotic harms side effects & bacterial resistance EVIDENCE AROUND REDUCING UNNECESSARY ANTIBIOTICS? + Studies have demonstrated patient satisfaction with care for acute bronchitis depends most on physcian-patient communication, not antibiotic treatment." * One study found thatthe duration of office visits for acute respiratory infection was only one minute longer when antibiotics, wore not prescribed. + A change in antibiotic reimbursement resulted in fewer antibiotics prescribed, anda reduction in the level of antimicrobial resistance. 1Thave examined you and Lam happy thece sno sign af serious illness, which would need an antibiotic today. Most chest colds get better on thei own, although the cough may take several weeks to ‘goaway completely. Antibiotics dont see to make much ciferenceto how quickly most ‘People recover. However, if you fel you ae actualy geting worse aftr awhile taking antibiotics then may be reasonable. So, here is an antibiotic prescription for you to keep at home. You are quit likely otto need it but if your symptoms get noticeably ‘worse, you can flit within 7 days Patint Pages, Tots, Links: 1) Why didnt get antibaties today: ‘ADDITIONAL TIPS FOR GETTING PATIENT BUY-IN > Use the term’ chest old” o ‘viral upper respiratory tract infection™ as this makes it easier to convince patents they donot need antici, > Viruses commonly make you fel sick allover your bod. > Viruses are more easly spread from ane person to anther, of you ae the 3*person in yout house who's ick. it’s probably virus > Fevers how our bodies fight off any infection and not an indication of a bacteria infection > Colored nasal secretions do nat equal a bacterial infection! Snot and sputum tat becomes yellow/reen sa sign your bodys, fighting off any infection. ‘> Most sore throats are viral infection. Strep throat can only be diagnosed by a throat swab => 70-80% of car infection get better without antibiotic. > Antbotic do not educe the duration of viral ness, but may cause harms (nausea diarthea, alge reactions, etc) => Always provide a) patent education, ) symptom duration, andc) wen to return. ‘=> Hand washing! Important fr sick contact prevention. TYPICAL SYMPTOM DURATION FOR SELECT VIRAL ILLNESS + Sore throat, pharyngitis: 6-10 days * Cough acute bronchitis 2-3 weeks ‘Anbitls;2ABX Puie/Patent Reoures& Links: i. les.a/AB Fr re lara & references, ee wv Railes a Potsie a DO RU Wee ira 2nd Edition Follow Us: through email updates