Let me clear my throat: empiric antibiotics in respiratory tract infections

Alexander John Langley, MD MS MPH Goals of this talk

 Overuse of antibiotics is a major issue, as a result many specialist medical groups have developed guidelines over the past 20 years to curb unnecessary empiric antibiotics  Many talks focus on when not to prescribe antibiotics, particularly in the outpatient setting  This talk is aimed at helping providers feel more comfortable in choosing antibiotics in the outpatient setting when data collection and follow up are more difficult than the inpatient setting, but where appropriate treatment may help to avoid expensive ED and inpatient care Outline

 There are many potential topics, we shall cover three outpatient topics  Cough – and the clinical diagnosis of pneumonia  Nasal congestion – and the clinical diagnosis of bacterial sinusitis  Sore throat – and the clinical diagnosis of strept throat

 What we will not cover  Special populations – kids, pregnant women, diabetics, immunocompromised, geriatric  Other settings – ED, inpatient, ICU, nursing home Cough and Pneumonia

 Why do we want to treat: dual goals of symptom relief, and preventing serious invasive disease including possible death  Why is it hard to treat: most where a pathogen can be isolated are viral, most commonly rhinovirus. Followed by influenza (not topic of today’s topic), and third is Strep Pneumo – representing 5% of cases (and 37% of bacterial cases)

Making the diagnosis

 There are two roles for the MD – does someone have pneumonia and need antibiotics, does someone need hospitalization  Diagnosis – Heckerling decision tool on the previous page can help, IDSA guidelines say diagnosis should include CXR (2 view) as part of standard part of assessment  CURB 65 and CRB 65 – used for triaging – 0 or 1 can be safely managed outpatient, >=3 should be hospitalized Treatment

 Mild with no recent antibiotics – choose a macrolide or doxycycline. 5 day treatment is as effective as longer courses  If recent antibiotics or comorbidities – use a different class than previously used, preferred for either is respiratory fluoroquinolone – either levofloxacin or moxifloxacin  Resistance to azithromycin in mycoplasma varies from 7% in Seattle to 50% in New Jersey  Resistance to azithromycin in Strep Pneumoniae can reach 60% (currently 9% in all Swedish inpatients) Nasal Congestion and bacterial sinusitis

 Why do we treat – mostly symptom relief, although invasive disease can occur  Why is it hard to treat – Cannot initially differentiate from viral process  Fortunately can usually delay treatment without significant risk of severe complications Making the diagnosis

 After 10 days of symptoms without improvement the probability of bacterial infection rises to 60%  There is also the concept of double sickening – primary viral infection starts getting better, than a secondary bacterial infection causes distinct worsening of symptoms after this improvement  Diagnosis –IDSA 2 major, or 1 major and 2 minor with symptoms  Major - purulent nasal discharge, nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, decreased sense of smell, fever  Minor - headache, ear pain, pressure, fullness; halitosis, dental pain; cough, fatigue Treatment

 70% of patients with bacterial rhinosinusitis resolved their infection within 2 weeks without antibiotics. Antibiotics do shorten symptoms – but main benefit is only seen in patients with symptoms persisting beyond 15 days  As a result watchful waiting is recommended for those presenting within 7 days regardless of severity (according to the 2015 AAO-HNS)  Antibiotic choice is amoxicillin or amoxicillin-clavunate (if risk of resistance) for 5- 10 days  Intranasal steroids provide modest benefit in combination with antibiotics Sore throat – group A strep

 Why do we treat: primarily to prevent rheumatic heart disease, some mild relief of symptoms  Does not prevent PANDAs or post streptococcal glomerulonephritis  Why its hard to diagnosis– even at it’s most prevalent (in November) it only represents 5-15% of pharyngitis, with mononucleosis a common culprit Diagnosis

Modified Centor score 1 Point for each of the following - Age (ranges from +1 to -1) - tender anterior cervical lymphadenopathy - Tonsillar exudates - Fever - No cough

Get a rapid strep for scores of 3-4 Culture no longer recommended routinely in adults, Unless patient is re-presenting after an initial evaluation Treatment

 Penicillin or amoxicillin  If penicillin allergic -> cephalosporins, clindamycin, macrolide  Only 66% of group A strep is sensitive to clindamycin at uw  If there is a recurrence broaden amoxicillin to augmentin, Keflex to Cefdinir. If due to non-compliance than give penicillin G benzathine Take home points

 Antibiotic usage is difficult to determine because of symptomatic overlap with viral infections  Using constellations of symptoms can help you determine patients with reasonably high likelihood of bacterial infections – but getting this likelihood to 100% is difficult or even impossible with even the most robust work up  Delayed treatment in selected patients is an effective way to safely manage a variety of infections while reducing antibiotic use Thank you

 Y’all the best