If you work in primary care, emergency medicine or urgent care, I think it’s important to have updated information on the latest antibiotics for common medical problems. I’ve gone through the Sanford Guide and broken down the common antibiotics. I have to tell you, there’s one update that will change my practice.
Pediatric Otitis Media
To diagnose otitis media in children, there are four options: moderate to severe bulging of the tympanic membrane, new onset of otorrhea, mild bulging and recent onset of ear pain (less than 48 hours of ear tugging and rubbing in a non-verbal child), or intense erythema of the tympanic membrane.
It’s recommended that if there’s severe otitis media as indicated by symptoms for more than 48 hours or a temp greater than 102.2, pull the trigger on antibiotics. For patients less than two years old, JAMA suggests you treat. If the patient is older than two, it’s reasonable to observe for 48 hours or begin antibiotics. In patients that aren’t febrile, there have been very good results in holding antibiotics.
For pediatric acute otitis media, they’re recommending high-dose amoxicillin or Augmentin. High-dose amoxicillin is 90 milligrams per kilogram per day, BID or TID. For Augmentin, high-dose is 90 milligrams per kilogram divided BID.
That’s under the condition that there has been no antibiotic use in the last 30 days, no conjunctivitis and no history of recurrent otitis media. You should be asking, like I did, why do they mention conjunctivitis here? I’m going to talk about that in a second because that is a practice-changing piece of information.
When is Augmentin preferred? If there has been antibiotic usage in the last 30 days. If they’ve failed amoxicillin, it may take three days to respond. If there are purulent conjunctivitis and a history of recurrent otitis media, JAMA found that Augmentin gave better resolution.
Conjunctivitis Otitis Syndrome
If you’ve seen a child with conjunctivitis, you need to look at the tympanic membrane. When we look at the eye, there are a couple of things you need to look for.
Make sure you’re always doing visual acuity. You want to look at the eye and see if there’s a white line next to the iris. If so, that’s the limbus and it’s clear. If it’s white, that suggests a more benign, superficial eye. If the injection goes right up to the iris, that tells me there’s a deeper problem. If there’s a line of white, that’s the cornea on top of the eye, which tells me it’s more of a superficial problem. Subconjunctival hemorrhage is homogeneously erythematous but again is that approximately 1-millimeter line surrounding the iris.
Conjunctivitis otitis syndrome means that one in four patients with conjunctivitis will have concurrent otitis media, even if they have no ear pain. The chief complaint is conjunctivitis. Every patient with conjunctivitis needs to have an examination of the tympanic membrane. If they have both together, they need oral antibiotics.
H. flu is the most commonly recovered bacteria in the middle ear and it’s the same germ found in conjunctival discharge. Therefore, they need oral Augmentin. With every single conjunctivitis case from here on out, you have to document a normal ear exam. If they have an abnormal ear exam, treat them with Augmentin.
Adult Otitis Media
If the patient hasn’t had any antibiotics in the prior month, treat with amoxicillin high-dose; that’s 1000 milligrams TID. That is a double dose, relative to how I used to treat; I used to treat with 500 milligrams TID and now they’re saying 1000 milligrams. One-gram TID or Augmentin-ER 2000 milligrams BID.
If the patient had antibiotics in the past month, JAMA recommends Augmentin, 2000 milligrams BID, or fluoroquinolone. Levofloxacin or moxifloxacin will be a five-day course of 750 milligrams daily. The other two are typically ten-day courses.
Cellulitis is marked by rapidly-spreading, red, erythematous, tender, plaque-like areas. It’s usually unilateral and often the patient is febrile. When a patient has cellulitis, you want to look for signs of systemic spread, such as lymphangitis or lymphadenopathy. When you have someone with cellulitis, it’s recommended you look at their feet, because the port of entry is often a tinea infection.
For the treatment of uncomplicated skin infections, the New England Journal of Medicine says the efficacy of clindamycin and Bactrim are comparable.
For a UTI in females with no signs of pyelo, you always do a culture and consider STDs. Bactrim is still recommended; use Bactrim-DS, one tab BID times three days, plus or minus Pyridium. If the patient has a sulfa allergy, use nitrofurantoin 120 milligrams, PO BID for five days. Do not use nitrofurantoin in the last trimester of pregnancy, because of a hemolytic anemia in the newborn. Fluoroquinolones are not recommended as a primary regime, because resistance to fluoroquinolones often parallels resistance to Bactrim.
When it comes to strep throat, use the CENTOR criteria. It’s not great but it’s the best we’ve got.
- Cough: That’s a pertinent negative. Strep should not cough.
- Nodes or cervical lymphadenopathy
- Temp: Do they have a fever?
- Or could they have mono?
According to CENTOR criteria, these give you the potential of five points. If the patient is between three and 12 years old, they also get a point. If the patient has three points, they have a 30% chance of strep. If they have four or more, the chance of strep goes up to about 52%. Not great, but a lot of times the rapid strep tests are not very reliable.
What’s the rationale for treating strep throat? Treatment decreases how contagious a patient is. Untreated strep can cause complications, including post-streptococcal reactive arthritis (Ryder’s syndrome), peri-tonsillar abscess or retropharyngeal abscess, suppurative phlebitis, jugular-venous thromboembolism-like disease, post-streptococcal glomerulonephritis (in kids under 7) and rheumatic fever.
Rheumatic fever is still a problem in many parts of the world, especially in children. Benzene penicillin in the treatment of group-A Streptococcus decreases the rate of acute rheumatic fever from 2.8% down to 0.2%.
To treat strep throat, the primary regime is penicillin, 250 milligrams PO BID or TID for less than 60 pounds and 500 milligrams PO BID for greater than 60 pounds, for 10 days. With benzene penicillin, 25,000 units per kilogram, IM one shot. The amoxicillin is a suspension because the amoxicillin suspension tastes a whole lot better than the penicillin does. The amoxicillin is 50 milligrams per kilogram PO once daily for ten days. Augmentin is 45 milligrams per kilogram BID.
In adults, it’s penicillin-V 500 milligrams BID or 250 PO QID times ten days, or Augmentin 875 PO BID times ten days.
I find it interesting that we use the Curb-65 rule to decide who needs to be admitted with pneumonia. I don’t feel that I ever struggle with that decision.
- U: BUN greater than 19
- Respiratory rate greater than 30
- Blood pressure: hypotensive with a pressure less than 90/60
- 65: Over the age of 65
A patient gets one point for each of these criteria. If their score is one, outpatient therapy is reasonable. However, if someone is breathing at 32, or they’re hypotensive, or they’re confused, I’m not sending them home. Use this mnemonic to leverage your hospitalists if you need to.
The primary regimes are:
- Azithromycin: 500 milligrams, PO, times one dose, then 250 PO Q-24 hours, for a five-day course.
- Clarithromycin: 500 milligrams PO BID or Clarithromycin-ER 1 gram BO Q-24 hours, times seven days.
If the patient had antibiotics in the last three months, a dual regime is recommended. Use azithromycin or clarithromycin, something that covers the atypicals with either amoxicillin, Augmentin or Levaquin:
- Macrolide antibiotic with amoxicillin one gram PO TID.
- Augmentin 1000 milligrams two tabs PO BID.
- Levaquin 750 POQ-24 hours.
- Levaquin 750 PO Q-24 hours times five days, if there are comorbidities present.
The patient has to have a temperature greater than 102 with costovertebral tenderness. You want to culture the urine and the blood. In males, look for any complicated pathology, including the presence of an obstruction, immunosuppression, past kidney stones, anatomical or functional urinary tract abnormalities or underlying renal disease; males shouldn’t have pyelos.
Treat with outpatient therapy, Cipro 500 milligrams PO BID, or the extended-release 1000 milligrams Q-24. Levaquin 750 milligrams Q-24 hours, or moxifloxacin 400 milligrams BID for five to seven days. For clinical settings with a prevalence of fluoroquinolones resistance greater than 10%, one gram of ceftriaxone or one dose of gentamicin is recommended.
There’s a high degree of spontaneous resolution. We need to be smart about the use of antihistamines because the gook in the sinuses is what’s making them sick, and antihistamines will dry them out and make them worse. Sinusitis is usually the result of obstruction of the sinus ostia, typically from viral infections or allergens. Allergies, smoking and URIs are typically what block the ostia and fill them up. Our goal with sinusitis is to get the gook out.
We thin the mucous with lots of fluids and open the ostia with decongestants, so antibiotics are rarely needed. Treatment is oral fluids and perhaps nasal saline irrigation.
Sinus symptoms are common with viral infections and allergies and are a common cause of antibiotic overuse. Guidelines indicate antibiotic therapy in one of three situations: the patient has a fever of greater than 102.2 in children, intense facial pain or purulent nasal discharge.
If, despite withholding antibiotics, patients still have symptoms after 10 days, it’s recommended that you pull the trigger on antibiotics. A meta-analysis of nine double-blind trials published in Lancet found no clinical signs or symptoms that justified treatment even after seven to ten days. In a randomized-placebo control trial in adults published in JAMA, a ten-day course of amoxicillin compared with placebo did not reduce symptoms at day three of therapy.
I hope that this helps you understand the update of antibiotics for primary and urgent care complaints.