OMR Roundup 9-11-13

Pharyngitis, Sinusitis and What's So Complicated About UTIs?  

Great session today - we looked over clinic notes to review how we diagnose and treat sinusitis and pharyngitis.  Jason Williams presented a clinic patient with complex urinary anatomy and symptoms of local cystitis and we considered the definitions of "complicated" UTIs and the prevention of recurrent UTI.

Sinusitis

Our small group session covered the management of acute bacterial sinusitis and making sense of the 2012 IDSA Guidelines.  It's worth digging into the document to learn more about the diagnostic criteria (think timing/course > signs/symptoms) and adjunctive treatments.  Also, for your over-65-year olds, did you consider high-dose amoxicillin/clavulanate?  See the quick algorithm below:

Link to Antibiotic Table

For the auditory learner: Sinusitis Podcast discussion of the guideline.  Or get it in iTunes.

Pharyngitis

Another 2012 IDSA Guideline document!  Can you use Centor criteria alone to make the diagnosis?  No!  You can use it to rule out patients at low risk (think Centor 1-2), but not to rule-in.  All patients that are going to get antibiotics require microbiologic confirmation.  This differs from the CDC/ACP/AFP guidelines.  What to be confused?  Check out this comparison table in the (free) AFP article: 

 Here's their algorithm (AFP):

(source: McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):79.)

For the auditory learner: GAS Pharyngitis Podcast discussion of the guideline.  Or get it in iTunes.

What's so complicated about UTIs?

Jason Williams led a great discussion in OMR today about recognition and treatment of complicated UTIs. Key points:

• “No clear definition of the term ‘complicated’ has ever existed, and current definitions of complicated UTI cause many controversies.”[1] 
• Broader range of bacteria with increased resistance and higher rate of treatment failure. As a result, get urine cultures and considered extending the length of treatment. [2] 

He brought to our attention a useful figure (table 1) from a NEJM article on Uncomplicated Cystitis.

Only 2 Trials Assessed Length of Therapy:

• Ciprofloxacin for 2 or 4 weeks in the treatment of febrile urinary tract infection in men: a randomized trial with a 1 year follow-up. Ulleryd P. Scand J Infect Dis. 2003 
• 114 patient 65 thought to have prostatitis 
• No significant difference in cure rate (89% vs 97%) at 3 months 
• A prospective, randomized trial of 3 or 14 days of ciprofloxacin treatment for acute urinary tract infection in patients with spinal cord injury. Dow G. Clin Infect Dis 2004. 
• 60 patients, excluded pyelonephritis, struvite stones, hydronephrosis, or long-term indwelling catheters 
• 3 days course had symptomatic relapse rate of 23% vs 0% (p = 0.01) at 6 weeks.

1. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Johansen TE, et al. Int J Antimicrob Agents. 2011 Dec
2. Complicated urinary tract infection in adults. LE Nicolle. Can J Infect Dis Med Microbiol Vol 16 No 6 November/December 2005
3. Uncomplicated Urinary Tract Infection. Hooton TM. New England Journal of Medicine 2012; 366:1028-37.