Ancc Board Review: Sinusitis And Allergic Rhinitis

Front 1

3 most common causative organisms in ABRS.

Back 1

S. pneumoniae (20-43%)
H. influenzae (22-35%)
M. catarrhalis (2-10%)

Front 2

Possible sequelae of failed antibiotic therapy in immunocompromised patients:

Back 2

Orbital cellulitis
Meningitis
Septicemia

Front 3

About S. pneumoniae

Back 3

Gram positive diplococcus.
Most common cause of ABRS, CAP and AOM.

Front 4

About H. influenzae

Back 4

Gram negative bacillus.
Commonly causes ABRS, CAP, and AOM.

Front 5

What factors favor H. influenzae as the causative agent?

Back 5

Tobacco use.
Recurrent infection.

Front 6

About M. catarrhalis.

Back 6

Gram negative coccus
Significantly less frequent cause of ABRS, CAP and AOM.

Front 7

Mechanism of resistance to penicillin of S. pneumo.

Back 7

Altered binding sites. This can be overcome by increasing drug concentration.

Front 8

Percent penicillin resistance of S. pneumo.

Back 8

25%

Front 9

Risk factors for DRSP.

Back 9

Antimicrobial use within 4-6 weeks.
Exposure to child in day care.
Elderly.

Front 10

Percent penicillin resistance of H. influenzae.

Back 10

30%

Front 11

Percent penicillin resistance of M. catarrhalis.

Back 11

90%

Front 12

Mechanism of penicillin resistance of M. cat and H. inf

Back 12

Beta lactamase. This is overcome by adding clavulanate to amoxicillin or using a non-penicillin class drug.

Front 13

Expected course of a viral URI.

Back 13

Some improvement by day 5. Lingering cough at day 7 is normal.

Front 14

When does viral replication peak in a URI?

Back 14

Day 2-3.

Front 15

Timing of symptoms that suggests bacterial etiology.

Back 15

Symptoms lasting > 7-10 days or worsening after 5-7 days.

Front 16

What is considered antimicrobial treatment failure?

Back 16

No improvement after 72 hours. Be sure to question about adherence.

Front 17

What organisms does amoxicillin treat?

Back 17

At 1.5 g/d, only susceptible organisms.

At 4.0 g/d, some DRSP and susceptible gram-negatives.

Does NOT treat beta-lactamase producing gram-negatives.

Front 18

What organisms does amoxicillin/clavulanate treat?

Back 18

At low dose this covers beta-lactamase producing gram negatives but not DRSP.

At high dose, it covers DRSP and resistant gram-negatives.

Front 19

Which cephalosporins are recommended for ABRS?

Back 19

cefpodoxime (Vantin) - 3rd gen
cefuroxime axetil (Ceftin) - 2nd gen
cefdinir (Omnicef) - 3rd gen

Front 20

What organisms do the cephalosporins for ABRS treat?

Back 20

Gram positives.

beta-lactamase producing gram negatives.

Front 21

What is the main factor that limits amoxicillin/clavulanate use?

Back 21

It causes significant GI upset. Counsel patients to take medication with food, especially fatty foods.

Front 22

What drugs are options for penicillin-allergic patients with mild disease and no antibiotic use in the last 4-6 weeks?

Back 22

TMP/SMX

Doxycycline

a macrolide

Front 23

First-line therapy for moderate ABRS or abx use in the last 4-6 weeks.

Alternates.

Back 23

High dose amoxicillin/clavulanate (4 g/day).

Respiratory fluroquinolone

Clindamycin + rifampin

Ceftriaxone IM

Front 24

Can patients with penicillin allergy take cephalosporins?

Back 24

No.

Front 25

Are cephalosporins stable in the presence of beta lactamase?

Back 25

Yes.

Front 26

What are the respiratory fluroquinolones?

Back 26

moxifloxacin
levofloxacin

Front 27

Why is clindamycin + rifampin not a preferred treatment?

Back 27

clindamycin has a high risk for GI side effects including C. diff colitis.

Front 28

Clindamycin is included in the drug regimen to cover:

Back 28

DRSP.

Front 29

What organisms are covered by respiratory fluroquinolones?

Back 29

DRSP and beta-lactamase producing gram-negatives.

Front 30

Best drug choice for a 25 year old college student with mild disease.

Back 30

low dose amoxicillin eg. 875 mg bid.

Front 31

Best ABRS drug choice for a 35 year old mother of a 3 year old in daycare with no recent antibiotic use.

Back 31

High dose amoxicillin (4 g daily)

Front 32

Best ABRS drug choice for a 50 year old male who was prescribed amoxicillin for sinusitis 4 weeks ago.

Back 32

HD amoxicillin/clavulanate

Front 33

Best ABRS drug choice for a very sick patient who is allergic to penicillin.

Back 33

respiratory fluroquinolone

Front 34

Best ABRS drug choice for a middle-aged man with uncertain medication history who is allergic to penicillin.
a) clarithromycin
b) azithromycin
c) amoxicillin
d) cefdinir

Back 34

b) azithromycin.

Clarithromycin is a CYP inhibitor and should be avoided if drug interactions cannot be managed.

Front 35

Which of the macrolides is NOT a CYP inhibitor?

Back 35

azithromycin

Front 36

Possible consequence of concomitant clarithromycin and atorvastatin use:

Back 36

Rhabdomyolysis from increased atorvastatin (CYP substrate) levels.

Front 37

Marked eyelid edema in the context of ABRS is suggestive of

Back 37

Extension of infection beyond the sinuses to periorbital cellulitis.

Front 38

Best ABRS drug choice for a 45 year old with 35 pack-year smoking history.

Back 38

Amoxicillin/clavulanate.

Front 39

When is CT of the sinuses indicated in w/u of ABRS?

Back 39

Only if there is treatment failure after escalating to strong therapy such as fluroquinolones or clindamycin + rifampin.

Not recommended for initial diagnosis.

Front 40

What is the most important component of allergic rhinitis/conjunctivitis therapy?

Back 40

Allergen avoidance.

Front 41

During what time of the day is the allergen concentration highest?

Back 41

In the morning, as pollen is released at night.

Front 42

Mechanism of action of decongestants:

Back 42

Vasoconstriction.

Front 43

Oral decongestants are contraindicated in these patients.

Back 43

Patients with CV disease or uncontrolled HTN.

Front 44

Why are first-generation antihistamines more sedating than second-generation?

Back 44

They penetrate the blood-brain barrier better.

Front 45

What classes of allergic rhinitis drugs are recommended for use as controller therapy?

Back 45

Nasal corticosteroid spray (most potent, as it works on the most inflammatory mediators)

Leukotriene modifiers.

Mast cell stabilizers.

Front 46

Name the leukotriene modifier medications used in allergic rhinitis.

Back 46

montelukast (Singluair) PO

zafirlukast (Accolate) PO

Front 47

Name the mast cell stabilizers used in allergic rhinitis.

Back 47

cromolyn (NasalCrom intranasal and Opticrom optic). These are OTC.

nedocromil (Alocril optic) Rx.

Note that inhaled cromolyn (Intal) is approved for asthma, NOT allergic rhinitis.

Front 48

What is one limitation of allergic rhinitis controller therapy?

Back 48

It requires 1-4 weeks to become effective.

Front 49

Name two first-generation antihistamines.

Back 49

diphenhydramine (Benadryl)
chlorpheniramine (Chlor-Trimeton)

Front 50

Are first or second generation antihistamines more effective as rescue therapy for allergic rhinitis?

Back 50

First generation antihistamines are more effective but also more sedating.

Front 51

Name 5 second generation antihistamines.

Back 51

loratadine (Claritin)
desloratadine (Clarinex)
cetirizine (Zyrtec)
fexofenadine (Allegra)
levocetirazine (Xyzal)

Front 52

Name the classes of drugs used in allergic rhinitis for PO rescue therapy aimed at deactivating formed inflammatory mediators.

Back 52

1st and 2nd generation antihistamines.

Front 53

Name classes of drugs used in allergic rhinitis for symptom relief targeted at profuse nasal discharge.

Back 53

Anticholinergic nasal spray

Antihistamine nasal spray

Front 54

Name classes of drugs used in allergic rhinitis for symptom relief targeted at nasal congestion.

Back 54

Oral decongestants

Nasal decongestants

Front 55

Name an anticholinergic nasal spray.

Back 55

Ipratropium nasal (Atrovent nasal)

Note ipratropium inhaled (Atrovent HFA) is approved for COPD and asthma, NOT allergic rhinitis.

Front 56

Name an antihistamine nasal spray.

Back 56

azelastine hydrochloride (Astelin, Astepro)

Front 57

Name an antihistamine for opthalmic use.

Back 57

olopatadine hydrocholride (Patanol)

Front 58

Name two nasal decongestants.

Back 58

phenylephrine (Neo-Synephrine and other trade names)

oxymetazoline (Afrin, Dristan, other trade names)

Front 59

Some information about Afrin.

Back 59

Afrin is a nasal decongestent/vasoconstrictor with generic name oxymetazoline. It can be used safely for up to 10 days, but may cause rebound stuffiness.

Front 60

Name two oral decongestants.

Back 60

pseudoephedrine (Sudafed)

phenylephrine (Sudafed PE)

Front 61

Anticholinergic drugs should be avoided in this population, if possible.

Back 61

Elders.

Front 62

Mnemonic for anticholinergic side effects.

Back 62

Dry as a bone (dry mouth)
Red as a beet (flushing)
Mad as a hatter (confusion)
Hot as a hare (hyperthermia)
Can's see (mydriasis/blurred vision)
Can't pee (urinary retention)
Can't spit (dry mouth)
Can't shit (constipation)

Front 63

When is urinary retention from anticholinergic use most concerning?

Back 63

In elderly male patients with BPH. It rarely occurs in younger patients.

Front 64

About agitation secondary to anticholinergic medications.

Back 64

Agitation occurs in 10% of the population. It is an atypical side effect, as 90% will experience sedation.

Front 65

Mechanism of action of decongestants.

Back 65

They are vasoconstrictors and alpha-adrenergic agonists.

Front 66

Therapeutic effect of anticholinergic nasal spray.

Back 66

Dries secretions.

Front 67

Safety considerations in prescribing antihistamine rescue therapy for allergic rhinitis.

Back 67

First generation antihistamines should be used only when there is no risk from sedation ie. not driving or operating machinery.