Ninja SMLE Recall

10 year old boy with frontal headache, fever, and runy nose. 2 days prior he had runny nose and sore throat he had left cheek tenderness He is vitally stable and his Labs was normal with 38.5 temperature even though they mentioned fever in the stem What is the next best management? A. Orofacial X-ray B. Reassurance C. Amoxicillin- clavulanate for 10 days Alhomrani: Reassurance Makrami-ENT: Agree , Reassurance Fay-ENT: Agree , Reassurance Athar The King: Amox Abdulmajeed-ENT: Amox ' Answer To This Recall Has Changed , NEW ONSET Of Fever Is Not An Indication For ABRS (It [IS] According To Up To Date , But Up To Date Was WRONG Unfortunately) It Should Be NEW Onset Of Fever After 5-6 Days or After Initial Improvement Up To Date Adopted Its Guidelines From IDSA (However , When I Checked IDSA Guidelines Myself I Found They Are Not "Exactly" The Same 🤪 ) Acute bacterial rhinosinusitis (ABRS) in children: Clinical features and diagnosis DIAGNOSIS Uncomplicated ABRS — The diagnosis of uncomplicated ABRS in children is made clinically. Imaging studies are not necessary to make the diagnosis [4]. We use both of the following criteria to establish a clinical diagnosis of ABRS [1,4,27,58-60]: • Symptoms and signs compatible with sinus inflammation (daytime cough, nasal symptoms, or both) (see 'Clinical features' above), and • Clinical course suggestive of bacterial rather than viral upper respiratory tract infection (URI), including one or more of the following (see 'Features suggestive of ABRS' above): • Persistent symptoms – Symptoms present without improvement for >10 and <30 days, or • Severe symptoms – Purulent nasal discharge associated with high fever (temperature ≥39°C [102.2°F]) for ≥3 consecutive days with or without ill appearance, or • Biphasic illness – Worsening symptoms after initial improvement (increase in upper respiratory symptoms, new onset of severe headache, new onset or recurrence of fever)

Severity Respiratory symptoms Fever 2 (days) Uncomplicated Viral URI Figure 2. Schematic characterization of the natural history and time course of fever and respiratory symptoms associated with an uncomplicated viral upper respiratory infection (URI) in children (courtesy of Dr Ellen Wald; adapted from Gwaltney et al [40] and Rosenfeld at al [13]).

the diagnosis. The following are considered "minor" symptoms: cough (more common in children), malaise, maxillary tooth pain, and ear fullness or pressure. The generally accepted time course for ABRS is persistent symptoms for at least 10 days (but less than 12 weeks) or worsening symptoms after 5 days that were initially improving ("double-sickening" or "worsening course"). Also warranting consideration of ABRS are patients with severe symptoms lasting 3 to 4 days that include high fever (>39°C) and purulent nasal discharge or facial pain.

on the effects of topical nasal steroids, allergen avoidance, or immunotherapy in preventing recurrent ABRS. RARS is defined by four or more episodes per year, with each lasting longer than 7 to 10 days, and an absence of intervening signs or symptoms that would suggest an ongoing or CRS.¹ Although recurrent viral respiratory tract infections are common, in general, it is rare for someone to develop true recurrent episodes of ABRS that meet the criteria for a diagnosis of recurrent ABRS. When they do, it is expected that the bacteriology and pathophysiology would be similar to individual episodes of ABRS. Although ABRS is a common disorder, the criteria used to make the diagnosis are fairly well established, and the treatment **Treatment** Because most cases of ARS are caused by viruses and are therefore self-limited, treatment is not needed, other than symptomatic management. In addition, even in the case of ABRS, most cases will be self-limited and will resolve even without treatment. This, along with the recognition that URTIs will typically not be bacterial until 7 to 14 days after onset, has led to growing conservatism in antibiotic treatment. The recent IDSA guidelines recommend a diagnosis and antibiotic treatment if there is “onset with ‘persistent’ symptoms or signs compatible with ARS lasting for 10 days or longer without any evidence of clinical improvement; onset with **646 PART IV Sinus, Rhinology, and Allergy/Immunology** ‘severe’ symptoms or signs of high fever 39°C or higher and purulent nasal discharge or facial pain lasting for at least 3 to 4 days at the beginning of illness; or onset with ‘worsening’ symptoms or signs such as new onset of fever, headache, or increase in nasal discharge following typical viral [upper respiratory infection] symptoms that lasted 5 to 6 days and were improving (i.e., ‘double sickening’).”³⁶ The IDSA also suggests that antibiotics should be begun once these criteria are met.³⁶ endemic rates of penicillin-nonsusceptible S. pneumoniae, combination therapy that includes clindamycin and a third-generation cephalosporin (cefixime or cefpodoxime) is recommended.³⁶ In cases of type I hypersensitivity allergy to penicillin or suspected allergy, doxycycline or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) may be recommended as alternative agents for empiric initial antimicrobial therapy in adults. In children, levofloxacin is recommended when there is a history of type I

3.5.3.d Antimicrobials for preventing recurrent cystitis 3.5.3.d.1 Continuous low-dose antimicrobial prophylaxis and postcoital prophylaxis Four meta-analyses and numerous systematic reviews and guidelines were identified [169, 211-221]. All available meta-analyses conclude that antibiotic prophylaxis is the most effective approach against cystitis recurrences compared with placebo or no treatment [211-213]. Antimicrobials may be given as continuous low-dose prophylaxis for longer periods or as post-coital prophylaxis. No significant difference was observed in the efficacy of the two approaches. There is no available evidence about the optimal duration of continuous antimicrobial prophylaxis, with studies reporting treatment duration of three to twelve months. After discontinuation of the drug, cystitis tends to recur, especially among those who have had three or more infections annually. After counselling, it is mandatory to offer either continuous low-dose antimicrobial prophylaxis or postcoital prophylaxis when behavioural modifications and non-antimicrobial measures have failed. The choice of strategy should be individualised based on whether episodes are temporally related to intercourse and on patient preference. Differences in outcomes between antibiotics did not reach statistical significance. The choice of agent should be based on the local resistance patterns. Regimens include nitrofurantoin 50mg or 100mg once daily, fosfomycin trometamol 3g once weekly, trimethoprim 100mg once daily and, during pregnancy, cephalexin 125mg or 250mg or cefaclor 250mg once daily [158, 222, 223]. Postcoital prophylaxis should be considered in pregnant women with a history of frequent cystitis before onset of pregnancy to reduce their risk of cystitis [224].

cystitis [5]. If symptoms resolve, a "proof of cure" culture is not necessary. If genitourinary symptoms persist after treatment or systemic symptoms develop, a repeat urinalysis (UA) and urine culture should be obtained [6, 35]. At this point, further evaluation to assess for structural or functional abnormalities of the genitourinary tract may be needed, if not already performed. Strategies to Prevent Future Recurrence After resolution of the acute UTI episode, the next step is to prevent further recurrences (Figure 3). There are multiple prevention strategies to prevent rUTIs, as shown in Table 1. These can be broadly broken down into the following: (1) behavioral strategies, (2) non-antimicrobial strategies, and (3) antimicrobial prevention strategies. Based on patient factors and patient preferences, behavioral and non-antimicrobial strategies should be optimized prior to pursuing antimicrobial strategies [36]. However, the timing and frequency of recent infections often guide the initial prevention strategy, with more frequent or higher acuity infections often requiring antimicrobial strategies initially. In many instances, several strategies are combined to help the local microenvironment, and to facilitate antimicrobial-sparing strategies long-term. Behavioral Strategies Increased hydration has been shown to prevent rUTIs, by increasing dilution and flushing of bacteria from the bladder. In a 2018 randomized controlled trial (RCT), women with rUTIs were assigned to drink an additional 1.5 L of water per day. During the 12-month study period, the mean number of cystitis episodes was 1.7 (95% confidence interval [CI]: 1.4–1.8) in the water group compared to 3.2 (95% CI: 3.0–3.4) in the control group, with a significant difference in mean UTIs of 1.5 (95% CI: 1.2–1.8; P < .001). The authors noted that, although increased hydration is not equivalent to daily antibiotic

prophylaxis, water is “safe, inexpensive, and does not select for antimicrobial resistance” [37]. A subsequent meta-analysis of 7 RCTs, including this one, found that increased fluid intake reduced the risk of cystitis recurrence at 6 months (odds ratio [OR], .13; 95% CI: .07–.25) but not at 12 months. Pelvic floor physical therapy (PT) has also been shown to decrease the incidence of UTI in patients with incomplete voiding due to high-tone pelvic floor dysfunction (overly constricted muscles contributing to aberrant neural signaling and poor bladder emptying) [38]. In 1 study of 86 women with voiding dysfunction, those who were assigned to pelvic floor PT and/or biofeedback had a lower prevalence of UTI at 12 months than those in the control group (20%–25% vs 90%; P < .05) [39].

**Antibiotic Prophylaxis** 12. Following discussion of the risks, benefits, and alternatives, clinicians may prescribe antibiotic prophylaxis to decrease the risk of future UTIs in women of all ages previously diagnosed with UTIs. *(Conditional Recommendation; Evidence Level: Grade B)* **Non-Antibiotic Prophylaxis** 13. Clinicians should offer cranberry as an option for prophylaxis for women with rUTIs. *(Moderate Recommendation; Evidence Level: Grade B)* 14. Clinicians should inform patients with rUTIs that D-mannose alone for prophylaxis may not be effective in UTI prevention. *(Moderate Recommendation; Evidence Level: Grade B)* 15. Clinicians may offer methenamine hippurate for prophylaxis for women with rUTIs. *(Conditional Recommendation; Evidence Level: Grade C)* 16. When women with rUTIs have a water intake below 1.5 L/day (50 oz), clinicians may offer increased water intake for prophylaxis. *(Conditional Recommendation; Evidence Level: Grade C)* **Follow-up Evaluation**

| Summary of Evidence | LE | | :--- | :--- | | Extensive routine workup including cystoscopy, imaging, etc. has a low diagnostic yield for the diagnosis of rUTI. | 3 | | Studies that have investigated behavioural risk factors in the development of rUTIs have consistently documented the lack of association with rUTI. | 3 | | Vaginal oestrogen replacement has shown a trend towards preventing rUTI in post-menopausal women. | 1b | | OM-89 has been shown to be more effective than placebo for immunoprophylaxis in female patients with rUTIs in several randomised trials with a good safety profile. | 1a | | Both continuous low-dose antimicrobial prophylaxis and post-coital antimicrobial prophylaxis, have been shown to reduce the rate of rUTI. | 1b | | A prospective cohort study showed that intermittent self-start therapy is effective, safe and economical in women with rUTIs. | 2b | | Recommendations | Strength rating | | :--- | :--- | | Diagnose recurrent UTI by urine culture. | Strong | | Do not perform an extensive routine workup (e.g cystoscopy, full abdominal ultrasound) in women younger than 40 years of age with recurrent UTI and no risk factors. | Weak | | Advise patients on behavioural modifications which might reduce the risk of recurrent UTI. | Weak | | Use vaginal oestrogen replacement in post-menopausal women to prevent recurrent UTI. | Weak | | Use immunoactive prophylaxis to reduce recurrent UTI in all age groups. | Strong | | Use continuous or post-coital antimicrobial prophylaxis to prevent recurrent UTI when non-antimicrobial interventions have failed. Counsel patients regarding possible side effects. | Strong | | For patients with good compliance self-administered short term antimicrobial therapy should be considered. | Strong |

3.5.3.2 Behavioural modifications Women with rUTI should be counselled on avoidance of risks (eg, insufficient hydration, habitual and post-coital delayed urination, wiping from back to front after defecation, douching and wearing occlusive underwear) before initiation of long-term prophylactic drug treatment, although there is limited evidence available regarding these approaches [128, 129]. A open-label RCT found that additional fluid intake of 1.5 L in pre-menopausal women with rUTI who were low-volume drinkers (< 1.5 L a day) reduced the number of cystitis episodes and antibiotic usage over a twelve-month period [130] 3.5.3.3 Non-antimicrobial prophylaxis 3.5.3.3.1 Hormonal replacement Based on the results of four meta-analyses topical oestrogen admission (either as a creme or a pessary) shows a trend towards rUTI prevention [131-134]. All studies reported that application was superior compared to placebo but was inferior compared to antibiotics. Due to its pharmacokinetics vaginal admission has no systematic side effects, however local irritation and minor bleeding can occur. The use of oral oestrogens was not effective for rUTI prophylaxis compared to placebo, furthermore it was associated with an unfavourable systematic side effect profile. A single prospective, non-comparative study of 30 pre-menopausal women with rUTI on oral contraceptives reported a beneficial effect of topical oestrogen admission [135].

3.5.3.4 Antimicrobials for preventing rUTI 3.5.3.4.1 Continuous low-dose antimicrobial prophylaxis and post-coital prophylaxis Four meta-analyses and numerous systematic reviews and guidelines were identified [134, 164-174]. All available meta-analyses conclude that antibiotic prophylaxis is the most effective approach against UTI recurrences compared with placebo or no treatment [164-166]. Antimicrobials may be given as continuous low-dose prophylaxis for longer periods, or as post-coital prophylaxis. There is no significant difference in the efficacy of the two approaches. There is no consensus about the optimal duration of continuous antimicrobial prophylaxis, with studies reporting treatment duration of three to twelve months. After discontinuation of the drug, UTIs tend to re-occur, especially among those who have had three or more infections annually. It is mandatory to offer both continuous low-dose antimicrobial and post-coital prophylaxis after counselling, and when behavioural modifications and non-antimicrobial measures have been unsuccessful. Differences in outcomes between antibiotics did not reach statistical significance. The choice of agent should be based on the local resistance patterns. Regimens include nitrofurantoin 50 mg or 100 mg once daily, fosfomycin trometamol 3 g every ten days, trimethoprim 100 mg once daily and during pregnancy cephalexin 125 mg or 250 mg or cefaclor 250 mg once daily [125, 175]. Post-coital prophylaxis should be considered in pregnant women with a history of frequent UTIs before onset of pregnancy, to reduce their risk of UTI [176].

Answer To This Recall Has Changed: Old Answer: A- Hydration New Answer: B- Prophylactic Abx Ideally , You Should Start Hydration Before You Jump To Abx (Because Abx Have Side Effects , Resistance , Etc) However , The Intervention That Has The STRONGEST DEGREE OF EVIDENCE Is Abx For Some Reason , Up To Date Graded Hydration As Grade B Evidence 🤒💔😵‍💫 AUA 2019: Abx (Grade B) , Hydration (Recommended But No Grade) AUA 2025: Abx (Grade B) , Hydration (Grade C) IDSA 2025: Abx Has The MOST RUBOST EVIDENCE !!! EUA 2021: There Insuffecient Evidence Regarding Effacy Of Behavioural Changes , However , They Should Be Tried Initially To Reduce The Need For Abx Prophylaxis EUA 2021: All 4 Meta Analyses Regarding Recurrent UTI Concluded That Abx Are The MOST Effective if It Asked Next , Then It Should Be Hydration , But [BEST EVIDENCE BASED] is Abx 5-10 July 40yo female healthy but recurrent UTI 4 times in 1 year wants to prevent it Whats the best clinical based evidence choice to prevent recurent uti? A-Hydration B-Cranberyy juice C-Postcoital hygiene D-Prophylactic abx A