Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 35-year-old presents with the chief complaint of, “My sinus infection is not getting any better,” with continued nasal and sinus congestion, yellow-to-white nasal discharge, and a feeling of sinus pressure, particularly when he bends over. He denies sore throat, headache, or GI symptoms, and previously reported fever prior to treatment that is now resolved. The EMR documentation notes a prescription for dose-appropriate amoxicillin with clavulanate written 2.5 days ago when he was seen for a sick visit. Patient states that he is taking the antibiotic as advised, starting the medication on the day of his sickness, and has not missed any doses.
Physical exam reveals no acute distress, mild tenderness to sinus palpation, and no fever. The next most appropriate step in this patient's treatment plan is to:
A: Advise the patient to continue this current course of therapy.
B: Switch his antimicrobial to moxifloxacin.
D: Order a CT of the sinuses.
D: Perform a posterior pharyngeal culture with sensitivity.
The correct answer is A: Advise the patient to continue his current course of therapy.
Where do you start with this question? First, determine what kind of a question this is. We've been given that the patient has been diagnosed and has been treated, and now we're looking at him status post-treatment. This is an evaluation question. Reminder what evaluation means: it's looking at response to care. As we do with all the podcasts, let's go through some background information.
Acute bacterial rhinosinusitis, also known as ABRS, is the result of inflammation of the paranasal sinus membranes. Given its name, select bacterial pathogens contribute to this condition. ABRS risk factors include any condition that alters the normal cleansing and drainage mechanisms of the sinuses, including viral respiratory tract infection (RTI), poorly controlled allergic rhinitis, tobacco use, and abnormalities in sinus structure.
Viral RTI is the most common antecedent event to ABRS development, but at the same time, less than 2% of all viral RTIs are complicated by
ABRS. ABRS is a clinical diagnosis arrived at as a result of careful analysis and synthesis of the patient's clinical presentation. Let's consider the natural history of viral RTIs. Viral RTIs typically resolve in 5-10 days, and therefore one of the chief diagnostic criteria for ABRS is when a person has persistent or worsening URI-like symptoms beyond 10 days.
Of course, in this question, we're actually not being asked to make the diagnosis. We're being told what the diagnosis is. With a question like this on boards, where you're being told what a given diagnosis is, simply proceed to answer the question as if those data are accurate. Don't say, ‘Yeah, but maybe it's not a diagnosis of ABRS. Maybe it could be something else.’
You say he's got ABRS and he was treated. Assume that that is accurate. So, let's get back to what to do next. We're being told the patient has been given an appropriate antimicrobial for the treatment of ABRS. Indeed, amox with clav, trade name Augmentin, has been talked about for literally decades as the gold standard for ABRS treatment.
And we're also being told that the patient is taking the medication appropriately. So, again, don't second guess this. Assume that this is correct. You might say, ‘All right, remember, he's 2.5 days into therapy. Why not just change his antimicrobial at this point? He's saying it really doesn't feel like he feels any better.’ Because the correct answer here tells us what we should do is stay the course, continue on the amox with clav, because it is an appropriate antibiotic.
But with that in mind, what we're going to do is break this down. Take a look at the question. Take a look at the answers. A 35-year-old presents with a chief complaint of, “My sinus infection is not getting any better," with continued sinus and nasal congestion, white-to-yellow nasal discharge, and a feeling of sinus pressure, particularly when he bends over.
He denies sore throat, headache, and GI symptoms, and previously reported fever has now resolved. EMR documentation notes a prescription for dose-appropriate amox with clavulanate written 2.5 days ago when he was seen for a sick visit. Patient states he has taken the antibiotic as advised, starting the medication on the day of his sick visit, and has not missed any doses.
Physical exam reveals no acute distress, mild tenderness to sinus palpation, and no fever. The next most appropriate step in the patient's treatment plan is to:
A: Advise the patient to continue on his current course of therapy.
Well, as I mentioned, of course, this is the correct answer. You might be really confused by this because the patient states he's not getting any better.
But at the same time, he's been on an appropriate antibiotic and the duration of therapy has been less than 3 days. An ABRS treatment failure, or at least consideration for changing an antimicrobial, should not be considered until the patient has been on the antibiotic for 3-5 days. Now. You might also mince the words here and say, ‘Two and a half days, 3 days, really kind of thought of the same, isn't it?’
But at the same time, take a look at the information we've been given. His fever's resolved, which it of course says, previously noted fever. Now, no more fever. So, he actually is getting better on this antibiotic. Now, ABRS or for all the symptomatology to resolve can take another 1-2 weeks and what I view this as, also his expectations of how he would feel with therapy, likely should have been managed a little bit better.
And that's something providers often forget to tell patients is, ‘Yeah, your fever will be gone in a couple of days. You're actually not going to feel that much better for another week, alright?’ And then if somebody gets better sooner, they're really pleased, but they're more accepting of the fact that it's taking a while to get over something.
One more comment I would make about this. As I mentioned, he’s on that “gold standard” medication for the treatment of ABRS. And that is going to cover all the assorted organisms that usually cause this condition. And the best treatment for him today would also be reassurance that his sinus pressure will persist, again, maybe another week, maybe another 2 weeks.
But he's without fever and he's going in the right direction. I'm going to add one more common thing, remember, with or without antibiotic therapy, ABRS gets better. And even people who truly have a bacterial sinus infection, if they never got an antibiotic, they're just going to get better in about a week to two weeks. Right. So, with that in mind, let's then take a look at option B. Option B: Switch his antimicrobial to moxifloxacin. Obviously, that’s not the correct answer.
Now, moxifloxacin is an antibiotic that's reached for sometimes when there has been treatment failure with other antibiotics, but there is no therapeutic advantage of going from amox-clav to a respiratory fluoroquinolone, such as moxifloxacin. Exact same spectrum of antimicrobial activity. Plus, one more time, he doesn't have treatment failure yet. He's only 2.5 days into treatment options.
C: Order a CT of the sinuses. Obviously not correct. When would imaging be considered part of the evaluation of the person with ABRS? General rule: sinus imaging is only considered when you look at the evidence-based guidelines. After a patient has failed, both the first-and a second-line antimicrobial for the treatment of ABRS. Another way of thinking of this is first-line therapy fails after 3-5 days, then second-line therapy fails after 3-5 days, you're now up to 6-10 days of treatment.
And the patient truly has not improved. What you should consider at that point is imaging could provide some information, including was ABRS the right diagnosis in the first place? Obviously, we don't have this situation with this particular patient.
C: Perform a posterior pharyngeal culture and sensitivity. It's tempting to think that you want to culture the sinus secretions, but the reality is this can only be accurately done with trans-sinus taps or another invasive procedure.
ABRS is almost always caused by the same three bugs. The gram-positive diplococci, Streptococcus pneumoniae, and one of two gram-negative organisms, Haemophilus influenzae and Moraxella catarrhalis. Sometimes it could be a mix. There were three of those and antimicrobial therapy is aimed at eradicating these organisms, and amox with clav covers all of them.
If you attempt to culture postnasal drip, which probably is coming from the sinuses, you're going to get a number of pharyngeal organisms, most of which are just sitting there colonizing the area. Key takeaway: safe and effective clinical practice dictates that we know when therapies need to be changed as well as when to simply stay the course and let the therapy the patient is currently taking do its work.
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