Episode Details

Episode 41: Otitis Media.

Diagnosis and treatment of acute otitis media in children, when to avoid antibiotics, use of short course of antibiotics, question of the week about polyarthralgia and fatigue.

Today is February 22, 2021.  

Question of the Month  
by Claudia Carranza  

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized.  She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, no chest pain, no SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA- and fatigue for 1 month, and what workup would you order (if any)? Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021. The winner will be announced and will receive a prize.

Introduction to episode:

This week we announced 3 new chief residents. Dr Manny Tu will replace Dr Lisa Manzanares, a big supporter of this podcast and chief for more than 1 year, who graduated last week as didactics chief. Dr McGill and Dr Gomes will continue to be chiefs until they hand over the baton to Dr Gina Cha and Dr Alejandro Gonzalez-Perez. Congrats, dear residents! (or should we say sorry?)

When you treat an infection, you need to know the recommended duration of treatment. Normally, the more severe an infection is, the longer the duration of treatment. 

In many instances, shorter courses of antibiotics can have similar efficacy to longer courses[1], and treating for shorter periods may also reduce the development of resistance and infections by C. difficile. 

Some infections in which this applies are, for example, community-acquired pneumonia (CAP), where treatment can be shortened to 3-5 days instead of 7-10 days; nosocomial pneumonia which can be treated for 7 days instead of 10-15 days; pyelonephritis, 5-7 days instead of 10-14 days; intra-abdominal infection (after source control) for 4 days instead of 10 days; COPD exacerbation, less than 5 days instead of more than 7 days; bacterial sinusitis, 5 days instead of 10; uncomplicated cellulitis, 5-6 days instead of 10 days. Of course, you must use your clinical judgement when deciding to use a shorter course of antibiotic treatment.

As a reminder, FDA has also warned about the relationship between fluoroquinolones and an increased risk of aortic dissection. On their website, it states that “Health care professionals should avoid prescribing fluoroquinolones to patients who have an aortic aneurysm or are at risk for an aortic aneurysm, such as patients with peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients”. They also say you “may prescribe fluoroquinolones to these patients only when no other treatment options are available”[2]. 

Other safety concerns reported by FDA about fluoroquinolones include: significant decrease in blood sugar and certain mental health side effects, disabling side effects of the tendons, muscles, joints, nerves, and central nervous system, restriction in use for certain uncomplicated infections, peripheral neuropathy, and tendinitis and tendon rupture.