25 - URT Infections Flashcards
What diagnostic tool is often used to investigate an upper respiratory infections and their sensitivity?
Culture!
- Easily accessible and allows for identification of offending agent
- Sensitivity testing directs antimicrobial treatment
What diagnostic tests other than culture can be used in an upper respiratory infection?
IMAGING (remember, one view is no view!)
- plain xray (airway only - sinus xrays are USELESS)
- CT scans (not standard!)
- CBC
- CRP
- Monospot
- Serum procalcitonin
What is serum procalcitonin? When does it rise and fall?
Amino acid biomarker made by thyroid c cells.
- Levels increase with bacterial infections and infmallatory insult.
- There’s a rapid decline with immune control.
- Helps us know in the hospital when patients can stop taking antibiotics.
What is antimicrobial stewardship?
Rational, systemic approach to the utilization of antimicrobials to optimize outcomes.
Involves selecting the correct agent, dosing the medication properly, and utilizing the appropriate duration all to minimize toxicity and resistance.
What are 5 the most common causative agents of viral upper respiraotry tract infections?
- Rhinovirus (30-50% of URIs)
- Coronavirus (10-15%)
- Influenza (5-15%)
- RV/parainfluenza (5%)
- Adenovirus/enteroviruses
How are viral URIs transmitted?
- Hand contact: direct or indirect (survives ~2 hours in skin)
- Large droplets
- Small droplets (aerosols)
Note: tissue and cotton handkerchiefs do NOT support viral survival
What are some symptoms of viral URIs?
- Odynophagia (painful swallowing)
- Nasal obstruction
- Malaise
- Low grade fever
- Cough
- Pkugged ears
- Rhinorrhea: color and consistency varies (yellow or green does not necessarily mean it’s bacterial!)
What is the difference between these two ears? How would each be treated?
The left ear is serous otitis media (non-infectious) - since it’s not infectious you don’t need an antibiotic!
Right right ear is suppurative otitis media (bacterial) - you can tell because it is erythematous, buldging from pus behidn the eardrum, and has dilated BVs. Treat with an antibiotic!
What are some risk factors for acute otitis media?
- Peak incidence from 6-24 months
- Family hx
- Daycare exposure
- Lack of breast feeding
- Tobacco or air pollution exposure
- Race and ethnicity
What organisms are common causes of acute bacterial otitis media?
- Strep pneumonia (50%)
- Haemophilus influenza (45%)
- Moraxella Catarrhalis (10%)
- Group A Strep
What organisms cause chronic bacterial otitis media?
- Staph aureus
- Pseudomonas
- Proteus
- Anaerobes: peptostreptococcus, fusobacterium, prevotella
What are the recommendations for therapy for bacterial otitis media?
Immediate antimicrobial therapy for:
- children less than 6mo
- children with severe symptoms (pain, fever over 102.2 (39)
- bilateral bacterial otitis media
- immune compromised pt
When should you choose to just observe pts with bacterial otitis media?
- Immune competent pts
- Non sevre otalgia (<48 hrs)
- Temp less than 39 C
- Unilateral infection
But - close follow-up is essential! Failure to improve within 48-72 hrs means you should start antimicrobial therapy.
What meds would you use to treat bacterial otitis media?
- Amoxicillin
- Augmentin (penicillin + Clavulanate)
If penicillin allergy:
- mild allergy (rash) use cephalosporins
- severe allergy: macrolides
What is the function of tympanostomy tube placement? When should pts get them?
They allow for ventilation of middle ear space and a conduit for topical mediactions.
They relieve effusions and improve hearing.
Should get tubes if you have an effusion lasting >3 months.
What are risk factors for acute rhinosinusitis?
- Previous viral URI
- Older age
- Smoking
- Allergies/asthma
- Immunocompromise
- Dental disease
- Swimming
- Deep sea diving
The VAST majority of acute rhinosinusitis is casused by what?
VIRUSES!!!!!!!! (>96%)
What are the symptoms of viral vs bacterial sinusitis?
They are the same!
- Nasal obstruction
- Nasal secretions (clear to discolored)
- Facial pain/pressure
- Diminished smell/taste
- Malaise
- Headache
- Ear pressure/fullness
What lab and diagnostic studies should be done if you suspect that a patient has acute sinusitis?
Physical exam can support diagnosis but findings are non-specific.
Imaging is NOT indicated in workup for acute sinusitis. Culture is very useful in confirming diagnosis and directing therapy.
What are the guidelines for treatment of acute sinusitis?
Symptoms of viral and bacterial sinusitis are very similar and viral sinusitis is more common, we treat based on the timeline and severity of symptoms.
- If symptoms last more than 7-10 days, treat with abx.
- Treat with abx if suspected infection is bacterial
- Abx if symptoms are biphasic: initial improvement followed by worsening symptoms
Although we know that acute sinusitis is viral 96% of the time, what are some bcterial causes of it?
- Streop pneuomoniae
- Haemophilus influenza
- Moraxella catarrhalis
- Fental infections: anaerobes
What is the treatment of acute viral sinusitis?
Symptom relief
- Intranasal steroids
- Analgesics
- Saline nasal irrigation
- Nasal decongestants
- Guaifenesin
How would you treat acute bacterial sinusitis?
Amoxicillin
Amox/claculanate
If penecillin allergy: doxycyclin or respiratory fluoroquinolone: levofloxacin or moxifloxacin
What are four complications of acute bacterial sinusitis? What are symptoms?
- Orbital cellulitis
- Meningitis
- Brain abcess
- Septic cavernous sinus thrombosis
Symptoms: fever is common, severe pain, vision loss, severe headahce, and mental status change.
What is the most common cause of bacterial pharyngitis? When does it peak? What can it lead to if untreated?
Group A Strep: most common cause of bacterial pharyngitis (30-40%)
Peaks in winter and early spring.
Untreated can cause acute rheumatic fever or peritonsilar abcess.
What are symptoms of peritonsillar abcess?
Rapid onset:
- fever
- odynophagia
- Tender cervical lymphadenopathy
- nausea/vomiting
- Tonsilar hypertrophy with or without exudate
- Scarlatiniform rash
What lab tests would you order when you suspect tonsillitis or a peritonsillar abcess?
- CBC
- Serum Electrolytes
- Rapid antigen detection test: ie a rapid strep test (70-90% sensitive and 95% specific)
- Throat culture
What are somebacterial and viral causes of tonsilitis?
Bacterial:
- group A strep
- Group C and D strep
- Neusseria gonorrhea
Viral:
- Infectiour mono (EBV or CMV)
- Primary HIV
- Herpes simplex
- Entero or adenovirus
How would you treat tonsillitis?
Penicillin V or amoxicillin for 10 days.
If poor response, consider amox with clavulanate.
Could also use 1st or 2nd gen cepharlosporins.
Clindamycin
Macrolides
What are three complications of group A strep tonsillitis?
Acute Rheumatic fever
Post strep glomerulonephritis
Peritonsllar abscess
What is a peritonsillar abcess?
Purulent infection in the peritonsilar space.
Most common deep neck space abcess.
Usually unilateral, polymicrobial.
What are symptoms seen with a peritonsillar abcess?
- Severe odynophagia
- Drooling
- Fever
- Arthralgias/myalgias
- Referred otalgia (ear pain)
- Difficulty opening mouth
How should you treat a peritonsillar abcess?
- Secure airway
- IV hydration
- IV steroids
- IV or PO abx
- Pain control
- Drain abscess
- Possible tonsillectomy (if it happens more than once)
What are complications of peritonsillar abcess?
Septicemia
Internal jugular trombosis
Carotid rupture
Mediastinitis
Aspiration pneumonia
What are two different types of candidiasis that can occur in the upper respiratory tract?
Pseudomembranous candidiasis (thrush) - white and can be scraped off
Erythematous (atrophic) candidiasis - papilla have flattended out and the tongue is red
How would you prevent fungal lesions of the URT?
- Good oral hygiene
- Maintain oral hydration
- Gargle/rinse after using inhaled corticosteroids
- Practive good antimicrobial stewardship (because antibiotics use can lead to candidiasis)
What is croup? Who gets it and when?
Viral Laryngotracheitis - self-limiting viral disease that occurs during the fall and early winter in children 6 mo - 3 yrs.
Family history increases risk.
What are the top five causes of croup?
Parainfluenza virus:
- type 1 in fall/winter
- type 2 is milder form
- type 3 is sporadic but more severe
RSV
Adenovirus
Measles
Human coronavirus
What occurs in the airway with croup?
Airway narrowing caused by inflammation.
Barking cough.
Inspiratory stridor
Airway distress and compromise.
How would you treat someone with croup?
Rapid assessment to rule out bacterial disease. Supportive case.
Respiratory support/ICU if warranted.
What is bacterial tracheitis? What organisms usually cause it?
A bacterial infection of the tracheal mucosa.
Rare, usually occursin kids <6 yo secondary infection following viral insult.
Staph aureus or strep pneumonia.
How would you treat bacterial tracheitis?
Endoscopy/culture
Airway control
Possible debridement
Abx
What is pediatric epiglottitis and what organism generally causes it?
Bacterial cellulitis of the epiglottis and surrounding supraglottic structures.
Rapidly progressive cellulitis with no effect on the vocal cords. Ultimately narrows the airway and risks obstruction/asphyxiation.
Haemophilius influenza type B most common (others: staph, strep pneumo, group A strep)
What vaccine prevents pediatric epiglottitis? How effective is it?
Hib vaccine: 3-4 doses starting at 6 months.
Decreased Hib infections by 90%.
What are (5) symptoms of pediatric epiglottitis?
- drooling
- anxiety
- lack of cough
- tripod position (to try to open airway)
- rapid progression
What is seen on Xray in pediatric epiglottitis?
Xray not necessary for diagnosis.
Thumb sign!!!!
How would you treat pediatric epiglottitis?
Secure the airway ASAP!!! This may mean intubation or a surgical airway.
Then: culture from the epiglottis, blood cultures, and abx therapy
Do NOT provoke anxiety or crying because that would make the child upset, worsen the swelling, and close the airway.
