Chapter 51 - Upper Respiratory Infections Flashcards
Week 2
URI S/s
Starts with nasal congestion, rhinorrhea, malaise, and scratchy throat
Peak severity days 3-6, may persist to 10-12 days, most symptom free 7-10 days after start
May have generalized muscle aches but no fever
Young children can have low-grade fever for 24-48 hours
Adults with fever or high-grade fever in children suggest influenza or secondary infection (eg. sinusitis/OM)
URI Pathophysiology
Primary cause is rhinovirus (160 serotypes; Multiple strains is reason for reinfections despite immunity)
Additional viruses
- Adenovirus
- Common cold coronaviruses
- COVID-19
- Respiratory syncytial virus
- Parainfluenza virus
- Influenza viral strain
- Human Metapneumovirus
URI Transmission
Airborne/DC via secretions
URI Goals of Treatment
Symptom relief
URI Drug Therapy
Decongestants
- Oral - Pseudoephedrine HCl, Pseudoephedrine sulfate, Phenylephrine (Pseudoephedrine can make meth. FDA restrictions)
- Topical - Phenylephrine HCl, Oxymetazoline HCL
(Vasoconstrict capillaries of nasal mucous membranes to promote drainage and decrease stuffiness)
URI Decongestants for children under 4?
Not recommended. Insufficient evidence for effectiveness
URI Nonpharm Therapy
Increased fluid intake, nonmedicated cough drops, nasal saline spray, rest
URI Monitoring
Watch for secondary bacterial infection
Cardiac patients - HTN from vasoconstriction by oral decongestant
Older - more likely to have adverse rxn
URI Complications
Most common is sinusitis (0.5-2% of adults, 6-7% in children,
Otitis Media in infants (27%)
- OM can be due to middle ear/etustachian tube anatomy
- Day care children tend to have more otopathogens - more likely to develop OM with URI
Exacerbation of asthma (30-50% of adults, 60-79% of children)
URI Education
Symptom management
Proper dosing of decongestants
Abx not necessary
Sinusitis
Diagnosed by persistent URI >10 days w/o clinical improvement likely to be bacterial sinusitis
Sinusitis s/s
High fever, facial pain, purulent nasal discharge for 3-4 days
Possible “Double-sickening”; worsening of symptoms that were previously improving
Adults
- Purulent Rhinorrhea, Facial Pain/Pressure, and Nasal obstruction
- H/A that worsens when they bend over
- Cough that’s worse at night
Children; S/s will be more subtle due to lack of development of frontal sinuses
- Increased frequency of colds require careful hx check to see if this is a new infection or prolonged s/s
Both
- Puffy eyes, cough that worsens when they lie down
Is imaging useful in Sinusitis
Questionable because sinus images will look the same in viral URI and sinus infection
Chronic Sinusitis
s/s for 8-12 weeks
Confirmed with Endoscopy or CT
Multiple episodes of acute bacterial sinusitis per year
Sinusitis Pathophysiology (Acute)
Common: Streptococcus Pneumoniae (Strep P), Haemophilus Influenzae, Moraxella Catarrhalis
Rarer: Staphylococcus
Sinusitis Pathophysiology (Chronic)
Common; Staphylococcus, Gram-Neg Enteric, Anaerobic Bacteria
Rarer; Fungal (Aspergillus)
Sinusitis Cause Agent finding requires
Sinus/Endoscopic aspiration for accurate organism. Nasal mucosa culture not useful
Sinusitis consideration for immunocompromised pt
Severe infections with possible invasive extensions to eye/mouth/brain
Sinusitis Goals of Treatment
Absence of infection, free of all s/s of sinus infection
Sinusitis Drug
First Choice ABX: Amoxicillin (PO) w or w/o clavulanate (Augmentin)
- Standard dose for bacterial sinusitis
- High-dose if patient is at risk for resistance
Alternate if allergic to Penicillins
- Adult: Doxycycline (PO) or Respiratory Fluoroquinolone (Levofloxacin/Moxifloxacin)
- Children: Gen 3 Cephalosporin (Cefdinir, Cefuroxime, Cefpodoxime)
Sinusitis Drug if not improving in 72 hours
Adults: High-dose amoxicillin-clavulanate or Fluoroquinolone (Levofloxacin/Moxifloxacin)
Children: High-dose Amoxicillin-clavulanate or gen 3 cephalosporins (listed above)
Patient failure to respond to drug therapy indicates?
Misdiagnosis or resistance
- CT/MRI to confirm dx
Sinusitis Monitoring
Should resolve in 7 days of treatment
Untreated, can lead to orbital cellulitis or brain involvement
Can exacerbate asthma
Sinusitis Education
Same as URI
Don’t go diving
If flying/driving over high altitude, use topical decongestants
Pharyngitis
Infection of pharynx or tonsils; Cause of Sore throat 20-30% in children, 5-15% in adults
Pharyngitis Causative Agent (Viral)
Adenovirus
Influenza
Parainfluenza
Rhinovirus
Coxsackievirus
RSV
Epstein-Barr
Pharyngitis Causative Agent (Bacterial)
Group A Streptococcal (GAS) most common, commonly seen in children 5-15
- Confirmed by Rapid Antigen Testing/culture
Pharygitis S/s
Presents sore throat, fever, Pharynx erthematous w or w/o exudate
- Children: H/A, N/V, abd pain
- Possible petechiae on soft palate, uvula red/swollen, strawberry tongue, confluent sandpaper rash (scarlatine rash aka scarlet fever)
Pharyngitis Treatment Goals
Eradicate bacteria
Prevent development of Acute Rheumatic Fever (ARF)
- Can be prevented if antimicrobial started within 9 days of onset of s/s
Pharygitis Drugs (Bacterial)
Beta-Lactams for GAS; Minimal resistance
- First Line: Penicillin V or Amoxicillin (PO)
- Penicillin G Benzathine (IM) can be given for children by weight
Nonanyphylactic allergy to penicillin
- Gen 1 Cephalosporin (Cephalexin)
Type 1 Penicillin allergy
- Clinamycin or Azithromycin
Pharyngeal carriers of GAS
- Clinamycin, Amoxicillin-Clavunalic Acid, or Penicillin w/Rifampin added on the last days of treatment
Pharyngitis Monitoring
ADR
S/s resolution
Pharyngitis Outcomes
Rapid antigen test to confirm GAS
S/s should improve within first 24 hours
Complete treatment to prevent ARF
Pharyngitis Education
Antipyretics for fever/discomfort
Take full therapy
Warm fluids and cool, soft foods tolerated better
Ottis Media
Most common reason for children getting abx
Most common in children <10 years
Vaccine PCV7, PCY13, and Haemophilus influenzae (HiB) decreased cases of AOM
Ottis Media s/s
Often fever, Possible hearing loss, tinnitus, dizziness, unsteady gain, balance problems
Children
- Tug and poke at ear, irritable, poor sleep, Vomiting/Diarrhea
Ottis Media Dx
1) Moderate-Severe bulging of Temporal Membrane or new onset of orrrhea
2) Mild bulging of TM and recent onset of ear pain or intense erythema of TM
***No diagnosis of AOM in children who do not have middle ear effusion
Ottis Media Pathophysiology
Eustachian tube dysfunction, blocking secretion flow from middle ear to pharynx; negative pressure develops in middle ear causing reflux of bacteria into middle ear space
Leads to MEE infected with nasopharyngeal bacteria
Children more susceptible due to shorter/more horizontal/more flaccid eustachian tubes
Risk factors
- URI
- Down
- Cleft palate
- HIV
- Eskimo/Native American
- Higher rate of infection in bottle vs breast fed and living with tobacco smokers
- Daycare doubles odds of AOM
- Immunocompromised/NG tubes
Ottis Media Causative Agent (Bacterial)
S Pneuimoniae
H Influenzae (Most common since PCV7 and PCV13)
- Approximate 90% nontypable
M Catarrhalis
Ottis Media Causative Agent (Viral)
RSV, Rhino, Corona, Adeno, Parainfluenza found alone (4%) or as a copathogen (66%)
Ottis Media Treatment Goals
Clear infection from ME with abx. If effective, infection clears
Treatment is empirical and may require change of abx
Ottis Media Drug
First Line: Amoxicillin
Repeated AOM/Abx in last 30 days: Beta-lactamase stable amoxicillin/clavulanate or Betalactamase-stable cephalosporin (for penicillin allergy)
Can choose to treat by waiting/observing with “safety net” prescription to use if needed
Ottis Media and Abx resistance
Frequent use of abx gave rise to resistance, causing reevaluation of use
Almost 100% of M Catarrhalis produce beta-lactamase (resistant to amoxicillin/other penicillins)
97% of pneumococci susceptible to penicillin; Amoxicillin remains first line
S Pneumoniae resistant to common macrolides
More frequent in
-Children attending daycare
-Recurrent AOM
-Younger than 2 years
-Recently treated with Beta-lactamase abx
Ottis Media Monitoring
Effectiveness of treatment based on 2-3 montoring or Abx prescription
If s/s resolve, should be reexamined
- Children <2: 8-12 weeks after starting sbx
- Children >2: Next scheduled wellness exam
Ottis media Education
Must be firm with treatment choice (observation or treatment)
Reexamine if still having significant pain after 48 hours
Ensure they finish treatment
Ottis Externa
Also known as “Swimmer’s Ear”
OM in external auditory canal
Ottis Externa S/s
Severe ear pain, starting with itching/irritation that is unilateral and localized
Pinna/Tragus manipulation causes pain
TM is normal but External canal is swollen
Ottis Externa Pathophysiology
Trauma/prolonged exposure to moisture
P Aeruginosa most common, then S Aureus
Ottis Externa Drug
Topical Therapy
- Combo med: Corticosteroids and Abx
- Solo Abx
- Acetic acid/alcohol drops
