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PR3151 Finals > IC15 Acute Respiratory Tract Infections (URTI) > Flashcards

IC15 Acute Respiratory Tract Infections (URTI) Flashcards

1
Q

What is the pathophysiology of URTI and its transmission?

A
  1. Transmission
    - Droplets or aerosols containing virus that are expelled - cough, sneeze, or talk
    - Spread indirectly - touches a surface (for example, a doorknob) and then touches nose or mouth.
    - Shares food without a serving spoon.
  2. These particles inhaled into the respiratory tract; invade upper airway mucosa
  3. Innate immunity against URTI
    - Nostril hair lining, Mucus
    - Angle between the pharynx and nose which prevents particles from falling into the airways
    - Mucociliary system in the lower airways that sweeps pathogens back to the pharynx
    - The adenoids and tonsils also contain immunological cells
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2
Q

What are some risk factors for URTI?

A
  • Close contact with children
  • Lack of personal/hand hygiene
  • Medical disorder: Chronic respiratory disease like asthma and allergic rhinitis
  • Smoking
  • Immunocompromised individuals - cystic fibrosis, HIV, corticosteroids, transplantation, and post-splenectomy
  • Anatomical anomalies including facial dysmorphic changes or nasal polyposis
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3
Q

How to prevent URTI?

A
  • Hand/personal hygiene
  • Wear masks
  • Stay away from crowds
  • Vaccinations (Influenza, Pneumococcal, Haemophilus influenzae)
  • Manage risk factors
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4
Q

How to manage URTI?

A
  1. Symptom management is key
  2. Antibiotic use is never indicated for common cold and influenza, sometimes pharyngitis, rhinosinusitis, otitis media
  3. Prevent future recurrence, manage risk factors
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5
Q

How to confirm and identify infection for common cold in diagnosis?

A
  1. Risk factors
  2. Low grade temperature 37 degrees, lack of high fever > 38 degrees
  3. Rhinorrhea, Nasal Congestion, Sneezing, Sore throat, Productive cough, headache, body ache
  4. Normal heart rate and lungs auscultation
  5. No need diagnostics
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6
Q

What pathogen is present in common cold?

A

Rhinovirus, coronavirus

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7
Q

What is the treatment and monitoring response? The duration of symptom recovery? If does not improve after ______ days or worsen, see a doctor?

A
  1. No antibiotics, symptomatic relief
  2. Self-limiting: 7-10 day recovery
  3. Normal to have nasal discharge with color change
  4. Cough: 2-3 weeks
  5. Symptom improvement within 3-4 days but can linger for weeks
  6. See doctor if after 10 days not improving
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8
Q

What is the clinical presentation of influenza?

A
  • Classic symptoms of fever, chills, headache, malaise, myalgia, and anorexia.
  • Respiratory symptoms include sore throat, dry cough and nasal discharge.
  • Elderly patients may present with confusion.
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9
Q

What are complications of influenza and the bacteria involve?

A

Primary viral pneumonia and secondary bacterial pneumonia (S. aureus, S. pneumoniae and H. influenzae)

Exacerbation of chronic respiratory disease, myocarditis (Rare)

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10
Q

What diagnostics on nasopharyngeal swab or aspirate can be done to confirm presence of influenza? When is it usually done or not done?

A
  • Rapid detection kits, POCT-immunofluorescence (IF), enzyme immunoassay (EIA), immunochromatographic method
  • Reverse-transcriptase PCR
  • More for hospitalized/ LTC, not routine in outpatient setting
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11
Q

What are some risk factors for flu complications caused by influenza?

A

Children < 5 years
Elderly ≥ 65 years
Women who are pregnant or within 2 weeks post-partum
Residents of nursing homes or long-term care facilities
Obese individuals with BMI ≥ 40 kg/m2
Individuals with chronic medical conditions (e.g. asthma, chronic obstructive pulmonary disease, heart failure, diabetes, chronic kidney disease, immunocompromised, etc.)

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12
Q

What are 2 similarities between flu and covid?

A
  • Wide spectrum of disease – form self-limiting to severe illness to complications resulting in hospitalization and death
  • Treatment and vaccination available
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13
Q

What are 2 differences between flu and covid?

A
  • Covid-19 more contagious than flu
  • Covid-19 causes more severe illness in vulnerable population
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14
Q

Which influenza virus is the only one causing pandemics? What are the subtypes characterised by?

A
  • Influenza A causes pandemics
  • Influenza A and B cause seasonal epidemics
  • Subtypes based on surface proteins hemagglutinin and neuraminidase
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15
Q

When does influenza A and B normally peak in Singapore?

A

Influenza A and B virus infections occur all year
round in Singapore with small peaks in the middle and the end/beginning of year

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16
Q

When is antiviral treatment suitable for influenza flu?

A

For documented or suspected influenza in hospitalized patients, patients with high risks for complications and severe / complicated / progressive illness

17
Q

When should antiviral treatment of influenza be initiated if indicated?

A

Initiate as soon as possible (best within first 48h, up to 5 days) of symptom onset

May be considered in outpatient setting presenting 48h of symptom onset

18
Q

What is the firstline antiviral treatment of influenza? What is its MOA, dosing regimen, dose adjustments and side effects?

A

Oseltamivir (Tamiflu) PO 75 mg BD for 5 days

MOA: Neuraminidase inhibitor (Interfere with protein cleavage and inhibits viral release)

Dose adjustment for CrCL < 60 mL/min

ADR: Well tolerated, headache, N/V (Mild GI)

19
Q

How to monitor response for influenza treatment?

A
  • Mostly no need antiviral drug or medical care
  • Symptoms for 1 week
  • Advise to see doctor if symptoms don’t improve after 10 days or improved first then develop new fevers, worsening dyspnea, cough
20
Q

What vaccine type is influenza?
How is it administered and how frequently?
Who is it recommended for?
How long does it take to confer immunity?
What is its efficacy?

A

Inactivated trivalent / quadrivalent vaccine

IM injection once per year (Community), and twice a year for hospitals

2 weeks to confer immunity

75% efficacy

21
Q

What are some clinical presentations of pharyngitis?

A
  • Sore throat (often worse with swallowing)
  • Fever
  • Erythema and inflammation of pharynx/tonsils
  • With or without patchy exudates
  • Tender and swollen lymph nodes
22
Q

What are some differences in symptoms for viral and bacterial pharyngitis?

A

Viral - Low grade fever, malaise, fatigue, rhinorrhea, cough, hoarseness, oropharyngeal lesions (ulcers or vesicles), and conjunctivitis

Bacterial - Tonsillar exudates & hypertrophy, fever > 38 degrees, and cervical lymphadenopathy WITHOUT viral symptoms

23
Q

What is the treatment of viral and GAS pharyngitis?

A

Self-limiting

24
Q

What complications can occur with GAS pharyngitis and when do they occur? Can they be prevented by antibiotics?

A

Complication occur 1-5 (usually 2-3) weeks later

  1. Acute rheumatic fever - Prevented with early initiation of effective antibiotics
  2. Acute glomerulonephritis - Not prevented by antibiotics
25
Q

What are some viral and bacterial causes of pharyngitis?

A
  • Rhinovirus, coronavirus, parainfluenza, Epstein-Barr
  • GAS (S pyogenes)
26
Q

What diagnostic tests can be done for S pyogene pharyngitis?

A

Gold standard - Throat culture (24-48 hours)

Rapid antigen detection test (RADT) (minutes) - Uncommon in Singapore

27
Q

What are the goals of antibiotic therapy?

A
  • Reducing symptom severity and duration
  • Prevention of acute complications, such as otitis media, peritonsillar abscesses, or other invasive infections
  • Prevention of delayed complications or immune sequelae, particularly acute rheumatic fever
  • Prevention of spread to others (no longer infectious after 24 hours of antibiotics)
28
Q

How does the point system work for the Modified Centor Criteria?

A

1 Point Each:
- Fever > 38 degrees
- Swollen tender anterior cervical lymph nodes
- Tonsillar exudates
- Absence of cough
- Age 3-14

Deduct 1 point for 45 years and above

0-1 point = No Abx needed
2-3 points = Do a diagnostic for S pyogenes
4-5 points = Empiric Abx initiation

29
Q

What antibiotic choice is suitable for GAS pharyngitis? (Regimen, dosing)

What antibiotic resistance should be taken as caution?

What is the duration of therapy? Why is it shorter for azithromycin?

A

First line:
- PO Penicillin 250 mg q6h or
- PO Amoxicillin 500 mg q12h

Penicillin allergy:
- Non-severe – PO Cephalexin 500 mg q12h
- PO Azithromycin 500 mg once daily
- PO Clarithromycin 250 mg q12h
- PO Clindamycin 300 mg q8h

Increasing resistance to macrolide

Duration: 10 days (5 days for azithromycin - Concentrate in the tonsils)

30
Q

How to monitor response for pharyngitis? For both on antibiotics on not on antibiotics.

A

No antibiotics – Assure that typical course
of a sore throat is < 1 week, abx not needed as they are likely having viral pharyngitis

Antibiotics – Fever and symptoms typically
resolve within 1-3 days of starting treatment

See doctor if symptoms does not improve or worsen

31
Q

What is the pathogenesis of acute rhinosinusitis? What is the duration of inflammation and infection of paranasal and nasal mucosa?

A

Pathogenesis
- Direct contact with droplets of infected saliva or nasal secretions
- Bacterial cases usually preceded by viral URTIs (e.g. common cold, pharyngitis)
- Inflammation results in sinus obstruction
- Nasal mucosal secretions are trapped
- Medium of bacterial trapping and multiplication

4 weeks

32
Q

What are common symptoms of acute rhinosinusitis?

A

 Purulent nasal discharge
 Facial pain or pressure
 Fever
 Nasal congestion and obstruction
 Reduced sense of taste or smell (hyposmia or anosmia)
 Headache
 Cough
 Ear fullness or pressure
 Bad breath
 Dental pain

33
Q

When should patients with sinusitis be referred to the emergency department?

A

Patients with sinusitis who have or develop evidence of spread of infection to the orbits or the central nervous system

34
Q

What are symptoms suggestive of orbital cellulitis or central nervous system infection?

A

 Limited ocular movements
 Acute vision changes
 Confusion
 Unilateral weakness

35
Q

Should culture or diagnostics be done to confirm viral or bacterial sinusitis?

What are the main bacterial pathogen?

What is bacterial rhinosinusitis considered?

A

No - Limited utility. Just look at clinical presentation

Most common: S pneumoniae, H influenzae
Some: S pyogenes, Moraxella catarrhalis, anaerobes

Bacterial rhinosinusitis is considered a secondary infection from obstruction of sinus obstruction from viral URTI

36
Q

Which clinical presentations are indications for antibiotic use for sinusitis?

A

If ≥ 1 of the following:

(1) Symptoms persist for > 10 days

(2) Symptoms are severe
- Fever > 39°C
- Purulent nasal discharge, or
- Facial pain lasting for > 3 consecutive days

(3) Symptoms worsen after initial improvement (double sickening) for > 3 days (5-6 days)
- New-onset fever
- Headache, or
- Increased nasal discharge

37
Q

What antibiotics can be used for bacterial rhinosinusitis? What antibiotics are not recommended due to resistance?

A

First-line:
- PO Amoxicillin 500 mg q8h
- PO Amoxicillin/clavulanate 625 mg q8h

Penicillin allergy:
- Non-severe allergy – PO cefuroxime 500 mg q12h
- PO levofloxacin 500 mg daily or moxifloxacin 400 mg daily

Duration: 5- to 7- day treatment course for adults

Tetracycline, trimethoprim/sulfamethoxazole and macrolides are not recommended because of increasing S. pneumoniae resistance

38
Q

What to monitor for clinical response in bacterial sinusitis? For those who received and didn’t receive antibiotics.

A

No antibiotics – Assure that typical course of 7-10 day antibiotics not needed as they are likely having viral or non-severe bacterial pharyngitis

Antibiotics - Patients should expect to have
sinusitis symptoms improve within 7-10 days.

See doctor Patient should return to medical attention if they develop persistent, severe, or worsening symptoms

PR3151 Finals (10 decks)

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