IC15 URTI

Question 1

Out of the 4 URTI, which would require antibiotics? What are their likely pathogens?

Answer 1

Bacterial pharyngitis (S. pyogenes) and bacterial rhinosinusitis (S. Pneumoniae, Hemophilus influenza)

Question 2

What are the clinical presentations of common cold?

Answer 2

Local symptoms: sore throat, sneezing, rhinorrhea, nasal block, productive cough (colourless, green, yellow),

Systemic Symptoms (rare): low grade fever, some headache and body aches

Question 3

Are objective evidences needed for common cold?

Answer 3

NO need
Unless to differentiate from influenza and COVID-19

Question 4

How to treat common cold?

Answer 4

Self-limiting
Symptomatic Relief
e.g. decongestant, nasal saline wash, lozenges, cough suppressants

Question 5

How to monitor response to common cold?

Answer 5

Step 4: Monitor Response

• Symptoms improve within 3-4 days
• Resolve/Recover within 7-10 days
• Cough will linger for 2-3 weeks
• See doctor
  o If symptoms worsen or do not improve after 10 days

Question 6

Compare between common cold and influenza, in terms of their signs and symptoms.

Answer 6

Symptoms Common Cold Influenza
Onset Gradual Rapid
Rhinorrhea Common Uncommon
Sneezing Common Uncommon
Nasal Block Common Sometimes
Sore throat Common Sometimes
Cough Common (productive) Common (dry cough)
Fever Rare Common
Ache Slight Common
Headaches Rare Common
Weaknesses, fatigue Sometimes Common
Chills Rare Common

Question 7

What are the signs and symptoms of influenza? When are the peak periods?

Answer 7

Rapid onset

Systemic symptoms: fever > 38, headache, malaise, chills, myalgia, anorexia, confusion (elderly)

Localized symptoms: sore throat, dry cough, nasal discharge

All year round, peak in Nov-Feb and May-July

Question 8

What are the complications of influenza?

Answer 8

Complications:
1. primary viral pneumonia,
2. secondary bacterial pneumonia (s. aureus, S. pneumonia, H. influenza),
3. exacerbation of chronic respiratory disease,
4. myocarditis

Question 9

What are the risk factors for the complications of influenza?

Answer 9

Risk factors for flu complications:
1. Child < 5y/o
2. Elderly 65 y/o and above
3. Pregnant or <2 weeks post-partum
4. Patients in nursing homes and long-term care facilities
5. Obese, BMI >40kg/m2
6. Chronic medical conditions e.g. asthma, COPD, HF, DM, CKD, immunocompromised patients

Question 10

When do you test for influenza?

Answer 10

Usually, NO need
unless hospitalized or in long term care facility

• POCT/ rapid detection kit (e.g. EIA)
• reverse transcriptase PCR

Question 11

What are some ways to prevent the spread and infection of influenza?

Answer 11

1. Good hand hygiene
2. Wear mask when sick
3. IM Vaccination trivalent and quadrivalent (1-2x/year) –> recommended for all >6 months old

Question 12

How to treat influenza?

Answer 12

Often self-limiting or symptomatic relief

Take antiviral if, meet any 1 of these criteria:
1. Hospitalized
2. High risk for complications
3. Severe, complicated or progressive illness
(Can consider for those outpatients too)

Step 3: Choice of antimicrobials
Oseltamivir 75 mg BD (5 days)

• Start within 48 hours, or at most within 5 days
• Covers Influenza A (hemagglutinin and neuraminidase) and B (Yamagata and Victoria)
• Neuraminidase inhibitor, prevents protein cleavage, preventing release of new virus
• ADR: headache, nausea and vomiting

Question 13

How to monitor response towards influenza?

Answer 13

Step 4: Monitor Response
- Resolve in 7-10 days
- See doctor
o If symptoms worsen or does not improve after 10 days
o Improved but then developed new fever, worsening dyspnea or cough

Question 14

What are the signs and symptoms of pharyngitis (both viral and bacterial)?

Answer 14

Viral:
1. sore throat (worse after swallowing),
2. erythematous pharynx and tonsils,
3. rhinorrhea,
4. cough,
5. hoarseness,
6. oropharyngeal lesions (ulcer or vesicles),
7. conjunctivitis,
8. low grade fever,
9. malaise, fatigue

Bacterial:
1. sore throat,
2. erythematous hypertrophy tonsils,
3. tonsil exudates,
4. swollen anterior cervical lymph node,
5. fever

Question 15

What are the acute and delayed complications of bacterial pharyngitis?

Answer 15

Acute complications of bacterial pharyngitis:

• Otitis media,
• peritonsillar abscesses,
• other invasive infections

Delayed complications (2-3 weeks later) of S. pyogenes Pharyngitis:
1. Acute rheumatic fever (prevented by early initiation of antibiotics)
2. Acute glomerulonephritis (CANNOT be prevented by antibiotics)

Question 16

What are do you use to decide how to assess and treat pharyngitis? What are the critieria? How would you categorize the results?

Answer 16

Use Median Centor Criteria to guide approach:
1. Fever > 38 degrees
2. Swollen, tender anterior cervical lymph node
3. Tonsillar exudate
4. No cough
5. 3-14 years old

0-1 –> NO test, viral pharyngitis, NO antibiotics
2-3 –> TEST for Streptococcus Pyogenes Pharyngitis using throat culture (24-48hrs), if positive then give antibiotics
4-5 –> highly likely S. pyogenes pharyngitis, give empiric antibiotics

Question 17

What is the likely pathogen that causes bacterial pharyngitis?

Answer 17

Streptococcus Pyogenes (Group A)

Question 18

What antibiotics would be used to treat bacterial pharyngitis?

Answer 18

Step 2: Identity of pathogen
- Usually is S. Pyogenes (Grp A)

Step 3: Choice of antimicrobials
1. PO penicillin V 250mg q6h
2. PO amoxicillin 500mg q12hr

If pen allergy, not amoxicillin allergy:
3. PO cephalexin 500mg q12hr
4. PO Azithromycin 500mg OD (5 days)
5. PO Clarithromycin 250mg q12h
6. PO Clindamycin 300mg q8h

Duration of therapy: 10 days

PO azithromycin and clarithromycin are based on antibiogram
Generally use lower dose according to the table

Question 19

What are the signs and symptoms of rhinosinusitis?

Answer 19

Fever, facial pain or pressure, purulent discharge, nasal block, reduced sense of taste and smell, headache, cough, ear fullness, bad breath, dental pain

Rare: spread to orbits or CNS –> limited ocular movements, acute vision changes, confusion, unilateral weakness

bacterial rhinosinusitis have similar S&S, just longer duration and more severe or usually is secondary to viral rhinosinusitis

Question 20

When to use microbiology test for rhinosinusitis? (objective evidence)

Answer 20

No need

Question 21

When to start antibiotics for rhinosinusitis?

Answer 21

If meet any one of these criteria, START antibiotics:
1. Symptoms do not improve after >10 days
2. Symptoms are severe for >3 consecutive days (fever > 39 degrees, severe facial pain, purulent nasal discharge)
3. Symptoms improve then worsen after >3 days (new onset fever, headache, increased nasal discharge)

Question 22

What are the likely pathogen that caused bacterial rhinosinusitis?

Answer 22

Step 2: Identity of pathogen
- Streptococcus Pneumonia*
- Hemophilus Influenza*
- Sometimes (S. pyogenes, Moraxella catarrhalis, anaerobes)

Question 23

What antibiotics are used to treat bacterial rhinosinusitis?

Answer 23

Step 3: Choice of antimicrobial
1. PO Amoxicillin 500mg q8h (increase dose if resistant)
2. PO Augmentin 625mg q8h (if more serious/ resistant to amoxicillin)

If amoxicillin allergy:
3. PO Cefuroxime 500mg q12h
4. PO Levofloxacin 500mg OD / PO Moxifloxacin 400mg OD
(Do NOT use tetracyclines, co-trimoxazole or macrolides, due to increasing resistant)

Duration: 5-7 days