Infectious Disease Flashcards
What is influenza?
Influenza is an acute viral infection of the respiratory tract caused by influenza viruses, leading to symptoms such as fever, cough, and muscle aches. It primarily affects the upper and lower respiratory systems.
Influenza viruses are family of _____
Orthomyxoviridae
What type of virus is influenza?
RNA virus
How many types of influenza affect humans?
Three types of influenza, A, B and C, affect humans (a D type affects cattle).
What are the most common types of influenza?
A and B are the most common.
What are the subtypes of Influenza A?
Type A has different H and N subtypes. Examples of A strains are H1N1 (which caused the Spanish flu pandemic of 1918 and the swine flu pandemic of 2009) and H5N1 (which causes bird flu). Influenza A is zoonotic (affects animals + humans), classified by haemagglutinin and neuraminidase proteins (e.g. H1N1).
Outbreaks of flu typically occur during the ____.
winter
Transmission of Influenza
spreads via respiratory droplets, aerosolisation, person-to-person contact, or contaminated surfaces
Incubation period following Influenza exposure ?
ranges from 1-4 days. Viral shedding peaks within 48-72 hours of exposure and rapidly declines following day 6. Viral shedding is usually undetectable by day 10
How often are influenza vaccines given?
Every year the influenza vaccine is altered to target multiple strains that are circulating that year. Yearly vaccines are required. Influenza viruses easily acquire point mutations, resulting in significant antigenic drift over time. This results in seasonal epidemics each year and occasional pandemics
The flu vaccine is free on the NHS to people at higher risk of developing flu or flu-related complications:
Aged 65 and over
Young children
Pregnant women
Chronic health conditions, such as asthma, COPD, heart failure and diabetes
Healthcare workers and carers
How long is the delay between exposure and symptoms of Influenza?
Usually around 2 days
How does Influenza enter the body and start replicating?
Influenza viruses enter the respiratory epithelium through interactions between the viral haemagglutinin protein and cell surface molecules, enabling viral replication to take place.
Acute Influenza Infection leads to what ?
Acute infection triggers a cascade of host responses, including the release of numerous pro-inflammatory cytokines (notably the interferons) and defence mechanisms such as programmed cell apoptosis to minimise viral replication and spread.
This results in mucosal inflammation and eventually progresses to destruction and desquamation of the pseudostratified columnar epithelium. Most influenza infections involve the upper respiratory tract and are self-limiting. However, significant lower respiratory tract infections can develop if the distal bronchial and alveolar epithelium are affected. As alveolar compromise progresses, acute respiratory distress syndrome (ARDS) and viral pneumonia can manifest.
Risk factors for Influenza
Extremes of age (over 90% of deaths occur in over 65s)
Immunocompromise
Comorbidities (e.g. cardiovascular, respiratory, renal disease and diabetes)
Pregnancy
Healthcare workers
Residence in nursing homes or long-term care facilities
Obesity
Symptoms of Influenza
Fever
Lethargy and fatigue
Anorexia (loss of appetite)
Muscle and joint aches
Headache
Dry cough
Sore throat
Coryzal symptoms General malaise accompanied by severe headache, myalgia and fever is a typical presentation of influenza.
Other typical symptoms include:
Pharyngitis
Rhinorrhoea
Dyspnoea
Gastrointestinal (GI) upset, including nausea, vomiting, and diarrhoea are common in children.
Signs of Influenza in uncomplicated infection
clinical findings may be non-specific. Oropharyngeal hyperaemia or cervical lymphadenopathy may be present
Signs of Influenza if there is LRT involvement
Vital sign derangement (e.g. hypoxia, tachycardia, fever, hypotension)
Respiratory distress (e.g. tachypnoea, unable to complete sentences, accessory muscle use)
Wheeze
Crepitations or bronchial breathing on auscultation
Differentials for Influenza Infection
SARS-CoV-2
Bacterial pneumonia
Respiratory syncytial virus
Rhinovirus
Parainfluenza virus
ARDS
Streptococcal pharyngitis
Pulmonary embolism
How can you differentiate common cold and flu?
Flu tends to have an abrupt onset, whereas a common cold has a more gradual onset. Fever is a typical feature of the flu but is rare with a common cold. Finally, people with the flu are “wiped out” with muscle aches and lethargy, whereas people with a cold can usually continue many activities.
What is the diagnostic test for influenza?
Viral PCR
Why is influenza testing done?
Testing may be considered to confirm the diagnosis and monitor circulation and outbreaks.
The ________________ monitors the number of flu cases and provides guidance when the numbers are high.
UK Health Security Agency (UKHSA)
What are the different types of testing available for Influenza?
Point of care tests, Viral nasal or Throat Swabs
What are point-of-care tests for in Influenza?
Point-of-care tests using swabs are available, giving a rapid result. They detect viral antigens. They are not as sensitive as formal lab tests and do not give information about the subtype of the virus.
What are nasal/throat swabs for in Influenza?
Viral nasal or throat swabs can be sent to the local virology lab for polymerase chain reaction (PCR) analysis. This can confirm the diagnosis and help with tracking case numbers and patterns.
Treatment of Influenza depends on ……
Healthy patients who are not at risk of complications do not need treatment. The infection will resolve with self-care measures, such as adequate fluid intake and rest.
There are two options for treatment in someone at risk of complications of influenza:
Oral oseltamivir (Tamiflu®) 75 mg (twice daily for 5 days)
Inhaled zanamivir 10 mg (twice daily for 5 days) (if oral administration not tolerated)
How do Oseltamivir (Tamiflu) & Zanamivir (Relenza) work?
both are neuraminidase inhibitors which prevent new viral particles from being released by infected cells
Common SE of Oseltamivir (Tamiflu)
nausea, vomiting, diarrhoea and headaches
SE of Zanamivir ?
may induce bronchospasm in asthmatics
Tx for life-threatening Influenza illness
IV zanamivir 600 mg BD for 5-10 days
Treatment of Influenza needs to be started within __ hours of the onset of symptoms to be effective.
48
What can be given post exposure to Influenza?
Post-exposure prophylaxis may be given where patients meet specific criteria:
It is started within 48 hours of close contact with influenza
Increased risk (e.g., chronic disease or immunosuppression)
Not protected by vaccination (e.g., it has been less than 14 days since they were vaccinated)
Options for post-exposure prophylaxis for Influenza are:
Oral oseltamivir 75mg once daily for 10 days
Inhaled zanamivir 10mg once daily for 10 days
Complications of Influenza
Otitis media, sinusitis and bronchitis
Viral pneumonia
Secondary bacteria pneumonia
Worsening chronic health conditions, such as COPD and heart failure
Febrile convulsions (young children)
Encephalitis
What is Mumps?
Mumps is an acute, generalised viral infection characterised by bilateral parotid swelling.1
Who is Mumps common in?
Prior to the introduction of the measles, mumps, and rubella (MMR) vaccine in 1987, it was common in children, but outbreaks are now more common among young adults at university, especially those who did not receive the MMR vaccine.
Transmission of Mumps?
Respiratory droplets & saliva
What causes Mumps?
RNA Paramyxovirus
When do Mumps cases typically rise?
Winter + Spring
Which organs does Mumps affect?
Although it can infect any organ, the salivary glands are most commonly affected. Less often affected are the testes, ovaries, pancreas, and brain.
Incubation period of Mumps?
14-25 days (Geeky medics says 16-18 days) (Passmed says 14-21 days)
When are transmission rates of Mumps highest?
1-2 days prior to the onset of symptoms.
How long does Mumps last?
~ 1 week
Tx of Mumps?
Management is supportive with rest, fluids and analgesia. Mumps is a self limiting condition. Management of complications is also mostly supportive.
The MMR vaccine offers ____% protection against Mumps
80
___ % of those infected with the mumps virus are asymptomatic
15-20
Presentation of Mumps
Patients experience an initial period of flu-like symptoms known as the prodrome. These occur a few days before the parotid swelling:
Fever
Muscle aches
Lethargy
Reduced appetite
Headache
Dry mouth
Key feature of Mumps
Parotid gland swelling, either unilateral or bilateral, with associated pain [develops in 95% of symptomatic cases and usually lasts three to four days, although can last up to ten]
Mumps can also present with symptoms of the complications, such as:
Abdominal pain (pancreatitis)
Testicular pain and swelling (orchitis)
Confusion, neck stiffness and headache (meningitis or encephalitis)
Confiriming Dx of Mumps
The diagnosis can be confirmed using PCR testing on a saliva swab. The blood or saliva can also be tested for antibodies to the mumps virus.
Is Mumps a notifiable disease?
Mumps is a notifiable disease, meaning you need to notify public health of any suspected and confirmed cases.
Complications of Mumps
Pancreatitis
Orchitis
Meningitis
Sensorineural hearing loss
The efficacy of the MMR vaccine (both doses) against mumps is __%
88
Complications of Mumps: Orchitis
Mumps orchitis often occurs without parotitis, but if both are present, orchitis generally develops four or five days after the parotitis onset.
Orchitis is found in 25% of post-pubertal males with mumps and is bilateral in 15-30% of cases.
It is associated with severe testicular pain and tenderness. Significant scrotal oedema may make the testes impalpable. Bilateral orchitis may lead to subfertility
Complications of Mumps: Meningitis/Encephalitis
Mumps meningitis and encephalitis also usually occur without parotitis.
In patients infected with the mumps virus, 15% develop meningism.8 Although mumps meningitis is usually mild and self-limiting, mumps encephalitis has a mortality rate of 1.5%.
Mumps encephalitis is rare, and may present as part of the initial infection, or later in the disease course
What is Infectious Mononucleosis?
Infectious mononucleosis (IM) is a condition caused by infection with the Epstein Barr virus (EBV). It is the symptomatic infection with EBV that is called infectious mononucleosis.
What causes Infectious Mononucleosis?
Epstein Barr virus (EBV) also known as human herpesvirus 4, HHV-4
Causes for EBV- negative mononucleosis?
HIV
Cytomegalovirus (CMV)
Other human herpes viruses
Toxoplasma gondii
Streptococcus pyogenes
Other names for Infectious Mononucleosis
It is commonly known as the “kissing disease”, “glandular fever” or “mono”.
How is Infectious Mononucleosis transmitted?
This virus is found in the saliva of infected individuals. Infection may be spread by kissing or by sharing cups, toothbrushes and other equipment that transmits saliva.
How long are people infected with EBV, infectious?
EBV is secreted in the saliva of infected individuals and can be infectious several weeks before the illness begins and intermittently for the remainder of the patient’s life
Who is Infectious Mononucleosis common in?
Most people are infected with EBV as children, when it causes very few symptoms. When infection occurs in teenagers or young adults, it causes more severe symptoms.
Typical symptoms of Infectious Mononucleosis
fever, sore throat and fatigue. classic triad of sore throat, pyrexia and lymphadenopathy
Classic exam style presentation of Infectious Mononucleosis
an adolescent with a sore throat, who develops an itchy rash after taking amoxicillin. Mononucleosis causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
Pathophysiology of IM
Following contact with EBV-positive oropharyngeal secretions, EBV infects the oropharyngeal epithelium and lymphoid tissues. Through infecting oropharyngeal B lymphocytes, EBV induces a lytic infection cycle, enabling viral replication, which is then disseminated via the lymphoreticular system.
Infected B lymphocytes also induce the release of heterophile antibodies, which can be detected in blood tests to support a diagnosis of EBV infection.
Disseminated EBV infection produces a T-cell-mediated immune response, which aims to suppress primary EBV infection. The efficiency of this process determines the extent to which clinical symptoms (i.e. IM) will manifest. This process results in atypical lymphocytosis (primarily CD8+ T cells and CD16+ natural killer cells), which is commonly associated with IM.3-4
Once primary infection is suppressed, EBV persists as a lifelong latent infection prone to periodic reactivation and viral shedding.4
Symptoms of Infectious Mononucleosis
Fever
Sore throat
Fatigue
Tonsillar enlargement
Signs of Infectious Mononucleosis
Lymphadenopathy (swollen lymph nodes) Splenomegaly and in rare cases splenic rupture
Which antibodies are produced in Infectious Mononucleosis?
In infectious mononucleosis, the body produces something called heterophile antibodies, which are antibodies that are more multipurpose and not specific to the EBV antigens. It takes up to 6 weeks for these antibodies to be produced.
Which 2 tests can be used to test for heterophile antiboides in Infectious Mononucleosis?
Monospot test & Paul-Bunnell test
What is the Monospot test in Infectious Mononucleosis?
this introduces the patient’s blood to red blood cells from horses. Heterophile antibodies (if present) will react to the horse red blood cells and give a positive result. The monospot test exposes a patient’s blood sample to a solution rich in equine erythrocytes. A positive agglutination reaction confirms the presence of heterophile antibodies, strongly suggesting a diagnosis of IM.
The test should be obtained in the second week of illness as tests within the first week are associated with a 25% false negative rate.
What is the Paul-Bunnell test in Infectious Mononucleosis?
this is similar to the monospot test but uses red blood cells from sheep.
Specifity and Sensitivity of the heterophile antibody tests in Infectious Mononucleosis.
These tests are almost 100% specific for infectious mononucleosis, however not everyone who has IM produces heterophile antibodies, and it can take up to six weeks for the antibodies to be produced. Therefore they are only 70 – 80% sensitive.
Specific Antibody Tests for Infectious Mononucleosis
It is possible to test for specific EBV antibodies. These antibodies target something called viral capsid antigen (VCA):
The IgM antibody rises early and suggests acute infection
The IgG antibody persists after the condition and suggests immunity
Management of Infectious Mononucleosis
Infectious mononucleosis is usually self limiting.
How long does Infectious Mononucleosis last?
The acute illness lasts around 2 – 3 weeks, however it can leave the patient with fatigue for several months once the infection is cleared.
Advice for patients with Infectious Mononucleosis
Patients are advised to avoid alcohol, as EBV impacts the ability of the liver to process the alcohol. Patients are advised to avoid contact sports due to the risk of splenic rupture. Emergency surgery is usually required if splenic rupture occurs.
Complications of Infectious Mononucleosis
Splenic rupture
Glomerulonephritis
Haemolytic anaemia
Thrombocytopenia
Chronic fatigue
EBV infection is associated with certain cancers, notable Burkitt’s lymphoma.
What is gastroenteritis?
Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with pain, nausea, vomiting and diarrhoea.
The most common causes of gastroenteritis are _____.
Viruses
Transmission of viral gastroenteritis
Viral gastroenteritis is very easily spread, and patients often have an affected family member or contact.
Why is isolation important in cases of viral gastroenteritis?
It is essential to isolate the patient in a healthcare environment, such as a hospital ward or assessment unit, as it can spread to other patients.
Prognosis of viral gastroenteritis
Most people recover well. However, gastroenteritis can rarely be fatal, especially in very young or old patients or those with other health conditions.
Common causes of viral gastroenteritis
Rotavirus
Norovirus
Adenovirus (tends to cause respiratory symptoms)
Management of Viral Gastroenteritis
Food poisoning is a notifiable disease. The UK Health Security Agency (UKHSA) should be notified of suspected cases. When notifiable organisms (e.g., Giardia) are identified on testing, the lab must notify UKHSA.
Good hygiene helps prevent gastroenteritis. When patients develop symptoms, they should immediately be isolated in order to avoid spread. Barrier nursing and rigorous infection control are important for inpatients.
A faeces sample can be tested with microscopy, culture and sensitivities to establish the causative organism and antibiotic sensitivities.
Dehydration is the primary concern. The key to management is establishing whether patients can keep themselves hydrated or need admission for IV fluids. Antibiotics are generally not recommended or required. Most patients make a full recovery with simple, supportive management.
Oral rehydration salt solution (e.g., Dioralyte sachets mixed with water) can help replace losses in patients at increased risk of dehydration (e.g., frail patients). These contain glucose, potassium and sodium.
Antidiarrhoeal drugs (e.g., loperamide) and antiemetics (e.g., metoclopramide) are generally avoided, as they can worsen the condition. The NICE Clinical Knowledge Summaries (updated June 2023) suggest antidiarrhoeal drugs may be helpful in mild-moderate diarrhoea but should be avoided with E. coli 0157, shigella or bloody diarrhoea.
Antibiotics are only used in patients at risk of complications once the causative organism is confirmed.
Once the oral intake is better tolerated, a light diet with small quantities of bland foods can be introduced. Patients should stay off work or school for 48 hours after symptoms resolve entirely.
Post-Gastroenteritis Complications
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
Haemolytic uraemic syndrome
What are UTIs?
Lower urinary tract infections (UTIs) involve infection in the bladder, causing cystitis (inflammation of the bladder). A urinary tract infection (UTI) is an inflammatory reaction of the urinary tract epithelium (affecting the kidneys, bladder, or urethra) in response to pathogenic microorganisms, most commonly bacteria.
What is Cystitis?
Cystitis, also referred to as a lower UTI, is a bladder infection. This is also categorised as an uncomplicated UTI, though it can progress to an upper or complicated UTI.
What is Pyelonephritis?
Pyelonephritis refers to inflammation of the kidney resulting from bacterial infection. The inflammation affects the kidney tissue (parenchyma) and the renal pelvis (where the ureter joins the kidney).
Why are UTIs more common in girls?
the urethra is much shorter.
Peak incidence of UTI is among ____
young, sexually active women aged 18 to 24
Common causative organisms for UTIs
E. coli, Klebsiella pneumoniae, and Enterococcus faecalis.
What is the primary source of bacteria for UTIs?
The primary source of bacteria for urinary tract infections is faeces. Intestinal bacteria, such as Escherichia coli (E. coli), Klebsiella pneumoniae and enterococci, can easily journey to the urethral opening from the anus.
Presentation of UTIs in Infants?
Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
Signs and Symptoms of UTIs in older infants and children?
Abdominal pain, particularly suprapubic pain
Dysuria (painful urination)
Urinary frequency
Urinary urgency
Urinary incontinence
Nocturnal enuresis (bedwetting)
Fever
Vomiting
The diagnosis of an acute upper urinary tract infection (pyelonephritis) is made if there is either:
Fever over 38°C
Loin pain or tenderness
How do you distinguish between Upper or Lower UTIs?
fever and loin pain are the two criteria for diagnosing upper urinary tract infections. The distinction between upper and lower UTIs is crucial as it determines the management.
What is the ideal urine sample type?
The ideal urine sample is a clean catch sample, avoiding contamination. This can be tricky in younger children and babies, particularly girls. It often involves the parent sitting with the infant without a nappy and a urine pot held ready to catch the sample. A clean catch sample helps avoid unreliable microbiology results. Specially designed urine collection pads may be helpful.
Nitrites on dipstick test =
Nitrites on a dipstick test suggest bacteria in the urine. Gram-negative bacteria (e.g., E. coli) break down nitrates (a normal waste product in urine) into nitrites.
Leukocytes on dipstick test =
Leukocytes are white blood cells. It is normal to have a small number of leukocytes in the urine, but a significant rise can result from an infection or other cause of inflammation. Leukocyte esterase (a product of leukocytes) is tested on a urine dipstick, indicating the number of leukocytes in the urine.
Red blood cells on dipstick test =
indicate bleeding. Microscopic haematuria is where blood is seen on a urine dipstick but not seen when looking at the sample. Macroscopic haematuria is where blood is visible in the urine. Haematuria is a common sign of infection but can also be present with other causes, such as nephritis and haemolytic uraemic syndrome.
How do you diagnose a UTI from dipstick results?
Positive nitrites and leukocytes indicate a urinary tract infection. Negative nitrites and leukocytes exclude a UTI. When one is positive and the other is negative, this is less convincing of an infection, and a sample should be sent for further testing.
What is a midstream urine sample and what does it test for?
Children under 3 months with a fever should have a full septic screen (including bloods, blood cultures, urine culture and considering a lumbar puncture) and start immediate IV antibiotics (e.g., ceftriaxone and amoxicillin).
UTI Management for children < 3 months
Children under 3 months with a fever should have a full septic screen (including bloods, blood cultures, urine culture and considering a lumbar puncture) and start immediate IV antibiotics (e.g., ceftriaxone and amoxicillin).
When would a UTI require inpatient treatment?
Children with features of sepsis or upper urinary tract infection will require inpatient treatment with IV antibiotics.
Tx of uncomplicated lower UTI
3 days of oral antibiotics. Typical choices in children are:
Trimethoprim (first-line if low risk of resistance)
Nitrofurantoin (first-line)
Cefalexin
Amoxicillin
Can trimethoprim be used for pregnant women who have a UTI?
No, it is contraindicated as it is teratogenic in the first trimester and should be avoided during pregnancy
Which drug is preferred for patients with eGFR ≥ 45 who have a UTI?
In individuals with an eGFR ≥ 45 ml/minute, nitrofurantoin is preferred, as it is renally excreted
UTI: NICE (2019) recommends an ultrasound scan for:
All children under 6 months with their first UTI (within 6 weeks)
Recurrent UTIs (within 6 weeks)
Atypical UTIs (e.g., very unwell or atypical organisms) (during the illness)
What is a DMSA scan?
A DMSA (dimercaptosuccinic acid) scan is recommended 4-6 months after the infection to assess for damage from recurrent or atypical UTIs. A radioactive material (DMSA) is injected, and a gamma camera is used to determine how well the kidneys take up the material. Patches of kidneys that do not take up the material suggest scarring
What is an MCUG scan?
A micturating cystourethrogram (MCUG) is used to test for vesicoureteral reflux (VUR) in infants under 6 months with recurrent or atypical UTIs. It is also considered where there is a family history of vesicoureteral reflux, dilatation of the ureter (on ultrasound) or poor urinary flow. It involves catheterising the child, injecting contrast into the bladder and taking a series of x-rays to determine whether the contrast is refluxing into the ureters. Prophylactic antibiotics are given for 3 days around the test to reduce the risk of infection.
What is Vesicoureteral Reflux (VUR)?
Vesicoureteral reflux (VUR) involves urine flowing back into the ureters from the bladder. This predisposes patients to develop upper urinary tract infections and subsequent renal scarring.
How is VUR diagnosed?
It is diagnosed using a micturating cystourethrogram (MCUG).
Management of VUR depends on severity and it may involve :
Avoiding constipation
Avoiding an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology
Complications of UTIs
persistent lower urinary tract symptoms, staghorn calculi, pyelonephritis, emphysematous pyelonephritis and cystitis, incontinence, renal abscess, prostatic abscess, chronic prostatitis, hypertension, renal failure.
Define “Recurrent bacterial cystitis”
two or more UTIs in six months or three or more in 12 months.
Differential diagnoses to consider in the context of a suspected UTI include:
Pyelonephritis
Renal stone
Vaginitis
Pelvic inflammatory disease (women)
Acute prostatitis (men)
Sexually transmitted infections
Renal infarction
What is the recommended oral antibiotics as first-line therapy for upper UTIs/acute pyelonephritis in men, non-pregnant women, and children?
Cefalexin and co-amoxiclav
What is the recommended First line oral and First line IV ABx for pregnant women who have an upper UTI?
In pregnant women, cefalexin is the first-line oral antibiotic, and cefuroxime is the first-line IV antibiotic
When would you send a urine culture for non-pregnant women who have a UTI?
aged > 65 years
visible or non-visible haematuria
Management of a symptomatic pregnant women with a UTI?
if the pregnant woman is symptomatic:
a urine culture should be sent in all cases
should be treated with an antibiotic for 7 days
first-line: nitrofurantoin (should be avoided near term)
second-line: amoxicillin or cefalexin
trimethoprim is teratogenic in the first trimester and should be avoided during pregnancy
Management of an asymptomatic pregnant woman with a UTI?
a urine culture should be performed routinely at the first antenatal visit
NICE recommend an immediate antibiotic prescription of either nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course
the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
a further urine culture should be sent following completion of treatment as a test of cure
Who can be offered UTI prophylaxis + what is it?
women who suffer regular urinary tract infections following sexual intercourse can be offered post-coital antibiotic prophylaxis - single dose trimethoprim or nitrofurantoin are used first-line
Management of a man who has a UTI?
an immediate antibiotic prescription should be offered for 7 days
as with non-pregnant women, trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected
a urine culture should be sent in all cases before antibiotics are started
NICE state: ‘Referral to urology is not routinely required for men who have had one uncomplicated lower urinary tract infection (UTI).’
Management of UTI in catheterised patients?
do not treat asymptomatic bacteria in catheterised patients
if the patient is symptomatic they should be treated with an antibiotic
a 7-day, rather than a 3-day course should be given
consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
Management of a patient with signs of acute pyelonephritis?
For patients with sign of acute pyelonephritis hospital admission should be considered
local antibiotic guidelines should be followed if available
the BNF currently recommends a broad-spectrum cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
What is Tonsilitis?
Tonsillitis refers to inflammation of the tonsils.
What is the most common cause of Tonsilitis?
The most common cause of tonsillitis is a viral infection. Viral (more common): rhinovirus, coronavirus, parainfluenza, Epstein-Barr virus (EBV).
What is the most common bacterial cause of Tonsilitis?
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.
Other causes of bacterial Tonsilitis?
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
What is Waldeyer’s Tonsillar Ring?
In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils on either side at the back of the throat.
Typical presentation of acute Tonsilitis?
Sore throat
Fever (above 38°C)
Pain on swallowing
Examination findings for Tonsilitis?
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).
What is used to decide whether or not to start Abx in Tonsilitis?
The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics.
How to interpret the Centor Criteria for Tonsilitis?
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics.
What are the 4 Centor Criteriae?
A point is given if each of the following features are present: Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
What is an alternative to the Centor Criteria for Tonsilitis?
The FeverPAIN score is an alternative to the Centor criteria
How to interpret the FeverPAIN score?
A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis:
What does FeverPAIN stand for?
Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza
When would you consider admission for a case of Tonsilitis?
Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
Management of Tonsilitis
When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score.
Educate patients with likely viral tonsillitis and give safety net advice about when to seek medical advice. Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered.
Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever.
Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.
First line Abx for Tonsilitis
Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.
First line Abx for Tonsilitis when there is a true penicillin allergy
Clarithromycin
Complications of Tonsilitis
Peritonsillar abscess, also known as quinsy
Otitis media, if the infection spreads to the inner ear
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
Differential Dx for Tonsilitis?
Epiglottitis: acute onset, muffled voice, drooling, stridor.
Infectious mononucleosis: pharyngitis, splenomegaly, raised WBC count with lymphocytosis, positive Monospot test.
Squamous cell carcinoma: unilateral tonsillar enlargement, dysphonia, ulcers.
Indications for tonsilectomy ?
recurrent acute tonsillitis, suspected malignancy, enlargement causing sleep apnoea.
What is sinusitis?
Sinusitis refers to inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis. It is very common.
Sinusitis can be:
Acute (less than 12 weeks)
Chronic (more than 12 weeks)
What is Rhinosinusitis?
inflammation of the paranasal sinuses and nasal cavity; acute (≤4 weeks), subacute (4-12 weeks), and chronic (>12 weeks).
What are the paranasal sinuses and what is their function?
The paranasal sinuses are hollow spaces within the bones of the face, arranged symmetrically around the nasal cavity. They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis.
What are the 4 sets of paranasal sinuses?
Frontal sinuses (above the eyebrows)
Maxillary sinuses (either side of the nose below the eyes)
Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity)
Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)
Causes of sinusitis?
Infection, particularly following viral upper respiratory tract infections
Allergies, such as hayfever (with allergic rhinitis)
Obstruction of drainage, for example, due to a foreign body, trauma or polyps
Smoking
Patients with ___ are more likely to suffer from sinusitis
Asthma
Typical presentation of acute sinusitis:
The typical presentation of acute sinusitis is someone with a recent viral upper respiratory tract infection presenting with:
Nasal congestion
Nasal discharge
Facial pain or headache
Facial pressure
Facial swelling over the affected areas
Loss of smell
Examination findings of sinusitis
Tenderness to palpation of the affected areas
Inflammation and oedema of the nasal mucosa
Discharge
Fever
Other signs of systemic infection (e.g., tachycardia)
Associations of chronic sinusitis
Chronic sinusitis involves a similar presentation but with a duration of more than 12 weeks. Chronic sinusitis may be associated with nasal polyps, which are growths of the nasal mucosa.
Ix for sinusitis
In most cases, investigations are not necessary. In patients with persistent symptoms despite treatment, investigations include:
Nasal endoscopy
CT scan
When may someone with sinusitis require hospital admission?
Patients with systemic infection or sepsis require admission to hospital for emergency management.
Management of sinusitis
NICE recommend not offering antibiotics to patients with symptoms for up to 10 days. Most cases are caused by a viral infection and resolve within 2-3 weeks.
NICE recommend for patients with symptoms that are not improving after 10 days, the options of:
High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)
A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)
Options for chronic sinusitis
Saline nasal irrigation
Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
Functional endoscopic sinus surgery (FESS)
Nasal spray technique : importance + how to check it?
Steroid nasal sprays are often misused, which means they will not be as effective. A good question to ask is, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa and will not be as effective.
The technique involves:
Tilting the head slightly forward
Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum)
NOT sniffing hard during the spray
Very gently inhaling through the nose after the spray
What is Functional Endoscopic Sinus Surgery?
Functional endoscopic sinus surgery (FESS) involves using a small endoscope inserted through the nostrils and sinuses. Instruments are used to remove or correct any obstructions to the sinuses. Obstruction may be caused by swollen mucosa, bone, polyps or a deviated septum (surgery to correct a deviated septum is call septoplasty). Balloons may be inflated to dilate the opening of the sinuses.
Patients need a CT scan before the procedure to confirm the diagnosis and assess the structures.
