Lecture 22: Upper and Lower RTI (info overload) Flashcards
Most common reason for anti-biotic prescribing in kids?
Otitis media
What is the main pathologies that lead to Otitis media?
URI or Allergy –> Congestion of Respiratory Mucosa –> Decreased clearance of middle ear secretions –> fluid accumulation in ME space –> Reflux of OP/NP flora –> Acute Otitis Media (biofilm)
What age group is at highest risk for Otitis media?
From birth to 3 years
What percent of kids from birth to age 3 get Otitis media?
80-90% of children
Define Otitis media
moderate or severe bulging of the TM or new onset otorrhea not due to otitis externa, with acute signs of illness and middle ear inflammation
Environmental factors that predispose to Otitis media
Day care attendance Tobacco smoke exp Winter more than summer Formula feeding (breast feeding > 3 months is protective) Siblings at home Lower Socioeconomic status Pacifier use
Acute Otitis media symptoms in infants include what?
Fever, night wakening, poor feeding/anorexia, vomiting, irritability, and diarrhea
Child symptoms of Otitis media include what?
Fever, night wakening, poor feeding/anorexia, vomiting, irritability, and diarrhea, + [ear pain (~80%), hearing loss]
What are the complication symptoms in Otitis media?
Tinnitus, vertigo, otorrhea (TM perf), nystagmus, swelling
Will see conjunctivitis in some kids with (H. influenzae)
Name the classic Physical exam findings for Otitis media
Membrane looks discolored (red, yellow, gray/cloudy) and bulging tympanic membrane. Loss of normal bony landmarks
+ immobile TM pneumatic otoscopy
+ (5%) TM perforation w/ purulent drainage
Name the top bacteria that cause Otitis media
Bacteria: TOP one is Strep pneumoniae (50%), Haemophilus influenza (up to 45%),
Moraxella catarrhalis (10%)
(many infections have mixed microbes/viruses)
Name the viruses that typically cause Otitis media?
Typical viruses: RSV, flu, enteroviruses, cold viruses, metapneumo
Atypical organisms (uncommon or rare) that may cause Otitis media
Mycoplasma, Chlamydia, TB
If a child has an ear infection, what are decongestants good for?
Nothing. They’re not good. Have no proven benefit.
For a kid with otitis media pain, what are the 2 main meds to give for relief of pain?
Ibuprofen or Tylenol
Antimicrobial therapy for otitis media
First target the most common bacterial pathogens,
- amoxicillin for 10 days
- If suspect resistance to amoxicillin (H. influenzae) use amoxicillin-clavulanate
- Kid has an allergy to PCN, use 2nd/3rd gen cephalosporin, macrolide, clindamycin.
When can observation be used?
If the age is > 6 mos (some docs say > 2 yrs); not severe & unilateral dz, not immunocompromised, no high fever; 48-72 hr follow-up or “wait-and-see” Rx
Otitis media complications: Extension of infection to contiguous structures can cause what?
Mastoiditis
CNS infection
Other complications of otitis media include what?
- Chronic perforation
- Cholesteatoma formation
- Hearing loss (conductive)
- Delayed language development
What is abnormal, invasive growth of sq epithelium in the ear canal called?
It’s called a Cholesteatoma
Sequelae of Acute Otitis Media : Chronic Otitis Media… What is the microbiology, and therapy?
Microbiology: often poly-microbial, resistant
Therapy: prolonged antibiotics + ENT referral
Pharyngitis: Most common bacterial cause is what?
(25-37% of all) S. pyogenes (Group A Strep»_space; Grp C, G)
What age and time of year is strep throat most common?
Affects primarily children 5-15 yrs of age
Higher infection rates in winter months
How is strep pharyngitis typically spread?
Person-to-person, mainly via respiratory droplets
Also, high carriage rates in asymptomatic individuals facilitates transmission
What are the symptoms of Streptococcal pharyngitis?
Acute onset of fever, sore throat cough and rhinorrhea absent Pharyngeal/tonsillar edema and erythema Nonadherent pharyngeal exudate Tender anterior cervical LAD associated head ache, Nausea, vomiting and malaise
What are the viral pharyngitis symptoms?
Sxs of viral infection w/ conjunctivitis, coryza (runny nose), cough, hoarseness, anterior stomatitis, discrete ulcers, viral exanthems +/- diarrhea
Causes of viral pharyngitis
Common cold, Adenovirus, Herpangina, EBV, (plus other stuff: HSV, HIV, CMV, influenza)
Causes of bacterial pharyngitis
Anaerobes (Lemierre’s), Arcanobacterium, Mycoplasma, Gonorrhea, and Diphtheria
List the complications of Group A Strep pharyngitis
Extension to contiguous structures: OM, sinuses, CNS abscess formation, peritonsillar, metastatic,
Nonsuppurative sequelae: rheumatic fever and glomerulonephritis
What is the gold standard for diagnosis of strep throat?
Throat culture, ~90% sensitivity
However, a 24-48 hr delay for results
What is it called when using agglutination or ELISA assay to detect a streptococcal wall antigen from a throat swab
“Rapid Strep” tests (RADS), 70-90% sensitivity, > 95% specific
If found to be negative, continue to do a culture
*Neither can differentiate acute infection from asymptomatic carriers with intercurrent viral pharyngitis
How do you treat strep throat?
Antibiotics: Penicillin is the drug of choice (for 10 days)/ (If found allergy use Cephalosporin, Clinda, Macrolide)
Acute illness is usually limited, but therapy shortens severity, duration of Sxs, lowers risk of Rheumatic fever, and lower chances of transmission
Define Acute Rhinosinusitis
“Symptomatic inflammation of the nasal cavity/paranasal sinuses”
Bacterial sinusitis risks to think about
Venous drainage of sinus to intracranial and orbital compartments confers risk of complications at those sites if there is a sinus infection w/bacteria
What is the most common cause of community acquired sinusitis? Virus or Bacteria?
Viral: vast majority (rhino-, flu/parainfluenza)
Majority resolve spontaneously
Bact. infections complicate 0.5-2%
List the 4 common bacteria that cause sinusitis
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
+ Anaerobes (esp if contiguous to dental infx)
What features distinguish bacterial sinusitis from viral infection?
Bacteria quality, duration, progression of sx’s:
No improvement after 7-10 days and/or worsens after initial improvement
Severe sx’s: early high fever, Pain
Physical Exam: facial erythema/swelling, focused/ unilateral facial pain, fever >38°C, concurrent odontogenic source
When to seek imaging and/or ENT consultation?
- CT scan if complicated, lack of response
2. Sinus aspirate by ENT if non-response and/or immunocompromised
List the complications of sinusitis
Intracranial: Meningitis, Abscess formation, Epidural/ or Subdural infection, Venous sinus thrombosis
Peroorbital/orbital - Periorbital (preseptal) cellulitis, Orbital cellulitis, Orbital abscess
What are the symptoms/indicators of bronchitis?
Cough longer than 5 days (10-20 days typically)
Purulent sputum (50%) (not equivalent to bacterial cause)
Wheezing 2nd bronchospasm
Rhonchi which often clear w/ cough
Fever: atypical (if so, consider influenza or pneumonia)
Absence of consolidative signs/hypoxemia
CXR: normal or thickened bronchial walls
Bacterial causes of bronchitis (3 main ones)
Mycoplasma pneumoniae
Chlamydia pneumonia
Bordetella pertussis
Viral causes of bronchitis (4 main ones)
Cold viruses
RSV
Influenza*/Para-flu
Human metapneumovirus
What leads to higher risk for post infectious pneumonia and bronchospasm?
Virus action: post viral pneumonia caused because of impaired barrier defense and virus specific damage to bronchial epithelium with denudation
What is the main clinical treatment of bronchitis if it is caused by influenza?
Symptomatic tx of URI, cough, pain
CXR if suspect pneumonia
Only treat with antivirals for patients at risk for complications
If pertussis suspected: NP PCR; tx if confirmed
Consider microscopic eval. if outbreak suspected
Abnormal vitals, rales that don’t clear with cough, hypoxemia, CXR shows inflitration - Typical for pneumonia or bronchitis?
Typically seen in pneumonia
Bronchitis presents with rales that clear w/ cough, rarely abnormal vitals, and clear CXR
What are the risk factors of complication for Community Acquired Pneumonia (CAP)?
Age over 65 COPD, malignancies RR ≥ 30, dBP ≤ 60, P ≥ 125 Low WBC (30K), high BUN Hypoxemia, anemia, coagulopathy
Name 5 CAP commonly seen organisms
S. pneumoniae Mycoplasma/Chlamydia H. influenzae (smokers, COPD) S. aureus (post influenza) Legionella
Aspiration pneumonia is associated with
altered mental status (may be episodic) and poor dentition
aspiration pneumonia complications, name two
Complications: lung abscess, empyema
What kinds of organisms are associated with aspiration pneumonia?
polymicrobial, including anaerobes
Name 3 hospital associated pneumonia organisms
Enteric gram negative bacilli
Pseudomonas aeruginosa + other GNR
S. aureus (incl MRSA)
(often seen in ventilated patients)
How do you initially treat community accquired pneumonia?
Outpatient CAP: Rx with Macrolides, doxycycline, (Floroquinolones or beta-lactams and macrolides)
How do you treat hospitalized CAP?
General Med Ward: 3rd G. cephalosporin + macrolide or Floroquinolones
ICU: 3rd G. cephalosporin + macrolide or 3rd G. cephalosporin + Floroquinolones
How do you treat Healthcare associated or ventilator associated pneumonia?
Give MRSA agent (eg Vancomycin) + GNR agents (eg Cefepime/Pip-Tazo + 2nd antibiotics)
also consider Legionella testing
What are the advantages of pathogen specific therapy?
Narrow antibiotic spectrum
Less antimicrobial pressure on normal flora
To determine: use gram stain (sputum), cultures (sputum, blood), and immunoassays (eg urine Ag tests)
