Respiratory Tract Infections CUE CARDS Flashcards
What is the anatomical basis for RTI?
Upper and Lower
What is pneumonia?
An infection of the lower RT with fluid and pus filled air space contained bacteria and blood cells
What is community acquired pneumonia
Infection caught by the patient in the community setting (not in hospital or in hospital for <48 hrs) and are not significantly immunocompromised
How is CAP classified in terms of its severity?
Is this person someone who has pneumonia who can be treated safely in community or do they need to be admitted to hospital?
What can be performed to diagnose pneumonia?
Chest X-ray = cloudiness = pneumonia in that lobe
What are red flags of CAP?
HR > 100bpm
Hypotension
Confusion
What are the assessment tools used to identify CAP?
Assessment tools are used to identify patients who are at greatest risk of having a poor outcome and therefore need for more aggressive management
What are the tools to assess severity of CAP?
> CORB
> SMARTCOP: adds in additional factors that influence risk
What are the typical and atypical causative organisms causing CAP?
> Typical: streptococcus pneumoniae (most causes of severe illness or death, increasing resistances to macrolides and doxycycline), haemophilus influenzae (<5%)
> Atypical: mycoplasma pneumoniae, chlamydia pneumoniae, legionella
What is the role of sputum and what is a problem with this?
> They are difficult to obtain and take longer to culture
> Understanding likely causal pathogens and sensitivity patterns very important for guiding empirical therapy
What is empirical treatment of CAP based on?
Based on severity assessed (SMARTCOP or CORB) and the need to cover both the typical and atypical organisms
How can pneumonia be prevented?
> Pneumococcal vaccination
> Recommended in 65 yrs or older
> Protects from a range of infections such as pneumonia, meningitis and septicaemia
What is hospital acquired pneumonia?
> Pneumonia which develops in a patient who had no signs or symptoms on admission, has been hospitalised for >48hrs, has been transferred from another healthcare facility including nursing homes
> Associated with multidrug resistant infections
> More likely in intubated patients
What is the treatment of HAP guided by?
> Guided by the likely risk that the patient has a resistant organism
> Due to breadth of causative organisms, patients may require a number of abx to cover all of these
What is the risk of HAP determined by?
> Location in hospital
> Amount of time they’ve spent there
Discuss the limitations of pneumonia in Nursing Home Residents
> Patients can be difficult to assess (cognitive impairment)
May have reduced renal function
May have increased vulnerability to adverse effects - particularly cardiac adverse effects including QT-interval prolongation (macrolides and quinolones)
Increased risk of drug interactions
What is aspiration pneumonia?
> Movement of gastric contents (and normal GI flora) into the lungs
Need to cover GI flora (gram +ve, -ve and anaerobes)
Risk of abscess formation
Who is at risk of aspiration pneumonia?
High risk patients
> swallowing difficulties e.g. post stroke
> decreased conscious state e.g. post-drug OD, post-ictal
> enteric feeding
Discuss pneumonia in the Immunocompromised
> May be caused by a range of organisms that are in addition to those that cause CAP
Pneumocystitis (PCP) is particular cause of pneumonia in those patients
Due to this risk: patients may receive prophylaxis against PCP using trimethoprim and sulphamethoxazole
What is Pertussis?
Is it contagious?
Who is most susceptible?
> Whooping cough
Highly contagious
Susceptibility in young children
What is whooping cough caused by?
What does it initially present as?
What are the signs?
> Bordetella Pertussis (gram -ve bacillus)
Initially presents as upper RTI
Followed by paroxysmal cough in 2nd and 3rd week (characteristic inspiratory whoop, spasms of coughing which can trigger vomiting)
How is pertussis managed?
> Exclusion from work, school and child care and restricted attendance from other settings, especially where there are infants (21 days after onset of any cough, 14 days after the onset of paroxysmal cough, completed 5 days of a course of abx)
> Contact notification (face-to-face exposure [1m] to an infectious case for a single period of at least 1 hour
> Prophylaxis may be considered in high risk contacts (e.g. expectant parents)
What is important with pertussis?
Immunisation of the community against pertussis helps to protect children who are under 12 months and not yet fully immunised against pertussis
Discuss the use of sympathomimetics for patients with hypertension
What about patients with hx of hypertensive emergencies
> May not be absolute contraindications - patients who are normotensive may have small rise in BP
Risk vs. benefit (small risk for a few days - no different in normotensive patients) - therefore if well controlled BP, a few days is ok
> In patients with hx of hypertensive emergencies, systemic sympathomimetics may trigger another serious rise in BP = serious risks
Avoid by using saline or topical sympathomimetics (but patient may still demand systemic - assess via risk vs. benefit)
What are the Causative Organisms of bacterial sinusitis?
What are the signs and symptoms?
> Causative organisms: streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis
> Signs/symptoms: purulent nasal discharge, nasal congestion and/or facial pain or pressure for more than 5-7 days as well as high fever, severe headache, unilateral maxillary sinus tenderness, worsening symptoms after initial improvement
What organisms cause otitis media?
> Streptococcus pneumoniae
Haemophilus Influenzae
Moraxella catarrhalis
Viral (25%)
What is an issue with otitis media?
> For may children, abx aren’t required and won’t change the outcome
The child will get better in the same period with or without abx
If the child is not getting better (with analgesia) after waiting the appropriate duration (24-48 hrs), only then abx should be considered
Why is cefuroxime preferred over cefaclor in otitis media?
> Cefaclor has a unique risk: associated with serum-sickness like reactions (symptoms of allergic reaction) but also other problems such as arthritis and arthralgia
> Cefuroxime doesn’t have same risk
What are the characteristics of Croup?
Characteristic barky cough, inspiratory stridor, hoarseness, airway obstruction
How is Croup managed?
> Steroid indicated in all cases, regardless of severity (dexamethasone 0.15mg/kg, prednisolone 1mg/kg)
Signs of hypoxia or severe obstruction (nebulised adrenaline)
What are the characteristics of Pharyngitis and/or Tonsillitis?
Why use abx?
> Usually viral: streptococcus pyogenes = greatest concern
> Use abx: to prevent suppurative complications (e.g. acute otitis media, quinsy, acute sinusitis) and to prevent non-suppurative complications e.g. ARF
Discuss the use of abx to prevent acute rheumatic fever
Evidence in patients at high risk of ARF using abx to treat tonsillitis can help to reduce those complications (in particular those who are Aboriginal/TSI)
Influenza: Discuss Surface Proteins
> Influenza A and B viruses have two main surface proteins
> Haemagglutinin (H) and Neuraminidase (N)
Who is eligible for free vaccination under NIP?
People at high risk of complications from influenza are eligible for free vaccination under the NPI (e.g. immunocompromised, diabetes, asthma)
What is the flu vaccine composed of?
Changes every year because strain of virus circulating changes every year (based on probability)
What is the Difference between the 2 Trivalent Forms (>65 yrs) of flu vaccine (fluad and fluzone)?
> Fluad: adjuvanted (adjuvant to stimulate the immune system against the flu vaccine/flu antigens in vaccine - enhancing immune response)
> Fluzone: contains much higher dose of antigen
What is the Quadvalent Flu Vaccine composed from?
Four different strains
Where are influenza vaccines produced?
What is a risk of this?
> Produced in egg
> Egg allergy (risk of egg protein present in product)
Discuss the Risk of Egg Allergy in Influenza Vaccine
> In egg allergy without anaphylaxis: can vaccinate
In egg allergy with anaphylaxis: considered appropriate but should occur in a medical facility that’s equipped and experienced in recognising and managing anaphylaxis
