Upper Respiratory Infections Flashcards
What is the main cause of the common cold?
Rhinovirus 30-50%
What are the most common symptoms of the common cold?
Rhinorrhea
Nasal congestion
Sore throat
Cough
Malaise
What would you see if you looked in the nose of someone with the common cold?
Mucosal swelling
Discharge that may be clear or purulent
What is the treatment for the common cold?
NOT antibiotics
NSAIDS, Tylenol
Antihistamine/decongestant combo
Expectorants/antitussives
Topical analgesics for sore throat
Who is at high risk of influenza?
Adults >65 yo
Children <5 and especially under 2 yo
Chronically ill (DM, COPD, cardiac, renal/liver)
Pregnant women
Healthcare workers
Nursing home residents
Native Americans (top 10 cause of death)
BMI 40+
Why do people die from the flu?
Secondary bacterial pneumonia
How does influenza present?
Abrupt onset- “I felt fine this morning and now i feel like i got hit by a truck”
Fever- may be very high
Myalgia
Sore throat- may be severely sore, but will not look like anything on exam
Who should be tested for influenza during flu season?
***
Healthy people with flu symptoms after a hospital admission, REGARDLESS of time of illness onset
healthy but high risk patients presenting WITHIN 5 DAYS of illness onset
Immunocompromised patients with acute febrile respiratory illness REGARDLESS of time of illness onset
ANY patient currently admitted to hospital who has acute febrile respiratory illness regardless of time of illness onset
Who should be tested for influenza even when it’s not flu season?
Healthcare workers, residents, or visitors in an institution experiencing a flu outbreak
Individuals who may have been exposed to the flu either in travel or on a cruise ship
When should any type of flu testing be done?
Within first 3-4 days of illness
What two types of flu tests are just screening tests?
Rapid antigen test (RAT)-takes 15 min
Immunofluorescence- takes 1-4 hrs
What is the MOST sensitive and specific flu test?
RT-PCR
Tells you influenza type and subtype
Takes 1-8 hrs
What is the gold standard flu test for lab diagnosis?
Viral cultures
Takes 3-10 days, so this is not for initial clinical management, but to confirm screening
When should you order RT-PCR or viral culture for influenza testing?
Negative RAT or immunofluorescence, and community flu rates are high
Positive RAT or immunofluorescence and community flu rates are low
Patient has recent exposure to pigs/poultry and there is worry for novel influenza A virus
Who should receive antiviral treatment for the flu?
People at high risk for complications**
Illness requiring hospitalization
Severe/complicated illness
When should antiviral treatment be given for the flu?
Within 24-30 hours from onset of symptoms.
Little benefit if given after 30 hrs
(Typically shortens course by 1-2 days)
What are the neuraminidase inhibitors for influenza?
Oseltamivir (Tamiflu) 75mg bid x 5 days
Zanamivir (Relenza) 10mg (2 inhalations) bid x 5 days
Peramivir (Rapivab) 600mg IV once
What influenza treatment is contraindicated in patients with asthma/chronic respiratory conditions?
Zanamavir (inhaled antiviral)
Can you give neurominidase inhibitors for flu treatment to pregnant women?
They are category C, but you should give them if you confirm or suspect influenza A
How long does it take after getting a flu shot for antibodies to develop?
2 weeks
How much protection does the flu shot provide against the flu
50-80% protection if its a close match
When is the best time to get the flu shot?
In October
Is the flu shot recommended for pregnant women?
Yes
What are the contraindications to getting a flu shot?
Current mod-severe illness
Hx of GUillain-barre within 6wks of previous flu shot
Hx of allergic reaction to flu shot
What is the most common etiology of pharyngitis?
Viral
Rhinovirus, adenovirus, parainfluenza, influenza
Which is more likely to cause pharyngeal exudate: viral or bacterial pharyngitis?
Bacterial
What viral cause of pharyngitis will be very painful and cause vesicles on an erythematous base?
HSV1 and HSV2
What viral cause of pharyngitis will cause tonsillar exudates, enlarged cervical nodes, and splenomegaly in 50 % of the time?
Mononucleosis (EBV)
What viral cause of pharyngitis will present with acute gingivitis, painful oropharyngeal ulceration, febrile illness, painless lymphadenopathy, and no tonsillar enlargement or exudates?
Acute Retroviral syndrome (HIV infection)
What should you consider testing for if pharyngitis symptoms are not improving in 5-7 days and your patient has risky behaviors
HIV testing
This might be acute retroviral syndrome and is often the first presentation of HIV
What is the treatment for viral pharyngitis?
- supportive care/magic mouthwash
- If caused by HSV- acyclovir, famciclovir
- If HIV, refer to infectious disease for retrovirals
Which bacteria most commonly causes bacterial pharyngitis?
Group A Strep (GAS)
Which bacteria are associated with bacterial pharyngitis from oral sex?
C. Trachomatis
N. Gonorrhea
Which bacteria causes pharyngitis with a gray exudate that is tightly adherent to the throat and nasal passageway?
C. Diphtheriae
Which bacteria commonly causes bacterial pharyngitis in kids?
H. Influenza
How will someone with streptococcal pharyngitis present?
Nausea**
Palatial petechiae** CLASSIC
Purulent exudate**
Painful swallowing
Fever, malaise
Swollen glands
What are the Centor Criteria?*
- tonsillar exudates
- tender anterior cervical adenopathy
- fever by history
- absence of cough
Patients with 3/4 of these should be tested for Group A Strep (GAS)
What are the 2 types of tests we can use to determine the cause of pharyngitis?
-Rapid antigen detection (Group A Strep) 70-80% sensitivity
-Throat culture- gold standard
Can order bacterial and viral
What diagnostic test is the gold standard for determining the cause of pharyngitis?
Throat culture
90-95% sensitive
95-99% specific
Which bacteria will the Rapid Antigen Detection Test (RADT) test for?
Group A Strep
What should you do if a patient meets 3/4 of the Centor Criteria, but their Rapid Antigen Detection Test came back negative for Group A Strep?
Treat them empirically for GAS while awaiting culture results.**
(RADT is only 70-90% sensitive)
What is the first line treatment for streptococcal pharyngitis?
Penicillin V 500mg P.O. TID x 10 days
Amoxicillin 500mg BID x 10 days
Penicillin G benzathine (bicillin) 1.2 mil units IM single dose
Cephalexin 500mg P.O. BID x 10 days
How do you treat streptococcal pharyngitis if someone has a penicillin allergy?
Azithromyin 500mg P.O. day 1 followed by 250 mg days 2-5
Clindamycin 300mg po x 10 days
Clarithromycin 250mg bid x 10 days
What kind of supportive care can you offer to patients with streptococcal pharyngitis in addition to antibiotics?
Lozenges, NSAIDS, Tylenol
What is scarlet fever?
A complication of streptococcal pharyngitis caused by a reaction to a toxin from the bacteria. 10% of patients will experience it. Will go away after abx treatment, but can predispose for acute rheumatic fever.
What are the symptoms of scarlet fever?**
Rash
Desquamation
Pastia’s lines (in AC fossa)**
Facial flushing with circumoral pallor**
Strawberry tongue**
What is the concern with scarlet fever?
Can predispose for acute rheumatic fever
What do you think it is:
- Pastia’s lines in AC fossa
- Strawberry tongue
- flushed face with circumoral pallor
- rash
- desquamation
Scarlet fever
How long after starting antibiotics will someone with streptococcal pharyngitis be contagious?
No longer contagious after 24 hours. Can return to school/work
How long will it take for streptococcal pharyngitis symptoms to improve after starting abx?
3-4 days
BUT no longer contagious after 24hrs
What is the most common deep neck infection in children and adolescents?
Peritonsillar abscess
What are the main differences between peritonsillar abscess and cellulitis?
Cellulitis:
No pus. Infection of tissue between palatine tonsils and pharyngeal muscles
Abscess: Collection of pus between tonsil and pharyngeal muscles. Usually a progression of cellulitis
WHat are the predominant bacteria that cause peritonsillar abscess?
GAS
Staph (including MRSA)
Mixed respiratory anaerobes
H.influenzae
What do you think it is: Unilateral sore throat Drooling Trismus Fever Neck pain/swelling Uvula deviation* Palpable fluctuance of soft palate* Hot Potato voice*
Peritonsillar abscess
When would you do imaging if you suspected a peritonsillar abscess?
To r/o spread to parapharyngeal space or if you can’t do the exam due to trismus.
Distinguishes cellulitis from abscess
If you did order imaging for suspected peritonsillar abscess, what imaging would you order?N
CT with IV contrast (soft tissue!)
Is imaging necessary in order to diagnose peritonsillar abscess?
No,
you can draw labs, do a throat culture, and do a culture and gram stain of aspirated abscess fluid
What is one of the main concerns with peritonsillar absecsS?
Airway obstruction
What is some of the supportive care you need to give to patients with peritonsillar abscess?
FLUIDS (super sore throat, probably haven’t been drinking)
Pain control
What antibiotics do you prescribe for peritonsillar abscess?
Parenteral:
Ampicillin-sulbactam
Clindamycin
Oral:
Augmentin
Clindamycin
What bacteria typically causes epiglottitis?
H influenzae
Is epiglottitis an emergency?
YES
Need hospitalization, intubation, and antibiotics
What do you suspect: Drooling Stridor Severe sore throat No cough Toxic appearance Unvaccinated child or older adult
Epiglottitis
What would you see on a lateral X-ray on someone with epiglottitis?
“Thumb sign”
What can cause retropharyngeal abscess/cellulitis?
Trauma (chicken bone) Recent instrumentation (tonsillectomy)
What do you suspect:
Very stiff neck
Minimal peritonsillar findings
No trismus
Retropharyngeal abscess or cellulitis
What is Ludwig’s Angina?
Submandibular space infection
What can cause Ludwig’s angina?
Tooth infection
What is it: Stiff neck Drooling Unable to speak “Woody” hardened submandibular area Crepitus of submandibular area No trismus Elevated, tender oropharynx
Ludwig’s angina (submandibular space infection)
What is the most common cause of infectious laryngitis?
Viruses (associated with URI)
What are non-infectious causes of laryngitis?
Vocal abuse Smoke inhalation Radiation GERD Vocal cord nodules Laryngeal nodules Cancer of vocal cords Neurologic dysfunction
What is the KEY symptom of laryngitis?
Hoarseness
When would you refer to ENT for laryngitis/
Hoarseness for more than 2 weeks in the absence of URI infection. Especially with hx of alcohol or tobacco.
What is treatment for laryngitis/
Treat underlying cause Voice rest Humidifier Hydration Stop smoking No antibiotics unless bacterial
What are the symptoms of all types of rhinosinusitis?
Purulent nasal drainage
AND
Nasal obstruction
And/or:
Facial pain
Pressure/fullness
What is the difference between acute, subacute and chronic rhinosinusitis/.
Acute <4 weeks
Subacute 4-12 weeks
Chronic >12 weeks
What is Recurrent acute rhinosinusitis?
4 or more episodes of acute rhinosinusitis per year
What is the most common etiology of acute rhinosinusitis?
Viral.
(“Acute viral rhinosinusitis” AVRS)
Rhinovirus
Influenza
Parainfluenza
What is the difference between AVRS and ABRS?
Acute viral rhinosinusitis
Acute Bacterial rhinosinusitis
Signs/symptom severity varies based on which one you have
What are some of the signs/symptoms of acute rhinosinusitis?
Low fever Nasal congestion Facial pain Fatigue Cough Maxillary tooth discomfort* Ear pressure Headache Purulent nose drainage Nasal mucosa swelling Edema over cheekbone/periorbital Tenderness to percussion of upper teeth Sinus tender to palpating Transillumination of frontal/maxillary sinuses may show opacity, unreliable
(Common cold would only share rhinorrhea, nasal congestion, low fever, nasal mucosal swelling, cough)
Should we do radiographs, cultures or sinus films to diagnose AVRS?
No
Sinus films won’t really help because we cant see ethmoid sinus and we are unable to distinguish polyps from fluid/edema
What is the treatment for AVRS/
Supportive- Analgesics Neti pot Mucolytics Intranasal decongestants Intranasal glucocorticoids
Where do most cases of Acute BACTERIAL rhinosinusitis come from?
A viral infection followed by a secondary bacterial infection
(The mucosal edema and inflammation leads to trapped bacteria)
What are the three cases where you would want to give antibiotics for ABRS?
- Persistent symptoms lasting more than 10 days with no improvement
- Onset with severe symptoms (<102 fever, purulent nasal discharge, facial pain lasting 3-4 consecutive days at onset)
- Viral URI that lasted 5-6 days and started to improve, followed by severe symptoms “double worsening”
What makes a patient at high risk for antibiotic resistance? **
65 or older
Severe infection, fever 102+
Hospitalized in last 5 days
Immunocompromised
Comorbidities (DM, cardiac)
Antibiotic use in the last month (no matter what for)
What is the first line antibiotic treatment for ABRS for a patient not at high risk for antibiotic resistance, and without a penicillin allergy?
Augmentin 500mg TID or 875mg BID
5-7 days**
What is the first line antibiotic treatment for ABRS in a pt who is not at high risk for antibiotic resistance but DOES have a penicillin allergy?
Doxycycline 100mg BID
Levofloxacin 500mg QD
Moxifloxacin 400mg QD
All for 5-7 days**
What is the antibiotic treatment for ABRS for a patient that is at risk for antibiotic resistance or for whom the first treament (Augmentin 500mg TID or 875mg BID x 5-7 days) did not work?
Augmentin 2000mg BID for 7-10 days
What is the antibiotic treatment for ABRS for a pt who is at high risk for antibiotic resistance or for whom the first treatment (levofloxacin 500mg, Doxycycline 100mg, or moxifloxacin 400mg x 5-7days)
Did not work AND they have a penicillin allergy?
Levofloxacin 500mg qd
Doxycycline 100mg bid
Moxifloxacin 400mg qd
x7-10 days
Same drugs and dosages, but now you do it longer! 7-10 days**
What is Complicated acute bacterial rhinosinusitis?
Spread of infection to the CNS, orbit, or surrounding tissues
What are some of the presentations of complicated ABRS?
Osteomyelitis- infection in bone after frontal sinus infection
Meningitis, brain abscess, epidural abscess
Periorbital/preseptal cellulitis
How do you diagnose complicated ABRS**
2 methods, which is gold standard?
CT scan With contrast**
Sinus Aspirate culture is Gold Standard (ENT will do this though)
How do you manage complicated ABRS?
Admit to hospital
URGENT ENT/ID CONSULT
What are the 4 cardinal symptoms of chronic rhinosinusitis in adults?
Mucopurulent nasal drainage
Nasal obstruction/congestion
Facial pain/pressure/fullness
Reduced sense of smell
What are the 4 cardinal symptoms of chronic rhinosinusitis in childern?
Mucopurulent nasal drainage
Nasal obstruction/congestion
Facial pain/pressure/fullness
Cough
(In adults the 4th one is loss of smell, not cough)
What are the diagnostic criteria for chronic rhinosinusitis?
The presence of at least 2 of the 4 cardinal symptoms of CRS lasting over 12 weeks with medical management,
PLUS either:
-Sinus mucosal disease with imaging showing mucosal thickening or pacification of the paranasal sinuses
OR
-direct visualization of mucosal inflammation, polyps in nasal cavity, and/or purulent mucus and edema
What, other than Chronic rhinosinusitis can cause loss of smell?
Facial/head trauma
Sinus surgery
Zinc supplements
When would you order a NON-contrast CT for rhinosinusitis?
When rhinosinusitis is recurrent or treatment resistant, and you want to look at the bony structures to see if there’s something causing that chronic rhinosinusitis
