Upper Respiratory Tract Infections

Question 1

What fraction of URI are Viral?

Answer 1

60%

Question 2

What are the most common URI viruses?

Answer 2

Rhinovirus, Human metapneumovirus, influenza, RSV, adenovirus

Question 3

In the 40% of URI’s that are bacterial, what are the most common offending organizms?

Answer 3

Strep pneumoniae (aka pneumococcus), H flu, Moraxella catarrhalis

Question 4

What are the two most common complications of URI?

Answer 4

Acute Rhinosinusitis and Acute Otitis Media

Question 5

Acute Otitis Media Symptoms

Answer 5

Discomfort, Fever, Irritable, Otorrhea (-/+), ear tugging, Rhinorrhea.

Question 6

What is the significance of a bulging tympanic membrane for acute otitis media?

Answer 6

Definitive diagnostic finding (w/fever for younger pts)

In one study, 75% are bacterial.

Question 7

What organism causes strep throat?

Answer 7

Strep pyogenes a.k.a. group a strep.

Question 8

What are the criteria for Severe AOM?

Answer 8

Mod-severe otalgia

Fever of 39 or higher

Question 9

What is the criteria for complicated AOM

Answer 9

otorrhea

Question 10

Who should get abx for AOM?

Answer 10

Children 6 mo- 2 years + Bilateral presentation
Anyone with Otorrhea
Anyone with severe symptoms

Question 11

Who can get watchful waiting?

Answer 11

6mo-2yr + Unilateral + Mild

2yr and older + Mild (unilat or bilat)

Question 12

What are potential complications of inappropriate management of AOM.

Answer 12

Meningitis, Recurrence, Hearing deficits, Intracranial involvement.

Question 13

What is first line therapy for AOM?

Answer 13

High dose Amoxicillin (90 mg/kg/day) (to overcome increased strep pneumo resistance)

Question 14

What is second line therapy for AOM?

Answer 14

High dose Augmentin (90 mg/kg/day amox component). Useful for pts who fail first-line, or those at high risk for H flu (beta-lactamase producer). Use concentrated formulation to avoid too much clavulanate)

Question 15

Third-line therapy for AOM?

Answer 15

Cephalosporin (like Rocephin 50 mg/kg daily for 1-3 doses). Use is discouraged though.

Question 16

What if AOM culture shows PCN Resistant Strep pneumo? (PRSP)

Answer 16

Clindamycin + 3rd Gen cephalosporin.

Question 17

How long should you treat AOM?

Answer 17

6-24 months old OR severe symptoms: 10 days
2-5 years without severe symptoms: 7 days
6 yr or older without severe symptoms: 5-7 days

Question 18

Who should get prophylactic abx for AOM?

Answer 18

Can be considered for > 6 episodes/year who fail appropriate first-line therapy. Surgery may be warranted.

Question 19

What is the time frame for acute vs sub-acute vs chronic sinusitis?

Answer 19

Acute: up to 4 weeks
Subacute: 4 weeks - 3 months
Chronic: > 3 months

Question 20

Risk Factors for Sinusitis

Answer 20

Smoking (or exposure)
Asthma
Allergic Rhinitis

Question 21

What signs of Rhinosinusitis is indicative of Acute Bacterial Rhinosinusitis (ABRS)?

Answer 21

Purulent nasal discharge
Persistent symptoms (longer course) - at least 10 days
High fever (> 39)
Facial pain for at least 3-4 days
“Double Sickening” - Initial improvement followed by decline.

Question 22

What are some potential complications of Acute Bacterial Rhinosinusitis (ABRS)?

Answer 22

Meningitis, orbital cellulitis.

Question 23

What 4 organizations have developed independent guidelines for Acute Bacterial Rhinosinusitis management?

Answer 23

IDSA (2012)
European Position Statement (2012)
Canadian Practice Guidelines (2011)
American Academy of Otolaryngology (2015)

Question 24

Can you employ watchful waiting for Acute Bacterial Rhinosinusitis?

Answer 24

IDSA guidelines say “no” because unless you can’t usually rule out bacterial etiology, it’s not safe. However, since those guidelines were published, ability to test for viral etiology has improved significantly. AAO (American Academy of Otolaryngology) recommends watchful waiting in all patients regardless of symptom severity. `

Question 25

What are the "Major Symptoms" of acute bacterial rhinosinusitis?

Answer 25

``` Purulent anterior nasal discharge Purulent or discolored posterior nasal discharge Nasal congestion or obstruction Facial congestion or fullness Hyposmia or anosmia Fever (if acute) ```

Question 26

What are the minor symptoms of Acute Bacterial Rhinosinisitis (ABRS)?

Answer 26

``` Headache Ear pain, pressure, or fullness Halitosis Dental Pain Cough Fever (if subacute or chronic) Fatigue ```

Question 27

What are the risk-factors for resistance in acute bacterial rhinosinusitis?

Answer 27

``` Age < 2 or > 65 Abx exposure within last month Hospitalization within last 5 days Comorbidities: Smoking, diabetes, cardiac dx, hepatic or renal disease. Immunocompromised. ```

Question 28

Likely pathogens of Acute Bacterial Rhinosinusitis?

Answer 28

Strep Pneumo - 40% H Flu. 35% (Beta-lactamase producer - Augmentin) Moraxella Catarrhalis - 15% (increasing Augment res) Staph Aureus - 10% (empiric coverage not needed) Strep Pyogenes (group a) - < 5%

Question 29

First line therapy for Acute Bacterial Rhinosinusitis?

Answer 29

Augmentin 500 mg TID or 875 mg BID OR Augmentin 2,000 mg BID (if high risk for resistance) -Severe presentation (T > 39, systemic sx) -Live in area with high S. Pneumo resistance to PCN -Pts at high risk for resistant pathogen Doxycycline 100 mg BID (first line alternative)

Question 30

What about FQs in ABRS?

Answer 30

"Last Line" Not superior to beta-lactams. Black box warning: reserve only for patients with no treatment alternative because of risk of ADRs like tendonitis/tendon rupture, peripheral neuropathy, CNS effects.

Question 31

What about Cephalosporins for ABRS

Answer 31

Non-preferred - second line - All are inferior to PCN's (amox/clav) - Monotherapy not rec'd - If you must, use a 3rd gen (cefixime or cefpodoxime) plus clinda. - Cefpodoxime is especially useful for H flu and M cat

Question 32

What about TMP/SMX or Macrolides for ABRS?

Answer 32

Don't use. High rates of resistance to TMP/SMX in S. pneumo and H flu. Macrolides aren't even recommended in combo therapy. They don't cover the right organisms since atypicals aren't really a problem in ABRS.

Question 33

What duration of therapy for Acute Uncomplicated Bacterial Rhinosinusitis?

Answer 33

5-7 Days in adults | 10-14 days in pediatrics

Question 34

What about adjunctive therapies for ABRS?

Answer 34

Intranasal corticosteroids - yes Nasal irrigation with saline - yes Systemic steroids? No. Provide slight benefit but overall poor risk to benefit profile.

Question 35

What about treatment failure for ABRS?

Answer 35

No improvement in 3 days or worsening symptoms -Did they get first line therapy? -Do they have risks for resistance? -Is there a non-infectious etiology? -Do they have structural abnormalities? You can get a culture, but it should be endoscopy guided (no nasopharyngeal swabs - they grow everything) You can get imaging (CT w/contrast) if complications

Question 36

When to treat ABRS?

Answer 36

Pts with sx for 7-10 days without improvement

Question 37

What about Chronis Sinusitis?

Answer 37

- Symptoms for at least 3 months - At least 2 symptoms plus 1 sign of inflamation - Symptoms include mucoprurulent discharge, nasal obstruction/congestion, decreased sense of smell, or facial pain/pressure/fullness. - Signs of inflammation are: prurulent mucus or edema in the middle meatus or anterior ethmoid sinus, polyps in the nasal cavity or middle meatus, radiographic imaging showing sinus inflammation. - Different organisms are typically involved, including resistant gram negative orgs and Staph aureus. - Role of abx unclear - It's mainly an inflammatory disease.

Question 38

What about treatment for chronic sinusitis?

Answer 38

- Studies show no benefit to topical abx - Studies show no benefit overall to systemic abx - Treat with saline irrigation +/- intranasal steroids