Upper Respiratory Tract Infections Flashcards
What fraction of URI are Viral?
60%
What are the most common URI viruses?
Rhinovirus, Human metapneumovirus, influenza, RSV, adenovirus
In the 40% of URI’s that are bacterial, what are the most common offending organizms?
Strep pneumoniae (aka pneumococcus), H flu, Moraxella catarrhalis
What are the two most common complications of URI?
Acute Rhinosinusitis and Acute Otitis Media
Acute Otitis Media Symptoms
Discomfort, Fever, Irritable, Otorrhea (-/+), ear tugging, Rhinorrhea.
What is the significance of a bulging tympanic membrane for acute otitis media?
Definitive diagnostic finding (w/fever for younger pts)
In one study, 75% are bacterial.
What organism causes strep throat?
Strep pyogenes a.k.a. group a strep.
What are the criteria for Severe AOM?
Mod-severe otalgia
Fever of 39 or higher
What is the criteria for complicated AOM
otorrhea
Who should get abx for AOM?
Children 6 mo- 2 years + Bilateral presentation
Anyone with Otorrhea
Anyone with severe symptoms
Who can get watchful waiting?
6mo-2yr + Unilateral + Mild
2yr and older + Mild (unilat or bilat)
What are potential complications of inappropriate management of AOM.
Meningitis, Recurrence, Hearing deficits, Intracranial involvement.
What is first line therapy for AOM?
High dose Amoxicillin (90 mg/kg/day) (to overcome increased strep pneumo resistance)
What is second line therapy for AOM?
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)
Third-line therapy for AOM?
Cephalosporin (like Rocephin 50 mg/kg daily for 1-3 doses). Use is discouraged though.
What if AOM culture shows PCN Resistant Strep pneumo? (PRSP)
Clindamycin + 3rd Gen cephalosporin.
How long should you treat AOM?
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
Who should get prophylactic abx for AOM?
Can be considered for > 6 episodes/year who fail appropriate first-line therapy. Surgery may be warranted.
What is the time frame for acute vs sub-acute vs chronic sinusitis?
Acute: up to 4 weeks
Subacute: 4 weeks - 3 months
Chronic: > 3 months
Risk Factors for Sinusitis
Smoking (or exposure)
Asthma
Allergic Rhinitis
What signs of Rhinosinusitis is indicative of Acute Bacterial Rhinosinusitis (ABRS)?
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.
What are some potential complications of Acute Bacterial Rhinosinusitis (ABRS)?
Meningitis, orbital cellulitis.
What 4 organizations have developed independent guidelines for Acute Bacterial Rhinosinusitis management?
IDSA (2012)
European Position Statement (2012)
Canadian Practice Guidelines (2011)
American Academy of Otolaryngology (2015)
Can you employ watchful waiting for Acute Bacterial Rhinosinusitis?
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. `
What are the “Major Symptoms” of acute bacterial rhinosinusitis?
Purulent anterior nasal discharge Purulent or discolored posterior nasal discharge Nasal congestion or obstruction Facial congestion or fullness Hyposmia or anosmia Fever (if acute)
What are the minor symptoms of Acute Bacterial Rhinosinisitis (ABRS)?
Headache Ear pain, pressure, or fullness Halitosis Dental Pain Cough Fever (if subacute or chronic) Fatigue
What are the risk-factors for resistance in acute bacterial rhinosinusitis?
Age < 2 or > 65 Abx exposure within last month Hospitalization within last 5 days Comorbidities: Smoking, diabetes, cardiac dx, hepatic or renal disease. Immunocompromised.
Likely pathogens of Acute Bacterial Rhinosinusitis?
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%
First line therapy for Acute Bacterial Rhinosinusitis?
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)
What about FQs in ABRS?
“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.
What about Cephalosporins for ABRS
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
What about TMP/SMX or Macrolides for ABRS?
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.
What duration of therapy for Acute Uncomplicated Bacterial Rhinosinusitis?
5-7 Days in adults
10-14 days in pediatrics
What about adjunctive therapies for ABRS?
Intranasal corticosteroids - yes
Nasal irrigation with saline - yes
Systemic steroids? No. Provide slight benefit but overall poor risk to benefit profile.
What about treatment failure for ABRS?
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
When to treat ABRS?
Pts with sx for 7-10 days without improvement
What about Chronis Sinusitis?
- 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.
What about treatment for chronic sinusitis?
- Studies show no benefit to topical abx
- Studies show no benefit overall to systemic abx
- Treat with saline irrigation +/- intranasal steroids
