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finals 3124 > URTI > Flashcards

URTI Flashcards

1
Q

types of URTIs

A
  1. common cold
  2. influenza
  3. pharyngitis
  4. rhinosinusitis
  5. laryngitis
  6. otitis media
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2
Q

clinical presentation of pharyngitis

A
  1. acute onset of sore throat
  2. pain with swallowing
  3. fever
  4. erythema and inflammation of pharynx and tonsils (may have patchy exudates)
  5. tender and swollen lymph nodes
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3
Q

microbiology of pharyngitis

A

> 80% viral:

  • rhinovirus
  • coronavirus
  • influenza
  • parainfluenza
  • epstein-barr

<20% bacterial:
- beta-hemolytic streptococcus pyogenes

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4
Q

pathogenesis of pharyngitis

A
  • direct contact with droplets of infected saliva or nasal secretion
  • short incubation of 24-48h
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5
Q

complications of S.pyogenes in pharyngitis

A
  1. acute rheumatic fever (prevented w early initiation of Abx)
  2. acute glomerulonephritis (not prevented by Abx)
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6
Q

benefit of Abx in bacterial pharyngitis

A
  1. prevent acute rheumatic fever
  2. shorten duration of symptoms by 1-2d
  3. reduce transmission (no longer infectious after 24h of antibiotics)
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7
Q

diagnostic test for S.pyogenes pharyngitis

A
  1. throat culture (24-48h)
    - gold standard
    - 90-95% sensitive
  2. rapid antigen detection test RADT (minutes)
    - 70-90% sensitive
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8
Q

modified centor criteria for S.pyogenes pharyngitis

A
  • fever >38 (1)
  • swollen, tender anterior cervical lymph nodes (1)
  • tonsillar exudate (1)
  • absence of cough (1)
  • 3-14yo (1)
  • > = 45yo (-1)
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9
Q

point evaluation for centor criteria

A

0-1: no additional testing indicated; low risk; presumed viral

2-3: test for S.pyogenes pharyngnitis or initiate empiric tx

4-5: high risk for s.pyogenes, initiate empiric

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10
Q

tx for s.pyogenes pharyngitis`

A 
first line: Penicillin VK 
alternative:
- amoxi
- cephalexin
- clinda
- clarithro
duration: 10d
clinical response within 24-48h
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11
Q

rhinosinusitis major symptoms

A
  1. purulent anterior nasal discharge
  2. purulent/ discolored posterior nasal discharge
  3. nasal congestion/ obstruction
  4. facial congestion/ fullness
  5. facial pain/pressure
  6. hyposmia/ anosmia
  7. fever
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12
Q

minor symptoms of rhinosinusitis

A
  1. headache
  2. ear pain, pressure, fullness
  3. halitosis
  4. dental pain
  5. cough
  6. fatigue
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13
Q

clinical determination of sinusitis

A

> = 2 major symptoms or 1 major + >=2 minor symptoms

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14
Q

microbiology of sinusitis

A

viral (>90%):

  • rhinovirus
  • adenovirus
  • influenza
  • parainfluenza

bacterial (<10%):

  • strepto pneumoniae
  • haemophilus influenzae
  • also moraxella catarrhalis
  • also strepto pyogenes
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15
Q

pathogenesis of sinusitis

A
  • direct contact w droplets of infected saliva or nasal secretions
  • bacterial cases usually preceded by viral URTI (common cold, pharyngitis)
  • inflammation results in sinus obstruction
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16
Q

limitation in diagnostic test for sinusitis

A
  • viral and bacterial symptoms very similar
  • imaging studies: non-specific, non-discriminatory
  • sinus aspirate (gold standard test): invasive, painful, time consuming
17
Q

clinical diagnosis of bacterial sinusitis

A

presence of any one:

  1. persistent symptoms >10d and not improving
    - viral tend to be self limiting and resolved ~7-10d
  2. severe symptoms at onset
    - purulent nasal discharge x 3-4d
    - high fever >=39 degree
  3. double sickening:
    - worsening symptoms after 5-6d after initial improvement
18
Q

tx for bacterial sinusitis

A

first line:

  • amoxi
  • amoxi clav

alternative:
- respi FQ (levo/moxi)
- cotrimoxazole
- 2nd gen cephalo (cefixime, cefuroxime)

duration: adults 5-10d, peds: 10-14d

19
Q

why are macrolides and tetracyclines not suitable for sinusitis

A

s. pneumoniae highly res to them (clarithro, azithro, doxy)

20
Q

why is ciprofloxacin not used?

A

poor respi FQ, poor activity against strep pneumoniae

21
Q

tx consideration for sinusitis

A

Strepro pneumoniae res

  • multi step penicillin-binding protein mutation
  • increase penicillin MIC
  • prefer high amoxi>pen (pk better)

haemophilus influenzae res:

  • beta lactamase production
  • inhibited by beta-lactams inhibitor
22
Q

consideration for amoxi dosing for strepto pneumoniae res

A
  • amoxi preferred over pen (better pk)
  • high dose amoxi preferred

normal amoxi: 45mg/kg OD (peds); 250-500mg (Adults)
high dose amoxi: 80-90mg/kg OD (peds), 1g (adults)

23
Q

when to use amoxi clav in sinusitis

A

if haemophilus res use amoxi/clav when either:

  • recent course of antibiotics
  • recent hospitalisation
  • failure to imrpove after 72h of amoxi
24
Q

acute otitis media signs and symptoms

A
  1. ear pain (otalgia)
  2. ear discharge (otorrhea)
  3. ear popping
  4. ear fullness
  5. hearing impairment
  6. dizziness
  7. fever
  8. non-specific in young infants: ear rubbing, excessive crying, changes in sleep pattern
25
Q

risk factors of AOM

A
  1. sibling
  2. attending day care
  3. supine position during feeding
  4. exposure to tobacco
  5. pacifier use
  6. winter
26
Q

prevention of AOM

A
  1. avoid exposure to tobacco
  2. exclusive breast feeding 1-6mth
  3. minimize use of pacifier
  4. vaccinations (influenza, pneumococcal, haemophilus)
27
Q

pathogenesis of AOM

A
  1. viral URTI (common cold)
    2a. nose sniffing: leading to reflux of secretions into middle ear

2b. secretions and inflammation
3. eustachian tube obstruction
4. negative eustachian tube pressure: leading to reflux of secretions into middle ear

providing a medium for bacteria accumulation and growth

28
Q

microbiology of AOM

A

bacterial (55-60%):

  • strepto pneumoniae
  • haemophillus influenzae
  • moraxella catarrhalis

viral (40-45%):

  • respiratory syncytial virus
  • rhinovirus
  • adenovirus
  • parainfluenza virus
29
Q

AOM diagnosis

A
  1. pneumatic otoscope (standard tool)
  2. acute onset (<48h)
  3. otalgia (holding, tugging, rubbing in non-verbal child) / erythema of tympanic membrane)
  4. bulging of tympanic membrane
30
Q

challenges in management of AOM

A
  • unable to distinguish bacterial vs viral etiologies
31
Q

when to consider observation period instead of starting tx

A
  1. pt >= 6mth old
  2. non severe illness (no mod-severe otalgia, no otalgia >=48h, no fever >39 degree in last 48h)
  3. no otorrhea
  4. possible for close follow up
32
Q

AOM tx timeline

A
  1. <6mth old: immediate abx
  2. 6mth-12yo: immediate abx, (if only unilateral AOM w/o otorrhea can consider observation first)
  3. > 2yo:
    - immediate abx for AOM with otorrhea/severe symptoms
    - uni/bi lateral AOM w/o otorrhea can consider observation first
33
Q

what is observation period

A

observation period: supportive care 48-72h

  • if improve: no Abx
  • if worsens of fail to improve: start Abx
34
Q

AOM tx

A

first line: amoxicillin if:

  1. no amoxicillin last 30d &
  2. no concurrent purulent conjunctivitis &
  3. no pen allergy

alternative first line : amoxi/clav if:

  1. amoxi taken in last 30d or
  2. concurrent purulent conjunctivitis or
  3. Hx of AOM non-responsive to amoxi

alternative:
1. cefuroxime/ ceftriazone IM (mild pen allergy)
2. Clindamycin (only good against s.pneumoniae)

35
Q

criteria for improvement of AOM

A

improvement expected in 28-72h

36
Q

duration of tx

A

<2 yo or severe symptoms (mod-severe symptoms): 10d duration
2-5yo + severe symptoms : 7d duration
>=6yo + non severe symptoms: 5-7d duration

finals 3124 (7 decks)

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