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PR3124 Finals > URTI > Flashcards

URTI Flashcards

1
Q

Clinical presentation of pharyngitis (5 signs & symptoms)

A
  • Acute onset of sore throat
  • Pain with swallowing
  • Fever
  • Erythema and inflammation of the pharynx and tonsils (w/ or w/o patchy exudates)
  • Tender and swollen lymph nodes
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2
Q

What bacteria most commonly causes pharyngitis?

A

Group A beta-haemolytic Streptococcus e.g. Streptococcus pyogenes -> strep throat

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3
Q

What are common complications of pharyngitis?

A

Complications usually occur 1-3 weeks later
Viral: self-limiting without complications
Bacterial/Streptococcus pyogenes:
- Acute rheumatic fever: serious, can damage heart or brain
- Acute glomerulonephritis

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4
Q

What are the common tests for pharyngitis? Why is testing not done usually?

A

Gold standard: throat culture - 24-48h, 90-95% sensitivity
Rapid antigen detection test (RADT) - minutes, 70-90% sensitivity
Not done: takes too long, use clinical diagnosis to initiate empiric antibiotics if necessary

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5
Q

Modified Centor Criteria for clinical diagnosis of pharyngitis

A 
Add 1 point:
- Fever > 38C
- Swollen, tender anterior cervical lymph nodes
- Tonsillar exudate
- Absence of cough
- Age: 3-14 y
Minus 1 point if >45 y/o
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6
Q

Whether to initiate antibiotics for pharyngitis?

A

0-1 points: no testing due to low risk of S. pyogenes, presumed viral
2-3 points: test for S. pyogenes & treat if positive
- OR initiate empiric antibiotics
4-5 points: initiate empiric antibiotics due to high risk of S. pyogenes

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7
Q

Treatment for pharyngitis

A

1st line: PO penicillin VK 250mg QDS or 500mg BD
- paediatric: PO 250mg BD-TDS
Alternative:
PO amoxicillin 1g OD or 500mg BD
- paediatric: PO 50mg/kg/d OD or divided BD
PO clindamycin 300mg TDS
- paediatric: PO 7mg/kg TDS
PO cephalexin
PO clarithromycin
Duration: 10 days w/ clinical response in 24-48h

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8
Q

List 7 major symptoms for acute rhinosinusitis

A
  1. Purulent anterior nasal discharge
  2. Purulent/discoloured posterior nasal discharge
  3. Nasal congestion/obstruction
  4. Facial congestion/fullness
  5. Facial pain/pressure
  6. Hyposmia/anosmia: reduced/loss of sense of smell
  7. Fever
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9
Q

List 6 minor symptoms for acute rhinosinusitis

A
  1. Headache
  2. Ear pain, pressure, fullness
  3. Halitosis: bad breath
  4. Dental pain
  5. Cough
  6. Fatigue
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10
Q

Clinical diagnosis of sinusitis

A

> 2 major symptoms
OR
1 major + >= 2 minor symptom

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11
Q

What are some common bacterial causes of acute rhinosinusitis?

A

Most common: Streptococcus pneumoniae, Haemophilus influenzae

  • Moraxella catarrhalis
  • Streptococcus pyogenes
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12
Q

What are some viruses that cause URTIs?

A

Pharyngitis (>80%): rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr
Sinusitis (>90%): rhinovirus, adenovirus, influenza, parainfluenza
AOM (40-45%): respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza

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13
Q

What is the pathogenesis for pharyngitis and sinusitis?

A

Direct contact with droplets of infected saliva or nasal secretions
Pharyngitis: short incubation time of 24-48h
Sinusitis: usually preceded by viral URTIs (e.g. common
cold, pharyngitis)
- Inflammation: nasal mucosal secretions are trapped -> medium of bacterial trapping and multiplication -> sinus obstruction

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14
Q

Clinical diagnosis of bacterial sinusitis

A

Presence of sinusitis (based on major/minor symptoms)
AND
Presence of bacterial sinusitis: any one criteria
1. Persistent symptoms > 10 days & not improving
2. Severe symptoms at onset
- Purulent nasal discharge x3-4 days or high fever > 39C
3. “Double sickening”: worsening symptoms after 5-6 days after initial improvement (recovery of viral URTI)

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15
Q

Treatment of bacterial sinusitis

A

1st line antibiotics:
PO amoxicillin 1g TDS
PO amoxicillin/clavulanate 625mg TDS or 1g BD
- Paediatric: either PO amox or amox/clav 80-90mg/kg/day divided BD
Alternative antibiotics
Respiratory fluoroquinolones:
- PO levofloxacin 500mg OD
- PO moxifloxacin
PO trimethoprim/sulfamethoxazole
PO cefuroxime
Duration: 5-10 days (adult), 10-14 days (paediatric)

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16
Q

Which antibiotics are not suitable for bacterial sinusitis? Why?

A
  1. Local S. pneumoniae resistant to macrolides & tetracycline
    - > Clarithromycin, azithromycin & doxycycline not appropriate
  2. Ciprofloxacin has poor activity against S. pneumoniae
    - > not a respiratory fluoroquinolone
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17
Q

What are the mechanisms of resistance for Streptococcus pneumoniae and Haemophilus influenzae?

A

S. pneumoniae: multi-step penicillin binding proteins (PBPs) mutation -> each step increases penicillin MIC
- uncommon locally
Haemophilus influenzae: beta-lactamase production (inhibit with beta-lactamase inhibitor e.g. clavulanate)
- around 18% locally

18
Q

When should amoxicillin/clavulanate be used for treatment of sinusitis?

A

Resistant Haemophilus influenzae: need beta-lactamase inhibitor -> clavulanate
Indications:
- Recent course of antibiotics
- Recent hospitalization
- Failure to improve after 72h of amoxicillin

19
Q

Why is amoxicillin preferred over penicillin for sinusitis?

A

More favourable PK (higher systemic concentration)
High dose amoxicillin more effective: 80-90mg/kg/day (paediatrics) or 1g (adults)
-> Compared to standard dose: 45mg/kg/day (paediatrics), 250-500mg (adults)

20
Q

What is the clinical presentation of acute otitis media? (5 signs and symptoms)

A

Mostly paediatric patient <5y (nasal discharge backflow into eustachian tube)

  1. Ear pain (otalgia), ear discharge (otorrhea), ear popping, ear fullness
  2. Hearing impairment
  3. Dizziness
  4. Fever
  5. Non-specific for young infants: ear rubbing, excessive crying, changes in sleep or behaviour patterns
21
Q

Risk factors for AOM

A
  • Siblings
  • Day care
  • Supine during feeding
  • Exposure to tobacco smoke at home
  • Pacifier use
  • Winter season
22
Q

Prevention of AOM

A
  • Avoid exposure to tobacco smoke
  • Exclusive breastfeeding for 1st 6 months
  • Minimize pacifier use
  • Vaccinations: influenza, pneumococcal, Haemophilus influenzae type B vaccine (HiB)
23
Q

Pathogenesis of AOM

A

2 pathways from viral URTI to reflux of secretions into middle ear -> medium for bacterial accumulation/growth

  1. Nose sniffling
  2. Secretions & inflammation -> eustachian tube obstruction -> negative eustachian tube pressure
24
Q

Which bacteria can cause AOM?

A

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

25
Q

How is AOM diagnosed?

A 
Pneumatic otoscope
Criteria:
- Acute onset <48h
- Otalgia (rubbing, holding, tugging) or erythema of tympanic membrane
- Bulging of tympanic membrane
26
Q

When should we consider an observation period instead of starting antibiotics for AOM?

A

Observation period: supportive care 48-72h, give abx only if worsen/fail to improve
Fulfill all 5 criteria:
- >6 months y/o
- Non-severe illness: NO moderate-severe otalgia, otalgia >48h or fever >39C in last 48h
- No otorrhea: if bilateral only >2y/o
- Possible for close follow-up
- Shared decision making with parent/caregiver

27
Q

What are the issues with prescribing antibiotics for AOM?

A

Can’t distinguish between bacterial or viral etiologies
Overprescribing abx -> resistance
Bacterial: prompt abx initiation reduces symptoms by 1 day -> 80% cases resolve in 3-4 days w/o abx

28
Q

1st line treatment for AOM

A

1st line: PO amoxicillin 80-90mg/kg/day divided into BD
- Provided that (all): no amoxicillin in last 30 days, no concurrent purulent conjunctivitis (likely S. aureus, can’t be covered), not allergic to penicillin
Alternative: PO amoxicillin/clavulanate 80-90mg/kg/day divided into BD
- If (any 1): amoxicillin in last 30 days, concurrent purulent conjunctivitis, or Hx of AOM non-responsive to amoxicillin

29
Q

Why is ceftazidime not suitable for treatment of AOM?

A

Poor gram +ve activity against S. pneumoniae

30
Q

What are some alternative treatment options for AOM for individuals with penicillin allergies?

A

PO cefuroxime 30mg/kg/day divided BD or IM ceftriaxone: mild penicillin allergy
PO clindamycin: severe penicillin allergy, only effective against S. pneumoniae

31
Q

What is the treatment duration for AOM?

A

10 days: <2 y/o or severe symptoms
7 days: 2-5 y/o w/ non-severe symptoms
5-7 days: >6 y/o w/ non-severe symptoms

32
Q

What are the differences in clinical presentation between influenza & the common cold?

A

Influenza has more severe symptoms:
Abrupt onset w/ fever, body aches, chills, chest discomfort, headache
Both go through 24-72h of incubation period

33
Q

List the 3 types of influenza and their differences

A

Influenza A: human, swine, equine, avian, multi-species
- most severe illness, significant mortality in young persons
- epidemics & pandemics
Influenza B: humans only
- severe illness in older adults or high risk persons
- less severe epidemics
Influenza C: humans & swine
- mild respiratory illness without seasonality

34
Q

How is influenza tracked in Singapore?

A

Number of people visiting polyclinics for acute respiratory tract infections
Bimodal distribution: Dec-Feb & May-July

35
Q

Complications of influenza

A
  • Viral pneumonia (LRTI)
  • Post-influenza bacterial pneumonia (esp S. aureus has high mortality >30%)
  • Respiratory failure
  • Exacerbate underlying cardiac or pulmonary comorbidities
  • Febrile seizures
  • Myocarditis or pericarditis
36
Q

High-risk for influenza complications

A

Age: children <5y or elderly >65y
Pregnant women or within 2 weeks post-partum
Residents of nursing homes or long-term care facilities
Obese individuals w/ BMI >40kg/m2
Chronic medical conditions: asthma, COPD, heart failure, DM, CKD, immunocompromised, etc

37
Q

What is in the influenza vaccine?

A

Inactivated trivalent or quadrivalent vaccine -> given IM once per year
- Indicated for everyone >6mo

38
Q

Why is chemoprophylaxis not recommended for influenza?

A

Increases risk of resistance -> avoid sub-therapeutic dosing

39
Q

Diagnosis of influenza

A

Inpatient: reverse-transcriptase polymerase chain reaction (RT-PCR)
Outpatient: treat empirically
Viral cultures not recommended

40
Q

When should treatment of influenza be initiated?

A

Initiate ASAP within 48h of onset if any 1:
- Hospitalized
- High risk for complications
- Severe, complicated or progressive illness
Consider also if presenting within 48h of symptom onset -> period with greatest benefit in preventing influenza complications

41
Q

Treatment of influenza

A

PO oseltamivir 75mg BD for 5d
- May prolong if patient is immunocompromised or critically ill
*Clinically significant: active against influenza A and B
MOA: neuraminidase inhibitor -> interfere with protein cleavage & inhibit release of new virus
Well-tolerated, minimal side effects: headache, mild GI

PR3124 Finals (5 decks)

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