URTI Flashcards
What are the 4 types of URTI?
- Common cold
- Influenza
- Pharyngitis
- Rhinosinusitis
Risk factors for URTI? (6)
- Close contact with children: daycares and schools
- Lack of personal/ hand hygiene
- Medical disorder: chronic respiratory disease like asthma and allergic rhinitis
- Smoking
- Immunocompromised individuals (cystic fibrosis, HIV, use of corticosteroids, transplantation, post-splenectomy)
- Anatomical anomalies (facial dysmorphic changes, nasal polyposis)
What are some risk factors of the pt we can manage to prevent URTI? (3)
- Smoking cessation
- Control asthma
- Allergic rhinitis
Is common cold a bacterial or viral infection?
Viral
What are the clinical presentations of a common cold?
- Low grade temp (~36.9 - 37°C)
- Rhinorrhea
- Blocked nose
- Sneezing
- Sore throat
- Productive cough
- Headache
- Body ache
What are the likely pathogens of common cold? (2)
Rhinovirus, coronavirus
Tx for common cold?
Should we use abx?
Symptomatic relief.
DO NOT use abx!
Monitoring for common cold?
When should the pt see a doctor?
- Self-limiting, most recover in 7-10 days
- Feel better within 3-4 days, but s/sx can linger for few weeks
- Normal for nasal discharge to change colour
- Cough may last 2-3 weeks
See doctor if s/sx does not improve after 10 days/ worsen
Clinical presentation for influenza?
What about for elderly?
- Fever
- Chills
- Headache
- Malaise
- Myalgia
- Anorexia
- Sore throat
- Dry cough
- Nasal discharge
Elderly may present with confusion
What are the complications that can happen with influenza?
What are the pathogens associated with the bacterial complication?
- Primary viral pneumonia
- Secondary bacterial pneumonia (most often Staph. aureus, Strep. pneumoniae and H. influenzae)
- Exacerbation of chronic respiratory disease
- Myocarditis
What kind of pts are at high risk for complications for influenza?
- Children < 5 y/o
- Elderly ≥ 65 y/o
- Pregnancy/ within 2 weeks postpartum
- Residents of nursing homes/ long-term care facilities
- Obese individuals with BMI ≥ 40 kg/m2
- Chronic medical conditions (eg asthma, COPD, HF, DM, CKD, immunocompromised)
When are diagnostics (nasopharyngeal swab or aspirate) for influenza required?
For hospitalised pts/ long term care pts.
Not commonly done for outpatient.
What are the likely pathogens for influenza?
Which one causes pandemics and is more common?
Human influenza A and B
Influenza A causes pandemics and is more common
What category of pts should we initiate antivirals for influenza ASAP?
When is the best time frame to initiate Tx?
Initiate ASAP from s/sx onset → best within first 48h, up to 5 days for:
- Hospitalised
- High-risk for complications
- Severe, complicated/ progressive illness
Is it necessary for outpatients with influenza to initiate Tx?
If so, what is the best time to initiate Tx?
Not necessary. Most pts do not need medical care or antiviral drug.
May be considered for outpatients who present within 48h of s/sx
First-line Tx for influenza?
Is dose adjusment needed? If so, what adjustments needed?
PO oseltamivir 75mg bid x 5d [Tamiflu]
Dose adjustment in renal impairment (CrCl < 60ml/min)
MOA of oseltamivir for influenza?
Is it active against both influenza A and B?
- Active against influenza A and B
- Neuraminidase inhibitor: interferes with protein cleavage → inhibits release of new virus
ADEs of oseltamivir for influenza?
- Headache
- GI discomfort (n/v)
When should (out)pts with influenza see a doctor?
What should we counsel them about the duration of the s/sx?
- S/sx does not improve after 10 days
- S/sx improved then worsened (ie new fevers, worsening dyspnea, cough)
Counsel pts s/sx last for a week
What type of people are the influenza vaccine (IM) recommended for?
How long does it take to confer immunity?
Recommended for: ALL persons ≥ 6 months old, esp if high risk of complications
Takes 2 weeks to confer immunity
Is pharyngitis bacterial or viral?
Both
What are the general clinical presentations of bacterial and viral pharyngitis? (5)
- Sore throat (worse with swallowing)
- Fever
- Erythema
- Inflammation of pharynx and tonsils (with or without patchy exudates)
- Tender, swollen lymph nodes
Elaborate more on the clinical presentations of bacterial pharyngitis (4)
- Sore throat
- Tonsillar exudates*
- Fever
- Cervical lymphadenopathy without viral s/sx
What is the criteria we can use to guide us to see whether there is a need to test for group A streptococcus or initiate abx Tx for bacterial pharyngitis?
Modified Centor Criteria
State the 5 criterions of the Modified Centor Criteria
- Fever > 38°C
- Swollen, tender anterior cervical lymph nodes
- Tonsillar exudate
- Absence of cough
- Age
3-14 y/o (1)
15-44 y/o (0)
45 y/o and above (-1)
State the actions for the number of points for the Modified Centor Criteria
0 or 1:
- No additional testing indicated
- Low risk of S. pyogenes pharyngitis
- Presumed viral
- No abx
2 or 3:
- TEST for S. pyogenes pharyngitis
- TREAT with abx
4 or 5:
- HIGH RISK for S. pyogenes pharyngitis
- Initiate empiric abx
Is bacterial pharyngitis self-limiting? Or are there complications?
Self-limiting/ complications possible
Complications usually occur 1-5 weeks later, usually 2-3 weeks:
- Acute rheumatic fever (preventable with early abx)
- Acute glomerulonephritis (preventable by abx
What is the pathogen that causes bacterial pharyngitis?
Group A Streptococcus (S. pyogenes)
What is the Gold Standard test for S. pyogenes pharyngitis?
Throat culture (takes 24 - 48h)
Other: Rapid Antigen Detection Test (RADT) (minutes)
Duration of Tx for bacterial pharyngitis?
Treat for 10 days (5 days for azithromycin)
First-line Tx for bacterial pharyngitis?
If penicillin allergy?
(What is one thing we have to note about the alternative regimen with regards to resistance?)
- PO penicillin 250mg q6h
- PO amoxicillin 500mg q12h
If penicillin allergy:
- PO Cephalexin 500mg q12h (non-severe)
More serious penicillin allergy:
- PO azithromycin 500mg OD
- PO clarithromycin 250mg q12h
- PO clindamycin 300mg q8h
Note: Increasing resistance to macrolides
Goals of Tx for bacterial pharyngitis?
- Reduce s/sx severity and duration
- Prevent of acute complications (ie otitis media, peritonsillar abscesses, invasive infections)
- Prevent delayed complications/ immune sequelae (esp rheumatic fever)
- Prevent spread to others (no longer infectious after 24h on abx)
Monitoring for bacterial pharyngitis?
For pts both NOT on abx and on abx
Is microbiological test for cure required?
- Pt not given abx: counsel that sore throat < 1 week, abx not needed as it is likely viral pharyngitis
- Pts given abx: fever and s/sx usually resolve within 1-3 days of starting Tx
- Microbiological test for cure NOT required
- Abx ADRs
Elaborate more on the clinical presentations of viral pharyngitis (6)
- Low-grade fever
- Malaise
- Fatigue
- Rhinorrhoea
- Cough
- Hoarseness
- Oropharyngeal lesions (ulcers/ vesicles)
- Conjunctivitis
Is viral pharyngitis self-limiting?
Do we prescribe anything for it?
Yes
No need any medications (maybe just symptomatic relief)
Likely pathogens for viral pharyngitis?
- Rhinovirus
- Coronavirus
- Influenza
- Parainfluenza
- Epstein-Barr
Define acute rhinosinusitis
Acute (within 4w) inflammation and infection of paranasal and nasal mucosa
Is acute rhinosinusitis typically bacterial or viral?
If bacterial, what are the pathogens involved? (Hint: most common and others)
> 90% viral
Bacterial < 2%
Most common:
- Strep. Pneumoniae
- H. influenzae
Others:
- Strep. pyogenes
- Moraxella catarrhalis
- Anaerobic bacteria
Risk factors of acute rhinosinusitis?
- Direct contact with droplets of infected saliva or nasal secretions
- Viral URTIs may result in bacterial cases
- Inflammation → sinus obstruction → bacterial multiplication
Common s/sx of acute rhinosinusitis?
When should we send pt to ED?
- Purulent nasal discharge
- Facial pain or pressure
- Fever
- Nasal congestion and obstruction
- Reduced sense of taste or smell (hyposmia or anosmia)
- Headache
- Cough
- Ear fullness/ pressure
- Bad breath
- Dental pain
Send to ED if spread of infection to orbits or CNS (ie limited ocular movements, acute vision changes, confusion, unilateral weakness)
Most of the time, how does bacterial rhinosinusitis occur?
Commonly occurs as a secondary infection from sinus obstruction due to viral URTI
When should we treat bacterial sinusitis? (what type of s/sx?)
Treat bacterial sinusitis with abx if ≥ 1 of the following:
1. S/sx persist > 10 days, no clinical improvement
2. Severe s/sx (fever > 39°C, purulent nasal discharge, facial pain > 3 consecutive days)
3. S/sx improve then worsen (new onset fever, headache, increase nasal discharge) for > 3 days (5-6 days)
Duration of Tx of bacterial sinusitis
Treat 5-7 days (adults)
First-line Tx for bacterial sinusitis?
If penicillin allergy? (non-severe?)
- PO amoxicillin 500mg q8h
- PO amoxicillin-clavulanate 625mg q8h
If penicillin allergy:
- Non-severe: PO cefuroxime 500mg q12h
- PO levofloxacin 500mg daily/ PO moxifloxacin 400mg daily (but last line)
What type of abx cannot be used for bacterial sinusitis due to increasing resistance?
Tetracycline, co-trimoxazole and macrolides not recommended due to increasing resistance
Goal of Tx for acute rhinosinusitis?
- Shorten duration of s/sx, faster s/sx relief
- Restore QoL
- Prevent complications
Monitoring for acute rhinosinusitis? (for pts not given abx and pts given abx)
When does the pt need to see doctor?
- Pts not given abx: counsel that s/sx last 7-10 days, abx not needed as likely having viral or non-severe bacterial pharyngitis
- Pts given abx: expect s/sx to improve within 7-10 days
- Abx ADRs
See doctor if pt develops persistent, severe or worsening s/sx
