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URTI Flashcards

1
Q

Pharyngitis - Site of infection

A

Oropharynx, nasopharynx (i.e. sore throat)

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2
Q

Pharyngitis - Clinical presentation

A

1) Acute onset of sore throat
2) Fever
3) Pain when swallowing
4) Erythema & inflammation of pharynx & tonsils, with/without patchy exudates
5) Tender & swollen lymph nodes

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3
Q

Pharyngitis - Microbiology

A

1) Virus (> 80%)
- Rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr

2) Bacteria (< 20%)
- No. 1 cause: Group A ß-hemolytic Streptococcus i.e. Streptococcus pyogenes (strep throat)

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4
Q

Pharyngitis - Prevalence of strep throat

A

US:

  • Adults: 5 - 15%
  • Children: 20 - 30%

SG:
- Less common

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5
Q

Pharyngitis - Pathogenesis

A

Transmitted via direct contact with droplets of infected saliva/nasal secretions
Short incubation: 24 - 48h
Causes acute inflammation at oropharynx & nasopharynx

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6
Q

Pharyngitis - Complications (viral pharyngitis)

A

Generally self-limiting

Recovers within a few days to weeks with rest & adequate hydration

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7
Q

Pharyngitis - Complications (strep throat)

A

May be self-limiting or complicated
Complications may occur 1 - 3 weeks later, after initial sore throat has gone away
- Due to initial infection triggering a systemic inflammatory response

Complications:

1) Acute rheumatic fever
- Fever due to severe inflammation caused by infection
- Prevented by early initiation of effective antibiotics –> should give antibiotics as soon as strep throat is diagnosed
2) Acute glomerulonephritis
- Low incidence
- NOT prevented by antibiotics

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8
Q

Pharyngitis - Differential diagnosis

A

Difficult to differentiate between viral VS bacterial pharyngitis, due to similar clinical presentation

Diagnose strep throat based on:

1) Diagnostic tests
2) Clinical diagnosis
- Frequently used for diagnosis

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9
Q

Pharyngitis - Diagnosis of strep throat

  • Diagnostic tests
  • Clinical diagnosis
A

Diagnostic tests:

1) Throat culture
- Advantages: Gold standard; High sensitivity (90 - 95%)
- Limitations: Takes time for cultures to grow (24 - 48h) –> delay initiation of Abx
- Clinical use: Not very useful
2) Rapid antigen detection test (RADT)
- Advantages: Very fast (within minutes)
- Limitations: Lower sensitivity (70 - 90%); Expensive

Clinical diagnosis:

1) Modified centor criteria
- Score given based on patient background & S/Sx
- Higher score –> higher risk of S. pyogenes pharyngitis
- Score used to make diagnosis / decide on need for antibiotics
- Score = 0, 1 - Presumed viral; No additional testing indicated
- Score = 2, 3 - Test for S. pyogenes pharyngitis (rarely done) OR Initiate empiric antibiotics (more common)
- Score = 4, 5 - Initiate empiric antibiotics
- Note: Children < 3 years - Presumed viral

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10
Q

Treatment of pharyngitis

A

1) Antibiotic treatment
- Indication: Strep throat
- Generally empiric
2) Supportive care
- Indication: Viral/Bacterial pharyngitis
3) Corticosteroids
- NOT recommended

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11
Q

Treatment of pharyngitis - Supportive care

A

Indicated for both bacterial & viral infection

1) Antipyretic / Analgesic - Paracetamol, NSAIDs
- Avoid Aspirin in children - Reye syndrome
2) Topical analgesic lozenges/sprays
- E.g. Benzydamine
3) Saltwater gargle
4) Adequate fluid & rest

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12
Q

Treatment of pharyngitis - Corticosteroids

A

Benefits
- Reduce duration & severity of symptoms by reducing inflammation

Limitations
- Associated with side effects

Overall: NOT recommended

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13
Q

Empiric antibiotic treatment of pharyngitis - Benefits

A

1) Prevent acute rheumatic fever
2) Shorten duration of symptoms by 1-2 days
3) Reduce transmission (no longer infectious after 24h of antibiotics)

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14
Q

Empiric antibiotic treatment of pharyngitis - Organisms to cover

A

S. pyogenes

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15
Q

Empiric antibiotic treatment of pharyngitis - Choice of antibiotics

A

1st Line:

1) Penicillin VK
- Most narrow, directed therapy

Alternative:

1) Amoxicillin OR Cephalexin
- Alternative in mild penicillin allergy
- Note: Amoxicillin alone is sufficient –> Augmentin is too broad spectrum
2) Clindamycin OR Clarithromycin
- Alternative in severe penicillin allergy
- Choice depends on patient preference, C/I

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16
Q

Empiric antibiotic treatment of pharyngitis - Dosing

A

Duration: 10 days

Adult Dosing:
Penicillin VK
- PO 250 mg QDS OR PO 500 mg BD
- Renal dose adjustment needed

Amoxicillin

  • PO 1g OD OR PO 500 mg BD
  • Renal dose adjustment needed

Clindamycin
- PO 300 mg TDS

Pediatric Dosing:
Penicillin VK
- PO 250 mg BD - TDS
- Renal dose adjustment needed

Amoxicillin

  • PO 50 mg/kg/day OD or divided BD
  • Renal dose adjustment needed

Clindamycin
- PO 7 mg/kg TDS

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17
Q

Pharyngitis - Monitoring

A

Therapeutic response

  • Clinical improvement expected within 24-48h after initiation of antibiotics
  • Resistance to antibiotics rare
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18
Q

Sinusitis - Site of infection

A

Paranasal & nasal mucosa

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19
Q

Sinusitis - Clinical presentation

A

Sinusitis:

  • ≥ 2 major symptoms OR
  • 1 major + ≥ 2 minor symptoms

Major symptoms

1) Purulent anterior nasal discharge
2) Purulent/Discoloured posterior nasal discharge
3) Nasal obstruction/congestion
4) Facial congestion/fullness
5) Facial pain/pressure
6) Hyposmia/Anosmia
7) Fever

Minor symptoms

1) Headache
2) Ear pain, pressure, fullness
3) Halitosis
4) Cough
5) Fatigue
6) Dental pain

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20
Q

Sinusitis - Microbiology

A

Viral (> 90%)
- Rhinovirus, adenovirus, influenza, parainfluenza

Bacteria (< 10%)

  • Most common: Streptococcus pneumoniae, Haemophilus influenzae
  • Others: Moraxella catarrhalis, Streptococcus pyogenes

Fungi
- Mainly occurs in immunocompromised patients

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21
Q

Sinusitis - Pathogenesis

A

Transmission: Direct contact with infected saliva / nasal secretions

Acute inflammation of paranasal & nasal mucosa –> sinus obstruction –> nasal mucosal secretions trapped in sinus cavities (accumulation) –> medium for bacterial trapping & multiplication

Bacterial sinusitis usually preceded by viral URTIs (e.g. common cold, pharyngitis) i.e. complication of viral URTIs
- Runny nose during viral URTIs –> sniff back mucus –> accumulation in sinus cavities –> medium for bacterial trapping & multiplication

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22
Q

Sinusitis - Differential diagnosis

A

Difficult to differentiate between bacterial VS viral sinusitis
- Similar clinical presentation

Diagnosis of bacterial sinusitis based on:

1) Diagnostic tests
- Limited use
2) Clinical diagnosis
- Frequently used

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23
Q

Sinusitis - Diagnosis of bacterial sinusitis

  • Diagnostic tests
  • Clinical diagnosis
A

Diagnostic tests

1) Imaging studies (e.g. CT scan)
- Limitation: Non-specific, non-discriminatory –> only tests for presence of inflammation but unable to differentiate between viral VS bacterial sinusitis
2) Sinus aspirate
- Gold standard
- Limitations: Painful, invasive, time-consuming
- Usually only used in immunocompromised patients –> may have polymicrobial infections / infected by organism other than bacteria/virus

Clinical diagnosis
Presence of sinusitis (≥ 2 major symptoms / 1 major + ≥ 2 minor symptoms)
AND
Any one of the following:
1) Persistent symptoms > 10 days AND no improvement
- Viral sinusitis is usually self-limiting & resolves within 7 - 10 days
2) Severe symptoms
- Purulent nasal discharge x 3 - 4 days OR
- High fever ≥ 39oC
3) Double worsening
- Worsening of symptoms 5 - 6 days after initial improvement
- Likely complicated by secondary bacterial infection

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24
Q

Treatment of sinusitis

A

1) Antibiotic treatment
- Indication: Bacterial sinusitis
- Generally empiric
2) Supportive care
- Indication: Viral/Bacterial sinusitis

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25
Q

Treatment of sinusitis - Supportive care

A

1) Antipyretic/Analgesic - NSAIDs, Paracetamol
- Avoid Aspirin in children
2) Nasal steroid spray
3) Saline irrigation
4) Expectorant - Guaifenesin
5) Nasal/Systemic decongestants/antihistamine
- NOT guideline recommended

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26
Q

Empiric antibiotic treatment of sinusitis - Benefits

A

1) Shorten duration of symptoms
2) Earlier symptom relief
3) Restore QOL
4) Prevent complications

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27
Q

Empiric antibiotic treatment of sinusitis - Organisms to cover

A

S. pneumoniae

H. influenzae

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28
Q

Empiric antibiotic treatment of sinusitis - Duration

A

Adults: 5 - 10 days

  • Studies supporting shorter duration, with similar cure
  • Improves compliance
  • Minimize ADR due to antibiotics

Paediatric: 10 - 14 days

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29
Q

Empiric antibiotic treatment of sinusitis - Choice of antibiotics

A

1st Line:
1) Amoxicillin
2) Amoxicillin-Clavulanate
- Used if suspect ß-lactamase producing H. influenzae
- Use if any ONE of the following:
• Recent antibiotic use in past 30 days
• Recent hospitalization in past 30 days
• Failure to improve after 72h of Amoxicillin

Alternatives in penicillin allergy:

1) Respiratory fluoroquinolones - Moxifloxacin, Levofloxacin
2) Cotrimoxazole
3) Cefuroxime
- Mild penicillin allergy

30
Q

Empiric antibiotic treatment of sinusitis - AVOID using

A

1) Ciprofloxacin
- Poor activity against S. pneumoniae
2) Macrolides, Tetracyclines
- High local resistance of S. pneumoniae to Macrolides & Tetracyclines
3) Penicillin VK
- Penicillin-resistant S. pneumoniae which requires high dose for effective treatment
- High dose Amoxicillin preferred over high dose Penicillin due to favourable PK (better bioavailability)

31
Q

Empiric antibiotic treatment of sinusitis - Dosing

A

Adult Dosing:
Amoxicillin
- PO 1g TDS (high dose)
- Renal dose adjustment needed

Amoxicillin-Clavulanate
- PO 1g BD (high dose) OR
- PO 625 mg TDS
• High dose –> risk of GI effects –> increase dosing frequency instead
• Most public hospitals carry 625 mg Augmentin (more cost-effective, readily available, smaller tablet size)
- Renal dose adjustment needed

Levofloxacin

  • PO 500 mg OD
  • Renal dose adjustment needed

Paediatric Dosing:
Amoxicillin
- PO 80-90 mg/kg/day, divided BD (high dose)

Amoxicillin-Clavulanate
- PO 80-90 mg/kg/day, divided BD (high dose)

Levofloxacin
- C/I in children

32
Q

Antibiotic resistance - S. pneumoniae

  • MOA
  • Prevalence
  • Treatment
A

MOA

  • Multi-step mutation of penicillin-binding proteins (PBP)
  • Results in increased penicillin MIC with each mutation

Prevalence

  • Penicillin-resistant isolates uncommon locally (< 5 - 10%)
  • May not be completely resistant –> requires higher dose

Treatment

  • High dose OR Increased frequency Amoxicillin
  • Amoxicillin preferred over penicillin due to favourable PK –> higher bioavailability –> achieves higher systemic concentrations
33
Q

Antibiotic resistance - H. influenzae

  • MOA
  • Prevalence
  • Treatment
A

MOA
- Production of ß-lactamase –> breaks down ß-lactams

Prevalence
- ß-lactamase positive: ~18% locally

Treatment
- Amoxicillin-Clavulanate (use of ß-lactamase inhibitors)

34
Q

AOM - Site of infection

A

Middle ear

35
Q

AOM - Clinical presentation

A

1) Otalgia
2) Otorrhoea
3) Ear popping/fullness
4) Hearing impairment
5) Dizziness
6) Fever

Young children/infants may present with non-specific symptoms

  • Ear rubbing
  • Excessive crying
  • Change in sleep/behavioural patterns
36
Q

AOM - Risk factors

A

1) Children (especially < 5 years)
- Eustachian tube in children is flatter, more horizontal –> easier for nasal discharge to flow backwards
2) Siblings
3) Daycare
4) Supine position when feeding
5) Exposure to tobacco smoke
6) Pacifier use
7) Winter season

37
Q

AOM - Pathogenesis

A

Generally occurs as a complication of viral URTI
During viral URTI
- Secretion & inflammation –> obstruction of Eustachian tube –> negative Eustachian tube pressure
- Nose sniffing
Overall: Results in reflux of secretions into middle ear –> accumulation of discharge/fluid in middle ear –> medium for bacterial accumulation & growth –> middle ear infection resulting in inflammation & fluid accumulation

38
Q

AOM - Microbiology

A

1) Viral (40-45%)
- Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza

2) Bacteria (55-60%)
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis

39
Q

AOM - Diagnosis

A

Diagnostic tool: Pneumatic otoscope

Diagnostic criteria in children:

1) Acute onset (< 48h)
2) Otalgia OR Erythema of tympanic membrane
- Rubbing, tugging, holding in non-verbal child
3) Bulging of tympanic membrane
- Usually due to fluid accumulation in middle ear

Note: Differential diagnosis (bacterial VS viral) difficult due to:

  • Similar clinical presentation
  • Similar prevalence
40
Q

Treatment of AOM - Supportive care

A

1) Analgesic / Antipyretic - NSAIDs, Paracetamol
- Avoid Aspirin in children

Decongestants & antihistamines NOT shown to be beneficial

41
Q

Empiric antibiotic treatment of AOM - Immediate initiation

1) How it works
2) Benefits
3) Limitations

A

How it works:
Start antibiotics at initial doctor’s visit

Benefits:
1) Prompt initiation of antibiotics decrease duration of symptoms by ~1 day

Limitations:
2) Risk of antibiotic overuse

42
Q

Empiric antibiotic treatment of AOM - Observation period

1) How it works
2) Benefits
3) Limitations

A

How it works:
No antibiotics given at initial doctor’s visit
Supportive care x 48-72h
If fail to improve/worsens: Antibiotics initiated

Benefits:

1) Prevents overuse of antibiotics
- Difficult to differentiate between viral VS bacterial AOM
- Most bacterial AOM are self-limiting –> resolve within 3-4 days without antibiotics

Limitations

1) Inconvenient (may require 2nd doctor’s visit)
2) Requires reliable follow-up
- Must be able to monitor child at home

43
Q

Empiric antibiotic treatment of AOM - Observation period criteria

A

May only be considered if ALL of the following are fulfilled:

1) ≥ 6 months
- Younger children at higher risk of complications/less likely to get better without antibiotics
- Older children better able to report symptoms

2) Non-severe illness
- Severe: Moderate-severe otalgia OR Otalgia ≥ 48h OR Fever ≥ 39oC
- Non-severe: Absence of ALL of the above
- Note: Assessing severity can be difficult –> severity of otalgia is subjective, difficult for younger patients to report symptoms

3) No otorrhoea
- Otorrhoea can indicate rupture of tympanic membrane

4) Possible for close-follow-up
5) Shared decision making with parent/caregiver

44
Q

Empiric antibiotic treatment of AOM - When can observation period be considered

A

1) No otorrhoea AND

2) Unilateral AOM + ≥ 6 months OR Bilateral AOM + ≥ 2 years

45
Q

Empiric antibiotic treatment of AOM - Watch & wait

1) How it works
2) Benefits
3) Use in SG

A

How it works:
Prescription given at initial doctor’s visit
Supportive care x 48h
Prescription only filled in after 48h if fails to improve/worsens

Benefits

1) Increased convenience
2) Parent satisfaction
3) Prevent overuse of antibiotics
- Only 2/3 of prescriptions filled –> most cases are self-limiting

Rarely used in SG

46
Q

Empiric antibiotic treatment of AOM - Organisms to cover

A

1) S. pneumoniae
2) H. influenzae
3) Moraxella catarrhalis

47
Q

Empiric antibiotic treatment of AOM - Duration

A

< 2 years: 10 days

Severe symptoms (moderate-severe otalgia OR otalgia ≥48h OR fever ≥ 39oC): 10 days

≥ 2 - 5 years AND non-severe: 7 days

≥ 6 years AND non-severe: 5 - 7 days

48
Q

Empiric antibiotic treatment of AOM - Choice of antibiotics

A 
1st Line: 
1) Amoxicillin
- Used if fulfil ALL of the following: 
• No Amoxicillin in past 30 days 
• No concurrent purulent conjunctivitis 
• Not allergic to penicillin

2) Amoxicillin-Clavulanate
- Used if ANY ONE of the following:
• Amoxicillin in past 30 days (suspect ß-lactamase producing H. influenzae)
• Concurrent purulent conjunctivitis (suspect MSSA)
• History of AOM non-responsive to Amoxicillin

Alternative

1) Ceftriaxone (IM) OR Cefuroxime
- Alternative in mild penicillin allergies

2) Clindamycin
- Alternative in severe penicillin allergies
- Note: Does NOT cover H. influenzae

3) Respiratory Fluoroquinolones
- Alternative in severe penicillin allergies
- For adults only; C/I in children

49
Q

Empiric antibiotic treatment of AOM - Dosing

A

Paediatric Dosing:

1) Amoxicillin
- PO 80 - 90 mg/kg/day divided BD (high dose)
- Renal dose adjustment needed

2) Amoxicillin-Clavulanate
- PO 80 - 90 mg/kg/day divided BD
- Renal dose adjustment needed

3) Cefuroxime
- PO 30 mg/kg/day divided BD
- Renal dose adjustment needed

50
Q

Non-pharmacological treatment of AOM - Prevention

A

1) Minimize exposure to tobacco smoke
2) Exclusive breastfeeding for first 6 months
3) Minimize pacifier use
4) Vaccinations
- Influenza
- Pneumococcal
- H. influenzae type B

51
Q

AOM - Monitoring

A

Treatment response

  • May worsen in first 24h
  • Improvements expected after 48-72h

Treatment failure

  • Initially Amoxicillin –> switch to Augmentin
  • Initially Augmentin –> switch to Cefuroxime / Ceftriaxone
  • Treatment failure is rare
52
Q

Influenza - Clinical presentation

A

Incubation period: 24 - 72h
Abrupt onset

Signs &amp; symptoms: 
Usual/Common:
1) Fever
2) Body aches
3) Chills
4) Fatigue, body weakness 
5) Chest discomfort 
6) Headache 
Less common: 
1) Sneezing
2) Stuffy nose 
3) Sore throat
53
Q

Influenza - Differential diagnosis

1) VS Common cold
2) VS Covid-19

A

Common cold:

  • Influenza: Abrupt onset VS Common cold: Gradual onset
  • More common in influenza: Fever, chills, body ache, fatigue, body weakness, chest discomfort, headache
  • More common in common cold: Sneezing, stuffy nose, sore throat

Covid-19:

  • Similar symptoms: Fever, body aches, chills, fatigue/body weakness, stuffy/runny nose, sore throat, chest discomfort, headache
  • Classical for Covid-19: Change in/Loss of taste/smell, N/V, diarrhea
54
Q

Influenza - Epidemiology in SG

A

Bimodal distribution - Peaks in:

1) Dec - Feb
2) May - Jul

55
Q

Influenza - Microbiology

A

1) Influenza A
- Host: Human, swine, equine, avian, other species
- Most severe illness
- Significant mortality in young persons
- Epidemics & pandemics

2) Influenza B
- Host: Human only
- Severe illness in elderly, high risk groups
- Less severe epidemics

3) Influenza C
- Host: Human, swine
- Mild illness
- No seasonality
- No epidemics

56
Q

Influenza - Diagnosis

A

1) Viral cultures
- Not recommended –> takes long time to get results

2) Molecular tests
- Outpatient: Limited use; Diagnosis mainly based on symptoms; Usually empiric treatment
- Inpatient: May be used; RT-PCR

57
Q

Influenza - Complications

A

1) Viral pneumonia
2) Post-infection bacterial pneumonia
- Especially those caused by S. aureus
- High mortality (> 30%)
- Can result in respiratory failure, organ damage
3) Respiratory failure
4) Exacerbation of cardiac/pulmonary comorbidities
5) Febrile seizures
6) Myocarditis, pericarditis

58
Q

Influenza - High risk group

A

1) Children < 5 years
2) Elderly ≥ 65 years
3) Pregnant women / Within 2 weeks post-partum
4) Residents of nursing homes/long-term care facilities
5) Obesity (BMI ≥ 40 kg/m^2)
6) Chronic medical conditions
- Mainly pulmonary / cardiac conditions
- E.g. Asthma, COPD, heart failure, DM, chronic kidney disease, immunocompromised

59
Q

Management of influenza

A

1) Prevention
- Chemoprophylaxis
- Non-pharmacological
- Vaccination

2) Antiviral treatment

60
Q

Influenza - Non-pharmacological prevention

A

1) Good personal hygiene
- Wash hands
- Minimize touching eyes, nose, mouth
- Cover nose & mouth when coughing/sneezing
- Wear mask if unwell
- Use serving spoon if sharing food

2) Maintain healthy lifestyle
- Exercise regularly
- Adequate sleep
- Balanced diet
- Do not smoke

61
Q

Influenza - Vaccination

1) Types of influenza vaccines
2) Administration
3) Indication

A

Types of influenza vaccines
- Inactivated trivalent / quadrivalent vaccine

Administration:

  • Route: IM
  • Administered yearly (only lasts for 1 year)
  • Onset: ~2 weeks from administration

Indication:
ALL individuals ≥ 6 months, unless contraindicated
- Very few contraindications

62
Q

Influenza - Types of chemoprophylaxis

A

1) Pre-exposure

2) Post-exposure

63
Q

Influenza - Pre-exposure chemoprophylaxis

1) Purpose
2) Indication
3) Initiation

A

Purpose:
- Prevent influenza before exposure to virus

Indication:

1) Institutional outbreaks - Given to ALL unvaccinated individuals in institution
- E.g. In hospitals, long-term care facilities, nursing homes
- Rarely occurs –> institutions should have good infection control
2) Unvaccinated high risk individuals ≥ 3 months
- C/I to influenza vaccine

Initiation
- Initiate as soon as outbreak is identified

64
Q

Influenza - Post-exposure chemoprophylaxis

1) Purpose
2) Indication
3) Initiation

A

Purpose:
- Prevent influenza after exposure

Indication:

1) ALL high risk individuals ≥3 months (vaccinated or unvaccinated)
2) Unvaccinated individuals ≥3 months who are household contacts of high risk individuals

Initiation
- Initiate as soon as possible - within 48h of exposure (less effective if given > 48h after exposure)

65
Q

Antiviral treatment of influenza - Initiation

A

Initiate as soon as possible - Within 48h of symptom onset

  • Benefit decreases if initiated > 48h of symptom onset
  • May consider initiating in inpatient setting, even if patient presents > 48h after symptom onset (still some benefit e.g. decrease symptom duration, incidence of complications)
66
Q

Antiviral treatment of influenza - Who to treat

A

Start antiviral (within 48h of symptom onset) for ANY ONE of the following:

1) Hospitalization
2) High risk individual
3) Severe, complicated or progressive illness

Other patients (e.g. outpatient setting): May be considered (if within 48h of symptom onset) BUT influenza is generally self-limiting –> usually not treated

67
Q

Antiviral used in chemoprophylaxis / treatment of influenza

A

Oseltamivir

68
Q

Oseltamivir - MOA

A

Neuraminidase inhibitor

  • Inhibit cleavage of viral proteins –> viral proteins no longer functional
  • Inhibit release of new virus –> inhibit viral replication

Note: Only effective against influenza A & B

69
Q

Oseltamivir - Indications

A

Chemoprophylaxis & treatment of influenza

- 1st line

70
Q

Oseltamivir - Dosing (Chemoprophylaxis)

A

PO 75 mg daily
- Renal dose adjustment needed

Duration:
Pre-exposure: 7 days after outbreak has resolved
Post-exposure: 7 days from exposure / from when starting Oseltamivir

71
Q

Oseltamivir - Dosing (Treatment)

A

PO 75 mg BD
- Renal dose adjustment needed

Duration: 5 days
- May be extended in immunocompromised / critically ill patients (but not a lot of evidence supporting) this

72
Q

Oseltamivir - ADR

A

Generally well tolerated

1) Headache
2) Mild GI effects

ID (12 decks)

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