URTI I

Question 1

What is pharyngitis?

Answer 1

Acute inflammation of the oropharynx or nasopharynx

Question 2

Microbiology of Pharyngitis?

Answer 2

• Viruses (> 80%)&raquo_space; bacteria (< 20%)
• Viruses: Rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr
• Bacteria: Group A β-hemolytic Streptococcus (Streptococcus Pyogenes) -> strep throat

Question 3

Pathogenesis of Pharyngitis

Answer 3

• Direct contact with droplets of infected saliva or nasal secretions
• Short incubation of 24 – 48 hours

Question 4

What are the complications of pharyngitis?

Answer 4

Viral: self-limiting
S. pyogenes pharyngitis: self-limiting or complications possible
– Complication occur 1-3 weeks later
– Acute rheumatic fever: Prevented with early initiation of effective antibiotics
– Acute glomerulonephritis: Not prevented by antibiotics

Question 5

Diagnosis for pharyngitis?

Answer 5

Testing for S. pyogenes pharyngitis
– Throat culture (24-48 hours) -> takes too long
• Gold standard • High sensitivity 90-95%

– Rapid antigen detection test (RADT) (minutes) -> expensive
• Sensitivity 70-90%

Not used much.

Question 6

What is the clinical diagnosis for pharyngitis?

Answer 6

Using Modified Centor Criteria

If total point is 2 or higher, start empiric abx for S pyogenes pharyngitis.

Question 7

Treatment for pharyngitis?

Answer 7

1st line: Penicillin VK
Adult dosing: 250mg PO QDS* or 500mg PO BD*
CHILDREN: 250mg PO BD – TDS*

Alternative:
Amoxicillin
Adult: 1g PO OD* or 500mg PO BD*
Children: 50mg/kg/day PO OD or divided BD*

• Cephalexin

If severe penicillin allergy: 
– Clindamycin: 
Adult: 300mg PO TDS
Children: 7mg/kg PO TDS
– Clarithromycin

Duration x 10 days

Clinical response in 24-48 hours, counsel on completing abx course.

Question 8

Diagnosis of sinusitis?

Answer 8

2 or more major symptoms OR
1 major + 2 or more minor symptoms

Major symptoms:
- Purulent anterior nasal discharge
- Purulent or discolored posterior nasal discharge
- Nasal congestion/obstruction
- Facial congestion/ fullness -Facial pain/pressure
Hyposmia/anosmia
Fever

Minor symptoms: 
§ Headache 
§ Ear pain, pressure, fullness 
§ Halitosis 
§ Dental pain 
§ Cough 
§ Fatigue

Question 9

Microbiology of sinusitis?

Answer 9

Virus&raquo_space; bacteria
viruses: Rhinovirus, adenovirus, influenza, parainfluenza

Bacteria:

• streptococcus pneumoniae and Haemophilus influenzae most common
• Moraxella catarrhalis
• Streptococcus pyogenes

Question 10

Clinical diagnosis of BACTERIAL sinusitis?

Answer 10

Presence of sinusitis + any ONE criterion:

• persistence of symptoms > 10 days AND not improving
• severe symptoms at onset: purulent nasal discharge x 3-4 days or high fever of 39 and above
• double sickening - worsening symptoms after 5-6 days after initial improvement

Question 11

Treatment for bacterial sinusitis?

Answer 11

1st line:
Amoxicillin:
Adult: 1g PO TDS*
Children: 80 – 90 mg/kg/day PO divided BD*

or Amoxicillin/clavulanate:
Adult: 625mg PO TDS; or 1g PO BD
Children: 80 – 90 mg/kg/day PO divided BD*

Alternatives

• respiratory fluroquinolones (levofloxacin 500mg PO OD for adults or moxifloxacin)
• trimethoprim/sulfamethoxazole
• cefuroxime

Duration:
Adults: 5-10 days
Pediatrics: 10-14 days

Question 12

Why is ciprofloxacin NOT a respiratory fluroquinolone?

Answer 12

Poor activity against streptococcus pneumoniae

Question 13

When do we use Amoxicillin/clavulanate for bacterial sinusitis?

Answer 13

Use amoxicillin/clavulanate only if any ONE of the following:

§ Recent course(s) of antibiotic(s) in last 30 days
§ Recent hospitalization in last 30 days
§ Failure to improve after 72 hours of amoxicillin

Question 14

What are the risk factors for AOM?

Answer 14

< 5 years old 
§ Siblings 
§ Attending day care 
§ Supine position during feeding 
§ Exposure to tobacco smoke at home 
§ Pacifier use 
§ Winter season

Question 15

How to prevent AOM?

Answer 15

§ Avoid exposure to tobacco smoke 
§ Exclusive breastfeeding for 1st 6 months 
§ Minimize pacifier use 
§ Vaccinations
– Influenza
– Pneumococcal
– Haemophilus influenzae type B vaccine

Question 16

Microbiology for AOM?

Answer 16

Viruses:
Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza virus

Bacteria:
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Question 17

Diagnostic criteria in children?

Answer 17

• acute onset (less than 48 hours)
• otalgia (ear pain) or erythema of tympanic membrane
• bulging of tympanic membrane

Question 18

What are the 2 approaches for treating AOM?

Answer 18

1. Immediate initiation as soon as AOM Is diagnosed
2. Observation period: Supportive care x 48-72 hours, if improves, no abx needed. If worsens or fails to improve, give abx.

Question 19

Observation period criteria?

Answer 19

Observation period may be considered if ALL 5 of the following
criteria are fulfilled
- 6 months and older
- non severe illness: none of the following 3 criteria: moderate-severe otalgia, or otalgia > 48 hours, or fever > 390C in the
last 48 hours
- no otorrhea (discharge from ear)
- possible for close follow up
- shared decision making with parent or caregiver

Question 20

What are the 3 instances where observation period can be CONSIDERED?

Answer 20

1. If at least 6 months to less than 2 years, if unilateral AOM without otorrhea
2. If 2 years and above, for both unilateral and bilateral AOM without otorrhea

If none of these 3 instances, use immediate abx therapy.

Question 21

Treatment for AOM?

Answer 21

1st line abx: Amoxicillin 80 – 90 mg/kg/day PO divided BD*
Patient needs to fulfill ALL 3 criteria
• No amoxicillin in the last 30 days 
• No concurrent purulent conjunctivitis 
• Not allergic to penicillin

Alternative first line abx:
Amoxicillin/clavulanate 80 – 90 mg/kg/day PO divided BD*
If any 1 of the following is applicable
• Amoxicillin in the last 30 days
• Concurrent purulent conjunctivitis
• History of AOM non-responsive to amoxicillin

Question 22

Alternative abx for AOM?

Answer 22

• For mild penicillin allergies, possible to use
  Cefuroxime 30 mg/kg/day PO divided BD* and Ceftriaxone (IM)
• Clindamycin (effective against strep pneumoniae only, not covering H influenzae, no choice). Use this if severe penicillin allergy.

Question 23

Treatment duration for AOM?

Answer 23

Improvement expected in 48-72 hours, complete the course.

< 2 years -> 10 days
Severe symptoms I.e. moderate-severe otalgia, or otalgia > 48 hours, or fever
> 390C in the last 48 hours —> 10 days
At least 2 years, to 5 yo, and non severe symptoms -> 7 days
At least 6 years and non severe symptoms -> 5-7 days