URTI: Pharyngitis, Rhinosinusitis, AOM Flashcards
What is the clinical presentation of pharyngitis?
- Acute onset of sore throat
- Pain with swallowing
- Fever
- Erythema and inflammation of the pharynx and tonsils (with or without patchy exudates) - redness at back of throat
- Tender and swollen lymph nodes
What is the microbiology for pharyngitis?
- Viruses (>80%)»_space; bacteria (<20%)
Virus: rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr
Bacteria: group A beta-haemolytic streptococcus (Streptococcus pyogenes)
S. pyogenes NO 1 cause of bacterial pharyngitis
Children»_space; adults
but less common in SG
What is the pathogenesis of pharyngitis? How does it transfer and its incubation period?
- Direct contact with droplets of infected saliva or nasal secretions
- Short incubation of 24-48 hours
What are the complications of Pharyngitis?
- viral: self-limiting
- S. pyogenes pharyngitis: self-limiting or complications possible
~ complication occur 1-3 wks later
~ acute rheumatic fever: prevented with early initiation of effective ABx
~ acute glomerulonephritis: not prevented by ABx
Another name for pharyngitis
Strep throat
What are the challenges in management of pharyngitis?
Viral and bacterial have similar clinical presentation
ABx have proven benefits in bacterial pharyngitis
~ prevent acute rheumatic fever
~ shorten duration of smx by 1-2 days
~ reduce transmission (no longer infectious after 24h of ABx)
How to diagnose Pharyngitis?
NOT DONE:
- throat culture (24-48h) (too long)
- rapid antigen detection test (minutes) (Expensive)
Clinical diagnosis DONE:
According to modified centor criteria:
~ Total points - 0 to 1
- no additional testing indicated
- low risk of S. pyogenes pharyngitis
- presume VIRAL
~ Total points - 2 to 3
- Test for S. pyogenes pharyngitis; treat if +ve
- Or initiate empiric ABx for S. pyogenes pharyngitis
~ Total points - 4 to 5
- High risk for S. pyogenes pharyngitis
- initiate empiric ABx
Which age group is rare to get pharyngitis?
children < 3yo
no testing indicated, presumed viral
Supportive care enough
What are the treatment options for Pharyngitis?
1ST LINE ABX: Pen VK
Adult dosing: 250mg PO QDS * or 500mg PO BD *
Paediatric dosing: 250mg PO BD-TDS *
*Normal Renal Function
Alternative ABx: - Amoxicillin Adult: 1g PO OD* or 500mg PO BD * Paediatric: 50mg/kg/day PO OD or divided BD* *Normal Renal Function
- Cephalexin
- Clindamycin
Adult: 300mg PO TDS
Paediatric: 7mg/kg PO TDS - Clarithromycin
Duration 10 days
Clinical response expected within 24-48 h ; counsel on completing ABx course
Another word for Rhinosinusitis is
Sinusitis
What is sinusitis?
Acute (within 4 wks) inflammation and infection of the paranasal and nasal mucosa
What are the major smx clinical presentations of sinusitis?
Major smx:
- purulent anterior nasal discharge
- purulent or discoloured posterior nasal discharge
- Nasal congestion/ obstruction
- Facial congestion/ fullness
- Facial pain/ pressure
- Hyposmia/ anosmia (Reduced/no sense of smell)
- Fever
What are the minor smx clinical presentations of sinusitis?
Minor smx:
- HA
- Ear pain, pressure, fullness
- Halitosis (bad breath)
- Dental pain
- Cough
- Fatigue
How many major and/or minor smx required to confirm someones has sinusitis?
> or = 2 major smx OR
1 major + > or = 2 minor smx
What is the microbiology for sinsitis?
Virus (90%)»_space; Bacteria (10%)
Viruses: rhinovirus, adenovirus, influenza, parainfluenza
Bacterial: Streptococcus pneumoniae and Haemophilus influenzae most common
- Moraxella catarrhalis
- S. pyogenes
What is the pathogenesis of sinusitis? How is it transmitted?
- Direct contact with droplets of infected saliva or nasal secretions
- Bacterial cases usually preceded by viral URTIs (common cold, pharyngitis) (1st viral, but after few days, bacterial sinusitis)
- Inflammation results in sinus obstruction: Nasal mucosal secretions are trapped; Medium of bacterial trapping and multiplication
What are some diagnostic challenges for sinusitis?
- Bacterial and viral sinusitis similar smx
- Limited use of diagnostic tests:
~ imaging studies: non-specific, non-discriminatory
~ Sinus aspirate (gold standard): invasive, painful, time-consuming
What is the clinical diagnosis of bacterial sinusitis? How to identify presence of bacterial sinusitis?
Any one criterion present:
- Persistent of smx > 10 days and not improving
~ Viral sinusitis: self-limiting, resolves in 7-10 days
- Persistent of smx > 10 days and not improving
- Severe smx at onset
~ Purulent nasal discharge x 3-4days or High fever > = 39oC
- Severe smx at onset
- “Double sickening”
~ Worsening smx after 5-6 days after initial improvement (normally happens after viral URTI)
- “Double sickening”
What is the purpose of treating sinusitis with empiric abx?
- shorten duration of smx
- earlier smx relief
- restore QOL
- prevent complications
- Hard to get culture because invasive and painful
What are the treatment options for bacterial sinusitis?
And what is the duration for adults and paediatrics?
1ST LINE:
- Amoxicillin
- Adult: 1g PO TDS
- Paediatric: 80-90 mg/kg/day PO divided BD
- Normal Renal Function
OR
- Amox/Clav Augmentin Adult: 625mg PO TDS* ; or 1g PO BD* Paediatric: 80-90 mg/kg/day PO divided BD * *Normal Renal Function
Alternative Abx:
- Resp FQs: Levo/Moxi
Adult Levo: 500mg PO OD *
*Normal Renal Function
- Co-TS
- Oral 2nd cephalosporin: cefuroxime
Duration:
adults: 5-10d
paediatrics: 10-14d
Why is clarithromycin, azithromycin and doxycycline not appropriate for alternative treatment of sinusitis?
S. pneumoniae inc resistance to macrolides and tetracycline
Cipro poor activity against S. pneumoniae (not a resp FQ)
What are some resistant mechanisms for S. pneumoniae?
- Multi-step penicillin-binding proteins (PBPs) mutation
- inc penicillin MIC
- Pen-resistant isolates uncommon locally (<5-10%)
What are the treatment considerations (changes/alterations to treatment) for resistant S. pneumoniae?
- Prefer AMOXICILLIN over penicillin - favourable PK (Amox better F, abs, achieve higher systemic conc of abx) (Amox also effective against penicillases)
- prefer “high-dose” amox for effective treatment
~ Standard dose: 45mg/kg/day (paediatrics); 250-500mg (adults)
~ High-dose: 80-90mg/kg/day (paediatrics); 1g (adults)
What are some resistant mechanisms by H. influenzae?
- beta-lactamase production
- inhibited by beta-lactamase inhibitor
- beta-lactamase +ve ~18% locally
What are the treatment considerations (changes) for resistant H. influenzae?
Use AUGMENTIN only if any one of the following:
- Recent course(s) of Abx(s)
- Recent hospitalisation
Recent: last 30 days
- Failure to improve after 72h of amoxicillin
if don’t have any of these, stick to AMOX itself
What is acute otitis media?
Infection of middle ear space resulting in inflammation and fluid accumulation
Eustachian tube connects middle ear and nasopharynx, regulates middle ear pressure
What are clinical presentations of AOM?
- Ear pain (otalgia)
- Ear discharge (otorrhea)
- Ear popping
- Ear fullness
- Hearing impairment
- Dizziness
- Fever
- Non-specific in young infants: ear rubbing, excessive crying, changes in sleep or behavioural pattern
Which age group is most common for AOM?
paediatric pts (<5yo)
Have runny nose, sniffles, if the tube is relatively flat; gravity; quite easy for nasal discharge to back flow and enter the tube
angle more horizontal 180o
What are the risk factors for AOM?
- siblings
- attending day care
- supine position during feeding
- exposure to tobacco smoke at home
- pacifier use
- winter season
How to prevent AOM?
- Avoid exposure to tobacco smoke
- Exclusive breastfeeding for 1st 6 months
- Minimise pacifier use
- Vaccinations: influenza, pneumococcal, H. influenzae type B vaccine
What is the pathogenesis of AOM? How does a child get AOM?
Viral URTIs (common cold) –> nose sniffling –> reflux of secretions into middle ear
OR
Viral URTIs (common cold) –> Secretions and inflammation –> Eustachian tube obstruction –> Negative eustachian tube pressure –> reflux of secretions into middle ear
Medium for bacterial accumulation and growth
What is the microbiology for AOM?
Bacteruals (55-60%) ~ Viral (40-45%)
Viruses: Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza virus
Bacteria: S. pneumoniae, H. influenzae, Moraxella catarrhalis
How to diagnose AOM?
- Pneumatic otoscope as standard tool
- Diagnostic criteria in children
~ Acute onset (<48h)
~ Otalgia (holding, tugging, rubbing in a non-verbal child) or erythema of tympanic memb
~ Bulging of tympanic memb (Red, inflamed memb, yellow
; Bulge: fluid build up in middle ear
Could rupture and flow out)
What are some challenges in the management of AOM?
- Unable to distinguish bacterial VS viral aetiologies
- Bacterial AOM
~ Prompt ABx initiation dec duration of smx by ~ 1 day
~ around 80% of cases resolve in 3-4days wo Abx (improve on their own)
If overprescribing Abx –> resistance
How do we approach ABX for AOM?
Immediate initiation: start Abx as soon as AOM is diagnosed
OR
Observation period:
Supportive care x 48-72h
Improves –> no Abx needed
If worsens/fails to improve –> Abx
When is observation period considered for AOM?
ONLY IF ALL the following criteria are fulfilled:
- > or = 6 mths of age; the younger, the more likely complications
- non-severe illness
~ Severe: moderate-severe otalgia, or otalgia >= 48h, or fever >= 39oC in the last 48h
~ Non-severe: absence of all 3 criteria above
- no otorrhoea (should not have discharge) ( if pt has discharge –> indication rupture of tympanic memb more severe - give Abx straight away)
- possible for close follow-up
- shared decision-making with pt/caregiver
What is the protocol for AOM treatment when pt has Otorrhoea with AOM?
Age
< 6mths: observation period not recommended; immediate Abx therapy
> = 6mths to < 2yrs: immediate Abx therapy
> =2 yrs: immediate Abx therapy
What is the protocol for AOM treatment when pt has Unilateral/Bilateral AOM with severe smx?
Age
< 6mths: observation period not recommended; immediate Abx therapy
> = 6mths to < 2yrs: immediate Abx therapy
> =2 yrs: immediate Abx therapy
What is the protocol for AOM treatment when pt has Bilateral AOM without Otorrhoea?
Age
< 6mths: observation period not recommended; immediate Abx therapy
> = 6mths to < 2yrs: immediate Abx therapy
> =2 yrs: immediate Abx therapy OR Observation period
What is the protocol for AOM treatment when pt has Unilateral AOM without Otorrhoea?
Age
< 6mths: observation period not recommended; immediate Abx therapy
> = 6mths to < 2yrs: immediate Abx therapy OR Observation period
> =2 yrs: immediate Abx therapy OR Observation period
What are the treatment options for AOM?
1ST LINE: Amoxicillin Patient needs to fulfill ALL 3 criteria to get Amox: 1. no amox in the last 30 days 2. no concurrent purulent conjuctivitis 3. not allergic to penicillin
Alternative 1ST line abx: Augmentin If any 1 of the following is applicable: - amox in last 30 days - concurrent purulent conjuctivitis - Hx of AOM non-responsive to amox
Amox and Augmentin
Paediatric dosing:
80-90 mg/kg/day PO divded BD*
* Normal renal fn
Alternative abx:
- Cefuroxime, Ceftriaxone (IM); possible option for mild pen allergies
Cefuroxime paediatric dosing: 30mg/kg/day PO divided BD*
* Normal renal fn
- Clindamycin: effective against S. pneumoniae only; option for pts with severe pen allergies
NO FQs for kids
How long to see improvement from AOM for various age groups?
Improvement expected in 48-72h
< 2yrs: 10 days
Severe smx (moderate-severe otalgia) or otalgia >= 48h, or fever >= 39oC in last 48h) : 10 days
> =2 to 5yrs and non-severe smx: 7 days
> = 6 yrs and non-severe smx: 5-7 days
