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Respi > URTIs & Influenza > Flashcards

URTIs & Influenza Flashcards

1
Q

What are the typical clinical presentations of pharyngitis?

A

1) Acute onset of sore throat
2) Pain upon swallowing
3) Fever
4) Redness & inflammation of pharynx & tonsils (with/out patchy exudates)
5) Tender, swollen lymph nodes

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2
Q

What are the microbes that can cause pharyngitis?

A

Viral (80%): rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr

Bacterial (20%): Streptococcus Pyogenes (grp A β-hemolytic streptococcus)

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3
Q

Describe the pathogenesis of pharyngitis.

A

Direct contact w/ droplets of infected saliva/ nasal secretions (coughing/ sneezing)

Short incubation period of 24~48 hrs

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4
Q

What are some complications that may arise in pharyngitis?

A

Viral: Self-limiting

Bacterial: Self-limiting/ may have complications which usually occur 1~3 wks later

1) Acute rheumatic fever (can be prevented w/ early & effective antibiotics)
2) Acute glomerulonephritis (X prevented with antibiotics)

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5
Q

What are the challenges in managing pharyngitis?

A

DIfficult to differentiate viral & bacterial pharyngitis as they have similar presentations; however initiation of antibiotics is only useful in bacterial pharyngitis

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6
Q

How does antibiotic use help in bacterial pharyngitis?

A
  1. Prevents rheumatic fever (complication)
  2. ↓ duration of symptoms by 1~2 days
  3. decreases transmission (with 24h of antibiotic use, pt becomes non-infectious)
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7
Q

How is pharyngitis clinically diagnosed?

A

Modified Centor Criteria
1 pt: fever > 38°C, swollen lymph nodes, tonsillar exudates, absence of cough, aged 3~14 yo

0 pt: age 15~44

-1 pt: age >44yo

**<3 yrs presumed to be viral (S. pyogenes less likely a cause)

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8
Q

Suggest appropriate response to pharyngitis if points = 0-1, 2-3, 4-5

A

0-1: No additional testing; presumed to be viral

2-3: Test for S. pyogenes pharyngitis & treat if +ve OR start empiric antibiotics for S. pyogenes

4-5: Start empiric antibiotics (high risk of bacterial pharyngitis)

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9
Q

Suggest appropriate antibiotic therapy and duration of therapy for S. pyogenes pharyngitis.

A

Fist line: Penicillin VK

Alternatives: Amoxicillin, Cefalexin, Clindamycin, Clarithromycin

for 10 days

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10
Q

How long does it typically take for the patient to respond to treatment against bacterial pharyngitis?

A

24-48 hours

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11
Q

Why is Augmentin not used to treat bacterial pharyngitis?

A

Too broad-spectrum; Main causative organism is S. pyogenes only

May cause C diff & emergence of more resistant strains

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12
Q

Define sinusitis.

A

Acute inflammation & infection of nasal & paranasal mucosa (w/in 4 wks)

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13
Q

What are the typical clinical presentations of sinusitis?

A

Major symptoms:

1) Purulent anterior nasal discharge
2) Purulent/discoloured posterior nasal discharge
3) Nasal congestion/ obstruction
4) Facial fullness/ congestion
5) face pain/ pressure
6) Hyposmia/ anosmia (↓/X smell)
7) fever >38°C

Minor symptoms:

1) headache
2) ear pain, pressure, fullness
3) halitosis (bad breath)
4) dental pain
5) cough
6) fatigue

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14
Q

What are the requirements to confirm that a patient has sinusitis?

A

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

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15
Q

What are the microbes that can cause sinusitis?

A

Viral (90%): rhinovirus, adenovirus, influenza, parainfluenza

Bacterial (10%): Strep pneumo & H. influenzae (most common), Moraxella catarrhalis, S. pyogenes

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16
Q

Describe the pathogenesis of sinusitis

A

Direct contact w/ infected droplets of saliva/ nasal secretions

Bacterial sinusitis usually preceded by viral URTIs (e.g. pharyngitis, common cold)

Inflammation → sinus obstruction; nasal mucosal secretions trapped; bacteria trapped & multiply

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17
Q

What are some challenges in diagnosing sinusitis?

A
  1. viral & bacterial sinusitis have similar symptoms
  2. diagnostic tests have limited use:
    - imaging studies: non-specific
    - Sinus aspirate: invasive, painful & time-consuming
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18
Q

How is bacterial sinusitis diagnosed clinically?

A

Presence of sinusitis (≥ 2 major symptoms OR 1 major + ≥ 2 minor symptoms)

+

Presence of any bacterial sinusitis criteria:
1) Persistent symptoms > 10days & not improving

2) Severe symptoms @ onset (purulent nasal discharge for 3-4 days or Fever >39°C)
3) “Double sickening” (symptoms worsen after 5-6 days of initial improvement; bacterial sinusitis often follows viral URTI)

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19
Q

Suggest appropriate antibiotic therapy for bacterial sinusitis.

A

First line: Amoxicillin OR Augmentin

Alternatives:

  1. Respiratory FQs (Moxi/ Levofloxacin)
  2. Cotrimoxazole (trimethoprim + sulfamethoxazole)
  3. Cefuroxime (2nd gen ceph)
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20
Q

Suggest an appropriate duration of treatment for Bacterial sinusitis.

A

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

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21
Q

What is the mechanism of resistance of Strep Pneumoniae?

A

Multistep mutation of bacterial transpeptidase/ PBP → penicillin unable to bind & inhibit bacterial cell wall synthesis (cross-linking)

** MIC of penicillin ↑; req higher dose to be effective

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22
Q

What are some considerations for the treatment regimen if resistant S. pneumonia is suspected?

A

1) Choose amoxicillin > penicillin
* * amoxicillin has better absorption ⇒ ↑ systemic exposure; require lower dosing to reach MIC

2) Use “high dose” amoxicillin (2 times of std dosing)

23
Q

What is the mechanism of resistance of H. influenzae?

A

Production of β-lactamase which cleave β-lactam rings

⇒ require β-lactamase inhibitor (e.g. clavulanic acid)

24
Q

When should Augmentin be initiated in treatment of bacterial sinusitis?

A

Use Augmentin (amox/clav) if any one:

  1. recent course of antibiotics (~30days)
  2. recent hospitalization (likely to have more resistant strains)
  3. Failure to improve after 72 hrs of amoxicillin
    - presence of organism X covered for
    - organism shows resistance (Production of β-lactamase)
25
Q

Define Acute Otitis Media (AOM)

A

Infection of the middle ear space leading to inflammation & fluid accumulation

26
Q

What are the typical clinical presentations of AOM?

A

1) Otalgia
2) Otorrhea
3) Ear fullness & popping
4) hearing impairment
5) Dizziness
6) fever
7) Non-specific in young infants: ear rubbing, excessive crying, change in sleep & behavioral pattern

27
Q

AOM is more common in _________ patients due to ______________

A

pediatric (esp < 5yrs)
;having a shorter & straighter eustachian tube allowing easier backflow of mucus & bacteria from the nasopharynx after viral URTI

28
Q

What are the microbes that can cause AOM?

A

Viral (40~45%):

  1. Respiratory Syncytial Virus (RSV)
  2. adenovirus
  3. rhinovirus
  4. parainfluenza

Bacterial (55~60%):

  1. Strep pneumo
  2. H. influenzae
  3. Moraxella catarrhalis
29
Q

Describe the pathogenesis of AOM

A 
Viral URTI (e.g. common cold) causes nose sniffing/ inflammation & secretions
⇒ eustachian tube becomes obstructed & has negative pressure
⇒ allow reflux of secretions into middle ear 
⇒ medium for bacteria accumulation & growth
30
Q

What are the risk factors for AOM?

A

1) siblings
2) attending daycare
3) supine position while feeding
4) exposure to tobacco smoke
5) pacifier use
6) winter season

31
Q

How can AOM be prevented?

A

1) decrease exposure to tobacco smoke
2) exclusive breastfeeding for the first 6 months
3) minimize pacifier use
4) vaccinations (influenza, pneumococcal, H. influenza type B Vaccine)

32
Q

How is AOM diagnosed? What are the diagnosis criteria in children?

A

Using a pneumatic otoscope

Diagnosis criteria in children:

  1. Acute onset < 48hrs
  2. Otalgia (non-verbal child may tug/ rub ear)
  3. erythema of tympanic membrane
  4. bulging tympanic membrane
33
Q

What are the challenges in managing AOM?

A

Viral & bacterial AOM are indistinguishable; however early Abx initiation in bacterial AOM can help ↓ symptom duration by ~1 day

** ~80% cases of bacterial AOM may resolve spontaneously w/in 3-4 days

** Overprescribing Abx may cause resistance

34
Q

What is the basis of allowing an observation period when managing bacterial AOM?

A

Some patients may X req Abx to recover
(~80% cases of bacterial AOM may resolve spontaneously w/in 3-4 days)

Supportive care for 48-72 hrs; if symptoms worsen/ don’t improve, initiate ABx therapy

35
Q

Under what conditions may an observation period be considered when managing bacterial AOM?

A

When all of the following criteria are fulfilled:

1) ≥ 6 months old
2) Non-severe illness
3) No otorrhea (suggests tympanic membrane perforation otherwise)
4) possible for a close follow up
5) Caregiver/ parents approve of the decision

36
Q

Define severe AOM (which warrants immediate Abx initiation)

A

Any one:

  • moderate to severe otalgia
  • otalgia ≥ 48 hrs
  • fever ≥ 39°C in last 48 hrs
37
Q

Suggest appropriate first-line antibiotic options for bacterial AOM & under what conditions they should be used

A 
1) High dose amoxicillin
if all 3 criteria are met:
- X amoxicillin in last 30 days
- X concurrent purulent conjunctivitis (✓ S. AUreus; X covered by amox alone)
- X penicillin allergy
2) Augmentin
if any is applicable:
- amoxicillin in the last 30 days
- concurrent purulent conjunctivitis
- ✓ history of AOM non-responsive to amoxicillin (recurrent AOM; resistant organisms)
38
Q

What are some alternative antibiotic options for bacterial AOM?

A

1) IM Cefuroxime/ Ceftriaxone (possible in mild pen allergy)

2) Clindamycin (for severe penicillin allergy; only covers S. pneumo)

39
Q

When should improvement of AOM symptoms be expected?

A

48-72hrs

40
Q

Suggest an appropriate duration of antibiotic treatment for Bacterial AOM

A

< 2 y/o: 10 days

Severe symptoms: 10 days

≥ 2-5 y/o & non-severe symptoms: 7 days

≥ 6 y/o & non-severe symptoms: 5-7 days

41
Q

What are the typical clinical presentations of influenza?

A 
Fever
Fatigue & weakness
Chills 
Chest discomfort & cough
Bodyache
Headache
Sore throat
42
Q

How do clinical presentations differ between influenza & COVID?

A

Loss of taste & smell + NVD are less likely to occur in influenza

43
Q

What are the possible complications associated with influenza?

A

1) viral pneumonia
2) Post influenza bacterial pneumonia (may involve S. AUreus; > 30% mortality)
3) Respiratory failure
4) exacerbate underlying cardiac/ pulmonary comorbidities
5) febrile seizures
6) myocarditis/ pericarditis

44
Q

Which groups of individuals are more at risk of influenza-associated complications?

A

1) extremes of age: <5 y/o , ≥65 y/o
2) Pregnant women or w/in 2 weeks postpartum
3) Residents of nursing homes/ long term care facilities
4) Obese; BMI ≥ 40 kg/m2
5) individuals w/ chronic medical conditions (e.g. asthma, CVD)

45
Q

How can influenzal infection be prevented?

A

1) good personal hygiene
2) healthy lifestyle (diet, exercise, sleep, X smoking)
3) vaccination (yearly IM tri/quadrivalent vaccine)

46
Q

How is influenza diagnosed?

A

Outpatient: empiric therapy
Inpatient: Reverse transcriptase PCR (RT-PCR)

47
Q

When is antiviral therapy considered in patients suspected of influenza?

A

Initiate asap w/in 48 hrs of symptom onset if:

hospitalised/ ↑ risk of complications/ severe or complicated or progressive illness

48
Q

What is the antiviral used to treat influenza?

A

Oseltamivir

49
Q

What is the mechanism of action of Oseltamivir?

A

neuraminidase inhibitor ⇒ interferes w/ protein cleavage & inhibits the release of new flu virion

50
Q

What is a suitable dosing regimen for Oseltamivir?

A

PO 75mg bd x 5 days

~10 days if immunocompromised/ critically ill

51
Q

What are the side effects of Oseltamivir?

A

generally well-tolerated

headache; mild NVD

52
Q

Dose adjustment for Oseltamivir is required in ___________

A

renal impairment

53
Q

Oseltamivir is used to treat influenza _________

A

A&B

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