Lecture 22: Upper and Lower RTI (info overload)

Question 1

Most common reason for anti-biotic prescribing in kids?

Answer 1

Otitis media

Question 2

What is the main pathologies that lead to Otitis media?

Answer 2

URI or Allergy –> Congestion of Respiratory Mucosa –> Decreased clearance of middle ear secretions –> fluid accumulation in ME space –> Reflux of OP/NP flora –> Acute Otitis Media (biofilm)

Question 3

What age group is at highest risk for Otitis media?

Answer 3

From birth to 3 years

Question 4

What percent of kids from birth to age 3 get Otitis media?

Answer 4

80-90% of children

Question 5

Define Otitis media

Answer 5

moderate or severe bulging of the TM or new onset otorrhea not due to otitis externa, with acute signs of illness and middle ear inflammation

Question 6

Environmental factors that predispose to Otitis media

Answer 6

Day care attendance
Tobacco smoke exp
Winter more than summer
Formula feeding (breast feeding > 3 months is protective)
Siblings at home
Lower Socioeconomic status
Pacifier use

Question 7

Acute Otitis media symptoms in infants include what?

Answer 7

Fever, night wakening, poor feeding/anorexia, vomiting, irritability, and diarrhea

Question 8

Child symptoms of Otitis media include what?

Answer 8

Fever, night wakening, poor feeding/anorexia, vomiting, irritability, and diarrhea, + [ear pain (~80%), hearing loss]

Question 9

What are the complication symptoms in Otitis media?

Answer 9

Tinnitus, vertigo, otorrhea (TM perf), nystagmus, swelling

Will see conjunctivitis in some kids with (H. influenzae)

Question 10

Name the classic Physical exam findings for Otitis media

Answer 10

Membrane looks discolored (red, yellow, gray/cloudy) and bulging tympanic membrane. Loss of normal bony landmarks
+ immobile TM pneumatic otoscopy
+ (5%) TM perforation w/ purulent drainage

Question 11

Name the top bacteria that cause Otitis media

Answer 11

Bacteria: TOP one is Strep pneumoniae (50%), Haemophilus influenza (up to 45%),
Moraxella catarrhalis (10%)
(many infections have mixed microbes/viruses)

Question 12

Name the viruses that typically cause Otitis media?

Answer 12

Typical viruses: RSV, flu, enteroviruses, cold viruses, metapneumo

Question 13

Atypical organisms (uncommon or rare) that may cause Otitis media

Answer 13

Mycoplasma, Chlamydia, TB

Question 14

If a child has an ear infection, what are decongestants good for?

Answer 14

Nothing. They’re not good. Have no proven benefit.

Question 15

For a kid with otitis media pain, what are the 2 main meds to give for relief of pain?

Answer 15

Ibuprofen or Tylenol

Question 16

Antimicrobial therapy for otitis media

Answer 16

First target the most common bacterial pathogens,

1. amoxicillin for 10 days
2. If suspect resistance to amoxicillin (H. influenzae) use amoxicillin-clavulanate
3. Kid has an allergy to PCN, use 2nd/3rd gen cephalosporin, macrolide, clindamycin.

Question 17

When can observation be used?

Answer 17

If the age is > 6 mos (some docs say > 2 yrs); not severe & unilateral dz, not immunocompromised, no high fever; 48-72 hr follow-up or “wait-and-see” Rx

Question 18

Otitis media complications: Extension of infection to contiguous structures can cause what?

Answer 18

Mastoiditis

CNS infection

Question 19

Other complications of otitis media include what?

Answer 19

1. Chronic perforation
2. Cholesteatoma formation
3. Hearing loss (conductive)
4. Delayed language development

Question 20

What is abnormal, invasive growth of sq epithelium in the ear canal called?

Answer 20

It’s called a Cholesteatoma

Question 21

Sequelae of Acute Otitis Media : Chronic Otitis Media… What is the microbiology, and therapy?

Answer 21

Microbiology: often poly-microbial, resistant
Therapy: prolonged antibiotics + ENT referral

Question 22

Pharyngitis: Most common bacterial cause is what?

Answer 22

(25-37% of all) S. pyogenes (Group A Strep&raquo_space; Grp C, G)

Question 23

What age and time of year is strep throat most common?

Answer 23

Affects primarily children 5-15 yrs of age

Higher infection rates in winter months

Question 24

How is strep pharyngitis typically spread?

Answer 24

Person-to-person, mainly via respiratory droplets

Also, high carriage rates in asymptomatic individuals facilitates transmission

Question 25

What are the symptoms of Streptococcal pharyngitis?

Answer 25

``` Acute onset of fever, sore throat cough and rhinorrhea absent Pharyngeal/tonsillar edema and erythema Nonadherent pharyngeal exudate Tender anterior cervical LAD associated head ache, Nausea, vomiting and malaise ```

Question 26

What are the viral pharyngitis symptoms?

Answer 26

Sxs of viral infection w/ conjunctivitis, coryza (runny nose), cough, hoarseness, anterior stomatitis, discrete ulcers, viral exanthems +/- diarrhea

Question 27

Causes of viral pharyngitis

Answer 27

Common cold, Adenovirus, Herpangina, EBV, (plus other stuff: HSV, HIV, CMV, influenza)

Question 28

Causes of bacterial pharyngitis

Answer 28

Anaerobes (Lemierre’s), Arcanobacterium, Mycoplasma, Gonorrhea, and Diphtheria

Question 29

List the complications of Group A Strep pharyngitis

Answer 29

Extension to contiguous structures: OM, sinuses, CNS abscess formation, peritonsillar, metastatic, Nonsuppurative sequelae: rheumatic fever and glomerulonephritis

Question 30

What is the gold standard for diagnosis of strep throat?

Answer 30

Throat culture, ~90% sensitivity | However, a 24-48 hr delay for results

Question 31

What is it called when using agglutination or ELISA assay to detect a streptococcal wall antigen from a throat swab

Answer 31

“Rapid Strep” tests (RADS), 70-90% sensitivity, > 95% specific If found to be negative, continue to do a culture *Neither can differentiate acute infection from asymptomatic carriers with intercurrent viral pharyngitis

Question 32

How do you treat strep throat?

Answer 32

Antibiotics: Penicillin is the drug of choice (for 10 days)/ (If found allergy use Cephalosporin, Clinda, Macrolide) Acute illness is usually limited, but therapy shortens severity, duration of Sxs, lowers risk of Rheumatic fever, and lower chances of transmission

Question 33

Define Acute Rhinosinusitis

Answer 33

"Symptomatic inflammation of the nasal cavity/paranasal sinuses"

Question 34

Bacterial sinusitis risks to think about

Answer 34

Venous drainage of sinus to intracranial and orbital compartments confers risk of complications at those sites if there is a sinus infection w/bacteria

Question 35

What is the most common cause of community acquired sinusitis? Virus or Bacteria?

Answer 35

Viral: vast majority (rhino-, flu/parainfluenza) Majority resolve spontaneously Bact. infections complicate 0.5-2%

Question 36

List the 4 common bacteria that cause sinusitis

Answer 36

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis + Anaerobes (esp if contiguous to dental infx)

Question 37

What features distinguish bacterial sinusitis from viral infection?

Answer 37

Bacteria quality, duration, progression of sx’s: No improvement after 7-10 days and/or worsens after initial improvement Severe sx’s: early high fever, Pain Physical Exam: facial erythema/swelling, focused/ unilateral facial pain, fever >38°C, concurrent odontogenic source

Question 38

When to seek imaging and/or ENT consultation?

Answer 38

1. CT scan if complicated, lack of response | 2. Sinus aspirate by ENT if non-response and/or immunocompromised

Question 39

List the complications of sinusitis

Answer 39

Intracranial: Meningitis, Abscess formation, Epidural/ or Subdural infection, Venous sinus thrombosis Peroorbital/orbital - Periorbital (preseptal) cellulitis, Orbital cellulitis, Orbital abscess

Question 40

What are the symptoms/indicators of bronchitis?

Answer 40

Cough longer than 5 days (10-20 days typically) Purulent sputum (50%) (not equivalent to bacterial cause) Wheezing 2nd bronchospasm Rhonchi which often clear w/ cough Fever: atypical (if so, consider influenza or pneumonia) Absence of consolidative signs/hypoxemia CXR: normal or thickened bronchial walls

Question 41

Bacterial causes of bronchitis (3 main ones)

Answer 41

Mycoplasma pneumoniae Chlamydia pneumonia Bordetella pertussis

Question 42

Viral causes of bronchitis (4 main ones)

Answer 42

Cold viruses RSV Influenza*/Para-flu Human metapneumovirus

Question 43

What leads to higher risk for post infectious pneumonia and bronchospasm?

Answer 43

Virus action: post viral pneumonia caused because of impaired barrier defense and virus specific damage to bronchial epithelium with denudation

Question 44

What is the main clinical treatment of bronchitis if it is caused by influenza?

Answer 44

Symptomatic tx of URI, cough, pain CXR if suspect pneumonia Only treat with antivirals for patients at risk for complications If pertussis suspected: NP PCR; tx if confirmed Consider microscopic eval. if outbreak suspected

Question 45

Abnormal vitals, rales that don’t clear with cough, hypoxemia, CXR shows inflitration - Typical for pneumonia or bronchitis?

Answer 45

Typically seen in pneumonia Bronchitis presents with rales that clear w/ cough, rarely abnormal vitals, and clear CXR

Question 46

What are the risk factors of complication for Community Acquired Pneumonia (CAP)?

Answer 46

``` Age over 65 COPD, malignancies RR ≥ 30, dBP ≤ 60, P ≥ 125 Low WBC (30K), high BUN Hypoxemia, anemia, coagulopathy ```

Question 47

Name 5 CAP commonly seen organisms

Answer 47

``` S. pneumoniae Mycoplasma/Chlamydia H. influenzae (smokers, COPD) S. aureus (post influenza) Legionella ```

Question 48

Aspiration pneumonia is associated with

Answer 48

altered mental status (may be episodic) and poor dentition

Question 49

aspiration pneumonia complications, name two

Answer 49

Complications: lung abscess, empyema

Question 50

What kinds of organisms are associated with aspiration pneumonia?

Answer 50

polymicrobial, including anaerobes

Question 51

Name 3 hospital associated pneumonia organisms

Answer 51

Enteric gram negative bacilli Pseudomonas aeruginosa + other GNR S. aureus (incl MRSA) (often seen in ventilated patients)

Question 52

How do you initially treat community accquired pneumonia?

Answer 52

Outpatient CAP: Rx with Macrolides, doxycycline, (Floroquinolones or beta-lactams and macrolides)

Question 53

How do you treat hospitalized CAP?

Answer 53

General Med Ward: 3rd G. cephalosporin + macrolide or Floroquinolones ICU: 3rd G. cephalosporin + macrolide or 3rd G. cephalosporin + Floroquinolones

Question 54

How do you treat Healthcare associated or ventilator associated pneumonia?

Answer 54

Give MRSA agent (eg Vancomycin) + GNR agents (eg Cefepime/Pip-Tazo + 2nd antibiotics) also consider Legionella testing

Question 55

What are the advantages of pathogen specific therapy?

Answer 55

Narrow antibiotic spectrum Less antimicrobial pressure on normal flora To determine: use gram stain (sputum), cultures (sputum, blood), and immunoassays (eg urine Ag tests)