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3151 Therapeutics > Upper Respiratory Tract Infections > Flashcards

Upper Respiratory Tract Infections Flashcards

1
Q

How is URTI transmitted?

A
  • Droplets or aerosols when infected person cough, sneeze, talk
  • Spread indirectly when person touches a surface, then touches nose or mouth
  • Share food without serving spoon

=> Particles inhaled into respiratory tract and invade upper airway mucosa

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2
Q

What are the innate immunity against URTI?

A
  1. Nostril hair lining traps organisms
  2. Mucus traps organisms
  3. Angle between the pharynx and nose which prevents particles from falling into the airways
  4. Mucociliary system in lower airways that transport pathogens back up the pharynx
  5. Adenoids and tonsils (secondary lymphoid tissues) that contain immunological cells
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3
Q

What are the risk factors for URTI?

A
  1. Close contact
  2. Lack of personal/hand hygiene
  3. Medical disorders: people with chronic respiratory disease like asthma and allergic rhinitis
  4. Smoking
  5. Immunocompromised individuals including CF, HIV, use of corticosteroids, transplant, post-splenectomy
  6. Anatomical anomalies, including facial dysmorphic changes or nasal polyposis
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4
Q

What are some ways to prevent URTI?

A
  1. Hand/personal hygiene, mask wearing, stay away from crowds
  2. Vaccination - e.g., influenza, pneumococcal, Hemophilus influenzae (others: varicella, BCG, pertussis, diphtheria, MMR)
  3. Manage known risk factors - e.g., smoking cessation, control asthma and AR
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5
Q

Management of URTI includes symptom management, use of antibiotics, and prevention of future recurrence by managing/reducting risk factors.

In what cases should antibiotics be used in the management of URTI?

A

NEVER USED:
- Common cold
- Influenza

SOMETIMES USED:
- Pharyngitis
- Rhinosinusitis
- Otitis media

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6
Q
  1. Confirm presence of infection [COMMON COLD]
    - Risk factors (as above)
    - Clinical presentation

Describe the subjective and objective clinical presentation

A

Low grade temp <38 (gradual)
Rhinorrhea
Nasal blockage
Sneezing
Sore throat
Productive (wet) cough
Some headache, body ache

*There should be NO high fever of >=38, HR should be normal, lungs clear to auscultation bilaterally (no compromised breathing)

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7
Q
  1. Identification of pathogens [COMMON COLD]
  • What microbiological diagnostics may be required?
  • What are the common pathogens of common cold?
A

No microbiological diagnostics required, unless to rule out influenza or covid-19

Pathogen - rhinovirus, coronavirus

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8
Q
  1. Selection of antimicrobial and regimen [COMMON COLD]

What antibiotics should be considered?

A

NIL

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9
Q
  1. Monitor response [COMMON COLD]

Describe the monitoring parameters

  • Recover in ____
  • Feel better within _____
  • See Dr if symptoms do not improve after _____
A

Self limiting, recover in 7-10 days
Cough lasts 2-3 weeks (due to postnasal drip)
Feel better within 3-4 days, but symptoms can linger for a few weeks
See doctor if symptoms does not improve after 10 days or if symptoms worsen

Normal for nasal discharge to change colour
- yellow/green may be due to inflammation, DOES NOT imply bacterial cause

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10
Q
  1. Confirm presence of infection [INFLUENZA]

What is the clinical presentation of influenza?

A

*more serious than common cold

Symptoms: fever (abrupt), chills, headache, malaise, myalgia, anorexia

Respi symptoms: sore throat, dry cough, nasal discharge

Elderly pt may present with confusion

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11
Q
  1. Confirm presence of infection [INFLUENZA]

What are some complications that may develop from influenza? (due to weakened respiratory tract)

A

Primary viral pneumonia

Secondary bacterial pneumonia
- often Staph Aureus and Strep Pneumoniae and Haemophilus Influenzae

Exacerbation of chronic respiratory disease

Myocarditis

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12
Q
  1. Confirm presence of infection [INFLUENZA]

What diagnostics may be used for influenza?

A

Nasopharyngeal swab or aspirate

  • Rapid detection kits, POCT - immunofluorescence (IF), enzyme immunoassay (EIA), immunochromatographic method
  • Reverse-transcriptase PCR

*More for hospitalized/LTC (to determine use of antivirals), not routine in outpatient setting (uncomplicated, hence symptomatic relief sufficient)

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13
Q
  1. Confirm presence of infection [INFLUENZA]

What groups of patients are at high risk for flu complications? (hence may need antivirals)

A
  1. Children <5yo
  2. Elderly >= 65yo
  3. Women who are pregnant or within 2 weeks post-partum
  4. Residents of nursing homes or long-term care facilities
  5. Obese individuals with BMI >=40kg/m2
  6. Individuals with chronic medical conditions (e.g., asthma, COPD, heart failure, diabetes, CKD, immunocompromised)
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14
Q
  1. Confirm presence of infection [INFLUENZA]

Describe the differences in symptoms of cold and flu

A

Symptom onset more gradual in cold, more abrupt in flu

Fever and aches and chills and fatigue more common in flu

Sore throat, rhinorrhea, nasal congestion, sneezing more common in cold

Cough occurs in both (wet in common cold, dry in flu)

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15
Q
  1. Confirm presence of infection [INFLUENZA]

Describe the similarities and differences in symptoms of flu and covid 19

A

Similar clinical presentation - need diagnostics tests to confirm

Similarities: wide spectrum of disease, treatment and vaccination available

Differences: covid 19 more contagious, covid 19 cause more severe illness in vulnerable population

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16
Q
  1. What is the pathogen [INFLUENZA]

What are the common influenza viruses in human

A

Influenza A - cause seasonal epidemics, can cause pandemics

  • Two surface proteins: Hemagglutinin (H) and Neuraminidase (N)
  • Usual circulating subtypes: H1N1, H3N2

Influenza B - cause seasonal epidemics

  • Two lineages: B/Yamagata and B/Victoria

Influenza C - causes febrile mild upper respiratory illness, does not occur in endemics

*D occurs in cattles

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17
Q
  1. What is the pathogen [INFLUENZA]

When do influenza peaks occur?

A

Influenza A and B cause seasonal epidemics

  • Middle (May to July): southern hemisphere winter
  • End/beginning of year (Nov to Feb): northern hemisphere winter

*Could be spread due to travel, close contacts during these seasons

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18
Q
  1. Selection of antimicrobial treatment [INFLUENZA]

Discuss the treatment option and when it should be initiated

A

Initiate antiviral as soon as possible (best within 48h, up to 5 days) of symptom onset for indiv who fulfill any ONE of the following (SERIOUS ILLNESS):

  • Hospitalized
  • High-risk complications
  • Severe, complicated or progressive illness

If started for oupatient setting, initiate within first 48h of symptom onset. If not, just offer symptomatic relief.

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19
Q
  1. Selection of antimicrobial treatment [INFLUENZA]

Discuss the MOA, dose, SE of the antiviral used.

A

Oseltamivir (PO) - Tamiflu

  • Active against influenza A and B
  • MOA: Neuraminidase inhibitor (interferes with protein cleavage and hence inhibit release of new virus)
  • Dose: PO 75mg bid x5d, require dose adj in renal impairment CrCl <60ml/min
  • SE: well tolerated, some headache and mild GI discomfort (N&V)
20
Q
  1. Monitor response [INFLUENZA]

What are the monitoring parameters

A

*Most ppl with flu do not need medical or antiviral, only those with serious illness

Symptoms should improve within 10 days
If symptoms does not improve after 10 days => doctor
If symptoms improve then develop new fevers, worsening dypsnea or cough => doctor (possible secondary bacterial infection)

21
Q

Discuss the influenza vaccines

A

Available type:

  • Inactivated trivalent (2A1B)
  • Inactivated Quadrivalent (2A2B)

=> Prepared from the prevailing strains of influenza A and B

Update:

  • Vaccine is updated every year based on the predicted predominant strain for the season by WHO

Administration:

  • IM, once a year
  • However, since there are two peaks, may also take 2 times (although normal popln >= 6 months is only recommended to take once a year)
  • Those at high risk of complications are recommended to take the vaccine

Vaccine property:

  • Confer immunity within 2 weeks
  • Efficacy: 75%
22
Q
  1. Confirm presence of infection [PHARYNGITIS]

What are the clinical presentations?

A

Sore throat (worse with swallowing)
Fever
Erythema and inflammation of the pharynx and tonsils (with or w/o patchy exudates)
Tender and swollen lymph nodes (esp cervical lymph nodes)

23
Q
  1. Confirm presence of infection [PHARYNGITIS]

Differentiate viral and bacterial pharyngitis

A

Viral Pharyngitis:

  • S&S of viral infections such as low-grade fever <38dc, malaise, fatigue, rhinorrhea, cough, hoarseness, oropharyngeal lesions (ulcers, vesicles), conjunctivitis
  • Self-limiting

Bacterial Pharyngitis:

  • Sore throat with tonsillar exudates, fever (>38dc), cervical lymphadenopathy, w/o typical viral symptoms
  • Modified centor criteria to guide GAS testing and/or antibiotic treatment
  • May be self-limiting or have complications
24
Q
  1. Confirm presence of infection [PHARYNGITIS]

What is the Modified Centor Criteria (to guide GAS testing and/or antibiotic treatment

  • May be self-limiting or have complications
A
  1. Fever >38dc
  2. Swollen, tender anterior cervical lymph nodes
  3. Tonsillar exudate
  4. Absence of cough
  5. Age 3-14 years

*Each criteria is 1 point
*Unlikely in 15-44yo (0 points), does not occur in 45yo and older (-1 points)
*Rare amongst <3yo, hence no testing

0-1: no testing indicated, low risk of GAS pharyngitis, presumed viral
2-3: test for S. pyogenes pharyngitis, treat with Abx if positive (culture-directed)
4-5: high risk for S. pyogenes, intitate empiric Abx

*IDSA: fewer than 3 do not need to be tested

25
Q
  1. Confirm presence of infection [PHARYNGITIS]

What are the complications of S. pyogenes pharyngitis?

A

Complications are RARE
Occur 1-5 (usually 2-3) weeks later:

  • Acute rheumatic fever
    => prevent with early initiation of effective Abx
  • Acute glomerulonephritis
    => not prevented by Abx
26
Q
  1. What is the pathogen [PHARYNGITIS]

Describe the common viruses and bacteria

A

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

Bacteria (<20%)
- Group A B-hemolytic Streptococcus (Strep Pyogenes)

27
Q
  1. What is the pathogen [PHARYNGITIS]

Indication for testing for S pyogenes pharyngitis is determined based on the Modified Centor Criteria (score of 2-3 should be tested)

What are the testing methods?

A
  1. Throat culture (24-48h) - GOLD STANDARD
  2. Rapid antigen detection test (RADT) within minutes

*Do not typically take culture

28
Q
  1. Choice of antibiotics [PHARYNGITIS]

What are the goals of Abx therapy in S. pyogenes pharyngitis?

A
  • Reduce symptom severity and duration
  • Prevent acute complications (otitis media, peritonsillar abscesses, other invasive infections)
  • Prevent delayed complications or immune sequelae (esp acute rheumatic fever)
  • Prevent spread to others (no longer contagious after 24h of Abx)
29
Q
  1. Choice of antibiotics [PHARYNGITIS]

Discuss the FIRSTLINE treatment options and duration of treatment

A

Should cover Strep Pyogenes

First line:

  • PO Amoxicillin 500mg q12h
  • PO Penicillin V 250mg q6h
    *No reported resistance
    *Amoxicillin longer interval as it concentrates well in pharynx and tonsils

Duration of treatment: 10 days

30
Q
  1. Choice of antibiotics [PHARYNGITIS]

Discuss the treatment options and duration of treatment (if penicillin allergy)

A

Should cover Strep Pyogenes

If penicillin allergy:

  • Non-severe: PO Cephalexin 500mg q12h (if Amoxicillin allergy, CANNOT use this)
  • PO Azithromycin 500mg once daily
  • PO Clarithromycin 250mg q12h
  • PO Clindamycin 300mg q8h

*However, increasing resistance to macrolides (macrolides should still be used first before clindamycin if no resistance)

Duration of treatment: 10 days (5 days for Azithromycin as it conc. well in tonsils)

31
Q
  1. Monitor response [PHARYNGITIS]

What are the monitoring parameters?

A

Clinical response

  • Pt NOT given Abx: (viral pharyngitis) typical course of sore throat is less than 1 week
  • Pt given Abx: fever and symptoms resolve within 1-3 days of starting treatment
  • See doctor if symptoms do not improve or worsen

Microbiological test of cure/clearance NOT required

Antibiotics ADR

32
Q

What is acute rhinosinusitis?
Describe the pathogenesis.

A

Acute (within 4 weeks) inflammation and infection of the paranasal and nasal mucosa

Pathogenesis:

  • Direct contact with droplets of infected saliva or nasal secretions
  • Bacterial usually preceded by viral URTIs (e.g., common cold, pharyngitis)
  • Inflammation results in sinus obstruction => impaired mucosal clearance, nasal mucosal secretions trapped, stagnation of discharge in the sinus, medium of bacterial overgrowth and trapping and multiplication
33
Q
  1. Confirm presence of infections [ACUTE RHINOSINUSITIS]

What are the symptoms?

A

*Related to sinus obstruction, pressure build up

Purulent nasal discharge
Facial pain or pressure
Fever
Nasal congestion/obstruction
Reduced sense of taste or smell (hyposmia and anosmia)
Headache
Cough
Ear fullness or pressure
Bad breath
Dental pain

34
Q
  1. Confirm presence of infection [ACUTE RHINOSINUSITIS]

Discuss the indication for cultures or imaging

A

Cultures or swabs of nasal discharge are NOT INDICATED

Imaging is NOT INDICATED (unless recurrent, may refer to ENT specialist)

[RARE] Pt who develop evidence of spread of infection to the orbits or CNS => REFER TO ED FOR IMAGING

  • Symptoms suggestive of orbital cellulitis or CNS infection include:
  1. Limited ocular movement
  2. Acute vision changes
  3. Confusion
  4. Unilateral weakness
35
Q
  1. What is the pathogen [ACUTE RHINOSINUSITIS]

List the common virus and bacterias

A

Virus (>90%)

Bacteria (<2%)
*Bacterial rhinosinusitis is considered a secondary infection of sinus obstruction from viral URTI

  • Common: Streptococcus Pneumoniae (alpha-hemolytic), Haemophilus influenzae
  • Some: Streptococcus Pyogenes, Moraxella Catharrhalis, Gram +ve anaerobic bacteria
36
Q
  1. What is the pathogen [ACUTE RHINOSINUSITIS]

How to confirm viral or bacterial sinusitis?

A

No culture or diagnostic

Determine treatment based on clinical presentation

37
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

When should bacterial sinusitis be treated with Abx?

A

Treat bacterial sinusitis with Abx if >= 1 of the following:

  1. Symptoms PERSIST for >10 days w/o clinical improvement
  2. Symptoms are SEVERE (fever >39dc and purulent nasal discharge, or facial pain lasting >3 consecutive days)
  3. Symptoms WORSEN (new onset fever, headache, increased nasal discharge) after an initial period of improvement (double sickening) for more than 3 days (5-6 days)

If not severe bacterial sinusitis, without any of the above, then DO NOT use Abx
Uncomplicated rhinosinusitis is self-limiting even if bacterial cause

38
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

What is the goal of treatment?

A
  • Reduce symptom severity and duration
  • Restore QoL
  • Prevent complications (e.g., infection to the orbits or CNS)
39
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

Discuss the FIRST LINE treatment option and duration of treatment

A

Should cover: Strep Pneumoniae, Haemophilus influenzae
*Empiric

First line:

  • PO Amoxicillin 500mg q8h (*more frequent compared to q12h in pharyngitis)
  • PO Amoxicillin-Clavulanate 625mg q8h

*Duration of therapy 5-7 days (adults)

40
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

Discuss the treatment option and duration of treatment (if penicillin allergy)

A

Should cover: Strep Pneumoniae, Haemophilus influenzae
*Empiric

Penicillin allergy:

  • Non-severe allergy: Cefuroxime 500mg q12h (*Cannot use Cephalexin)
  • PO Levofloxacin 500mg daily
  • PO Moxifloxacin 400mg daily

*Duration of therapy 5-7 days (adults)

41
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

Discuss the treatment option and duration of treatment (for vv sick pt, requiring IV)

A

Should cover: Strep Pneumoniae, Haemophilus influenzae
*Empiric

IV Ceftriaxone 1-2g q12-24h can be considered for vv sick patients

*Duration of therapy 5-7 days (adults)

42
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

Discuss when to use Amoxicillin and when to use Amoxicillin-Clavulanate

A

Amoxicillin: milder presentation, never used amoxicillin before

Augmentin: more severe, recent use of amoxicillin, used amoxicillin and got worse

43
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

Explain Amoxicillin and Amoxicllin-Clavulanate activity against
1. Haemophilus Influenzae
2. Strep pneumoniae

A
  1. Haemophilus Influenzae
  • Amoxicillin has some resistance as Haemophilus can produce Beta-lactamase
  • Augmentin (+BLI) can overcome this resistance mechanism (Clavulanic acid is a suicide inhibitor – covalently bonds to the B-lactamase and restructures it, permanently inactivating it)
  1. Strep Pneumoniae
  • Both have similar activity against Strep Pneumoniae as mechanism of resistance is related to PBP configuration
  • Increase dose of Amoxicillin to overcome resistance
44
Q
  1. Choice of antibiotics [ACUTE RHINOSINUSITIS]

What are some other choices not recommended due to increasing strep pneumoniae resistance? (but may recommend if previous culture showed susceptibility)

A

Tetracycline
Co-trimoxazole
Macrolides

45
Q
  1. Monitoring response

What are the monitoring parameters?

A

Clinical response

  • Pt NOT given Abx: (viral or non-severe bacterial) typical course of 7-10 days
  • Pt given Abx: Sinusitis symptoms should improve within 7-10 days
  • See doctor if develop persistent, severe, or worsening symptoms (1 of the 3 criteria)

Antibiotic ADR

3151 Therapeutics (12 decks)

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