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Pharmacotherapy > Upper Respiratory Tract Infections > Flashcards

Upper Respiratory Tract Infections Flashcards

1
Q

What is part of the Upper respiratory tract?

A

Nasal Cavity
Pharynx
Larynx

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2
Q

What is part of the Lower Respiratory tract?

A

Trachea
Primary Bronchi
Lungs

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3
Q

What are the Upper tract Respiratory infections (URTIs)?

A 
 Common cold
 Influenza
 Pharyngitis
 Rhinosinusitis
 Laryngitis
 Otitis media
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4
Q

What are the Lower Respiratory Tract Infections (LRTIs)?

A

 Pneumonia
 Bronchitis
 Tracheitis

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5
Q

What is pharyngitis?

A

Acute inflammation of the oropharynx or nasopharynx

*Sore throat

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6
Q

What is the clinical presentation of pharyngitis?

A 
 Acute onset of sore throat
 Pain with swallowing
 Fever (low grade)
 Erythema and inflammation of the pharynx and tonsils (With or without patchy exudates)
 Tender and swollen lymph nodes*

*checked using tongue depressors (ice cream sticks) to look for erythema at back of throat to confirm pharyngitis

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7
Q

What is the microbiology of pharyngitis?

A

 Viruses* (> 80%)&raquo_space; bacteria (< 20%)

– Group A β‐hemolytic Streptococcus** (i.e. Streptococcus Pyrogenes)
• # 1 cause of bacterial pharyngitis
• US prevalence: 5‐15% (adults); 20‐30% (pediatrics)
• Less common in Singapore

*Rhinovirus, coronavirus, influenza, parainfluenza, Epstein‐Barr (common cold viruses)

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8
Q

What is the pathogenesis of pharyngitis?

A

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

*requires close proximity for transmission to occur

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9
Q

What are the complications of pharyngitis?

A

 Viral: self‐limiting
 S. pyogenes pharyngitis: self‐limiting or complications possible (occur 1‐3 weeks later)
– Acute rheumatic fever (Prevented with early initiation of effective abx)
– Acute glomerulonephritis (Not prevented by abx)

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10
Q

What are the challenges in pharyngitis management?

A
  1. Antibiotics have proven benefits in bacterial pharyngitis
    – Prevent acute rheumatic fever
    – Shorten duration of symptoms by 1‐2 days
    – Reduce transmission (no longer infectious after 24 hours of antibiotics)
  2. Viral and bacterial pharyngitis have similar clinical presentation (hard to DDX)
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11
Q

How is the lab/test diagnosis done for Pharyngitis?

A 
Testing for S. pyogenes pharyngitis
1. Throat culture (24‐48 hours)
• Gold standard
(+) High sensitivity 90‐95%
(-) long delay*, not very useful clinically
  1. Rapid antigen detection test (RADT) (minutes)
    (-) Sensitivity 70‐90%
    (-) expensive, not available in all GPs
    (+) used for local infection tracking

*starting abx too late for strep throat

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12
Q

What is the challenge in diagnosing pharyngitis?

A

It is challenging to find diagnosis of strep throat, no good, inexpensive and fast test + similar sx between viral and bacterial

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13
Q

What is the framework used to clinically* diagnose pharyngitis?

*Using patient sx and severity instead of labs

A

Modified Centor criteria

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14
Q

What should be the follow up when a patient is evaluated to have a modified Centor criteria of 0 or 1 point?

A
  • No additional testing indicated
  • Low risk of S. pyogenes pharyngitis
  • Presumed viral
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15
Q

What should be the follow up when a patient is evaluated to have a modified Centor criteria of 2 or 3 points?

A
  • Test for S. pyogenes pharyngitis; treat if positive

- Or initiate empiric antibiotics for S. pyogenes pharyngitis

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16
Q

What should be the follow up when a patient is evaluated to have a modified Centor criteria of 4 or 5 points?

A
  • High risk for S. pyogenes pharyngitis

- Initiate empiric antibiotics

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17
Q

Why is there is no age category <3 years old under the age criteria of the modified Centor criteria?

A
  • no age category <3 as strep throat is extremely uncommon in children < 3 years (presumed to be viral)
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18
Q

What is a characteristic clinical symptom of bacterial pharyngitis?

A

Absence of cough

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19
Q

What are the supportive care we can provide for a patient with viral pharyngitis?

A

 Analgesic/antipyretic: paracetamol, NSAIDs
 Topical analgesic lozenges/sprays (e.g. benzydamine)
 Saltwater gargle
 Adequate fluid and rest

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20
Q

How can we treat a patient with bacterial pharyngitis?

A 
Supportive care (as per viral pharyngitis) AND
PO abx for 10days (mild disease tx OP)
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21
Q

What is the Empiric abx tx selection for Bacterial pharyngitis?

Organism to cover is Streptococcus pyrogenes (gram pos)

A 
 1st line antibiotic – Penicillin VK
 Alternative antibiotics
– Amoxicillin
– Cephalexin*
– Clindamycin**
– Clarithromycin**
  • Mild Penicillin allergy alternative (mild rash)
  • *Severe Penicillin allergy alternative
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22
Q

Why is Augmentin (Amoxicillin/Clavulanate) not used for Bacterial pharyngitis?

A

Overkill (no need broad coverage for gram negs/anaerobes -> not found in strep throat)

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23
Q

Comment on the use of corticosteroids in Pharyngitis

A

 Use of corticosteroids is controversial
– Reduce duration and severity of symptoms
– Associated with adverse effects*
– Not recommended in clinical practice guidelines

*Increased BP, Blood glucose, harder to sleep at night etc..

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24
Q

What is the expected clinical response for abx tx of bacterial pharyngitis?

A

 Clinical response expected within 24‐48 hours
– Counsel on completing antibiotic course

  • fast response (adherence may drop as a result)
  • counseling is key to prevent resurgence of infection
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25
Q

What is Rhinosinusitis? (sinusitis)

A

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

  • Unlike chronic sinusitis (always inflammed)
  • usually due to allergies or structural issues in sinus
  • need to manage allergy or structural issues
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26
Q

What are the 7 Major* clinical symptoms for Sinusitis?

*more common and classic sx

A 
 Purulent anterior nasal discharge
 Purulent or discolored posterior nasal discharge
 Nasal congestion/obstruction
 Facial congestion/ fullness
 Facial pain/pressure
 Hyposmia/anosmia*
 Fever

*loss/reduced sense of smell
Note: anterior nasal (nostrils) and posterior nasal (throat)

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27
Q

What are 6 Minor* clinical symptoms for Sinusitis?

*non-specific sx

A 
 Headache
 Ear pain, pressure, fullness*
 Halitosis*
 Dental pain
 Cough
 Fatigue
  • Due to connection of sinus with ears
  • *Bad breath
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28
Q

How can we clinically decide on presence of Sinusitis?

A

> 2 major symptoms; OR

1 major + > 2 minor symptoms

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29
Q

How can we distinguish between Sinusitis and Pharyngitis based on clinical symptoms?

A
  • Use location: sinusitis tend to have more nasal/facial sx (nasal blockage/pain) vs pharyngitis more throat sx
  • There is some overlap in sx i.e. non-specific ones such as fever that occurs for any infection
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30
Q

What is the microbiology of Sinusitis?

A

Virus* (> 90%)&raquo_space; bacteria (< 10%)

 Bacterial
– Streptococcus pneumoniae** and Haemophilus influenza) most common
– Moraxella catarrhalis
– Streptococcus pyogenes

  • Rhinovirus, adenovirus, influenza, parainfluenza (common cold viruses)
  • *very different from strep pyrogenes with tx implications
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31
Q

What is the pathogenesis of Sinusitis?

A
  1. Direct contact with droplets of infected saliva or nasal secretions
  2. Bacterial cases usually preceded by viral URTIs (e.g. common cold, pharyngitis)
  3. Inflammation results in sinus obstruction
    – Nasal mucosal secretions are trapped
    – Medium of bacterial trapping and multiplication

*Similar mode of transmission as other URTIs

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32
Q

What are the 2 Diagnostic challenges in Sinusitis?

A
  1. Bacterial and viral sinusitis have similar symptoms
  2. Limited use of diagnostic tests
    – Imaging studies: non‐specific, non‐discriminatory
    – Sinus aspirate* (gold standard): invasive, painful, time‐consuming
  • Take fluid clogged up in sinus -> send for culture
  • very telling (growth of bacteria vs no bacterial growth (viral)
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33
Q

When will sinus aspirate be collected for diagnosis?

A
  • For infection control purposes (i.e. tracking strep throat in envt) -> ID perspective to get sense of prevalence of infections
  • Identify causative organisms in possible fungal/other bacterial causes for sinusitis (in immunocompromised pts)
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34
Q

How is the clinical diagnosis of bacterial sinusitis done?

A
  1. Presence of Sinusitis*
  2. Presence of any ONE of the following:
    I) Persistent of symptoms > 10 days AND not improving
    - Viral sinusitis: self‐limiting, resolves in 7‐10 days

II) Severe symptoms at onset
- Purulent nasal discharge x 3‐4 days or high fever > 39C

III) “Double sickening”
- Worsening symptoms after 5‐6 days after initial improvement

  • > 2 major symptoms; OR 1 major + > 2 minor symptoms
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35
Q

When clinical diagnosis of bacterial sinusitis is established*, what should we do?

*Presence of sinusitis + Presence of bacterial sinusitis

A

Start empiric abx to cover for strep pneumoniae and H flu

- no need to wait for cultures

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36
Q

What is the supportive care for Viral Sinusitis?

A

 Analgesic/antipyretic*: paracetamol, NSAIDs
 Nasal steroid spray
 Saline irrigation
 Expectorant: guaifenesin
 Nasal/systemic decongestants/anti‐histamines (not guideline recommended)

*Aspirin is not recommended for children due to risk of Reye syndrome

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37
Q

What is the treatment plan for Bacterial Sinusitis?

A 
Supportive care (as per viral Sinusitis) AND
PO abx (usually empiric)
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38
Q

What is the empiric abx (including alternatives) tx selection for Bacterial Sinusitis?

Common organisms to cover: Streptococcus pneumoniae and Haemophilus influenzae

A

1st line antibiotic: Amoxicillin OR Augmentin

Alternative antibiotics (i.e. penicillin allergy)
– Respiratory fluoroquinolone (Levofloxacin OR moxifloxacin)
– Trimethoprim/sulfamethoxazole
– Cefuroxime PO*

*Mild rash penicillin allergy alternative

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39
Q

Can Ciprofloxacin be used in the tx of bacterial Sinusitis?

A

• Cipro is NOT respiratory FQ (due to poor activity against Streptococcus pneumoniae*)
- Despite penetration to lungs and good Haemophilus influenzae cover

*one of the more common pathogens causing sinusitis and many respiratory tract infections

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40
Q

US IDSA guidelines recommend the use of Macrolides and Tetracyclines for the cover of Streptococcus Pneumoniae (gram pos). Can we do the same in SG?

A

Local: S. pneumoniae ↑ resistance to
macrolides and tetracycline
- Clarithromycin, azithromycin, doxycycline
are NOT appropriate

*Local guidelines are therefore different from IDSA

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41
Q

What are the Bacterial Sinusitis treatment considerations for Streptococcus Pneumoniae?

A

Resistance
– Streptococcus pneumoniae
• Multi‐step penicillin‐binding proteins (PBPs) mutation
• ↑ penicillin MIC
• Penicillin‐resistant isolates uncommon locally (< 5‐10%)

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42
Q

What is the solution to combat Streptococcus pneumoniae resistance?

A
  • Prefer amoxicillin over penicillin: favorable pharmacokinetics*
  • Prefer ”high‐dose” amoxicillin for effective treatment
    ‐ Standard‐dose: 45mg/kg/day (pediatrics); 250‐500mg (adults)
    ‐ High‐dose: 80‐90mg/kg/day (pediatrics); 1g (adults)

*Better oral bioavailability when using amoxicillin compared to penicillin = higher systemic conc

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43
Q

What are the Bacterial Sinusitis treatment considerations for Haemophilus influenzae?

A 
Resistance
– Haemophilus influenzae
• Beta‐lactamase production
• Inhibited by beta‐lactamase inhibitor
• Beta‐lactamase positive: ~ 18% locally
44
Q

What are the indications for Haemophilus influenzae resistance coverage in empiric treatment?

A

Use amoxicillin/clavulanate only if any ONE of the following:
 Recent** course(s) of antibiotic(s)
 Recent hospitalization
 Failure to improve after 72 hours of amoxicillin

Note: BL expression drives choice of augmentin vs amox in 1st line tx of bacterial sinusitis

  • these factors point towards higher likelihood of bacterial resistance
  • *recent duration is not really defined –> about last 30days (clinically)
45
Q

What is the treatment duration of Bacterial Sinusitis?

A 
– Adults: 5 – 10 days
• Improves compliance
• Reduces antibiotic‐related adverse effects
• Similar clinical cure
– Pediatrics: 10 – 14 days*

*longer duration as evidence that supports shorter duration only done for adults, no pediatric data

46
Q

What is Acute Otitis media (AOM)?

A

Infection of middle ear space* resulting in inflammation and fluid accumulation

*behind tympanic membrane/ear drum (separates middle ear space and external ear canal)

47
Q

What are the clinical presentations of AOM?

A 
 Ear pain (i.e. otalgia)
 Ear discharge (i.e. otorrhea)
 Ear popping
 Ear fullness
 Hearing impairment
 Dizziness
 Fever
 Non‐specific in young infants*: ear rubbing, excessive crying, changes in sleep or behavioral pattern

*AOM is an infection in pediatric patients (usually < 5 years old)

48
Q

What are some risk factors for AOM?

A 
 Siblings/Attending day care*
 Supine position during feeding**
 Exposure to tobacco smoke at home
 Pacifier use
 Winter season***
  • AOM is a common complication of common cold/ viral URTI and siblings/day care are risk factors for transmission of viral URTIs/common cold
  • *if baby is flat, it is easier for fluid from nose to backflow into ear
  • **not applicable in SG
49
Q

Why do younger children get AOM more frequently than older children/adults?

A
  • Angle is key (flatter for child) vs adult eustachian tube more angled
  • More angled –> discharge from nose more unlikely to backflow into eustachian tube compared to a more horizontal eustachian tube
50
Q

What are some strategies to prevent AOM?

A 
 Avoid exposure to tobacco smoke
 Exclusive breastfeeding for 1st 6 months (passive immunity)
 Minimize pacifier use
 Vaccinations*
– Influenza
– Pneumococcal
– Haemophilus influenzae type B vaccine

*as early as 6 months and older, protects against sinusitis (other than protecting against AOM)

51
Q

What is the pathogenesis of AOM?

A
  1. Viral URTIs (e.g. common cold)
  2. Secretions and inflammation
  3. Eustachian tube obstruction
  4. Negative eustachian tube pressure
  5. Nose sniffing
  6. Reflux of secretions into the middle ear (Medium for bacterial accumulation and growth)

Route A: 1 - 2 - 3 - 4 - 6
Route B: 1 - 5 - 6

52
Q

What is the microbiology of AOM?

A

 Bacterial (55‐60%) ~ viral (40‐45%)
 Viruses*
 Bacteria
– Streptococcus pneumoniae**, Haemophilus influenzae, Moraxella catarrhalis

Note: microbiologically, sinusitis is quite similar to AOM

  • Also cause Viral Respiratory tract infections: Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza
  • *most common
53
Q

How is AOM diagnosed (tool and criteria)?

A 
 Pneumatic otoscope* as standard tool
 Diagnostic criteria in children
– Acute onset (< 48 hours)
– Otalgia (holding, tugging, rubbing in a non‐verbal child) or erythema of tympanic membrane
– Bulging of tympanic membrane**
  • pointed area enters child’s ear canal to look for bulging tempanic membrane, for s/sx of inflammation
  • *due to fluid buildup behind membrane space (in middle ear space) + more erythema
54
Q

What are the challenges in AOM management?

A
  1. Unable to distinguish bacterial versus viral etiologies*

Bacterial AOM
– Prompt antibiotic initiation decreases duration of symptoms by ~1 day
– ~80% of cases resolve in 3‐4 days without antibiotics

  1. Overprescribing antibiotics = resistance

Note: Kids just cry, dont report severity well and there is hesitancy in giving children abx

*Sx exactly the same

55
Q

What is the supportive care tx for AOM?

A

– Analgesic/antipyretic*: paracetamol, NSAIDs
– Decongestants and anti‐histamines have NOT shown to be beneficial

*for all AOM pts (regardless bacterial/viral etiology)

56
Q

Are ear drop abx recommended for AOM?

A

No, AOM is a systemic infection, need PO abx for tx

57
Q

What are the 3 approaches to AOM abx tx initiation?

A
  1. Immediate Initiation
  2. Observation period
  3. Watch and Wait Prescription
58
Q

What is the Immediate initiation method in AOM tx?

A

Start antibiotics at the initial doctor’s visit where AOM is diagnosed
(-) many AOM due to viral (50-50)
(-) 80% bacterial AOM self limiting
(-) causes abx overuse in young pt (more side effects + hard to get young pt to take meds)

Easy strategy but should be avoided

59
Q

What is the Observation method in AOM tx?

A

 No antibiotics given at the initial doctor’s visit
 Supportive care* x 48‐72 hours

Depending on pt:
 Improves = no antibiotics
 Worsens or fails to improve = antibiotics

(-) Requires reliable follow‐up (may be inconvenient)
(-) May require 2nd trip to the doctor
(+) cautious and mindful usage of abx

*paracetamol for fever and pain

60
Q

What is the Watch and Wait Prescription (WAWP) method in AOM tx?

A

 Prescription given at the initial doctor’s visit
 Fill in 48 hours only if pt worsens or fails to improve
(+) 2/3 prescriptions not filled (reduced abx use)
(+) ↑ convenience and parent satisfaction

Note: meant to address inconvenience factor

  • not used alot locally in SG as it is convenient to see a doctor
  • popular in western countries (big countries with a few hours drive to see paediatrician) –> convenience is a big factor
61
Q

What are the criteria to fulfil in order to warrant Observation period for AOM tx?

A

ALL of the following criteria must be fulfilled
– ≥ 6 months*
– Non‐severe** illness
• Severe: moderate‐severe otalgia***, or otalgia > 48 hours, or fever > 39C in the last 48 hours
– No otorrhea
– Possible for close follow‐up
– Shared decision‐making with the parent/caregiver

  • Younger = more likely to have complications = more unlikely to self-resolve
  • *Absence of all 3 ‘severe’ criteria above
  • **Assessment is subjective i.e. otalgia (kids cant report severity) –> usually pediatrician err on side of caution and provide abx tx when child presents with AOM
62
Q

What should we consider for a pt who is:

  • < 6 months of age
  • Has unilateral AOM w/o Otorrhea
A

Observation period not recommended for all children < 6 months; immediate antibiotic therapy

63
Q

What should we consider for a pt who is:

  • ≥ 6 months to < 2 years of age
  • Has unilateral AOM w/o Otorrhea

*non-severe

A

Immediate antibiotic therapy
OR
Observation* period

*ALL of the following criteria must be fulfilled
– Possible for close follow‐up
– Shared decision‐making with the parent/caregiver

64
Q

What should we consider for a pt who is:

  • 2 years of age or older
  • Has unilateral AOM w/o Otorrhea
A

Immediate antibiotic therapy
OR
Observation* period

*ALL of the following criteria must be fulfilled
– Possible for close follow‐up
– Shared decision‐making with the parent/caregiver

65
Q

What should we consider for a pt who is:

  • 2 years of age or older
  • Has Bilateral AOM w/o Otorrhea
A

Immediate antibiotic therapy
OR
Observation* period

*ALL of the following criteria must be fulfilled
– Possible for close follow‐up
– Shared decision‐making with the parent/caregiver

66
Q

What should we consider for a pt who is:

  • 2 years of age or older
  • Has Bilateral AOM with Severe sx
A

Immediate antibiotic therapy

67
Q

What should we consider for a pt who is:

  • 2 years of age or older
  • Has Bilateral AOM with Otorrhea
A

Immediate antibiotic therapy

Regardless of age
- if Otorrhea/severe sx -> start abx

68
Q

What is the empiric 1st line abx selection and criteria for AOM?

Recall

  • Bacteria in AOM: S. pneumoniae, H. influenzae, M. catarrhalis
  • “High‐dose” amoxicillin for effective treatment, especially S. pneumoniae (think sinusitis dosing)
A 
1st line antibiotic: Amoxicillin 
– MUST fulfill ALL 3 criteria
• No amoxicillin in the last 30 days*
• No concurrent purulent conjunctivitis
• Not allergic to penicillin

Alternative 1st line antibiotic: Augmentin
– ANY 1 of the following:
• Amoxicillin in the last 30 days*
• Concurrent purulent conjunctivitis**
• History of AOM non‐responsive to amoxicillin

  • amoxicillin use in last 30 days = higher likelihood of amox resistance, worried about BL producing H flu
  • *AOM commonly presents as a complication post viral URTI (can be post purulent conjunctivitis caused by SA)
  • need to have MSSA cover
69
Q

What is the empiric abx selection and criteria for AOM if the patient has penicillin allergies?

Recall
- Bacteria in AOM: S. pneumoniae, H. influenzae, M. catarrhalis

A

– Cefuroxime PO, ceftriaxone (IM)
• Possible option for mild penicillin allergies

– Clindamycin*
• Effective against S. pneumoniae only
• Option for patients with severe penicillin allergies

  • No H flu cover
  • but ok as there are few alternatives to cover H flu if pt has severe penicillin allergy in kids (can use FQs for adult, not for kids)
  • Note 80% AOM self recover + cover S pneumo (most common) –> most kids do fine
70
Q

Can we use ceftazidime for the tx of AOM?

Recall
- Bacteria in AOM: S. pneumoniae, H. influenzae, M. catarrhalis

A

No, Ceftazidime is a 3rd gen cephalosporin (poor gram pos cover despite having pseudomonal cover)

71
Q

Is Clarithromycin used in the tx of AOM or Sinusitis in SG?

Recall
- Bacteria in AOM: S. pneumoniae, H. influenzae, M. catarrhalis

A
  • High rate of local resistance of strep pneumoniae for macrolides and tetracyclines –> not appropriate
  • This applies to sinusitis as well (same pathogens)
72
Q

What are some things to note for AOM monitoring, counselling and subsequent response?

A

 Symptoms may worsen in the first 24 hours
 Improvement expected in 48‐72 hours
– Worsens or fails to improve*: re‐evaluate
– If amoxicillin –> amoxicillin/clavulanate
– If amoxicillin/clavulanate –> cefuroxime, ceftriaxone

Note: impt to counsel caretakers that the abx take time for effect and the transient worsening of sx prior to improvement
*uncommon as amox/augmentin are usually effective

73
Q

What is the tx duration for AOM?

A
  1. < 2 years: 10 days
  2. Severe symptoms* : 10 days
  3. > 2 to 5 years AND non- severe symptoms: 7 days
  4. > 6 years AND non‐severe symptoms: 5‐7 days

*i.e. moderate‐severe otalgia, or otalgia > 48 hours, or fever > 39C in the last 48 hours

Note:

  • Younger kids = longer tx duration (due to immature immune system or less data for younger kids <2years)
  • More severe initial sx = longer duration
74
Q

What are the adult and pediatric dose of Penicillin VK used in the tx of pharyngitis?

*Bacterial (Streptococcus pyogenes)

A

Adult: 250mg PO QDS* or 500mg PO BD*
Pediatric: 250mg PO BD – TDS*

75
Q

What are the adult and pediatric dose of Amoxicillin used in the tx of pharyngitis?

*Bacterial (Streptococcus pyogenes)

A

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

Larger OD dosing may have more GI side effects

76
Q

What are the adult and pediatric dose of Clindamycin used in the tx of pharyngitis?

*Bacterial (Streptococcus pyogenes)

A

Adult: 300mg PO TDS
Pediatric: 7mg/kg PO TDS

77
Q

What are the adult and pediatric dose of Amoxicillin used in the tx of Sinusitis?

*Bacterial (mainly S. pneumoniae, H. influenzae)

A

Adult: 1g PO TDS
Pediatric: 80 – 90 mg/kg/day PO divided BD*

Here, we are using high dose Amoxicillin

78
Q

What are the adult and pediatric dose of Augmentin used in the tx of Sinusitis?

*Bacterial (mainly S. pneumoniae, H. influenzae)

A

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

True high dose: 1g PO BD
Convenient high dose option: 625mg TDS

79
Q

What are the adult and pediatric dose of Levofloxacin used in the tx of Sinusitis?

*Bacterial (mainly S. pneumoniae, H. influenzae)

A

Adult only: 500mg PO OD

*not for pediatric pts

80
Q

What are the pediatric dose of Amoxicillin and Augmentin used in the tx of AOM?

*Bacterial (mainly S. pneumoniae, H. influenzae, M. catarrhalis)

A

80 – 90 mg/kg/day PO divided BD*

*Similar to Bacterial Sinusitis pediatric dosing

81
Q

What are the pediatric dose of Cefuroxime used in the tx of AOM?

*Bacterial (mainly S. pneumoniae, H. influenzae, M. catarrhalis)

A

30 mg/kg/day PO divided BD

82
Q

What is the next step in care for this pt?
1) 3yo boy with AOM (left) and no otorrhea; per mom: no fever at home, mild ear pain and still able to go to kindergarten as usual, mom is hesitant to use antibiotics

PMH: AOM x 1 (18mo) (treated with amoxicillin x 10 days – diarrhea)
Allergy: none
Weight: 16.8kg

A

Observational period reasonable

esp if recurrent AOM, parents have some comparison of sx to tell if ‘mild/severe’

  • Unilateral
  • ‘non-severe’ presentation
  • pt experienced side effects from previous amoxicillin use
83
Q

What is the next step in care for this pt?

2) 8mo boy with AOM (left) and no otorrhea; per mom: fever 39.2C at home last night, irritable and rubbing on his ears x 2 days, mom is hesitant to use antibiotics her baby

PMH: none; never taken antibiotics
Allergy: none
Weight: 8.6kg

A

Amoxicillin 90mg/kg/day

Unilateral

  • ‘severe’ presentation (objective due to fever) -> need to tx w abx
  • no PMH/Allergies/purulent conjunctivitis/past amox use
84
Q

What are some differences between influenza and the common cold in terms of s/sx?

A

Influenza tends to have a more severe presentation with a greater amount of systemic symptoms (fever, body aches, chills, malaise, chest discomfort, headache)

Common cold symptoms are more restricted to local symptoms (stuffy nose, sore throat, sneezing)

85
Q

What is a hallmark sx of influenza?

A

Abrupt onset

86
Q

How does Covid-19 differ from influenza?

A

 Change in or loss of taste or smell (hallmark)
 Nausea, vomiting, diarrhea

  • Both causes similar systemic symptoms
87
Q

What is the type of influenza infection distribution in SG and reason for it?

A

SG has a bimodal distribution

December – February (winter in northern hemisphere)
May – July (winter in southern hemisphere)

Travelers bring the influenza with them when trying to escape winter

88
Q

What is the microbiology, epidemic potential and severity of clinical presentation of influenza?

A

Influenza A: Humans and animals, severe illness, mostly in younger pts

Influenza B: Humans only, severe illness in older/high risk pt, less severe epidemics

Influenza C: Humans and swine, mild disease with no epidemics

89
Q

What are some complications of influenza?

A

 Viral pneumonia
 Post‐influenza bacterial pneumonia (particularly those caused by S. aureus) – Mortality > 30%
 Respiratory failure
 Exacerbate underlying pulmonary or cardiac comorbidities
 Febrile seizures
 Myocarditis or pericarditis

90
Q

Which individuals are high risk for influenza related complications?

A

– Children < 5 years
– Elderly ≥ 65 years
– Women who are pregnant or within 2 weeks post‐partum
– Residents of nursing homes or long‐term care facilities
– Obese individuals with BMI ≥ 40 kg/m2
– Individuals with chronic medical conditions (e.g. asthma, COPD, HF, DM, CKD, immunocompromised, etc.)

91
Q

What are some prevention strategies for influenza?

A

1) Good Personal Hygiene
2) Healthy Lifestyle
3) Vaccination (annual)
4) Chemoprophylaxis

92
Q

Is there a delay between vaccine administration and its protective effects?

A
  • delay is about 2weeks from administration of vaccine to full protection
  • if exposure to influenza within 2 weeks –> tx as a unvax individual
93
Q

Who/when pre-exposure chemoprophylaxis indicated?

How do we initiate in this case?

A

 Institutional outbreaks; OR
 High‐risk individuals ≥ 3 months of age who CANNOT receive vaccination
 Initiate as soon as outbreak or influenza activity is identified

94
Q

Who/when is POST-exposure chemoprophylaxis indicated?

How do we initiate in this case?

A

 ALL* high‐risk individuals ≥ 3 months of age; OR
 Unvaccinated individuals ≥ 3 months of age who are household contacts of high‐risk individuals
 Initiate as soon as possible (within 48 hours) of exposure

*regardless of vax status

95
Q

What are the available diagnostics for influenza? Comment on their place in therapy

A

 Viral cultures are not recommended
 Molecular tests are available for use in practice
– Limited use in outpatient (Mostly treated empirically)
– Used inpatient; Reverse‐transcriptase polymerase chain reaction (RT‐PCR)

96
Q

What is the treatment criteria for influenza?

A

 For documented or suspected influenza
– Initiate as soon as possible (within 48h) of symptom onset for individuals who fulfill any ONE of the following
• Hospitalized
• High‐risk for complications
• Severe, complicated or progressive illness
– May be considered for others (e.g. outpatients) presenting within 48 hours of symptom onset

97
Q

If a patient discovers they have influenza >48h post symptom onset?

A
  • for inpatient setting ONLY –> sometimes can still give tx after 48h (anti-virals) for IP pts
  • may still have some benefit (reducing sx duration and complication incidence)
98
Q

What is the main drug used in the treatment of Influenza and its side effects?

A

Oseltamivir (Tamiflu) for both tx and chemoprophylaxis
- Neuraminidase inhibitor
Side effects: Headache, Mild gastrointestinal effects

99
Q

What is the tx regimen for chemoprophylaxis of influenza?

A

75mg PO daily x 7days
Renal adjustment necessary

  • Tx duration may be longer to cover at risk period
  • can be 7 days after exposure (post exposure prophylaxis)
  • pre-exposure prophylaxis (7 days from resolution of influenza activity/outbreak) i.e. duration of outbreak + 7days
100
Q

What is the tx regimen for treatment of influenza?

A

75mg PO BD x 5days

Renal adjustment necessary

101
Q

Suggest clinical response for this patient:

20yo NUS student who is suspected of influenza in his GP’s office. Symptoms started 4 days ago. He is otherwise healthy

A

can consider antiviral for OP within 48h of presentation
NO NEED TX
- if healthy, stable OPs might not need anything -> rest is enough
2 reasons why no tx:
- pt low risk
- > 48h since onset (the giving of tx >48h is for IP who are presenting w severe illness)

102
Q

Suggest clinical response for this patient:

7yo boy whose mother is diagnosed with influenza. He last received influenza vaccine 2 months ago.
– What if this is a 2yo boy?

A

vaccine is preventive and effective (2mo ago)

  • considering post-exposure prophylaxis (presumably exposed to the mom)
  • only high risk pts 3mo or older will receive tx
  • 7yo not high risk (5yo is high risk)
  • does not meet post exposure indication –> NO TX
  • if 2yo –> high risk category –> then we can give post exposure prophylaxis
103
Q

Suggest clinical response for this patient:

63yo M with hyperlipidemia who is exposed to influenza. He lives at home with family members who are healthy.

A

hyperlipidemia = obese (no mention + needs to be morbid obesity, BMI 40 and above) –> number is impt

  • no indication for tx
  • family members are generally healthy
104
Q

Suggest clinical response for this patient:

70yo M with heart failure who is exposed to influenza. He last received influenza vaccine 2 months ago.

A

most appropriate for tx

  • post exposure prophylaxis
  • age + HF puts him in high risk
  • HF -> underlying co-morbidity increases risk for complication
  • indicated for post exposure prophylaxis (regardless of vaccination status)
105
Q

Suggest clinical response for this patient:

40yo F with no PMH is exposed to influenza. She last received influenza vaccine 2 months ago and lives with her 86yo mother.

A

lady not high risk

  • mom is high risk (age)
  • lady does not need post exposure prophylaxis as she is vaccinated
  • tx is for unvax individuals with vulnerable household contacts only

Pharmacotherapy (10 decks)

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