URTI Flashcards by Charmain Ng

Describe the pathophysiology behind URTI.

Transmission can happen leading to inhalation of particles and invade upper airway mucosa.

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How can URTI be transmitted

Droplets / aerosol containing virus that are expelled when people with URTI cough, sneeze and talk

Person touches surface with virus on it and then touch his nose

Infected person shares food with others during mealtime

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Explain the innate immunity of the respiratory tract

Nostrail hair lining
Mucus
Angle between pharynx and nose: prevent particle from falling into airway
Mucociliary system: transport pathogen back into pharynx
Adenoids and tonsils: immunological cells attack pathogen

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What are the risk factors associated with URTI?

Anatomical abnormalities

Immunocompromised: cystic fibrosis, transplant, HIV, corticosteroids, post spleenectomy

Smoking

Medical disorder: Asthma, COPD

Lack of personal and hand hygiene

Close contact with children in daycare and school

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What are some preventive measures to take to discuss patients in reducing URTI?

Manage known risk factors with smoking cessation; asthma and allergic rhinitis

Vaccinations: Influenza, Pneumococcal, H.Influenzae

Hand/ Personal hygiene
Mask wearing
Stay away from crowds

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How do I confirm the diagnosis of a common cold?

Risk factors - same as ARTI

Clinical presentations: low grade fever, rhinorrhea, sore throat, nasal blockade, sneezing, productive cough, headache, bodyache

Diagnosis: lack high fever, lung clear to ausculation, normal HR

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Is there a need for microbiological test to identify the type of pathogens in a URTI?

No. Unless to rule out influenza and covid 19

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Is there a need for antibiotics to treat a common cold ? If no, what can I do for the patient?

No. Symptomatic relief is sufficient

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How long would it take for a common cold to recover? What do I advice a patient?

7-10 days
Nasal discharge can change colour
Cough may last for 2-3 weeks

Improvement in symptoms should take about 3-4 days

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What is the difference between a cold and flu?
HINT: Consider onset, type of symptoms between both conditions

https://www.google.com/search?q=cold+vs+flu&rlz=1C1CHBD_enSG825SG825&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjiiriH8bT7AhXCS2wGHXPlBjcQ_AUoAXoECAIQAw&biw=1280&bih=569&dpr=1.5

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Discuss the group of patients who are at risk of the potential complications of influenza

Children < 5y
Elderly > 65y
Pregnant
2 weeks post partum
Obese
Nursing homes
Long term care facilities
Chronic medical conditions (e.g. asthma, COPD, HF, CKD, DM, Immunocompromised)

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What are the clinical presentations associated with influenza?

Fever
Chills
Headache
Sore throat
Dry cough
Nasal discharge

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What are some potential complications associated with influenza?

Primary viral pneumonia

Secondary bacterial pneumonia from S.Aureus, S.Pnuemoniae, H.Influenzae

Exacerbation of chronic respiratory diseases

Myocarditis

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What are some potential complications associated with influenza?

Primary viral pneumonia

Secondary bacterial pneumonia from S.Aureus, S.Pnuemoniae, H.Influenzae

Exacerbation of chronic respiratory diseases

Myocarditis

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Are there any diagnostic test available for the diagnosis of influenza?

Nasopharyngeal swab / Aspirate
Test with POCT, EIA, IF

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Do all patients need a diagnostic test for influenza? Why?

No. Only those who are hospitalized and have severe symptoms
Young and uncomplicated groups will not benefit antiviral use.

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What are the types of pathogen associated with influenza?

Influenza A: H1N1 and H3N2
Influenza B: B/Yamagata and B/Victoria

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When should antivirals be considered for use?

Hospitalization
High risk for complications based on risk factors
Severe, complicated or progressive illness

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What is the ideal timeframe for antivirals to be initiated?

Within 48h of symptoms onset, best within 5 days of symptoms

Name the antiviral used for influenza and describe its mode of action

Oseltamivir

Interfere with protein cleavage and inhibits the release of new virus

What is the starting dose and duration of antivirals used?

PO 75mg two times a day for a duration of 5 days

When should antivirals be renally dose adjusted?

CrCl < 60mL/min

What are the ADR associated with antivirals used?

Headache

Nausea and vomiting

What is the duration of treatment for those with influenza?

7 days

What do you advice a patient on influenza self-management?

See a doctor if symptoms do not improve after 10 days OR if symptoms improve then develops new fever, worsening dyspnea and cough Vaccinations should be done every year

What are the clinical presentations associated with viral pharyngitis?

Low grade fever, malaise, fatigue, rhinorrhea, cough, hoarseness, oropharyngeal lesions, conjunctivitis

What are the clinical presentations associated with bacterial pharyngitis?

Fever Sore throat with tonsillar exudates Cervical lymphadenopathy

What are the complications associated with bacterial pharyngitis?

Acute rheumatic fever Acute glomerulonephritis: Not preventable by antibiotics Happens 1-5 weeks later

What are the viruses that causes pharyngitis?

Rhinovirus Coronavirus Influenza Para-influenza

What is the main bacteria causing pharyngitis? How can it be detected?

Group A Streptococcus Detected using a throat culture that gives results 24-48 hours

How do I determine if a patient requires antibiotics for their pharyngitis? HINT: Modified centor criteria

Modified centor criteria assess if patient has fever, swollen and tender anterior cervical lymph nodes, absence of cough, tonsillar exudate and age Upon cumulation of total points, decide if patient has a need to be treated with antibiotics. 0-1: No antibiotics or testing needed 2-3: Antibiotics needed if culture positive 4-5: Initiate empiric antibiotics

What empiric antibiotic should be initiated for a patient with bacterial pharyngitis?

PO Penicillin V 250mg q6h for 10 days OR PO Amoxicillin Clavulanate 500mg q12h for 10 days

For patients presenting with bacterial pharyngitis, and have a non-severe beta lactam allergy, what can you consider giving?

PO Cephalexin 500mg q12h for 10 days

For patients presenting with bacterial pharyngitis, but have a severe beta lactam allergy, what can you consider giving?

PO Azithromycin 500mg once daily for 5 days PO Clarithromycin 250mg q12h for 10 days PO Clindamycin 300mg q8h for 10 days

For the last stage of the systemic approach, what should I look out for and advice the patient for pharyngitis?

Duration of treatment usually takes 1-3 days for bacterial pharyngitis upon initiation of treatment If not given antibiotics, sore throat takes a week to clear and inform patient of viral pharyngitis, hence antibiotic use not necessary. No need for microbiological test clearance Advice ADR and see doctor if symptoms worsen

What is acute rhinosinusitis?

Acute inflammation of the paranasal and nasal mucosa

Describe the pathogenesis of acute rhinosinusitis

Direct contact with droplets of infected saliva/ nasal secretion Inflammation result in sinus obstruction Nasal mucosa secretion trapped Bacteria is then trapped and multiplication occurs

What are the clinical presentations of acute rhinosinusitis?

Purulent nasal discharge Facial pain/pressure Fever Nasal congestion Loss of taste and smell Headache Cough Ear fullness Bad breath Dental pain

Are there any diagnostics available for the diagnosis of acute rhinosinusitis?

No.

What are the possible complications of acute rhinosinusitis? What are some symptoms?

Orbital cellulites and CNS infection Symptoms include: limited ocular movement, acute vision change, confusion, unilateral weakness

What are the type of pathogen associated with bacterial rhinosinusitis?

S.Pneumoniae and H.Influenzae

When should I consider initiating antibiotics for bacterial rhinosinusitis?

Symptoms persisting for more than 10 days without clinical improvement Symptoms severe for more than 3 consecutive days (fever, purulent nasal discharge, facial pain) Symptoms worsen after initial improvement for more than 3 days

What are the antibiotics to start patient on for acute rhinosinusitis? Include dose, frequency and duration

PO Amoxicillin 500mg q8h PO Amoxicillin clavulanate 625mg TD Duration 5-7 days

For patients presenting with acute rhinosinusitis, and have a non-severe beta lactam allergy, what can you consider giving?

PO Cefuroxime 500mg q12h

For patients presenting with acute rhinosinusitis, and have a severe beta lactam allergy, what can you consider giving?

PO Levofloxacin 500mg daily OR PO Moxifloxacin 400mg daily duration 5-7 days

What agents should be avoided for treatment of acute rhinosinusitis and why?

Tetracyclines, co-trimoxazole, macrolides - Increased S.Aureus resistance

How do I monitor response for acute rhinosinusitis?

Advice that those those on antibiotics should improve in 7-10 days See doctor if symptoms worsen, persist or become severe Educate on antibiotics ADR