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URTI Flashcards

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1
Q

Pharyngitis - Site of infection

A

Oropharynx, nasopharynx (i.e. sore throat)

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2
Q

Pharyngitis - Clinical presentation

A

1) Acute onset of sore throat
2) Fever
3) Pain when swallowing
4) Erythema & inflammation of pharynx & tonsils, with/without patchy exudates
5) Tender & swollen lymph nodes

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3
Q

Pharyngitis - Microbiology

A

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

2) Bacteria (< 20%)
- No. 1 cause: Group A ß-hemolytic Streptococcus i.e. Streptococcus pyogenes (strep throat)

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4
Q

Pharyngitis - Prevalence of strep throat

A

US:

  • Adults: 5 - 15%
  • Children: 20 - 30%

SG:
- Less common

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5
Q

Pharyngitis - Pathogenesis

A

Transmitted via direct contact with droplets of infected saliva/nasal secretions
Short incubation: 24 - 48h
Causes acute inflammation at oropharynx & nasopharynx

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6
Q

Pharyngitis - Complications (viral pharyngitis)

A

Generally self-limiting

Recovers within a few days to weeks with rest & adequate hydration

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7
Q

Pharyngitis - Complications (strep throat)

A

May be self-limiting or complicated
Complications may occur 1 - 3 weeks later, after initial sore throat has gone away
- Due to initial infection triggering a systemic inflammatory response

Complications:

1) Acute rheumatic fever
- Fever due to severe inflammation caused by infection
- Prevented by early initiation of effective antibiotics –> should give antibiotics as soon as strep throat is diagnosed
2) Acute glomerulonephritis
- Low incidence
- NOT prevented by antibiotics

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8
Q

Pharyngitis - Differential diagnosis

A

Difficult to differentiate between viral VS bacterial pharyngitis, due to similar clinical presentation

Diagnose strep throat based on:

1) Diagnostic tests
2) Clinical diagnosis
- Frequently used for diagnosis

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9
Q

Pharyngitis - Diagnosis of strep throat

  • Diagnostic tests
  • Clinical diagnosis
A

Diagnostic tests:

1) Throat culture
- Advantages: Gold standard; High sensitivity (90 - 95%)
- Limitations: Takes time for cultures to grow (24 - 48h) –> delay initiation of Abx
- Clinical use: Not very useful
2) Rapid antigen detection test (RADT)
- Advantages: Very fast (within minutes)
- Limitations: Lower sensitivity (70 - 90%); Expensive

Clinical diagnosis:

1) Modified centor criteria
- Score given based on patient background & S/Sx
- Higher score –> higher risk of S. pyogenes pharyngitis
- Score used to make diagnosis / decide on need for antibiotics
- Score = 0, 1 - Presumed viral; No additional testing indicated
- Score = 2, 3 - Test for S. pyogenes pharyngitis (rarely done) OR Initiate empiric antibiotics (more common)
- Score = 4, 5 - Initiate empiric antibiotics
- Note: Children < 3 years - Presumed viral

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10
Q

Treatment of pharyngitis

A

1) Antibiotic treatment
- Indication: Strep throat
- Generally empiric
2) Supportive care
- Indication: Viral/Bacterial pharyngitis
3) Corticosteroids
- NOT recommended

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11
Q

Treatment of pharyngitis - Supportive care

A

Indicated for both bacterial & viral infection

1) Antipyretic / Analgesic - Paracetamol, NSAIDs
- Avoid Aspirin in children - Reye syndrome
2) Topical analgesic lozenges/sprays
- E.g. Benzydamine
3) Saltwater gargle
4) Adequate fluid & rest

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12
Q

Treatment of pharyngitis - Corticosteroids

A

Benefits
- Reduce duration & severity of symptoms by reducing inflammation

Limitations
- Associated with side effects

Overall: NOT recommended

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13
Q

Empiric antibiotic treatment of pharyngitis - Benefits

A

1) Prevent acute rheumatic fever
2) Shorten duration of symptoms by 1-2 days
3) Reduce transmission (no longer infectious after 24h of antibiotics)

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14
Q

Empiric antibiotic treatment of pharyngitis - Organisms to cover

A

S. pyogenes

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15
Q

Empiric antibiotic treatment of pharyngitis - Choice of antibiotics

A

1st Line:

1) Penicillin VK
- Most narrow, directed therapy

Alternative:

1) Amoxicillin OR Cephalexin
- Alternative in mild penicillin allergy
- Note: Amoxicillin alone is sufficient –> Augmentin is too broad spectrum
2) Clindamycin OR Clarithromycin
- Alternative in severe penicillin allergy
- Choice depends on patient preference, C/I

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16
Q

Empiric antibiotic treatment of pharyngitis - Dosing

A

Duration: 10 days

Adult Dosing:
Penicillin VK
- PO 250 mg QDS OR PO 500 mg BD
- Renal dose adjustment needed

Amoxicillin

  • PO 1g OD OR PO 500 mg BD
  • Renal dose adjustment needed

Clindamycin
- PO 300 mg TDS

Pediatric Dosing:
Penicillin VK
- PO 250 mg BD - TDS
- Renal dose adjustment needed

Amoxicillin

  • PO 50 mg/kg/day OD or divided BD
  • Renal dose adjustment needed

Clindamycin
- PO 7 mg/kg TDS

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17
Q

Pharyngitis - Monitoring

A

Therapeutic response

  • Clinical improvement expected within 24-48h after initiation of antibiotics
  • Resistance to antibiotics rare
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18
Q

Sinusitis - Site of infection

A

Paranasal & nasal mucosa

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19
Q

Sinusitis - Clinical presentation

A

Sinusitis:

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

Major symptoms

1) Purulent anterior nasal discharge
2) Purulent/Discoloured posterior nasal discharge
3) Nasal obstruction/congestion
4) Facial congestion/fullness
5) Facial pain/pressure
6) Hyposmia/Anosmia
7) Fever

Minor symptoms

1) Headache
2) Ear pain, pressure, fullness
3) Halitosis
4) Cough
5) Fatigue
6) Dental pain

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20
Q

Sinusitis - Microbiology

A

Viral (> 90%)
- Rhinovirus, adenovirus, influenza, parainfluenza

Bacteria (< 10%)

  • Most common: Streptococcus pneumoniae, Haemophilus influenzae
  • Others: Moraxella catarrhalis, Streptococcus pyogenes

Fungi
- Mainly occurs in immunocompromised patients

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21
Q

Sinusitis - Pathogenesis

A

Transmission: Direct contact with infected saliva / nasal secretions

Acute inflammation of paranasal & nasal mucosa –> sinus obstruction –> nasal mucosal secretions trapped in sinus cavities (accumulation) –> medium for bacterial trapping & multiplication

Bacterial sinusitis usually preceded by viral URTIs (e.g. common cold, pharyngitis) i.e. complication of viral URTIs
- Runny nose during viral URTIs –> sniff back mucus –> accumulation in sinus cavities –> medium for bacterial trapping & multiplication

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22
Q

Sinusitis - Differential diagnosis

A

Difficult to differentiate between bacterial VS viral sinusitis
- Similar clinical presentation

Diagnosis of bacterial sinusitis based on:

1) Diagnostic tests
- Limited use
2) Clinical diagnosis
- Frequently used

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23
Q

Sinusitis - Diagnosis of bacterial sinusitis

  • Diagnostic tests
  • Clinical diagnosis
A

Diagnostic tests

1) Imaging studies (e.g. CT scan)
- Limitation: Non-specific, non-discriminatory –> only tests for presence of inflammation but unable to differentiate between viral VS bacterial sinusitis
2) Sinus aspirate
- Gold standard
- Limitations: Painful, invasive, time-consuming
- Usually only used in immunocompromised patients –> may have polymicrobial infections / infected by organism other than bacteria/virus

Clinical diagnosis
Presence of sinusitis (≥ 2 major symptoms / 1 major + ≥ 2 minor symptoms)
AND
Any one of the following:
1) Persistent symptoms > 10 days AND no improvement
- Viral sinusitis is usually self-limiting & resolves within 7 - 10 days
2) Severe symptoms
- Purulent nasal discharge x 3 - 4 days OR
- High fever ≥ 39oC
3) Double worsening
- Worsening of symptoms 5 - 6 days after initial improvement
- Likely complicated by secondary bacterial infection

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24
Q

Treatment of sinusitis

A

1) Antibiotic treatment
- Indication: Bacterial sinusitis
- Generally empiric
2) Supportive care
- Indication: Viral/Bacterial sinusitis

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25
Treatment of sinusitis - Supportive care
1) Antipyretic/Analgesic - NSAIDs, Paracetamol - Avoid Aspirin in children 2) Nasal steroid spray 3) Saline irrigation 4) Expectorant - Guaifenesin 5) Nasal/Systemic decongestants/antihistamine - NOT guideline recommended
26
Empiric antibiotic treatment of sinusitis - Benefits
1) Shorten duration of symptoms 2) Earlier symptom relief 3) Restore QOL 4) Prevent complications
27
Empiric antibiotic treatment of sinusitis - Organisms to cover
S. pneumoniae | H. influenzae
28
Empiric antibiotic treatment of sinusitis - Duration
Adults: 5 - 10 days - Studies supporting shorter duration, with similar cure - Improves compliance - Minimize ADR due to antibiotics Paediatric: 10 - 14 days
29
Empiric antibiotic treatment of sinusitis - Choice of antibiotics
1st Line: 1) Amoxicillin 2) Amoxicillin-Clavulanate - Used if suspect ß-lactamase producing H. influenzae - Use if any ONE of the following: • Recent antibiotic use in past 30 days • Recent hospitalization in past 30 days • Failure to improve after 72h of Amoxicillin Alternatives in penicillin allergy: 1) Respiratory fluoroquinolones - Moxifloxacin, Levofloxacin 2) Cotrimoxazole 3) Cefuroxime - Mild penicillin allergy
30
Empiric antibiotic treatment of sinusitis - AVOID using
1) Ciprofloxacin - Poor activity against S. pneumoniae 2) Macrolides, Tetracyclines - High local resistance of S. pneumoniae to Macrolides & Tetracyclines 3) Penicillin VK - Penicillin-resistant S. pneumoniae which requires high dose for effective treatment - High dose Amoxicillin preferred over high dose Penicillin due to favourable PK (better bioavailability)
31
Empiric antibiotic treatment of sinusitis - Dosing
Adult Dosing: Amoxicillin - PO 1g TDS (high dose) - Renal dose adjustment needed Amoxicillin-Clavulanate - PO 1g BD (high dose) OR - PO 625 mg TDS • High dose --> risk of GI effects --> increase dosing frequency instead • Most public hospitals carry 625 mg Augmentin (more cost-effective, readily available, smaller tablet size) - Renal dose adjustment needed Levofloxacin - PO 500 mg OD - Renal dose adjustment needed Paediatric Dosing: Amoxicillin - PO 80-90 mg/kg/day, divided BD (high dose) Amoxicillin-Clavulanate - PO 80-90 mg/kg/day, divided BD (high dose) Levofloxacin - C/I in children
32
Antibiotic resistance - S. pneumoniae - MOA - Prevalence - Treatment
MOA - Multi-step mutation of penicillin-binding proteins (PBP) - Results in increased penicillin MIC with each mutation Prevalence - Penicillin-resistant isolates uncommon locally (< 5 - 10%) - May not be completely resistant --> requires higher dose Treatment - High dose OR Increased frequency Amoxicillin - Amoxicillin preferred over penicillin due to favourable PK --> higher bioavailability --> achieves higher systemic concentrations
33
Antibiotic resistance - H. influenzae - MOA - Prevalence - Treatment
MOA - Production of ß-lactamase --> breaks down ß-lactams Prevalence - ß-lactamase positive: ~18% locally Treatment - Amoxicillin-Clavulanate (use of ß-lactamase inhibitors)
34
AOM - Site of infection
Middle ear
35
AOM - Clinical presentation
1) Otalgia 2) Otorrhoea 3) Ear popping/fullness 4) Hearing impairment 5) Dizziness 6) Fever Young children/infants may present with non-specific symptoms - Ear rubbing - Excessive crying - Change in sleep/behavioural patterns
36
AOM - Risk factors
1) Children (especially < 5 years) - Eustachian tube in children is flatter, more horizontal --> easier for nasal discharge to flow backwards 2) Siblings 3) Daycare 4) Supine position when feeding 5) Exposure to tobacco smoke 6) Pacifier use 7) Winter season
37
AOM - Pathogenesis
Generally occurs as a complication of viral URTI During viral URTI - Secretion & inflammation --> obstruction of Eustachian tube --> negative Eustachian tube pressure - Nose sniffing Overall: Results in reflux of secretions into middle ear --> accumulation of discharge/fluid in middle ear --> medium for bacterial accumulation & growth --> middle ear infection resulting in inflammation & fluid accumulation
38
AOM - Microbiology
1) Viral (40-45%) - Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza 2) Bacteria (55-60%) - Streptococcus pneumoniae - Haemophilus influenzae - Moraxella catarrhalis
39
AOM - Diagnosis
Diagnostic tool: Pneumatic otoscope Diagnostic criteria in children: 1) Acute onset (< 48h) 2) Otalgia OR Erythema of tympanic membrane - Rubbing, tugging, holding in non-verbal child 3) Bulging of tympanic membrane - Usually due to fluid accumulation in middle ear Note: Differential diagnosis (bacterial VS viral) difficult due to: - Similar clinical presentation - Similar prevalence
40
Treatment of AOM - Supportive care
1) Analgesic / Antipyretic - NSAIDs, Paracetamol - Avoid Aspirin in children Decongestants & antihistamines NOT shown to be beneficial
41
Empiric antibiotic treatment of AOM - Immediate initiation 1) How it works 2) Benefits 3) Limitations
How it works: Start antibiotics at initial doctor's visit Benefits: 1) Prompt initiation of antibiotics decrease duration of symptoms by ~1 day Limitations: 2) Risk of antibiotic overuse
42
Empiric antibiotic treatment of AOM - Observation period 1) How it works 2) Benefits 3) Limitations
How it works: No antibiotics given at initial doctor's visit Supportive care x 48-72h If fail to improve/worsens: Antibiotics initiated Benefits: 1) Prevents overuse of antibiotics - Difficult to differentiate between viral VS bacterial AOM - Most bacterial AOM are self-limiting --> resolve within 3-4 days without antibiotics Limitations 1) Inconvenient (may require 2nd doctor's visit) 2) Requires reliable follow-up - Must be able to monitor child at home
43
Empiric antibiotic treatment of AOM - Observation period criteria
May only be considered if ALL of the following are fulfilled: 1) ≥ 6 months - Younger children at higher risk of complications/less likely to get better without antibiotics - Older children better able to report symptoms 2) Non-severe illness - Severe: Moderate-severe otalgia OR Otalgia ≥ 48h OR Fever ≥ 39oC - Non-severe: Absence of ALL of the above - Note: Assessing severity can be difficult --> severity of otalgia is subjective, difficult for younger patients to report symptoms 3) No otorrhoea - Otorrhoea can indicate rupture of tympanic membrane 4) Possible for close-follow-up 5) Shared decision making with parent/caregiver
44
Empiric antibiotic treatment of AOM - When can observation period be considered
1) No otorrhoea AND | 2) Unilateral AOM + ≥ 6 months OR Bilateral AOM + ≥ 2 years
45
Empiric antibiotic treatment of AOM - Watch & wait 1) How it works 2) Benefits 3) Use in SG
How it works: Prescription given at initial doctor's visit Supportive care x 48h Prescription only filled in after 48h if fails to improve/worsens Benefits 1) Increased convenience 2) Parent satisfaction 3) Prevent overuse of antibiotics - Only 2/3 of prescriptions filled --> most cases are self-limiting Rarely used in SG
46
Empiric antibiotic treatment of AOM - Organisms to cover
1) S. pneumoniae 2) H. influenzae 3) Moraxella catarrhalis
47
Empiric antibiotic treatment of AOM - Duration
< 2 years: 10 days Severe symptoms (moderate-severe otalgia OR otalgia ≥ 48h OR fever ≥ 39oC): 10 days ≥ 2 - 5 years AND non-severe: 7 days ≥ 6 years AND non-severe: 5 - 7 days
48
Empiric antibiotic treatment of AOM - Choice of antibiotics
``` 1st Line: 1) Amoxicillin - Used if fulfil ALL of the following: • No Amoxicillin in past 30 days • No concurrent purulent conjunctivitis • Not allergic to penicillin ``` 2) Amoxicillin-Clavulanate - Used if ANY ONE of the following: • Amoxicillin in past 30 days (suspect ß-lactamase producing H. influenzae) • Concurrent purulent conjunctivitis (suspect MSSA) • History of AOM non-responsive to Amoxicillin Alternative 1) Ceftriaxone (IM) OR Cefuroxime - Alternative in mild penicillin allergies 2) Clindamycin - Alternative in severe penicillin allergies - Note: Does NOT cover H. influenzae 3) Respiratory Fluoroquinolones - Alternative in severe penicillin allergies - For adults only; C/I in children
49
Empiric antibiotic treatment of AOM - Dosing
Paediatric Dosing: 1) Amoxicillin - PO 80 - 90 mg/kg/day divided BD (high dose) - Renal dose adjustment needed 2) Amoxicillin-Clavulanate - PO 80 - 90 mg/kg/day divided BD - Renal dose adjustment needed 3) Cefuroxime - PO 30 mg/kg/day divided BD - Renal dose adjustment needed
50
Non-pharmacological treatment of AOM - Prevention
1) Minimize exposure to tobacco smoke 2) Exclusive breastfeeding for first 6 months 3) Minimize pacifier use 4) Vaccinations - Influenza - Pneumococcal - H. influenzae type B
51
AOM - Monitoring
Treatment response - May worsen in first 24h - Improvements expected after 48-72h Treatment failure - Initially Amoxicillin --> switch to Augmentin - Initially Augmentin --> switch to Cefuroxime / Ceftriaxone - Treatment failure is rare
52
Influenza - Clinical presentation
Incubation period: 24 - 72h Abrupt onset ``` Signs & symptoms: Usual/Common: 1) Fever 2) Body aches 3) Chills 4) Fatigue, body weakness 5) Chest discomfort 6) Headache Less common: 1) Sneezing 2) Stuffy nose 3) Sore throat ```
53
Influenza - Differential diagnosis 1) VS Common cold 2) VS Covid-19
Common cold: - Influenza: Abrupt onset VS Common cold: Gradual onset - More common in influenza: Fever, chills, body ache, fatigue, body weakness, chest discomfort, headache - More common in common cold: Sneezing, stuffy nose, sore throat Covid-19: - Similar symptoms: Fever, body aches, chills, fatigue/body weakness, stuffy/runny nose, sore throat, chest discomfort, headache - Classical for Covid-19: Change in/Loss of taste/smell, N/V, diarrhea
54
Influenza - Epidemiology in SG
Bimodal distribution - Peaks in: 1) Dec - Feb 2) May - Jul
55
Influenza - Microbiology
1) Influenza A - Host: Human, swine, equine, avian, other species - Most severe illness - Significant mortality in young persons - Epidemics & pandemics 2) Influenza B - Host: Human only - Severe illness in elderly, high risk groups - Less severe epidemics 3) Influenza C - Host: Human, swine - Mild illness - No seasonality - No epidemics
56
Influenza - Diagnosis
1) Viral cultures - Not recommended --> takes long time to get results 2) Molecular tests - Outpatient: Limited use; Diagnosis mainly based on symptoms; Usually empiric treatment - Inpatient: May be used; RT-PCR
57
Influenza - Complications
1) Viral pneumonia 2) Post-infection bacterial pneumonia - Especially those caused by S. aureus - High mortality (> 30%) - Can result in respiratory failure, organ damage 3) Respiratory failure 4) Exacerbation of cardiac/pulmonary comorbidities 5) Febrile seizures 6) Myocarditis, pericarditis
58
Influenza - High risk group
1) Children < 5 years 2) Elderly ≥ 65 years 3) Pregnant women / Within 2 weeks post-partum 4) Residents of nursing homes/long-term care facilities 5) Obesity (BMI ≥ 40 kg/m^2) 6) Chronic medical conditions - Mainly pulmonary / cardiac conditions - E.g. Asthma, COPD, heart failure, DM, chronic kidney disease, immunocompromised
59
Management of influenza
1) Prevention - Chemoprophylaxis - Non-pharmacological - Vaccination 2) Antiviral treatment
60
Influenza - Non-pharmacological prevention
1) Good personal hygiene - Wash hands - Minimize touching eyes, nose, mouth - Cover nose & mouth when coughing/sneezing - Wear mask if unwell - Use serving spoon if sharing food 2) Maintain healthy lifestyle - Exercise regularly - Adequate sleep - Balanced diet - Do not smoke
61
Influenza - Vaccination 1) Types of influenza vaccines 2) Administration 3) Indication
Types of influenza vaccines - Inactivated trivalent / quadrivalent vaccine Administration: - Route: IM - Administered yearly (only lasts for 1 year) - Onset: ~2 weeks from administration Indication: ALL individuals ≥ 6 months, unless contraindicated - Very few contraindications
62
Influenza - Types of chemoprophylaxis
1) Pre-exposure | 2) Post-exposure
63
Influenza - Pre-exposure chemoprophylaxis 1) Purpose 2) Indication 3) Initiation
Purpose: - Prevent influenza before exposure to virus Indication: 1) Institutional outbreaks - Given to ALL unvaccinated individuals in institution - E.g. In hospitals, long-term care facilities, nursing homes - Rarely occurs --> institutions should have good infection control 2) Unvaccinated high risk individuals ≥ 3 months - C/I to influenza vaccine Initiation - Initiate as soon as outbreak is identified
64
Influenza - Post-exposure chemoprophylaxis 1) Purpose 2) Indication 3) Initiation
Purpose: - Prevent influenza after exposure Indication: 1) ALL high risk individuals ≥ 3 months (vaccinated or unvaccinated) 2) Unvaccinated individuals ≥ 3 months who are household contacts of high risk individuals Initiation - Initiate as soon as possible - within 48h of exposure (less effective if given > 48h after exposure)
65
Antiviral treatment of influenza - Initiation
Initiate as soon as possible - Within 48h of symptom onset - Benefit decreases if initiated > 48h of symptom onset - May consider initiating in inpatient setting, even if patient presents > 48h after symptom onset (still some benefit e.g. decrease symptom duration, incidence of complications)
66
Antiviral treatment of influenza - Who to treat
Start antiviral (within 48h of symptom onset) for ANY ONE of the following: 1) Hospitalization 2) High risk individual 3) Severe, complicated or progressive illness Other patients (e.g. outpatient setting): May be considered (if within 48h of symptom onset) BUT influenza is generally self-limiting --> usually not treated
67
Antiviral used in chemoprophylaxis / treatment of influenza
Oseltamivir
68
Oseltamivir - MOA
Neuraminidase inhibitor - Inhibit cleavage of viral proteins --> viral proteins no longer functional - Inhibit release of new virus --> inhibit viral replication Note: Only effective against influenza A & B
69
Oseltamivir - Indications
Chemoprophylaxis & treatment of influenza | - 1st line
70
Oseltamivir - Dosing (Chemoprophylaxis)
PO 75 mg daily - Renal dose adjustment needed Duration: Pre-exposure: 7 days after outbreak has resolved Post-exposure: 7 days from exposure / from when starting Oseltamivir
71
Oseltamivir - Dosing (Treatment)
PO 75 mg BD - Renal dose adjustment needed Duration: 5 days - May be extended in immunocompromised / critically ill patients (but not a lot of evidence supporting) this
72
Oseltamivir - ADR
Generally well tolerated 1) Headache 2) Mild GI effects

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