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PT > URTI: Pharyngitis, Rhinosinusitis, AOM > Flashcards

URTI: Pharyngitis, Rhinosinusitis, AOM Flashcards

1
Q

What is the clinical presentation of pharyngitis?

A
  • Acute onset of sore throat
  • Pain with swallowing
  • Fever
  • Erythema and inflammation of the pharynx and tonsils (with or without patchy exudates) - redness at back of throat
  • Tender and swollen lymph nodes
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2
Q

What is the microbiology for pharyngitis?

A
  • Viruses (>80%)&raquo_space; bacteria (<20%)
    Virus: rhinovirus, coronavirus, influenza, parainfluenza, Epstein-Barr

Bacteria: group A beta-haemolytic streptococcus (Streptococcus pyogenes)

S. pyogenes NO 1 cause of bacterial pharyngitis
Children&raquo_space; adults
but less common in SG

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3
Q

What is the pathogenesis of pharyngitis? How does it transfer and its incubation period?

A
  • Direct contact with droplets of infected saliva or nasal secretions
  • Short incubation of 24-48 hours
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4
Q

What are the complications of Pharyngitis?

A
  • viral: self-limiting
  • S. pyogenes pharyngitis: self-limiting or complications possible

~ complication occur 1-3 wks later
~ acute rheumatic fever: prevented with early initiation of effective ABx
~ acute glomerulonephritis: not prevented by ABx

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5
Q

Another name for pharyngitis

A

Strep throat

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6
Q

What are the challenges in management of pharyngitis?

A

Viral and bacterial have similar clinical presentation

ABx have proven benefits in bacterial pharyngitis
~ prevent acute rheumatic fever
~ shorten duration of smx by 1-2 days
~ reduce transmission (no longer infectious after 24h of ABx)

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7
Q

How to diagnose Pharyngitis?

A

NOT DONE:

  • throat culture (24-48h) (too long)
  • rapid antigen detection test (minutes) (Expensive)

Clinical diagnosis DONE:
According to modified centor criteria:

~ Total points - 0 to 1

    • no additional testing indicated
    • low risk of S. pyogenes pharyngitis
    • presume VIRAL

~ Total points - 2 to 3

    • Test for S. pyogenes pharyngitis; treat if +ve
    • Or initiate empiric ABx for S. pyogenes pharyngitis

~ Total points - 4 to 5

    • High risk for S. pyogenes pharyngitis
    • initiate empiric ABx
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8
Q

Which age group is rare to get pharyngitis?

A

children < 3yo
no testing indicated, presumed viral

Supportive care enough

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9
Q

What are the treatment options for Pharyngitis?

A

1ST LINE ABX: Pen VK
Adult dosing: 250mg PO QDS * or 500mg PO BD *
Paediatric dosing: 250mg PO BD-TDS *
*Normal Renal Function

Alternative ABx:
- Amoxicillin 
Adult: 1g PO OD* or 500mg PO BD * 
Paediatric: 50mg/kg/day PO OD or divided BD*
*Normal Renal Function
  • Cephalexin
  • Clindamycin
    Adult: 300mg PO TDS
    Paediatric: 7mg/kg PO TDS
  • Clarithromycin

Duration 10 days

Clinical response expected within 24-48 h ; counsel on completing ABx course

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10
Q

Another word for Rhinosinusitis is

A

Sinusitis

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11
Q

What is sinusitis?

A

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

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12
Q

What are the major smx clinical presentations of sinusitis?

A

Major smx:

  • purulent anterior nasal discharge
  • purulent or discoloured posterior nasal discharge
  • Nasal congestion/ obstruction
  • Facial congestion/ fullness
  • Facial pain/ pressure
  • Hyposmia/ anosmia (Reduced/no sense of smell)
  • Fever
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13
Q

What are the minor smx clinical presentations of sinusitis?

A

Minor smx:

  • HA
  • Ear pain, pressure, fullness
  • Halitosis (bad breath)
  • Dental pain
  • Cough
  • Fatigue
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14
Q

How many major and/or minor smx required to confirm someones has sinusitis?

A

> or = 2 major smx OR

1 major + > or = 2 minor smx

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15
Q

What is the microbiology for sinsitis?

A

Virus (90%)&raquo_space; Bacteria (10%)
Viruses: rhinovirus, adenovirus, influenza, parainfluenza

Bacterial: Streptococcus pneumoniae and Haemophilus influenzae most common

  • Moraxella catarrhalis
  • S. pyogenes
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16
Q

What is the pathogenesis of sinusitis? How is it transmitted?

A
  • Direct contact with droplets of infected saliva or nasal secretions
  • Bacterial cases usually preceded by viral URTIs (common cold, pharyngitis) (1st viral, but after few days, bacterial sinusitis)
  • Inflammation results in sinus obstruction: Nasal mucosal secretions are trapped; Medium of bacterial trapping and multiplication
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17
Q

What are some diagnostic challenges for sinusitis?

A
  • Bacterial and viral sinusitis similar smx
  • Limited use of diagnostic tests:
    ~ imaging studies: non-specific, non-discriminatory
    ~ Sinus aspirate (gold standard): invasive, painful, time-consuming
18
Q

What is the clinical diagnosis of bacterial sinusitis? How to identify presence of bacterial sinusitis?

A

Any one criterion present:

    • Persistent of smx > 10 days and not improving
      ~ Viral sinusitis: self-limiting, resolves in 7-10 days
    • Severe smx at onset
      ~ Purulent nasal discharge x 3-4days or High fever > = 39oC
    • “Double sickening”
      ~ Worsening smx after 5-6 days after initial improvement (normally happens after viral URTI)
19
Q

What is the purpose of treating sinusitis with empiric abx?

A
  • shorten duration of smx
  • earlier smx relief
  • restore QOL
  • prevent complications
  • Hard to get culture because invasive and painful
20
Q

What are the treatment options for bacterial sinusitis?

And what is the duration for adults and paediatrics?

A

1ST LINE:

  • Amoxicillin
  • Adult: 1g PO TDS
  • Paediatric: 80-90 mg/kg/day PO divided BD
  • Normal Renal Function

OR

- Amox/Clav Augmentin
Adult: 625mg PO TDS* ; or
1g PO BD* 
Paediatric: 80-90 mg/kg/day PO divided BD * 
*Normal Renal Function

Alternative Abx:
- Resp FQs: Levo/Moxi
Adult Levo: 500mg PO OD *
*Normal Renal Function

  • Co-TS
  • Oral 2nd cephalosporin: cefuroxime

Duration:

adults: 5-10d
paediatrics: 10-14d

21
Q

Why is clarithromycin, azithromycin and doxycycline not appropriate for alternative treatment of sinusitis?

A

S. pneumoniae inc resistance to macrolides and tetracycline

Cipro poor activity against S. pneumoniae (not a resp FQ)

22
Q

What are some resistant mechanisms for S. pneumoniae?

A
  • Multi-step penicillin-binding proteins (PBPs) mutation
  • inc penicillin MIC
  • Pen-resistant isolates uncommon locally (<5-10%)
23
Q

What are the treatment considerations (changes/alterations to treatment) for resistant S. pneumoniae?

A
  • Prefer AMOXICILLIN over penicillin - favourable PK (Amox better F, abs, achieve higher systemic conc of abx) (Amox also effective against penicillases)
  • prefer “high-dose” amox for effective treatment

~ Standard dose: 45mg/kg/day (paediatrics); 250-500mg (adults)

~ High-dose: 80-90mg/kg/day (paediatrics); 1g (adults)

24
Q

What are some resistant mechanisms by H. influenzae?

A
  • beta-lactamase production
  • inhibited by beta-lactamase inhibitor
  • beta-lactamase +ve ~18% locally
25
Q

What are the treatment considerations (changes) for resistant H. influenzae?

A

Use AUGMENTIN only if any one of the following:
- Recent course(s) of Abx(s)
- Recent hospitalisation
Recent: last 30 days
- Failure to improve after 72h of amoxicillin

if don’t have any of these, stick to AMOX itself

26
Q

What is acute otitis media?

A

Infection of middle ear space resulting in inflammation and fluid accumulation

Eustachian tube connects middle ear and nasopharynx, regulates middle ear pressure

27
Q

What are clinical presentations of AOM?

A
  • Ear pain (otalgia)
  • Ear discharge (otorrhea)
  • Ear popping
  • Ear fullness
  • Hearing impairment
  • Dizziness
  • Fever
  • Non-specific in young infants: ear rubbing, excessive crying, changes in sleep or behavioural pattern
28
Q

Which age group is most common for AOM?

A

paediatric pts (<5yo)

Have runny nose, sniffles, if the tube is relatively flat; gravity; quite easy for nasal discharge to back flow and enter the tube
angle more horizontal 180o

29
Q

What are the risk factors for AOM?

A
  • siblings
  • attending day care
  • supine position during feeding
  • exposure to tobacco smoke at home
  • pacifier use
  • winter season
30
Q

How to prevent AOM?

A
  • Avoid exposure to tobacco smoke
  • Exclusive breastfeeding for 1st 6 months
  • Minimise pacifier use
  • Vaccinations: influenza, pneumococcal, H. influenzae type B vaccine
31
Q

What is the pathogenesis of AOM? How does a child get AOM?

A

Viral URTIs (common cold) –> nose sniffling –> reflux of secretions into middle ear

OR

Viral URTIs (common cold) –> Secretions and inflammation –> Eustachian tube obstruction –> Negative eustachian tube pressure –> reflux of secretions into middle ear

Medium for bacterial accumulation and growth

32
Q

What is the microbiology for AOM?

A

Bacteruals (55-60%) ~ Viral (40-45%)

Viruses: Respiratory syncytial virus (RSV), rhinovirus, adenovirus, parainfluenza virus

Bacteria: S. pneumoniae, H. influenzae, Moraxella catarrhalis

33
Q

How to diagnose AOM?

A
  • Pneumatic otoscope as standard tool
  • Diagnostic criteria in children
    ~ Acute onset (<48h)
    ~ Otalgia (holding, tugging, rubbing in a non-verbal child) or erythema of tympanic memb
    ~ Bulging of tympanic memb (Red, inflamed memb, yellow
    ; Bulge: fluid build up in middle ear
    Could rupture and flow out)
34
Q

What are some challenges in the management of AOM?

A
  • Unable to distinguish bacterial VS viral aetiologies
  • Bacterial AOM
    ~ Prompt ABx initiation dec duration of smx by ~ 1 day
    ~ around 80% of cases resolve in 3-4days wo Abx (improve on their own)

If overprescribing Abx –> resistance

35
Q

How do we approach ABX for AOM?

A

Immediate initiation: start Abx as soon as AOM is diagnosed

OR

Observation period:
Supportive care x 48-72h
Improves –> no Abx needed
If worsens/fails to improve –> Abx

36
Q

When is observation period considered for AOM?

A

ONLY IF ALL the following criteria are fulfilled:
- > or = 6 mths of age; the younger, the more likely complications
- non-severe illness
~ Severe: moderate-severe otalgia, or otalgia >= 48h, or fever >= 39oC in the last 48h
~ Non-severe: absence of all 3 criteria above
- no otorrhoea (should not have discharge) ( if pt has discharge –> indication rupture of tympanic memb more severe - give Abx straight away)

  • possible for close follow-up
  • shared decision-making with pt/caregiver
37
Q

What is the protocol for AOM treatment when pt has Otorrhoea with AOM?

A

Age
< 6mths: observation period not recommended; immediate Abx therapy

> = 6mths to < 2yrs: immediate Abx therapy

> =2 yrs: immediate Abx therapy

38
Q

What is the protocol for AOM treatment when pt has Unilateral/Bilateral AOM with severe smx?

A

Age
< 6mths: observation period not recommended; immediate Abx therapy

> = 6mths to < 2yrs: immediate Abx therapy

> =2 yrs: immediate Abx therapy

39
Q

What is the protocol for AOM treatment when pt has Bilateral AOM without Otorrhoea?

A

Age
< 6mths: observation period not recommended; immediate Abx therapy

> = 6mths to < 2yrs: immediate Abx therapy

> =2 yrs: immediate Abx therapy OR Observation period

40
Q

What is the protocol for AOM treatment when pt has Unilateral AOM without Otorrhoea?

A

Age
< 6mths: observation period not recommended; immediate Abx therapy

> = 6mths to < 2yrs: immediate Abx therapy OR Observation period

> =2 yrs: immediate Abx therapy OR Observation period

41
Q

What are the treatment options for AOM?

A 
1ST LINE: Amoxicillin
Patient needs to fulfill ALL 3 criteria to get Amox:
1. no amox in the last 30 days
2. no concurrent purulent conjuctivitis
3. not allergic to penicillin
Alternative 1ST line abx: Augmentin
If any 1 of the following is applicable:
- amox in last 30 days
- concurrent purulent conjuctivitis
- Hx of AOM non-responsive to amox

Amox and Augmentin
Paediatric dosing:
80-90 mg/kg/day PO divded BD*
* Normal renal fn

Alternative abx:
- Cefuroxime, Ceftriaxone (IM); possible option for mild pen allergies

Cefuroxime paediatric dosing: 30mg/kg/day PO divided BD*
* Normal renal fn

  • Clindamycin: effective against S. pneumoniae only; option for pts with severe pen allergies

NO FQs for kids

42
Q

How long to see improvement from AOM for various age groups?

A

Improvement expected in 48-72h

< 2yrs: 10 days

Severe smx (moderate-severe otalgia) or otalgia >= 48h, or fever >= 39oC in last 48h) : 10 days

> =2 to 5yrs and non-severe smx: 7 days

> = 6 yrs and non-severe smx: 5-7 days

PT (19 decks)

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