Clin Med Exam 3 (1) Upper Respiratory Infections (URI)

Bacterial Pharyngitis- GAS "Other" possible infections

1) Peritonsillar abscess 2) Cervical lymphadenitis 3) Mastoiditis 4) Sinusitis 5) Otitis media

Upper airways or upper respiratory tract

Nose and nasal passages Paranasal sinuses Pharynx Portion of the larynx above the vocal cords.

Bacterial Pharyngitis: GAS antibiotic Management

**Antibiotic therapy** Reduce the duration by 1 to 2 days Reduce the risk of acute rheumatic fever even when initiated within 9 days of the onset of symptoms Reduce disease transmission 1. Penicillin (PCN)- recommended agent by the AHA and the Infectious Diseases Society of America. 2. Amoxicillin endorsed as an alternative to penicillin by the AHA, although it offers no advantage Both antibiotics require a 10 day course to eradicate GAS 3. Macrolides (e.g., erythromycin, azithromycin)- option for individuals with PCN allergy, BUT decreased utility due to increasing prevalence of macrolide resistant S. pyogenes. In the US, in 2003, macrolide resistance was found in 3 to 9% of isolates (Clindamycin is another alternative)

Actual treatment of bronchitis

**See slide on symptomatic treatment of cough** 1. Beta-agonists, NSAIDs, and first generation antihistamines (e.g., diphenhydramine) all can reduce cough 2. Decongestants- pseudoephedrine (Sudafed) or phenylephrine (Neo-Synephrine and others) reduce mucus formation and cough related to post-nasal drip Small studies have suggested that use of an albuterol MDI reduces cough severity and duration 3. Cough suppressants (dextromethorphan, codeine, carbetapentane, and benzonatate) have not proven to be beneficial in managing cough associated with acute bronchitis, although individual patients may experience symptomatic improvement **No alternative or naturopathic therapy has demonstrated consistent benefit**

Bacterial Pharyngitis: GAS Symptomatic Management

**Symptomatic therapy** Rest Fluids Non-steroidal anti-inflammatory drugs Salt water gargles OTC menthol lozenges

Pharyngitis: CENTOR criteria for Group A beta-hemolytic Streptococcus (GAS

0 or 1 - Not tested/minimal risk / Symptomatic treatment 2 - 23%: RSAT, Abx only if positive 3 - 41%: RSAT, Abx only if positive 4. 60 Empiric Abx or RSAT w/ Abx if positive%

Acute Bronchitis differential diagnosis

1) Pneumonia- most common serious condition to be considered 2) Acute bronchitis 3) Chronic bronchitis with acute exacerbation 4) Pertussis 5) Asthma 6) Gastroesophagealreflux disease (GERD)

In otherwise healthy individuals, pneumonia can be ruled out by:

1) absence of fever 2) absence of rigors 3) absence of tachycardia 4) absence of tachypnea (RR>24 breaths/minute) 5) absence of hemoptysis 6) absence of pleuritic chest pain (sharp localized chest pain upon deep inspiration or coughing) 7) absence of findings of consolidation on chest auscultation **pneumonia can present differently in the elderly**

Common Cold: Differential Dx

1. A1llergic or seasonal rhinitis 2. Bacterial pharyngitis or tonsillitis 3. Acute bacterial rhinosinusitis 4. Influenza 5. Pertussis

When are antibiotics recommended with bronchitis

1. Elderly 2. Cardiopulmonary diseases + cough > 7-10 d 3. Immunocompromised

Common Cold: Complications

1. Exacerbation of underlying asthma or COPD is most common 2. Very rarely (<2% of cases) do URIs progress to bacterial infection in adults (usually bacterial sinusitis or otitis media) = secondary bacterial infection Development of fever and/or symptoms of otitis media or sinusitis after initial improvement are suggestive of these diagnoses **Purulent nasal secretions alone do not suggest bacterial super-infection!**

Influenza: Prevention

1. Hand hygiene 2. Facemasks- efficacy unclear 3. Respirator masks (e.g., N95) may provide some benefit and should be worn by health care personnel when caring for an individual with suspected influenza

Influenza: Diagnosis

1. Molecular assays Rapid molecular tests: results in <20 minutes; very sensitive and specific; can distinguish between A and B only (not subtypes) RT-PCR: results take 1-8 hours; most sensitive method; can differentiate b/wn types and subtypes 2. Antigen detection tests: results in ≤ 15 minutes; not as sensitive or specific as PCR and viral culture Rapid influenza diagnostic tests (RIDTs) Rapid immunologic test for viral antigen (e.g., EIA) 3. Viral culture takes 48-72 hours. Not used by clinicians, but is used in public health surveillance.

Neuraminidase Inhibitors

1. Oseltamivir phosphate- po (Tamiflu- currently the drug of choice due to low resistance) 2. Zanamivir- inhaled (Relenza) 3. Peramivir- IV (Rapivab- available for emergencies with severely ill patients) Function by inhibiting viral propagation Reduce duration and severity of symptoms and duration of viral shedding

Common Cold: Risk Factors

1. Psychological stress is the most consistently demonstrated risk for development of URI 2. Poor hand hygiene (fomites are a major source for transmission) 3. Decreased sleep 4. Adults with exposure to children (daycare, stay-at-home parent, etc.) 5. Smoking: Risk for lower respiratory infections Not demonstrated to increase the risk for URIs Does increase duration and severity of URI 6. Asthma and emphysema: Do not appear to increase the risk, URI can lead to exacerbations of both of these conditions **No evidence suggests that cold exposure increases the risk of URI**

Common Cold: Risk Factors that increase severity

1. Underlying chronic diseases 2. Congenital immunodeficiency disorders 3. Malnutrition 4. Cigarette smoking

Surveys of clinicians evaluating clinical perceptions towards use of antibiotics for URI have identified the following as patient characteristics leading to prescribing antibiotics:

1.Current tobacco use 2.Green or yellow nasal discharge or phlegm 3.Tonsillar exudates ***None of these symptoms are specific to bacterial infection and all can occur with viral URI!*** Patient expectations also play an important role in clinician prescribing practices Study: > 50% of adults surveyed believed that antibiotics were effective against viral infection

CDC recommends antiviral treatment for any individual with suspected or confirmed influenza who fulfill what criteria?

1.Is hospitalized 2.Has severe, complicated or progressive illness 3.Is at high risk for influenza complications: Aged <2 years or >65 years, Chronic pulmonary, cardiac, renal, hepatic, hematologic, or metabolic disease, Immunosuppression, including HIV, Women who are pregnant., BMI>40, Resident in a nursing home

Criteria for selecting patients for influenza immunoprophylaxis:

1.Persons at high risk for influenza who were vaccinated after the onset of an influenza outbreak 2.Persons with significant immune deficiency during an outbreak 3.Individuals unable to receive influenza vaccination due to contraindications 4.For control of an outbreak in a chronic care institution

1918 Influenza Pandemic this is stupid

1918 - 1919 - deadliest in modern history Infected ~500 million people worldwide (~ 1/3 of the planet's population at the time) Killed ~20-50 million >25 % of the U.S. population became sick 675,000 Americans died

Influenza antigenic shift

2nd mechanism of variation occurs only in influenza A an abrupt and major change via gene re-assortment resulting in a new HA or NA Little or no cross-reactivity exists between previous strains and new strains of influenza A occurring via antigenic shift

URTIs: drug Management 2nd half

3. First-generation antihistamines (e.g., diphenhydramine [Benadryl]) More effective in reducing rhinorrhea and sneezing than second-generation antihistamines (e.g., loratadine [Claritin]) due to their greater anticholinergic properties 4. Nasal saline irrigation - another popular remedy, but no evidence of reduced duration or symptoms

chart comparing bronchitis to pneumonia on slide 114

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Upper Respiratory Tract Infections (URTI)

A benign self-limited syndrome representing a group of diseases caused by members of several families of viruses Very common presenting complaint in primary care

Cmplications Lemierre syndrome

A rare complication of either viral or bacterial pharyngitis Pharyngeal inflammation may lead to invasive infection by Fusobacterium necrophorum, followed by sepsis and internal jugular vein thrombosis Classic symptoms are high fevers and rigors occurring as early as two days after the onset of sore throat On examination, tenderness is often detected over the sternocleidomastoid muscle Septic jugular vein thrombosis èseptic emboli lodging in the lungs and the classic cannonball finding on CT of the chest

Acute Bronchitis Epidemiology and presentation

A respiratory illness of < 3 weeks duration in which cough is the primary complaint Usually begins as a URI or 'cold', followed by persistence of cough after resolution of other URI symptoms, hence the term 'chest cold' The cough usually tends to persist 1 - 2 weeks after the resolution of all other URI symptoms, and may be either productive or non-productive Can affect both upper and lower respiratory tract

URTIs: Prevention

A variety of vitamins (e.g., vitamin C) and herbal supplements (e.g., Echinacea) have been promoted and marketed for prevention No adequately blinded studies support a prophylactic effect of popular supplements such as zinc, Echinacea, garlic, or vitamin C Fastidious hand hygiene- most efficacious method of reducing URI-related illness Washing hands and keeping them away from the eyes and mouth reduces frequency of URI by ~ 20%

Croup: Treatment

ABCs Single dose of dexamethasone (0.15 to 0.6 mg/kg) In moderate to severe, also administer nebulized epinephrine

Influenza: Epidemiology

Acute respiratory illness Caused by Influenza A or B (Orthomyxoviridae family of viruses) Highly contagious Infection is common: Mainly during winter 10 - 20% of the population infected each season Average of 50,000 annual influenza-associated deaths in the United States

Bacterial Pharyngitis- GAS complications

Acute rheumatic fever has become very rare in the United States among all age groups Post-streptococcal glomerulonephritis is also rare Given the potential severity of the sequelae of untreated streptococcal pharyngitis, identifying and treating suspected cases of streptococcal pharyngitis is important! Therapy for streptococcal pharyngitis can be delayed for up to 9 days after the onset of symptoms and still prevent the onset of acute rheumatic fever

Antibiotic problem with Pharyngitis

Although 90% of pharyngitis is viral in etiology, antibiotics are prescribed for 50 - 90% of cases seen in primary care visits The most common reason sited for over-prescribing is the concern about the two most serious complications 1) Acute rheumatic fever 2) Post streptococcal glomerulonephritis

Influenza: Annual variation

Annual variation in the glycoproteins, hemagglutinin (HA) and neuraminidase (NA) enables influenza viruses to evade antibodies developed during previous seasons from infection or vaccination.

Influenza:Prophylaxis

Anti-viral meds ideally used during the week of peak influenza activity Does NOT substitute for vaccination

Using antibiotics for treatment of Acute Bronchitis

Antibiotics are not indicated for acute bronchitis However, antibiotics are prescribed for 50-90% of 'bronchitis' cases Patient expectation of antibiotics can be partially overcome through education during the clinical encounter 1. Includes describing the expected 10 - 14 day duration in symptoms and the lack of utility of antibiotics 2. Using specific language for the diagnosis can sometimes help (e.g., labeling the diagnosis 'chest cold' rather than 'bronchitis' decreases expectation of antibiotics)

The American College of Physicians has issued a position paper on the diagnosis and management of URI. what do they state specifically?

Antibiotics should not be used to treat nonspecific upper respiratory tract infections in previously healthy adults.

What is the clinical course of Influenza: Complications Secondary Bacterial Pneumonia

Can cause a rapidly progressive necrotizing pneumonia and requires selection of antibiotics not usually used for community-acquired pneumonia The pattern of secondary bacterial pneumonia usually follows a course of initial improvement in symptoms and resolution of fever followed by clinical decline 4 to 10 days later.

Common Cold and antibiotic problem

Challenge is differentiating between viral and bacterial etiology since clinical presentation can be similar Inappropriate prescribing of antibiotics has led to bacteria resistant to antibiotics Despite the fact that URIs are nearly always caused by viruses, they are the main reason for outpatient antibiotic Rxs 30% of medical provider visits for URIs result in an antibiotic prescription

Influenza: Symptoms

Classically begins with abrupt onset of fever, headache, myalgias, and malaise - may be able to pinpoint the hour of onset of symptoms. 1. Fever, with or without rigors 2.Myalgias (often of the back and large muscles in the extremities) 3. Malaise/lethargy 4. Non-productive cough and sore throat 5. Delirium 6. Rash 7. Abdominal pain, diarrhea

Bacterial Pharyngitis: Causes

Common 1) Group A beta-hemolytic Streptococcus 2) Group C and G streptococci Uncommon 1) Neisseria gonorrhea 2) Arcanobacterium haemolyticum 3) Corynebacterium diptheriae 4) Mycoplasma pneumoniae 5) Chlamydia trachomatis

Viral Pharyngitis: Causes

Common (Rhinovirus, Coronavirus, Adenovirus) Uncommon (EBV, Coxsackievirus, HSV, HIV)

common symptoms of Acute Bronchitis

Cough, productive or non-productive lasting 1-3 weeks Nasal congestion or drainage Often occurs after resolution of typical URI symptoms

URTIs: Management

Current therapy of URI is based on symptomatic management Recommendation made to a patient should focus on the major symptoms: Nasal congestion & sinus pressure or pain Cough Sore throat

Bacterial Pharyngitis: GAS diagnosis

Diagnosis Good algorithms + clinical findings + lab testing The best tested algorithmè Centor Criteria, followed by rapid streptococcal antigen testing (RSAT or RADT) for individuals with moderate to high likelihood based on the Centor criteria.

Croup Diagnosis and classes

Diagnosis - Clinical MILD Absence of stridor at rest Minimal respiratory distress Occasional cough MODERATE Stridor at rest Increased amount of respiratory distress Behavior and mental status are normal SEVERE Stridor at rest Retractions, air hunger, cyanosis, significant respiratory distress Mental status changes, with increasing somnolence and decreasing air entry signifying impending respiratory failure

Common Cold: Epidemiology

Each person typically has 2-4 URIs per year in the U.S. (6-8 for kids) Incidence peaks during the fall and winter, varies considerably from person to person, and declines with age.

Influenza: vaccine

Effective method of prevention 1/3 of adults aged 18-49 years ½ of adults aged 50-64 2/3 of adults aged ≥65 **Numbers from 2009-2010**

Influenza: Physical Exam

Flushed face and toxic appearance Hyperemic mucosal membranes Clear nasal discharge Mild, tender lymphadenopathy Rales or rhonchi in < 20% of cases Dehydration and orthostatic hypotension may also be present **S/S and severity varies with different types of influenza and different hosts**

Bacterial Pharyngitis

Group A beta-hemolytic Streptococcus (GAS or GABHS) (a.k.a. Streptococcus pyogenes) is the most common bacterial cause of pharyngitis.

Hemagglutinin (HA)

HA attaches to host receptors present on the surface of erythrocytes So viruses with HA glycoproteins called hemagglutination when mixed with red blood cells? Host cell receptors also are on respiratory tract cell membranes HA binds to these receptors then activates fusion of the host cell membrane with the virion membrane dumping the viral genome into the host cell So...HA is needed for absorption Antibodies against HA will block this binding and prevent infection

Common Cold: 3 modes of transmission

Hand contact (via direct contact with an infected person or via indirect contact with a contaminated environmental surface) Small particle droplets (droplet nuclei or aerosols) that become airborne from sneezing or coughing Large particle droplets (droplet transmission) that typically require close contact with an infected person

Bacterial Pharyngitis epidemiology

Incidence of GAS as a cause of pharyngitis in adults ranges from only 5-10%* and 20-30% of sore throat cases in children GAS has highest incidence in children ages 5-15 yo Infections in late fall through early spring with bimodal peaks in Nov/Dec and Apr/May Incubation period is 1-2 days

How is influenza transmitted?

Infection occurs via aerosolized secretions (in contrast with rhinoviruses/cold viruses, which are usually spread via fomites)

Croup Epidemiological Features

Inflammation of the airway with swelling and erythema of the trachea in the subglottic area Commonly caused by parainfluenza virus (types 1-3) Peak incidence in Fall and early winter months Incubation period is 3 - 6 days Affects children 6 - 36 mos with peak in second year of life Males affected > female Usually benign disease with low mortality rate

Influenza: Complications Cardiac

Influenza infection increase the risk for cardiovascular mortality, including death from stroke, MI, and CHF Mortality associated with influenza is highest among individuals >60 years old Influenza vaccination is included on the American Heart Association's Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease

Differential diagnosis of acute cough based on type of cough and breathing (used for localizing the bronchitis)

Inspiratory stridor - upper airway disease Rhonchi, expiratory wheezing - lower airway disease Inspiratory crackles; rales - suggest involvement of lung parenchyma (i.e., pneumonia, interstitial disease, edema)

URTI chart slides 27 -29 and all over the place

Just go look at them all

Common Cold: PE labs diagnosis and treatment

Labs - None indicated Diagnosis - Clinical- based on S/S Treatment - Symptomatic

Croup HPI

Low grade fever, prodrome of URI symptoms followed by a barking cough, inspiratory stridor, dyspnea and respiratory distress Symptoms usually last 3 - 5 days and subside, but can also unpredictably worsen causing respiratory failure requiring intubation

Common Cold: Clinical Features (this is terrible)

Mild, self-limited illness characterized by one or more of the following: 1.Nasal congestion & discharge - clear to yellow-green 2.Rhinitis 3.Dry or "scratchy" sore throat 4.Coughing 5.Sneezing 6.Hoarseness 7.Headache 8.Sinus pressure 9.Malaise Constitutional symptoms like myalgias and arthalgias are not prominent Fever is uncommon in adults

Common Cold: PE

Minimal findings on PE: 1. Nasal congestion, mucosal swelling, secretions in nasal cavity 2. Oral respiration 3. Mild tonsillar and pharyngeal injection w/o exudate 4. Conjunctival injection

Avian influenza A (H5N1)

Minor genetic changes could adapt it to a human host and to human to human transmission Symptoms reported from known cases include fever, watery diarrhea, and leukopenia preceding pneumonitis by an average of 7 days Pneumonitis may progress rapidly to respiratory distress and acute respiratory distress syndrome (ARDS)

URI: Epidemiology

Most common cause of ambulatory care visits in U.S. Most common acute illness in U.S. Leading reason for missed work days In 1998, 25 million individuals received care for URI and 20 million days were missed from work.

Influenza: Complications Secondary Bacterial Pneumonia

Most common complication of influenza Typical organisms 1. Streptococcus pneumonia 2. Haemophilus influenza 3. Staphylococcus aureus MOST IMPORTANT pathogen to consider, particularly community acquired methicillin resistant S. Aureus (CA-MRSA) Uncommon without preceding influenza infection

strains of influenza A that exist within fowl populations that are transmittable to humans

Multiple strains of influenza A exist within fowl populations, most of which are not transmissible to humans. One strain that is highly pathogenic to fowl and has been transmitted to humans is avian influenza A (H5N1). Currently, it is an exceedingly rare zoonotic infection spread by contact with birds.

Croup Physical Exam

Nasal flaring, respiratory retractions, stridor, absence of wheezing Mild, moderate, or severe croup depending on presence of stridor at rest, degree of respiratory distress, and mental status changes

Neuraminidase (NA) (so confused)

Neuraminic acid is important component of mucin Mucin covers mucosal epithelial cells and forms integral part of host's upper respiratory defense barrier Viral neuraminidase cleaves neuraminic acid and disrupts the mucin barrier exposesing binding sites beneath NA also needed for release of newly formed virion from infected host cells Antibodies and drugs directed against neuraminidase are protective

URTIs: Management for just sore throat

Non-steroidal anti-inflammatory drugs (NSAIDs) may help with sore throat, headache, and fever Zinc lozenges - 2 studies included in a meta-analysis reported a reduction in symptom duration and severity with lozenges taken every 2 hours while awake A variety of supplements and naturopathic products have been promoted for treatment of URI: vitamin C, zinc, and Echinacea - none of which have consistently demonstrated efficacy in blinded studies

Fungal Acute Sinusitis

Ocurs in populations with underlying immune disorders (poorly controlled diabetes, hematologic malignancies, and chronic renal failure) Patients may present with symptoms similar to acute rhinosinusitis, but imaging may reveal a mass in the sinus and erosion into contiguous bone Rapid management, including surgical debridement and anti-fungal therapy is essential

URTIs: drug Management 1st half

Oral decongestants 1. phenylephrine (Sudafed PE and other brand names) 2. pseudoephedrine (Sudafed) Topical nasal preps 1. Decongestants: oxymetazoline (Afrin), phenylephrine (Neo-Synephrine) Use for as little as 3 days. may lead to rebound nasal congestion (rhinitis medicamentosa) Recommended with caution and education! 2. Anticholinergic ipratropium nasal spray (Atrovent Nasal)- relieves rhinorrhea and also used for Allergic Rhinitis

microbiology of acute bronchitis

Organisms are often identical to those responsible for the common cold Organisms typically associated with persistent cough: VIRAL- rhinoviruses, coronaviruses, influenza, adenovirus, and RSV BACTERIAL- Mycoplasma pneumoniae and Chlamydophila pneumoniae There is no evidence to indicate Streptococcus pneumoniae, Moraxella catarrhalis, or Haemophilus influenzae cause acute bronchitis.

Common Cold: Microbiology

Over 200 viral subtypes have been associated with the common cold - Rhinoviruses are most common Most common transmission: Hands touch fomites then touch nose, eyes, or mouth allowing viruses to migrate to the nasopharynx 75% of individuals who are infected develop symptoms (some as early as 10 hours after exposure) Shedding of viral particles peaks 3 days after infection, but may continue at low levels for 1 - 2 weeks

Bronchitis Epidemiology and presentation

PE may be unremarkable, or rhonchi may be present. Acute respiratory tract infection, including bronchitis, accounts for 70% of primary care visits for new onset cough. In 5% of cases of new onset cough, underlying pneumonia is diagnosed Given the frequency of pneumonia and the importance of appropriate treatment to prevent morbidity and mortality, exclusion of pneumonia is important

Lower airways or lower respiratory tract

Portion of the larynx below the vocal cords Trachea Bronchi Bronchioles

What is the most significant potential adverse outcome of having a URI

Probably most significant potential adverse outcome of having a URI is inappropriately receiving antibiotics! There is NO evidence to support use of antibiotics for URI to reduce duration, severity, or risk of complications Antibiotic prescribing has two direct negative effects Adverse drug effects 1. Selection of resistant bacteria among an individual's colonizing flora 2. increasing the risk of a future infection with antibiotic resistant bacteria

Acute Bronchitis position statement

Recommendation 1. The evaluation of adults with an acute cough or a presumptive diagnosis of uncomplicated bronchitis should focus on clinically ruling out pneumonia. Recommendation 2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of the duration of cough.

Most common respiratory viruses in children: (stupid pointless list)

Rhinoviruses Coronaviruses - Pneumonia and croup Influenza viruses - Influenza, pneumonia, and croup Respiratory syncytial virus (RSV) - Bronchiolitis in children younger than the age of two years Parainfluenza viruses - Croup Adenoviruses - Pharyngoconjunctival fever (palpebral conjunctivitis, watery eye discharge, and pharyngeal erythema) Coxsackievirus A (an enterovirus) - Herpangina Other nonpolio enteroviruses - Aseptic meningitis Human metapneumovirus - Pneumonia and bronchiolitis

Influenza risk of transmission

Risk of contagion minimal 7 days after symptom onset in otherwise healthy patients Viral carriage and shedding may be much longer in individuals with compromised immunity

Influenza: Epidemiology pathophysiology

Self-limited infection in healthy individuals Most influenza related mortality occurs indirectly as a result of complications of influenza: 1. Secondary bacterial pneumonia 2. Secondary otitis media 3. Cardiovascular compromise in patients with preexisting congestive heart failure (CHF) or coronary artery disease (CAD)

Viral Pharyngitis

Sore throat is a common symptom 10-20% of adults develop pharyngitis annually Symptoms may be mild or severe, and may include fever Clinical features suggestive of viral pharyngitis: cough hoarseness, rhinorrhea, conjunctivitis, rash, diarrhea, and stomatitisor ulcerative lesions in the oropharynx

Bacterial Pharyngitis- GAS clinical features

Sore throat of GAS is typically of sudden onset, associated with odynophagia, and is usually accompanied by fever In severe cases, headache, nausea, vomiting and abdominal pain may develop Some patients may appear toxic, but symptoms can also be mild

URTIs: Management for just cough

Symptomatic relief - keep throat moist with warm liquids, cough drops Nocturnal cough when associated with a URI, may be the result of post-nasal drip Reduce mucus drainage - antihistamines & nasal decongestants (e.g., phenylephrine & pseudoephedrine) OTC cough syrups containing dextromethorphan may provide relief and suppress nocturnal cough

Pharyngitis: CENTOR criteria for Group A beta-hemolytic Streptococcus (GAS)

Temperature ≥38° C Tonsillar exudates Tender cervical adenopathy No cough or rhinitis

Lemierre syndrome treatment

Treatmentèantibiotics with good anaerobic activity, such as ampicillin-sulbactam (inhibitor of bacterial beta-lactamase) or clindamycin.

Fungal acute sinusitis etiology

The specific organism depends on the nature of the underlying immune disorder Aspergillus is the most common Mucorales are next most common (e.g., mucormycosis). They classically occur during episodes of diabetic ketoacidosis, and are uncommon in the normal host.

Influenza treatment general guidelines

These medications must be started early to provide clinical benefit in otherwise healthy adults. Optimally, the first dose is given within 24 hours of symptom onset. After 48 hours, there is limited evidence of benefit among patients with intact immune systems. Review local or state influenza surveillance data during influenza season to determine which types of influenza (A or B) and subtypes of influenza A (H1N1 or H3N2) are circulating, as well as antiviral resistance patterns.

Common cold why people think they need antibiotics

This change in nasal discharge results from recruitment of leukocytes, and is a natural part of the progression of a viral URI! Patients who note this change in sputum often seek medical evaluation, concerned that this is evidence of bacterial infection. But, purulent sputum and phlegm are not associated with bacterial infection or risk for bacterial infection!

Influenza: Treatment and Prevention

Three classes of antiviral drugs used for treatment of influenza infection: 1.Adamantanes: Treat Influenza A only 2.Neuraminidase Inhibitors 3.*New drug - Baloxavir marboxil (Xofluza)

Influenza: Diagnosis: time of year

Time of year and local influenza activity can help in clinical decision making Influenza season occurs from October - April in the northern hemisphere (peak of activity in any area generally lasts < 6 weeks) During this peak of activity, >30% of patients with fever and cough have influenza During summer months, influenza is exceedingly rare

Bacterial Pharyngitis- GAS classical physical findings

Tonsillopharyngeal erythema (usually with exudates, but they may be absent) Tender, enlarged anterior cervical lymph nodes Some individuals may develop a sandpaper-like papular erythematous rash (scarlatiniform) as a result of streptococcal endotoxins. This condition is known as scarlet fever, and is often accompanied by fever and tachycardia Scarlet fever rash typically begins on face or neck often spreads to trunk and the extremities, sparing palms and soles, before desquamating Strawberry tongue

Adamantanes:

Treat Influenza A only Amantadine (Symmetrel), Rimantadine (Flumadine) High levels of resistance to these and therefore are NOT USED.

Influenza: Clinical Course

Typical duration of severe symptoms is 3 - 4 days in healthy adults (very rarely > 7 days) Patients with compromised immune systems may have an extended duration of symptoms and viral shedding Neither history, symptoms, or physical exam can differentiate influenza A from influenza B Complications tend to occur more frequently with influenza A Influenza B may cause more abdominal and gastrointestinal symptoms

Upper Respiratory Tract Infections (URTI) may be referred to as a "common cold" this is an umbrella term for what pathologies?

URI (AKA rhinosinusitis, rhinopharyngitis, acute coryza, nasopharyngitis...) Has no particular localizing feature

Common Cold: Pathophysiology

URIs usually caused by viral infection of anterior nasal mucosa Virus inefects nasal epithelium via aerosol spread or direct contact with infectious secretions on the skin or other surfaces (fomites) Viral replication within epithelial cells of oral, nasal and upper respiratory mucosa Viral replication triggers cytokine mediated inflammatory reactions à typical cold symptoms Symptoms begin about 2-8 days after viral inoculation

Influenza antigenic drift

Usual mechanism of antigenic variation Occurring in both influenza A and B Occurs through constant and ongoing small mutations of HA and NA during the replication cycle of the virus People previously infected by strains differing by antigenic drift often have some antibody cross-reactivity with the new strain, and are more likely to have milder illness

Acute Sinusitis etiologies

Viral Rhinovirus Coronavirus Adenovirus Parainfluenza Bacterial Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus

When a specific localizing symptom is present in a URTI, the diagnosis is made based on location: what are some examples of this?

Viral pharyngitis Acute sinusitis Acute bronchitis Laryngitis Croup Otitis media

Acute Sinusitis Microbiology

Viruses are a common cause of acute rhinosinusitis Common viral causes include rhinoviruses (i.e., the most common cause of the common cold), as well as other viruses that cause upper respiratory tract infections (i.e., coronaviruses, adenoviruses) Bacterial- most common cause is S. pneumoniae, followed by H. influenzae and Moraxella

Common Cold: Clinical Course

Within 2 - 3 days the sore throat usually resolves and the rhinorrhea becomes more purulent, appearing thick and yellow to green. Symptoms usually peak within 2 - 3 days and resolve over 5 - 10 days. Cough may persist for several weeks after resolution of other symptoms. When this occurs it is usually referred to as bronchitis or a "chest cold". Influenza is included in the URI differential diagnosis, but with influenza, myalgias and fever are more prominent, and the illness is usually more severe.

Chart on slide 95 and position statements on slides 96 and 97 about treatment for GAS that looks very important

bummer

Infection with the influenza A and B viruses

cause a spectrum of diseaseè from asymptomatic to serious systemic illness Symptoms usually occur after an incubation period between 18 - 72 hours (peak of viral titer) The virus titer then declines rapidly and is no longer detectable within 5 - 10 days of initial infection

4 "advice" slides at the end of this powerpoint

dont look to important

Consequences of new strains occurring via antigenic shift

have been responsible for global influenza epidemics and pandemics 2009 influenza A H1N1 swine-origin influenza pandemic 1918 "Spanish flu"

Bacterial Pharyngitis: GAS diagnosis RSAT

have high sensitivity and specificity (sensitivity 80-90%; specificity greater than 95%) High accuracy eliminates the need for confirmatory bacterial culture among adults In children and adolescents, must backup negative RADT with throat culture

more charts on slide 11 and 12

i hate my life

When would Further evaluation for pneumonia with a chest x-ray be indicated?

if fevers or rigors and any of the following are present: hemoptysis, pleuritic chest pain, tachypnea, hypoxia, examination findings of consolidation Asthma and GERD can be further explored by history, symptom pattern, and absence of fevers

Viruses chart on slide 9

mad about that

New drug - Baloxavir marboxil (Xofluza)-

po- Treats Influenza A & B Approved last year (1o/18) to treat flu Indicated for acute, uncomplicated influenza ≥ 12 years not symptomatic > 48 hours Cap-dependent endonuclease inhibitor- blocks influenza viral proliferation by inhibiting the initiation of mRNA synthesis

Chart on neuramindase inhibitors on slide 62

yikes