Respiratory tract infections -

What are respiratory tract infections divided into?

Upper and lower respiratory tract infections

What is included in upper respiratory tract infections?

Common cold, influenza, sinusitis, pharyngitis, otitis media

What is a main property of upper respiratory tract infections?

Usually self-limiting and caused by viruses

What are included in lower respiratory tract infections?

Pneumonia, tuberculosis, exacerbation of COPD, bronchitis 

What is acute otitis media?

Infection of middle ear 

What are the main symptoms of acute otitis media?

Middle ear effusion, signs of ear inflammation such as pain, fever and irritability especially in children

What is a middle ear effusion?

Build up of fluid in the middle ear space behind the ear drum 

What bacterial pathogens are usually associated with acute otitis media?

Streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis

What other agents can cause acute otitis media?

Viral agents e.g., respiratory syncytial virus

What is the main treatment with acute otitis media?

Usually self limiting - most resolve within 3 days to a week - analgesics usually given e.g., paracetamol, ibuprofen to manage pain 

What can be considered if no immediate antibiotic is started in acute otitis media?

Ear drops containing an anaesthetic and analgesic for symptomatic relief can be considered as long as there is no perforation or discharge

When may antibiotics be considered to be used in acute otitis media?

Under 2 years with bilateral infection, with discharge from ear, those who are systemically unwell e.g., fever or vomiting, with recurrent infections

What is the first line treatment for acute otitis media if antibiotics are indicated?

Amoxicillin 

What is the alternative first line antibiotic treatment for acute otitis media in the case of a penicillin allergy?

Clarithromycin

What is the usual course of antibiotics for treatment of acute otitis media?

5-7 days, review if symptoms worsen or fail to improve within 3 days

What is acute sinusitis?

Common infection of paranasal sinuses, with inflammation of the nasal and sinus mucosa

What is sinusitis usually caused by?

Viral infection but may be complicated by a secondary bacterial infection

What are the symptoms of acute sinusitis?

Nasal discharge, nasal congestion, headache, earache, facial pain, maxillary tooth discomfort and fever 

What is the usual treatment for sinusitis?

Self-limiting so usual Abx treatment not necessary

When may a backup prescription be issued for acute sinusitis?

if symptoms such as purulent discharge have persisted for 7-10 days to take in case symptoms do not clear up in the next 7 days

What antibiotics are prescribed if necessary for sinusitis as first line treatment?

Amoxicillin, doxycycline or Clarithromycin

What is acute bronchitis caused by?

Often viral but secondary infections of bacteria can follow by streptococcus pneumoniae and haemphilus influenzae

What group are more susceptible to acute bronchitis?

Smokers and those with COPD 

What are the symptoms of acute bronchitis?

Irritating, non-productive cough with discomfort behind the sternum, chest tightness, wheezing and shortness of breath, mild pyrexia. Cough can be productive with yellow/green sputum 

When do symptoms usually resolve spontaneously in acute bronchitis in healthy patients?

3-4 days

What medications may be used if necessary in acute bronchitis?

Amoxicillin or tetracycline

What is pneumonia?

Infection of lung tissue called parenchyma - impacts the alveoli

What is the parenchyma responsible for in the lungs?

Gas exchange

What are the 2 classifications for pneumonia?

Community acquired pneumonia and hospital-acquired pneumonia

What happens to the alveoli in pneumonia?

Become filled with microorganisms, fluid and inflammatory cells that affect function of the lungs

What is used to diagnose pneumonia?

Symptoms such as focal chest signs, increased respiratory rate, low O2 saturations, illness severity and other features 

How is pneumonia usually confirmed in a hospital setting?

Chest X-Ray

What is a new requirement for pneumonia management from the quality of service guidance?

CRB65 and CURB65 must be undertaken once pneumonia diagnosed

What is community acquired pneumonia - CAP?

Pneumonia acquired outside of the hospital or within 48 hours of admission 

What are the symptoms of CAP?

Dyspnoea, cough, malaise, fever, sweats, aches and pains, pleural pain, tachypnoea, confusion 

What is dyspnoea?

Shortness of breath

What is tachypnoea?

Abnormally rapid, shallow breathing - more than 20 breaths per minute

How is severity assessed in CAP?

clinical judgement - consider stability of comorbidities and patients social circumstances 

What are investigations dependant on in CAP?

If patient is treated in community or hospital and severity of pneumonia - clinical judgement used

What scoring system is used to assess adults in the community for pneumonia?

CRB65 score

What does CRB65 stand for?

• Confusion 

• Raised respiratory rate - 30 breaths per min or more

• Low blood pressure - diastolic 60mmHg or less, systolic less than 90mmHg

• Age 65 years or more

What do the scores for CRB65 mean?

• 0 = low risk - less than 1% mortality risk

• 1 or 2 = intermediate risk - 1-10% mortality risk

• 3 or 4 = high risk - 10% mortality risk or more 

What non-pharmacological management advice can be given to manage adults in the community with pneumonia?

Patients should rest, drink plenty of fluids, smoking cessation to aid recovery

What analgesics should be recommended to manage pain and fever in CAP?

Paracetamol

What should you use to monitor oxygen levels for adults in community with pneumonia?

Pulse oximetry 

What should be considered if patients with CAP do not improve within 48 hours?

Review again and consider hospital admission or chest radiography

What scoring is used for adults admitted to hospital with CAP?

CURB-65

What does CURB-65 stand for?

• Confusion

• Raised blood urea nitrogen (over 7mmol/L)

• Raised respiratory rate (30 breaths or more per minute)

• Low blood pressure - systolic less than 90mmHg, diastolic under 60mmHg

• Age 65+

What do the scores mean for CURB-65?

• 0-1 - low risk - less than 3% mortality

• 2 - intermediate risk - 3-15% mortality risk

• 3-5 - high risk, more than 15% mortality risk 

What general investigations are done for adult patients admitted to hospital with CAP?

O2 saturations/arterial blood gases, chest radiography, U and Es, CRP, FBC, LFTs

What is the general management for hospital CAP?

Appropriate O2 therapy, assess for volume depletion and may need IV fluids, consider prophylaxis of VTE, mobilisation, nutritional support in prolonged illness and advice and treatment regarding expectoration if sputum present 

What monitoring should be done in hospital?

Temperature, respiratory rate, pulse, blood pressure, mental status, O2 saturation, inspired O2 concentration

What should be done if patients not progressing satisfactorily when admitted for CAP in hospitals?

Repeat CRP and chest radiography and review within 24 hours of planned discharge

When should microbiological investigations be performed in CAP in hospitals?

Patients with moderate and high severity CAP 

What should diagnosis of CAP using microbiological investigations be guided by?

Prior Abx therapy, epidemiological factors and clinical factors such as patient age, comorbidities and severity indicators 

What are some examples of CAP pneumonia microbiological investigations

Sputum cultures and sensitivities, blood cultures, urine antigen tests, PCR, serology 

What is serology?

Scientific study of serum and other bodily fluids

What does antibiotic treatment of CAP depend on?

Severity of CAP

When should antibiotic therapy be started for CAP in hospitals?

As soon as possible after diagnosis and within 4 hours of presentation to the hospital 

What should be considered when initiating Abx treatment for CAP in hospital?

Consider local issues e.g., resistance patterns, C. diff associated diarrhoea, empirical therapy change according to cultures and sensitivities, switch from IV to oral abx 48 hours after treatment, complications

What prevention and vaccination can be advised for CAP?

Pneumococcal vaccination and annual influenza vaccination

What is the first line treatment antibiotic for treating CAP in adults for low-severity disease?

Amoxicillin 

What is an alternative antibiotic for low severity CAP in adults?

Doxycycline, clarithromycin (for penicillin allergy or if amoxicillin unsuitable) or erythromycin in pregnancy

What is the first line oral antibiotic treatment for CAP in moderate severity?

Amoxicillin with clarithromycin or erythromycin in pregnancy - addition is if atypical pathogens suspected 

What is the alternative oral antibiotic treatment for CAP in moderate severity?

Doxycycline or clarithromycin

What is the first line antibiotic treatment for CAP in high severity disease?

Co-amoxiclav with clarithromycin or erythromycin 

What is the alternative oral therapy for high severity CAP?

Levofloxacin (if penicillin allergy)

What resources should be looked at for CAP in children?

BTS guidelines - different assessment criteria and causative organisms may vary

What is hospital acquired pneumonia?

A respiratory infection developing more than 48 hours after hospital admission

What is the causative organism unlikely to be in HAP?

Unlikely to be same as CAP

What does the choice of empirical antibiotic treatment depend on in HAP?

Knowledge of local sensitivity and resistance patterns and individual patients circumstances 

What course of antibiotics should be considered for patients with HAP?

5-10 day course of antibiotic therapy

What are the criteria that mean adults should NOT be discharged from hospital with CAP? (if they’ve had 2 or more in the past 24 hours)

• temperature above 37.5

• Resp rate 24 breaths per minute or more

• Heart rate more than 100bpm

• Systolic blood pressure less than 90

• O2 sat of less than 90% on room air

• Abnormal mental status

• Inability to eat without assistance

What is the new length of antibiotic treatment for babies and children aged 3 months to 11 years with non-severe CAP?

3 days from 5 days 

When should corticosteroids be used with high severity CAP?

Co-administered for high severity CAP for up to 7 days or until patient improvement