URTI/FLU/COVID (Taylor)

Risk factors for sinusitis

• older age

• smoking

• air travel

• changes in atmospheric pressure

• swimming

• asthma

• allergies

• dental disease

• immunodeficiency

How is sinusitis classified by?

• Duration of illness

• infectious vs noninfectious (etiology)

What is the difference between acute, subacute, and chronic sinusitis?

Acute: lasts up to 4 weeks

Subacute: 4-8 weeks

Chronic: lasts longer than 8 weeks

Is sinusitis mainly viral or bacterial?

Viral

True or false: acute sinusitis typically presents after or in conjunction with a viral upper respiratory tract infection

true

What are some clinical manifestations of acute sinusitis?

• nasal drainage and/or congestion

• facial pain and/or pressure

• headache

• coughing, sneezing, fever

• tooth pain, halitosis

True or false: sinusitis has a higher incidence in women

true

What are the most common viruses in sinusitis?

• rhinovirus

• parainfluenza virus

• influenza virus

What bacterial organisms seen in rhinosinusitis?

• streptococcus pneumoniae

• haemophillus influenza

• Moraxella catarrhalis

• Staphylococcus aureus

• streptococcus pyrogens

Clinical manifestations of acute sinusitis?

• nasal drainage and/or congestion

• facial pain and/or pressure

• coughing, sneezing, fever

• tooth pain, halitosis

Acute viral sinusitis has symptoms that peak within _____ to _____ days and have complete/ partial resolution within ______- _______ days

3-6; 7-10

True or false: bacterial sinusitis tends to have symptoms that last longer than viral

true

What are some signs and symptoms of acute rhinosinusitis?

Less than 4 weeks of purulent nasal drainage AND nasal obstruction, facial/pain/pressure/fullness ± secondary symptoms (anosmia, ear fullness, cough, ha)

What are some signs/symptoms for bacterial sinusitis?

• Persistent signs, symptoms of acute rhinosinusitis >10 days without clinical improvement

• worsening s/s, new onset fever, headache, increased nasal discharge following a viral URI after initially improving

What classifies as “severe s/s”?

• fever> 39 degrees Celsius

• purulent nasal discharge

• facial pain > 3-4 days at onset

True or false: severe s/s support the diagnosis of bacterial infection, but alone, is not sufficient criteria for starting antibiotics

true

What is the go-to empiric therapy for bacterial sinusitis in children AND adults

Augementin

What ABX can you give with B-lactam allergy? (bacterial sinusitis)

Children:

• Clindamycin + Cefixime or Cefpodoxime

• Levofloxacin

Adults:

• Doxy, levofloxacin, or moxifloxacin

What ABX can you give if risk of resistance or failed initial therapy? (bacterial sinusitis)

Children:

• Augmentin

• Clindamycin + Cefixime or Cefpodoxime

• Levofloxacin

Adults:

• Augmentin

• Levofloxacin

• Moxifloxacin

What ABX can you give in severe infection, hospitalized? (bacterial sinusitis)

Children:

• Ampicillin/Sulbactam

• Ceftriaxone

• Cefotaxime

• Levofloxacin

Adults:

• Ampicillin/Sulbactam

• Levofloxacin

• Moxifloxacin

• Ceftriaxone

With bacterial sinusitis, the duration of ABX therapy is typically ___ to _____ days in children and ____ to ____ days in adults

10-14; 5-7

Adjunctive therapy for nonbacterial rhinosinusitis

• nasal or oral decogs

• intranasal saline irrigation

Adjunctive therapy for bacterial rhinosinusitis

• decogs and antihistamines NOT RECOMMENDED

• intranasal saline irrigation

• intranasal corticosteroids only for those with hx of allergic rhinitis

What is the triad of pharyngitis?

1. sore throat

2. fever

3. pharyngeal inflammation

Pharyngitis is highest in which groups?

• 5-15 years old

• parents of school-age children

• those who work with children

Pharyngitis is highest in which season?

winter and early spring

True or false: Pharyngitis is mainly bacterial

false; viral

What are the top 3 organisms that cause pharyngitis? (viral)

1. rhinovirus

2. enterovirus

3. coronavirus

What are the top 3 organisms that cause pharyngitis? (bacterial)

1. Streptococcus pyogenes (GAS)

2. B-hemolytic strepto (not group A)

3. H. influenzae

What are some signs suggestive of viral pharygitis?

• conjunctivitis

• coryza

• cough

• ear pain

• oral ulcers

• viral exanthem

Signs suggesting group A strep

• sore throat

• pain on swallowing

• fever

• HA, N/V, abdominal pain

• erythema/inflammation of tonsils and pharynx w/ patchy exudates

• enlarged, tender lymph nodes

• red, swollen uvula, petechiae on soft palate, and a scarlatiniform rash

Diagnosis of S. pyogenes consists of:

• throat swab

• Identification of GAS via rapid antigen detection test (RADT) and/or culture

True or false: in children, if RADT is negative, this is sufficient to rule out GAS pharygitis

false; need additional throat culture

What is the preferred therapies for bacterial pharyngitis?

• Penicillin V (10 days)

• Amoxicillin (10 days)

• Benzathine penicillin G - IM (1 dose)

If patients have penicillin allergies, what are the alternative therapies for bacterial pharyngitis?

For 10 days:

• Keflex

• Cefadroxil

• Clindamycin

• Clarithromycin

• Azithromycin (5 days)

What adjunctive therapy can be offered with pharyngitis?

• supportive care

• analgesic/antipyretic agents

• lozenges and sprays

• AVOID corticosteroids

Bacterial pharyngitis typically resolves within _______ to ______ days

3-4

For bacterial pharyngitis, you are no longer contagious how many hours after ABX therapy/

24

True or false: follow up testing is recommended in bacterial pharyngitis

false

Describe influenza organism

• orthomyxoviridae family

• single-stranded, segmented RNA genome

What are the different types of influenza types?

• A and B - seasonal epidemics

• C -mild disease

Influenza A is subtyped based on what 2 surface glycoproteins?

1. hemagglutinin

2. neuraminidase

What is antigenic drift in influenza?

• virus makes small mutations (point mutations) in its genes over time

• unpredictable, evolutionary

• slight changes to the surface proteins

• results in seasonal epidemics (need for new vaccine each year)

What is antigen “shift”

• 2 different influenza viruses infect the same cell and exchange genetic material

• New combo of H and/or N proteins through genetic reassortment

• potential to cause pandemics

What is the role of the Hemagglutinin

allows influenza virus to enter host cells

What is the role of neuraminidase

allows the release of new viral particles from host cells

What is the pathophysiology of influenza?

• Attaches to and replicates in epithelial cells of both the upper and lower respiratory tract

• Viral replication + immune response leads to destruction and loss of epithelial cells

• As infection subsides, the epithelium is regenerated ( up to 1 month)

How is influenza transmitted?

Person-to-person via inhalation of respiratory droplets

With large droplets, a sneeze can travel up to ____ ft, a cough up to ____ft, and is suspended for up to 10 minutes

26; 20

True or false: small droplets can drift for up to 26 feets

true

Transmission can occur for how long in adults, children, and immunocompromised?

Adults: 1 day before to 7 days after onset

Children: potentially infectious for >10 days

Immunocompromised: weeks to months

What are some influenza-associated s/s?

• Abrupt onset of fever and dry cough accompanied by chills, ha, myalgia, malaise, anorexia

• Non-productive cough, nasal discharge, sore throat

• typically resolve 3-7 days

What months does influenza season most commonly occur?

• September to April

• Peaks from December to March

What group has the highest rate of infection for influenza

children

What risk factors are associated with higher morbidity and mortality?

• Children < 2

• Adults > 65

• Pregnant or postpartum

• Chronic medical conditions

• immunosuppression

• American Indians/Alaskan natives

• Morbid obesity

• Residents of nursing homes/chronic care facilities

What is the gold standard diagnostic test for influenza?

RT-PCR or viral culture

Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:

• hospitalized

• outpatient with severe, complicated, or progressive illness

• outpatient at higher risk for influenza complications

Antiviral treatment can be considered for any previously healthy, symptomatic outpatient not at high risk for influenza complications, who is diagnosed with confirmed or suspected influenza if:

• tx can be initiated within 48 hours

• household contacts of persons who are at high risk of developing complications

• healthcare providers who care for patients at high risk of developing complications

What are some antivirals for influenza?

Neuraminidase inhibitors:

1. Zanamivir

2. Oseltamivir

3. Peramivir

Cap-dependent endonuclease inhibitor:

1. Baloxavir

Treatment for outpatients with acute uncomplicated influenza

• oral oseltamivir (5 days)

  • preferred treatment for pregnant women

• inhaled zanamivir (5 days)

• IV peramivir (single dose)

Treatment for patients with severe or complicated illness who are NOT hospitalized

• Antiviral treatment with oral oseltamivir is recommended ASAP

For patients unable to tolerate or absorb oral oseltamivir, what should be considered?

IV peramivir

What is the typical duration of treatment in influenza?

5 days (zanamivir, oseltamivir)

1 day (peramivir, baloxavir)

What medications should be avoided as supportive care with influenza?

ASA and ASA containing medication due to Reye syndrome

When is post exposure prophylaxis not recommended for influenza?

if >48 hours after first exposure to influenza

Duration of PEP in influenza

7 days or 14 days if in long-term care facilities

Which drugs are used in PEP for influenza?

Oseltamivir and zanamivir

What are some common and serious symptoms of COVID-19?

Common:

• fever, cough, fatigue, loss of taste or smell

Serious:

• chest pain, SOB, hypoxia, tachypnea, confusion

How is COVID-19 transmitted?

Person-to-person contact via inhalation of infected particles/droplets

Close contact or being indoors

This (PrEP) drug may be used in patients who are moderately or severely immunocompromised in areas where variants are susceptible (COVID)

Pemivibart

true or false: outpatient use of dexamethasone in COVID-19 is recommended

false

What are the treatment options for patients at high risk of progressing to severe disease? (COVID)

1. Ritonavir-boosted nirmatrelvir (Paxlovid) orally for 5 days

2. Remdesivir IV X 3 days

3. Molnupiravir orally X 5 days (alternative)

What classifies a patient as severe with COVID-19?

• SpO2 <94% on room air

• RR >30

• PaO2/FiO2 <300

• Lung infiltrates >50%

What are some conventional oxygen supports?

• nasal canula

• oxygen mask

• nonrebreather mask

• can be delivered on regular hospital floor

What are some advanced oxygen supports?

• high flow nasal canula (HFNC)

• non-invasive ventilation:

  • CPAP

  • BiPAP

What are some invasive ventilation methods?

• mechanical ventilation

• ECMO

How should anticoagulation be initiated with COVID 19?

Initiate based on disease severity in hospitalized patients

If a patient is admitted with or develops a bacterial co-infection, immunomodulators such as ___________ or _______ should be held or d/c

• tocilizumab

• baricitinib

Which COVID-19 drugs are IL-6 receptor antagonists?

• Tocilizumab

• Sarllumab

Which COVID-19 drugs are JAK inhibitors and have BBW for thrombosis

• Baricitinib

• Tofacitinib

Which COVID drug is a nucleoside analog?

Remdesivir

Remdesivir is NOT recommended in patients wiith eGFR < ______

30

Which COVID drug can be given via NG tube?

Baricitinib

Which COVID drug is alternative to baricitinib?

Tofacitinib

Which COVID drug is an alternative to tociizumab

Sarilumab

Which COVID drug can you see an increase in BG and WBC count

dexamethasone