Upper Respiratory Tract Infections

What is the most common cause of sinusitus?

Viruses

Which bacteria most commonly cause bacterial sinusitus?

S. pneumoniae, H. influenzae, Moraxella catarrhalis, S. aureus, S. pyogenes

What symptomology is most associated with bacterial sinusitus?

worsening sx, new onset fever, purulent nasal drainage, facial obstruction, and facial pain lasting >10 days. Especially a few days after 1-2 days of illness

In a sinusitis patient, what symptoms may be indicative of meningitis and warrant a referral to the ED?

persistent HA, mental status change, neck stiffness

(T/F) In a patient with one severe sinusitis symptom (ie fever >39 C, purulent nasal discharge, 3-4days of facial pain, etc) it is appropriate to assume they have bacterial sinusitis and start antibiotics

False

What is the recommended first-line empiric treatment for bacterial sinusitis in adults with no allergies?

Amoxicillin/Clavulanate x5-7d

What is the recommended first-line empiric treatment for bacterial sinusitis in adults with a B-lactam allergy?

Doxycycline OR Levofloxacin OR Moxifloxacin x5-7d

What is the recommended first-line empiric treatment for bacterial sinusitis in adults with a high risk of resistance or failed initial therapy?

Amoxicillin/Clavulanate OR Levofloxacin OR Moxifloxacin x5-7d

What is the recommended first-line empiric treatment for bacterial sinusitis in adults with severe infection warranting hospitalization?

Ampicillin/Sulbactam OR Levofloxacin OR Moxifloxacin OR Ceftriaxone x5-7d

What is the recommended first-line empiric treatment for bacterial sinusitis in children with no allergies?

Amoxicillin/Clavulanate x10-14d

What is the recommended first-line empiric treatment for bacterial sinusitis in children with a B-lactam allergy?

Clindamycin PLUS Cefixime or Cefuroxime

OR

Levofloxacin

x10-14 d

What is the recommended first-line empiric treatment for bacterial sinusitis in children with a high risk of resistance or failed initial therapy?

Amoxicillin/Clavulanate

OR

Clindamycin PLUS Cefixime or Cefuroxime

OR

Levofloxacin

x10-14 d

What is the recommended first-line empiric treatment for bacterial sinusitis in children with severe infection warranting hospitalization?

Ampicillin/Sulbactam OR Ceftriaxone OR Cefotaxime OR Levofloxacin x10-14d

(T/F) Decongestants and antihistamines are NOT recommended for patients with acute bacterial rhinosinusitis

True

What are the key symptoms involved with pharyngeal infection?

Sore throat, fever, pharyngeal inflammation

What are the most common viral causes of pharyngitis?

Rhinovirus and enterovirus

What are the most common bacterial causes of pharyngitis?

Strep pyogenes (Group A strep)

What signs/symptoms are suggestive of viral pharyngitis?

Conjunctivitis, coryza (inflammation of the mucus membrane), cough, ear pain, oral ulcers, viral exanthem

What signs/symptoms are suggestive of bacterial pharyngitis?

Sore throat, pain on swallowing, fever, HA, N/V, abdominal pain, Erythema and inflammation on the tonsils and pharynx with or without patchy exudates, enlarged and tender lymph nodes, red and swollen uvula, petechiae on the soft palate, scarlatiniform rash

When should a patient be treated with antibiotics for pharyngitis?

When they exhibit signs and symptoms consistent with GAS pharyngitis AND have a POSITIVE RADT or throat culture

(may need to do a 2nd culture in children if 1st is negative)

What are severe sequelae associated with GAS pharyngitis? (especially in children)

Acute rheumatic fever, acute glomerulonephritis, necrotizing fasciitis

What are the preferred, first-line therapies for GAS pharyngitis in pts with no allergies?

Penicillin VK OR Amoxicillin x10d

OR

Benzathine penicillin G x1 dose

What are the preferred, first-line therapies for GAS pharyngitis in pts with a non-severe penicillin allergy?

Cephalexin OR Cefadroxil x10d

What are the preferred, first-line therapies for GAS pharyngitis in pts with a severe penicillin allergy?

Clindamycin OR Clarithromycin x10d

OR

Azithromycin x5d

What adjunctive therapy can be offered to pts with GAS pharyngitis?

Analgesic/antipyretic agents, non-Rx lozenges and sprays

What is an antigenic DRIFT of the influenza virus?

Antigenic change in hemagglutinin resulting in season flu epidemics

What is an antigenic SHIFT of the influenza virus?

New influenza strain genetically different from circulating strains. May result in a flu pandemic

What symptoms are associated with an influenza infection?

Abrupt onset of high fever, dry cough, chills, HA, myalgia, malaise, anorexia, nasal discharge, sore throat. Typically resolves in 3-7d

What are risk factors associated with higher morbidity and mortality with the flu?

Childern

What is the gold-standard diagnostic test for an influenza infection?

RT-PCR OR viral culture

What is the benefit of using an antiviral to treat influenza?

It can shorten duration of symptoms and may reduce complications

When can you initiate anti-virals for an influenza infection?

Within 48h of symptom onset

Which patients are recommended to receive treatment for influenza?

Hospitalized patients, severe, complicated, or progressive illness, higher risk for influenza complications

What should you know about Zanamivir?

MOA: neuraminidase inhibitor

Route: Inhaled orally

C/I: underlying respiratory disease, allergy to milk protein

Indications: Treatment and prophylaxis of flu

Treatment duration: 5 days

Prophylaxis duration: 7 days

What should you know about oseltamivir?

MOA: neuraminidase inhibitor

Route: Oral

Indications: Treatment and prophylaxis of flu

-Preferred in pregnant women and those who have severe or complicated illness

Treatment duration: 5 days

Prophylaxis duration: 7 days

What should you know about peramivir?

MOA: neuraminidase inhibitor

Route: Intravenous

Indications: Treatment ONLY of flu

Treatment duration: 1 day

What should you know about baloxavir?

MOA: Cap-dependent endonuclease inhibitor

Route: Oral

Indications: Treatment and prophylaxis of flu

C/I: Avoid in pregnant women

Treatment duration: 1 day

Prophylaxis duration: 7 days

(T/F) You may see benefit from initiating anti-viral therapy in a critically ill patient who has had symptoms of the flu for 4-5 days

True

(T/F) You should withhold anti-virals from patients with flu-like symptoms until it is laboratory confirmed

False

(T/F) You should avoid recommending aspirin for fever reduction in children and adolescents with influenza

True

When is it appropriate to give patients post exposure prophylaxis for the flu?

High risk of influenza complications, severe immune deficiencies, long-term care facility residents, pregnancy or post partum

What are common symptoms associated with COVID-19 infection?

fever, cough, fatigue, loss of taste/smell

What are the risk factors for severe COVID-19 infection?

Age >/= 50yo, residence in nursing home or long-term care facility, chronic medical conditions

What is a mild COVID-19 infection?

Typical symptoms without SOB, dyspnea, or abnormal imaging

What is a moderate COVID-19 infection?

Lower respiratory disease with SpO2 >/= 94% on room air

What is severe COVID-19 infection?

SpO2

What is critical COVID-19 infection?

Respiratory failure, septic shock, and/or multiple organ dysfunction

When is it appropriate to provide patients pre-exposure prophylaxis for COVID-19? What agent would you use?

Severely immunocompromised pts in areas with susceptible strains. Pemivibart

What are treatments available for out-patient treatment of COVID-19 in pts at high risk of progressing to severe disease?

Paxlovid PO x5d OR Remdesivir IV x3d

Alt: Molnupiravir PO x5d

What modes of oxygenation are considered "conventional oxygen support"?

nasal canula, oxygen mask, non-rebreather mask

What modes of oxygenation are considered "advanced support"?

High-flow nasal cannula (HFNC), non-invasive ventilation (CPAP, BiPAP)

What modes of oxygenation are considered "invasive ventilation"?

mechanical ventilation, Extracorporeal membrane oxygenation (ECMO)

What is the recommended treatment of COVID-19 in a patient who is hospitalized without any supplemental oxygen?

Remdesivir (IF high risk)

What is the recommended treatment of COVID-19 in a patient who is hospitalized with conventional oxygen support?

Remdesivir AND Dexamethasone

PO Baricitinib or IV tocilizumab (IF pt has rapidly increasing O2 requirements and systemic inflammation (increased CRP))

What is the recommended treatment of COVID-19 in a patient who is hospitalized with advanced support?

Dexamethasone

PO Baricitinib or IV tocilizumab (IF pt has systemic inflammation (increased CRP))

What is the recommended treatment of COVID-19 in a patient who is hospitalized with invasive ventilation??

Dexamethasone

PO Baricitinib or IV tocilizumab (IF pt has systemic inflammation (increased CRP))

If a patient is hospilized for something other than COVID-19 (ie COVID not severe), how should you treat those patients?

Treat those patients like outpatient

What should you know about Dexamethasone?

MOA: long-acting corticosteroid

Recommended in pts hospitalized with COVID-19 who require any form of oxygen support

What should you know about Remdesivir?

MOA: nucleoside analog that inhibits RdRp of coronaviruses

Recommended in pts hospitalized with COVID-19 who do not require oxygen or only need conventional oxygen support

What should you know about baricitinib?

MOA: JAK inhibitor

BBW: thrombosis

What should you know about Tocilizumab?

MOA: IL-6 receptor antagonist

ADRs: Increased risk of infection, neutropenia, thrombocytopenia

Pts who are hospitalized with COVID-19 are recommended to receive prophylactic doses of anticoagulants for VTE prophylaxis. Which patients should instead receive therapeutic doses?

Pts receiving conventional oxygen support who are not pregnant, have an elevated d-dimer, and who don't have increased bleeding risk