ID - Pharyngitis & Bronchitis

Question 1

Define upper RTI

Answer 1

Acute infections, typically viral but sometimes bacterial or rarely fungal, cause mild, self-limiting symptoms e.g. congestion, sore throat, and occasional fever

Question 2

URTI consists of what two syndromes that we care about?

Answer 2

1. Acute rhinopharyngitis
   - Inflammatoin of the nasopharynx
2. Acute pharyngitis
   - Inflammation of the pharynx, commonly caused by a virus or, less commonly, GAS

Question 3

What syndrome makes up the only lower RTI that we care about?

Answer 3

Acute bronchitis - inflammation of the bronchi, usually from viral infection but sometimes bacterial or due to irritant exposure (e.g., smoke)

Question 4

What are some risk factors for RTIs? (4)

Answer 4

1. Exposure to others with infection
2. Inadequate hand hygiene
3. Crowded environments
4. Exposure to lung irritants that compromise respiratory tract ciliary function: chemicals, smoking

Question 5

Describe the pathogenesis of an RTI? (4)

Answer 5

1. Colonization of pathogens in URT –>
2. Aspiration to bronchae –>
3. Bronchial irritation and ciliary dysfunction –>
4. Clogged airways, mucus secretion and cough

Question 6

Most cases of acute pharyngitis are _____ and _____-________

Answer 6

viral; self-limiting

Question 7

Symptoms of viral acute pharyngitis can include: (6)

Answer 7

1. Low-grade fever
2. Coughing
3. Rhinorrhea
4. Rash
5. Headache
6. Conjunctivitis

Question 8

Sometimes acute pharyngitis can be caused by GAS (strep throat). What are some symptoms? (5)

Answer 8

1. Sudden onset of sore throat
2. Fever
3. Absence of cough
4. Palatal petechiae
5. Possible scarlet fever (rare)

Question 9

Acute bronchitis usually follows a ______ ____, and adult symptoms are often ____-_________

Answer 9

viral URTI (>90% of cases); self-limiting (10-14 days)

Question 10

Adult symptoms of acute bronchitis include? (2)

Answer 10

1. Coughing (+/- sputum production)
2. URTI symptoms (e.g. nasal congestion, runny nose, watery eyes)
   – Cough can last 3 – 4 weeks (bronchitis often suspected following > 5 days of coughing). Purulent sputum is not an indication of bacterial infection, but rather the presence of leukocytes and inflammation

Question 11

Symptoms of acute bronchitis in children can include? (7)

Answer 11

1. Wheezing
2. Chills
3. Chest congestion
4. Vomiting
5. Tachypnea
6. Respiratory distress
7. Hypoxemia (rare)

Question 12

What is the best way to diagnose bacterial pharyngitis in adults and children?

Answer 12

1. Rapid antigen test (RAT) or throat culture is best way to diagnose GAS
2. RAT ok to rule out adults, need culture for children

Question 13

For acute pharyngitis, what are the main bacterial organism that can cause it? What are 2 other rare ones?

Answer 13

1. Streptococcus pyogenes (Group A β-Hemolytic streptococci) which is also known as ‘strep throat’
   Rarely others like:
2. Fusobacterium
3. Neisseria

Question 14

For RTIs, what are some non-pharm measures to consider? (5)

Answer 14

1. Education
2. OTC - lozenges and lidocaine to provide mild pain relief
3. Humidity up to reduce cough
4. Fluids - prevent dehydration and reduce viscosity of respiratory secretions
5. Comfort - improve pt’s comfort by rest, activity as tolerated

Question 15

What are some topics of education to provide a patient when it comes to their RTI? (4)

Answer 15

1. Likely viral cause of URTI/bronchitis/pharyngitis
2. NO benefit from antibiotics except in the cases of pertussis or acute pharyngitis secondary to bacterial pathogen. Risk of antibiotic resistance if antibiotics used
3. Limiting spread of infection through proper hand washing
4. Avoiding environmental irritants such as toxin/allergen exposure (tobacco smoke, pollen)

Question 16

What are 3 natural remedies to consider in RTI?

Answer 16

1. Honey - may help symptomatic treatment of cough and sore throat
   - Use pasteurized, and in children > 1 year old
2. Nasal saline spray - helps with symptomatic treatment of nasal congestion and discomfort
3. Zinc (in lozenges) - some evidence it shortens duration and severity of a cold

Question 17

What are some potential medications that people use for symptomatic relief of RTIs? (and which ones have little evidence of helping) (5)

Answer 17

1. Analgesics and antipyretics
2. Antitussives
3. Bronchodilators, inhaled corticosteroids (used in pts with wheezing; no evidence of efficacy unless airway obstruction is present)
4. Antihistamines (avoid - they cause drying of mucous secretions, which prevents effective clearance)
5. Mucolytics (no evidence of efficacy)

Question 18

What to know about analgesics and antipyretics in RTI symptom relief? (2)

Answer 18

1. Acetaminophen and ibuprofen for fever, headache and pain
2. Avoid aspirin in children and adolescents due to risk of Reye’s syndrome

Question 19

What to know about antitussives in RTI symptom relief? (5)

Answer 19

1. Dextromethorphan
2. Antitussives are not recommended for productive coughs
3. Avoid in children < 6 years of age: lack of evidence for efficacy and risk of adverse effects
4. As per Health Canada: recommended to NOT use opioid-containing products in <18 years old
5. Both have risk for abuse

Question 20

What is the Modified Centor Score?

Answer 20

Estimates the probability of streptococcal pharyngitis based on symptoms and physical findings

Question 21

If you ever need to do the Modified Centor Score off the top of your head, remember TASTA. What is that?

Answer 21

T = temperature >38C –> 1 point
A = absence of cough –> 1 point
S = swollen tender cervical nodes –> 1 point
T = tonsillar swelling/exudate –> 1 point
A = age:
3-14 years –> 1 point
15-44 –> 0 points
45+ years –> -1 point

Question 22

What are the Modified Centor Score cutoffs?

Answer 22

2 or less = no further testing or antibiotics
3+ = Perform RADT (throat culture is gold standard, and should especially be done in children)
- If positive –> treat with Abx
- If negative & < 20 years → throat
culture, if positive for GAS, then start Abx
- If negative & ≥ 20 years → No antibiotics

Question 23

In terms of pharmacological measures, what 2 key things do we need to know about bronchitis?

Answer 23

1. Routine antibiotic treatment is not recommended for acute bronchitis, since virus account for up to 95% cases
2. Consider further investigation: symptoms last >14 days without improvement or worsening, if linked to a pertussis case OR if immunocompromised

Question 24

In terms of pharmacological measures for bacterial pharyngitis, what are 2 key points to remember? (not medications themselves)

Answer 24

1. Antibiotic therapy aimed at eradicating GAS is recommended for cases of bacterial pharyngitis confirmed by throat culture or antigen testing
2. Concurrent use of corticosteroids with antibiotics is not recommended

Question 25

Bacterial pharyngitis treatment in children is indicated within _ days of symptom onset

Answer 25

9

Question 26

In children, optimal treatment against GAS is ___________ or __________ for __ days

Answer 26

amoxicillin or penicillin (V specifically); 10 days

Question 27

For patients (children and adults) who are unlikely to complete the 10-day antibiotic course for GAS, what can be given?

Answer 27

Penicillin G Benzathine x 1 dose (IM injection)

Question 28

If a child has a non-anaphylactic hypersensitivity reaction to penicillins, what 2 things can be tried to help treat their GAS?

Answer 28

1. Amoxicillin challenge (low-risk pt is given a small initial dose of amox and observed for 20-30 minutes) 2. Cephalexin 20mg/kg/dose BID x 10 days

Question 29

If a child has documented type 1 (row 1) hypersensitivity to penicillin (meaning, anaphylaxis), what can be given instead to treat their GAS? (Remember, ROW 1 ACC with my son)

Answer 29

A = azithromycin x 5 days C = clarithromycin x 10 days C = clindamycin x 10 days

Question 30

What is first-line therapy for majority of GAS cases in adults?

Answer 30

Amoxicillin x 6-10 days

Question 31

If an adult has type 4 penicillin allergy or amoxicillin hypersensitivity (e.g., rash) how else could their GAS be treated?

Answer 31

1. Cephalexin 2. Clindamycin (C. diff risk) or 3. Clarithromycin (QT prolongation risk) All x 10 days

Question 32

If an adult with GAS has a refractory infection to first-line agents, what 2 meds can be tried instead?

Answer 32

1. Amox/clav x 3 days 2. Clindamycin x 3 days