Pharyngitis & Bronchitis - Med/High Priority

Question 1

What are the two types of URTI?

Answer 1

acute rhinopharyngitis:
-inflammation of the nasopharynx
acute pharyngitis:
-inflammation of the pharynx, commonly caused by a virus or, less commonly GAS

Question 2

What is acute bronchitis?

Answer 2

inflammation of the bronchi, usually from viral infection but sometimes bacterial or due to irritant exposure
-a type of LRTI

Question 3

What are the risk factors for pharyngitis & bronchitis?

Answer 3

exposure to others with infection
inadequate hand hygiene
crowded environments
exposure to lung irritants that compromise respiratory tract ciliary function (chemicals, smoking)

Question 4

What are most cases of acute pharyngitis caused by?

Answer 4

viruses

Question 5

What are the symptoms that might be seen in GAS strep throat?

Answer 5

sudden onset of sore throat, fever, absence of cough, palatal petechiae, and possible scarlet fever (rare)

Question 6

What are the rare complications of GAS strep throat?

Answer 6

invasive GAS
neck space infection
glomerulonephritis

Question 7

What are most cases of acute bronchitis caused by?

Answer 7

viruses
-usually follows a viral URTI

Question 8

How long does a case of acute bronchitis typically last?

Answer 8

often self-limiting to 10-14 days

Question 9

What are the typical symptoms of acute bronchitis?

Answer 9

coughing (+/- sputum production)
URTI symptoms (congestion, runny nose, watery eyes)

Question 10

How long might a cough from acute bronchitis last?

Answer 10

3-4 weeks

Question 11

Is purulent sputum a sign of bacterial infection causing bronchitis?

Answer 11

purulent sputum is not an indication of bacterial infection, but rather the presence of leukocytes and inflammation

Question 12

How is bacterial pharyngitis diagnosed?

Answer 12

rapid antigen test (RAT) or throat culture is best way to diagnose GAS
-RAT ok to rule out adults, need culture for children

Question 13

What are some symptoms that would prompt referral in a patient with acute bronchitis?

Answer 13

high fever
systemic signs such as tachypnea and tachycardia

Question 14

What are the non-pharmacological measures for pharyngitis and bronchitis?

Answer 14

education:
-no benefit from antibiotics except in cases of pertussis or acute pharyngitis secondary to bacterial pathogen
-likely viral cause of URTI/bronchitis/pharyngitis
-limiting spread of infection through proper hand hygiene
-avoiding environmental irritants (smoke, pollen)
OTC:
-lozenges and lidocaine for mild pain relief
humidity:
-increase humidity to reduce cough
fluids:
-use fluids to prevent dehydration in children and reduce viscosity of respiratory secretions
comfort:
-improve pts comfort by rest, activity as tolerated

Question 15

What is the benefit of echinacea for pharyngitis or bronchitis?

Answer 15

no conclusive evidence showing it reduces severity or duration

Question 16

What is the benefit of honey for pharyngitis or bronchitis?

Answer 16

no evidence it reduces duration but may help with symptomatic treatment of sore throat or cough
-use pasteurized honey

Question 17

At what age can honey be used for symptom management of bronchitis or pharyngitis?

Answer 17

> 1 yrs old

Question 18

What is the evidence for vitamin C for pharyngitis or bronchitis?

Answer 18

no conclusive evidence that it reduces duration or severity of URTI

Question 19

What is the benefit of nasal saline spray for pharyngitis or bronchitis?

Answer 19

helps with symptomatic treatment of nasal congestion and discomfort

Question 20

What is the evidence for zinc for pharyngitis or bronchitis?

Answer 20

there is evidence that zinc shortens the duration and severity of a cold
-intranasal zinc has side effect of permanent anosmia
-lozenges can cause mouth irritation

Question 21

What can be used for fever, headache, or pain associated with URTIs?

Answer 21

acetaminophen or ibuprofen

Question 22

Which analgesic or antipyretic should be avoided in children and adolescents?

Answer 22

ASA
-risk of Reyes syndrome

Question 23

Which drug is an antitussive?

Answer 23

dextromethorphan

Question 24

What is the use of dextromethorphan for productive coughs?

Answer 24

not recommended for a productive cough

Question 25

In which age group should dextromethorphan be avoided?

Answer 25

children < 6 yrs of age -lack of evidence for efficacy and risk of AE

Question 26

What is the benefit of bronchodilators or ICS for URTI?

Answer 26

use in pts with wheezing; no evidence of efficacy unless airway obstruction is present

Question 27

What is the use of antihistamines for URTI?

Answer 27

avoid antihistamines as they cause drying of mucus secretions, which prevents effective clearance

Question 28

What is the benefit of guaifenesin for URTI?

Answer 28

no evidence of efficacy

Question 29

What is the use of the Modified Centor Score?

Answer 29

estimates probability of streptococcal pharyngitis based on symptoms and physical findings -guides clinicians on when to perform diagnostic testing and when empirical antibiotics may be appropriate -also helps to identify pts unlikely to benefit from antibiotics

Question 30

What are the parameters of the Modified Centor Score?

Answer 30

TASTA acronym -temperature > 38 C = 1 point -absence of cough = 1 point -swollen lymph nodes = 1 point -tonsillar swelling/exudate =1 point -age (3-14 yrs =1 point, 15-44 yrs = 0 point, > 45 yrs = -1 point)

Question 31

Provide an interpretation of the Modified Centor Score based on a pts score.

Answer 31

less than or equal to 2 points: -risk of GABHS: 1-17% -no further testing or antibiotics 3 points or greater: -risk of GABHS: 28-53% -perform RADT -if positive RADT --> treat with ABX -if negative RADT & < 20 yrs old --> throat culture, ABX if + -if negative RADT & > 20 yrs --> no ABX

Question 32

Why do pts < 20 yrs old require a throat swab if their RADT is negative and their Modified Centor Score is 3 points or greater?

Answer 32

RADT is not sensitive in children (risk of false negatives) -if a RADT is negative in a child, then perform culture to confirm results

Question 33

Are routine antibiotics recommended for most cases of bronchitis?

Answer 33

not recommended for acute bronchitis -since virus accounts for up to 95% of cases

Question 34

Are corticosteroids recommended with antibiotics for bacterial pharyngitis?

Answer 34

corticosteroids with antibiotics is not recommended

Question 35

When should antibiotics be started for children with bacterial pharyngitis?

Answer 35

within 9 days of symptom onset

Question 36

What is the optimal treatment against GAS pharyngitis in children?

Answer 36

amoxicillin or penicillin for 10 days

Question 37

What is the dose of amoxicillin in kids for GAS pharyngitis?

Answer 37

50 mg/kg/day

Question 38

Which antibiotic can be used for GAS pharyngitis in children who are unlikely to complete a 10-day antibiotic course?

Answer 38

penicillin G benzathine x 1 dose (IM)

Question 39

What is the treatment for GAS pharyngitis in children who have a non-anaphylactic hypersensitivity reaction to penicillin?

Answer 39

amoxicillin challenge -low risk pt is given small initial dose of amoxicillin and observed for 20-30 minutes cephalexin 20 mg/kg/dose BID x 10 days

Question 40

What is the treatment for GAS pharyngitis in children who have a documented type 1 hypersensitivity to penicillin (anaphylaxis)?

Answer 40

row 1 = ACC -azithromycin x 5 days -clarithromycin x 10 days -clindamycin x 10 days

Question 41

What is the mainstay of treatment for GAS pharyngitis in adults?

Answer 41

6-10 day course of amoxicillin or penV

Question 42

What is an alternate treatment option for GAS pharyngitis in adults who have adherence concerns?

Answer 42

penicillin G benzathine IM x 1 dose

Question 43

What are the causes of acute pharyngitis?

Answer 43

non-bacterial organisms: -viral (rhinovirus, coronavirus, adenovirus common) bacterial organisms: -Strep pyogenes (GAS) -others: Neisseria, Fusobacterium

Question 44

What are the causes of acute bronchitis?

Answer 44

non-bacterial organisms: -viral causes account for > 90% of cases -rhinovirus, influenza A and B, parainfluenza, RSV, coronavirus, enterovirus, and adenovirus bacterial organisms: -uncommon causes -S. pneumoniae, H. influenzae, M. catarrhalis, M. pneumoniae, C. pneumoniae, Bordatella pertussis

Question 45

What is the treatment for GAS pharyngitis in adults if refractory infection to 1st line agents?

Answer 45

amoxicillin/clavulanic acid x 3 days clindamycin x 3 days

Question 46

What is the treatment for GAS pharyngitis in adults with a type 4 penicillin allergy or amoxicillin hypersensitivity?

Answer 46

cephalexin or clindamycin or clarithromycin - x 10 days