CONTINUITY CLINICAL WEB-BASED CURRICULUM - TAKE HOME POINTS MODULE: UPPER RESPIRATORY TRACT INFECTIONS (PHARYNGITIS, URTI, SINUSITIS,

AND BRONCHITIS)
(1) Pharyngitis Group A beta hemolytic streptococcal (GABHS) pharyngitis is an uncommon cause of pharyngitis in adults (it causes 5 15% of adult cases of pharyngitis). Risks associated with untreated streptococcal pharyngitis: rheumatic fever (can be prevented with Abx), GN (cannot be prevented with Abx) Other potential complications of streptococcal pharyngitis include peritonsillar abscess (Quinsy), cervical lymphadenitis, mastoiditis, sinusitis, otitis media, and infectivity to others. Differential Diagnosis Viral Accounts for the majority of pharyngitis in adults. Symptoms of viral pharyngitis may be mild or severe, and is often accompanied by rhinorrhea or cough. Uncommon causes: Viral - Epstein-Barr virus, Acute infection with HIV Bacterial GABHS is the most common bacterial cause of pharyngitis The sore throat of GABHS is typically of sudden onset, with pain on swallowing and fever. In severe cases, headache, nausea, vomiting and abdominal pain may develop. Classic physical findings include tonsillopharyngeal erythema (usually with exudates, but they may be absent), and tender, enlarged anterior cervical lymph nodes. The signs and symptoms of GABHS overlap significantly with other causes of pharyngitis, and the combination of enlarged tonsils, creamy white exudates, fever, and tender adenopathy occurs in fewer than 10% of cases of streptococcal pharyngitis. Other bacterial causes of pharyngitis include group C and G streptococci, but do not result in an increased risk of developing rheumatic fever. Uncommon causes: Bacterial Gonococcal, Diphtheria Laboratory testing for pharyngitis The gold standard for diagnosis of GABHS pharyngitis remains bacterial culture, 9095% sensitivity. Rapid antigen detection kits: >95% specificity, with 80-90% sensitivity Clinical prediction rules for pharyngitis (a) The Centor criteria have a demonstrated sensitivity and specificity of 75%, if three or four of the features are present Tonsillar exudate Tender anterior cervical adenopathy History of fever, or T>38 Absence of cough

(b) University of Michigan Prediction rule (add up score, if +3 then highly likely GABHS pharyngitis, if 1 or 2 then highly unlikely GABHS pharyngitis, if 0,1,2 consider testing) +1 for each of fever, tonsillar exudates, cervical lymphadenopathy -1 for each of cough, post-nasal drip Treatment of pharyngitis Supportive: salt-water gargles, hydration, and analgesics. If GABHS: 10 days of penicillin (Penicillin V, 250mg QID or 500mg BID). Alternatively, Erythromycin (250mg QID or 500mg BID) should be used in patients allergic to penicillin. Family members of individuals with streptococcal pharyngitis should be treated with antibiotics only if they are symptomatic with suggestive features.

(2) Upper respiratory tract infections (URTIs) The most common reason for seeking medical evaluation (more common than pharyngitis), and are the second most common reason that antibiotics are prescribed in the outpatient setting. The most common cause of URTI is rhinovirus, which is responsible for 80% of all URTI. Other viral causes include coronavirus, respiratory syncytial virus, and adenoviruses. Symptoms typically begin as a scratchy throat, which resolves after two to three days. Nasal symptoms then predominate, with cough following the nasal symptoms. The typical duration of symptoms is one week, but in 25% of patients, symptoms last two weeks. Risks associated with URTIs Bacterial sinusitis is a rare complication of URTI; only 2% of URTIs are complicated by bacterial sinusitis. Pneumonia is an even less common complication of URTI. Differential Diagnosis Influenza Abrupt onset of symptoms, with fever, rigors, myalgias and headache. Sore throat may be severe, and myalgias predominate early in illness. GABHS Pharyngitis Predominant pharyngeal symptoms, with the absence of cough and rhinorrhea. Management URTI Supportive care is the only uniformly accepted management of URTI. Adequate hydration, bed rest and antipyretics are commonly recommended. First generation antihistamines (e.g. diphenhydramine) are effective at treating rhinorrhea. Nasal congestion and obstruction may respond to oral adrenergic agents (e.g. pseudoephedrine) or topical agents. Zinc and Echinacea: studies on both these agents show mixed results, perhaps shorter duration of symptoms. Influenza Immunization (to prevent infection) Two classes of agents used to decrease the severity and duration of symptoms. - Amantadine and rimantadine: useful only for the treatment of influenza A if initiated within the first 48H of symptoms. - Zanamivir (delivered via inhalation) and oseltamivir (delivered orally): useful for both influenza A and B infection. They also must be initiated within the first 48H of illness to be effective.

(3) Acute sinusitis (rhinosinusitis) ACP definition: inflammation of the mucosa of the paranasal sinuses, regardless of cause. Sinus inflammation can occur in non-infectious situations: allergies and irritants both may lead to sinusitis. The most common risk factor for acute bacterial sinusitis is a preceding viral URTI, allergic rhinitis, trauma, dental infections. The most common bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Complications of untreated bacterial sinusitis are very uncommon, and include orbital cellulitis, tooth abscess, and meningitis. Diagnosis Duration: The ACP suggests that duration of symptoms greater than seven days is a moderately sensitive, but nonspecific predictor of bacterial sinusitis. The best predictors of acute bacterial sinusitis include the following: 1. Duration of symptoms greater than 7 days 2. Purulent nasal discharge (by history or physical examination), although most patients with purulence will have VIRAL sinusitis. 3. Maxillary tooth or facial pain (especially unilateral) 4. Unilateral maxillary sinus tenderness 5. Lack of response to decongestants Radiographic imaging adds little to the evaluation of the patient with suspected acute bacterial sinusitis, unless after failed to respond to prolonged therapy. Management Topical or oral adrenergics are typically used as nasal decongestants and to help the sinuses drain (will help if NOT bacterial). Topical steroid sprays are also often used to help reduce inflammation and swelling, allowing the sinuses to drain. Antibiotics: For patients with clinical evidence of severe sinusitis require antibiotics. May not be required if symptoms are mild or moderate. If antibiotics are prescribed, narrow spectrum antibiotics should be used (amoxicillin or trimethoprim/sulfamethoxazole as first line) unless the patient has received antibiotics in the previous 4-6 weeks (for

(4) Bronchitis Bronchitis is not only a very frequent cause of visits to the physician, but also a frequent cause of inappropriate antibiotic prescriptions. Definition: an acute respiratory tract infection of less than 3 weeks duration, with cough (productive or non-productive) a predominant feature. Differential Diagnosis Acute viral respiratory illness (70%), asthma (6%) and pneumonia (5%). Viral bronchitis may be caused by rhinovirus, adenovirus, coronavirus, respiratory syncytial virus, and influenza and parainfluenza. Diagnosis Primary objective: to differentiate patients with pneumonia from those with other illnesses that present with cough. Purulence is of no help in distinguishing between bacterial and viral causes. Pneumonia is very unlikely if the following are true: - All vital signs are essentially normal (specifically, pulse is <100, RR < 24, T<38) - Chest auscultation is normal Management Bacterial bronchitis does not require antibiotics. However, there is evidence that antibiotics may be beneficial in patients who have COPD. Beta-agonist inhalers such as albuterol will reduce the severity and duration of cough. Cough suppressants, such as dextromethorphan and codeine, may improve symptoms in some. Patients should otherwise expect the cough to persist from 10-14 days.