Christopher Hoffmann MD, Stephen D. Sisson MD/Ambulatory Curriculum
Section 1: Upper respiratory tract infection Causes: rhinovirus (30-50%); coronavirus (7-18%); influenza (5-7%); RSV (5%); parainfluenza, adenovirus and enterovirus each <5% Symptoms: sore throat, sneezing, cough, nasal congestion, headache, sinus pressure, malaise Complications: rare (<2%), include bacterial sinusitis or otitis media Treatment: symptomatic; antibiotics are not indicated
Section 2: Influenza Causes: influenza A; influenza B o Antigenic drift: small changes in HA and NA antigens o Antigenic shift: major change in HA or NA antigen; results in pandemic. Swine-origin H1N1 in 2009 represented antigenic shift. Symptoms: fever, myalgias, malaise/lethargy, non-productive cough, sore throat, delirium Diagnosis: consider EBV, acute HIV in differential, as clinical overlap significant Treatment: treatment must begin within 48H of onset of symptoms; vaccination always preferable o Amantadine/rimantadine: treats only influenza A; resistance widespread Amantadine: 100mg bid (100mg qd if age>65 or renal insuff) Rimantadine: 100mg bid (100mg qd if age >65 or renal insuff o Oseltamivir/zanamivir: treats influenza A and B. Zanamivir is by inhalation; use with caution if h/o reactive airways. Oseltamivir: 75mg bid x 5d; Widespread Influenza A H1N1 resistance to this drug seen in 2008-09 season. Zanamivir: 100mg bid inhalation. Influenza A resistance not seen but use limited by contraindications (e.g., lung disease, elderly)
Section 3: Pharyngitis Causes: Same as URTI, but add EBV, HIV, HSV, gonorrhea to differential. o Major clinical concern is etiology of Streptococcus pyogenes (GABHS) Complications: major concerns are rheumatic fever and post-streptococcal glomerulonephritis o Treatment must begin within 9 days of onset of symptoms to prevent these complications Diagnosis o Centor criteria T>38C Tonsillar exudates Tender cervical adenopathy No cough or rhinitis Treatment (penicillin is antibiotic of choice, with erythromycin used if allergic) o 0-1 Centor criteria: symptomatic treatment o 2 or 3 Centor criteria: rapid strep antigen test; antibiotics only if positive o 4 Centor criteria: empiric antibiotics or rapid strep test and antibiotics if positive
Section 4: Sinusitis Causes: Same as URTI; major clinical concern is presence of bacterial infection (S. pneumoniae most common; H. influenzae second most common) Diagnosis: Features suggestive of acute bacterial sinusitis include fever or any of the following: o Presence of symptoms>7d or symptoms worsening after initial improvement o Maxillary tooth pain o Unilateral facial pain or unilateral sinus tenderness o Purulent nasal discharge Treatment: amoxicillin, doxycycline, trimethoprim/sulfamethoxazole are best options; use amoxicillin/clavulanate or moxi/levofloxacin if recent antibiotic exposure
Section 5: Acute bronchitis Definition: a respiratory illness of <3wks duration in which cough is primary complaint Causes: same as URTI, but may include Mycoplasma pneumoniae, Chlamydophila pneumoniae Diagnosis: differential includes pneumonia or pertussis. American College of Physicians states evaluation should focus on clinically ruling out pneumonia Treatment: antibiotics are not indicated for treatment of bronchitis. Beta-agonist inhalers, NSAIDs, first-generation antihistamines may improve cough
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