Common Infections Redirected from Family Medicine/Common Infections

     

     

    Pharyngitis (Sore Throat)

    • Inflammation of the oropharynx
    • Wide range of organisms:
      • Viral
        • Adenovirus, rhinovirus, influenza virus, RSV, EBV, coxsackie virus, HSV, CMV, HIV.
        • Most common cause - year around.
      • Bacterial
        • Group A beta-hemolytic Strep (most common bacterial cause 5-15% adult, 50% peds, usually in winter)
        • Croup C and G beta-hemolytic Step, N. gonorrheae, Chlamydia pneumoniae, Mycoplasma pneumoniasee, Corynebacterium diphtheriae.
      • See Streptococcal Pharyngitis
    • If suspect EBV (mononucleosis) - do peripheral blood smear ("monospot")
      • Giving Ampicillin produces rash.
      • Rest, supportive care (tylenol, NSAIDs)
      • Avoid contact sports until splenomegaly resolves - to prevent splenic rupture.

    Streptococcal Pharyngitis

    Symptoms:

    • Sore Throat
    • Fever
    • Enlarged Tonsils + exudate (could be tonsillar abscess)

    DDx

    • Strep Pharyngitis
    • Mononucleosis
    • STI: gonococcal or chlamydial
    • Viral Pharyngitis

    Dx: 

    • Use Rapid Strep Test (in-office) 95% sensitivity, 50-90% specificity.
      • If positive - treat
      • if negative - take culture, treat if positive.
    •  
    • Who to swab for B-Hemolytic strep?  - Use Modified Santor Score:
      • Modified Centor Score
        • Temp >38
        • Tonsillar Swelling or Exudate
        • Absence of Cough
        • Tender anterior lymph nodes

        Interpretation:

        • 0-1 --> Do not swab (2.5% risk of strep)
        • 2-3 --> Swab, treat if positive (28% risk of strep)
        • 4 --> Likely strep, treat (53% risk of strep)
    •  
    • How to distinguish strep from mono?
      • Anterior cervical lymph nodes for strep, and both anterior and posterior for mono
      • Mono spot
      • Blood CBC - Atypical lymphocytosis in mono
      • LFTs elevated in mono
    • Complications
      • Rheumatic fever
      • Glomerulonephritis
      • Suppurative complications (abscess, sinusitis, otitis media, penumonia)
      • meningitis
      • impetigo

    Tx:

    • Drugs:
      • Penicillin --> Cheapest penicillin 300mg qid x10 days
      • Amoxicillin 500mg tid x10 days
      • Cephalosporins (cost 50-60x more)
      • Macrolides (cost 30x more) - azithromycin 500mg first day, then 250mg x5 days (take two pills on day 1)
      • Amox-Clav - (50x more expensive, rarely used in this)
    • Why do we treat? - to prevent Rheumatic Fever, however evidence shows we cannot prevent post-strep glomerulonephritis

    Sinusitis

    • Presentation:
      • Congestion +/- nasal discharge
      • Fever
        Headache, sinus pain    
      • Post-nasal drip
    • Causes:
      • Strep pneumoniae
      • H. influenza
      • Staph aureus
      • Moraxella catarrhalis
      • Viral

    DDx

    • Viral URI
    • Allergies
    • etc.

    Dx:

    TREAT IF >7 DAYS

    • What increases the likelihood the pt has sinusitis?
      • if lasts 10-14d with no improvement
      • If nasal congestion, nasal pain, purulent discharge after day 5

    Tx:

    • Acute sinusitis: (i.e. ~7 days)
      • Symptom management
        • Analgesics
        • Decongestants such as chlorpheniramine.
        • Intra-nasal steroids. (try others first).
      • Most resolve in 7-10 days.
      • Abx if complicated by fever or worsening symptoms (efficacy not well documented).
        • First line: Amoxicillin 500mg tid 7-10 days
        • Recent review 2009 - 10 days of rhinosinusitis sx: abx = watchful waiting.
    • Why do we treat? - can get complications such as:
      • chronic sinusitis
      • tracking to CNS --> meningitis, cavernous sinus thrombosis etc..
    • Imaging:
      • Typically reserved for those with a complicated presentation (headache, visual changes etc..)
    • Note:
      • Nasal cultures: not shown to help identify organism. 

    Acute Otitis Media

    • Presentation:
      • Common triad: otalgia, fever, conductive hearing loss
      • May include poor sleep, irrititability, poor feeding
      • Hyperemia, opaque bulging tympanic membrane on direct otoscopy
    • Organisms:
      • Strep pneumoniae
      • H. influenza
      • Moraxella catarrhalis

    Tx:

    • 80-90% will resolve with watchful waiting in 48-72hrs..treat fever.  Watch for rash, drowsiness, vomiting, SOB
    • To treat or not to treat:
      • Acute Otitis Media Guidelines
        • <6mo of age - Antibiotic therapy
        • 6mo-2yrs - Antibiotic therapy if certain of diagnosis.  Observation if uncertain diagnosis
        • >2hrs - Antibiotic therapy if severe illness.  Observation if non-severe or uncertain diagnosis.
        (AAP & AAFP Clinical Practice Guidelines)
      • Reasons to treat right away:
        • <6mo
        • Fever >39C
        • Perforation
        • Toxic
        • Unreliable parents
        • symptoms not improving after 2-3 days.
    • Drugs:
      • 1st line: Amoxicillin 80-90 mg/kg/d  (use macrolides if penicillin allergy)
      • 2nd line: Amoxicillin-clavulanate (6.4 mg/kg/d)
      • Antipyretic: 10-15 mg/kg acetaminophen, max 75mg/kg/day
    • Antipyretics/Analgesics: Acetaminophen 10-15mg/kg/dose PO Q4H prn
    • If TM perforation, use drops.

    Bronchitis (Acute)

    • Symptoms
      • SOB
      • Productive cough
      • Fever
    • Etiology
      • 80% viral: rhinovirus, coronavirus, adenovirus, influenza, parainfluenza, RSV
      • 20% bacterial: M. pneumoniae, C. pneumoniae, S. pneumoniae
    • Dx: clinical, R/O pneumonia, asthma, COPD
    • Tx:
      • frequent hand washing, smoking
      • Symptom relief: rest, fluids (3-4L/d), humidity, analgestics, antitussives
      • bronchodilators can relieve sx.
      • Abx not supported in literature unless chronic or comorbidities.
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