Table of contents
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
- Viral
- 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:
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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.
- Symptom management
- 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.
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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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