Croup is an acute viral infection that is the most common cause of upper airway obstruction in children between 6 months to 6 years of age; affected patients typically manifest a low-grade fever, barking cough, inspiratory stridor, and refusal to lie down.
Croup is a clinical diagnosis; in most patients, the key alternative diagnosis is epiglottis. However, croup tends to have a more gradual onset, with patients rarely displaying drooling or dysphagia; conversely, a barking cough is not seen in epiglottitis.
Laryngoscopy is the technique of choice to diagnose suspected epiglottitis; this is also useful in determining the need for an airway intervention (e.g., intubation, cricothyroidotomy or tracheotomy).
As the procedure may set off acute upper airway obstruction, it should always be performed in the operating theatre, under general anesthesia, and with staff and equipment prepared for emergency intervention.
Epiglottitis: securing the airway
Once epiglottitis has been diagnosed, the immediate priority is to secure the airway - especially if features of respiratory distress are present.
Features of respiratory distress include stridor, a muffled voice, a rapidly worsening clinical course, and severe swelling of the epiglottis, arytenoids, and aryepiglottic folds upon laryngoscopic visualization.
Epiglottitis: empirical antibiotic therapy
Most cases of epiglottitis are due to Haemophilus influenzae (Hib) type B and type A streptococcus. Intravenous third-generation cephalosporins (e.g., ceftriaxone) are the empirical antibiotics of choice.
Epiglottitis due to MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon cause of epiglottitis. However, where this occurs, the classical empiric antibiotic regimen is ineffective, and vancomycin should be commenced instead.
MRSA: preventing spread
As MRSA is a drug-resistant pathogen, it is essential to adopt measures to prevent its spread.
This includes isolation of the patient, using disposable equipment where possible, frequent environmental cleaning and disinfection, proper hand cleansing, and the use of protective measures such as face masks, gloves, and gowns
Methicillin-resistant Staphylococcus aureus (MRSA) can be transmitted to the household contacts of infected individuals, especially if they had a respiratory infection. However, current guidelines do not recommend the screening of these contacts or the use of prophylactic antibiotics.
An exception to the above rule is if the patient falls into one or more specific categories (e.g., being on hemodialysis or if they are to undergo surgery in the near future).
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