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Upper Respiratory Upper Respiratory Tract InfectionsTract Infections

Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine

Dr. Zekeriya Aktürkzekeriya.akturk@gmail.com

www.aile.netUtilized work: Dr. Aynur Engin, Cumhuriyet University, Sivas, Turkey and Dr. Ela Eker, Trakya University, Edirne, Turkey

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• Acute tonsillitis• Acute pharyngitis• Acute otitis media• Acute sinusitis• Common cold• Acute laryngitis• Otitis externa• Mastoiditis• Acute apiglottis

Upper Respiratory Tract Infections

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Objectives

• At the end of this session, the participants should be able to;– List upper respiratory tract infections– Make differential diagnosis between URTI– Define criteria for antibiotic use– Apply and interpret the McIsaac scoring

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• Bacteria– S. pyogenes– C. diphteriae– N. gonorrhoeae

• Viruses– Epstein-Barr virus– Adenovirus– Influenza A, B– Coxsackie A – Parainfluenzae

Tonsilitis-pharyngitis

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• < 3 years 100 % viral

• 5-15 years– 15-30 % GABHS

• Adult– 10 % GABHS

Causative organisms

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• Spreads by close contact and through air• Spread more in crowded areas (KG, school,

army..)• Most common among 5-15 age group• More frequent among lower socio-

economic classes• Most common during winter and spring• Incubation period 2-4 days

Due to streptococci:

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Sore throat Anterior cervical LAP Fever > 38 C Difficulty in swallowing Headache, fatigue Muscle pain Nausea, vomiting

Signs/symptoms

Tonsillar hyperemia / exudates

Soft palate petechiaAbsence of coughingAbsence of nose dripAbsence of hoarseness

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• Having additional rhinitis, hoarseness, conjunctivitis and cough

• Pharyngitis is accompanied by conjunctivitis in adenovirus infections

• Oral vesicles, ulcers point to viruses

Viral tonsillitis/pharyngitis

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• GABHS• EBV • Adenovirus• Primary HIV infection• Candida albicans• Francisella tularensis

Exudates

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• GABHS• Epstein-Barr virus• Adenovirus• Human herpesvirus type 6• Tularemia• HIV infection

Lymphadenopathy

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• Throat swab– Gold standard

• Rapid antigen test– If negative need swab

• ASO– May remain + for 1 year

• WBC count• Peripheral smear

Laboratory

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• Pathogens looked for– Group A beta hemolytic streptococci– C. diphteriae (rare)– N. gonorrhoeae (rare)

• If GABHS do we need antibiogram?– Is there resistence to penicilline?

Throat Culture

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• Supurative complications– Abscess

– Sinusitis, otitis, mastoiditis

– Cavernous sinus thrombosis

– Toxic shock syndrome

– Cervical lymphadenitis

– Septic arthritis, osteomyelitis

– Recurrent tonsillitis/pharyngitis

• Nonsupurative complications– Acute romatoid fever

– Acute glomerulonephritis

Tonsillitis due to Streptococci

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• Prevention of complications

• Symptomatic improvement

• Bacterial eradication

• Prevention of contamination

• Reducing unnecessary antibiotic use

Aim of Treatment

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• Many different antibiotics can eradicate GABHS from pharynx

• Starting treatment within 9 days is enough to prevent ARF

Treatment

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• Tetracycline

• Sulphonamides

• Co-trimoxasole

• Cloramphenicole

• Aminoglycosides

Antibiotics NOT to be used

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• Control culture after full dose treatment?– NO

• If history of ARF:– Take control culture after treatment

• No need to screen or treat carriers

GABHS

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• Developed by Mc Isaac and friends

• Decreases antibiotic usage by 48%

• No increase in throat swabs

Mc Isaac Scoring

http://www.cmaj.ca/cgi/content/abstract/163/7/811

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Clinical Findings Score

Fever > 38 C 1

Absence of coughing 1

Tonsillary hypertrophy or exudates

1 (If < 6 years give 0)

Sensitivity at the anterior cervical nodes

1

Age 3 – 14 1

Age > 45 -1

Mc Isaac Scoring

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Total score Suggestions

0 - 1 points No culture, no antibiotics

2 - 3 points Take culture (or antigen test), order antibiotics only if GABHS +

4 - 5 points Take culture (or antigen test), order antibiotics only if GABHS +.

If the clinic is severe, start antibiotics without testing

Mc Isaac Scoring

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ORAL

Penicilline V Children:2x250 mg or 3x250mg,10 days

Adults:3x500 mg or 4x500mg,10 days

PARENTERAL

Benzathine penicilline Adults:<27kg:600 000 U single dose, IM

>27 kg:1.200 000 U single dose, IM

ALLERGY TO PENICILLINE

Erithromycine estolate 20-40 mg/kg/day, 2x1 or 3x1, 10 days

Erithromycine ethyl succinate

40 mg/kg/day, 2x1 or 3x1, 10 days

Antibiotics in Tonsillitis/pharyngitis due to GABHS

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• AOM• AOM not responding to treatment: Sustained

clinical and autoscopy findings despite 48-72 therapy

• Recurrent atitis media: 3 AOM attacks within 6 moths or 4 attacks within 1 year

Acute Otitis Media

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• S. pneumoniae 30%• H. İnfluenzae 20%• M. Catarrhalis 15%• S. pyogenes 3%• S. aureus 2%• No growth 10-30%• Chronic otitis media: P. aeruginosa, S. aureus,

anaerobic bacteria

AOM causes

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• 85% of children up to 3 years experience at least one,

• 50% of children up to 3 years experience at least two attacks

• AOM is usually self-limited. Rarely benefits from antibiotics.

• 81 % undergo spontaneus resolution.

Acute Otitis Media

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• Symptoms– Autalgia– Ear draining– Hearing loss– Fever– Fatigue– Irritability– Tinnitus, vertigo

• Otoscopic findings– Tympanic membrane

erythema– Inflammation– Bulging– Effusion

• Hearing loss

Signs and Symptoms

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First choice

Amoxicilline 40 mg/kg/day, 3 doses

Trimet./Sulfamethoxazole 8mg TM/40mg SMX/kg 2 dose

Second choice

Amoxicilline/clavulanate 45 mg/kg/day, 2 doses

Erythromycin 40-50 mg/kg/day, 3 doses

Reurrent AOM prophylaxis

Sulfisoxazole 75 mg/kg/day, single dose 3-6 mo

Amoxicilline 20 mg/kg/day, sinle dose 3-6 mo

Antibiotics

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Acute sinusitis• Str. pneumoniae %41

• H. influenzae %35

• M. catarrhalis %8

• Others %16Strep. pyogenes S. aureus

Rhinovirus

Parainfluenzae

Veilonella, peptokoccus

Chronic sinusitis• Anaerob bakteria:

Bactroides, Fusobacterium

• S. aureus

• Strep. pyogenes

• Str. pneumoniae

• Gram (-) bakteria

• Fungi

Acute Rhinitis / Sinusitis

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• Paranasal sinuses:– Frontal– Ethmoid– Maxillary– Sphenoid

• Most common during childhood– Maxillary– Ethmoid

• After age 10 – Frontal

Acute Sinusitis

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• Anatomical: septal deviation,

• Mukociliary functions: cystic fibrosis, immotile cilia synd.

• Systemic dis., immune deficiency.: DM, AIDS, CRF

• Allergy: Nasal poliposis, asthma

• Neoplasia

• Environmental: smoking, air pollution, trauma...

Predisposition to Sinusitis

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• Most important: Headache and postnasal dripping• Face congestion• Fever, fatigue, headache increased by leaning

forward• Nose obstruction• Nose dripping• Purulent secretions (rhinoscopy)• Sensitivity over the sinuses• Halitosis

Acute Rhinosinusitis

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Rhinitis

• Increased symptoms after 5 days

• Symptoms lasting > 10 days

• Decreasing viral symptoms, nasal secretion becoming more purulent

are indicative for acute rhinosinusitis

Acute rhinosinusitis

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• Direct x-ray– Diffuse opacification– Mucosal thickening >4 mm– air-fluid level

• Sinus aspiration– Rarely performed

• Nasal endoskopy• Tomography

– More sensitive compared with direct x-ray

– Indicated before surgery

Diagnosis

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• Ampirical– Specific microbiologic diagnosis difficult

• Primary pathogens– S. pneumoniae– H. influenzae

Treatment

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• Antibiotics questionable

• Stalman: 192 patients. No difference between placebo and doxycycline.

• Van Buchem: 214 patients. No difference between amoxycilline and placebo.

• Lindbaek: 130 patients. compared Pen V, Amoxycilline and placebo. 86 % of patients receiving antibiotics and 57% of patients receiving placebo improved.

Treatment

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• Amoxycilline (Alfoxil) 3x500mg/d PO 10 d

• Amoxycilline/clavulonate (Augmentin) 3x625 mg/d PO 10 d

• Sefprosil(Serozil) 2x1000 mg/d PO 10 d

• Sefuroxim (Zinnat) 2x250 mg/d PO 10 d

• Azithromycine (Zitromax) First day 1x500 mg, then 1x250 mg/d PO 5 d

Antibiotics for Sinusitis

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• Decongestants– Short duration 3-5 days

• Antihistamines– If allergy

• Normal saline

• Local steroids

Support Therapy

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• Adults Rhinovirus

• Children Parainfluenzae and RSV

Common Cold

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• Fatigue

• Feeling cold, shuddering

• Nose burning, obstruction, running

• Sneezing

• Fever

Common Cold

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• Causes epidemics and pandemics

• Highly contagious

• Viral infection.

Influenza (flu)

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Cause

• 80 % Influenzae virus

• Parainfluenza %2-9

• Rhinovirus %3

• Adenovirus %4

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• Sudden onset after 12-24 hours incubation

• General weakness and fatigue

• Feeling cold, shivering, temp. Up to 39-40 C

• No sore throat or running nose

• Severe back, muscle and joint pain

Influenza