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Upper Respiratory Tract Infection.

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  1. 1. Objectives•Management principles• Effects of Rx• Antibiotic in specific URTI• Factors affect prescription
  2. 2. DefinitionURTI inflammation of respiratory mucosa fromthe nose to the lower respiratory tree notincluding the alveoli.
  3. 3. Symptoms•Sore throat•Rhinorrhea•Facial fullness and Pain•Headache•Cough•Fever•Tender lymph nodes•Ear Pain
  4. 4. Epidemiology•In average Children will have 5 URTI/Year, & adults 2-3/Year•Acute rhinitis is by far the most common cause of doctorsvisit.•Otitisto visit aisphysician.common cause for a child underage 15 media the most•Acute Otitis Media, the most common condition forantibiotics (50%).
  5. 5. Types and causative agents
  6. 6. Management PrinciplesViral infections need only symptomatic treatment: -Analgesics (Paracetamol, Aspirin, Ibuprofen) -Anti-histamines -Cough suppressants -Nasal decongestants -Vitamin C -Increase fluid intakeBacterial Infections need antibiotics in addition ofsymptomatic treatment
  7. 7. Management PrinciplesViral (Don’t Use Antibiotics) Bacterial (Use antibiotics)Why? Why?-Promotes antibiotic resistance - To prevent rheumatic fever-Adverse reactions such as allergy - To prevent suppurativeand anaphylaxis complications (e.g., peritonsillar abscess)-Costly - To speed up recovery-Patients do not need antibiotics tofeel satisfied - To reduce spread to others
  8. 8. Management PrinciplesViral (Don’t Use Antibiotics) Bacterial (Use antibiotics)-Influenza, Common Cold -GABHS Pharyngitis-Viral Pharyngitis -Moderately to severe-Mild Acute Sinusitis Acute Sinusitis-Mild Acute Otitis Media -Moderately to severe Acute Otitis Media -Special Cases (Pertussis, Croup)
  9. 9. ManagementAntibiotic therapy has a small protective effect on the risk of developing sinusitis, otitis media and possibly peritonsillar abscess (quinsy). 30 children and 145 adults need treatment to prevent one case of acute otitis media.]
  10. 10. But how can we differentiate between Viral and ? Bacterial Pharyngitis, Sinusitis & Otitis Media
  11. 11. Acute Pharyngitis (Sore Throat) Viral Erythema
  12. 12. Acute Pharyngitis Bacterial Vs Viral-No Evidence that there is diff. in severity or durationof illness in either cases.80% by Adenovirous20% bacterial ( Grp A strp, H.inf , Staph Aureus)-Based on symptoms they are limited to bedistinguished.-Clinical examination should not be relied upon todifferentiate between them-Sensitivity and Specificity suggest that reliance onclinical diagnoses will miss 25-50% of GABHSPharyngitis cases.
  13. 13. SymptomsSore throatStrep Throat: fever, headeach, swollen lymph node in the neckViral pharyngitis: runny nose and postnasal dripSever cases  difficult swallowing and rarly difficult breathing
  14. 14. Acute Pharyngitis To determine bacterial Pharyngitis Strep. ScoreMcIsaac Criteria
  15. 15. Acute Pharyngitis Rapid Antigen Test (RAT)Sensitivity of RAT against culture varies between 61-95%.Specificity of RAT 88-100%Takes 10 min to be performed-ve results should be confirmed by culture.Not found in Jordan
  16. 16. Acute Pharyngitis Throat Culture20-40% of those with negative throat culture will be labeled as havingGABHS.+ve culture makes the Dx of GABHS likely , but –Ve culture does notrule out.
  17. 17. Acute Pharyngitis (Drug Of choice)-Oral penicillin or erythromycin (in penicillin-allergic individuals), given for 10 days.-Fortunately, no resistance to penicillin has beenreported, so far, among GABHS-relatedPharyngitis patients.
  18. 18. ComplicationRheumatic Fever - Major Criteria: - polyarithritis - Post strep. GN - carditis - Bactermia - sydenham chorea - subcutaneous nodules - erythema marginatum- Minor Criteria: - fever - leukocytosis - elevated ESR,CRP - arthralgia with evidence of recent group A strep infection
  19. 19. Treatment Aim of Tt: - prevention of complications. - symptomatic improvement. - bacterial eradication. - prevention of contamination. - reducing unnecessary antibiotic use.
  20. 20. Treatment Bed rest. Soft diet with fluid replacement. Warm salt water gargle to relieve sore throat. Analgesics and antipyretics. Antibiotic in case of bacterial  - Penicillin 1st line. - Erythromycin  if allergy to penicillin. In case of viral cause, the length of illness depends on the virus involved.
  21. 21. CaseA 25 year old man comes to your office with thecomplaint of a bad sore throat for 2 days. He hasfelt chills and fever today but has not measured histemperature. He has some pain on swallowing. Hehas a slight runny nose and denies cough and othersymptoms. He was previously healthy. T= 38.5 ears - TMs normal nose – clear neck - no cervical adenopathy lungs – clear
  22. 22. How many points does our patienthave?Fever over 38 C 1Absence of cough 1Tender ant. cervical adenopathy 0Tonsillar swelling or exudate 1Age< 15 y 0Age> 45 0Total = 3
  23. 23. What are the tests?Rapid strep test -veThroat culture + veGive Penicillin + Symptomatic treatment
  24. 24. Acute otitis media
  25. 25. Normal Tympanic Membrane
  26. 26. Acute otitis media Redness Bulging
  27. 27. Acute otitis media Bullae Perforation
  28. 28. Acute otitis media Dutch Guidelines-Dutch study found no difference in outcome betweenantibiotics, myringotomy, antibiotics combined withmyringotomy and placebo.-Only 1 in 7 children under 2 year old with 1st episode ofA.O.M derived significant benefit from antibiotictreatment.-Although it reduce fever faster , it does not reduceduration of pain or crying.Most common cause: Streptococcus pneumoniae,nontypeable Haemophilus influenzae, Moraxella catarrhalis
  29. 29. SymptomsEarache, fever, trouble sleeping, Fullness in theear, Vomiting, Diarrhea, Hearing loss in theaffected earcomplicationPerforated eardrumEnlarged adenoids or tonsilsMastoiditisHearing loss
  30. 30. Acute otitis media Dutch GuidelinesDiagnostic criteria- Recent perforation of the tympanic membrane with discharging pus- Inflamed and bulging tympanic membrane- One ear drum redder than the other- Bullae on tympanic membrane
  31. 31. TREATMENT GUIDELINES Symptomatic treatment is provided in all cases The patient or the parents are instructed to contact the general practitioner if there is an abnormal clinical course, in other words: - increasing illness or earache, decreased drinking - no improvement within 3 days
  32. 32. TREATMENT GUIDELINES (cont.) Antibiotics , For children >2 years recurrent+ Children within 12 months orChildren < 6 months 6 months - 2 years + , Downs syndrome abnormal clinical course , cleft palate compromised immune system
  33. 33. Treatment : - Amoxcillin – Clavulanic acid 80-90 mg/kg per day - Clarithromycin 15 mg/kg twice per dayComplication: - meningitis - brain abscess - mastoiditis - cholesteatoma
  34. 34. Acute sinusitis-Usually comlicateallergic rhinitis orcommon cold withincrease in symptoms-Symptoms: nasalcongestion, sore throat,postnasal drip, frontalheadeach, cough, fever
  35. 35. Acute sinusitis AntibioticsModerate symptoms Moderate symptoms not improving that worsen Severe symptoms after 10 days after 5 to 7 days -Oral amoxicillin, trimethoprim-sulfamethoxazole, or doxycycline, given for 3 to 10 days are the favored antibiotics for treatment.
  36. 36. Influenza- Influenzathroat, bronchi and, occasionally, the nose, is a viral infection that affects mainly lungs. Infection usually lasts for about a week- is an acute viralperson that spreads easily from person to infection- circulates worldwide and can affect anybody in any age group.- Influenza causes temperate regionsthat peak during winter in annual epidemics- serious publicdeaths for higherthat causes severe illnesses and health problem risk populations.
  37. 37. Seasonal influenza• is an acutevirus infection caused by an influenza viral• There C. three types of seasonal influenza – A, B and are• Transmission:airborne(by droplets and close personal contact.)• Virus types A and(changeconstantly changing due to mutations B are in the viral RNA ) and are more common and more serious forms.
  38. 38. • Type A virusestwo viral surface proteins called differences in are divided into types based on the hemagglutinin (H) and the neuraminidase (N). There are 16 known H subtypes and nine known N subtypes• currentlyare circulating among humans subtypes influenza A(H1N1) and A(H3N2)• Type C influenza is stable B . occur much less frequently than A and cases
  39. 39. Antigenic shift and drift• Influenza type A viruses undergo two kinds of changes :i. Antigenic drift:is a series of mutations that occurs over time and causes a gradual evolution of the virusi. Antigenic shift:is an abrupt change in the hemagglutinin and/or the neuraminidase proteins• influenza type B viruses change only by the more gradual process of antigenic drift and therefore do not cause pandemics..
  40. 40. Signs and symptoms:• sudden onset of high fever• cough (usually dry)• headache• muscle and joint pain• malaise• sore throat and runny nose
  41. 41. ComplicationsPneumoniaEncephalitisBronchitisSinus infectionsEar infections
  42. 42. Who is at risk?highest risk of complications occur among-children younger than age two-adults age 65 or older-people of any age with certain medical conditions, such as chronic heart, lung.-weakened immune systems.
  43. 43. Diagnosis• History• Physical exam :1. individuals may seem weary and tired2. Their skin may feel warm3. may have a fever and runny nose4. The mucous membrane of the throat may appear reddened5. Lymph nodes in the neck may be slightly swollen.
  44. 44. TreatmentThe flu goes away within 7 to 10 days-Bed rest-Paracetamol-Oseltmivir best for children or zanamivir for >65 or high risk-Antibiotics only in people with chronic or heart or renal diseaseProphylaxis : vaccination 70% for 1 year protection
  45. 45. Common cold
  46. 46. Common coldis a viral infectious disease of the upper respiratory system, caused primarily by rhinoviruses and corona viruses Common symptoms include a cough, sore throat, runny nose, and fever.Incidence: The common cold is the most frequent infectious disease in humans with on average two to four infections a year in adults and up to 6–12 in childrenTransmission: airborne (by droplets and close personal contact.)
  47. 47. SymptomsSymptoms of the common cold usually begin 2 to 3 days after infection and often include :Low grade feverMucus buildup in your noseDifficulty breathing through your noseSwelling of your sinusesSneezingSore throatCoughHeadacheCold symptoms can last from 2 to 14 days, but like most people, you’ll probably recover in a weekIf symptoms come back often or last much longer than 2 weeks, you might have an allergy rather than a cold.
  48. 48. complicationsBronchitisPneumoniaEar infectionSinusitisAggravation of asthma
  49. 49. management• There is no cure for coldcommon cold, but you can get relief from your the symptoms by:• Resting in bed• Drinking of fluids• Gargling with warm salt sore throat throat sprays for a scratchy or water or using• Taking aspirin or Paracetamol, for example—for headache or fever• Never take by viruses .to treat a colduse these colds are caused antibiotics You should because prescription medicines only if you have a rare bacterial complication, such as sinusitis or ear infection.
  50. 50. RhinitisRhinitis is a reaction that occurs in the eyes, nose and throat when airborne irritants (allergens) trigger the release of histamine. Histamine causes inflammation and fluid production in the fragile linings of nasal passages, sinuses, and eyelids.What are the different types of rhinitis? -allergic rhinitis :seasonal - occurs particularly during pollen seasonsperennial - occurs throughout the year
  51. 51. nonallergic rhinitis :Causes :fumesodorstemperatureatmospheric changessmokeother irritants
  52. 52. managementAvoid allergensAntihistamineDecongestantTopical steroids or oral prednisolone
  53. 53. Symptomatic Effects ofPharmacologic Treatments Nasal Eye Rhinorrhe Nasal Inflammatio Onset ofDrug Class Sneezing Obstructio Symptom a Itch n Action n sH1-antihistamines ++ ++ + +++ ++ +/- Rapid oral intranasal ++ ++ + ++ - + Rapid intraocular - - - - +++ ++ RapidCorticosteroids intranasal +++ +++ +++ ++ + ++++ SlowCromones intranasal + + + + - ++ Slow intraocular - - - - ++ ++ SlowDecongestants intranasal - + +++ - - - Rapid oral - + ++ - - - RapidAnticholinergics - ++ - - - - RapidAntileukotriene - + +Adapted from Van Cauwenberge et al. Allergy. 2002.s - ++ +/- Rapid
  54. 54. is an inflammation of the tonsils most commonlycaused by viral or bacterial infection. It is a type of pharyngitis.
  55. 55. Symptoms:red and/or swollen tonsilswhite or yellow patches on the tonsilstender, stiff, and/or swollen neckbad breathsore throatpainful or difficult swallowingcoughheadachesore eyesbody achesotalgiafeverbad breathchillsnasal congestions
  56. 56. If your tonsils become very swollen, you may also notice other symptoms. These may includesleep apnea (when breathing stops briefly during sleep), trouble swallowing food and a “throaty”voice.
  57. 57. Diagnosis:Tonsillitis can be diagnosed by performing a rapid strep test, also called a throat culture. To perform the throat culture, the doctor will use a long cotton swab to swipe off some of the stuff on the surface of the back of your throat. The doctor will then test the "stuff" on the cotton swab. This test will determine whether you have tonsillitis and whether it is caused by a bacteria or a virus.Tonsillitis usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.
  58. 58. Treatment: Treatment for tonsillitis depends on whether it was caused by a virus or bacteria. If the tonsillitis was caused by strep bacteria (streptococci), the doctor will prescribe antibiotics. If the tonsillitis was caused by a virus, your body will fight off the infection on its own. However, medication can be prescribed to releive the symptoms.Encourage rest. Provide adequate fluidsProvide comforting foods and beverage.Prepare a saltwater gargleHumidify the airAvoid irritants.Treat pain and fever. Ibuprofen & acetaminophenAntibioticsIf tonsillitis is caused by a bacterial infectionPenicillin taken by mouth for 10 days is the most common antibiotic treatment prescribed for tonsillitis caused by group A streptococcus.
  59. 59. Surgery: Surgery to remove tonsils (tonsillectomy) may be used to treat frequently recurring tonsillitis, chronic tonsillitis, or bacterial tonsillitis that doesnt respond to antibiotic treatment. Frequent tonsillitis is generally defined as:More than six episodes in one yearMore than four episodes a year over two yearsMore than three episodes a year over three years A tonsillectomy may also be performed if tonsillitis results in difficult to manage complications, such as:1. Obstructed sleep apnea2. Breathing difficulty3. A peritonsillar abscess that doesnt improve with antibiotic treatment.
  60. 60. How long does Tonsillitis Last?If tonsillitis is caused by bacteria, with antibiotic treatment, the illness is usually cured within 1 week. However, it may take several weeks for the tonsils and swollen glands to return to normal size.When tonsillitis is caused by viruses, the length of illness depends on which virus is involved. Usually, people are almost completely recovered within 1 week.
  61. 61. Pertussis:also known as whooping cough; is a highly contagious disease caused by the bacterium Bordetella pertussis. It is known to last for a duration of approximately 6 weeks before subsiding. The disease derives its name from the "whoop" sound made from the inspiration of air after a cough.Whooping People with whooping cough are most contagious during the earliest stages of the illness up to about 2 weeks after the cough begins.If you take the whooping cough vaccine, you will lower your risk of contracting whooping cough. So it can be prevented. The whooping cough vaccine is part of the DTaP (diphtheria, tetanus, acellular pertussis) immunization. DTaP immunizations are routinely given in five doses before a childs sixth birthday.
  62. 62. The initial symptoms of whoopingcough are:runny nosesneezingmild coughlow feverAfter about 1 week, the dry, irritating cough evolves into coughing spells that last for about one minute. During the coughing spell, the person may become red or purple. After the coughing spell, the person may vomit or make a whooping sound when breathing in.
  63. 63. Diagnosis:Culturing of nasopharyngeal swabs
  64. 64. Treatment: Antibiotics Treatment with an effective antibiotic (erythromycin or azithromycin) shortens the infectious period but does not generally alter the outcome of the infection; however, when treatment is initiated during the catarrhal stage, symptoms may be less severe. Three macrolides (erythromycin, azithromycin and clarithromycin) are used in the U.S. For treatment of pertussis; trimethoprim-sulfamethoxazole is generally used when a macrolide is ineffective or is contraindicated. Close contacts who receive appropriate antibiotics (chemoprophylaxis) during the 7–21 day incubation period may be protected from developing symptomatic disease. Close contacts are defined as anyone coming into contact with the respiratory secretions of an infected person in the 21 days before or after the infected persons cough began. There is no known antitoxin. Cough Effective treatments of the cough associated with this condition have not yet been developed. Herbal treatments and vitamin C in the form of sodium ascorbate have been said to greatly decrease the severity of the cough caused by pertussis, but scant scientific studies have been performed to investigate this claim.
  65. 65. Croup (or laryngotracheobronchitis)is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night.
  66. 66. Signs & symptoms:"barking" cough stridor hoarsenessdifficult breathing which usually worsens at nightalso; fever, coryza (symptoms typical of the common cold), and chest wall indrawing.
  67. 67. Causes:1. viral infection: parainfluenza virus, primarily types 1 and 2, in 75% of cases, influenza A and B, measles, adenovirus and respiratory syncytial virus (RSV). 2. bacterial infection: laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis.
  68. 68. Pathophysiology:The viral infection that causes croup leads to swelling of the larynx, trachea, and large bronchi due to infiltration of white blood cells; (especially histiocytes, lymphocytes, plasma cells, and neutrophils).Swelling produces airway obstruction which, when significant, leads to dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as stridor.
  69. 69. Diagnosis:clinical diagnosis. The first step is to exclude other obstructive conditions of the upper airway, especially epiglottitisThe most commonly used system for classifying the severity of croup is the Westley score.
  70. 70. Treatment:Children with croup are generally kept as calm as possible. Steroids are given routinely, with epinephrine used in severe cases. Children with oxygen saturations under 92% should receive oxygen, and those with severe croup may be hospitalized for observation. If oxygen is needed, "blow-by" administration (holding an oxygen source near the childs face) is recommended, as it causes less agitation than use of a mask. With treatment, less than 0.2% of people require endotracheal intubation.
  71. 71. Steroids:Corticosteroids, such as; dexamethasone and budesonide, have been shown to improve outcomes in children with all severities of croup. However, significant relief is often not obtained for up to six hours after administration, and lasts for only about 12 hours. While effective when given orally, parentally, or by inhalation, the oral route is preferred.A single dose is usually all that is required, and is generally considered to be quite safe. Dexamethasone at doses of 0.15, 0.3 and 0.6 mg/kg appear to be all equally effective.
  72. 72. Epinephrine:Moderate to severe croup may be improved temporarily with nebulized epinephrine. While epinephrine typically produces a reduction in croup severity within 10–30 minutes, the benefits last for only about 2 hours. If the condition remains improved for 2–4 hours after treatment and no other complications arise, the child is typically discharged from the hospital.
  73. 73. Epiglottitis:is inflammation of the epiglottis - the flap that sits at the base of the tongue, which keeps food from going into the trachea (windpipe). Due to its place in the airway; swelling of this structure can interfere with breathing and constitutes a medical emergency. The infection can cause the epiglottis to either obstruct or completely close off the windpipe.
  74. 74. Symptoms of Epiglottitis:There are many symptoms. The most common symptoms are:DroolingSore throatDifficulty swallowingDifficulty breathingHoarsenessChillsFeverBlue skin
  75. 75. What Causes Epiglottitis?The most common cause of epiglottitis is infection with the bacteria called Haemophilus influenza type b, also called HIB.Epiglottis can also be caused by other types of bacteria including some types of Streptococcus bacteria and the bacteria responsible for causing diphtheria.
  76. 76. Treatment of Epiglottitis:Epiglottitis can be treated. If proper treatment is given, the patient can fully recover. Some of the treatment options are: (1)Administration of humidified oxygen. Oxygen will help the patient breathe. (2)Intravenous fluids. Intravenous fluids are given to increase hydration. (3)Antibiotics to treat the infection. (4)Corticosteroids to decrease the swelling of the throat.
  77. 77. Question 1 - Single Best Answer What is the most common cause of pharyngitis? a)Epstein Barr virus b) Streptococcus pyogenes c) Streptococcus pneumoniae d)Candida albicans e) none of the above The answer is (e)24/9/2008 81
  78. 78. Question 2 - Single Best Answer All cases of pharyngitis should be treated with antibiotics? A) true B) false The answer is (b)24/9/2008 82
  79. 79. Question 3 - Single Best Answer A bacterial etiology of sore throat can be determined clinically? A) True B) False The answer is (b)24/9/2008 83
  80. 80. Question 4 - Single Best Answer The bacterial causes of sore throat include A) Streptococcus pyogenes and Treponema pallidum B) Neisseria gonorrhoea and Streptococcus pneumoniae C) Corynebacterium diphtheriae and Streptococcus pyogenes D) Treponema pallidum and Bordetella pertussis E) Corynebacterium diphtheriae and Bordetella pertussis The answer is (c)24/9/2008 84
  81. 81. Question 5 - Single Best Answer Pharyngitis caused by ____________________in a child is considered indicative of child sexual abuse? a) Streptococcus pyogenes b) Streptococcus pneumonia c) Corynebacterium diphtheria d) Neisseria gonnorheae e) none of the above The answer is (d)24/9/2008 85
  82. 82. Question 6 - Single Best Answer How much time does it take to determine if a sore throat is caused by Streptococcus pyogenes? a) 10 minutes b) 4 hours c) Overnight d) two weeks The answer is (a)24/9/2008 86
  83. 83. Question 7 - Single Best Answer What does a grayish pseudomembrane in the throat suggest? A) Clostridium difficile B) Streptococcus pyogenes C) Streptococcus pneumonia No, (sigh) D) Corynebacterium diphtheria E) Neisseria gonorrhoea The answer is (d)24/9/2008 87
  84. 84. Question 8 - Single Best Answer The most common cause of epiglottitis is_____________________? A) Neisseria gonorrhoea B) Epstein-Barr virus C) Haemophilus influenzae D) Streptococcus pyogenes E) Streptococcus pneumoniae The answer is (c)24/9/2008 88
  85. 85. Question 9 - Single Best Answer What do you think is the most important virulence factor for bacteria that cause pharyngitis, epiglottitis, or bronchitis? a) membrane ruffling to induce uptake by cells b) adhesins c) toxins d) ability to kill non-specific phagocytes The answer is (b)24/9/2008 89
  86. 86. ‫‪Thank You‬‬ ‫تمت بحمد ال‬
  87. 87. Treatment Plan for AllergicRhinitisby Disease Severity Mild Antihistamine or antihistamine-decongestant combination (non- sedating preferred) OR Intranasal cromolyn sodium Moderate Intranasal corticosteroid* Antihistamine-decongestant combination Consider immunotherapy if symptoms persist ≥2-3 mo. Severe Intranasal corticosteroid* Antihistamine-decongestant combination Consider short course (3-7 days) of oral corticosteroid Consider immunotherapy *Most effective when started 1 week before anticipated onset of Sx.