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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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• 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 petechia
Absence of coughing
Absence of nose drip
Absence 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
• 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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• 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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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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• 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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• 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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• 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
