UPPER RESIRATORY TRACT INFECTIONS IN CHILDREN , ACUE PHARYGITIS , COMMON COLD , ACUTE SINUSITIS , ACUTE OTITIS MEDIA , APPROACH TO PATIENT WITH URTI , MANAGEMENT OF URTI IN CHILDREN

1. DIAGNOSIS AND
TREATMENT OF
URTIS
GUIDELINES AND RECOMMENDATIONS
Sayed Ismail, MD
Professor of pediatrics
sayedahmed1900@yahoo.com

2. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

3. Objectives
• What Are The common URTI ?
• The guidelines in diagnosis of common URTI
• The guidelines in treatment of URTI

4. Upper respiratory tract infection (URTI)
• The upper respiratory tract includes airways outside the
thorax
– The sinuses
– Nasal passages
– Middle ear
– Pharynx
– Larynx

5. UTRI
1. Nasopharyngitis ( the common cold)
2. Pharyngitis
3. AOM
4. Rhinosinusitis (sinusitis)
5. Parapharyngeal abscess
6. Epiglottitis
7. Laryngitis
8. Croup

6. • Viruses cause 80–90% of childhood respiratory
infections.
• Bacteria
– Strep. Pyogenes
– Strept. Pneumoniae
– H influenzae
– M catarrhalis
– staph aureus, pseudomonas
– Mixed aerobes and anaerobes
Pathogens of URTI

7. Frequency of Different Viruses Detected in Nasopharyngeal
Swabs of Children With URTI in 2009-2010
Archives of Pediatric Infectious Diseases. 2012 October;

8. What are The 4 most frequent URTIs ?
1. The common cold
2. Pharyngitis and Tonsillitis
3. Acute otitis media
4. Sinusitis
Shaun et al, Annals of Clinical Microbiology and Antimicrobials 2004

9. Common cold

10. Common Cold
– Commonest Viral URTI
– The body can never build a solid resistance to it (changes in
antigenicity) › 200 viruses
– Rhinovirus
– Coronavirus
– RSV
– Parainfluenza virus
– Influenza virus
– Metapneumovirus
– Adenovirus
– coxsackieviruses,
– Others
Heikkinen T, Jarvinen A. The common cold. Lancet. 2003;361:51-59.

11. Common Cold… Clinical Picture
• Rhinorhea early watery Later, thicker and darker.
• Nasal obstruction
• Difficulty in feeding in infants as their noses are
• blocked and this obstructs breathing
• Mild or no Fever
• Cough
• Sore Throats
• Sneezing
• Duration 4-10 days
Heikkinen T, Jarvinen A. The common cold. Lancet. 2003;361:51-59.

12. Colds in healthy school children . Pappas et al, Pediatr Infect Dis J 2008

13. Complications
• Acute exacerbations of asthma
• Secondary bacterial infections
– 2% of colds are complicated
• Rhinosinusitis
• Otitis media .. Most common
• Pneumonia

14. Differential Diagnosis Of Cold
1. Allergic rhinitis
2. Influenza (Flu)
3. Acute bacterial Sinusitis

15. 1- How can I tell that this is a Cold not a Flu?
Colds Flu
1- No or low grade fever High fever
2- No or mild systemic
manifestations
Systemic manifestations

16. 2- Features Suggestive Allergic rhinitis
• Prolonged sneezing.
• Redness, swelling and
itching of the eyes
• Itchy and runny nose
• Itchy throat ,Itchy skin
• Dennie's lines
• Allergic shiners. (bluish-
brownish discoloration
around the eyes )
Dennie's lines

17. Allergic crease
Allergic shiners.

18. Treatment of cold
Symptomatic:
1. Analgesics
2. Antihistamines
3. Decongestants
4. Antitussives

19. Antibiotics
 Delayed antibiotics for complications of colds

20.  70% of GP and 50% of Pediatricians
prescribe antimicrobial agents if
mucopurulent nasal secretions seen in
first days of cold.
 Indeed, purulent sputum production is
a normal part of viral infection
 Color and opacity do not reliably
distinguish viral from bacterial illness.
Nyquist et al, JAMA. 1998;279:875-877
0%
10%
20%
30%
40%
50%
60%
70%
80%
GP Pediatrician

22. Pathogen Disease
1. Strep. Pyogenes Tonsillitis and scarlet fever
2. Mixed aerobes and
anaerobes
Pharyngitis , Parapharyngeal
abscess
3. Epstein-barr virus
4. Rhinovirus/coronavirus
5. Coxsackie virus
6. Herpes simplex virus
7. Adenovirus
Infectious mononucleosis
Common cold
Herpangina
Gingivostomatitis
Pharyngoconjunctival fever
Microbial Etiology Of Pharyngitis
Bartlett, 1997

23. Causative organisms of pharyngitis
• < 3 years ≤ 100 % viral
• 5-15 years 15-30 % GABHS
• Adult 10 % GABHS
GABHS = GROUP A BETA HEMOLYTIC STREPTOCOCCUS

24. Viral Pharyngitis
1. Sore throat
2. Cough
3. Rhinorrhea
4. Hoarseness
5. Conjunctivitis
6. Red throat →
7. Oral vesicles, ulcers

25. Streptococcal Pharyngitis
Clinical Diagnosis
1. History
2. Examination
1. Pharyngeal exudates
2. Enlarged and tender cervical node.
3. Tonsillopharyngeal erythema
4. Red uvula
5. Palatal petechiae
3- Lab.
1. Rapid diagnostic tests , if negative
2. Throat culture.
•Leung et al , Expert Rev Mol Diagn. 2006 Sep;6(5):761-6 Canada

26. Scarlet Fever

27. Scarlet fever
Desquamation
Toward the end of the first
week of illness, the rash
begins to fade and is followed
by a desquamation over the
trunk, which progresses to the
hands and feet.

28. Patient Characteristic Points
History of fever or temperature >38ºC +1
Absence of Cough +1
Tender Anterior Cervical Adenopathy +1
Tonsillar Swelling or exudates +1
Age <15 years +1
Age >45 years -1
Score % Likelihood of GAS
-1 or 0 2-3
1 4-6
2 10-12
3 27-28
4 or 5 38-63
Score Suggested Management
-1 or 0 No antibiotics or culture required
1 No antibiotics or culture required
2 Culture all; treat patients with positive results
3 Culture all; treat patients with positive results
4 or 5 Treat with antibiotics without culture
Clinical decision rule for streptococcal pharyngitis

29. Clin Infect Dis 2012; 55:1279
• To optimise the use of antibiotics, in 2012 the Infectious Diseases
Society of America (IDSA) recommended the use of pharyngeal
swabs to take samples for bacterial cultures or rapid diagnostic
tests because the clinical features alone do not reliably
discriminate between GAS and viral pharyngitis
Recommendation:

30. Diagnosis of Streptococcal Pharyngitis
1-Rapid antigen tests – > 95% specific ,90% sensitive
2-Throat culture is the gold standard
• 100% specific & 95% sensitive
Leung et al , Expert Rev Mol Diagn. 2006 Sep;6(5):761-6 Canada.

31. What about antistreptolysin O titer?
• Streptococcal antibodies (antistreptolysin O) levels do not
peak until 4-5 weeks after the onset of pharyngitis.
• Therefore, testing for these antibodies has no role in the
diagnosis of acute pharyngitis

32. Differential diagnosis of Pharyngitis
• Strep. Pyogenes Tonsillitis
• Viral Pharyngitis
1. EBV (Infectious mononucleosis)
2. Coxsackie virus ( Herpangina)
3. Herpes simplex virus (Gingivostomatitis)
4. Adenovirus (Pharyngoconjunctival fever )
5. Rhinovirus / coronavirus ( cold)

33. Viral Pharyngitis Strep. Pharyngitis
•Sore throat
•Conjunctivitis
• Nasal discharge
•Cough
•Diarrhea
•Ulcers
•Sore throat
• Fever
• Headache
•Abdominal pain, vomiting
•Tender, enlarged L nodes
•Palatal petechiae
•Patient aged ≥ 3
S.Ismail

34. Viral versus bacterial Pharyngitis
A B

35. Pharyngoconjunctival fever
(Adenovirus)

36. 1. The throat is red and tonsils covered with a whitish material.
2. Enlarged lymph nodes
3. HSM
4. Fatigue.
EBV and streptococcal tonsillitis appear quite similar. A throat culture and blood studies
may be necessary to make an accurate diagnosis.
Infectious Mononucleosis

37. This patient with infectious mononucleosis
had been placed on ampicillin which
resulted in a macular-papular skin rash
Cervical lymphadenopathy

38. Streptococcal Pharyngitis Infectious Mononucleosis
• Cervical adenopathy
• No splenomegaly or
Hepatomegaly
• Fatigue is less prominent
Lab.
1. Rapid diagnostic tests
2. Throat culture
3. CBC
• Generalised lymphadenopathy
• HSM
• Fatigue
Lab.
1. Blood smear
2. CBC
3. Monospot test
4. Serology
Petechiae are present on the posterior hard palate

39. Scarlet fever DD
Typical scarlet fever is not generally difficult
to diagnose, but it may be confused with:
1. Roseola
2. Kawasaki syndrome
3. Drug eruptions
4. Toxigenic S aureus infections.

40. Roseola
Appears first on chest and abdomen
Rose-colored
May spread to arms, legs, neck, and face
Lasts for a few hours to a few days and does not itch Scarlet fever

41. Kawasaki syndrome
(a) Red, cracked lips and conjunctival inflammation. (b) Peeling of the fingers, which developed on the
15th day of the illness.

42. Drug eruptions (dermatitis medicamentosa)
erythematous, morbilliform or maculopapular), urticaria, fixed drug eruptions, and
erythema multiforme are the most common. urticarial reaction from Augmentin

43. Toxic Shock Syndrome
Dx: 5/6 Critera:
Fever,
rash,
hypotension,
3 or more organs involved

44. Ulcerative stomatitis
• Mucosal ulcers, erosions,
vesicles:
– HSV
– Coxsackievirus

45. Coxsackievirus, ( herpangina)

46. Foot and mouth
disease
Coxsackie virus

47. Vesicles with ulceration in gingivostomatitis.
3 year old boy with primary herpetic infection

48. Kissing" Tonsils
Difficulty breathing, including loud snoring, gasping, and even sleep
apnea resulting in fatigue due to enlarged tonsils and/or adenoids

49. 49
PARAPHARYNGIAL ABCESS

50. Treatment of group A streptococcal
• Penicillin remains the drug of choice
• Single-dose IM of benzathine penicillin is effective
• Alternative choices :
– Cephalexin ,Erythromycin ,clarithromycin or azithromycin
• For recurrent cases
– Clindamycin or
– Amoxicillin-clavulanic acid for 10 days
Bisno et al, Infectious Diseases,Society of America. Clin Infect Dis 2002;35:113-25.

51. Disease Features
S. Pyogenes Scarlet fever
Cold Nasal obstruction, discharge
Influenza Cough & fever ,systemic symptoms
Adenovirus Conjunctivitis
EBV Splenomegaly & lymphadenopathy
HSV Stomatitis or vesicles
Coxsackie virus
Para influenza
Hand , mouth and foot disease
Hoarseness , Croup
Hints to Determine Cause of Pharyngitis
S.Ismail

52. ACUTE OTITIS MEDIA

53. 53
Acute Otitis
Media

54. AAOP criteria for diagnosis of OM
1- Recent onset (˂ 48 hrs) of ME inflammation i.e otalgia, fever, otorrhea
2-The presence of MEE indicated by :-
• Bulging of the tympanic membrane
• Limited or absent mobility of TM
• Air-fluid level behind theTM
• Otorrhea
3- S/S middle-ear inflammation as indicated by either
• Distinct erythema of the tympanic membrane
• Distinct otalgia
Pediatrics. 113(5):1451-65, 2004 May.

55. Ear drum examination
Normal Tympanic Membrane
• is a semi-transparent
• The "cone of light“
Acute otitis media
• Red bulging
• No cone of light

56. Otoscopic findings in AOM
1- Opacification of TM
2-Reduced mobility of TM
3-Redness and Bulging of (TM)
AOM

58. Purulent discharge due to middle ear infection

59. A otitis M with perforation

60. The Pathogens in AOM
Strept. Pneumoniae
H influenzae
M catarrhalis.
Other, staph aureus, pseudomonas
American Academy of pediatrics Pediatrics 2004;113:1451

61. Differential diagnosis of AOM
Otitis externa
Otalgia, may be seen with upper RT infection.
OME
Foreign body or wax in external auditory canal

62. wax
FB

63. Do Fever and Earache indicate AOM?
• Fever, earache are present in (90%) of
AOM cases.
• Present in 72% children without AOM.
• So, clinical history alone is poorly
predictive of the presence of AOM.
Niemela et al Pediatr Infect Dis J. 1994;13 :765 –768

66. Modality Comments
Acetaminophen, ibuprofen For mild to moderate pain, mainstay of pain
management for AOM
Benzocaine (Auralgan, Americaine Otic) Additional but brief benefit over
acetaminophen in patients >5 y
Naturopathic agents (Otikon Otic Solution) Comparable with ametocaine/phenazone
drops (Anaesthetic) in patients >6 y
Narcotic analgesia with codeine or analogs For moderate or severe pain; requires
prescription; risk of respiratory depression
Tympanostomy/myringotomy Requires skill and entails potential risk
Treatments for Otalgia in AOM
PEDIATRICS Volume 131, Number 3, March 2013

67. Observation
option Antibiotic
option
Treatment of ear infections

68. PEDIATRICS Volume 131, Number 3, March 2013

69. Criteria for Initial Antibacterial-Agent Treatment
in Children With AOM
• Severe AOM
– (bilateralor unilateral) in children 6 months and older with
severe signs or symptoms (ie, moderate or severe otalgia or
otalgia for at least 48 hours or temperature 39°C or higher).
• Non severe bilateral AOM in young children: 6 months -
23 months of age
PEDIATRICS Volume 131, Number 3, March 2013

70. Criteria for Initial Antibacterial-Agent Treatment
or Observation in Children With AOM
• Non severe unilateral AOM in young children:
– The clinician should either prescribe antibiotic therapy or offer observation
with close follow-up for unilateral AOM in children 6 months to 23 months
of age without severe signs or symptoms
– begin antibiotic therapy if the child worsens or fails to improve within 48 to
72 hours of onset of symptoms.
• Nonsevere AOM in older children: children 24 months or
older without severe signs or symptoms (ie, mild otalgia for less
than 48 hours and temperature less than 39°C
PEDIATRICS Volume 131, Number 3, March 2013

71. Initial Antibacterial
Treatment
Initial Antibacterial-Treatment
or Observation in Children
1. Severe AOM
2. Non severe bilateral AOM in
young children
1. Non severe unilateral AOM in
young children (6-24mo)
2. Nonsevere AOM in older
children( more than 24mo)
Criteria for Initial Antibacterial-Agent Treatment or
Observation in Children With AOM
PEDIATRICS Volume 131, Number 3, March 2013

72. PEDIATRICS Volume 131, Number 3, March 2013

73. Treatment course:
 10 days : younger children, children with severe
disease
 5~7 days :children 6 years of age and older with
mild to moderate disease
Pediatrics. 113(5):1451-65, 2004 May.

74. ACUTE SINUSITIS

76. Acute bacteria sinusitis
Acute severe
bacterial
sinusitis
1. Purulent nasal
discharge for 3
days with:
2. Toxic appearing
child.
3. High Fever ≥
39º C
1. Persistent
nasal
discharge for
greater than
10 days
+
2. Persistent
daytime cough
> 10 days
NEW Sinusitis Guideline 2012 : IDSA
Onset with
worsening
symptoms or signs
characterized by
the new onset of
fever, headache, or
increase in nasal
discharge
following a typical
viral (URI) that
lasted 5–6 days and
were initially
improving (‘‘double
sickening’’)

77. Periorbital
cellulitis
It should be treated
promptly with
intravenous
antibiotics to prevent
spread into the orbit.

78. Indication First-line (Daily
Dose)
Second-line (Daily Dose)
Initial empirical
therapy
Amoxicillin-
clavulanate
(45 mg/kg/day PO
bid)
Amoxicillin-clavulanate (90 mg/kg/day
PO bid)
b-lactam allergy
Type I
hypersensitivity
Non–type I
hypersensitivity
Levofloxacin (10–20 mg/kg/day PO every 12–24 h)
Clindamycina (30–40 mg/kg/day PO tid)
plus cefixime (8 mg/kg/day PO bid) or
cefpodoxime (10 mg/kg/day PO bid)
Severe infection
requiring
hospitalization
For IV antibiotic
Ampicillin/sulbactam (200–400
mg/kg/day IV every 6 h)
Ceftriaxone (50 mg/kg/day IV every 12 h)
Cefotaxime (100–200 mg/kg/day IV every
6 h)
Levofloxacin (10–20 mg/kg/day IV every
12–24 h)
IDSA Guideline for ABRS ,2012
Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in children

79. Indication First-line (Daily Dose) Second-line (Daily Dose)
Initial empirical
therapy
Amoxicillin-clavulanate (500
mg/125 mg PO tid,
or 875 mg/125 mg PO bid)
Amoxicillin-clavulanate (2000
mg/125 mg PO bid)
Doxycycline (100 mg PO bid or 200
mg PO qd)
b-lactam allergy Doxycycline (100 mg PO bid or 200
mg PO qd)
Levofloxacin (500 mg PO qd)
Moxifloxacin (400 mg PO qd)
Severe infection
requiring
hospitalization
Levofloxacin (500 mg PO or IV qd)
Moxifloxacin (400 mg PO or IV qd)
Ceftriaxone (1–2 g IV every 12–
24 h)
Cefotaxime (2 g IV every 4–6 h)
IDSA Guideline for ABRS ,2012
Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in adults

80. Algorithm for the
management of acute
bacterial rhinosinusitis
IDSA Guideline for ABRS ,2012

81. Differential diagnosis of sinusitis
• Recurrent URTI
• Allergic rhinitis
• Enlarged adenoids
• Deviated nasal septum, choanal atresia, nasal polyp, FB
S. Ismail 2013

82. Diagnosis Drug of Choice Alternative
Common cold No antimicrobials
Acute
pharyngotonsillitis
Penicillin V
Benzathine penicillin
Clindamycin
1st Cephalosporins
Azithromycin
Acute otitis media Amoxicillin (high dose) Amoxicillin/clavulanate
2nd or 3rd
Cephalosporins
Acute sinusitis Amoxicillin-
clavulanate
Amoxicillin (low dose)
Amoxicillin/clavulanate
(High dose)
3nd Cephalosporins +
clindamycin
Antimicrobial Therapy Guidelines for URTI in Children

83. Thank you