Infectious disease Pharmacotherpay

1. Infectious diseases Pharmacotherapy
Lesson 2
Upper respiratory tract infections[URTI]
Lesson 2
Upper respiratory tract infections[URTI]
By: Tsegaye Melaku
[B.Pharm, MSc, Clinical Pharmacist]
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.etMay, 2017 +251913765609+251913765609
1

2.  Upon completion of the chapter, you will be able toUpon completion of the chapter, you will be able to::
 List common bacteria that cause specific upper respiratory tract
infections (URTIs)
 Explain the pathophysiology and risk factors for URTIs
 Identify clinical features associated with specific URTIs
 Develop a treatment plan for a patient with URTIs based on patient
specific information.
 Create a monitoring plan for a patient presented with URTIs
 Upon completion of the chapter, you will be able toUpon completion of the chapter, you will be able to::
 List common bacteria that cause specific upper respiratory tract
infections (URTIs)
 Explain the pathophysiology and risk factors for URTIs
 Identify clinical features associated with specific URTIs
 Develop a treatment plan for a patient with URTIs based on patient
specific information.
 Create a monitoring plan for a patient presented with URTIs
2

3. 3

4.  URTIs: comprehensive term for upper airway infections, including otitis
media, sinusitis, pharyngitis, laryngitis, common cold & other.
 3 most common URTIs: of bacteria cause
 Otitis media.
 Pharyngitis.
 Sinusitis.
 Less common infections: laryngitis, rhinitis, and epiglottitis.
 Most URIs are caused by viruses, have nonspecific symptoms, and resolve
spontaneously.
 Antibiotics used for the treatment of URTIs serve as catalysts for the
emergence and spread of antibiotic resistance.
 Thereby making prudent antibiotic use critically important.
 URTIs: comprehensive term for upper airway infections, including otitis
media, sinusitis, pharyngitis, laryngitis, common cold & other.
 3 most common URTIs: of bacteria cause
 Otitis media.
 Pharyngitis.
 Sinusitis.
 Less common infections: laryngitis, rhinitis, and epiglottitis.
 Most URIs are caused by viruses, have nonspecific symptoms, and resolve
spontaneously.
 Antibiotics used for the treatment of URTIs serve as catalysts for the
emergence and spread of antibiotic resistance.
 Thereby making prudent antibiotic use critically important. 4

5. Otitis Media
5

6.  A 13-month-old boy presents to the pediatric clinic with 2 days of fever
(maximum temperature of 39.3°C [102.7°F]), rhinorrhea, and fussiness.
His mother reports that he was rubbing his left ear throughout the day
yesterday. She states that he is irritable and he was crying intermittently
throughout the night last night. He has not eaten much today. He attends
day care 3 days a week and has a 5-year-old sister who recently had
a cold.
1. What information is suggestive of acute otitis media (AOM)?
2. What risk factors does this child have for AOM?
3. Is there any additional information you need to know before recommending
a treatment plan?
4. Which drug of choice and supportive care you recommend?
 A 13-month-old boy presents to the pediatric clinic with 2 days of fever
(maximum temperature of 39.3°C [102.7°F]), rhinorrhea, and fussiness.
His mother reports that he was rubbing his left ear throughout the day
yesterday. She states that he is irritable and he was crying intermittently
throughout the night last night. He has not eaten much today. He attends
day care 3 days a week and has a 5-year-old sister who recently had
a cold.
1. What information is suggestive of acute otitis media (AOM)?
2. What risk factors does this child have for AOM?
3. Is there any additional information you need to know before recommending
a treatment plan?
4. Which drug of choice and supportive care you recommend? 6

7.  Otitis media: Latin oto- for "ear," -itis for "inflammation," and
medi- for "middle"
 Otitis media: an inflammation of the middle ear.
 Most common childhood illness
 Usually results from a nasopharyngeal viral infection
7

8. Otitis MediaOtitis Media
Acute Otitis
media
Acute Otitis
media
Otitis media with
effusion
Otitis media with
effusion
Chronic Otitis
media
Chronic Otitis
media
– They are differentiated by onset, signs and symptoms of
infection, and the presence of fluid in the middle ear.
– Acute otitis media: greatest role for antibiotics.
8
Acute Otitis
media
Acute Otitis
media
Otitis media with
effusion
Otitis media with
effusion
Chronic Otitis
media
Chronic Otitis
media
Not an acute illness but is
characterized by middle ear
effusion. Effusions resolve slowly.
(3 months)
No pain & bulging ear drum
Rapid, symptomatic
infection with effusion,
or fluid.

9.  Most common reason for an emergency room /physician office
visit.
 Occurs in all ages (common between 6 months and 2 yrs of age).
 >15 million emergency room and clinic visits annually.
 ~~ 65% recurrence
 >80% of patients seen for AOM receive a prescription.
 Direct and indirect costs almost $3 billion annually.
 Most common reason for an emergency room /physician office
visit.
 Occurs in all ages (common between 6 months and 2 yrs of age).
 >15 million emergency room and clinic visits annually.
 ~~ 65% recurrence
 >80% of patients seen for AOM receive a prescription.
 Direct and indirect costs almost $3 billion annually.
9

10.  ~~ 40% to 75% of AOM causes: viral.
 Common bacterial pathogens:
 Streptococcus pneumoniae (50%),
 Non-typeable H. influenzae (30%),
 Moraxella catarrhalis (20%).
 S. pneumoniae, H. influenzae, and M. catarrhalis can all possess
resistance to ß-lactams.
 S. pneumoniae develops resistance through alteration of
penicillin-binding proteins.
 H. influenzae and M. catarrhalis produce ß-lactamases.
 ~~ 40% to 75% of AOM causes: viral.
 Common bacterial pathogens:
 Streptococcus pneumoniae (50%),
 Non-typeable H. influenzae (30%),
 Moraxella catarrhalis (20%).
 S. pneumoniae, H. influenzae, and M. catarrhalis can all possess
resistance to ß-lactams.
 S. pneumoniae develops resistance through alteration of
penicillin-binding proteins.
 H. influenzae and M. catarrhalis produce ß-lactamases.
10

11.  The risk factors for resistance:
Attendance at child care centers.
Antibiotic treatment hx (within the past 30 days).
Age younger than 2 years.
 The risk factors for resistance:
Attendance at child care centers.
Antibiotic treatment hx (within the past 30 days).
Age younger than 2 years.
11

12.  AOM is caused by an interplay of factors.
 Usually follows a viral upper respiratory tract infection
 Viral URIs impair eustachian tube function  
Mucosal inflammation,
Impairing mucociliary clearance
– Bacteria that colonize the nasopharynx enter the
middle ear and are not cleared properly.
Promoting bacterial proliferation and infection.
 AOM is caused by an interplay of factors.
 Usually follows a viral upper respiratory tract infection
 Viral URIs impair eustachian tube function  
Mucosal inflammation,
Impairing mucociliary clearance
– Bacteria that colonize the nasopharynx enter the
middle ear and are not cleared properly.
Promoting bacterial proliferation and infection.
12

13.  Tympanic membrane becomes blocked with fluid, resulting in a
bulging and erythematous ear drum
 Children tend to be more susceptible to otitis media than adults
Shorter eustachian tube
More horizontal (facilitating bacterial entry into the middle
ear).
– So, it is less functional for middle ear drainage and
protection
 Tympanic membrane becomes blocked with fluid, resulting in a
bulging and erythematous ear drum
 Children tend to be more susceptible to otitis media than adults
Shorter eustachian tube
More horizontal (facilitating bacterial entry into the middle
ear).
– So, it is less functional for middle ear drainage and
protection
13

14.  Acute onset of ear pain.
 Irritability and tugging on the ear  clue for Dx in young children.
 Otitis media with effusion
– fluid in the middle ear without signs and symptoms of acute
ear infection, such as pain and a bulging eardrum.
 3 criteria to Dx AOM:
Acute onset of signs and symptoms,
Middle ear effusion,
Middle ear inflammation.
 Acute onset of ear pain.
 Irritability and tugging on the ear  clue for Dx in young children.
 Otitis media with effusion
– fluid in the middle ear without signs and symptoms of acute
ear infection, such as pain and a bulging eardrum.
 3 criteria to Dx AOM:
Acute onset of signs and symptoms,
Middle ear effusion,
Middle ear inflammation.
14

15.  Middle ear effusion is indicated by:
Bulging of the tympanic membrane,
Limited or absent mobility of the tympanic membrane,
Air-fluid level behind the tympanic membrane, or
Otorrhea.
 Signs and symptoms of middle ear inflammation:
Distinct erythema of the tympanic membrane or
Distinct ear otalgia (or ear pain).
 Middle ear effusion is indicated by:
Bulging of the tympanic membrane,
Limited or absent mobility of the tympanic membrane,
Air-fluid level behind the tympanic membrane, or
Otorrhea.
 Signs and symptoms of middle ear inflammation:
Distinct erythema of the tympanic membrane or
Distinct ear otalgia (or ear pain).
15

16.  General
Acute onset of signs and symptoms of middle ear infection
following cold symptoms of runny nose, nasal congestion, or
cough
 Signs and Symptoms
Ear pain that can be severe (>75% of patients)
Irritable, tug on the involved ear,& have difficulty sleeping
Fever (<25% of patients) and, when present, occurs more
often in younger children
16
 General
Acute onset of signs and symptoms of middle ear infection
following cold symptoms of runny nose, nasal congestion, or
cough
 Signs and Symptoms
Ear pain that can be severe (>75% of patients)
Irritable, tug on the involved ear,& have difficulty sleeping
Fever (<25% of patients) and, when present, occurs more
often in younger children

17. Examination shows a discolored (gray), thickened, bulging
eardrum
Pneumatic otoscopy or tympanometry demonstrates an
immobile eardrum; 50% of cases are bilateral
Draining middle ear fluid occurs in less than 3% of patients
and usually has a bacterial etiology
 Laboratory Tests
Gram stain, culture, and sensitivities of draining fluid or
aspirated fluid if tympanocentesis is performed
Adapted from Hendley JO. Clinical practice: Otitis media. N Engl J Med
2002;347(15):1169–1174.
Examination shows a discolored (gray), thickened, bulging
eardrum
Pneumatic otoscopy or tympanometry demonstrates an
immobile eardrum; 50% of cases are bilateral
Draining middle ear fluid occurs in less than 3% of patients
and usually has a bacterial etiology
 Laboratory Tests
Gram stain, culture, and sensitivities of draining fluid or
aspirated fluid if tympanocentesis is performed
Adapted from Hendley JO. Clinical practice: Otitis media. N Engl J Med
2002;347(15):1169–1174. 17

18. 18

19. 19
Taken from google.com

20.  Complications of otitis media are infrequent but include
Mastoiditis, bacteremia, meningitis,
Auditory sequelae with potential for speech and language
impairment.
 Complications of otitis media are infrequent but include
Mastoiditis, bacteremia, meningitis,
Auditory sequelae with potential for speech and language
impairment.
20

21.  Onset within 48 hours of symptoms that parents rated > 3 on
Acute Otitis Media Severity of Symptoms (AOM-SOS) scale
0 to 14 – higher scores indicating greater severity
 Middle-ear effusion
 Moderate or marked bulging of the tympanic membrane or slight
bulging accompanied by either otalgia or marked erythema of
the membrane
 Onset within 48 hours of symptoms that parents rated > 3 on
Acute Otitis Media Severity of Symptoms (AOM-SOS) scale
0 to 14 – higher scores indicating greater severity
 Middle-ear effusion
 Moderate or marked bulging of the tympanic membrane or slight
bulging accompanied by either otalgia or marked erythema of
the membrane
21

22.  Seven discrete items:
 Parents rate comparison with child’s usual state
“none,” “a little,” or “a lot,”
0, 1, and 2 points, respectively
1. Tugging of ears,
2. Crying,
3. Irritability,
4. Difficulty sleeping,
5. Diminished activity,
6. Diminished appetite,
7. Fever
 Seven discrete items:
 Parents rate comparison with child’s usual state
“none,” “a little,” or “a lot,”
0, 1, and 2 points, respectively
22
1. Tugging of ears,
2. Crying,
3. Irritability,
4. Difficulty sleeping,
5. Diminished activity,
6. Diminished appetite,
7. Fever

23.  Goal of therapy:
– Alleviate ear pain and fever,
– Prudent antibiotic use/avoid unnecessary antibiotic use.
– 2˚ disease prevention/eradicate infection
– Prevent complications;
 Consider: 1˚ prevention of acute otitis media through the use of
bacterial and viral vaccines.
– Hib/pneumococcal vaccine
– Influenza vaccine
 Goal of therapy:
– Alleviate ear pain and fever,
– Prudent antibiotic use/avoid unnecessary antibiotic use.
– 2˚ disease prevention/eradicate infection
– Prevent complications;
 Consider: 1˚ prevention of acute otitis media through the use of
bacterial and viral vaccines.
– Hib/pneumococcal vaccine
– Influenza vaccine
23

24.  1st Differentiate acute otitis media from otitis media with effusion or
chronic otitis media  the latter two types do not benefit substantially
from antibiotic therapy.
– Tympanostomy tube placement with or without adenoidectomy
 2nd  address pain with oral analgesics.
 3rd  Consider if a brief observation period is warranted or if the
disease severity or patient characteristics require immediate antibiotic
therapy.
– Majority of uncomplicated cases resolve spontaneously.
 1st Differentiate acute otitis media from otitis media with effusion or
chronic otitis media  the latter two types do not benefit substantially
from antibiotic therapy.
– Tympanostomy tube placement with or without adenoidectomy
 2nd  address pain with oral analgesics.
 3rd  Consider if a brief observation period is warranted or if the
disease severity or patient characteristics require immediate antibiotic
therapy.
– Majority of uncomplicated cases resolve spontaneously.
24

25. 25

26.  Watchful waiting and “safety-net” antibiotic prescriptions!!
 Acetaminophen or
 NSAID (ibuprofen): early to relieve pain.
– Avoided in children <6 months [increased toxicity concerns]
 Ear-drops with a local anesthetic (ametocaine, benzocaine, or
lidocaine)
– Provide pain relief when administered with oral pain
medication (ages 3 to 18 yrs).
 Don’t used decongestants or antihistamines routinely
– Minimal benefit and increased side effects.
 Watchful waiting and “safety-net” antibiotic prescriptions!!
 Acetaminophen or
 NSAID (ibuprofen): early to relieve pain.
– Avoided in children <6 months [increased toxicity concerns]
 Ear-drops with a local anesthetic (ametocaine, benzocaine, or
lidocaine)
– Provide pain relief when administered with oral pain
medication (ages 3 to 18 yrs).
 Don’t used decongestants or antihistamines routinely
– Minimal benefit and increased side effects.
26

27.  One strategy before Rx: "delayed therapy“
Encourage the patient to wait to use the medication for 48
to 72 hrs to see if the symptoms will resolve on their own.
 Candidates for ‘’delayed therapy’’:
Age 6 months - 2 yrs + No severe symptoms + uncertain dx.
Age ≥2 years + without severe symptoms.
Age ≥2 years + uncertain diagnosis.
 One strategy before Rx: "delayed therapy“
Encourage the patient to wait to use the medication for 48
to 72 hrs to see if the symptoms will resolve on their own.
 Candidates for ‘’delayed therapy’’:
Age 6 months - 2 yrs + No severe symptoms + uncertain dx.
Age ≥2 years + without severe symptoms.
Age ≥2 years + uncertain diagnosis.
27

28.  Bulging tympanic membrane with visible pus
Immediate antibiotic therapy
 Acute otitis without bulging eardrums
Likely to clear spontaneously
Consider delayed antibiotic-prescribing strategy (while
giving acetaminophen).
 Bulging tympanic membrane with visible pus
Immediate antibiotic therapy
 Acute otitis without bulging eardrums
Likely to clear spontaneously
Consider delayed antibiotic-prescribing strategy (while
giving acetaminophen).
28

29.  Amoxicillin: mainstay of therapy:
Proven effectiveness,
High middle ear concentrations,
Excellent safety profile,
Low cost, good-tasting suspension,
Relatively narrow spectrum
 High-dose amoxicillin: overcome resistance
80 to 90 mg/kg/day unlike conventional doses (40–45
mg/kg/day)
» Results in higher middle ear fluid concentrations
 Change Rx: if complications symptoms unresolved within 3 days.
 Amoxicillin: mainstay of therapy:
Proven effectiveness,
High middle ear concentrations,
Excellent safety profile,
Low cost, good-tasting suspension,
Relatively narrow spectrum
 High-dose amoxicillin: overcome resistance
80 to 90 mg/kg/day unlike conventional doses (40–45
mg/kg/day)
» Results in higher middle ear fluid concentrations
 Change Rx: if complications symptoms unresolved within 3 days.29

30.  High dose amoxicillin-clavulanate:
(Amox. 90 mg/kg/day/Clav. 6.4 mg/kg/day) into 2 doses
Considered for
– Children who received amoxicillin in the previous 30 days,
– have concurrent purulent conjunctivitis,
– have a hx of recurrent AOM unresponsive to amoxicillin
– Suspected ß-lactamase producing organisms.
– Moderate to severe illness ( T˚>39°C [102°F] and/or
severe otalgia),
 High dose amoxicillin-clavulanate:
(Amox. 90 mg/kg/day/Clav. 6.4 mg/kg/day) into 2 doses
Considered for
– Children who received amoxicillin in the previous 30 days,
– have concurrent purulent conjunctivitis,
– have a hx of recurrent AOM unresponsive to amoxicillin
– Suspected ß-lactamase producing organisms.
– Moderate to severe illness ( T˚>39°C [102°F] and/or
severe otalgia),
30

31.  2nd line agents:
Cefuroxime, cefdinir, cefpodoxime, and ceftriaxone.
2nd-gen. cephalosporins [ß-lactamase stable, expensive,
increased incidence of side effects].
– Most cephalosporins do not achieve adequate middle ear
fluid concentrations against drug-resistant S. pneumoniae
for the desired duration of the dosing interval.
 2nd line agents:
Cefuroxime, cefdinir, cefpodoxime, and ceftriaxone.
2nd-gen. cephalosporins [ß-lactamase stable, expensive,
increased incidence of side effects].
– Most cephalosporins do not achieve adequate middle ear
fluid concentrations against drug-resistant S. pneumoniae
for the desired duration of the dosing interval.
31

32.  Trimethoprim-sulfamethoxazole and macrolides have limited efficacy
against S. pneumoniae and H. influenzae: not DOC
 Ceftriaxone :
Achieve MIC for >40% of the dosing interval at middle ear
 50 mg/kg/day IM/IV stat have been used.
– But, daily doses for 3 days are recommended to optimize clinical
outcomes.
Reserved for:
– Severe and unresponsive infections or
– Unable to take PO (V, D, or non-adherence].
 Trimethoprim-sulfamethoxazole and macrolides have limited efficacy
against S. pneumoniae and H. influenzae: not DOC
 Ceftriaxone :
Achieve MIC for >40% of the dosing interval at middle ear
 50 mg/kg/day IM/IV stat have been used.
– But, daily doses for 3 days are recommended to optimize clinical
outcomes.
Reserved for:
– Severe and unresponsive infections or
– Unable to take PO (V, D, or non-adherence].
32

33.  Penicillin allergic patients
Non-type I [non- IgE] hypersensitivity
– Cefdinir, cefpodoxime, or cefuroxime
Type I (anaphylactic) [IgE]
– Macrolide (azithromycin or clarithromycin)
Clindamycin:
– If penicillin allergy +documented S. pneumoniae
– To cover penicillin-resistant S. pneumoniae.
 Penicillin allergic patients
Non-type I [non- IgE] hypersensitivity
– Cefdinir, cefpodoxime, or cefuroxime
Type I (anaphylactic) [IgE]
– Macrolide (azithromycin or clarithromycin)
Clindamycin:
– If penicillin allergy +documented S. pneumoniae
– To cover penicillin-resistant S. pneumoniae.
33

34.  Tympanocentesis
For treatment failure or persistent acute otitis media.
Can relieve pain and pressure.
Used to collect fluid to identify the causative agent.
 Tympanocentesis
For treatment failure or persistent acute otitis media.
Can relieve pain and pressure.
Used to collect fluid to identify the causative agent.
34

35. Acute Otitis Media Antibiotic Recommendations
Initial Diagnosis Failure at 48–72 Hours
Non-severe Severea Nonsevere Severea
First line Amoxicillin, high-
dose; 80–90
mg/kg/day
divided twice
daily
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
6.4 mg/kg/day
of clavulnate
divided twice
daily
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
6.4 mg/kg/day
of clavulanate
divided twice
daily
Ceftriaxone (1–3
days)
35
Amoxicillin, high-
dose; 80–90
mg/kg/day
divided twice
daily
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
6.4 mg/kg/day
of clavulnate
divided twice
daily
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
6.4 mg/kg/day
of clavulanate
divided twice
daily
Non–type 1
allergy
Cefdinir,
cefuroxime,
cefpodoxime
Ceftriaxone (1–3
days)
Ceftriaxone (1–3
days)
Clindamycin
Type 1 allergy Azithromycin,
clarithromycin
Clindamycin Clindamycin
aSevere = temperature 39°C (102°F) and/or severe otalgia.
bAmoxicillin-clavulanate 90:6.4 or 14:1 ratio

36. Defined: at least 3 episodes in 6 months or at least 4
episodes in 12 months.
This is concern in < 3 years children; [are at high risk for
hearing loss and language and learning disabilities].
Do not use prophylaxis.
Use of tympanostomy tubes (T-tubes): effective its prevention
Current insight: Oral fluoroquinolones ???
Defined: at least 3 episodes in 6 months or at least 4
episodes in 12 months.
This is concern in < 3 years children; [are at high risk for
hearing loss and language and learning disabilities].
Do not use prophylaxis.
Use of tympanostomy tubes (T-tubes): effective its prevention
Current insight: Oral fluoroquinolones ???
36

37.  Traditional recommendations: 10 to 14 days
For all severe infections and
For children < 2 years.
 7 day regimens
For mild to moderate AOM in children 2 to 5 years
 5- to 7 day regimens
For mild to moderate AOM in children≥ 6 years.
 Short treatment courses (<10 days) not recommended
In children < 2 years.
Perforated eardrums
 Traditional recommendations: 10 to 14 days
For all severe infections and
For children < 2 years.
 7 day regimens
For mild to moderate AOM in children 2 to 5 years
 5- to 7 day regimens
For mild to moderate AOM in children≥ 6 years.
 Short treatment courses (<10 days) not recommended
In children < 2 years.
Perforated eardrums
37

38. 38

39. 39

40. 40

41. 41

42. 42

43. Pharyngitis
43

44.  A 7-year-old girl presents to the pediatrician with a sore throat and fever of
39.1°C (102.4°F) for the past 12 hours. She has pain while swallowing, so she is
unable to eat or drink as much as usual. She also complains of a “belly ache.”
She has no other symptoms and takes no medications. She is allergic to
amoxicillin (rash). Her mother reports that two children in her daughter’s class
had “strep throat” recently. Physical examination reveals halitosis, pharyngeal
and tonsillar erythema with exudates, and cervical lymphadenopathy.
 How should the patient be evaluated and treated?
 Does this child have streptococcal pharyngitis?
 Any risk factors she had??
 Is antibiotic therapy indicated? If so, what agent should be initiated and for
how long?
 What education should be provided to her mother regarding treatment?
 A 7-year-old girl presents to the pediatrician with a sore throat and fever of
39.1°C (102.4°F) for the past 12 hours. She has pain while swallowing, so she is
unable to eat or drink as much as usual. She also complains of a “belly ache.”
She has no other symptoms and takes no medications. She is allergic to
amoxicillin (rash). Her mother reports that two children in her daughter’s class
had “strep throat” recently. Physical examination reveals halitosis, pharyngeal
and tonsillar erythema with exudates, and cervical lymphadenopathy.
 How should the patient be evaluated and treated?
 Does this child have streptococcal pharyngitis?
 Any risk factors she had??
 Is antibiotic therapy indicated? If so, what agent should be initiated and for
how long?
 What education should be provided to her mother regarding treatment? 44

45.  Acute infection of the oropharynx or nasopharynx
 Inflammation of the throat often caused by infection.
 Associated with rare but severe sequelae if not treated
appropriately
Non suppurative complications
– Acute rheumatic fever, acute glomerulonephritis, and reactive
arthritis
Suppurative complications
– Peritonsillar abscess, retropharyngeal abscess, cervical
lymphadenitis, mastoiditis, otitis media, sinusitis, and necrotizing
fasciitis
 Acute infection of the oropharynx or nasopharynx
 Inflammation of the throat often caused by infection.
 Associated with rare but severe sequelae if not treated
appropriately
Non suppurative complications
– Acute rheumatic fever, acute glomerulonephritis, and reactive
arthritis
Suppurative complications
– Peritonsillar abscess, retropharyngeal abscess, cervical
lymphadenitis, mastoiditis, otitis media, sinusitis, and necrotizing
fasciitis
45

46.  1% to 2% adults visits in and 6% to 8% of pediatric visits
 Children ages 5 to 15 years are most susceptible
 More common at crowd, institutions areas
 Cost ~$1.2 billion total and up to $539 million for children alone.
 1% to 2% adults visits in and 6% to 8% of pediatric visits
 Children ages 5 to 15 years are most susceptible
 More common at crowd, institutions areas
 Cost ~$1.2 billion total and up to $539 million for children alone.
46

47.  Viral causes: most common.
 Rhinovirus (20%), coronavirus (<5%), adenovirus (5%), HSV(4%),
influenza virus (2%), parainfluenza virus (2%), and EBV(<1%).
 GABHS: primary bacterial cause.
 20% to 30% of cases in children and 5% to 15% of adult infections
 Less common bacterial cause
 Groups C and G Streptococcus, Corynebacterium diphtheriae, N.
gonorrhoeae, Mycoplasma/Chlamydia pneumoniae, Yersinia enterocolitica,
 Viral causes: most common.
 Rhinovirus (20%), coronavirus (<5%), adenovirus (5%), HSV(4%),
influenza virus (2%), parainfluenza virus (2%), and EBV(<1%).
 GABHS: primary bacterial cause.
 20% to 30% of cases in children and 5% to 15% of adult infections
 Less common bacterial cause
 Groups C and G Streptococcus, Corynebacterium diphtheriae, N.
gonorrhoeae, Mycoplasma/Chlamydia pneumoniae, Yersinia enterocolitica,
47

48.  Mxm not well defined
 If alteration in host immunity (a breach in the pharyngeal mucosa)
 If disruption in mucosal integrity
Asymptomatic pharyngeal carriers or colonization by GABHS
  InfectionInfection
Pathogenic factors associated with the organism [pyrogenic
toxins, hemolysins, streptokinase, and proteinase] itself play a
role.
 Mxm not well defined
 If alteration in host immunity (a breach in the pharyngeal mucosa)
 If disruption in mucosal integrity
Asymptomatic pharyngeal carriers or colonization by GABHS
  InfectionInfection
Pathogenic factors associated with the organism [pyrogenic
toxins, hemolysins, streptokinase, and proteinase] itself play a
role.
48

49.  Sudden onset of sore throat, Pain on swallowing
 Fever, Headache, Abdominal pain
 Nausea and vomiting, Tonsillopharyngeal erythema
 Tonsillopharyngeal exudate
 Soft-palate petechiae (“doughnut” lesions)
 Beefy red, swollen uvula
 Anterior cervical lymphadenitis
 Scarlatiniform rash
 Sudden onset of sore throat, Pain on swallowing
 Fever, Headache, Abdominal pain
 Nausea and vomiting, Tonsillopharyngeal erythema
 Tonsillopharyngeal exudate
 Soft-palate petechiae (“doughnut” lesions)
 Beefy red, swollen uvula
 Anterior cervical lymphadenitis
 Scarlatiniform rash
49

50. Cont’d…
Soft-palate petechiae
(“doughnut” lesions)
50
Scarlatiniform rash Beefy red, swollen uvula
Soft-palate petechiae
(“doughnut” lesions)

51.  Symptoms suggestive of other dx like common cold (Rhinovirus,
Coronovirus)
Coryza, Hoarseness, Cough, Diarrhea, Conjunctivitis, Anterior
stomatitis, Discrete ulcerative lesions
 Laboratory Tests
Throat swab and culture
Rapid antigen detection testing (RADT)
 Symptoms suggestive of other dx like common cold (Rhinovirus,
Coronovirus)
Coryza, Hoarseness, Cough, Diarrhea, Conjunctivitis, Anterior
stomatitis, Discrete ulcerative lesions
 Laboratory Tests
Throat swab and culture
Rapid antigen detection testing (RADT)
51

52.  Scoring System: Modified Centor Criteria for Clinical Prediction of Group A ß
-Hemolytic Streptococcal Pharyngitis
of streptococcal infection
52

53.  Goals of therapy:
 Eradication of GAS from the pharynx
 Reducing duration and severity of clinical signs and symptoms.
 Reducing incidence of non-suppurative complications & suppurative
complications
 Reducing transmission to close contacts by reducing infectivity
 Goals of therapy:
 Eradication of GAS from the pharynx
 Reducing duration and severity of clinical signs and symptoms.
 Reducing incidence of non-suppurative complications & suppurative
complications
 Reducing transmission to close contacts by reducing infectivity
53

54.  Symptomatic treatment (pain)
 Acetaminophen (better option than NSAID)
 Rest, fluid, lozenges, salt water gargles
 Antibiotics: if clinical signs & symptoms consistent with GAS and positive
laboratory test (rapid strep screen or culture)
 Goals of antibiotic therapy:
 Prevent suppurative complications (abscess etc.)
 Prevent rheumatic fever (reduces from 2.8 % to 0.2 %)
 Decrease infectivity
 Shorten clinical course by 1-2 days (if started early)
 Symptomatic treatment (pain)
 Acetaminophen (better option than NSAID)
 Rest, fluid, lozenges, salt water gargles
 Antibiotics: if clinical signs & symptoms consistent with GAS and positive
laboratory test (rapid strep screen or culture)
 Goals of antibiotic therapy:
 Prevent suppurative complications (abscess etc.)
 Prevent rheumatic fever (reduces from 2.8 % to 0.2 %)
 Decrease infectivity
 Shorten clinical course by 1-2 days (if started early)
54

55.  10 days of:
 Penicillin VK 250 mg 3-4 times daily or 500 mg twice daily
 Amoxicillin 500 mg 3 times daily
– Avoid if patient likely to have mononeucleosis as will cause rash
 Cephalexin 250 – 500 mg PO 4 times daily
 Benzathine Penicillin 1.2 million Units IM once: if unable to take PO
 Macrolides
 Erythromycin 250 mg PO 4 times daily
 Azithromycin 12 mg / kg (max 500 mg) PO daily for 5 days
– 7 – 30 % of strains are now resistant
 Amoxicillin-clavulanate or clindamycin
 For recurrent episodes of pharyngitis
 10 days of:
 Penicillin VK 250 mg 3-4 times daily or 500 mg twice daily
 Amoxicillin 500 mg 3 times daily
– Avoid if patient likely to have mononeucleosis as will cause rash
 Cephalexin 250 – 500 mg PO 4 times daily
 Benzathine Penicillin 1.2 million Units IM once: if unable to take PO
 Macrolides
 Erythromycin 250 mg PO 4 times daily
 Azithromycin 12 mg / kg (max 500 mg) PO daily for 5 days
– 7 – 30 % of strains are now resistant
 Amoxicillin-clavulanate or clindamycin
 For recurrent episodes of pharyngitis
55

56. 56

57. Drug Adult Dosage Pediatric Dosage
Clindamycin 600 mg orally divided in two to
four doses
20 mg/kg/day orally in
three divided doses
(maximum 1.8 g/day)
Amoxicillin-
clavulanate
500 mg orally twice daily 40 mg/kg/day orally in
three divided doses
Penicillin benzathine 1.2 million units IM for one dose 0.6 million units IM for
weight <27 kg (50,000
units/kg)
57
Penicillin benzathine 1.2 million units IM for one dose 0.6 million units IM for
weight <27 kg (50,000
units/kg)
Penicillin benzathine
with rifampin
As above As above
Rifampin 20 mg/kg/day orally
in two divided doses during last
4 days of treatment with
penicillin (maximum daily dose
600 mg)
Rifampin dose same

58. Sinusitis
58

59.  A 43-year-old man has a two-week history of nasal congestion,
postnasal drip, and fatigue. He has used an over the- counter nasal
decongestant and acetaminophen, without relief. During the past few
days, facial pain and pressure have developed and have not
responded to decongestants. In addition, his nasal discharge has turned
from clear to yellow
 Sign and symptoms consistent to sinusitis?
 Could you suspect bacterial cause at this time? Why??
 How should he be treated?
 A 43-year-old man has a two-week history of nasal congestion,
postnasal drip, and fatigue. He has used an over the- counter nasal
decongestant and acetaminophen, without relief. During the past few
days, facial pain and pressure have developed and have not
responded to decongestants. In addition, his nasal discharge has turned
from clear to yellow
 Sign and symptoms consistent to sinusitis?
 Could you suspect bacterial cause at this time? Why??
 How should he be treated?
59

60.  Paranasal sinuses (“the sinuses”) are air-filled cavities located within
the bones of the face and around the nasal cavity and eyes.
 Each sinus is named for the bone in which it is located:
 Maxillary sinus
 Ethmoid sinus
 Frontal sinus
 Sphenoid sinus
 Paranasal sinuses (“the sinuses”) are air-filled cavities located within
the bones of the face and around the nasal cavity and eyes.
 Each sinus is named for the bone in which it is located:
 Maxillary sinus
 Ethmoid sinus
 Frontal sinus
 Sphenoid sinus
60

61.  The pink membranes lining the sinuses make mucus that is cleared out of
the sinus cavities and drains into the nasal passage.
 Both airflow & mucus ends up in a part of throat [nasopharynx]
Air is then breathed into the windpipe and lungs, while the
mucus is swallowed
 The pink membranes lining the sinuses make mucus that is cleared out of
the sinus cavities and drains into the nasal passage.
 Both airflow & mucus ends up in a part of throat [nasopharynx]
Air is then breathed into the windpipe and lungs, while the
mucus is swallowed
61

62.  Other structures associated with the nasal and sinus tract:
 Tear duct (nasolacrimal duct): drains tears from the inside corner of
the eye into the nasal cavity
 Eustachian tube: responsible for clearing air pressure in the ears; it
opens into the back of the sidewall of the nasopharynx.
 Adenoids: collection of tonsil-like tissue [at top of the nasopharynx]
 Other structures associated with the nasal and sinus tract:
 Tear duct (nasolacrimal duct): drains tears from the inside corner of
the eye into the nasal cavity
 Eustachian tube: responsible for clearing air pressure in the ears; it
opens into the back of the sidewall of the nasopharynx.
 Adenoids: collection of tonsil-like tissue [at top of the nasopharynx]
62

63. 63
F – frontal sinus S - sphenoid sinus ST – superior turbinate
MT - middle turbinate IT – inferior turbinate
E – Eustachian tube opening A – Adenoid
NP –nasopharynx
nasal airflow (arrows)

64. 64

65. 65

66.  Inflammation and/or infection of the para-nasal sinuses, or
membrane-lined air spaces, around the nose
 Aka rhinosinusitis [involves contiguous nasal mucosa]
 Occurs in nearly all viral URIs
 Inflammation and/or infection of the para-nasal sinuses, or
membrane-lined air spaces, around the nose
 Aka rhinosinusitis [involves contiguous nasal mucosa]
 Occurs in nearly all viral URIs
66
Sinusitis
Acute
Chronic
Symptoms persist for up to 4 wks
Lasts for more than 12 weeks.

67.  > 31million cases annually
 ~ ~9% of all adult and 21% of pediatric antibiotic prescriptions
 6 to 8x occurrence/year
 5.8 billion expenditures/year
 > 31million cases annually
 ~ ~9% of all adult and 21% of pediatric antibiotic prescriptions
 6 to 8x occurrence/year
 5.8 billion expenditures/year
67

68.  Mainly respiratory viruses
 Can be triggered by allergies or environmental irritants.
 Complicated viral rhinosinusitis [2° bacterial infection]: 0.2% to 2%
of adults and 5% to 13% of children.
 Viral: Usually improves in 5-7 days
 Bacterial: if severe & symptoms > 10 days or worsens after 5-7
days
– 50-60 % : S. pneumoniae & H. influenzae
– 8% to 16%: M. catarrhalis
 Mainly respiratory viruses
 Can be triggered by allergies or environmental irritants.
 Complicated viral rhinosinusitis [2° bacterial infection]: 0.2% to 2%
of adults and 5% to 13% of children.
 Viral: Usually improves in 5-7 days
 Bacterial: if severe & symptoms > 10 days or worsens after 5-7
days
– 50-60 % : S. pneumoniae & H. influenzae
– 8% to 16%: M. catarrhalis
68

69. Allergic or non-allergic rhinitis
Intranasal medications or illicit
drugs
Anatomic defects (eg, septal
deviation)
Mechanical ventilation
Aspirin allergy, nasal polyps, and
asthma
Nasogastric tubes
Cystic fibrosis or ciliary dyskinesia
Swimming or diving
Dental infections or procedures
Tobacco smoke exposure
Traumatic head injury
Gastroesophageal reflux
Viral respiratory tract infection
Winter season
Immunodeficiency
69
Allergic or non-allergic rhinitis
Intranasal medications or illicit
drugs
Anatomic defects (eg, septal
deviation)
Mechanical ventilation
Aspirin allergy, nasal polyps, and
asthma
Nasogastric tubes
Cystic fibrosis or ciliary dyskinesia
Swimming or diving
Dental infections or procedures
Tobacco smoke exposure
Traumatic head injury
Gastroesophageal reflux
Viral respiratory tract infection
Winter season
Immunodeficiency

70.  Mucosal inflammation and mucociliary dysfunction from viral
infection or allergy  obstruction of the sinus ostia [pathways
that drain the sinuses].
 Trapped mucosal secretions & impaired local defenses 
bacteria from adjacent surfaces begin to proliferate.
 Maxillary and ethmoid sinuses: most involved
 Mucosal inflammation and mucociliary dysfunction from viral
infection or allergy  obstruction of the sinus ostia [pathways
that drain the sinuses].
 Trapped mucosal secretions & impaired local defenses 
bacteria from adjacent surfaces begin to proliferate.
 Maxillary and ethmoid sinuses: most involved
70

71. 71

72.  General
– A nonspecific upper respiratory tract infection that persists beyond 7 to 14
days
 Acute
Adults
– Nasal discharge/congestion, Maxillary tooth pain, facial or sinus pain that
may radiate (unilateral in particular) or that is made worse by bending
forward,
– Purulent nasal discharge, maxillary tooth discomfort, hyposmia or anosmia,
cough, Headache, fever, and malaise
Children
– Morning periorbital edema or facial swelling; Nasal discharge and cough
for longer than 10 to 14 days or severe signs and symptoms such as
temperature above 39°C (102°F) or facial swelling or pain are indications
for antibiotic therapy 72
 General
– A nonspecific upper respiratory tract infection that persists beyond 7 to 14
days
 Acute
Adults
– Nasal discharge/congestion, Maxillary tooth pain, facial or sinus pain that
may radiate (unilateral in particular) or that is made worse by bending
forward,
– Purulent nasal discharge, maxillary tooth discomfort, hyposmia or anosmia,
cough, Headache, fever, and malaise
Children
– Morning periorbital edema or facial swelling; Nasal discharge and cough
for longer than 10 to 14 days or severe signs and symptoms such as
temperature above 39°C (102°F) or facial swelling or pain are indications
for antibiotic therapy

73.  Chronic
– Symptoms are similar to acute sinusitis but more nonspecific
– Rhinorrhea is associated with acute exacerbations
– Chronic unproductive cough, laryngitis, and headache may occur
– Chronic/recurrent infections occur 3-4x/year and are unresponsive
to steam and decongestants
 Laboratory Tests
– Gram stain, culture, and sensitivities of draining fluid or aspirated
fluid if sinus puncture is performed
 Chronic
– Symptoms are similar to acute sinusitis but more nonspecific
– Rhinorrhea is associated with acute exacerbations
– Chronic unproductive cough, laryngitis, and headache may occur
– Chronic/recurrent infections occur 3-4x/year and are unresponsive
to steam and decongestants
 Laboratory Tests
– Gram stain, culture, and sensitivities of draining fluid or aspirated
fluid if sinus puncture is performed
73

74.  Orbital cellulitis or abscess,
 Periorbital cellulitis,
 Meningitis,
 Cavernous sinus thrombosis,
 Ethmoid or frontal sinus erosion,
 Chronic sinusitis, and
 Exacerbation of asthma or bronchitis
 Orbital cellulitis or abscess,
 Periorbital cellulitis,
 Meningitis,
 Cavernous sinus thrombosis,
 Ethmoid or frontal sinus erosion,
 Chronic sinusitis, and
 Exacerbation of asthma or bronchitis
74

75.  Goals of therapy
 Relieve symptoms,
 Promote sinus drainage/achieve and maintain patency of the ostia
 Use antibiotics when appropriate[minimize resistance],
 Prevent development of chronic disease or complications.
 Goals of therapy
 Relieve symptoms,
 Promote sinus drainage/achieve and maintain patency of the ostia
 Use antibiotics when appropriate[minimize resistance],
 Prevent development of chronic disease or complications.
75

76.  1st: delineate viral and bacterial sinusitis
 Based on disease duration, rather than symptomatology
– [Signs and symptoms are similar for viral and bacterial sinusitis]
 Viral sinusitis: improves in 7 to 10 days;
 Acute bacterial sinusitis:
 Persistent symptoms (10 days) or
 Worsening of symptoms after 5 to 7 days.
 If symptoms do not respond to non-prescription nasal decongestants
and acetaminophen.
 1st: delineate viral and bacterial sinusitis
 Based on disease duration, rather than symptomatology
– [Signs and symptoms are similar for viral and bacterial sinusitis]
 Viral sinusitis: improves in 7 to 10 days;
 Acute bacterial sinusitis:
 Persistent symptoms (10 days) or
 Worsening of symptoms after 5 to 7 days.
 If symptoms do not respond to non-prescription nasal decongestants
and acetaminophen.
76

77.  If bacteria cause,,,,Decide: whether complicated or uncomplicated
 Complicated: mental status changes, immunosuppressive illness,
unilateral findings, significant coexisting illnesses, risk factors for B-
lactam-resistant strains, history of antibiotic failure, isolated frontal
or sphenoid sinusitis, or intense periorbital swelling, erythema, and
facial pain.
 If bacteria cause,,,,Decide: whether complicated or uncomplicated
 Complicated: mental status changes, immunosuppressive illness,
unilateral findings, significant coexisting illnesses, risk factors for B-
lactam-resistant strains, history of antibiotic failure, isolated frontal
or sphenoid sinusitis, or intense periorbital swelling, erythema, and
facial pain.
77

78.  Initiate antibiotics
 Persistent symptoms for greater than 10 days with no improvement;
 Sudden worsening of symptoms within 5 to 10 days of initial
improvement;
 Severe symptoms for 3 to 4 days at illness onset.
 Initiate antibiotics
 Persistent symptoms for greater than 10 days with no improvement;
 Sudden worsening of symptoms within 5 to 10 days of initial
improvement;
 Severe symptoms for 3 to 4 days at illness onset.
78

79.  Supportive measures
Analgesics/antipyretics
 Humidifiers and saline nasal sprays or drops
– Moisturize the nasal canal, impair crusting of secretions, and
promote ciliary function.
 Isotonic/hypertonic saline nasal irrigation
– Specially in patients with recurrent or chronic sinusitis
 Decongestant: phenylephrine, oxymetazoline
– Reduce inflammation by vasoconstriction
 Mucolytics (e.g., guaifenesin)
– Decrease the viscosity of nasal secretions.
 Supportive measures
Analgesics/antipyretics
 Humidifiers and saline nasal sprays or drops
– Moisturize the nasal canal, impair crusting of secretions, and
promote ciliary function.
 Isotonic/hypertonic saline nasal irrigation
– Specially in patients with recurrent or chronic sinusitis
 Decongestant: phenylephrine, oxymetazoline
– Reduce inflammation by vasoconstriction
 Mucolytics (e.g., guaifenesin)
– Decrease the viscosity of nasal secretions.
79

80.  Antihistamines
 Should not be used for acute bacterial sinusitis
– Have anticholinergic effects that can dry mucosa and disturb
clearance of mucosal secretions.
 2nd -generation may have a role in chronic sinusitis,
– Because frequently accompanied by concomitant allergic rhinitis.
 Glucocorticoids [intranasal]
 Decrease inflammation causing headache, nasal congestion, and
facial pain.
 But, limited data to support
 Antihistamines
 Should not be used for acute bacterial sinusitis
– Have anticholinergic effects that can dry mucosa and disturb
clearance of mucosal secretions.
 2nd -generation may have a role in chronic sinusitis,
– Because frequently accompanied by concomitant allergic rhinitis.
 Glucocorticoids [intranasal]
 Decrease inflammation causing headache, nasal congestion, and
facial pain.
 But, limited data to support
80

81.  Antibiotics:
 Amoxicillin: DOC
 High-dose amoxicillin: in high risk of penicillin-resistant S.
pneumoniae (PRSP)
– Day care attendance, recent antibiotic use, age younger than 2
years
 Amoxicillin-clavulanate: alternative
– If no improvement on amoxicillin after 3 days
– If took antibiotics 4- 6 weeks back
– Need of Improved coverage of H. influenzae and M. catarrhalis
 Antibiotics:
 Amoxicillin: DOC
 High-dose amoxicillin: in high risk of penicillin-resistant S.
pneumoniae (PRSP)
– Day care attendance, recent antibiotic use, age younger than 2
years
 Amoxicillin-clavulanate: alternative
– If no improvement on amoxicillin after 3 days
– If took antibiotics 4- 6 weeks back
– Need of Improved coverage of H. influenzae and M. catarrhalis
81

82. Penicillin allergies
– None-type I: 2nd gen. cephalosporin: cefprozil, cefuroxime,
or cefpodoxime
» β-lactamase-stable cephalosporin
– Type I: trimethoprim-sulfamethoxazole, doxycycline,
Macrolides, Respiratory fluoroquinolones
Clindamycin: but, not active against H. influenzae and M.
catarrhalis.
Penicillin allergies
– None-type I: 2nd gen. cephalosporin: cefprozil, cefuroxime,
or cefpodoxime
» β-lactamase-stable cephalosporin
– Type I: trimethoprim-sulfamethoxazole, doxycycline,
Macrolides, Respiratory fluoroquinolones
Clindamycin: but, not active against H. influenzae and M.
catarrhalis.
82

83.  For uncomplicated:
5 to 10 days in adults
10 to 14 days in children
 A 3 or 5-day course of azithromycin 500 mg daily
 Generally treat for
10 to 14 days of antibiotic therapy or
At least 7 days after signs and symptoms are under control.
 For uncomplicated:
5 to 10 days in adults
10 to 14 days in children
 A 3 or 5-day course of azithromycin 500 mg daily
 Generally treat for
10 to 14 days of antibiotic therapy or
At least 7 days after signs and symptoms are under control.
83

84. 84

85. 85

86. 86

87. 87

88. 88

89.  For effectiveness and safety
Clinical signs and symptoms
Laboratory data and diagnostic procedures
89

90. 90