Approach to Patient with

Upper Respiratory Tract

Infection(URTI) Dr Duaa Hiasat

1

URTIs : inflammation of the respiratory

mucosa from the nasal cavity down to the bronchus. (above the level of the carina).

Includes : common colds , influenza ,

sinusitis , rhinitis , tonsillitis , otitis media ,

pharyngitis ,

laryngitis,epiglottitis,Tracheitis and croup.

2

Epidemiology:

In average , children will have 5 URTIs/

year and adults 2-3/year.

70-80 % of these infections are caused

by viruses ; rhinoviruses and

adenoviruses are the most common.

3

Management principles:

*Viral infections need ONLY symptomatic

treatment , NO need for antibiotics(Abs).

Viral URTIs :

1. Influenza

2. Common cold

3. Mild acute sinusitis

4. Mild acute otitis media

4

*Bacterial infections need ABs for

treatment in addition to the

symptomatic treatment.

Bacterial URTIs :

1. GABHS pharyngitis

2. Moderately to severe acute sinusitis

3. Moderately to severe acute otitis media

4. Special cases ( pertussis , epiglottitis )

5

*Why not to use Abs for viral infections ?

1. Promotes Abs resistance.

2. Adverse reactions such as allergy and

anaphylaxis

3. Patients do not need Abs to feel

satisfied

4. costly

6

Why to use Abs for bacterial infections?

1. To prevent suppurative complications

2. To prevent rheumatic fever

3. To speed up recovery

4. To reduce spread to others

7

Common cold

8

Common cold is a self-limiting , viral

infectious disease of the upper respiratory

system.

Incidence : most frequent infectious

disease in humans ; 2-4 infections / year

in adults and 6-12 in children.

Transmitted by droplets and close

personal contact / airborne.

usually occurs in the fall and winter

months. 9

Causative agents :

Rhinovirus (50%) , coronavirus (10-20%),

adenovirus (5%) , others :RSV , parainfluenza virus.

Bacterial infections are unlikely:

Mycobacterium leprae, Klebsiella rhinoscleromatis, Pseudomonas mallei (glanders), Rhinosporidium seeberi (rhinosporidiosis), Leishmania mexicana (leishmaniasis)

10

Symptoms:

The first symptom is usually a sore or “scratchy

throat” , followed soon after by nasal stuffiness

and discharge ( rhinorrhea ) , sneezing and

coughing. The throat is usually sore for a brief time. The cough symptoms

are usually worse on the 4th or 5th day of illness , while the

nasal symptoms improve.

Symptoms generally last for 7 to 10 days.

Cough may continue up to 4 weeks.

11

If the nasal discharge becomes viscous

and green with time ; it doesn’t mean

superimposed bacterial infection . It’s a

normal course of common cold.

12

Complications:

1. Acute otitis media (most common in children)

2. Pharyngitis

3. Sinusitis

4. Bronchitis and pneumonia

5. Conjunctivitis

6. Adenitis

7. Aggravation of asthma

13

Management:

Symptomatic Treatment : comfort is the goal of treatment which may include: *nasal suction for infants

*steam/mist inhalation

*nasal irrigation

*humidified air

14

*consume extra fluids (warm fluids may be soothing for irritated throats

*consume nutritious diet as tolerated

*elevate head of bed

*salt water gargle for sore throat .

*get adequate rest

15

*Vitamin C may reduce duration of common cold in children.

*Zinc syrup associated with reduced duration of cold symptoms in children

*Honey may reduce nocturnal cough and sleep disruption in children

with acute cough, and might be more effective than

dextromethorphan or diphenhydramine

16

Medication :

1. Antipyretics: no evidence that fever or antipyretic treatment affects illness course or neurologic complications:

2. Ibuprofen appears more effective than acetaminophen for reducing fever in single-dose comparisons and ibuprofen and acetaminophen appear to have similar analgesic effects .

17

*Combined or alternating acetaminophen and ibuprofen regimens may be more effective than either monotherapy for reducing fever in children.

*Ibuprofen approved for use( by FDA)

after 6 months of age.

*Paracetamol: may be used after 2-3

months of age. 18

Nasal Decongestants and

Antihistamines:

*Nonprescription medicines (antihistamines and antitussives) do not appear effective for acute cough in children ) *FDA recommends against use of nonprescription cough and cold products in children < 2 years old and supports not using them in children < 4 years old.

*nonprescription cough and cold preparations may not be safe in children

19

*Aspirin is contraindicated in children with viral infections due to association with increased risk for

Antibiotics :

*Abs do not appear to reduce symptoms of common cold or acute purulent rhinitis.

* No role of antibiotics in common cold ( viral infection ).

20

Prevention:

*Wash hands after contact with common

cold patients.

*Do not touch any surfaces or objects that

may have been contaminated.

*Keep fingers out of eyes and nose.

21

Influenza:

*Influenza is a viral infection that affects

mainly the nose , throat , bronchi , and

occasionally lungs.

*Influenza causes annual epidemics that

peak during winter.

22

Seasonal influenza

*Acute viral infection caused by influenza type A , B and

C.

*Type A and B are constantly changing due to

mutations ( antigenic drift and shift ) , more serious

than type C.

*Type C is stable , it’s cases occur much less

frequently than type A and B.

*Currently influenza A (H1N1) and A (H3N2) subtypes

are circulating among humans.

*Transmitted by droplets and close person contact /

airborne.

23

*Following an incubation period of 1-2 days, flu

presents with abrupt onset of fever (39 – 40 c)

,muscle aches , headache and fatigue. The

individual may have respiratory symptoms such as

a dry cough , sore throat , and occasionally a

runny nose.

*Other symptoms related to systemic illness

include chills and sweats , loss of appetite ,

diarrhea and vomiting.

Signs and symptoms

24

Prognosis: These symptoms generally improve over two to

five days, though may last one or more weeks.

*Some patients experience postinfluenzal

asthenia (persistent weakness or becoming tired

easily) which may be present for several weeks

following the illness.

* A dry cough (post viral cough syndrome) may

also persists for several weeks. 25

Common cold Vs Influenza:

*Influenza is different from the common cold in that

it causes a more severe illness , with fever ,

headache , significant fatigue and muscle aches

and systematic manifestations.

*It’s less likely to cause sneezing or a blocked

nose with thick nasal discharge.

26

Complications

1. Bronchitis

2. Sinus infections

3. Ear infections

4. Pneumonia

5. Encephalitis

27

Highest risk of complications occurs

among :

1. Children < 2 years

2. Adults 65 years or older

3. Medical chronic illnesses

4. Immunocompromised patients

28

Treatment:

1. Bed rest

2. Antipyretic/Analgesics

3. Fluid intake

29

4-Antiviral treatment:

antiviral treatment recommended as soon as possible (and not delayed while awaiting diagnostic confirmation) for patients with confirmed or suspected influenza who:

*have severe, complicated, or progressive illness

*require hospitalization

*are at higher risk for influenza complications

1. - children < 2 years,

2. -adults ≥ 65 years ,

3. -pregnant women ,

4. -chronic medical illnesses ,

5. -immunocompromised patients

1-oseltamivir adult dosing 75 mg orally twice daily for 5 days weight-based dosing used for oseltamivir in

children up to age 12 2-zanamivir

10 mg (2 inhalations) twice daily for 5 days in patients aged ≥ 7 years

not recommended in patients with airways disease not approved for children aged < 7 years

3-peramivir dosing 600 mg IV single dose in patients aged ≥

18 years not approved for children or adolescents.

amantadine and rimantadine not recommended due to widespread resistance.

Prevention:

1. Frequent hand washing.

2. Wear masks and gloves.

3. Isolation of patient until 24 hours of

afebrile period.

4. Vaccination ; most effective measure of

prevention .

32

Influenza vaccine

Annual vaccine

Two types :

1. Injectable : killed vaccine

2. Nasal spray : live but weakened virus

70% protection in 1 year.

Reduces severe complications by 60% , and

death by 80%.

33

Recommended for : 1. *all persons ≥ 50 years old

2. *Infants and children aged from 6 months to 4 years.

3. *women who are or will be pregnant during

the influenza season.

adults who have chronic pulmonary (including asthma)

or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus)

34

*household contacts and caregivers of children < 5 years old.

*Immunocompromised patients and immunosuppressive treatment.

*Health care professionals. *residents of nursing homes and other long-term care facilities. *persons who are morbidly obese (body mass index ≥ 40

kg/m2

Pharyngitis/Tonsillitis

36

Pharyngitis/Tonsillitis:

It is an inflammation of the pharynx, w/o tonsilles.most

commonly caused by viral or bacterial infection.

Causative agents :

1. Viral : adenovirus (80% most common ) , enterovirus , EBV ,

herpes simplex virus.

2. Bacterial : GABHS (5-15%), mycoplasma.

GAS uncommon in children younger than 2-3 years, and the peak is between 5-11 years.

Peak Winter to early Spring.

Spread by direct contact. 37

Clinical presentation: *The main symptom is a sore throat.

*Other symptoms may include:

- Fever

- Headache

- Joint pain and muscle aches

- Skin rashes

- Swollen lymph nodes in the neck

38

Bacterial Vs. Viral *Viral Infection:

-Clinically: Gradual, more likely to have rhinorrhea, cough, diarrhea,

hoarseness of voice.

Adenovirus: conjunctivitis, most common cause in children < 3 years of age.

- Coxsackieviruses: ulcer on posterior pharynx, herpangina (mouth blisters).

- EBV: prominent tonsils with white exudates, posterior cervical LN enlargement, Palatal rash, Hepatosplenomegaly, high fever and fatigue.

39

Bacterial Infection:

*Clinically: Rapid onset fever, prominent throat pain, headache, abdominal pain, vomiting, dysphagia and malaise.

*On exam: Pharynx are erythematous, tonsils enlarged with yellow-blood tinged exudate, petichia may be present on soft palate, anterior cervical lymph nodes enlarged and tender.

40

41

Age-modified Centor score (McIsaac

score):

1 point for each of

tonsillar exudate

swollen tender anterior cervical nodes

absence of cough

history of fever or measured temperature > 38 degrees C (100.4 degrees F)

age modification

1 point if age < 15 years

-1 point if age > 45 years

43

Why we treat GAS pharyngitis

*decrease risk of Rheumatic fever, but not of PSGN.

*shorten duration of illness.

*decrease risk of complication (mainly abscess).

44

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.

Throat Culture 20-40% of those with negative throat culture will be labeled as having GABHS.

+ve culture makes the Dx of GABHS,

but –ve culture does not rule out.

45

1. Differential diagnosis - 2. Infectious mononucleosis, when a membranous exudate is

present. 1. - Diphtheria, especially in the underimmunized. 1. - Herpangina, with many vesiculoulcerative lesions in the

anterior pillars & soft palate. 1. - Agranulocytosis, yellowish dirty white exudates covering the

tonsils & post pharyngeal wall. 1. - Kawasaki disease.

46

Complication of GAS pharyngitis: 1- otitis media

2- Glomerulonephritis and Rheumatic Fever may follow streptococcal infection.

3- Monoarthritis.

4- Mesenteric adenitis (viral or bacterial) abdominal pain with or without vomiting.

5- In debilitated children, large chronic ulcers in the pharynx (viral or bacterial).

47

Rheumatic Fever

Major Criteria:

- Polyarithritis

- Carditis

- Sydenham Chorea

- Subcutaneous nodules

- Erythema Marginatum

Minor Criteria:

Fever of 38.2–38.9 °C (101–102 °F)

Arthralgia: Joint pain without swelling (Cannot be included if polyarthritis is present as a major symptom)

Raised ESR or CRP

Leukocytosis

ECG showing features of heart block, such as a prolonged PR

interval (Cannot be included if carditis is present as a major

symptom)

Previous episode of rheumatic fever or inactive heart disease 48

According to revised Jones criteria, the diagnosis of rheumatic fever can be made when: 2 major criteria, or 1 major criterion plus 2 minor criteria, are present along with evidence of streptococcal infection: (elevated or rising ASO titre or DNAase). Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.

*Encourage fluid intake *Acetaminophen or NSAID may reduce pain. *Benzydamine oral rinse or mouth spray may reduce pain and improve symptoms. *Other supportive measures without direct evidence include

topical analgesics (such as nonprescription throat sprays) and anesthetics (such as viscous lidocaine 2%)

warm salt water gargles throat lozenges, hard candy, or frozen desserts soft foods or cold thick liquids such as ice cream Humidifier.

Supportive Measures

Bacterial Pharyngitis: Antibiotics:

Penicillin V 500mg twice daily for 10 days oral or once IM benzathine penicillin 1.2 million unit.

safe , cheap , narrow spectrum , no resistance.

or amoxicillin 500mg twice daily for 10 days.

If penicillin allergic:

Cephalexin or azithromycin or clarithromycin or clindamycin.

Corticosteroids such as dexamethasone 0.6 mg/kg orally may hasten pain relief in acute pharyngitis.

51

Carriers: Small RCTs suggest that intramuscular benzathine penicillin combined with four days of oral rifampin (Rifadin) or a 10-day course of oral clindamycin effectively eradicates the carrier state

Tonsillectomy

Recommended for recurrent severe sore throat if

more than 6 episodes in past year,more than 4

episodes per year in 2 years or more than 2 per

year in 3 years.

54

Sinusitis

Sinusitis:

Inflammation of mucosa of paranasal sinuses.

Most commonly it is viral, especially post common cold,: Rihnovirus, Influenza virus, parainfluenza virus.

Could be bacterial: Strep. Pneumoniae, H. Influenzae, M. Catarrhalis, Staph. Aureus.

55

Sinusitis: Risk Factors:

Allergic rhinitis or hay fever

Cystic fibrosis.

Day care, Weakened immune system from HIV or chemotherapy

Changes in altitude (flying or scuba diving)

Large adenoids, Nasal polyps

Smoking

Nasogastric and nasotracheal intubation

56

*Clinical presentation *The symptoms of acute sinusitis in adults usually

follow a cold that does not improve, or one that gets worse after 5 - 7 days of symptoms.

*Symptoms: Mucopurulent Rhinorrea

Nasal congestion

Facial pain, pressure and fullness

Decrease sense of smell

Exam: Looking in the nose for signs of polyps

Shining a light against the sinus (transillumination) for signs of inflammation

Tapping over a sinus area to find infection (tenderness), very painful

57

Diagnosis of Sinusitis: Clinically

We use radiological evaluation if there is warning signs:

-Severe swelling and redness of the tissues around the eye

-Limitations of eye movement

-Swelling of the forehead

-High fever

-Altered consciousness

Radiological evaluation: Regular x-rays of the sinuses are not recommended.

CT scan of the sinuses for suspected complications.

58

Complications of Sinusitis: Periorbital cellulites

Meningitis

Brain abscesses

Cavernous sinus thrombosis

Osteomylitis of frontal bane.

59

Treatment of Sinusitis:

*Analgesics and antipyretics as needed

*Intranasal corticosteroids.

*Consider intranasal saline with either physiologic or hypertonic saline.

*Decongestants and antihistamines: lack evidence for effectiveness unless evidence of allergic component.

60

*antibiotics for acute bacterial sinusitis: -most cases resolve without antibiotic treatment.

-only consider treatment with antibiotics if patient meets criteria for acute bacterial sinusitis.

consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature < 101 degrees F [38.3 degrees C]) with assurance of follow-up .

*if decision made to treat with antibiotics, amoxicillin is first-line therapy for most patients

61

Criteria for acute bacterial sinusitis:

*persistent symptoms or signs lasting ≥ 10 days without evidence of clinical improvement .

*severe symptoms or signs of high fever (≥ 39 degrees C and purulent nasal discharge or facial pain lasting for ≥ 3-4 consecutive days at beginning of illness.

*worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following typical viral upper respiratory infection that lasted 5-6 days and were initially improving ("double-sickening") .

62

Antibiotic choice

Amoxicillin or amoxicillin clavulanate is preferred first-line treatment (500 mg/125 mg orally 3 times daily or 875 mg/125 mg orally twice daily). Alternative choices: levofloxacin,doxycyclin.

For chronic or recurrent sinusitis addition of intranasal steroid accelerates recovery.

Otitis Media

64

*Suppuratice or acute otitis media (AOM):

usually a complication of eustachian tube

dysfunction that occurs during a viral URTI.

Streptococcus pneumoniae, Haemophilus

influenzae, and Moraxella catarrhalis are the

most common organisms isolated from middle

ear fluid.

*Non-suppurative or secretory otitis media or otitis media with effusion (OME)

Usually non infective

Cultures are sterile, but in 30% same organisms

Recurrent otitis media

3 times in 6 months or more than 4 times in a year

Chronic otitis media

Foul-smelling otorrhea.

65

Risk factors:

Age: 6-20 months- decrease with age

Male gender

Low socioeconomic status

Exposure to smoking and day care attendance

More in cold weather

Bottle feeding while sleeping, breast feeding (protective)

Congenital anomalies: Down syndrom, cleft palate.

66

Clinical Presentation:

In infants, are nonspecific and include fever,

irritability, excessive crying and poor feeding.

In older children and adolescents, fever, otalgia

(acute ear pain), otorrhea (ear drainage); after

spontaneous rupture of the tympanic membrane.

Signs of a common cold are often present.

Nausea, Vomiting, dizziness, fever.

TM exam: red, bulge, loss of land marks, decrease

mobility (by pneumatic otoscopy), apparent light

reflex, perforation.

67

•Normal tympanic membrane: 1. Shiny 2. Translucent. 3. +ve light reflux 4. No air fluid border 5. No bulge.

68

Red bulging TM

Red, bulge, distortion of normal landmarks, loss of the cone of light.

69

Acute otitis media

70 Redness Bulging

Complication of Otitis Media : Chronic suppurative otitis media

Acute mastoiditis

Facial paralysis

Cholesteatoma (cyst like lesion in middle ear, tend to expand and cause bone resorption)

Intracranial complications: meningitis, abscess, lateral sinus thrombosis

Conductive hearing loss and possible developmental sequelae

71

How to manage it?

Natural history of OME is spontaneous resolution … days-months.

• Prompt surgical referral for structural damage to TM or ME (e.g. cholesteatoma).

• Surgical referral for children with OME with hearing loss independent on OME, speech or language disorder, developmental delay and uncorrectable visual impairment.

• Antihistamines, decongestants, or steroids should not be used in the management of OME in children.

72

Treatment of Otitis Media: Give drugs to decrease pain (oral-topical analgesics)

Antibiotics :Indications:

moderate or severe otalgia

otalgia for ≥ 48 hours

temperature ≥ 39 degrees C (102.2 degrees F)

age < 24 months and bilateral AOM

Antibiotic therapy can be deferred in children two years or older with mild symptoms.

73

Antibiotic Choice:

*Amoxicillin 90mg/kg/days…first choice.

*Amoxicillin 90 mg/kg/day plus clavulanate 6.4 mg/kg/day in 2 divided doses…second choice if not improving on amoxicillin after 2-3 days.

Other choices: if allergy to amoxicillin or not improving.

Cefdinir(omnicef),cefuroxime(zinat),ceftriaxone(rocephen)and Cefpodoxime.

74

If the patient fails to respond to the initial

management option within 48-72 hours, clinician must reassess to confirm AOM and exclude other causes of illness. If AOM is confirmed in:

Patient initially managed with observation, begin antibacterial therapy.

Patient initially managed with antibacterial agent, change the agent.

If treatment failed: tympanocentesis and culture may be needed

Clinician should encourage the prevention of otitis media through decrease the risk factors.

75

Croup 76

Croup: LaryngoTracheoBronchitis

Caused by ParaInfluenza virus

Age: 3 months – 5 years, peak 2 year

More in male

More in Winter

77

Clinical presentation: Some Rhinorrhea, mild cough, low grade fever,

1-3 days then characteristic barking cough, hoarseness and inspiratory stridor (70% obstruction)

Worse at night, usually resolve in 1 week.

Exam: hoarseness of the voice, mild tachypnea, child prefer to sit upright, more symptoms with crying and agitation.

( seal-like )Barking cough is the hallmark of croup among infants and young children, whereas hoarseness predominates in older children and adults.

78

Diagnosis is usually based on history, physical, and response to treatment.

sudden onset of barking cough, hoarseness, and inspiratory stridor in a child (especially if aged 6-36 months)

absence of atypical findings (for example, wheezing, drooling, or toxic appearance)

improved respiratory symptoms after treatment with

corticosteroids, with or without nebulized epinephrine

79

Diagnosis of Croup:

Airway management is the priority:

*Use cool mist *corticosteroids usually indicated for children with croup. *corticosteroids improve croup symptoms and reduce return visits or readmissions. *Dexamethasone 0.6 mg/kg orally or intramuscularly given once. *Or prednison oral for 3 days. *Epinephrine(racemic)nebulizer- for children with severe croup

80

Treatment of Croup:

Epiglottitis

81

Epiglottitis: *A life-threatening disease.

*Caused by H. Influenzae, S. pneumoniae, S. aureus

now uncommon, because the H. influenzae type B vaccine is a routine childhood immunization.

82

Clinical Presentation: *high fever and sore throat.

Dyspnea, progressive upper airway obstruction in hours.

On Exam: Toxic, ill looking, difficulty swallowing, drooling, hyper extended neck (tripod sign)

Stridor is a late sign

• Complications: the airway may become totally obstructed , empyema or epiglottic abscess.

83

Diagnosis: Clinical

Large cherry red swollen epiglottis by laryngoscope

Lateral neck x-ray: thumb sign

(swollen epiglottis)

84

It is a Medical Emergency : establish airway by intubation, rarely tracheotomy regardless of the degree of obstruction.

Antibiotics: broad-spectrum second- or third-generation

cephalosporins recommended.

Corticosteroids :IV dexamethasone or budesonides aerosols.

Oxygen and IV fluid.

85

Treatment of Epiglottitis:

Laryngitis

86

An inflammation of the larynx, manifests in both acute and chronic forms.

Acute : less than 3 weeks

Chronic : last more than 3 weeks Acute laryngitis has an abrupt onset and is

usually self-limited.

The etiology of acute laryngitis includes vocal misuse, exposure to noxious agents, or infectious agents.

The infectious agents are most often viral but sometimes bacterial

87

Causes: Infection (usually viral upper respiratory tract

infection) Rhinoviruses

Parainfluenza viruses

Respiratory syncytial virus

Adenoviruses

Influenza viruses

Measles virus

Mumps virus

Bordetella pertussis

Varicella-zoster virus

Gastroesophageal reflux disease

Environmental insults (pollution)

Vocal trauma

Use of asthma inhalers

88

Generally associated with hoarseness or loss of voice.

Symptoms: hoarseness of the voice,Fever Swollen lymph nodes, dysphagia,

odynophagia, dyspnea, rhinorrhea, postnasal discharge, sore throat, congestion, fatigue, and malaise.

Complications: rarely respiratory distress

Treatment:voice rest, analgesia,cool mist,hydration.

Nebulized epinephrine or oral steroid for sever cases. 89

Last slide