Upper Respiratory Tract Infections

Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine
Dr. Zekeriya Aktrk zekeriya.akturk@gmail.com www.aile.net
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Utilized work: Dr. Aynur Engin, Cumhuriyet University, Sivas, Turkey and Dr. Ela Eker, Trakya University, Edirne, Turkey

Upper Respiratory Tract Infections

Acute tonsillitis Acute pharyngitis Acute otitis media Acute sinusitis Common cold Acute laryngitis Otitis externa Mastoiditis Acute apiglottis
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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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Tonsilitis-pharyngitis
Bacteria
S. pyogenes C. diphteriae N. gonorrhoeae

Viruses
Epstein-Barr virus Adenovirus Influenza A, B Coxsackie A Parainfluenzae

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Causative organisms
< 3 years
100 % viral

5-15 years
15-30 % GABHS

Adult
10 % GABHS

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Due to streptococci:
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 socioeconomic classes Most common during winter and spring Incubation period 2-4 days
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Signs/symptoms
Sore throat Anterior cervical LAP Fever > 38 C Difficulty in swallowing Headache, fatigue Muscle pain Nausea, vomiting Tonsillar hyperemia / exudates Soft palate petechia Absence of coughing Absence of nose drip Absence of hoarseness

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Viral tonsillitis/pharyngitis
Having additional rhinitis, hoarseness, conjunctivitis and cough Pharyngitis is accompanied by conjunctivitis in adenovirus infections Oral vesicles, ulcers point to viruses

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Exudates
GABHS EBV Adenovirus Primary HIV infection Candida albicans Francisella tularensis

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Lymphadenopathy
GABHS Epstein-Barr virus Adenovirus Human herpesvirus type 6 Tularemia HIV infection

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Laboratory
Throat swab
Gold standard

Rapid antigen test

If negative need swab

ASO
May remain + for 1 year

WBC count Peripheral smear

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Throat Culture
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?

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Tonsillitis due to Streptococci

Supurative complications
Abscess Sinusitis, otitis, mastoiditis Cavernous sinus thrombosis Toxic shock syndrome Cervical lymphadenitis Septic arthritis, osteomyelitis Recurrent tonsillitis/pharyngitis

Nonsupurative complications
Acute romatoid fever Acute glomerulonephritis
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Aim of Treatment
Prevention of complications Symptomatic improvement Bacterial eradication Prevention of contamination Reducing unnecessary antibiotic use

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Treatment
Many different antibiotics can eradicate GABHS from pharynx Starting treatment within 9 days is enough to prevent ARF

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Antibiotics NOT to be used

Tetracycline Sulphonamides Co-trimoxasole Cloramphenicole Aminoglycosides

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GABHS
Control culture after full dose treatment?
NO

If history of ARF:
Take control culture after treatment

No need to screen or treat carriers

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Mc Isaac Scoring
Developed by Mc Isaac and friends Decreases antibiotic usage by 48% No increase in throat swabs

http://www.cmaj.ca/cgi/content/abstract/163/7/811

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Mc Isaac Scoring
Clinical Findings Fever > 38 C Absence of coughing Score 1 1

Tonsillary hypertrophy or 1 (If < 6 years give 0) exudates Sensitivity at the anterior cervical nodes Age 3 14 Age > 45 1 1 -1
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Mc Isaac Scoring
Total score 0 - 1 points 2 - 3 points Suggestions No culture, no antibiotics Take culture (or antigen test), order antibiotics only if GABHS + Take culture (or antigen test), order antibiotics only if GABHS +. If the clinic is severe, start antibiotics without testing
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4 - 5 points

Antibiotics in Tonsillitis/pharyngitis due to GABHS

ORAL Penicilline V PARENTERAL Benzathine penicilline Adults:<27kg:600 000 U single dose, IM >27 kg:1.200 000 U single dose, IM 20-40 mg/kg/day, 2x1 or 3x1, 10 days Children:2x250 mg or 3x250mg,10 days Adults:3x500 mg or 4x500mg,10 days

ALLERGY TO PENICILLINE Erithromycine estolate Erithromycine ethyl succinate 40 mg/kg/day, 2x1 or 3x1, 10 days
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Acute Otitis Media

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

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AOM causes
S. pneumoniae 30% H. nfluenzae 20% M. Catarrhalis 15% S. pyogenes 3% S. aureus 2% No growth 10-30% Chronic otitis media: P. aeruginosa, S. aureus, anaerobic bacteria
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Acute Otitis Media

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.
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Signs and Symptoms

Symptoms

Otoscopic findings

Tympanic membrane Autalgia erythema Ear draining Inflammation Hearing loss Bulging Fever Effusion Fatigue Hearing loss Irritability Tinnitus, vertigo
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Antibiotics
First choice Amoxicilline Trimet./Sulfamethoxazole Second choice Amoxicilline/clavulanate Erythromycin Reurrent AOM prophylaxis Sulfisoxazole Amoxicilline 40 mg/kg/day, 3 doses 8mg TM/40mg SMX/kg 2 dose 45 mg/kg/day, 2 doses 40-50 mg/kg/day, 3 doses 75 mg/kg/day, single dose 3-6 mo 20 mg/kg/day, sinle dose 3-6 mo
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Acute Rhinitis / Sinusitis

Acute sinusitis
Str. pneumoniae %41 H. influenzae %35 M. catarrhalis %8 Others %16
Strep. pyogenes S. aureus Rhinovirus Parainfluenzae Veilonella, peptokoccus

Chronic sinusitis
Anaerob bakteria: Bactroides, Fusobacterium S. aureus Strep. pyogenes Str. pneumoniae Gram (-) bakteria Fungi
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Acute Sinusitis
Paranasal sinuses:
Frontal Ethmoid Maxillary Sphenoid

Most common during childhood

Maxillary Ethmoid

After age 10
Frontal

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Predisposition to Sinusitis
Anatomical: septal deviation, Mukociliary functions: cystic fibrosis, immotile cilia synd. Systemic dis., immune deficiency.: DM, AIDS, CRF Allergy: Nasal poliposis, asthma Neoplasia Environmental: smoking, air pollution, trauma...

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Acute Rhinosinusitis
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
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Acute rhinosinusitis
Rhinitis Increased symptoms after 5 days Symptoms lasting > 10 days Decreasing viral symptoms, nasal secretion becoming more purulent are indicative for acute rhinosinusitis
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Diagnosis
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

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Treatment
Ampirical
Specific microbiologic diagnosis difficult

Primary pathogens
S. pneumoniae H. influenzae

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Treatment
Antibiotics questionable Stalman: 192 patients. No difference between placebo and doxycycline. Van Buchem: 214 patients. No difference between amoxycilline and placebo. Lindbaek: 130 patients. compared Pen V, Amoxycilline and placebo. 86 % of patients receiving antibiotics and 57% of patients receiving placebo improved.
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Antibiotics for Sinusitis

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

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Support Therapy
Decongestants
Short duration 3-5 days

Antihistamines
If allergy

Normal saline Local steroids

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Common Cold

Adults Rhinovirus Children Parainfluenzae and RSV

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Common Cold
Fatigue Feeling cold, shuddering Nose burning, obstruction, running Sneezing Fever

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Influenza (flu)
Causes epidemics and pandemics Highly contagious Viral infection.

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Cause
80 % Influenzae virus Parainfluenza %2-9 Rhinovirus %3 Adenovirus %4

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Influenza
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
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