Respiratory tract infections

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ASSOCIATE PROFESSOR
P.R.R.M.C.P
 epidemilogy
• Pandemics (or global epidemics) of influenza A occur around every 25
years and affect huge numbers of people. The 1918 ‘Spanish flu’
pandemic is estimated to have killed 20 million people.
• Further pandemics have taken place in 1957–1958 (Asian flu), 1968–
1969 (Hong Kong flu) and 1977 (Russian flu). An avian strain, H5N1,
emerged in South East Asia in 2003 and is now considered endemic in
many parts of South East Asia and remains a concern for public health
(WHO, 2010).
• The World Health Organisation declared a worldwide
• influenza pandemic in June 2009 following the emergence of a
novel H1N1 strain of swine lineage. In the UK, NICE guidance was
superseded during the pandemics.
• A vaccine was also developed. Pandemic planning had been in
operation for many years with plans for rapid vaccine development
and stockpiling of antivirals.
Respiratory tract infections
• Respiratory tract infections are the most common group of infections.

• Viral respiratoryt ract infections are usually mild and self-limiting, but

influenza and severe acute respiratory syndrome (SARS) can have severe

consequences for individuals, for public health and for economic activity.

• The respiratory tract is divided into upper and lower parts:

• The upper respiratory tract consists of the sinuses, middle ear, larynx, pharynx,

and epiglottis

• The lower respiratory tract consists of the structures below the larynx, the

bronchi, bronchioles and alveoli .

 Upper respiratory tract infections

• Colds and flu

infections are usually caused by viruses
• rhinovirus, parainfluenza virus,
• respiratory syncytial virus,
• coronavirus,
• influenza virus and adenovirus families, although new viruses continue to be identified.
• Viral URTIs causing-Colds and flu coryzal symptoms, rhinitis, pharyngitis and laryngitis, and associated with varying
degrees of systemic symptoms.
• For instance, in 2001, a novel respiratory pathogen was described that has become known as human
metapneumovirus (hMPV).
• This causes a spectrum of respiratory illnesses particularly in young children, the elderly and the immuno
compromised patients .
• The management of these infections is symptomatic and
consists of rest, adequate hydration, simple analgesics and
antipyretics. Apart from one or two exceptional situations,
antiviral drugs are not indicated and in most cases are not
active.
• Antibacterial drugs have no activity against viral infections,
although in the past they were widely prescribed.
• Influenza

• True influenza is caused by one of the influenza viruses (influenza A, B or rarely C).
• It can be a serious condition characterised by severe malaise and myalgia and
potentially complicated by life-threatening secondary bacterial infections such as
staphylococcal pneumonia.

• Symptoms
• Sore throat (pharyngitis)
• Acute epiglottitis
• Acute sinusitis
Otitis media
• Coryzal symptoms are not usually a feature of influenza, but the patient may have
a cough.
• Influenza tends to occur during the winter months
 Sore throat (pharyngitis)

• Pharyngitis is a common condition. In most cases, Many cases are not due to
infection at all but are caused by other factors such as smoking.
• it never comes to medical attention and is treated with simple therapy directed at
symptom relief.
• Causative organisms
• Epstein–Barr virus (EBV),
• The common bacterial cause of sore throat is
• Streptococcus pyogenes, Group A β-haemolytic streptococcus.
• Infrequent causes include β-haemolytic streptococci of groups C and G,
Neisseria gonorrhoeae and mycoplasmas.
• Corynebacterium diphtheriae
• Clinical features
• Sore throat.
• fever.
• Common cold.
• Nevertheless.
• Inflammation of the pharynx with a whitish
exudate on the tonsils,
• Enlarged and tender cervical lymph nodes.
• Acute Epiglottitis
• It is a rapidly progressive cellulitis of the epiglottis and
adjacent structures. Local swelling has the potential to cause
rapid-onset airway obstruction, so the condition is a medical
emergency.
• Caused by
Haemophilus influenzae type b (Hib),
• pneumococci, Streptococci and staphylococci.
• Symptoms - fever and difficulty speaking and breathing.
With the advent of routine vaccination against
• H. influenzae type b in October 1992, this disease has become
uncommon.
 Otitis media
• Causative organisms Inflammation of the middle
ear (otitis media) is a common condition seen most
frequently in children under 3 years of age. Most
cases are due to bacteria, although viruses such as
influenza virus and rhinoviruses have been
implicated
• S. pneumoniae and H. influenzae are the two most
commonly encountered bacterial pathogens.
Moraxella catarrhalis and S. pyogenes account for a
smaller proportion of cases, perhaps 10%, and
other bacteria are seen only rare.
• Classically, otitis media presents with ear pain,
which may be severe.
• If the drum perforates, the pain is relieved and a
purulent discharge may follow. There may be a
degree of hearing impairment plus non-specific
symptoms such as fever or vomiting.
• Complications include mastoiditis (which is now
rare), meningitis and, particularly in the case of H.
influenzae infection, septicaemia and disseminated
infection. With the advent of routine vaccination
against H. influenzae type b, these complications
have become uncommon.
 Acute sinusitis
• Causative organisms
The paranasal sinuses are sterile but they can become infected
following damage to the mucous membrane which lines them. This
usually occurs following a viral URTI but is sometimes associated with
the presence of dental disease.
• Acute sinusitis is usually caused by the same organisms
which cause otitis media, but occasionally other organisms such as S.
aureus, viridans streptococci (a term used to describe α-haemolytic
streptococci other than S. pneumoniae) and anaerobes may be found.
Viruses are occasionally found in conjunction with the bacteria.
Clinical features
The main feature of acute sinusitis is facial pain and tenderness, often
accompanied by headache and a purulent nasal discharge.
Complications include frontal bone osteomyelitis, meningitis and brain
abscess .
 Diagnosis

• Bacterial diagnosis is required,

• throat swab
• viral culture or serology
• blood test serological confirmation
• ‘monospot test’ for atypical lymphocytes or
specific tests for antibodies to EBV.
• Ear swab of the external auditory canal,
• sinus washouts may yield Specimens for
microbiological culture.
 Treatment
• Colloquially, milder infections are called ‘colds’, while more severe infections
may be known as ‘flu’.
• This term should be distinguished from true influenza, reserved for infection
caused by the influenza virus. In general, the management of
MANAGEMENT:
• 1. Symptomatic and consists of rest, adequate hydration,
• 2. Antipyretics.- Paracetamol-500,650 mg
• 3. Analgesics –Aceclofenac ,diclofenac, indomethasin and ibuprofen (4-10
mg/kg/dose) are considered as the standard analgesics
• 4. Antivirals:Viral DNA polymerase:
• This target enzyme,inhibit the Viral Replication:
• Acyclovir, Valacyclovir, Famciclovir: Used to treat herpes simplex virus (HSV)
infections, including cold sores, genital herpes, and shingles.
• Ganciclovir, Valganciclovir: Used to treat cytomegalovirus (CMV) infections,
especially in immunocompromised individuals.
• Foscarnet, Cidofovir: Used for CMV retinitis and other resistant HSV infections
Influenza:
Neuraminidase:
Oseltamivir, zanamivir, and peramivir:
inhibit this enzyme, which is involved in the
release of new influenza virus particles.
• Used to treat influenza A and B infections
Reverse Transcriptase: Drugs like Zidovudine
(AZT), lamivudine, and tenofovir target this
enzyme, which is essential for retroviral
replication (like HIV).
•
• Antibacterial drugs
• influenzae and M. catarrhalis are the most common isolated bacteria.
• Amoxicillin-500mg bd (50 mg/kg/day) alone or with clavulanate is the first line
antibiotic.
• Ceftriaxone 1gm iv-bd (50 mg/kg/day) should be given to children who cannot
take oral medications.
• Duration of the treatment varies from 10 to 28 days.
• The antibiotic may be changed if the symptoms get worse or do not improve
within 72 hours(cefixime 8 mg/kg/day).
• Penicillins
• Benzylpenicillin (penicillin G) - 600- 1200 mg iv-6th hourly- 30 mg /kg
• Phenoxymethylpenicillin- penicillin V 125-250 mg/5ml.( 8 mg/kg/day)
• have traditionally been regarded as the treatment of choice for streptococcal
sore throat S. pneumoniae for respiretory tract infections

• Macrolides :
• Erythromycin -500mg- bd-tid
• Azithromycin-500mg- od
• Alternative initial antibiotics include:
• cefaclor (40-50 mg/kg/day) and
• cefuroxime-axetil (30 mg/kg/day) or
cefpodoxima-proxetil (8 mg/kg/day) Ceftriaxone
(50 mg/kg/day)
• can be given to children who cannot take oral
medications or when the symptoms do not
improve within 72 hours.
• middle ear infections :
• The duration of the treatment may vary from 5
to 10 days chemoprophylaxis with once daily oral
amoxicillin or trimethoprim/sulfamethoxazole .
• acute sinusitis, particularly if associated with dental
disease, and in such cases, the addition of
• TAB-Metronidazole may be use full.
• TAB-Amoxicillin/clavulanate 625mg (coamoxiclav)- has
also demonstrated effectiveness.
• Doxycycline 50-100mg od-bd
has proved popular due to its broad spectrum of
activity and once-daily dosage.
• vaccines: Use of polyvalent pneumococcal vaccines
has been evaluated for the prevention of otitis media
in children.
Lower Respiratory Infections
• Lower Respiratory Infections:
• Bronchitis, Bronchiolitis and Pneumonia.
• Etiology: Causative agents of lower respiratory
infections are viral, bacterial and fungal.
• Viruses cause most cases respiretory syncystial
virus (RSV) Flu, bronchitis and bronchiolitis.
• In community-acquired pneumonias,
• The most common bacterial agent is Streptococcus
pneumoniae or Staphylococcus aureus.
• fungal infections
• Mycoplasma, which are neither viruses or bacteria
but are small organisms with characteristics of both.
• In some cases, substances from the
environment can irritate or
cause Inflammation in the airways or lungs,
which can lead to an infection. These include:
• tobacco smoke
• dust
• chemicals
• vapors and fumes
• allergens
• air pollution
• Pathogenesis: Organisms enter the distal airway by
inhalation, aspiration or by hematogenous seeding.
• The pathogen multiplies in or on the epithelium,
causing inflammation, increased mucus secretion,
and impaired mucociliary function; other lung
functions may also be affected.
• In severe bronchiolitis, inflammation and necrosis
of the epithelium may block small airways leading
to airway obstruction.
• SYMPTOMS
• In more severe infections, symptoms can include:
• Cough that may produce phlegm
• Fever, myalgia
• Common colds
• Difficulty breathing
• headache,
• abdominal pain,
• Chest pain
• Wheezing
• sinus infections,
• Tonsilllitis,
• Laryngitis
 Complications
• Complications of lower respiratory tract
infections can include:
• Congestive heart failure
• Respiratory failure
• Respiratory arrest
• Sepsis which is a blood infection that can lead
to organ shutdown
• Lung abscesses
 Diagnosis
• Diagnostic -tests to help the problem:
• 1. Sputum specimens are cultured for bacteria, fungi and viruses.
• 2. Culture of nasal washings is usually sufficient in infants with
bronchiolitis.
• 3. Fluorescent staining technic can be used for legionellosis.
• 4. Blood cultures and/or serologic methods are used for viruses,
rickettsiae, fungi and many bacteria.
• 5. Enzyme-linked immunoassay methods can be used for detections of
microbial antigens as well as antibodies.
• 6. Detection of nucleotide fragments specific for the microbial antigen in
question by DNA probe or polymerase chain reaction can offer a rapid
diagnosis.
• 7. pulse oximetry to find how much oxygen is in the blood
• 8. chest X-rays
 Treatment
• 1. Symptomatic treatment is used for most viral infections.
• [Link]-antibiotics, such as ampicillin, amoxicillin, and penicillin G, are still
available to treat a variety of infections and have been in use for many years.
• [Link]

• 4. Aminoglycosides
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• 7. Carbapenems

• Bacterial pneumonias are treated with antibacterials.

• VACCINE : A polysaccharide vaccine against 23 serotypes of Streptococcus
pneumoniae is recommended for individuals at high risk.
 Steps to prevent getting a lower respiratory
tract infection
• Washing hands frequently
• avoiding touching the face with unwashed hands
• staying away from people with respiratory symptoms
• cleaning and disinfecting surfaces regularly
• getting vaccines, such as the pneumococcal vaccine and
MMR vaccine
• getting a flu shot every year
• avoiding known irritants, such as chemicals, fumes, and
tobacco.