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Acute Upper Respiratory


Mohamed Khashaba,MD
Professor of Pediatrics/ Neonatology
Mansoura Faculty of Medicine

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• Stress the importance of ARI from both the
epidemiologic and clinical aspects.
• Guide the clinical diagnosis and treatment of
common URI.
• Point to the importance of proper selection of
antibiotic for the specific patient.

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Acute Respiratory infections
• Children experience five to eight episodes of
respiratory infections every year.
• Acute Respiratory Infections account for 19%
of all deaths in children younger than five
years, and 8.2% of all disability and premature
• *International Conference on Acute Respiratory Infection. Canberra-
Australia. 1997

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Upper respiratory tract infection is the most
common diagnosis in ambulatory visits (37 million

Rates of antibiotic prescription for
uncomplicated URTIs are 52%, and it accounts
for 10% of all antibiotics prescribed annually in
ambulatory practice.
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• Acute rhinosinusitis (25 million visits).
– Is frequently caused by viral infection.
– In 85% to 98% of cases, physicians
prescribe an antibiotic.
– 5th most common diagnosis for which an
antibiotic is prescribed.

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• Uncomplicated acute bronchitis (10 million
office visits).
– About 5% of adults self-report an
episode of acute bronchitis each year.
– Up to 90% seek medical attention

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Population at Risk for RTIs in
Developing countries
• Several Risk Factors for acquiring RTIs in
developing countries include:
• Poverty
• Restricted family income
• Low parental education level
• Low birth weight
• Malnutrition
• Lack of breastfeeding
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ARTIs in developing countries
among children 5 years of age

• Most infections are limited to the upper
respiratory tract and 5% involve the lower
respiratory tract.

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ARTIs in developing countries among
children below 5 years of age

• In all countries ARTI is a leading cause of
hospitalization and death.

• Antibiotics are the most commonly Rx
medications, but this does not prevent
hospitalization which indicates misusage either
by doctors or families.

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IMCI (Case management technique)

Classifies ARI on the basis of severity.
presence or absence of fast breathing
low chest indrawing
in a child who presents with cough or difficult
separate children with serious illness ( severe
disease and pneumonia)
from those with mild self-limiting conditions (no
pneumonia: cough and cold).

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Case management technique
Very severe disease ,needs urgent hospitalization.
inability to drink,
abnormally sleepy or difficult to wake,
stridor in calm child,
severe malnutrition
chest indrawing and wheezing.

. Home setting Treatment
If a child is breathing fast for his age,
chest is not indrawing,

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Etiology of URI
• Most upper respiratory infections are of viral
• Epiglottitis and laryngotracheitis are
exceptions with severe cases likely caused by
Haemophilus influenzae type b.
• Bacterial pharyngitis is often caused by
Streptococcus pyogenes

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Clinical Manifestations
• Initial symptoms of a cold are runny, stuffy
nose and sneezing, usually without fever.
Other upper respiratory infections may have
• Epiglottitis :may have difficulty in breathing,
muffled speech, drooling and stridor.
laryngotracheitis (croup) :may also have
tachypnea, stridor and cyanosis.

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Upper Respiratory Infections
• Common Cold
• Sinusitis
• Otitis media
• Pharyngitis
• Epiglottitis and

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Upper Respiratory Infections
• Common Cold
• Sinusitis
• Otitis media
• Pharyngitis
• Epiglottitis and
• Laryngotracheitis

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• Inhalation of droplets then invasion of the
• Epithelial destruction may ensue, along with
redness, edema, hemorrhage and sometimes an

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Common Cold

• Most caused by viruses.
• Rhinoviruses with more than 100 serotypes causing at
least 25% of colds.
• Coronaviruses may be responsible for more than 10%
of cases.
• Parainfluenza, RSV, adeno and influenza viruses have
all been linked to the common cold syndrome.
• 30% to 40% of cold syndromes cause has not been

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• Viruses invade epithelial cells of the respiratory
mucosa leading to:
2. Destruction and sloughing of cells or
3. Loss of ciliary activity depends on the specific
organism involved.
4. Increase in leukocyte infiltration and nasal
secretions, suggesting that cytokines and
immune mechanisms may be responsible for
some of the manifestations of the common cold
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Microbiologic Diagnosis
• Common colds can usually be recognized
• Bacterial and viral cultures of throat swab
specimens are used for pharyngitis, epiglottitis
and laryngotracheitis.
• Blood cultures are also obtained in cases of

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Clinical Manifestations
• Incubation period : 48-72 hours,
• Symptoms of nasal discharge and obstruction,
sneezing, sore throat and cough
• Myalgia and headache .
• Fever is rare.
• The duration of symptoms and of viral shedding
varies with the pathogen and the age of the
• Complications are usually rare, but sinusitis and
otitis media may follow

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Microbiologic Diagnosis
• Is usually based on the symptoms (lack of
fever combined with symptoms of localization
to the nasopharynx).
• Unlike allergic rhinitis, eosinophils are absent
in nasal secretions.
• Usually no need to isolate the virus.

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Prevention and Treatment

• Symptomatic.
• Decongestants, antipyretics, fluids and bed rest
Restriction of activities to avoid infecting
others, along with good hand washing.
• No vaccine is commercially available .

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Predictors for prescribing

• Green nasal discharge (reported or observed).
• Production of green phlegm.
• Coplications e.g. sinusitis

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Aphthous Ulcers DD
Herpes virus Vesicular lesions, Tzank stain positive
for inclusion-bearing giant cells
• CMV Immunocompromised patient, biopsy
positive for multinucleated giant cells
• Varicella Characteristic skin lesions
• Coxsackievirus mouth and/foot/buttock lesions,
• Immunocompromised patient, chronicity, biopsy
and culture positive

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• Behçet's syndrome Genital ulceration, uveitis, retinitis

• Reiter's syndrome Uveitis, conjunctivitis, HLA B27,
arthritis Inflammatory bowel disease other GI
• Lupus erythematosus Malar rash, ANA-positive
• Bullous pemphigoid & Pemphigus vulgaris
• Diffuse skin involvement

• Hematologic Cyclic neutropenia Periodic fever,
neutropenia N

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• The lack of clarity regarding etiology has
resulted in treatments that are largely empiric
Tetracycline rinse ( not in children).
• Triamcinolone 0.1% in Orabase applied to the
ulcers two to four times daily until healed
Dexamethasone elixir, 0.5 mg per 5 mL Swish
and spit with 5 mL every 12 hours
Viscous lidocaine, 2% Apply to ulcer as
needed For brief local pain

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Upper Respiratory Infections
• Common Cold
• Sinusitis
• Otitis media
• Pharyngitis
• Epiglottitis and
• Laryngotracheitis

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• Acute inflammatory condition of one or more
of the paranasal sinuses. Infection plays an
important role.
• Sinusitis often results from infections of other
sites of the respiratory tract since the paranasal
sinuses are contiguous to, and communicate
with, the upper respiratory tract

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Etiology & Predisposing Factors

• Acute sinusitis most often follows a common cold
which is usually of viral etiology.
• Vasomotor and allergic rhinitis .
• Obstruction of the sinusal ostia due to deviation
of the nasal septum,
• presence of foreign bodies, polyps or tumors.
• dental extraction or extension of infection from
the roots of the upper teeth

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Bacterial agents

• St. pneumoniae,HIb, and M catarrhalis.
• Other organisms including Staph. aureus,
Strept. pyogenes, gram-ve organisms and
anaerobes have also been recovered.
• Chronic sinusitis is commonly a mixed
infection of aerobic and anaerobic organisms.

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• Infections causes impairment of ciliary activity of the
epithelial lining of the sinuses and increased mucous
• obstruction of the paranasal sinusal ostia which
impedes drainage
• bacterial multiplication in the sinus cavities, the mucus
is converted to mucopurulent exudates.
• pus further irritates the mucosal lining causing more
edema, epithelial destruction and ostial obstruction.
When acute sinusitis becomes chronic, mucosal
thickening results and the development of mucoceles
and polyps may ensue

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Clinical Manifestations
• Maxillary and ethmoid sinuses are most
commonly involved.
• Frontal sinuses are less often involved and the
sphenoid sinuses are rarely affected.
• Pain, sensation of pressure and tenderness over
the affected sinus are present.
• Malaise and low grade fever may also occur.
• Physical examination usually is not remarkable
with no more than an edematous and hyperemic
nasal mucosa.

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• In uncomplicated chronic sinusitis, a purulent
nasal discharge is the most constant finding.
There may not be pain nor tenderness over the
sinus areas.
• Thickening of the sinus mucosa and a fluid
level are usually seen in x-ray films or
magnetic resonance imaging.

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Prevention and Treatment
• Analgesics and moist heat over the affected sinus
Decongestant to promote sinus drainage may
• Beta-lactamase resistant antibiotic or
• For chronic sinusitis, when conservative treatment
does not lead to a cure, irrigation of the affected
sinus may be necessary. Culture from an antral
puncture of the maxillary sinus can be performed
to identify the causative organism for selecting
antimicrobial therapy.

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• Proper care of infectious and/or allergic
• Surgical correction to relieve or avoid
obstruction of the sinusal ostia are important.
Root abscesses of the upper teeth should
receive proper dental care to avoid secondary
infection of the maxillary sinuses

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Upper Respiratory Infections
• Common Cold
• Sinusitis
• Otitis media
• Pharyngitis
• Epiglottitis and
• Laryngotracheitis

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Otitis media
• Strept. pneumoniae, HI and beta-lactamase
producing M catarrhalis.
• Respiratory viruses role remains uncertain.
Morax. pneumoniae has been reported to cause
hemorrhagic bullous myringitis in an
experimental study among nonimmune human
volunteers inoculated with M pneumoniae..

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• Commonly follows an upper respiratory
infection extending from the nasopharynx via
the eustachian tube.
• Vigorous nose blowing during a common cold,
sudden changes of air pressure, and
perforation of the tympanic membrane .
• The presence of purulent exudate in the middle
ear may lead to a spread of infection to the
inner ear and mastoids or even meninges

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Clinical manifestations
• The initial complaint usually is persistent severe
earache (crying in the infant) accompanied by fever,
and, and vomiting.
• Otologic examination reveals a bulging, erythematous
tympanic membrane with loss of light reflex and
• If perforation of the tympanic membrane occurs,
serosanguinous or purulent discharge may be present.
In the event of an obstruction of the eustachian tube,
accumulation of a usually sterile effusion in the middle
ear results in serous otitis media.

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• The diagnosis made from history, clinical
symptomatology and physical examinations.
• Inspection of the tympanic membrane . All
discharge, ear wax and debris must be removed
and to perform an adequate otoscopy.
• If the patient is immunocompromised or is toxic
and not responding to initial l therapy
tympanocentesis (needle aspiration) to obtain
middle ear effusion for microbiologic culture is
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• Amoxicillin
• amoxicillin-clavulanate
• trimethoprim/sulfamethoxazole,
• cephalosporins,
• and macrolides
• When there is a large effusion, tympanocentesis
may hasten the resolution
• Patients with frequent recurrences of middle ear
infections may be benefitted by chemoprophylaxis
during the winter and spring months.
• patients with persistent effusion of the middle ear,
surgical interventions has been helpful.
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• New vaccines composed of pneumococcal
capsular polysaccharides conjugated to
proteins increase the immunogenicity .

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Upper Respiratory Infections
• Common Cold
• Sinusitis
• Otitis media
• Pharyngitis
• Epiglottitis and
• Laryngotracheitis

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Inflammation of the pharynx involving
lymphoid tissues of the posterior pharynx and
lateral pharyngeal bands.
• Etiology can be bacterial, viral and fungal
infections as well as noninfectious etiologies.
Most cases are due to viral infections and
accompany a common cold or influenza

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• Type A coxsackieviruses can cause a severe
ulcerative pharyngitis in children (herpangina),
adenovirus and herpes simplex virus, although
less common, also can cause severe
• Pharyngitis is a common symptom of Epstein-
Barr virus and cytomegalovirus infections

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• Group A beta-hemolytic streptococcus is the most
important bacterial agent associated with acute
pharyngitis and tonsillitis.
• mixed anaerobic infections (Vincent's angina),
Corynebacterium haemolyticum, N.gonorrhoeae,
and C. trachomatis.. Mycoplasma pneumoniae and
Mycoplasma hominis
• Candida albicans as extension of oral candidiasis
or thrush,

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Treatment of Acute Tonsillo- Pharyngitis

• If tonsillitis is caused by a bacterial infection,

• Antibiotics must be prescribed & the patient should
finish the full course of antibiotics.

• Early stopping of medication may cause the recurrent
infection which can lead to potentially serious

• If there is difficulty swallowing, antibiotics may be
given by injection

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Predictors of AntibioticTreatment

• Tonsillar exudates
• Tender cervical lymphadenopathy
• Absence of cough
• History of fever.

– Presence of 3 or 4 of these criteria has a positive
predictive value of 40-60%.
– Absence of 3 or 4 of the criteria has a negative
predictive value of 80%.
• Both the sensitivity and specificity of this prediction rule are 75% compared
with throat cultures

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Infectious Mononucleosis / Glandular
fever / Kissing Disease

• Symptoms : fever, sore throat.
• Splenic enlargement in 50% .
• lymphadenopathy in 90%.
• liver enlargement in 10%
• Severe pharyngitis with exudate
• and petechiae .
• maculopapular rash in 80% given
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• Stridor or respiratory distress, which may be
treated with steroids.
• CNS: ataxia, fits, Guillain Barr.
• Carditis , hemolysis.

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Antibiotic Use

When and what antibiotic ?

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• Widespread use of antibiotics resulted in
antibiotic resistance to many bacteria.
• S.pneumoniae, one of the most important
causes of ARI is rapidly becoming resistant to
Penicillins and Cotrimoxazole
WHO is enforcing to establish a system for
antimicrobial resistance monitoring

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Overuse of antibiotics Factors

1. Lack of careful history taking & examination.
2. Clinical presentation of patients.
3. Patient pressure to prescribe antibiotics.
4. Insufficient time to educate patients about the
ineffectiveness of the misuse of antibiotics.

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Overuse of antibiotics Factors
• The clinical diagnosis of acute bacterial
rhinosinusitis is difficult with frequent
misclassification of viral cases.
– Signs and symptoms of acute bacterial rhino-
sinusitis and of prolonged viral upper respiratory
tract infections are extraordinarily similar.
– No simple and accurate office-based tests are
available for acute bacterial rhinosinusitis.

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Clinical decision making:
•Several distinctive features of the drug under
consideration, include:
– Antibacterial spectrum (Broad Spectrum)
– PK/PD (MIC, Tissue concentration & Eradication)
– Patient Satisfaction (e.g. Number of daily doses, Duration of
therapy & Early relief of Symptoms)
– Tolerability
– Palatability
– Reasonable Cost

• Clinicians also consider therapeutic efficacy based
on clinical trials and the recommendations of
respectful organizations.
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Upper respiratory tract infection represents
the leading cause of doctor’s visits in
ambulatory setting .

Thourgh history and clinical examination
will help proper decision of when to start and
what antibiotic to use.

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There should be significant efforts to
regulate the use of antibiotics, for example, by
making antibiotics available only on
prescription from a health worker.

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Additional Important Issues

Completing immunization in all children including
Hib and Pneumococcal vaccine.

• Utilizing the standardized case management for
diagnosis and treatment .

• Health education for the community health
worker and mothers.

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Objectives & take home message

• Stress the importance of ARI from both the
epidemiologic and clinical aspects.
• Guide the clinical diagnosis and treatment of
common URI.
• Point to the importance of proper selection of
antibiotic for the specific patient.

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