Upper Respiratory Tract Infections Saudi Diploma in Family

Upper Respiratory Tract Infections Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine Dr. Zekeriya Aktürk zekeriya. akturk@gmail. com www. aile. net 1 / 42 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 2 / 42

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 Mc. Isaac scoring 3 / 42

Tonsilitis-pharyngitis • Bacteria – S. pyogenes – C. diphteriae – N. gonorrhoeae • Viruses – Epstein-Barr virus – Adenovirus – Influenza A, B – Coxsackie A – Parainfluenzae 4 / 42

Causative organisms • < 3 years – 100 % viral • 5 -15 years – 15 -30 % GABHS • Adult – 10 % GABHS 5 / 42

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 socio-economic classes • Most common during winter and spring • Incubation period 2 -4 days 6 / 42

Signs/symptoms v v v v Sore throat Anterior cervical LAP Fever > 38 C Difficulty in swallowing Headache, fatigue Muscle pain Nausea, vomiting v Tonsillar hyperemia / exudates v Soft palate petechia v Absence of coughing v Absence of nose drip v Absence of hoarseness 7 / 42

Viral tonsillitis/pharyngitis • Having additional rhinitis, hoarseness, conjunctivitis and cough • Pharyngitis is accompanied by conjunctivitis in adenovirus infections • Oral vesicles, ulcers point to viruses 8 / 42

Exudates • • • GABHS EBV Adenovirus Primary HIV infection Candida albicans Francisella tularensis 9 / 42

Lymphadenopathy • • • GABHS Epstein-Barr virus Adenovirus Human herpesvirus type 6 Tularemia HIV infection 10 / 42

Laboratory • Throat swab – Gold standard • Rapid antigen test – If negative need swab • ASO – May remain + for 1 year • WBC count • Peripheral smear 11 / 42

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? 12 / 42

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 13 / 42

Aim of Treatment • • • Prevention of complications Symptomatic improvement Bacterial eradication Prevention of contamination Reducing unnecessary antibiotic use 14 / 42

Treatment • Many different antibiotics can eradicate GABHS from pharynx • Starting treatment within 9 days is enough to prevent ARF 15 / 42

Antibiotics NOT to be used • • • Tetracycline Sulphonamides Co-trimoxasole Cloramphenicole Aminoglycosides 16 / 42

GABHS • Control culture after full dose treatment? – NO • If history of ARF: – Take control culture after treatment • No need to screen or treat carriers 17 / 42

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 18 / 42

Mc Isaac Scoring Clinical Findings Score Fever > 38 C 1 Absence of coughing 1 Tonsillary hypertrophy or 1 (If < 6 years give 0) exudates Sensitivity at the anterior 1 cervical nodes Age 3 – 14 1 Age > 45 -1 19 / 42

Mc Isaac Scoring Total score Suggestions 0 - 1 points No culture, no antibiotics 2 - 3 points Take culture (or antigen test), order antibiotics only if GABHS +. If the clinic is severe, start antibiotics without testing 4 - 5 points 20 / 42

Antibiotics in Tonsillitis/pharyngitis due to GABHS ORAL Penicilline V Children: 2 x 250 mg or 3 x 250 mg, 10 days Adults: 3 x 500 mg or 4 x 500 mg, 10 days PARENTERAL Benzathine penicilline Adults: <27 kg: 600 000 U single dose, IM >27 kg: 1. 200 000 U single dose, IM ALLERGY TO PENICILLINE Erithromycine estolate 20 -40 mg/kg/day, 2 x 1 or 3 x 1, 10 days Erithromycine ethyl succinate 40 mg/kg/day, 2 x 1 or 3 x 1, 10 days 21 / 42

Acute Otitis Media • 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 22 / 42

AOM causes • • S. pneumoniae 30% H. İnfluenzae 20% M. Catarrhalis 15% S. pyogenes 3% S. aureus 2% No growth 10 -30% Chronic otitis media: P. aeruginosa, S. aureus, anaerobic bacteria 23 / 42

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. 24 / 42

Signs and Symptoms • Symptoms • Otoscopic findings – Autalgia – Ear draining – Hearing loss – Fever – Fatigue • – Irritability – Tinnitus, vertigo – Tympanic membrane erythema – Inflammation – Bulging – Effusion Hearing loss 25 / 42

Antibiotics First choice Amoxicilline Trimet. /Sulfamethoxazole Second choice Amoxicilline/clavulanate Erythromycin Reurrent AOM prophylaxis Sulfisoxazole Amoxicilline 40 mg/kg/day, 3 doses 8 mg TM/40 mg 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 26 / 42

Acute Rhinitis / Sinusitis Acute sinusitis Chronic sinusitis • • • Anaerob bakteria: Bactroides, Fusobacterium • S. aureus • Strep. pyogenes • Str. pneumoniae • Gram (-) bakteria • Fungi Str. pneumoniae %41 H. influenzae %35 M. catarrhalis %8 Others %16 Strep. pyogenes S. aureus Rhinovirus Parainfluenzae Veilonella, peptokoccus 27 / 42

Acute Sinusitis • Paranasal sinuses: – – Frontal Ethmoid Maxillary Sphenoid • Most common during childhood – Maxillary – Ethmoid • After age 10 – Frontal 28 / 42

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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. . . 30 / 42

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 31 / 42

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 32 / 42

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 33 / 42

Treatment • Ampirical – Specific microbiologic diagnosis difficult • Primary pathogens – S. pneumoniae – H. influenzae 34 / 42

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. 35 / 42

Antibiotics for Sinusitis • Amoxycilline (Alfoxil) 3 x 500 mg/d PO 10 d • Amoxycilline/clavulonate (Augmentin) 3 x 625 mg/d PO 10 d • Sefprosil(Serozil) 2 x 1000 mg/d PO 10 d • Sefuroxim (Zinnat) 2 x 250 mg/d PO 10 d • Azithromycine (Zitromax) First day 1 x 500 mg, then 1 x 250 mg/d PO 5 d 36 / 42

Support Therapy • Decongestants – Short duration 3 -5 days • Antihistamines – If allergy • Normal saline • Local steroids 37 / 42

Common Cold • Adults Rhinovirus • Children Parainfluenzae and RSV 38 / 42

Common Cold • • • Fatigue Feeling cold, shuddering Nose burning, obstruction, running Sneezing Fever 39 / 42

Influenza (flu) • Causes epidemics and pandemics • Highly contagious • Viral infection. 40 / 42

Cause • • 80 % Influenzae virus Parainfluenza %2 -9 Rhinovirus %3 Adenovirus %4 41 / 42

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 42 / 42