•Management principles

• Effects of Rx

• Antibiotic in specific URTI

• Factors affect prescription

Objectives

DefinitionURTI inflammation of respiratory mucosa from the nose to the lower respiratory tree not including the alveoli.

Symptoms•Sore throat

•Rhinorrhea

•Facial fullness and Pain

•Headache

•Cough

•Fever

•Tender lymph nodes

•Ear Pain

Epidemiology•In average Children will have 5 URTI/Year, & adults 2-3/Year

•Acute rhinitis is by far the most common cause of doctors visit.

•Otitis media is the most common cause for a child under age 15 to visit a physician.

•Acute Otitis Media, the most common condition for antibiotics (50%).

•Group A beta-hemolytic streptococcus is only found in 15% to 36% of children with sore throat.

Types and causative agents

Management PrinciplesViral infections need only symptomatic treatment:

-Analgesics (Paracetamol, Aspirin, Ibuprofen)

-Anti-histamines

-Cough suppressants

-Nasal decongestants

-Vitamin C

-Increase fluid intake

Bacterial Infections need antibiotics in addition of symptomatic treatment

Management Principles

Viral (Don’t Use Antibiotics)

Why?

-Promotes antibiotic resistance

-Adverse reactions such as allergy and anaphylaxis

-Costly

-Patients do not need antibiotics to feel satisfied

Bacterial (Use antibiotics)

Why?

- To prevent rheumatic fever

- To prevent suppurative complications (e.g., peritonsillar abscess)

- To speed up recovery

- To reduce spread to others

Management Principles

Viral (Don’t Use Antibiotics)

-Influenza, Common Cold

-Viral Pharyngitis

-Mild Acute Sinusitis

-Mild Acute Otitis Media

Bacterial (Use antibiotics)

-GABHS Pharyngitis

-Moderately to severe Acute Sinusitis

-Moderately to severe Acute Otitis Media

-Special Cases (Pertussis, Croup)

ManagementAntibiotic therapy has a small protective effect on

the risk of developing sinusitis, otitis media and possibly peritonsillar abscess (quinsy). 30 children and 145 adults need treatment to prevent

one case of acute otitis media.

]

But how can we differentiate between Viral and Bacterial Pharyngitis, Sinusitis & Otitis Media?

Acute Pharyngitis (Sore Throat)

Viral

Erythema

Acute Pharyngitis Bacterial Vs Viral-No Evidence that there is diff. in severity or duration of illness in either cases.

80% by Adenovirous

20% bacterial ( Grp A strp, H.inf , Staph Aureus)

-Based on symptoms they are limited to be distinguished.

-Clinical examination should not be relied upon to differentiate between them

-Sensitivity and Specificity suggest that reliance on clinical diagnoses will miss 25-50% of GABHS Pharyngitis cases.

SymptomsSore throat

Strep Throat: fever, headeach, swollen lymph node in the neck

Viral pharyngitis: runny nose and postnasal drip

Sever cases difficult swallowing and rarly difficult breathing

Acute Pharyngitis To determine bacterial Pharyngitis

Strep. ScoreMcIsaac Criteria

Acute PharyngitisRapid 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.

Not found in Jordan

Acute PharyngitisThroat Culture

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

+ve culture makes the Dx of GABHS likely , but –Ve culture does not rule out.

Acute Pharyngitis (Drug Of choice)

-Oral penicillin or erythromycin (in penicillin-allergic individuals), given for 10 days.

-Fortunately, no resistance to penicillin has been reported, so far, among GABHS-related Pharyngitis patients.

ComplicationRheumatic Fever

- Major Criteria:

- polyarithritis - Post strep. GN

- carditis - Bactermia

- sydenham chorea

- subcutaneous nodules

- erythema marginatum

- Minor Criteria:

- fever

- leukocytosis

- elevated ESR,CRP

- arthralgia

with evidence of recent group A strep infection

Treatment

Aim of Tt:

- prevention of complications.

- symptomatic improvement.

- bacterial eradication.

- prevention of contamination.

- reducing unnecessary antibiotic use.

Treatment

Bed rest.

Soft diet with fluid replacement.

Warm salt water gargle to relieve sore throat.

Analgesics and antipyretics.

Antibiotic in case of bacterial - Penicillin 1st line.

- Erythromycin if allergy to penicillin.

In case of viral cause, the length of illness depends on the virus involved.

CaseA 25 year old man comes to your office with the complaint of a bad sore throat for 2 days. He has felt chills and fever today but has not measured his temperature. He has some pain on swallowing. He has a slight runny nose and denies cough and other symptoms. He was previously healthy.

T= 38.5ears - TM's normalnose – clearneck - no cervical adenopathylungs – clear

How many points does our patient have?Fever over 38 C

Absence of cough

Tender ant. cervical adenopathy

Tonsillar swelling or exudate

Age< 15 y

Age> 45

Total = 3

1

1

0

1

0

0

What are the tests?Rapid strep test -ve

Throat culture + ve

Give Penicillin + Symptomatic treatment

Acute otitis media

Normal Tympanic Membrane

Acute otitis media

Redness Bulging

Acute otitis media

Bullae Perforation

Acute otitis mediaDutch Guidelines

-Dutch study found no difference in outcome between antibiotics, myringotomy, antibiotics combined with myringotomy and placebo.

-Only 1 in 7 children under 2 year old with 1st episode of A.O.M derived significant benefit from antibiotic treatment.

-Although it reduce fever faster , it does not reduce duration of pain or crying.

Most common cause: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis

SymptomsEarache, fever, trouble sleeping, Fullness in the ear, Vomiting, Diarrhea, Hearing loss in the affected ear

Perforated eardrum

Enlarged adenoids or tonsils

Mastoiditis

Hearing loss

complication

Acute otitis mediaDutch Guidelines

Diagnostic criteria

- Recent perforation of the tympanic membrane with discharging pus

- Inflamed and bulging tympanic membrane

- One ear drum redder than the other

- Bullae on tympanic membrane

TREATMENT GUIDELINES

Symptomatic treatment is provided in all cases

The patient or the parents are instructed to contact the general practitioner if there is an

abnormal clinical course, in other words:

- increasing illness or earache, decreased drinking

- no improvement within 3 days

TREATMENT GUIDELINES (cont.)

Antibiotics

Children < 6 months

Children

6 months - 2 years +

abnormal clinical course

For children >2 years , +recurrent

within 12 months or Down's syndrome ,

cleft palate , compromised immune

system

Treatment :

- Amoxcillin – Clavulanic acid

80-90 mg/kg per day

- Clarithromycin

15 mg/kg twice per day

Complication:

- meningitis

- brain abscess

- mastoiditis

- cholesteatoma

Acute sinusitis

-Usually comlicate allergic rhinitis or common cold with increase in symptoms

-Symptoms: nasal congestion, sore throat, postnasal drip, frontal headeach, cough, fever

Acute sinusitis

Antibiotics

Moderate symptoms not improving after 10 days

Moderate symptoms that worsen

after 5 to 7 daysSevere symptoms

-Oral amoxicillin, trimethoprim-sulfamethoxazole, or doxycycline, given for 3 to 10 days are the favored antibiotics for treatment.

Influenza

- Influenza is a viral infection that affects mainly the nose, throat, bronchi and, occasionally, lungs. Infection usually lasts for about a week

- is an acute viral infection that spreads easily from person to person

- circulates worldwide and can affect anybody in any age group.

- Influenza causes annual epidemics that peak during winter in temperate regions

- serious public health problem that causes severe illnesses and deaths for higher risk populations.

Seasonal influenza• is an acute viral infection caused by an

influenza virus

• There are three types of seasonal influenza – A, B and C.

• Transmission:airborne(by droplets and close personal contact.)

• Virus types A and B are constantly changing due to mutations (change in the viral RNA ) and are more common and more serious forms

.

• Type A viruses are divided into types based on differences in two viral surface proteins called the hemagglutinin (H) and the neuraminidase (N). There are 16 known H subtypes and nine known N subtypes

• currently influenza A(H1N1) and A(H3N2) subtypes are circulating among humans

• Type C influenza is stable cases occur much less frequently than A and B .

Antigenic shift and drift

• Influenza type A viruses undergo two kinds of changes :

i. Antigenic drift:

is a series of mutations that occurs over time and causes a gradual evolution of the virus

i. Antigenic shift:

is an abrupt change in the hemagglutinin and/or the neuraminidase proteins

• influenza type B viruses change only by the more gradual process of antigenic drift and therefore do not cause pandemics.

.

Signs and symptoms:

• sudden onset of high fever

• cough (usually dry)

• headache

• muscle and joint pain

• malaise

• sore throat and runny nose

Complications

Pneumonia

Encephalitis

Bronchitis

Sinus infections

Ear infections

Who is at risk?

highest risk of complications occur among

-children younger than age two

-adults age 65 or older

-people of any age with certain medical conditions, such as chronic heart, lung.

-weakened immune systems.

Diagnosis

• History

• Physical exam :

1. individuals may seem weary and tired

2. Their skin may feel warm

3. may have a fever and runny nose

4. The mucous membrane of the throat may appear reddened

5. Lymph nodes in the neck may be slightly swollen.

TreatmentThe flu goes away within 7 to 10 days

-Bed rest

-Paracetamol

-Oseltmivir best for children or zanamivir for >65 or high risk

-Antibiotics only in people with chronic or heart or renal disease

Prophylaxis : vaccination 70% for 1 year protection

Common cold

Common coldis a viral infectious disease of the upper respiratory

system, caused primarily by rhinoviruses and corona viruses Common symptoms include a cough, sore throat, runny nose, and fever.

Incidence: The common cold is the most frequent infectious disease in humans with on average two to four infections a year in adults and up to 6–12 in children

Transmission: airborne (by droplets and close personal contact.)

SymptomsSymptoms of the common cold usually begin 2 to 3 days after

infection and often include :Low grade feverMucus buildup in your nose Difficulty breathing through your nose Swelling of your sinuses Sneezing Sore throat Cough Headache Cold symptoms can last from 2 to 14 days, but like most

people, you’ll probably recover in a week If symptoms come back often or last much longer than 2

weeks, you might have an allergy rather than a cold.

complications

Bronchitis

Pneumonia

Ear infection

Sinusitis

Aggravation of asthma

management

• There is no cure for the common cold, but you can get relief from your cold symptoms by:

• Resting in bed

• Drinking of fluids

• Gargling with warm salt water or using throat sprays for a scratchy or sore throat

• Taking aspirin or Paracetamol, for example—for headache or fever

• Never take antibiotics to treat a cold because colds are caused by viruses . You should use these prescription medicines only if you have a rare bacterial complication, such as sinusitis or ear infection.

RhinitisRhinitis is a reaction that occurs in the eyes, nose

and throat when airborne irritants (allergens) trigger the release of histamine. Histamine causes inflammation and fluid production in the fragile linings of nasal passages, sinuses, and eyelids.

What are the different types of rhinitis?-allergic rhinitis :

seasonal - occurs particularly during pollen seasons

perennial - occurs throughout the year

nonallergic rhinitis :

Causes :

fumes

odors

temperature

atmospheric changes

smoke

other irritants

managementAvoid allergens

Antihistamine

Decongestant

Topical steroids or oral prednisolone

Symptomatic Effects of Pharmacologic Treatments

Adapted from Van Cauwenberge et al. Allergy. 2002.

Drug ClassDrug Class SneezingSneezing RhinorrheRhinorrheaa

Nasal Nasal ObstructioObstructio

nn

Nasal Nasal ItchItch

Eye Eye SymptomSymptom

ss

InflammatioInflammationn

Onset of Onset of ActionAction

H1-antihistamines

oral

intranasal

intraocular

++

++

-

++

++

-

+

+

-

+++

++

-

++

-

+++

+/-

+

++

Rapid

Rapid

Rapid

Corticosteroids

intranasal +++ +++ +++ ++ + ++++ Slow

Cromones

intranasal

intraocular+

-

+

-

+

-

+

-

-

++

++

++

Slow

Slow

Decongestants

intranasal

oral-

-

+

+

+++

++

-

-

-

-

-

-

Rapid

Rapid

Anticholinergics - ++ - - - - Rapid

Antileukotrienes - + + - ++ +/- Rapid

is an inflammation of the tonsils most commonly caused by viral or bacterial infection. It is a type

of pharyngitis.

Symptoms:red and/or swollen tonsilswhite or yellow patches on the tonsilstender, stiff, and/or swollen neckbad breathsore throatpainful or difficult swallowingcoughheadachesore eyesbody achesotalgiafeverbad breathchillsnasal congestions

If your tonsils become very swollen, you may also notice other symptoms. These may include sleep apnea (when breathing stops briefly during sleep), trouble swallowing food and a “throaty” voice.

Diagnosis:Tonsillitis can be diagnosed by performing a rapid

strep test, also called a throat culture. To perform the throat culture, the doctor will use a long cotton swab to swipe off some of the stuff on the surface of the back of your throat. The doctor will then test the "stuff" on the cotton swab. This test will determine whether you have tonsillitis and whether it is caused by a bacteria or a virus.

Tonsillitis usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.

Treatment: Treatment for tonsillitis depends on whether it was caused by a virus or

bacteria. If the tonsillitis was caused by strep bacteria (streptococci), the doctor will prescribe antibiotics. If the tonsillitis was caused by a virus, your body will fight off the infection on its own. However, medication can be prescribed to releive the symptoms.

Encourage rest. Provide adequate fluids Provide comforting foods and beverage. Prepare a saltwater gargle Humidify the air Avoid irritants. Treat pain and fever. Ibuprofen & acetaminophenAntibiotics If tonsillitis is caused by a bacterial infection Penicillin taken by mouth for 10 days is the most common antibiotic treatment

prescribed for tonsillitis caused by group A streptococcus.

Surgery:

Surgery to remove tonsils (tonsillectomy) may be used to treat frequently recurring tonsillitis, chronic tonsillitis, or bacterial tonsillitis that doesn't respond to antibiotic treatment.

Frequent tonsillitis is generally defined as:More than six episodes in one yearMore than four episodes a year over two yearsMore than three episodes a year over three years A tonsillectomy may also be performed if tonsillitis

results in difficult to manage complications, such as:1. Obstructed sleep apnea2. Breathing difficulty3. A peritonsillar abscess that doesn't improve with

antibiotic treatment.

How long does Tonsillitis Last?If tonsillitis is caused by bacteria, with antibiotic

treatment, the illness is usually cured within 1 week. However, it may take several weeks for the tonsils and swollen glands to return to normal size.

When tonsillitis is caused by viruses, the length of illness depends on which virus is involved. Usually, people are almost completely recovered within 1 week.

Pertussis:also known as whooping cough; is a highly

contagious disease caused by the bacterium Bordetella pertussis. It is known to last for a duration of approximately 6 weeks before subsiding. The disease derives its name from the "whoop" sound made from the inspiration of air after a cough.

Whooping People with whooping cough are most contagious during the earliest stages of the illness up to about 2 weeks after the cough begins.

If you take the whooping cough vaccine, you will lower your risk of contracting whooping cough. So it can be prevented. The whooping cough vaccine is part of the DTaP (diphtheria, tetanus, acellular pertussis) immunization. DTaP immunizations are routinely given in five doses before a child's sixth birthday.

The initial symptoms of whooping cough are:

runny nose

sneezing

mild cough

low fever

After about 1 week, the dry, irritating cough evolves into coughing spells that last for about one minute. During the coughing spell, the person may become red or purple. After the coughing spell, the person may vomit or make a whooping sound when breathing in.

Diagnosis:Culturing of nasopharyngeal swabs

Treatment: Antibiotics Treatment with an effective antibiotic (erythromycin or azithromycin) shortens

the infectious period but does not generally alter the outcome of the infection; however, when treatment is initiated during the catarrhal stage, symptoms may be less severe. Three macrolides (erythromycin, azithromycin and clarithromycin) are used in the U.S. For treatment of pertussis; trimethoprim-sulfamethoxazole is generally used when a macrolide is ineffective or is contraindicated. Close contacts who receive appropriate antibiotics (chemoprophylaxis) during the 7–21 day incubation period may be protected from developing symptomatic disease. Close contacts are defined as anyone coming into contact with the respiratory secretions of an infected person in the 21 days before or after the infected person's cough began. There is no known antitoxin.

Cough Effective treatments of the cough associated with this condition have not yet

been developed. Herbal treatments and vitamin C in the form of sodium ascorbate have been said to greatly decrease the severity of the cough caused by pertussis, but scant scientific studies have been performed to investigate this claim.

 

Croup (or laryngotracheobronchitis)

is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness. It may produce mild, moderate, or severe symptoms, which often worsen at night.

Signs & symptoms:"barking" cough

 stridor

 hoarseness

difficult breathing which usually worsens at night

also;  fever, coryza (symptoms typical of the common cold), and chest wall indrawing.

Causes:1. viral infection:  parainfluenza virus,  primarily

types 1 and 2, in 75% of cases,  influenza A and B, measles, adenovirus and respiratory syncytial virus (RSV).

2. bacterial infection: laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis.

Pathophysiology:The viral infection that causes croup leads to

swelling of the larynx, trachea, and large bronchi due to infiltration of  white blood cells; (especially  histiocytes,  lymphocytes, plasma cells, and neutrophils).

 Swelling produces airway obstruction which, when significant, leads to dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as stridor.

Diagnosis: clinical diagnosis. The first step is to exclude

other obstructive conditions of the upper airway, especially epiglottitis

The most commonly used system for classifying the severity of croup is the Westley score.

Treatment:Children with croup are generally kept as calm as

possible. Steroids are given routinely, with epinephrine used in severe cases. Children with oxygen saturations under 92% should receive oxygen, and those with severe croup may be hospitalized for observation. If oxygen is needed, "blow-by" administration (holding an oxygen source near the child's face) is recommended, as it causes less agitation than use of a mask. With treatment, less than 0.2% of people require endotracheal intubation.

Steroids:Corticosteroids, such as;  dexamethasone  and 

budesonide, have been shown to improve outcomes in children with all severities of croup. However, significant relief is often not obtained for up to six hours after administration, and lasts for only about 12 hours. While effective when given orally, parentally, or by inhalation, the oral route is preferred. 

A single dose is usually all that is required, and is generally considered to be quite safe. Dexamethasone at doses of 0.15, 0.3 and 0.6 mg/kg appear to be all equally effective.

Epinephrine:Moderate to severe croup may be improved

temporarily with nebulized epinephrine. While epinephrine typically produces a reduction in croup severity within 10–30 minutes, the benefits last for only about 2 hours. If the condition remains improved for 2–4 hours after treatment and no other complications arise, the child is typically discharged from the hospital.

Epiglottitis:is inflammation of the epiglottis - the flap that sits

at the base of the tongue, which keeps food from going into the trachea (windpipe). Due to its place in the airway; swelling of this structure can interfere with breathing and constitutes a medical emergency. The infection can cause the epiglottis to either obstruct or completely close off the windpipe.

Symptoms of Epiglottitis:There are many symptoms. The most common

symptoms are:DroolingSore throatDifficulty swallowingDifficulty breathingHoarsenessChillsFeverBlue skin

What Causes Epiglottitis?The most common cause of epiglottitis is infection

with the bacteria called Haemophilus influenza type b, also called HIB.

Epiglottis can also be caused by other types of bacteria including some types of Streptococcus bacteria and the bacteria responsible for causing diphtheria.

Treatment of Epiglottitis:Epiglottitis can be treated. If proper treatment is

given, the patient can fully recover. Some of the treatment options are:

(1)Administration of humidified oxygen. Oxygen will help the patient breathe.

(2)Intravenous fluids. Intravenous fluids are given to increase hydration.

(3)Antibiotics to treat the infection.

(4)Corticosteroids to decrease the swelling of the throat.

24/9/2008 81

Question 1 - Single Best Answer

What is the most common cause of pharyngitis?

a)Epstein Barr virus

b) Streptococcus pyogenes

c)Streptococcus pneumoniae

d)Candida albicans

e)none of the above

The answer is (e)

24/9/2008 82

Question 2 - Single Best Answer

All cases of pharyngitis should be treated with antibiotics? A) true

B) false

The answer is (b)

24/9/2008 83

Question 3 - Single Best Answer

A bacterial etiology of sore throat can be determined clinically?

A) TrueB) False

The answer is (b)

24/9/2008 84

Question 4 - Single Best Answer

The bacterial causes of sore throat include

A) Streptococcus pyogenes and Treponema pallidum

B) Neisseria gonorrhoea and Streptococcus

pneumoniae

C) Corynebacterium diphtheriae and Streptococcus pyogenes

D) Treponema pallidum and Bordetella pertussis

E) Corynebacterium diphtheriae and Bordetella

pertussis

The answer is (c)

24/9/2008 85

Question 5 - Single Best Answer

Pharyngitis caused by ____________________in a child is considered indicative of child sexual abuse?

a)Streptococcus pyogenes

b) Streptococcus pneumonia

c) Corynebacterium diphtheria

d) Neisseria gonnorheae

e) none of the above

The answer is (d)

24/9/2008 86

Question 6 - Single Best Answer

How much time does it take to determine if a sore throat is caused by Streptococcus pyogenes?

a)10 minutes

b) 4 hours

c)Overnight

d) two weeks

The answer is (a)

24/9/2008 87

Question 7 - Single Best Answer

What does a grayish pseudomembrane in the throat suggest?

A) Clostridium difficileB) Streptococcus pyogenesC) Streptococcus pneumonia No, (sigh)D) Corynebacterium diphtheriaE) Neisseria gonorrhoea

The answer is (d)

24/9/2008 88

Question 8 - Single Best Answer

The most common cause of epiglottitis is_____________________?

A) Neisseria gonorrhoeaB) Epstein-Barr virusC) Haemophilus influenzaeD) Streptococcus pyogenes E) Streptococcus pneumoniae

The answer is (c)

24/9/2008 89

Question 9 - Single Best Answer

What do you think is the most important virulence factor for bacteria that cause pharyngitis, epiglottitis, or bronchitis?

a)membrane ruffling to induce uptake by cells

b) adhesins

c) toxins

d) ability to kill non-specific phagocytes

The answer is (b)

Thank You

الله بحمد تمت

Treatment Plan for Allergic Rhinitisby Disease Severity

MildAntihistamine or antihistamine-decongestant combination (non-

sedating preferred)ORIntranasal cromolyn sodium

ModerateIntranasal corticosteroid*Antihistamine-decongestant combinationConsider immunotherapy if symptoms persist 2-3 mo.

SevereIntranasal corticosteroid*Antihistamine-decongestant combinationConsider short course (3-7 days) of oral corticosteroidConsider immunotherapy

*Most effective when started 1 week before anticipated onset of Sx.