Upper Respiratory Tract
Infections
URTI
Dr. Salah Wageehuddein, Clincial
Pharmacy
URTI
They Include:
• OTITIS MEDIA
• PHARYNGITIS
• SINUSITIS
Dr. Salah Wageehuddein, Clincial
Pharmacy
OTITIS MEDIA
• Otitis media is an inflammation of the middle ear.
• Otitis media with effusion (accumulation of liquid in the
middle ear cavity)
• Otitis media is most common in infants and children.
• Risk factors contributing to increased incidence of otitis
media include the:
– winter season,
– attendance at a daycare center,
– non–breast-feeding in infants,
– early age at first infection, and
– nasopharyngeal colonization with middle ear pathogens.
Dr. Salah Wageehuddein, Clincial
Pharmacy
PATHOPHYSIOLOGY
• Streptococcus pneumoniae (20% to 35%).
• Haemophilus influenzae and
• Moraxella catarrhalis
Dr. Salah Wageehuddein, Clincial
Pharmacy
CLINICAL PRESENTATION
• Otalgia (pain in the ear),
• irritability,
• bulging,
• nonmotile tympanic membrane.
• cold symptoms: runny nose, nasal
congestion, or cough
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Resolution of acute otitis media occurs
over 1 week.
• Pain and fever tend to resolve over 2 to 3
days, with most children becoming
asymptomatic at 7 days.
• Effusions resolve slowly, 90% have
disappeared by 3 months.
Dr. Salah Wageehuddein, Clincial
Pharmacy
DESIRED OUTCOME
The goals of treatment include:
• Reduction in signs and symptoms,
eradication of infection, and prevention of
complications.
Dr. Salah Wageehuddein, Clincial
Pharmacy
TREATMENT
• High percentage of children will be cured
with symptomatic treatment alone.
• Antibiotic use reduces the duration of
symptoms by about 1 day.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Amoxicillin is the drug of choice for acute otitis media.
• High-dose amoxicillin (80 to 90 mg/kg/day) is
recommended.
• If treatment failure occurs with amoxicillin, an agent
should be chosen with activity against β-lactamase–
producing H. influenzae and M. catarrhalis as well as
drug-resistant S. pneumoniae (such as high-dose
amoxicillin-clavulanate (recommended), or, cefuroxime,
cefdinir, cefpodoxime, cefprozil, or intramuscular
ceftriaxone).
• Five to 7 days of therapy may be used in children at
least 6 years old who have mild to moderate acute otitis
media.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Acetaminophen or a nonsteroidal
antiinflammatory agent, such as
ibuprofen can be used to relieve pain and
malaise in acute otitis media.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Recurrent otitis media is defined as at
least three episodes in 6 months or at
least four episodes in 12 months.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Recurrent infections are of concern because patients
younger than 3 years of age are at high risk for hearing
loss and language and learning disabilities.
• Vaccination against influenza and pneumococcus may
decrease risk of acute otitis media, especially in those
with recurrent episodes.
• Immunization with the influenza vaccine reduces the
incidence of acute otitis media.
Dr. Salah Wageehuddein, Clincial
Pharmacy
Dr. Salah Wageehuddein, Clincial
Pharmacy
PHARYNGITIS
• Pharyngitis is an acute infection of the
oropharynx or nasopharynx
• Viral causes: rhinovirus, coronavirus, and
adenovirus
• Bacteria: group A β-hemolytic
Streptococcus, or Streptococcus
pyogenes
Dr. Salah Wageehuddein, Clincial
Pharmacy
PHARYNGITIS
• Complications such as acute rheumatic
fever, acute glomerulonephritis, and
reactive arthritis may occur as a result of
pharyngitis with Group A Streptococcus
Dr. Salah Wageehuddein, Clincial
Pharmacy
CLINICAL PRESENTATION
• Sore throat.
• Pain on swallowing.
• Fever.
• Headache, nausea, vomiting, and abdominal pain
(especially children).
• Erythema/inflammation of the tonsils and pharynx
• Enlarged, tender lymph nodes.
*Only those with a positive test for Group A Streptococcus
require antibiotic treatment.
Dr. Salah Wageehuddein, Clincial
Pharmacy
TREATMENT
• Penicillin is the drug of choice in the
treatment of Group A streptococcal
pharyngitis dosing guidelines for recurrent
infections.
Dr. Salah Wageehuddein, Clincial
Pharmacy
TREATMENT
• In patients allergic to penicillin, a macrolide such
as erythromycin or a first-generation
cephalosporin such as cephalexin can be used.
• Newer macrolides such as azithromycin and
clarithromycin are as effective as erythromycin
and cause fewer GI adverse effects.
• If patients are unable to take oral medications,
intramuscular benzathine penicillin
Dr. Salah Wageehuddein, Clincial
Pharmacy
TREATMENT
• The duration of therapy for Group A
streptococcal pharyngitis is 10 days to
maximize bacterial eradication.
Dr. Salah Wageehuddein, Clincial
Pharmacy
Dr. Salah Wageehuddein, Clincial
Pharmacy
SINUSITIS
• Sinusitis is an inflammation and/or
infection of the paranasal sinus mucosa.
• The majority of these infections are viral in
origin.
• It is important to differentiate between viral
and bacterial sinusitis to aid in optimizing
treatment decisions.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Acute sinusitis lasts less than 30 days with
complete resolution of symptoms.
• Chronic sinusitis is defined as episodes of
inflammation lasting more than 3 months with
persistence of respiratory symptoms.
• Acute bacterial sinusitis caused by the S.
pneumoniae and H. influenzae
• Chronic sinusitis can be polymicrobial including
anaerobes, gram-negative bacilli and fungi.
Dr. Salah Wageehuddein, Clincial
Pharmacy
CLINICAL PRESENTATION
• Nasal discharge/congestion.
• Maxillary tooth pain, facial or sinus pain
that may radiate
• Severe or persistent (beyond 7 days)
signs and symptoms are most likely
bacterial and should be treated with
antimicrobials.
Dr. Salah Wageehuddein, Clincial
Pharmacy
TREATMENT
• Approximately 65% of patients with acute
sinusitis will recover spontaneously (these
are likely patients with viral sinusitis).
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Nasal decongestant sprays such as phenylephrine and
oxymetazoline that reduce inflammation by
vasoconstriction are often used in sinusitis.
• Use should be limited to the recommended duration of
the product to prevent rebound congestion.
• Guaifenesin may be used to decrease the viscosity of
nasal secretions.
• Antihistamines should not be used for acute bacterial
sinusitis in view of their anticholinergic effects that can
dry mucosa and disturb clearance of mucosal secretions.
Dr. Salah Wageehuddein, Clincial
Pharmacy
• Amoxicillin is first-line treatment for acute
bacterial sinusitis.
• The current recommendations are 10 to 14
days, or at least 7 days, of antimicrobial
therapy after signs and symptoms are
under control.
Dr. Salah Wageehuddein, Clincial
Pharmacy
Dr. Salah Wageehuddein, Clincial
Pharmacy
