Upper Respiratory Tract Infections

Gosaye M, (B.pharm, MSc.)

 Introduction
• URTIs include
– Otitis media, sinusitis, pharyngitis, ,
rhinitis,

• They responsible for the majority of

antibiotics prescribed at OPD.

• They can be bacterial, viral or non-specific

in nature.
OTITIS MEDIA
• An inflammation of the middle ear.
• Most common in infants and children,
– 75% of whom have had at least one episode by
the age of 1 year.
• Risk factors:
– Winter season/outbreaks of respiratory
syncytial or influenza virus
– Attendance at day care centers
– Lack of breast-feeding in infants
– Anatomical defect
Risk factors cont…
– Nasopharyngeal colonization with
middle ear pathogens
– Genetic predisposition
– Siblings in the home
– Lower socioeconomic status
– Exposure to tobacco smoke
– Male gender
– Immunodeficiency
– Allergy
– Urban population
Risk factors for resistant bacterial OM
• (a) day-care attendance,
• (b) recent antibiotic exposure,
• (c) age younger than 2 years, and
• (d) frequent bouts of otitis media
PATHOPHYSIOLOGY
• Usually follows a viral URTI.
– Eustachian tube dysfunction
– Mucosal swelling in the middle ear.
• Bacteria colonizes the nasopharynx
– Then enter the middle ear and are not cleared
properly.
• In the presence of effusion, the bacteria
proliferate and cause infection.
• Children are more prone to this. why???
– Because of the anatomy of their
eustachian tube.
MICROBIOLOGY/ etiology
• S. pneumoniae- 20-35%
• Haemophilus influenzae- 20% to 30%
• Moraxella catarrhalis - 20%
– Less common: staph.aureus, s.pyogens, gram-
negative bacilli such as P. aeruginosa.
• No bacterial pathogen- 20 to 30%

• Viral etiology with or without concomitant

bacteria- 44%
 Clinical Presentation of Acute Bacterial
Otitis Media and its dx
• General
– Cold symptoms of runny nose, nasal
congestion, or cough
– Acute onset of signs and symptoms of
middle ear infection
• Signs and symptoms
– Pain that can be severe (more than 75% of
patients)….resolve after 2 to 3 days
– Children may be irritable, tug on the involved
ear, and have difficulty sleeping
– Fever is present in less than 25%...resolves 2 to
3 d.
Sn & sx cont…
– Examination shows a discolored (gray), thickened,
bulging eardrum.
– Pneumatic otoscopy or tympanometry
demonstrates an immobile eardrum; 50% of cases
are bilateral.
– Draining middle ear fluid occurs (less than 3% of
patients) that usually reveals a bacterial etiology
• Laboratory tests
– Gram stain, culture, and sensitivities of
draining fluid .
Otitis media with effusion
• Over a period of 1 week, changes in the
eardrum normalize, and the pus becomes
serous fluid.
• Air–fluid levels are apparent behind the
eardrum.
• Does not represent ongoing infection, nor
are additional antibiotics required.
• It also can occur de novo and is thought to
be a result of respiratory viruses.
• Usually occurs in spring or autumn, not
winter.
• Pain is not present, nor a bulging eardrum.
• Effusions resolve slowly.
 Complications
• Are infrequent
• Mastoiditis ,
• Bacteremia ,
• Meningitis , and
• Auditory sequelae with potential for
speech and language impairment.
TREATMENT of AOM
• DESIRED OUTCOME
– Reduction in signs and symptoms
– Eradication of the infection
– Prevention of complications
– Avoidance of unnecessary antibiotic
prescribing.
GENERAL APPROACH TO TREATMENT
• Acetaminophen or Ibuprofen should be
offered early regardless of the use of
antibiotics.
• Decongestants, antihistamines, topical
corticosteroids, and expectorants have not
been proven effective.
– Side effects associated with these
treatments may be unpleasant.
• Surgical insertion of tympanostomy tubes
(T tubes) is an effective method for the
prevention of recurrent otitis media.
Antimicrobial Therapy
• Delayed –vs- immediate antibiotic therapy…no
consensus reached.
• Rx recommendation:
– First line - Amoxicillin high dose 80–90
mg/kg/day divided twice daily
If Penicillin Allergy- Non–type I:
Cefuroxime 30 mg/kg / day divided twice
daily Cefpodoxime 10 mg/kg / day once
daily ….
If Type I: Azithromycin 10 mg/kg/ day 1,
then 5 mg /kg / day for days 2–5,
Clarithromycin 15 mg / kg /day divided
twice daily.
If Treatment Failure
• Non type 1 allergy- Amoxicillin-clavulanate
• Or Ceftriaxone 50 mg /kg / day IM/IV for 3
days.
• If severe symptoms (severe otalgia and
temperature above 39°C [102.2°F])…
Amoxicillin-clavulanate
• Alternatives:
– Clindamycin 30–40 mg/ kg /day in 3 divided
Doses
– Adult- 300 to 450 mg tid
• Tympanocentesis
 AOM-severity of symptom scale
0 point 1 point 2 popints

Tugging of ear
Irritability
Difficulty of sleep
Diminished
activity
Diminished
appetite
Fever
Crying
N.B: parents comparison with child’s usual condition; 0= none, 1= a little, 2= a
lot
0 to 14 score
>3 score indicate AOM
The higher score indicate the severity
Duration of Rx for AOM
• Short-course therapy may be considered
in some instances.
– 5 to 10 days
– It depends on age and severity
• <2years
• Severe 10 days
– 2 to 5 yrs- 7 days
– > 6 years 5 to 7 days
 Prevention
• Exclusive breast-feeding for the first 6 months
of life

• Handwashing, and limiting exposure to

daycare, and second-hand smoke.

• Influenza vaccine is recommended in children

with chronic medical conditions.
• Pneumococcal conjugate vaccine is
recommended for children ages 2 months to
2 years,
– and in those with high-risk conditions and older
than age 2.
 Patient case #1
• A 13-month-old boy presents to the pediatric clinic
with 2 days of fever (maximum temperature of
39.3°C [102.7°F]), rhinorrhea, and fussiness. His
mother reports that he was rubbing his left ear
throughout the day yesterday.
• She states that he is irritable and he was crying
intermittently throughout the night last night. He has
not eaten much today. He attends daycare 3 days a
week and has a 5-year-old sister who recently had a
cold.
 Patient case #1…
• HEENT: Erythema and severe bulging of the
left tympanic membrane with the presence of
middle ear fluid; the right tympanic
membrane is obscured with cerumen.
1. What information is suggestive of acute otitis media
(AOM)?
2. What risk factors does this child have for AOM?
3. Is there any additional information you need to know
before recommending a treatment plan?
4. Treatment duration and medication?
 OUTCOME EVALUATION
• Improvement of signs and symptoms (ie, pain,
fever, and tympanic membrane inflammation)
should be evident by 72 hours of proper
therapy.
– Presence of middle ear effusion in the absence of
symptoms is not an indicator of treatment failure.
• Evaluate hearing in children who are
otherwise healthy and have persistent
effusion lasting 3 months in duration.
SINUSITIS
• An inflammation and/or infection of the
paranasal sinus mucosa.
• Even though the majority of these
infections are viral in origin, antimicrobials
are prescribed frequently.
– Persistence of symptoms beyond 7 to 10 days
or worsening of symptoms likely indicates a
bacterial infection.
• Acute bacterial sinusitis lasts less than 30
days with complete resolution of
symptoms.
• Chronic ≥3 months
PATHOPHYSIOLOGY
• Usually is preceded by a viral respiratory
tract infection that causes mucosal
inflammation.
• Can lead to obstruction of the sinus ostia
—the pathways that drain the sinuses.
– Mucosal secretions become trapped,
– Local defenses are impaired, and
– Bacteria from adjacent surfaces begin
to proliferate.
• For chronic one, pathogenesis has not
been well studied.
Complications
• Include
– Osteitis ,
– Orbital cellulitis,
– Meningitis ,
– Brain abscess, but are extremely rare.
MICROBIOLOGY
• Viruses are responsible for most cases of
acute sinusitis.
• S. pneumoniae and H. influenzae.
– for approximately 70% of bacterial causes
of acute sinusitis in both adults and
children.
• M. catarrhalis is also frequently implicated
in children
– approximately 25%.
• S. pyogenes, S. aureus, fungi, and
anaerobes are associated less frequently
with acute sinusitis.
 Diagnosis of ABRS

At least 2 major or 1 major and >=2 minor criteria

 Clinical Presentation and Diagnosis of
Bacterial Sinusitis
• General
– A nonspecific upper respiratory tract
infection that persists beyond 7 to 14 days.
• Signs and symptoms
• Acute : Adults
– Nasal discharge/congestion.
– Maxillary tooth pain, facial or sinus pain
that may radiate (unilateral in particular) as
well as deterioration after initial
improvement.
– Severe or persistent (beyond 7 days) signs
and symptoms.
Clinical presentation cont…
• Children
– Nasal discharge and cough for greater than 10 to
14 days or severe signs and symptoms such as
temperature above 39°C (102.2°F) or
– Facial swelling or pain are indications for
antimicrobial therapy
• Chronic
– Symptoms are similar to acute sinusitis but more
nonspecific
– Rhinorrhea is associated with acute
exacerbations
– Chronic unproductive cough, laryngitis, and
headache may occur
– Chronic/recurrent infections occur three to four
times a year and are unresponsive to steam and
decongestants
 Rx of ABRS
• DESIRED OUTCOME
– Reduction in signs and symptoms,
– Achieving and maintaining patency of
the ostia,
– Limiting antimicrobial treatment to
those who may benefit,
– Eradicating bacterial infection with
appropriate antimicrobial therapy,
– Minimizing the duration of illness,
– Preventing complications, and
progression from acute disease to
chronic disease.
Principles of therapy
• Acute rhinosinusitis resolves without
antibiotic therapy in most cases.
• No recommendations are made for adjuvant
therapies or antibiotic prophylaxis.
– Analgesics
– Antihistamines should not be used for acute
bacterial sinusitis.
• Second-generation antihistamines may play a role in
chronic sinusitis where allergy is a component.
– Glucocorticoids intranasally may decrease
inflammation
– Saline nasal spray
– Expectorant
Antimicrobial Therapy
• Uncomplicated Sinusitis- amoxicillin
• Uncomplicated sinusitis, penicillin allergic
patient
– Non–immediate-type hypersensitivity: β-
lactamase– stable cephalosporin

– Immediate-type hypersensitivity:
Clarithromycin or azithromycin or
trimethoprims ulfamethoxazole or
doxycycline or respiratory
fluoroquinolone.
 Antimicrobial Therapy cont…
• Treatment failure or prior antibiotic therapy
in past 4 to 6 weeks
– High-dose amoxicillin with clavulanate or
β lactamase–stable cephalosporin
– Second choice: respiratory
fluoroquinolone
• High suspicion of penicillin-resistant
Streptococcus pneumoniae
– High-dose amoxicillin or clindamycin
– Second choice: respiratory
fluoroquinolone
 Duration of RX & outcome
evaluation
• For uncomplicated infections,
– from 5 to 10 days in adults and
– 10 to 14 days in children

• Clinical improvement (eg, lack of fever,

reduced nasal congestion and discharge,
improvements in pain or facial pressure)
– should be evident within 5 days of therapy.
Pharangitis
PHARYNGITIS
• An acute infection of the oropharynx or
nasopharynx.
• It is the reason for 1% to 2% of all outpatient
visits.
• MICROBIOLOGY
– Viruses cause the majority of cases.
– Of all the bacterial causes, group A
Streptococcus is the most common (10% to
30% of persons of all ages with pharyngitis),
o The only commonly occurring form of
acute pharyngitis for which antimicrobial
therapy is indicated
PATHOPHYSIOLOGY
• The mechanism by which group A
Streptococcus causes pharyngitis is not well
defined.
• Asymptomatic pharyngeal carriers of the
organism may have an alteration in host
immunity (e.g., a breach in the pharyngeal
mucosa) and the bacteria of the oropharynx,
allowing colonization to become infection.
• Pathogenic factors associated with the
organism itself also may play a role.
– These include pyrogenic toxins,
hemolysins, streptokinase, and
proteinase.
Risk factors
• Age: Children ages 5 to 15 years old are
most susceptible.
• Parents of school-age children .
• Those who work with children are also at
increased risk.
• Winter and early spring- highest
prevalence.
• Over crowding.
CLINICAL PRESENTATION of GAS P
• General
– A sore throat of sudden onset that is mostly self-
limited.
– Fever and constitutional symptoms resolving in
about 3 to 5 days.
– Clinical signs and symptoms are similar for viral
causes as well as nonstreptococcal bacterial causes.
• Signs and symptoms
– Sore throat
– Pain on swallowing and Fever
– Headache, nausea, vomiting, and abdominal pain
(especially children)
– Erythema/inflammation of the tonsils and pharynx
with or without patchy exudates
CLINICAL PRESENTATION of GAS P
• Sn and sx cont….
– Enlarged, tender lymph nodes
– Red swollen uvula, petechiae on the soft
palate, and a scarlatiniform rash
– Several symptoms that are not suggestive
of group A Streptococcus are cough,
• Conjunctivitis, and diarrhea
• Laboratory tests
– Throat swab and culture or rapid antigen
detection testing.
Dx. Of bacterial Pharangitis
Complications of GAS
• Nonsuppurative complications:
– Acute rheumatic fever
– Acute glomerulonephritis
– Reactive arthritis may occur
• suppurative complications:
– Peritonsillar abscess
– Retropharyngeal abscess
– Cervical lymphadenitis, mastoiditis,
otitis media, sinusitis, and necrotizing
fasciitis.
TREATMENT
• DESIRED OUTCOME
– Improve clinical signs and symptoms
– Minimize adverse drug reactions
– Prevent transmission to close contacts
– Prevent complications
 GENERAL APPROACH TO TREATMENT
• Antimicrobial therapy should be limited to
– Those who have clinical and
epidemiologic features of group A
streptococcal pharyngitis
• with a positive laboratory test.
• Empiric therapy is not recommended.
– Antimicrobial overuse and underuse is
common.
Antimicrobial Therapy: primary
Antimicrobial Therapy: recurrent
Summary
• Most nonspecific upper respiratory tract
infections have a viral, not bacterial,
etiology and tend to resolve spontaneously.
• Each time antibiotics are administered for
an URTI, the recipient is at increased risk of
selection and carriage of resistant
organisms that can be passed to others.
• Amoxicillin is the drug of choice for acute
otitis media. Highdose amoxicillin (80 to 90
mg/kg/day) is recommended as it is not
always known if the patient is at high risk
for a penicillin resistant pneumococcal
infection.
Summary cont…
• Vaccination against influenza and
pneumococcus may decrease the risk of acute
otitis media, especially in those with recurrent
episodes.
• Viral and bacterial sinusitis are difficult to
differentiate because their clinical
presentations are similar.
• Amoxicillin is first-line treatment for acute
bacterial sinusitis.
Summary cont…
• Viruses cause the majority of acute
pharyngitis cases.
• Of all the bacterial causes, group A β-
hemolytic Streptococcus (S. pyogenes) is the
most common and it is the only commonly
occurring form of acute pharyngitis for which
antimicrobial therapy is indicated.
• Penicillin is the drug of choice; amoxicillin can
be used for children because of its better
taste.
Thank you!!