Urti

Objectives

•Management principles
• Effects of Rx
• Antibiotic in specific URTI
• Factors affect prescription

Definition
URTI 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.

•Otitisto visit aisphysician.common cause for a child under
age 15
media the most

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

Management Principles
Viral 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


Viral (Don’t Use Antibiotics) Bacterial (Use antibiotics)
Why? Why?

-Promotes antibiotic resistance - To prevent rheumatic fever
-Adverse reactions such as allergy - To prevent suppurative
and anaphylaxis complications (e.g., peritonsillar
abscess)
-Costly
- To speed up recovery
-Patients do not need antibiotics to
feel satisfied - To reduce spread to others


Viral (Don’t Use Antibiotics) Bacterial (Use antibiotics)

-Influenza, Common Cold -GABHS Pharyngitis
-Viral Pharyngitis -Moderately to severe
-Mild Acute Sinusitis Acute Sinusitis
-Mild Acute Otitis Media -Moderately to severe
Acute Otitis Media
-Special Cases (Pertussis,
Croup)

Management
Antibiotic 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.

Symptoms
Sore 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. Score
McIsaac Criteria

Acute Pharyngitis
Rapid 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 Pharyngitis
Throat 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.

Complication
Rheumatic 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.

Case
A 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= 38.5
ears - TM's normal
nose – clear
neck - no cervical adenopathy
lungs – clear

How many points does our patient
have?
Fever over 38 C 1
Absence of cough 1
Tender ant. cervical adenopathy 0
Tonsillar swelling or exudate 1
Age< 15 y 0
Age> 45 0

Total = 3

What are the tests?
Rapid strep test -ve

Throat culture + ve

Give Penicillin + Symptomatic treatment

Acute otitis media

Redness Bulging

Acute otitis media

Bullae Perforation

Acute otitis media
Dutch 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

Symptoms
Earache, fever, trouble sleeping, Fullness in the
ear, Vomiting, Diarrhea, Hearing loss in the
affected ear
complicatio
n
Perforated eardrum
Enlarged adenoids or tonsils
Mastoiditis
Hearing loss

Acute otitis media
Dutch 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

, For children >2 years
recurrent+
Children within 12 months or
Children < 6 months 6 months - 2 years + , Down's syndrome
abnormal clinical course , 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 Moderate symptoms
not improving that worsen Severe symptoms
after 10 days after 5 to 7 days

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

Influenza
- Influenzathroat, bronchi and, occasionally,
the nose,
is a viral infection that affects mainly

lungs. Infection usually lasts for about a week

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

- circulates worldwide and can affect anybody in
any age group.
- Influenza causes temperate regionsthat peak
during winter in
annual epidemics

- serious publicdeaths for higherthat causes severe
illnesses and
health problem
risk populations.

Seasonal influenza
• is an acutevirus infection caused by an
influenza
viral

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

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

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

.

• Type A virusestwo viral surface proteins called
differences in
are divided into types based on

the hemagglutinin (H) and the neuraminidase
(N). There are 16 known H subtypes and nine
known N subtypes

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

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

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.

Treatment
The 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
is 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.)

Symptoms
Symptoms of the common cold usually begin 2 to 3 days after
infection and often include :
Low grade fever
Mucus 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 coldcommon cold, but you can
get relief from your
the
symptoms by:
• Resting in bed
• Drinking of fluids
• Gargling with warm salt sore throat throat
sprays for a scratchy or
water or using

• Taking aspirin or Paracetamol, for example—for
headache or fever
• Never take by viruses .to treat a colduse these colds
are caused
antibiotics
You should
because

prescription medicines only if you have a rare
bacterial complication, such as sinusitis or ear
infection.

Rhinitis
Rhinitis 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

management
Avoid allergens

Antihistamine

Decongestant

Topical steroids or oral prednisolone

Symptomatic Effects of
Pharmacologic Treatments
Nasal Eye
Rhinorrhe Nasal Inflammatio Onset of
Drug Class Sneezing Obstructio Symptom
a Itch n Action
n s
H1-
antihistamines
++ ++ + +++ ++ +/- Rapid
oral
intranasal ++ ++ + ++ - + Rapid
intraocular - - - - +++ ++ Rapid
Corticosteroid
s
intranasal +++ +++ +++ ++ + ++++ Slow

Cromones
intranasal + + + + - ++ Slow
intraocular - - - - ++ ++ Slow
Decongestants
intranasal - + +++ - - - Rapid
oral - + ++ - - - Rapid
Anticholinergic
s
- ++ - - - - Rapid

Antileukotriene
- + +
Adapted from Van Cauwenberge et al. Allergy. 2002.
s
- ++ +/- 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 tonsils
white or yellow patches on the tonsils
tender, stiff, and/or swollen neck
bad breath
sore throat
painful or difficult swallowing
cough
headache
sore eyes
body aches
otalgia
fever
bad breath
chills
nasal 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 & acetaminophen
Antibiotics
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 year
More than four episodes a year over two years
More 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 apnea
2. Breathing difficulty
3. 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:
Drooling
Sore throat
Difficulty swallowing
Difficulty breathing
Hoarseness
Chills
Fever
Blue 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.

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 81

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

The answer is (b)

24/9/2008 82

A bacterial etiology of sore throat can be
determined clinically?
A) True
B) False

The answer is (b)

24/9/2008 83

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 84

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 85

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 86

What does a grayish pseudomembrane in the
throat suggest?
A) Clostridium difficile
B) Streptococcus pyogenes
C) Streptococcus pneumonia No, (sigh)
D) Corynebacterium diphtheria
E) Neisseria gonorrhoea

The answer is (d)

24/9/2008 87

The most common cause of epiglottitis
is_____________________?
A) Neisseria gonorrhoea
B) Epstein-Barr virus
C) Haemophilus influenzae
D) Streptococcus pyogenes
E) Streptococcus pneumoniae
The answer is (c)

24/9/2008 88

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)

24/9/2008 89

‫‪Thank You‬‬

‫تمت بحمد ال‬

Treatment Plan for Allergic
Rhinitis
by Disease Severity
Mild
Antihistamine or antihistamine-decongestant combination (non-
sedating preferred)
OR
Intranasal cromolyn sodium
Moderate
Intranasal corticosteroid*
Antihistamine-decongestant combination
Consider immunotherapy if symptoms persist ≥2-3 mo.
Severe
Intranasal corticosteroid*
Antihistamine-decongestant combination
Consider short course (3-7 days) of oral corticosteroid
Consider immunotherapy

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

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