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Upper Respiratory Tract Infections
Mark S. Johnson, Pharm.D., BCPS Associate Professor and Director of Postgraduate Education
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RespiratoryTract
• Two sections– Upper Respiratory Tract (URT)
• Most have viral etiology;• Self-limiting and resolve
on own
– Lower Respiratory Tract (LRT)
http://dsa.csupomona.edu/shs/twc/images/respiratory_full.jpg
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Respiratory Tract Infections
• Major cause of morbidity from acute illness in U.S. – Most common reason patients seek medical care– Accounts for majority of prescribed antibiotics
• Most common cause for LRTI– Follow colonization of upper respiratory tract– Gain access by aspiration of oropharyngeal
secretions • Usually during sleep
• Other sources for LRTI infection– Extrapulmonary source through blood– Inhaled aersolized, infected particles
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http://www.fluwikie.com/uploads/Science/resp.jpg
Otitis media Rhinitis
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Types of Infections
• Upper Respiratory Tract Infections– Otitis media– Sinusitis– Epiglottitis– Pharyngitis– Laryngitis (croup)– Rhinitis
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Upper Respiratory Tract Components
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19378.jpg
Epiglottis
Middle Ear
Sinuses
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Otitis Media
• Inflammation of the middle ear– Follows cold symptoms – Common occurrence: infants and children (esp. < 3 yr)
• Otitis media with effusion– Acute infection is not present
• Signs and symptoms– Otalgia (sometimes severe)*– Fever– Irritability, lethargy, anorexia, vomiting – Hearing loss
• Presence of fluid in the middle ear– Tympanic membrane: discolored, bulging, thickened, and
immobile
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Otitis Media Otoscopy and Tympanometry
Grade 1
Grade 4
Grade 7
Tympanometry
Otoscopy
http://www.ems-ceu.com/courses/122/index_ems.html
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Otitis MediaRisk factors
• Race– Aboriginal or Inuit Origin
• Age– Early age of 1st diagnosis
(esp. < 6 mo)• Family
– Siblings at home• Genetic predisposition
– Malformations• Gender
• Environmental– Second-had smoke– Urban population– Lower socioeconomic status– Daycare attendance – Use of a pacifier– Winter season– Virus outbreak
• Immunodeficiency– Allergy– Nasopharyngeal
colonization with middle ear pathogens
– Prior antibiotic exposure– Lack of breastfeeding
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Otitis MediaEtiology, Diagnosis, Resolution
• Pathogenic Causes– Bacteria (most common): S. pneumoniae
• Common: H. influenzae, M. catarrhalis• Less frequent: S. aureus, S. pyogenes, P. aeruginosa
– Viruses• Lab Tests that can be used
– Gram stain, culture and sensitivities of draining or aspirated fluid• Duration without treatment
– Resolution in one week (pain and fever in 2-3 days)
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Otitis MediaTreatment
• Goals– Reduce and control of symptoms (esp. pain)– Eradicate infection– Prevent complications (mastoiditis, bacteremia,
meningitis, auditory problems)– Minimize adverse drug reactions (ADRs)– Avoid unnecessary antibiotic use
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Otitis MediaTreatment• Drug of choice (DOC): Amoxicillin (high dose, HD)*
– Dose: 80-90 mg/kg/day– PCN allergy (non Type I): Beta-lactamase stable cephalosporin
(cefuroxime, cefdinir, cefpodoxime)• Anaphylaxis (Type I): Macrolides (azithro-, clarithomycin)
• Second-line (if failure on amox 48-72 hours after initiated)– DOC: HD amoxicillin-clavulanate
• Dose: Amox 80-90 mg/kg/d + clavulanate 6.4 mg/kg/d in 2 divided doses
– Others include beta lactamase stable cephaloporins as noted above
– Ceftriaxone*50mg/kg/d IM/IV for 3 days– Clindamycin 30-40mg/kg/day if resistant Stept pneumo is
documented
• Duration of therapy: 10 days– Shorter course: 5-7 days (age > 6 yrs generally)
*Achieve concentrations above MIC > 40% of dosing interval in middle ear fluids
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Otitis MediaTreatment
• Adjunct therapy– Analgesics and antipyretics
• Other – Tympanostomy tube (T-tube) placement– Adenoidectomy– Tympanocentesis
• Propylaxis– Antibiotics: Controversial
• Consider if 3 infections (6 mo) or 4 infections (12 mo)– Vaccines: Influenza and Pneumococcal
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Sinusitis• Inflammation of sinus mucosa
– Types: Acute or chronic– Children (common); adults (less frequent)
• Signs and symptoms – Acute
• Adult– Mucopurulent nasal discharge, congestion– Maxillary tooth, sinus, or facial pain (unilateral)
» Morning preorbital swelling– Halitosis
• Children– Cough, nasal discharge (> 10-14 days)– Fever (> 39C), facial swelling, pain
• Resolution without treatment– Acute: duration of 4 weeks; Chronic: duration of 12
weeks
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Acute SinusitisEtiology and Diagnosis
• Pathogens– Primary: Viruses– Bacteria (most common): S. pneumoniae
• Common: Haemophilus influenzae, Moroxella catarrhalis • Less frequently: S. pyogenes, S. aureus, anaerobes
– Fungi• Other: Allergens• Diagnosis
– Determination of causative organism• Viral: 7-10 days; Bacterial: >7-14 days
– Transillumination of maxillary sinuses– X-ray, CT/MRI of sinuses– Sinus puncture, aspiration, and culture
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Acute Sinusitis Treatment
• Goals– Reduce and improve symptoms– Improve and restore sinus function– Resolve bacterial infection– Minimize illness duration– Prevent complications– Prevent disease progression– Limit unnecessary antibiotics use
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Acute SinusitisTreatment
• Mild disease– Nasal or oral decongestants – Expectorant – Saline and steam inhalation– Possibly intranasal steroids– Not antihistamines (unless possibly chronic sinusitis)
• Moderate to severe disease (> 7 days)– Antimicrobial therapy
• Referral to specialist– No response to 1st and 2nd line therapy– Recurrent and chronic disease– At risk for complications
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Acute SinusitisTreatment
• DOC: Amoxicillin (500mg TID PO)– PCN allergy: beta-lactamase stable cephalosporin
• Anaphylaxis: Macrolides or resp quinolone or doxycycline or TMP-SMX
• High suspicion of drug-resistance (S. pnemo): HD amoxicillin (1gm TID PO) or Clindamycin
• Alternative: resp quinolone• Treatment failure or recent prior antibiotic therapy in past 4-6 weeks
– HD Amoxicillin-clavulanate (2gm/125mg BID PO) or beta-lactamase stable cephalosporin
» Alternates: Resp quinolone• Duration of therapy: 10-14 days
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Chronic SinusitisClinical Presentation and Etiology
• Signs and Symptoms– Similar to acute sinusitis – Inflammation lasting > 3 months– Rhinorrhea, headache– Chronic unproductive cough– Laryngitis– Recurrent or chronic infections (3-4 x’s per year)
• Unresponsive to decongestants or steam • Pathogens
– Bacteria• Common anaerobes: Prevotella, anerobic strep, fusobacterium• Aerobes: Strep, sp., Haemophilus, P. aeruginosa, S. aureus, M.
catarrhalis– Fungi
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Chronic SinusitisTreatment
• Antibiotics usually not effective for long-term treatment– Only use with an acute exacerbation
• Supportive care• Otolarygology consult
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Epiglottitis
• Inflammation of the epiglottis– Present commonly: ages 2-6
• Airway emergency– Rapid onset– No culture: Acute obstruction
• Signs and symptoms– Stridor– Fever– 4 D’s: respiratory distress, drooling, dysphagia,
dysphonia• Diagnosis
– Neck X-ray or CT/MRI
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Epiglotitis Etiology and Treatment
• Pathogenic Causes– Bacteria: Haemophilus influenzae type B (HIB) – Other: S. pneumoniae, S. aureus, Group A strep (adult) (S.
pyogenes)• Treatment
– Maintain airway– DOC: 2nd or 3rd generation cephalosporin (e.g., cefotaxime or
ceftriaxone)• Alternate: Ampicillin-sulbactam or TMP-SMX
– Other: Ertapenem, imipenem; respiratory quinolones (moxi- or levofloxacin); cefprozil
– Corticosteroids– Other: Tracheostomy
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Pharyngitis
• Acute inflammation of the naso- or oropharynx– All ages susceptible– Highest risk
• Children (ages 5-15), Individuals who work with children, Parents of children
• Signs and symptoms– Sudden onset of sore throat, fever, dysphagia– Headache, N/V, abdominal pain (children)– Tender, enlarged lymph nodes– Inflammation and erythema of uvula, pharynx and tonsils,
possibly with exudates– Rash, petechiae
• Resolution without treatment– 3-7 days; Few weeks: lymph nodes and tonsils
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PharyngitisEtiology
• Pathogens– Primary: Viruses – Bacterial: group A beta-hemolytic Streptococcus (S. pyogenes),
others– Fungal: Candida albicans
• Other causes: Allergens
• Diagnosis– Rapid antigen detection testing (RADT)
• Results in 10 min – 1 hour• Positive test = antibiotic therapy
– Traditional throat swab and culture if negative RADT in children, adolescents, parents, schoolteachers—24-48h for results
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PharyngitisTreatment
• Goals– Improve symptoms– Minimize adverse drug reactions– Prevent transmission– Prevent complications
• Cervical lymphadenitis• Mastoiditis• Peritonsillar abcess
• Additional Complications– Acute rheumatic fever or reactive arthritis– Acute glumerulonephritis– Otitis media, sinusitis– Necrotizing fascitis
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PharyngitisTreatment
• DOC: Penicillin VK (250mg TID or QID PO or 500mg BID PO)– Children: PCN VK (50mg/kg/d TID PO) or Amoxicillin (has better
taste) 40-50mg/kg/d PO– NPO: Benzathine G PCN 1.2MU IM– PCN allergy: 1st gen cephalosporin (cephalexin 250mg-500mg QID
PO)• Anaphylaxis: macrolide (erythro-, azithro-, clarithromycin)
• Drug-resistance or failure – 2nd or 3rd gen oral cephalosporin with B-lactamase stability
• 2nd gen: Cefuroxime, cefprozil• 3rd gen: Cefpodoxime, cefdinir
• Documented macrolide resistance: clindamycin• Recurrent episodes
– Amox-clav or clindamycin• Duration of therapy: 10 days
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Laryngitis (Croup)
• Inflammation of the larynx– Common presence: age < 3
• Causes – Three types
• Viral – parainfluenza virus, RSV• Spasmodic• Bacterial: S. aureus, Group A Strep (beta-hemolytic), HIB
• Signs and symptoms– Hoarseness– Stridor, barking cough
• Treatment– Antibiotics not indicated, unless bacterial etiology– Corticosteroids– Racemic epinephrine– Humidified oxygen