Approach to Patient with Upper Respiratory Tract Infection(URTI) Dr Duaa Hiasat

1. Approach to Patient withUpper Respiratory Tract Infection(URTI) Dr Duaa Hiasat 1

2. URTIs :inflammation of the respiratory mucosa from the nasal cavity down to the bronchus. (above the level of the carina). Includes : common colds , influenza , sinusitis , rhinitis , tonsillitis , otitis media , pharyngitis , laryngitis,epiglottitis,Tracheitis and croup. 2

3. Epidemiology: In average , children will have 5 URTIs/ year and adults 2-3/year. 70-80 % of these infections are caused by viruses ; rhinoviruses and adenoviruses are the most common. 3

4. Management principles: *Viral infections need ONLY symptomatic treatment , NO need for antibiotics(Abs). Viral URTIs : • Influenza • Common cold • Mild acute sinusitis • Mild acute otitis media 4

5. *Bacterial infections need ABs for treatment in addition to the symptomatic treatment. Bacterial URTIs : • GABHS pharyngitis • Moderately to severe acute sinusitis • Moderately to severe acute otitis media • Special cases ( pertussis , epiglottitis ) 5

6. *Why not to use Abs for viral infections ? • Promotes Abs resistance. • Adverse reactions such as allergy and anaphylaxis • Patients do not need Abs to feel satisfied • costly 6

7. Why to use Abs for bacterial infections? • To prevent suppurative complications • To prevent rheumatic fever • To speed up recovery • To reduce spread to others 7

8. Common cold 8

9. Common cold is a self-limiting , viral infectious disease of the upper respiratory system. Incidence : most frequent infectious disease in humans ; 2-4 infections / year in adults and 6-12 in children. Transmitted by droplets and close personal contact / airborne. usually occurs in the fall and winter months. 9

10. Causative agents : Rhinovirus (50%) , coronavirus (10-20%), adenovirus (5%) , others :RSV , parainfluenza virus. Bacterial infections are unlikely: Mycobacterium leprae, Klebsiella rhinoscleromatis, Pseudomonas mallei (glanders), Rhinosporidium seeberi (rhinosporidiosis), Leishmania mexicana (leishmaniasis) 10

11. Symptoms: The first symptom is usually a sore or “scratchy throat” , followed soon after by nasal stuffiness and discharge ( rhinorrhea ) , sneezing and coughing. The throat is usually sore for a brief time. The cough symptoms are usually worse on the 4th or 5th day of illness , while the nasal symptoms improve. Symptoms generally last for 7 to 10 days. Cough may continue up to 4 weeks. 11

12. If the nasal discharge becomes viscous and green with time ; it doesn’t mean superimposed bacterial infection . It’s a normal course of common cold. 12

13. Complications: • Acute otitis media (most common in children) • Pharyngitis • Sinusitis • Bronchitis and pneumonia • Conjunctivitis • Adenitis • Aggravation of asthma 13

14. Management: Symptomatic Treatment : comfort is the goal of treatment which may include: *nasal suction for infants *steam/mist inhalation *nasal irrigation *humidified air 14

15. *consume extra fluids (warm fluids may be soothing for irritated throats *consume nutritious diet as tolerated *elevate head of bed *salt water gargle for sore throat . *get adequate rest 15

16. *Vitamin C may reduce duration of common cold in children. *Zinc syrup associated with reduced duration of cold symptoms in children *Honey may reduce nocturnal cough and sleep disruption in children with acute cough, and might be more effective than dextromethorphan or diphenhydramine 16

17. Medication : • Antipyretics: no evidence that fever or antipyretic treatment affects illness course or neurologic complications: • Ibuprofen appears more effective than acetaminophen for reducing fever in single-dose comparisons and ibuprofen and acetaminophen appear to have similar analgesic effects . 17

18. *Combined or alternating acetaminophen and ibuprofen regimens may be more effective than either monotherapy for reducing fever in children. *Ibuprofen approved for use( by FDA) after 6 months of age. *Paracetamol: may be used after 2-3 months of age. 18

19. Nasal Decongestants and Antihistamines: *Nonprescription medicines (antihistamines and antitussives) do not appear effective for acute cough in children ) *FDA recommends against use of nonprescription cough and cold products in children < 2 years old and supports not using them in children < 4 years old. *nonprescription cough and cold preparations may not be safe in children 19

20. *Aspirin is contraindicated in children with viral infections due to association with increased risk for Antibiotics: *Abs do not appear to reduce symptoms of common cold or acute purulent rhinitis. * No role of antibiotics in common cold ( viral infection ). 20

21. Prevention: *Wash hands after contact with common cold patients. *Do not touch any surfaces or objects that may have been contaminated. *Keep fingers out of eyes and nose. 21

22. Influenza: *Influenza is a viral infection that affects mainly the nose , throat , bronchi , and occasionally lungs. *Influenza causes annual epidemics that peak during winter. 22

23. Seasonal influenza *Acute viral infection caused by influenza type A , B and C. *Type A and B are constantly changing due to mutations ( antigenic drift and shift ) , more serious than type C. *Type C is stable , it’s cases occur much less frequently than type A and B. *Currently influenza A (H1N1) and A (H3N2) subtypes are circulating among humans. *Transmitted by droplets and close person contact / airborne. 23

24. Signs and symptoms *Following an incubation period of 1-2 days, flu presents with abrupt onset of fever (39 – 40 c) ,muscle aches , headache and fatigue. The individual may have respiratory symptoms such as a dry cough , sore throat , and occasionally a runny nose. *Other symptoms related to systemic illness include chills and sweats , loss of appetite , diarrhea and vomiting. 24

25. Prognosis: These symptoms generally improve over two to five days, though may last one or more weeks. *Some patients experience postinfluenzal asthenia (persistent weakness or becoming tired easily) which may be present for several weeks following the illness. * A dry cough (post viral cough syndrome) may also persists for several weeks. 25

26. Common cold Vs Influenza: *Influenza is different from the common cold in that it causes a more severe illness , with fever , headache , significant fatigue and muscle aches and systematic manifestations. *It’s less likely to cause sneezing or a blocked nose with thick nasal discharge. 26

27. Complications • Bronchitis • Sinus infections • Ear infections • Pneumonia • Encephalitis 27

28. Highest risk of complications occurs among : • Children < 2 years • Adults 65 years or older • Medical chronic illnesses • Immunocompromised patients 28

29. Treatment: • Bed rest • Antipyretic/Analgesics • Fluid intake 29

30. 4-Antiviral treatment: antiviral treatment recommended as soon as possible (and not delayed while awaiting diagnostic confirmation) for patients with confirmed or suspected influenza who: *have severe, complicated, or progressive illness *require hospitalization *are at higher risk for influenza complications - children < 2 years, -adults ≥ 65 years , -pregnant women , -chronic medical illnesses , -immunocompromised patients

31. 1-oseltamivir adult dosing 75 mg orally twice daily for 5 days weight-based dosing used for oseltamivir in children up to age 12 2-zanamivir 10 mg (2 inhalations) twice daily for 5 days in patients aged ≥ 7 years not recommended in patients with airways disease not approved for children aged < 7 years 3-peramivir dosing 600 mg IV single dose in patients aged ≥ 18 years not approved for children or adolescents. amantadine and rimantadine not recommended due to widespread resistance.

32. Prevention: • Frequent hand washing. • Wear masks and gloves. • Isolation of patient until 24 hours of afebrile period. • Vaccination ; most effective measure of prevention . 32

33. Influenza vaccine Annual vaccine • Two types : • Injectable : killed vaccine • Nasal spray : live but weakened virus • 70% protection in 1 year. • Reduces severe complications by 60% , and death by 80%. 33

34. Recommended for : • *all persons ≥ 50 years old • *Infants and children aged from 6 months to 4 years. • *women who are or will be pregnant during the influenza season. adults who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus) 34

35. *household contacts and caregivers of children < 5 years old. *Immunocompromised patients and immunosuppressive treatment. *Health care professionals. *residents of nursing homes and other long-term care facilities. *persons who are morbidly obese (body mass index ≥ 40 kg/m2

36. Pharyngitis/Tonsillitis 36

37. Pharyngitis/Tonsillitis: • It is an inflammation of the pharynx, w/o tonsilles.most commonly caused by viral or bacterial infection. • Causative agents : • Viral : adenovirus (80% most common ) , enterovirus , EBV , herpes simplex virus. • Bacterial : GABHS (5-15%), mycoplasma. • GAS uncommon in children younger than 2-3 years, and the peak is between 5-11 years. • Peak Winter to early Spring. • Spread by direct contact. 37

38. Clinical presentation: *The main symptom is a sore throat. *Other symptoms may include: - Fever - Headache - Joint pain and muscle aches - Skin rashes - Swollen lymph nodes in the neck 38

39. Bacterial Vs. Viral *Viral Infection: -Clinically: Gradual, more likely to have rhinorrhea, cough, diarrhea, hoarseness of voice. • Adenovirus: conjunctivitis, most common cause in children < 3 years of age. • - Coxsackieviruses: ulcer on posterior pharynx, herpangina (mouth blisters). • - EBV: prominent tonsils with white exudates, posterior cervical LN enlargement, Palatal rash, Hepatosplenomegaly, high fever and fatigue. 39

40. Bacterial Infection: *Clinically: Rapid onset fever, prominent throat pain, headache, abdominal pain, vomiting, dysphagia and malaise. *On exam: Pharynx are erythematous, tonsils enlarged with yellow-blood tinged exudate, petichia may be present on soft palate, anterior cervical lymph nodes enlarged and tender. 40

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42. Age-modified Centor score (McIsaac score): 1 point for each of tonsillar exudate swollen tender anterior cervical nodes absence of cough history of fever or measured temperature > 38 degrees C (100.4 degrees F) age modification 1 point if age < 15 years -1 point if age > 45 years

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44. Why we treat GAS pharyngitis *decrease risk of Rheumatic fever, but not of PSGN. *shorten duration of illness. *decrease risk of complication (mainly abscess). 44

45. 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. Throat Culture • 20-40% of those with negative throat culture will be labeled as having GABHS. • +ve culture makes the Dx of GABHS, but –ve culture does not rule out. 45

46. Differential diagnosis - • Infectious mononucleosis, when a membranous exudate is present. • - Diphtheria, especially in the underimmunized. • - Herpangina, with many vesiculoulcerative lesions in the anterior pillars & soft palate. • - Agranulocytosis, yellowish dirty white exudates covering the tonsils & post pharyngeal wall. • - Kawasaki disease. 46

47. Complication of GAS pharyngitis:1- otitis media • 2- Glomerulonephritis and Rheumatic Fever may follow streptococcal infection. • 3- Monoarthritis. • 4- Mesenteric adenitis (viral or bacterial) abdominal pain with or without vomiting. • 5- In debilitated children, large chronic ulcers in the pharynx (viral or bacterial). 47

48. Rheumatic Fever Major Criteria: - Polyarithritis - Carditis - Sydenham Chorea - Subcutaneous nodules - Erythema Marginatum Minor Criteria: • Fever of 38.2–38.9 °C (101–102 °F) • Arthralgia: Joint pain without swelling (Cannot be included if polyarthritis is present as a major symptom) • Raised ESR or CRP • Leukocytosis • ECG showing features of heart block, such as a prolonged PR interval (Cannot be included if carditis is present as a major symptom) • Previous episode of rheumatic fever or inactive heart disease 48

49. According to revised Jones criteria, the diagnosis of rheumatic fever can be made when: 2 major criteria, or 1 major criterion plus 2 minor criteria, are present along with evidence of streptococcal infection: (elevated or rising ASO titre or DNAase). Exceptions are chorea and indolent carditis, each of which by itself can indicate rheumatic fever.

50. Supportive Measures *Encourage fluid intake *Acetaminophen or NSAID may reduce pain. *Benzydamine oral rinse or mouth spray may reduce pain and improve symptoms. *Other supportive measures without direct evidence include topical analgesics (such as nonprescription throat sprays) and anesthetics (such as viscous lidocaine 2%) warm salt water gargles throat lozenges, hard candy, or frozen desserts soft foods or cold thick liquids such as ice cream Humidifier.