Upper Respiratory Tract Infections

1. Upper Respiratory Tract Infections Mark S. Johnson, Pharm.D., BCPS Associate Professor and Director of Postgraduate Education

2. 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

3. 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

4. Otitis media Rhinitis http://www.fluwikie.com/uploads/Science/resp.jpg

5. Types of Infections • Upper Respiratory Tract Infections • Otitis media • Sinusitis • Epiglottitis • Pharyngitis • Laryngitis (croup) • Rhinitis

6. Upper Respiratory Tract Components Sinuses Middle Ear Epiglottis http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19378.jpg

7. 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

8. Otitis Media Otoscopy and Tympanometry Otoscopy Grade 1 Grade 4 Grade 7 Tympanometry http://www.ems-ceu.com/courses/122/index_ems.html

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Chronic SinusitisTreatment • Antibiotics usually not effective for long-term treatment • Only use with an acute exacerbation • Supportive care • Otolarygology consult

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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