1. / 421 Upper Respiratory Tract Infections Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine Dr. Zekeriya Aktürk zekeriya.akturk@gmail.com www.aile.net Utilized work: Dr. Aynur Engin, Cumhuriyet University, Sivas, Turkey and Dr. Ela Eker, Trakya University, Edirne, Turkey

2. / 422 Acute tonsillitis Acute pharyngitis Acute otitis media Acute sinusitis Common cold Acute laryngitis Otitis externa Mastoiditis Acute apiglottis Upper Respiratory Tract Infections

3. / 423 Objectives At the end of this session, the participants should be able to; –List upper respiratory tract infections –Make differential diagnosis between URTI –Define criteria for antibiotic use –Apply and interpret the McIsaac scoring

4. / 424 Bacteria –S. pyogenes –C. diphteriae –N. gonorrhoeae Viruses –Epstein-Barr virus –Adenovirus –Influenza A, B –Coxsackie A –Parainfluenzae Tonsilitis-pharyngitis

5. / 425 < 3 years –  100 % viral 5-15 years –15-30 % GABHS Adult –10 % GABHS Causative organisms

6. / 426 Spreads by close contact and through air Spread more in crowded areas (KG, school, army..) Most common among 5-15 age group More frequent among lower socio- economic classes Most common during winter and spring Incubation period 2-4 days Due to streptococci:

7. / 427  Sore throat  Anterior cervical LAP  Fever > 38  C  Difficulty in swallowing  Headache, fatigue  Muscle pain  Nausea, vomiting Signs/symptoms  Tonsillar hyperemia / exudates  Soft palate petechia  Absence of coughing  Absence of nose drip  Absence of hoarseness

8. / 428 Having additional rhinitis, hoarseness, conjunctivitis and cough Pharyngitis is accompanied by conjunctivitis in adenovirus infections Oral vesicles, ulcers point to viruses Viral tonsillitis/pharyngitis

9. / 429 GABHS EBV Adenovirus Primary HIV infection Candida albicans Francisella tularensis Exudates

10. / 4210 GABHS Epstein-Barr virus Adenovirus Human herpesvirus type 6 Tularemia HIV infection Lymphadenopathy

11. / 4211 Throat swab –Gold standard Rapid antigen test –If negative need swab ASO –May remain + for 1 year WBC count Peripheral smear Laboratory

12. / 4212 Pathogens looked for –Group A beta hemolytic streptococci –C. diphteriae (rare) –N. gonorrhoeae (rare) If GABHS do we need antibiogram? –Is there resistence to penicilline? Throat Culture

13. / 4213 Supurative complications –Abscess –Sinusitis, otitis, mastoiditis –Cavernous sinus thrombosis –Toxic shock syndrome –Cervical lymphadenitis –Septic arthritis, osteomyelitis –Recurrent tonsillitis/pharyngitis Nonsupurative complications –Acute romatoid fever –Acute glomerulonephritis Tonsillitis due to Streptococci

14. / 4214 Prevention of complications Symptomatic improvement Bacterial eradication Prevention of contamination Reducing unnecessary antibiotic use Aim of Treatment

15. / 4215 Many different antibiotics can eradicate GABHS from pharynx Starting treatment within 9 days is enough to prevent ARF Treatment

16. / 4216 Tetracycline Sulphonamides Co-trimoxasole Cloramphenicole Aminoglycosides Antibiotics NOT to be used

17. / 4217 Control culture after full dose treatment? – NO If history of ARF: –Take control culture after treatment No need to screen or treat carriers GABHS

18. / 4218 Developed by Mc Isaac and friends Decreases antibiotic usage by 48% No increase in throat swabs Mc Isaac Scoring http://www.cmaj.ca/cgi/content/abstract/163/7/811

19. / 4219 Clinical FindingsScore Fever > 38 C1 Absence of coughing1 Tonsillary hypertrophy or exudates 1 (If < 6 years give 0) Sensitivity at the anterior cervical nodes 1 Age 3 – 141 Age > 45 Mc Isaac Scoring

20. / 4220 Total scoreSuggestions 0 - 1 pointsNo culture, no antibiotics 2 - 3 pointsTake culture (or antigen test), order antibiotics only if GABHS + 4 - 5 pointsTake culture (or antigen test), order antibiotics only if GABHS +. If the clinic is severe, start antibiotics without testing Mc Isaac Scoring

21. / 4221 ORAL Penicilline VChildren:2x250 mg or 3x250mg,10 days Adults:3x500 mg or 4x500mg,10 days PARENTERAL Benzathine penicillineAdults:<27kg:600 000 U single dose, IM >27 kg:1.200 000 U single dose, IM ALLERGY TO PENICILLINE Erithromycine estolate20-40 mg/kg/day, 2x1 or 3x1, 10 days Erithromycine ethyl succinate40 mg/kg/day, 2x1 or 3x1, 10 days Antibiotics in Tonsillitis/pharyngitis due to GABHS

22. / 4222 AOM AOM not responding to treatment: Sustained clinical and autoscopy findings despite 48-72 therapy Recurrent atitis media: 3 AOM attacks within 6 moths or 4 attacks within 1 year Acute Otitis Media

23. / 4223 S. pneumoniae30% H. İnfluenzae20% M. Catarrhalis15% S. pyogenes3% S. aureus2% No growth10-30% Chronic otitis media: P. aeruginosa, S. aureus, anaerobic bacteria AOM causes

24. / 4224 85% of children up to 3 years experience at least one, 50% of children up to 3 years experience at least two attacks AOM is usually self-limited. Rarely benefits from antibiotics. 81 % undergo spontaneus resolution. Acute Otitis Media

25. / 4225 Symptoms –Autalgia –Ear draining –Hearing loss –Fever –Fatigue –Irritability –Tinnitus, vertigo Otoscopic findings –Tympanic membrane erythema –Inflammation –Bulging –Effusion Hearing loss Signs and Symptoms

26. / 4226 First choice Amoxicilline40 mg/kg/day, 3 doses Trimet./Sulfamethoxazole8mg TM/40mg SMX/kg 2 dose Second choice Amoxicilline/clavulanate45 mg/kg/day, 2 doses Erythromycin40-50 mg/kg/day, 3 doses Reurrent AOM prophylaxis Sulfisoxazole75 mg/kg/day, single dose 3-6 mo Amoxicilline20 mg/kg/day, sinle dose 3-6 mo Antibiotics

27. / 4227 Acute sinusitis Str. pneumoniae %41 H. influenzae %35 M. catarrhalis %8 Others %16 Strep. pyogenes S. aureus Rhinovirus Parainfluenzae Veilonella, peptokoccus Chronic sinusitis Anaerob bakteria: Bactroides, Fusobacterium S. aureus Strep. pyogenes Str. pneumoniae Gram (-) bakteria Fungi Acute Rhinitis / Sinusitis

28. / 4228 Paranasal sinuses: –Frontal –Ethmoid –Maxillary –Sphenoid Most common during childhood –Maxillary –Ethmoid After age 10 –Frontal Acute Sinusitis

29. / 4229

30. / 4230 Anatomical: septal deviation, Mukociliary functions: cystic fibrosis, immotile cilia synd. Systemic dis., immune deficiency.: DM, AIDS, CRF Allergy: Nasal poliposis, asthma Neoplasia Environmental: smoking, air pollution, trauma... Predisposition to Sinusitis

31. / 4231 Most important: Headache and postnasal dripping Face congestion Fever, fatigue, headache increased by leaning forward Nose obstruction Nose dripping Purulent secretions (rhinoscopy) Sensitivity over the sinuses Halitosis Acute Rhinosinusitis

32. / 4232 Rhinitis Increased symptoms after 5 days Symptoms lasting > 10 days Decreasing viral symptoms, nasal secretion becoming more purulent are indicative for acute rhinosinusitis Acute rhinosinusitis

33. / 4233 Direct x-ray –Diffuse opacification –Mucosal thickening >4 mm –air-fluid level Sinus aspiration –Rarely performed Nasal endoskopy Tomography –More sensitive compared with direct x-ray –Indicated before surgery Diagnosis

34. / 4234 Ampirical –Specific microbiologic diagnosis difficult Primary pathogens –S. pneumoniae –H. influenzae Treatment

35. / 4235 Antibiotics questionable Stalman: 192 patients. No difference between placebo and doxycycline. Van Buchem: 214 patients. No difference between amoxycilline and placebo. Lindbaek: 130 patients. compared Pen V, Amoxycilline and placebo. 86 % of patients receiving antibiotics and 57% of patients receiving placebo improved. Treatment

36. / 4236 Amoxycilline (Alfoxil) 3x500mg/d PO 10 d Amoxycilline/clavulonate (Augmentin) 3x625 mg/d PO 10 d Sefprosil(Serozil) 2x1000 mg/d PO 10 d Sefuroxim (Zinnat) 2x250 mg/d PO 10 d Azithromycine (Zitromax) First day 1x500 mg, then 1x250 mg/d PO 5 d Antibiotics for Sinusitis

37. / 4237 Decongestants –Short duration 3-5 days Antihistamines –If allergy Normal saline Local steroids Support Therapy

38. / 4238 Adults Rhinovirus Children Parainfluenzae and RSV Common Cold

39. / 4239 Fatigue Feeling cold, shuddering Nose burning, obstruction, running Sneezing Fever Common Cold

40. / 4240 Causes epidemics and pandemics Highly contagious Viral infection. Influenza (flu)

41. / 4241 Cause 80 % Influenzae virus Parainfluenza %2-9 Rhinovirus %3 Adenovirus %4

42. / 4242 Sudden onset after 12-24 hours incubation General weakness and fatigue Feeling cold, shivering, temp. Up to 39-40 C No sore throat or running nose Severe back, muscle and joint pain Influenza