Upper Respiratory Tract Infections

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Upper Respiratory Tract Infections

• Jerome Fennell
• AMNCH
• Department of Clinical Microbiology
• http//www.tcd.ie/Clinical_Microbiology

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OBJECTIVES

• Understanding of
• Presentation of Upper Respiratory Infections
• Causative organisms
• Pathogenesis
• Diagnosis(clinical, laboratory, other)
• Clinical Management( treatment, preventative
  measures)

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Infection Syndromes

• Common Cold
• Conjunctivitis
• Pharyngitis/Tonsillitis
• Quinsy
• Epiglottitis
• Otitis Media
• Sinusitis

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Anatomy
Sinusitis
Pharyngitis,Epiglottis
Otitis Media
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Anatomy

• Ciliated columnar epithelium in nose, paranasal
  sinuses, nasopharynx
• Stratified squamous epithelium in oropharynx,
  vocal cords, upper posterior epiglottis, mastoid
  antrum of middle ear, cornea and conjunctiva
• Lymph adenoids and tonsils
• Hollow structures with narrow outlets (ostia of
  the sinuses and the Eustachian tubes of the
  middle ears)

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Normal Upper Respiratory Tract Flora

• 1. Streptococcus pneumoniae
• 2. Anaerobic streptococci
• 3. S. milleri
• 4. Haemophilus influenzae
• 5. Haemophilus species
• 6. Diphtheroids
• 7. CNS
• 8 Staphylococcus aureus
• 9. Moraxella catarrhalis and Neisseria spp.
• 10. Prevotella melaninogenicus

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The Common Cold

• Causative agents Coronaviruses, etc
• Epidemiology usually common in the winter months
• Presentation rhinitis, headache, conjunctival
  suffusion
• Management Antimicrobial agents not to be given.
  Symptomatic relief may be accompanied by
  mucopurulent rhinitis (thick,opaque or discolored
  nasal discharge), this is not an indication for
  antimicrobial treatment unless it persists
  without signs of improvement 10-14 days
  suggesting possible sinusitis.

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Conjunctivitis Keratoconjunctivitis

• Protection
• Tears (lysozymes and immunoglobulins)
• Modes of transmission
• fingers, poor hygiene, flies and fomites e.g.
  ophthalmological instruments, contact lens,

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Organism list

• Adenoviruses
• Enteroviruses
• HSV
• Staphylococus aureus
• Moraxella lacunata
• Streptococcus pneumoniae
• Haemophilus influenzae
• Neisseria gonorrhoea and N. meningitidis
• Chlamydia trachomatis
• Pseudomonas aeruginosa
• Acanthomoeba spp
• Naegleria spp

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Clinical features

• C/O sore and itchy eyes, discharge, glue,
  swelling of eyelids
• Clearing around cornea
• If cornea involved Keratitis (need to assess for
  dendritic ulcer HSV or glaucoma- red eye severely
  painful)

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Pharyngitis

• Definition Inflammatory Syndrome of the pharynx
  caused by several microorganisms
• Causes most commonly viral also occur as part of
  common cold or influenza syndrome
• The most common bacterial cause is Group A
  Streptococcus (Streptococcus pyogenes)-5-20
• Review NEJM 344205 2001

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Pharyngitis Presentation
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Pathogen Syndrome/Disease Estimated Importance
Viral Rhinovirus (100 types and 1 subtype) Coronavirus (3 or more types) Adenovirus (types 3, 4, 7, 14, 21) Herpes simplex virus (types 1 and 2) Parainfluenza virus (types 1-4) Influenza virus (types A and B) Cocksackievirus A (types 2, 4-6, 8, 10) Epstein-Barr virus Cytomegalovirus HIV-1 Common cold Common cold Phayrngoconjunctival fever, ARD Gingivitis, stomatitis, Pharyngitis Common cold, croup Influenza Herpangina Infectious mononucleosis Infectious mononucleosis Primary HIV infection 20 ?5 5 4 2 2 lt1 lt1 lt1 lt1
Bacterial Streptococcus pyogenes (group A b-hemolytic streptococci) Group C b-hemolytic streptococci Mixed anaerobic infection Neisseria gonorrhoeae Corynebacterium diphtheriae Corynebacterium ulcerans Arcanobacterium haemolyticum (Corynebacterium haemolyticum) Yersinia enterocolitica Treponema pallidum Chlamydial Chlamydia pneumoniae Mycoplasmal Mycoplasma pneumoniae Mycoplasma hominis (type 1) Unknown Pharyngitis/tonsillitis, scarlet fever Gingivitis, Pharyngitis (Vincents angina) Peritonsillitis/peritonsillar abscess (quinsy) Pharyngitis Diphtheria Pharyngitis, diphtheria Pharyngitis, scarlatiniform rash Pharyngitis, enterocolitis Secondary syphilis Pneumonia/bronchitis/Pharyngitis Pneumonia/bronchitis/Pharyngitis Pharyngitis in volunteers 15-30 5-10 lt1 lt1 lt1 ?1 lt1 lt1 lt1 lt1 Unknown lt1 Unknown
ETIOLOGY
Approximately 15 of all cases of Pharyngitis are
due to S. pyogenes. Strep. Group C and B have
also been implicated in some cases.
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Pharyngitis - Clinical Presentation

• Clinical presentation with sore throat, may be
  dysphagia and pain on swallowing
• fever and additional upper respiratory symptoms
  may also be present
• Tender cervical lymphadenopathy

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Pharyngitis-Clinical Presentation

• Exudative or Diffuse erythema-Group A , C, G
  Streptococcus , EBV, Neisseriae gonococcus
  C.diphtheriae, A.haemolyticum, Mycoplasma
  pneumoniae
• Vesicular, ulcerative- Coxsackie A9, B 1-5, ECHO,
  Enterovirus 71, Herpes simplex 1 and 2
• Membranous- Corynebacterium diphtheriae or
  Vincents Angina (anaerobes/spirochetes)

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Pharyngitis - Diagnosis

• Clinical Presentation
• Determine if Group A Streptococcus is present by
  throat swab onto blood agar
• Antigen Kit may also be used
• Important to determine if present as treatment
  reduces risk of acute rheumatic fever and will
  reduce duration of symptoms

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Pharnygitis - Diagnosis

• ß-Haemolytic colonies of Group A Streptococcus
  from a throat swab

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Quinsy - Clinical Presentation

• Tonsillar Abscess with pain,fever, difficulty
  swallowing

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Quinsy- Diagnosis

• Tonsillar Abscess examination

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Quinsy - Clinical Management

• Drainage of Abscess and antimicrobial therapy

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Retropharyngeal Abscess

• Abscess in tissues behind the pharynx
• With oedema and pus, may get compression and
  airway obstruction
• Potential medical emergency
• X-rays show wide soft tissue space
• Emergency tracheostomy

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Epiglottitis

• Definition Inflammation of the epiglottis due to
  infection
• Epidemiology usually occurs in the winter months
• Causative Bacterial Organisms H.influenzae (now
  rare), S.pyogenes, Pneumococcus, Staphylococcus
  aureus

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Epiglottitis - Clinical Presentation

• In children because of the small airway may
  obstruct breathing additional symptoms of adults
• In adults fever, pain on swallowing, sore throat,
  cough sometimes with purulent secretions

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Epiglottitis - Diagnosis

• Clinical presentation
• Lateral X-ray
• Blood Cultures/Respiratory Secretions for Culture
  (once airway secure)

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Epiglottitis - Clinical Management

• Maintain airway in children may require
  tracheostomy
• (tracheostomy set should be at bedside)
• Cefotaxime IV

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Haemophilus influenzae on Culture
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OTITIS MEDIAAmerican Academy of Pediatrics and
American Academy of Family PhysiciansClinical
Practice GuidelinesPediatrics Vol. 113 No.5 May
2004
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Otitis Media

• Definition for diagnosis requires 3 things
• Confirmation of acute onset
• Signs of Middle Ear Effusion (Pneumatic
  otoscopy) Bulging of TM, limited mobility,
  air-fluid level, otorrhoea
• Evaluation of Signs and Symptoms of Middle Ear
  Inflammation Erythema of TM or Distinct otalgia
  ( interferes with sleep)
• Epidemiology AOM must common cause of
  antibiotic prescribing in paediatric population,
  cost 1.96 billion in U.S, more common in some
  conditions such as cleft palate, Down's syndrome,
  genetic influences, occurs in the winter months
  but may be recurrent

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Otitis Media

• Causative Organisms
• Streptococcus pneumoniae-25-50
• Haemphilus Influenzae-15-30
• Moraxella catarrhalis-3-30
• Rhinovirus/RSV/Coronaviruses/Adenoviruses/Enterovi
  ruses 40-75

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Streptococcus pneumoniae
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Otitis Media Clinical Presentation

• Symptoms Infant excessive crying, pulling ear
• Toddler irritability , earache
• Both may have otorrhoea
• Signs Fever , bulging eardrum, fullness and
  erythema of tympanic membrane
• May also be additional upper respiratory symptoms

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Recommendation 2

• The management of Acute Otitis Media should
  include an assessment of Pain
• and treatment accordingly

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Recommendation 3a

• Observation without use of antimicrobial agents
  in a child with uncomplicated AOM is an option
  for selected children based on diagnostic
  certainty, age, illness severity and assurance of
  follow-up

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Otitis Media Clinical Management

• Analgesia
• Observation if appropriate
• If a decision is made to treat with an
  antibacterial agent amoxicillin should be
  prescribed for most children at a dose of 80-90
  mg/kg/day.

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Recommendation 4

• If there is no clinical improvement in 48-72
  hours
• Reassess and confirm or exclude diagnosis of AOM
• If Observation arm treat
• If Treatment arm Change therapy
• Duration of therapy 10 days if 2 or less or
  severe 10 days , if gt 2 years 5-7 days

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Recurrent Otitis Media
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Sinusitis

• DefinitionAcute Bacterial Sinusitis, subacute
  Bacterial Sinusitis, Recurrent acute, Chronic
  sinusitis , Superimposed
• Epidemiologychildren has 6-8 viral URTI per year
  and 5-13 may be complicated by sinusitis

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Definitions of Sinusitis

• Acute Bacterial Bacterial Infection of the
  paranasal sinuses lasting less than 30days in
  which symptoms resolve completely
• Subacute Bacterial Sinusitis Lasting between 30
  and 90 days in which symptoms resolve completely
• Recurrent acute bacterial sinusitis Each episode
  lasting less than 30 days and separated by
  intervals of at least 10days during which the
  patient is asymptomatic
• Chronic Sinusitis Episode lasting longer than 90
  days Patients have persistent residual
  respiratory symptoms such as cough, rhinnorrhoea
  or nasal obstruction
• Chronic Sinusitis New symptoms resolve but
  underlying residue symptoms do not.

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Sinusitis

• Pathogens
• Streptococcus pneumoniae-30
• Haemphilus Influenzae-20
• Moraxella catarrhalis-20

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Sinusitis

• Diagnosis gt or 10,000 cfu/ml from the cavity
  of paranasal sinus- but this is invasive

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Recommendation 1

• Diagnosis is based on clinical criteria who have
  upper RT symptoms that are persistent or severe
• Acute bacterial
• Persistent symptoms nasal or postnasal D/C ,
  daytime cough(worse at night) or both
• Severe Symptoms Temp(gt39 C) and purulent nasal
  D/C present concurrently for at least 3-4 days in
  a child who seems ill

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Recommendation 2a

• Imaging studies are not necessary to confirm a
  diagnosis of clinical sinusitis in children less
  than 6 year of age

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X-ray of Sinuses

• Opacification and fluid levels

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Recommendation 2b

• CT scans should be preserved for those who may
  require surgery as part of management

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Recommendation

• Antibiotics are recommended for Acute Bacterial
  Sinusitis to achieve a more rapid clinical cure
• Amoxicillin at 45 or 90 mg/kg.day recommended
• Most response in 48-72 hours
• Duration until symptom free plus 7 days

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Recommendation

• Children with complications or suspected should
  be treated promptly and aggressively
• Referral to ENT specialist, Ophthalmologist, ID
  physicians and neurosurgeon
• Complications involve orbit and Central Nervous
  System

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• Thank you