Upper Respiratory Tract Infections and Influenza

Upper Respiratory Tract Infections and Influenza

Upper Respiratory Tract Infections

• Common cold • Pharyngitis • Acute laryngitis • Acute

laryngothracheobronchitis

• Otitis externa• Otitis media• Mastoiditis• Acute sinusitis

Common cold

• Generally mild, self-limiting • Many viruses can cause similar clinical

picture• 2-4 times/year in adults 6-8 years in children.• September to August• Transmitted with respiratory secretions.

Common Cold: etiology

Virus Antigenic type %• Rhinovirus 101 30-40• Coronavirus >3 >10• Parainfluenza virus 4 10• RSV 2 10• Influenza virus 3 10-15• Adenovirus 47 5• Undefined viruses 25-30• Group A beta-hemolytic strep. 5-10

Common Cold

• Clinical: nasal congestion, sneezing, sore throat, decreased taste

• Complications: acute sinusitis and acute otitis media

Common Cold: Treatment

• NO ANTIBIOTICS.• Drops and sprays with 0.25-0.5% phenilephin

or 1% ephedrine • Antitussives, antipyretics • Bed rest • High dose vitamin C?

Acute Pharyngitis

• Majority (40%) due to viruses• Group A beta-hemolytic streptococcus 15-30%

• May associate:– Common cold– Influenza– Herpetic – Infectious mononucleosis– Vincent’s angina– Peritonsillar abscess– Dyphteria

Acute Pharyngitis

• The majority (75%) are given antibiotics – To prevent rheumatic fever – Patient’s expectations!

Acute Pharyngitis: diagnosis

• Yielding GABHS in throat swab culture is diagnostic in 90-95%

• Acute infection-carrier?• Clinical features and rapid antigen

tests are helpful

Acute pharyngitid: Dx

• Clinical features:– Tonsillary exudate– Painfull anterior cervical lymphadenopathy– Absence of cough – Fever *any 3, sensitivity and specificity around 75%

CDC Position Paper, 2001

Acute Pharyngitis: Throat culture

Exam.: GABHS

Exam.: EBV

EBV

Acute Pharyngitis: Tx

• In GABHS, it decreases complications, decreases the course of the disease by 1-2 days

Acute pharyngitis: Tx

1. Look for 4 criteria: a. feverb. tonsillary exudate, c. No coughd. Painful anterior cervical LAP.

2. 0-1 criterion: no lab study, no antibiotics tx.

CDC Position Paper, 2001.

Acute Pharyngitis: Tx

3. If >2 criteria: you may, a. For those with 2,3, or 4 criteria, study rapid

antigen test, and if positive give antibiotics b. For those with 2 or 3, study rapid antigen test,

and if positive or with 4 criteria c. No further test is needed, for those with For

those 3, or 4 criteria give antibioticsCDC Clinical Practice Guideline, 2001.

Acute Pharyngitis

• First choice– Benzathin penicillin: 1.2 MU, IM, single dose – Penicillin V: 500 mg, 2-3 times in a day, for 10 days

• Penicillin allergy – Erythromycine

Acute Rhinosinusitis

• Frequently antibiotics are given (85-98%).• Almost always follows an upper RTI

(inflammation in mucosa and obstruction of ostia of sinuses)

• Acute sinusitis lasts <4 weeks

Mucus secretionNormal

Mucus contentNormal

Viscosity and content of secretionsNormal

Mucus absorbtion Normal

Mucociliary activity Normal

Systemic Host Defense Normal

OSTIUM OPEN

Acute sinusitis: Etiology

• S. pneumoniae %31• H. influenzae %20• Anaerobs %6• S. aureus %4• S. pyogenes %2• M. catarrhalis %2• Gram-negative bacteria %5• Viruses %30

Viral-Bacterial Rhinosinusitis

• Diagnosis: Sinus sampling • Clinical clues for bacterial sinusitis:

– Purulant nasal discharge, unilateral maxillary or fascial pain

– Unilateral sinus tenderness– Deterioration of symptoms after initial

improvement

Plain x-ray

• Full opacity or air-fluid level specificity 85% (76-91%)

• Mucosal thickening specificity 40-50%.

Treatment

1. If not complicated, no need for X-ray. Consider clinical clues

2. If symptoms are mild to moderate, antibiotics are not given

3. Severe or persisting moderate symptoms are treated with antibiotics

CDC Clinical Practice Guideline, 2001.

Tx

• Amoxicillin 500 mg x 3 (10-14

days)

• Amox/clav. 500/125 mg X 3 (10-

14 days)

• Amp/sul. 375-750 mg x 2 (10-14

day)

• Cefuroxim axetil 250 mg X 2 (10-

14 day)

• Clarithromycine 500mg X 2 (10-

14 days)• Azithromycine 500 mg (5 days)• Levofloxacin 500mg (10-14 days

Acute Otitis Media

• <15 y, a frequent cause of admission to doctor

• <3 y, most frequent– 2/3 children >1, 1/3

children >3 times• Hearing loss,

cholesteatoma, chronic perforation

Acute Otitis Media: Etiology

40

25

3

10

32 S. pneumoniae

H. influenzae

GABHS

Moraxella

Unknown

Acute Otitis MediaClinical features and diagnosis

• Ear pain, discharge, hearing loss.• Fever, irritability • Erythema on tympanic membrane • Fluid accumulation in middle ear• Tympanic f. sampling in selected cases

– Severe disease– Unresponse to antibiotics within 48-72 h. – Immunsuppressives

Acute Otitis Media: Tx

• Amoxicillin• Beta-laktamase inhibitors

– SAM, CAM

• 2nd gen. Cephalosporins – Cefuroxim, cefaclor, cefprozil, loracarbef

• Macrolides– Clarithromycine, azithromycine

• Antihistamines

Influenza

1918 , Oakland

1918, Iowa

Ryan JR. Pandemic influenza

İnfluenza Nedir?

• A highly contagious respiratory infection caused by Influenza A and B

• Symptoms:– High fever, cough, myalgias, fatigue, headache, sore throat

and nasal congestion

• May last 1-2 week• Affects individuals, families, populations, and

economy of the countries• May cause significant mortality in vulnerable patients

Influenza

Nicholson et al. Lancet 2003; 362: 1733–45.

• Incubation period 1-2 days• A sudden beginning • May cause a mild hyperemia in throat.

UpToDate 2009

• Improvement: 2-5 days (>1 week in some)• In some, fatigue, tiredness may last for weeks

Differential Dx

• Common cold

Influenza & Common Cold

Common ColdSymptom

Mild-to-moderateGeneral, may be severe Chest discomfort

Very rarely Cough without sputumCough

Usual Sometimes Sneezing

CommonSometimes Nasal congestion/ sore throat

Never Early and severe Severe tiredness

Moderate Fatigue, tiredness

Mild Usually, generally severeGeneralized pain

Unusual YesHeadache

unusualFever Generally high, 3-4 days

May last 2-3 weeks

Influenza

National Institute of Allergy and Infectious Diseases

Common cold etiology

• 6 virus family– Orthomyxoviridae (Influenza virus)– Paramyxoviridae (Parainfluenza, RSV)– Picornaviridae (Rhinovirus-89 tip,

Coxsackievirus, Echovirus, Poliovirus)– Coronaviridae (Coronavirus)– Adenoviridae (Adenovirus)– Herpetoviridae (HSV, EBV)

Complications

• Pneumonia: most frequent • Generally seen in those with underlying disorders

– Cardiovascular – Pulmonary – Renal dis.– DM– Immunosuppressives – Those in long term care – >50 y.

Pneumonia

• Primary (influenza pneumonia)– A gradual increase in signs and symptoms (high

fever, dispnea, cyanosis)

• Secondary (bacterial)– Deterioration after a temporary improvement– ¼ of death due to influenza– Pnomococci, staph.

22 ,F, SLE 76, F, Cerebrovascular disease

Myositis, rhabdomyolysis

• Myalgias are frequent • True myositis is rare • Tenderness and edema

• CNS complications: encephalitis, transverse myelitis, aseptic meningitis, Guillain-Barré syndrome…

• Myocarditis, pericarditis

İnfluenza Çok Bulaşıcıdır

transmission Cough, sneezing Hand contact, utensils, Influenza period

December to April Every season in tropics

Diagnosis

• During Outbreak • Without outbreak

During outbreak

• Clinical findingsfever, cough, fatigueNo sneezing

In a study of 3744 adults, Considering fever and cough within 48 hours,

80% Arch Intern Med 2000;160:3243

Without Outbreak

• Clinical findings are not diagnostic!

In a study of 497 elderly patients with upper resp. tract infection:

43% yielded the etiologyrhinovirus (52%), coronavirus (26%),Influenza A and B (10%)

BMJ 1997;315:1060

Without Outbreak

• Serology• Rapid tests (IF, ELISA, PCR)• Virus culture

• Research, epidemiology…

Influenza

RNA

M2 protein (type A )

Neuraminidase

Hemaglutinin

Hemaglutinin binds to sialic acid

Antigenic shift

Tx?

• Paracethamol• Non-steroids• (No aspirin-Reye’s syndrome)• Antitussives• Specific antivirals

– Adamantans (amantadin, rimantadin-resistance)– Neuraminidase inh. (oseltamivir, zanamivir)

Specific Antivirals

• Effective against Influenza A and B• Decreases hospital stay• Decreases severity and complication rate• Decreases mortality

Arch Intern Med 2003;163:1667

Antivir Ther 2007;12:501Clin Infect Dis 2007;45:1568

J Am Geriatr Soc 2002;50:608

Indications • Influenza pneumonia• Influenza pneumonia with bacterial penumonia• Those with high risk to complications

– Those living in care centers– Pulmonary dis. – Cardiovascular dis.– Cancer– Chronic renal failure– DM– Immunosuppressed– Neurologic dis. MMWR Recomm Reb 2008;57:1

• Within 48 h: more effective• 3rd trimester pregnancy • 2nd timester (plus risk factors)

Obstet Gynecol 2006;107:1315

Control

• Mask• HAND WASHING

2009H1N1-Swine flu• 2 swine -1 bird-1 human • Can be transmitted from human-to-human• Symptoms

– fever– Cough– Sore throat– Nasal congestion/rhinitis– Headache – Chills – Myalgias – Nausea/vomiting

• Contamination – 1 day before overt disease and following 5/7 days

• Tx– Like seasonal flu.