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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.
