PRESENTATION OF PHARM D 3RD YEAR

UPPER RESPIRATORY TRACT INFECTIONS

PRESENTATION BY : AFNAN
• The respiratory tract is divided into upper and lower parts.
• The upper respiratory tract consists of the sinuses, middle ear, pharynx, epiglottis.
• URTIs with coryzal symptoms, rhinitis, pharyngitis and laryngitis, associated with varying
degrees of systemic upset, are extremely common; adults average 2–4 infections per year
and children, 6–8.
• These infections are usually caused by viruses.
• Rhinoviruses cause up to 50% of colds and up to 70% in the autumn.
• Most viral URTIs are mild and self-limiting.
• However, new respiratory viruses continue to be identified, some of which produce more
serious illness, for example, Middle East respiratory syndrome (MERS) coronavirus, first
described in 2012, which can cause a spectrum of disease from asymptomatic infection to
respiratory failure.
• In general, the management of URTIs is symptomatic and consists of rest, adequate
hydration, simple analgesics and antipyretics.
• Apart from one or two exceptional situations, antiviral drugs are not indicated and in most
cases are not effective.
• Antibacterial drugs have no activity against viral infections.
Influenza
• True influenza is caused by one of the influenza viruses (influenza A, B or, rarely, C).
Influenza commonly causes a syndrome of fever (greater than 38 °C), myalgia, headache,
sore throat and cough. It is usually self-limiting in healthy adults but can cause a severe
pneumonitis and can be complicated by secondary bacterial infection.
• 30–50% of infections in this group are asymptomatic, but this may vary with strain.
• Vaccination with an inactivated quadrivalent vaccine is used in patients at higher risk of
severe disease and healthcare workers.
• Oseltamivir is the first-line agent in most situations, but zanamivir is preferred where
oseltamivir resistance is suspected or for severely immunocompromised patients when
H1N1 is the predominant strain of influenza A.
PHARYNGITIS
Definition: Pharyngitis is an acute infection of the oropharynx or nasopharynx and commonly
referred as sore throat.

Etiology and Causative organism :

• Many cases are not due to infection at all but are caused by other factors, such as smoking.
Where infection is the cause, most cases are viral and form part of the cold-and-flu
spectrum.
• Group A β-hemolytic Streptococcus, or Streptococcus pyogenes, is the primary bacterial
cause. Other include Arcanobacterium haemolyticum.
• Viruses (such as rhinovirus, coronavirus, and adenovirus) cause most of the cases of acute
pharyngitis.
• A bacterial etiology for acute pharyngitis is far less likely. Of all of the bacterial causes,
Group A Streptococcus is the most common (15% to 30% of persons of all ages with
pharyngitis), and it is the only commonly occurring form of acute pharyngitis for which
antimicrobial therapy is indicated.
Clinical presentation and diagnosis:
General
 A sore throat of sudden onset that is mostly self-limited.
 Fever and constitutional symptoms resolving in about 3–5 days.
 Clinical signs and symptoms are similar for viral causes as well as nonstreptococcal bacterial
causes.
Signs and symptoms
 Sore throat.
 Pain on swallowing.
 Fever.
 Headache, nausea, vomiting, and abdominal pain (especially children).
 Erythema/inflammation of the tonsils and pharynx with or without patchy exudates.
 Enlarged, tender lymph nodes.
 Red swollen uvula, petechiae on the soft palate, and a scarlatiniform rash.
Laboratory tests
 Throat swab and culture or rapid antigen detection testing.
 Microbiological diagnosis of the cause of pharyngitis is not usually required in a primary care
setting.
 If a specific bacterial diagnosis is needed, a swab is sent for microbiological culture.
 Group A β-haemolytic streptococci are usually the organism sought, but if there is a history
of treatment failure or recurrent infection, the plates are incubated for 48 hours to look for
Arcanobacterium haemolyticum.
 Rapid antigen tests (RATs) for the detection of group A streptococcal antigens.

TREATMENT:
NON-PHARMACOLOGICAL THERAPY
supportive care including rest, fluids, lozenges, and saltwater gargles.

PHARMACOTHERAPY
 Most people will recover from sore throat after 7 days.
 Analgesics such as paracetamol and ibuprofen are useful for reducing pain and fever.
 Under current guidance, most patients should not be prescribed an antibiotic.
 Delayed antibiotic prescriptions may be useful.
 Antimicrobial treatment should be limited to those who have clinical and epidemiologic
features of Group A streptococcal pharyngitis with a positive laboratory test.
 Penicillin is the drug of choice in the treatment of Group A streptococcal pharyngitis should
be given for 10 day.
 In patients allergic to penicillin, a macrolide such as erythromycin or a first-generation
cephalosporin such as cephalexin (if the reaction is non immunoglobulin E–mediated
hypersensitivity) can be used for 10 days.
 Newer macrolides such as azithromycin and clarithromycin are as effective as erythromycin
and cause fewer GI adverse effects.
 If patients are unable to take oral medications, intramuscular benzathine penicillin(One
dose) can be given although it is painful.
 Example: Penicillin VK 250 mg three to four times daily or 500 mg twice daily –adult dose
and 50 mg/kg/day divided in three doses as children dose for 10 days.
 Amoxicillin 500 mg three times daily adult and 40–50 mg/kg/day divided in three doses for
children for 10 days .
 Erythromycin Estolate 20–40 mg/kg/day divided two to four times daily (maximum: 1
g/day) for 10 days.
 Cephalexin 250–500 mg orally four times daily 25–50 mg/kg/day divided in four doses 10
days .
 Amoxicillin clavulanate 500 mg twice daily adult and children 40 mg/kg/day in three div
doses and others can be given for 10 days for recurrent pharyngitis.
ACUTE EPIGLOTTITIS
Definition:Acute epiglottitis is a rapidly progressive cellulitis of the epiglottis and adjacent
structure.

Causative organism: Haemophilus influenzae type b (Hib), with the rest being caused by
other organisms such as pneumococci, streptococci and staphylococci.

Clinical presentation and diagnosis:

 The typical patient is a child between 2 and 4 years old with fever and difficulty speaking
and breathing.
 The patient may drool because of impaired swallowing. Local swelling has the potential
to cause rapid-onset airway obstruction, so the condition is a medical emergency.
 The diagnosis is made clinically, and initial management is concentrated on establishing
or maintaining an airway.
 Thereafter, the diagnosis may be confirmed by visualization of the epiglottis, typically
described as ‘cherry red’.
 Microbiological confirmation may be obtained by culturing the epiglottis and the blood,
but not until the airway is secure.
TREATMENT:
PHARMACOTHERAPY
 If a sensitive organism is recovered, high-dose parenteral amoxicillin.
 In amoxicillin resistance among encapsulated H. inluenzae, the treatment of choice is a
cephalosporin. A third-generation cephalosporin such as cefotaxime or ceftriaxone, but
most infections should respond to a second-generation agent such as cefuroxime.

OTITIS MEDIA
Definition : Otitis media is an inflammation of the middle ear.

Etiology and pathophysiology:

• Acute bacterial otitis media usually follows a viral upper respiratory tract infection that
causes eustachian tube dysfunction and mucosal swelling in the middle ear.
• Streptococcus pneumoniae is the most common cause of acute otitis media (20% to 35%).
Nontypable strains of Haemophilus influenzae and Moraxella catarrhalis are each
responsible for 20% to 30% and 20% of cases, respectively.
• In 44% of cases, a viral etiology is found with or without concomitant bacteria.
Clinical presentation and diagnosis:
General and signs and symptoms:
 Otalgia, irritability, and tugging on the ear, accompanied by signs such as a gray, bulging,
nonmotile tympanic membrane. These often follow cold symptoms of runny nose, nasal
congestion, or cough.
 Fever is present in less than 25% of patients and, when present, is more often in younger
children.
 Draining middle ear fluid occurs (<3% of patients) that usually reveals a bacterial etiology.
Laboratory tests
 Gram stain, culture, and sensitivities of draining fluid or aspirated fluid if tympanocentesis
is performed.

TREATMENT:
Antimicrobial therapy is used to treat otitis media; however, a high percentage of children
will be cured with symptomatic treatment alone. Antibiotic use reduces the duration of
symptoms by about 1 day.
 PHARMACOTHERAPY
 Acetaminophen or a nonsteroidal anti inflammatory agent, such as ibuprofen, can be
use to relieve pain and malaise in acute otitis media.
 Amoxicillin is the drug of choice for acute otitis media. High-dose amoxicillin (80 to 90
mg/kg/day) is recommended.
 If treatment failure occurs with amoxicillin, an agent should be chosen with activity
against β-lactamase–producing H. influenzae and M. catarrhalis as well as drug-resistant
S. pneumoniae (such as high-dose amoxicillin-clavulanate (recommended), or,
cefuroxime, cefdinir, cefpodoxime, cefprozil, or intramuscular ceftriaxone).
 Five to 7 days of therapy may be used in children at least 6 years old who have mild to
moderate acute otitis media.
 Penicillin Allergy Non–type I: ,Cefdinir 14 mg/kg/day once or twice daily, Cefuroxime 30
mg/kg/day divided twice daily ,Cefpodoxime 10 mg/kg/day once daily ,Cefprozil 30
mg/kg/day divided twice daily.
 And treatment failure – Amoxicillin clavulanate
 Type I: Azithromycin 10 mg/kg/day 1, Clarithromycin 15 mg/kg/day divided twice daily.
Treatment failure- Ceftriaxone 50 mg/kg/day , then 5 IM/IV for 3 days.
 If severe symptoms (severe otalgia and temperature above 39°C [102.2°F]) Amoxicillin
clavulanate.
 Alternatives: Clindamycin 30–40 mg/kg/ day in 3 divided doses or Tympanocentesis.

NON PHARMACOLOGICAL THERAPY

 Surgical insertion of tympanostomy tubes (T tubes) is an effective method for the
prevention of recurrent otitis media.
 Vaccination against influenza and pneumococcus may decrease risk of acute otitis media,
especially in those with recurrent episodes. Immunization with the influenza vaccine
reduces the incidence of acute otitis media by 36%.

SINUSITIS
Definition: Sinusitis is an inflammation and/or infection of the paranasal sinus mucosa.
The term rhinosinusitis is also used.
Causative organism and etiology : The majority of these infections are viral in origin.
• Acute bacterial sinusitis is most often caused by the same bacteria implicated in acute
otitis media: S. pneumoniae and H. influenzae.
• These organisms are responsible for about 70% of bacterial causes of acute sinusitis in
both adults and children.
• Chronic sinusitis can be polymicrobial, with an increased prevalence of anaerobes as well
as less common pathogens including gram-negative bacilli and fungi.
• Bacterial sinusitis can be categorized into acute and chronic disease.
• Acute disease lasts less than 30 days with complete resolution of symptoms.
• Chronic sinusitis is defined as episodes of inflammation lasting more than 3 months with
persistence of respiratory symptoms.

Clinical presentation and diagnosis:

The main feature of acute sinusitis is facial pain and tenderness, often accompanied by
headache and a purulent nasal discharge. The average duration of the illness is 2.5 weeks,
although most patients will be improving after 7–15 days.
 Bacterial infection should be suspected when three or more of the following criteria are
present: discoloured or purulent discharge greater on one side, severe local pain greater on
one side, a fever above 38 °C, deterioration after an initial milder illness and a raised
erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) .
 The condition may become chronic with persistent low-grade pain and nasal discharge,
sometimes with acute exacerbations.
 Chronic Symptoms are similar to those of acute sinusitis but more nonspecific. Rhinorrhea
is associated with acute exacerbations. Chronic unproductive cough, laryngitis, and
headache may occur. Chronic/recurrent infections occur three to four times a year and are
unresponsive to steam and decongestants.
 Diagnosis is usually clinical. However, in chronic cases, samples from sinus washouts may
be sent for bacterial culture in an attempt to isolate the causative organism.
TREATMENT:
NON PHARMACOLOGICAL THERAPY
 Steam inhalation.
 Irrigation of the nasal cavity with saline.
 Warm face packs.

PHARMACOTHERAPY
 Nasal decongestant sprays such as phenylephrine and oxymetazoline that reduce
inflammation by vasoconstriction are often used in sinusitis.
 Mucolytics (e.g., guaifenesin) may be used to decrease the viscosity of nasal secretions.
 Amoxicillin is first-line treatment for acute bacterial sinusitis.
 Paracetamol or ibuprofen is used to alleviate pain
 Uncomplicated sinusitis, penicillin-allergic patient Immediate-type hypersensitivity:
Clarithromycin or azithromycin or trimethoprim–sulfamethoxazole or doxycycline or
respiratory fluoroquinolone (levofloxacin or gatifloxacin). Nonimmediate-type
hypersensitivity: β-Lactamase–stable cephalosporin.
 Treatment failure or prior antibiotic therapy in past 4–6 weeks High-dose amoxicillin with
clavulanate or β-lactamase–stable cephalosporin. Second choice: respiratory
fluoroquinolone.
 High suspicion of penicillin-resistant Streptococcus pneumoniae High-dose amoxicillin or
clindamycin. Second choice: respiratory fluoroquinolone.
 Amoxicillin 500 mg three times daily and high dose 1 g three times daily and Low dose:
40–50 mg/kg/day divided in three doses High dose: 80–100 mg/kg/day divided in three
doses for children, Amoxicillin-clavulanate 500/125 mg three times daily doses High dose:
2 g/125 mg twice daily , 40–50 mg/kg/day divided in three doses High dose: Can add 40–
50 mg/kg/day amoxicillin in children.
 Clarithromycin 250–500 mg twice daily and pediatric :15 mg/kg/day divided in two
doses.
 Azithromycin 500 mg day 1, then 250 mg/day for days 2–5,and pediatric 10 mg/kg day 1,
then 5 mg/kg/day for days 2–5.
 Levofloxacin 500 mg daily.
 Ceftriaxone 1 g daily 50–75 mg/kg/day divided every 12–24 hours.
 Cefpodoxime 200 mg twice daily 10 mg/kg/day in two divided doses (maximum: 400 mg
daily).
Thank
you

Afnan