Upper Respiratory Tract Infections (URTI)

Pathogens commonly responsible for: pharyngitis, otitis media, sinusitis, and acute epiglotitis

  • Otitis media (2nd most common type of pediatric infection)
    • Causes:  Strept pneumoniae (most common), H influenzae ( 1/2 of H influenzae is beta-lactamase producing), M. Catarrhalis (usually self limiting, 90% of m. catt. Produces beta lactamase), viruses
      • Penicillin resistant strept pneumoniae is on the rise
  • Acute Pharyngitis (most common infectious reason for seeking a MD)
    • Causes:  group A beta hemolytic streptococci (most common;  GABHS, streptococcus pyogenes), non-group A strept (B, C, G)
  • Sinusitis
    • Caused by inflammation and edema of the sinus mocusa (combined with impaired mucociliary clearance) resulting in an obstruction to flow
    • Acute sinusitis:  H. Influenzae, streptococcus pneumoniae, moracella cattarhalis
    • Chronic sinusitis:  H. Influenzae, alpha-hemolytic streptococci, veillonella, corynebacterium, bacteroides
  • Epiglottitis  (LIFE THREATENING URTI)
    • Inflammation of the epiglottis that causes an airway obstruction
    • Causes:  haemophilus inflenzae, streptococcus (A, B, C, & pneumoniae), K pneumoniae, N meningitidis

Signs and symptoms of the above mentioned infectious diseases

  • Otitis media
    • Signs/symptoms:  fever (102-104 degrees), earache/tugging at the ear, anorexia, irritability, lethargy, hearing loss
    • Complications:  hearing impairment, mastoiditis, perforated tympanic membrane, meningitis
    • Risk factors:
      • age (6-18 months)– due to the development of the eustachian tube lying more flat in kids < 6 years old allowing more fluid to get trapped there, leading to bacterial colonization & infection
      • Season  (winter months)–due to being in a confined space & greater exposure to bacterial pathogens
      • Day care attendance — kids in daycare are 7x more likely to undergo surgery for tube placement
      • Bottle feeding –breast feeding provides immunologic protection & a decreased likelihood of milk getting into the middle ear
      • 2nd hand smoke exposure (respiratory tract irritant)
      • Pre-existing URTI or allergy
      • + family history
  • Acute pharyngitis
    • Most often seen in kids from ages 5-10
    • Commonly seen in the fall, winter & spring
    • Sign/symptoms:  sore throat, fever, tonsillar exudates, tender lymph nodes, acute onset, absence of rhinorrhea/cough/horseness, scarlet fever rash
    • Complications:  rheumatic fever (especially if they don’t finish antiobiotic course), post-streptococcal glomerulonephritis
  • Sinusitis
    • Risk factors:  viral URTI, allergic rhinitis, tobacco smoke, anatomical disruption
    • Signs/symptoms:  cough, HA, dental/facial pain, fever, nasal discharge, halotosis, sore throat
  • Epiglottitis
    • Signs/symptoms:  fever, drooling, respiratory distress, dysphagia, dysphonia, sore throat

Tests employed in the diagnosis of the above mentioned infectious diseases.

  • Otitis media
    • Diagnosis is based on:  history +
      • Otoscopic examination (most common)–reveals fullness/bulging of tympanic membrane with increased vascularity.  Reduced/absent motility of tympanic membrane due to fluid in the middle ear.  May see mucopurulent secretions.  Redness of tympanic membrane due to inflammation.
      • Tympanometry–air pressure into the air is varied to test the condition & mobility of the tympanic membrane (ear drum)
      • Tympanocentesis (used in difficult to resolve cases)–piercing the tympanic membrane with a needle to aspirate the contents of the middle ear & collect the material for diagnostic purposes
  • Acute Pharyngitis
    • Diagnosis is based on a rapid streptococcal antigen test or a throat culture  (potential for false negatives though)
      • History & physical findings alone aren’t diagnostic
      • Cultures take 24-36 hours turn around, expensive
      • The following is the decision tree for managing a sore throat
Criteria

Points

Cough absent

1

Swollen & tender anterior cervical nodes

1

Temp > 100.4

1

Tonsillar exudates or swelling

1

Age 3-14 years

1

Age 14-44 years

0

Age 45+ years

-1

Cumulative Score

> 4 = Treat empirically 1-3 = Culture & Treat if Positive if 0 = 1-2.5% risk, manage symptoms

  • Sinusitis
  • Diagnosis is usually based on:  history & physical exam, translumination (rare), radiographic CT or plain sinus films
    • The occipitomental view on a radiographic CT will show significant mucosal thickening
    • Physical exam may reveal a subperiosteal abscess (which may cause an eye to become swollen shut) or Pott’s Puffy tumor

Pharmacologic treatment options

  • General recommendations w/ antibiotics:
    • All kids < 6 months should receive antibiotics
    • 6 months to 2 years old should receive antibiotics if diagnosis is certain or symptoms are severe
    • Kids > 2 years old may want to try observing with antibiotics if diagnosis is uncertain &/or symptoms aren’t severe
  • Otitis media
    • Oral (APAP or IBU) or topical (auralgan–antipyrine + benzocaine) analgesics
    • Antipyretics (APAP or IBU)
    • May also use decongestants or antihistamines
    • Antibiotics (consider spectrum, middle ear penetration, cost, taste, dosage form, dose frequency)
      • Amoxicillin is the drug of choice
        • Effective, well tolerated (rash, diarrhea are only common SE), cheap, tastes good
          • Bad: beta-lactamase susceptibility, increasing penicillin resistance @ lower doses
        • 90 mg/kg/day up to 1500 mg/day (max) divided BID to TID
        • 80% effective
        • Requires refrigeration
        • DON’T USE IF:  penicillin allergy, kid has received an antibiotic within the last 30 days, concurrent purlent conjunctivitis (pathogen is probably resistant to amox), kids receiving amox for prophylaxis
  • Acute pharyngitis
    • Drugs of choice:  Pen VK or benzathine penicillin G (Bicillin LA)
      • Penicillin VK:
        • <  60 lbs = 250 mg PO BID for 10 days
        • > 60 lbs = 500 mg PO BID for 10 days
      • Benzathine Penicillin G (Bicillin LA)
        •  < 60 lbs = 600,000 units IM
        •  > 60 lbs = 1.2 million units IM
  • Sinusitis
    • Acute:  10 days of therapy
      • Amoxicillin
      • Augmentin
      • 2nd or 3rd generation cephalosporin
      • Clarithromycin or z-pak
  • Epiglottitis
    • Antibiotics  (ceftriaxone or cefotaxime for 10 days)
      • Ceftriaxone 80-100 mg/kg/day IV divided up BID for 10 days
      • Cefotaxime 150-225 mg/kg/day IV divided up QID for 10 days
        • Both of these antibiotics should be changed to oral doses after the pts fever has been good for 24 hrs (afebrile) and they’re able to swallow
    • Use rifampin 20 mg/kg/day for 4 days for prophylaxis for  kids < 4 years old, household members or ppl in close contact

Secondary agents and useful nonpharmacologic therapies.

  • Otitis media   (should get better/therapeutic benefit within 24-48 hours)
    • Alternatives to amox
      • cefuroxime axetil (Ceftin)—2nd gen ceph—most expensive
      • amoxicillin/clavulanate (Augmentin)–more expensive than amox or zpak
      • cefprozil(Cefzil)—2nd gen ceph—expensive
      • cefpodoxime proxetil (Vantin)—3rd gen ceph
      • cefdinir (Omnicef)—3rd gen ceph
      • Azithromycin (Zithromax)–macrolide–least expensive next to amox
      • Clarithromycin (Biaxin)–macrolide
        • If one antibiotic fails, change to an antibiotic w/ improved Beta-lactamase activity or one that’s active against penicillin-resistant strept
    • Other treatment options:
      • tympanocentesis/myringotomy
      • Tympanostomy tubes & antibiotics for chronic otitis media w/ effusion
        • These tubes are designed to stay in the eardrum for one to several years
      • May want to culture the middle ear fluid to determine what antibiotic to use in pts w/ chronic purulent otitis media
  • Acute pharyngitis  (may return to school/work after 24 hours of antibiotics)
    • Alternative to Pen VK or Pen G
      • Erythromycin ethylsuccinate 40 mg/kg BID for 10 days
      • 1st or 2nd generation cephalosporin
      • Clarithromycin
      • Azithromycin
  • Sinusitis
    • Ancillary trxt = humidified air/saline irrigation
    • Symptomatic trxt
      • decongestants (topical or systemic)
      • antihistamines
    • Prevention:
      • antihistamines
      • Topical corticosteroids (if the pt has severe allergies start these in ~ april)
        • Betamethasone, flunisolide, triamcinolone

SUMMARY of URTIs

  • Acute otitis media (AOM) & Streptococcal Pharyngitis are primarily infections of childhood.
  • Pathogens most common for Acute otitis mediainclude: Streptococcus pneumoniae, H. influenzae, Moraxella cattarhalis
  • H. influenzae & M. cattarhalis are commonly beta-lactamase producing
  • Acute otitis media drug of choice is amoxicillin
  • Treatment of Strep. pharyngitis decreases contagiousness, minimizes symptoms and prevents ARF & PSGN
  • DOC is penicillin
  • Sinusitus common in adults & children
  • Bacterial pathogens similar to Acute otitis media
  • Useful antibiotics similar to Acute otitis media

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