Transcript Document
ARI Done by: Ahmad Mukharsham 423 810 212 Almoatasim….. 424 810 305 Abdulmohsen Abdullah Saad 425810059 1 / 42 Upper Respiratory Tract Infections • • • • • • • • • Acute tonsillitis Acute pharyngitis Acute otitis media Acute sinusitis Common cold Acute laryngitis Otitis externa Mastoiditis Acute apiglottis 2 / 42 Objectives • At the end of this session, the participants should be able to; – – – – List upper respiratory tract infections Make differential diagnosis between URTI Define criteria for antibiotic use Apply and interpret the McIsaac scoring 3 / 42 Tonsilitis-pharyngitis • Bacteria – S. pyogenes – C. diphteriae – N. gonorrhoeae • Viruses – – – – – Epstein-Barr virus Adenovirus Influenza A, B Coxsackie A Parainfluenzae 4 / 42 Causative organisms • < 3 years – 100 % viral • 5-15 years – 15-30 % GABHS • Adult – 10 % GABHS 5 / 42 Due to streptococci: • Spreads by close contact and through air • Spread more in crowded areas (KG, school, army..) • Most common among 5-15 age group • More frequent among lower socioeconomic classes • Most common during winter and spring • Incubation period 2-4 days 6 / 42 Signs/symptoms Sore throat Anterior cervical LAP Fever > 38 C Difficulty in swallowing Headache, fatigue Muscle pain Nausea, vomiting Tonsillar hyperemia / exudates Soft palate petechia Absence of coughing Absence of nose drip Absence of hoarseness 7 / 42 Viral tonsillitis/pharyngitis • Having additional rhinitis, hoarseness, conjunctivitis and cough • Pharyngitis is accompanied by conjunctivitis in adenovirus infections • Oral vesicles, ulcers point to viruses 8 / 42 Exudates • • • • • • GABHS EBV Adenovirus Primary HIV infection Candida albicans Francisella tularensis 9 / 42 Lymphadenopathy • • • • • • GABHS Epstein-Barr virus Adenovirus Human herpesvirus type 6 Tularemia HIV infection 10 / 42 Laboratory • Throat swab – Gold standard • Rapid antigen test – If negative need swab • ASO – May remain + for 1 year • WBC count • Peripheral smear 11 / 42 Throat Culture • Pathogens looked for – Group A beta hemolytic streptococci – C. diphteriae (rare) – N. gonorrhoeae (rare) • If GABHS do we need antibiogram? – Is there resistence to penicilline? 12 / 42 Tonsillitis due to Streptococci • Supurative complications – – – – – – – Abscess Sinusitis, otitis, mastoiditis Cavernous sinus thrombosis Toxic shock syndrome Cervical lymphadenitis Septic arthritis, osteomyelitis Recurrent tonsillitis/pharyngitis • Nonsupurative complications – Acute romatoid fever – Acute glomerulonephritis 13 / 42 Aim of Treatment • • • • • Prevention of complications Symptomatic improvement Bacterial eradication Prevention of contamination Reducing unnecessary antibiotic use 14 / 42 Treatment • Many different antibiotics can eradicate GABHS from pharynx • Starting treatment within 9 days is enough to prevent ARF 15 / 42 Antibiotics NOT to be used • • • • • Tetracycline Sulphonamides Co-trimoxasole Cloramphenicole Aminoglycosides 16 / 42 GABHS • Control culture after full dose treatment? – NO • If history of ARF: – Take control culture after treatment • No need to screen or treat carriers 17 / 42 Mc Isaac Scoring • Developed by Mc Isaac and friends • Decreases antibiotic usage by 48% • No increase in throat swabs http://www.cmaj.ca/cgi/content/abstract/163/7/811 18 / 42 Antibiotics in Tonsillitis/pharyngitis due to GABHS ORAL Penicilline V Children:2x250 mg or 3x250mg,10 days Adults:3x500 mg or 4x500mg,10 days PARENTERAL Benzathine penicilline Adults:<27kg:600 000 U single dose, IM >27 kg:1.200 000 U single dose, IM ALLERGY TO PENICILLINE Erithromycine estolate 20-40 mg/kg/day, 2x1 or 3x1, 10 days Erithromycine ethyl succinate 40 mg/kg/day, 2x1 or 3x1, 10 days 19 / 42 Acute Otitis Media • AOM • AOM not responding to treatment: Sustained clinical and autoscopy findings despite 48-72 therapy • Recurrent atitis media: 3 AOM attacks within 6 moths or 4 attacks within 1 year 20 / 42 AOM causes • • • • • • • S. pneumoniae 30% H. İnfluenzae 20% M. Catarrhalis 15% S. pyogenes 3% S. aureus 2% No growth 10-30% Chronic otitis media: P. aeruginosa, S. aureus, anaerobic bacteria 21 / 42 Acute Otitis Media • 85% of children up to 3 years experience at least one, • 50% of children up to 3 years experience at least two attacks • AOM is usually self-limited. Rarely benefits from antibiotics. • 81 % undergo spontaneus resolution. 22 / 42 Signs and Symptoms • Symptoms – – – – – – – • Otoscopic findings Autalgia Ear draining Hearing loss Fever Fatigue • Irritability Tinnitus, vertigo – Tympanic membrane erythema – Inflammation – Bulging – Effusion Hearing loss 23 / 42 Antibiotics First choice Amoxicilline Trimet./Sulfamethoxazole Second choice Amoxicilline/clavulanate Erythromycin Reurrent AOM prophylaxis Sulfisoxazole Amoxicilline 40 mg/kg/day, 3 doses 8mg TM/40mg SMX/kg 2 dose 45 mg/kg/day, 2 doses 40-50 mg/kg/day, 3 doses 75 mg/kg/day, single dose 3-6 mo 20 mg/kg/day, sinle dose 3-6 mo 24 / 42 Acute Rhinitis / Sinusitis Acute sinusitis Chronic sinusitis • • • • • Anaerob bakteria: Bactroides, Fusobacterium • S. aureus • Strep. pyogenes • Str. pneumoniae • Gram (-) bakteria • Fungi Str. pneumoniae %41 H. influenzae %35 M. catarrhalis %8 Others %16 Strep. pyogenes S. aureus Rhinovirus Parainfluenzae Veilonella, peptokoccus 25 / 42 Acute Sinusitis • Paranasal sinuses: – – – – Frontal Ethmoid Maxillary Sphenoid • Most common during childhood – Maxillary – Ethmoid • After age 10 – Frontal 26 / 42 27 / 42 Predisposition to Sinusitis • Anatomical: septal deviation, • Mukociliary functions: cystic fibrosis, immotile cilia synd. • Systemic dis., immune deficiency.: DM, AIDS, CRF • Allergy: Nasal poliposis, asthma • Neoplasia • Environmental: smoking, air pollution, trauma... 28 / 42 Acute Rhinosinusitis • Most important: Headache and postnasal dripping • Face congestion • Fever, fatigue, headache increased by leaning forward • Nose obstruction • Nose dripping • Purulent secretions (rhinoscopy) • Sensitivity over the sinuses • Halitosis 29 / 42 Acute rhinosinusitis Rhinitis • Increased symptoms after 5 days • Symptoms lasting > 10 days • Decreasing viral symptoms, nasal secretion becoming more purulent are indicative for acute rhinosinusitis 30 / 42 Diagnosis • Direct x-ray – Diffuse opacification – Mucosal thickening >4 mm – air-fluid level • Sinus aspiration – Rarely performed • Nasal endoskopy • Tomography – More sensitive compared with direct x-ray – Indicated before surgery 31 / 42 Treatment • Ampirical – Specific microbiologic diagnosis difficult • Primary pathogens – S. pneumoniae – H. influenzae 32 / 42 Antibiotics for Sinusitis • Amoxycilline (Alfoxil) 3x500mg/d PO 10 d • Amoxycilline/clavulonate (Augmentin) 3x625 mg/d PO 10 d • Sefprosil(Serozil) 2x1000 mg/d PO 10 d • Sefuroxim (Zinnat) 2x250 mg/d PO 10 d • Azithromycine (Zitromax) First day 1x500 mg, then 1x250 mg/d PO 5 d 33 / 42 Support Therapy • Decongestants – Short duration 3-5 days • Antihistamines – If allergy • Normal saline • Local steroids 34 / 42 Common Cold • Adults Rhinovirus • Children Parainfluenzae and RSV 35 / 42 Common Cold • • • • • Fatigue Feeling cold, shuddering Nose burning, obstruction, running Sneezing Fever 36 / 42 Influenza (flu) • Causes epidemics and pandemics • Highly contagious • Viral infection. 37 / 42 Cause • • • • 80 % Influenzae virus Parainfluenza %2-9 Rhinovirus %3 Adenovirus %4 38 / 42 Influenza • Sudden onset after 12-24 hours incubation • General weakness and fatigue • Feeling cold, shivering, temp. Up to 39-40 C • No sore throat or running nose • Severe back, muscle and joint pain 39 / 42 Treatment of common cold and influenza 40 / 42