Pediatric Upper Respiratory Infections

Acute Upper Respiratory Infections Mohamed Khashaba,MD Professor of Pediatrics/ Neonatology Mansoura Faculty of Medicine

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Objectives • Stress the importance of ARI from both the epidemiologic and clinical aspects. • Guide the clinical diagnosis and treatment of common URI. • Point to the importance of proper selection of antibiotic for the specific patient.

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Acute Respiratory infections Epidemiology • Children experience five to eight episodes of respiratory infections every year. • Acute Respiratory Infections account for 19% of all deaths in children younger than five years, and 8.2% of all disability and premature mortality.* •

*International Conference on Acute Respiratory Infection. CanberraAustralia. 1997

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Epidemiology Upper respiratory tract infection is the most common diagnosis in ambulatory visits (37 million visits).

Rates of antibiotic prescription for uncomplicated URTIs are 52%, and it accounts for 10% of all antibiotics prescribed annually in ambulatory practice. 12/20/08

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Epidemiology • Acute rhinosinusitis (25 million visits). – Is frequently caused by viral infection. – In 85% to 98% of cases, physicians prescribe an antibiotic. – 5th most common diagnosis for which an antibiotic is prescribed. 12/20/08

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Epidemiology • Uncomplicated acute bronchitis (10 million office visits).

– About 5% of adults self-report an episode of acute bronchitis each year. – Up to 90% seek medical attention

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Population at Risk for RTIs in Developing countries • Several Risk Factors for acquiring RTIs in developing countries include: • Poverty • Restricted family income • Low parental education level • Low birth weight • Malnutrition • Lack of breastfeeding 12/20/08

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ARTIs in developing countries among children 5 years of age • Most infections are limited to the upper respiratory tract and 5% involve the lower respiratory tract.

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ARTIs in developing countries among children below 5 years of age • In all countries ARTI is a leading cause of hospitalization and death. • Antibiotics are the most commonly Rx medications, but this does not prevent hospitalization which indicates misusage either by doctors or families. 12/20/08

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IMCI (Case management technique) Classifies ARI on the basis of severity. presence or absence of fast breathing low chest indrawing in a child who presents with cough or difficult breathing. separate children with serious illness ( severe disease and pneumonia) from those with mild self-limiting conditions (no pneumonia: cough and cold). 12/20/08

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Case management technique Very severe disease ,needs urgent hospitalization. inability to drink, convulsions, abnormally sleepy or difficult to wake, stridor in calm child, severe malnutrition chest indrawing and wheezing. . Home setting Treatment If a child is breathing fast for his age, chest is not indrawing, 12/20/08

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UPPER RESPIRATORY INFECTIONS

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Etiology of URI • Most upper respiratory infections are of viral etiology. • Epiglottitis and laryngotracheitis are exceptions with severe cases likely caused by Haemophilus influenzae type b. • Bacterial pharyngitis is often caused by Streptococcus pyogenes

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Clinical Manifestations • Initial symptoms of a cold are runny, stuffy nose and sneezing, usually without fever. Other upper respiratory infections may have fever. • Epiglottitis :may have difficulty in breathing, muffled speech, drooling and stridor. laryngotracheitis (croup) :may also have tachypnea, stridor and cyanosis. 12/20/08

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Upper Respiratory Infections • • • • •

Common Cold Sinusitis Otitis media Pharyngitis Epiglottitis and Laryngotracheitis

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Upper Respiratory Infections • • • • • •

Common Cold Sinusitis Otitis media Pharyngitis Epiglottitis and Laryngotracheitis

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Pathogenesis • Inhalation of droplets then invasion of the mucosa. • Epithelial destruction may ensue, along with redness, edema, hemorrhage and sometimes an exudate

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Common Cold Etiology • Most caused by viruses. • Rhinoviruses with more than 100 serotypes causing at least 25% of colds. • Coronaviruses may be responsible for more than 10% of cases. • Parainfluenza, RSV, adeno and influenza viruses have all been linked to the common cold syndrome. • 30% to 40% of cold syndromes cause has not been determined 12/20/08

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Pathogenesis •

Viruses invade epithelial cells of the respiratory mucosa leading to: 2. Destruction and sloughing of cells or 3. Loss of ciliary activity depends on the specific organism involved. 4. Increase in leukocyte infiltration and nasal secretions, suggesting that cytokines and immune mechanisms may be responsible for some of the manifestations of the common cold 12/20/08

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Microbiologic Diagnosis • Common colds can usually be recognized clinically. • Bacterial and viral cultures of throat swab specimens are used for pharyngitis, epiglottitis and laryngotracheitis. • Blood cultures are also obtained in cases of epiglottitis

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Clinical Manifestations • Incubation period : 48-72 hours, • Symptoms of nasal discharge and obstruction, sneezing, sore throat and cough • Myalgia and headache . • Fever is rare. • The duration of symptoms and of viral shedding varies with the pathogen and the age of the patient. • Complications are usually rare, but sinusitis and otitis media may follow 12/20/08

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Microbiologic Diagnosis • Is usually based on the symptoms (lack of fever combined with symptoms of localization to the nasopharynx). • Unlike allergic rhinitis, eosinophils are absent in nasal secretions. • Usually no need to isolate the virus.

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Prevention and Treatment • Symptomatic. • Decongestants, antipyretics, fluids and bed rest Restriction of activities to avoid infecting others, along with good hand washing. • No vaccine is commercially available .

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Predictors for prescribing antibiotics • Green nasal discharge (reported or observed). • Production of green phlegm. • Coplications e.g. sinusitis

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APHTHOUS ULCERS

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Aphthous Ulcers DD Infections Viral Herpes virus Vesicular lesions, Tzank stain positive for inclusion-bearing giant cells • CMV Immunocompromised patient, biopsy positive for multinucleated giant cells • Varicella Characteristic skin lesions • Coxsackievirus mouth and/foot/buttock lesions, Fungal • Immunocompromised patient, chronicity, biopsy and culture positive 12/20/08

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Autoimmune • Behçet's syndrome Genital ulceration, uveitis, retinitis • Reiter's syndrome Uveitis, conjunctivitis, HLA B27, arthritis Inflammatory bowel disease other GI ulcerations • Lupus erythematosus Malar rash, ANA-positive • Bullous pemphigoid & Pemphigus vulgaris • Diffuse skin involvement • Hematologic Cyclic neutropenia Periodic fever, neutropenia N 12/20/08

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Treatment • The lack of clarity regarding etiology has resulted in treatments that are largely empiric Tetracycline rinse ( not in children). • Triamcinolone 0.1% in Orabase applied to the ulcers two to four times daily until healed Dexamethasone elixir, 0.5 mg per 5 mL Swish and spit with 5 mL every 12 hours Viscous lidocaine, 2% Apply to ulcer as needed For brief local pain 12/20/08

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Upper Respiratory Infections • • • • • •

Common Cold Sinusitis Otitis media Pharyngitis Epiglottitis and Laryngotracheitis

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Sinusitis • Acute inflammatory condition of one or more of the paranasal sinuses. Infection plays an important role. • Sinusitis often results from infections of other sites of the respiratory tract since the paranasal sinuses are contiguous to, and communicate with, the upper respiratory tract

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Etiology & Predisposing Factors • Acute sinusitis most often follows a common cold which is usually of viral etiology. • Vasomotor and allergic rhinitis . • Obstruction of the sinusal ostia due to deviation of the nasal septum, • presence of foreign bodies, polyps or tumors. • dental extraction or extension of infection from the roots of the upper teeth

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Bacterial agents • St. pneumoniae,HIb, and M catarrhalis. • Other organisms including Staph. aureus, Strept. pyogenes, gram-ve organisms and anaerobes have also been recovered. • Chronic sinusitis is commonly a mixed infection of aerobic and anaerobic organisms.

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Pathogenesis • Infections causes impairment of ciliary activity of the epithelial lining of the sinuses and increased mucous secretions. • obstruction of the paranasal sinusal ostia which impedes drainage • bacterial multiplication in the sinus cavities, the mucus is converted to mucopurulent exudates. • pus further irritates the mucosal lining causing more edema, epithelial destruction and ostial obstruction. When acute sinusitis becomes chronic, mucosal thickening results and the development of mucoceles and polyps may ensue 12/20/08

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Clinical Manifestations • Maxillary and ethmoid sinuses are most commonly involved. • Frontal sinuses are less often involved and the sphenoid sinuses are rarely affected. • Pain, sensation of pressure and tenderness over the affected sinus are present. • Malaise and low grade fever may also occur. • Physical examination usually is not remarkable with no more than an edematous and hyperemic nasal mucosa. 12/20/08

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• In uncomplicated chronic sinusitis, a purulent nasal discharge is the most constant finding. There may not be pain nor tenderness over the sinus areas. • Thickening of the sinus mucosa and a fluid level are usually seen in x-ray films or magnetic resonance imaging.

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Prevention and Treatment • Analgesics and moist heat over the affected sinus Decongestant to promote sinus drainage may suffice. • Beta-lactamase resistant antibiotic or cephalosporin • For chronic sinusitis, when conservative treatment does not lead to a cure, irrigation of the affected sinus may be necessary. Culture from an antral puncture of the maxillary sinus can be performed to identify the causative organism for selecting antimicrobial therapy. 12/20/08

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• Proper care of infectious and/or allergic rhinitis, • Surgical correction to relieve or avoid obstruction of the sinusal ostia are important. Root abscesses of the upper teeth should receive proper dental care to avoid secondary infection of the maxillary sinuses

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Upper Respiratory Infections • • • • • •

Common Cold Sinusitis Otitis media Pharyngitis Epiglottitis and Laryngotracheitis

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Otitis media • Strept. pneumoniae, HI and beta-lactamase producing M catarrhalis. • Respiratory viruses role remains uncertain. Morax. pneumoniae has been reported to cause hemorrhagic bullous myringitis in an experimental study among nonimmune human volunteers inoculated with M pneumoniae..

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Pathogenesis • Commonly follows an upper respiratory infection extending from the nasopharynx via the eustachian tube. • Vigorous nose blowing during a common cold, sudden changes of air pressure, and perforation of the tympanic membrane . • The presence of purulent exudate in the middle ear may lead to a spread of infection to the inner ear and mastoids or even meninges 12/20/08

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Clinical manifestations • The initial complaint usually is persistent severe earache (crying in the infant) accompanied by fever, and, and vomiting. • Otologic examination reveals a bulging, erythematous tympanic membrane with loss of light reflex and landmarks. • If perforation of the tympanic membrane occurs, serosanguinous or purulent discharge may be present. In the event of an obstruction of the eustachian tube, accumulation of a usually sterile effusion in the middle ear results in serous otitis media. 12/20/08

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Diagnosis • The diagnosis made from history, clinical symptomatology and physical examinations. • Inspection of the tympanic membrane . All discharge, ear wax and debris must be removed and to perform an adequate otoscopy. • If the patient is immunocompromised or is toxic and not responding to initial l therapy tympanocentesis (needle aspiration) to obtain middle ear effusion for microbiologic culture is indicated. 12/20/08

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Treatment • • • • • •

Amoxicillin amoxicillin-clavulanate trimethoprim/sulfamethoxazole, cephalosporins, and macrolides When there is a large effusion, tympanocentesis may hasten the resolution • Patients with frequent recurrences of middle ear infections may be benefitted by chemoprophylaxis during the winter and spring months. • patients with persistent effusion of the middle ear, surgical interventions has been helpful. 12/20/08

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Prophylaxis • New vaccines composed of pneumococcal capsular polysaccharides conjugated to proteins increase the immunogenicity .

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Upper Respiratory Infections • • • • • •

Common Cold Sinusitis Otitis media Pharyngitis Epiglottitis and Laryngotracheitis

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Pharyngitis Inflammation of the pharynx involving lymphoid tissues of the posterior pharynx and lateral pharyngeal bands.

• Etiology can be bacterial, viral and fungal infections as well as noninfectious etiologies. Most cases are due to viral infections and accompany a common cold or influenza 12/20/08

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• Type A coxsackieviruses can cause a severe ulcerative pharyngitis in children (herpangina), adenovirus and herpes simplex virus, although less common, also can cause severe pharyngitis. • Pharyngitis is a common symptom of EpsteinBarr virus and cytomegalovirus infections

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• Group A beta-hemolytic streptococcus is the most important bacterial agent associated with acute pharyngitis and tonsillitis. • mixed anaerobic infections (Vincent's angina), Corynebacterium haemolyticum, N.gonorrhoeae, and C. trachomatis.. Mycoplasma pneumoniae and Mycoplasma hominis • Candida albicans as extension of oral candidiasis or thrush, 12/20/08

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Treatment of Acute Tonsillo- Pharyngitis • If tonsillitis is caused by a bacterial infection, • Antibiotics must be prescribed & the patient should finish the full course of antibiotics. • Early stopping of medication may cause the recurrent infection which can lead to potentially serious complications. • If there is difficulty swallowing, antibiotics may be given by injection 12/20/08

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Predictors of AntibioticTreatment • • • •

Tonsillar exudates Tender cervical lymphadenopathy Absence of cough History of fever.

– Presence of 3 or 4 of these criteria has a positive predictive value of 40-60%. – Absence of 3 or 4 of the criteria has a negative predictive value of 80%. •

Both the sensitivity and specificity of this prediction rule are 75% compared with throat cultures

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Infectious Mononucleosis / Glandular fever / Kissing Disease • • • • • • •

Symptoms : fever, sore throat. Splenic enlargement in 50% . lymphadenopathy in 90%. liver enlargement in 10% Severe pharyngitis with exudate and petechiae . maculopapular rash in 80% given Amoxycillin.

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Complications • Stridor or respiratory distress, which may be treated with steroids. • CNS: ataxia, fits, Guillain Barr. • Carditis , hemolysis.

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Antibiotic Use When and what antibiotic ?

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• Widespread use of antibiotics resulted in antibiotic resistance to many bacteria. • S.pneumoniae, one of the most important causes of ARI is rapidly becoming resistant to Penicillins and Cotrimoxazole WHO is enforcing to establish a system for antimicrobial resistance monitoring

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Overuse of antibiotics Factors 1. Lack of careful history taking & examination. 2. Clinical presentation of patients. 3. Patient pressure to prescribe antibiotics. 4. Insufficient time to educate patients about the ineffectiveness of the misuse of antibiotics.

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Overuse of antibiotics Factors • The clinical diagnosis of acute bacterial rhinosinusitis is difficult with frequent misclassification of viral cases. – Signs and symptoms of acute bacterial rhinosinusitis and of prolonged viral upper respiratory tract infections are extraordinarily similar. – No simple and accurate office-based tests are available for acute bacterial rhinosinusitis.

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Clinical decision making: •Several distinctive features of the drug under consideration, include: – Antibacterial spectrum (Broad Spectrum) – PK/PD (MIC, Tissue concentration & Eradication) – Patient Satisfaction (e.g. Number of daily doses, Duration of

therapy & Early relief of Symptoms)

– Tolerability – Palatability – Reasonable Cost

• Clinicians also consider therapeutic efficacy based on clinical trials and the recommendations of respectful organizations. 12/20/08

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Summary Upper respiratory tract infection represents the leading cause of doctor’s visits in ambulatory setting . Thourgh history and clinical examination will help proper decision of when to start and what antibiotic to use.

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There should be significant efforts to regulate the use of antibiotics, for example, by making antibiotics available only on prescription from a health worker.

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Additional Important Issues Completing immunization in all children including Hib and Pneumococcal vaccine. • Utilizing the standardized case management for diagnosis and treatment . • Health education for the community health worker and mothers. 12/20/08

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Objectives & take home message • Stress the importance of ARI from both the epidemiologic and clinical aspects. • Guide the clinical diagnosis and treatment of common URI. • Point to the importance of proper selection of antibiotic for the specific patient.

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