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1、URTI&AntibioticsDr.KarinaPresentedbyKhalidAbdallaAbdallahbaniFaresRasheedJanaidehDefinitionEpidemiologyTypesandcausativeagentsManagementprinciplesEffectsofRxAntibioticinspecificURTIFactorsaffectprescriptionObjectivesDefinitionURTIinflammationofrespiratorymucosafromthenosetothelowerrespiratorytreenot
2、includingthealveoli.SymptomsSorethroatRhinorrheaFacialfullnessandPainHeadacheCoughFeverTenderlymphnodesEarPainTypesandcausativeagentsManagementPrinciplesViralinfectionsneedonlysymptomatictreatment:-Analgesics(Paracetamol,Aspirin,Ibuprofen)-Anti-histamines-Coughsuppressants-Nasaldecongestants-Vitamin
3、C-IncreasefluidintakeBacterialInfectionsneedantibioticsinadditionofsymptomatictreatmentManagementPrinciplesViral(DontUseAntibiotics)Why?-Promotesantibioticresistance-Adversereactionssuchasallergyandanaphylaxis-Costly-PatientsdonotneedantibioticstofeelsatisfiedBacterial(Useantibiotics)Why?-Topreventr
4、heumaticfever-Topreventsuppurativecomplications(e.g.,peritonsillarabscess)-Tospeeduprecovery-ToreducespreadtoothersButhowcanwedifferentiatebetweenViralandBacterialPharyngitis,Sinusitis&OtitisMedia?AcutePharyngitis(SoreThroat)ViralErythemaSymptomsSorethroatStrepThroat:fever,headeach,swollenlymphnodei
5、ntheneckViralpharyngitis:runnynoseandpostnasaldripSevercasesdifficultswallowingandrarlydifficultbreathingAcutePharyngitisRapidAntigenTest(RAT)SensitivityofRATagainstculturevariesbetween61-95%.SpecificityofRAT88-100%Takes10mintobeperformed-veresultsshouldbeconfirmedbyculture.NotfoundinJordanAcutePhar
6、yngitis(DrugOfchoice)-Oralpenicillinorerythromycin(inpenicillin-allergicindividuals),givenfor10days.-Fortunately,noresistancetopenicillinhasbeenreported,sofar,amongGABHS-relatedPharyngitispatients.ComplicationRheumatic Fever-MajorCriteria:-polyarithritis-Poststrep.GN-carditis-Bactermia-sydenhamchore
7、a-subcutaneousnodules-erythemamarginatum-MinorCriteria:-fever-leukocytosis-elevatedESR,CRP-arthralgiawith evidence of recent group A strep infectionCaseA25yearoldmancomestoyourofficewiththecomplaintofabadsorethroatfor2days.Hehasfeltchillsandfevertodaybuthasnotmeasuredhistemperature.Hehassomepainonsw
8、allowing.Hehasaslightrunnynoseanddeniescoughandothersymptoms.Hewaspreviouslyhealthy.T=38.5ears-TMs normalnose clearneck-no cervical adenopathylungs clearHow many points does our patient have?Feverover38CAbsenceofcoughTenderant.cervicaladenopathyTonsillarswellingorexudateAge45Total=3110100Acuteotitis
9、mediaNormalTympanicMembraneAcuteotitismediaRednessBulgingAcuteotitismediaDutchGuidelines-Dutchstudyfoundnodifferenceinoutcomebetweenantibiotics,myringotomy,antibioticscombinedwithmyringotomyandplacebo.-Only1in7childrenunder2yearoldwith1stepisodeofA.O.Mderivedsignificantbenefitfromantibiotictreatment
10、.-Althoughitreducefeverfaster,itdoesnotreducedurationofpainorcrying.Mostcommoncause:Streptococcuspneumoniae,nontypeableHaemophilusinfluenzae,MoraxellacatarrhalisSymptomsEarache,fever,troublesleeping,Fullnessintheear,Vomiting,Diarrhea,HearinglossintheaffectedearPerforatedeardrumEnlargedadenoidsortons
11、ilsMastoiditisHearinglosscomplicationTREATMENTGUIDELINESSymptomatictreatmentisprovidedinallcasesThepatientortheparentsareinstructedtocontactthegeneralpractitionerifthereisanabnormalclinicalcourse,inotherwords:-increasingillnessorearache,decreaseddrinking-noimprovementwithin3daysTREATMENTGUIDELINES(c
12、ont.)AntibioticsChildren2years,+recurrentwithin12monthsorDownssyndrome,cleftpalate,compromisedimmunesystemTreatment:-AmoxcillinClavulanicacid80-90mg/kgperday-Clarithromycin15mg/kgtwiceperdayComplication:-meningitis-brainabscess-mastoiditis-cholesteatomaAcutesinusitis-Usuallycomlicateallergicrhinitis
13、orcommoncoldwithincreaseinsymptoms-Symptoms:nasalcongestion,sorethroat,postnasaldrip,frontalheadeach,cough,feverAcutesinusitisAntibioticsModerate symptoms not improving after 10 daysModerate symptoms that worsen after 5 to 7 daysSevere symptoms-Oral amoxicillin,trimethoprim-sulfamethoxazole,or doxyc
14、ycline,given for 3 to 10 days are the favored antibiotics for treatment.Influenza-Influenzaisaviralinfectionthataffectsmainlythenose,throat,bronchiand,occasionally,lungs.Infectionusuallylastsforaboutaweek-isanacuteviralinfectionthatspreadseasilyfrompersontoperson-circulatesworldwideandcanaffectanybo
15、dyinanyagegroup.-Influenzacausesannualepidemicsthatpeakduringwinterintemperateregions-seriouspublichealthproblemthatcausessevereillnessesanddeathsforhigherriskpopulations.Seasonal influenzaisanacuteviralinfectioncausedbyaninfluenzavirusTherearethreetypesofseasonalinfluenzaA,BandC.Transmission:airbor
16、ne(bydropletsandclosepersonalcontact.)VirustypesAandBareconstantlychangingduetomutations(changeintheviralRNA)andaremorecommonandmoreseriousforms.TypeAvirusesaredividedintotypesbasedondifferencesintwoviralsurfaceproteinscalledthehemagglutinin(H)andtheneuraminidase(N).Thereare16knownHsubtypesandninekn
17、ownNsubtypescurrentlyinfluenzaA(H1N1)andA(H3N2)subtypesarecirculatingamonghumansTypeCinfluenzaisstablecasesoccurmuchlessfrequentlythanAandB.Antigenic shift and driftInfluenzatypeAvirusesundergotwokindsofchanges:i.Antigenicdrift:ii.isaseriesofmutationsthatoccursovertimeandcausesagradualevolutionofthe
18、virusiii.Antigenicshift:iv.isanabruptchangeinthehemagglutininand/ortheneuraminidaseproteinsinfluenzatypeBviruseschangeonlybythemoregradualprocessofantigenicdriftandthereforedonotcausepandemics.Signs and symptoms:suddenonsetofhighfevercough(usuallydry)headachemuscleandjointpainmalaisesorethroatandrun
19、nynoseComplicationsPneumoniaEncephalitisBronchitisSinusinfectionsEarinfectionsWho is at risk?highestriskofcomplicationsoccuramong-childrenyoungerthanagetwo-adultsage65orolder-peopleofanyagewithcertainmedicalconditions,suchaschronicheart,lung.-weakenedimmunesystems.DiagnosisHistoryPhysicalexam:1.indi
20、vidualsmayseemwearyandtired2.Theirskinmayfeelwarm3.mayhaveafeverandrunnynose4.Themucousmembraneofthethroatmayappearreddened5.Lymphnodesintheneckmaybeslightlyswollen.TreatmentTheflugoesawaywithin7to10days-Bedrest-Paracetamol-Oseltmivirbestforchildrenorzanamivirfor65orhighrisk-Antibioticsonlyinpeoplew
21、ithchronicorheartorrenaldiseaseProphylaxis:vaccination70%for1yearprotectionCommoncoldCommoncoldisaviralinfectiousdiseaseoftheupperrespiratorysystem,causedprimarilybyrhinovirusesandcoronavirusesCommonsymptomsincludeacough,sorethroat,runnynose,andfever.Incidence:Thecommoncoldisthemostfrequentinfectiou
22、sdiseaseinhumanswithonaveragetwotofourinfectionsayearinadultsandupto612inchildrenTransmission:airborne(bydropletsandclosepersonalcontact.)SymptomsSymptomsofthecommoncoldusuallybegin2to3daysafterinfectionandofteninclude:LowgradefeverMucusbuildupinyournoseDifficultybreathingthroughyournoseSwellingofyo
23、ursinusesSneezingSorethroatCoughHeadacheColdsymptomscanlastfrom2to14days,butlikemostpeople,youllprobablyrecoverinaweekIfsymptomscomebackoftenorlastmuchlongerthan2weeks,plicationsBronchitisPneumoniaEarinfectionSinusitisAggravationofasthmamanagementThereisnocureforthecommoncold,butyoucangetrelieffromy
24、ourcoldsymptomsby:RestinginbedDrinkingoffluidsGarglingwithwarmsaltwaterorusingthroatspraysforascratchyorsorethroatTakingaspirinorParacetamol,forexampleforheadacheorfeverNevertakeantibioticstotreatacoldbecausecoldsarecausedbyviruses.Youshouldusetheseprescriptionmedicinesonlyifyouhaveararebacterialcom
25、plication,suchassinusitisorearinfection.RhinitisRhinitisisareactionthatoccursintheeyes,noseandthroatwhenairborneirritants(allergens)triggerthereleaseofhistamine.Histaminecausesinflammationandfluidproductioninthefragileliningsofnasalpassages,sinuses,andeyelids.Whatarethedifferenttypesofrhinitis?-alle
26、rgicrhinitis:seasonal-occursparticularlyduringpollenseasonsperennial-occursthroughouttheyearnonallergicrhinitis:Causes:fumesodorstemperatureatmosphericchangessmokeotherirritantsmanagementAvoidallergensAntihistamineDecongestantTopicalsteroidsororalprednisoloneisaninflammationofthetonsilsmostcommonlyc
27、ausedbyviralorbacterialinfection.Itisatypeofpharyngitis.Symptoms:redand/orswollentonsilswhiteoryellowpatchesonthetonsilstender,stiff,and/orswollenneckbadbreathsorethroatpainfulordifficultswallowingcoughheadachesoreeyesbodyachesotalgiafeverbadbreathchillsnasalcongestionsIf your tonsils become very sw
28、ollen,you may also notice other symptoms.These may include sleep apnea(when breathing stops briefly during sleep),trouble swallowing food and a“throaty”voice.Diagnosis:Tonsillitiscanbediagnosedbyperformingarapidstreptest,alsocalledathroatculture.Toperformthethroatculture,thedoctorwillusealongcottons
29、wabtoswipeoffsomeofthestuffonthesurfaceofthebackofyourthroat.Thedoctorwillthentestthestuffonthecottonswab.Thistestwilldeterminewhetheryouhavetonsillitisandwhetheritiscausedbyabacteriaoravirus.Tonsillitisusuallyspreadsfrompersontopersonbycontactwiththethroatornasalfluidsofsomeonewhoisalreadyinfected.
30、Treatment:Treatmentfortonsillitisdependsonwhetheritwascausedbyavirusorbacteria.Ifthetonsillitiswascausedbystrepbacteria(streptococci),thedoctorwillprescribeantibiotics.Ifthetonsillitiswascausedbyavirus,yourbodywillfightofftheinfectiononitsown.However,medicationcanbeprescribedtoreleivethesymptoms.Enc
31、ouragerest.ProvideadequatefluidsProvidecomfortingfoodsandbeverage.PrepareasaltwatergargleHumidifytheairAvoidirritants.Treatpainandfever.Ibuprofen&acetaminophenAntibioticsIftonsillitisiscausedbyabacterialinfectionPenicillintakenbymouthfor10daysisthemostcommonantibiotictreatmentprescribedfortonsilliti
32、scausedbygroupAstreptococcus.Surgery:Surgerytoremovetonsils(tonsillectomy)maybeusedtotreatfrequentlyrecurringtonsillitis,chronictonsillitis,orbacterialtonsillitisthatdoesntrespondtoantibiotictreatment.Frequenttonsillitisisgenerallydefinedas:MorethansixepisodesinoneyearMorethanfourepisodesayearovertw
33、oyearsMorethanthreeepisodesayearoverthreeyearsAtonsillectomymayalsobeperformediftonsillitisresultsindifficulttomanagecomplications,suchas:1.Obstructedsleepapnea2.Breathingdifficulty3.Aperitonsillarabscessthatdoesntimprovewithantibiotictreatment.How long does Tonsillitis Last?Iftonsillitisiscausedbyb
34、acteria,withantibiotictreatment,theillnessisusuallycuredwithin1week.However,itmaytakeseveralweeksforthetonsilsandswollenglandstoreturntonormalsize.Whentonsillitisiscausedbyviruses,thelengthofillnessdependsonwhichvirusisinvolved.Usually,peoplearealmostcompletelyrecoveredwithin1week.Pertussis:alsoknow
35、naswhoopingcough;isahighlycontagiousdiseasecausedbythebacteriumBordetella pertussis.Itisknowntolastforadurationofapproximately6weeksbeforesubsiding.Thediseasederivesitsnamefromthewhoopsoundmadefromtheinspirationofairafteracough.WhoopingPeoplewithwhoopingcougharemostcontagiousduringtheearlieststageso
36、ftheillnessuptoabout2weeksafterthecoughbegins.Ifyoutakethewhoopingcoughvaccine,youwillloweryourriskofcontractingwhoopingcough.Soitcanbeprevented.ThewhoopingcoughvaccineispartoftheDTaP(diphtheria,tetanus,acellularpertussis)immunization.DTaPimmunizationsareroutinelygiveninfivedosesbeforeachildssixthbi
37、rthday.The initial symptoms of whooping cough are:runnynosesneezingmildcoughlowfeverAfterabout1week,thedry,irritatingcoughevolvesintocoughingspellsthatlastforaboutoneminute.Duringthecoughingspell,thepersonmaybecomeredorpurple.Afterthecoughingspell,thepersonmayvomitormakeawhoopingsoundwhenbreathingin
38、.Diagnosis:CulturingofnasopharyngealswabsTreatment:AntibioticsTreatmentwithaneffectiveantibiotic(erythromycinorazithromycin)shortenstheinfectiousperiodbutdoesnotgenerallyaltertheoutcomeoftheinfection;however,whentreatmentisinitiatedduringthecatarrhalstage,symptomsmaybelesssevere.Threemacrolides(eryt
39、hromycin,azithromycinandclarithromycin)areusedintheU.S.Fortreatmentofpertussis;trimethoprim-sulfamethoxazoleisgenerallyusedwhenamacrolideisineffectiveoriscontraindicated.Closecontactswhoreceiveappropriateantibiotics(chemoprophylaxis)duringthe721dayincubationperiodmaybeprotectedfromdevelopingsymptoma
40、ticdisease.Closecontactsaredefinedasanyonecomingintocontactwiththerespiratorysecretionsofaninfectedpersoninthe21daysbeforeoraftertheinfectedpersonscoughbegan.Thereisnoknownantitoxin.CoughEffectivetreatmentsofthecoughassociatedwiththisconditionhavenotyetbeendeveloped.HerbaltreatmentsandvitaminCinthef
41、ormofsodiumascorbatehavebeensaidtogreatlydecreasetheseverityofthecoughcausedbypertussis,butscantscientificstudieshavebeenperformedtoinvestigatethisclaim.Croup(orlaryngotracheobronchitis)isarespiratoryconditionthatisusuallytriggeredbyanacuteviralinfectionoftheupperairway.Theinfectionleadstoswellingin
42、sidethethroat,whichinterfereswithnormalbreathingandproducestheclassicalsymptomsofabarkingcough,stridor,andhoarseness.Itmayproducemild,moderate,orseveresymptoms,whichoftenworsenatnight.Signs&symptoms:barkingcoughstridorhoarsenessdifficultbreathingwhichusuallyworsensatnightalso;fever,coryza(symptomsty
43、picalofthecommoncold),andchestwallindrawing.Causes:1.viralinfection:parainfluenzavirus,primarilytypes1and2,in75%ofcases,influenzaAandB,measles,adenovirusandrespiratorysyncytialvirus(RSV).2.bacterialinfection:laryngealdiphtheria,bacterialtracheitis,laryngotracheobronchitis,andlaryngotracheobronchopne
44、umonitis.Pathophysiology:Theviralinfectionthatcausescroupleadstoswellingofthelarynx,trachea,andlargebronchiduetoinfiltrationofwhitebloodcells;(especiallyhistiocytes,lymphocytes,plasmacells,andneutrophils).Swellingproducesairwayobstructionwhich,whensignificant,leadstodramaticallyincreasedworkofbreath
45、ingandthecharacteristicturbulent,noisyairflowknownasstridor.Diagnosis:clinicaldiagnosis.Thefirststepistoexcludeotherobstructiveconditionsoftheupperairway,especiallyepiglottitisThemostcommonlyusedsystemforclassifyingtheseverityofcroupistheWestleyscore.Treatment:Childrenwithcrouparegenerallykeptascalm
46、aspossible.Steroidsaregivenroutinely,withepinephrineusedinseverecases.Childrenwithoxygensaturationsunder92%shouldreceiveoxygen,andthosewithseverecroupmaybehospitalizedforobservation.Ifoxygenisneeded,blow-byadministration(holdinganoxygensourcenearthechildsface)isrecommended,asitcauseslessagitationtha
47、nuseofamask.Withtreatment,lessthan0.2%ofpeoplerequireendotrachealintubation.Steroids:Corticosteroids,suchas;dexamethasoneandbudesonide,havebeenshowntoimproveoutcomesinchildrenwithallseveritiesofcroup.However,significantreliefisoftennotobtainedforuptosixhoursafteradministration,andlastsforonlyabout12
48、hours.Whileeffectivewhengivenorally,parentally,orbyinhalation,theoralrouteispreferred.Asingledoseisusuallyallthatisrequired,andisgenerallyconsideredtobequitesafe.Dexamethasoneatdosesof0.15,0.3and0.6mg/kgappeartobeallequallyeffective.Epinephrine:Moderatetoseverecroupmaybeimprovedtemporarilywithnebuli
49、zedepinephrine.Whileepinephrinetypicallyproducesareductionincroupseveritywithin1030minutes,thebenefitslastforonlyabout2hours.Iftheconditionremainsimprovedfor24hoursaftertreatmentandnoothercomplicationsarise,thechildistypicallydischargedfromthehospital.Epiglottitis:isinflammationoftheepiglottis-thefl
50、apthatsitsatthebaseofthetongue,whichkeepsfoodfromgoingintothetrachea(windpipe).Duetoitsplaceintheairway;swellingofthisstructurecaninterferewithbreathingandconstitutesamedicalemergency.Theinfectioncancausetheepiglottistoeitherobstructorcompletelycloseoffthewindpipe.Symptoms of Epiglottitis:Therearema