Diagnosis and treatment of URTI

UPPER RESIRATORY TRACT INFECTIONS IN CHILDREN , ACUE PHARYGITIS , COMMON COLD , ACUTE SINUSITIS , ACUTE OTITIS MEDIA , APPROACH TO PATIENT WITH URTI , MANAGEMENT OF URTI IN CHILDREN

1. Diagnosis And Treatment Of URTIs Guidelines And Recommendations Sayed Ismail , MD Professor of pediatrics [email protected]

2. بسم الله الرحمن الرحيم

3. Objectives What Are The common URTI ? The guidelines in d iagnosis of common URTI The guidelines in treatment of URTI

4. Upper respiratory tract infection (URTI) The upper respiratory tract includes airways outside the thorax The sinuses Nasal passages Middle ear Pharynx Larynx

5. UTRI Nasopharyngitis ( the common cold) Pharyngitis AOM Rhinosinusitis (sinusitis) Parapharyngeal abscess Epiglottitis Laryngitis Croup

6. Viruses cause 80–90% of childhood respiratory infections. Bacteria Strep. Pyogenes Strept . Pneumoniae H influenzae M catarrhalis staph aureus , pseudomonas Mixed aerobes and anaerobes Pathogens of URTI

7. Frequency of Different Viruses Detected in Nasopharyngeal Swabs of Children With URTI in 2009-2010 Archives of Pediatric Infectious Diseases. 2012 October ;

8. What are The 4 most frequent URTIs ? The common cold Pharyngitis and Tonsillitis Acute otitis media Sinusitis Shaun et al, Annals of Clinical Microbiology and Antimicrobials 2004

9. Common cold

10. Common Cold Commonest Viral URTI The body can never build a solid resistance to it ( changes in antigenicity) › 200 viruses Rhinovirus Coronavirus RSV Parainfluenza virus Influenza virus Metapneumovirus Adenovirus coxsackieviruses , Others Heikkinen T, Jarvinen A. The common cold. Lancet. 2003;361:51-59.

11. Rhinorhea early watery Later , thicker and darker. Nasal obstruction Difficulty in feeding in infants as their noses are blocked and this obstructs breathing Mild or no Fever Cough Sore Throats Sneezing Duration 4-10 days Heikkinen T, Jarvinen A. The common cold. Lancet. 2003;361:51-59.

12. Colds in healthy school children . Pappas et al, Pediatr Infect Dis J 2008

13. Complications Acute exacerbations of asthma Secondary bacterial infections 2% of colds are complicated Rhinosinusitis Otitis media .. Most common Pneumonia

14. Differential Diagnosis Of Cold Allergic rhinitis Influenza (Flu) Acute bacterial Sinusitis

15. 1- How can I tell that this is a Cold not a Flu? Colds Flu 1- No or low grade fever High fever 2- No or mild systemic manifestations Systemic manifestations

16. 2- Features Suggestive Allergic rhinitis Prolonged sneezing . Redness, swelling and itching of the eyes Itchy and runny nose Itchy throat , Itchy skin Dennie's lines Allergic shiners . (bluish-brownish discoloration around the eyes ) Dennie's lines

17. Allergic crease Allergic shiners.

18. Treatment of cold Symptomatic : Analgesics Antihistamines Decongestants Antitussives

19. Antibiotics Delayed antibiotics for complications of colds

20. 70% of GP and 50% of Pediatricians prescribe antimicrobial agents if mucopurulent nasal secretions seen in first days of cold. Indeed, purulent sputum production is a normal part of viral infection Color and opacity do not reliably distinguish viral from bacterial illness. Nyquist et al, JAMA. 1998;279:875-877

21. Acute Pharyngitis

22. Pathogen Disease Strep. Pyogenes Tonsillitis and scarlet fever Mixed aerobes and anaerobes Pharyngitis , Parapharyngeal abscess Epstein- barr virus Rhinovirus/ coronavirus Coxsackie virus Herpes simplex virus Adenovirus Infectious mononucleosis Common cold Herpangina Gingivostomatitis Pharyngoconjunctival fever Bartlett, 1997

23. Causative organisms of pharyngitis < 3 years ≤ 100 % viral 5-15 years 15-30 % GABHS Adult 10 % GABHS GABHS = GROUP A BETA HEMOLYTIC STREPTOCOCCUS

24. Sore throat Cough Rhinorrhea Hoarseness Conjunctivitis Red throat → Oral vesicles, ulcers

25. Clinical Diagnosis History Examination Pharyngeal exudates Enlarged and tender cervical node. Tonsillopharyngeal erythema Red uvula Palatal petechiae 3- Lab . Rapid diagnostic tests , if negative Throat culture. Leung et al , Expert Rev Mol Diagn. 2006 Sep;6(5):761-6 Canada

26. Scarlet Fever

27. Scarlet fever Desquamation Toward the end of the first week of illness, the rash begins to fade and is followed by a desquamation over the trunk, which progresses to the hands and feet.

28. Patient Characteristic Points History of fever or temperature >38ºC +1 Absence of Cough +1 Tender Anterior Cervical Adenopathy +1 Tonsillar Swelling or exudates +1 Age <15 years +1 Age >45 years -1 Score % Likelihood of GAS -1 or 0 2-3 1 4-6 2 10-12 3 27-28 4 or 5 38-63 Score Suggested Management -1 or 0 No antibiotics or culture required 1 No antibiotics or culture required 2 Culture all; treat patients with positive results 3 Culture all; treat patients with positive results 4 or 5 Treat with antibiotics without culture Clinical decision rule for streptococcal pharyngitis

29. Clin Infect Dis 2012 ; 55:1279 To optimise the use of antibiotics, in 2012 the Infectious Diseases Society of America (IDSA) recommended the use of pharyngeal swabs to take samples for bacterial cultures or rapid diagnostic tests because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis Recommendation:

30. Leung et al , Expert Rev Mol Diagn. 2006 Sep;6(5):761-6 Canada.

31. What about antistreptolysin O titer? Streptococcal antibodies ( antistreptolysin O) levels do not peak until 4-5 weeks after the onset of pharyngitis . Therefore, testing for these antibodies has no role in the diagnosis of acute pharyngitis

32. Differential diagnosis of Pharyngitis Strep. Pyogenes Tonsillitis Viral Pharyngitis EBV (Infectious mononucleosis) Coxsackie virus ( Herpangina) Herpes simplex virus (Gingivostomatitis) Adenovirus (Pharyngoconjunctival fever ) Rhinovirus / coronavirus ( cold)

33. Viral Pharyngitis Strep. Pharyngitis Sore throat Conjunctivitis Nasal discharge Cough Diarrhea Ulcers Sore throat Fever Headache Abdominal pain, vomiting Tender, enlarged L nodes Palatal petechiae Patient aged ≥ 3 S.Ismail

34. Viral versus bacterial Pharyngitis A B

35. Pharyngoconjunctival fever (Adenovirus)

36. The throat is red and tonsils covered with a whitish material. Enlarged lymph nodes HSM Fatigue. EBV and streptococcal tonsillitis appear quite similar. A throat culture and blood studies may be necessary to make an accurate diagnosis. Infectious Mononucleosis

37. This patient with infectious mononucleosis had been placed on ampicillin which resulted in a macular- papular skin rash Cervical lymphadenopathy

38. Streptococcal Pharyngitis Infectious Mononucleosis Cervical adenopathy No splenomegaly or Hepatomegaly Fatigue is less prominent Lab. Rapid diagnostic tests Throat culture CBC Generalised lymphadenopathy HSM Fatigue Lab. Blood smear CBC Monospot test Serology Petechiae are present on the posterior hard palate

39. Scarlet fever DD Typical scarlet fever is not generally difficult to diagnose, but it may be confused with: Roseola Kawasaki syndrome Drug eruptions Toxigenic S aureus infections .

40. Roseola Appears first on chest and abdomen Rose-colored May spread to arms, legs, neck, and face Lasts for a few hours to a few days and does not itch Scarlet fever

41. Kawasaki syndrome (a) Red, cracked lips and conjunctival inflammation. (b) Peeling of the fingers, which developed on the 15 th day of the illness.

42. Drug eruptions (dermatitis medicamentosa ) erythematous , morbilliform or maculopapular ), urticaria , fixed drug eruptions, and erythema multiforme are the most common. urticarial reaction from Augmentin

43. Toxic Shock Syndrome Dx : 5/6 Critera : Fever, rash, hypotension, 3 or more organs involved

44. Ulcerative stomatitis Mucosal ulcers, erosions, vesicles: HSV Coxsackievirus

45. Coxsackievirus , ( herpangina )

46. Foot and mouth disease Coxsackie virus

47. Vesicles with ulceration in gingivostomatitis . 3 year old boy with primary herpetic infection

48. Kissing" Tonsils Difficulty breathing, including loud snoring, gasping, and even sleep apnea resulting in fatigue due to enlarged tonsils and/or adenoids

49. 49 PARAPHARYNGIAL ABCESS

50. Penicillin remains the drug of choice Single-dose IM of benzathine penicillin is effective Alternative choices : Cephalexin ,Erythromycin ,clarithromycin or azithromycin For recurrent cases Clindamycin or Amoxicillin- clavulanic acid for 10 days Bisno et al, Infectious Diseases,Society of America. Clin Infect Dis 2002;35:113-25.

51. Disease Features S. Pyogenes Scarlet fever Cold Nasal obstruction, discharge Influenza Cough & fever ,systemic symptoms Adenovirus Conjunctivitis EBV Splenomegaly & lymphadenopathy HSV Stomatitis or vesicles Coxsackie virus Para influenza Hand , mouth and foot disease Hoarseness , Croup Hints to Determine Cause of Pharyngitis S.Ismail

52. Acute Otitis M edia

53. 53 Acute Otitis Media

54. AAOP criteria for diagnosis of OM Pediatrics. 113(5):1451-65, 2004 May.

55. Normal Tympanic Membrane is a semi-transparent The "cone of light“ Acute otitis media Red bulging No cone of light

56. AOM

57. Purulent discharge due to middle ear infection

58. A otitis M with perforation

59. American Academy of pediatrics Pediatrics 2004;113:1451

60. wax FB

61. Fever, earache are present in (90%) of AOM cases. Present in 72% children without AOM. So, clinical history alone is poorly predictive of the presence of AOM. Niemela et al Pediatr Infect Dis J. 1994;13 :765 –768

62. Modality Comments Acetaminophen, ibuprofen For mild to moderate pain, mainstay of pain management for AOM   Benzocaine ( Auralgan , Americaine Otic ) Additional but brief benefit over acetaminophen in patients >5 y  Naturopathic agents ( Otikon Otic Solution) Comparable with ametocaine / phenazone drops ( Anaesthetic ) in patients >6 y Narcotic analgesia with codeine or analogs For moderate or severe pain; requires prescription; risk of respiratory depression Tympanostomy / myringotomy Requires skill and entails potential risk PEDIATRICS Volume 131, Number 3, March 2013

63. Treatment of ear infections

64. PEDIATRICS Volume 131, Number 3, March 2013

65. Criteria for Initial Antibacterial-Agent Treatment in Children With AOM Severe AOM ( bilateralor unilateral) in children 6 months and older with severe signs or symptoms ( ie , moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C or higher). Non severe bilateral AOM in young children : 6 months - 23 months of age PEDIATRICS Volume 131, Number 3, March 2013

66. Criteria for Initial Antibacterial-Agent Treatment or Observation in Children With AOM Non severe unilateral AOM in young children : The clinician should either prescribe antibiotic therapy or offer observation with close follow-up for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. Nonsevere AOM in older children : children 24 months or older without severe signs or symptoms ( ie , mild otalgia for less than 48 hours and temperature less than 39°C PEDIATRICS Volume 131, Number 3, March 2013

67. Initial Antibacterial Treatment Initial Antibacterial-Treatment or Observation in Children Severe AOM Non severe bilateral AOM in young children Non severe unilateral AOM in young children (6-24mo) Nonsevere AOM in older children( more than 24mo) Criteria for Initial Antibacterial-Agent Treatment or Observation in Children With AOM PEDIATRICS Volume 131, Number 3, March 2013

68. PEDIATRICS Volume 131, Number 3, March 2013

69. Treatment course: 10 days : younger children, children with severe disease 5~7 days :children 6 years of age and older with mild to moderate disease Pediatrics. 113(5):1451-65, 2004 May.

70. Acute Sinusitis

71. Acute severe bacterial sinusitis Purulent nasal discharge for 3 days with: Toxic appearing child. High Fever ≥ 39º C Persistent nasal discharge for greater than 10 days + Persistent daytime cough > 10 days NEW Sinusitis Guideline 2012 : IDSA Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral (URI) that lasted 5–6 days and were initially improving (‘‘double sickening’’)

72. Periorbital cellulitis It should be treated promptly with intravenous antibiotics to prevent spread into the orbit.

73. Indication First-line (Daily Dose) Second-line (Daily Dose) Initial empirical therapy Amoxicillin- clavulanate (45 mg/kg/day PO bid) Amoxicillin- clavulanate (90 mg/kg/day PO bid) b-lactam allergy Type I hypersensitivity Non–type I hypersensitivity Levofloxacin ( 10–20 mg/kg/day PO every 12–24 h) Clindamycina (30–40 mg/kg/day PO tid ) plus cefixime ( 8 mg/kg/day PO bid ) or cefpodoxime (10 mg/kg/day PO bid) Severe infection requiring hospitalization For IV antibiotic Ampicillin/ sulbactam (200–400 mg/kg/day IV every 6 h) Ceftriaxone (50 mg/kg/day IV every 12 h) Cefotaxime (100–200 mg/kg/day IV every 6 h) Levofloxacin (10–20 mg/kg/day IV every 12–24 h) IDSA Guideline for ABRS ,2012 Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in children

74. Indication First-line (Daily Dose) Second-line (Daily Dose) Initial empirical therapy Amoxicillin- clavulanate (500 mg/125 mg PO tid , or 875 mg/125 mg PO bid) Amoxicillin- clavulanate (2000 mg/125 mg PO bid) Doxycycline (100 mg PO bid or 200 mg PO qd ) b-lactam allergy Doxycycline (100 mg PO bid or 200 mg PO qd ) Levofloxacin (500 mg PO qd ) Moxifloxacin (400 mg PO qd ) Severe infection requiring hospitalization Levofloxacin (500 mg PO or IV qd ) Moxifloxacin (400 mg PO or IV qd ) Ceftriaxone (1–2 g IV every 12–24 h) Cefotaxime (2 g IV every 4–6 h) IDSA Guideline for ABRS ,2012 Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in adults

75. Algorithm for the management of acute bacterial rhinosinusitis IDSA Guideline for ABRS ,2012

76. Differential diagnosis of sinusitis Recurrent URTI Allergic rhinitis Enlarged adenoids Deviated nasal septum, choanal atresia, nasal polyp, FB S. Ismail 2013

77. Diagnosis Drug of Choice Alternative Common cold No antimicrobials Acute pharyngotonsillitis Penicillin V Benzathine penicillin Clindamycin 1st Cephalosporins Azithromycin Acute otitis media Amoxicillin (high dose) Amoxicillin/clavulanate 2nd or 3 rd Cephalosporins Acute sinusitis Amoxicillin- clavulanate Amoxicillin (low dose) Amoxicillin/clavulanate (High dose) 3nd Cephalosporins + clindamycin Antimicrobial Therapy Guidelines for URTI in Children

78. Thank you