R t i ppt

respiratory tract infections

1. RESPIRATORY TRACT INFECTIONS Presented by; Aiswarya.A.T First year M.Pharm Dept. of Pharmacy Practice Grace College of Pharmacy

2. RESPIRATORY TRACT INFECTIONS Respiratory tract infections  refers to any of a number of infectious diseases involving the respiratory tract . It is classified in to 2 types they are: UPPER RESPIRATORY TRACT INFECTIONS LOWER RESPIRATORY TRACT INFECTIONS

3. AGENT FACTORS BACTERIA AGE GROUP AFFECTED CHARACTERISTIC CLINICAL FEATURES Bordetella pertussis Infants & young children Poroxysmal cough Corynebacterium diphtheriae Children diphtheria Hemophilus influenzae Adults Children Acute ex of ch bronchitis Acute epiglottitis Klebsiella pneumoniae Adults Lobar pneumonia Legionella pneumophila Adults Pneumonia Staph. pyogenes All ages Lobar and bronchopneumonia Strep. pneumoniae All ages Pneumonia Strep. pyogenes All ages Acute pharyngitis and tonsillitis

4. VIRUSES AGE GROUP AFFECTED CHARACTERISTIC CLINICAL FEATURES Enterovirus All ages Febrile pharyngitis Influenza A, B, C All ages variable Measles Young children variable Parainfluenza 1, 2, 3 Young children variable Respiratory Syncytial Virus Infants and young children Severe bronchiolitis and pneumonia Rhinovirus All ages Common cold Coronavirus All ages Common cold

5. LOWER RESPIRATORY TRACT INFECTIONS (LRTI) Inflammation of the air passages within the lungs. Trachea(windpipe),and the large & small bronchi(airways)within the lungs become inflamed because of the infection. The infections of LRT includes: BRONCHITIS BRONCHEOLITIS PNEUMONIA

6. Health care systems, Smoking, microorganisms, etc Inflammation Bradykinins , Histamines, Prostaglandins Increasing capillary permeability Fluid/ cellular exudation Oedema of mucous membrane Hypersecretion of mucous Persistant cough LRTI General Pathophysiology of LRTI

7. Inflammatory disease of the bronchi Peak age of onset : 6 months Occurs mostly in winter/spring BRONCHITIS

8. There are two types of bronchitis: Acute bronchitis Acute (i.e. recent onset) bronchitis is an inflammation of the lower respiratory passages (bronchi). 2. Chronic bronchitis Chronic bronchitis is defined as a cough that occurs every day with sputum production that lasts for at least 3 months, two years in a row.

9. CAUSES: Viral infection Bacteria Chemical irritants ( tobacco smoke, gastric reflux solvents)

10. SIGNS AND SYMPTOMS Cough persisting >5 days to wks Production of clear, white, yellow, grey, or green mucus (sputum) Wheezing Fatigue Chest pain or discomfort Blocked or runny nose Coryza , sore throat, malaise, headache Dyspnea , cyanosis, or signs of airway obstruction rarely Fever rarely >39°C

11. TREATMENT Acute bronchitis Aspirin or acetaminophen Ibuprofen In combination with antihistamines, sympathomimetics , and antitussives Hypnotics / sedatives in mild dose Routine antibiotic use is discouraged In elderly & immunocompramised patients, fluoroquinolones , azithromycin , amantadine or rimantadine (for influenza A), neuraminidase inhibitors e.g., zanamivir and oseltamivir (for both influenza A & B)

12. Chronic bronchitis

13. BRONCHIOLITIS Inflammatory disease of the bronchioles Peak age of onset : 6 months Male : female :- 2:1 Occurs mostly in winter Cause : Respiratory syncytial virus (RSV), Parainfluenza viruses type 3, type 1 and type 2. Bacteria serve as secondary pathogens in a minority of cases.

14. Signs and symptoms Prodrome with irritability, restlessness, and mild fever Cough and coryza Vomiting, diarrhea, noisy breathing, and increased respiratory rate as symptoms progress Labored breathing with retractions of the chest wall, nasal flaring, and grunting

15. TREATMENT Mainly supportive Oxygen inhalation If tachypneic , limit the oral feeds and use a nasogastric tube for feeding Parenteral fluids to limit dehydration Correct respiratory acidosis and electrolyte imbalance Bronchodilators for wheeze ( nebulized adrenaline) Mechanical ventilation (severe resp distress or apnoea )

16. Inflammation of the lung parenchyma and is associated with the consolidation of the alveolar spaces Developed world : Viral infections Low morbidity and mortality Š Developing world : Common cause of death Š ARI case management -WHO : 84% reduction in mortality Respiratory rate, recession, ability to drink Cheap, oral and effective antibiotics, Co- trimoxazole , amoxycillin Maternal education Referral PNEUMONIA

17. AGE GROUP CAUSATIVE ORGANISM NEONATES GROUP B STREPTOCOCCUS E.COLI KLEBSIELLA STAPH AUREUS INFANTS PNEUMOCOCCUS CHLAMYDIA RSV H.INFLUENZA TYPE b CHILDREN 1 TO 5 YRS RESPIRATORY VIRUSES PNEUMOCOCCUS H.INFLUENZA TYPE b C.TRACHOMATIS M.PNEUMONIAE S.AUREUS GP A STREPTOCOCCUS CHILDREN 5 TO 18 YRS M.PNEUMONIAE PNEUMOCOCCUS C.PNEUMONIAE H.INFLUENZA TYPE b

18. NO PNEUMONIA COUGH NO TACHYPNEA -HOME CARE -SOOTHE THE THROAT AND RELIEVE COUGH -ADVISE MOTHER WHEN TO RETURN -FOLLOWUP IN 5 DAYS IF NOT IMPROVING PNEUMONIA -COUGH -TACHYPNEA -NO RIB OR STERNAL RETRACTION -ABLE TO DRINK - NO CYANOSIS -HOME CARE -ANTIBIOTICS FOR 5 DAYS -SOOTHE THE THROAT AND RELIEVE COUGH -ADVISE MOTHER WHEN TO RETURN -FOLLOWUP IN 2 DAYS SEVERE PNEUMONIA -COUGH -TACHYPNEA -RIB AND STERNAL RETRACTION -ABLE TO DRINK -NO CYANOSIS -ADMIT IN HOSPITAL -GIVE RECOMMENDED ANTIBIOTICS -MANAGE AIRWAY -TREAT FEVER IF PRESENT VERY SEVERE PNEUMONIA -COUGH -TACHYPNOEA -CHEST WALL RETRACTION -UNABLE TO DRINK -CENTRAL CYANOSIS -ADMIT IN HOSPITAL -GIVE RECOMMENDED ANTIBIOTICS -OXYGEN -MANAGE AIRWAY -TREAT FEVER IF PRESENT WHO Classification and management

19. Significant risk factors are younger age (2-6 months), low parental education, smoking at home, prematurity, low birth weight, weaning from breast milk at < 6 months, a negative history of diphtheria, pertussis and tetanus vaccination, anaemia, malnutrition and overcrowding. Infection rate higher in siblings of school children who introduce infection in the household. Other risk factors Congenital lung cysts Chronic lung disease Immunodeficiency Cystic fibrosis Sickle cell disease Tracheostomy in situ HIGH RISK CHILDREN FOR PNEUMONIA

20. Community acquired Pneumonia Health care associated Pneumonia Pneumonia in HIV patients Pneumonia in neutropenic lost Hospital acquired Pneumonia / Nosocomial Pneumonia Ventilator associated Pneumonia Atypical Pneumonia/ Nonbacterial Pneumonia Legionella Pneumophila Mycoplasma Pneumonia Chlamydophila Pneumonia Viral Pneumonia Tuberculosis Severe Acute Respiratory Syndrome(SARS) H1 N1 influenza (swine flu) Avian influenza (bird flu) TYPES OF PNEUMONIA

21. BACTERIAL VIRAL MYCOPLASMIC ASPIRATION

22. FUNGAL

23. Many other causes of Pneumonia with Acute Respiratory Disease & Fever Plague Tularemia RICIN toxin Staphylococcal Enterotoxin B TB Legionella SARS S.Pneumoniae

24. TREATMENT ADULTS

25. Age Usual Pathogen(s) Presumptive Therapy 1 month Group B streptococcus, Haemophilus influenzae ( nontypeable ), Escherichia coli , Staphylococcus aureus , Listeria , CMV, RSV, adenovirus Ampicillin–sulbactam, cephalosporin carbapenem Ribavirin for RSV 1–3 months Chlamydia , possibly Ureaplasma , CMV, Pneumocystis carinii (afebrile pneumonia syndrome) RSV Pneumococcus, S. aureus Macrolide/azalide, trimethoprim- Sulfamethoxazole Ribavirin Semisynthetic penicillin or Cephalosporin 3 months– 6 years Pneumococcus , H. influenzae , RSV, adenovirus, parainfluenza Amoxicillin or cephalosporin Ampicillin–sulbactam, amoxicillin– clavulanate Ribavirin for RSV >6 years Pneumococcus, Mycoplasma pneumoniae , adenovirus Macrolide / azalide cephalosporin, amoxicillin– clavulanate PEDIATRICS

26. UPPER RESPIRATORY TRACT INFECTIONS (URTI) Upper respiratory tract infections (URI or URTI) are the illnesses caused by an acute infection which involves the upper respiratory tract; i.e. nose, sinuses, pharynx or larynx. It include otitis media, sinusitis, pharyngitis , laryngitis(croup), tonsillitis, rhinitis(Common cold), Diphtheria and epiglottitis .

27. General Pathophysiology of URTI Bacteria, viruses Direct hand-hand contact droplet infection Enters the nose by inhaling Immune defences Hair lining filters & trap some pathogens Traps in upper respiratory tract which coats by mucous Junction of the posterior nose to pharynx Impinge on the back of the throat Transport pathogens upto pharynx Inflammatory response to immune system Increased mucous secretion, fever, swelling, runny nose, etc..

28. OTITIS MEDIA Critical role of eustachian tube as conduit between nasopharynx , middle ear, and mastoid air cells Children have shorter, wider eustachian tubes than adults S. pneumoniae is the most common bacterial cause . Non typeable Haemophilus influenzae and Moraxella catarrhalis is also responsible. Bacterial organisms that have been associated less frequently with otitis media include Staphylococcus aureus , Streptococcus pyogenes , and gram-negative bacilli such as Pseudomonas aeruginosa .

29. Signs and symptoms Pain that can be severe Children may be irritable, tug on the involved ear, and have difficulty sleeping Fever is present in less than 25% of patients and, when present, occurs more often in younger children Examination shows a discolored (gray), thickened, bulging eardrum Pneumatic otoscopy or tympanometry demonstrates an immobile eardrum; 50% of cases are bilateral Draining middle ear fluid occurs (less than 3% of patients) that usually reveals a bacterial etiology

30. TREATMENT

31. SINUSITIS Community acquired bacterial sinusitis S.pneumoniae H. influenzae S. Pyogenes Nosocomial sinusitis Seen in critically ill, mechanically ventilated S. aureus Pseudomonas aeruginosa Serratia marcescens fungal

32. Signs and symptoms Acute: Adults Nasal discharge/congestion Maxillary tooth pain, facial or sinus pain that may radiate (unilateral in particular) as well as deterioration after initial improvement Severe or persistent (beyond 7 days) signs and symptoms are most likely bacterial and should be treated with antimicrobials Children Nasal discharge and cough for greater than 10 to 14 days or severe signs and symptoms such as temperature above 39°C (102.2°F) or facial swelling or pain are indications for antimicrobial therapy Chronic: Symptoms are similar to acute sinusitis but more nonspecific Rhinorrhea is associated with acute exacerbations Chronic unproductive cough, laryngitis, and headache may occur Chronic/recurrent infections occur three to four times a year and are unresponsive to steam and decongestants

33. TREATMENT

34. PHARYNGITIS Inflammatory syndrome of the pharynx( oro / nasopharynx ) Most cases are viral Most important bacterial cause is Streptococcus pyogenes Presents with sore or scratchy throat In severe bacterial cases there may be odynophagia , fever, headache

35. Signs and symptoms Sore throat Pain on swallowing Fever Headache, nausea, vomiting, and abdominal pain (especially children) Erythema /inflammation of the tonsils and pharynx with or without patchy exudates Enlarged, tender lymph nodes Red swollen uvula, petechiae on the soft palate, and a scarlatiniform rash Several symptoms that are not suggestive of group A Streptococcus are cough, conjunctivitis, coryza , and diarrhea

36. TREATMENT

37. RHINITIS/ COMMON COLD Children average 8 episodes per year, adults 3 episodes per year Etiologies : Rhinoviruses 30 to 35% Coronaviruses about 10% Miscellaneous known viruses about 20% Influenza and adenovirus-30% Presumed undiscovered viruses up to 35% Group A streptococci 5% to 10% Seasonal variation: Rhinovirus early fall Coronavirus - winter

38. Common symptoms are sore throat, runny nose, nasal congestion, sneezing, Sometimes accompanied by conjunctivitis, myalgias , fatigue

39. ACUTE EPIGLOTTITIS Life- threatning infection of the epiglottis, the aryepiglottic folds and arytenoid soft tissue Occurs mostly in winters Peak incidence :- 1 – 6 years Male affected more bacterial infection ( Hemophilus influenza type b) Concomitant bacteremia , pneumonia, otitis media, arthritis and other invasive infections caused by H.influenza type b may be present

40. INTRAVENOUS AMPLICILLIN 100 mg/kg/day OR CEFTRIAXONE 100 mg/kg/day . OTHER OPTIONS: (CEFUROXIME OR CEFOTAXIME) TOTAL TREATMENT :-7-10 DAYS CHOLRAMPHENICOL 50-75 mg/kg/day IV RIFAMPICIN PROPHYLAXIS TO CLOSE CONTACTS TREATMENT

41. TONSILLITIS Tonsillitis is a viral or bacterial infection in the throat that causes inflammation of the tonsils. Tonsils are small glands (lymphoid tissue) in the pharyngeal cavity. In the first six months of life tonsils provide a useful defense against infections. Tonsillitis is one of the most common ailments in pre-school children, but it can also occur at any age. Children are most often affected from around the age of three or four, when they start nursery or school and come into contact with many new infections. A child may have tonsillitis if he/she has a sore throat, a fever and is off food.

42. Symptoms Pain in the throat (sometimes severe) that may last more than 48 hours and be associated with difficulty in swallowing. The pain may spread to the ears. The throat is reddened , the tonsils are swollen and may be coated or have white spots on them. Possibly a high temperature. Swollen lymph glands under the jaw and in the neck. Headache. Loss of voice or changes in the voice.

43. Encourage bed rest. Introduce soft liquid diet according to the child's preferences. Provide cool mist atmosphere to keep the mucous membranes moist during periods of mouth breathing. Warm saline gargles & paracetamol are useful to promote comfort. If antibiotics are prescribed, counsel the child's parents regarding the necessity of completing the treatment period The controversy of tonsillectomy: Surgical removal of chronic tonsillitis (tonsillectomy) is controversial. Generally, tonsils should not removed before 3 or 4 yrs of age , because of the problem of excessive blood loss & the possibility of re-growth or hypertrophy of lymphoid tissue , in young children. TREATMENT

44. DIPHTHERIA Classic diphtheria ( Corynebacterium diphtheriae ): slow onset, then marked toxicity Arcanobacterium hemolyticum (formerly Cornyebacterium hemolyticum ): exudative pharyngitis in adolescents and young adults with diffuse, sometimes pruritic maculopapular rash on trunk and extremities

45. TREATMENT Symptomatic Penicillin for Strep throat Macrolides for penicillin allergic patients

46. CROUP/ LARYNGOTRACHEOBRONCHITIS Rhinorrhea , sore throat, mild cough, fever Parainfluenzae and influenza can be identified by nasopharyngeal swab Rapid tests are available Treat with vaporizers, nebulized adrenaline Systemic or nebulized corticosteroids in the severely sick

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