10 – RESPIRATORY TRACT INFECTIONS 1 (PHARYNGITIS, OTITIS, SINUSITIS) (2/14/25)

Describe what are the causes of PHARYNGITIS.

• Viruses are the MOST COMMON cause of Pharyngitis

• BUT Bacteria can also cause Pharyngitis which is usually due to STREPTOCOCCUS PYOGENES (Group A Streptococcus)

Describe what are common symptoms of PHARYNGITIS. Which are more common among Bacterial vs, Viral?

EITHER Viral or Bacterial

• Sudden Sore Throat

• Pain Upon Swallowing

More towards BACTERIAL Pharyngitis

• Tonsillar Erythema (Redness) and Swelling

• Enlarged Lymph Nodes

• Fever

More towards VIRAL Pharyngitis

• Conjunctivas

• Coughing

• Congestion

What are COMPLICATIONS that can occur from Untreated GAS Pharyngitis?

SUPPURATIVE COMPLICATIONS

• This is pus-forming

• This is an extension of the current infection that expands to Peritonsillar Abscess, Retropharyngeal Abscess, and rarely Brain Abscess

NON-SUPPURATIVE COMPLICATIONS

• This is non-pus forming

• This is an immune response TO the Group A Streptococcus (Streptococcus Pyogenes) antigens. These antibodies can then cross-react with Host Tissues resulting into:

  • Acute Rheumatic Fever

    • This immune response can cause damages to the Mitral Valve of the Heart

  • Acute Glomerulonephritis

    • This immune response causes complexes of these antibodies to deposit in the Kidneys, causing damage.

What are Diagnostic Tests for GAS Pharyngitis?

• Clinical Presentation based on symptoms more associated with GAS Pharyngitis

• Rapid Antigen Detection Tests (RADT)

  • These are most convenient as they provide results in minutes, with HIGH SPECIFICITY but slightly LOW SENSITIVITY

  • Because of this, a POSITVE TEST ensures that there is an infection. BUT a NEGATIVE TEST does NOT always indicate an infection

    • If a Child tests Negative, it is recommended to confirm this with a THROAT CULTURE

• Throat Cultures

  • These are the gold standard for Diagnostics, but it is less convenient due to the turnaround time being about 24-48 hours.

Explain the process in determining whether a Pharyngitis case will need Antibiotic Treatment or not.

FIRST DETERMINE IF THEY HAVE SIGNS/SYMPTOMS OF GAS PHARYNGITIS

• If they present with Fever, Lack of Cough/Congestion, Tonsil Exudates, Swollen Lymph Nodes then:

  • Perform a RAPID ANTIGEN DETECTION TEST

    • If POSITIVE, then provide ANTIBIOTIC TREATMENT

    • If NEGATIVE, then test THOAT CULTURE (if child) or just provide Symptomatic Therapy (if adult)

      • If THROAT CULTURE is NEGATIVE, then just provide Symptomatic Treatment.

      • If THROAT CULTURE is POSITIVE then Antibiotic Treatment is needed.

• If they present with Congestion, Coughing, or Conjunctivas then:

  • Provide SYMPTOMATIC TREATMENT (NSAIDs or APA)

If Antibiotic Treatment is chosen for PHARYNGITIS, which antibiotics are used?

FIRST-LINE

• Penicillin V ± Symptomatic Treatment (NSAIDs or Acetaminophen)

• Amoxicillin ± Symptomatic Treatment (NSAIDs or Acetaminophen)

SECOND-LINE

• 1st Generation Cephalosporin (Cephalexin) ± Symptomatic Treatment (NSAIDs or Acetaminophen)

• 2nd Generation Cephalosporin (Cefuroxime) ± Symptomatic Treatment (NSAIDs or Acetaminophen)

• Macrolide ± Symptomatic Treatment (NSAIDs or Acetaminophen)

• Clindamyin ± Symptomatic Treatment (NSAIDs or Acetaminophen)

Describe what are the causes of SINUSITIS

• Sinusitis is more commonly VIRAL, but bacterial infections can occur as well

• Bacterial Sinusitis is often caused by:

  • Streptococcus Pneumoniae (most common)

  • Haemophilus Influenzae (most common)

  • Streptococcus Pyogenes

  • Moraxella Catarrhalis

Describe what are common symptoms of SINUSITIS. Which are more common among Bacterial vs, Viral?

EITHER VIRAL or BACTERIAL

• Facial Pressures/Congestion

• Nasal Congestion

• Purulent Nasal Discharge

• Decreased Sense of Smell

• Cough

More towards BACTERIAL SINUSITIS

• Facial Pains

• Headache

• Fever

What are Risk Factors for developing BACTERIAL SINUSITIS?

• Prior or Concomitant Viral URTI

  • This is the MAIN CAUSE of Bacterial Sinusitis

  • This is due to the Viral URTI causing Congestion, which leads to poor sinus drainage. Normally, sinus drainage allows for clearance of sinus bacteria, but due to the congestion this can allow for BACTERIAL OVERGROWTH. This then causes a Bacterial Superinfection that then causes Bacterial Sinusitis that presents as:

    • “Double Worsening”

      • This is when Initial Symptoms (usually from Viral URTI) improve, then all of a sudden WORSEN (as indicated by a new onset Bacterial Sinusitis)

    • Severe Symptoms

      • Bacterial Sinusitis can present with much more SEVERE SYMPTOMS compared to Viral Sinusitis as patients can experience more Severe Facial Pain/Headaches and a Fever (>39F)

    • Prolonged Infection

      • Bacterial Sinusitis can cause LONGER INFECTIONS lasting from 12 - 21 days

• Allergies

• Decongestant Overuse

• Changing of Pressures (Diving or Flying)

What are Complications associated with BACTERIAL SINUSITIS?

• Complication are VERY RARE for Bacterial Sinusitis, but if it does occur, it will present as an expansion of the initial infection:

  • Periorbital Cellulitis

  • Meningitis

  • Brain Abscess

What are Diagnostic Tests for BACTERIAL SINUSITIS?

• Diagnosis is mainly based on Clinical Presentation:

  • Prolonged Symptoms lasting 10days or LONGER

  • Experiencing Double Worsening (worsening of symptoms despite initial improvement)

  • MAYBE Severe symptoms like Severe Facial Pain/Headache for 3-4days and/or Fever of >39F

• Laboratory Diagnostics are NOT useful in this case since all cultures will normally just present with the Normal Flora

Explain the process in determining whether a SINUSITIS case will need Antibiotic Treatment or not.

FIRST determine if they present with SIGNS/SYMPTOMS of BACTERIAL SINUSITIS:

• Prolonged symptoms lasting 10 days or more

• Experiencing Double Worsening (worsening of symptoms despite initial improvement)

• MAYBE Severe Symptoms like Severe Headache/Facial Pain lastinf 3-4days and/or Fever >39F

If they DON’T present with SIGNS/SYMPTOMS

• Provide SYMPTOMATIC TREATMENT

  • Analgesics (Acetaminophen)

  • Nasal Irrigation

  • Nasal Corticosteroids (MAYBE, but less likely)

If they DO PRESENT with SIGNS/SYMPTOMS then can do either:

• Watchful Waiting

  • Recommend the patient to monitor their symptoms, if there is NO IMPROVEMENT or it has WORSENED within 7 days, then provide Antibiotic Treatment

• IMMEDIATE Antibiotic Treatment

If Antibiotic Treatment is chosen for SINUSITIS, which antibiotics are used?

FIRST LINE OPTIONS:

• Amoxicillin (Preferred)

• Amoxicillin/Clavulanate

  • This is more reserved if the patient shows more signs of Haemophilus Influenzae or Moraxella Catarrhalis infections, indicated by:

    • History of H. Flu or Moraxella infections

    • FAILED Amoxicillin

SECOND LINE OPTIONS:

• More reserved for patients with increased RISK of Antibiotic Resistance:

  • Beta-Lactam Allergies

  • <2 or >65 of age

  • Recent Hospitalization or Antibiotic use within 30 days

• Then the options are:

  • Doxycycline

  • Levofloxacin

Describe what are the causes of OTITIS MEDIA

• Otitis Media can be either Viral or Bacterial, but can be more Bacterial

• If it is a Bacterial infection causing the Otitis Media then it is usually:

  • Streptococcus Pneumoniae

  • Haemophilus Influenzae

  • Moraxella Catarrhalis

Describe what are common symptoms of OTITIS MEDIA. Which are more common among Bacterial vs, Viral?

EITHER Viral or Bacterial

• Ear Pain (Ear Pulling)

• Reduced Hearing

• Irritation/Restlessness

More towards BACTERIAL OTITIS MEDIA

• Fever

More towards VIRAL OTITIS MEDIA

• Cough

• Nasal Congestion

What are Risk Factors for developing BACTERIAL OTITIS MEDIA?

• Recent or Prior Viral URTI

  • This is for reasons similar to Bacterial Sinusitis.

  • A Viral URTI causes inflammation that then blocks the normal drainage of the Eustachian Tube. This results in Bacterial Overgrowth causing a Bacterial Superinfection that leads to BACTERIAL OTITIS MEDIA

• Male

• Infants (6-18 months)

• Exposure to Secondhand Smoke or Allergens

• Lack Breastfeeding, more Bottle use or Pacifiers

• More in Day Care setting, or in a Crowded Living Space

What are Complications associated with BACTERIAL OTITIS MEDIA?

• Complications are VERY RARE but it can occur and present as expansion of the current infection:

  • Osteomyelitis of Mastoid and/or Temporal Bones

  • Labyrinthitis (inflammation of the Vestibular Apparatus)

  • Meningitis

  • Brain Abscess

What are Diagnostic Tests for BACTERIAL OTITIS MEDIA?

• Mainly based on Clinical Presentation:

  • Abrupt Onset of Ear Specific Symptoms (Ear Pain, Reduced Hearing, etc)

  • Bulging Tympanic Membrane (Indicates Fluid Build up in Middle Ear)

  • Erythematous Tympanic Membrane (Inflammation of Tympanic Membrane)

  • Otorrhea (Fluid discharge from middle ear)

• Laboratory Tests include Tympanocentesis which is very INVASIVE and Painful which is why it is NOT recommended

Explain the process in determining whether an OTITIS MEDIA case will need Antibiotic Treatment or not.

FIRST determine if there are SIGNS/SYMPTOMS of BACTERIAL OTITIS MEDIA:

• Age <2

• Severe Symptoms (Fever >39F, Severe Otalgia, Otalgia > 48hours)

• Signs of Otorrhea

IF they DON’T show SIGNS/SYMPTOMS can either:

• Provide immediate ANTIBIOTIC TREATMENT

• Provide SYMPTOMATIC TREATMENT

  • Acetaminophen OR Ibuprofen

  • Decongestant

  • Antihistamine

    • If there is NO RESPONSE in 48 HOURS then provide ANTIBIOTIC TREATMENT

    • If there is RESPONSE within 48 HOURS then just monitor

IF they DO SHOW SIGNS/SYMPTOMS

• Provide ANTIBIOTIC TREATMENT

If Antibiotic Treatment is chosen for OTITIS MEDIA, which antibiotics are used?

FIRST LINE

• Amoxicillin

SECOND LINE

• This is more reserved for patients who:

  • Had Amoxicillin within the past 30 days

  • Present with Purulent Conjunctivitis (this can indicate Haemophilus Influenza infection)

• If they have the ABOVE, then options are:

  • Amoxicillin/Clavulanate

  • PO 2nd Generation Cephalosporin (Cefuroxime)

    • If they CAN’T take Augmentin

  • IM Ceftriaxone

    • If they CAN’T take anything Orally, then this can be given as 1 dose