(2/21) Wenzler Lecture: Upper Respiratory Tract Infections & Acute Bronchitis Upper Respiratory Tract Anatomy: Includes the Ear, Nose, Sinuses, Pharynx, Larynx, and Trachea. Anything below the larynx is a lower respiratory tract infection, with bronchitis being a special exception (chill, you’ll see) Sinusitis: An inflammatory disorder of the paranasal sinuses. The paranasal sinuses are coated in a sterile fluid and lined with pseudostratified columnar epithelium. There are 4 pairs of paranasal sinuses. The maxillary sinus is the most commonly infected due to muco-ciliary clearance being the only defense against gravity. The dominant pathogens causing sinusitis have not changed for the past many decades. Thanks to vaccines reducing their prevalence, the incidence of pneumonia and influenza has gone down greatly. Sinusitis diagnosis is categorized by the duration of Sx

- Techniques to Diagnose: Imaging is not recommended. Cultures not recommended. Duration of Sx is key factor. - Acute Infection: S. pneumoniae, H influenzae, M catarrhalis… sometimes Viral…. Rarely fungal.. Sinusitis is

most commonly secondary to an initial insult, such as a viral URTI or allergies impairing ciliary clearance o Viral causes depend on the season and the age of the patient o Acute Bacterial: Sure they’re infected, but it is self-limiting, in 10 days they will not be sick.

§ Sx: Congestion and Discharge - Chronic Infection (12w+): Almost never an infectious process, most often Allergy. Less often Aspergillis (fungi,

slow-growing mold). Time to see an allergist or get out the anti-fungals - Nosocomial: S. aureus. Referring to hospital-acquired. Ignore this. Rarely happens due to new tubing techniques. - Viral Infection: Typical duration of Sx is 5-10 days, peaking at 3-6 days.

o Sx: Mild Fever (<102º F, < 38.9 C), Congestion and Discharge. Purulent or thick discharge DOES NOT differentiate between viral and bacterial.

- Risk Factors: Debris capable of inducing mucosal swelling/obstruction (smoking, cocaine, viral products). o Negative pressure: Negative pressure in the sinuses will propel the bacteria-coated nasal passage

inhabitants into the sinuses. This can be due to obstructive debris or blowing your nose violently. o Epidemiology: Women are 2x more likely than men to be affected

- Fun fact: The number 1 prescribed antibiotic for Sinusitis is Zpak, even though it has very poor coverage. ‘80% of patients complaining of sinusitis receive an abx Rx, 70% of which are inappropriate.’

Treating Sinusitis - Viral: In 10 days they will not be ill. Find them a box of tissues PRN nose-blowing - Acute Bacterial Sinusitis: We prefer not to treat. Consider observing for 3 days before treating.

Criteria for treatment include: o (1) Persistence of Symptoms for ³ 10 days o (2) Severe Symptoms such as Fever ³ 102ºF, Facial pain lasting 3-4 consecutive days o (3) Double Sickness: General initial viral infection, improve, then BOOM new onset fever/HA/discharge

n Adult à Augmentin 875mg q12º x5-7 days or Amoxicillin 500/875mg q12º x5-7days § PCN ALL: Levofloxacin 500mg Qdaily x5-7 days

n Pediatric à Amoxicillin 40-80mg/kg/day div. q12º x10-14 days § PCN ALL: Levofloxacin 16mg/kg/day div.q12 x10-14 days

o Adjunctive Tx: Saline nasal spray. Surgery for polyp removal if necessary o Prevention Tx: Vaccination, Smoking cessation

CONDITION 2 random words Common Cause Purpose of Abx Tx Dx Tx PCN ALL TX

Sinusitis Pressure + Discharge

S. pneumoniae H. influenzae M. cattarhalis

Should Not. But will reduce rate of sx. Little benefit

Severe = ³10d, T³102, Double Sickness

Adult: Amox or Augmentin, 5-7d Child: Amox, 10-14d

Levofloxacin Moxifloxacin

Pharyngitis Rheumatic Exudates

Group A Step (GAS)

Prevent Rheumatic Fever

Risk of Infection scoring table

Adult: PCN, BID Child: PCN, BID Tx for 10 days.

Macrolide

Bronchitis Viral Cough Viral Distinguish from pneumonia

Rapid Antigen Test

Symptomatic N/A

Pharyngitis: Most commonly occurring during the winter and early spring, pharyngitis can be primary or secondary syndrome, most of which is self-limiting. Children are affected the most, with a prevalence of 41% in the US each year versus 16% adults. Pharyngitis is a concern due to the potential of post-streptococcal syndromes, namely rheumatic fever

- Sx: ‘Triad’- Sore Throat, Fever, Pharyngeal Inflammation. Additionally, patients may have erythema, exudates, vesicles, ulcerations

- Dx: Due to viral/bacterial overlap in terms of symptoms, accurate dx cannot be based on clinical characteristics

o à A point system has been developed to determine eligibility for treatment - GAS: Group A Streptococci (+) most common bacterial cause, worried about S. pyrogenes

o GAS: Infection caused by GAS is the greatest concern due to an association with Rheumatic Fever (RF) and other post-streptococcal syndromes. GAS have multiple virulence and immune avoidance factors. RF pyrogenes produces a multitude of mediators that attack heart valves, joints, and meninges. We must treat pharyngitis to prevent RF from occurring.

§ Sx: Tonsillar swelling + gray/white exudate), sudden onset fever, HA, GI Sx, Rash

• Anterior cervical lymphadenopathy – swelling of lymph nodes by cervix-neck

- Other: Gram(-) Anaerobes, atypical but notable is chlamydia pneumoniae o Viral: Presents moreso as systemic sx, such as full-body malaise,

fever, HA, sore throat, lymphadenopathy, conjunctivitis, oral ulcers, cough, diarrhea (Bacterial is localized to throat)

Treating Pharyngitis: Though there are conflicting arguments among the IDSA, CDC, and ACP, assessment of the risk factors suggests empiric therapy is required for the prevention of potential Rheumatic Fever if sufficient criteria are met. The goal of treatment is to reduce time to resolution, decrease contagiousness, and reduce the risk of sequelae

n GAS Adult à Penicillin V 500mg BID x10days or Amoxicillin 25mg/kg BID (max 500) x10 days o PCN ALL: Macrolides (erythromycin) and first-generation cephalosporins for 10 days

n GAS Pediatric à Penicillin V 250mg BID/TID x 10 days or Amoxicillin 25mg/kg/BID (max 500) x10 days o PCN ALL: Macrolides (erythromycin) and first-generation cephalosporins for 10 days o Caveat: Children < 3yo are not at risk of RF due to the development of their immune system

- Adjunctive NSAIDs may be used Acute Bronchitis: Clinical syndrome distinguished by brief, self-limiting inflammatory processes of the large and mid-sized airways. It is located below the larynx, but above the lungs just before the bronchial split.

- Epidemiology: Affects 5% of Americans annually, most commonly in the winter months and in kids < 5yo - Etiology: Primarily caused by viruses, and array of which depends on the season (Influenza, Rhinovirus,

coronavirus, etc). The specific microbial cause is rarely identified due to the relative difficulty. o Again, less than 10% of cases are bacterial, but boom, here they are (atypical)

§ Mycoplasma pneumoniae § Chlamydia pneumoniae § Bodatella pertussis

- Sx: The dominant symptom is a productive or dry cough that persists. Overall, the sx overlap with common cold, pneumonia, and asthma, making it difficult to diagnose – congestion, rhinitis, sore throat, malaise, mild fever

- Dx: The primary goal of diagnosis is to discriminate from pneumonia. While we do not traditionally treat bronchitis with abx, pneumonia MUST be treated with abx.

o Condition suggesting absence of pneumonia: RR < 24, HR < 100, Afebrile, Clean CXR o Rapid Ag Detection test: Nasopharyngeal swab for influenza and RSV

Treatment of Acute Bronchitis - Symptomatic tx: Involves addressing the cough, however cough treatment has NEVER shown to help an

infection (expectorants, antihistamines, decongestants, beta2- agonists. - Influenza-Infection: Ceramidase inhibitors (Tamiflu) help but nothing special. - Antibiotic Tx: Definitively shown to offer no benefit.

o Bordatella Pertussis: Abx decrease transmission rate, but do not affect sx resolution. Get Tdap!