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Upper Respiratory Tract Infection

(URTI)

URT

Paranasal sinuses, nasopharynx, oropharynx, epiglottis, larynx

LRT

Trachea (windpipe), bronchial tubes, lungs, alveoli

Upper Respiratory Tract Infection (URTI) 1

 Defenses against URTI
there are a lot of MO in the air

most are harmless unless we are exposed to an infected px harboring large

numbers of pathogenic MO

reservoir

Mucociliary System (Escalator)

major barrier against infection

covers most of the bronchi, bronchioles, and nose

1st line of defense

2 basic parts

mucus-producing goblet cells

produces the sticky mucus to trap the MO

the mucus should be thin and slippery

brushing action of the cilia

cilia in the epithelium continually beating and pushing mucus up and

out into the throat

expel phlegm

The Flushing action of saliva

Upper Respiratory Tract Infection (URTI) 2

 Normal Flora of the Respiratory Tract
Common residents

50% of normal people

oral streptococci, Neisseria spp., Branhamella catarrhalis, Bacteroides

anaerobic cocci, Candida albicans, Streptococcus mutans, H. influenzae

Occasional residents

< 10% of normal people

Streptococcus pyogenes, Streptococcus pneumoniae, Neisseria meningitidis

Uncommon residents

< 1% normal people

Corynebacterium diphtheriae, Klebsiella pneumoniae, Pseudomonas*, E.

coli*, C. albicans*

*Especially after antibiotic treatment

opportunistic pathogens

colonize the body if the normal flora has been washed off

C. diphtheriae

Upper Respiratory Tract Infection (URTI) 3

 nonmotile, non-capsulated gram (+) bacillus organism that causes
diphtheria

diphtheria causes a thick covering in the back of the throat, which

could lead to difficulty in breathing, heart failure, paralysis, and death

DPT vaccine (diphtheria, pertussis, tetanus)

Residents in latent state in tissues, lungs, lymph nodes, etc

Pneumocystis carinii (now jirovecii), Mycobacterium tuberculosis,

Cytomegalovirus (CMV), Herpes Simplex Virus, Epstein –Barr virus

Upper and Lower Respiratory Tract

Nose to Alveoli is a continuum of infectious agents

dere-deretsong tube

post-nasal drip → sipon mapupunta sa throat

malilipat ung infection

preferred “focus” of infections

Coronaviruses and Rhinoviruses

nasopharynx

Parainfluenza viruses

can inflict the nasopharynx to give rise to a cold called “laryngotracheitis”

aka “croup” or “laryngotracheobronchitis”

swelling inside the trachea, which can interfere with normal

breathing and produce classic symptoms: barking cough, stridor
(difficulty in breathing), hoarseness of voice

bronchitis, bronchiolitis, or pneumonia

Upper Respiratory Tract Infections

Upper Respiratory Tract Infection (URTI) 4

 The Common Cold
Viruses — a common cause of colds

Rhinovirus and coronaviruses

cause more than 50% of colds

connected ang olfactory and taste senses naten so if inflamed ung olfactory
nerve, nawawala ung pang-amoy and panlasa

MOT = aerosol and also by virus-contaminated hands (fomites)

Diagnosis (Dx) of Common Colds

Lab tests are not worthwhile

cuz common colds that are viral in origin are self-limiting

Dx becomes important when the lower respiratory tract is involved (i.e

influenza viruses)

pedeng magkaroon ng pneumonia or other severe manifestation of the

disease

Detection of viruses

Antigens in exfoliated cells in nasopharyngeal aspirates

malalaman specific CA para specific treatment ang mabibigay

especially pag nagprogress sa LRT

Virus-specific antibodies

Treatment (Tx) of Common Colds

Symptomatic treatment

fever → antipyretic

pain → analgesic

congestion/allergies → nasal decongestant/antihistamines/intranasal

steroids

nasal decongestants are pharmaceutical products used to relieve

nasal congestion of the URT

Upper Respiratory Tract Infection (URTI) 5

 kasi namamaga ung NASA passage kaya there is the difficulty of
breathing (DOB)

Examples

Phenylephrine

Usually, resolve in 48 hrs

Antibiotics are ineffective for tx of the common cold and should not be
prescribed

cuz usually viral and pang bacteria yung antibiotics

Analgesics (NSAIDs) , Decongestants, Antihistamines

No vaccines for common colds

there are, however, vaccines for the influenza virus (flu)

2-17 yrs old → live attenuated quadrivalent flu vaccine

18-64 yrs old → quadrivalent influenza vaccine (injected)

there are vaccines for diff types of influenza — influenza A and B

viruses

Pharyngitis and Tonsilitis

70% of acute sore throats are caused by viruses

Symptoms usually go away around 3-4 days

Tx = rest, drink water to soothe the throat, paracetamol or ibuprofen, gargle w

warm salty water

Tx = antibiotic pag bacteria ang CA and may nana na (complication)

Pharyngitis

inflammation of the mucous membrane underlying tissue of the pharynx

occurs because the underlying mucosa is infected due to an inflammatory

or immune response in the lymphoid tissue

aka sore throat

Upper Respiratory Tract Infection (URTI) 6

 Tonsilitis

inflammation of the tonsils to alert the body of a foreign invader

infection of the tonsils at the back of our throat

Strep throat → caused by bacteria

Pharyngoconjunctival fever (PCF)

caused by adenovirus infecting the conjunctiva and the pharynx

acute and highly infectious illness characterized by fever, pharyngitis, and

acute follicular conjunctivitis (enlarged oracular and can affect the ear)

Epstein-Barr virus

multiplies locally in the pharynx to produce a sore throat

under Herpes Virus

Herpes Simplex and Coxsackie A Virus

multiply in the oral mucosa to produce painful lesions or ulcers

Coxsackie A Virus

from Picornaviridae family

CA of hand, foot, and mouth disease

disease common in children under 5 yrs old (anyone can get it)

not usually serious but very contagious

Sx

Upper Respiratory Tract Infection (URTI) 7

 fever, flu-like sx, painful mouth sores that start as small red
spots at the back of the mouth and blisters that eventually
become painful, skin rashes in the palms of the hands and
soles of the feet

OTC medications lang for fever and pain sa mouth sores

food and fluid intake should be monitored lalo na if di nakakakain yung

child dahil sa pain → confinement and IV electrolyte replenisher

Pharyngitis caused by bacteria

Streptococcus pyogenes

Streptococcal pharyngitis

most common and most important to diagnose because it can lead to a lot
of complications

can cause sore throat, chills, fever, headache, beefy red throat, white
patches with pus, enlarged tonsils, and enlarged and tender cervical
lymph nodes (malalaking lymph nodes sa leeg)

Tx = Penicillin

oral Penicillin for 10 days or IM Benzathine Penicillin

if allergic sa Penicillin, Macrolides and 1st generation

Cephalosporins are given

Macrolides = Erythromycin, Clarithromycin, Azithromycin

S. pyogenes usually develop resistance to macrolides so it is

considered the third line of drug lang ito

Upper Respiratory Tract Infection (URTI) 8

 Corynebacterium diphtheriae

Tx = administration of diphtheria antitoxin together w antibiotic

coverage

Haemophilus influenzae (type B)

causes severe epiglottitis with obstruction of the airways especially in

young children

responsible for severe pneumonia, meningitis, and other invasive diseases,

most exclusively in children aged less than 5 yrs old

Tx = Hib vaccine (Haemophilus influenzae type B vaccine)

vaccines are the only public health tool capable of preventing the
majority of serious illnesses by H. influenza type B

if di navaccine and nahawaan, antibiotics binibigay

3rd generation Cephalosporins = Cefotaxime, Ceftriaxone

Ampicillin w Chloramphenicol

Sx = inflammatory infection in the face, mouth, blood, peritoneum, trachea

Diagnosis (Dx)

EBV → presence of lymphocytosis, atypical and heterophile antibodies

HSV → clinical diagnosis

Bacterial → throat swabs especially in S. pyogenes infection

Complications of Streptococcus pyogenes

Peritonsillar abscess

collection of infected material

pus in the area around the tonsils

uncommon complications of untreated streptococcal sore throat

Otitis media, sinusitis, and mastoiditis

caused by the local spread of S. pyogenes

mastoiditis

Upper Respiratory Tract Infection (URTI) 9

 inflammation of the mastoid bone behind the ear

Scarlet fever

the organism produces toxins that spread through the body and localize in
the skin to induce a punctate erythematous rash, red tongue

toxin damages the plasma membrane of the blood capillaries under

the skin

blood capillaries rupture → Redness on the skin

2nd disease

Sx = exudative pharyngitis, fever, bright red exanthem caused by

streptococcal pyrogenic exotoxin

group A beta-hemolytic streptococci

can be found in the discharges from the nose, ears, throat, and skin

Tx

10 days course of antibiotics

DOC = Penicillin

if allergic sa Penicillin, Macrolides (erythromycin) or other

antibiotics

fever usually goes away within 12-24hrs when the px starts to take
antibiotic

px normally recovers 4-5 days after the start of the treatment

Upper Respiratory Tract Infection (URTI) 10

 Rheumatic fever

indirect complication

antibodies formed to antigens in the streptococcus cell wall cross-

react with the sarcolemma of the human heart and with tissues
elsewhere.

pag pabalik-balik na yung S. pyogenes, nagdedevelop yung body ng

antibodies that are not directed to the bacteria but to the sarcolemma of
the heart

Granulomas are formed in the heart 2 – 4 weeks after the sore throat
and then the patient develops myocarditis or pericarditis

granuloma — a small area of inflammation cuz of tissue injury

myocarditis — inflammation of the myocardium (heart muscle)

pericarditis — inflammation of the pericardium

common in children aged 5-15 yrs old

Sx = fever, muscle ache, swollen and painful joints, red rashes like scarlet
fever

Tx = eradicate the streptococcal infection

10-day course of antibiotic

Benzathine Penicillin (IM) in a single shot in a depot formulation

IM injection stays in the body for a long period of time — creates a

reservoir or depot of the drug

Penicillin hypersensitivity → Cephalexin is given

immediate yung Penicillin hypersensitivity → Azithromycin is

given cuz beta-lactam din si Cephalexin — orally daily for 5 days

Rheumatic Heart Disease (RHD)

Rheumatic fever can progress to RHD if left untreated

bacteria can damage the heart valves

Upper Respiratory Tract Infection (URTI) 11

 permanent damage in one or both of the heart valves — tricuspid
or bicuspid valve

due to recurrent and untreated streptococcal infection → heart

becomes inflamed and blood may flow backward (valves don't
close properly)

breathlessness, chest pain, weakness (cuz low O2 levels), edema

(swelling of the legs and face

Children have a genetic predisposition to this immune-mediated disease

The primary attack is accompanied by the elevation of antistreptolysin O

(ASO) antibody levels in the throat → Diagnosis

Penicillin for 10 days is used as prophylaxis throughout childhood to

prevent attacks

or other antibiotics if may Penicillin hypersensitivity

📌 Px who have previously contracted rheumatic fever, binibigyan na ng

continuous daily or monthly antibiotic tx (possibly for life) to
prevent future attacks of rheumatic fever and lowers the risk of heart
damage

If too severe, surgery may be required to replace or repair the

damaged valve

Acute glomerulonephritis or Acute post-streptococcal glomerulonephritis

(APSGN)

damage in the kidney

antibodies to strep components form circulating immune complexes,

which are deposited in the glomeruli

SIGNS AND SYMPTOMS

Blood appears in the urine (RBC, protein)

Upper Respiratory Tract Infection (URTI) 12

 Signs of acute nephritis syndrome (edema, HPN) 7-10 days after
the strep. pharyngitis

Otitis and Sinusitis

otitis — a general term for inflammation of the ear

Viruses are capable of invading air spaces associated with URT (sinuses,
middle ear, mastoid)

Mumps virus → can cause vestibulitis

Secondary bacterial invaders → S. pneumoniae & H. influenzae

Sometimes anaerobes Bacteroides fragilis

Upper Respiratory Tract Infection (URTI) 13

 Swelling of the eustachian (auditory) tube and opening of sinuses may cause
blockage

prevents mucociliary clearance of infection

local accumulation of inflammatory bacterial products

further swelling and blockage

Acute Otitis Media

aka “blue ear” or “luga” in Filipino

presence of exudates or sticky fluid because of severe infection

infected fluid in the middle ear occurs

inflammation in the middle ear and without reference to etiology (kahit

anong organism ang nagcause dun), common in children

purulent effusion and bulging of the tympanic membrane

swelling, fluid buildup, pressure on the eardrum → kaya sumasakit

50% caused by Viruses, S. pneumoniae, H. Influenzae

Sometimes caused by S. pyogenes or S. aureus

Extremely common in infants and small children because of the widely

open eustachian (auditory) tube

SIGNS AND SYMPTOMS

unexplained fever, diarrhea, vomiting

Upper Respiratory Tract Infection (URTI) 14

 eardrum shows dilated vessels with bulging of the drum at a later
stage

fluid persists in the middle ear for weeks or months “glue ear” →
impaired hearing and learning difficulties

Inadequate treatment may lead to suppurative otitis media — chronic

SIGNS AND SYMPTOMS

chronic discharge through the perforated drum

nagkakaroon ng perforation yung eardrum or tympanic

membrane with persistent drainage from the middle ear

can last for 6-12 weeks

impaired hearing

Tx

Amoxicillin is the first-line drug for otitis media.

effective second-line drug especially if resistant sa beta-lactam

Trimethoprim + sulfamethoxazole = Co-trimoxazole

Erythromycin, Cefaclor, Cefuroxime, Cefixime

Otitis Externa (external canal)

affecting the outer ear or ear canal

Causes:

Upper Respiratory Tract Infection (URTI) 15

 S. aureus, Candida albicans, and gm (-) opportunists

Bacterial flora is similar to the skin — staphylococcus, corynebacteria, and

to a lesser extent propionibacteria

Pathogens responsible for otitis media are rarely found in otitis external

SIGNS AND SYMPTOMS

irritation and pain

Moist warm environment favors the pathogens

Tx:

Ear drops containing Polymyxin or other antibiotics

otic solutions

Acute Sinusitis

often starts with a cold, and then turns into a bacterial infection → nagkakaroon
ng allergy, nasal problem

fever, cough, nasal congestion, mucus drainage in the back of the throat (post
nasal drip)

post-nasal drip refers to mucus that drips from your nose into the back
of your throat

URT to LRT

Causes

Similar to those of otitis media

SIGNS AND SYMPTOMS

facial pain and localized tenderness

Dx

microscopy and culture of pus aspirated from the sinus

Tx

empirically with Ampicillin or Amoxicillin or with newer Cephalosporins

(ex. Cefixime — 3rd generation Cephalosporin)

Upper Respiratory Tract Infection (URTI) 16

 Cefixime is beta-lactamase stable

empiric treatment

kahit di pa lumalabas yung lab results, kung ganon yung

manifestation based on the assessment of the doctor, binibigay na
agad yung gamot (while waiting for the results)

when a dangerous infection by an unknown organism is treated

with a broad-spectrum antibiotic while the results of bacterial
culture and other tests are awaited. Medical treatment that is given
on the basis of the doctor's observations and experience

Acute Epiglottitis
inflammation of the epiglottis and the soft tissue surrounding it

epiglottis is the flap of cartilage located in the throat behind the tongue
and in front of the larynx

Causes

H. influenzae capsular type B infection

Organism spreads from the nasopharynx to the epiglottis

Often seen in young children for an unknown reason

SIGNS AND SYMPTOMS

severe inflammation and edema usually (+) bacteremia

bacteremia = bacteria present in the blood

DOB due to respiratory obstruction

pedeng magkaroon ng laryngospasm and irrevocable loss of the airway

Tx

Antibiotics — Cefotaxime, Chloramphenicol

Chloramphenicol

MOA = blocks protein synthesis by binding to the 50S ribosomal

subunit

Upper Respiratory Tract Infection (URTI) 17

 Intubation

insertion of the tube either through the mouth or nose into the airway
to aid breathing

especially pag blocked yung airway and di makahinga

Oral Cavity Infections

Oral candidiasis

Caries

Periodontal disease

Oral Candidiasis
fungal infection by gram(+) C. albicans — unicellular yeast

Causes:

prolonged use of antibiotics or steroids and allows C. albicans to flourish

Oral thrush is also seen when immunity is impaired

i.e malignancy, HIV infection

opportunistic pathogen kasi si C. albicans

It may spread to the esophagus

Dx

gram staining and culture-scraped material

Tx

Antifungal agents

i.e Nystatin, Clotrimazole troches

troches = candy-like and are dissolved in the mouth for over 20

mins

Clotrimazole troches = 10mg orally 5 times daily

Upper Respiratory Tract Infection (URTI) 18

 Nystatin oral suspension = 5mL orally 4 times daily (gargle for
several minutes and then it is swallowed)

Caries
affects dental tissues

Causes:

S. mutans, S. sobrinus, anaerobic fusobacteria, and actinomycetes become

attached and multiply

They use dietary sugar and form lactic acid which decalcifies the tooth
locally

enamel is broken down, the tooth loses its ability to reinforce its
calcium and phosphate structure cuz of the lactic acid

Periodontal disease
aka “periodontitis” or gum disease

can cause serious gum infections that could damage the soft tissue and without
treatment, pedeng madestroy yung bone structure ng teeth that could lead to
tooth loss

Causes:

Actinomyces viscosus, Actinobacillus, Bacteroides spp.

Space enlarges and becomes a “pocket” with local inflammation

It may cause teeth to loosen

Upper Respiratory Tract Infection (URTI) 19

 Tx

Chlorhexidine (mouthwash)

oral antibiotics

prescription antibiotic mouthwash

topical antibiotic gel that is directly applied on the gums and consists of
tetracycline hydrochloride, penicillin, doxycycline, metronidazole,
ciprofloxacin, clindamycin

Laryngitis and Tracheitis

Laryngitis

inflammation of the larynx (voice box) which is triggered by URTI

can be a result of smoking, vaping, allergies, sinus disease, acid reflux (GERD)

Causes

Parainfluenza viruses, Diphtheria, and Viral infection of URT may spread

downwards to involve the larynx and trachea

SIGNS AND SYMPTOMS

hoarseness and burning retrosternal pain on breathing in and out

dry cough

Tx

steroids to reduce swelling

bacterial laryngitis or tracheitis → antibiotics

Upper Respiratory Tract Infection (URTI) 20

 pain → acetaminophen or ibuprofen

voice therapy if damaged larynx

electrolarynx

Upper Respiratory Tract Infection (URTI) 21