Respiratory Tract

Infections

MS. ZAKIAH MOHD NOORDIN

Lecturer (RPh : 20048)
Faculty of Pharmacy, UiTM
Learning
Outcomes Describe the pathophysiology of common respiratory tract
infections

Describe the common clinical presentations and causative

pathogens associated with specific respiratory tract infections

Recommend appropriate antimicrobial regimen for the management

of specific respiratory infections

Design plan for monitoring therapeutic response to the antimicrobial

regimen.
 Tonsilitis/pharyngitis

Bronchiolitis and Bronchitis

Pneumonia
Tonsilitis/ Pharyngitis
• Inflammation of the pharynx or tonsil (with or without
exudates) caused by infection
• Causative pathogens:
⚬ Virus: Rhinovirus, coronavirus, adenovirus
⚬ Bacteria: Group A streptococci (Streptococcus
pyogenes)
⚬ Pharyngitis due to GABHS is commonly known as
“strep throat.”
⚬ Fungi
• Children 5 to 15 years of age are most susceptible
• Rare in children younger than 3 years of age
 Pathophysiology

• Direct invasion of the pharyngeal mucosa.

• Rhinovirus can cause irritation secondary to nasal secretions.
• Local invasion of the pharyngeal mucosa results in excess secretion and edema.
• Route of transmission: direct contact, airborne droplets, shared food or drinks.
 Clinical Presentation

• Severe sore throat (sudden onset)

• Dysphagia
• Fever
Palatal petechiae in a child with
• Erythema/inflammation of tonsils and pharynx Streptococcus pyogenes pharyngitis.

• Enlarged, tender lymph nodes

• Red swollen uvula
• Petechiae on the soft palate
Pharyngotonsillitis. - (Left) The diffuse tonsillar
• Halitosis and pharyngeal erythema seen here is a
nonspecific finding that can be produced by a
• Malaise variety of pathogens. (Right) This photograph of
exudative tonsillitis is most commonly seen in
either group A streptococcal or Epstein-Barr virus
infection
 Clinical Presentation
• Pediatric patients with streptococcal pharyngitis may
also complain of:
o Headache
o Abdominal pain
Palatal petechiae in a child with
o Vomiting Streptococcus pyogenes pharyngitis.

o Rash

• Children younger than 3 years frequently have

atypical symptoms with a streptococcal infection Pharyngotonsillitis. - (Left) The diffuse tonsillar
and pharyngeal erythema seen here is a
o Protracted nasal congestion and purulent rhinorrhea. nonspecific finding that can be produced by a
variety of pathogens. (Right) This photograph of
exudative tonsillitis is most commonly seen in
either group A streptococcal or Epstein-Barr virus
• Viral origin for Pharyngitis infection

o Conjunctivitis
o Coryza
o Cough
 Treatment Goals

1. Eradicate infection

2. Symptomatic care

3. Appropriate antimicrobial selection

• Efficacy, safety and cost

4. Prevent complication
• Acute rheumatic fever
• Peritonsillar abscess, cervical lymphadenitis, mastoiditis

5. Prevent transmission to close contacts

Modified Centor Score (McIsaac Score)
Pharmacotherapy (Adult)

• Antibiotics should be used only in cases of laboratory-confirmed

streptococcal pharyngitis with associated clinical symptoms.

• Penicillin is the drug of choice because of its narrow spectrum, documented

safety and efficacy in nasopharyngeal streptococcal eradication, and low

cost.
Pharmacotherapy (Paediatric)

• Amoxicillin may be preferable for children with GABHS pharyngitis because the

suspension is more palatable than penicillin.

• Gastrointestinal (GI) adverse effects and rash are more common with amoxicillin.
 Pharmacotherapy (Cont.)
Penicillin Allergy Supportive Care
• First generation cephalosporin
• Macrolide/azalide 1. Analgesics/Anti-pyrectics
• Clindamycin 2. Soft diet and fluids
3. Local soothing
4. Avoid irritants
Treatment Failure
• Retreated with the same initial antibiotic or
• Amoxicillin-clavulanate
• First-generation cephalosporin,
• Clindamycin
• Penicillin G benzathine
 Bronchiolitis
• Clinical syndrome of respiratory distress that occurs in children <2 years of age and is
characterized by:
– upper respiratory symptoms (eg, rhinorrhea)
– followed by lower respiratory infection with inflammation, which results in wheezing and/or
crackles (rales)
• Primarily caused by viral infection (Respiratory syncytial virus (RSV), rhinovirus,
parainfluenza virus
• Risk factors for severe or complicated bronchiolitis:
– Prematurity (gestational age ≤36 weeks)
– Low birth weight
– Age less than 12 weeks
– Chronic pulmonary disease, particularly bronchopulmonary dysplasia
– Anatomic defects of the airways
– Hemodynamically significant congenital heart disease
– Immunodeficiency
– Neurologic disease
 Management of Bronchiolitis
Non-severe bronchiolitis – manage in
outpatient setting
Severe bronchiolitis – supportive care in
inpatient setting
• Hydration: Parenteral fluid administration
or enteral feeding
• Stabilisation of respiratory status:
– Nasal suctioning (Nasal saline drops)
– Supplemental oxygen (SpO2 > 90 – 92%)
– HFNC and CPAP (At risk of respiratory
failure)
– Endotracheal intubation
Severe bronchiolitis:
●Persistently increased respiratory effort
(tachypnea; nasal flaring; intercostal,
subcostal, or suprasternal retractions;
accessory muscle use; grunting) as
assessed during repeated examinations
separated by at least 15 minutes
●Hypoxemia (SpO2 <95 percent)
●Apnea
●Acute respiratory failure
• Inflammation of the bronchi.
• Causes
– Virus (85-95%)
• influenza A and B, respiratory syncytial virus (RSV),
and parainfluenza virus
– Bacteria
• Mycoplasma pneumoniae, Streptococcus pneumonia,
Haemophilus influenzae, Moraxella catarrhalis
– Exposure to irritant substances
– Occupational exposure
• Clinical presentations
– Persistent cough ± sputum
– Low grade fever
– Mild dyspnea or wheeze
• Diagnosis:
o Clinical presentation,
o Physical Examination
o Patient hx
– Limited use of sputum gram staining and culture
• Acute or chronic
 Treatment Goal
• To provide symptomatic relief to the patient and, in the unusually severe case, to treat associated
dehydration and respiratory compromise

Management
• Mild analgesic-antipyretic therapy
• Relieve associated lethargy, malaise, and fever.
• Paracetamol, ibuprofen, aspirin
• Bronchodilators
• Improve cough symptom in adults with airflow obstruction
• Cough medications
o Dextromethorphan
• Non-pharmacological intervention
o Throat lozenges
o Honey (in hot water or tea)
o Encourage fluid intake
o Mist therapy
o Smoking cessation
 Follow-up
• Most patients recover without complications within 1 to 3 weeks.
• Red flag symptoms:
• new-onset fever
• difficulty breathing
• symptoms lasting >3 to 4 weeks
• bloody sputum
Pneumonia: Pathophysiology
 Pneumonia
• Inflammation of the lung with consolidation
• Caused by a variety of viral and bacterial pathogens
– CAP: S. pneumonia, H. influenza, rhinovirus, influenza,
RSV
– HAP: gram-negative aerobic bacilli (P. aeruginosa,
Acinetobacter spp., K. pneumoniae and E. coli) or S. aureus
(MDR isolate)
• Dx based on clinical and chest radiograph evidence
Community-acquired Aspiration Hospital-acquired Ventilator-associated Healthcare-associated
(CAP) (HAP) (VAP) (HCAP)
 Treatment Goal
• Eradication of the offending organism through selection of the
appropriate antibiotic(s)
• Minimization of the unintended consequences of therapy

Management
• Decide on level of medical care (OP vs IP vs IP-ICU)
– CURB-65
• Follow the principles of good antimicrobial stewardship while ensuring adequate
treatment of the potential infection.
– provision of the right antimicrobial(s) at the right time, at the right dose, for the right
duration
– empirical use of broad-spectrum antibiotic therapy that is effective against probable
pathogens
– continual monitoring of patient clinical status and diagnostic data to support the decision
– employ pathogen-directed antimicrobial therapy
• Optimize patient outcome
• mitigate potential negative impacts of ongoing broad spectrum antimicrobial use
 Patient Monitoring & Therapy Modification

• Observe gradual and persistent improvement in the resolution of symptoms and oxygen
therapy
• Hospitalized patients with CAP should be switched from IV to oral therapy when
o hemodynamically stable,
o improving clinically as described above,
o have normal gastrointestinal tract function, and
o be able to ingest oral medications
• Worsening pt:
o changing the initial antibiotic therapy to expand antimicrobial coverage not included in the
original regimen
o Diagnostic report (respiratory culture) should also be used alongside clinical response to
streamline therapy
 Conclusion
• Group A β-hemolytic Streptococcus is the common bacterial cause for acute pharyngitis.
• Appropriate treatment regimen for uncomplicated LRTI can be established by evaluating the
patient hx, PE, chest radiograph, and interpretation of sputum culture result based on the current
data of most common lung pathogens and their antibiotic susceptibility patterns within the
community.
• Acute bronchitis is commonly caused by respiratory viruses and is almost always self-limiting.
Therapy targets associated symptoms and routine use of antibiotics should be avoided and
medication to suppress cough is rarely indicated.
• The most prominent pathogen causing CAP in otherwise healthy adults is Streptococcus
pneumoniae, whereas in HAP are Staphylococcus aureus and gram-negative aerobic bacilli.
• Empiric antimicrobial therapy for pneumonia should consist of antibiotic regimens targeting
presumed causative pathogens based on clinical presentation and patient-specific characteristics,
local epidemiology, and resistance patterns.
• Microbiologic tests for pneumonia etiology should be performed when clinically indicated and
used along with patient clinical response to tailor antibiotic therapy using evidence-based
pathogen-directed therapy when possible.
 References
• DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach 11th Edition.
New York: McGraw-Hill. ISBN:978-1-260-11681-6
• Pharmaceutical Services Programme. National Antimicrobial Guideline 2019.
https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-anti
microbial-guideline-2019-full-version-3rd-edition.pdf
• Uptodate (Tonsillopharyngitis, Bronchiolitis, Bronchitis, Pneumonia)
ANY QUESTIONS?
THANK YOU!