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Infection

Upper Respiratory Tract Infection

Dr.Nizar Naji(Respiratory Registrar-St.James's Hospital)
Prof.Luke Clancy(Respiratory Consultant -St.James's Hospital)

Background

Upper respiratory tract infections (URTI) is non specific term used to describe acute infections involving the nose, pharynx, larynx and Para nasal sinuses. They can be caused by viruses , bacteria and other micro organisms. The prototype is the illness known as common cold.

Influenza is a systemic illness that involves the upper respiratory tract and should be differentiated from other causes of URTI because in some cases particularly in elderly the flu can be very severe and evolve into pneumonia.

Although viruses cause most URTIs, antibiotics continue to be widely used for these illnesses. Unnecessary adverse effects of antibiotics and development of antimicrobial resistance can be reduced by judicious use of these drugs. However, antibiotic use has been shown to result in symptom resolution 1 to 2 days sooner than when symptomatic measures alone are used.

There are over 200 viruses that can cause URTIs.

Organisms are generally spread by the following ways:

  • direct contact (such as hand to mouth)
  • coughing or sneezing droplets that contain these organisms in the air.

Pathophysiology

Pharyngitis is an inflammation of the pharynx, hypopharynx, uvula, and tonsils. Viral or bacterial infection or occasionally both can cause it. Bacteria or viruses may invade the pharyngeal mucosa directly, causing a local inflammatory response. Some viruses, such as Rhinovirus, cause irritation of pharyngeal mucosa secondary to nasal secretion.

Other pathogens include Strep.Pneumonia, Hemophilus Influenza and Staphylococcus particularly in recurrent tonsillitis.

Sinusitis is an inflammatory process involving the paranasal sinuses, it usually is a bacterial complication of a viral upper respiratory tract infection, and maxillary sinus is the most commonly involved. Organisms isolated include Strep.Pneumonia, H.Influenza and M.Catarrhallis.

The common cold is the most common URTI; the most common cause is the Rhinovirus, which is responsible for about half of all colds. It usually takes between one to three days from exposure to the virus until symptoms start. Other frequent pathogens include Corona virus, Influenza virus, and RSV.

Influenza is an acute viral infection of the URT. Epidemics in the 20th century were caused by influenza A, but few have been due to influenza B. It is usually occur between December and March. Annual influenza epidemics result from minor mutated influenza virus (drift) to which most humans do not have immunity. Pandemics occur when there a major changes in virus (shift) The source of these new influenza viruses are thought to often be swine or birds and unusually are transmitted to human from those species.

Presentation

Pharyngitis/Tonsillitis

Sore throat is the principle symptom and often seen as part of flu like infection.

Sinusitis

Occurs in up to 5% of patient with URTI.the main symptoms include purulent discharge, malaise, cough, fever for more than a week, facial pain, nasal obstruction (unilateral or alternating), headache, impaired smell and is difficult to distinguish from allergic rhinitis but this is suggested by watery rhinorrhoea, sneezing and nasal itch.

Common Cold

Nasal congestion, sneezing, and sore throat are the hallmark of common cold; conjunctivitis is characteristically seen with adenovirus infection.

Influenza

Presents as sudden illness characterized by high fever, severe headache, myalgia and dry cough, which is usually severe and protracted, followed by lingering fatigue.

Symptoms usually resolve within 2-7 days, but fatigue may last weeks.

The elderly patient may also present with confusion and somnolence and they are at greater risk of developing severe complications.

Influenza virus can cause viral pneumonia directly, which is nearly always fatal. Death is reported in 0.5-1 per 1000 cases of influenza according to National Disease Surveillance Centre and Approximately 80% of influenza-related deaths occur in those over 65 years of age.

Diagnosis

Because viruses cause most URTIs,the diagnostic role of laboratory investigations and radiologic studies is limited.

Pharyngeal swab for Rapid antigen detection (RAD) my be performed in those where GABHS-pharyngitis is suspected as it is 80-95% sensitive and should be considered in those patients.

Blood cultures should be done in severely ill patient or in those with epiglottits or pharyngeal abscess.

Every effort should be taken to diagnose influenza. RAD of influenza virus on a nasopharyngeal swab is indicated in cases where specific antiviral therapy is recommended and to role out other viruses like RSV. Influenza serology is also available from a variety of specimen. However, the best diagnostic test is using PCR on nasopharyngeal aspirate and if it is not possible nasal swab can be taken.

Treatment

  • Symptomatic treatment for URTI should be directed to maximise relief of the most prominent symptoms. Rest and increase fluid intake are non specific measures recommended for all URTIs.
  • The role of antitussives and expectorant in the treatment of URTI remains controversial.
  • Simple painkillers such as paracetamol to relieve headache and muscle aches.
  • Non-steroidal anti-inflammatory drugs are used in relieving fever, headache and malaise but these drugs may be associated with gastrointestinal irritation especially in old people.
  • Warm saline gargle and steam inhalation are inexpensive measures to relieve throat symptoms. Voice rest is important in patient with hoarseness.
  • Topical nasal steroid such as fluticazone propionate improve clinical success rate of patient with chronic or recurrent sinusitis who present with acute exacerbation.
  • Antibiotics have no role in the management of the common cold or any URTI, unless Bacterial Pneumonia evolves.
  • Patient with only mild symptoms of sinusitis improve with symptomatic treatment only.
  • Oral amoxicillin or doxacycline given for 3-10 days are the favoured antibiotics for treatment of moderate to severe sinusitis.
  • Amoxicillin plus Clavulanate is effective in most cases with resistant organisms.
  • Annual vaccine remains the best protection against influenza in high risk individuals. The vaccine needs to be given annually considering the variation in influenza strains that occur every year.

Persons with influenza should limit contact with other people as much as possible. It is important that health care workers with flu avoid any patient contact.