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Upper Respiratory Tract Infections

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Upper Respiratory Tract Infections Upper Respiratory Tract Infections Babak Valizadeh,DCLS [email protected] 1389 / 07 / 29 2010.10.21 Upper Respiratory Tract Infections Pharyngitis Sinusitis Otitis Diphtheria Pertussis Laryngitis Most caused by viruses Rhinovirus Influenza Adenovirus Parainfluenza : Larygotracheobronchitis M. catarrhalis is the most common bacterial species isolated from adult patients with laryngitis Epiglottitis Children : 2-6 Life-threatening Bacteria **** Bacteriologic culture ??? Direct swab of epiglottis, blood cultures Direct swab should be performed only if airway is secure Epiglottitis Epiglottitis Most common:H.influenza type b **** Less common: H. influenzae type A Nontypable Haemophilus Haemophilus parainfluenzae Streptococci Staphylococci Epiglottitis Throat swabs can be a useful specimen in determining upper airway colonization with H. influenzae type b and are usually only taken for epidemiological studies. Pharyngitis & tonsillitis Pharyngitis Viruses are the most common cause of pharyngitis in both adult and pediatric populations Primary infection with herpes simplex virus may be indistinguishable from infections due to other viruses or GAS Patients with Epstein-Barr virus (EBV) infection may present with an exudative tonsillitis or pharyngitis Epstein-Barr virus (EBV) infection Adenoviruses Adenoviruses produce an acute pharyngitis that resembles streptococcal pharyngitis Conjunctivitis often is present in addition/ Pharyngoconjunctival fever Coxsackie A virus Some serotypes of Coxsackie A virus produce acute pharyngitis with vesicles in the posterior pharynx as part of hand, foot, and mouth disease. The infection typically occurs in children Antibiotics Often Overprescribed for Viral Respiratory Infections Infect Contr Hosp Epidemiol. 2010;31:11 In Pennsylvania ; 196 had a viral assay positive for influenza A or B, parainfluenza, adenovirus, or respiratory syncytial virus Of these, 131 (69%) patients received antibiotics, including 125 (64%)who continued to receive antibiotics after diagnosis of viral RTI Clostridium difficile infection developed in 8 patients (6%) who continued on antibiotics Pharyngitis Normal pharyngeal flora, such as Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae, should not be reported from routine throat cultures To do so encourages inappropriate antimicrobial therapy Group A Streptococci GAS Pharyngitis Presentation of upper respiratory tract infection with cough and rhinorrhea is suggestive of a nonstreptococcal etiology In one study of pediatric patients : 36% of those presenting with cough & 45% of pediatric patients presenting with coryza symptoms had throat cultures that were positive for group A streptococci (GAS) Throat culture Throat culture remains the gold standard for the diagnosis of streptococcal pharyngitis Sensitivity : 90% & Specificity : 99 % Group A streptococci (GAS) Rapid antigen detection test in 10-30 minutes. (1980s) > 40 commercial Kit (POCT) Specificity > 95 % & sensitivity 62-90 % Negative Result Should be cultured or confirming using a Nucleic Acid method Group A Streptococcal Pharyngitis Therapy For almost 5 decades, penicillin has been the drug of choice Over the past 40 years have reported penicillin bacteriologic failure rates ranging from 10 to 30 percent and clinical failure rates ranging from 5 to 15 percent Group A Streptococcal Pharyngitis Treatment Failure and Reinfection Group A beta-hemolytic streptococci persist for up to 15 days on unrinsed toothbrushes Pathogens are not isolated from rinsed toothbrushes after three days Group A Streptococcal Pharyngitis Treatment Failure and Reinfection Close Contacts :During epidemics, 50 percent of the siblings and 20 percent of the parents of infected children develop streptococcal pharyngitis Group A Streptococcal Pharyngitis Treatment Failure and Reinfection Beta-lactamase– producing copathogens Amoxicillin-clavulanate is often used to treat recurrent streptococcal pharyngitis Throat culture Throat culture / 2006 Diagnosis of Streptococcal Pharyngitis by Detection of Streptococcus pyogenes in Posterior Pharyngeal versus Oral Cavity Specimens Carbohydrate antigen detection, nucleic acid probe detection, and bacterial culture When testing for GAS pharyngitis, the throat remains the optimum site for sampling Pharyngitis Group A streptococci (GAS) INOCULATION OF CULTURE MEDIA 1+ to 4+ Throat culture Throat culture Streptococcus pyogenes Gram-positive cocci in pairs and chains Catalase-negative Beta-hemolytic colonies large colony >0.5 mm in diameter on sheep BAP after 24 hours incubation Colonies are usually dry, peaked, or convex with a sharp periphery to the zone of hemolysis Group A streptococci (GAS) on sheep blood agar < 1% Nonhemolytic Medium and atmosphere of incubation 24 & 48 hrs .(96%) Medium and atmosphere of incubation 24 & 48 hrs ,OLD Sheep blood agar with Bacitracin incubated aerobically • Presumptive Identification Of GAS • Reduces sensitivity & Specificity Sheep blood agar with Bacitracin & SXT incubated aerobically Group A streptococci (GAS) on sheep blood agar Group A streptococci (GAS) on sheep blood agar Group A streptococci (GAS) Bacitracin : S/rare R & SXT : R Pyrrolidonyl arylamidase (PYR): + Serogrouping by particle agglutination approaches 100% accuracy Group A streptococci (GAS) Bacitracin 0.04 S>1 or 12-15mm ASM 2004 Group B Streptococci are not associated with pharyngitis Group A Streptococci (GAS) vs. Group B Streptococci Group B Streptococci CAMP Group B Streptococci Hippurate Hydrolysis : + Group B streptococci Bacitracin :R rare s & SXT : R Groups C and G Streptococci Groups C and G streptococci produce infections quite similar to GAS but milder than those of group A strains Some strains contain fibrinolysins and streptolysins and infections can stimulate antistreptolysin O titers (ASO), similar to S. pyogenes. Groups C and G Streptococci Beta-hemolytic Streptococci Most of the evidence of Lancefield groups C and G Streptococci causing pharyngitis comes from reports of outbreaks Group C Streptococci The beta-hemolytic group C Streptococci infecting humans include the large colony (>0.5 mm) S.dysgalactiae subsp. equisimilis,the most common human isolate. Group G Streptococci Lancefield group G streptococci are subdivided into the "large colony" form and the "minute colony“ form (S. anginosus , VP : + ) The "minute colony ( < 0.5 mm) form is not thought to cause pharyngitis. Groups C and G streptococci Groups C and G streptococci are usually, but not exclusively, beta hemolytic Unlike GAS, which are inhibited by 0.04 units/mL of bacitracin, the group C and G isolates are extremely variable in their bacitracin sensitivity, ranging from as few as 6 to 8 percent to as many as 30 to 67 percent Groups C and G Streptococci SXT : S & Bacitracin :R-s Groups C Streptococci SXT : S & Bacitracin :R-s Groups C Streptococci latex agglutination for Serogrouping S.dysgalactiae subsp. equisimilis Reporting NO β-hemolytic Streptococci isolated . No Streptococcus pyogenes isolated. Streptococcus pyogenes isolated. 1+... 4+ β-hemolytic Streptococci ,Group C / G isolated. Beta-hemolytic Streptococci . Arcanobacterium haemolyticum Formerly Corynebacterium haemolyticum Tonsillitis, pharyngitis and causing rash in young adults (15 to 25 years old) and occasionally in children It is suggested that in cases of treatment failure and repeat incidences of tonsillitis, isolation of A. hemolyticum should be considered Arcanobacterium haemolyticum Treatment of pharyngitis with penicillin may fail to eradicate Erythromycin has also been used in the treatment of A. haemolyticum infections Arcanobacterium haemolyticum After 48 hours incubation on blood agar A. haemolyticum colonies exhibit narrow zones of ß -hemolysis and are 0.5mm in diameter In cases where A. haemolyticum is suspected, incubation of culture plates may need to be extended up to 72h Arcanobacterium haemolyticum CO2-enriched atmosphere A. haemolyticum, whose hemolysis is more pronounced on human and rabbit blood agar than on SBA Two different biotypes of A. hemolyticum • Smooth type isolated mainly from wounds • Rough type isolated mainly from respiratory tracts Arcanobacterium haemolyticum The majority of A. haemolyticum isolates produce small, dark pits under colonies growing on ordinary BA medium The pitting of the agar underneath the colony, when the colony is pushed aside Arcanobacterium haemolyticum A. haemolyticum is a catalase-negative, gram- positive or variable rod whose morphology is dependent on the growth media and conditions Similar to that of C. pseudotuberculosis and C. ulcerans , positive reverse CAMP test • A. haemolyticum is Catalase & Urea negative Arcanobacterium haemolyticum SBA 48hrs Arcanobacterium haemolyticum Arcanobacterium haemolyticum Reverse CAMP tests Arcanobacterium haemolyticum Reverse CAMP tests Mixed Aerobic / Anaerobic Infection or Colonization Borrelia vincentii and Fusobacterium species are associated with the infection known as Vincent's angina It is characterized by ulceration of the pharynx or gums and occurs in adults with poor mouth hygiene or serious systemic disease VINCENT'S ANGINA >2 Borrelia & Fusobacterium / OIF Lemierre's Syndrome / postanginal septicemia / 1936 Acute pharyngeal infection with the anaerobe Fusobacterium necrophorum The acute pharyngitis is followed by a septic thrombophlebitis of the internal jugular vein Dissemination of the infection to multiple sites distant from the pharynx In the preantibiotic era, Lemierre's syndrome
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