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Respiratory tract infection

Respiratory tract infection. By Dr.Preaw(General medicine ). Scope. Diagnosis : CAP , HCAP , VAP Pathophysiology Investigation Management and treatment. Community-acquired pneumonia (CAP) Diagnosis. 1. Temperature > 38 ºC 2. Purulent secretion 3. Leucocytosis or leucopenia.

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Respiratory tract infection

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  1. Respiratory tract infection • By Dr.Preaw(General medicine )

  2. Scope • Diagnosis : CAP , HCAP , VAP • Pathophysiology • Investigation • Management and treatment

  3. Community-acquired pneumonia (CAP)Diagnosis • 1. Temperature > 38 ºC • 2. Purulent secretion • 3. Leucocytosis or leucopenia Moderate recommendation; level III evidence. IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2)

  4. Pathophysiological modes of spreading

  5. 1. Alteration of normal oropharyngeal flora. 2. Depressed Cough and glottis reflexes. 3. Altered consciousness. 4. Impaired mucociliary apparatus mechanism. 5.Alveolar macrophage dysfunction. 6. Immune dysfunction. Pathophysiology :Failure of defences mechanisms

  6. Classification of pneumonia (based on anatomical part ) Bronchopneumonia: terminal bronchiole ( patchy consolidation) -Streptococci -Staphylococcus aureus -B Haemolytic streptocci -Haemophilus influenzae -Klebsiella pneumonia -Pseudomonas Interstitialpneumonia : without alveolar exudates -virus: Respiratory syncytial virus Influenza virus Adenoviruses Cytomegaloviruses -Mycoplasma pneumoniae Lobar pneumonia -Streptococci pneumoniae -Staphylococcus aureus -B Haemolytic streptocci

  7. Pathologic Stages of Pneumococcal Lobar Pneumonia

  8. Criteria for severe community-acquired pneumonia. Minor criteria • confusion /disorentation • V/S RR> 30/min ,T < 36 ºC , hypotension • multilobar infiltration • Lab : BUN > 20 mg/dL , WBC < 4,000 cells/mm3 , platelet count <100,000 cells/mm3 • PaO2/FiO2 ratio > 250 Major criteria

  9. Investigation and management

  10. Diagnosis testing remain controversial sensitivity 15-100% specificity 11-100% Adequate sputum PMN >25 cells/LPF epithelium < 10 cells/LPF sensitivity 70-90 % specificity 99 % Sensitivity 69% false negative 1.dehydration 2. early onset of PCP 3. neutropenic patient

  11. Classification of pneumonia (based on anatomical part ) Bronchopneumonia Lobar pneumonia Interstitial pneumonia

  12. Gram : positive dipplococci :Streptococcus pneumoniae

  13. Gram : negative bacilli

  14. Management and treatment :hospital admission decisionCURB -65 score strong recommendation :level I evidence

  15. PSI score

  16. PSI score

  17. Summary

  18. ICU case PIRO score for CAP Predisposition Insult Response Organ dysfunction

  19. Management

  20. Management : outpatient C.pneumoniae (29%) M.pneumoniae(20%) S.pneumoniae(8%) unknown (30%)

  21. Management : inpatient -gram negative bacilli(20%) -S.pneumoniae(19%) -C.pneumoniae(19%) -M.pneuminiae(9%) -unknown (31%) levofloxacin,moxifloxacin ,gemifloxacin -S.pneumoniae(24%) -gram negative bacilli(20%)-C.pneumoniae(15%) -unknown (31%) cefotaxime , ceftriaxone,ampicillin-sulbactam

  22. Special condition piperacillin-tazobactam cefepime,imipenem meropenem *CA-MRSA:community-acquired methicillin-resistant staphylococcus aureus

  23. Temperature < 37.8 ºC Heart rate < 100 beats/min Respiratory rate < 24 breaths/min Systolic blood pressure > 90 mmHg Aterial oxygen saturation > 90 % or PaO2 > 60 mmHg on RA Ability to maintain oral intake Normal mental status Criteria for clinical stability

  24. Hospital-acquired pneumonia(HAP) :definition Presence of new chest X-ray infiltration plus one of the three clinical variables -fever > 38 ºC -leukocytosis or leukopenia (WBC >12,000 cells/mm3 or < 4,000 cells/mm3 ) -purulent secretions Pneumonia that occurs 48 hours or more after admission Ventilator-associated pneumonia : definition Pneumonia that occurs 48 hours or more after intubation of endotracheal tube until 48 hours after extubation Definition:HAP, VAP, HCAP ● ●

  25. - Any patient who was hospitalized in acute care hospital for > 2 days within 90 days of the infection - Resided in a nursing home or long-term care facility - Received recent IV antibiotic therapy, chemotherapy or wound care within the past 30 days of the current infection - Attended a hospital or hemodialysis clinic Healthcare-associated pneumonia(HCAP)

  26. Early onset pneumonia (within < 4 days of hospital admission) pathogens -> S.aureus -> S.pneumoniae -> H.influenzae Late onset pneumonia ( > 4days of hospital admission) pathogens ->MRSA ->drug-resistant GNEB ->P.aeruginosa ->A.baumannii Hospital-acquired pneumonia(HAP)

  27. -Microaspiration:from oropharynx to lungs -Aspirationfrom stomach to lungs -Colonization of ET tube with bacteria encased in biofilm result into alveoli during suctioning or bronchoscope -Inhalation of pathogens form contaminated aerosols direct inoculation -Hematogenous spread HAP : pathogenesis

  28. -Antimicrobial therapy in preceding 90 days -Current hospitalization of 5 days or more -High frequency of antibiotic resistance in the community or in the specific hospital unit -Presence of risk factor for HCAP Hospitalization for 2 days or more in preceding 90 days Residence in a nursing home or extended care facility Home infusion therapy ( including antibiotics) Chronic dialysis within 30 days Home wound care Family member with multidrug- resistant pathogen -Immunosuppressive disease and/or therapy Risk factor for multidrug-resistant pathogens causing HAP, HCAP, VAP

  29. Assessment of nonresponders wrong organism drug-resistant pathogen inadequate antimicrobial therapy wrong diagnosis ARDS atelectasis pulmonary emboli pulmonary hemorrhage neoplasm underlying disease complication empyema or lung abcess Clostridium difficile coliitis occult infection drug fever

  30. Summary • Diagnosis : • CAP • HCAP • VAP

  31. Summary CURB-65 PSI score PIRO score

  32. Summary -Management -Prevention -Accessment of nonresponder

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