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Upper and Lower Respiratory Tract Infections
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Upper and Lower Respiratory Tract Infections

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  1. Upper and Lower Respiratory Tract Infections Meral SÖNMEZOĞLU, MD Yeditepe UniversityHospital AssociateProfessor of Department of InfectiousDiseasesandMicrobiology

  2. Infections of the Respiratory tract • Most common entry point for infections • Upper respiratory tract • nose, nasal cavity, sinuses, mouth, throat • Lower respiratory tract • Trachea, bronchi, bronchioles, and alveoli in the lungs

  3. Fig. 21.1a

  4. Upper Respiratory Infections • Common Cold/ Influenza • Pharyngitis, tonsillitis • Acute sinusitis • Acute laryngitis • Acute laryngotracheobronchitis (Croup) • Otitis media, otitis externa, mastoitidis

  5. Bacterial causes of URIs • Streptococcus pyogenes (group A ßhemolytic) • Group C streptococci • Haemophylus influenza • Moraxella catarrhalis • Staphylococcus aureus • Klebsiella pneumoniae • Haemophylus parainfluenzae • Mycoplasma pneumoniae • Chlamydia pneumoniae

  6. Viral causes of URIs • Rhinovirus (100 types and 1 subtype) • Coronavirus (>3 types) • Parainfluenza virus • Respiratory syncytial virus • İnfluenza virus • Adenovirus (type 3,4,7,14,21) • Coxsackievirus A (type 2,4-6,8,10) • Epstein Barr virus • Cytomegalovirus • HIV-1

  7. Clinical characteristics of “common cold” • Incubation period 12-72 hrs • Cardinal symptoms: • Nasal discharges • Nasal obstuctions • Sneezing • Sore and scratchy throat • Cough • Slight fever • Duration 1 week, self limited

  8. Diagnosis • Typical and easy • Differential diagnosis; • -hay fever • -vasomotor rhinitis • Major challenge is to distinguish the uncomplicated cold from secondary bacterial sinusitis and otitismedia

  9. Treatment • First generation antihistaminics • Nonsteroidal anti-inflammatory drugs • Sore throat reliefs with warm saline gargles and topical anesthetics • Oseltamivir?

  10. Prevention • Isolation of the patients for first days • Influenza vaccines

  11. Respiratory Syncytial Virus • Enveloped (membrane) RNA virus • Spread by respiratory droplets • Community outbreaks in late fall to spring • Upper respiratory tract infection – epithelial cells • May be fatal in infants

  12. Influenza Virus An enveloped RNA virus Structure

  13. Influenza Virus • New human strains every year • Mutations • Pandemic strains  • Genetic Recombinant Viruses • 1957 Asian Flu H2N2 • 1968 Hong Kong Flu H3N2 • 1977 Russian Flu H1N1 • Bird Flu • Directly from birds • ?? H5N1

  14. ‘H’ and ‘N’ Flu Glycoproteins • H – Hemagglutinin  • Specific parts bind to host • cells of the respiratory mucosa • Different parts are • recognized by the host antibodies • Subject to changes • N - Neuraminidase • Breaks down protective • mucous coating • Assist in viral release

  15. Influenza • Epidemics and pandemics, mostly in winter • Upper respiratory tract infection – epithelial cells • Multivalent killed virus vaccine with strains from the previous year (Grown in embryonated eggs) • Bird flu (H5N1) pandemic in birds

  16. Pathogenesis of Influenza • Influenza can be transmitted through small or large particle • aerosols or through contact with contaminated surfaces • If not neutralized by mucosal antibodies, virus attacks respiratory tract epithelium • Infection of respiratory epithelial cells leads to cellular dysfunction, viral replication, and release of viral progeny • Release of inflammatory mediators contributes tosystemic manifestations of disease Bridges CB et al. Clin Infect Dis. 2003;37:1094-101. Heikkinen T et al. Lancet. 2003;361:51-9.

  17. Clinical Features of Influenza • Sudden onset of symptoms, persist for 7+ days • Incubation period: 1-4 days, average 2 days • Infectious period of wild type virus: • Adults shed virus typically from 1 day before through 5 days after onset of symptoms • Children shed higher titers for a longer duration than adults ACIP. MMWR. 2004,53(RR06)1-40. Kavet J. Am J Public Health. 1977;67:1063-70. Frank AL et al. J Infect Dis. 1981;144:433-441. Hayden FG et al. JAMA. 1999;282:1240-6.

  18. Influenza Manifestations & Complications Loughlin J et al. Pharmocoeconomics. 2003;21:273-283. Treanor JJ. Influenza virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, PA: Churchill Livingstone; 2000:1823-1849. ACIP. MMWR 2004;53 (RR06):1-40.

  19. Patient Groups at Risk for Complications • Increased risk of influenza complications among: • Children <2 years • Children and adolescents receiving long-term aspirin therapy • Children and adults with chronic conditions • Chronic pulmonary, metabolic, or CV disorders • Renal dysfunction • Hemoglobinopathies • Immunosuppression, including HIV infection • Pregnant women • Residents of chronic care facilities • Persons 65 years old • ACIP. MMWR. 2004;53(RR06):1-40.

  20. Pulmonary: Primary influenza viral pneumonia Secondary bacterial pneumonia Croup Asthma, COPD,* bronchitis, cystic fibrosis exacerbation Increased severity of influenza in HIV patients * Chronic obstructive pulmonary disease Non-Pulmonary: Myositis Cardiac complications Toxic shock syndrome Guillain-Barré syndrome Transverse myelitis Encephalitis Reye syndrome Complications

  21. Influenza Diagnostic Testing • Rapid Antigen (EIA) • NP aspirates and swabs only • Detects Influenza A/B nucleoproteins • 1 hour TAT, batched on the hour • Viral Culture (Shell Vial) • Upper and lower respiratory specimens • Detects Influenza A/B, Parainfluenza 1/2/3, Adenovirus and RSV • 24-72 hour TAT • Real-time RT-PCR • Upper and lower respiratory specimens • Detects Influenza A matrix gene • Influenza B validation in progress • 24 hour TAT Increase in Sensitivity

  22. Treatment • Rest, liquids, anti-febrile agents (no aspirin for ages 6mths-18yrs) • Be aware of complications and treat appropriately • Oseltamivir for patients at risk

  23. Sinusitis — facts and figures Definition:–infection of frontal, ethmoidal or maxillary sinuses Symptoms:– facial pain, headache, nasal discharge, fever Prevalence:– 31.2 million cases per year in the USA – 16 million outpatient visits Complications:– permanent mucosal damage and chronic sinusitis – rarely, optic neuritis, subdural abscess and meningitis Schwartz. Nurse Pract 1994;19:58–63

  24. Etiology of acute sinusitis Streptococci8% S. aureus 6% Staphylococci7% M. catarrhalis 1% Anaerobes7% Other bacteria5% S. pneumoniae34% H. influenzae35% Total percentages greater than 100% because of multiple organisms Willett et al. J Gen Intern Med 1994;9:38–45

  25. Sinusitis • Acute sinusitis ; • into three main syndromes: • acute, • subacute • chronic • In young adults, acute sinusitis is responsible for 4.6% of physician consultations

  26. RV in Acute Sinusitis • Sinusitis is an extremely common part of the common cold syndrome • RV has been detected in 50% of adult patients with sinusitis by RT-PCR of maxillary sinus brushings or nasal swabs1 • Frequency of association of RV infection with sinusitis suggests the common cold could be considered a rhinosinusitis2 • Pitkäranta A et al. J Clin Microbial. 1997;35:1791. • Gwaltney JM Jr. Clin Infect Dis. 1996;23:1209.

  27. Acute pharyngitis/tonsillitis — facts and figures Definition: – inflammation of the pharynx or tonsils Symptoms: – pharyngeal pain, dysphagia and fever Epidemiology: – 1% physician visits/year – most common childhood bacterial infectiona Complications: – acute rheumatic fever and glomerulonephritisa Gwaltney. In: Principles and Practicesof Infectious Disease 1990;43:493–8 aStreptococcal pharyngitis

  28. Acute streptococcal pharyngitis/tonsillitis

  29. Etiology of pharyngitis Coronavirus(5%) Rhinovirus(20%) Adenovirus(5%) Other bacteria/viruses(7%) S. pyogenes(15–30%) Unknown(40%) Gwaltney. In: Principles and Practices of Infectious Disease 1990;43:493–8

  30. Acute otitis media — facts and figures Definition: – infection of the middle ear leading to accumulation of fluid and inflammation of the tympanic membrane Symptoms: – cough, fever, irritability, earache Epidemiology: – 24.5 million physician visits per year – majority of cases occur in children <2 years – most frequent indication for antimicrobial treatment in children in the USA Complications: – loss of hearing Garau et al. Clin Microbiol Infect 1998;4:51–8 Klein. Clin Infect Dis 1994;19:823–33

  31. Infected Middle Ear(otitis media)

  32. Acute otitis media — etiology M. catarrhalis 14% H. influenzae 23% S. pneumoniae 35% Unknown 16% S. pyogenes 3% S. aureus 1% Others 32% 2807 effusions from patients in the USA 1980–1989 Total percentages greater than 100% because of multiple organisms Bluestone et al. Paediatr Infect Dis J 1992;11:7–11

  33. Acute Bronchitis Inflammation of the bronchial respiratory mucosa leading to productive cough.

  34. Acute Bronchitis • Etiology: A)Viral B) Bacterial (Bordetella pertussis, Mycoplasma pneumoniae, and Chlamydia pneumoniae) • Diagnosis: Clinical • S/S: Productive cough, rarely fever or tachypnea.

  35. Treatment Symptomatic If cough persists for more than 10 days: Azithro x 5 days OR Clarithro x 7 days

  36. PNÖMONİ

  37. Pneumonia Bacterial, viral or fungal infection can cause Inflammation of the lung with fluid filled alveoli

  38. Aetiology

  39. Frequency of causative organisms of community-acquired pneumonia (CAP) in Europe. Welte T et al. Thorax 2012;67:71-79

  40. Treatment setting

  41. Frequency of Isolation of Causative Organisms of CAP in Europe by Country

  42. Protective Mechanisms Normal flora: Commensal organisms • Limited to the upper tract • Mostly Gram positive or anaeorbic • Microbial antagonist (competition)

  43. Defense Mechanisms • 80% of cells lining central airways are ciliated, pseudostratified, columnar epithelial cells • Each ciliated cell contains about 200 cilia that beat in coordinated waves about 1000x/minute • So the lower respiratory tract is normally sterile

  44. Protective Mechanisms Clearance of particles and organisms from the respiratory tract Cilia and microvilli move particles up to the throat  where they are swallowed. Alveolar macrophages migrate and engulf particles and bacteria in the alveoli deep in the lungs.

  45. Other Protective Mechanisms • Nasal hair, nasal turbinates • Mucus • Involuntary responses (coughing) • Secretory IgA • Immune cells

  46. First cause of death in the United States from infectious disease is: A. Meningitis B. Pneumonia C. Gastroenteritis D. Urinary Tract Infections E. Toe fungus