Lower Respiratory Tract

Infection tutorial for

National Licence 2015
.

1.

CXR : Patchy infiltration

Cr: raising

U/S : multiple nodular hypoechoic mass

Ans: Melioidosis

Lower Respiratory Tract

Infection

Pneumonia

Community-acquired pneumonia
(CAP)

Healthcare-associated pneumonia
(HCAP)

Hospital-acquired pneumonia (HAP)

Ventilator-associated pneumonia
(VAP)

Lung abscess

Pulmonary tuberculosis(TB)

Risk factors for HCAP

Hospitalization 2 days in preceding 90 days

Residence in nursing home or long-term care

facility

Home infusion therapy (including antibiotics)

Home wound care or Chronic dialysis within 30

days

Family member with multidrug-resistant pathogen

IDSA/ATS 2007

Definition of HAP and VAP

HAP: pneumonia that occurs 48 hours after

admission, not incubating at the time of
admission

Early onset<5 days

Late onset 5 days: risk of MDR organism

VAP: pneumonia that arises more than 4872

hours after endotracheal intubation
IDSA/ATS 2007

Community-acquired pneumonia
(CAP)

Diagnosis of CAP
1. New pulmonary infiltration
2. Acute onset ( < 2 wk )
3. Symptoms and Signs of LRI (3/5)
Fever
Dyspnea
Cough,
Pleuritic

productive sputum
chest pain

Consolidation

or crackles on P.E.

R/O criteria:
Recently d/c from hospital (< 3 wk), Immunocompromised
host

Thai guideline for CAP 2001

Route of entry
Micro-aspiration of oropharyngeal content
Direct inhalation
Hematogenous
Direct invasion

CXR normal in

Dehydration

Neutropenia

First few hours

Infiltration in silent area

Interstitial infiltration (early)

Melioidosis

environmental gram-negative bacillus

Burkholderia pseudomallei

classically characterized by pneumonia and

multiple abscesses

mortality rate of up to 40%

N Engl J Med 2012; 367:1035-1044

Global&Distribution&of&Melioidosis.

Global distribution of melioidosis

N Engl J Med 2012; 367:1035-1044

Pneumonia is the most common

clinical presentation of melioidosis

Acute: high fever, cough, sputum, chills,

rigors, and respiratory distress with or
without shock

Subacute or Chronic: cough, purulent

sputum production, hemoptysis, and night
sweats, suggestive of tuberculosis

Acute

Chronic

Risk factors for melioidosis

diabetes (present in 23 to 60% of patients)

heavy alcohol use (in 12 to 39%)

chronic pulmonary disease (in 12 to 27%)

chronic renal disease (in 10 to 27%)

thalassemia (in 7%)

glucocorticoid therapy (in <5%)

cancer (in <5%)

N Engl J Med 2012; 367:1035-1044

Gram stain

Gram negative bacilli

with bipolar staining

2.

2 crepitation

CXR: RLL infiltration

A) H.influenza

B) S.pneumonae

C) Mycloplasma pneumoniae

D) Chlamydia

E) S.aureus

IDSA/ATS 2007

Common causes of CAP in

Thailand

Wattanathum A, et al. Chest 2003;123;1512-19

Geographic area
Mixed organism 13.6%

N=110

44.5

Atypical+virus

26.4

Scrub typhus

5.5

TB

2.7

Meliodosis

2.7

Leptospirosis

0.9

Fungus

0.9

0%

12.5%

25%

37.5%

50%

* P.aeruginosa, Hemophilus spp., S.pneumo,K.Pneumo, Anerobe

C.Pothirat. et al,
Presented in Annual TST meeting 2003

RISK of specific pathogen

Alcohol abuse - K. pneumoniae, S. pneumoniae,

Anaerobes

Injecting drug abuse - S. aureus, S. pneumoniae

Influenza outbreak in community - Influenza

viruses, S. aureus (bacteria super-infection)

Exposure to bat or bird droppings - H.

capsulatum

Travel to or residence in Southeast and East

Asia- B. pseudomallei

RISK of specific pathogen

COPD, Smokers - S. pneumoniae, H. influenzae,

M. catarrhalis, P.aeruginosa, C. pneumoniae,

Structural lung disease(bronchiectasis) - P.

aeruginosa

Cough >2 weeks with whoop or post-tussive

vomiting- B. pertussis

Aspiration Anaerobes, gram-neg enteric

pathogen, Mixed infections

RISK of specific pathogen

HIV infection (early) - S. pneumoniae, TB, H.

influenzae

Recent antibiotic therapy or hospitalization

Enterobacteriaceae, P.aeruginosa

Chronic treatment with steroids - P. aeruginosa,

Aspergillus spp., Enterobacteriaceae, nocardia

Specific epidemiologic conditions - SARS

associated coronavirus, Avian influenza virus(H5N1)

CXR suggest pathogen

Necrotizing pneumonia - Staphylococcus

aureus, Klebsiella pneumoniae

Lung abscess -TB, Staphylococcus aureus,

Fungi

Pneumatocele: Staphylococcus aureus

Bulging fissure sign

lobar consolidation

affected portion of
the lung is
expanded.

now rarely seen

http://radiopaedia.org

Bulging fissure sign

The most common infective

causative agents
Klebsiella pneumoniae
S. pneumoniae
P.aeruginosa
Staphylococcus aureus
http://radiopaedia.org

3.

RLL pneumonia+Bullous myringitis common

pathogen?

A. S. Pneumonia

B. Mycoplasma

C. H. Influenza

Bullous myringitis

presentation of acute otitis

media (AOM)

blisters (bullae) on tympanic

membrane.

S. pneumoniae is the most

important bacterial cause of
AOM in adults

Role of macrolide in Rx of
bacteremic pneumococcal CAP

CID 2003; 36:389-95

3.

RLL pneumonia+Bullous myringitis common

pathogen?

A. S. Pneumonia

B. Mycoplasma

C. H. Influenza

4.
CXR:patchy infiltration
Sputum exam: gram positive cocci augmentin 3
CXR pleural fluid wbc 2500 N90% LDH 900

A) aminoglycosides
B) carbapenem
C) ICD ATB
D) Observe

BTS 2009

BTS 2009

CURB-65 score 0-1 but need admission in

1.Pneumonia with complication

2.Exacerbation of underlying disease
3.Inability to take oral medications or receive
OPD care

4.Multiple risk factors

IDSA/ATS 2007

ICU admission

1 major or 3 minors

IDSA/ATS 2007

IDSA/ATS 2007

Not recommend monoRx

with macrolide due to high
rate of resistance

Modifying factors:
Ps. aeruginosa
Severe structural lung disease:

Bronchectasis
Repeated severe AE-COPD (steroid ABO)

Steroid use: Pred > 10 mg/d

Resent board spectrum ABO use: > 7 days with in
past
mth
Severe malnutrition
Alcoholism
IDSA/ATS 2007

CAP Response to Rx

2/3 improve in first 3 days

Most non-ICU pts 7 days

Resolution of CAP

Clinical resolution

Improved of dyspnea

Improved of oxygenation

Resolution of fever

Decrease WBC

Radiographic resolution

2wks 6m.

Treatment failure

Host

Immune defect

Anatomical defect

Organism

Virulence

Resistant

Atypical

Inappropriate treatment

Treatment failure
Complication of pneumonia
Parapneumonic effusion
Lung abscess
Complication of treatment
Thrombophlebitis
Drug fever

Misdiagnosis

Malignancy
Autoimmune
Organising pneumonia

parapneumonic effusion

ACCP consensus guidelines 2000

4.
CXR:patchy infiltration
Sputum exam: gram positive cocci augmentin 3
CXR pleural fluid wbc 2500 N90% LDH 900

A) aminoglycosides
B) carbapenem
C) ICD ATB
D) Observe

5.

2HRZE/4HR liver
function test

a.

b. INH

c. INH, rifampin

d. INH, rifampin, pyrazinamide

Guidelines

2013

2010

Drug induced hepatitis

HRZ induced hepatitis

AST/ALT >3x

AST/ALT >5x

TB >3, AST/ALT <3x R

If the patient is severely ill with TB

Streptomycin + Ethambutol + Fluoroquinolone

Dose related

5.

2HRZE/4HR liver
function test

a. ( E )

b. INH

c. INH, rifampin

d. INH, rifampin, pyrazinamide

Cutaneous reactions

Idiosyncratic reaction

itching without a rash - antihistamine

If a skin rash develops, all anti-TB drugs must be

stopped
Day$1

Day$2

Day$3

Day$4

Day$5

Day$6

Day$7

Day$8

WHO guidelines 2010

6.

60 2 55

1. CXR

2. sputum AFB

3. INH prophylaxis

4. Tuberculin skin test

5.

Sputum collection

6.

60 2 55

1. CXR

2. sputum AFB

3. INH prophylaxis

4. Tuberculin skin test

5.

7.

34 8 2 BT
37.9 c PR 110 /min BP 110/60 mmHg White patch on
buccal mucosa and tongue,no adventitious sound, O2
sat 88% CXR interstitial infiltration diagnosis

1.

Pneumococcal pneumonia

2.

Mycoplasma pneumonia

3.

Melioidosis

4.

PCP

5.

TB

no specific to organism
must find the clues

7.

34 8 2 BT
37.9 c PR 110 /min BP 110/60 mmHg White patch on
buccal mucosa and tongue, no adventitious sound, O2
sat 88% CXR interstitial infiltration diagnosis

1.

Pneumococcal pneumonia

2.

Mycoplasma pneumonia

3.

Melioidosis

4.

PCP

5.

TB

oral leukoplakia

8.

50 1
Pulmonary TB BT 38.5, RR 16,
Coarse crep at RLL,

cavitary lesion+air fluid level at Superior Segment of

RLL, Mx?

1. metronidazole
2. Anti-TB drugs
3. Oflaxacin
4. Roxithromaycin
5. Bactrim+Doxycycline

antibiotics (
fluoroquinolone)

sputum AFB +/- culture for TB

 common TB

1. posterior segment of upper lobe

2. superior segment of lower lobe
3. anterior segment of upper lobe

8.

50 1
Pulmonary TB BT 38.5, RR 16,
Coarse crep at RLL,

cavitary lesion+air fluid level at Superior Segment of

RLL, Mx?

1. metronidazole
2. Anti-TB drugs
3. Oflaxacin
4. Roxithromaycin
5. Bactrim+Doxycycline

9.
55 2
enalapril amlodipine 2
PE: lungs are clear

1. chest x-ray
2. dextromethophan
3. inhaled corticosteroids
4. reduced amlodipine dosage
5. enalapril

Cough

Acute: < 3 weeks

Subacute: 3-8 weeks

Chronic: > 8 weeks

Chronic cough with normal

CXR

Upper airway cough syndrome (UACS)

Cough varient asthma

GERDs

Smoking

Drug induced cough (ACEI)

ACEI induced cough

Dry cough, F > M

5-20% of patients on ACEI (Ann Intern Med 1992; 117:234.)

5% Severe cough need to stop drugs

1-2 week after start medication (up to 6 months)

1 week after stop (up to 1 month)

70% Recur after rechallenge

9.
55 2
enalapril amlodipine 2
PE: lungs are clear
1. chest x-ray
2. dextromethophan
3. inhaled corticosteroids
4. reduced amlodipine dosage
5. enalapril

10.
+ OSA tonsils gr.2 MX?
1. tonsillectomy
2. uvuloplasty
3. diazepam hs
4. corticosteroid
5. on CPAP

10.
+ OSA tonsils gr.2 MX?
1. tonsillectomy
2. uvuloplasty
3. diazepam hs > OSA
4. corticosteroid
5. on CPAP

Thank you for your attention