LOWER RESPIRATORY TRACT INFECTION

often used as a synonym for pneumonia, can also be applied to other types of infection including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, high fever, coughing and fatigue. The two most common infections here in the Philippines are Pulmonary Tuberculosis and Pneumonia

Pneumonia 3rd leading cause of morbidity ( 2001) and mortality (1998) in Filipinos based on the Philippine Health Statistics from the Department of Health. An infection of the pulmonary parenchyma Typical symptoms include cough, chest pain, fever, and difficulty breathing.. typically classified as being either community-acquired or health care-associated. Results from the proliferation of microbial pathogens at the alveolar level and the host's response to those pathogens. A. Pathophysiology : 1. Microorganisms gain access to the lower respiratory tract. 2. When e inhaled to the alveolar level, resident alveolar macrophages are extremely efficient at clearing and killing pathogens. 3. when the capacity of the alveolar macrophages to ingest or kill the microorganisms is exceeded does clinical pneumonia become manifest

B. Pathology (phases)

1. Edema presence of a proteinaceous exudates in the alveoli. This phase is rarely evident in clinical or autopsy specimens because it is so rapidly followed by a red hepatization phase. 2. Red hepatization Characterized by the presence of erythrocytes in the cellular intraalveolar exudate, but neutrophil influx is more important from the standpoint of host defense. Bacteria are occasionally seen in pathologic specimens collected during this phase. 3. Gray hepatization, no new erythrocytes are extravasating those already present have been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is abundant, bacteria have disappeared. This phase corresponds with successful containment of the infection and improvement in gas exchange. 4. Resolution the macrophage reappears as the dominant cell type in the alveolar space, and the debris of neutrophils, bacteria, and fibrin has been cleared, as has the inflammatory response.

C. Infiltrate Patterns Pattern Lobar Patchy Interstitial Cavitary Possible Diagnosis S. pneumo, Kleb, H. flu, GN Atypicals, viral, Legionella Viral, Legionella Anaerobes, Kleb, TB, S. aureus, fungi Large effusion Staph, anaerobes

D. 1. 2. 3.

Morphologic types Lobar Broncho Interstitial 1. LOBAR PNEUMONIA - Middle age 20-50 y/o, males - 95% - Strep pneumonia .(Klebsiella in aged, DM, alcoholics) - Diffuse, exudation - consolidation - High fever, rusty sputum, Pleuritic chest pain. - Primary in a healthy - Usually unilateral

2. BRONCHOPNEUMONIA Extremes of age. (infancy and old age) Staph, Strep, Pneumonia & H. influenza Patchy consolidation not limited to lobes Suppurative inflammation Usually bilateral Lower lobes common

3. INTERSTITIAL PNEUMONIA - Primary atypical pneumonia in the immunocompetent host (Mycoplasma or Chlamydia) - Interstitial pneumonitis - immunocompromised host : Pneumocystic carinii; CMV - Immunocompetant host: Influenza A - Gross features: Lungs are heavy but not firmly consolidated - Microscopic features: -Septal Mononucler Infiltrates - Alveolar air spaces either empty or filled with proteinaceous fluid with few or no inflammatory cells

Community Acquired Pneumonia (CAP) an acute infection of the pulmonary parenchyma that is associated with some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiograph, or auscultatory findings consistent with pneumonia, in a patient not hospitalized or residing in a long term care facility for > 14 days before onset of symptoms CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. Streptococcus pneumoniae is most common Typical microorganism includes S. pneumoniae, Haemophilus influenzae, and (in selected patients) S. aureus and gram-negative bacilli such as Klebsiella pneumoniae and Pseudomonas aeruginosa. Atypical microorganism includes Mycoplasma pneumoniae and Chlamydia pneumoniae (in outpatients) and Legionella spp. (in inpatients) as well as respiratory viruses such as influenza viruses, adenoviruses, and respiratory syncytial viruses.

Typical Onset Clinical Presentation Sudden High fever, shaking chills Pleuritic chest pain, SOB Productive cough Rusty sputum, blood tinge Poor general condition Leukocytosiis, increased ESR and increased CReactive Protein Lobar or segmental homogeneous opacity

Atypical Gradual and Insiduous Low grade fever Dry cough, No blood tinge Good General Condition Walking CAP

Laboratory

Parameters are usually normal or slightly raised Diffuse patchy or ground glass shadows cannot be cultured on standard media, nor can they be seen on Gram's stain intrinsically resistant to all Beta -lactam agents

Treatment

May not be resistant to all beta lactam agents

Mortality

High mortality up to 20% Low mortality 1-2%; in patients with except in cases of bacteremia Legionellosis

Anaerobes play a significant role only when an episode of aspiration has occurred days to weeks before presentation for pneumonia.

Causes of CAP

Risk Factors of CAP 1. alcoholism, 2. asthma, 3. immunosuppression, 4. institutionalization, and 5. an age of >/=70 years

Clinical Manifestations The patient is frequently febrile with tachycardia or may have a history of chills and/or sweats Cough may be either nonproductive or productive of mucoid, purulent, or blood-tinged sputum. If the pleura is involved, the patient may experience pleuritic chest pain. Patient may have gastrointestinal symptoms such as nausea, vomiting, and/or diarrhea. Other symptoms may include fatigue, headache, myalgias, and arthralgias. Findings on physical examination vary with the degree of pulmonary consolidation and the presence or absence of a significant pleural effusion. An increased respiratory rate and use of accessory muscles of respiration are common. Palpation may reveal increased or decreased tactile fremitus the percussion note can vary from dull to flat, reflecting underlying consolidated lung and pleural fluid, respectively. Crackles, bronchial breath sounds, and possibly a pleural friction rub may be heard on auscultation..

Clinical Diagnosis The differential diagnosis includes both infectious and noninfectious entities such as acute bronchitis, acute exacerbations of chronic bronchitis, heart failure, pulmonary embolism, and radiation pneumonitis. chest radiography is often necessary to differentiate CAP from other conditions. CAP CLASSIFICATION 1. LOW RISK CAP - Stable vital signs RR < 30/min PR < 125/min SBP > 90, DBP > 60 mmHg Temp. < 40 C - No or stable co-morbid conditions DM, neoplastic disease, neurologic disease, CHF Class I, CAD, immunosuppressive therapy Renal insufficiency COPD, chronic liver disease, or chronic alcohol abuse 2. MODERATE RISK CAP - Vital Signs: any one of the following RR > 30/min PR > 125/min Temp. > 40 C - X-ray findings of: Multi-lobar involvement Progression of lesion to 50% within 24 hours Abscess Pleural effusion - with suspected aspiration - extra-pulmonary findings of sepsis: hepatic, hematologic, gastrointestinal, endocrine

- Unstable comorbid condition: uncontrolled DM, active malignacies, neurologic disease in evolution, CHF Class II-IV, unstable CAD, renal failure on dialysis, uncompensated COPD, decompensated liver disease 3. HIGH RISK CAP - All criteria under moderate risk plus - Impending or frank respiratory failure Hypoxemia with PaO2 < 60 mmHg Acute hypercapnia with PaCO2 > 50 mmHg - Hemodynamic alterations and hypoperfusion: SBP < 90mmHg, DBP < 60mmHg Urine output < 30cc/hour Altered mental state

Etiologic Diagnosis 1. Gram's Stain and Culture of Sputum .To be adequate for culture, a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field. 2. Blood Cultures Only ~514% of cultures of blood from patients hospitalized with CAP are positive, and the most frequently isolated pathogen is S. pneumoniae. high-risk patientsincluding those with neutropenia secondary to pneumonia, asplenia, or complement deficiencies; chronic liver disease; or severe CAPshould have blood cultured. 3. Antigen Tests Detect pneumococcal and certain Legionella antigens in urine. The sensitivity and specificity of the Legionella urine antigen test are as high as 90% and 99%, respectively. The pneumococcal urine antigen test is also quite sensitive and specific (80% and >90%, respectively). 4. Polymerase Chain Reaction

 the use of these PCR assays is generally limited to research studies. In patients with pneumococcal pneumonia, an increased bacterial load documented by PCR is associated with an increased risk of septic shock, need for mechanical ventilation, and death. 5. Serology A fourfold rise in specific IgM antibody titer between acute- and convalescent-phase serum samples is generally considered diagnostic of infection with the pathogen in question.

Treatment 1. Site of Care There are currently two sets of criteria: 1. Pneumonia Severity Index (PSI), a prognostic model used to identify patients at low risk of dying; To determine the PSI, points are given for 20 variables, including age, coexisting illness, and abnormal physical and laboratory findings. On the basis of the resulting score, patients are assigned to one of five classes with the following mortality rates: class 1, 0.1%; class 2, 0.6%; class 3, 2.8%; class 4, 8.2%; and class 5, 29.2%. Clinical trials demonstrate that routine use of the PSI results in lower admission rates for class 1 and class 2 patients. Patients in classes 4 and 5 should be admitted to the hospital, while those in class 3 should ideally be admitted to an observation unit until a further decision can be made. The PSI is less practical in a busy emergency room setting because of the need to assess 20 variables.

2. CURB-65 criteria, a severity-of-illness score. The CURB-65 criteria include five variables: confusion (C); urea >7 mmol/L (U); respiratory rate </=30/min (R); blood pressure, systolic >/+90 mmHg or diastolic >/=60 mmHg (B); and age </=65 years (65). Patients with a score of 0, among whom the 30-day mortality rate is 1.5%, can be treated outside the hospial. With a score of 2, the 30-day mortality rate is 9.2%, and patients should be admitted to the hospital. Among patients with scores of >/=3, mortality rates are 22% overall; these patients may require admission to an ICU.

Algorithm for the management oriented risk stratification of CAP among immunocompetent adult

Antibiotics 1. LOW RISK CAP Previously healthy and no antibiotics in past 3 months Macrolide (Clarithromycin 500mg BID or Azithromycin 500mg OD) or Doxycycline 100mg BID Comorbidities or antibiotics in past 3 months: select an alternative from a different class Fluoroquinolone (Moxifloxacin 400mg OD, Gemifloxacin 320mg OD, Levofloxacin 750mg OD) or Beta-lactam (Amoxicillin 1gm TID, Amoxicillin/Clavulanate 2gm BID, Cefpodoxime 200mg BID, Cefuroxime 500mg BID) plus Macrolide 2. MODERATE RISK CAP Fluoroquinolone (Moxifloxacin 400mg PO or IV OD, Gemifloxacin 320mg PO OD, Levofloxacin 750mg PO or IV OD) Beta-lactam (Cefotaxime 1-2gm IV q8h, Ceftriaxone 1-2gm IV OD, Ampicillin 1-2gm IV q4-q6) plus macrolide 3. HIGH RISK CAP (no risk for Pseudomonas) Beta-lactam (Cefotaxime 1-2gm IV q8h, Ceftriaxone 2gm IV OD, Ampicillin-Sulbactam 2gm IV q8) plus Azithromycin or a fluoroquinolone

4. SPECIAL CONCERNS If Pseudomonas is a consideration An antipseudomonal, antipneumococcal beta-lactam (Piperacillin/Tazobactam 4.5 gm IV q4-q6, Cefepime 1-2gm IV q12, Imipinem 500mg IV q6, Meropenem 1 g IV q8) plus either Ciprofloxacin 400mg IV q12) or Levofloxacin 750mg IV OD The above beta-lactams plus an aminoglycoside (Amikacin 15mg/kg OD or Tobramycin 1.7 mg/kd OD) and Azithromycin The above beta-lactams plus an aminoglycoside plus an antipneumococcal fluoroquinolone If CA-MRSA is a consideration Add Linezolid 600mg IV q12 or Vancomycin 1gm IV q12

FAILURE TO IMPROVE W/N 48-72 HRS OF THERAPY Cancer, embolus, hemorrhage Resistant pathogen Wrong drug Right drug, wrong dose Unusual pathogens - Mycobacterial, anaerobic, viral, fungal Nosocomial superinfections COMPLICATIONS - Respiratory failure - Shock; Multiorgan failure - Bleeding diathesis - Exacerbation of comorbid illnesses - Metastatic infections - Brain abscess; Endocarditis - Lung abscess - usually occurs in the setting of aspiration, should be drained - Pleural effusion - should be tapped for diagnostic and therapeutic purposes RATE OF RESOLUTION Fever Cough Crackles leukocytosis CXR abnormalities

2-4days 4-9days 3-6days 3-4days 4-12wks

Patient is considered to have responded if: - Fever declines within 72 hrs - Temperature normalizes within 5 days - Respiratory signs (tachypnea) return to normal Prevention The main preventive measure is vaccination. The recommendations of the Advisory Committee on Immunization Practices should be followed for influenza and pneumococcal vaccines.

In the event of an influenza outbreak, unprotected patients at risk from complications should be vaccinated immediately and given chemoprophylaxis with either oseltamivir or zanamivir for 2 weeks An available 7-valent pneumococcal conjugate vaccine produces T cell dependent antigens that result in long-term immunologic memory. Administration of this vaccine to children has led to an overall decrease in the prevalence of antimicrobial-resistant pneumococci and in the incidence of invasive pneumococcal disease among both children and adults. 1. PNEUMOCOCCAL VACCINE 60 yrs old and above Chronic illness: cardiovascular disease, lung disease, DM, alcohol abuse, chronic liver disease, asplenia Immune system disorder: HIV, malignancy 2. INFLUENZA VACCINE 50 yrs old and above Chronic illness Immune system disorder Residents of nursing homes Health care workers Persons in contact with high risk patients

Health Care Associated Pneumonia (HCAP) - Hospitalization for 2 or more days within 90 days of the present infection - Resident of a nursing home or long-term care facility - Received recent IV antibiotic therapy, chemotherapy or wound care in the past 30 days of the current infection - Attended a hospital or hemodialysis clinic a. Ventilator Associated Pneumonia (VAP) - Pneumonia that arises more than 48-72 hours after endotracheal intubation b. Hospital Acquired Pneumonia (HAP) - pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission

The main differences are in the higher frequency of non-MDR pathogens and the better underlying host immunity in nonintubated patients.

PATHOGENS 1. Colonization of the oropharynx with pathogenic microorganisms 2. Aspiration from the oropharynx into the lower respiratory tract 3. Compromise of the normal host defense mechanisms

RISK FACTORS: ET- Most common Antibiotic selection pressure Cross infection from other infected patients or contaminated equipment Malnutrition CLINICAL FEATURES Fever Leukocytosis Increase in respiratory secretions PE findings of consolidation New or changing radiographic infiltrate Tachypnea Tachycardia Worsening oxygenation Increased minute ventilation DIAGNOSIS Blood culture Endotracheal aspiration bronchoscopy

Approach to patient 1. Clinical Pulmonary Infection Score CPIS allows the selection of low-risk patients who may need only short-course antibiotic therapy or no treatment at all.

Treatment 1. Antibiotic Patients w/o risk factors for MDRpathogens Ceftriaxone 2g IV q24 hours or Moxifloxacin 400mg IV q24 hours, Ciprofloxacin 400mg IV q8 hours, Levofloxacin 750mg IV q24 hours or Ampicillin/Sulbactam 3 gm IV q6 hours or Ertapenem 1gm IV q24 hours Patients with risk factors for MDR pathogens 1. A beta-lactam: Ceftazidime 2 gm IV q8 hours or Cefepime 2 gm IV q8-q12 hours or Piperacillin/Tazobactam 4.5 gm IV q6 hours, Imipinem 500mg IV q6 hours or 1 gm IV q8 hours, Meropenem 1 gm IV q8 hours plus 2. A second agent active against gram-negative bacterial pathogens: Gentamicin or Tobramycin 7 mg/kg IV q24 hours or Amikacin 20 mg/kg IV q24 hours or

 Ciprofloxacin 400mg IV q8 hours or Levofloxacin 750mg IV q24 hours plus 3. An agent active against gram-positive bacterial pathogens: Linezolid 600 mg IV q 24 hours or Vancomycin 15mg/kg q12 hours

FAILURE TO IMPROVE Due to MDR pathogens Reintroduction of the microorganisms Superinfection Extrapulmonary infections Drug toxicity

COMPLICATIONS Death Prolonged mechanical ventilation Prolonged hospital stay Development of necrotizing pneumonia Long-term pulmonary complications Inability of the patient to return to independent function

Switch of oral antibiotic agent - There is less cough and resolution of respiratory distress (normalization of RR) - The patient is afebrile for > 24 hours. - The etiology is not a high risk (virulent/resistant) pathogen. - There is no unstable co-morbid condition or life-threatening complication such as MI, CHF, complete heart block, new atrial fibrillation, supraventricular tachycardia, etc. - There is no obvious reason for continued hospitalization such as hypotension, acute mental changes, BUN: Cr of >10:1, hypoxemia, metabolic acidosis, etc.

PREVENTION 1. Decreasing likelihood of encountering the pathogen - hand washing - use of gloves - Use of face mask - Negative pressure room - Prompt institution of effective chemotherapy for patients with contagious illnesses - Correction of condition that facilitate aspiration o Maintenance of gastric acidity 2. Strengthening the hosts response once the pathogen is encountered - Chemoprophylaxis - Immunizing of patients at risk 3. Surveillance of pneumonia 4. For mechanically ventilated: extubate rapidly, minimize circuit changes, drain tubings regularly 5. Small bore feeding tube 6. Elevation of head to 30

CRITERIA FOR HOSPITAL DISCHARGE STABLE VITAL SIGNS FOR 24HOUR PERIOD Temperature 100 F (37.8 C) Respiratory rate 24 cpm Heart rate 100 bpm Systolic blood pressure 90 mm Hg Oxygen saturation 90% on room air Patient able to take oral antibiotics Patient is able to maintain adequate hydration and nutrition Patients mental status is at baseline Patient has no other active clinical or psychological problems

OUR LADY OF FATIMA UNIVERSITY DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY HEALTH

LOWER RESPIRATORY TRACT INFECTION

OCAMPO, JOHN VINCENT DY