Download - Respiratory tract infection
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Respiratory tract infection
By Dr.Preaw(General medicine )
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Scope
Diagnosis : CAP , HCAP , VAP
Pathophysiology
Investigation
Management and treatment
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Community-acquired pneumonia (CAP)
Diagnosis
1. Temperature > 38 ºC
2. Purulent secretion
3. Leucocytosis or leucopenia
IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2)
Moderate recommendation; level III evidence.
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Pathophysiological modes of spreading
Aerosols inhalation Mycoplasma pneumoniae Chlamydophila psittaci Chlamydophila pneumoniae Legionella pneumophila
Orophryngeal secretions Streptococcus pneumoniae
Aspiration Haemophilus influenzae anaerobes , gram- negative bacilli
Hematogenous spread Staphylococcus aureus
Reactivation of latent Mycobacterium tuberculosismicroorganism Pneumocystis jirovecci
Mechanism Example
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Pathophysiology :Failure of defences mechanisms
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.
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Classification of pneumonia (based on anatomical part )
Bronchopneumonia : terminal bronchiole ( patchy consolidation)-Streptococci-Staphylococcus aureus-B Haemolytic streptocci-Haemophilus influenzae-Klebsiella pneumonia-Pseudomonas
Lobar pneumonia -Streptococci pneumoniae-Staphylococcus aureus-B Haemolytic streptocci
Interstitialpneumonia : without alveolar exudates-virus: Respiratory syncytial virus Influenza virus Adenoviruses Cytomegaloviruses-Mycoplasma pneumoniae
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Pathologic Stages of Pneumococcal Lobar Pneumonia
Stage onset Affected lobe
congestion 1-2 day-proteinaceous fluid -neutrophils and many bacteria in aveoli
red hepatisation 2-4 day -red, firm and liver like consistency-proteinaceous fluid -> fibrin strands
gray hepatisation 4-7 day
-dry,firm and gray (lysed red cells)-neutrophils and bacteria also reduces-macrophages are seen
resolution over 3 wk( in normal )
-fibrinous matter
-macrophage ( major cells)
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Criteria for severe community-acquired pneumonia.
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
Minor criteria
Major criteria
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Investigation and management
Evidence level Definition
Level I (high) well-conducted,RCT
Level II ( moderate)well -designed,controlled trials without
randomization
Level III ( low) case studies and expert opinion
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Diagnosis testing remain controversial
InvestigationModerate
recommendation
hemocultureOPD case :level IIIIPD case : level I
sputum gram stain and culture level II
urine antigen for Legionella pneumophila and streptococcus pneumoniae level II
chest x ray level III
Sensitivity 69%false negative
1.dehydration2. early onset of PCP3. neutropenic patient
sensitivity 15-100%specificity 11-100%Adequate sputum PMN >25 cells/LPF
epithelium < 10 cells/LPF
sensitivity 70-90 %specificity 99 %
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Classification of pneumonia (based on anatomical part )
Lobar pneumonia
Bronchopneumonia
Interstitial pneumonia
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Gram : positive dipplococci :Streptococcus pneumoniae
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Gram : negative bacilli
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Management and treatment :hospital admission decision
CURB -65 score
strong recommendation :level I evidence
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PSI score
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Stratification of risk score
risk risk class score mortality
low Ibased on algorithm
0.1%
outpatient treatment
low II <70 0.6%
low III 71-90 0.9%
moderate IV 91-130 9.3%hospital
admissionhigh V >130 27%
PSI score
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CURB-65 Treatment PSI scores Treatment
012345
OPDOPDIPDICUICUICU
-IIIIIIIVV
-OPDOPD
observe or hospitalizationIPDIPD
Summary
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PIRO score for CAP
Factor Point Scores Risk
P
COPD or immunosuppresive 1
0-2low risk (1 in 30 )for ICU
mortalityAge > 70 yr 1
I
bacteremia
13
Mild risk (1 in 8) for ICU mortality
multilobar opacity 1
R
shock1
4high risk ( 2 in 5) for ICU
mortalitysevere hypoxia 1
O
ARDS1
5-8very high risk (3 in 4)
for ICU mortalityacute renal failure
1
Predisposition
Insult
Response
Organ dysfunction
ICU case
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Management
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Management : outpatient
setting antibiotic drugs recommendation
previous healthy (no use ABO in 3 month)
macrolide ordoxycycline
level I(strong)level III(weak)
comorbiditiesimmunosuppressing
conditon
respiratory fluoroquinolone orB-lactam +macrolide
level I(strong)level I(strong)
region with high rate (>25%)infection with high level ( MIC>16
mcg/ml)macrolide-resist streptococcus pneumoniae
ceftriaxone, cefuroxime doxycycline
level II (moderate)
C.pneumoniae (29%)M.pneumoniae(20%)S.pneumoniae(8%)
unknown (30%)
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Management : inpatient
setting antibiotic drugs recommendation
non-ICU-respiratory quinolone or-B -lactam+macrolide or level I
ICU -B-lactam +azithromycin -respiratory quinolone
level IIlevel I (penicillin allergic patient)
levofloxacin,moxifloxacin ,gemifloxacin
cefotaxime , ceftriaxone,ampicillin-sulbactam
-gram negative bacilli(20%)-S.pneumoniae(19%)-C.pneumoniae(19%)-M.pneuminiae(9%)
-unknown (31%)
-S.pneumoniae(24%)-gram negative bacilli(20%)-
C.pneumoniae(15%)-unknown (31%)
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Special condition
special concerns antibiotic drugs recommedation
Pseudomonas
-B-lactam+ ciprofloxacin or levofloxacin or
-B-lactam +aminoglycoside+azithromycin or
-B-lactam +aminoglycoside+fluoroquinolone
level III(moderate)
*CA-MRSA add vancomycin or linezolidlevel III
(moderate)
*CA-MRSA:community-acquired methicillin-resistant staphylococcus aureus
piperacillin-tazobactamcefepime,imipenem
meropenem
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Criteria for clinical stability
Temperature < 37.8 ºCHeart rate < 100 beats/minRespiratory rate < 24 breaths/minSystolic blood pressure > 90 mmHgAterial oxygen saturation > 90 % or PaO2 > 60 mmHg on RAAbility to maintain oral intakeNormal mental status
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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 secretionsPneumonia 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
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Healthcare-associated pneumonia(HCAP)
- 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
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Hospital-acquired pneumonia(HAP)
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
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HAP : pathogenesis
-Microaspiration:from oropharynx to lungs-Aspiration from 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
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Risk factor for multidrug-resistant pathogens causing
HAP, HCAP, VAP
-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
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Assessment of nonresponders
wrong organismdrug-resistant pathogeninadequate antimicrobial
therapy
wrong diagnosisARDS
atelectasispulmonary emboli
pulmonary hemorrhageneoplasm
underlying disease
complicationempyema or lung abcess
Clostridium difficile coliitisoccult infection
drug fever
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Summary
Diagnosis :
CAP
HCAP
VAP
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Summary
CURB-65
PSI score
PIRO score
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Summary
-Management-Prevention-Accessment of nonresponder
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