Lower respiratory tract infection

"Lower respiratory tract infection"
I would especially like to thank Prof. dr. Dragan Danilovski for support

1. Lower respiratory tract infection (Epidemiology and statistics) Ass. Dr. Suzana Arbutina Clinic of Pulmonology and Allergology Skopje

2. Lower respiratory (tract) infection or LTRI is a generic term for an acute infection of the trachea (windpipe), airways and lungs, which make up the lower respiratory system. LTRIs include acute bronchitis , AECB,and pneumonia . Definition

3. Symptoms include - shortness of breath, - weakness , - high fever, coughing and fatigue . Lower respiratory tract infections place a considerable strain on the health budget and are generally more serious than upper respiratory infections. Since 1993 there has been a slight reduction in the total number of deaths from lower respiratory tract infection. However in 2012 they were still the leading cause of deaths among all infectious diseases , and they accounted for 3.9 million deaths worldwide and 6.9% of all deaths that year .

4. Every year about 5 million people die of acute respiratory infections. Among these, pneumonia represents the most frequent cause of mortality, hospitalization and medical consultation. Several factors (age, underlying disease, environment) influence mortality, morbidity and also microbial etiology. The authors also refer to recent data on the most frequently identified antibiotic resistance of respiratory pathogens. The knowledge of such different clinico-epidemiological situations is essential to physicians for an effective approach to treatment of pneumonia and bronchitis.

5. The aim of this review is to focus on the epidemiology of lower respiratory tract infections and the etiology , dividing these problems into the following issues: global impact of these afflictions, community-acquired pneumonia, hospital acquired pneumonia, acute bronchitis and exacerbations of chronic bronchitis

6. Bronchitis can be classified as either acute or chronic. Acute bronchitis can be defined as acute bacterial or viral infection of the larger airways in healthy patients with no history of recurrent disease . It affects over 40 adults per 1000 each year and consists of transient inflammation of the major bronchi and trachea. Most often it is caused by viral infection and hence antibiotic therapy is not indicated in immunocompetent individuals

7. Acute Exacerbations of Chronic Bronchitis ( AECB ) are frequently due to non-infective causes along with vira l ones. 50 % of patients are colonised with Haemophilus influenzae , Streptococcus pneumoniae or Moraxella catarrhalis . Antibiotics have only been shown to be effective if all three of the following symptoms are present:- increased dyspnoea , increased sputum volume and purulence .

8. Most commmon cause AECB Respiratory viruses are associated with 30 % of cases, atypical bacterial (mostly Chlamydophila pneumoniae ) infections are implicated in less than 10% , and bacterial pathogens in approximately 40–50% of exacerbations.

9. Pneumonia occurs in a variety of situations and treatment must vary according to the situation . It is classified as either community or hospital acquired depending on where the patient contracted the infection. It is life-threatening in the elderly or those who are immunocompromised.

10. H. influenzae and M. catarrhalis are of increasing importance in both community acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis (AECB ) while the importance of S. pneumoniae is declining . It has also become apparent the importance of atypical pathogens such as C. pneumoniae , M. pneumoniae and L. pneumophila , in CAP .

11. The most common cause of pneumonia is pneumococcal bacteria, Streptpcoccus pneumoniae accounts for 2/3 of bacteremic pneumonias . This is a dangerous type of lung infection with a mortality rate of around 25%

12. Viral pathogens associated with AECB include influenza, parainfluenza , rhinovirus, coronavirus, adenovirus and respiratory syncytial virus . The three major bacteria l causes of AECB in mild COPD exacerbations include nontypeable Haemophilus influenzae , Moraxella catarrhalis and Streptococcus pneumoniae . In one study , patients undergoing mechanical ventilation for their AECB/COPD exacerbations were frequently found to have Pseudomonas aeruginosa and Stenotrophomonas spp . Patients who were less severely ill tended to have S. pneumoniae and other Gram-positive cocci isolated from sputum, while more severe baseline airway obstruction was associated with H. influenzae and M. catarrhalis . The most severely obstructed AECB/COPD patients tended to have Pseudomonas and Enterobacterace spp . cultured from sputum . Mycoplasma pneumoniae is thought to be a rare cause of AECB, while C . pneumoniae may be isolated in as many as 5–10% of cases .

13. Bronchiectasis patients also frequently have nonenteric Gram-negative bacteria isolated from sputum during exacerbations . H. influenzae has been isolated in 30–47% of cases, P . aeruginosa (including mucoid species) in 12–31%, M . catarrhalis in 2.4–20% , S . pneumoniae in 7–10%, Staphylococcus aureus in 4–14% , Mycobacterium (primarily Mycobacterium avian intracellular complex) in 2–17%, and no organisms in 21–23 % of sputum cultures obtained during exacerbations

14. ADV: Adenoviruses; CoV : Coronaviruses (types 229E, NL63, OC43 and HKU1); Cp: Chlamydophila pneumoniae ; Ent : Enterobacteria; EV : Enterovirus; Hi : Haemophilus influenzae ; Inf : Influenza viruses (A, B and C); Leg Legionella spp.; Mc : Moraxella catarrhalis ; Misc : Miscellaneous; Mp : Mycoplasma pneumoniae ; MPV : Metapneumovirus; PIV: Parainfluenza viruses (types 1 – 4); Pse : Pseudomonas spp.; RSV: Respiratory syncytial virus; RV : Rh inovirus; Sa : Staphylococcus aureus ; Spn : Streptococcus pneumoniae ; Spy : Streptococcus pyogenes . Pathogen by pathogen detection rates of respiratory viruses and bacteria in adults with Community acquired pneumonia

15. Disability-adjusted life year for lower respiratory infections per 100,000 inhabitants in 2004

16. Thorax 2008; 63:817-822 Incidence and predictive factors of lower respiratory tract infections among the very elderly in the general population. The Leiden 85-plus Study A Sliedrecht W P J den Elzen , T J M Verheij , R G J Westendorp , J Gussekloo

17. Participants: Unselected cohort of 587 participants aged 85 years in Leiden , The Netherlands. Measurements: As reported in the literature, predictive factors were selected and assessed at baseline. During a 5 year follow-up period , information on the development of lower respiratory tract infections was obtained from general practitioners or nursing home physicians. Associations between predictive factors were analysed with Cox regression, and population attributable risks were calculated. Results : The incidence of lower respiratory tract infections among persons aged 85–90 years was 94 (95% CI 80–108) per 1000 person years . After multivariate analysis, history of chronic obstructive pulmonary disease (COPD), smoking, oral glucocorticosteroid use, severe cognitive impairment, history of stroke and declined functional status remained independently associated with the occurrence of lower respiratory tract infections. Smoking was the greatest contributor with a population attributable risk of 32%. Conclusion: In the very old, smoking, COPD, stroke and declined functional status were associated with the occurrence of lower respiratory tract infections and provide a means of targeting patients at risk of severe health complications.

18. LRTI incidence increased with fluctuations over time, was higher in men than women aged ≥70 and increased with age from 92.21 episodes/1000 person-years (65-69 years) to 187.91/1000 (85-89 years).

19. CAP incidence increased more markedly with age, from 2.81 to 21.81 episodes/1000 person-years respectively, and was higher among men

20. Community-acquired lower respiratory tract infections (LRTI ) and pneumonia (CAP ) are common causes of morbidity and mortality among those aged ≥65 years; a growing population in many countries. Detailed incidence estimates for these infections among older adults in the United Kingdom (UK) are lacking . We used electronic general practice records from the Clinical Practice Research Data link, linked to Hospital Episode Statistics inpatient data, to estimate incidence of community-acquired LRTI and CAP among UK older adults between April 1997-March 2011, by age, sex, region and deprivation quintile Incidence of Community-Acquired Lower Respiratory Tract Infections and Pneumonia among Older Adults in the United Kingdom: A Population-Based Study Elizabeth R. C. Millett mail, Jennifer K. Quint, Liam Smeeth , Rhian M. Daniel, Sara L. Thomas Published: September 11, 2013

21. Pneumonia and lower respiratory tract infections (LRTI) are major causes of morbidity and mortality among those aged 65 years and over in the UK and other European countries The UK’s population is aging; recent estimates suggest that in 2035, 23% of the UK will be aged ≥65 years and 5% will be ≥85, compared to 17% and 2% respectively in 2010 . The ‘oldest old’ (≥85 years) are at particularly high risk of infections due to co-morbidities and waning immune function. Community-acquired pneumonia (CAP) in older individuals is a particular concern, as it can aggravate underlying co-morbidities and have serious consequences Incidence of Community-Acquired Lower Respiratory Tract Infections and Pneumonia among Older Adults in the United Kingdom: A Population-Based Study Elizabeth R. C. Millett mail , Jennifer K. Quint, Liam Smeeth , Rhian M. Daniel, Sara L. Thomas Published: September 11, 2013

22. In the U.S ., pneumonia is the sixth most common cause of death and the leading cause of death from infectious diseases The death rate from pneumonia increases Annually in the United States: • to 2-3 million people with CAP • ~ 10 million physician visits, 500,000 hospitalizations • 45,000 deaths

23. Of the LRT infections pneumonia remains the most common infections seen in the community and among hospitalized patients . Despite the use of antibiotics the mortality associated with pneumonia is still quite high . In 2000 pneumonia and influenza were the seventh leading cause of death in the United States (24.3 deaths per 100,000 population ). Approximately , 1.8 cases of pneumonia were reported for every 100 Americans in 1996 Pneumonia is also a very common case of nosocomial infections ranking third in occurrence behind urinary tract infections and surgical wound infections (33% of the infections acquired in the hospital).

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