Respiratory Infections | Jindal Chest Clinics

Understanding Respiratory Infection- Their Causes, Symptoms, Prevention, and Treatment. For more information, please contact us: 9779030507.

1. Respiratory Infections Pneumonia

2. An inflammation of the mucous membranes of your mouth, nose, airways and/ or lung parenchyma brought on by a virus or bacteria is known as a respiratory infection. What is Respiratory infection?

3. Upper Respiratory Infections: Infections in the mouth, nose and throat - Sinusitis, Tonsillitis, Pharyngitis , Laryngitis etc. Lower Respiratory Infections: Infections of the trachea, bronchi and lung parenchyma - Tracheo -bronchitis, Chronic bronchitis, Pneumonias, Lung abscess, Bronchiectasis Pleural Infections: Pleurisy, Pleural effusion, Empyema Types of Respiratory infections:

4. Pneumonia – Alveolar infection resulting from the invasion and overgrowth of microorganisms in lung parenchyma. Classification Anatomical- Depending upon the part of the lung involved: Lobar / segmental Bronchopneumonia Microbiological – Depending upon the type of organism responsible for infection Empirical – Depending upon the setting of occurrence of pneumonia Pneumonia or Pneumonitis

5. Community-acquired pneumonia - infection in a non-hospitalized population. Health-Care associated pneumonia (HCAP ) Hospital-acquired pneumonia Ventilator-associated pneumonia Pneumonia in an Immunosuppressed individual. Commonly recognized CLASSIFICATION OF PNEUMONIAS

6. A. Bacterial : Pneumococal , H. influenzae , Atypical, Staphylococcal, Gram – ve , Anaerobic, and others B. Mycobacterial : Caused by Tubercle bacillus C. Viral: Respiratory Syncytial Virus, Corona, others D. Fungal : Aspergillus , Mucor , Cryptococcus, others E. Chemical: Inhalation of acid and other chemical vapours Microbiological Classification

7. Homeostasis - unbalanced in CAP The germ is NOTHING… the soil is EVERYTHING… Louis Pasteur 1895 Infection occurs whenever there is disturbance in the ‘homeostasis’ normally maintained by the interaction between the: Host Pathogen and Environment

8. ENVIRONMENT Infected air , water , fomites , instruments Cross-contamination HOST Impaired immune function Comorbid illness Prior surgery/antibiotics PATHOGEN Inoculum - Virulent strain (MDR)

9. Increased prevalence/ occurence Comorbidities : DM, CAD, CHF, neurologic disease, Immunosuppression , active malignancies, HIV infection, Cortico -steroid use Increasing age, Age > 65 yrs, Recent influenza, Bacteraemia , leukopenia , Alcoholism, Tobacco-smoking, Air-pollution Exposure/s to child in a day care centre Risk Factors

10. Risk for enteric gram – ve infections Recent antibiotic therapy Underlying cardiopulmonary disease Resident of a nursing home Multiple medical co-morbidities Risk for P. aeruginosa Structural lung disease ( Bronchiectasis , CF) BSA therapy for > 7 days in the past month Corticosteroids (at least 10 mg predn /day) Malnutrition

11. Symptoms General: Fever, pains, night sweats Respiratory: Cough/sputum, dyspnea , chest pain, hemoptysis , others Signs General: Rash, hemorrhage Chest: Normal, crackles, bronchial, wheeze Systemic: Meningitis, carditis Clinical features

12. Pulmonary tuberculosis Pulmonary infarction Vasculitis Eosinophilic pneumonia Collapse, Malignancy Loculated effusion Uncommonly: ILD, Organizing Pneumonia Differential Diagnosis

13. Pulmonary: Para-pneumonic effusion Empyema, Broncho -Pleural Fistulae Cavitation , Lung abscess, Pneumothorax Sputum impaction, collapse ARDS, Respiratory failure Systemic: Deep vein thrombosis, Ectopic abscesses, Pericarditis, Myocarditis, Renal failure Hepatitis, Meningo -encephalitis Multi-organ failure Complications

14. CXR CT chest only in those with non-resolution or for assessment of complications Bl. Culture in hospitalized patients Sputum/BAL smear and culture for hospitalized patients Sputum for AFB Diagnosis of Community Acquired Pneumonia is largely clinical and CXR based in the out-patient setting. Role of diagnostic tests

15. Leucocytosis (polymorphonuclear) Raised ESR Arterial blood gases S. electrolytes; liver & renal function tests Blood sugar H.I.V. serology Blood cultures Others General Laboratory Tests

16. New infiltrates / opacities Alveolar shadows – consolidation Lobar / segmental / others Pleural effusion / pneumothorax Air cysts / cavities Interstitial / miliary shadows Hilar L.N. ± infiltrates Chest Roentgenography

17. Chest radiographs False-negative Interstitial lung dis PJP pneumonia Miliary TB Dehydration Neutropenia False-positive Early course Vasculitis Atelectasis CHF Pulmonary infarcts Malignancies Miscellaneous

18. Microbiological tests Blood culture- Positive in around 25%; indicator of severity Sputum smear and culture- Rapid, inexpensive, variable sensitivity & specificity Serology- Initial testing only if onset > 7 days, or severe or unresponsive to - lactams Legionella urine antigen- Highly specific & sensitive; intubated patients with severe disease

19. Sputum / induced sputum Bronchoscopic - Washings - Bronchial / bronchoalveolar lavage - Biopsy (bronchial / TBLB) - Needle aspiration Transthoracic needle biopsy Transtracheal aspiration Pleural aspirate / biopsy Thoracoscopic specimens “Pulmonary Samples” for Diagnosis

20. Routine C linical Assessment Host factors General indicators: Fever, Leucocytosis, blood cultures, C Reactive Protein Clinical Scoring System Micro organism pattern Biomarkers Assessment of Severity

21. CURB – 65, CRB Pneumonia Severity Index (PSI) Apache scoring system (APACHE II) Others Clinical Assessment Scores

22. Inflammatory biomarker Acute phase reactant primarily produced by liver in bacterial infections Inhibited by viral related cytokines Increased PCT: helps to identify patients who: - Benefit from antibiotics - Increased risk of death PCT-guided group had significantly less antibiotic use and duration of therapy Procalcitonin (PCT)

23. Anti-microbial therapy - Antibiotics Supportive & symptomatic therapy: Fever, Dehydration, Systemic symptoms Stabilization of severity parameters: De-oxygenation, Organ failure, Shock Treatment of complications: Empyema , Cavitation, BP Fistulae Management of drug-toxicities Preventive strategies Management of CAP

24. Presence of comorbid medical conditions Chronic heart, lung, liver or renal disease Diabetes mellitus Alcoholism Malignancies Use of antimicrobials within the previous 3 months Severe CAP with or without comorbidities Indications for empiric combination therapy in CAP

25. No cardiopulmonary disease / No disease modifying factors β -lactam, macrolide, doxycycline Cardiopulmonary disease / disease modifying factors Beta lactam + macrolide (or doxy) Out-patients Recommendations

26. Non-severe CAP β -lactam or macrolide Severe CAP/No risk factor for Pseudomonas IV Beta lactam + azithromycin Severe CAP/Risk factor for Pseudomonas IV anti-pseudomonal β -lactam + anti-pseudomonal fluoroquinolones IV antipseudomonal β -lactam + amino-glycoside + azithromycin Inpatient Recommendations Fluoroquinolones should be used judiciously

27. Duration of therapy Pneumococcus, Gram negative bacteria - 7 to 10 d M. pneumoniae & C. pneumoniae - 10 to 14 d Legionella, Pseudomonas, Staph. aureus – 14 to 21 d Switch to Oral Therapy Improvement in cough and dyspnea, afebrile (< 100 F) on two occasions 8 h apart, WBC count decreasing, functioning GIT with adequate oral intake Duration of therapy

28. Antimicrobial failure Patient noncompliance, improper dosing regimen, resistant pathogen, unusual or unsuspected pathogen Infectious complications Empyema, endocarditis, super-infection Incorrect diagnosis Malignancy, pulmonary embolism, other noninfectious etiologies Non-Resolving Pneumonia

29. Death Need for mechanical ventilation RR > 25 / min SaO 2 < 90%; PaO 2 < 55 mmHg Hemodynamic instability Less than 1 o C decline in admission temp. of > 38.5 o C Altered mental state Severe Pneumonia/ Clinical Failure

30. Antimicrobial failure Patient noncompliance, improper dosing regimen, resistant pathogen, unusual or unsuspected pathogen Infectious complications Empyema, endocarditis, superinfection Incorrect diagnosis Malignancy, pulmonary embolism, other noninfectious etiologies Causes of Clinical Failure

31. Pneumococcal & influenza vaccine Immune-competent patients > 65 yr Persons < 65 yr - CHF, COPD (not asthma), diabetes mellitus, alcoholism, chronic liver disease, asplenia etc. Immunosuppressed states (HIV infection, leukemia-lymphoma, immunosuppressive therapy etc.) Can be given immediately (after CAP) Prevention

32. Hospital-acquired pneumonia - pneumonia 48 hours or more after admission, and was not incubating at the time of admission Ventilator-associated pneumonia - pneumonia that arises more than 48-72 hours after endotracheal intubation Nosocomial Pneumonias

33. Hospital Acquired Pneumonia (HAP) ≥48 h after hospital admission (excluding an incubating infection) Early onset HAP vs Late onset HAP Ventilator Associated Pneumonia (VAP) ≥48-72 h after endotracheal intubation Early onset VAP vs Late onset VAP Health Care Associated Pneumonia (HCAP) i . hospitalized in an acute care hospital ≥ 2days in preceding 90 days; ii. nursing home or long-term care facility resident; iii. recent iv chemotherapy, or wound care within past 30 days iv. attended a hospital or hemodialysis clinic DEFINITIONS

34. Clinical + Chest X ray + Microbiology DIAGNOSIS OF HAP New onset fever Purulent expectoration Tachycardia, Tachypnoea Leukocytosis / Leukopenia Need of higher FiO2 Clinical diagnosis: high sensitivity, low specificity empiric treatment Microbiology to identify etiology de-escalate therapy decide duration of therapy

35.   Sicker inpatient population Immuno -compromised patients New procedures & instrumentation Emerging pathogens Complacency regarding antibiotics Ineffective infection control and compliance Increased antibiotic use DRUG RESISTANCE: Factors

36. Management strategies summary HAP, VAP or HCAP suspected Obtain lower respiratory tract (LRT) sample for culture (quantitative or semi-quantitative) and microscopy Begin empiric antimicrobial therapy using local microbiological data Days 2 and 3: check cultures and assess clinical response: (temperature, WBC, chest X-ray, oxygenation, purulent sputum, haemodynamic changes and organ function) Clinical improvement at 48–72 hours No Yes Cultures + Cultures – Cultures- - Cultures + Adjust antibiotic therapy, search for other pathogens, Search for other pathogens , complications etc Consider stopping antibiotics De-escalate antibiotics , if possible,

37. Community Acquired Pneumonia are common, mostly diagnosed on clinical and radiological criteris . Hospital aquired pneumonias are associated with excess mortality initiate prompt appropriate & adequate therapy Pathogens for HAP are distinct from one hospital to another, specific sites within the hospital, and from one time period to another Avoid overuse of antibiotics, focus on accurate diagnosis, tailor therapy to recognized pathogen and shorten duration of therapy to the minimum effective period Apply prevention strategies aimed at modifiable risk factors S UMMARY