Lower Respiratory Tract Infections Méhes Leonóra, MD Department of Infectious and Pediatric Immunology

LRTI - Bronchiolitis viral infection severe symptoms - young infants, < 2 y, peak: infants aged 3-6 months self-limiting condition, RSV Other causes: parainfluenza, Influenza B, echovirus, Rhinovirus, Adenovirus, Mycoplasma Cough, dyspnea, wheezing, poor feeding, hypothermia or hyperthermia Th: humidified oxygen, nebulized epinephrin, mechanical ventillation, bronchodilator, corticosteroid, ribavirin

CAP Typical bacterial pathogens: Streptococcus pneumoniae (penicillin-sensitive and -resistant strains), Haemophilus influenzae (ampicillin- sensitive and -resistant strains), Moraxella catarrhalis (all strains penicillin-resistant) CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms Aspiration pneumonia is the only form of CAP caused by multiple pathogens (eg, aerobic/anaerobic oral organisms). Patients with CAP who have impaired splenic function may develop overwhelming pneumococcal sepsis, potentially leading to death within hours, regardless of the antimicrobial regimen used.

Diagnosis Sputum Gram stain Blood culture Blood tests: liver, renal function, CBC, ESR, CRP level Hypophosphataemia + hematuria – Legionellosis Cold agglutinin level – Mycoplasma Serology: Clamydia, Mycoplasma, Legionella Periferal smear: impaired splenic function: Howell-Jolly bodies Urinary antigen test: S.pneumoniae, Legionella serotype I (80%) Chest X-ray, CT scan Bronchoscopy: BAL

Staphylococcus aureus: secondary to influenza ICU: polymicrobial infections (K.pneumoniae, P.aeruginosa) gram-negative pathogens (eg, Enterobacter species, Serratia species, Stenotrophomonas maltophilia, Burkholderia cepacia) rarely cause CAP. Atypical pneumonia: zoonotic atypical: Chlamydia psittaci, Francisella tularensis, Coxiella burnetii (Q fever). Nonzoonotic atypical: Legionella species, M pneumoniae, Chlamydia pneumoniae -15% of all CAP cases

a variety of pulmonary and extrapulmonary findings (eg, CAP plus diarrhea) bacterial CAP: fever, productive cough, pleuritic chest pain. atypical CAP: subacute, 1 or more extrapulmonary features Legionella pneumonia: productive or nonproductive cough M pneumoniae or Chlamydia pneumoniae: nonproductive cough. Zoonotic CAP: patients with tularemia have had recent close contact with rabbits or have recently been bitten by a tick.

Etiology - microbi S. pneumoniae inf multiple letality >> Mycoplasma pneumoniae inf Streptococcus pneumoniae etiol not excluded Mycoplasma pneumoniae,Chlamydophila pneumoniae: macrolid, doxycyclin, fluoroq Legionella pneumophila: macrolid, fluoroq S. pneumoniae strains 95 %: ampicillin/amoxicillin, cephalosporin (cefuroxim, cefotaxim, ceftriaxon), carbapen (ertapenem, imipenem, meropenem) 3rd gen levofloxacin, 4th gen moxifloxacin (resp fluroq) good spectrum against S. pneumoniae macrolid derivatives S. pneumoniae efficacy the same multiresistant G - microb, S.aureus

Risk factors S. pneumoniae - 40%, childhood, elderly, severe basic disease Young adult: Mycoplasma pneumoniae elderly, with risk factors: G - bacilli (Haemophilus influenzae, E. coli, Klebsiella pneumoniae) Aspiration pneumonia viral pneumonia – immunocompetent, spontaneously healed Poor prognosis: elderly (>65 y) basic diseases chronic cardio-pulmonary hepatic, renal insufficiency neoplasiaimmunodeficiency diabetes mellitus smoker

Scoring systems CURB65: Confusion, Urea, Respiratory rate, Blood pressure (systolic value  90, diastolic value  60 mmHg), 65 (y) CRB65 – each 1 point 0 - moderately severe status, mortality rate <3%, ambulantory th severe st, mort. rate 10%, 2 p = hospitalization very severe st, mort rate 15-40%, ICU treatment

Criteria of severe pneumonia Major criteria (first visit): mechanical ventillation vasopressor therapy (> 4 hours) (septic shock) Minor criteria (first visit): Respiration rate  30/min Severe respiratory insuff. (PaO2/FiO2  250) multilobular infiltrate - desorientation - uraemia - leucopenia - thrombocytopenia - hypothermia - aggressiv fluid supplementation, hypotension 1 major or 3 or more minor criteria

Treatment severe septicaemia, septic shock – first ab dosis within 1 hour Sample taking for microbiological exam. Efficacy of the chosen ab – severity of clinical situation Parenteral administration, sequential therapy Deescalation Length of treatment: good response to th: 7-10 days (radiol. positivity for weeks) legionellosis treament: 3 w

Treatment Typical +atypical coverage Monotherapy: doxycyclin, resp quinolons, tigecyclin Combination: Ceftriax + doxyc/ azithro / resp quinolon day sequential therapy: iv – oral Avoid empiric macrolide monotherapy: 25% of S pneumoniae strains are naturally resistant to all macrolides Monotherapy: doxycycline/ resp quinolone highly penicillin-resistant S pneumoniae infections: beta lactams, doxycycline, respiratory quinolones Very highly penicillin-resistant S pneumoniae (MIC 6 µg/mL): ceftriaxone Chest X-ray: after 1 week

Empirical ab gr.1 Ambul treat pn: < 65 y, without any basic disease CRB65 score = 0 amoxicillin (min 3 g/d) or macrolid or doxycyclin penicillin allergy: resp fluoroq macrolid deriv monotherapy No improvement within 48 h, chest X ray, lab parameters Resp fluoroq (levofloxacin, moxifloxacin)

Empir th gr. 2 Ambul treat pneumonia: basic disease a/o > 65 y CRB65 score =1 amoxi/clav, cefuroxim +/- macrolid or resp fluoroq (levofloxacin, moxifloxacin) parent th: ceftriaxon, cefuroxim +/- macrolid - letal: < 5 %, finally 20 % hospit - hospit decision within 48 h

Empir th gr. 3 CAP + hospit CRB65 score = 2 amoxi/clav, cefuroxim, ceftriaxon/cefotaxim + macrolid or resp fluoroq Empir ab: atypical microbi multires G - bacil, ESBL+ Klebsiella spp., E.coli - ertapenem P.aeruginosa: imipenem, meropenem, doripenem, ceftazidim, cefepim – an.: bronchiectasia, severe COPD, cystic fibrosis steroid th: controversial, no effect on prognosis, no evidence based th efficacy

Empir th gr. 4 Severe, ICU CRB65 score = 3 – 4 1. Pseudomonas aeruginosa low incidence: ceftriaxon/cefotaxim, carbapenem (ertapenem), pip/tazo + macrolid or resp fluoroq 2. Pseudomonas aeruginosa possible Ceftazidim, carbapenem (imipenem, meropenem), pip/tazo + ciprofl or beta-lact + aminogl + macrolid or resp fluoroq G – bacil: diabetes mellitus, COPD, alkoholism levofloxacin higher dose: Streptococcus pneumonia, Pseudomonas aeruginosa, Klebsiella pneumoniae ( mg/nap) aspir pneumonia: anaerob spectrum (not metronidazol)

Influenza prim/sec pneumonia Outbreak period influenza A és B virus early pn within 48 h: oseltamivir, zanamivir Primary viral pneumonia: rapid hospital, spec antivir, antibact th Spec antivir th: oseltamivir 2x75 mg/d per os + amoxi/clav or ceftriaxon or moxifloxacin or levofloxacin Secondary, bacterial pneumonia: Streptococcus pneumoniae, Staphylococcus aureus moderately severe: amoxi/clav 3x1,2 g/d (iv) severe: ceftriaxon 2 g/d or moxifloxacin 400 mg/d or levofloxacin mg/d

Vaccination Pneumococcal vaccines: prevent pneumococcal bacteremia but not necessarily pneumococcal pneumonia Prevenar: 13-valent conjugate vaccine, children aged 6 weeks to 5 years 23-valent vaccine (Pneumovax 23) is approved for adults aged 50 years or older and persons aged 2 years or older

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