1. Respiratory tract infection By Dr.Preaw(General medicine )

2. Scope ✤ Diagnosis : CAP, HCAP, VAP ✤ Pathophysiology ✤ Investigation ✤ Management and treatment

3. 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.

4. 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 tuberculosis microorganism Pneumocystis jirovecci Mechanism Example

5. 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.

6. 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

7. Pathologic Stages of Pneumococcal Lobar Pneumonia Stageonset Affected lobe congestion1-2 day -proteinaceous fluid -neutrophils and many bacteria in aveoli red hepatisation2-4 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 resolutionover 3 wk ( in normal ) -fibrinous matter -macrophage ( major cells)

9. 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/mm 3, platelet count <100,000 cells/mm 3 ✤ PaO 2 /FiO 2 ratio > 250 Minor criteria Major criteria

10. Investigation and management Evidence levelDefinition Level I (high)well-conducted,RCT Level II ( moderate) well -designed,controlled trials without randomization Level III ( low)case studies and expert opinion

11. Diagnosis testing remain controversial InvestigationModerate recommendation hemoculture OPD case :level III IPD 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.dehydration 2. early onset of PCP 3. neutropenic patient sensitivity 15-100% specificity 11-100% Adequate sputum PMN >25 cells/LPF epithelium < 10 cells/LPF sensitivity 70-90 % specificity 99 %

12. Classification of pneumonia (based on anatomical part ) Lobar pneumoniaBronchopneumoniaInterstitial pneumonia

13. Gram : positive dipplococci :Streptococcus pneumoniae

14. Gram : negative bacilli

15. Management and treatment :hospital admission decision CURB -65 score strong recommendation :level I evidence

16. PSI score

17. Stratification of risk score riskrisk classscoremortality lowI based on algorithm 0.1% outpatient treatment lowII<700.6% lowIII71-900.9% moderateIV91-1309.3% hospital admission highV>13027% PSI score

18. CURB-65TreatmentPSI scoresTreatment 012345012345 OPD IPD ICU - I II III IV V - OPD observe or hospitalization IPD Summary

19. PIRO score for CAP FactorPointScoresRisk P COPD or immunosuppresive 1 0-2 low risk (1 in 30 )for ICU mortality Age > 70 yr1 I bacteremia 1 3 Mild risk (1 in 8) for ICU mortality multilobar opacity1 R shock 1 4 high risk ( 2 in 5) for ICU mortality severe hypoxia1 O ARDS 1 5-8 very high risk (3 in 4) for ICU mortality acute renal failure 1 Predisposition Insult Response Organ dysfunction ICU case

20. Management

21. Management : outpatient settingantibiotic drugsrecommendation previous healthy (no use ABO in 3 month) macrolide or doxycycline level I(strong) level III(weak) comorbidities immunosuppressing conditon respiratory fluoroquinolone or B-lactam +macrolide 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%)

22. Management : inpatient settingantibiotic drugsrecommendation non-ICU -respiratory quinolone or -B -lactam+macrolide orlevel I ICU -B-lactam +azithromycin -respiratory quinolone level II level 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%)

23. Special condition special concernsantibiotic drugsrecommedation Pseudomonas -B-lactam+ ciprofloxacin or levofloxacin or -B-lactam +aminoglycoside+azithromycin or -B-lactam +aminoglycoside+fluoroquinolone level III (moderate) *CA-MRSAadd vancomycin or linezolid level III (moderate) *CA-MRSA:community-acquired methicillin-resistant staphylococcus aureus piperacillin-tazobactam cefepime,imipenem meropenem

24. Criteria for clinical stability Temperature < 37.8 ºC Heart rate < 100 beats/min Respiratory rate < 24 breaths/min Systolic blood pressure > 90 mmHg Aterial oxygen saturation > 90 % or PaO2 > 60 mmHg on RA Ability to maintain oral intake Normal mental status

25. 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 secretions Pneumonia 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

26. 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

27. 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

28. 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

29. 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

33. Assessment of nonresponders wrong organism drug-resistant pathogen inadequate antimicrobial therapy wrong diagnosis ARDS atelectasis pulmonary emboli pulmonary hemorrhage neoplasm underlying disease complication empyema or lung abcess Clostridium difficile coliitis occult infection drug fever

35. Summary Diagnosis : ✤ CAP ✤ HCAP ✤ VAP

36. Summary CURB-65 PSI score PIRO score

37. Summary -Management -Prevention -Accessment of nonresponder