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Semester 3 - respiratory > 13. Lower Respiratory Tract Infection and Pneumonia > Flashcards

13. Lower Respiratory Tract Infection and Pneumonia Flashcards

1
Q

What are the common organisms found in the respiratory tract?

A

Viridans streptococci, Neisseria spp,

Anaerobes, Candida sp

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2
Q

What are the less common organisms found in the respiratory tract?

A

Streptococcus pneumoniae
Streptococcus pyogenes
Haemophillus influenzae

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3
Q

is the lung sterile?

A

no

has normal alveolar microbiota

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4
Q

How can pathogens spread to the lungs?

A

aspiration
blood stream spread
direct spread

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5
Q

What are 4 defences of the respiratory tract?

A
  • Muco-ciliary clearance mechanisms nasal hairs, ciliated columnar epithelium
  • Cough & the sneezing reflex
  • Respiratory mucosal immune system
  • Alveolar microbiota (prevent attachment of other organisms)
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6
Q

What contributes to the respiratory mucosal immune system?

A

Lymphoid follicles of the pharynx and tonsils,

alveolar macrophages, secretary IgA and IgG

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7
Q

What is the course of a typical infection in the lungs?

A
  1. alveolar macrophage fails to stop pathogen
  2. activation of macrophages release cytokines to recruit more macrophages
  3. inflammation = increased blood flow and permeability
  4. more WBCs/proteins (neutrophils/lymphocytes/antibodies to aid
    macrophages)
    Inflammation causes damage to lung tissue
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8
Q

What factors can cause dysregulation of the host immune response to an infection?

A
  • The pathogen
  • Host factors
  • Drugs
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9
Q

What are some common organisms that cause LRTI and how do they affect defences of the respiratory tract?

A
  • Chlamydia pneumoniae (ciliostatic factor)
  • Mycoplasma pneumoniae (shear off cilia)
  • Influenza virus (reduces mucus viscosity)
  • Strep pneumoniae / Neisseria meningitides (split immunoglobin (IgA))
  • Pneumococcus (capsule inhibits phagocytosis (pneumolysin))
  • Mycobacterium / Nocardia / Leigonella (resistant to phagocytosis (intracellular survival))
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10
Q

WHat are some host factors that lead to dysregulation of the immune response?

A
  • Age > 65
  • Lifestyle — smoking (abnormal ciliary function) / alcohol / drugs
  • Chronic lung diseases (bronchiectasis, cystic fibrosis)
  • Aspiration - poor swallow (CVA, muscle weakness, alcohol)
  • Immunocompromised - i.e. DM / HIV
  • Metabolic - malnutrition / hypoxaemia / acidosis / uraemia
  • Co-infection with viruses (abnormal ciliary function)
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11
Q

What drugs could lead to respiratory tract infections?

A
  • antacids (PPI/H2 antagonists)
  • antipsychotics
  • ACE inhibitors
  • glucocorticoids (e.g. ICS)
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12
Q

How do antacids increase risk of respiratory tract infections?

A

PPI - increases risks for pneumonia

H2 antagonist - myelosuppression (rare, long term)

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13
Q

What are some common upper respiratory tract infections?

A 
• Rhinitis (common
cold)
• Pharyngitis
• Epiglottis
• Laryngitis
• tracheitis
• Sinusitis
• Otitis media
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14
Q

What are the common viral causes of URTI?

A

Rhinovirus, coronavirus, influenza / parainfluenza, Respiratory syncytial virus (RSV)

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15
Q

What type of pathogen commonly causes upper respiratory tract infections?

A

Viruses

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16
Q

What commonly leads to bacterial infections of the respiratory tract?

A

Secondary bacterial infections after initial viral infections
- viruses cause damage to cilia, reduced mucus viscosity etc. so more vulnerable

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17
Q

What are some common LRTIs?

A

Acute bronchitis, pneumonia, bronchiolitis, empyema, bronchiectasis, lung abscess

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18
Q

What is acute bronchitis and who does it commonly occur in?

A
  • Inflammation of medium sized airways.
  • oedema of bronchial wall
  • infective process
  • Mainly in smoker
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19
Q

What are the symptoms of acute bronchitis?

A

Cough, fever, increased sputum production,

increased shortness of breath.

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20
Q

What would a CXR of acute bronchitis show?

A

Usually normal - differentiate from pnuemonia

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21
Q

What common organisms cause acute bronchitis?

A
  • viruses (most common)
  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
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22
Q

What is the treatment for acute bronchitis?

A

Bronchodilation; Physiotherapy; +/- Antibiotics

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23
Q

what is chronic bronchitis

A
  • not infective process
  • recurrent episodes of difficulty breathing with cough
  • triggered by chemical, pollen, microorganism?
24
Q

What is pneumonia?

A

General term denoting inflammation of the lung parenchyma due to infection

25
Q

What is pneumonitis?

A

Inflammation due to non-infective causes, such as physical or chemical damage

26
Q

What is the common feature of pneumonias?

A

Cellular exudate in the alveolar spaces

- fibrin rich fluid

27
Q

What are the different types of anatomical pneumonias?

A

Lobar: localised to a particular lobe/s
Broncho: more diffuse and patchier

28
Q

What are the different classifications of pneumonia

A
  • Community acquired pneumonia
  • Hospital acquired pneumonia
  • Ventilated acquired pneumonia
  • Aspiration pneumonia
  • (Pneumonia in the immuno-compromised patient)
29
Q

describe the pathology of pneumonia?

A
  • inflammation of alveoli leading to production of exudate and accumulation of inflammatory cells
  • air filled alveoli are spongy and light - appear translucent on xray
  • fluid filled lungs displace air leading to shortness of breath and opaque on xray - crackles on auscultation
30
Q

What are the common typical organisms that cause CAP?

A

85% are typical organisms:

  • Strep pneumoniae (most common)
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Klebsiella pneumoniae and
  • Staphylococcus aureus & MRSA
  • Strep pyogenes
31
Q

What are the common atypical organisms that cause CAP?

A

• Mycoplasma - commonest - do not have a cell wall
• Legionella – contaminated water sources
(aerosols / travel associated)
• Coxiella burnetii (Q fever)- worldwide, farm
animals, (hepatitis)
• Chlamydophila pneumoniae
• Chlamydophila psittaci (Psittacosis)-exposure to
birds (splenomegaly, rash, haemolytic anaemia)

32
Q

What are the clinical features of pneumonia?

A
  • malaise, fever
  • cough +- productive of sputum
  • pleuritic chest pain
  • fever
  • dysponea
  • bronchial breathing
  • crackles
  • organ dysfunction (hypotension, mental status change)
  • tachycardia
33
Q

What is the characteristic of sputum produced?

A

May be purulent, or rusty coloured (due to blood) or frankly blood stained

34
Q

What is seen in CXR of pneumonia?

A

Consolidations/infiltrates/cavitations

35
Q

What is used to assess severity of pneumonia?

A

CURB-65 score

  • presence of 2 or more signs is indications for hospital treatment
  • patients with scores 2-5 may require ICU treatment
36
Q

What is CURB-65?

A 
(New mental) Confusion
Urea >7mmol/L
RR >30
BP low <90 systolic or <60 diastolic
65 years or older
37
Q

What investigations can be done for pneumonia?

A
  • Full Blood Count,
  • Urea & Electrolytes
  • C Reactive Protein
  • Arterial Blood Gases
  • Chest X Ray
38
Q

Where can microbiological samples be taken from?

A
  • Sputum / Induced sputum
  • Blood culture
  • Broncho Alveolar Lavage fluid (BAL)
  • Nose & Throat swabs or NPAs (viruses)
  • Urine (antigen test for legionella / pneumococcus, have polysaccharide antigens which are soluble and filtered by kidneys)
  • Serum (antibody test)
39
Q

What are the general managements of pneumonia?

A
  • maintain good oral fluid intake to avoid dehydration
  • anti-pyretic drugs to reduce fever
  • stronger analgesics for pleuritic pain
  • more severe illness may require IV fluids and oxygen
40
Q

Which antibiotics would you use for CAP?

A

Typically need to treat pneumococcus (gram positive)

- amoxicillin

41
Q

What are the UHL guideline for antibiotic treatment of CAP

A

Mild-moderate:
- Amoxicillin
- Or doxycycline or erythromycin/ clarithromycin
Moderate-severe:
- Needing hospital admission:
- Co-amoxiclav AND clarithromycin / doxycycline

5-7 days for mild CAP
7 - 10 days for severe CAP

42
Q

what are the guideline on managing/investigating CAP?

A
  • mild CAP: treat empirically
  • moderate CAP: blood cultures/sputum
    culture/urinary streptococcal antigen, legionella (+PCR)/viral screen
  • severe CAP: moderate + bronchoscopic specimens
43
Q

What antibiotics should be used for atypical organisms?

A

Penicillin wouldn’t work (target cell wall synthesis)

- tetracyclines (clarithromycin)or macrolides

44
Q

What are some differential diagnoses of CAP?

A 
Heart failure + pulmonary oedema
Pulmonary embolism
Atelectasis
Aspiration / chemical pneumonitis
Drug reactions
Lung cancer
Vasculitis
Acute exacerbation of bronchiectasis
Interstial Lung Disease
45
Q

what are some of the complications of CAP?

A

empyema / lung abscess / bacteraemia

46
Q

What is empyema?

A

infection of pleural cavity

47
Q

How is hospital acquired pneumonia defined?

A

Infection of the lower respiratory tract in hospitalised patients, occurring > 48 hours
after admission and was not incubating at the time of admission

48
Q

What common organisms cause hospital acquired pneumonia?

A
  • Staphylococcus aureus (gram -)
  • MRSA
  • Enterobacteriaciae (E coli and Klebsiella spp)
  • Pseudomonas spp
  • Acinetobacter baumanii
  • Fungi (Candida sp.)
  • Other
49
Q

What type of bacteria typically cause hospital acquired pneumonia?

A

Gram negative bacteria

- Staph aureus, MRSA, enterobacteriacia

50
Q

What are the UHL guild lines for antibiotic treatment of HAP?

A
  • First line: Co-amoxiclav(Cover Staph aureus + gram negative enteric bacilli (e.g. Klebsiella) + typical/atypical pathogens)
  • Second line/ITU: Piperacillin / tazobactam Or Meropenem (antipseudomonal)

Vancomycin for MRSA

51
Q

What causes aspiration pnuemonia?

A

Aspiration of exogenous material or endogenous

secretions into the respiratory tract

52
Q

Who are aspiration pnuemonia common in?

A

• Common in patients with neurological dysphagia (strokes), epilepsy, alcoholics, drowning
• At risk groups - nursing home residents and drug
overdose

53
Q

How is ventilation acquired pneumonia defined?

A

pneumonia that develops 48 hours post intubation

54
Q

What are some prevention strategies for pneumonia?

A
  • Immunization (flu, pneumococcal)
  • Chemoprophylaxis
  • Smoking advice
55
Q

What can cause immunosuppression and which organisms are likely to cause infection in these conditions?

A

• HIV: Pneumocystis jirovecci, TB, atypical
mycobacteria
• Neutropenia: fungi e.g. Aspergillus spp
• Bone marrow transplant: Cytomegalo virus
• Splenectomy: encapsulated organisms
- e.g. S. pneumoniae, H. influenzae, malaria

56
Q

What can be taken for chemoprophylaxis?

A

Oral penicillin / erythromycin to patients with higher risk of lower respiratory tract infections
e.g. asplenia, dysfunctional spleen, immunodeficiency

Semester 3 - respiratory (20 decks)

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