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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
What is pneumonitis?
Inflammation due to non-infective causes, such as physical or chemical damage
26
What is the common feature of pneumonias?
Cellular exudate in the alveolar spaces | - fibrin rich fluid
27
What are the different types of anatomical pneumonias?
Lobar: localised to a particular lobe/s Broncho: more diffuse and patchier
28
What are the different classifications of pneumonia
- Community acquired pneumonia - Hospital acquired pneumonia - Ventilated acquired pneumonia - Aspiration pneumonia - (Pneumonia in the immuno-compromised patient)
29
describe the pathology of pneumonia?
- 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
What are the common typical organisms that cause CAP?
85% are typical organisms: - Strep pneumoniae (most common) - Haemophilus influenzae - Moraxella catarrhalis - Klebsiella pneumoniae and - Staphylococcus aureus & MRSA - Strep pyogenes
31
What are the common atypical organisms that cause CAP?
• 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
What are the clinical features of pneumonia?
- malaise, fever - cough +- productive of sputum - pleuritic chest pain - fever - dysponea - bronchial breathing - crackles - organ dysfunction (hypotension, mental status change) - tachycardia
33
What is the characteristic of sputum produced?
May be purulent, or rusty coloured (due to blood) or frankly blood stained
34
What is seen in CXR of pneumonia?
Consolidations/infiltrates/cavitations
35
What is used to assess severity of pneumonia?
CURB-65 score - presence of 2 or more signs is indications for hospital treatment - patients with scores 2-5 may require ICU treatment
36
What is CURB-65?
``` (New mental) Confusion Urea >7mmol/L RR >30 BP low <90 systolic or <60 diastolic 65 years or older ```
37
What investigations can be done for pneumonia?
* Full Blood Count, * Urea & Electrolytes * C Reactive Protein * Arterial Blood Gases * Chest X Ray
38
Where can microbiological samples be taken from?
* 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
What are the general managements of pneumonia?
- 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
Which antibiotics would you use for CAP?
Typically need to treat pneumococcus (gram positive) | - amoxicillin
41
What are the UHL guideline for antibiotic treatment of CAP
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
what are the guideline on managing/investigating CAP?
- mild CAP: treat empirically - moderate CAP: blood cultures/sputum culture/urinary streptococcal antigen, legionella (+PCR)/viral screen - severe CAP: moderate + bronchoscopic specimens
43
What antibiotics should be used for atypical organisms?
Penicillin wouldn't work (target cell wall synthesis) | - tetracyclines (clarithromycin)or macrolides
44
What are some differential diagnoses of CAP?
``` Heart failure + pulmonary oedema Pulmonary embolism Atelectasis Aspiration / chemical pneumonitis Drug reactions Lung cancer Vasculitis Acute exacerbation of bronchiectasis Interstial Lung Disease ```
45
what are some of the complications of CAP?
empyema / lung abscess / bacteraemia
46
What is empyema?
infection of pleural cavity
47
How is hospital acquired pneumonia defined?
Infection of the lower respiratory tract in hospitalised patients, occurring > 48 hours after admission and was not incubating at the time of admission
48
What common organisms cause hospital acquired pneumonia?
* Staphylococcus aureus (gram -) * MRSA * Enterobacteriaciae (E coli and Klebsiella spp) * Pseudomonas spp * Acinetobacter baumanii * Fungi (Candida sp.) * Other
49
What type of bacteria typically cause hospital acquired pneumonia?
Gram negative bacteria | - Staph aureus, MRSA, enterobacteriacia
50
What are the UHL guild lines for antibiotic treatment of HAP?
* 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
What causes aspiration pnuemonia?
Aspiration of exogenous material or endogenous | secretions into the respiratory tract
52
Who are aspiration pnuemonia common in?
• Common in patients with neurological dysphagia (strokes), epilepsy, alcoholics, drowning • At risk groups - nursing home residents and drug overdose
53
How is ventilation acquired pneumonia defined?
pneumonia that develops 48 hours post intubation
54
What are some prevention strategies for pneumonia?
* Immunization (flu, pneumococcal) * Chemoprophylaxis * Smoking advice
55
What can cause immunosuppression and which organisms are likely to cause infection in these conditions?
• 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
What can be taken for chemoprophylaxis?
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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