Respiratory Infections

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1 Respiratory Infections NISHANT PRASAD, MD THE DR. JAMES J. RAHAL, JR. DIVISION OF INFECTIOUS DISEASES NEWYORK-PRESBYTERIAN QUEENS

2 Disclosures Stockholder: Contrafect Corp., Bristol-Myers Squibb Co Research Grant: Site Co-Primary Investigator for Crestovo LLC Generic names of drugs will be used Off label uses of drugs will be indicated

3 Objectives Review cases of both upper and lower respiratory tract infections Refresher on the diagnosis and management of upper and lower respiratory tract infections Reminder to consider atypical infections causing respiratory infections as part of the differential diagnosis

4 Evidence Based Medicine Recommendations Severity-of-illness scores, such as the CURB-65/CRB-65 criteria, or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment 3. Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in adults and children 2. Treatment of CAP should always include atypical coverage as empiric therapy: macrolide, doxycycline, respiratory fluoroquinolone or beta-lactam combined with one of the above 3.

5 Case 1 A 43 year old woman with a history of well controlled diabetes mellitus presents to the office with complaints of 2 days of sore throat, cough, copious bilateral clear rhinorrhea, and inability to breathe through the nares. She notes that her husband had a similar syndrome about a week ago but he is mostly recovered. She is afebrile, normotensive, nontachycardic, and has swollen, erythematous nasal turbinates on physical examination.

6 The Common Cold Definition: upper respiratory infection that includes rhinorrhea and nasal obstruction as the prominent symptoms Epidemiology: Occur 5-7 times a year in children, 2-3 times a year in adults, mostly between early fall and late spring (temperate climates) Microbiology: rhinoviruses are the most common, followed by coronaviruses, respiratory syncytial virus, and human-metapneumovirus Diagnosis: clinical. PCR assays have very little utility

7 The Common Cold Therapy: Symptomatic care is the mainstay of therapy as this is a self limiting illness, usually resolving in 5-10 days In adults the following symptomatic therapies have been shown to be effective: Symptom Nasal obstruction Rhinorrhea Sneezing Sore throat Treatment Topical adrenergic agents, oral adrenergic agents First-generation antihistamines, ipratropium bromide First-generation antihistamines Acetaminophen, ibuprofen, other NSAIDs Cough First-generation antihistamines; bronchodilators (?) Adapted from Table 58-2: Effective Treatments for Symptoms of the Common Cold - Mandell, Douglas, and Bennett s Principles and Practice of Infectious Diseases, Eighth Edition (p. 750) Philadelphia: Elsevier

8 Case 2 The same patient presents 10 days later, now reporting she had improved by day 6, but day 7 developed fevers, headache, recrudescence of the cough, and right-side greenish grey nasal discharge. The mucopurulent discharge has continued for the past 3 days. She appears in pain in the office, is febrile to 39C, tachycardic to 110 and normotensive. The right nares is completely plugged with mucopurulent discharge and she has tenderness to percussion of the right maxillary sinus. Her lungs remain clear to auscultation.

9 Acute Bacterial Sinusitis Definition: bacterial inflammatory disorder of the paranasal sinuses. Epidemiology: true bacterial sinusitis occurs in 0.5-2% of viral upper respiratory illnesses in adults, and 6-13% of children Microbiology: Streptococcus pneumoniae, Haemophilus influenza, anaerobes, Streptococcal sp., Moraxella catarrhalis, Staphylococcus aureus Diagnosis: still largely clinical, some radiologic diagnoses, however many false positives

10 Acute Bacterial Sinusitis Three common clinical presentations: Persistent symptoms at least 10d without improvement Severe symptoms with high fever (>39C) and purulent nasal discharge for 3-4 days URI with initial improvement followed by worsening characterized by fevers, headache, increased nasal discharge (known as double sickening ) Therapy if truly consistent with bacterial sinusitis 2 : Amoxicillin-clavulanate (#1) Doxycycline (#2) Respiratory fluoroquinolone (#3/penicillin allergy) All for 5-7 days in adults, days in children

11 Imaging in ABS MRI, T2 weighted axial imaging Note the air fluid levels in the maxillary sinuses bilaterally This is a common finding, and does not necessarily indicate an active infection

12 Case 3 64 year old man with a history of BPH and HTN presents to the office with complaints of 3 days of cough with phlegm production, dyspnea, fevers, and left sided pleuritic chest pain. He is febrile to 38.5C in the office, but is otherwise hemodynamically stable. He has rales on auscultation of the left lower lobe. He has never smoked, drinks alcohol only occasionally, and knows of no sick contacts or other unusual exposures. You send him for a chest X-ray.

13 Community Acquired Pneumonia Definition: Acute bacterial pneumonia in a patient without immunosuppression and without exposure to healthcare facilities Microbiology: Streptococcus pneumoniae still #1 but decreasing; then Haemophilus influenza, Mycoplasma pneumoniae, and Chlamydia pneumoniae, also others. Specific exposures predispose to certain organisms, for example: bird exposure to Chlamydia psittaci, or alcoholism to Klebsiella pneumoniae Signs and symptoms: Cough, sputum production, dyspnea, chest pain, fever, fatigue, sweats, headache, nausea, myalgia, infiltrate on chest X-ray, leukocytosis, purulent sputum on Gram stain

14 Community Acquired Pneumonia Management: Determine severity to see if the patient requires admission to the hospital. Scores such as PORT (PSI), CURB, CURB-65, CRB-65 can be helpful CRB-65 is easily performed in the office without blood test results Therapy: Without comorbidities a macrolide alone or doxycycline is reasonable; with comorbidities a respiratory fluoroquinolone alone or beta-lactam plus macrolide is recommended

15 Case 4 62 year old man with a history of diabetes, HTN, BPH presents to the office with complaints of cough, purulent rust-colored sputum, myalgias, fevers and fatigue. He reports visiting a water park with his grand-children a week prior. He is febrile to 39C, tachypneic to 28 breaths/min, normotensive and hypoxic to 90% SaO2 on room air. He has markedly decreased breath sounds on auscultation of the right lower lobe. You send him to the hospital and the following chest X-ray is found.

16

17 Legionella Pneumonia Definition: Non-contagious bacterial pneumonia caused by Legionella spp. bacteria Epidemiology: Acquired by inhaling aerosolized contaminated water, also possibly through microaspiration of water cases per million on average, with occasional outbreaks from contaminated water supplies Microbiology: Legionella spp. are Gramnegative facultative intracellular parasites of free-living amoeba and monocytes and macrophages

18 Legionella Pneumonia Diagnosis: No clinical characteristics effectively differentiate this from usual bacterial pneumonia. Requires high index of suspicion to send urine antigen for detection and special respiratory cultures Therapy: Lacks a cell wall, so beta-lactams are not effective. Macrolides, tetracyclines, and quinolones can all be used to successfully treat. Azithromycin and levofloxacin are the most active. Courses range from 3 to 14 days depending on severity and drug choice Prevention: Test and clean contaminated common water supplies

19 Bibliography 1. MacDougall, C. (2014), J.E., Dolin, R. and Blaser, M.J. Mandell, Douglas, and Bennett s Principles and Practice of Infectious Diseases, Eighth Edition Philadelphia: Elsevier 2. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis Apr;54(8). PMID: Mandell LA, Wunderink RG, Anzueto A, etal. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of communityacquired pneumonia in adults. Clin Infect Dis Mar 1;44 Suppl 2:S PMID: CDC Legionella Fact Sheet. Accessed August 2017

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