Upper...and Lower Respiratory Tract Infections

Transcription

1 Upper...and Lower Respiratory Tract Infections Robin Jump, MD, PhD Cleveland Geriatric Research Education and Clinical Center (GRECC) Louis Stokes Cleveland VA Medical Center Case Western Reserve University or

2 Speaker Disclosures Dr. Jump has no direct conflicts of interest related to this presentation. The opinions presented herein are my own and do not represent those of the Veterans Affairs system or the federal government.

3 Learning Objectives 1. Understand differences among upper respiratory tract infections, acute bronchitis and pneumonia. 2. Initiate and assist with a bedside evaluation of a patient with a suspected lower respiratory tract infection. 3. Consider risk factors and empiric treatment for people with community-acquired and hospitalacquired pneumonia. Photo: Ulrich Joho

4 Terminology Each dot indicates a different type of infection of the upper or lower respiratory tract. Blue dots are syndromes caused by viruses. Green dots are syndromes caused primarily by bacteria.

5 Common Cold & Sinusitus Common Cold Infection caused by many different viruses. Affects sinuses, throat and may also cause headache, fatigue, lowgrade fever. Sinusitis Inflammation and infection of the sinuses; ~98% caused by viruses and usually part of a common cold.

6 Strept Throat & Laryngitis Strept Throat Infection of the tonsils and posterior oropharynx. Caused by Group A Streptococcus. Requires a diagnostic test. Laryngitis Hoarse voice; inflammation and infection of the vocal cords; nearly always a viral infection and usually part of a common cold.

7 Bronchitis & Pneumonia Bronchitis Inflammation and infection of the large airways; 90% caused by viruses. Pneumonia Inflammation and infection of lung tissue; ~75% caused by bacteria.

8 Acute Bronchitis vs. Pneumonia Acute Bronchitis Pneumonia Definition Self-limited inflammation of bronchi, the large airways of the lung Inflammation or infection of the lung tissue Cause Viral (with rare exceptions)* ~75% bacteria, ~25% viral Symptoms Cough for 5 days to 3 weeks Fever less common (unless influenza) 50% have sputum production Cough Fever is common Sputum production Chest wall pain Decline in oxygenation Diagnosti c Studies Normal to slightly elevated WBC No specific chest x-ray findings Elevated WBC Infiltrate, effusions **bacterial causes include Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Bordatella pertussis (causes whooping cough). Antibiotics are only appropriate for bronchitis caused by Bordatella pertussis, diagnosed using special tests on nasopharyngeal samples.

9 Type of Pneumonia Bacterial Communityacquired pneumonia (CAP) Hospitalacquired pneumonia (HAP) Aspiration Typical Pathogen Streptococcus pneumoniae Pseudomonas aeruginosa, MRSA, other multi-drug resistant organisms Bacteria from the mouth Other Comments Wide range in severity. Mild cases may be treated with oral antibiotics as an outpatient. Severe cases may require intubation. The concern here is that the pathogen is resistant to typical antibiotics. These require broad antibiotics at the outset with treatment that is narrowed once the pathogen is known. This occurs when people inhale oral or gastric contents into their lungs. It may start with a chemical inflammation and resolve in 1-2 days or may blossom into a full-fledged bacterial pneumonia. Viral Influenza We often overlook viruses as a cause of pneumonia. Sometimes people will develop a post-influenza pneumonia caused by bacteria.

10 Evaluation for Bacterial Pneumonia Assessment Among LTCF residents: Cough 75% Fever 62% Rales 55% No symptoms 7.5% Pulse oximetry: < 93% is 80% sensitive, 91% specific for pneumonia Diagnostic Testing Sputum culture and Gram stain Streptococcus pneumoniae urinary antigen Legionella urinary Ag Swab oropharynx for influenza Blood cultures Clinical Infectious Diseases 2009; 48:

11 Tips for Bedside Assessment If you hear the same (usually coarse) sounds in all lung fields, it is most likely transmitted upper airway noise. A good cough might clear it. Pneumonia often hurts. People will complain of pleuritic (noncardiac) chest pain with a deep breath or cough. Sometimes, older adults will develop a bacterial pneumonia after a bed viral infection. We see this most often following influenza.

12 Suggested Empirical Antibiotic Therapy for Nursing Home-Acquired Pneumonia Clinical Context First-line Second-Line Mild to moderate pneumonia symptoms Severe pneumonia symptoms OR failure to improve with appropriate empiric therapy Severe pneumonia symptoms AND concern for MRSA in respiratory tract Known history or strong suspicion of Pseudomonas or resistant Gram-negative bacteria in respiratory tract Jump et al JAGS in press. - Cefpodoxime OR - Amoxicillin/clavulanic acid (first choice if aspiration suspected) - Ceftriaxone and azithromycin - Consider adding vancomycin or doxycycline - Cefepime OR - Piperacillin/tazobactam - Doxycycline OR - Levofloxacin - Ertapenem OR - Levofloxacin - - Consider adding linezolid - Levofloxacin OR - Carbapenem (other than ertapenam) OR - Aztreonam

13 Supportive Care Oxygen Albuterol Cough syrup, Tessalon perles Incentive spirometry Swallow evaluation if concern for aspiration

14 Opportunities for Antibiotic Stewardship Re-assess the need for antibiotics after 2-3 days. CXR: Cannot rule out infiltrate may be radiologistspeak for poor film and I can t see the patient. Candida, MRSA are common colonizers in sputum. People w/ pneumonia due to S. aureus are usually quite ill. Length of therapy; 5 7 days for most residents (7 10 days if slow to respond...)

15 Case: Pneumonia vs. No-monia Diagnostic Testing 2 weeks ago Current

16 Influenza Attack rates range from 25 70% in NHs Mortality can be >10% Typical presentation is fever, cough, aches for 3 7 days. In older adults, Cough are coryza are common, fever less so. Presentation may be worsening of chronic health conditions (e.g., heart failure). Oseltamivir Dosing Treatment Indication Chemoprophylaxis 75mg twice daily x 5 days Usual Dose 75mg once daily for 2 weeks or 7 days after last known case whichever is longer Courtesy of CDC

17 Many other Viruses Cause Outbreaks in Nursing Homes Courtesy of CDC Respiratory Syncytial Virus (RSV) In older adults, morbidity & mortality similar to influenza Parainfluenza 1, 2, 3 Adenovirus Rhinovirus Human Metapneumovirus Coronavirus Supportive Care, Infection Prevention and Control Rapid Diagnostics?

18 Take Home Messages Viruses cause upper respiratory infections (colds) and bronchitis. The treatment is supportive care. Making a diagnosis of pneumonia is challenging, even to experienced providers. The distinction between community-acquired and healthcareassociated pneumonia is important for making antibiotic choices. Supportive care remains the same. Routine vaccinations reduce the risk of developing communityacquired pneumonia. Thank you! robinjump@gmail.com or Robin.Jump@va.gov