"Lower respiratory tract infection" I would especially like to thank Prof. dr. Dragan Danilovski for support

1. Lower respiratory tract
infection
(Epidemiology and statistics)
Ass. Dr. Suzana Arbutina
Clinic of Pulmonology and Allergology
Skopje

2.  Lower respiratory (tract) infection or LTRI is a
generic term for an acute infection of the trachea
(windpipe), airways and lungs, which make up the
lower respiratory system.
 LTRIs include acute bronchitis, AECB,and pneumonia.
Definition

3. • Symptoms include
- shortness of breath,
- weakness,
- high fever, coughing and fatigue.
• Lower respiratory tract infections place a considerable strain on
the health budget and are generally more serious than upper
respiratory infections.
• Since 1993 there has been a slight reduction in the total number
of deaths from lower respiratory tract infection.
• However in 2012 they were still the leading cause of deaths
among all infectious diseases, and they accounted for 3.9 million
deaths worldwide and 6.9% of all deaths that year.

4.  Every year about 5 million people die of acute
respiratory infections.
 Among these, pneumonia represents the most
frequent cause of mortality, hospitalization and
medical consultation. Several factors (age,
underlying disease, environment) influence
mortality, morbidity and also microbial etiology.
 The authors also refer to recent data on the most
frequently identified antibiotic resistance of
respiratory pathogens. The knowledge of such
different clinico-epidemiological situations is
essential to physicians for an effective approach to
treatment of pneumonia and bronchitis.

5. The aim of this review is to focus on the
epidemiology of lower respiratory tract
infections and the etiology, dividing
these problems into the following issues:
global impact of these afflictions,
community-acquired pneumonia,
hospital acquired pneumonia, acute
bronchitis and exacerbations of chronic
bronchitis

7. Bronchitis can be classified as either acute or chronic.
Acute bronchitis can be defined as acute bacterial or
viral infection of the larger airways in healthy patients
with no history of recurrent disease.
It affects over 40 adults per 1000 each year and
consists of transient inflammation of the major bronchi
and trachea.
Most often it is caused by viral infection and hence
antibiotic therapy is not indicated in
immunocompetent individuals

8. Acute Exacerbations of Chronic Bronchitis (AECB) are
frequently due to
non-infective causes along with viral ones.
50% of patients are colonised with Haemophilus influenzae,
Streptococcus pneumoniae or Moraxella catarrhalis.
Antibiotics have only been shown to be effective if all
three of the following symptoms are present:- increased
dyspnoea, increased sputum volume and purulence.

9. Most commmon cause AECB
Respiratory viruses are associated with 30%
of cases,
atypical bacterial (mostly Chlamydophila
pneumoniae) infections are implicated in less
than 10%,
and bacterial pathogens in approximately
40–50% of exacerbations.

11. Pneumonia occurs in a variety of situations
and treatment must vary according to the
situation.
It is classified as either community or hospital
acquired depending on where the patient
contracted the infection.
It is life-threatening in the elderly or those
who are immunocompromised.

12. H. influenzae and M. catarrhalis are of increasing
importance in both community acquired pneumonia
(CAP) and acute exacerbation of chronic bronchitis
(AECB) while the importance of S. pneumoniae is
declining.
It has also become apparent the importance of atypical
pathogens such as C. pneumoniae, M. pneumoniae and L.
pneumophila, in CAP.

13. The most common cause of pneumonia is
pneumococcal bacteria, Streptpcoccus
pneumoniae accounts for 2/3 of bacteremic
pneumonias.
This is a dangerous type of lung infection with a
mortality rate of around 25%

14. Viral pathogens associated with AECB include influenza, parainfluenza,
rhinovirus, coronavirus, adenovirus and respiratory syncytial virus.
The three major bacterial causes of AECB in mild COPD exacerbations include
nontypeable Haemophilus influenzae, Moraxella catarrhalis and Streptococcus
pneumoniae.
In one study, patients undergoing mechanical ventilation for their AECB/COPD
exacerbations were frequently found to have Pseudomonas aeruginosa and
Stenotrophomonas spp.
Patients who were less severely ill tended to have S. pneumoniae and other
Gram-positive cocci isolated from sputum, while more severe baseline airway
obstruction was associated with H. influenzae and M. catarrhalis.
The most severely obstructed AECB/COPD patients tended to have
Pseudomonas and Enterobacterace spp. cultured from sputum.
Mycoplasma pneumoniae is thought to be a rare cause of AECB,
while C. pneumoniae may be isolated in as many as 5–10% of cases.

15. Bronchiectasis patients also frequently have nonenteric Gram-negative
bacteria isolated from sputum during exacerbations.
H. influenzae has been isolated in 30–47% of cases,
P. aeruginosa (including mucoid species) in 12–31%,
M. catarrhalis in 2.4–20%,
S. pneumoniae in 7–10%,
Staphylococcus aureus in 4–14%,
Mycobacterium (primarily Mycobacterium avian intracellular complex)
in 2–17%,
and no organisms in 21–23% of sputum cultures obtained during
exacerbations

17. ADV: Adenoviruses; CoV: Coronaviruses (types 229E, NL63, OC43 and HKU1); Cp: Chlamydophilapneumoniae
; Ent: Enterobacteria; EV: Enterovirus; Hi:Haemophilus influenzae; Inf : Influenza viruses (A, B and C);
Leg Legionella spp.; Mc: Moraxella catarrhalis; Misc: Miscellaneous; Mp: Mycoplasma pneumoniae
; MPV: Metapneumovirus; PIV: Parainfluenza viruses (types 1 – 4); Pse: Pseudomonas spp.;
RSV: Respiratory syncytial virus; RV: Rh inovirus; Sa: Staphylococcus aureus ; Spn: Streptococcuspneumoniae
; Spy: Streptococcus pyogenes .
Pathogen by pathogen detection rates of respiratory viruses and bacteria in adults with
Community acquired pneumonia

19. no data
less than 100
100–700
700–1,400
1,400–2,100
2,100–2,800
2,800–3,500
Disability-adjusted life year for lower respiratory
infections per 100,000 inhabitants in 20043,500–4,200
4,200–4,900
4,900–5,600
5,600–6,300
6,300–7,000
more than 7,000

20. Thorax 2008; 63:817-822
Incidence and predictive factors of lower respiratory tract
infections among the very elderly in the general
population. The Leiden 85-plus Study
A Sliedrecht
W P J den Elzen,
T J M Verheij,
R G J Westendorp,
J Gussekloo

21. Participants: Unselected cohort of 587 participants aged 85 years in Leiden, The
Netherlands.
Measurements: As reported in the literature, predictive factors were selected and
assessed at baseline. During a 5 year follow-up period, information on the development
of lower respiratory tract infections was obtained from general practitioners or nursing
home physicians. Associations between predictive factors were analysed with Cox
regression, and population attributable risks were calculated.
Results: The incidence of lower respiratory tract infections among persons aged 85–90
years was 94 (95% CI 80–108) per 1000 person years. After multivariate analysis, history
of chronic obstructive pulmonary disease (COPD), smoking, oral glucocorticosteroid
use, severe cognitive impairment, history of stroke and declined functional status
remained independently associated with the occurrence of lower respiratory tract
infections. Smoking was the greatest contributor with a population attributable risk of
32%.
Conclusion: In the very old, smoking, COPD, stroke and declined functional status were
associated with the occurrence of lower respiratory tract infections and provide a
means of targeting patients at risk of severe health complications.

22. Between September 1997 and September 1999, 705 participants were eligible for participation in
the Leiden 85-plus Study. Ninety-two participants refused to participate and 14 participants died
before enrolment, resulting in a study population of 599 participants (response rate of 87%).

23. LRTI incidence increased with fluctuations
over time,
was higher in men than women aged ≥70
and increased with age from 92.21
episodes/1000 person-years (65-69 years) to
187.91/1000 (85-89 years).

24. CAP incidence increased more markedly
with age, from 2.81 to 21.81 episodes/1000
person-years respectively, and was higher
among men

25. Community-acquired lower respiratory tract infections (LRTI)
and pneumonia (CAP) are common causes of morbidity and
mortality among those aged ≥65 years; a growing population in
many countries.
Detailed incidence estimates for these infections among older
adults in the United Kingdom (UK) are lacking.
We used electronic general practice records from the Clinical
Practice Research Data link, linked to Hospital Episode Statistics
inpatient data, to estimate incidence of community-acquired
LRTI and CAP among UK older adults between April 1997-March
2011, by age, sex, region and deprivation quintile
Incidence of Community-Acquired Lower Respiratory Tract Infections and Pneumonia among
Older Adults in the United Kingdom: A Population-Based Study
Elizabeth R. C. Millett mail, Jennifer K. Quint, Liam Smeeth, Rhian M. Daniel, Sara L. Thomas
Published: September 11, 2013

26. Pneumonia and lower respiratory tract infections (LRTI) are major causes of
morbidity and mortality among those aged 65 years and over in the UK and
other European countries
The UK’s population is aging; recent estimates suggest that in 2035, 23% of
the UK will be aged ≥65 years and 5% will be ≥85, compared to 17% and 2%
respectively in 2010.
The ‘oldest old’ (≥85 years) are at particularly high risk of infections due to co-
morbidities and waning immune function.
Community-acquired pneumonia (CAP) in older individuals is a particular
concern, as it can aggravate underlying co-morbidities and have serious
consequences
Incidence of Community-Acquired Lower Respiratory Tract Infections and Pneumonia among Older Adults in the
United Kingdom: A Population-Based Study
Elizabeth R. C. Millett mail, Jennifer K. Quint, Liam Smeeth, Rhian M. Daniel, Sara L. Thomas
Published: September 11, 2013

27. In the U.S., pneumonia is the sixth most common
cause of death and the leading cause of death from
infectious diseases
The death rate from pneumonia increases
Annually in the United States:
• to 2-3 million people with CAP
• ~ 10 million physician visits, 500,000
hospitalizations
• 45,000 deaths

29. Of the LRT infections pneumonia remains the most common
infections seen in the community and among hospitalized patients.
Despite the use of antibiotics the mortality associated with
pneumonia is still quite high.
In 2000 pneumonia and influenza were the seventh leading cause
of death in the United States (24.3 deaths per 100,000 population).
Approximately, 1.8 cases of pneumonia were reported for every 100
Americans in 1996
Pneumonia is also a very common case of nosocomial infections
ranking third in occurrence behind urinary tract infections and
surgical wound infections (33% of the infections acquired in the
hospital).

34. THANK YOU