With more focus on latest guidelines and changes in hospital acquired infections

1. APPROACH TO A PATIENT WITH
ACUTE RESPIRATORY INFECTION

2. Learning Objectives
• Spectrum
• Pathophysiology
• Classification
• Approach
• Clinical syndromes
• Case discussion

3. Impact
• Sixth most common cause of death
• Second biggest cause of DALY(disability
adjusted life years)
• Most common infectious cause of death
• Most common cause of intravenous antibiotic
use in hospitals
ATS Global Scholars program, Pneumonia in children and adults, 2016

4. ATS Global Scholars program, Pneumonia , in children and adults, 2016

5. Spectrum
Rhinitis
Tonsillitis
Sinusitis
Otitis media
Pharyngitis
Epiglottitis
Laryngitis
Tracheitis
Bronchitis
Bronchiolitis
Pneumonia
Pleurisy

6. Upper respiratory tract infection

7. Etiology
Rhinovirus(45)
Influenza(25)
Coronavirus(10)
Adenovirus(10)
Metapneumovirus(5)
Enterovirus(10)
RSV(5)
Mandell 8th edition

8. Acute rhinosinusitis
• Inflammation of nasal cavity and sinuses
• <4 weeks
Symptoms Suggesting Bacterial Infection
Prolonged symptoms (> 10 days)
Unilateral maxillary sinus tenderness
Unilateral purulent nasal discharge
Double sickening (symptoms improve then worsen)
Chow et al. Clin Infect Dis. 2012; 54(8):e72-112

9. Acute Pharyngitis
Sudden onset
High fever
Lymph nodes
Treatment: Penicillin V 500mg BD x 10 days
or Amoxicillin 1000mg OD x 10 days

10. Influenza virus

11. Pneumonia
• Inflammation of the pulmonary parenchyma
plus clinical evidence that the infiltrate is of an
infectious origin, which include new onset of
– Fever(< 7 days)
– Purulent sputum
– Leukocytosis
– Decline in oxygenation
ATS 2005 HAP/VAP Guildelines

12. Classification
• Viral
• Bacterial
• Fungal
Etiological
• Lobar
• Broncho
• Interstitial
Morphological
• Community acquired
• Hospital Acquired
• Ventilator acquired
Clinical
syndrome

13. Epidemiological
triad
Agent
Environmental
Host
factors
Age
Normal flora
Glottis reflex
Immunity
Epithelial
shedding
Mucociliary
clearance

14. Condition Organism
In almost all cases Strep and H. influenzae are predisposed as they are most common.
In Indian settings, most conditions also pre dispose to Tuberculosis
Bat exposures, Bird droppings Histoplasma, Cryptococcus
Paddy fields, farmers, rodent exposure Leptospira
Hilly areas(Himalyan belt) Scrub typhus
Birds Chlamydia psittaci
Farm animals Q fever(Coxiella)
North America travel
Aspiration risk/Alcohol Anaerobes
Structural lung disease Pseudomonas, Burkholderia, NTM, fungal
Injection drug users Staphylococcus, Anaerboes
Influenza outbreak Influenza, Staphylococcus
Air conditioners, cooling towers, pot
water
Leigionella
COPD Moraxella, Pseudomonas
Fishmans Pulmonary Medicine 5th edition

15. Physical examination
• Respiratory system examination
– Respiratory rate
– Bronchial sounds, dullness to percussion, crackles
• Additional exam
– Cutaneous abscess
– Skin lesions
– Lymph nodes
– Periodontal hygiene
– Gag reflex
– Ear examination

16. Investigations
NON
INVASIVE
INVASIVE
Hematological
1. CBC with
DLC
2. KFT
3. LFT
4. Biomarkers
Microbiology
1. Sputum
2. Nasal Swab
3. Blood
cultures
4. ET aspirate
5. Newer test
Radiology
1. Chest X-ray
2. CT scan
1. Bronchoscopy
2. Lung Biopsy

17. Biomarkers
• Erythrocyte sedimentation rate(ESR)
• C- Reactive Protein(CRP)
• Procalcitonin(PCT)
• Trigerring receptor expressed on Myeloid
cells(sTREM1)

18. Procalcitonin
• Precursor of calcitonin – Thyroid and K cells of lung
• CAP – Only role may be to differentiate from decompensated
heart failure and non infective causes
• HAP/VAP – Not used for diagnosis and initiation of antibiotics
but clinical as well as Procalcitonin may be used to stop
antibiotics
• Sequential use of Procalcitonin for levels maybe useful
Sensitivity Specificity False Positive False negative
67% 83% 33% 17%
Negative Positive Sepsis Severe sepsis
<0.05ng/ml >0.5ng/ml >2 ng/ml > 5 ng/ml
Gilbert N. D. , Procalcitonin in Respiratory Tract Infections d CID 2011:52 S347
Kidney
dysfunction??

19. Sputum examination
• Collection
– Morning before breakfast
– Induced or spontaneous
– Deep breath
– Direct into container
• Adequacy
– <10 squamous ep. Cells/lpf
– >25 or more PMNL/lpf
• Processing
Washington Murray grading system

20. • Stains
– Gram stain
– Ziehl-Neelsen(AFB**)
– Fungal wet mount(KOH)
– Giemsa
• Culture (Agar)
– Blood
– Mac Conkey
– Chocolate

21. Culture methods
Quantitative Semi- Quantitative
In terms of cfu/ml
Cut offs
1. Sputum – 105-106
2. ET aspirate – 105-106
3. Mini Bal – 103-104
4. BAL – 103-104
5. PSB - >103
Types
1. 1+ 2+ 3+ 4+
2. Rare /Light /Mod
/Heavy
Moderate or 3+ are
considered significant
Ref

22. Newer tests
• Urinary Antigen
– Streptococcus(X) and Gp 1 Legionella (Room 2079)
– Sensitivity – 75%, Specificity - >95%
– Early(<15 min), no effect with antibiotics
• Serological tests(Anaerobe lab)
– IgM for Chlamydia and Mycoplasma
• Molecular diagnostics
– Sensitive but no resistance pattern
and costly(X)

23. Radiological tests
• Chest X ray
– 75% sensitivity
– Lateral view
• CT scan
– Gold standard
– Definite indications – fungal, unclear CXR, COPD
patient, non resolving pneumonia

24. Radiological classification
• Alveolar pneumonia
• Bronchopneumonia
• Interstitial pneumonia

25. Common X-rays

26. CT(Computed tomography) scan

28. Lung Ultrasound
• Sensitivity – 60-90%, Specificity – >90%
• Advantages
– Radiation free, bedside and quick
– Pregnant women
– Dynamic evaluation
• Appearence
– Serrated margins with hepatization
– Air bronchogram(dynamic)
– Pleural shred sign
Chaves MA et al. , Lung ultrasound for the diagnosis of pneumonia in adults: Respir Res 2014;
15:50

29. Flexible Bronchoscopy
• Endoscopic procedure to visualise
tracheobronchial tree
• Various specimens:
– Bronchial brush
– Bronchial washing
– Bronchoalveolar lavage(BAL)
– Endobronchial biopsy
– Transbronchial(TB) lung biopsy
– TB needle aspiration
– Endobronchial ultrasound

30. Other samples
ET aspirate**
• Non invasive
• No special
equipment
required
Mini BAL(mBAL)
• Advantage:
Possible
bedside,
cheaper
• Disadv: Blind
procedure
PSB
• Newer
technique
• Less chances
of
contamination
ET- Endotracheal
PSB – Protected specimen brush

31. Clinical syndromes
• Community Acquired pneumonia
– Typical and atypical
• Hospital acquired pneumonia
• Ventilator acquired pneumonia
• Health care associated pneumonia

32. Community Acquired Pneumonia

33. 0
50
100
150
200
250
LRTI mortality Tuberculosis Infectious diseases
Mortality per year /1,00,000 people

34. Etiology
Gupta D et al. Guidelines for diagnosis and management of community-and hospital-acquired
pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India. 2012
0
10
20
30
40
50
60
40-71% had a microbiological diagnosis

35. B. A. Cunha et al. Clin Microbiol Infect 2006; 12 (Suppl. 3): 12–24
Atypical pneumonia
• Walking pneumonia
• Difference:
– Systemic manifestations**
– Minimal sputum
– Sub acute progression
– Chest X ray pattern
– Fever and leukocytosis less common
• Mycoplasma(25%), Chlamydia(12-21%), Legionella, Q
fever

36. Admission decision
CURB 65(BTS)
Confusion
Urea(>20mg/dL)
Respiratory rate >30
Blood pressure <90
systolic ; or < 60 diastolic
Age>65 years
Pneumonia Severity Index
Gender
Demography
Co morbidities
Physical examination
Lab and radiographic findings
Scored in points
I – 0-50
II – 51-70
III – 71-90
IV – 91-130
V – 131-395
Fine MJ et al. N Engl J Med. 1997;336:243-250.
Capelastegui A et al. Eur Respir J. 2006;27:151-157
Each gets one point
BTS – British Thoracic society

37. Severity Assessment
Pneumonia
Severity Index
30 day
mortality(%)
CURB-65 30 day
mortality(%)
Where to
manage?
I 0.1 0 0.7 Outpatient
II 0.6 1 2.1 Outpatient
III 0.9 2 9.2 Inpatient
(Short
observation)
IV 9.3 3 15 Inpatient
V 27 4 40 Inpatient-ICU
Fine MJ et al. N Engl J Med. 1997;336:243-250.
Capelastegui A et al. Eur Respir J. 2006;27:151-157
Physicians decision

38. IDSA 2007 severity assessment
1 MAJOR
OR
3 MINOR
ICU/HDU
IDSA/ATS Guidelines for CAP in Adults, Mandell A. L et al CID 2007:44 (Suppl 2)

39. Treatment
Clinical Profile Antibiotic
Outpatient
Previously healthy and no antibiotic in last 90
days
Macrolide(Aithromycin/Clarithromycin/Eryth
romycin) OR Doxycycline
Comorbidity or antibiotic in 90 days Respiratory
Fluoroquinolone(Gemifloxacin/Moxifloxacin/
Levofloacin)
Or β-lactam + macrolide
Inpatient
Non ICU Same as above
ICU admission β-lactam + Fluoroquinolone/Azithromycin
Or Aztreonam + Fluoroquinolone
ICU with ? Pseudomonas Antipneumococcal, antipseudomonal β-
lactam plus Ciprofloxacin/Levofloxacin
Or Aminoglycoside + Azithromycin
ATS/IDSA Guidelines 2007

40. Clinical response of pneumonia
Pneumonia
Tachycardia and
hypotension
Fever, tachypnea and
arterial oxygenation
Cough and fatigue
Radiological
resolution
2 days
3 days
14 days
3-4 weeks
Highly variable
1. Co morbidity
2. Age
3. Severity
Marrie TJ, et al. Resolution of symptoms in CAP on ambulatory basis, J Infect 2004; 49:302

41. Other considerations
• Role of steroids
• IV to oral shifting
• Duration of antibiotics
1.No role in non severe(2A)
2. Role in severe CAP with severe
inflammation(CRP>15mg/dL),
septic shock or ARDS
2. Mortality risk reduction
3. Contraindications to be ruled out
4. Dose regimen
5-7 days, if MRSA/Leigionella/ pneumococcal
sepsis; may require for longer time, but clinical
stability and 48-72 hours afebrile
Patient is cinically better
ATS 2007 Guidelines and 2012 Lung India guidelines

42. Non community acquired
Hospital acquired Ventilator associated
Non - ICU ICU Early Late(>4)
48 48-72

43. Healthcare associated pneumonia
• Hospitalization for more than 48 hours in the last 90 days
• residence in a nursing home or extended care facility
• home infusion therapy
• chronic dialysis within one month
• home wound care
• a family member with a multi-drug resistant organism.
Controversy
Next guidelines of CAP will likely include it
ATS /IDSA HAP/VAP Guidelines 2005

44. Etiology
Incidence of VAP is much higher in developing countries
Study at AIIMS, 478 BAL samples tested, 192(40%) showed isolates
Ritu Singhal, Srujana Mohanty. Profile of bacterial isolates from patients with VAP. Indian J Med Res 121, January 2005,
pp 63-64
Khilnani GC, Jain N. Ventilator-Associated pneumonia. Indian J Crit Care Med 2013;17:331-2.
Organism Number
Acinetobacter 86(44.8%)
Psudomonas 77(40.1%)
Others- E. Coli 8(4.2%) ; Citrobater 4(2.1%) ; Enterobacter – 3(1.6%)
Staph. Aureus 2 (1.1%)

45. Diagnosis of HAP/VAP
Radiology Sign/Symptoms/Lab
2 or more serial X-rays with at least one of
the following:
1. New or Progressive and persistent
infiltrates
2. Consolidation
3. Cavitation
At least one :
1. Fever
2. Leukopenia or leucocytosis
3. If age>70; altered mental status
At least 2 of the following:
1. Sputum ( new onset/ change in
character) or increased secretions
increased suctioning requirement
2. Worsening gas
exchange(desaturation/increased oxygen
requirement/ increased ventilatory
requirements)
3. New onset dyspnea/cough/tachypnea
4. Rales or bronchial breath sounds
2013 CDC definitions for Healthcare associated infections
At least 2/3
Persistent infiltrates
+
1. Leucocytosis
2. Change in oxygen/ventilatory
requirement
3. Secretions

46. Risk factors for MDR VAP
1. Prior antibiotic use in 90 days
2. Septic shock at time of VAP
3. ARDS preceding VAP
4. >5 days of admission before VAP
6. Dialysis before VAP
Risk factors for MDR HAP/MRSA or MDR Pseudomonas in HAP or VAP
Injectable antibiotic use in last 90 days
Risk of death in HAP
1. Ventilatory support
2. Septic shock
ATS Guidelines for HAP/VAP Management, 2016

47. ATS/IDSA Guidelines for HAP/VAP 2016
7

48. Prevention of VAP
Nancy Munro et al. Ventilator-Associated Pneumonia Bundle, AACN 2014 Vol 25 175-183

49. Changes in 2016 guidelines
• Removal of HCAP
• Equal efficacy of non invasive sampling(like
endotracheal aspirate) and semiquantitative culture
• Systemic colistin used only with inhaled colistin
• Use dual antibiotics(for Pseudomonas) even after
culture if patient has septic shock or high risk of
death.

50. Fungal pneumonia
• Mortality – 50-90%
• Structural lung disease
• Risk factors:
• Broad spectrum antibiotics
• TPN, Central catheters
• Prolonged ICU stay
• Renal/hepatic dysfunction
• Large BT requirements
• Leading causes –Aspergillus, Mucor, Candida
• Endemic fungi(Cryptococcus, Histoplasma etc)

51. Pneumocystis jiroveci(PJP)
• Immunocompromised
• (A-a) gradient
• Induced sputum (Variable), BAL(90% yield)
• Treatment needs to be started empirically
• Treatment – 15-20mg/kg/day of
Cotrimoxazole QID (2tab DS TDS) x 21 days
• Steroids-PaO2<70, A-a gradient>35, hypoxia

52. Aspergillus
ABPA
• Refractory
asthma
• Mucus plugs
• NOT A TRUE
INFECTION
Aspergilloma
• Patients
withprior co
morbidities
• Sub acute
pneumonia
with
constitution
al
symptoms
CNPA
• History of
disease
suggestive
of cavity
?TB
• Asymptoma
tic or
hemoptysis
• Rarely fever
Invasive
Aspergillosis
• Immunoco
mpromised
patients
• Rapidly
progressive
pneumonia
ABPA- Allergic bronchopulmonary aspergillosis
CNPA- Chronic Necrotizing Pulmonary Aspergillosis

53. • Specific
criteria
• Fleeting
opacities,
HAM
• Treat with
steroids and
if reuired
Itraconazole
• Chest X ray
and CT
shows cavity
with soft
tissue
density
• Itraconazole
, inhaled
KTZ
• Other
antifungals
• Tissue and sputum needs to
demonstrate Aspergillus (GMS
stain)
• Serial Galactomannan
monitoring
• CT signs – Halo sign
• DOC- Voriconazole
ABPA Aspergilloma CNPA
Invasive
Aspergillosis

54. Parasitic
Focal
Consolidation
Paragonimus
Cystic
Entamoeba
Coin lesion
Dirofilaria
Diffuse
Transient
(Loeffler’s)
Hookworm
Roundworm
Alveolar
Schistosoma
Strongyloides
Tropical
Pulmonary
eosinophilia

55. Mycobacteria
• As community acquired pneumonia 3-16% but
even as high as 30%
• Fluoroquinolones – Do not use as earlly
resistance(5-10 days)
• Clues – Endemic, co morbidities, pleural
effusion, chronicity of symptoms, upper lobe,
cavity, norrmal TLC
L.M. Pinto et al. / Respiratory Medicine (2011) 138e140
R.F. Grossman et al. / International Journal of Infectious Diseases 18 (2014) 14–21

56. TAKE HOME MESSAGES
• Investigate in a planned way
• Know the interpretation
• Lung USG is a must
• “Pneumonia” or “LRTI” is not the complete
diagnosis
• Evidence based management and de
escalation
• Never forget “TB” and avoid Levofloxacin