Lower respiratory tract infections

1. Infectious diseases Pharmacotherapy
Lesson 3
Lower respiratory tract infections[LRTIs]
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.etJuly, 2018 +251913765609+251913765609
By: Tsegaye Melaku [MSc]
Lower respiratory tract infections[LRTIs]

2.  Session Tips:Session Tips:
 Epidemiology/etiology/pathogenesis of common LRTIs.
 Comparative assessment among LRTIs [clinical pictures]
 Pneumonia classification [on microbiology/settings].
 Bronchitis versus bronchiolitis.
 Appropriate management strategy for LRTIs
 Monitor and evaluate treatment outcome
2

3.  Anatomy of the Respiratory Tract
 Sinuses
 Ear (otic)
 Pharynx
 Lungs
– Bronchus
– Alveolus
3

4. 4

5.  Host defenses: humoral immunity,
cellular immunity, & anatomic
mechanisms.
Protect pathogen invasion
Removing infectious agentsRemoving infectious agents
from the lungs.
– Mucocillary
clearance,
– Secretory IgA,
– Cough,
– Mechanical Barrier
5

6. 6

7. 7

8. A
B
8
A. Host defense in the respiratory tract.
B. Factors that interfere with host defense
of the respiratory tract
B

9.  Upper respiratory tract
Otitis Externa & Media
Sinusitis
Pharyngitis
 Lower respiratory tract Lower respiratory tract
Bronchitis/Bronchiolitis
Pneumonia
– Community Acquired
– Nosocomial (HAP, VAP, HCAP)
– Aspiration…
9

10.  Respiratory tract infections: major cause of morbidity[acute illness].
 In most of cases, LRTIs occur only when defense mechanisms
impaired.
 They may also follow colonization of the URT with potential pathogens:
Gain access to the lung via aspiration of oropharyngealGain access to the lung via aspiration of oropharyngeal
secretions.
 Less commonly, via
Blood [from an extra-pulmonary source] or
Inhalation of infected aerosolized particles.
10

11.  Its management depends on:
Risk factors,
Predominate pathogens within the community
Isolation of the etiologic agentIsolation of the etiologic agent
11

12. 12

13.  A 15 year old female with a history of hay fever develops fever, headache
and malaise for 4 days followed by a non-productive cough and scratchy
throat. Despite chicken soup and orange juice, the cough and fever persist,
and her mother drags her to your office. On examination, her T:101ºF,
PR:90 bpm, BP:110/70mmHg, RR:20 bpm Physical examination is
unremarkable except for scattered rales over the left lower lung, and small
bullae in her left tympanic membrane. Chest x-ray reveals a patchy left
lower lobe infiltrate. At your request, she makes a heroic effort but is unablelower lobe infiltrate. At your request, she makes a heroic effort but is unable
to produce sputum
a. What is the type of pneumonia this patient is likely to have?
b. What is "atypical pneumonia"?
c. What is the differential diagnosis of atypical pneumonia?
d. What is the most likely organism in this patient and why?
e. What antimicrobial agent(s) would you use ?
13

14.  Infection of the lung tissue [bacterial , viruses, fungi or parasites].
 B/c of the serious nature of the infection, antibiotic treatment
should be started immediately.
 Decision: need for hospital admission
– Pts at extremes of age, SOB, rapid pulse rate [ ≥120 bpm],
low BP [<90/60mmHg], restlessness, confusion, or excessive
drowsiness, coexisting disease[ HF, hepatic failure, renal
disease]
14

15.  Accounts for 16% of all deaths of <5 y/old
 Killing 920,136 children in 2015.
 Almost 3.5 million deaths yearly [WHO]
 Costs $109 million per year in US
 Ethiopia: 5th country from 15 countries
 62 deaths in 1000
 940,000 Children/Year,, UNICEF, 2014
 14.7 % case fatality rate
15

16.  Depressed cough reflex resulting in aspiration:
– Impaired consciousness, endotracheal tube, obstructive lung disease,
malnutrition, neuromuscular disease
 Impaired mucociliary clearance:
– Alcohol, cigarette smoke, endotracheal obstruction, cystic fibrosis, viral
infectionsinfections
 Inhibition of alveolar function:
– Cigarette smoke, hypoxia, malnutrition, pulmonary edema, cellular or
humoral immunity deficiencies
 Bugs get there by inhalation of aerosolized particles:
– Aspiration of oropharyngeal flora, Hematogenous, Trauma
16

17.  Signs and symptoms
– Abrupt onset of fever, chills, dyspnea,
– Productive cough
– Rust-colored sputum or hemoptysis
– Pleuritic chest pain
 Laboratory tests
– Leukocytosis [predominant polymorphonuclear cells]
– Low O2 saturation
17

18. 18

19.  P/E
– Tachypnea and tachycardia
– Dullness to percussion
– Increased tactile fremitus, whisper pectoriloquy, and egophony
–– Chest wall retractions and grunting respirations
– Diminished breath sounds over affected area
– Inspiratory crackles during lung expansion
19

20. 20
 CxR
Dense lobar/segmental infiltrate/consolidation

21. 21
Normal
Abnormal

22. 22
Landmarks on CxR

23. 23

24. 24
6
5

25. 25

26. 26

27. 27
BA

28. 28

29.  All patients:
– History, Physical Exam, CxR
– +/- Sputum Gram stain & culture
 Admitted to hospital:
– Sputum Gram stain & Culture, Urine antigens
– Blood culture before treatment (5-14 % yield)
– CBC with diff, Electrolytes +/- HIV, O2
 Healthcare Associated
– If intubated: tracheal aspirate, bronchoscopy
29

30.  Depends on severity & risk factors/site of acquisition
 Community Acquired (CAP)
– Outpatient, Inpatient, Inpatient ICU
– S. pneumoniae, H. influenzae; Mycoplasms, Chlamydia
 Healthcare Associated (HCAP)
– Hospital – acquired (HAP), ventilator-associated (VAP)
– Early per CAP + MS-SA, Susceptible GNR
– Late includes MR-SA, MDR GNR (Pseudomonas,
Acinetobacter)
 Specific organism risk factors
– Aspiration (anaerobes), Post-influenza (S. aureus)…
30

31.  Anaerobic Pneumonia
– Typically indolent course with cough, low grade fever, and weight loss
– Putrid sputum: highly suggestive
– CxR: infiltration, and lung abscesses [20% of patients ]
 Mycoplasma pneumoniae
– Gradual onset of fever, headache, and malaise,
– Hacking cough [initially is non-productive]
– Sore throat, ear pain, and rhinorrhea are often present
– Lung findings: limited to rales and rhonchi;
– Findings of consolidation (rare).
31

32.  Viral Pneumonia
– Variable clinical pictures
– Radiographic findings are nonspecific
– Serology test
 Nosocomial Pneumonia ( replaced by HCAP, VAP, HAP)
– Predisposing factor:
– Mechanical ventilation
– Prior antibiotic use, use of PPI, H2RA, and severe illness
– Dx: presence of a new infiltrate on CxR , fever, worsening respiratory
status, and the appearance of thick, neutrophil-laden respiratory
secretions
32

33.  Community acquired pneumonia(CAP)
– In patients with no contact to a medical facility
 Nosocomial Pneumonia
– Health care associated pneumonia (HCAP)
– Hospitalized** > 2 days within last 90 days
– Hospital acquired pneumonia (HAP)
– Develop >48 hrs after hospital admission
– Ventilator associated pneumonia (VAP)
– Develop >48 hrs after intubation & mechanical ventilation
33

34.  CAP defined both on clinical and radiographic findings.
 In the absence of CxR, CAP is defined as:
– Symptoms of an acute LRT illness (coughcough ±± expectoration,expectoration,
SOB, pleuritic chest pain)SOB, pleuritic chest pain) for less than 1 week; and
– At least one systemic feature (temperature >37.7°C,– At least one systemic feature (temperature >37.7°C,
chills, and rigors, and/or severe malaise); and
– New focal chest signs on examination (bronchial breath
sounds and/or crackles); with
– No other explanation for the illness.
BTS guidelines for the management of community acquired pneumonia in adults

35.  S. pneumoniae: most common
 S. aureus:
– young infants, cystic fibrosis, antecedent viral infection
 Group A Streptococcus: uncommon
– Follows a viral infection.
– Associated with streptococcal pharyngitisstreptococcal pharyngitis.
– pyogenic [so severe presentation]
 Enteric gram-negative:
– With chronic illness (DM); alcoholism
 Viral: preschool-aged children
35

36. File TM. Community-acquired pneumonia. Lancet 2003; 362:1991–2001.

38. REFERENCE- NEJM REVIEW ARTICLE FEBRUARY 2014

39.  CURB-65 criteria: ≥2 should be hospitalized
– Confusion,
– Uremia (BUN > 19),
– Respiratory rate (RR> 30bpm),
– Low Blood pressure ( < 90/60mmHg),– Low Blood pressure ( < 90/60mmHg),
– Age > 65yrs
39

40.  Can be decided on the basis of pneumonia severity index, that
can assessed by following methods: PORT Study
 Port Score / Pneumonia Severity Index (PSI)
– I-II Outpatient
– III 24 hour observation– III 24 hour observation
– IV Inpatient
– V Inpatient ICU
40

42. If any major criterion or ≥3 minor criteria are fulfilled, patients should
generally be admitted to the ICU

44. THE ATS GUIDELINES,2014

45.  Previously healthy & no risk factors for DRSP
– Macrolide (Azithromycin or Clarithromycin)
– Doxycycline
 Comorbidities (HF, lung, liver or renal disease, DM,
malignancies; antimicrobial use in past 3 months)malignancies; antimicrobial use in past 3 months)
– Respiratory fluroquinolone (moxifloxacin or levofloxacin)
– Macrolide (Azith or Clarith) plus ß-lactam
(amoxicillin/clavulanate, cefuroxime, cefpodoxime, 3rd gen.)
45

46.  Hemodynamically stable, adequate oxygenation, no
contraindications to outpatient care & per CURB-65 & PORT/PSI
 Treated as an outpatient on oral antibiotic that covers typical
and atypical organisms
– Macrolide or anti-pneumococcal fluoroquinolone
 Pneumococcal & Influenza Vaccine if he has not previously been
immunized
46

47.  Respiratory fluroquinolone
– Levofloxacin (750 mg daily) or Moxifloxacin
 Beta-lactam plus a macrolide
– Ceftriaxone or cefotaxime with Azithromycin*,– Ceftriaxone or cefotaxime with Azithromycin*,
Clarithromycin or Erythromycin
– * As monotherapy in some patients; not recommended
47

48.  ß-lactam (cefotaxime, ceftriaxone OR amoxicillin/clavulanate)
– With Azithromycin OR Respiratory FQ
 If Pseudomonas risk
– Antipneumococcal, antipseudomonal beta-lactam
(Piperacillin/Tazo, Cefepime, Imipenem OR Meropenem)
– With Ciprofloxacin /Levofloxacin/Combination of Aminoglycoside
AND Azithromycin
 If MRSA
– Add Vancomycin OR Linezolid
48

49. 49

50. 50

51.  Prescribing of 1st , 2nd and 3rd generation FQ[ciprofloxacin,
levofloxacin, etc] should be avoided in managing CAP because
they are WHO recommended second line drugs for MDR
TB!!!!!!!!!!TB!!!!!!!!!!
51

52.  Steroids:
– Not recommended for use in non-severe CAP (2A).
– Used for septic shock or in ARDS 2º to CAP (1A).

53.  S. pneumoniae
 Penicillin non-resistant (MIC < 2):
– Penicillin G, Amoxicillin; etc
 Penicillin resistant (MIC ≥2)
– Based on susceptibilities:
– Ceftriaxone or Cefotaxime; Vancomycin or Linezolid
 H. influenzae
 Beta-lactamase negative
– Amoxicillin; etc
 Beta-lactamase positive
– Cefuroxime, amoxicllin/clav.
 Mycoplasma or Chlamydophila
– Macrolide, tetracycline or respiratory FQ
53

54.  Temperature < 37.8 C
 Heart rate < 100 beats/min
 Respiratory rate < 24 breaths/min
 Systolic blood pressure > 90 mm Hg
 O2 saturation > 90 %
 Able to maintain oral intake
 Normal mental status
 No need to observe inpatient on oral antibiotics
54

55.  Hospital-acquired pneumonia (HAP)
– Develops 48 hours or more after admission (& wasn’t incubating at
admission)
 Ventilator-associated pneumonia (VAP)
– Arises more than 48-72 hours after endotracheal intubation
 Healthcare Associated Pneumonia (HCAP)
– Hospitalized > 2 days within last 90 days
– Nursing home / long term care facility, IV antibiotic therapy, chemotherapy,
wound care within past 30 days
– Attended hospital or hemodialysis clinic.
55

56. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated
infection and criteria for specific types of infections in the acute care setting. Am J Infect
Control 2008;36:309-32.

57.  2nd most common nosocomial infection
– 25% of all ICU infections, 50% of antibiotics.
 Increases length of stay 7-9 days
 Attributable Mortality 33-50% Attributable Mortality 33-50%
 Excess cost of $40,000 / patient
 5-15 per 1,000 admission
57

58.  Varies by ICU, found in environment on surfaces etc. &
transferred by hospital staff
– Colonizes patient within 48-72 hours
 Inoculates lung via intubation, aspiration Inoculates lung via intubation, aspiration
– S. aureus (MR-SA)
– P. aeruginosa
– K. pneumoniae (ESBL)
– Acinetobacter
58

59.  Antimicrobial therapy in preceding 90 day
 Current hospitalization of 5 day or more
 High frequency of antibiotic resistance in the community or in the
specific hospital unit
 Presence of risk factors for HCAP: Presence of risk factors for HCAP:
– Hospitalization for 2 day or more in the preceding 90 day.
– Residence in a nursing home or extended care facility
– Home infusion therapy (including antibiotics)
– Chronic dialysis within 30 day, Home wound care
– Family member with multidrug-resistant pathogen
 Immunosuppressive disease and/or therapy
59

60.  History & Physical Examination, Chest X Ray
 O2 saturation, ABG; CBC, serum electrolytes, LFT
 Blood culture
 Lower respiratory culture
– Endotracheal aspirate (ET)
– Broncoscopic Aveolar Lavage (BAL)– Broncoscopic Aveolar Lavage (BAL)
– Protected Specimen Bronchoscopy (PSB)
60

62. Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia
during mechanical ventilation: The clinical pulmonary infection score revisited. Am J Respir Crit
Care Med 2003;168:173-9.

63. 63

64. 64

66. 66

67. Antibiotic Pediatric Adult (Total Dose/Day)
Ampicillin ± sulbactam
Amoxicillin ± clavulanate
Piperacillin/tazobactam
Penicillin
150-200 mg/kg/day
45-100 mg/kg/day
200-300 mg/kg/day
100,000-250,000 units/kg/day
6-12 g
0.75-1 g
12-18 g
12-18 million units
Ceftriaxone
Cefotaxime
Ceftazidime
Cefepime
50-75 mg/kg/day
150 mg/kg/day
90-150 mg/kg/day
100-150 mg/kg/day
1-2 g
2-12 g
4-6 g
2-6 g
Clarithromycin
Erythromycin
15 mg/kg/day
30-50 mg/kg/day
0.5-1 g
1-2 g
67
Azithromycin 10 mg/kg × 1 day (× 2 days if parenteral),
and then 5 mg/kg days 2-5
500 mg × 1 day (× 2 days if parenteral), and
then 250 mg days 2-5
Moxifloxacin
Gemifloxacin
Levofloxacin
Ciprofloxacin
–
–
8-20 mg/kg/day
30 mg/kg/day
400 mg
320 mg
750 mg
1.2 g
Doxycycline
Tetracycline HCl
2-5 mg/kg/day
25-50 mg/kg/day
100-200 mg
1-2 g
Gentamicin
Tobramycin
7.5-10 mg/kg/day
7.5-10 mg/kg/day
7.5 mg/kg
7.5 mg/kg
Imipenem
Meropenem
60-100 mg/kg/day
30-60 mg/kg/day
2-4 g
1-3 g
Vancomycin
Linezolid
Clindamycin
45-60 mg/kg/day
20-30 mg/kg/day
30-40 mg/kg/day
2-3 g
1.2 g
1.8 g

68.  CAP 7-10 days
 At least 5 days of therapy
 Nosocomial pneumonia: 14 -21 days
 Afebrile for 48-72 hours
 No more than 1 sign of clinical instability No more than 1 sign of clinical instability
 Longer if needed per pathogen (P. aeruginosa)
 Prevention:
 Vaccination, smoking cessation
68

69. 69

70.  Dose adequately, switch to PO when able
 Use combinations if MDR likely
– Avoid inadequate therapy
– Monotherapy once Culture &Sensitivity test back
 Limit aminoglycosides to 5-7 days if possible Limit aminoglycosides to 5-7 days if possible
 Treat for 14-21 days
– 7 days if not P. aeruginosa or S. aureus & good clinical
response with resolution.
70

71.  P. aeruginosa combination therapy recommended.
– Development of resistance on monotherapy
– Combination therapy may not prevent resistance, may
avoid Inappropriate and ineffective treatment
 Acinetobacter
– Carbapenems, Ampicillin-Sulbactam, colistin, and polymyxin
most active; no data supporting combination regimen
 ESBL Enterobacteriaceae
– Use carbapenem
– Avoid monotherapy with 3rd generation cephalosporin
71

72.  Considered adjunctive therapy with an aminoglycoside or polymyxin
for MDR gram-negative
 Linezolid is alternative to vancomycin for MRSA VAP
– May be preferred on the basis of a subset analysis of two
prospective randomized trials
 Antibiotic restriction can limit epidemics of specific resistant pathogens.
– Antibiotic cycling etc. may help but data not conclusive / not
recommended
72

73.  67 y/o woman from Asendabo, who has a 2-day history of
productive cough, fever, and altered behavior is brought to the
JUMC. Vital Signs: BT 101.2 F, BP 140/80 mmHg, HR 120/min,
RR 30/min, SpO2 91% (room air). P/E: Crepts in B/L I/S I/
area; disoriented to time/place/person; Lab: WBC 4500, Na+area; disoriented to time/place/person; Lab: WBC 4500, Na+
130, BUN 25
 CXR: infiltrates in both lower lobes
1. Where should this patient be treated ?
2. Which initial antibiotics should she be started on ?

74.  Confusion
 BUN ≥20
 Respiratory rate ≥30 bpm
 BP: SBP <90 mmHg or DBP ≤60 mmHg
 Age ≥65 years
✔
✔
✔
✔
✔

75. Minor criteria
 Respiratory rate 30 breaths/min
 PaO2/FiO2 ratio < 250
 CXR: Multilobar infiltrates
 Confusion/disorientation
 BUN > 20 mg/dL
 Leukopenia (WBC <4000)
✔
✔
✔
✔
 Leukopenia (WBC <4000)
 Thrombocytopenia (platelet <100,000)
 Hypothermia (core temperature < 36 ºC)
 Hypotension (SBP < 90 mmHg) requiring aggressive fluid resuscitation
Major criteria
 Invasive mechanical ventilation
 Septic shock with the need for vasopressors Tsegaye
Melaku
Digitally signed by
Tsegaye Melaku
DN: cn=Tsegaye
Melaku
gn=Tsegaye
Melaku c=Ethiopia
l=ET o=Jimma
University
e=tsegayemlk@ya
hoo.com
Reason: I am the
author of this
document
Location:
Date: 2018-07-09
23:15+03:00

78. Initiate antibiotics treatment?
   Ceftriaxone + Azithromycin

79. • A 72-year-old man is hospitalized because of fever, chills, and
cough that have persisted for the past week. His medical history
includes congestive heart failure, chronic bronchitis, and diabetes
mellitus.
• On physical examination, he is alert and in moderate respiratory
distress. His temperature is 39 °C (102.2 °F), pulse rate is
Mini case 2
distress. His temperature is 39 °C (102.2 °F), pulse rate is
120/min, respiration rate is 36/min, and blood pressure is
100/60 mm Hg. The physical examination reveals crackles in
both lung fields at the bases. The jugular venous wave is noted
12 cm above the right atrium, and a soft S3 gallop is present on
auscultation.
79

80. • The leukocyte count is 21,000/μL, serum sodium is 124 meq/L,
and serum creatinine is 2.4 mg/dL. Chest x-ray shows infiltrates
in the right upper, left upper, and left lower lobes..
Measurement of arterial blood gases obtained on room air
shows the following: pH, 7.38; Paco2, 32 mm Hg; and Pao2, 58
mm Hg.
• Which one of the following antibiotic regimens is the most
Mini case 2…
• Which one of the following antibiotic regimens is the most
appropriate for this patient?
A. Doxycycline
B. Azithromycin
C. Ceftriaxone
D. Ciprofloxacin
E. Piperacillin-tazobactam and levofloxacin
80

81. 81

82.  M.A., 5 years of age, has been brought to his paediatrician by his mother for a
dry hacking cough since the last 3-4 days. It all began with a cold, slight fever
and sore throat 7-10 days back. This was followed by a watery nasal discharge
which later became thicker and colored. On examination, the child was afebrile;
pulse was 80/min, regular, General examination was normal, Examination of the
chest showed scattered and bilateral rhonci.
1. Based on the history and examination the clinical diagnosis is
a) Rhinitsa) Rhinits
b) Bronchitis
c) Pneumonia
d) None of the above
2. The causes of bronchitis are
a) Viral infections
b) Secondary bacterial infection
c) Allergies
d) All of the above
82

83.  Bronchitis & bronchiolitis: inflammatory conditions of the large &
small airways (tracheobronchial tree), respectively.
Inflammatory process does not extend to the alveoli.
 Bronchiolitis: disease of infancy.
83
Bronchitis
Acute
Chronic Primarily affects adults
Occurs in individuals of all ages

84. 84

85.  Most common cause: Respiratory viruses.
 Common cold viruses (rhinovirus & coronavirus).
 LRT pathogens (influenza virus & adenovirus).
 Bacterial
 M. pneumoniae: frequent cause. M. pneumoniae: frequent cause.
 C. pneumoniae (Chlamydophila), B. pertussis
 S. pneumoniae, other streptococcus, Staphylococcus species, and
Haemophilus species less common.
 Precipitating factors: Cold, damp climates and irritating substances (e.g., air
pollution, cigarette smoke).
85

86.  Primarily a self-limiting, rarely cause death.
 Infection of the trachea and bronchi  hyperemic and edematous mucous
membranes  increase in bronchial secretions.
 Destruction of epithelium [mild/extensive] affect mucociliary function.
 Desquamated epithelial cells and thick/tenacious bronchial secretions 
impairs mucociliary activity.
 Recurrent infections  increased airway hyper-reactivity  asthma,
COPD. ACOS
86

87. 87

88.  Begins with nonspecific complaints.
 Cough: hallmark[occurs early].
– May be insidious or abrupt.
– may persist for up to 3 or more weeks.
 Sputum:
– Initially is non-productive; later mucopurulent
– In older children and adults, it is raised and expectorated.
– In the young child, often is swallowed[result in gagging &
vomiting].
88

89.  Dyspnea, cyanosis, or signs of airway obstruction [if comorbid with
emphysema or COPD].
 Fever:
 Rarely exceeds 39°C.
 Commonly with adenovirus, influenza virus, and M. pneumoniae
infections.
 Dx
 On the basis of a x- tic hx and P/E.
 Bacterial cultures of expectorated sputum??
89

90. Evaluate for
90

91.  Goals of therapy
 Provide comfort.
 Treat associated dehydration and respiratory compromise.
 Use antibiotics carefully
91

92.  Reassurance, Bed rest
 Antipyretics
– Relieve lethargy, malaise, and fever
– Acetaminophen: max. 60 mg/kg/day
– Aspirin**: 650 mg;10 to 15 mg/kg per dose
**Avoid aspirin in children
,instead acetaminophen
– Aspirin**: 650 mg;10 to 15 mg/kg per dose
– Ibuprofen: 200 to 800 mg or 10 mg/kg per dose; Max. 40
mg/kg/day; ~ 3.2 g.
 Increase fluid intake
– Prevent dehydration and decrease the viscosity of
respiratory secretions.
 Mist therapy: Promote thinning and loosening of respiratory secretions.
92

93.  Ibuprofen vs aspirin or acetaminophen
 Identical antipyretic efficacy
 Long duration of action of Ibuprofen[3 to 4 hrs vs 5 to 6 hrs]
 Caution in use of ibuprofen [< 6 months, elderly, poor renal
function].function].
93

94.  Mild to moderate wheezing.
– ß2-receptor agonists and/or corticosteroids: not routinely
 Brief trial (5 to 7 days) of oral or inhaled corticosteroid for
patients with persistent (>14 to 20 days), troublesome cough.patients with persistent (>14 to 20 days), troublesome cough.
 Antihistamines, sympathomimetics, and antitussives??
– They dehydrate bronchial secretions  aggravate and
prolong the recovery process.
94

95.  Dextromethorphan: Persistent, mild cough[bothersome]; not routine
 More severe coughs:
 Intermittent codeine or other similar agents.
 Severe persistent cough (which may disrupt sleep)
 Mild sedative–hypnotic + cough suppressant (e.g. codeine).
 Expectorants: clinical effectiveness??.
95

96.  Its routine use discouraged.
 Initiate in
 Previously healthy with persistent fever or respiratory symptoms
for more than 4 to 6 days or
 For predisposed patients (e.g., elderly, immunocompromised),
 Doc:
– Amoxicillin
– Macrolides[azithromycin]: M. pneumoniae
– Fluoroquinolone [levofloxacin]: Alternative
 Suspected viral cause [e.g. influenzae]
– Amantadine, rimantadine, zanamivir or oseltamivir 96

97.  Chronic bronchitis: a component of the COPD.
 Primarily affects adults.
 Affects most patients with COPD.
 Cough and excessive sputum expectoration
 It is the presence of a chronic cough of productive sputum lasting more
than 3 consecutive months of the year for 2 consecutive years.
– Without an underlying etiology of bronchiectasis or
tuberculosis.
97

98.  Contributing factors:
– Cigarette smoking  airway irritant and predominant
factor in the etiology of chronic bronchitis.
– Exposure to occupational dusts, fumes, and environmental
pollution.pollution.
– Host factors [e.g., genetic factors and bacterial and viral
infections].
– Recurrent childhood respiratory infections.
98

99.  Chronic inhalation of an irritating noxious substance   compromises
the normal secretory and mucociliary function of bronchial mucosa.
 Bronchial wall thickened
 Number of mucus-secreting goblet cells on the surface epithelium of both
larger and smaller bronchi is increased markedly.larger and smaller bronchi is increased markedly.
 Hypertrophy of the mucous glands and dilation of the mucous gland
ducts
99
By and large more mucus in their peripheral airways, further
impairing normal lung defenses.

100.  Tenacious secretions [bronchial tree]  mucous plugging of the
smaller airways
 Proteases: continued destruction of connective tissue.
 Edema, and increased vascularity of the basement membrane.
100

101.  Mild/severe, incessant coughing productive of purulent sputum:
– Hall mark symptoms.
 Cough precipitated by multiple stimuli (simple, normal conversation).
 Morning expectoration sputum in largest quantity [throughout the day].
– As much as 100 mL/day
 White to yellow-green, tenacious sputum.
– Many patients complain of a frequent bad taste in their
mouth and of halitosis.
101

102. 102

103.  Primarily: clinical and history.
 Coughing sputum on most days for at least 3 consecutive months each
year for 2 consecutive yrs chronic bronchitis.
 Lab: Gm stain [early morning sputum]
– Non-typeable H. influenzae (45%), S. pneumoniae (20%),
and M. catarrhalis(30%)
 More severe airflow disease [e.g., FEV1<40%], enteric Gm(-) bacilli
(5%): E. coli, Klebsiella sp., Enterobacter sp., and P. aeruginosa
103

104. 1. Simple chronic bronchitis
– Patients with no major risk factors .
– Common associated pathogens: responds to 1st-line antibiotic
2. Complicated chronic bronchitis
– Patients with "simple chronic bronchitis" exacerbation + have
two or more disease-associated risk factors
» FEV1 <50% predicted, Age >64 years, >4 exacerbations/yr,
» Home oxygen use, Underlying cardiac disease, Use of
immunosuppressants, or
» Use of antibiotics for an exacerbation within the past 3 months.
104

105. 3. Severe complicated chronic bronchitis
– Patients with group II symptoms but clinically are much worse.
– FEV1 <35% predicted,
– >4 acute exacerbations per year,
– P. aeruginosa & other MDR suspect
– Need aggressive parenteral antibiotic [combination therapy].
105

106. Goals of therapy
 Reduce the severity of symptoms.
 Ameliorate acute exacerbations
 Achieve prolonged infection-free intervals.
106

107.  Reduce risk/irritants (e.g., smoking, workplace pollution).
 Mist: humidified air/fluid
– Promote the hydration (liquefaction) of tenacious
secretions[allowing for removal]
 Mucolytics aerosols Mucolytics aerosols
– Small reduction in acute exacerbations
– Especially after ICS for COPD
107

108.  Bronchodilators
– Increase mucociliary and cough clearance
– ß2-agonist
» Improve pulmonary function.
» Improve exercise tolerance.
» Reduce the sense of breathlessness.
» SABA
 Therapeutic challenge for patient with air flow
limitation
» LABA: for symptoms control for long duration
– Anticholinergic: Ipratropium/Tiotropium
– Combined with ICS: salmeterol + fluticasone propionate
108

109.  ICS
– If severe disease (FEV1 <50%)
– history of frequent exacerbations.
 Systemic corticosteroid
– For an acute exacerbation
» Reduces treatment failures and hospital stay
 Antibiotics
– For an acute exacerbation
– Cover H. influenzae, S. pneumoniae, M. catarrhalis, and M.
pneumoniae
» For less severe disease: Trimethoprim/sulfamethoxazole
» Moderate to severe disease: Amox-clav/macrolide
Fluoroquinolone (levofloxacin), ceftriaxone, doxycycline
– Depending on Anthonisen criteria
109

110.  Guide antibiotic therapy initiation.
 If 2 of the following 3 criteria start antibiotics:
– Increase in shortness of breath.
– Increase in sputum volume.– Increase in sputum volume.
– Production of purulent sputum.
110

111. 111

112. 112

113. 113

114.  Microbial Pathogens in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease (AECB)
– Haemophilus influenzae 20-30 %
– Streptococcus pneumoniae 10-15 %
– Moraxella catarrhalis 10-15 %– Moraxella catarrhalis 10-15 %
– Rhinovirus 20-25 %
– Parainfluenza virus 5-10 %
– Influenza virus 5-10 %
– Respiratory Syncytial virus 5-10 %
– Coronavirus 5-10 %
114

115. Antibiotic Usual Adult Dose (mg)
Ampicillin 250–500 QID
Amoxicillin 500–875 BID/TID
Amoxicillin/clav. 500–875 BID/TID
Ciprofloxacin 500–750 BID
Levofloxacin 500–750 QD
Moxifloxacin 400 QD
Preferred drugs
Moxifloxacin 400 QD
Doxycycline 100 BID
Minocycline 100 BID
Tetracycline HCl 500 QID
Cotrimoxazole 1 DS BID
Azithromycin 250–500 QD
Erythromycin 500 QID
Clarithromycin 250–500 BID
Cephalexin 500 QID 115
Supplemental drugs

116.  For effectiveness and safety
Clinical signs and symptoms
Laboratory data and diagnostic procedures
116

117.  Bronchiolitis
 Pneumonia in special population
HIV
CancerCancer
Neutropenic
117