Respiratory Tract Infections

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Respiratory Tract Infections by Mind Map: Respiratory Tract  Infections

1. 2. Respiratory tract Infections- Types

1.1. Viral

1.1.1. Common Cold

1.1.1.1. Mainly viruses (Rhinovirus)

1.1.2. Bronchiolitis/Croup

1.1.2.1. Viral

1.1.2.1.1. (RSV) Respiratory Scycntial virus

1.2. Bacterial

1.2.1. Strep. pneumoniae

1.2.2. H. influenzae

1.2.3. S. aureus

1.2.4. Streptococcus pyogenes

1.2.5. Corynebacteria diptheriae (DTaP)

1.2.6. B.pertussis

1.3. Fungal

1.4. Parasitic

1.5. Middle Ear /Sinuses

1.5.1. Strep. pneumoniae

1.5.2. H. influenzae

1.5.3. S. aureus

1.5.4. Common Cold

1.5.4.1. Mainly viruses (Rhinovirus)

1.5.5. Otitis media (Ear infection)

1.6. Throat/ Pharynx

1.6.1. Streptococcus pyogenes

1.6.2. Corynebacteria diptheriae (DTaP)

1.6.3. Viral

1.6.4. Laryngitis

1.6.5. Tonsillitis

1.7. Trachea/bronchi

1.7.1. Epiglottitis

1.7.1.1. H. influenzae

1.7.1.2. Viral

1.7.2. Tracheitis

1.7.2.1. B.pertussis

1.7.2.2. Viral

1.7.3. Bronchiolitis/Croup

1.7.3.1. Viral

1.7.3.1.1. (RSV) Respiratory Scycntial virus

1.8. Lungs

1.8.1. High Mortality

1.8.2. Pneumonia (Bacterial, Viral)

1.8.3. Tuberculosis

1.8.4. Lung abscess

1.8.5. Empyema

2. Disease of the Ancients

3. 1. Host Defences

3.1. Anatomy of Respiratory Tract

3.1.1. Upper RT

3.1.2. Lower RT

3.1.2.1. (Below Larynx)

3.1.3. http://www2.bc.cc.ca.us/bio16/images/lrt_anat.jpg

3.1.4. Notes

3.1.4.1. Many Toxins and particle (sizes)

3.1.4.2. Balancing act

3.1.4.3. Very Close contact with environment

3.2. Defences of Respiratory Tract

3.2.1. Specialised Epithelium

3.2.1.1. Mucus and Cilia

3.2.1.1.1. Mucociliary clearance

3.2.1.2. Cell based anti-microbial peptides

3.2.1.2.1. Lactoferrin

3.2.1.2.2. Defensins

3.2.1.2.3. Collectins

3.2.1.2.4. Lysozyme

3.2.2. Angulation

3.2.3. Macrophages

3.2.4. Neutrophils

3.2.5. Surfactant

3.2.6. Opsonins

3.2.6.1. IgA (upper)

3.2.6.2. IgG (lower) , (IgM , recent )

3.2.6.3. Complement

3.2.6.4. Surfactants (Collectins, SPA-SPD)

3.2.6.5. PRR activation

3.2.6.6. enhanced Phagocytosis

4. 3. Lower Respiratory Tract infections- Pneumonia

4.1. Largest Single infective cause of death in developed countries

4.1.1. (4th in Ireland)

4.2. Age: Increased incidence in < 2 and >65

4.3. Community acquired pneumonia (CAP)

4.3.1. 3% Mortality

4.4. Hospital admission

4.4.1. 10 % Mortality

4.5. ITU Admission /Ventilation

4.5.1. >50% Mortality

5. 4. Pneumonia- common presentations/causes

5.1. Lobar Pneumonia

5.1.1. Consolidation in one Lobe/segment

5.1.2. S. pneumoniae

5.1.2.1. 75 % Pneumonia cases, Also M.O.P.S

5.1.2.1.1. M.O.P.S

5.1.2.2. Normal Upper RT commensal ( 30% Adults , 70% Infants )

5.1.2.2.1. Pneumococcal carriage

5.1.2.3. Gram Positive, diplococcus, Alpha hemolytic (H2O2)

5.1.2.4. Optochin sensitive*

5.1.2.5. Bile soluble (lysed)

5.1.2.6. Non-Groupable

5.1.2.7. Polysaccharide capsule

5.1.2.7.1. over 91 serotypes, different arrangement of sugars)

5.1.2.7.2. Negative charge reduces ability of complement , antibody to enhance phagocytosis

5.1.2.8. Virulence factors:

5.1.2.8.1. Encapsulated Bacteria

5.1.2.8.2. Hydrogen peroxide

5.1.2.8.3. IgA protease- cleaves IgA

5.1.2.8.4. Pneumolysin: Pore forming exotoxin

5.1.2.8.5. Transformation- Can take up DNA from environment (competence)

5.1.2.8.6. Can alter Penicillin resistance (PBP)

5.1.3. (Legionella, Klebsiella)

5.2. Bronchopneumonia

5.2.1. Bilateral scattered Consolidation

5.2.2. S. pneumoniae

5.2.3. S. aureus

5.2.4. H. influenzae

5.2.5. Enterobacteria

5.2.6. Klebsiella

5.3. Atypical Pneumonia

5.3.1. Cough no sputum

5.3.1.1. Persistent Cough, diffuse interstitial infiltrate

5.3.1.2. Fever, headache, myalgia,

5.3.2. Patchy consolidation

5.3.3. Bronchiolar Infiltration

5.3.4. CXR changes, clinical signs

5.3.5. Patients usually < 40

5.3.6. Bacteria

5.3.6.1. Mycoplasma pneumoniae

5.3.6.1.1. NO cell wall

5.3.6.1.2. “Walking” Pneumonia

5.3.6.1.3. Cold agglutinins IgM- RBC

5.3.6.2. Chlamydophila pneumoniae

5.3.6.3. Chlamydophila psittaci

5.3.6.4. Legioneilla spp.

5.3.6.5. Coxiella burnetti

5.3.7. Viral

5.3.7.1. Influenza

5.3.7.2. RSV

5.3.7.3. Parainfluenza

5.3.7.4. Adenovirus

5.3.7.5. Human metapneumovirus

5.3.7.6. Corona virus (SARS)

5.3.7.7. CMV (HIV/IC)

5.3.8. Diagnosis identification by Serology or Molecular techniques

5.4. S. pneumoniae

5.4.1. 75 % Pneumonia cases, Also M.O.P.S

5.4.1.1. M.O.P.S

5.4.1.1.1. Meningitis

5.4.1.1.2. Otitis Media

5.4.1.1.3. Pneumonia

5.4.1.1.4. Sinusitis

5.4.1.1.5. MOPS are Most Optochin Sensitive

5.4.2. Normal Upper RT commensal ( 30% Adults , 70% Infants )

5.4.2.1. Pneumococcal carriage

5.4.3. Gram Positive, diplococcus, Alpha hemolytic (H2O2)

5.4.4. Optochin sensitive*

5.4.5. Bile soluble (lysed)

5.4.6. Non-Groupable

5.4.7. Polysaccharide capsule

5.4.7.1. over 91 serotypes, different arrangement of sugars)

5.4.7.2. Negative charge reduces ability of complement , antibody to enhance phagocytosis

5.4.8. Virulence factors:

5.4.8.1. Encapsulated Bacteria

5.4.8.1.1. Attach to epithelia

5.4.8.1.2. Serve as anti-phagocytic strategy

5.4.8.2. Hydrogen peroxide

5.4.8.3. IgA protease- cleaves IgA

5.4.8.4. Pneumolysin: Pore forming exotoxin

5.4.8.5. Transformation- Can take up DNA from environment (competence)

5.4.8.6. Can alter Penicillin resistance (PBP)

5.5. Other Bacterial causes

5.5.1. Haemophilus influenzae

5.5.1.1. prior lung disease

5.5.1.1.1. Endogenous/Flora

5.5.2. Staphylocccocus aureus

5.5.2.1. after Influenza

5.5.2.1.1. Endogenous/Flora

5.5.3. Mycoplasma pneumoniae

5.5.3.1. Young people <30

5.5.3.1.1. Aerosol

5.5.4. Chlamydophila pneumoniae

5.5.4.1. Young people <30

5.5.4.1.1. Aerosol

5.5.5. Chlamydophila psittaci

5.5.5.1. Psittacosis

5.5.5.1.1. Animal (bird) contact

5.5.6. Coxiella burnetti

5.5.6.1. Q fever

5.5.6.1.1. Unpasteurised Dairy

5.5.7. Legioneilla spp.

5.5.7.1. Environmental aerosols

5.5.7.1.1. Air Conditioning

5.5.8. Mycobacterium tuberculosis

5.5.8.1. Endemic areas

5.5.8.1.1. Aerosol

5.6. Pneumonia associated complications

5.6.1. 3-5 % Pleural Effusion

5.6.1.1. Clear fluid = +/- pus cells

5.6.2. 1% Empyema thoracis

5.6.2.1. Pus in pleural space

5.6.3. Lung abscess

5.6.3.1. Suppuration + destruction of lung parenchyma

5.6.3.2. Single (aspiration) anaerobes, Pseudomonas

5.6.3.3. Multiple (metastatic) , S. aureus.

5.7. Hospital acquired Pneumonia

5.7.1. 15 % of Hospital acquired infections

5.7.2. 20-50% Mortality

5.7.3. IC patients

5.7.4. Anaesthesia, Intubation, Ventilation predispose to infection

5.7.4.1. Mucocilary escalator compromised

5.7.5. Often Gram negatives, resistant organisms

5.7.5.1. Pseudomonas aeruginosa , Enterobacter

5.8. Specific associations

5.8.1. Influenza

5.8.1.1. Post-influenzal bacterial infection

5.8.1.1.1. S. pneumoniae, S. aureus, S. pyogenes

5.8.2. Pre-existing Respiratory disease (COPD)

5.8.2.1. H. influenzae and resistant Gram negatives

5.8.3. Aspiration Pneumonia ( & Alcoholics)

5.8.3.1. Anaerobes, Klebsiella and oral Streptococci

6. 5. Specimen & Lab procedures

6.1. Sputum

6.1.1. Culture , Blood agar, Flora contamination

6.2. Blood Culture

6.2.1. pre antibiotic, (15% pneumococcal pnuemonia +ve )

6.3. Non Culture

6.3.1. Blood PCR ( DNA)

6.3.2. Urine Antigen detection*/Cell Wall polysaccharide C

6.4. Chest X Ray

6.5. Invasive Sampling

6.5.1. Nasopharyngeal aspirate

6.5.1.1. infuse saline, aspirate, cilitaed cells (viral)

6.5.2. Bronchoscopic lavage

6.5.3. Transtracheal aspirate

6.5.3.1. percutaneous needle aspiration

6.5.4. open lung biopsy

6.6. Microscopy Stains

6.6.1. Acid Fast/ Ziehl-Neelsen (TB)

6.6.2. Gram

6.6.3. Special Stains

6.6.3.1. Histology/ Immunofluorescent

6.6.3.1.1. Pneumocystis jiroveci

6.6.3.1.2. Legionella

6.6.3.1.3. Viruses

6.7. Antibiotic sensitivity testing still needed

6.8. Growth can be an issue

7. 6.Therapy- Antimicrobial & Vaccination

7.1. Treatment – Blind therapy of CAP

7.1.1. Previously Healthy <60 Years of age - S. pneumoniae

7.1.1.1. = Amoxicllin

7.1.2. Requires hospital admission , possible Intensive care

7.1.2.1. S. pneumoniae, - L.pneumophila

7.1.2.2. = Amoxicllin + Erythromycin/Clarithromycin

7.1.3. Community acquired pneumonia

7.1.4. CURB65 & CAP

7.1.4.1. Confusion

7.1.4.2. Urea> 7mmol/L

7.1.4.3. Respiratory rate >= 30/min

7.1.4.4. Blood pressure low: Systolic <90mm Hg or Diastolic ≤ 60 mm Hg

7.1.4.5. Age  65 years

7.1.4.6. Score of 1 for each

7.1.4.7. CURB-65 Score

7.1.4.7.1. 0

7.1.4.7.2. 1

7.1.4.7.3. 2

7.1.4.7.4. 3-5

7.2. Specific Therapy

7.2.1. Atypical

7.2.1.1. Macrolide, Azithromcyin, Erythromycin/Tetracycline

7.2.1.2. (no cell wall)

7.2.1.3. Bacteria

7.2.1.3.1. Mycoplasma pneumoniae

7.2.1.3.2. Chlamydophila pneumoniae

7.2.1.3.3. Chlamydophila psittaci

7.2.1.3.4. Legioneilla spp.

7.2.1.3.5. Coxiella burnetti

7.2.2. S. aureus

7.2.2.1. MRSA

7.2.2.1.1. Vancomycin, linezolid

7.2.2.2. Flucloaxcillin + fusidic acid

7.2.3. Pseudomonas aeruginosa

7.2.3.1. Aminoglycoside + beta-lactam

7.3. Vaccines against Respiratory disease

7.3.1. Influenza: Killed virus (live attenuated also but less utilised)

7.3.2. Pneumococcal vaccine

7.3.2.1. Pneumococcal conjugated vaccine (PCV)- PCV-7/13

7.3.2.1.1. Prevnar 13 strains

7.3.2.2. Pneumococcal polysaccharide (PPSV)- PPSV23

7.3.2.3. Increasingly important due to resistance (PBP)

7.3.2.4. Herd immunity increasing disease causing serotype not in vaccine

8. Asthma- Lung Flora