Bronchitis-Pneumonia

‫ד"ר ניבה אזוז‬

4 Questions:

(a) Bronchitis or Pneumonia?

(b) Is a diagnostic workup indicated?
(c) Are antibiotics indicated
(d) Is hospital admission necessary?
Bronchitis or Pneumonia?
 Symptoms are similar

may all be present in both entities:

• Cough (productive or nonproductive),
• Fever,
• chest discomfort,
• and fatigue.
 Classic symptoms
• “Classic” pneumococcal pneumonia:
o sudden chill ->
o fever, pleuritic pain,
o productive cough (rusty sputum).
• The “atypical pneumonia” ( Mycoplasma or
Chlamydia):
o sore throat and headache ->
o nonproductive cough and dyspnea.
 Signs
• Pleuritis or dyspnea - tends to suggest
pneumonia.

• Evidence of consolidation is indicative of

pneumonia but is present only in few
outpatients.

• Findings may be Misleading if underlying

lung disease.
 Even CXR is problematic
1.In bronchitis - Chronic
lung disease can
simulate new infiltrates
2.In pneumonia
-Dehydration can
minimize radiographic
abnormalities
Is a diagnostic workup indicated?
 Diagnosis
• URI – predominant nasal discharge, sore throat, or ear
pain.
• LRI – predominant cough.
• But Symptoms – are unreliable to differentiate bronchitis
from pneumonia
• Signs - entirely normal vital signs (no tachypnea,
tachycardia, high fever, hypothermia) decreases the
probability of pneumonia in outpatients to less than 1%!
 Workup
• crackles – are not specific – can be in bronchitis
too!
• The classic findings of lung consolidation:
1.dullness to percussion,
• egophony,
• bronchial breath sounds
o are more specific for pneumonia - but found only in 25%
of patients
• Signs with etiologic significance:
• Erythema multiforme - Mycoplasma pneumonia,
• Confusion - Legionella.
 ?CXR – when to order? And Why
• If pneumonia is suspected, PA and lateral CXR is
indicated.
1.to confirm the diagnosis.
– If pleural effusion
o poorer outcome
o thoracentesis should be performed to assess for the
presence of an empyema (Unless the pleural effusion
is minimal)
• Additional labs are not necessary (unless
hospitalized).
Is hospital admission necessary?
PORT guidelines (NEJM 1997;336:243)
PORT SCORE > 90 = Hospital

Score < 51: Risk Class I, 0.1-0.4% mortality. Outpatient

Score 51-70: Risk Class II, 0.6-0.7% mortality. Outpatient

-------------------------------------------------------------------------------
Score 71-90: Risk Class III, 0.9-2.8% mortality. Outpatient or
inpatient
-------------------------------------------------------------------------------
Score 91-131: Risk Class IV, >2.8% mortality. Inpatient
Score > 130: Risk Class V, >>2.8% mortality. Inpatient
CURB 65 prediction rule

Confusion,
Uremia (blood urea nitrogen >20 mg/dL),
Respiratory rate greater than 30 per minute,
Blood pressure less than 90 mm Hg systolic or 60 mm Hg diastolic,
and age 65 years or older.
 
0 - 1  risk factors - mortality low (0.7% and 2.1%, respectively).
 
These rules perform poorly in extreme or unusual
circumstances. (eg: 20yr bp low, tachycardia, hypoxia).
Are antibiotics indicated
 Antibiotic Therapy
• Pneumonia –
o Empiric Antibiotic Tx initially
o treatment for 10 - 14 days.
• Acute bronchitis - is usually of viral origin -
empiric use of antibiotics does not improve
outcomes!!!
Rule: Acute Bronchitis – No Abx!
• Most cases are viral
• Spontaneous resolution 1-2 weeks with or w/o Tx
• Overprescription of antibiotics in this population
is a major source of resistance.
• Also if Abx - X2 risk for an individual of later
contracting a resistant infection!
 :Exception to the rule
1.antibiotics are indicated for COPD patients with
acute exacerbation:
2.severe underlying disease (eg, congestive heart
failure)
3.patients who are symptomatic for more than 10 days
1.Mycoplasma infection becomes a greater possibility.
2.Pertussis “ “ “
If an antibiotic is to be used, a macrolide is a
reasonable first choice!
because the macrolides are active against mycoplasmal
and chlamydial and B pertussis.
 :Bordetella pertussis
• Young adults (childhood immunity wanes after 15-20 yrs )
• 25% of patients with bronchitis lasting 2 weeks or more.
• three phases of disease:
o catarrhal phase - rhinorrhea, low-grade fever, and mild congestion
-1 to 2 weeks.
o paroxysmal phase severe paroxysms of nonproductive cough,
with 10-30 coughs in a row. 2 to 4 weeks
 Posttussive syncope and vomiting.
 the characteristic “whoop” is absent in adults
o convalescent phase – symptoms gradually resolve during the next
1 to 3 months.
• A single elevated pertussis serology has been
advocated as a rapid means of diagnosing pertussis.
 Pertusis Tx
• Antibiotics are advocated if the first 4 weeks of
illness (still infective).
• The preferred drugs are the following:
• Erythromycin: 500mg X4/d - 14 days
• Azithromycin: 500 mg day 1- then 250 mg for 4
additional days
• Clarithromycin: 500mgX 2/d - 7 days
• Alternative: Resprim (800/160) X 2/d - 14 days
• ‫צריך להנתן לכל בני הבית‬ ‫טיפול מניעתי באותה תרופה ומינון‬ 
o TMP-SMZ- not useful in mycoplasmal infections
o Doxycycline – not useful for Pertussis
- Amoxicillin – not so useful for pertusis or mycoplasma
 ‫טיפול בברונכיטיס – לפי המלצות‬
‫בכללית‬
‫‪ .1‬אם יש חום מעל ‪ 38.5‬או ממצאים ממוקמים‬
‫בריאות – לשלוח לצילום לשלול דלקת ריאות‬
‫‪ .2‬בד"כ – טיפול סימפטומטי בלבד‪.‬‬
‫‪ .3‬נשקול אנטיביוטיקה רק אם‪:‬‬
‫‪ .1‬אין שיפור לאחר ‪ 3-5‬ימים או‬
‫‪ .2‬יש מחלות לב‪ COPD ,‬או סכרת‬
‫‪ .3‬חום מעל ‪ 38.5‬או כיח מוגלתי‬
‫טיפול אנטיביוטי בדלקת ריאות‬
‫(מפחית תמותה וסיבוכים)‬
Tx for persons less than 60 years old:
• S. pneumoniae, Mycoplasma, Chlamydia,Legionella.
Covered with:
 
• Erythromycin 500 mg X 4/d = first-line. or
• Azithromycin 500 mg on day 1, followed by 250 mg daily for 4 days,
• or Clarithromycin 500 mg twice daily for 10 days
 
Second-line:
• doxycycline (100 mg twice daily).
 
• Respiratory fluoroquinolones: levofloxacin (TAVANIC
500 mg), moxifloxacin (MEGAXIN 400 mg) = X 1/day.
 
• Older quinolones (e.g., ciprofloxacin) = less activity
against the pneumoco = not recommended.
•  
Penicillins /cephalosporins - not cover atypical pneum.
Older Adults (>60) and Patients with Comorbidities:
. S.pneumoniae remains the most common BUT:
•  H. influenzae, M. catarrhalis, and other gram-negative
are possibilities. 
•  New Evidence: Mycoplasma and Chlamydia
still important!
• also for patients with recent (within 3 months) exposure
to antibiotics (pneumococal resistance).
 
• first-line: is
• a 2nd-generation macrolide (azithromycin or clarithromycin)
PLUS a  high-dose β-lactam:
o amoxicillin, 1 g X 3/d, or
o  amoxicillin-clavulanate, 2 g twice daily.
 
o Alternative a respiratory fluoroquinolone. 
For hospitalized patients:
First-line: 
 3rd-generation cephalosporin (1 g of ceftriaxone
daily) PLUS a second-generation macrolide 
in a dose sufficient for Legionella infection:
 azithromycin 500 mg daily or clarithromycin 500 mg X2/d
 
Provides  coverage for  resistant S. pneumoniae.
 
Therapy narrowed after diagnostic test results: such as
Legionella urinary antigen and blood cultures.
 
The alternative empiric treatment:
• respiratory fluoroquinolone.
concern about emerging resistance.
penicillin resistance of pneumococci
• mutations in penicillin-binding proteins
 
• 30% intermediate resistance ([MIC] of 0.1 to 1.0 µg/mL),
 
• 10% are highly penicillin resistant (MIC >2.0 µg/mL).
 
• These highly resistant are often cross-resistant to
multiple antibiotics, including
trimethoprim/sulfamethoxazole and erythromycin.
 
• Fluoroquinolone resistance has been very low in S.
pneumoniae (<2%); now increasing.
 
•  emphasize the need to vaccinate high-risk patients.
•  more than 85% of resistant organisms are serotypes
contained in the 23-valent vaccine
•  80% by prevnar (year 2000).
Monitoring
•  PORT study: temperature, RR, HR, and BP - reliable
measures of stability.
•  average: “normal” vital signs at 3 days after hospitalization
•  Often: Completely afebrile: 6 days.
 
 
• Repeating CXR at frequent intervals is wasteful.
• particularly true of pneumocc or Legionella - still show an
infiltrate a months later.
 
• However, when worsening or fever not resolving, CXR for 
complications (abscess and empyema)
• unusual or resistant organisms should be considered in these
patients and antibiotic therapy appropriately adjusted.
• More than 50% of patients with pneumonia continue to report
fatigue and cough 1 month after diagnosis
Pneumococcal and Flu Vaccine
pneumococcal vaccine 23 capsular types of pneumococci, which
together account for about 90% of cases.
 
Indications: recovery from CAP, elderly (older than 65 years),  CHF
or COPD/ASTHMA, are immunosuppressed, or have undergone
splenectomy.
 
One-time revaccination after 5 years is recommended for:
immunosuppressed , functional asplenia, and elderly persons who
received the initial vaccination before age 65 years.
 
influenza vaccine -  inactivated virus,
modified each year to include prevalent strains of influenza A and B.
Indications: all patients older than age 50, pregnant women, and the
high-risk groups mentioned previously.
C/I: Hypersensitivity to eggs .
 
**The vaccines may be given at the same time without an increase in
side effects or decrease in immunogenicity.
Pathogens
 Gram-Positive Organisms
• Streptococcus pneumoniae –
o 30% to 50% of all cases of bacterial
pneumonia.
o especially young ambulatory patients
o also acute exacerbations in COPD
Staphylococcus aureus –
o 10% of bacterial pneumonia
o most commonly follows a viral URI (influenza)
o Patients - usually extremely ill.
 Gram-Negative Organisms
H. influenzae
• common cause of bronchitis in COPD
• Bronchitis – untypeable H.Flu
• Pneumonias - especially type B.
• CXR - Bronchopneumonia
• Complications are uncommon – unless
COPD (hypoxia)
 Gram-Negative Organisms
Klebsiella pneumoniae:
• In debilitated patients, especially
alcoholics,
• usually - acute illness;
• Rarely, chronic pneumonitis.
• tissue necrosis -> hemoptysis, Abcess.
• CXR - dense lobar consolidation,
Sputum may appear dark red and
mucoid (“currant jelly” sputum).
Other Gram-Negative- Hospitally
acquires Pneumonias
• Rare in Ambulatory setting
• Patients: Chronic disease or elderly
and frequently have received antibiotic
therapy.
1.Moraxella (Branhamella) catarrhalis.
– Bordetella pertussis.
– Legionnaires' Disease
 :Moraxella (Branhamella) catarrhalis

• flora - oropharynx of normal hosts

• Usually underlying pulmonary disease
• Other risk factors: Diabetes, alcoholism,
malignancy, and steroid use
• mild and sometimes self-limited
• CXR interstitial+/-air space infiltrate.
 :Bordetella pertussis
• Young adults (childhood immunity wanes after 15-20 yrs )
• 25% of patients with bronchitis lasting 2 weeks or more.
• three phases of disease:
o catarrhal phase - rhinorrhea, low-grade fever, and mild congestion
-1 to 2 weeks.
o paroxysmal phase severe paroxysms of nonproductive cough,
with 10-30 coughs in a row. 2 to 4 weeks
 Posttussive syncope and vomiting.
 the characteristic “whoop” is absent in adults
o convalescent phase – symptoms gradually resolve during the next
1 to 3 months.
• A single elevated pertussis serology has been
advocated as a rapid means of diagnosing pertussis.
 Legionnaires' Disease
• in 5%-10% of all community-acquired
pneumonias (upto 30% of severe cases)
• infection is acquired by inhalation of aerosols or
contaminated water.
• Risk factors:cigarette smoking, chronic lung
disease, and immunosuppression.
• Spectrum of clinical illness: from mild URI and
self-limited atypical pneumonia to multifocal
pneumonia and respiratory failure.
Legionnaires' Disease (Cont)
• short prodrome, then acutely high fever, nonproductive
cough, dyspnea,Pleuritic chest pain
• Extrapulmonary findings are uncommon but include:
myocarditis, pericarditis, rhabdomyolysis, and renal
dysfunction.
• Diarrhea or confusion are often seen
• Relative bradycardia
• CXR - interstitial infiltrates or areas of patchy
consolidation with a rapid progression.
• Legionella urinary antigen is very sensitive for disease
caused by L. pneumophila serogroup 1 (about 70% of
all cases) and is easy to obtain.
 Mixed Flora –
Aspiration pneumonias
• Aerobic & anaerobic streptococci,
Bacteroides, and Fusobacterium.
• Risk factors: impaired consciousness
(drugs, anesthesia, alcohol, head trauma)
and diminution of the gag reflex.
• Lung abscess and empyema are fairly
common complications - especially if
therapy is delayed.
 Nonbacterial Organisms
• Mycoplasma pneumoniae
• Chlamydia pneumoniae (TWAR).
• Viruses.
• Psittacosis.
• Q Fever.
• Fungi and Other Opportunistic
Organisms.
 Mycoplasma pneumoniae
• 10% to 25% of community-acquired pneumonia.
• leading cause of the atypical pneumonia and also a
cause of acute bronchitis in healthy adults.
• long incubation period
• begins with headache, sore throat, and malaise, then
progresses to a nonproductive cough.
• Signs - usually un-impressive
o erythema multiforme, is highly correlated with Mycoplasma
infection in the patient with pneumonia.
o Bullous myringitis – not common
• CXR - patchy peribronchial infiltrates
• Lab:
o CBC – normal
o Cold agglutinins in 50%
• Uncommon complications: hemolytic anemia, aseptic
meningitis, Guillain-Barré syndrome, and myopericarditis.
Chlamydia pneumoniae -TWAR
• 10% to 20% of of community-acquired
pneumonia
• Also - acute bronchitis.
• young adults
• The prodrome resembles Mycoplasma
• CXR - less extensive involvement
• usually self-limited;
 Viruses
• the most common cause of acute bronchitis
• more than 80% of all cases!!!
• Viral pneumonia resembles an atypical
pneumonia
• Common: influenza, adeno, RSV,
parainfluenza.
• immunocompromised – CMV
• influenza pneumonia - fever and myalgia,
mild or a fulminant, Bacterial pneumonia
(pneumococcal, staphylococcal) is a
frequent complication.
 Psittacosis
• Chlamydia group
• also responsible for trachoma
• transmitted from parrots or other birds
• Atypical pneumonia
 Q Fever
• Coxiella burnetii
• unique among rickettsial infections in that
pneumonia is prominent,
• no rash is associated
• spread is through inhalation of infected dust
particles rather than by way of the bite of an
insect.
• reside principally in animals; human contact with
cattle, sheep,goats, or infected animal skin or skin
products.
• Clinically –
o atypical pneumonia
o hepatitis occurs in upto 33% of patients.
Fungi & Other Opportunistics
• Immunosuppressed patients - Aspergillus, Candida, or
PCP
• However, some fungal infections may occur in
immunocompetent hosts:
o exposure to spore-containing dusts – histoplasmosis,
coccidioidomycosis
• nonproductive cough, flulike illness,
• liver or splenic enlargement,
• CXR - alveolar infiltrates, sometimes hilar adenopathy;
• fungal pneumonia, is usually self-limited without
treatment except in immunocompromised hosts
‫המלצות שרותי בריאות כללית לטיפול‬
‫בדלקת ריאות‪:‬‬
‫• בחולים עד גיל ‪( 60‬וללא מחלות רקע)‬
‫‪ .1‬רוליד ‪ X 2 150‬ליום – ‪ 10‬ימים‬
‫‪ .2‬אריתרומיצין ‪ X 3-4 500‬ליום – ‪ 10‬ימים‬
‫‪ .3‬דוקסילין ‪ X 2 100‬ליום – ‪ 7‬ימים (אבל לא כ"כ יעיל נגד‬
‫פנאומוקוק וכלמידיה)‬
‫‪ .1‬מעל גיל ‪ 60‬או מחלות רקע כמו מחלת לב‪ ,‬סוכרת‬
‫‪:COPD‬‬
‫‪ .1‬זינת ‪ – X 2 500‬ל ‪ 10‬ימים‬
‫‪ +‬רוליד או אריתרו‬ ‫• אוגמנטין ‪ – X 2 875‬ל ‪ 10‬ימים‬
‫• קווינולונים אנטי‪-‬פנאומוקוקלים – כמו ‪Tavanic‬‬
‫)‪.(levofloxacine‬‬