Approach to

Respiratory
Tract Infection
IKA TRISNAWATI

Pulmonology Department/
Internal Medicine
Dr. Sardjito Hospital
Yogyakarta
 INTRODUCTION
L
O Lower respiratory tract infection:
W describes a range of symptom and signs, varying in
E severity from non pneumonic in the healthy people
R through to pneumonia or life threatening
exacerbations in patient with severe disabling
R chronic obstructive pulmonary disease (COPD).
E
S
Common symptom:
P
1. Cough
T 2. Sputum production
R 3. Breathlessness
A 4. Wheeze
C 5. Chest pain
T 6. Fever
7. Sore throat
I 8. Coryza
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F
 ANATOMY
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 ANATOMY
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TOP:
Defenses of the
Lungs against
Pathogens

RIGHT:
Alveolar macrophage
 PATOFISIOLOGI
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 PATOFISIOLOGI
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 DISEASES
L
O 1. ACUTE INFECTIONS
W
E a. Bronchitis
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b. Pneumonia
R • Typical
E
S • Atypical
P
• Chronic
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A 2. CHRONIC INFECTIONS
C
T a. Tuberculosis
I b. Cystic fibrosis
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 BRONCHITIS

Bronchitis is an
inflammation of the
lining of the bronchial
tubes, the airways that
connect the trachea to
the windpipe.

Structure of the It may be caused by

bronchi
viral, bacterial or
environmental factors.

Slide 002
 ACUTE BRONCHITIS

• Among the two types of bronchitis, acute

bronchitis is more common and usually is
caused by a viral agents.

• Bacterial etiologic agent: Mycoplasma

pneumoniae
– Secondary bacterial infection of S.
pneumoniae and H. influenzae may play a
role in pathogenesis
 Etiologic Agent

• Mycoplasma pneumoniae
• 0.2 µm diameter.
• Lacks cell wall
• Slow growth
• Aerobic
• Fried egg appearance
 Pathogenesis

Mode of entry Adherence Effects on the lower

respiratory system

Enters lower •Attach to specific •Cause ciliated cells

respiratory tract receptors in to slough off
with inspired air or respiratory
by aerosol epithelium •Causes
inhalation inflammatory
response that
thickens bronchial
tube and alveoli
 CHRONIC BRONCHITIS

• Chronic bronchitis is a cough that persists for

two to three months each year for at least two
years. Smoking is the most common cause of
chronic bronchitis.
 CHRONIC BRONCHITIS

• Nonencapsulated strains of H. influenzae, S.

pneumoniae and Moraxella catarrhalis are
frequently cultured in bronchi of patients,
although it is difficult to incriminate the cause of
infection due to chronic colonization of the
bronchi.
 CHRONIC BRONCHITIS

The lines that leave the right hilum horizontally show irregular borders
because of chronic inflammation.
 Pneumonia
ATS/IDSA Guidelines Definitions

• Community-acquired pneumonia (CAP) is an acute

infection of the pulmonary parenchyma in an individual
who is not hospitalized or residing in a long term care
facility before the onset of symptoms.

• HAP( Hospital Acquired Pneumonia) ; occurs 48

hours or more after admission

• VAP ( Ventilator Associated Pneumonia) ; pneumonia

that arises more than 48-72 hours after endotracheal
intubation
Pneumonia Severity Index
CURB Index
 Pneumonia
Difference in clinical picture
between typical & atypical pneumonia
Feature Typical pneumonia Atypical pneumonia
Onset Sudden Gradual
Rigors Single chill “Chilliness”
Cough Productive Nonproductive
Sputum Purulent (bloody) Mucoid
Temperature 103-1040 F <1030 F
Pleurisy Frequent Rare
Gram stain (sputum) Neutrophils Mononuclear cells
Chest Xray Defined density Non-defined density
 Types of Pneumonia
(according to affected site)

• Lobar pneumonia
– in one distinct lobe of the lung
– PMN exudate in response to infection
– clots in alveoli thus solidifying them
– One lobe in complete consolidation
– Usual causative agents:
• Streptococcus pneumoniae
• Klebsiella pneumoniae
Lobar pneumonia
(Klebsiella pneumoniae)
 Types of Pneumonia
(according to affected site)

• Bronchopneumonia
– Diffuse, patchy consolidation throughout both lungs
– Goes through the bronchioles and bronchi, enabling
its spread to both lungs
– Common in hospital-acquired pneumonias
– Etiologic agents:
• S. aureus
• K. pneumoniae
• E. coli
• P. aeruginosa
Bronchopneumonia
 Types of Pneumonia
(according to affected site)

• Interstitial pneumonia
– Invades lung interstitium
– Usual in viral infections
– Sometimes can be caused by Mycoplasma
pneumoniae
– More often caused by agents of atypical
pneumonia
Interstitial Pneumonia
 TYPICAL PNEUMONIA

Streptococcal Pneumonia

• Causative agent: Streptococcus pneumoniae

– Normal inhabitant of the upper respiratory
tract
– Usually causes bronchopneumonia in infants,
young children and aged adults and lobar
pneumonia in younger adults
 Signs and Symptoms

• Acute or subacute onset of fever, cough with or

without sputum production

• Other common symptoms: rigor, sweats, chills,

chest discomfort, pleurisy, fatigue, anorexia,
headache, and abdominal pain
 Diagnosis

• Gram staining – gram positive cocci in chains

• Lung fluid sample
• XRay
• Sputum test: presence of blood and sputum
color
• Blood test: white blood cell count, detection of
antibodies
Haemophilus influenzae Pneumonia

 Etiological agent:
Haemophilus influenzae
Classified into 2 broad categories:
• nontypeable (noncapsulated) – common cause
pneumonia
• typeable (encapsulated)

Has 6 serotypes (based of characteristics of

the capsule): a to f.
Serotype B occasionally causes pneumonia
Haemophilus influenzae Pneumonia

 Signs and Symptoms:

– rapid or difficult breathing
– Cough
– Fever
– Chills
– loss of appetite
 Haemophilus
influenzae

Diagnosis:
non-motile gram-
negative
coccobacilli
 N
• Etiological agents: P
o
(arranged according to frequency) n
s
a. Klebsiella pneumoniae e
b. Staphylococcus aureus
o
u
c. Pseudomonas aeruginosa c
m
d. Escherichia coli o
o
e. Serratia marcescens m
f. Proteus mirabilis n
i
g. Acinetobacter baumannii i
a
a
l
 N
K pP
• Signs and Symptoms: o p
l nn
– sudden onset, prostration (exhaustion) s n
e ee
– high fever, chills, flu-like symptoms e
bo u
– Hemoptysis (coughing up blood)
uu
sc m
– Pleuritic chest pain and dyspnea mm
io o
(difficult respiration) o o
emn
n n
li i
i i
la a
a
a ea
l
 Chest radiography frequently demonstrates cavity formation and
swelling of the affected lobe caused by K. pneumoniae, which causes bulging of the
interlobar fissures.
 ATYPICAL PNEUMONIA

Atypical pneumonia is a pneumonia not

caused by one of the more traditional
pathogens. It can be caused by a variety of
microorganisms.

When developed independently from another

disease it is called Primary Atypical Pneumonia
(PAP)
 Mycoplasmal Pneumonia

• Mycoplasma
pneumoniae
– has a plasma
membrane but no
cell wall
– aerobic
– Motile and slender
– measuring 0.1 by
2μm
 Signs and Symptoms

• Initial symptom
– sore throat in many cases and hoarseness may occur
within a few days
• On physical examination
– rales (abnormal rattle or crackling sound heard in a
stethoscope during breathing) are often the only
abnormality detected
• fever
• non-productive cough
• Headache
• Legionella pneumophila L
– rod-shaped, gram-negative e
– Flagellated g
– non-sporulating i D
– Aerobic o i
– non-fermentative n s
– produces beta-lactamase n e
a a
i s
r e
e
’
s
• Typically begins with headaches S
S
• Chest pains i
• Fever y
g
• Mental status change m
n
• Chills p
• Dry cough
s
t
• Sputum sometimes streaked with
o
blood a
• Diarrhea m
n
s
d
 L
e
g
i D
o i
n s
n e
a a
i s
r e
e
’
s
Progression of Legionnaire’s disease in an HIV+ patient.
 CAP Empiric therapy
IDSA 2000 ATS 2001
Out patient Out patient
Macrolide or doxycycline or Without cardiopulmonary disease
Flouroquinolone or modifying factor :
 Macrolide or doxycycline

With cardiopulmonary disease or

modifying factors :
ß lactam : high dose
amoxicillin,
amoxycillin/clavulanate, oral
cefpodoxim, oral cefuroxim,
parenteral ceftriaxon followed
by oral cefpodoxime) plus
macrolide or doxycycline or
anti pneumococcal
fluoroquinolone alone.
 CAP Empiric therapy
General ward
3 G cephalosporin + macrolide or
ß-lactam / Betalactamase
inhibitor + macrolide or
fluoroquinoline alone
General ward
 With cardiopulmonary disease
or modifying factor : ß-lactam iv
(cefotaxim, ceftriaxon,
amoxicillin/sulbactam, high
dose ampicillin) plus iv or oral
macrolide or doxycicline or iv
anti pneumococcal
fluoroquinolone alone.
 Without cardiopulmonary
disease or modifying factors : iv
azithromycin alone
If allergic : doxycycline and ß-
lactam
OR oral anti pneumococcal
fluoroquinalone alone
 CAP Empiric therapy

ICU ICU
3 G or 4 G - No risk for pseudomonas Aeroginosa
Cephalosporin or β-  iv β-lactam (cefotaxim, ceftriaxone) plus
lactam / β laktamase either iv macrolide (azithromycin) or iv
inhibitor + fluoroquinolone
fluoroquinolone or - Risk for Pseudomonas Aeroginosa
macroline  iv anti pseudomonas β-lactam (cefepim,
imipinem, meropenem, piperazilin /
tazobactam) plus iv anti pseudomonas
quinolone (ciprofloxacin)
OR
iv anti pseudomonas β-lactam (see above) plus
iv aminoglycosile plus either iv macrolide
(azithromycin) or iv non pseudomonas
fluoroquinolone