Infectious Diseases of The Lungs Hu Suping Pulmonary Department 1st clinical college, Wuhan University Case A 35 y.o. M presents with 2d cough, productive of green-yellow sputum. He complains of fever, chills, and dyspnea PE: T 38.7℃, RR 26/min, BP 110/65 mmHg, HR 125/min Examination of the lungs reveals increased fremitus and dullness at the right posterior base. Crackles and bronchial breath sounds are audible at the right base Gram stain of the sputum reveals grampositive cocci and numerous neutrophils 目的和要求 • 掌握肺炎的临床表现和诊断程序 重点掌握肺炎球菌肺炎的病因、发病机制 和病理、临床表现、诊断、鉴别诊断和防 治。熟悉其它病原体所致肺炎的临床特点 和诊治 • 掌握肺脓肿的临床表现、诊断和鉴别诊断、 治疗原则 • 熟悉支气管扩张症的临床表现、诊断要点 • Overview of pneumonia • Pneumococcal pneumonia • Staphylococcal pneumonia • Mycoplasma pneumonia • Pulmonary mycosis • Lung abscess • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Definition Inflammation of the distal lung terminal airways, alveolar spaces, and interstitium Causes: pathogen, physiochemical factors, allergy, etc • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Pathophysiology of bacterial pneumonia Sources of bacteria Route of inoculation Response Outcome Colonization of Naso/oropharynx Air Microaspiration Inhalation Lung defenses Non-pulmonary infection Bloodstream Contiguous infection Sterile lung Direct extension Pneumonia Usual routes of inoculation • Microaspiration:most bacterial pneumonia, anaerobic pleuropulmonary infections The concentration of aerobic bacteria in upper respiratory tract secretions is about 108 organisms per milliliter, and that of anaerobic bacteria is about 10 times greater, aspiration of even small quantities of oropharyngeal secretions introduces an enormous bacterial challenge to the lungs • Ambient air: Mycobacterium tuberculosis Viruses, including influenza plague and anthrax bacilli Organisms that are present in large numbers in contaminated air in confined spaces, such as Legionella organisms • Bloodstream: Staphylococcal endocarditis, septic emboli • Direct extension: Amebic liver abscess (uncommon) Pathogenesis • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Symptoms and signs depending on the offending pathogen and the state of the host (1)Previously healthy person with pneumococcal pneumonia (typical) a brief prodromal upper respiratory illness fever, chill cough with purulent or “rusty” sputum pleuritic chest pain signs of consolidation (2) Elderly confused patient maybe only deterioration of mental function rhonchi without signs of consolidation (3) Predisposing factors old age, previous pulmonary diseases, smoking history A. a history of alcoholism, seizure disorder, previous stroke, recent dental procedures aspiration pneumonia or lung abscess caused by oral anaerobes and mixed aerobic/anaerobic flora B. a history of intravenous drug use Staphylococcus aureus pneumonia with tricuspid endocarditis (sepsis) C. persons with depressed cell-mediated immunity increased incidence of bacterial, fungal, and tuberculous pneumonia Categories Anatomy: lobar pneumonia; bronchopneumonia; interstitial pneumonia Causes: bacterial pneumonia; viral pneumonia; mycoplasma, chlamydia pneumonia; fungal pneumonia; radiopneumonitis; etc Contaminant source: community-acquired pn(CAP) hospital-acquired pn(HAP) Lobar pneumonia: whole lobe(s) involved Fixed specimen, grey hepatization Lobar pneumonia Bronchopneumonia, patchy involvement → 间质性肺炎 病理切片 间质性肺炎X片 间质性肺炎 CT片肺窗 CAP an acute infection of the pulmonary parenchyma in a patient who is not hospitalized or residing in a long-term-care facility for the 14 days before the onset of illness Common pathogens: S. pneumoniae, H. influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Moraxella catarrhalis HAP or nosocomial pneumonia Colonization of the upper respiratory tract with potentially pathogenic organisms, including gram-negative bacilli and S. aureus, commonly occurs in hospitalized patients The prevalence of colonization is proportional to the duration of hospitalization and the severity of underlying illness Organisms most frequently involved in HAP S. aureus, H. influenzae, K. pneumonia, Pseudomonas species, Escherichia coli, Enterobacter species, Acinetobacter, et al • often resistant to multiple antimicrobials • knowledge of the resistance patterns in a given hospital is essential Chest radiograph Lobar consolidation with small pleural effusion —pneumococcal pneumonia Cavitation — S, aureus, gram-negative bacilli or mixed anaerobic infection, or Mycobacterium tuberculosis Multilobar or segmental consolidation with large pleural effusion — H. influenzae Chest radiograph Upper-lobe air space consolidation, abscess formation, bulging interlobar fissure with the accumulation of large amounts of inflammatory exudate — K. pneumoniae • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Sputum (1) before antimicrobial is instituted (2) a deep cough (3) be transported to the laboratory and processed within 2 hours (4) include Gram’s stain, cytologic evaluation, and aerobic culture Cytologic criteria for sputum culture purulent, <10 squamous cells and >25 leukocytes/low power field Gram’s stain: predominated organism encapsulated gram-positive cocci – Pneumococci Quantitative culture Cp ≥107 cfu/ml definitive pathogen 104< Cp<107cfu/ml Cp≤104cfu/ml undetermined exclusive 肺炎链球菌纯培养的 镜下形态 (革兰染色) 肺炎链球菌肺炎患者 痰标本直接涂片 (革兰染色) 肺炎链球菌在血琼脂 平板上的菌落特征 (18~24h) 肺炎链球菌荚膜形态 (Hiss荚膜染色) 金黄色葡萄球菌纯 培养的镜下形态 (革兰染色) 流感嗜血杆菌纯培养 镜下形态(革兰染色) 军团菌纯培养的镜下 形态(革兰染色) 军团菌在荧光显微镜 军团菌在BCYE琼脂 下的形态(荧光染色) 平板上培养的菌落 特征(3~5d) Limitation (1) difficulties in obtaining a proper specimen pneumococci: extremely fastidious (2) difficulties in interpreting the results overgrowth with less fastidious oral flora false positive diagnoses of GNB and S. aureus prior antimicrobial treatment false negative Cultures of transtracheal aspirates, transthoracic needle aspirates, and bronchoalveolar lavage fluids or protected brush catheter specimens more sensitive and more specific Blood cultures (1) not necessary when the patient does not require admission (2) should be obtained from all hospitalized patients before treatment is initiated • Pleural fluid cultures • Special tests Antigen tests for viral pneumonia (influenza virus, respiratory syncytial virus, adenovirus, and parainfluenza viruese1,2, and 3) Urine antigen assays for pneumococci and legionella pneumoniae: very specific (>90%) but low sensitivity(50%~60%) • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Diagnostic procedure (1) Clinical diagnosis of pneumonia a chest radiograph, WBC count and DC, sputum examination, history and physical examination Differential diagnosis: pulmonary tuberculosis lung cancer lung abscess pulmonary thromboembolism noninfectious diseases Diagnostic procedure (2) Identifying the etiologic pathogen (3) Assessing the severity of infection and need for hospitalization In general, hospitalization is needed if patients have multiple risk factors for a complicated course Risk factors 1. Age over 65 yr 2. Presence of coexisting illnesses such as COPD, bronchiectasis, malignancy, diabetes mellitus, chronic alcohol abuse, malnutrition, cerebrovascular disease, and postsplenectomy 3. Certain physical findings: RR ≥ 30 /min; DBP≤ 60 mmHg or SBP < 90 mmHg; pulse ≥ 125/min; T< 35 ℃ or ≥ 40 ℃; confusion; and extrapulmonary infection 4. Laboratory findings also predict increased morbidity or mortality: a. WBC < 4×109/L or > 30 × 109/L, or N <1 × 109/L b. PaO2< 60 mm Hg or PaCO2 of > 50 mm Hg (room air) c. Serum Cr >1.2 mg/dl or BUN > 20 mg/dl (> 7 mM) d. Chest radiograph findings: multilobar involvement, presence of a cavity, rapid radiographic spreading and the presence of a pleural effusion e. HCT of <30% or Hb < 9 mg/dl f. Sepsis or organ dysfunction as manifested by a metabolic acidosis, or coagulopathy g. Arterial pH < 7.35 Severe pneumonia ICU The major criteria included (1) a need for mechanical ventilation, (2) septic shock The minor criteria included (1) RR ≥ 30 /min; (2) PaO2/FIO2 ≤ 250; (3) multilobar pneumonia; (4) confusion; (5)BUN ≥ 20mg/dL;(6) WBC < 4×109/L;(7) BPC < 10×109/L;(8)T<36℃;(9) systolic BP≤ 90mm Hg Definition of severe CAP: the presence of one major criteria or three minor criteria • Definition of pneumonia • Pathophysiology of pneumonia • Clinical manifestation & Categories • Microbiologic examination • Diagnostic procedure • Treatment and Prevention Determine the most likely causative pathogen • Interpret clinical and epidemiological clues • Obtain appropriate microbiological sampling Determine appropriate breadth of coverage • Estimate the likelihood of antimicrobial resistance • Consider the severity of the patient’s condition Integrate Pharmacologic Considerations • Pharmacokinetics and pharmacodynamics • Interactions and toxicity Narrow to directed therapy • Interpret microbiological findings • Assess clinical response Determine the likely pathogen • Clinical presentation • Clinical course • Acute vs. sub-acute vs. chronic (consider TB, fungus) • Sputum characteristics • Amount, color, bloody, odor • Extrapulmonary features • Body aches, gastrointestinal complaints (suggests Legionella) Determine the likely pathogen • Epidemiologic Clues • Geography • Endemic mycoses (e.g. histoplasmosis), travel • Contacts and exposures • Comorbidity • Alcoholism, diabetes, COPD • Community epidemiology • Seasonal illness, clusters Determine breadth of coverage • Physiologic Reserve • Severely ill patients • Consequences of inappropriate therapy may be dire • Usually provide more broad coverage initially • Mildly ill patients • Will tolerate even a bad choice of therapy • Coverage could be broadened if no improvement Determine breadth of coverage • Likelihood of resistance • Highly variable between community- versus healthcare-associated pneumonia • Clinicians require ready access to information about national, regional, local and institutional resistance trends CTX ERY LEV PCN VAN S. pneumoniae 100% 70% 96% 67% 100% Duration of therapy • For bacteria, usually treat for 10- 14 days • Less therapy may be sufficient • When hospitalized, usually begin IV therapy • Treat longer for abscess or cavitary disease • For fungi and mycobacteria, treatment duration is measured in months Response to therapy • Fever can last for 2–4 d, with defervescence occurring most rapidly with S. pneumoniae infection, and slower with other etiologies • Leukocytosis usually resolves by Day 4 • Physical findings (crackles) persist beyond 7 d in 20 ~ 40% of patients Three groups according to clinical response to therapy (1) patients with early clinical response be considered for rapid switch to oral therapy, followed by prompt hospital discharge (2) patients with lack of clinical response, which should be defined at Day 3 of hospitalization (3) patients with clinical deterioration, which can occur as early as after 24 – 48 h of therapy Patients in the second and third categories need an evaluation of host and pathogen factors, along with a reevaluation of the initial diagnosis and a search for complications of pneumonia Because of the natural course of treatment response, antibiotic therapy should not be changed within the first 72 h, unless there is marked clinical deterioration or if bacteriologic data necessitate a change The common causes for clinical deterioration • Inadequate Antimicrobial Selection • Unusual Pathogens • Complications of Pneumonia • Noninfectious Illness Prevention pneumococcal and influenza vaccine: safe and effective • Pneumococcal vaccine The vaccine contains the purified capsular polysaccharide from the 23 serotypes that cause 85–90% of the invasive pneumococcal infections in adults and children Effectiveness ranged 56 ~ 81% The vaccine in its current form leads to an antibody response that declines over 5–10 yr Recommendations for use • All patients aged 65 yr or greater • Persons age ≤ 64 yr if they have chronic illnesses or if they are living in special environments or social settings • Immunosuppressed patients: HIV, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, or nephrotic syndrome, and immunosuppressive therapy (including long-term steroids). If immunosuppressive therapy is being contemplated, vaccination should be given at least 2 wk before, if possible Influenza vaccine the current vaccine contains three strains of virus: an influenza A strain (H3N2), an influenza A strain (H1N1), and an influenza B strain is modified annually to reflect the anticipated strains in the upcoming season Recommendations for use • Those at increased risk for influenza complications • Those who can transmit influenza to high-risk patients • Those who wishes to reduce the chance of becoming infected with influenza Since the relevant viral strain changes annually, revaccination is needed yearly, and should be given from the beginning of September through mid-November