Pulmonary Infections
C. Richard Finley, Ed.D, PA-CAssociate Professor
Physician Assistant DepartmentCollege of Allied Health & Nursing
Nova Southeastern University
ObjectivesHaving access to lecture notes the attendee
should be able to:Recall the basic pathophysiology involved
with lower respiratory tract infectionsRecall the presenting signs and symptoms
of lower respiratory tract infectionsRecall the essentials of diagnosis and
treatment of lower respiratory tract infections
PneumoniaTuberculosis (TB)Influenza (Flu)Acute Bronchitis
A 44-year-old male presents to your office complaining of a “bad cough” for the past 3-4 weeks. Over the past several days he has developed a low-grade fever, chills, and night sweats. Physical exam is notable for cachexia, hypoxia, and bilateral rales with scant hemoptysis. Which of the following is the most likely diagnosis?
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2. Tuberculosis
3. Acute bronchitis
4. Influenza
5. Lung abscess
Epidemiology Pneumonia is the fourth leading cause
of death among the elderlyespecially when it develops in
connection with a long-term illness Cases of Tuberculosis in the U.S. have
declined since 1992now is being found more often among
foreign-born people age 45 and older
The Flu also can hit the elderly hardest50% of influenza-caused
hospitalizations80% of flu deaths involve elderly
Acute Bronchitis is one of the most common problems seen in clinical practicefrequently follows viral infection
Mechanics of Pulmonary Infections
In as many as half of Pneumonia cases, pathogen remains unknown
Tuberculosis is caused by a bacterium called tubercle bacilli, which can enter the body and remain dormant sometimes for years - until the
body’s immune system weakens for some reason
The Flu is a virus that’s spread “from one lung to another”—by coughing or sneezing
Smokers are at higher risk of getting acute Bronchitis
Symptoms of Pulmonary Infections
Which of the following is a hallmark symptom of bronchitis?
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2. Chills
3. Night sweats
4. Hemoptysis
5. Cough
Pneumonia Fever Cough Congestion In older patients
fever might not be presentconfused or deliriouslose control of basic functions
Tuberculosis
Fever Cough Congestion Night sweats Weight loss Fatigue
Influenza
Fever Chills Headache Muscle aches Sore throat
Runny nose Hot, moist skin Fatigue Dry cough
Acute Bronchitis
Cough is the chief complaint SOB Wheezing
Causes of Pulmonary Infections
Pneumonia Serious illness Smoking Malnutrition Surgery Repeated antibiotic therapy Aspiration due to reduced cough
reflex (food “down the wrong pipe”) The flu
Tuberculosis
Poor nutrition Alcoholism or drug addiction Immune dysfunction
disease, drugs, or aging Homelessness or imprisonment Diabetes, malignancies, chronic
renal failure
Influenza
A variety of chronic medical illnesses
Seasonal local outbreaks or epidemics
Acute Bronchitis
Often attributed to a respiratory tract virus
When purulent sputum is presentthe bacteria that cause
community-acquired pneumonias
A 35-year-old male presents to the clinic with complaints of a sore throat and a “harsh cough with chest congestion” over the past 3-5 days. He relates slight yellowish sputum production. Which of the following would confirm your suspicions?
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1. Throat culture
2. Nasal swab
3. Sputum culture
4. Chest x-ray
5. Lung biopsy
Diagnosing Pulmonary Infections
Pneumonia
Chest x-ray Blood test
Tuberculosis
Sputum Skin test to determine the presence of
“viable organisms” Chest x-ray Biopsy and examination of lung tissue Urine sample
three consecutive days
Influenza
Confirmation of an outbreak Nasal or throat swab Nasal wash Sputum exam
Acute Bronchitis
History Chest x-ray
Treating Pulmonary Infections
Your 30-year-old male patient is a household member of a patient being treated for active TB. Which of the following is an acceptable treatment regimen?
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2 months3. High-dose amoxicillin-clavulanate, 2 g
p.o. BID for 1 week4. Isoniazid (INH), once daily for 6 months5. Observation, with monthly chest x-rays
for 3 months
Pneumonia
Antimicrobials Respiratory care Drainage of fluid from the lungs and
chest cavity
Tuberculosis Isoniazid (INH) for six to 12 months Fully developed disease
A regimen of INH and 3 other for two monthsRifampin (Rifadin)Ethambutol (Myambutol)Pyrazinamide
Selected antituberculosis drugs (depending on test results) for four more months
Influenza Bedrest – aspirin – chicken soup (fluids) Oseltamivir (Tamiflu) and zanamivir
(Relenza), given within 48 hrs of symptomsTypes A & B
Amantadine (Symmetrel) and rimantadine (Flumadine)Type A CDC recommendations - resistance
Acute Bronchitis 70% to 90% of patients are treated with
antibioticstrials demonstrate little clinical benefit
High fever, chills, respiratory distress, underlying pulmonary or immunosuppressive disorders, or signs of parenchymal infectionshould be evaluated for pneumonia treated according to the guidelines for
community-acquired pneumonia
Clinical Variables/Settings Preferred Treatment Options
Outpatient therapy
Previously healthy
Antibiotic therapy within 3 mo
A respiratory fluoroquinolone,1 a macrolide,2 or doxycycline
A respiratory fluoroquinolone1 alone; an advanced macrolide3 plus high-dose amoxicillin4; or high-dose amoxicillin-clavulanate5
Comorbidities6
No recent antibiotics
Antibiotic therapy within 3 mo
A respiratory fluoroquinolone1 or an advanced macrolide3
A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7
Suspected aspiration pneumonia
Influenza with suspected bacterial superinfection
Amoxicillin-clavulanate8 or clindamycin9
A b-lactam7 or a respiratory fluoroquinolone1
Inpatient therapy
No recent antibiotics
Antibiotic therapy within 3 mo
A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7
A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7
ICU therapy
Pseudomonas not an issue
Pseudomonas a concern
A b-lactam7; vancomycin plus a respiratory fluoroquinolone1; or an advanced macrolide3
An antipseudomonal agent10 plus ciprofloxacin; an antipseudomonal agent8 plus a respiratory fluoroquinolone1; or an advanced macrolide3
Which of the following does not significantly increase an individual’s risk for developing tuberculosis?
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Note: all superscript numbers in table refer to footnotes below:
1. Respiratory fluoroquinolones: levofloxacin, moxifloxacin, or gemfloxacin.
2. Macrolides: erythromycin, clarithromycin, azithromycin.3. Advanced macrolides: clarithromycin, azithromycin.4. High-dose amoxicillin, 1 g p.o. three times a day.5. High-dose amoxicillin-clavulanate, 2 g p.o. two times a day.6. Comorbidities: chronic obstructive pulmonary disease, congestive heart
failure, diabetes, renal insufficiency, malignancy.7. b-Lactam antibiotics: high-dose amoxicillin or amoxicillin-clavulanate,
cefpodoxime, cefprozil, or cefuroxime.8. Amoxicillin-clavulanate, 500 mg p.o., q. 8 hr.9. Clindamycin, 150–300 mg p.o., q. 6 hr.10. Antipseudomonal agents: piperacillin-tazobactam, imipenem,
meropenem, ceftazidime, cefepime, or aztreonam (should be chosen for b-lactam-allergic patients).