Lower Respiratory Tract Infections

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Lower Respiratory Tract Infections

• Jennifer Santee, Pharm.D.
• Winter Semester 2006

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Defining Bronchitis

• Acute bronchitis
• COPD (aka COLD)
• emphysema
• chronic bronchitis
• acute exacerbation (AECB)
• Differ in presentation and possible cause and
  therefore treatment

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Organisms Possibly Involved in AECB

• Same organisms that you might see in upper
  respiratory tract infections
• As the patient has more severe COPD, consider
  other gram (-)s as well (for e.g. P.aeruginosa,
  K.pneumoniae)

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Differences Between ATS and IDSA Getting a
Culture

• What do the IDSA guidelines recommend as far as
  getting cultures?

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Differences Between ATS and IDSA Getting a
Culture

• ATS
• Outpatient sputum culture and Grams stain not
  required
• Inpatient
• Two sets of blood cultures
• Sputum culture if organism suspected to be
  resistant or covered by empiric therapy

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Sings of adequate sputum sample

• lt 10 squamous epithelial cells
• gt 25 polymorphonuclear neutrophils (aka segs) per
  LPF

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Why Are They Called Atypicals?

• Previous thought
• Patients with S.pneumoniae, H.influenzae,
  S.aureus, gram (-) enterics caused a more typical
  presentation of symptoms
• Patients with other organisms such as
  M.pneumoniae and Legionella caused an atypical
  presentation
• Current thought cant identify infecting
  organism on presentation
• Atypical classification stuck though

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Site of Treatment

• Several tools to determine need for inpatient
  treatment available
• PORT prediction rule table 3 and 4 in IDSA 2000
  guidelines
• BTS prediction rule
• These are not to be followed strictly, need to
  use clinical judgement as well

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Deciding What Antibiotic to Use

• IDSA Treat empirically first, then narrow
  spectrum based on culture results
• ATS Treat empirically, use culture results to
  expand spectrum

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Treating Children for CAP

• ATS and IDSA guidelines are for adults
• BTS does provide guidelines for treatment of
  children

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When to Hospitalize Infants

• O2 Sat lt or 92, cyanosis
• RR gt 70
• Difficulty breathing intermittent apnea,
  grunting
• Not feeding
• Family not able to provide outpatient care

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When to Hospitalize Older Children

• O2 Sat lt or 92, cyanosis
• RR gt 50
• Difficulty breathing grunting
• Dehydration
• Family not able to provide outpatient care

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Whats Included with the Exam

• Typical doses, routes of administration
  available, and cost of selected antibiotics
• For amoxicillin, you will need to justify dose
• Normal lab values
• From IDSA guidelines tables 3 and 4