Pulmonary%20Infectious%20Disease

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Pulmonary Infectious Disease

• Tory Davis, PA-C

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Pneumonia

• What is it?
• Acute infection of the lung parenchyma, including
  alveolar spaces and interstitial tissue
• Alveoli fill with exudate (pus), fibrin, cells
• Usually bacterial or viral infection
• May be fungi, rickettsial, yeasts, parasites

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Classification of Pneumonia

• Typical vs. Atypical
• By site of acquisition (ie where the pt picked up
  the bug)
• By location in lung
• Other pt factors (such as imunocompromised,
  HIV-associated, aspiration)

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General Info

• Community acquired pneumonia (CAP)- 2-3 million
  cases per year
• Most deadly infectious disease in US
• 6th leading cause of death in US
• 60,000 deaths annually
• Worldwide leading cause of death in children

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Community Acquired Pneumonia (CAP)

• Definition
• Onset outside hospital or diagnosed within 48
  hours of admission in a patient who has NOT been
  in long-term care facility for ? 14d prior to
  symptom onset AND who does not meet the criteria
  for health-care associated pneumonia (HCAP)

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HAP VAP

• Hospital Acquired pneumonia
• New infection occurring 48 hours or longer after
  hospital admission
• Ventilator Associated Pneumonia
• 48-72 hours after endotracheal intubation

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HealthCare Associated Pneumonia (HCAP)

• Infection occurring within 90 days of a 2-day or
  longer hospitalization
• In nursing home or long-term care residence
• Within 30 days of IV abx therapy, chemotherapy,
  wound care or hemodialysis in a hospital or
  hemodialysis clinic
• Pneumonia in any pt in contact with a
  multi-drug-resistant pathogen

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HCAP

• Includes many pts who used to be considered CAP
• Newer evidence suggest that pts with HCAP are
  more like pts with HAP (than CAP) and may need
  HAP-like treatments

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Other things to consider

• Aspiration pneumonia- who would get this?
• Opportunistic organisms- such as
• Pneumocystis jerovecii pneumonia (seen only in
  immunocompromised patients.)

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Classify by Location

• Primarily from x-ray observation
• Lobar pneumonia- Entire lobe
• Segmental or lobular pneumonia (segment of lobe)
• Bronchopneumonia- (alveoli contiguous with
  bronchi)
• Interstitial pneumonia- (Involvement of tissue
  between the alveoli)

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Common Signs and Symptoms

• Fever
• Cough ? sputum
• Dyspnea
• Chills/Rigors
• Diaphoresis
• Chest pain
• Abd pain

• Pleurisy
• Hemoptysis
• Fatigue
• Myalgias
• Arthralgias
• Anorexia
• Headache

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Typical Presentation

• Sudden onset fevers, cough with purulent sputum,
  dyspnea, occasional pleuritic chest pain
• Signs of consolidation, x-ray abnormalities
• Usually caused by more common bacteria
• Pneumoccocus, H. influenza, etc.

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Remember Clinical Assessment?

• Consolidation
• ? tactile fremitus (Ninety-nine)
• Bronchophony (Auscultate Ninety nine) sounds
  like listening without stethoscope
• Egophony (E?A changes)
• Rales (crackles)
• Associated pleural effusion
• ? tactile fremitus
• Distant breath sounds
• Pleural friction rub (creaking leather)

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Atypical Presentation

• Gradual onset, dry cough, myalgias, fatigue, sore
  throat, N/V, diarrhea, dyspnea
• Less remarkable pulmonary exam despite abnormal
  x-ray findings
• Organisms Mycoplasma pneumoniae, Legionella
  pneumophila, Chlamydia pneumoniae, Chlamydia
  psittaci, Francisella tularensis, viruses

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Pathogenesis

• Some combination of
• Defect in normal host defenses, which include
• Cough reflex
• Mucociliary clearance system
• Immune response
• Very large infectious inoculation
• Highly virulent pathogen

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Mechanism of spread

• Most common
• Inhalation of droplets small enough to get to
  alveoli
• Aspiration of secretions from upper airways
• Other
• Hematogenous or lymphatic dissemination
• Direct spread from nearby infection

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Predisposing factors

• URI
• Smoking
• Alcoholism dec immune fxn and inc aspiration
• Institutionalization
• Heart failure
• COPD
• Age extremes
• Debility or ? consciousness
• Immunocompromise (including CRF, DM)
• Dysphagia

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Whats Buggin Ya?

• Community Acquired (CAP)- bacterial
• Streptococcus pneumoniae (pneumococcus) 20-60 of
  CAP
• Haemophilus influenzae (H. flu)
• Mycoplasma pneumoniae
• And a bunch of others

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Whats Buggin Ya 2

• Viral
• Infants and children major pulmonary pathogens
  are VIRAL RSV, parainfluenza, influenza A and B
• Adults influenza A (B less often), rare
  varicella-zoster
• Fungal Histoplasma capsulatum, coccidiodies
  immitis, blastomyces dermatitidis, cryptococcus
  neoformans, aspergillus fumigatus, pneumocystis
  carinii/jerovecii
• Rickettsial primarily Coxiella burnetii

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Whats Buggin You Worse?

• HAP/HCAP
• Enteric aerobic gram-negative bacilli
• Pseudomonas aeruginosa
• S. aureus (includng MRSA)
• Oral anaerobes
• HIV Infection-Associated
• Pneumocystis jerovecii
• M. tuberculosis
• S. pneumoniae
• H. influenzae

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Demographics Aids Diagnosis

• Influenza assoc with community outbreaks
• Typical pneumonia outbreak after flu outbreak
• Legionella exposure to aerosolized water vapor
  (cooling systems) ? outbreak
• Mycoplasma in younger pts in conjugate settings
  (college, military), with slow transmission
• Chlamydia psittaci in bird handlers, Tularemia
  from cute bunnies, Anthrax from pigs

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Pneumococcal pneumonia

• Caused by Streptococcus pneumoniae (gt80
  serotypes)
• Most common cause of bac-t pnu
• Most frequent in winter
• Most common in age extremes
• Inhaled/aspirated pneumococci lodge in alveoli.
  Inflammatory process in alveolar spaces, causes
  accumulation of protein-rich fluid which is great
  growth medium for bac-t, helps them spread to
  nearby alveoli

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Pneumococcal S S

• Often preceded by URI
• Sudden onset with SINGLE shaking chill, followed
  by fever up to 40.5º, pleurisy, cough, dyspnea
• Tachypnea with RR rising to 20-45
• Tachycardia P 100-140
• Can have n/v, malaise, myalgias
• Cough initially dry, progresses to producing
  purulent, rusty or blood streaked sputum
• Exam may show signs of lobar consolidation or
  pleural effusion (know exam signs)

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Complications

• Progressive pneumonia
• Respiratory distress
• Septic shock
• Contiguous infections
• Bacteremia ? extrapulmonary infections

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Prognosis- Pneumococcus

• Pneumococcus accounts for 85 of lethal CAP cases
• Overall, 10 mortality
• Poor prognostic markers
• age lt1 or gt60
• positive blood cx
• involvement of gt1 lobe
• low WBC count
• extrapulm complication
• immunosupression
• CHF
• Cirrhosis
• asplenia

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Staphylococcal Pneumonia

• 2 of CAP, 10-15 of HAP/HCAP are caused by Staph
  aureus
• Risks age extremes, hospitalized pts,
  intubated, tracheostomy, immuno-suppressed,
  recent surgery, pts with cystic fibrosis, IVDU
  (who are prone to tricuspid valve endocarditis
  with resultant embolic pneumonia)
• CXR- multiple bilateral nodular infiltrates with
  central cavitation

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Staph Aureus S S

• Similar to pneumococcus, except
• Recurrent rigors (vs single chill)
• Tissue necrosis and abscess formation
• Empyema common- suspect S. aureus in post
  thoracotomy empyema or an empyema complicating
  chest tube drainage s/p chest wall trauma
• Fulminant course with prostration

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Staph Aureus prognosis

• Mortality 30-40, often (but not always) due to
  serious associated conditions
• Can be lethal in previously healthy adult who
  develops Staph superinfection after influenza
• Slow response to abx, prolonged convalescence

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Gram Negative Bacilli

• Account for lt2 CAP, but the majority of HAP/HCAP
  pneumonias
• Klebsiella, Pseudomonas aeruginosa, Escherichia
  coli, Enterobacter sp, Proteus sp, Acinetobacter
  sp
• Rare in healthy adults
• Seen in infants, elderly, alcoholics,
  debilitated/immunocompromised hosts, esp those
  with neutropenia
• Bronchopneumonia similar to other infections,
  except very high mortality 25-50 despite abx

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Klebsiella pneumoniae

• CAP in alcoholics, common HAP
• Frequent abscess formation
• causes Friedlanders pneumonia- affects upper
  lobes, produces current jelly sputum, tissue
  necrosis, early abscess, and fulminant course
• CXR- bulging fissure sign. Upper lobar
  consolidation with bowing fissure, also abscess
  and lung necrosis

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Pseudomonas aeruginosa

• Common VAP pathogen
• Seen in neutropenic, intubated, ICU or burn unit
  pts, CF, AIDS
• High mortality
• CXR- microabscesses coalescing into large
  abscesses

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Haemophilus influenza

• 2nd most common cause of CAP (when bug is IDd)
• Strains containing type B polysaccharide capsule
  most virulent cause meningitis, epiglottitis,
  bacteremic pneumonia. Nearly gone in US due to
  HiB vaccine.
• Non-type B strains colonize lower resp tract of
  pts with chronic bronchitis, implicated in
  exacerbations (thus abx in bronchitis in pts w/
  COPD)

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H. influenza

• Hib pneumonia usually in kids- median age 1 year
  esp if not immunized
• Usually proceeded by coryza
• Early pleural effusion in 50
• In adults, presentation similar to other bac-t
  pneumonias
• Bacteremia and empyema uncommon

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Legionnaires Disease

• Pneumonia caused by Legionella pneumophilia.
  Discovered in members of American Legion during
  1976 convention in Philadelphia.
• 1-8 of CAP and 4 of lethal nosocomial cases.
• Occurs in late summer, early fall.
• Caused by aerosolization of contaminated water
  source, spread by AC systems or shower heads.
• Risk factors smoking, etoh abuse,
  immunosuppression

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Legionella

• Incubation 2-10 days
• Prodrome resembles influenza malaise, fever,
  myalgia, headache, cough- initially
  non-productive, then productive of mucoid sputum
• Characteristic high fever, relative bradycardia,
  commonly diarrhea
• Less common altered mental status

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Legionella

• CXR shows patchy segmental or lobar infiltrate,
  unilateral progressing to bilateral, often with
  pleural effusion. Abnormalities persist
• Labs leukocytosis, hyponatremia,
  hypophosphatemia, abnl LFTs
• Mortality gt15 in CAP, higher in hospitalized or
  immunosuppressed pts
• Slow convalescence

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Mycoplasma pneumoniae

• Most common pathogen in ages 5-35
• Walking pneumonia
• Slow spreading epidemics due to incubation time
  of 10-14 days. Spread common thru close
  contacts, closed populations such as military,
  families, PA students
• Attaches to and destroys ciliated epithelial
  cells of respiratory tract mucosa

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M. pneumoniae

• Initial sx are flu-like malaise, sore throat,
  dry cough with progressive severity
• Gradual progression (vs fast onset of typicals)
• Coughing may be paroxysmal, produces mucoid,
  mucopurulent, or blood-streaked sputum
• Acute sx 1-2 weeks, then slow recovery. Often
  mild sx, spontaneous recovery usually- pts will
  recover with or without treatment

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M. pnemoniae

• Prolonged cough due to inhibition of ciliary
  action
• Exam unimpressive, esp compared to pt complaint
  and xray findings
• Prognosis good. Abx tx will ? fever and pulm
  infiltrates and ? recovery speed- BUT pts will
  continue to carry mycoplasma for weeks-
• NB! Mycoplasma doesnt have cell wall, and
  therefore wont respond to abx that interfere
  with cell wall-go with macrolides

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Chlamydia pneumoniae

• 5-10 of CAP and nosocomial pnu in adults.
• May be provocative for asthma
• Resembles Mycoplasma pneumoniae symptoms
• Cough, sputum, fever- most not seriously ill,
  but can require admit
• Older kids, young adults usually

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Chlamydia psittaci

• Bird handlers pneumonia
• Clinically and antigenically distinct from C.
  pneumo
• Atypical pneumonia transmitted to humans by
  psitticine birds via inhalation of dust from
  feathers, excreta or by bite
• Clinically similar to other atypicals, plus
  epistaxis, splenomegaly
• CXR- Pneumonitis radiating from hilum

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Pneumocystis jerovecii

• Fungal agent (previously thought to be parasite)
  and previously called P. carinii causes pnu only
  in immunocompromised pts
• SS fever, dyspnea, nonproductive cough.
  Evolves over days to weeks
• CXR- diffuse bilateral perihilar infiltrates,
  but 20-30 of CXR are normal

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PCP/PJP and HIV/AIDS

• 30 of HIV pts get PCP/PJP as initial AIDS
  defining illness
• Become vulnerable when CD4 count lt200
• 80 of AIDS pts will get PCP if not prophylaxed,
  usually with TMP/SMX (Bactrim) 80/400 mg daily
  starting when CD4 count hits 200

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Post-Op/ Post-traumatic

• Hypoventilation
• Poor diaphragmatic excursion
• Impaired cough reflex
• Bronchospasm
• Dehydration
• Combine to cause retention of bronchial
  secretions, segmental atelectasis, and ultimately
  pnu

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Aspiration

• 3 syndromes from aspiration
• Chemical pneumonitis (when aspirated material is
  directly toxic, i.e. gastric acid)
• Mechanical obstruction (So you inhale a
  meatball)
• Bacterial pneumonia caused by anaerobic bacteria
  colonizing oropharynx.
• CXR will show infiltrate in whatever lung segment
  was dependant at time of aspiration.

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Workup

• Hx and PE good psx hx
• CXR- PA and Lateral
• CBC with diff
• BMP (glucose and lytes)
• Liver function tests (LFTs)
• Remember CMPBMPLFTs
• Renal function
• Pulse ox /or ABG

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What else?

• Consider EKG, HIV test
• If immunocompromised pt, consider other causes
  fungal, viral, TB, PCP
• Flu season rapid flu test with back-up culture

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PORT severity index

• Prediction model for prognosis of CAP
• Scoring system based on 19 variables
• Demographics
• Comorbid disease
• PE Findings
• Lab findings

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PSI

• Risk stratification for death from all causes in
  next 30 days
• Class I (by algorithm) LOW (outpt tx)
• Class II ? 70 points LOW (outpt tx)
• Class III 71-90 points LOW (consider admit)
• Class IV 91-130 MODERATE (admit, maybe
  intermediate care)
• Class V gt130 HIGH (likely ICU)

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Other Admission Considerations

• Virulence of organism if known (S. aureus)
• Support at home and functional status
• Ability to comply with medications
• Ability to afford treatment
• Immune status
• Multilobar involvement
• Follow-up
• Clinical judgment paramount

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Drugs

• Tx with abx usually initiated before ID of
  causative agent, then modified
• Outpatient tx usually empiric ( guided by
  practical experience)
• Often institutions have rotating schedule of 1st
  choice abx
• Treat pneumococcus PLUS other likely bugs

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Antibiotics for Pneumonia

• Choose least-toxic, most cost-effective,
  narrowest spectrum possible
• Penicillin was mainstay anti-pneumococcal
• BUT 40 resistance in many locales
• If you know resistance rates in your community,
  can consider its use
• IDSA Guidelines for outpts
• Macrolide (e.g. azithromycin, clarithromycin)
• Doxycycline
• Fluoroquinolone (levofloxacin, moxifloxacin,
  gatifloxacin)

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IDSA Antibiotics for Pneumonia

• Hospitalized pts
• Fluoroquinolone, or
• Ceftriaxone (or cefotaxime) plus macrolide
• ICU pts
• Fluoroquinolone or macrolide plus ceftriaxone or
  cefotaxime or ampicillin-sulbactam or
  piperacillin-tazobactam

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Antibiotics

• Switch to oral Abx when clinically stable
• Afebrile 8 hrs, nl resp rate, reduced oxygen
  requirement, wbc ?
• Fluoroquinolones same bioavailability (IV and
  oral)
• Treat for 7 to 14 days total

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Other Therapies

• IV fluids
• Oxygen
• Incentive spirometry
• Anti-pyretics like acetaminophen
• Cough suppressants and mucolytics
• Chest physical therapy
• PT/OT and consider rehab hospital

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Preventing Pneumonia

• Infection control handwashing, cleaning, gloves,
  isolate if indicated, treat promptly
• Chemoprophylaxis antivirals during flu
  outbreaks, TMP-SMZ for PCP prevention
• Vaccinations
• Aspiration precautions
• Incentive spirometry post-op

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Follow up

• Consider repeat CXR in 4-6 weeks to demonstrate
  resolution of imaging findings.
• Opportunity to address risk factors, possibly
  modify them
• Great time for intervention with smokers

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Acute Bronchitis
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What is it?

• Inflammation of tracheobronchial tree
• Usually infectious, but can also be irritant
• Often occurs in relation to other respiratory
  illness (ie common cold)
• 5 of US population dx with bronchitis yearly
• Tends to be self-limited

60
Bronchitis is not pneumonia

• Infection of bronchial tree by similar organisms
  but no parenchymal infection
• Cough, sputum, upper respiratory symptoms
• No lung findings except wheeze, nl xray
• Usually viral infection, rarely bacterial ( see
  Pertussis)

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Pathogenesis

• Infectious
• Viral adenovirus, influenza, parainfluenza,
  rhinovirus
• Bacterial chlamydia, pertussis
• Noninfectious
• GERD
• Irritant
• Asthmatic

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Risk Factors for Infectious Bronchitis

• Recent URI
• Recent LRI
• Smoker
• Lung compromise, ie COPD

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Symptoms

• Cough (/- purulent)
• Fever
• Malaise
• Nasal congestion
• /- rhinorrhea
• Sore throat
• Looks a lot like a cold so far

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More sx

• Wheeze
• Dyspnea
• Chest pain-costochondritis inflammation from
  coughing so much (press on it by sternum to
  elicit pain)
• Myalgia/arthralgia

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Physical exam

• No uniform description
• Can be normal exam
• /- wheeze/rhonchi
• No signs of consolidation
• Because if there IS consolidation, its NOT
  bronchitis

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DDX

• Asthma
• COPD
• Bronchiolitis
• Croup
• Pneumonia
• Bronchiectasis

• Influenza
• TB
• Cancer
• Foreign body
• URI
• Sinusitis

67
Work up

• Thorough history
• PE
• CXR? can r/o pneumonia if you cant do it with
  hx and PE

68
Treatment

• Generally aimed at symptoms
• Analgesics
• Antipyretic
• Anti-inflammatory
• Antitussives
• Expectorants
• Bronchodilators

69
but my doc always gives me.

• In immunocompetent individuals, no abx needed.
  BUT 80 get them.

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Who should get abx?

• Moderate-severe COPD
• Asthmamaybe
• Immunocompromised pts
• Suspected pertussis
• NB! lt5 of bronchitis pts will develop
  pneumonia.
• Prophylactic antibiotics will NOT decrease
  incidence of pneumonia

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ABX

• Macrolides effective against mycoplasma
  chlamydial organisms and B. pertussis
• Erythromycin, Clarithromycin, Azithromycin
• Also tetracyclines, tmp/smx (Bactrim), and
  cefditoren (Spectracef)

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Prevention

• Stop smoking
• Influenza vaccines
• Stop smoking
• Tdap vaccine
• Stop smoking
• Cover that cough
• Stop smoking
• Pneumococcal vaccine
• And WASH YOUR HANDS

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Pertussis
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Pertussis

• aka whooping cough
• Classic at least 21 days of cough illness with
  paroxysms, associated whoops or post-tussis
  vomiting
• Bordatella Pertussis highly contagious gram neg
  bac-t in respiratory tract, spread by direct
  contact with secretions
• Incubation 7-10 days

75
Pertussis Phases

• Catarrhal (1-2 weeks) Looks like URI, rhinorrhea,
  sneezing, fever, occasional cough
• Paroxysmal-severe spasms of quick, short, coughs
  like a machine gun without breathing in between
  coughs. Gagging and gasping. After cough spasm,
  pts strain to inhale, making high-pitched
  whooping sound. May be followed by vomiting and
  exhaustion
• Convalescent- Gradual recovery

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Pertussis

• Nearly eradicated in 70s (1,000 cases in 1976),
  now increased incidence (11,000 in 2007)
• Waning immunity, under-vaccination
• Infants at greatest risk for complications
  apnea, pneumonia, seizures, brain damage,
  cerebral hemorrhage
• Milder disease in older children can contribute
  to spread

77
Diagnosis

• Hx
• PE
• Culture respiratory secretions
• Elevated white count with lymphocytosis

78
Treatment

• Macrolides for 5 days erythromycin,
  clarithromycin, azithromycin. (2nd line TMP/SMX)
  Treat EARLY, treat often, treat contacts to
  reduce spread
• If no abx (ie pt refuses), then no contact with
  other humans for 21 days. No work, school,
  daycare, etc.
• Fluids (IV prn)
• O2
• Sedatives

79
Prevention

• Vaccination with DTaP (kiddos) and Tdap
  (adolescents and adults)
• Handwashing
• Prophylactic abx to close contacts to prevent
  spread

80
Tuberculosis

• Infection with Mycobacterium tuberculosis
• Most commonly attacks the lungs (as pulmonary TB)
  but can also affect the CNS, the lymphatics, the
  circulatory system, the genitourinary system,
  bones, joints and skin.

81
Background

• Among communicable diseases, 2nd leading cause of
  death worldwide.
• Prevalence 2 billion
• Incidence 8 million
• Mortality 2 million people yearly
• 20-40 of world population is infected
• 15 million people infected in US

82
Mycobacterium tuberculosis

• Non-motile pleomorphic rod
• Highly resistant to desiccation
• Very slow growing- generation time 12-18 hours
  (vs 20 min for E. coli)

83
Pathophysiology

• Aerosol transmission cough, sneeze, speak or
  sing
• One cough? 3000 infective droplets
• 10 bacilli can initiate pulmonary infection
• In alveoli, taken up by alveolar macrophage, then
  on to the nodes, and to organs- 80 of disease is
  in lung, but can affect ANY organ

84
Risk

• Minority 2/3 of cases
• Indigent 300x risk of national average
• HIV 200-400 increase risk
• Other high risk groups hospital employee, inner
  city resident, nursing home resident, alcoholic,
  incarcerated, illicit drug users, travel to
  endemic area

85
LTBI vs Active Disease

• Two forms- distinct
• Latent TB Infection- pt is infected with M.
  tuberculosis, but is NOT sick, NOT infectious
• Active Disease- Pt is infected, sick, and
  contagious

86

• 2-8 weeks after inoculation, PPD caused by
  cell-mediated immunity and hypersensitivity
  reaction
• 90-95 primary infections are unrecognized
• 10-30 of healthy pts will proceed directly to
  active disease (up to 50 if MDR- TB)
• The rest will have latent infection. No
  symptoms, non-infectious. Can convert to active
  ANY time.

87
Stages

• Primary or initial infection- often leaves
  nodular scars called Simon foci in one/both
  lungs.
• Simon foci provide seeds for reactivation
• Latent or dormant infection
• Can convert to active later
• Can be treated to decrease risk/likelihood of
  conversion

88
Active TB

• Either direct from initial infection, or
  reactivated latent infection
• Symptomatic
• Infectious
• Must be treated to decrease mortality and spread
• Increasingly RESISTANT to treatment
• MDR-TB
• XDR-TB

89
Classic Symptoms of Active TB

• Productive cough
• Hemoptysis
• Fever
• Weakness

• Anorexia
• Weight loss
• Night sweats
• Malaise

90
Physical Findings

• Fever
• Cachexia
• Hypoxia
• Tachycardia
• Lymphadenopathy
• Abnormal lung sounds- post-tussive rales

91
Extrapulmonary Symptoms

• Skin
• Kidney
• Bone
• Brain
• More common with decreased immune function

92
Lab

• Presence of acid-fast bacteria in sputum is a
  rapid presumptive positive
• Definitive dx from sputum cx or DNA/RNA
  amplification demonstrating M tuberculosis
• Culture takes weeks

93
PPD/Mantoux Test

• 0.1ml intradermal purified protein derivative
• Area of INDURATION (NOT erythema) seen 48-72h
  after placement
• I said INDURATION, not erythema
• Measure transverse to long axis of arm
• Expressed in mm- and a lack of induration is
  written as 0 mm, not neg

94
False Neg PPD

• 20 of active cases
• Cancer/recent chemo
• Anergy
• Drugs (steroids)
• AIDS
• Recent live attenuated virus vaccines (so place
  PPD same day or 6 weeks after vax)

• Concurrent infection
• Metabolic derangement (CRF)
• Lymphoid disease
• Stress (surgery, burn, graft-vs-host)
• Distant primary infection- role for 2-step
  testing, booster reaction

95
Population Based PPD Criteria

• gt5 mm HIV , abnl CXR, recent TB contact
• gt10 mm IVDU, nursing home, jail, minority
  groups, age lt 4, DM, CRF
• gt15 mm no risk factors
• Positives are reportable to state
• False positives may occur in persons with
  previous BCG vaccine
• This will be on boards!

96
QuantiFERON-TB Gold Test

• Whole blood test to detect both latent and active
  TB
• One visit/one sample testing
• Results in 24 hrs
• No reader bias
• Not affected by BCG vaccine

97
Imaging

• Pos CXR trumps neg PPD, but neg CXR doesnt r/o
  active TB
• Classic xray of active TB shows lesions in
• Post RUL
• Apicoposterior LUL
• Apical segments of LLL

98
Differential

• Asthma
• Pneumonia
• Influenza
• CA
• HIV/AIDS
• ARDS

• Pneumothorax
• Pleural effusion
• MAC (mycobacterium avian complex)

99
Treatment

• Therapeutic principles
• Must use multiple drugs to which M. tuberculosis
  is susceptible
• Must be taken regularly
• Must have sufficient duration to resolve the
  illness

100
Treatment Active TB

• Isolation
• Negative pressure rooms
• Mask- N95
• Abx - First dose decreases bacillary load 10
  fold
• 2 weeks decreases load 100-fold
• 4 wk tx plus 3 neg sputum smears means pt is no
  longer infectious

101
Tx Daily Regimen

• Initial 4 drug regimen
• INH (isoniazid) 300 mg po q day
• Hepatitis, rash, GI upset, neuropathy
• Co-administer pyridoxine (vitamin B6)
• RIF (rifampin) 600 mg po q day
• GI upset, rash, orange body fluids, hepatitis
• PZA (pyrazinamide) 2 g po q day
• Hepatotoxicity, rash, GI upset
• ETB (ethambutol) 2 g po q day
• Optic neuritis

102
Daily Regimen

• Drop ETB if cx favorable
• Drop ETB and PZA after 2 mo if decreased symptoms
  and nl smear
• 6 month total
• Compliance 60.

103
Denver Protocol DOT

• 91 compliance
• First 2 weeks DAILY INH 300mg, RIF 600 mg, PZA
  2g, streptomycin 1g
• Next 6 weeks, Same doses, 2 x/week
• Next 18 weeks INH RIF 2x/wk
• Relapse comparable to daily protocol (1.6)

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Exceptions

• HIV tx to 9 months min
• Pregnant- tx 9 months, daily INH, RIF, ETB. OK
  to breastfeed
• Meningitis- add dexamethasone
• MDR TB- 7 (yup, seven) drug daily protocol, DOT
  essential. There are organisms resistant to
  SEVEN drugs. What then? XDR-TB

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Latent infection

• PPD or QFT-G
• Neg CXR
• No signs/symptoms of active disease
• In healthy adult, 1 per year conversion to
  active
• HIV person has 10 per year conversion

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Latent Infection Tx

• INH 300 qd x 12 m has 75 risk reduction for
  converting to active disease
• INH 300 qd x 6 m (65 RR)
• INH 900 2x/wk for 12 m

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Seasonal Influenza

• Respiratory illness usually occurring in epidemic
  form in Oct- April, epidemics in US q 2-3 years
• Caused by strains of influenza virus (an
  orthomyxovirus)
• Annually in US
• Affects 5-20 of population
• Results in 200k hospitalizations for
  complications
• Causes 36,000 deaths

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Tell me you already know this...

• Influenza has 2 surface glycoproteins to allow
  virus to attach to and infect hosts
• HA- hemagglutinin-to fuse to host membrane
• NA- neuraminidase- enzyme to allow dispersion of
  new budding viruses
• Mutations of HA or NA ? drift
• Exchange of entire gene segments (usually between
  human flu and animal flu)? shift

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Influenza Acute SS

• Chills, fever to 39.5?C
• Sudden onset myalgias- worse in back and legs
• Prominent HA with photophobia and retrobulbar
  aching
• Sore throat, retrosternal burning
• /- coryza
• Nonproductive cough

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Later on

• Lower respiratory symptoms become dominant with
  persistent productive cough
• Acute symptoms and fever resolve in about 3 days
• Weakness, diaphoresis and fatigue can persist for
  weeks
• Secondary bacterial pneumonia suggested by
  recurrence of symptoms in 2nd week

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Transmission

• Droplet nuclei (not large particle aerosol like
  the common cold.) Rare fomite transmission.
• Cough or sneeze
• Incubation average 48 hours (range 1-4 days)
• Infectious for
• 1 d before sx onset to 5 d after (Adults)
• 1 d before to 10d after (Kiddos)
• Several days before sx 10d after (Wee kiddos)
• Immunocompromised folks can shed virus for weeks
  to months

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Complications

• Bacterial pneumonia
• Purulent bronchitis
• Otitis media
• Sinusitis
• Dehydration
• Worsening of chronic medical illnesses, ie CHF,
  DM, asthma

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Rarer complications

• Encephalopathy
• Myocarditis
• Pericarditis
• Rhabdomyolysis
• Reyes Syndrome- (fatty liver with
  encephalopathy) no ASA for children under 18

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Diagnosis

• Good history, incl knowledge of current local
  trends.
• As of October 3, 2009, 99 of circulating
  influenza viruses in the United States were 2009
  H1N1 influenza
• PE febrile, tachycardic, flushed face,
  pharyngeal, tonsillar and soft and hard palates
  injected without exudate. Conjunctival
  injection. Usually normal lung exam. No signs
  of consolidation.
• Clinical alone ? low sensitivity and specificity
• Check some labs?

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Better living thru nasopharyngeal swabs

• Rapid testing (30 min)-often performed in office.
  Vary in types of flu detected, ability to
  distinguish types, also in specimen type needed.
  Know your lab!
• Viral culture, esp to f/u negative rapid test
  when clinical suspicion is high. Results in 3 to
  10 days
• Also available immunofluorescence, EIA, PCR.
  Use of serology reserved for public
  health/research.

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Treat em

• Conservative tx rest, fluids, acetominophen for
  fever, headache, myalgia, cough suppressant prn.
• NB- NO ASA for children!! (Why?)
• Monitor for complications
• Antivirals effective in ? sx duration,
  severity, also to ? contagion. Ideally initiate
  tx within 2 d of sx onset, duration of tx 5 days
• Currently reserving antivirals for ill, high-risk
  folks with H1N1

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Antivirals

• Oseltamavir (Tamiflu)- seasonal and H1N1
• Zanamavir (Relenza)- seasonal and H1N1
• Amantidine and rimantidine- Only effective
  against influenza A. Rapidly developing
  resistance to these drugs, so use of these agents
  is currently NOT advised. Awaiting
  reestablishment of susceptibility.

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PREVENTION

• Vaccinations
• Chemoprophylaxis with antivirals (70-90
  effective)
• Handwashing- soap and water or waterless alcohol
  based
• Education
• Fingers out of nose, eyes, mouth
• Good respiratory hygiene
• Avoid sick people if youre well, and well people
  if youre sick

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The Flu Shot

• Trivalent inactivated vaccine-
• Killed viruses- 2 A strains, and a B
• Representative of the influenza strains predicted
  to circulate
• New vaccine yearly.
• Usually one strain changes.
• Available thimerosal-free

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This years model

• A/Brisbane/59/2007(H1N1)-like virus
• A/Brisbane/10/2007 (H3N2)-like virus
• B/Brisbane/60/2008-like virus
• Too early to tell if we got it right!
• Also, attention and data is all about H1N1

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Vaccine

• If well matched to circulating strains, vaccine
  can decrease risk of flu 70-90 in healthy adults
  and 66-90 in children
• Can be 30-70 effective in preventing
  hospitalization for pneumonia in elderly
• Decrease risk of death from influenza by 80 in
  elderly people in nursing homes
• Even poorly matched vax can provide
  cross-protection

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Other option LAIV

• Live attentuated influenza vaccine
• Nasal spray
• LIVE virus, weakened
• Only for healthy, non-preg people ages 5-49

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Who gets flu shot?

• People at ? risk for complications kids 6
  months to 19 years, pregnant women, age over 50,
  residents of LTC facilities or nursing homes,
  those with chronic medical conditions (see next
  slide), healthcare workers
• Folks who live with/care for the above
• Anyone who wants to ? risk of flu

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Chronic Medical Conditions

• Pulmonary ds (incl asthma and any other disease
  that can compromise respiratory function)
• Cardiovascular ds (except HTN)
• Renal ds
• Hepatic ds
• Hematologic ds
• Metabolic ds (including diabetes!)
• Immunosuppressed folks

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NO SHOT for you

• Severe egg allergy
• Hx of severe reaction to a flu vax
• Hx Guillain Barre Syndrome
• Age lt6 months
• Currently moderately ill with fever
• Fine to give to pt w/ low-grade fever

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Influenza vaccine factoids

• Production starts in January
• Usually available in October and after
• Works by provoking immune response and antibody
  development
• Effective in about 2 weeks. Immunity lasts
  months to a year

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Pandemics

• 1918- Spanish influenza. Killed 40-50 million
  people worldwide.
• 1957- Asian Influenza (2 million dead)
• 1968- Hong Kong Influenza (1 million)
• 2009- H1N1 Swine Flu
• ????- Avian Influenza. WHO conservative estimate
  of about 7.4 million deaths. Pandemic within 3
  months of evolution of virus to easily
  transmissible state. Are we ready?