BACTERIAL RESPIRATORY INFECTIONS

PNEUMONIA
Epidemiology
- leading global killer of children under five
- 1.6 million deaths per year
- in developed nations, adults over 65 years old and
people with chronic health problems bear the
greater burden of pneumonia.
estimated 156 million new cases of pneumonia
occur each year
97 % in the developing world
7 13 % require hospitalization
74% OF cases occur in just 15 countries,
mostly in Asia and sub-Saharan Africa

Common Causes of Pneumonia
Bacterial
Streptococcus pneumoniae
Hemophilus pneumoniae
Chlamydia pneumoniae
Mycoplasma pneumoniae

Viral
Influenza virus
Respiratory Syncytial Virus

Others
Pneumocystis jiroveci

Transmission
- Inhalation of airborne particles or droplets
- colonize the nose or throat
- carriers



Clinical Manifestations
High fever
chills
production of yellow or brown sputum
chest pain
shortness of breath
change in their mental abilities
Poor oxygenation
fast breathing
shortness of breath
Cyanosis
Altered sensorium


Prevention
healthy lifestyle
vaccine
breastfeeding
improved living standards

STREPTOCOCCUS PNEUMONIAE
General Features
gram (+), non motile, encapsulated cocci
lancet shaped, in pairs
fastidious
common cause of respiratory infections

Epidemiology
found nasopharynx
sensitive to environmental agents
endogenous
carriers due to impaired immune system
exogenous
droplet transmission

Clinical Significance
Acute bacterial pneumonia
otitis media
bacteremia/sepsis
meningitis



Treatment
- Antibiotics: penicillin, cephalosporins, macrolides,
quinolones - penicillin resistance due to alteration
of PBP
- Bedrest
- Hydration

Prevention
Vaccine: polyvalent antipneumococcal capsular
polysaccharide
- protection against 85 90% of pneumococcal
infection

CDC recommends 2 kinds of pneumococcal
vaccines for adults

Polysaccharide Pneumococcal Vaccine
All adults 65 years and older should still get one
dose (PPSV23).
Respiratory Transmission
http://sphweb.bumc.bu.edu/otlt/mph-
modules/ph/ph709_c_transmission/ph709_c_transmission4.html
Adults 19 through 64 years old with certain
medical conditions should receive one or two doses
of PPSV23.
- kidney diseases, cigarette smoking, chronic
heart or lung disease, asplenia, alcoholism, cochlear
implants and conditions that cause weakening of
the immune system
Persons with asymptomatic or symptomatic HIV
infection
When cancer chemotherapy or other
immunosuppressive therapy is being considered

Conjugate Pneumococcal Vaccine One dose of
pneumococcal conjugate vaccine (PCV13) is
recommended for adults aged 19 years and older
with
asplenia, sickle cell disease, cerebrospinal fluid
leaks, cochlear implants, or conditions that cause
weakening of the immune system

If you are recommended to get both PPSV23 and
PCV13 vaccines, get the PCV13 first followed by
PPSV23 eight weeks later.

HAEMOPHILUS INFLUENZA
- childhood pneumonia
- associated with invasive infections: i.e. meningitis,
pneumonia, septic arthritis and localized diseases
of the respiratory tract
- blood loving

General Features
- gram (-), small uniform coccobacillus
- aerobic or facultative anaerobic
- encapsulated
demonstrated by capsule stains and Quellung
reaction
- 6 distinct antigenic types
a- glucose
b- ribose
c- galactose
d- hexose
e- hexosamine
f- galactosamine

Epidemiology
- normal flora of upper respiratory tract
- nonencapsulated strain in 25 80%
- capsulated strain in 5 10%may colonize the
conjunctiva and genital tract
- humans only natural host immunization reduced
incidence

Clinical Significance
A. Invasive Infection
1. epiglottitis
- cellulitis of epiglottis and surrounding tissues
- peak at 2 4 years old
- life threatening
2. Pneumonia
3. bacterial meningitis
4. Septic arthritis
5. Cellulitis
6. Bacteremia
- associated with pharyngitis or septic
arthritis or localized disease

Laboratory Identification
- Direct examination - Gram stain: small gram (-)
coccobacilli Presumptive identification
- Culture
General Considerations
- viability decrease with time and in 40 C -
for optimal yield:
- transport immediately and inoculate on
appropriate media without delay
- chocolate agar
- incubate in aerobic atmosphere enriched
with 5 10% carbon dioxide
- Immunologic Assay
rapid detection of free, soluble form of
type b capsule
counterimmunoelectophoresis latex
agglutination test
- Sensitized particles with antibody against
specific antigen
- Definitive Diagnosis
use biochemical test
molecular techniques

Treatment
- inhibited by ampicillin, chloramphenicol,
tetracycline, 3rd generation cephalosporins, co-
amoxyclav, ciprofloxacin, azithromycin
for meningitis
- 3rd generation cephalosporins - chloramphinicol

Prevention
immunization with conjugate Hib vaccine
2, 4, 6 months
Prophylaxis - Rifampicin daily for 4 days

INFLUENZA VIRUS
RNA virus
Orthomyxovirus
Major Serotypes:
Influenza A
Influenza B
Influenza C


Influenza Viral Structure
Enveloped,ssRNA negative-strand virus
segmented genome
Influenza A and B: 8 segments
Influenza C: 7 segments
each segment encodes a different viral protein


Summary of Influenza Viruses
Dr. M. Lota 41
Surface Glycoproteins
Antigenic
Special functional importance to the virus
Hemagglutinin and Neuraminidase
High frequency of variations result in new
serologic types

a. Hemagglutinin
- Binding to host receptor
- Internalization of the virus
- Facilitation of membrane- fusion events
- Target of neutralizing antibodies
- H1, H2 and H3 most commonly associated with
human infection

b. Neuraminidase
Hydrolyzes the mucus on
respiratory epithelium
Assist in viral budding and release of virion from
cells
N1 and N2 most commonly associated with
human infection

Types of Flu


Virus Reservoirs
- Major reservoir Birds, swine, horses, dogs,
cats, domestic poultry
- reservoirs provide new strains by recombination
between influenza viruses of man, animals and
birds

Changing Pattern in Influenza
- characteristic that enables influenza A viruses to
cause annual epidemics, even pandemics
Minor changes - antigenic drift
Major changes - antigenic shift

Antigenic drift
- minor mutations in the hemagglutinin antigen
- makes prior immunity less effective
- Occurs among influenza A viruses
- resulting in emergence of new variants of
prevailing strains every year



Antigenic shift
- occur when two separate strains of influenza
infect the same cell simultaneously
- major changes occur in surface antigens occurs
by reassortment virus strains appear more
different antigenically from previously seen strains
- changes lead to emergence of potentially
pandemic strains



Theories for Emergence of Pandemic Viruses
Genetic reassortment between human and animal
viruses
Direct transfer of viruses between animals and
humans
Re-emergence of viruses from unrecognized or
unsuspected reservoirs.

Flu Pandemic
- avian strain named H5N1 raised the concern of a
new influenza pandemic, after it emerged in Asia in
the 1990s
- novel flu strain evolved that combined genes from
human, pig, and bird flu
- "swine flu" and also known as influenza A/H1N1,
emerged in Mexico
- World Health Organization officially declared the
outbreak to be a "pandemic" on June 11, 2009
Types of Flu
Seasonal
Circulate and cause
disease yearly
Mild to severe illness
Cause:
influenza A(H1N1)
and A(H3N2)
type B (Victoria and
Yamagata lineage)
type C
Multiple infections in
a lifetime
Pandemic
Cause large outbreak
Majority of population
lack immunity
Mild to severe
infection
Cause:
Spanish Flu
A(H1N1)

Zoonotic or Variant
Routinely circulating
in animals
Animal virus distinct
from human influenza
virus
Not easily transmitted
from man-to-man
Acquired through
direct contact
Cause: Avian A(H5N1),
A(H9N2)
Swine A(H1N1),
A(H3N2)
January 26, 2014 Dr. M. Lota 46
http://www.who.int/influenza/GIP_InfluenzaVirusInfectionsHumans_Jul13.pdf
January 26, 2014 Dr. M. Lota 50


Influenza A(H7-N9)
Natural Infection
Birds: Chicken, ducks
asymptomatic
Transmission: respiratory droplets or contact
considered to be low pathogenic avian influenza

Human Infection
- March 2013 outbreak in China
- laboratory confirmed cases are commonly
admitted to the ICU
Complications: septic shock, respiratory failure,
ARDS, refractory hypoxemia, acute renal
dysfunction, multiple organ dysfunction,
rhabdomyolysis, encephalopathy, and bacterial and
fungal infections

Clinical Manifestations
- Incubation period 2 days (range 1-4 days)
- Abrupt onset of fever, myalgia, sore throat,
nonproductive cough, headache
- May have gastrointestinal symptoms (nausea,
vomiting and/or diarrhea)
- Severity of illness depends on prior experience
with related variants

Treatment Considerations
- Self-limiting
- Hospitalization isolation and observation
treatment of seriously ill patients
Supportive care includes antipyretics, such as
Paracetamol for fever or pain.
- Fluid rehydration

ANTIVIRAL THERAPY
- neuraminidase inhibitors (NAIs) Oseltamivir and
Zanamivir

Early administration of NAIs
- may reduce severity and duration of illness
- may also contribute to prevent progression to -
severe disease and death
Beneficial for
pregnant patients
patients with progressing lower
respiratory disease or pneumonia


patients with underlying medical
conditions.

Prevention and Control
o Because of antigenic drift , new vaccine has to be
prepared every year
o killed vaccine o Live-attenuated
o Because of limited supply, vaccine given to HIGH
RISK groups only:
o Children 6 mos 18y
o Elderly
o Chronically ill
o Institutionalized as well as healthcare
professional

MYCOBACTERIUM TUBERCULOSIS

General Features
thin straight rods (tissues); coccoid and
filamentous (artificial media)
acid fast
non motile, non spore forming
resistant to chemical agents and drying
60% of its dry weight is its lipid content

Clinical Manifestation
A. Pulmonary/Endothoracic TB
1. Asymptomatic or Latent TB Infection
2. Primary/Childhood TB
3. Pleurisy with Effusion
4. Progressive Primary TB
5. Endobronchial TB
6. Miliary TB
7. Chronic Pulmonary TB
8. Tuberculoma
9. Pericardial TB

Extrapulmonary TB
1. TB of the Cervical Lymph Nodes (Scrofula)
2.TB of the CNS
TB meningitis
Tuberculoma/TB Abscess
3. Skeletal TB
TB of bones and joints:
TB of the spine (Potts disease)
TB arthritis
4. Gastrointestinal TB
TB enteritis
TB peritonitis
Hepatobiliary TB
TB of the pancreas
5. Cutaneous TB (scrofuloderma)
6. Ocular TB
7. Genitourinary TB
Renal TB
Genital TB
8. TB of the middle ear

Laboratory Diagnosis
a. Specimen
- sputum, gastric lavage, bronchoalveolar lavage,
lung tissue, lymph node tissue, bone marrow,
Flu Pandemic
avian strain named H5N1 raised the concern of a new
influenza pandemic, after it emerged in Asia in the 1990s

novel flu strain evolved that combined genes from human,
pig, and bird flu
"swine flu" and also known as influenza A/H1N1, emerged in
Mexico

World Health Organization officially declared the outbreak
to be a "pandemic" on June 11, 2009

January 26, 2012 Dr. M. Lota 54
blood, liver, cerebrospinal fluid(CSF), genital
discharge, urine, and stool
- decontamination of the specimens obtained may
be performed by the addition of sodium hydroxide,
usually in combination with N-acetyl-L-cysteine

b. Staining and Microscopy
- preliminary confirmation
- give a quantitative assessment of the number of
bacilli (eg, 1+, 2+, 3+)
- estimate the infectiousness of the patient -
disadvantage: cannot be used to differentiate M
tuberculosis from other acid-fast organism

Conventional methods
Ziehl-Neelsen staining method
Kinyoun stain - modified to make heating
unnecessary
Fluorochrome stains - auramine and rhodamine -
advantage: slides can be screened faster
- fluorochrome-positive smears must be confirmed
by Ziehl- Neelsen staining

Evaluation of sputum microscopy-for diagnosis
First set of 3 sputum samples
One sample (+) doubtful
Two samples ( +) positive
All 3 samples (-), collect three more samples
Second set of 3 sputum samples
One sample (+) case is positive
All samples negative, do chest X-ray

c. Culture
- definitive method to detect bacilli - more
sensitive than sputum microscopy
- allows specific species identification and for drug
susceptibility patterns
- requires a period of 6-8 weeks for colonies to
appear on conventional culture media

Conventional solid media
Lwenstein-Jensen medium- egg-based medium
Middlebrook 7H10 and the 7H11 media- agar-
based media
Liquid media (eg, Dubos oleic-albumin media)

Note: - required incubation in 5-10% carbon
dioxide for 3-8weeks.
- usually have antibiotics

BACTEC system
Allows detection in 9 to 16 days vs. 4 to 6 weeks
in LJ media
Mycobacteria utilize 14C-palmitic acid
(radioactive) as sole carbon source, releasing 14-
CO2, which is detected by a machine.

d. PCR
Sensitive when even one bacillus is present
National TB Program

- TB control services are provided mainly through
public primary health care facilities
additional DOTS facilities within the NTPs
network of service providers that either refer
diagnosed TB patients for treatment or directly
provide TB treatment services using DOTS strategy
NTP has also established publicpublic and public
private partnerships for TB control
public hospitals, public medical colleges,
prisons/detention centres and military facilities
private DOT providers include private
physicians, private hospitals, private clinics, private
workplaces and NGOs.
- Nationwide expansion of TB testing in children
has been part of NTP since 2004


Treatment
DOTS
- Shortcourse chemotherapy
2 months of Isoniazid, rifampicin, pyrazinamide,
ethambutol
4 months of isoniazid and rifampicin




Work-up of PTB Suspect