Institute for Microbiology, Faculty of Medicine, Masaryk University and St. Anna Faculty Hospital, Brno Miroslav Votava Vladana Woznicová Ondřej Zahradníček Clinical Microbiology Lecture for 3rd-year dentistry students Institute for Microbiology, Faculty of Medicine, Masaryk University and St. Anna Faculty Hospital, Brno Agents of respiratory diseases Part One Importance of respiratory infections •The most important/frequent infections in GP‘s office (respiratory tract = an ideal incubator) •Big economic impact on the economics in general and on the health care in particular •Often produce outbreaks and epidemics •75 % (and even more in children) are caused by viruses Where is RTI localized? •clinical symptomatology + specific agents •It is necessary to distinguish: –upper respiratory tract (URT) infections (+ adjacent organs infections) –lower respiratory tract (LRT) infections (infections of lower respiratory ways + pneumonias) > URT infections and infections of adjacent organs – infections of nose a nasopharynx – infections of oropharynx incl. tonsillae – infections of paranasal sinuses – otitis media – conjunctivitis LRT infections and lung infections Infections of LRT – infection of epiglottis – infection of larynx and trachea – infection of bronchi – infection of bronchioli •infections of lungs Common flora in respiratory ways •i.e. bacteria typically found in respiratory tract of a healthy person •Nasal cavity: usually Staph. epidermidis, less often sterile, coryneform rods, Staph. aureus, pneumococci •Pharynx: always neisseriae and streptococci (viridans group), usually haemophili, rarely pneumococci, meningococci, enterobacteriae, yeasts •LRW: sterile, clinical materials from these sites are often contaminated by URW flora Rhinitis/nasopharyngitis - ETIOLOGY •Viruses – the most common - „common cold“: –more than 50 % rhinoviruses –coronaviruses (2nd position) –other respiratory viruses (but NOT flu!) •Bacteria: –Acute infections: usually secondary •Staph. aureus, Haem. influenzae, Strep. pneumoniae, Moraxella catarrhalis –Chronic infections: •Klebsiella ozaenae, Kl. rhinoscleromatis Rhinitis/nasopharyngitis - TREATMENT •Viral etiology - the majority of rhinitis and nasopharyngitis does not need antibiotic treatment and bacteriological examination •If necessary (pus full of polymorphonuclears, high CRP levels  markers of bacterial infection) treatment based on the result of bacteriological examination •Topical treatment - carriers of epidemiologically important pathogens - e.g. MRSA – mupirocin (Bactroban) Infectious rhinitis VS. allergic/vasomotoric rhihitis http://www.bupa.co.uk/health_information/asp/direct_news/general_health/rhinitis_240706.asp http://www.drgreene.org/body.cfm?xyzpdqabc=0&id=21&action=detail&ref=1285 Sinusitis/otitis media – ETIOLOGY I •Acute sinusitis and otitis usually started by respiratory viruses, M. pneumoniae (myringitis) •Secondary pyogenic inflammations: S. pneumoniae, H. influenzae type b, Moraxella catarrhalis, Staph. aureus, Str. group A, OR even anaerobes: genus Bacteroides, Prevotella, Porphyromonas, Peptostreptococcus •Complications: mastoiditis, meningitis purulenta Sinusitis/otitis media – ETIOLOGY II •Sinusitis maxillaris chronica, sinusitis frontalis chronica: Staph. aureus, genus Peptostreptococcus •Otitis media chronica: Pseudomonas aeruginosa, Proteus mirabilis Sinusitis/otitis media - EXAMINATION + TREATMENT •Relevant specimen – only a punctate from the middle ear or paranasal sinus; NOT nasal swab and NOT ear swab (contaminants, no pathogens) •Sinusitis ATB treatment ONLY in case of painful sinusitis, with teathache, headache, fever, lasting at least a weak, eventually neuralgia of N. Trigeminus •Otitis media ATB treatment only when inflammation (pain, red colour, fever) is presented and anti-inflammatory treatment is not sufficient •Aminopenicillin or a 1st gen. cephalosporin http://www.drgreene.org/body.cfm?xyzpdqabc=0&id=21&action=detail&ref=1285 Otitis media http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZPMV6D1AC&sub_cat=544 http://www.otol.uic.edu/research/microto/Microtoscopy/acute1.htm •Causative agents • same as in sinusitis Conjunctivitis - ETIOLOGY •Usually viral, accompanies acute URT infections/ adenovirus, enterovirus - hemorrhagic conjunctivitis, HSV - herpetic keratoconjunctivitis •Bacterial a. Acute: suppurative conjunctivitis: S. pneumoniae, S. aureus inclusion conjunct.: C. trachomatis D – K b. Chronic: S. aureus, C. trachomatis A – C (trachoma) •Allergic, mechanic (allien body) •Usually topical treatment Oropharyngeal infections - ETIOLOGY •Acute tonsillitis and pharyngitis: usually viral (rhinoviruses, coronaviruses, adenoviruses, EBV – inf. mononucleosis, coxsackieviruses – herpangina) •Among bacterial, the most important: ac. tonsillitis or tonsillopharyngitis due to S. pyogenes (= β-haemolytic streptococcus group A) •Other bacterial agents: streptococci group C, F, G, pneumococci, Arcanobacterium haemolyticum, H. influenzae?, N. meningitidis?, anaerobes? •Rare, but important: Corynebacterium diphtheriae, Neisseria gonorrhoeae Oropharyngeal infections -TREATMENT •Bacteriological examination recommended in all cases, incl. a „typical tonsilitis“ •When Streptococcus pyogenes is found, the „old good“ Fleming‘s penicillin is the best •Macrolides, e.g. clarithromycin should be used in allergic persons only (resistance, worse effect) •determination of CRP level (marker of a bacterial infection) is recommended Tonsilopharyngitis http://medicine.ucsd.edu/Clinicalimg/Head-Pharyngitis.htm http://www.newagebd.com/2005/sep/12/img2.html Viral tonsilopharyngitis http://upload.wikimedia.org/wikipedia/commons/thumb/b/b1/Pharyngitis.jpg/250px-Pharyngitis.jpg Purulent bacterial tonsilitis http://www.meddean.luc.edu/lumen/MedEd/medicine/PULMONAR/diseases/pul43b.htm Epiglottitis http://health.allrefer.com/health/epiglottitis-throat-anatomy.html de.wikipedia.org/wiki/Epiglottitis George Washington died of epiglottitis www.fathom.com/course/10701018/session4.html Epiglottitis • Serious disease – medical emergency The child may suffocate! •Practically only important agent: Haemophilus influenzae type b („Hib“) - vaccination Laryngitis and tracheitis •Respiratory viruses (other than agents of nasopharyngitis):parainfluenza/influenza A viruses & RSV •Bacterial: Chlamydophila pneumoniae, Mycoplasma pneumoniae, secondarily: S. aureus and Haemophilus influenzae, laryngotracheitis pseudomembranosa (croup): Corynebacterium diphtheriae •Throat swab is useless (different bacteria in pharynx than in larynx), except for chronical situations, microbiological examination is not indicated. •Treatment symptomatic - antibiotics NOT recommended Lagyngitis acuta http://www.emedicine.com/asp/image_search.asp?query=Acute%20Laryngitis www.cartoonstock.com/directory/l/laryngitis.asp www.cartoonstock.com/directory/l/laryngitis.asp Bronchitis - ETIOLOGY •Acute bronchitis: influenza, parainfluenza, adenoviruses, RSV Bacterial, secondarily after viruses: pneumococci, haemofili, stafylococci, moraxellae Bacterial, primarily: Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella pertussis •Chronic bronchitis (cystic fibrosis): Pseudomonas aeruginosa, Burholderia cepacia Bronchitis acuta http://www.yourlunghealth.org/lung_disease/copd/nutshell/index.cfm http://www.lhsc.on.ca/resptherapy/students/patho/brnchit5.htm Bronchiolitis •Isolated bronchiolitis in newborns and infants only: Pneumovirus (= RSV) Metapneumovirus https://www.nlm.nih.gov Pneumonia www.medicinenet.com/pneumonia/article.htm Types of pneumoniae •Acute – community-acquired pneumoniae –in originally healthy •adults •children –in debilitated persons –after a contact with animals (e.g. Pasteurella multocida, Coxiella burnetii - Q-fever, Chlamydophila psittaci - psittacosis) •Acute – nosocomial pneumoniae - ventilator-associated a) early b) late - others •Subacute and chronic pneumoniae Pneumoniae – ETIOLOGY I Acute, community- acquired, in healthy adults •bronchopneumonia and lobar pneumonia: –Streptococcus pneumoniae –Staph. aureus –Haemophilus influenzae type b •atypical pneumonia: –Mycoplasma pneumoniae –Chlamydophila pneumoniae –Influenza A virus (during an epidemic only) Pneumoniae – ETIOLOGY II Acute, community-acquired, in healthy children •Bronchopneumonia: –Haemophilus influenzae –Streptococcus pneumoniae –Moraxella catarrhalis –In newborns: Streptococcus agalactiae enterobacteriae •atypical pneumonia: –respiratory viruses (RSV, infl. A, adenoviruses) –Mycoplasma pneumoniae –Chlamydophila pneumoniae –in newborns: Chlamydia trachomatis D-K Pneumoniae – ETIOLOGY III •Acute, community-acquired, in debilitated individuals: –pneumococci, staphylococci, haemofili –Klebsiella pneumoniae (alcoholics) –Legionella pneumophila •In more serious immunodeficiency: –Pneumocystis jirovecii –CMV –atypical mycobacteria –Nocardia asteroides –aspergilli, candidae Pneumoniae – ETIOLOGY IV Acute, nosocomial: •Ventilator-associated pneumonia - VAP: –early (up to the 4th day of hospitalization): sensitive community strains –late (from the 5th day): resistant hospital strains •Others –viruses (RSV, CMV) –Legionella Pneumoniae – ETIOLOGY V •Subacute and chronic: –aspiration pneumonia and lung abscesses •Prevotella melaninogenica •Bacteroides fragilis •peptococci and peptostreptococci –lung tuberculosis and mycobacterioses •Mycobacterium tuberculosis •Mycobacterium bovis •atypical mycobacteria Pneumonia http://www.uspharmacist.com/index.asp?page=ce/105057/default.htm Bronchopneumonia www.szote.u-szeged.hu/radio/mellk1/amelk4a.htm See the inhomogenous shadow in the lower and middle lobes of the right lung Lobar and lobular pneumonia www.supplementnews.org/pneumonia Lung infections - EXAMINATION •Clinical examination and chest X-ray, differentiation classical × atypical pneumonia •Classical pneumoniae - properly taken sputum is useful, blood for blood culture, S. pneumoniae Ag in urine •Atypical pneumoniae - serology - mycoplasma and chlamydophila (+ „viral screen“). •Hospital pneumoniae also Legionella examination – Ag in urine Bronchitis and pneumonia - TREATMENT •In classic community pneumoniae amoxicilin, (eventually according to a causative agent and its antibiotic susceptibility) •In atypical pneumoniae tetracyclins or (especially in children < 8) macrolids. •Combination therapy •In hospital infections treatment according to in vitro susceptibility test - resistances! •In TB usually combination of three drugs Gerrit Dou (1613 - 1675) The Physician