Institute for Microbiology, Faculty of Medicine, Masaryk University and St. Anna Faculty Hospital, Brno Vladana Woznicová Miroslav Votava Ondřej Zahradníček Clinical Microbiology Lectures - dentistry studies 2013 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 –other respiratory viruses (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 - 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...) Complications: mastoiditis, purulent meningitis 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, ear swabs (contaminants) •Sinusitis ATB treatment ONLY in painful sinusitis, with teathache, headache, fever, lasting at least a weak, eventually neuralgia of N. Trigeminus •Otitis media ATB when inflammation (pain, red colour, fever) and anti-inflammatory treatment not sufficient •e.g. Aminopenicillin or 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 • 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) Most important bacterial: S. pyogenes (= β- haemol. streptococcus group A) •Other bacterial: streptococci group C, F, G, pneumococci, H. influenzae?, N. meningitidis?, •Rare, but important: Corynebacterium diphtheriae, Neisseria gonorrhoeae Oropharyngeal infections -TREATMENT •Throat swab recommended in all cases, incl. a „typical tonsilitis“ •Streptococcus pyogenes - penicillin still the best! •Macrolides, e.g. clarithromycin in allergic patients only (resistance, worse effect) •determination of CRP level (marker of a bacterial infection) 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! • Haemophilus influenzae type b („Hib“) - vaccination Laryngitis and tracheitis •Respiratory viruses (other than in nasopharyngitis): parainfluenza/influenza A viruses & RSV Treatment symptomatic - antibiotics NOT recommended •Bacterial: Chlamydophila pneumoniae, Mycoplasma pneumoniae, secondary: S. aureus and Haemophilus influenzae, laryngotracheitis pseudomembranosa (croup): Corynebacterium diphtheriae •Throat swab is useless, except for chronical situations. Lagyngitis acuta http://www.emedicine.com/asp/image_search.asp?query=Acute%20Laryngitis www.cartoonstock.com/directory/l/laryngitis.asp Bronchitis - ETIOLOGY •Acute bronchitis: influenza, parainfluenza, adenoviruses, RSV Bacterial - secondary: pneumococci, haemofili, stafylococci, moraxellae Bacterial - primary: 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 CAP –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 Pneumoniae – ETIOLOGY II •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 III 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 IV •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 - 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 •CAP amoxicilin, (eventually according to a causative agent and antibiotic susceptibility) •In atypical pneumoniae tetracyclins or (esp. in children < 8) macrolides. •Combination therapy •In hospital infections - susceptibility test - resistances! •In TB usually combination of three drugs Gerrit Dou (1613 - 1675) The Physician