LOWER RESPIRATORY BACTERIAL INFECTIONS

AETIOLOGY, DIAGNOSIS
Dr.T.V.Rao MD

DR.T.V.RAO MD

RESPIRATORY SYSTEM ENVIRONMENT IS DIVERSE

Upper respiratory system

Nose, pharynx, associated structures

Purpose: to take in, warm and moisten air Most common site of infections Lower respiratory system Larynx, trachea, bronchi, alveoli Purpose: ventilation, gas exchange
DR.T.V.RAO MD

ANATOMY OF THE RESPIRATORY SYSTEM (AND SITES OF INFECTION)

DR.T.V.RAO MD

CLINICAL PRESENTATION: LOWER RESPIRATORY TRACT INFECTION

Acute Infection:
Fever, chills Back pain, myalgias, arthralgias Headache, malaise, chills Nausea, vomiting

Chest Infection:
Cough Chest pain Rales, wheezing, noisy chest

Characteristic changes on chest x-rays Increasing respiratory distress, may require mechanical ventilation
DR.T.V.RAO MD

LOWER RESPIRATORY TRACT INFECTIONS EPIDEMIOLOGY

Pneumonia is the sixth leading cause of death in US

Increasing numbers of patients at risk
Aging population Increase in patients with immunocompromising conditions

DIAGNOSIS DEPENDS ON CLINICAL PRESENTATION AND AGE TOO

Most of these cases diagnosis depends on clinical presentation and minimum laboratory and radiologic investigations may be needed most of these cases recovered smoothly with appropriate management unless an underlying lung pathological or systemic disease may worsen the condition or continue with chronicity appropriate follow-up of these patients in OPC is appreciated especially after discharge from hospital
DR.T.V.RAO MD

LOWER RESPIRATORY TRACT

Infections of the lower respiratory tract are the leading cause of cause of mortality world wide. Streptococcus pneumoniae is the leading bacterial agent of community acquired pneumonia along with Haemophilus influenza and Moraxella catarrhalis

DR.T.V.RAO MD

PNEUMOCOCCUS A SIGNIFICANT PATHOGEN

Pneumococcus is the most common bacterial pathogen causing febrile pneumonia in children and adults The clinical syndrome is characteristic and distinctive : acute onset of high, spiking fever, with chills, cough, and sputum production
DR.T.V.RAO MD

CATEGORIES OF LOWER RESPIRATORY TRACT INFECTIONS

Acute bronchitis Community acquired pneumonia Hospital acquired pneumonia
Pneumonia in the immunocompromised host

DR.T.V.RAO MD

COMMUNITY ACQUIRED PNEUMONIA ETIOLOGIC AGENTS

Pathogen
Streptococcus pneumoniae

Frequency (%)
66

Haemophilus influenza
M catarrhalis Legionella species Mycoplasma pneumoniae Klebsiella species Enteric gram negative bacilli Staphylococcus aureus Chlamydia species Influenza viruses Other viruses Unknown
DR.T.V.RAO MD

1-12
10 2-15 2-14 3-14 6-9 3-14 5-15 5-12 <1-12 23-49
Sharp SE, et.al. Cumitech 2003
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Carroll KC. 2002. J Clin Microbiol 40:3115-3120.

SPECIMEN COLLECTION:

The patient should be standing, If possible or sitting upright in bed. He or she should take deep breath to full the lungs, and empty then in one breath, coughing as hard and as deeply as possible. Sputum brought up should be spit into screw capped container. Visually inspect the specimen. Tighten the cap of the container and send immediately to lab.
DR.T.V.RAO MD

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SPUTUM COLLECTION
Sputum of less than 2ml should not be processed unless obviously purulent Only 1 sputum per 24hr .submitted

Some scoring system should be used to reject specimen that re oral contamination.

DR.T.V.RAO MD

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TRANSPORTATION OF SPUTUM
Transportation in <2 hr is recommended with refrigeration if delays anticipated. Handle all samples using universal precautions. Perform Gram stain and plant specimen as soon as possible

DR.T.V.RAO MD

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INDUCED SPUTUM
Patients who are unable to produce sputum may be assisted by respiratory therapy technician. Aerosol induced specimen are collected by allowing the patient to breath aerosolized droplets of a solution of 15% sodium chloride and 10% glycerin for approximately 10 minute obtaining such specimen may avoid the need for a more invasive procedures ,such as bronchoscopy or needle aspiration, in many cases.

DR.T.V.RAO MD

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BRONCHOALVEOLAR LAVAGE (BAL) SPECIMEN ACCEPTABILITY

Microscopic examination of Gram-stained smear

Acceptable
<1% of cells present are squamous epithelial cells

Unacceptable >1% of cells present are squamous epithelial cells

ThorpeMD et. al. 1987. Bronchoalveolar lavage for diagnosing acute bacterial JE DR.T.V.RAO 15 pneumonia. J. Infect. Dis. 155:855-861

METHODS OF COLLECTION IS IMPORTANT..

Sputum collected under supervision of nurse or resident
Samples were processed immediately
Screened for epithelial cells Screened for predominant morphotype (> 75% of the organisms seen) Sputum planted to blood agar, chocolate agar and MacConkey agar

Strictly defined clinical and diagnostic parameters

DR.T.V.RAO MD

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MICROSCOPIC EXAMINATION
Prepare a gram stain smear for all lower respiratory tract specimens to determine the presence of oropharyngeal contamination (indicated by squamous epithelial cells) and lower respiratory tract secretions (indicated by WBCs) as well as to identity the most likely pathogens (Indicated by the predominant organisms associated with WBCs).

DR.T.V.RAO MD

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SPUTUM GRAM STAIN

Good quality specimens Quantify number and types of inflammatory cells Note presence of bronchial epithelial cells Concentrate on areas with WBCs when looking for organisms Determine if there is a predominant organism (> 10 per oil immersion field)
Semiquantitate and report organism with descriptive
If no predominant organism is present, report mixed gram positive and gram negative flora
DR.T.V.RAO MD

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SPUTUM GRAM STAIN IS HELPFUL - YES

Proponents

Demonstration of predominant morphotype on Gram stain guides therapy

Accuracy is good when strict criteria are used

Antagonists Poor specimen collection Intralaboratory variability (Gram stain interpretation) Low sensitivity and specificity Empiric treatment guidelines

Cheap, so why not?

DR.T.V.RAO MD

Do much dependence ???

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STUDIES PROVE ...

Overall sensitivity and specificity for pneumococcal pneumonia: 57% and 97% Overall sensitivity and specificity for H. influenza pneumonia: 82 % and 99%

Gram stain gave presumptive diagnosis in 80% of patients who had a good specimen submitted
> 95% of patients in whom a predominant morphotype was seen on Gram stain received monotherapy

DR.T.V.RAO MD

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REPORT GRAM STAINING WITH CAUTION

Be as descriptive as possible

Moderate neutrophils
Moderate Gram positive diplococcic suggestive of Streptococcus pneumoniae Few bacteria suggestive of oral flora Keep report shortavoid line listing of all morphotypes present
DR.T.V.RAO MD

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SQUAMOUS EPITHELIAL CELLS

If no squamous epithelial cell are found, report No epithelial cells seen If only a few epithelial cells are found report Few epithelial cells seen

If abundant epithelial cells seen, indicating oropharyngeal contamination, such specimens are graded as unsatisfactory sample.

DR.T.V.RAO MD

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REPORTING THE PRESENCE OF LEUCOCYTES:

If no WBC are found report No WBCs seen If WBCs are present in any amount state as few, moderate or numerous WBCs seen.
DR.T.V.RAO MD

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INTERPRETATION OF GRAM STAIN:

Squamous epithelial cells/ LPF*

None
0
0

Few

Moderate

Numerous

1-9
1-9

10-24
10-24

>25
>25

Neutrophils/LPF*

DR.T.V.RAO MD

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GRAM STAINING REPORTING MICROBIAL OBSERVATIONS

Type / Number of organisms / HPF**

Gram-positive cocci
Gram-negative cocci Gram-negative rods Gram-positive rods

PF*: (low power field) x 10 (examine 10-20 fields) HPF**: (high power field) oil immersion

DR.T.V.RAO MD

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PROCESSING SPECIMENS FOR CULTURE

Process specimens in biological safety cabinet, as aerosol can result in laboratory-squired respiratory infections. Process all specimens as rapidly as possible, especially specimen from emergency department, and inpatients. Select the most purulent or most bloodtinged portion of the specimen. Significant growth above the cutoff should be reported; however if more than one pathogen is isolated than it is suggestive of oropharyngeal contamination and clinical correlation should be done before reporting the samples.

DR.T.V.RAO MD

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CHOOSING CULTURE MEDIA:

Sheep Blood Agar MacConkey agar Chocolate agar
DR.T.V.RAO MD

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ROUTINE CULTURE
Most of the commonly sought etiologic agents of lower respiratory tract infection will isolated on routinely used media : 5% sheep blood agar ,MacConkey agar for isolation and differentiation of gram-negative bacilli ,and chocolate agar for Neisseria spp and Haemophilus .

DR.T.V.RAO MD

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CONTAMINATION WITH ORAL FLORA INTERFERES RESULTS

Because of contaminating oral flora ,sputum specimens, specimens obtained by bronchial washing, and lavage tracheostomy, or endotracheal tube aspirates are not inoculated to enriched broth or incubated anaerobically. Only specimens obtained by percutaneous aspiration (including trans tracheal aspiration )and by protected bronchial brush are suitable for anaerobic culture: he latter must be done quantitatively for proper interpretation.

DR.T.V.RAO MD

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CULTURING SPECIMENS FROM CYSTIC FIBROSIS Sputum specimens from patients known to have cystic fibrosis should be inoculated to selective agar ,such as manitol salt agar for recovery of S .aureus and selective horse blood-bacitracin ,incubated anaerobically and aerobically ,for recovery of H,influenzae that may be obscured by the mucoid P,aeroginosa on routine media.
DR.T.V.RAO MD

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SPUTUM AND ENDOTRACHEAL SUCTION

CULTURE EVALUATION
Identify and perform susceptibility testing on 2-3 potential pathogens seen as predominant on Gram stain Alpha streprule out S. pneumoniae Yeastrule out Cryptococcus neoformans only

S. aureus, Gram negative bacilli

< normal flora, quantify and limit ID; no susceptibility Add comment that organism not predominant on stain ID mould, Mycobacteria or Nocardia spp.
Modified from Sharp SE, et. Al. 2003. Cumitech 7B. ASM Press.
DR.T.V.RAO MD

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INTERPRETATION OF QUANTITATIVE PSB/BAL

Dilution Method
Quantify each morphotype present and express as CFU/ml

Calibrated Loop Method

Quantify each morphotype present and express as log 10 colony count ranges

Thresholds for significance

PSB > 103 CFU/ml BAL > 104 CFU/ml
Baselski and Wunderink. 1994. Clin Micro Rev 7:547

DR.T.V.RAO MD

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EXAMINE FOR AND ALWAYS REPORT.

Streptococcus pyogenes

Group B streptococci in pediatric population

Francisella tularensis Bordetella spp., especially Bordetella bronchiseptica

Yersinia pestis
Nocardia spp. Bacillus anthracis

Cryptococcus neoformans
Molds, not considered saprophytic contaminants Neisseria gonorrhoeae
DR.T.V.RAO MD

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ALWAYS REPORT, BUT DO NOT MAKE AN EFFORT TO FIND LOW NUMBERS, UNLESS THEY ARE SEEN IN THE SMEAR.

Streptococcus pneumoniae Haemophilus influenza report beta-lactamase

DR.T.V.RAO MD

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REPORT IF PRESENT IN SIGNIFICANT AMOUNTS, EVEN IF NOT PREDOMINANT

1 Moraxella catarrhalis

2 Neisseria meningitides

Report the following for nosocomial infections:

3. Pseudomonas aeruginosa 4. Stenotrophomonas maltophilia 5. Acinotobacter spp. 6. Burkholderia spp.
DR.T.V.RAO MD

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REPORT IF PRESENT IN SIGNIFICANT AMOUNT AND IF IT IS THE PREDOMINANT ORGANISM IN THE CULTURE, PARTICULARLY IF SUGGESTS INFECTION WITH MORPHOLOGY CONSISTENT WITH ISOLATE.

Staphylococcus aureus Beta-hemolytic streptococcus B (adults), C, or G Single morphotype of gram-negative rod (especially Klebsiella pneumoniae) Fastidious gram-negative rods; usually report betalactamase Corynebacterium spp. if urea positive or from ICU Rhodococcus equi in immunocompromised patients

DR.T.V.RAO MD

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ATS GUIDELINES DIAGNOSTIC TESTS FOR CAP

Empiric therapy for outpatients
Macrolide or tetracycline
Hospitalized patients with CAP

2 sets of pre-treatment blood cultures Pleural fluid Gram stain/culture when appropriate Studies for Legionella, Mtb, fungi in select patients Sputum Gram stain/culture only if resistant or unusual pathogen is suspected Avoid extensive testing ATS. 2001. Am J Respir Crit Care Med 163: 1730-1754.
DR.T.V.RAO MD

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CRITERIA FOR REJECTING SAMPLES

Mismatch of information on the label and the request

Inappropriate transport temperature

Excessive delay in transportation Inappropriate transport medium
specimen received in a fixative dry specimen sample with questionable relevance

Insufficient quantity Leakage

DR.T.V.RAO MD

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IMMUNOCOMPROMISED PATIENTS SUGGESTED BAL PROTOCOL

Aerobic Gram stain quantitative bacterial culture Fungal stain and culture Mycobacterial stain and culture Viral culture/Respiratory DFA Pneumocystis DFA

Legionella culture

DR.T.V.RAO MD

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MANY OTHER CAUSES OF PNEUMONIA WITH ACUTE RESPIRATORY DISEASE & FEVER

S.Pneumoniae

Legionella

TB

Plague

Tularemia

RICIN toxin Staphylococcal Enterotoxin B

SARS

SUMMARY
Respiratory system can host a variety of microbes

Normal flora in restricted areas

Susceptibility depends on age, immune system

Some organisms are adept at evading immune system

Damage generally due to cytotoxicity and inflammation Vaccines are available for some organisms
DR.T.V.RAO MD

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CHILDHOOD IMMUNIZATIONS CAN REDUCE RESPIRATORY INFECTIONS FOLLOW THE SCHEDULES

Birth 1m 2m 3m 4m 6m 12m 15m 18m 4-6y 11-12y

HBV2
DTP DTP Hib Hib Polio Hib DTP

HBV1

HBV3
DTP Hib Polio MMR
Varicella MMR or MMR Varicella

Polio

DO REMEMBER
The culture of lower respiratory specimens may result in more unnecessary microbiologic effort than any other type of specimen.
Raymond C Bartlett
DR.T.V.RAO MD

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 Programme created by Dr.T.V.Rao MD for Medical and Health Workers in the Developing World
Email
doctortvrao@gmail.com

DR.T.V.RAO MD

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