Bronchitis vs Pneumonia Goroll 2009

8/8/2019 Bronchitis vs Pneumonia Goroll 2009

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Bronchitis-Pneumonia

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4 Questions:

(a) Bronchitis or Pneumonia?

(b) Is a diagnostic workup indicated?(c) Are antibiotics indicated(d) Is hospital admission necessary?



Bronchitis or Pneumonia?



Symptoms are similar

may all be present in both entities: Cough (productive or nonproductive),

Fever, chest discomfort, and fatigue.



Classic symptoms

³Classic´ pneumococcal pneumonia:o sudden chill -> o f ever, pleuritic pain, o

productive cough (rusty sputum). The ³atypical pneumonia´ ( Mycoplasma or Chlamydia):o sore throat and headache ->o nonproductive cough and dyspnea.



Signs

Pleuritis or dyspnea - tends to suggestpneumonia.

Evidence of consolidation is indicative of pneumonia but is present only in fewoutpatients.

Findings may be Misleading if underlyinglung disease.



Even CXR is problematic

1.In bronchitis - Chronic lung disease can simulate new inf iltrates

2.In pneumonia -Dehydration can minimize radiographic abnormalities



Is a diagnostic workup indicated?



Diagnosis

URI ± predominant nasal discharge, sore throat, or ear pain.

LRI ± predominant cough. But Symptoms ± are unreliable to diff erentiate bronchitis

f rom pneumonia Signs - entirely normal vital signs (no tachypnea,

tachycardia, high f ever, hypothermia) decreases the probability of pneumonia in outpatients to less than 1%!



Workup

crackles ± are not specif ic ± can be in bronchitis too!

The classic f indings of lung consolidation:

1.dullness to percussion, 2.egophony, 3.bronchial breath soundso are more specif ic f or pneumonia - but f ound only in 25%

of patients

Signs with etiologic signif icance: Er ythema multif orme - Mycoplasma pneumonia, Conf usion - Legionella.



CXR ± when to order? And Why?

If pneumonia is suspected, P A and lateral CXR is indicated.

1.to conf irm the diagnosis.

2.If pleural eff usion o poorer outcomeo thoracent esis should be per f ormed to assess f or the

presence of an empyema (Unless the pleural eff usion is minimal)

Additional labs are not necessar y (unless hospitalized).



Is hospital admission necessary?



PORT guidelines (NEJ M 1997;336:243)



PORT SCORE > 90 = Hospital

Score < 51: Risk Class I, 0.1-0.4% mortality. Outpatient

Score 51-70: Risk Class II, 0.6-0.7% mortality. Outpatient -------------------------------------------------------------------------------Score 71-90: Risk Class III, 0.9-2.8% mortality. Outpatient or inpatient -------------------------------------------------------------------------------Score 91-131: Risk Class IV, >2.8% mortality. Inpatient

Score > 130: Risk Class V, >>2.8% mortality. Inpatient



CURB 65 prediction rule

Conf usion, Uremia (blood urea nitrogen >20 mg/dL), Respirator y rate greater than 30 per minute, Blood pressure less than 90 mm Hg systolic or 60 mm Hg diastolic,

and age 65 years or older.

0 - 1 risk f actors - mortality low (0.7% and 2.1%, respectively).

These rules per f orm poorly in extreme or unusual circumstances. (eg: 20yr bp low, tachycardia, hypoxia).



Are antibiotics indicated



Antibiotic Therapy

Pneumonia ±o Empiric Antibiotic Tx initially o treatment f or 10 - 14 days.

Acut e bronc hi t is - is usually of viral origin -

empiric use of antibiotics does not improve outcomes!!!



Rule: Acute Bronchitis ± No Abx!

Most cases are viral Spontaneous resolution 1-2 weeks with or w/o Tx Overprescription of antibiotics in this population

is a major source of resistance. Also if Abx - X2 risk f or an individual of later

contracting a resistant inf ection!



Exception to the rule:

1.antibiotics are indicated f or COPD patients with acute exacerbation:

2.severe underlying disease (eg, congestive heart f ailure)

3.patients who are symptomatic f or more than 10 days1.Mycoplasma inf ection becomes a greater possibility. 2.P er t ussis ³ ³ ³

If an ant ibiot ic is t o be used, a macrolide is areasonable first c hoice!

because the macrolides are ac t ive against mycoplasmal and c hlamydial and B per t ussis.



Bordetella pertussis:

Young adults (childhood immunity wanes af ter 15-20 yrs )

25% of patients with bronchitis lasting 2 weeks or more. three phases of disease:

o cat arr hal phase - rhinorrhea, low-grade f ever, and mild congestion

-1 to 2 weeks.o paroxysmal phase severe paroxysms of nonproductive cough,

with 10-30 coughs in a row. 2 to 4 weeks Posttussive syncope and vomiting. the characteristic ³whoop´ is absent in adults

o convalescent phase ± symptoms gradually resolve during the next

1 to 3 months. A single elevated pertussis serology has been

advocated as a rapid means of diagnosing pertussis.



Pertusis Tx

Antibiotics are advocated if the f irst 4 weeks of illness (still inf ective).

The pref erred drugs are the f ollowing: Er ythromycin: 500mg X4/d - 14 days

Azithromycin: 500 mg day 1- then 250 mg f or 4additional days

Clarithromycin: 500mgX 2/d - 7 days Alternative: Resprim (800/160) X 2/d - 14 days

o TMP-SMZ - not usef ul in mycoplasmal inf ectionso Doxycycline ± not usef ul f or Pertussis

- Amoxicillin ± not so usef ul f or pertusis or mycoplasma



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Tx f or persons less than 60 years old: S. pneumoniae, Mycoplasma, Chlamydia,Legionella. Covered with:

Er ythromycin 500 mg X 4/d = f irst-line. or Azithromycin 500 mg on day 1, f ollowed by 250 mg daily f or 4 days,

or Clarithromycin 500 mg twice daily f or 10 days

Second-line: doxycycline (100 mg twice daily).

Respirator y f luoroquinolones: levof loxacin (T AV ANIC 500 mg), moxif loxacin (MEG AXIN 400 mg) = X 1/day.

Older quinolones (e.g., ciprof loxacin) = less activity against the pneumoco = not recommended.

Penicillins /cephalosporins - not cover atypical pneum.



Older Adults (>60) and Patients with Comorbidities:. S.pneumoniae remains the most common BUT: H. inf luenzae, M. catarrhalis, and other gram-negative

are possibilities. New Evidence: Mycoplasma and Chlamydiastill important!

also f or patients with recent (within 3 months) exposure to antibiotics (pneumococal resistance).

first-line: is a 2nd-generation macrolide (azithromycin or clarithromycin)

PLUS a high-dose -lactam: o amoxicillin, 1 g X 3/d, or o amoxicillin-clavulanate, 2 g twice daily.

o Alternative a respirator y f luoroquinolone.



For hospitalized patients:First-line:3rd-generation cephalosporin (1 g of cef triaxone

daily) PLUS

a second-generation macrolidein a dose suff icient f or Legionella inf ection:azithromycin 500 mg daily or clarithromycin 500 mg X2/d

Provides coverage f or resistant S. pneumoniae.

Therapy narrowed af ter diagnostic test results: such as Legionella urinar y antigen and blood cultures.

The alternative empiric treatment:

respirator y f luoroquinolone. concern about emerging resistance.



penicillin resistance of pneumococci mutations in penicillin-binding proteins

30% intermediate resistance ([MIC] of 0.1 to 1.0 µg/mL),

10% are highly penicillin resistant (MIC >2.0 µg/mL).

These highly resistant are of ten cross-resistant to multiple antibiotics, including trimethoprim/sulf amethoxazole and er ythromycin.

Fluoroquinolone resistance has been ver y low in S.

pneumoniae (<2%); now increasing.

emphasize the need to vaccinate high-risk patients. more than 85% of resistant organisms are serotypes

contained in the 23-valent vaccine

80% by prevnar (year 2000).



Monitoring

PORT study: temperature, RR, HR, and BP - reliable measures of stability.

average: ³normal´ vital signs at 3 days af ter hospitalization Of ten: Completely af ebrile: 6 days.

Repeating CXR at f requent intervals is wastef ul. particularly true of pneumocc or Legionella - still show an

inf iltrate a months later.

However, when worsening or f ever not resolving, CXR f or complications (abscess and empyema)

unusual or resistant organisms should be considered in these patients and antibiotic therapy appropriately adjusted.

More than 50% of patients with pneumonia continue to re ort f ati ue and cou h 1 month af ter dia nosis



Pneumococcal and Flu Vaccinepneumococcal vaccine 23 capsular types of pneumococci, which

together account f or about 90% of cases.

Indications: recover y f rom C AP, elderly (older than 65 years), CHF or COPD/ ASTHM A, are immunosuppressed, or have undergone splenectomy.

One-time revaccination af ter 5 years is recommended f or:immunosuppressed , f unctional asplenia, and elderly persons who received the initial vaccination bef ore age 65 years.

inf luenza vaccine - inactivated virus,

modif ied each year to include prevalent strains of inf luenza A and B. Indications: all patients older than age 50, pregnant women, and the high-risk groups mentioned previously. C/I: Hypersensitivity to eggs .

**The vaccines may be given at the same time without an increase in side eff ects or decrease in immunogenicity.



Pathogens



Gram-Positive Organisms

S treptococcus pneumoniae ±o 30% to 5 0% of all cases of bacterial pneumonia.

o especially young ambulatory patientso also acute exacerbations in COPDS taphylococcus aureus ±

o 10% of bacterial pneumonia

o most commonly follows a viral URI (influenza)o Patients - usually extremely ill.



Gram-Negative Organisms

H . influenzae common cause of bronchitis in COPD Bronchitis ± untypeable H.Flu

Pneumonias - especially type B. CXR - Bronchopneumonia Complications are uncommon ± unless

COPD (hypoxia)



Gram-Negative Organisms

K lebsiella pneumoniae: In debilitated patients, especially

alcoholics,

usually - acute illness; Rarely, chronic pneumonitis. tissue necrosis -> hemoptysis, Abcess.

CXR - dense lobar consolidation,Sputum may appear dark red andmucoid (³currant jelly´ sputum).



Other Gram-Negative- Hospitally acquires Pneumonias

Rare in Ambulator y setting Patients: Chronic disease or elderly

and frequently have received antibiotic

therapy.1.Moraxella (Branhamella) cat arr halis.2.Bordet ella per t ussis.

3.Legionnaires' Disease



catarrhalis:)Branhamella(Moraxella

f lora - orophar ynx of normal hosts Usually underlying pulmonary disease Other risk fac t ors: Diabet es, alcoholism,

malignancy, and st eroid use mild and somet imes self-limi t ed CXR interstitial+/-air space inf iltrate.



Bordetella pertussis:

Young adults (childhood immunity wanes af ter 15-20 yrs )

25% of patients with bronchitis lasting 2 weeks or more. three phases of disease:

o cat arr hal phase - rhinorrhea, low-grade f ever, and mild congestion

-1 to 2 weeks.o paroxysmal phase severe paroxysms of nonproductive cough,

with 10-30 coughs in a row. 2 to 4 weeks Posttussive syncope and vomiting. the characteristic ³whoop´ is absent in adults

o convalescent phase ± symptoms gradually resolve during the next

1 to 3 months. A single elevated pertussis serology has been

advocated as a rapid means of diagnosing pertussis.



Legionnaires' Disease

in 5%-10% of all community-acquired pneumonias (upto 30% of severe cases)

inf ection is acquired by inhalation of aerosols or

contaminated water. Risk f actors:cigarette smoking, chronic lung disease, and immunosuppression.

Spectrum of clinical illness: f rom mild URI and

self -limited atypical pneumonia to multif ocal pneumonia and respirator y f ailure.



Legionnaires' Disease (Cont)

short prodrome, then acutely high f ever, nonproductive cough, dyspnea,P leuri t ic c hest pain

E x t rapulmonary findings are uncommon but include: myocardi t is, pericardi t is, r habdomyolysis, and renal

dysfunc t ion. Diarr hea or confusion are of ten seen Relative bradycardia CXR - interstitial inf iltrates or areas of patchy

consolidation with a rapid progression. Legionella urinar y antigen is ver y sensitive f or disease

caused by L. pneumophila serogroup 1 (about 70% of all cases) and is easy to obtain.



Mixed Flora ±Aspiration pneumonias

Aerobic & anaerobic streptococci, Bac t eroides, and Fusobac t erium.

Risk f actors: impaired consciousness

(drugs, anesthesia, alcohol, head trauma) and diminution of the gag ref lex.

Lung abscess and empyema are f airly

common complications - especially if therapy is delayed.



Nonbacterial Organisms

Mycoplasma pneumoniae Chlamydia pneumoniae (TWAR). Viruses.

Psittacosis. Q Fever. F ungi and Other Opportunistic

Organisms.



Mycoplasma pneumoniae

10% to 25% of community-acquired pneumonia. leading cause of the at ypical pneumonia and also a

cause of acute bronchitis in healthy adults. long incubation period begins with headache, sore throat, and malaise, then

progresses to a nonproductive cough. Signs - usually un-impressive

o ery thema mul t iforme, is highly correlated with Mycoplasmainf ection in the patient with pneumonia.

o Bullous myringitis ± not common

CXR - pat c hy peribronc hial infil t rat es Lab:

o CBC ± normalo C old agglut inins in 50%

Uncommon complications: hemolytic anemia, aseptic

meningitis, Guillain-Barré syndrome, and myopericarditis.



Chlamydia pneumoniae - TWAR

10% to 20% of of community-acquired pneumonia

Also - acute bronchitis.

young adults The prodrome resembles Mycoplasma CXR - less extensive involvement

usually self -limited;



Viruses

the most common cause of acute bronchitis more than 80% of all cases!!! Viral pneumonia resembles an atypical

pneumonia

Common: inf luenza, adeno, RSV, parainf luenza.

immunocompromised ± CMV inf luenza pneumonia - f ever and myalgia,

mild or a f ulminant, Bacterial pneumonia (pneumococcal, staphylococcal) is a f requent complication.



Psittacosis

C hlamydia group also responsible f or trachoma transmitted f rom parrots or other birds

Atypical pneumonia



Q Fever

C oxiella burnet ii unique among rickettsial inf ections in that

pneumonia is prominent, no rash is associated

spread is through inhalation of inf ected dust particles rather than by way of the bite of an insect.

reside principally in animals; human contact with

cattle, sheep,goats, or inf ected animal skin or skin products. Clinically ±

o atypical pneumonia o hepatitis occurs in upto 33% of patients.



F ungi & Other Opportunistics

Immunosuppressed patients - Aspergillus, C andida, or PCP

However, some f ungal inf ections may occur in immunocompetent hosts:o exposure to spore-containing dusts ± hist oplasmosis,

coccidioidomycosis

nonproductive cough, f lulike illness, liver or splenic enlargement, CXR - alveolar inf iltrates, sometimes hilar adenopathy;

f ungal pneumonia, is usually self -limited without treatment except in immunocompromised hosts



:

60 ().1150 X 2 ± 10 .2500 X 3-4 ± 10 .3100 X 2 ± 7 ("

)

60 , COPD:

.1500 X 2 ±10

.2875 X 2 ±10

.3- ±Tavanic (levof loxacine).

+

Bronchitis vs Pneumonia Goroll 2009

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