Selected Respiratory Infections

1. Selected Respiratory Infections Toronto, November 09, 2013 Lionel A. Mandell MD FRCPC FRCP(LOND) Professor Emeritus of Medicine McMaster University

2. ACUTE BACTERIAL SINUSITIS • CAP • COUGHING • IMMUNIZATION

3. Acute Bacterial Sinusitis

5. Problems/Issues with AS Non infectious and infectious causes Infectious causes include viruses and bacteria Sinus involvement is an integral part of common cold syndrome (CCS) CCS is, in fact a viral rhinosinusitis (VRS) and not just a viral rhinitis

6. Clinical Manifestations Usually can’t separate clinical manifestations of VRS from acute bacterial sinusitis In both: sneezing nasal discharge (purulence) facial pressure/pain headache

7. Conventional Criteria for the Diagnosis of Sinusitis Based on the Presence of at Least 2 Major or 1 Major and ≥2 Minor Symptoms Major Symptoms Minor Symptoms • Purulent anterior nasal discharge • Headache • Purulent or discolored posterior nasal discharge • Ear pain, pressure or fullness • Nasal congestion or obstruction • Halitosis • Facial congestion or fullness • Dental pain • Facial pain or pressure • Cough • Hyposmia or anosmia • Fever (for subacute or chronic sinusitis) • Fever (for acute sinusitis only) • Fatigue

8. Summary • Diagnosis of ABS primarily clinical • Imaging helps if • Symptoms vague • Physical findings ambiguous • Symptoms persist despite medical treatment

9. Antimicrobials for ABS Indication Drug Initial Therapy Amox-Clav Beta-lactam allergy f/q doxy Risk of Resistance f/q Severe (hospital) f/q 3GC

10. Adjunctive Treatment

11. Intranasal corticosteroids (INCs) • Decongestants • Antihistamines • Nasal irrigants • Surgery

12. 62 yr old female healthy, “colds” since helping with grand kids x 7 days - cough - rhinorrhea - “pressure” O/E - pharyngeal erythema - slight discomfort palpation max. sinuses

13. Same patient - 1 week later Persistent rhinorrhea – purulent Persistent pressure Headache

14. Take Home Points- Acute Bacterial Sinusitis hard to distinguish viral from bacterial 2 major or 1 major / 2 minor x-rays may not help CT- max. sinus positive in 87% with “colds” 21% persist day 13 20 adjunctive Rx - INCs - nasal irrigants

15. CAP

17. Pneumonia CAP HCAP HAP/VAP

18. Impact 4 million cases annually 45,000 deaths 70 million days lost activity $ 10 billion

19. Pneumonia – Still the Old Man’s Friend? Kaplan V et al. Arch Internal Med 2003;163:317-323

20. Figure 3. Unadjusted and comorbidity-adjusted Kaplan-Meier survival estimates for age-, sex-, and race-matched cohorts of elderly patients hospitalized with community-acquired pneumonia (CAP) and for reasons other than CAP. Comorbidities were defined using the Charlson-Deyo comorbidity index. Unadjusted (A) and comorbidity-adjusted (B) survival estimates are presented for CAP patients and hospitalized controls. Expected survival in an age-, sex-, and race-matched US population is presented as a dotted line and was generated from US life tables. Unadjusted and comorbidity-adjusted 1-year mortality was higher for CAP patients than for hospitalized controls (P<.001).

21. Ambulatory Pts Hosp. non-ICU Severe (ICU) S. pneumoniae S. pneumoniae S. pneumoniae M. pneumoniae M. pneumoniae S. aureus H. influenzae C. pneumoniae Legionella sp. C. pneumoniae H. influenzae Gram-negative bacilli Respiratory Viruses* Legionella spp. H. influenzae Aspiration Respiratory Viruses* Most Common Etiologies of Community-Acquired Pneumonia # *Influenza A and B; Adenovirus; RSV; Parainfluenza; # Based on collective data from recent studies [223]

22. Diagnosis of CAP History Physical Lab/Procedures(X-ray)

23. CAP 80%20% outpts inpts <1% die 14% die

24. Outpatient Treatment • Previously healthy and no use of antimicrobials within the previous 3 months: A macrolide Doxycyline • Presence of comorbidities or use of antimicrobials within the previous 3 months (in which case, an alternative from a different class should be selected) Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin [750 mg]) Beta lactam PLUSa macrolide • In regions with a high rate of “high-level” macrolide-resistant S. pneumoniae, consider use of alternative agents listed above in 2 for patients with comorbidities

25. 31 year old female healthy, on BC pill x 13 yrs NP cough and fatigue x 2-3 days sharp, right midax pain x 1 day pain with inspiration O/E- rub right midax. area

26. 69 year old male diabetes, chronic bronchitis 45 pack year smoker cough x 4 days purulent sputum slight SOB

27. Take Home Points - CAP need CXR for diagnosis Rx: Cover S. pneumo and atypicals } macrolides, fqs length of Rx – uncomplicated : 5 - 7 days f/u CXR – 4 – 6 / 52

28. POST INFECTION COUGH

29. COUGH Acute <3 Chronic >8 Subacute 3-8

30. Post infection Cough Prior URTI (RTI) Normal CXR Cough x 3-8/ 52

31. Postulated Pathogenesis • disruption of epithelial integrity of airways • airway inflammation • bronchial hyperresponsiveness • Mucous hypersecretion • Impaired m-c clearance

32. CNS Efferent Afferent

33. Cough Triggers • Endogenous • upper airway secretions • gastric contents • Exogenous • smoke • dust

34. Treatment • self limited • usually resolves with time • can try ipratropium (atrovent) • if very bothersome – PO prednisone • inhaled steroids • antitussives

35. 58 year old male BP, asthma as child runny nose, sore throat, cough x 5-6 days cough persistent - now > 3/ 52 chest discomfort with cough initially given amox, then azithro x 2

36. Same story but more severe cough Cough to point of vomiting

37. Take Home Points-Post Infection Cough “cold” - most frequent cause of acute No infection - No antibiotics CXR - normal Rx - can try : atrovent ICS PO prednisone antitussive

38. IMMUNIZATION / PREVENTION

39. “WHEN MEDITATING OVER A DISEASE, I NEVER THINK OF FINDING A REMEDY FOR IT, BUT, INSTEAD, A MEANS OF PREVENTION.” LOUIS PASTEUR

40. Immunization / Prevention • Passive • antibodies • drugs • Active • disease • toxoid • vaccine

41. Important Now Aging population recognition of burden of vaccine preventable disease evidence of vaccine benefit and under utilization pneumococcal pneumonia can complicate influenza

42. Influenza • Agriflu (Novartis) (TIV) - IM • Fluad (Novartis) (TIV) - IM • Fluviral (GSK) (TIV) - IM • Fluzone (Sanofi Pasteur) (TIV) - IM • Influvac (Abbott) (TIV) - IM • Vaxigrip (Sanofi Aventis) (TIV) - IM • Intanza (Sanofi Pasteur) (TIV) - ID • Flumist (AStra Zeneca) (LAIV) - nasal spray

43. A / California / 7/ 2009 (H1N1) pdm- 09 like virus • A (H3N2) - antigenically like A /Victoria/ 361/2011 • B/ Massachusetts / 2/ 2012 – like virus

44. Focus on: Those at high risk of influ. complications Those able to spread virus to high risk Essential workers and those in poultry culling

45. Pneumococcal Vaccine – PSV (23) PCV (13)

46. Focus on High risk from disease > 65 years any age – resident of residential or group facility Defences (> 2 years age) asplenia sickle cell chronic liver, kidney, heart, lung disease immunity by disease, treatment transplant pts. diabetes CSF leaks alcohol / drugs homeless

47. PCV (13) • children (with other shots, age: 2,4,12 month) • extra dose PCV(13) at 6 mo. age } if defences PSV(23) at 2yrs age }

48. Drugs Drugs Treatment(5days)Prevention(10 days) Oseltamivir 75 mg PO bid 75 mg PO OD Zanamivir 10mg ( 2x 5mg inhal’ns) bid 10 mg (2x5mg inhal’ns) OD

50. Nursing Home • 4 residents with “influenza” • how to manage others - watch and wait - immunize - drugs - send home