Lower respiratory tract infection

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2009)

Lower respiratory tract infection

Classification and external resources

Conducting passages.

ICD-10 J10-J22, J40-J47

Lower respiratory tract is the part of the respiratory tract below the vocal cords. While often used as a synonym
for pneumonia, the rubric of lower respiratory tract infection can also be applied to other types of infection
including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, high fever,
coughing and fatigue.

Lower respiratory tract infections place a considerable strain on the health budget and are generally more
serious than upper respiratory infections. Since 1993 there has been a slight reduction in the total number of
deaths from lower respiratory tract infection. However in 2002 they were still the leading cause of deaths
among all infectious diseases, and they accounted for 3.9 million deaths worldwide and 6.9% of all deaths that
year.[1]
There are a number of acute and chronic infections that can affect the lower respiratory tract. The two most
common infections are bronchitis and pneumonia.[2] Influenza affects both the upper and lower respiratory
tracts. Antibiotics are often thought to be the first line treatment in lower respiratory tract infections; however,
these are not indicated in viral infections. It is important to use appropriate antibiotic selection based on the
infecting organism and to ensure this therapy changes with the evolving nature of these infections and the
emerging resistance to conventional therapies.[3] H. influenzae and M. catarrhalis are of increasing importance
in both community acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis (AECB) while the
importance of S. pneumoniae is declining. It has also become apparent the importance of atypical pathogens
such as C. pneumoniae, M. pneumoniae andL. pneumophila, in CAP.[3]

Contents
[hide]

• 1 Classification

o 1.1 Bronchitis

o 1.2 Pneumonia

• 2 Treatment

o 2.1 Antibiotic Choice

o 2.2 Non-Pharmacological

Treatments

o 2.3 Complementary

Therapies

• 3 Epidemiology

• 4 Research

• 5 See also

• 6 References

[edit]Classification

[edit]Bronchitis

Main article: Bronchitis

Bronchitis can be classified as either acute or chronic. Acute bronchitis can be defined as acute bacterial or
viral infection of the larger airways in healthy patients with no history of recurrent disease.[2]It affects over 40
adults per 1000 each year and consists of transient inflammation of the major bronchi and trachea.[4] Most often
it is caused by viral infection and hence antibiotic therapy is not indicated in immunocompetent individuals.[5]
[6]
There are no effective therapies for viral bronchitis.[6][7] Treatment of acute bronchitis with antibiotics is
common but controversial as their use has only moderate benefit weighted against potential side effects
(nausea and vomiting), increased resistance, and cost of treatment in a self-limiting condition.[4][8] Beta2
agonists are sometimes used to relieve the cough associated with acute bronchitis. In a recent systematic
review it was found there was no evidence to support their use.[6]

Acute Exacerbations of Chronic Bronchitis (AECB) are frequently due to non-infective causes along with viral
ones. 50% of patients are colonised with Haemophilus influenzae, Streptococcus pneumoniae or Moraxella
catarrhalis.[2] Antibiotics have only been shown to be effective if all three of the following symptoms are
present:- increased dyspnoea, increased sputum volume and purulence. In these cases 500 mg of Amoxycillin
orally, every 8 hours for 5 days or 100 mg doxycycline orally for 5 days should be used.[2]

[edit]Pneumonia

Main article: Pneumonia

Pneumonia. It occurs in a variety of situations and treatment must vary according to the situation.[7] It is
classified as either community or hospital acquired depending on where the patient contracted the infection. It
is life-threatening in the elderly or those who are immunocompromised.[9][10] The most common treatment is
antibiotics and these vary in their adverse effects and their effectiveness.[9]Pneumonia is also the leading cause
of death in children less than five years of age.[11] The most common cause of pneumonia is pneumococcal
bacteria, Streptococcus pneumoniae accounts for 2/3 of bacteremic pneumonias.[12] A dangerous type of lung
infection with a mortality rate of around 25%.[10] For optimal management of a pneumonia patient the following
must be assessed;- pneumonia severity (including where to treat e.g. Home, hospital or intensive care),
identification of causative organism, analgesia of chest pain, the need for supplemental oxygen, physiotherapy,
Hydration, bronchodilators and possible complications of emphysema or lung abscess.[13]

For community acquired respiratory infections the appropriate use of fluoroquinolones is a therapeutic option.
These have been demonstrated to have targeted in vitro activity against both the typical and atypical
pathogens of interest.[14][15] The newer fluoroquinolones (e.g., moxifloxacin or gatifloxacin) have extended gram
+ve activity and once daily dosing and hence are potential first line in the treatment of lower respiratory tract
infections.[3] However it is clinical response that is the best indicators of efficacy and moxifloxacin or gatifloxacin
have been proven to be effective against community acquired respiratory tract infections clinically.[16][17]

[edit]Treatment

[edit]Antibiotic Choice
With increased development of drug resistance, traditional empirical treatments are becoming less effective,
hence it is important to base antibiotic choice on isolated bacteria and sensitivity tests. According to the
Cochrane review of antibiotic use in CAP in adults, the current evidence from RCTs is insufficient in order to
make evidenced based decisions on the antibiotic of choice. Further studies are required to make these
decisions.[9] For children they found amoxicillin or procaine penicillin to have greater effect than co-trimoxazole
for the treatment of CAP. In hospital settings, penicillin and gentamicin was found to be more effective than
chloramphenicol, with oral amoxicillin giving similar results to injectable penicillins.[11] In another review of
children with severe pneumonia, oral antibiotics were found to be as effective as injectable ones without the
side effects of pain, risk of infection, or high cost.[18] Also in a Cochrane review azithromycin has been shown to
be no better than Amoxycillin or Amoxycillin with clavulanic acid in the treatment of lower respiratory infections.
[19]
The AMH list Amoxycillin as first line of AECB and community acquired pneumonia where as IV
azithromycin is first line if high risk of death. If severe hospital acquired pneumonia it recommends IV
gentamicin and ticarcillin with clavulanic acid.[20]

[edit]Non-Pharmacological Treatments
In 2003 a very high quality, published research was done about the risk of hospitalization due to respiratory
illness and type of infant feeding in developed countries. It involved 3,201 breastfed babies and 1,324 non –
breastfed babies. It showed an overall 72 % reduction in the risk of hospitalization in infants who exclusively
breastfed for 4 or more months compared to those who were formula-fed. Therefore, exclusive breastfeeding
for 4 or more months is associated with a reduction in the risk of hospitalization secondary to lower respiratory
tract diseases.[21]

The mainstay of non pharmacological treatment for many years has been rest and increased fluid intake.
Although it is common for doctors and other health professional to recommend extra fluid intake a Cochrane
systematic review could find no evidence for or against increased fluid intake. Although the idea of replacing
fluids lost through fever and rapid breathing was sound, some observational studies reported harmful effects
such as dilution of blood sodium concentration leading to headache, confusion or possibly seizures.[22] Rest will
allow the body to conserve energy to fight off the infection. Physiotherapy is indicated in some types of
pneumonia and should be encouraged where appropriate.

[edit]Complementary Therapies
Chickweed taken orally has been used for many years to reduce fever and phlegm associated with bronchitis. It
is believed to act as an expectorant and although the pharmacological actions of several constituents suggest it
may be useful, controlled studies are not available to confirm its effectiveness.[23]

A systematic review of Chinese herbs used in the treatment of acute bronchitis found that there was weak
evidence for their use, but there were insufficient quality data to recommend them. The benefit found may be
due to study design or publication bias. Hence they should be used carefully because their safety is largely
unknown.[24]

Thyme is approved by commission E in the treatment of bronchitis and there are encouraging data for its use in
chronic bronchitis when used in combination with other herbs, however there is no stand-alone data.[23]
The use of Vitamin C is commonly thought to act to prevent colds and other respiratory infections. However
according to a recent Cochrane review the evidence is too weak to support its widespread use as a
prophylactic in preventing pneumonia in the general population. It may be reasonable to use in high risk
patients with low plasma levels of vitamin C due to its low cost and risk associated with is use.[25] Vitamin C
used as an orthomolecular antibiotic, is most effective when used in the same way; i.e., on timetable dosages.

Vitamin A has been successfully used to reduce the mortality and severity of respiratory infection with measles.
However in a review of non-measles pneumonia it was not found to have any benefit or harmful effects.[26]

Used by native healers for millennia, garlic contains allicin, a powerful anti-fungal and antibiotic compound.
Native American tribes have used garlic to treat coughs and croup. British herbalists use garlic for hoarseness
and coughs. Louis Pasteur studied garlic's antibacterial properties. During both World Wars, Allium
sativum was used as an antiseptic.

For the treatment of pneumonia baical skullcap was shown to be as effective as piperacillin after one treatment.
The piperacillin group resulted in 4 of 30 patients with fungal infections while there were none in the baical
skullcap group.[23]

[edit]Epidemiology

Disability-adjusted life year for lower respiratory infections per 100,000 inhabitants in 2002.[27]

no data less than 100 100-700 700-1400 1400-2100 2100-2800 2800-3500 3500-4200 4200-4900 4900-5600 5600-

6300 6300-7000 more than 7000

[edit]Research

It is likely that the future treatment of lower respiratory tract infections will consist of new antibiotics aimed at
facing the problems associated with the constant emergence of antibiotic resistance. With resistance evolving
so rapidly future treatments may include the use of vaccines to prevent these infections. Although a Cochrane
systematic review of a polysaccharide pneumococcal vaccine didn’t reduce the pneumonia or their related
deaths in adults, but was able to reduce incidence of more specific outcomes such as pneumococcal disease in
the elderly.[10] So it is hoped with further developments these will become more effective against pneumonia.

Vaccination of patients with AECB in the autumn months is thought to have a positive effect in reducing the
severity and number of exacerbations over winter. The oral vaccine described in this review was able to
decrease the carriage or non-typeable Haemophilus influenzae that is a common cause of exacerbations to
chronic bronchitis.[28] With good planning and further research these types of vaccines may reduce the burden
associated with lower respiratory diseases.

There are few treatments available for viral forms of bronchitis and pneumonia. Respiratory syncytial virus
(RSV), the main cause of these in children, could be potentially treated using a new monoclonal antibody
(mAb) Motavizumab. In animal trials it reduced antibody titres 100 lower than the only drug currently available
to treat the condition.[29] This holds great promise for future treatments of LRTI.

[edit]See also