Infecciones de las vías respiratorias bajas
GeneralidadesFredy RS Gutierrez MD, MSc, PhD
Hehkuviini @ Wikimedia Commons
Objetivos de aprendizaje
• Identificar los mecanismos que favorecen el desarrollo de Infecciones respiratorias bajas (IRB)
• Identificar los factores de riesgo para IRB• Identificar los principales cuadros de IRB• Reconocer los principales patógenos asociados a
las IRB• Identificar los principales aspectos en el enfoque
diagnóstico y terapéutico inicial de las IRB
Defensas Naturales
Defensas naturales
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Inflamación pulmonar
Nature Rv Microbiol 2012 June
Respuesta inmune pulmonar
Nature Rvev Immunol 2008 Feb
Moléculas de defensa de primera línea producidos por las células epiteliales de la vía aérea (AECS)
AEC-secreted product ActionMucins Host defence; bind infectious agentsSurfactant protein C Maintenance of surfactant proteins; bind
infectious agentsSurfactant protein A and surfactant protein D (collectins)
Opsoninsfor pathogen clearance; direct inhibition; activate other immune cellular functions
Complement and complement cleavage products
Promote phagocytosis; bridging of innate and adaptive immunity; resolution and repair
Antimicrobial peptides (defensins, cathelicidins, histatins, lysozyme, lactoferrin, SfPI, Elafin, PLUNC and BPI)
Direct antimicrobial action; effector molecules; activation of adaptive immunity
Nature Rvev Immunol 2008 Feb
Mecanismos de defensa pulmonar
Mecanismos de defensa pulmonar
Mecanismos pulmonares de defensa
Kumar, 2013 . Robbins Basic Pathology 9th Ed
Etiologia de las IR bajas
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Bronchitis Haemophilus infl uenzaeStreptococcus pneumoniaeMoraxella catarrhalisMycoplasma pneumoniaeAdenovirusesInfl uenzaRhinovirusRespiratory syncytial virus
Bronchiolitis Respiratory syncytial virusParainfluenza virusAdenovirusesRhinovirus
Community-acquired pneumonia (CAP) Streptococcus pneumoniaeLegionella pneumophilaM pneumoniaeH infl uenzaeAnaerobesStaphylococcus aureusEnteric gram-negative aerobesInfl uenza virusRespiratory syncytial virusAdenovirusChlamydia pneumoniaePneumocystis carinii (jiroveci)
Bronchiectasis Pseudomonas aeruginosaS aureusMucoid Escherichia coliH infl uenzae
BRONQUITIS AGUDA
Bronquitis aguda
• Viral 90%• Tos, broncoespasmo.• Cuadro hemático no diferencia virus vs bacterias;
Procalcitonina sí (<0.1ng/ml)• Puede haber + neumonía (7% de casos)• Ibuprofeno (400 mg) + clorfeniramina (12 mg),
c/12h; Broncodilatadores• Antibióticos, si se confirma etiología bacteirana• Vacunado para gripa no excluye etiol viral
Bronquitis aguda (etiologia)
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
BRONQUILITIS
Bronquiolitis
• Primer episodio de sibilancias, fiebre, tos, rinorrea y taquipnea en menor de 2 años.
• > 1°-10° mes de vida• Estacional; no en los trópicos (todo el año)• Causa: virus (VRS: 66%) • Hemograma: no útil• Diagnostico virológico: Ptes alto riesgo
Bronquiolitis (f. riesgo)
• Varones (1,5:1)• Madre joven• ↓Títulos anticuerpos VRS en sangre del cordón • ↓ nivel socioeconómico • Humo del tabaco• Hacinamiento,• Hermanos mayores• Guardería• No lactancia materna• Atopia o hiperreactividad Resp• Enfermedades causadas por el VRS
Bronquiolitis (patogénesis)
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Bronquiolitis (etiologia)
Bronquilitis (etiologia)
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Bronquilitis Dx Diferencial
• Reflujo GE• Aspiración• Cuerpo extraño• Absceso retro faríngeo• Adenoides hipertróficas• Fibrosis quística• Insuficiencia cardiaca congestiva
Exacerbaciones de la EPOC
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Bronquitis crónica
NEUMONIA
Neumonia bacteriana
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Neumonía: Enfoque inicial HC
• Síntomas• Entorno • Defectos en defensas• Exposición a microorganismos
Neumonia (manejo inicial)• Soporte vital• Directo (gram) y cultivo de esputo• Fibrobroncoscopia (indicaciones puntuales)
– Lavado Bronquio Alveolar• Aspirado endotraqueal• Hemocultivos (indicaciones puntuales: intrahospital)• Serologia (IgM; 4x IgG o 1:16)• Procalcitonina, prot C react, • Biopsia (transbronquial o abierta)• Toracoscopia• Análisis del derrame pleural: cult, PCR
– Exudativa (cult neg, ph>7.2, grlucosa > 60, LDH 3x↓)– Fibropurulenta drenaje– Costra pleural
• Antibiótico (cuál?)
Neumonía (Factores de riesgo )
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonía (Factores de riesgo )
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia bacteriana
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia en niños (etiologia)
Long Principles and Practice of Pediatrics Infectious Diseases 4th Ed 2012
Como se determina la severidad?Indicador Alta severidad
Age >65 years
Gender Male
Comorbidities Multiple or clinically significant
Presence of fever <35°C or >40°C
Cardiovascular instability Heart rate >125/mi
Respiratory rate >30 breaths/min
Arterial oxygen pressure <60 mm Hg
Saturation <90%
Metabolic derangement Blood urea nitrogen ≥ 30 mEq/L
Sodium 130 mEq/L
Glucose >250 mg/L
pH <7 .35
Manejo ambulatorio de la neumonia
• Patients < 65 years of age without coexisting disease:– Antimicrobial therapy: an oral macrolide or oral
doxycycline• Patients > 65 years of age and/or coexisting disease– Antimicrobial therapy: second-generation cephalosporin,
a β-lactam/β-lactamase inhibitor combination, – or trimethoprim-sulfamethoxazole – with or without a macrolide or new-generation
fluoroquinolone
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Manejo hospitalario de la neumonía
• Antimicrobial therapy: second- or third-generation cephalosporin or a β-lactam/β-lactamase inhibitor combination with a macrolide, oran advanced fl uoroquinolone
• Severe CAP generally requiring intensive care unit admission:– Antimicrobial therapy:β-lactam inhibitor plus either an
azilide/macrolide or an advanced fluoroquinolone (one from each group); consider adding vancomycin if methicillin-resistant S aureusis suspected until culture results are in
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Neumonía Nosocomial
• Hospital-acquired pneumonia: Dx > 48h postadmission• Ventilator-Associated Pneumonia: Dx 48-72h after
endotracheal intubation• Health care–associated pneumonia: Dx made < 48h after
admission with any of the following risk factors:– (1) hospitalized in an acute care hospital for > 48h within 90d of
the diagnosis; – (2) resided in a nursing home or long-term care facility; – (3) received recent IV antibiotic therapy, chemotherapy, or
wound care within the 30d preceding the current diagnosis; and – (4) attended a hospital or hemodialysis clinic
Neumonia nosocomial (etiologia)
• Pseudomonas aeruginosa• Klebsiella pneumoniae• Acinetobacter baumannii• Methicillin-resistant Staphylococcus aureus (MRSA)• Methicillin-sensitive Staphylococcus aureus (MSSA)• Legionella pneumophila• Stenotrophomonas maltophilia
http://emedicine.medscape.com/article/2012038-overview
NEUMONIA VIRAL
Neumonía viral
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia viral
Holt PG, Nature Immunol 2008;9:9 PMID:18711441
Neumonia viral
Holt PG, Nature Immunol 2008;9:9 PMID:18711441
Neumonia viral
Holt PG, Nature Immunol 2008;9:9 PMID:18711441
NEUMONIA POR HONGOS
Neumonía por hongos
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonía (otros agentes)
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia (etiologia)situaciones especiales
Long Principles and Practice of Pediatrics Infectious Diseases 4th Ed 2012
Neumonía «atípica»
• Mycoplasma pneumoniae– Bacteria sin pared (Mollicutes) muy pequeña– Ataca las celulas epiteliales del TR– Produce peróxido de Hidrógeno– Fuerte activacion del sist inmunitario– > de20 años; raro en < de 5– Macrólidos, tetraciclinas, quinolonas
NEUMONIA CRONICA
Neumonia cronica
• Semanas, mesesAlcoholismo, DM, tumor maligno intratorácico y EPOC, aspiración recurrente
Neumonias persistente y recurrente
Long Principles and Practice of Pediatrics Infectious Diseases 4th Ed 2012
Neumonia cronica
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia cronica
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia cronica
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Neumonia (Complicaciones)
• Absceso pulmonar• Derrame• Empiema
Abscesos pulmonares (etiologia)
Long Principles and Practice of Pediatrics Infectious Diseases 4th Ed 2012
Derrame pleural (causas no infecciosas)
Long Principles and Practice of Pediatrics Infectious Diseases 4th Ed 2012
TUBERCULOSIS PULMONAR
Tuberculosis
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
TB: Países endémicos
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Tb Primaria
Kumar, 2013 . Robbins Basic Pathology 9th Ed
Tb Primaria
Kumar, 2013 . Robbins Basic Pathology 9th Ed
Tuberculosis
Kumar, 2013 . Robbins Basic Pathology 9th Ed
Riesgo de infección
• Hospitales • Personal asistencial hospitalario• Centros de atención a pacientes con VIH• Albergues• Presidios
TB: Riesgo de infección
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Tb y VIH
Tratamiento de la TB
Mandell Principles and Practice of Infectious Diseases 7th Ed 2010
Lecturas sugeridas
• Mandell PPID 2010, Cap 61-64, 67• Long, Principles and Practice of Pediatric
Infectious Diseases 2012 Cap34
Pneumocystis carinii
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
Blastomyces dermatitidis
Juzar Ali Pulmonary Pathophysiology A CLINICAL APPROACH 3 rd Ed
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