Reference: Medical

Bacteriology
Sleigh & Timbury
Chapter 28

Normal flora of the URT

Respiratory viruses

Orthomyxoviruses

Paramyxoviruses

Influenza virus A, B, C

Parainfluenza virus 1-4, Respiratory syncytial virus

Picorna viruses

Rhinoviruses
Enteroviruses
Echoviruses
Coxsackie A & B viruses

Adenoviruses

Coronaviruses

Pathogenesis

Source of infection

Usually human

Route of transmission

Patient with URTI

Carrier (incubation, subclinical or convalescent)

Shed in the respiratory secretions

Droplets are transmitted into the air
Inhaled into the respiratory tract

Infection

Infects the cells of the respiratory tract

Attaches to receptors on cell membrane and enters
Multiplies, destroys the cell and infects the adjacent
cells
May enter the blood giving rise to a viraemia

The upper respiratory

tract
Nose
Rhinitis

Throat

Pharyngitis

Epiglottis

Epiglottitis

Larynx

Laryngitis

Trachea

Laryngotracheobronchitis (croup)

Bronchus

Acute bronchitis

Bronchioles Bronchiolitis

Middle ear Otitis media

Sinuses

Sinusitis

Rhinitis

Pharyngitis and Tonsillitis

Otitis Media and Sinusitis

Epiglottitis

Laryngitis

Laryngotracheobronchitis (Croup)

Whooping Cough

Acute/Chronic Bronchitis

Bronchiolitis

Influenza

Pneumonia

Pleural effusion & Empyema

Lung Abscess

Tuberculosis

Commonest infections worldwide

Source: usually humans
carriers are important
Route of transmission : Inhalation
of droplets into the respiratory tract
The same clinical syndrome is
produced by a variety of agents
The same agent may produce a
variety of syndromes

Rhinitis
Also known as coryza or the common
cold
Aetiology: viruses eg. rhinoviruses
(more than
200 serotypes)
also coronavirus, RSV,
influenza virus, adenovirus,
parainfluenza virus
Clinical diagnosis
Hot drinks (coriander) and rest

Pharyngitis and Tonsillitis

Mainly

viruses eg. adenoviruses, EB

virus, rhinovirus, coronavirus

BUT

a few important bacteria 1. Group

A streptococcus
2.Diphtheria (Corynebacterium
diphtheriae)

Group A
StreptococcalPharyngitis

Source is usually a carrier with S.pyogenes

in the throat. 10-20% of children are carriers

Cannot clinically differentiate from viral

But more likely to have fever, exudate, cervical

lymphadenopathy
Less likely to have rhinitis, conjunctivitis

Have to take a throat swab for culture

Group A Streptococcal
Pharyngitis

Complications

LOCAL (peritonsillar abscess, retropharyngeal

abscess, sinusitis, otitis media) and DISTANT
(scarlet fever due to erythrogenic toxin)
LATE complications are rheumatic fever and
post-streptococcal glomerulonephritis

Treat with oral penicillin for 10 days or give

one injection of benzathine penicillin i.m.
Erythromycin in patients allergic to penicillin

Diphtheria
(Corynebacterium
diphtheriae)
Severe disease with a high mortality
Source: asymptomatic carriers
Spread by droplets
Inhaled into the respiratory tract
Disease due to diphtheria toxin (an
exotoxin)

Diphtheria
(Corynebacterium
diphtheriae)
Local necrosis in the throat may give rise to a

Local necrosis in the throat may give rise to a

grey-white membrane -- asphyxia
Distant effects of the toxin are on the heart and
the peripheral nerves
Throat swab has to be cultured on special media
Treatment is mainly antitoxin, equine antidiphtheritic serum (ADS)
Antibiotics : penicillin or erythromycin
Preventable by vaccination with diphtheria toxoid

Otitis media

Very common in childhood

Often viral
Secondary bacterial infection is common
Usually from normal flora (endogenous)
Streptococcus pneumoniae Haemophilus influenzae
(non-capsulated) Moraxella catarrhalis
Streptococcus pyogenes
Treatment: Empiric
Coamoxyclav, cefuroxime
Complications: chronic suppurative otitis media

Sinusitis

Often viral
Secondary bacterial infection is common
Usually from normal flora (endogenous)
Streptococcus pneumoniae Haemophilus
influenzae (non-capsulated) Moraxella
catarrhalis Streptococcus pyogenes
Treatment: Empiric
Coamoxyclav, cefuroxime
Complications: chronic sinusitis

Epiglottitis
Serious infection. May rapidly progress
to respiratory obstruction and death
Children < 5 y
Haemophilus influenzae b
Take blood cultures, do not swab
Ampicillin IV
Preventable by Hib vaccine

Laryngitis
hoarseness and loss of
voice

mainly in adults

mainly viral

Laryngotracheobronchitis
Also known as `croup
Children < 3 y
barking cough
Parainfluenza viruses
Steam inhalation

Pertussis (Whooping cough)

Bordetella pertussis
3 phases - catarrhal (like a rhinitis)
- paroxysmal (cough with
inspiratory whoop)
- convalescent
Complications: encephalopathy,
intracranial haemorrhage
bronchiecatasis

Pertussis (Whooping cough)

Pernasal swab or nasopharyngeal
aspirate
Cultured on special media
Erythromycin effective only in the
catarrhal phase
Preventable to a certain extent by
vaccination (killed pertussis bacteria in
the DPT)

Bronchitis

Acute bronchitis is mainly viral

Acute on Chronic bronchitis in people with damaged
bronchi (chronic bronchitis) due to smoking is mainly
bacterial
Infernal trio ( S.pneumoniae, H. influenzae,
Branhamella catarrhalis) Endogenous infections
Use antibiotics when the sputum turns purulent
(coamoxyclav, 1st or 2nd generation cephalosporin,
tetracycline)
Vaccinate COPD patients for influenza annually and for
pneumococcus

Bronchiolitis

Infants especially under 6 months

Present with an acute wheezy bronchitis
Mainly due to RSV
Clinical diagnosis
Nasopharyngeal aspirate for indirect
immunofluoresence to detect RSV antigen
Oxygenation and hydration

Influenza

Influenza viruses A , B, C
Systemic infection
Contain antigens H and N currently H3N2
Can undergo antigenic drift and lead to
outbreaks eg. A/Sydney/93/H3N2
OR
Influenza A can undergo antigenic shift
eg. H2N2 to H3N2 and lead to epidemics and
pandemics. (due to mixing with animal virus)

Influenza

High morbidity but usually self-limiting

Mortality in epidemics due to viral pneumonia
or secondary bacterial pneumonia (S.aureus)
Laboratory diagnosis : Nasopharyngeal
aspirate is tested for Influenza virus antigen
by indirect immunofluorescence.
Now treatment is available - amantadine
Prevention is by vaccination. Has to be
updated every year. Given to the elderly and
to people with chronic respiratory or heart
disease.
WHO conducts surveillance to detect a new
virus that may lead to a pandemic.

Pneumonia
Mostly bacterial
Lobar pneumonia, Bronchopneumonia
and Interstitial pneumonia
Community acquired or Hospital acquired
Community acquired
Typical and
Atypical

Typical CAP - Streptococcus pneumoniae

Haemophilus influenzae b
Atypical CAP - Mycoplasma pneumoniae
Chlamydiae pneumoniae

Pneumonia

Laboratory diagnosis of typical pneumonia

gram stain and culture of sputum and blood
Laboratory diagnosis of atypical pneumonia
serology for antibodies
Treatment of community acquired pneumonia
S.pneumoniae - penicillin / cefotaxime
H.influenzae - ampicillin/ cefotaxime
M.pneumoniae erythromycin/tetracycline
C.pneumoniae erythromycin/tetracycline
Vaccine is used in high-risk groups

Pneumonia
Hospital acquired pneumonia
Enterobacteria Pseudomonas aeruginosa
S.aureus
Less common causes of pneumonia
Viral pneumonia - influenza virus, RSV in
infants
Legionnaires disease (Legionella
pneumophila)
Zoonoses like psittacosis due to Chlamydia
psittaci and Q fever due to Coxiella burnetii

Pneumonia

Neonatal pneumonia
Chlamydia trachomatis in babies of
infected mothers

Pneumonia in the
immunocompromised
Mycobacterium tuberculosis
Pneumocystic carinii Atypical
mycobacteria Candida Aspergillus

Legionnaires disease

Legionella pneumophila
Source - Environment (water)
Transmission - aerosols that are inhaled into
the respiratory tract eg. airconditioning,
nebulisers, droplets from cooling towers
Severe in elderly
Mild fever (Pontiac fever) in the young
Laboratory diagnosis - detection of
legionella antigen in urine
Treatment - erythromycin
Prevention - proper management of water
systems in offices and hotels

Pleural effusion and

empyema
Complication of pneumonia
Complication of trauma or
surgery
Complication of tuberculosis

Aspiration pneumonia and

Lung abscess

May follow inhalation of vomit or

aspiration in an unconcious patient

Mainly oral flora including

anaerobes

BRONCHIECTASIS

Chronic suppuration of lungs

Chronic cough, fever, anorexia, loss of

weight, clubbing

Purulent sputum, haemoptysis

Mixed infection mainly anaerobes

Physiotherapy and surgical management

Tuberculosis