Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)

Antibiotic Strategy in Lower
Respiratory Tract Infections
Gamal Rabie Agmy, MD,FCCP
Professor and Head of Chest Department ,
Assiut University

Learning Objectives
Recent guidelines for CAP
Recent updates in COVID 19
Imaging trends and algorithms.
What can I do if treatment of CAP had
failed?
HAP&VAP
AECOPD
Lung abscess and bronchiectasis
TB
Mycosis and parasitic diseases
Infections in immunocompromised patients

Should a Clinical Prediction Rule for
Prognosis plus Clinical Judgment
versus Clinical Judgment Alone Be Used
to Determine Inpatient versus Outpatient
Treatment Location for Adults with CAP?
In addition to clinical judgment, we recommend that
clinicians use a validated clinical prediction rule for
prognosis, preferentially the Pneumonia Severity Index
(PSI) over the CURB-65 to determine the need for
hospitalization in adults diagnosed with CAP.

15
PORT Scoring – PSI
Clinical Parameter Scoring
Age in years Example
For Men (Age in yrs) 50
For Women (Age -10) (50-10)
NH Resident 10 points
Co-morbid Illnesses
Neoplasia 30 points
Liver Disease 20 points
CHF 10 points
CVD 10 points
Renal Disease (CKD) 10 points
Clinical Parameter Scoring
Clinical Findings
Altered Sensorium 20 points
Respiratory Rate > 30 20 points
SBP < 90 mm 20 points
Temp < 350 C or > 400 C 15 points
Pulse > 125 per min 10 points
Investigation Findings
Arterial pH < 7.35 30 points
BUN > 30 20 points
Serum Na < 130 20 points
Hematocrit < 30% 10 points
Blood Glucose > 250 10 points
Pa O2 10 points
X Ray e/o Pleural Effusion 10 points
Pneumonia Patient Outcomes
Research Team (PORT)

16
Classification of Severity - PORT
Predictors
Absent
Class
I
 70
Class
II
71 – 90
Class
III
91 - 130
Class
IV
> 130
Class
V

17
CAP – Management based on PSI Score
PORT Class PSI Score Mortality % Treatment Strategy
Class I No RF 0.1 – 0.4 Out patient
Class II  70 0.6 – 0.7 Out patient
Class III 71 - 90 0.9 – 2.8 Brief hospitalization
Class IV 91 - 130 8.5 – 9.3 Inpatient
Class V > 130 27 – 31.1 IP - ICU

18
CURB 65 Rule – Management of CAP
CURB 65
Confusion
BUN > 30
RR > 30
BP SBP <90
DBP <60
Age > 65
CURB 0 or 1 Home Rx
CURB 2 Short Hosp
CURB 3 Medical Ward
CURB 4 or 5 ICU care

Need for ICU admission
We recommend direct admission to an ICU for patients
with hypotension requiring vasopressors or respiratory
failure requiring mechanical ventilation

MECHANISMS OF ACTION OF
ANTIBACTERIAL DRUGS
 Mechanism of action
include:
 Inhibition of cell wall
synthesis
 Inhibition of protein
synthesis
 Inhibition of nucleic acid
synthesis
 Inhibition of metabolic
pathways
 Interference with cell
membrane integrity

Patterns of Microbial Killing
Concentration dependent
– Higher concentration greater killing
Aminoglycosides, Flouroquinolones, Ketolides,
metronidazole, Ampho B.
Time-dependent killing
– Minimal concentration-dependent killing (4x
MIC)
– More exposure more killing
Beta lactams, glycopeptides, clindamycin,
macrolides, tetracyclines, bactrim

Table 1. Antibiotic Pharmacodynamic
Categories
Time-Dependent
(with minimal or
no PAE)
Concentration-
Dependent (with
PAE)
Time-Dependent,
Concentration-
Enhanced (with
PAE)
Beta-lactams
Vancomycin
Aminoglycosides
Daptomycin
Fluoroquinolones
Metronidazole
Azithromycin
Ketolides
Clarithromycin
Clindamycin
Erythromycin
Linezolid
Streptogramins
Tetracyclines
Tigecycline

 LOW VOLUME OF DISTRIBUTION
 INABILITY OF DIFFUSING THROUGH MEMBRANES
 INACTIVE AGAINST INTRACELLULAR PATHOGENS
 RENAL ELIMINATION AS UNCHANGED DRUG
HYDROPHILIC ANTIBIOTICS
• BETA-LACTAMS
 PENICILLINS
 CEPHALOSPORINS
 CARBAPENEMS
 MONOBACTAMS
• GLYCOPEPTIDES
• AMINOGLYCOSIDES
LIPOPHILIC ANTIBIOTICS
• MACROLIDES
• FLUOROQUINOLONES
• TETRACYCLINES
• CHLORAMPHENICOL
• RIFAMPICIN
• LINEZOLID
 HIGH VOLUME OF DISTRIBUTION
 ABILITY OF DIFFUSING THROUGH MEMBRANES
 ACTIVE AGAINST INTRACELLULAR PATHOGENS
 ELIMINATION AFTER LIVER METABOLIZATION
Pea F, Viale P, Furlanut M. Clin Pharmacokinet 2005, 44: 1009-1034

EFFECTS OF
COMBINATIONS OF DRUGS
 Sometimes the chemotherapeutic effects of
two drugs given simultaneously is greater than
the effect of either given alone.
 This is called synergism. For example,
penicillin and streptomycin in the treatment
of bacterial endocarditis. Damage to
bacterial cell walls by penicillin makes it
easier for streptomycin to enter.

EFFECTS OF
 Other combinations of drugs can be
antagonistic.
 For example, the simultaneous use of penicillin
and tetracycline is often less effective than
when wither drugs is used alone. By stopping
the growth of the bacteria, the
bacteriostatic drug tetracycline interferes
with the action of penicillin, which requires
bacterial growth.

EFFECTS OF
 Combinations of antimicrobial drugs should
be used only for:
1. To prevent or minimize the emergence of
resistant strains.
2. To take advantage of the synergistic effect.
3. To lessen the toxicity of individual drugs.

Resistance
Physiological Mechanisms
1. Lack of entry – tet, fosfomycin
2. Greater exit
 efflux pumps
 tet (R factors)
3. Enzymatic inactivation
 bla (penase) – hydrolysis
 CAT – chloramphenicol acetyl transferase
 Aminogylcosides & transferases
REVIEW

Resistance
Physiological Mechanisms
4. Altered target
 RIF – altered RNA polymerase (mutants)
 NAL – altered DNA gyrase
 STR – altered ribosomal proteins
 ERY – methylation of 23S rRNA
5. Synthesis of resistant pathway
 TMPr plasmid has gene for DHF reductase;
insensitive to TMP
(cont’d)
REVIEW

In the Outpatient Setting, Which
Antibiotics Are Recommended for
Empiric Treatment of CAP in Adults?
.
For healthy outpatient adults without comorbidities or risk
factors for antibiotic resistant pathogens, we recommend :
• amoxicillin 1 g three times daily or
• doxycycline 100 mg twice daily or
• a macrolide (azithromycin 500 mg on first day then 250
mg daily or clarithromycin 500 mg twice daily or
clarithromycin extended release 1,000 mg daily) only in
areas with pneumococcal resistance to macrolides <25%

In the Outpatient Setting, Which Antibiotics Are Recommended for
. 2. For outpatient adults with comorbidities such as chronic heart,
lung, liver, or renal disease; diabetes mellitus; alcoholism;
malignancy; or asplenia we recommend (in no particular order of
preference)
Combination therapy:
∘ amoxicillin/clavulanate 500 mg/125 mg three times daily, or
amoxicillin/clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125
mg twice daily, or a cephalosporin (cefpodoxime 200 mg twice
daily or cefuroxime 500 mg twice daily); AND
∘ macrolide (azithromycin 500 mg on first day then 250 mg daily,
clarithromycin [500 mg twice daily or extended release 1,000 mg
once daily])
or doxycycline 100 mg twice daily
OR

In the Outpatient Setting, Which Antibiotics Are Recommended for
. • Monotherapy:
∘ respiratory fluoroquinolone (levofloxacin 750 mg daily,
moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily)

In the Inpatient Setting, Which Antibiotic Regimens Are Recommended for
Empiric Treatment of CAP in Adults without Risk Factors for MRSA and P.
aeruginosa?
. In inpatient adults with nonsevere CAP without risk
factors for MRSA or P. aeruginosa ,we recommend the
following empiric treatment regimens :
• combination therapy with a β-lactam
(ampicillin + sulbactam 1.5–3 g every 6 h, ceftriaxone 1–2 g
daily ,cefotaxime 1–2 g every 8 h, or ceftaroline 600 mg
every 12 h) and a macrolide (azithromycin 500 mg daily or
clarithromycin 500 mg twice daily) or
• monotherapy with a respiratory fluoroquinolone
(levofloxacin 750 mg daily, moxifloxacin 400 mg daily)

Empiric Treatment of CAP in Adults without Risk Factors for MRSA and P.
aeruginosa?
. A third option for adults with CAP who have
contraindications to both macrolides and fluoroquinolones
is:
combination therapy with a β-lactam (ceftriaxone
,ampicillin + sulbactam, cefotaxime, ceftaroline, or, and
doxycycline 100 mg twice daily

Empiric Treatment of Severe CAP in Adults without Risk Factors for MRSA
and P. aeruginosa?
. In inpatient adults with severe CAP without risk
factors for MRSA or P. aeruginosa, we recommend :
• a β-lactam plus a macrolide (strong
recommendation, moderate quality of evidence);
or
• a β-lactam plus a respiratory fluoroquinolone
(strong recommendation, low quality of evidence).

In the Inpatient Setting, Should Patients with Suspected Aspiration
Pneumonia Receive Additional Anaerobic Coverage beyond Standard
Empiric Treatment for CAP?
. We suggest not routinely adding anaerobic
coverage for suspected aspiration
pneumonia unless lung abscess or
empyema is suspected

In the Inpatient Setting, Should Adults with CAP and Risk Factors for
MRSA or P. aeruginosa Be Treated with Extended-Spectrum Antibiotic
Therapy Instead of Standard CAP Regimens?
. We recommend abandoning use of the prior
categorization of healthcare-associated
pneumonia (HCAP) to guide selection of
extended antibiotic coverage in adults with CAP

In the Inpatient Setting, Should Adults with CAP and Risk Factors for
MRSA or P. aeruginosa Be Treated with Extended-Spectrum Antibiotic
Therapy Instead of Standard CAP Regimens?
. We recommend clinicians only cover empirically for
MRSA or P. aeruginosa in adults with CAP if locally
validated risk factors for either pathogen are present
Empiric treatment options for MRSA include vancomycin
(15 mg/kg every 12 h, adjust based on levels) or linezolid
(600 mg every 12 h). Empiric treatment options for P.
aeruginosa include piperacillin-tazobactam (4.5 g every 6
h), cefepime (2 g every 8 h), ceftazidime (2 g every 8 h),
aztreonam (2 g every 8 h), meropenem (1 g every 8 h), or
imipenem (500 mg every 6 h).

In the Inpatient Setting, Should Adults with CAP Be Treated with
Corticosteroids?
. We recommend not routinely using corticosteroids in
adults with nonsevere CAP (strong recommendation, high
quality of evidence).
We suggest not routinely using corticosteroids in adults
with severe CAP (conditional recommendation, moderate
quality of evidence).
We suggest not routinely using corticosteroids in adults
with severe influenza pneumonia (conditional
recommendation, low quality of evidence).
We endorse the Surviving Sepsis Campaign
recommendations on the use of corticosteroids in patients
with CAP and refractory septic shock

: In Adults with CAP Who Test Positive for Influenza, Should the
Treatment Regimen Include Antiviral Therapy?
. We recommend that antiinfluenza treatment, such as
oseltamivir, be prescribed for adults with CAP who test
positive for influenza in the inpatient setting, independent of
duration of illness before diagnosis (strong
recommendation, moderate quality of evidence).
We suggest that antiinfluenza treatment be prescribed for
adults with CAP who test positive for influenza in the
outpatient setting, independent of duration of illness before
diagnosis (conditional recommendation, low quality of
evidence).

In Adults with CAP Who Test Positive for Influenza, Should the Treatment
Regimen Include Antibacterial Therapy?
We recommend that standard antibacterial
treatment be initially prescribed for adults
with clinical and radiographic evidence of
CAP who test positive for influenza in the
inpatient and outpatient settings (strong
recommendation, low quality of evidence).

In Outpatient and Inpatient Adults with CAP Who Are Improving, What Is
the Appropriate Duration of Antibiotic Treatment?
We recommend that the duration of antibiotic
therapy should be guided by a validated measure of
clinical stability (resolution of vital sign
abnormalities [heart rate, respiratory rate, blood
pressure, oxygen saturation, and temperature],
ability to eat, and normal mentation), and antibiotic
therapy should be continued until the patient
achieves stability and for no less than a total of 5
days

In Adults with CAP Who Are Improving, Should Follow-up Chest Imaging
Be Obtained?
In adults with CAP whose symptoms have resolved
within 5 to 7 days, we suggest not routinely
obtaining follow-up chest imaging

COVID-19 (coronavirus disease 2019) is
an infectious disease caused by severe
acute respiratory syndrome coronavirus
2 (SARS-CoV-2), previously known
as 2019 novel coronavirus (2019-nCoV),
a strain of Corona Virus

The first cases were seen in Wuhan, China
in December 2019 before spreading globally.
The current outbreak was recognized as a
P a n d e m i c o n 1 1 M a r c h 2 0 2 0 .

Most people infected with the COVID-19
virus will experience mild to moderate
respiratory illness and recover without
requiring special treatment. Older people,
and those with underlying medical
problems like cardiovascular disease,
diabetes, chronic respiratory disease, and
cancer are more likely to develop serious
illness.

What about mild or asymptomatic cases of
COVID-19?
Asymptomatic transmission has not only been confirmed
in China, but recent modeling data found that mild or
asymptomatic cases that went undetected
("undocumented") accounted for 85% of total infections in
the earliest stages of the outbreak. The study found these
cases were less infectious on a per-contact basis, but
because those individuals weren't isolated they infected
more people in total.

How do you contract COVID-19?
A small cohort study in China found the virus present in
two patients' tears, indicating it might be transmissible
through eye secretions.
Research is starting to come from China that COVID-
19 vertical transmission from mother to baby is possible,
given several isolated case reports, and reports
of miscarriage related to placental infection, and maternal
death from cardiopulmonary complications are also
starting to emerge.

What are early symptoms of COVID-19?
In addition to fever, cough and shortness of breath, CDC now
lists several other symptoms: chills, repeated shaking with
chills, new loss of taste or smell, muscle aches, headache
and sore throat.
Examining data from patients admitted in New York City, prior
to respiratory symptoms, including about three-quarters
presented with cough or fever, and almost 60% with
shortness of breath. Gastrointestinal symptoms seem to be
more common in U.S. patients, with about a quarter
reporting diarrhea and 20% reporting vomiting.
It appears not all patients present with symptoms,
with research out of Germany in February finding patients
testing positive for COVID-19 despite being afebrile and
otherwise normal-seeming.

How is COVID-19 diagnosed?I
CDC criteria for testing include hospitalized patients with
symptoms of COVID-19, older symptomatic adults with
chronic medical conditions and/or who are
immunocompromised, and anyone who has been in close
contact with a suspected or confirmed COVID-19 case within
14 days, including healthcare professionals, or anyone who
has traveled to affected geographic areas within 14 days of
symptom onset..
A patient is swabbed, then the sample is tested via reverse
transcription polymerase chain reaction (RT-PCR) to
determine presence of viral RNA.
The FDA recently authorized the first serology test to
detect IgM and IgG antibodies under Emergency Use
Authorization, for diagnosing COVID-19 infection in
combination with other clinical and lab data.

What are risk factors for more severe
disease?
Reports from China indicate disease is much more severe in
older patients, with the highest mortality rate among adults
age 80 and older. Patients with other comorbidities are also
the most at risk, with U.S. data finding hypertension and
obesity were the most common chronic medical
conditions among patients hospitalized with COVID-19,
followed by chronic lung conditions, diabetes and
cardiovascular disease.
Data out of New York City found obesity as a risk factor for
mechanical ventilation. Patients requiring mechanical
ventilation were also more likely to need vasopressors, and
experienced other complications such as atrial arrhythmias
and new renal replacement therapy.

What does severe disease look like?
JAMA detailed 21 patients from Washington state 15 of
whom needed mechanical ventilation. All 15 had acute
respiratory distress syndrome, and eight developed
severe ARDS by 72 hours. Vasopressors were used for 14
patients, though most patients did not present with evidence
of shock, and seven patients developed cardiomyopathy.
Mortality among this group was 67%, 24% remained critically
ill and 9.5% were discharged from the ICU, as of March 17.
In New York City, a third of patients required intubation, and of
these, 30% did not get supplemental oxygen, meaning they
deteriorated quickly.
However, U.K. research indicated a lower proportion of
COVID-19 patients in the critical care unit survived
compared to patients with non-COVID-19 viral pneumonia
(52.1% vs 77.8%, respectively).

How is the disease treated?
Treatment mainly consists of supportive care, according to
CDC recommendations. The most common complications of
severe disease include pneumonia, hypoxemic respiratory
failure/ARDS, shock, multiorgan failure.
Since pneumonia is common, IV antibiotic use has been
widely reported, along with supplemental oxygen, with
anecdotal reports of proning and ultimately, mechanical
ventilation, including some patients who receive extra
corporeal membrane oxygenation (ECMO).

How is the disease treated?
Although corticosteroids were widely used in China, the CDC
generally recommends against them except in patients with
steroid-responsive comorbidities such as septic shock. "[Patients
with MERS-CoV or influenza who were given corticosteroids
were more likely to have prolonged viral replication, receive
mechanical ventilation, and have higher mortality," whereas
reports from China in COVID-19 were uncontrolled and
observational, the CDC explained
Research indicates patients hospitalized with COVID-19 often
develop blood clots, leading some international societies to call
for patients to receive prophylactic anticoagulant treatment to
prevent this complication. Additional research found longer
duration of anticoagulation therapy tied to reduced risk of
mortality in certain mechanically ventilated patients.

What are potential therapeutic options for
treating the virus?
There are currently no approved therapies to treat COVID-19,
although some have emergency use authorization (EUA),
including hydroxychloroquine and remdesivir. The NIH
released treatment guidelines, which noted both insufficient
clinical data to recommend for or against use of both
remedisivir and hydroxychloroquine and chloroquine.
Specifically, the agency noted monitoring patients who receive
HCQ for adverse effects, especially prolonged QTc interval.
The FDA recently issued a warning about the heart risks of the
drug.

What are potential therapeutic options for
treating the virus?
NIH also said there is insufficient clinical data to recommend
use of convalescent plasma or hyperimmune globulin, as
well as interleukin-6 inhibitors and interleukin-1 inhibitors.
The agency recommended against the use
of hydroxychloroquine plus azithromycin ,
lopinavir/ritonavir (Kaletra) or other HIV protease inhibitors,
interferons and Janus kinase inhibitors.

What is the status of clinical trials for
potential therapies?
Remdesivir has been available for compassionate use.
Many hospitals have begun to use hydroxychloroquine or
chloroquine, which is most commonly used to treat patients
with malaria, as well as arthritis and systemic lupus
erythematosus, although the supporting evidence is anecdotal at
best. The FDA has issued an Emergency Use Authorization
for hydroxychloroquine held in the National Strategic
Stockpile, although that does not make COVID-19 an approved
indication. Research found no difference in risk of ventilation
the drug in male veterans with severe COVID-19, and data out
of New York City found no difference in the risk of intubation
or death in hospitalized patients treated with
hydroxychloroquine.A small case series in China found three
of five patients treated with convalescent plasma were later
discharged from the hospital.

What is the status of clinical trials for
potential therapies?
Small trials overseas found improvements in overall survival of
hospitalized patients with cytokine-targeting therapy, anakinra
(Kineret) in Italy, and a three-drug regimen including lopanivir-
ritonavir (Kaletra), ribavirin and interferon beta-1b shortened
time to virus elimination in mild to moderate hospitalized cases
in Hong Kong.
For anti-cytokine agents such as tocilizumab (Actemra)
but evidence of benefit over standard treatment remains
scant. Controlled trials with tocilizumab are now underway,
including one sponsored by drugmaker Genentech/Roche.
Sanofi and Regeneron announced a phase II/III trial for
sarilumab (Kevzara), another anti-interleukin-6 agent, for
patients with severe COVID-19.
The Milken Institute has collated currently ongoing trials for
COVID-19 interventions on its website

What are the vaccine prospects?
Several companies and public health agencies have vaccines in
development, including the National Institute of Allergy and
Infectious Diseases. Phase I trials with vaccines are underway,
with a timeline of 12-18 months for a vaccine to be ready for
wide-scale deployment.
As of April 21, the Milken Institute counted 115 vaccine
candidates in development, including six in phase I and five in
phase I-II safety and efficacy studies in humans.

What is the prognosis for patients with
COVID-19?
Older patients and those with other comorbidities are the most at
risk, whereas the disease appears to be less severe among
younger patients. U.S. data seems to indicate fewer children
contract severe disease than adults, and hospitalization in this
population is most common among infants and children with
underlying conditions.
Research is starting to come from China that COVID-19 vertical
transmission from mother to babyis possible, given several
isolated case reports, and reports of miscarriage related to
placental infection, and maternal death from
cardiopulmonary complications are also starting to emerge.

What are some potential complications of
COVID-19?
Data from New York City indicated ST-segment elevation on the
EKG was complex, and confirmed COVID-19 cases were
complicated by ST-segment elevation, which could have
indicated potential acute MI.
Neurologic complications have been reported, with limited case
reports from Italy linking COVID-19 infection to Guillain-Barré
syndrome. And in China, more than a third of confirmed
COVID-19 cases had neurologic symptoms, such as acute
cerebrovascular events, impaired consciousness and muscle
injury, which were more common among patients who required
mechanical ventilation.
Acute ischemic stroke can be another complication of COVID-
19, with reports out of the U.K. indicating a series of patients
with large vessel occlusion, and U.S. reports finding acute
ischemic large vessel stroke even among younger adult

What are the long-term sequelae of COVID-
19?
It is unclear whether or how often COVID-19 survivors will
experience persistent pulmonary or other problems, or for how
long. Many patients have remained hospitalized with the illness
for weeks outside of China, out of an abundance of caution and
for public health reasons.
Researchers from China pointed to cardiovascular system
abnormalities in nearly half of a small group of SARS patients
in a 12-year follow-up cohort, as well as about two-thirds with
high lipids and 60% with glucose metabolism problems. They
suggested COVID-19 may also cause chronic damage to the
cardiovascular system, as the virus has a similar structure to
SARS.

70
CAP – Value of Chest Radiograph
• Usually needed to establish diagnosis
• It is a prognostic indicator
• To rule out other disorders
• May help in etiological diagnosis
J Chr Dis 1984;37:215-25

71
Infiltrate Patterns and Pathogens
CXR Pattern Possible Pathogens
Lobar S.pneumo, Kleb, H. influ, Gram Neg
Patchy Atypicals, Viral, Legionella
Interstitial Viral, PCP, Legionella
Cavitatory
Anerobes, Kleb, TB, S.aureus,
Fungi
Large effusion Staph, Anaerobes, Klebsiella

72
Normal CXR & Pneumonic Consolidation

73
Lobar Pneumonia – S.pneumoniae

S Curve of
Golden
When there is a mass
adjacent to a fissure, the
fissure takes the shape
of an "S". The proximal
convexity is due to a
mass, and the distal
concavity is due to
atelectasis. Note the
shape of the transverse
fissure.
This example represents
a RUL mass with
atelectasis

88
CXR – PA and Lateral Views

89
Lobar versus Segmental - Right Side

91
Special forms of Consolidation

92
Round Pneumonic Consolidation

Round pneumonia due to Streptococcus pneumoniae in a 53-yr-old male.
©2001 by European Respiratory Society
Round pneumonia due to Streptococcus pneumoniae in a 53-yr-old male.
Computed tomography demonstrates a focal area of homogeneous consolidation
in the left upper lobe. Note the presence of air-bronchogram within the
consolidation. Sputum culture produced a heavy growth of S. pneumoniae. In
adults, this form of pneumonia may mimic bronchogenic carcinoma.

Computed tomography scan in a 35-yr-old female demonstrates multiple ill-defined
subsegmental opacities in the middle and right lower lobe.
T. Franquet Eur Respir J 2001;18:196-208
Computed tomography scan in a 35-yr-old female demonstrates multiple ill-
defined subsegmental opacities in the middle and right lower lobe. Small cavities
and moderate right pleural effussion are also appreciated. Note a focus of
infection in the left lower lobe. Cultures from a bronchoscopic specimen grew
Staphylococcus aureus.

Close-up view of a posteroanterior chest radiograph in a 43-yr-old
alcoholic male with acute cavitating pneumonia by Staphylococcus
aureus.
Close-up view of a posteroanterior chest radiograph in a 43-yr-old alcoholic male with
acute cavitating pneumonia by Staphylococcus aureus. A poorly defined area of
airspace consolidation containing a rounded radiolucency (arrowheads) is depicted in
the right upper lung.

Adenovirus pneumonia in a 28-yr-old female. a) Close-up
view of a posteroanterior chest radiography demonstrates
poorly defined nodular opacities. b) Corresponding high-
resolution computed tomography scan shows multiple poorly defined bilateral
nodular opac...

Posteroanterior chest radiography in a patient with acquired immune
deficiency syndrome and a CD4+ count of 50 cells·mm3.
Posteroanterior chest radiography in a patient with acquired immune deficiency
syndrome and a CD4+ count of 50 cells·mm3. Bilateral asymetric mixed pattern
(interstitial and confluent alveolar opacities) are clearly demonstrated. In this clinical
setting, radiographical findings are considered highly diagnostic of Pneumocystis
carinii pneumonia.

A 28-yr-old patient with acute leukaemia presented with fever and a normal chest radiograph.
A 28-yr-old patient with acute leukaemia presented with fever and a normal chest
radiograph. High-resolution computed tomography scan demonstrates thickening of
the bronchial and bronchiolar walls and multiple bilateral ill-defined nodular opacities
with a “tree-in-bud” appearance. The final diagnosis was Aspergillus bronchiolitis.

Posteroanterior chest radiograph reveals bilateral nonsegmental
consolidations in the lingula and in the right upper and lower lobes.

Bronchial obstructing aspergillosis in a 24-yr-old male with acquired
immune deficiency syndrome.

Cytomegalovirus pneumonia in a 36-yr-old female after bone marrow
transplantation.
transplantation. A high-resolution computed tomography scan demonstrates multiple
nodular opacities with irregular margins surrounded by an area of ground-glass
attenuation. This halo of ground-glass attenuation is due to the haemorrhagic nature
of nodules

Angioinvasive aspergillosis in a 68-yr-old male with severe
neutropenia.
transplantation. A high-resolution computed tomography scan demonstrates
multiple nodular opacities with irregular margins surrounded by an area of ground-
glass attenuation. This halo of ground-glass attenuation is due to the
haemorrhagic nature of nodules

a) Close-up view of a posteroanterior chest radiography shows a
rounded cavitary consolidation in the left upper lobe. b) Material for
culture was obtained through fibreoptic bronchoscopy.

Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)

Antibiotic Strategy in Lower Respiratory Tract Infections (part 1)

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