Chapter 15 : Lower Respiratory Tract Infections

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This chapter focuses on the infectious etiologies and more common noninfectious causes of lower respiratory tract syndromes among major immunosuppressed populations. The changing epidemiology of infections in the era of highly active antiretroviral therapy (HAART) in the case of human immunodeficiency virus (HIV)-positive patients and the impacts of both newer immunosuppressant therapies and anti-infective prophylaxis for other immunocompromised hosts are discussed. The chapter emphasizes diagnostic approaches and practice algorithms. Both solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) patients are particularly at risk for , whereas the risk in HIV patients is not substantially higher than that seen in nonimmunocompromised patients. Plain chest radiographs are often inadequate for the immunocompromised host but may be helpful in the setting of new infiltrates. A recent retrospective study was performed in a medical/surgical intensive care unit on patients admitted with severe community-acquired pneumonia. A recent retrospective study was performed in a medical/surgical intensive care unit on patients admitted with severe community-acquired pneumonia. The performance of the immunochromatographic assay in this study was comparable to that in other published series. Tests for measurement of antibody are more useful for prescreening patients likely to be at risk for reactivation of infection or in the case of SOT and HSCT recipients, who are at risk for new infection from a seropositive donor. Studies reporting upon the diagnostic utility of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) provide conflicting and often controversial findings.

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15
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Image of Figure 1.
Figure 1.

Proposed infection timeline for SOT recipients. Dotted lines indicate the onset of infection that would occur without prophylaxis; solid lines indicate the most common times to onset of infection for each pathogen. Time zero indicates the time of transplantation. CAP, community-acquired pneumonia; Mtb, . (Modified with permission from reference .)

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15
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Image of Figure 2.
Figure 2.

Proposed infection timeline for HSCT recipients, based on the use of common prophylaxis. Dotted lines indicate the onset of infection that would occur without prophylaxis; solid lines indicate the most common times to onset of infection for each pathogen. Time zero indicates the time of transplantation, and each number following indicates months posttransplantation. CAP, community-acquired pneumonia; MTB, . (Modified with permission from reference .)

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15
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Image of Figure 3.
Figure 3.

Diagnostic approach to pulmonary infiltrates in the immunocompromised host, stratified by type of process and response to empiric management. FOB, fiber-optic bronchoscopy. (Modified with permission from reference .)

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15
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Table 1.

Radiographic appearances of pulmonary infiltrates in the immunocompromised host and likely etiologic agents

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15
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Table 2.

Recommended diagnostic studies for BAL, TBB, and SLB specimens

Citation: Carroll K. 2009. Lower Respiratory Tract Infections, p 333-356. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch15

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