Etiology of community-acquired pneumonia in adults: a systematic review

Outcomes and Predictors of Severe Community-acquired Pneumonia Among Adults Admitted to the University of Gondar Comprehensive Specialized Hospital: A Prospective Follow-up Study

Background

Severe community-acquired pneumonia is a common life-threatening infection with a high rate of unfavorable outcome. This study aimed to assess the outcomes and predictors of hospitalized severe community-acquired pneumonia patients at University of Gondar comprehensive specialized hospital.

Methods

A prospective follow-up study was conducted at University of Gondar comprehensive specialized hospital from May 1 to September 31, 2021. The data was collected by reviewing patients' charts and interviewing the patients themselves. Descriptive statistics, binary and multivariable logistic regression analysis were performed accordingly. Variables with p-value <0.2 on binary logistic regression were analyzed using multivariable logistic regression and variables with p<0.05 were considered to have significant association.

Results

A total of 239 admitted patients with severe community-acquired pneumonia were enrolled in the study. An unfavorable outcome was observed in 105 (44%) patients; 24.27% was in-hospital all-cause mortality, 12.5% was nonresolution, 5.8% was complicated cases, and 1.26% were gone against medical care for poor prognosis. After analyzing multivariable logistic regression, confusion (OR= 4.84; 95%CI: 1.47-15.88), anemia (OR= 2.36; 95%CI: 1.01-5.52), leukopenia (OR=4.38; 95%CI: 1.26-15.25), leukocytosis (OR=3.15; 95%CI: 1.23-7.96), elevated creatinine (OR=5.67; 95%CI: 1.72-18.65), intubation (OR=7.27; 95%CI: 1.58-33.37) and antibiotic revision during treatment for a different reason (OR=0.02; 95%CI: 0.01-0.07) were variables significantly associated with unfavorable outcome.

Conclusion

Unfavorable outcome was high among hospitalized severe community acquired pneumonia patients, and confusion, elevated creatinine, anemia, leukopenia, leukocytosis, intubation during admission, and antibiotic revision during the course were independent predictors associated significantly with the unfavorable outcome. It is important to consider the development of a treatment protocol for the hospital and to further research incorporating the microbiologic profile of the patients.

Adults with symptoms of pneumonia: a prospective comparison of patients with and without infiltrates on chest radiography

OBJECTIVE

Most studies on patients hospitalized with community-acquired pneumonia (CAP) require confirmation of an infiltrate by chest radiography, but in practice admissions are common among patients with symptoms of pneumonia without an infiltrate (SPWI). The aim of this research was to compare clinical characteristics, microbial etiology, and outcomes among patients with CAP and SPWI.

METHODS

Adults suspected of CAP were prospectively recruited at Landspitali University Hospital over a 1-year period, 2018 to 2019. The study was population based. Those admitted with two or more of the following symptoms were invited to participate: temperature ≥38°C or ≤36°C, sweating, shaking/chills, chest pain, a new cough, or new onset of dyspnea. Primary outcome was mortality at 30 days and one year.

RESULTS

Six hundred twenty-five cases were included, 409 with CAP and 216 with SPWI; median age was 75 (interquartile range [IQR] 64-84) and 315 (50.4%) were females. Patients with CAP were more likely to have fever (≥38.0°C) (66.9% [273/408]) vs. 49.3% (106/215), p < 0.001), a higher CRP (median 103 [IQR 34-205] vs. 55 (IQR 17-103), p < 0.001), identification of Streptococcus pneumoniae (18.0% [64/355]) vs. 6.3% (10/159) of tested, p = 0.002) and to receive antibacterial treatment (99.5% [407/409]) vs. 87.5% (189/216), p < 0.001) but less likely to have a respiratory virus detected (25.4% [33/130]) vs. 51.2% (43/84) of tested, p < 0.001). The adjusted odds ratios for 30-day and 1 year mortality of SPWI compared to CAP were 0.86 (95% CI 0.40-1.86) and 1.46 (95% CI 0.92-2.32), respectively.

DISCUSSION

SPWI is a common cause of hospitalization and despite having fever less frequently, lower inflammatory markers, and lower detection rate of pneumococci than patients with CAP, mortality is not significantly different.

Clinical, economic, and humanistic burden of community acquired pneumonia in Europe: a systematic literature review

BACKGROUND

Community-acquired pneumonia (CAP) is an infectious lung inflammation contracted outside the hospital. CAP is a leading cause of death among young children, elderly, and immunocompromised persons. Incidence can reach 14 cases/1,000 adults. Up to 50% of cases require inpatient hospitalization. Mortality is 0.7/1,000 cases or 4 million deaths per year. We sought to summarize multi-dimensional burden of CAP for selected European countries.

METHODS

We conducted a systematic literature review of literature published from 2011 to 2021 whereby we sought information pertaining to the epidemiologic, clinical, economic, and humanistic burden of CAP. Findings were summarized descriptively.

RESULTS

CAP incidence in Europe is variable, with the highest burden among those of advanced age and with chronic comorbidities. Etiology is primarily bacterial infection with Streptococcus pneumoniae being the most frequently implicated. Direct medical costs are primarily attributable to inpatient stay, which is exacerbated among high-risk populations. Higher mortality rates are associated with increasing age, the need for inpatient hospitalization, and antibiotic resistance.

CONCLUSIONS

A better understanding of CAP is needed, specifically the economic and quality of life burden on patients and caregivers. We recommend further assessments using population-level and real-world data employing consistent disease definitions.

Prevalence of Pneumococcal Serotypes in Community-Acquired Pneumonia among Older Adults in Italy: A Multicenter Cohort Study

Pneumococcal community-acquired pneumonia (CAP) is a leading cause of mortality. Following the introduction of pneumococcal conjugate vaccines (PCVs) in children, a decrease in the burden of the disease was reported. In parallel, an increase in non-vaccine serotypes was also noted. The objective of this study was to assess the current serotype-specific epidemiology of pneumococci among Italian older adults hospitalized for CAP. A prospective study was conducted between 2017 and 2020 in four Italian regions. Subjects aged ≥65 years hospitalized with confirmed CAP were tested for pneumococci using both pneumococcal urinary antigen and serotype-specific urine antigen tests able to identify all 24 serotypes included in the available vaccines. Of the 1155 CAP cases, 13.1% were positive for pneumococci. The most prevalent serotypes were 3 (2.0%), 8 (1.7%), 22F (0.8 %) and 11A (0.7%). These serotypes are all included in the newly licensed PCV20. The serotypes included in PCV13, PCV15 and PCV20 contributed to 3.3%, 4.4% and 7.5% of the CAP cases, respectively. In the context of a low PCV13 coverage among older adults and a high PCV coverage in children, a substantial proportion of CAP is caused by PCV13 serotypes. Higher valency PCV15 and PCV20 may provide additional benefits for the prevention of CAP in vaccinated older adults.

The Microbial Etiology of Community-Acquired Pneumonia in Adults: from Classical Bacteriology to Host Transcriptional Signatures

All modern advances notwithstanding, pneumonia remains a common infection with substantial morbidity and mortality. Understanding of the etiology of pneumonia continues to evolve as new techniques enable identification of already known organisms and as new organisms emerge. We now review the etiology of pneumonia (at present often called "community-acquired pneumonia") beginning with classic bacteriologic techniques, which identified Streptococcus pneumoniae as the overwhelmingly common cause, to more modern bacteriologic studies, which emphasize Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Enterobacteriaceae, Pseudomonas, and normal respiratory flora. Urine antigen detection is useful in identifying Legionella and pneumococcus. The low yield of bacteria in recent studies is due to the failure to obtain valid sputum samples before antibiotics are administered. The use of high-quality sputum specimens enables identification of recognized ("typical") bacterial pathogens as well as a role for commensal bacteria ("normal respiratory flora"). Nucleic acid amplification technology for viruses has revolutionized diagnosis, showing the importance of viral pneumonia leading to hospitalization with or without coinfecting bacterial organisms. Quantitative PCR study of sputum is in its early stages of application, but regular detection of high counts of bacterial DNA from organisms that are not seen on Gram stain or grown in quantitative culture presents a therapeutic dilemma. This finding may reflect the host microbiome of the respiratory tract, in which case treatment may not need to be given for them. Finally, host transcriptional signatures might enable clinicians to distinguish between viral and bacterial pneumonia, an important practical consideration.

Characteristics, Management, and Outcomes of Community-Acquired Pneumonia Due to Human Rhinovirus-A Retrospective Study

INTRODUCTION

Human rhinovirus (HRV) can lead to a variety of respiratory illnesses; it is also an uncommon cause of community-acquired pneumonia (CAP). We described the characteristics and outcomes of patients hospitalized for CAP due to HRV.

METHODS

We retrospectively studied consecutive adult patients admitted to King Abdulaziz Medical City-Riyadh with CAP due to HRV between 2016 and 2019. The diagnosis was made by respiratory multiplex PCR within 48 hours of hospitalization. We compared patients requiring ICU admission to those who did not.

RESULTS

One-hundred-and-six patients were studied (peak hospitalization between November and January, median age 71.5 years, hypertension 59%, diabetes 50%, and chronic respiratory disease 44.3%); 16 (15.1%) patients required ICU admission. The median pneumonia severity index score (PSI) was 107, with no significant difference between ICU and nonICU patients. ICU patients had a higher prevalence of tachypnea (62.5% vs. 26.7%, p=0.005), hemoptysis (12.5% vs 0%, p=0.001), and lymphopenia (71.4% vs 26.3%, p=0.01). Chest X-ray on presentation showed bilateral infiltrates in 47/101 (46.5%) patients and unilateral infiltrates in 26/101 (25.7%) patients. Systemic corticosteroids were used in 54.7% of patients (the median initial dose was 120 mg of prednisone equivalent and was higher in nonICU patients). Most (69.2%) ICU patients received mechanical ventilation (median duration of 8 days). Bacterial coinfection (6.6%) and superinfection (3.8%) were rare. The overall hospital mortality was 9.4% (higher for ICU patients: 37.5% vs. 4.4%, p < 0.001).

CONCLUSIONS

Most patients with CAP due to HRV were elderly and had significant comorbidities. ICU admission was required in almost one in six patients and was associated with higher mortality.

Young Healthy Patient With Severe COVID-19 and Fulminant Community-Acquired Pseudomonas aeruginosa Pneumonia: A Case Report

Community-acquired pneumonia (CAP) caused by Pseudomonas aeruginosa in healthy adults can rapidly lead to severe outcomes. We treated a case of P. aeruginosa-induced CAP and concurrent severe coronavirus disease (COVID-19) in a healthy 39-year-old man without other serious risk factors for severe illness except smoking. Immediately after admission, the patient developed sepsis and received intensive broad-spectrum antibacterial therapy with meropenem and vancomycin, veno-arterial extracorporeal membrane oxygenation (VAECMO), and catecholamine supplementation. Despite receiving multidisciplinary treatment, the patient died within 24 hours. P. aeruginosa with normal antimicrobial susceptibility was identified in blood and sputum cultures of samples taken at admission. Gram staining of the bacteria detected in blood cultures was suspicious for non-glucose-fermenting Gram-negative rods, including P. aeruginosa, and the antimicrobial regimen that was initiated following admission was considered effective. The patient was a plumber and a smoker, which are risk factors for P. aeruginosa-induced CAP, and the clinical course matched those in previous reports of P. aeruginosa-induced CAP, including necrotizing pneumonia with cavities and rapid progression of sepsis. Although COVID-19 can be the sole cause of septic shock, the combination of P. aeruginosa bacteremia and COVID-19 was possibly the cause of septic shock in this case. Even during an infectious disease pandemic, reviewing the patient's occupational history and comorbidities and performing blood and sputum culture tests, including Gram staining, are important for the provision of appropriate treatment.

Community-acquired pneumonia in hospitalised patients: changes in aetiology, clinical presentation, and severity outcomes in a 10-year period

BACKGROUND AND OBJECTIVE

Community-acquired pneumonia (CAP) is a frequent cause of hospitalisation. Several factors, such as pandemics, vaccines and globalisation may lead to changes in epidemiology, clinical presentation, and outcomes of CAP, which oblige to a constant actualisation. We performed this study to analyse how these factors have evolved over a 10-year period.

MATERIALS AND METHODS

Patients diagnosed with CAP for two 1-year periods that were 10 years apart (2007-2008 and 2017-2018) were included. We compared microbiological information, clinical data and evolutive outcomes in the two periods. A mortality analysis was performed.

RESULTS

1043 patients were included: 452 during the first period (2007- 2008), and 591 during the second period (2017-2018). Bacterial aetiology did not change during the 10-year period, besides a slight increase in Staphylococcus aureus (0.9% vs 2.9%, p = 0.026). There was a decline in the proportion of bacteraemia in the second period (14.8% vs 9.6%, p = 0.012). The incidence of complicated pleural effusion and septic shock declined too (6.4% vs 3.6%, p = 0.04 and 15.5% vs 6.3%, p < 0.001). Respiratory failure and Intensive care unit (ICU) admission were similar in both periods. Variables independently associated with mortality were age and septic shock. Influenza vaccine was a protective factor against mortality in the second period.

CONCLUSIONS

We have not found relevant differences in the bacterial aetiology of CAP over this 10-year period. There has been a decline in septic complications of CAP such as septic shock, bacteraemia, and complicated pleural effusion. Influenza vaccination is an important tool to reduce mortality.KEY MESSAGESThere were no differences in the bacterial pathogens causing CAP among the 10-year study period. There has been a decline in septic complications of CAP such as septic shock, bacteraemia, and complicated pleural effusion.

Atypical Pathogens in Adult Community-Acquired Pneumonia and Implications for Empiric Antibiotic Treatment: A Narrative Review

Atypical pathogens are intracellular bacteria causing community-acquired pneumonia (CAP) in a significant minority of patients. Legionella spp., Chlamydia pneumoniae and psittaci, Mycoplasma pneumoniae, and Coxiella burnetii are commonly included in this category. M. pneumoniae is present in 5-8% of CAP, being the second most frequent pathogen after Streptococcus pneumoniae. Legionella pneumophila is found in 3-5% of inpatients. Chlamydia spp. and Coxiella burnetii are present in less than 1% of patients. Legionella longbeachae is relatively frequent in New Zealand and Australia and might also be present in other parts of the world. Uncertainty remains on the prevalence of atypical pathogens, due to limitations in diagnostic means and methodological issues in epidemiological studies. Despite differences between CAP caused by typical and atypical pathogens, the clinical presentation alone does not allow accurate discrimination. Hence, antibiotics active against atypical pathogens (macrolides, tetracyclines and fluoroquinolones) should be included in the empiric antibiotic treatment of all patients with severe CAP. For patients with milder disease, evidence is lacking and recommendations differ between guidelines. Use of clinical prediction rules to identify patients most likely to be infected with atypical pathogens, and strategies of narrowing the antibiotic spectrum according to initial microbiologic investigations, should be the focus of future investigations.

Building on a Strong Foundation to Address a New Era to Help Protect Against Pneumococcal Disease

Antoni Torres, Respiratory Intensive Care Unit, Department of Pneumology and Respiratory Allergy, Hospital Clinic of Barcelona, University of Barcelona, Spain, opened the symposium, noting that pneumococcal conjugate vaccines (PCV) have reduced pneumococcal disease through direct and indirect effects. However, the burden of pneumococcal disease remains substantial in adults, supporting the importance of further reducing vaccine-preventable disease and its impact on healthcare resource utilisation and public health. Mário Ramirez, Faculty of Medicine, University of Lisbon, Portugal, and Molecular Microbiology and Infection Laboratory, Institute of Molecular Medicine, University of Lisbon, Portugal, reviewed the changing serotype epidemiology of pneumococcal disease in Europe, and described important differences between pneumococcal polysaccharide vaccines and PCVs. He detailed the dramatic direct impact of PCVs in children in decreasing the burden of vaccine-type (VT) pneumococcal disease, as well as indirect effects in unvaccinated populations, particularly adults. Residual VT-disease and increases in non-PCV13 disease underscore the need for additional disease coverage that may be afforded by higher-valent PCVs. Charles Feldman, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa, reviewed the considerable worldwide burden of lower respiratory tract infections (LRTI), including pneumococcal pneumonia. He noted that indirect effects in adults may be suboptimal, and herd effects may have reached their limit. Feldman described adult populations that should be prioritised for pneumococcal vaccination based on risk factors, and stressed the importance of a comprehensive approach to increase adult vaccination. Finally, Wendy Watson, Vaccines Clinical Research, Pfizer, Collegeville, USA, described the adult PCV20 clinical development programme, emphasising that it was built on the well-established PCV13 platform. In the Phase III clinical trial programme, PCV20 was well tolerated, with a safety profile similar to PCV13, regardless of prior pneumococcal vaccination history. Importantly, it was immunogenic across all ages studied and in those with chronic medical conditions. Wendy Watson concluded that PCV20 has the potential to simplify adult vaccination and help reduce the burden of adult pneumococcal disease.

The remarkable history of pneumococcal vaccination: an ongoing challenge

Although it varies with age and geographical distribution, the global burden of infection with Streptococcus pneumoniae (pneumococcus) remains considerable. The elderly, and younger adults with comorbid conditions, are at particularly high risk of pneumococcal infection, and this risk will increase as the population ages. Vaccination should be the backbone of our current strategies to deal with this infection.

Main body: This manuscript reviews the history of the development of pneumococcal vaccines, and the impact of different vaccines and vaccination strategies over the past 111 years. It documents the early years of vaccine development in the gold mines of South Africa, when vaccination with killed pneumococci was shown to be effective, even before the recognition that different pneumococci were antigenically distinct. The development of type-specific vaccines, still with whole killed pneumococci, showed a high degree of efficacy. The identification of the importance of the pneumococcal capsule heralded the era of vaccination with capsular polysaccharides, although with the advent of penicillin, interest in pneumococcal vaccine development waned. The efforts of Austrian and his colleagues, who documented that despite penicillin therapy, patients still died from pneumococcal infection in the first 96 h, ultimately led to the licensing first of a 14-valent pneumococcal polysaccharide in 1977 followed by the 23-valent pneumococcal polysaccharide in 1983. The principal problem with these, as with other polysaccharide vaccines, was that that they failed to immunize infants and toddlers, who were at highest risk for pneumococcal disease. This was overcome by chemical linking or conjugation of the polysaccharide molecules to an immunogenic carrier protein. Thus began the era of pneumococcal conjugate vaccine (PCV), starting with PCV7, progressing to PCV10 and PCV13, and, most recently, PCV15 and PCV20. However, these vaccines remain serotype specific, posing the challenge of new serotypes replacing vaccine types. Current research addresses serotype-independent vaccines which, so far, has been a challenging and elusive endeavor.

Conclusion: While there has been enormous progress in the development of pneumococcal vaccines during the past century, attempts to develop a vaccine that will retain its efficacy for most pneumococcal serotypes are ongoing.

Development and Validation of a Sensitive and Robust Multiplex Antigen Capture Assay to Quantify Streptococcus pneumoniae Serotype-Specific Capsular Polysaccharides in Urine

Streptococcus pneumoniae is a major cause of community-acquired pneumonia (CAP) in young children, older adults, and those with immunocompromised status. Since the introduction of pneumococcal vaccines, the burden of invasive pneumococcal disease caused by vaccine serotypes (STs) has decreased; however, the effect on the burden of CAP is unclear, potentially due to the lack of testing for pneumococcal STs. We describe the development, qualification, and clinical validation of a high-throughput and multiplex ST-specific urine antigen detection (SSUAD) assay to address the unmet need in CAP pneumococcal epidemiology. The SSUAD assay is sensitive and specific to the 15 STs in the licensed pneumococcal conjugate vaccine V114 (STs 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F) and uses ST-specific monoclonal antibodies for rapid and simultaneous quantification of the 15 STs using a Luminex microfluidics system. The SSUAD assay was optimized and qualified using healthy adult urine spiked with pneumococcal polysaccharides and validated using culture-positive clinical urine samples (n = 34). Key parameters measured were accuracy, precision, sensitivity, specificity, selectivity, and parallelism. The SSUAD assay met all prespecified validation acceptance criteria and is suitable for assessments of disease burden associated with the 15 pneumococcal STs included in V114.

IMPORTANCEStreptococcus pneumoniae has more than 90 serotypes capable of causing a range of disease manifestations, including otitis media, pneumonia, and invasive diseases, such as bacteremia or meningitis. Only a minority (<10%) of pneumococcal diseases are bacteremic with known serotype distribution. Culture and serotyping of respiratory specimens are neither routine nor reliable. Hence, the serotype-specific disease burden of the remaining (>90%) noninvasive conditions is largely unknown without reliable laboratory techniques. To address this need, a 15-plex urine antigen detection assay was developed and validated to quantify pneumococcal serotype-specific capsular polysaccharides in urine. This assay will support surveillance to estimate the pneumococcal disease burden and serotype distribution in nonbacteremic conditions. Data obtained from this assay will be critical for understanding the impact of pneumococcal vaccines on noninvasive pneumococcal diseases and to inform the choice of pneumococcal serotypes for next-generation vaccines.

Acetylsalicylic acid use is associated with improved survival in bacteremic pneumococcal pneumonia: A long-term nationwide study

BACKGROUND

Pneumonia is commonly caused by Streptococcus pneumoniae (pneumococcus) and associated with subsequent cardiovascular complications and increased mortality. Potential short-term survival benefits conferred by acetylsalicylic acid (ASA) use in pneumonia remain controversial, and long-term outcomes have not been studied.

OBJECTIVES

To evaluate the association between ASA use and survival for up to 1 year following bacteremic pneumococcal pneumonia.

METHODS

All bacteremic pneumococcal episodes in Iceland from 1975 to 2019 were reviewed. The study cohort consisted of individuals at least 18 years of age with symptoms and imaging results consistent with pneumonia. Differences in survival were assessed at 30 days, 90 days and 1 year using propensity score weighting (inverse probability weighting). Splitting and stratifying on survival at 7 days was done for the 30-day survival, because of nonproportionality.

RESULTS

In total, 815 bacteremic pneumococcal pneumonia episodes (median age 67 years, females 48%) were identified. Cox regression using propensity score weighting on the association of ASA with survival at 30 days showed an average hazard ratio (HR) of 0.60 (95% confidence interval [CI] 0.34-1.05). A significantly improved survival was observed within 7 days (HR = 0.42, 95% CI 0.19-0.92) but not during days 7-30 (HR = 1.08, 95% CI 0.46-2.55). ASA was associated with survival at 90 days (HR = 0.53, 95% CI 0.32-0.87) and 1 year (HR = 0.48, 95% CI 0.31-0.75).

CONCLUSION

Use of ASA upon admission for bacteremic pneumococcal pneumonia is associated with significantly reduced mortality for up to 1 year after diagnosis. ASA therapy in patients with pneumonia and other infectious syndromes warrants further study.

Ceftriaxone dosing based on the predicted probability of augmented renal clearance in critically ill patients with pneumonia

OBJECTIVES

PTA of protein-unbound ceftriaxone may be compromised in critically ill patients with community-acquired pneumonia (CAP) with augmented renal clearance (ARC). We aimed to determine an optimized ceftriaxone dosage regimen based on the probability of developing ARC on the next day (PARC,d+1; www.arcpredictor.com).

PATIENTS AND METHODS

Thirty-three patients enrolled in a prospective cohort study were admitted to the ICU with severe CAP and treated with ceftriaxone 2 g once daily. Patients contributed 259 total ceftriaxone concentrations, collected during 1 or 2 days (±7 samples/day). Unbound fractions of ceftriaxone were determined in all peak and trough samples (n = 76). Population pharmacokinetic modelling and simulation were performed using NONMEM7.4. Target attainment was defined as an unbound ceftriaxone concentration >4 mg/L throughout the dosing interval.

RESULTS

A two-compartment population pharmacokinetic model described the data well. The maximal protein-bound ceftriaxone concentration decreased with lower serum albumin. Ceftriaxone clearance increased with body weight and PARC,d+1 determined on the previous day. A high PARC,d+1 was identified as a clinically relevant predictor for underexposure on the next day (area under the receiver operating characteristics curve 0.77). Body weight had a weak predictive value and was therefore considered clinically irrelevant. Serum albumin had no predictive value. An optimal PARC,d+1 threshold of 5.7% was identified (sensitivity 73%, specificity 69%). Stratified once- or twice-daily 2 g dosing when below or above the 5.7% PARC,d+1 cut-off, respectively, was predicted to result in 81% PTA compared with 47% PTA under population-level once-daily 2 g dosing.

CONCLUSIONS

Critically ill patients with CAP with a high PARC,d+1 may benefit from twice-daily 2 g ceftriaxone dosing for achieving adequate exposure on the next day.

Chinese Patent Medicine Shufeng Jiedu Capsules as an Adjuvant Therapy for Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Shufeng Jiedu (SFJD) capsules can be used as adjunctive treatment for patients with community-acquired pneumonia, but the effectiveness and safety of SFJD are not clear. This review aims to evaluate the effectiveness and safety of SFJD based on randomized controlled trials (RCTs). Methods: A systematic review was conducted by searching PubMed, Embase, Scopus, Web of Science, CENTRAL, CNKI, VIP, CBM, Wanfang and trial registry platforms from their inception to March 2022. Two reviewers screened studies, extracted the data and assessed risk of bias independently. The data were pooled for meta-analysis or presented narratively. Results: Seventeen RCTs involving 1840 participants were included. All trials compared SFJD plus antibiotics to antibiotics, or combined with symptomatic treatment in both groups. The overall certainty of evidence was assessed as moderate to very low certainty. Compared with routine treatment (antibiotics alone or antibiotics plus symptomatic treatment), SFJD plus routine treatment showed beneficial effects in resolution of fever (MD -1.20 days, 95%CI -1.73 to -0.67; 10 RCTs; very low certainty), cough (MD -1.02 days, 95%CI -1.23 to -0.81; 9 RCTs; moderate certainty), phlegm (MD -1.46 days, 95%CI -2.84 to -0.08; 6 RCTs; very low certainty), pulmonary crepitations (MD -1.61 days, 95%CI -2.64 to -0.59; 8 RCTs; low certainty), shortness of breath (MD -2.80 days, 95%CI -2.88 to -2.72; 2 RCTs; low certainty) and chest pain (MD -2.85 days, 95%CI -3.01 to -2.69; 1 RCT; low certainty). There was no significant difference in pathogen clearance (1 RCT). No serious adverse events were reported, but 2.60% (5/192) patients reported nausea in the SFJD groups, 1.04% (2/192) participants in routine group, and no significant difference was identified. Conclusions: Current evidence suggests that adding SFJD may shorten the duration of symptom relief in community-acquired pneumonia for 1-2 days. The adverse events were minor and controllable, and no serious adverse events were reported. Well-reported trials and potential of reducing antibiotics were expected in the future studies.

Performance of PCR-based syndromic testing compared to bacterial culture in patients with suspected pneumonia applying microscopy for quality assessment

Syndromic testing for lower respiratory tract infections with BioFire® FilmArray® Pneumonia Panel Plus (BF) detects 27 pathogens with a turn-around-time of one hour. We compared the performance of BF with culture. Samples from 298 hospitalized patients with suspected pneumonia routinely sent for culture were also analyzed using BF. Retrospectively, patients were clinically categorized as having "pneumonia" or "no pneumonia." BF and culture were compared by analytical performance, which was evaluated by pathogen concordance, and by clinical performance by comparing pathogen detections in patients with and without pneumonia. The BF results for viruses and atypical bacteria were not included in the performance analysis. In 298 patient samples, BF and culture detected 285 and 142 potential pathogens, respectively. Positive percent agreement (PPA) was 88% (125/142). In patients with community-acquired pneumonia (CAP), clinical sensitivity was 70% and 51%, and specificity was 43% and 71% for BF and culture, respectively. In patients with hospital-acquired pneumonia, the corresponding numbers were 55% and 23%, and 47% and 68%. There was no significant improvement of performance, when only high-quality sputum samples were considered. Efficacy of both BF and culture was low. Both tests are best used in CAP patients for whom the diagnosis has already been clinically established. Indiscriminate use may be clinically misleading and a cause of improper use of antibiotics.

The host response in different aetiologies of community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) can be caused by a variety of pathogens, of which Streptococcus pneumoniae, Influenza and currently SARS-CoV-2 are the most common. We sought to identify shared and pathogen-specific host response features by directly comparing different aetiologies of CAP.

METHODS

We measured 72 plasma biomarkers in a cohort of 265 patients hospitalized for CAP, all sampled within 48 hours of admission, and 28 age-and sex matched non-infectious controls. We stratified the biomarkers into several pathophysiological domains- antiviral response, vascular response and function, coagulation, systemic inflammation, and immune checkpoint markers. We directly compared CAP caused by SARS-CoV-2 (COVID-19, n=39), Streptococcus pneumoniae (CAP-strep, n=27), Influenza (CAP-flu, n=22) and other or unknown pathogens (CAP-other, n=177). We adjusted the comparisons for age, sex and disease severity scores.

FINDINGS

Biomarkers reflective of a stronger cell-mediated antiviral response clearly separated COVID-19 from other CAPs (most notably granzyme B). Biomarkers reflecting activation and function of the vasculature showed endothelial barrier integrity was least affected in COVID-19, while glycocalyx degradation and angiogenesis were enhanced relative to other CAPs. Notably, markers of coagulation activation, including D-dimer, were not different between the CAP groups. Ferritin was most increased in COVID-19, while other systemic inflammation biomarkers such as IL-6 and procalcitonin were highest in CAP-strep. Immune checkpoint markers showed distinctive patterns in viral and non-viral CAP, with highly elevated levels of Galectin-9 in COVID-19.

INTERPRETATION

Our investigation provides insight into shared and distinct pathophysiological mechanisms in different aetiologies of CAP, which may help guide new pathogen-specific therapeutic strategies.

FUNDING

This study was financially supported by the Dutch Research Council, the European Commission and the Netherlands Organization for Health Research and Development.

Utilidad del cultivo de esputo en una población adulta con neumonía adquirida en la comunidad

Introducción. La neumonía adquirida en la comunidad (NAC) es una de las principales causas de muerte en el mundo ocupando el tercer lugar con aproximadamente 1,6 millones de muertes por año en personas mayores de 59 años. Al tratarse de una patología frecuente, precisa de métodos diagnósticos efectivos, rápidos y de bajo costo que permitan su ejecución cotidiana, entre estos, se han planteado la tinción de Gram y el cultivo de esputo como métodos disponibles desde el servicio de urgencias. Objetivo. Indagar la utilidad del cultivo de esputo en pacientes con NAC, en función de la modificación terapéutica.  Metodología. Estudio de corte transversal retrospectivo. Se tomaron todos los pacientes con diagnóstico relacionado con neumonía por CIE-10 entre los años 2011-2018 y se seleccionaron aquellos con cultivo de esputo positivo y se aplicaron los criterios de elegibilidad. Las variables continuas se presentaron a través de media y desviación estándar y las categóricas en frecuencias y porcentajes. Se realizó análisis bivariado en variables cualitativas mediante la construcción de tablas de contingencia de 2x2. En adición, para las variables cuantitativas se determinó la normalidad con la prueba de Shapiro-Wilk, posteriormente se hizo la relación de la variable desenlace con los días de hospitalización mediante una prueba de T student comprobando los supuestos de normalidad y homogeneidad considerando significativo un valor p menor a 0.05. Todo el análisis estadístico se realizó en el software RStudio 1.2.5001. Resultados. Se obtuvieron 255 registros de cultivos de esputo positivo, se incluyeron 49 pacientes; el 71.4% (n=35) de los pacientes presentaban como enfermedad concomitante la alteración pulmonar estructural. Los aislamientos identificados fueron Klebsiella pneumoniae (36.73%, n=18), Staphylococcus aureus (8.16%, n=4) y Cándida albicans en un 12.24% (n=6). El 71.4% (n=35) de los pacientes presentaban como enfermedad concomitante la alteración pulmonar estructural y en los factores de riesgo con mayor impacto se destacó el alcoholismo en el 10% (n=5) de la población. Conclusiones. El cultivo de esputo es útil solo en aquellos casos con empeoramiento del estado general, sin respuesta al manejo inicial, ya que la mayoría de los pacientes responden de forma adecuada al tratamiento farmacológico inicial recomendado por las guías internacionales y nacionales independiente del aislamiento microbiológico.

Respiratory etiological surveillance among quarantined patients with suspected lower respiratory tract infection at a medical center in southern Taiwan during COVID-19 pandemic

Background

A comprehensive study of respiratory pathogens was conducted in an area with a low prevalence of COVID-19 among the adults quarantined at a tertiary hospital.

Methods

From March to May 2020, 201 patients suspected lower respiratory tract infection (LRTI) were surveyed for etiologies by multiplex polymerase chain reaction (PCR: FilmArray TM Respiratory Panel) test combination with cultural method, viral antigen detection and serologic surveys.

Results

Total 201 patients tested with FilmArray TM Respiratory Panel were enrolled, of which 68.2% had sputum bacterial culture, 86.1% had pneumococcus and Legionella urine antigen test. Their median age was 72.0 year-old with multiple comorbidities, and 11.4% were nursing home residents. Bacteria accounted for 59.7% of identified pathogens. Atypical pathogens were identified in 31.3% of total pathogens, of which viruses accounted for 23.9%. In comparison to patients with bacterial infection, patients with atypical pathogens were younger (median= 77.2 vs 67.1, years, P = 0.017) and had shorter length of hospital (8.0 vs 4.5, days, P = 0.007).

Conclusions

Patients with LRTI caused by atypical pathogens was indistinguishable from those with bacterial pathogens by clinical manifestations or biomarkers. Multiplex PCR providing rapid diagnosis of atypical pathogens enhance patient care and decision making when rate of sputum culture sampling was low in quarantine ward during pandemic.

Accuracy of a score predicting the presence of an atypical pathogen in hospitalized patients with moderately severe community-acquired pneumonia

BACKGROUND

Atypical pathogens (AP), present in some patients with community-acquired pneumonia (CAP), are intrinsically resistant to betalactam drugs, the mainstay of empirical antibiotic treatment. Adding antibiotic coverage for AP increases the risk of adverse effects and antimicrobial selection pressure, while withholding such coverage may worsen the prognosis if an AP is causative. A clinical model predicting the presence of AP would allow targeting atypical coverage for patients most likely to benefit.

METHODS

This is a secondary analysis of a multicentric randomized controlled trial that included 580 adults patients hospitalized for CAP. A predictive score was built using independent predictive factors for AP identified through multivariate analysis. Accuracy of the score was assessed using area under the receiver operating curve (AUROC), sensitivity, and specificity.

RESULTS

Prevalence of AP was 5.3%. Age < 75 years (OR 2.7, 95% CI 1.2-6.2), heart failure (OR 2.6, 95% CI 1.1-6.1), absence of chest pain (OR 3.0, 95% CI 1.1-8.2), natremia < 135 mmol/L (OR 3.0, 95% CI 1.4-6.6) and contracting the disease in autumn (OR 2.7, 95% CI 1.3-5.9) were independently associated with AP. A predictive score using these factors had an AUROC of 0.78 (95% CI 0.71-0.85). A score of 0 or 1 (present in 33% of patients) had 100% sensitivity and 35% specificity.

CONCLUSION

Use of a score built on easily obtained clinical and laboratory data would allow safe withholding of atypical antibiotic coverage in a significant number of patients, with an expected positive impact on bacterial resistance and drug adverse effects.

TRIAL REGISTRATION

NCT00818610.

Pneumococcal vaccination rates in immunocompromised patients in Germany: A retrospective cohort study to assess sequential vaccination rates and changes over time

Background

Pneumococcal vaccination is recommended by the German Standing Committee on Vaccination (STIKO) for infants, elderly 60+ years and patients at risk. In 2016, a sequential pneumococcal vaccination schedule (conjugate vaccine followed by polysaccharide vaccine 6–12 months later) supplemented this recommendation for immunocompromised patients ≥2 years of age. Previous research showed low pneumococcal vaccination rates (pnc-VR) in this vulnerable group. Moreover, no evidence is available on adherence to the newer sequential schedule. This study aimed to analyze the development of pnc-VRs in immunocompromised patients and rates of sequential vaccinations according to the STIKO recommendations.

Methods

Using a representative health claims database, we assigned incident immunocompromised patients ≥2 years of age to one of two successive cohorts to observe trends over time: cohort A (first diagnosis of immunocompromised condition between 01/2013 and 12/2014), and cohort B (first diagnosis between 01/ 2015 and 12/2017). Pnc-VR within two years after first diagnosis and cumulative pnc-VR was compared among both cohorts. In cohort B, we assessed sequential pnc-VR within 15 months of the first vaccination. For additional analyses, patients were stratified by age, gender and immunocompromising condition.

Results

Cohort A and B comprised 193,521 and 289,279 patients, respectively. Overall pnc-VR increased over time from 4.3% (cohort A; 95%-confidence interval: 4.3%-4.4%) to 6.0% (cohort B; 5.9%-6.1%), with highest pnc-VRs in men ≥60 years (11.3%: 11.1%-11.6%) and HIV patients (15.2%: 13.1%-17.4%). Cumulative pnc-VRs in cohort B were higher in any quarter following diagnosis when compared with cohort A. Overall sequential pnc-VR in cohort B was 4.0% (3.7%-4.3%), with a higher rate observed in patients aged 16–59 (6.8%: 6.0%-7.7%) vs. patients aged ≥60 years (3.1%: 2.8%-3.4%).

Conclusion

While some improvements were seen over time, pnc-VRs remain very low in immunocompromised patients, as did sequential vaccination rates. Current recommendations to protect immunocompromised patients from pneumococcal infections are not being sufficiently implemented.

Non-invasive pneumococcal pneumonia due to vaccine serotypes: A systematic review and meta-analysis

BACKGROUND

Non-invasive pneumococcal pneumonia causes significant morbidity and mortality in older adults. Understanding pneumococcal sero-epidemiology in adults ≥50 years is necessary to inform vaccination policies and the updating of pneumococcal vaccines.

METHODS

We conducted a systematic review and random-effects meta-analysis to determine the proportion of community-acquired pneumonia (CAP) in people ≥50 years due to pneumococcus and the proportion caused by pneumococcal vaccine serotypes. We searched MEDLINE, EMBASE and PubMed from 1 January 1990 to 30 March 2021. Heterogeneity was explored by subgroup analysis according to a) patient group (stratified versus age) and depth of testing, b) detection/serotyping method, and c) continent. The protocol is registered with PROSPERO (CRD42020192002).

FINDINGS

Twenty-eight studies were included (34,216 patients). In the period 1-5 years after introduction of childhood PCV10/13 immunisation, 18% of CAP cases (95% CI 13-24%) were attributable to pneumococcus, with 49% (43-54%) of pneumococcal CAP due to PCV13 serotypes. The estimated proportion of pneumococcal CAP was highest in one study that used 24-valent serotype-specific urinary-antigen detection (ss-UAD)(30% [28-31%]), followed by studies based on diagnostic serology (28% [24-33%]), PCR (26% [15-37%]), ss-UAD14 (17% [13-22%]), and culture alone (14% [10-19%]). A higher estimate was observed in Europe (26% [21-30%] than North America (11% [9-12%](p<0·001). PCV13-serotype estimates were also influenced by serotyping methods.

INTERPRETATION

Non-invasive pneumococcal CAP and vaccine-type pneumococcal CAP remains a burden in older adults despite widespread introduction of pneumococcal infant immunisation. Studies heavily reliant on ss-UADs restricted to vaccine-type serotypes may overestimate the proportion of potentially vaccine-preventable pneumococcal pneumonia. Sero-epidemiological data from low-income countries are lacking.

A population-based analysis to determine the impact of the 13-valent pneumococcal conjugate vaccine on community-acquired pneumonia in British Columbia, Canada

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality globally. We determined the impact of 13-valent pneumococcal conjugate vaccine (PCV13) use on community-acquired pneumonia (CAP) rates eight years after the vaccine was introduced in the infant immunization program.

METHODS

Using diagnostic codes from administrative databases, we calculated the overall and age-specific CAP incidence per month (2000-2018). Changes in the CAP incidence before and after the PCV13 vaccine program introduction were evaluated using negative binomial regression model adjusting for 7-valent pneumococcal conjugate vaccine program.

RESULTS

The PCV13 vaccine infant immunization program was associated with declining CAP incidence among children aged 0-2 years (adjusted Incidence Rate Ratio (aIRR): 0.91; 95% CI: 0.87-0.96). Overall CAP incidence did not decrease in those aged 3-5 years (0.98; 95% CI: 0.93-1.04), 6-17 years (1.02; 95% CI: 0.97-1.08), 18-49 years (1.02; 95% CI:0.98-1.05), 50-64 years (1.07; 95% CI: 1.04-1.11), ≥65 years (1.05; 95% CI:1.02-1.08).

CONCLUSIONS

The PCV13 infant immunization program is temporally associated with a reduction in CAP incidence in vaccine target age group. However, no significant decrease in CAP incidence in other age groups warrants further study of the etiology of CAP to develop and implement effective prevention programs.

Clinical use of lefamulin: A first-in-class semisynthetic pleuromutilin antibiotic

Lefamulin is a novel antibiotic agent within the pleuromutilin derivative class approved for the treatment of community-acquired bacterial pneumonia (CABP) by the United States Food and Drug Administration and the European Commission in 2019 and 2020, respectively. The objective of this article is to provide a summary of clinically relevant data underlying lefamulin and to provide recommendations for its place in therapy. In vitro data establish lefamulin's activity against a number of Gram-positive, Gram-negative and atypical organisms relevant in the treatment of CABP, including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Legionella pneumophila, Mycoplasma pneumoniae and Chlamydophila pneumoniae. Two phase-3 studies, the Lefamulin Evaluation Against Pneumonia trials, established non-inferiority of lefamulin against moxifloxacin in the treatment of CABP, including the sequential transition from intravenous to oral therapy and across a broad set of patient demographics and severities. Pooled and post hoc analyses have confirmed these effects for a variety of subgroups and secondary endpoints. Real-world study data post-approval have largely not yet emerged for lefamulin, and there is a need for further investigation into safety/efficacy for off-label indications such as acute bacterial skin and skin structure infections and sexually transmitted infections. Further data regarding tolerability, particularly with long-term use, as well as the emergence of resistance over time, are still undefined.

In vitro activity of a novel aminomethylcycline antibacterial (KBP-7072), a third-generation tetracycline, against clinical isolates with molecularly characterized tetracycline resistance mechanisms

Objectives

This study evaluated the in vitro activity of KBP-7072 against 413 contemporary surveillance isolates, including subsets with known tetracycline resistance genes.

Materials

In total, 105 Klebsiella pneumoniae (51 tetracycline resistant), 103 Escherichia coli (52 tetracycline resistant), 103 Staphylococcus aureus (51 tetracycline resistant) and 102 Streptococcus pneumoniae (51 tetracycline resistant) isolates were included. These isolates were tested by broth microdilution using fresh media. CLSI/EUCAST breakpoints were applied, except for tigecycline and omadacycline, which used FDA criteria.

Results

KBP-7072 (MIC₅₀, 0.06 mg/L), tigecycline (MIC₅₀, 0.12 and 0.25 mg/L) and omadacycline (MIC₅₀, 0.12 and 0.5 mg/L) showed similar MIC₅₀s for tetracycline-susceptible and -resistant S. aureus. Other tetracycline comparators had their MIC₅₀ increased 64- to 256-fold by tet. For S. pneumoniae, KBP-7072 (MIC_50/90, ≤0.015/0.03 mg/L) showed the lowest MICs, which remained unchanged for tetracycline-susceptible or -resistant isolates [mostly tet(M)]. Similar MICs were observed for omadacycline (MIC_50/90, 0.03–0.06/0.06 mg/L) and tigecycline (MIC_50/90, 0.03/0.03 mg/L) in the S. pneumoniae population. Tetracycline-susceptible and -resistant E. coli [94.2% tet(A)/tet(B)], KBP-7072 (MIC₉₀, 0.25 and 1 mg/L, respectively) and tigecycline (MIC₉₀, 0.25 and 0.5 mg/L) showed similar MIC₉₀s. KBP-7072 (MIC_50/90, 0.25/0.5 mg/L) and tigecycline (MIC_50/90, 0.5/0.5 mg/L) had the lowest MIC for tetracycline-susceptible K. pneumoniae. The MIC for KBP-7072 (MIC_50/90, 1/4 mg/L) and tigecycline (MIC_50/90, 1/2 mg/L) increased 2- to 8-fold for tetracycline-resistant K. pneumoniae, which mostly produced Tet(A).

Conclusions

KBP-7072 activity was minimally affected by the presence of acquired tetracycline genes.

Multiplex polymerase chain reaction detection of Streptococcus pneumoniae and Haemophilus influenzae and their antibiotic resistance in patients with community-acquired pneumonia from southwest Iran

BACKGROUND

This study aimed to evaluate the occurrence of Streptococcus pneumoniae and Haemophilus influenzae in sputum of patients with community-acquired pneumonia (CAP) using culture and multiplex polymerase chain reaction (M-PCR) methods and to survey the antibiotic resistance patterns of aforesaid isolates.

RESULT

In total, 23.9 % (n = 22/92) of sputum samples showed positive results in the culture method. S. pneumoniae and H. influenzae were isolated from 15 (16.3 %) and 7 (7.6%) samples, respectively. Using M-PCR, 44 (47.8 %) samples were positive for S. pneumoniae and H. influenzae. Of these, S. pneumoniae and H. influenzae were detected in 33 (35.8%) and 11 (11.9%) of the sputum samples, respectively. The sensitivity, specificity, and accuracy rates of PCR in detection of S. pneumoniae in comparison with culture method were 100, 76.6, and 83.6%, respectively. While, the sensitivity, specificity, and accuracy rates of PCR in detection of H. influenzae in comparison with culture method were 100, 95.3, and 95.8%, respectively. Out of 11 isolates of H. influenzae, two strains confirmed as H. influenzae type b (Hib) and 3 isolates were type f. However, 6 isolates were non-typable. The co-trimoxazole and amoxicillin/clavulanate were the less effective antibiotics against S. pneumonia and H. influenzae, respectively. Ceftriaxone with 13.3% resistance rates was the most effective antibiotic against S. pneumoniae, while, clarithromycin, ceftriaxone, and gentamicin with resistance rates of 28.6% for each one were the most effective chemicals against H. influenzae isolates.

CONCLUSION

In this study, the prevalence of S. pneumoniae was more than H. influenzae using culture and M-PCR methods. The M-PCR provided better efficiency in detecting the bacterial agents in CAP patients compared to culture method. This method can improve the early detection of pathogens contributed to CAP. The drug resistant S. pneumoniae and H. influenzae indicated the need to develop a codified monitoring program to prevent further spread of these strains.

Comparison of rapid molecular testing methods for detecting respiratory viruses in emergency care: a prospective study

BACKGROUND

Respiratory tract infections (RTIs) caused by contagious viruses are common among patients presenting to the emergency department (ED). Early detection of these viruses can help prevent nosocomial transmission.

AIM

To investigate the efficacy of three rapid molecular methods, namely FilmArray^® Pneumonia Panel plus (FAP plus), ID NOW^™ Influenza A and B 2 (ID NOW2) point-of-care test, and an in-house real-time polymerase chain reaction (RT-PCR) test, to identify patients with viral RTIs requiring isolation in an emergency setting.

METHODS

We included a FilmArray^® Pneumonia Panel plus in the initial workup of patients with suspected RTIs during a flu season. The RT-PCR and the influenza point-of-care test were performed as part of routine diagnostics, on demand from the treating physicians. We compared viral detections and compared time to positive test results for each method.

FINDINGS

The FAP plus significantly reduced the turnaround time and was able to identify 95% patients with potential contagious viral RTI. Routine diagnostics ordered by the treating physician had a turnaround time of a median 22 h and detected 87% of patients with potential contagious viral RTI. In patients that had all three tests, the ID NOW2 detected 62% of patients with influenza.

CONCLUSIONS

The FAP plus was able to rapidly and reliably identify patients with potential contagious viral RTIs; its use was feasible in the ED setting. Failing to test patients with viral RTI and using tests with long turnaround time may lead to nosocomial transmission of viral infections and adverse patient outcomes.

Association of Admission Blood Glucose Level with All-Cause Mortality According to Age in Patients with Community Acquired Pneumonia

Objective

To assess the impact of blood glucose levels on the prognosis of patients with community-acquired pneumonia (CAP) who were elderly or middle-aged.

Methods

From January 1, 2018, to December 31, 2020, patients with CAP (≥45 years) were retrospectively enrolled in this observational study. They were stratified by age (45-64 or ≥65 years) and blood glucose level (≥11.1 or <11.1 mmol/l). The effect of admission blood glucose on 28-day mortality was assessed with the Cox proportional hazards model, adjusted for demographic factors and comorbidity.

Results

Among 1656 patients with CAP, increased blood glucose (HR=2.08, 95% CI: 1.38-3.49; P<0.01) and advanced age (HR=2.76, 95% CI: 1.65-3.77; P<0.01) were significantly associated with a higher risk of 28-day mortality, after controlling for potential confounding factors. The strength of the association of blood glucose level with 28-day mortality decreased with age (P=0.01 for the interaction) as the adjusted HRs for death were 4.48 (95% CI: 1.40-13.65; P<0.01) for middle-age patients 45-64 years and 1.52 (95% CI: 1.09-2.17; P=0.05) for elderly patients ≥65 years.

Conclusion

The association of blood glucose level upon admission for CAP with all-cause mortality was stronger at younger ages.

Community-acquired pneumonia: Trends in and research on drug resistance and advances in new antibiotics

Community-acquired pneumonia (CAP) refers to infectious inflammation of the lung parenchyma developing outside of a hospital. CAP has quite a high mortality and morbidity rate worldwide, and especially among elderly patients. The increasing burden of CAP is due to antibiotic resistance, the growth of the elderly population, and underlying comorbidities. Streptococcus pneumoniae remains the most common bacterial pathogen causing CAP, but multi-drug resistance bacteria and potential pathogens have increased the difficulty and challenges of managing CAP. Although preventive measures, diagnostic techniques, and treatment strategies are constantly advancing and improving, the susceptibility of multi-drug resistant pathogens, such as including Methicillin-Resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, and Pseudomonas aeruginosa, has not improved significantly in recent decades, thus highlighting the importance and necessity of developing new antibiotics for the treatment of CAP. New antimicrobials have been approved over the past few years that will expand treatment options for CAP, and especially for patients with potential comorbidities. This situation also offers the chance to reduce the abuse of antibiotics, their toxicities, and their adverse reactions and to provide effective personalized antibiotic treatment.

Co-infection with Legionella and SARS-CoV-2: a case report

INTRODUCTION

We report a case of COVID-19 with Legionella co-infection that was treated successfully.

CASE REPORT

A 73-year-old man presented to the hospital with symptoms of fatigue that continued for the next 5 days. The patient was receiving docetaxel and prednisolone chemotherapy for prostate cancer. Laboratory findings on admission showed positive urine Legionella antigen test and SARS-CoV-2 test. He was administered antiviral and antibacterial agents, and a corticosteroid. Pneumonia exacerbated on day 2 of hospitalization. The patient underwent tracheal intubation and began receiving multidisciplinary care. On day 8 of hospitalization, his oxygenation improved, and the patient was extubated. He discharged on day 27 of hospitalization.

CONCLUSIONS

The patient had a favorable outcome with early diagnosis and early treatment of both diseases. Patients with severe COVID-19 disease need to be evaluated for co-infection. Further, early diagnosis and early treatment of the microbial bacteria causing the co-infection are important.

Pneumonia

Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.

Clinical Features and Outcomes of Community-Acquired Pneumonia Caused by Haemophilus Influenza

Background

Long regarded as the second most common cause of community-acquired pneumonia (CAP), Haemophilus influenzae has recently been identified with almost equal frequency as pneumococcus in patients hospitalized for CAP. The literature lacks a detailed description of the presentation, clinical features, laboratory and radiologic findings, and outcomes in Haemophilus pneumonia.

Methods

During 2 prospective studies of patients hospitalized for CAP, we identified 33 patients with Haemophilus pneumonia. In order to provide context, we compared clinical findings in these patients with findings in 36 patients with pneumococcal pneumonia identified during the same period. We included and analyzed separately data from patients with viral coinfection. Patients with coinfection by other bacteria were excluded.

Results

Haemophilus pneumonia occurred in older adults who had underlying chronic lung disease, cardiac conditions, and alcohol use disorder, the same population at risk for pneumococcal pneumonia. However, in contrast to pneumococcal pneumonia, patients with Haemophilus pneumonia had less severe infection as shown by absence of septic shock on admission, less confusion, fewer cases of leukopenia or extreme leukocytosis, and no deaths at 30 days. Viral coinfection greatly increased the severity of Haemophilus, but not pneumococcal pneumonia.

Conclusions

We present the first thorough description of Haemophilus pneumonia, show that it is less severe than pneumococcal pneumonia, and document that viral coinfection greatly increases its severity. These distinctions are lost when the label CAP is liberally applied to all patients who come to the hospital from the community for pneumonia.

Impact of obesity on influenza compared to pneumonia hospitalization outcomes

OBJECTIVES

Previous literature has suggested that obesity impacts mortality risk differently in bacterial versus viral infections. This study sought to further elucidate this association in pneumonia versus influenza.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data were collected from the US Nationwide Readmission Database from 2013 to 2014.

METHODS

Patients were categorized into three weight groups: normal weight (BMI 18.5-25.0 kg/m²), obese (BMI 30-40.0 kg/m²), and morbidly obese (BMI ≥ 40 kg/m²). To minimize confounding, we excluded patients with a history of smoking, alcoholism, or chronic wasting conditions, as suggested by the Global BMI Mortality Collaboration. To further isolate obesity from baseline differences across cohorts, we performed a three-way propensity matching analysis. The association between body weight and in-hospital all-cause 30-day mortality was assessed using Cox proportional hazard regression analysis.

RESULTS

132,965 influenza and 34,177 pneumonia hospitalizations were identified. For patients with influenza, obesity (hazard ratio [HR]: 1.51; 95% CI: 1.01-2.26) and morbid obesity (HR: 1.64; 95% CI: 1.10-2.44) were associated with higher in-hospital 30-day mortality compared to normal weight. For pneumonia, obesity (HR, 0.41; 95% CI, 0.20-0.84) and morbid obesity (HR, 0.49; 95% CI, 0.25-0.96) were associated with reduced 30-day mortality compared to normal weight.

CONCLUSIONS AND IMPLICATIONS

Obesity may increase 30-day mortality risk during influenza hospitalization but provide mortality benefit in pneumonia, a divergent effect not adequately explained by lower admission threshold.

[Current microbiological aspects of community respiratory infection beyond COVID-19]

From a microbiological point of view, both empirical and targeted antimicrobial treatment in respiratory infection is based on the sensitivity profile of isolated microorganisms and the possible resistance mechanisms that they may present. The latter may vary in different geographic areas according to prescription profiles and vaccination programs. Beta-lactam antibiotics, fluoroquinolones, and macrolides are the most commonly used antimicrobials during the exacerbations of chronic obstructive pulmonary disease and community-acquired pneumonia. In their prescription, different aspects such as intrinsic activity, bactericidal effect or their ability to prevent the development of resistance must be taken into account. The latter is related to the PK/PD parameters, the mutant prevention concentration and the so-called selection window. More recently, the potential ecological impact has grown in importance, not only on the intestinal microbiota, but also on the respiratory one. Maintaining the state of eubiosis requires the use of antimicrobials with a low profile of action on anaerobic bacteria. With their use, the resilience of the bacterial populations belonging to the microbiota, the state of resistance of colonization and the collateral damage related to the emergence of resistance to the antimicrobials in pathogens causing the infections and in the bacterial populations integrating the microbiota.

Corticosteroids for CAP, influenza and COVID-19: when, how and benefits or harm?

PURPOSE

Corticosteroids have been considered in medicine for a long time, and they are broadly prescribed. In infectious diseases, corticosteroids have been regarded as a thread due to their immunosuppressive effects and therefore their anti-inflammatory properties. MAIN: In recent years, there have been several studies published that aimed to determine the role of corticosteroids in patients with community-acquired pneumonia (CAP), because, despite significant advances in new antibiotics and supportive care, deaths of patients with CAP remain unacceptably high. While the 2007 Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) CAP guidelines did not mention the use of corticosteroids in the management of CAP, the recently published 2019 IDSA/ATS guidelines recommended their use in patients with septic shock refractory to vasopressors and fluid resuscitation. Regarding viral infection, the use of corticosteroids in patients with influenza has shown to be associated with significantly higher mortality and higher incidence of nosocomial infection, while in patients with coronavirus disease 2019 (COVID-19) there is a good body of evidence of the benefit of corticosteroids in terms of mortality.

CONCLUSIONS

The use of corticosteroids has been considered as a potential alternative co-adjuvant treatment in patients with pneumonia. In patients with COVID-19, the evidence is quite strong and there is a clear benefit of the use of corticosteroids in those patients presenting severe forms of disease.