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Musher DM, Abers MS, Bartlett JG. Evolving Understanding of the Causes of Pneumonia in Adults, With Special Attention to the Role of Pneumococcus. Clin Infect Dis 2018; 65:1736-1744. [PMID: 29028977 PMCID: PMC7108120 DOI: 10.1093/cid/cix549] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 09/05/2017] [Indexed: 01/18/2023] Open
Abstract
Before 1945, Streptococcus pneumoniae caused more than 90% of cases of pneumonia in adults. After 1950, the proportion of pneumonia caused by pneumococcus began to decline. Pneumococcus has continued to decline; at present, this organism is identified in fewer than fewer10%-15% of cases. This proportion is higher in Europe, a finding likely related to differences in vaccination practices and smoking. Gram-negative bacilli, Staphylococcus aureus, Chlamydia, Mycoplasma, and Legionella are each identified in 2%-5% of patients with pneumonia who require hospitalization. Viruses are found in 25% of patients, up to one-third of these have bacterial coinfection. Recent studies fail to identify a causative organism in more than 50% of cases, which remains the most important challenge to understanding lower respiratory infection. Our findings have important implications for antibiotic stewardship and should be considered as new policies for empiric pneumonia management are developed.
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Affiliation(s)
- Daniel M Musher
- Departments of Medicine and Molecular Virology and Microbiology, Baylor College of Medicine.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Michael S Abers
- Massachusetts General Hospital.,Harvard Medical School, Boston, Massachusetts
| | - John G Bartlett
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Røysted W, Simonsen Ø, Jenkins A, Sarjomaa M, Svendsen MV, Ragnhildstveit E, Tveten Y, Kanestrøm A, Waage H, Ringstad J. Aetiology and risk factors of community-acquired pneumonia in hospitalized patients in Norway. CLINICAL RESPIRATORY JOURNAL 2015; 10:756-764. [PMID: 25764275 DOI: 10.1111/crj.12283] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/28/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS In Norway, data on the aetiology of community-acquired pneumonia (CAP) in hospitalized patients are limited. The aims of this study were to investigate the bacterial aetiology of CAP in hospitalized patients in Norway, risk factors for CAP and possible differences in risk factors between patients with Legionnaire's disease and pneumonia because of other causes. METHODS Adult patients with radiologically confirmed CAP admitted to hospital were eligible for the study. Routine aerobic and Legionella culture of sputum, blood culture, urinary antigen test for Legionella pneumophila and Streptococcus pneumoniae, polymerase chain reaction detection of Chlamydophila pneumoniae, Mycoplasma pneumoniae and Bordetella pertussis from throat specimens, and serology for L. pneumophila serogroup 1-6 were performed. A questionnaire, which included demographic and clinical data, risk factors and treatment, was completed. RESULTS We included 374 patients through a 20-month study period in 2007-2008. The aetiological agent was detected in 37% of cases. S. pneumoniae (20%) was the most prevalent agent, followed by Haemophilus influenzae (6%) and Legionella spp. (6%). Eight Legionella cases were diagnosed by urinary antigen test, of which four also had positive serology. In addition, 13 Legionella cases were diagnosed by serology. The degree of comorbidity was high. An increased risk of hospital-diagnosed Legionella pneumonia was found among patients with a diagnosis of chronic congestive heart failure. CONCLUSION Our results indicate that S. pneumoniae is the most common bacterial cause of pneumonia in hospitalized patients, and the prevalence of Legionella pneumonia is probably higher in Norway than recognized previously.
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Affiliation(s)
- Wenche Røysted
- Department of Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway.
| | - Øystein Simonsen
- Clinic of Internal Medicine, Østfold Hospital Trust, Fredrikstad, Norway
| | - Andrew Jenkins
- Unilabs Telelab AS, Skien, Norway.,Department of Environmental and Health Sciences, Telemark University College, Bø, Telemark, Norway
| | | | - Martin Veel Svendsen
- Department of Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway
| | | | - Yngvar Tveten
- Department of Medical Microbiology, Unilabs Telelab AS, Skien, Norway.,Department of Medical Biochemistry, Telemark Hospital, Skien, Norway
| | - Anita Kanestrøm
- Center for Laboratory Medicine, Østfold Hospital Trust, Fredrikstad, Norway
| | - Halfrid Waage
- Department of Research and Development, Telemark Hospital, Skien, Norway
| | - Jetmund Ringstad
- Clinic of Internal Medicine, Østfold Hospital Trust, Fredrikstad, Norway
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Lai CH, Chang LL, Lin JN, Chen WF, Wei YF, Chiu CT, Wu JT, Hsu CK, Chen JY, Lee HS, Lin HH, Chen YH. Clinical characteristics of Q fever and etiology of community-acquired pneumonia in a tropical region of southern Taiwan: a prospective observational study. PLoS One 2014; 9:e102808. [PMID: 25033402 PMCID: PMC4102556 DOI: 10.1371/journal.pone.0102808] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 06/24/2014] [Indexed: 12/11/2022] Open
Abstract
Background The clinical characteristics of Q fever are poorly identified in the tropics. Fever with pneumonia or hepatitis are the dominant presentations of acute Q fever, which exhibits geographic variability. In southern Taiwan, which is located in a tropical region, the role of Q fever in community-acquired pneumonia (CAP) has never been investigated. Methodology/Principal Findings During the study period, May 2012 to April 2013, 166 cases of adult CAP and 15 cases of acute Q fever were prospectively investigated. Cultures of clinical specimens, urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila, and paired serologic assessments for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Q fever (Coxiella burnetii) were used for identifying pathogens associated with CAP. From April 2004 to April 2013 (the pre-study period), 122 cases of acute Q fever were also included retrospectively for analysis. The geographic distribution of Q fever and CAP cases was similar. Q fever cases were identified in warmer seasons and younger ages than CAP. Based on multivariate analysis, male gender, chills, thrombocytopenia, and elevated liver enzymes were independent characteristics associated with Q fever. In patients with Q fever, 95% and 13.5% of cases presented with hepatitis and pneumonia, respectively. Twelve (7.2%) cases of CAP were seropositive for C. burnetii antibodies, but none of them had acute Q fever. Among CAP cases, 22.9% had a CURB-65 score ≧2, and 45.8% had identifiable pathogens. Haemophilus parainfluenzae (14.5%), S. pneumoniae (6.6%), Pseudomonas aeruginosa (4.8%), and Klebsiella pneumoniae (3.0%) were the most common pathogens identified by cultures or urine antigen tests. Moreover, M. pneumoniae, C. pneumoniae, and co-infection with 2 pathogens accounted for 9.0%, 7.8%, and 1.8%, respectively. Conclusions In southern Taiwan, Q fever is an endemic disease with hepatitis as the major presentation and is not a common etiology of CAP.
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Affiliation(s)
- Chung-Hsu Lai
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
- Division of Infection Control Laboratory, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Lin-Li Chang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Faculty of Medicine, Department of Microbiology, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Jiun-Nong Lin
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Wei-Fang Chen
- Division of Infection Control Laboratory, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
| | - Yu-Feng Wei
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Chien-Tung Chiu
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Jiun-Ting Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Chi-Kuei Hsu
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Jung-Yueh Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Ho-Sheng Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan
| | - Hsi-Hsun Lin
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung City, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Yen-Hsu Chen
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
- * E-mail:
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High seroprevalence of Mycoplasma pneumoniae IgM in acute Q fever by enzyme-linked immunosorbent assay (ELISA). PLoS One 2013; 8:e77640. [PMID: 24147043 PMCID: PMC3798658 DOI: 10.1371/journal.pone.0077640] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/13/2013] [Indexed: 11/23/2022] Open
Abstract
Q fever is serologically cross-reactive with other intracellular microorganisms. However, studies of the serological status of Mycoplasma pneumoniae and Chlamydophila pneumoniae during Q fever are rare. We conducted a retrospective serological study of M. pneumoniae and C. pneumoniae by enzyme-linked immunosorbent assay (ELISA), a method widely used in clinical practice, in 102 cases of acute Q fever, 39 cases of scrub typhus, and 14 cases of murine typhus. The seropositive (57.8%, 7.7%, and 0%, p<0.001) and seroconversion rates (50.6%, 8.8%, and 0%, p<0.001) of M. pneumoniae IgM, but not M. pneumoniae IgG and C. pneumoniae IgG/IgM, in acute Q fever were significantly higher than in scrub typhus and murine typhus. Another ELISA kit also revealed a high seropositivity (49.5%) and seroconversion rate (33.3%) of M. pneumoniae IgM in acute Q fever. The temporal and age distributions of patients with positive M. pneumoniae IgM were not typical of M. pneumoniae pneumonia. Comparing acute Q fever patients who were positive for M. pneumoniae IgM (59 cases) with those who were negative (43 cases), the demographic characteristics and underlying diseases were not different. In addition, the clinical manifestations associated with atypical pneumonia, including headache (71.2% vs. 81.4%, p=0.255), sore throat (8.5% vs. 16.3%, p=0.351), cough (35.6% vs. 23.3%, p=0.199), and chest x-ray suggesting pneumonia (19.3% vs. 9.5%, p=0.258), were unchanged between the two groups. Clinicians should be aware of the high seroprevalence of M. pneumoniae IgM in acute Q fever, particularly with ELISA kits, which can lead to misdiagnosis, overestimations of the prevalence of M. pneumoniae pneumonia, and underestimations of the true prevalence of Q fever pneumonia.
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Wang CC, Peng CL, Wang GJ, Sung FC, Kao CH. Pneumococcal pneumonia and the risk of acute coronary syndrome: A population-based cohort study. Int J Cardiol 2013; 168:4480-1. [DOI: 10.1016/j.ijcard.2013.06.134] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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Sicras-Mainar A, Ibáñez-Nolla J, Cifuentes I, Guijarro P, Navarro-Artieda R, Aguilar L. Retrospective epidemiological study for the characterization of community- acquired pneumonia and pneumococcal pneumonia in adults in a well-defined area of Badalona (Barcelona, Spain). BMC Infect Dis 2012; 12:283. [PMID: 23114195 PMCID: PMC3532136 DOI: 10.1186/1471-2334-12-283] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 10/25/2012] [Indexed: 11/06/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) has large impact on direct healthcare costs, especially those derived from hospitalization. This study determines impact, clinical characteristics, outcome and economic consequences of CAP in the adult (≥18 years) population attended in 6 primary-care centers and 2 hospitals in Badalona (Spain) over a two-year period. Methods Medical records were identified by codes from the International Classification of Diseases in databases (January 1st 2008-December 31st 2009). Results A total of 581 patients with CAP (55.6% males, mean age 57.5 years) were identified. Prevalence: 0.64% (95% CI: 0.5%-0.7%); annual incidence: 3.0 cases/1,000 inhabitants (95% CI: 0.2-0.5). Up to 241 (41.5%) required hospitalization. Hospital admission was associated (p<0.002) with liver disease (OR=5.9), stroke (OR=3.6), dementia (OR=3.5), COPD (OR=2.9), diabetes mellitus (OR=1.9) and age (OR=1.1 per year). Length of stay (4.4±0.3 days) was associated with PSI score (β=0.195), in turn associated with age (r=0.827) and Charlson index (r=0.497). Microbiological tests were performed in all inpatients but only in 35% outpatients. Among patients with microbiological tests, results were positive in 51.7%, and among them, S pneumoniae was identified in 57.5% cases. Time to recovery was 29.9±17.2 days. Up to 7.5% inpatients presented complications, 0.8% required ICU admission and 19.1% readmission. Inhospital mortality rate was 2.5%. Adjusted mean total cost was €2,332.4/inpatient and €698.6/outpatient (p<0.001). Patients with pneumococcal CAP (n=107) showed higher comorbidity and hospitalization (76.6%), higher PSI score, larger time to recovery and higher overall costs among inpatients. Conclusions Strategies preventing CAP, thus reducing hospital admissions could likely produce substantial costs savings in addition to the reduction of CAP burden.
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Affiliation(s)
- Antoni Sicras-Mainar
- Planning Management Department, Dirección de Planificación y Desarrollo Organizativo, Badalona Serveis Assistencials SA, Gaietà Soler, 6-8 entlo, 08911, Badalona, Barcelona, Spain.
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Abidi K, Khoudri I, Belayachi J, Madani N, Zekraoui A, Zeggwagh AA, Abouqal R. Eosinopenia is a reliable marker of sepsis on admission to medical intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R59. [PMID: 18435836 PMCID: PMC2447615 DOI: 10.1186/cc6883] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 03/30/2008] [Accepted: 04/24/2008] [Indexed: 01/31/2023]
Abstract
Introduction Eosinopenia is a cheap and forgotten marker of acute infection that has not been evaluated previously in intensive care units (ICUs). The aim of the present study was to test the value of eosinopenia in the diagnosis of sepsis in patients admitted to ICUs. Methods A prospective study of consecutive adult patients admitted to a 12-bed medical ICU was performed. Eosinophils were measured at ICU admission. Two intensivists blinded to the eosinophils classified patients as negative or with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, or septic shock. Results A total of 177 patients were enrolled. In discriminating noninfected (negative + SIRS) and infected (sepsis + severe sepsis + septic shock) groups, the area under the receiver operating characteristic curve was 0.89 (95% confidence interval (CI), 0.83 to 0.94). Eosinophils at <50 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 91% (95% CI, 79% to 96%), a positive likelihood ratio of 9.12 (95% CI, 3.9 to 21), and a negative likelihood ratio of 0.21(95% CI, 0.15 to 0.31). In discriminating SIRS and infected groups, the area under the receiver operating characteristic curve was 0.84 (95% CI, 0.74 to 0.94). Eosinophils at <40 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 80% (95% CI, 55% to 93%), a positive likelihood ratio of 4 (95% CI, 1.65 to 9.65), and a negative likelihood ratio of 0.25 (95% CI, 0.17 to 0.36). Conclusion Eosinopenia is a good diagnostic marker in distinguishing between noninfection and infection, but is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients. Eosinopenia may become a helpful clinical tool in ICU practices.
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Affiliation(s)
- Khalid Abidi
- Medical Intensive Care Unit, Ibn Sina University Hospital, 10000, Rabat, Morocco.
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