Viral pathogens associated with acute lower respiratory tract infections in children younger than 5 years of age in Bulgaria

Rhinovirus infection and co-infection in children with severe acute respiratory infection during the COVID-19 pandemic period

Rhinovirus causes respiratory tract infections in children and is found in co-infections. The objective of this research was to study the clinical profile of rhinovirus infection and co-infection in children with severe acute respiratory infection (SARI) during the COVID-19 pandemic period. We included 606 children ranging in age from 0.1 to 144 months of age from March 2020 to December 2021, hospitalized in the Pediatric Intensive Care Unit (PICU). The samples were collected by secretion from the nasopharynx region. A total of 259 children were tested positive for viral infection, 153 (59.07%) of them had a single rhinovirus infection and, 56 (36.6%) were aged between 60.1 and 144 months. Nine types of co-infections were identified and were found coinfection with three or more viruses (22/104, 21.15%). Observing the seasonality, the number of cases was similar between 2020 (49.53%) and 2021 (51.47%). Patients with a single infection (86.88%) and coinfection (67.30%) were more likely to have coughed. Patients with co-infection required the use of O2 for longer than those with a single rhinovirus infection. Hemogram results obtained from individuals with a single infection had higher levels of urea when compared to patients with co-infection with and other respiratory viruses. Multiple correspondence analyses indicated different clinical symptoms and comorbidities in patients with co-infection compared to those with single infection. The results found that the rhinovirus was much prevalent virus during the pandemic period and was found in co-infection with other virus types, what is important to diagnostic for the correct treatment of patients.

Alterations in Patients' Clinical Outcomes and Respiratory Viral Pathogen Activity following the COVID-19 Pandemic

BACKGROUND

Before the COVID-19 pandemic, respiratory pathogens such as influenza, parainfluenza, and respiratory syncytial virus were the most commonly detected viruses among hospitalized patients with respiratory tract infections.

METHODS

This was a retrospective observational study of inpatients and outpatients who attended Jordan University Hospital and underwent Nasopharyngeal Aspiration (NPA) in the periods from December 2017 to December 2018 and from December 2021 to December 2022. The results of multiplex respiratory pathogen real-time PCR tests for nasopharyngeal swab specimens were extracted from the electronic-based molecular diagnostic laboratory record of JUH. We compared the prevalence of the detected viruses as well as the patients' characteristics and outcomes between the two periods.

RESULTS

The total number of included patients was 695. Our analysis showed that a higher percentage of patients with hypertension and diabetes presented before the pandemic compared to the same period after it (p-value < 0.001). The need for O2 devices, white blood cell counts, diastolic blood pressure, and the length of hospital stay were significantly higher among patients who presented before the pandemic (p-value < 0.050). Influenza H1N1 (8.70% vs. 4.03%), influenza B (1.67% vs. 0.25%), parainfluenza (1.00% vs. 0.00%), human metapneumovirus (5.35% vs. 0.76%), adenoviruses (6.35% vs. 3.02%), and coronaviruses (8.70% vs. 3.53%) were detected with higher frequency in the period before the pandemic (p-value = 0.011, 0.045, 0.045, 0.000, 0.035, 0.004). These results were similar in terms of changes in the detection rates of viruses after matching the number of tested patients between the periods before and after the pandemic.

CONCLUSIONS

We have demonstrated a reduction in the detection of several viruses, which might be due to the increase in public awareness toward infection protection measures after the COVID-19 pandemic.

Respiratory viruses among pediatric inpatients with acute lower respiratory tract infections in Jinan, China, 2016-2019

The viral etiologies responsible for acute lower respiratory tract infections (ALRI) are a major cause of pediatric hospitalization, and some develop severe diseases requiring pediatric intensive care unit (PICU) admission. The aim of this study was to determine the prevalence of viruses and risk factors associated with PICU admission among patients hospitalized for ALRI. Nasopharyngeal swabs were collected to detect human rhinovirus (HRV), influenza A and B viruses (IAV, IBV), parainfluenza viruses (PIV), and respiratory syncytial virus (RSV) by reverse transcription-polymerase chain reaction (RT-PCR) and adenovirus (ADV) by PCR. Of the 5590 pediatric inpatients enrolled, respiratory viral infection occurred in 2102 (37.60%) patients, including 1846 (33.02%) single and 256 (4.58%) mixed viral infections. Among the nasopharyngeal swabs from pediatric inpatients, HRV accounted for the highest detection rate (16.48%), followed by PIV (8.35%), RSV (7.41%), ADV (4.63%), IAV (3.51%), and IBV (2.08%). The positive rate of viral tests decreased with increasing age and was higher in males (39.29%) than females (34.67%). The prevalence of viral infection was the highest in winter (41.57%) and lowest in autumn (31.78%). Each virus had a seasonal pattern, with peaks occurring in months of their epidemic seasons. RSV infection and the presence of comorbidities including congenital tracheal stenosis, congenital heart disease, metabolic disorder, immunodeficiency, renal disease, gastrointestinal disease and neurological disorder might be associated with the need for PICU admission. Therefore, this study provides useful information for the prevention and control of virus-related respiratory diseases and the early identification of and the intervention in severe cases. This article is protected by copyright. All rights reserved.

Epidemiological studies on lower respiratory tract infection in children in the District Bannu, Khyber Pakhtunkhwa, Pakistan

Background

Lower respiratory tract infections are the leading cause of death in children globally and are transmitted by inhaling airborne droplets. The study demonstrated the prevalence of lower respiratory tract infections in children admitted to the Women and Children Hospital Bannu from February through November 2019. The cross-sectional study was conducted by obtaining indoor data from the official record maintained in the children’s wards.

Results

Males accounted for 649 (61.6%) and females 405 (38.4%) cases out of 1054 cases of the disease. Age group of ≤ 6 months showed 36.2% prevalence, followed by > 6 m ≤ 1 y (25.6%), > 1 y ≤ 2 y (17.1%), > 2 y ≤ 5 y (14.3%), > 5 ≤ 10 y (6.0%), and > 10 y ≤ 15 y (0.8%). Pediatric patients of age ≤ 2 y and ≤ 5 y contributed 78.9% and 93.3% to overall disease, respectively. The disease was at its peak in February (17.9%) while lowest in May (5.5%). The age group (≤ 6 m) was the dominant group in all months except August when replaced by the age group (> 6 m ≤ 1 y). The disease revealed higher prevalence during February-April and October-November.

Conclusions

Different age groups showed variation in the prevalence of the disease with an age group of ≤ 5 y contributing the largest share and seasonal peaks in the disease occurred. The present findings help in adopting strategies for effective control of the disease in different age groups of the children for their peak season.

An outbreak of RSV infections in a neonatology clinic during the RSV-season

BACKGROUND

Respiratory syncytial virus (RSV) is the predominant cause of lower respiratory tract infections (LRTI) in infancy. Preterm infants with bronchopulmonary dysplasia (BPD) are at the highest risk of severe RSV-LRTI. This is a retrospective study that analyses a nosocomial outbreak of RSV infections in the Neonatology clinic of the University Hospital of Obstetrics and Gynecology, Sofia, 2019.

METHODS

Two groups of infants without contact between them were diagnosed with RSV-infection: 14 infants were treated in the Department for healthy newborns - Group 1, and 7 preterm infants were treated in the Neonatal Intensive Care Unit (NICU) - Group 2. The detection of RSV was performed using Real-Time PCR in nasal/throat swabs.

RESULTS

Respiratory symptoms occurred 2-5 days after discharge in 14 of 148 healthy term infants born February 5 to 18, 2019; 12 babies were re-hospitalized with LRTI and recovered in a few days. RSV-PCR was positive in 6 infants, while in the others, RSV etiology was suggested, due to similar symptoms and contact between them. The first NICU patient with RSV-LRTI was one of the 26 gestational weeks (GW) twins, who had severe BPD. The other twin was always discharged home without LRTI-symptoms. In the period February 19 to March 15, 2019, 26 premature babies born at 26-34 GW, were tested for RSV (33 nasal/throat swabs). They received a first or subsequent palivizumab injection. We identified 11 positive samples in 7 of the babies. Despite the clinical recovery, the second RSV-PCR remained positive in 4 babies. Six of the 7 NICU patients had symptoms of LRTI, and two of them needed mechanical ventilation. Six babies were discharged home after stabilization, one was transferred to the Pediatric department for further treatment of BPD and later discharged too.

CONCLUSIONS

This was the most serious outbreak of RSV infections in neonates since the RSV-PCR diagnostic in Bulgaria was introduced. The course of RSV-LRTI was severe in extremely preterm patients with underlying BPD. So, routine in-hospital RSV-prophylaxis with palivizumab should be considered for infants at the highest risk.

Prevalence and Genetic Characteristics of Human Bocaviruses Detected in Patients with Acute Respiratory Infections in Bulgaria

Нuman bocaviruses (hBoVs) are often associated with acute respiratory infections (ARIs). Information on the distribution and molecular epidemiology of hBoVs in Bulgaria is currently limited. The objectives of this study were to investigate the prevalence and genetic characteristics of hBoVs detected in patients with ARIs in Bulgaria. From October 2016 to September 2019, nasopharyngeal/oropharyngeal swabs were prospectively collected from 1842 patients of all ages and tested for 12 common respiratory viruses using a real-time RT-PCR. Phylogenetic and amino acid analyses of the hBoV VP1/VP2 gene/protein were performed. HBoV was identified in 98 (5.3%) patients and was the 6^th most prevalent virus after respiratory-syncytial virus (20.4%), influenza A(H1N1)pdm09 (11.1%), A(H3N2) (10.5%), rhinoviruses (9.9%), and adenoviruses (6.8%). Coinfections with other respiratory viruses were detected in 51% of the hBoV-positive patients. Significant differences in the prevalence of hBoVs were found during the different study periods and in patients of different age groups. The detection rate of hBoV was the highest in patients aged 0-4 years (6.9%). In this age group, hBoV was the only identified virus in 9.7%, 5.8%, and 1.1% of the children diagnosed with laryngotracheitis, bronchiolitis, and pneumonia, respectively. Among patients aged ≥5 years, hBoV was detected as a single agent in 2.2% of cases of pneumonia. Phylogenetic analysis showed that all Bulgarian hBoV strains belonged to the hBoV1 genotype. A few amino acid substitutions were identified compared to the St1 prototype strain. This first study amongst an all-age population in Bulgaria showed a significant rate of hBoV detection in some serious respiratory illnesses in early childhood, year-to-year changes in the hBoV prevalence, and low genetic variability in the circulating strains.

Impact of Guidelines Publication on Acute Bronchiolitis Management: 10-Year Experience from a Tertiary Care Center in Italy

Bronchiolitis is the most common lower respiratory tract infection in infants. According to evidence-based guidelines, diagnosis is clinical, there is no need for routine use of laboratory or instrumental tests and therapy is primarily supportive, based on oxygen and adequate fluid supplementation. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. The aim of this retrospective cohort study was to evaluate how the management of bronchiolitis has changed in the last ten years in a Tertiary Care Center in Italy, assessing adherence to national guidelines. Considering the publication of the Italian inter-society consensus document in 2014, we compared patients admitted in the prior four epidemic seasons with patients admitted in the latter six epidemic seasons. The comparison between the two groups showed a significant reduction in the prescription of systemic corticosteroids (58.9% vs. 41.8%, p < 0.001), nebulized epinephrine (73.8% vs. 38.3%, p < 0.001) and antibiotics (59.5% vs. 42.3%, p < 0.001), together with a drastic decrease in the use of chest X-ray (92.2% vs. 54.4%, p < 0.001). On the contrary, the use of inhaled salbutamol remained substantially stable over time (39.4% vs. 37.6%, p = 0.505). Despite the encouraging results, further efforts are needed to limit the prescription of ineffective therapies like antibiotics and inhaled salbutamol.

Distribution of spreading viruses during COVID-19 pandemic: Effect of mitigation strategies

Background

The study aimed to evaluate the distribution of circulating respiratory viral pathogens other than severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) during the first year of the coronavirus disease-2019 (COVID-19) pandemic with especially focusing on the effects of the national-based mitigation strategies.

Methods

This single-center study was conducted between March 11, 2020-March 11, 2021. All children who were tested by polymerase chain reaction on nasopharyngeal swabs for SARS-CoV-2 and other common respiratory viral pathogens were included in the study.

Results

A total of 995 children with suspected COVID-19 admitted to the study center. Of these, 513 patients who were tested by polymerase chain reaction for both SARS-CoV-2 and common respiratory viral pathogens were included in the final analysis. Two hundred ninety-five patients were (57.5%) male. The median age was 3 years of age (27 days-17 years). A total of 321 viral pathogens identified in 310 (n: 310/513, 60.4%) patients, and 11 of them (n: 11/310, 3.5%) had co-detection with more than 1 virus. The most common detected virus was rhinovirus (n: 156/513, 30.4%), and SARS-CoV-2 (n: 122/513, 23.8%) followed by respiratory syncytial virus (n: 18/513, 3.5%). The influenza virus was detected in 2 patients (0.4%). A total of 193 patients were negative for both SARS-CoV-2 and other pathogens.

Conclusions

There is a decline in the frequency of all viral pathogens like SARS-CoV-2 in correlation with the national-based mitigation strategies against COVID-19 during the pandemic.

Impacts of Pharmacy Intervention on Appropriateness of Antibiotics Use in Pneumonia Patients

AIM: This study analyzed the impact of pharmacy intervention on appropriateness of antibiotics use in the treatment of inpatients with pneumonia admitted to Universitas Sumatera Utara (USU) Hospital, Medan, Indonesia. METHODS: This cohort study analyzed appropriateness of antibiotic use in the treatment of in-patients with pneumonia without interventions or baseline group (n = 33) admitted to USU Hospital year 2018 and 3-month period admission with pharmacy intervention (n = 42) year 2019. Characteristics of the patients and antibiotics provided to both groups were descriptively analyzed. The appropriateness of antibiotics use in both groups was analyzed based on their medical conditions, culture and sensitivity tests, and trustable literatures, and then categorized applying Gyssens method regarding dose, intervals, routes, length of provision, effectivity, and costs. The significant difference in inappropriate use of antibiotics between groups with and without interventions was analyzed applying unpaired t-test (p < 0.05 was considered statistically significant). RESULTS: Most of the pneumonia patients in both groups were male. Mean age of the patients (years) in group: without intervention, 60.20 ± 15.48; with intervention, 60.48 ± 14.76. The three most widely provided antibiotics were ceftriaxone, meropenem, and ciprofloxacin. Incidence of inappropriate use of antibiotics per patient in group: without intervention, 0.66; with intervention, 0.33. The inappropriate use of antibiotics reduced significantly in group with intervention, p = 0.049. CONCLUSIONS: Pharmacy intervention is crucial to reduce the inappropriate use of antibiotics in the treatment of pneumonia.

The Prevalence and Genetic Characterization of Human Metapneumovirus in Bulgaria, 2016-2019

INTRODUCTION

We investigated the prevalence of human metapneumovirus (hMPV) among patients with acute respiratory infections in Bulgaria, and performed genetic characterization of the F gene of these strains.

METHODS

Nasopharyngeal swabs collected from patients of a range of ages were tested by using real-time PCR for 12 respiratory viruses. The F gene was sequenced, and phylogenetic and amino acid analyses of the F gene/protein were performed.

RESULTS

A total of 1,842 patients were examined during a 3-year period; 1,229 patients (66.7%) were positive for at least one respiratory virus. hMPV was identified in 83 (4.5%) patient samples. Eleven (13%) of hMPV-positive patients were coinfected with another respiratory virus. The hMPV incidence rate in the 2016/2017, 2017/2018, and 2018/2019 winter seasons was 5.4, 5.4, and 3.1%, respectively. hMPV was mainly detected in specimens collected between January and May (89.2% of cases). The incidence of hMPV infection was highest (5.1%) among the youngest age-group (0-4 years), where hMPV was a causative agent in 8.1 and 4.8% of bronchiolitis and pneumonia cases, respectively. Among the patients aged ≥5 years, hMPV was detected in 2.2 and 3.2% of cases of pneumonia and central nervous system infections, respectively. Phylogenetic analysis of the F gene showed that the sequenced hMPV strains belonged to the A2b, B1, and B2 genotypes. Numerous amino acid substitutions were identified compared with the NL00/1 prototype strain.

CONCLUSION

This study revealed the significant role of hMPV as a causative agent of serious respiratory illnesses in early childhood, and also demonstrated year-to-year changes in hMPV prevalence and genetic diversity in circulating strains.

Prevalence of human bocavirus infections in Europe. A systematic review and meta-analysis

Human bocaviruses (HBoVs) are recently described as human emergent viruses, especially in young children. In this study, we undertook a systematic review and meta-analysis to estimate their prevalence in Europe. PubMed, Web of Science and Scopus databases were systematically screened for clinical studies, up to October 2020. Study eligibility criteria were primary full-text articles from clinical studies, conducted using valid screening test methods and published in peer-reviewed journals, in English or Spanish and from European countries. The overall pooled prevalence, prevalence by country as well as the prevalence of HBoV as a single or co-pathogen were estimated using a random-effects model. Sub-group and meta-regression analyses explored potential sources of heterogeneity in the data. A total of 35 studies involving 32,656 subjects from 16 European countries met the inclusion criteria. Heterogeneity (I²  = 97.0%, p < .01) was seen among studies; HBoV prevalence varied from 2.0 to 45.69% with a pooled estimate of 9.57% (95%CI 7.66-11.91%). The HBoV prevalence both as a single infection (3.99%; 95%CI 2.99-5.31%) or as co-infection with other viruses (5.06%; 95%CI 3.88-6.58%) was also analysed. On a geographic level, prevalence by country did not show statistical differences, ranging from 3.24% (Greece) to 21.05% (Denmark). An odds ratio analysis was also included in order to evaluate the relevance of the variable 'age' as a risk factor of HBoV infection in children <5 years old. The OR value of 1.77 (95%CI 1.13-2.77; p < .01) indicated that being <5 years old is a risk factor for HBoV infection. This study showed that HBoV has a moderate prevalence among European countries.

Prevalence and Risk Factors of Respiratory Syncytial Virus in Children under 5 Years of Age in the WHO European Region: A Systematic Review and Meta-Analysis

A respiratory syncytial virus (RSV) is the major cause of respiratory tract infection in children under 5 years. However, RSV infection in the European Region of the World Health Organization has not been systematically reviewed. The aim was to determine the prevalence and factors associated with RSV in children under 5 years of age in European regions. A systematic review and meta-analysis was performed. CINAHL, Medline, LILACS, ProQuest, SciELO, and Scopus databases were consulted for studies published in the last 5 years, following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The search equation was "respiratory syncytial virus AND (newborn OR infant OR child) AND (prevalence OR risk factors)". Studies reporting the prevalence of RSV were eligible for inclusion in the meta-analysis. A total of 20 articles were included. The meta-analytic prevalence estimation of RSV, with a sample of n = 16,115 children, was 46% (95% CI 34-59%). The main risk factors were age, male gender, winter season, and environmental factors such as cold temperatures, higher relative humidity, high concentrations of benzene, exposure to tobacco, and living in urban areas. Robust age-specific estimates of RSV infection in healthy children should be promoted in order to determine the optimal age for immunization. In addition, it is necessary to analyse in greater depth the potentially predictive factors of RSV infection, to be included in prevention strategies.

Peripheral blood T cells response in human parainfluenza virus-associated lower respiratory tract infection in children

Human Parainfluenza virus (HPIV) causes lower respiratory tract infections (LRTI) mostly in young children. Respiratory viral infections may decline T cells in circulation and display enhanced pathogenicity. This study is aimed to analyze T cells alterations due to HPIV in children with LRTIs. Children (N = 152) with bronchitis or pneumonia, admitted in tertiary care hospitals were included in the study. Respiratory samples (throat or nasopharyngeal swabs) were taken and HPIV genotypes (1-4) were analyzed through RT-PCR. Peripheral blood T cells, CD3+, CD4+, CD8+, and CD19+, were analyzed in confirmed HPIV positive and healthy control group children through flow cytometry. The positivity rate of HPIV was 24.34% and the most prevalent genotype was HPIV-3 (20.40%). HPIV-1 and HPIV-2 were detected in 0.66% and 02% children respectively. The T lymphocyte counts were observed significantly reduced in children infected with HPIV-3. CD4+ cell (1580 ± 97.87) counts did not change significantly but the lowest CD8+ T cell counts (518.5 ± 74.00) were recorded. Similarly, CD3+ and CD19 cell ratios were also reduced. The CD4/CD8 ratio was significantly higher (3.12 ± 0.59) in the study population as compared to the control group (2.18 ± 0.654). Changes in the count of CD8+ T cells were more pronounced in patients with bronchiolitis and pneumonia. It is concluded that CD8+ T cells show a reduced response to HPIV-3 in children with severe LRTIs suggesting a strong association of these cells with disease severity.

Superior mesenteric vein thrombosis induced by influenza infection: A case report

BACKGROUND

Among the various types and causes of mesenteric ischemia, superior mesenteric vein (SMV) thrombosis is a rare and ambiguous disease. If a patient presents with SMV thrombosis, past medical history should be reviewed, and the patient should be screened for underlying disease. SMV thrombosis may also occur due to systemic infection. In this report, we describe a case of SMV thrombosis complicated by influenza B infection.

CASE SUMMARY

A 64-year-old male visited the hospital with general weakness, muscle aches, fever, and abdominal pain. The patient underwent computed tomography (CT) and was diagnosed with SMV thrombosis. Since the patient’s muscle pain and fever could not be explained by the SMV thrombosis, the clinician performed a test for influenza, which produced a positive result for influenza B. The patient had a thrombus in the SMV only, with no invasion of the portal or splenic veins, and was clinically stable. Anticoagulation treatment was prescribed without surgery or other procedures. The follow-up CT scan showed improvement, and the patient was subsequently discharged with continued oral anticoagulant treatment.

CONCLUSION

This case provides evidence that influenza may be a possible risk factor for SMV thrombosis. If unexplained abdominal pain is accompanied by an influenza infection, examination of an abdominal CT scan may be necessary to screen for possible SMV thrombosis.

Respiratory Syncytial Virus in Greece, 2016-2018

Human respiratory syncytial virus (RSV) is the leading cause of acute bronchiolitis in infants and young children. Children under the age of 2 years, hospitalized for bronchiolitis in the pediatric clinic of a tertiary hospital in northern Greece, were tested for RSV infection during two RSV seasons (2016-2017 and 2017-2018). RSV was detected in 37 of 71 (52.1%) patients, most of them younger than 6 months. Both RSV subtypes were detected - RSV-A (54.1%) and RSV-B (45.9%) - with predominance of RSV-A during the 2016-2017 and RSV-B during the 2017-2018 season. RSV-A and RSV-B sequences clustered within the ON1 and BA genotypes, respectively. Compared to the prototype strains, several amino acid substitutions were observed in the duplication region of the G gene. The study provides a first insight into the molecular epidemiology of RSV in Greece.

Epidemiology of Respiratory Syncytial Virus-related Hospitalizations and the Influence of Viral Coinfections in Southern Austria in a 7-year Period

OBJECTIVE

The aim of this study was to determine the respiratory syncytial virus (RSV) epidemiology and to analyze the influence of risk factors and coinfections over the last years.

METHODS

Retrospectively all infants, children and adolescents hospitalized due to respiratory disease with positive RSV test [hospitalized for RSV infection (RSV-H)] between January 1, 2009, and December 31, 2015, at a tertiary care center in the southern part of Austria were included for analysis. Patients were all identified by a search via International Classification of Diseases and Related Health Problems, 10th Edition codes, and all medical data were collected from the local electronic databases called openMedocs. RSV tests had to prove true infection case definition.

RESULTS

During a 7-year study period, 745 infants, children and adolescents exhibited RSV-H. Main diagnosis was bronchiolitis (70%). Nearly half of all cases (44%) were born during the first half of the RSV season (November-January), and seasonal peak of RSV-H was in January. Predominant underlying condition was history of prematurity in 15% followed by neurologic impairment (3.5%) and hemodynamically significant congenital heart disease (2.95%). Age ≤2 months and underlying conditions/morbidities were associated with more severe disease. The majority of cases (96%) had an age below 24 months, and 91% below 12 months. Viral coinfection (most common influenza virus, adenovirus and rhinovirus) was diagnosed in 37 cases (5%) resulting in a more severe course of disease. Main risk factors of coinfection were siblings and crowding. Mortality was 0.27% (2/745). Both children had coinfection with influenza A virus and were multihandicapped (15 and 20 years of age, respectively).

CONCLUSIONS

Prematurity and underlying morbidities play a marked role in RSV-H. Viral coinfections aggravated disease with death in 2 multihandicapped adolescents.