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Pickens CI, Wunderink RG. Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient. Infect Dis Clin North Am 2024; 38:51-63. [PMID: 38280767 DOI: 10.1016/j.idc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.
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Affiliation(s)
- Chiagozie I Pickens
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, 303 E. Superior Street Simpson Querrey 5th Floor, Suite 5-406, Chicago, IL 60611-2909, USA.
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, 303 E. Superior Street Simpson Querrey 5th Floor, Suite 5-406, Chicago, IL 60611-2909, USA
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2
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Dumas G, Bertrand M, Lemiale V, Canet E, Barbier F, Kouatchet A, Demoule A, Klouche K, Moreau AS, Argaud L, Wallet F, Raphalen JH, Mokart D, Bruneel F, Pène F, Azoulay E. Prognosis of critically ill immunocompromised patients with virus-detected acute respiratory failure. Ann Intensive Care 2023; 13:101. [PMID: 37833435 PMCID: PMC10575827 DOI: 10.1186/s13613-023-01196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) is the leading cause of ICU admission. Viruses are increasingly recognized as a cause of pneumonia in immunocompromised patients, but epidemiologic data are scarce. We used the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie's database (2003-2017, 72 intensive care units) to describe the spectrum of critically ill immunocompromised patients with virus-detected ARF and to report their outcomes. Then, patients with virus-detected ARF were matched based on clinical characteristics and severity (1:3 ratio) with patients with ARF from other origins. RESULTS Of the 4038 immunocompromised patients in the whole cohort, 370 (9.2%) had a diagnosis of virus-detected ARF and were included in the study. Influenza was the most common virus (59%), followed by respiratory syncytial virus (14%), with significant seasonal variation. An associated bacterial infection was identified in 79 patients (21%) and an invasive pulmonary aspergillosis in 23 patients (6%). The crude in-hospital mortality rate was 37.8%. Factors associated with mortality were: neutropenia (OR = 1.74, 95% confidence interval, CI [1.05-2.89]), poor performance status (OR = 1.84, CI [1.12-3.03]), and the need for invasive mechanical ventilation on the day of admission (OR = 1.97, CI [1.14-3.40]). The type of virus was not associated with mortality. After matching, patients with virus-detected ARF had lower mortality (OR = 0.77, CI [0.60-0.98]) than patients with ARF from other causes. This result was mostly driven by influenza-like viruses, namely, respiratory syncytial virus, parainfluenza virus, and human metapneumovirus (OR = 0.54, CI [0.33-0.88]). CONCLUSIONS In immunocompromised patients with virus-detected ARF, mortality is high, whatever the species, mainly influenced by clinical severity and poor general status. However, compared to non-viral ARF, in-hospital mortality was lower, especially for patients with detected viruses other than influenza.
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Affiliation(s)
- Guillaume Dumas
- Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes; Université Grenoble-Alpes, INSERM U1300-HP2, Grenoble, France.
| | - Maxime Bertrand
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Emmanuel Canet
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, 44000, Nantes, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orleans, Orleans, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers Teaching Hospital, Angers, France
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, and AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Kada Klouche
- Medical Intensive Care Unit, CHU de Montpellier, Montpellier, France
| | - Anne-Sophie Moreau
- Service de Réanimation Polyvalente, CHRU de Lille - Hôpital Roger Salengro, Lille, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hospices Civils de Lyon, Hopital Edouard Herriot, Lyon, France
| | - Florent Wallet
- Intensive Care Unit, Lyon Sud Medical Center, Lyon, France
| | | | - Djamel Mokart
- Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | - Fabrice Bruneel
- Medical Intensive Care Unit, Andre Mignot Hospital, Versailles, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, AP-HP, Paris, France
- Institut Cochin, INSERM Unité 1016/Centre National de La Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 8104/Université de Paris, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
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Risk Factors for Influenza-Induced Exacerbations and Mortality in Non-Cystic Fibrosis Bronchiectasis. Viruses 2023; 15:v15020537. [PMID: 36851751 PMCID: PMC9961441 DOI: 10.3390/v15020537] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Influenza infection is a cause of exacerbations in patients with chronic pulmonary diseases. The aim of this study was to investigate the clinical outcomes and identify risk factors associated with hospitalization and mortality following influenza infection in adult patients with bronchiectasis. Using the Chang Gung Research Database, we identified patients with bronchiectasis and influenza-related infection (ICD-9-CM 487 and anti-viral medicine) between 2008 and 2017. The main outcomes were influenza-related hospitalization and in-hospital mortality rate. Eight hundred sixty-five patients with bronchiectasis and influenza infection were identified. Five hundred thirty-six (62%) patients with bronchiectasis were hospitalized for influenza-related infection and 118 (22%) patients had respiratory failure. Compared to the group only seen in clinic, the hospitalization group was older, with more male patients, a lower FEV1, higher bronchiectasis aetiology comorbidity index (BACI), and more acute exacerbations in the previous year. Co-infections were evident in 55.6% of hospitalized patients, mainly caused by Pseudomonas aeruginosa (15%), fungus (7%), and Klebsiella pneumoniae (6%). The respiratory failure group developed acute kidney injury (36% vs. 16%; p < 0.001), and shock (47% vs. 6%; p < 0.001) more often than influenza patients without respiratory failure. The overall mortality rate was 10.8% and the respiratory failure group exhibited significantly higher in-hospital mortality rates (27.1% vs. 6.2%; p < 0.001). Age, BACI, and previous exacerbations were independently associated with influenza-related hospitalization. Age, presence of shock, and low platelet counts were associated with increased hospital mortality. Influenza virus caused severe exacerbation in bronchiectasis, especially in those who were older and who had high BACI scores and previous exacerbations. A high risk of respiratory failure and mortality were observed in influenza-related hospitalization in bronchiectasis. We highlight the importance of preventing or treating influenza infection in bronchiectasis.
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Pickens CI, Wunderink RG. Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient. Clin Chest Med 2022; 43:401-410. [PMID: 36116810 DOI: 10.1016/j.ccm.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.
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Affiliation(s)
- Chiagozie I Pickens
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, 303 E. Superior Street Simpson Querrey 5th Floor, Suite 5-406, Chicago, IL 60611-2909, USA.
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, 303 E. Superior Street Simpson Querrey 5th Floor, Suite 5-406, Chicago, IL 60611-2909, USA
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6
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Nonimaging Diagnostic Tests for Pneumonia. Radiol Clin North Am 2022; 60:521-534. [DOI: 10.1016/j.rcl.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Respiratory viral infections in pragmatically selected adults in intensive care units. Sci Rep 2021; 11:20058. [PMID: 34625621 PMCID: PMC8501073 DOI: 10.1038/s41598-021-99608-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/23/2021] [Indexed: 12/21/2022] Open
Abstract
Respiratory viruses can be detected in 18.3 to 48.9% of critically ill adults with severe respiratory tract infections (RTIs). The present study aims to assess the clinical significance of respiratory viruses in pragmatically selected adults in medical intensive care unit patients and to identify factors associated with viral respiratory viral tract infections (VRTIs). We conducted a prospective study on critically ill adults with suspected RTIs without recognized respiratory pathogens. Viral cultures with monoclonal antibody identification, in-house real-time polymerase chain reaction (PCR) for influenza virus, and FilmArray respiratory panel were used to detect viral pathogens. Multivariable logistic regression was applied to identify factors associated with VRTIs. Sixty-four (40.5%) of the included 158 critically ill adults had respiratory viruses detected in their respiratory specimens. The commonly detected viruses included influenza virus (20), followed by human rhinovirus/enterovirus (11), respiratory syncitial virus (9), human metapneumovirus (9), human parainfluenza viruses (8), human adenovirus (7), and human coronaviruses (2). The FilmArray respiratory panel detected respiratory viruses in 54 (34.6%) patients, but showed negative results for seven of 13 patients with influenza A/H3 infection. In the multivariable logistic regression model, patient characters associated with VRTIs included those aged < 65 years, household contact with individuals with upper RTI, the presence of fever, cough with sputum production, and sore throat. Respiratory viruses were not uncommonly detected in the pragmatically selected adults with critical illness. The application of multiplex PCR testing for respiratory viruses in selected patient population is a practical strategy, and the viral detection rate could be further improved by the patient characters recognized in this study.
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Gonzalez F, Beschmout S, Chow-Chine L, Bisbal M, d'Incan E, Servan L, de Guibert JM, Vey N, Faucher M, Sannini A, Mokart D. Herpesviridae in critically ill hematology patients: HHV-6 is associated with worse clinical outcome. J Crit Care 2021; 66:138-145. [PMID: 34547554 DOI: 10.1016/j.jcrc.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/29/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Although viral infections are frequent among patients with hematological malignancies (HM), data about herpesviridae in critically ill hematology patients are scarce. We aimed at determining the impact of herpesviridae reactivation/infection in this population. MATERIAL AND METHODS We performed a single center retrospective study including all consecutive adult hematology patients admitted to our comprehensive cancer center ICU on a 6-year period. Clinical characteristics, microbiological findings, especially virus detection and outcome were recorded. RESULTS Among the 364 included patients, HHV-6 was the predominant retrieved herpesviridae (66 patients, 17.9%), followed by HSV1/2 (41 patients, 11.3%), CMV (38 patients, 10.4%), EBV (24 patients, 6.6%) and VZV (3 patients). By multivariable analysis, HHV-6 reactivation was independently associated with hospital mortality (OR, 2.35; 95% CI, 1.03-5.34; P = 0.042), whereas antiviral prophylaxis during ICU stay had a protective effect (OR, 0.41; 95% CI, 0.18-0.95; P = 0.037). HHV-6 pneumonitis was independently associated with 1-year mortality (OR, 6.87; 95% CI, 1.09-43.3; P = 0.04). CONCLUSIONS Among critically ill hematology patients, HHV-6 reactivation and pneumonitis are independent risk factors for hospital and 1-year mortality, respectively. Impact of prevention and treatment using agents active against HHV-6 should be assessed to define a consensual diagnostic and therapeutic strategy.
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Affiliation(s)
- Frédéric Gonzalez
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Samuel Beschmout
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France
| | - Laurent Chow-Chine
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Magali Bisbal
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Evelyne d'Incan
- Hematology Department, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Luca Servan
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Jean-Manuel de Guibert
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Norbert Vey
- Hematology Department, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Marion Faucher
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Antoine Sannini
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli-Calmettes, 232 boulevard de Sainte Marguerite, 13009 Marseille, France.
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Schubert L, Steininger J, Lötsch F, Herdina AN, Redlberger-Fritz M, Tobudic S, Kundi M, Strassl R, Steininger C. Surveillance of respiratory syncytial virus infections in adults, Austria, 2017 to 2019. Sci Rep 2021; 11:8939. [PMID: 33903713 PMCID: PMC8076173 DOI: 10.1038/s41598-021-88537-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022] Open
Abstract
Respiratory syncytial virus (RSV) testing is generally available in most care centres, but it is rarely performed because clinicians' seldom suspect RSV to be the underlying pathogen in adults with respiratory disease. Here, we evaluate the impact of broad combined influenza/RSV testing on the clinical practice. Overall, 103 patients were tested positively for RSV. Our study indicates that positively tested patients were mostly of advanced age and suffered from chronic diseases. Mortality was significant in our cohort and higher in patients with advanced age. Further, we report a significant increase in detected RSV cases but also in detection rate. Together, these findings suggest that implementation of a combined influenza/RSV testing led to a significant increase in detection rate, supported clinicians establishing the correct diagnosis and allowed a safe and controlled handling of RSV patients.
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Affiliation(s)
- Lorenz Schubert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-10, 1090, Vienna, Austria
| | - Johanna Steininger
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-10, 1090, Vienna, Austria
| | - Felix Lötsch
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-10, 1090, Vienna, Austria
| | - Anna Nele Herdina
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Selma Tobudic
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-10, 1090, Vienna, Austria
| | - Michael Kundi
- Department for Environmental Health, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph Steininger
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-10, 1090, Vienna, Austria.
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Feldman C, Anderson R. The role of co-infections and secondary infections in patients with COVID-19. Pneumonia (Nathan) 2021; 13:5. [PMID: 33894790 PMCID: PMC8068564 DOI: 10.1186/s41479-021-00083-w] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/12/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND It has been recognised for a considerable time-period, that viral respiratory infections predispose patients to bacterial infections, and that these co-infections have a worse outcome than either infection on its own. However, it is still unclear what exact roles co-infections and/or superinfections play in patients with COVID-19 infection. MAIN BODY This was an extensive review of the current literature regarding co-infections and superinfections in patients with SARS-CoV-2 infection. The definitions used were those of the Centers for Disease Control and Prevention (US), which defines coinfection as one occurring concurrently with the initial infection, while superinfections are those infections that follow on a previous infection, especially when caused by microorganisms that are resistant, or have become resistant, to the antibiotics used earlier. Some researchers have envisioned three potential scenarios of bacterial/SARS-CoV-2 co-infection; namely, secondary SARS-CoV-2 infection following bacterial infection or colonisation, combined viral/bacterial pneumonia, or secondary bacterial superinfection following SARS-CoV-2. There are a myriad of published articles ranging from letters to the editor to systematic reviews and meta-analyses describing varying ranges of co-infection and/or superinfection in patients with COVID-19. The concomitant infections described included other respiratory viruses, bacteria, including mycobacteria, fungi, as well as other, more unusual, pathogens. However, as will be seen in this review, there is often not a clear distinction made in the literature as to what the authors are referring to, whether true concomitant/co-infections or superinfections. In addition, possible mechanisms of the interactions between viral infections, including SARS-CoV-2, and other infections, particularly bacterial infections are discussed further. Lastly, the impact of these co-infections and superinfections in the severity of COVID-19 infections and their outcome is also described. CONCLUSION The current review describes varying rates of co-infections and/or superinfections in patients with COVID-19 infections, although often a clear distinction between the two is not clear in the literature. When they occur, these infections appear to be associated with both severity of COVID-19 as well as poorer outcomes.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand Medical School, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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11
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[Virological diagnosis of lower respiratory tract infections]. Rev Mal Respir 2021; 38:58-73. [PMID: 33461842 DOI: 10.1016/j.rmr.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 08/06/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The etiological diagnosis of bronchopulmonary infections cannot be assessed with clinical, radiological and epidemiological data alone. Viruses have been demonstrated to cause a large proportion of these infections, both in children and adults. BACKGROUND The diagnosis of viral bronchopulmonary infections is based on the analysis of secretions, collected from the lower respiratory tract when possible, by techniques that detect either influenza and respiratory syncytial viruses, or a large panel of viruses that can be responsible for respiratory disease. The latter, called multiplex PCR assays, allow a syndromic approach to respiratory infection. Their high cost for the laboratory raises the question of their place in the management of patients in terms of antibiotic economy and isolation. In the absence of clear recommendations, the strategy and equipment are very unevenly distributed in France. OUTLOOK Medico-economic analyses need to be performed in France to evaluate the place of these tests in the management of patients. The evaluation of the role of the different viruses often detected in co-infection, especially in children, also deserves the attention of virologists and clinicians. CONCLUSIONS The availability of new diagnostic technologies, the recent emergence of SARS-CoV-2, together with the availability of new antiviral drugs are likely to impact future recommendations for the management of viral bronchopulmonary infections.
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Ojemolon PE, Trelles-Garcia VP, Trelles-Garcia D, Kichloo A, Raghavan S, Abusalim AI, Eseaton P. Racial Disparities in Outcomes of Adults Hospitalized for Viral Pneumonia. Cureus 2020; 12:e11909. [PMID: 33415059 PMCID: PMC7781858 DOI: 10.7759/cureus.11909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/12/2022] Open
Abstract
Background Viral pneumonia is an important cause of respiratory morbidity and mortality. Cases of viral pneumonia are becoming increasingly more common as at-risk populations increase globally. We sought to highlight the racial distribution of hospitalized patients with viral pneumonia and compare their outcomes. Materials and methods Data were obtained from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. The study involved adults who had a principal discharge diagnosis of viral pneumonia. The primary outcome analyzed was inpatient mortality. Secondary outcomes included the development of sepsis, septic shock, acute respiratory failure, acute respiratory distress syndrome, non-ST segment elevation myocardial infarction (NSTEMI), acute kidney failure, deep vein thrombosis, pulmonary embolism, cerebrovascular accident, need for mechanical ventilation, and use of vasopressors as well as mean length of hospitalization and mean total hospital charges. Results Blacks and Hispanics had lower inpatient mortality adjusted odds (aOR: 0.39, 95% CI = 0.229 - 0.662, p<0.001 and aOR: 0.55, 95% CI = 0.347 - 0.858, p=0.009, respectively) compared to Whites. Black and Hispanic patients were also found to have lower adjusted odds ratio of having acute respiratory failure (aOR: 0.54, 95% CI = 0.471 - 0.614, p<0.001, and 0.66, 95% CI = 0.576 - 0.753, p<0.001, respectively). Conclusion Black and Hispanic patients are at lower risk of adverse outcomes when compared to White patients with viral pneumonia.
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Affiliation(s)
- Pius E Ojemolon
- Anatomical Sciences, St. George's University, St. George's, GRD
| | | | | | - Asim Kichloo
- Internal Medicine, Central Michigan University, Saginaw, USA
| | - Sairam Raghavan
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
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Torres A, Martin-Loeches I. Invasive Pulmonary Aspergillosis in Ventilator-associated Pneumonia: The Hidden Enemy? Am J Respir Crit Care Med 2020; 202:1071-1073. [PMID: 32730104 PMCID: PMC7560816 DOI: 10.1164/rccm.202006-2605ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Antoni Torres
- Hospital Clinic, IDIBAPS Universitat de Barcelona Barcelona, Spain.,Universitat de Barcelona Barcelona, Spain.,CIBERes, Barcelona Spain.,ICREA, Institución Catalana de Investigación y Estudios Avanzados Barcelona, Spain
| | - Ignacio Martin-Loeches
- Hospital Clinic, IDIBAPS Universitat de Barcelona Barcelona, Spain.,Universitat de Barcelona Barcelona, Spain.,CIBERes, Barcelona Spain.,Multidisciplinary Intensive Care Research Organization (MICRO) Department of Intensive Care Medicine, St. James's University Hospital Dublin, Ireland and.,Trinity Centre for Health Sciences Department of Intensive Care Medicine, Dublin, Ireland
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Tang H, Abouleila Y, Si L, Ortega-Prieto AM, Mummery CL, Ingber DE, Mashaghi A. Human Organs-on-Chips for Virology. Trends Microbiol 2020; 28:934-946. [PMID: 32674988 PMCID: PMC7357975 DOI: 10.1016/j.tim.2020.06.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 02/03/2023]
Abstract
While conventional in vitro culture systems and animal models have been used to study the pathogenesis of viral infections and to facilitate development of vaccines and therapeutics for viral diseases, models that can accurately recapitulate human responses to infection are still lacking. Human organ-on-a-chip (Organ Chip) microfluidic culture devices that recapitulate tissue–tissue interfaces, fluid flows, mechanical cues, and organ-level physiology have been developed to narrow the gap between in vitro experimental models and human pathophysiology. Here, we describe how recent developments in Organ Chips have enabled re-creation of complex pathophysiological features of human viral infections in vitro. Microfluidic Organ Chip culture devices are emerging alternatives to conventional in vitro and animal models due to their ability to replicate many structural and functional features of human physiology and disease states. Recent innovations demonstrate that Organ Chip technology is a promising strategy for virology studies where there have been successes in reproducing various viral disease phenotypes. Organ Chips have enabled investigation of many aspects of viral infection, including virus–host interactions, viral therapy-resistance evolution, and development of new antiviral therapeutics, as well as underlying pathogenesis. As Organ Chip-based assays provide accessibility to study virus-induced diseases in real time and at high resolution, they can open new avenues to uncover viral pathogenesis in a human-relevant environment and may eventually enable development of novel therapeutics and vaccines.
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Affiliation(s)
- Huaqi Tang
- Medical Systems Biophysics and Bioengineering, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands
| | - Yasmine Abouleila
- Medical Systems Biophysics and Bioengineering, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands
| | - Longlong Si
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA
| | | | - Christine L Mummery
- Department of Anatomy and Embryology, Leiden University Medical Center, Einthovenweg 20, 2333 ZD, Leiden, The Netherlands
| | - Donald E Ingber
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA 02115, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA; Vascular Biology Program and Department of Surgery, Harvard Medical School and Boston Children's Hospital, Boston, MA 02115, USA
| | - Alireza Mashaghi
- Medical Systems Biophysics and Bioengineering, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC, Leiden, The Netherlands.
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Severe influenza/respiratory syncytial virus infections and hospital antimicrobial stewardship opportunities: impact of a 4-year surveillance including molecular diagnosis. Infect Control Hosp Epidemiol 2020; 41:1184-1189. [PMID: 32624029 DOI: 10.1017/ice.2020.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the prevalence of influenza and respiratory syncytial virus (RSV) in adults hospitalized for a respiratory infection in the winter months and to evaluate the impact of a viral diagnosis on empirical antimicrobial management (antibiotics and antivirals). DESIGN Observational cohort study. SETTING Acute-care university hospital. PATIENTS The study included 963 adult patients hospitalized over a 4-year surveillance period. METHODS Annual surveillance timelines were defined according to epidemiological criteria related to the circulation of RSV and influenza viruses in the general population. Patients were screened following a severe acute respiratory infection (SARI) case definition at the emergency department and were enrolled for molecular assay targeting influenza/RSV viruses after oral informed consent. Epidemiological and clinical data were recorded prospectively, microbiological investigations, antimicrobial management, and outcome data were reviewed retrospectively. RESULTS An influenza or RSV virus was documented in 316 of 963 patients (33%). Optimization of antimicrobial management (AM) was achieved in 162 of 265 patients (61%) with a positive viral diagnosis and no bacterial infection at admission (AM treatment not initiated, n = 111; discontinued, n = 51). In contrast, only 128 of 462 patients (28%) with negative microbiological investigations did not have AM treatment initiated (n = 116) or had such treatment discontinued (n = 12). Early, targeted antiviral treatment was prescribed in 235 of 253 patients (93%) confirmed with influenza. Epidemiological, clinical, and outcome data were similar in both groups. CONCLUSION Epidemiological surveillance associated with influenza/RSV molecular diagnosis in adults hospitalized for severe winter respiratory infections dramatically enhanced antimicrobial management.
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16
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Rello J, Storti E, Belliato M, Serrano R. Clinical phenotypes of SARS-CoV-2: implications for clinicians and researchers. Eur Respir J 2020; 55:13993003.01028-2020. [PMID: 32341111 PMCID: PMC7236837 DOI: 10.1183/13993003.01028-2020] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/11/2020] [Indexed: 02/07/2023]
Abstract
Patients with COVID-19 present a broad spectrum of clinical presentation. Whereas hypoxaemia is the marker of severity, different strategies of management should be customised to five specific individual phenotypes. Many intubated patients present with phenotype 4, characterised by pulmonary hypoxic vasoconstriction, being associated with severe hypoxaemia with "normal" (>40 mL·cmH2O-1) lung compliance and likely representing pulmonary microvascular thrombosis. Phenotype 5 is often associated with high plasma procalcitonin and has low pulmonary compliance, Which is a result of co-infection or acute lung injury after noninvasive ventilation. Identifying these clinical phenotypes and applying a personalised approach would benefit the optimisation of therapies and improve outcomes.
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Affiliation(s)
- Jordi Rello
- Centro de Investigación Biomedica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain .,CRIPS, Vall d'Hebron Institute of Research, Barcelona, Spain.,Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
| | - Enrico Storti
- Anesthesia and ICU Dept, Hospitale de Lodi, Lodi, Italy
| | - Mirko Belliato
- UOC Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Abstract
PURPOSE OF REVIEW Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity. RECENT FINDINGS Pandemic influenza A (H1N1) virus circulates seasonally and remains the predominant subtype among intensive care patients. Mortality in acute respiratory failure (ARF) is around 20%, independent of influenza subtypes. During severe infection, the imbalance between pro-inflammatory and anti-inflammatory molecules, such as Th1 and Th17 cytokines, is associated with complicated infections and mortality. Primary viral pneumonia presents in more than 70% of ICU influenza patients and more than 50% develop acute respiratory distress syndrome. Bacterial secondary infection occurs in 20% of severe cases and Streptococcus pneumoniae and Staphylococcus aureus remain the prevalent pathogens. Myocarditis and late-onset cardiovascular complications are associated with mortality. Antiviral therapy within 48 h after onset, avoidance of corticosteroids and rescue therapies for ARF or myocarditis, such as extracorporeal membrane oxygenation, improve survival. SUMMARY The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes.
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18
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Azoulay E, Russell L, Van de Louw A, Metaxa V, Bauer P, Povoa P, Montero JG, Loeches IM, Mehta S, Puxty K, Schellongowski P, Rello J, Mokart D, Lemiale V, Mirouse A. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46:298-314. [PMID: 32034433 PMCID: PMC7080052 DOI: 10.1007/s00134-019-05906-5] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.
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Affiliation(s)
- Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
- Université de Paris, Paris, France.
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal
| | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Ireland
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain
- CRIPS Department, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Adrien Mirouse
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
- Université de Paris, Paris, France
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Opportunities Revealed for Antimicrobial Stewardship and Clinical Practice with Implementation of a Rapid Respiratory Multiplex Assay. J Clin Microbiol 2019; 57:JCM.00861-19. [PMID: 31413077 PMCID: PMC6760939 DOI: 10.1128/jcm.00861-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Few studies assess the utility of rapid multiplex molecular respiratory panels in adult patients. Previous multiplex PCR assays took hours to days from order time to result. We analyze the clinical impact of switching to a molecular assay with a 3-h test-turnaround-time (TAT). We performed a retrospective review of adult patients who presented to our emergency departments with respiratory symptoms and had a respiratory viral panel (xTAG RVP; RVP) or respiratory pathogen panel (ePlex RP; RPP) within 48 h of presentation. The average TATs for the RVP and RPP were 27.9 and 3.0 h, respectively (P < 0.0001). In RVP-positive and RPP-positive patients, 68.9 and 44.5% of those with normal chest imaging received antibiotics (P = 0.013), while 95.4 and 89.6% of those with abnormal imaging received antibiotics, respectively (P = 0.187). There was no difference in antibiotic duration in RVP-positive and RPP-positive patients with abnormal chest imaging (6.2 and 6.0 days, respectively; P = 0.923) and normal chest imaging (4.5 and 4.3 days, respectively; P = 0.922). Fewer patients were admitted in the RPP-positive compared to the RVP-positive group (76.9 and 88.6%, respectively; P = 0.013), while the proportion of admissions were similar among RPP-negative and RVP-negative patients (85.3 and 87.1%, P = 0.726). Switching to a multiplex respiratory panel with a clinically actionable TAT is associated with reduced hospital admissions and, in admitted adults without focal radiographic findings, reduced antibiotic initiation. Opportunities to further mitigate inappropriate antibiotic use may be realized by combining rapid multiplex PCR with provider education, clinical decision-care algorithms, and active antibiotic stewardship.
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Drews SJ, Branche AR, Falsey AR, Lee N. What is the role of rapid molecular testing for seniors and other at-risk adults with respiratory syncytial virus infections? J Clin Virol 2019; 117:27-32. [PMID: 31158780 DOI: 10.1016/j.jcv.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/16/2022]
Abstract
Lower respiratory tract infections are a leading cause of hospitalization and viruses are important causal pathogens, especially in the elderly, immunocompromised patients and those with respiratory or cardiovascular comorbidities. Respiratory syncytial virus (RSV) is recognized as comprising a substantial burden of morbidity and mortality in older and at-risk adults, and the emergence of rapid point-of-care molecular testing has made it possible to confirm an RSV diagnosis accurately, in a clinically actionable timeframe. RSV patients have significantly higher healthcare resource use (including hospital stays and emergency room/urgent care visits) than non-RSV matched controls, especially if aged ≥65 years, a longer length of hospitalization than those with influenza, and associated costs nearly three times higher. We found no direct clinical outcome data specific to rapid molecular testing for RSV in adults and very little in children. There is very limited evidence that prompt diagnosis may reduce hospital length of stay but this and other outcome parameters need confirmation in larger, prospective clinical trials. Regarding reducing inappropriate antibiotic prescribing, the picture is mixed and testing alone is unlikely to change entrenched habits. There is little incentive for clinicians to order routine RSV tests in adults given the absence of a specific antiviral therapy. However, with numerous vaccine and antiviral candidates in clinical development, we believe it is good practice to plan and start establishing standardized testing protocols - perhaps as part of outcome studies. For especially vulnerable patients, e.g., immunocompromised and transplant patients, prompt accurate RSV diagnosis may prevent disease spread and save lives.
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Affiliation(s)
- Steven J Drews
- 2B1.03 WMC University of Alberta Hospital, 8440 112th St NW, Edmonton, Alberta, T6J 1L9, Canada.
| | - Angela R Branche
- University of Rochester, 601 Elmwood Avenue, Box 689, Rochester, NY 14642, USA.
| | - Ann R Falsey
- 1425 Portland Avenue, Rochester General Hospital, Rochester, NY 14621, USA.
| | - Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Clinical Sciences Building (CSB), 1-124, 11350-83 Avenue NW, Edmonton, Alberta, T6G 2G3, Canada.
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