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Chean D, Windsor C, Lafarge A, Dupont T, Nakaa S, Whiting L, Joseph A, Lemiale V, Azoulay E. Severe Community-Acquired Pneumonia in Immunocompromised Patients. Semin Respir Crit Care Med 2024; 45:255-265. [PMID: 38266998 DOI: 10.1055/s-0043-1778137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.
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Affiliation(s)
- Dara Chean
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Camille Windsor
- Medical Intensive Care Unit, AP-HP Henri Mondor University Hospital, Créteil, France
| | - Antoine Lafarge
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Thibault Dupont
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Sabrine Nakaa
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Livia Whiting
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Adrien Joseph
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
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O'Grady NP, Alexander E, Alhazzani W, Alshamsi F, Cuellar-Rodriguez J, Jefferson BK, Kalil AC, Pastores SM, Patel R, van Duin D, Weber DJ, Deresinski S. Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Crit Care Med 2023; 51:1570-1586. [PMID: 37902340 DOI: 10.1097/ccm.0000000000006022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
RATIONALE Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation. OBJECTIVES This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. PANEL DESIGN The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline. METHODS We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements. RESULTS The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data. CONCLUSIONS The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.
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Affiliation(s)
- Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health Clinical Center, Bethesda, MD
| | - Earnest Alexander
- Clinical Pharmacy Services, Department of Pharmacy, Tampa General Hospital, Tampa, FL
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Jennifer Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, Bethesda, MD
| | - Brian K Jefferson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Internal Medicine-Critical Care Services, Atrium Health Cabarrus, Concord, NC
| | - Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Rochester, MN
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - David J Weber
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - Stanley Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA
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Lee J, Kim SC, Rhee CK, Lee J, Lee JW, Lee DG. Prevalence and clinical course of upper airway respiratory virus infection in critically ill patients with hematologic malignancies. PLoS One 2021; 16:e0260741. [PMID: 34905565 PMCID: PMC8670702 DOI: 10.1371/journal.pone.0260741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background The clinical significance of upper airway respiratory virus (RV) detection in patients with hematologic malignancies remains unclear. We aimed to investigate the association between upper airway RV detection and prognosis in critically ill patients with hematologic malignancies. Methods This retrospective observational study included 331 critically ill patients with hematologic malignancies who presented respiratory symptoms and their nasopharyngeal swab was tested using a multiplex PCR assay between January 2017 and December 2018. A logistic regression model was used to adjust for potential confounding factors in the association between assay positivity and in-hospital mortality. Results Among the 331 analyzed patients, RVs were detected in 29.0%. The overall mortality rates in the intensive care unit and hospital were 56.8% and 65.9%, respectively. Positive upper airway RV detection was associated with relapsed hematologic malignancies, higher level of C-reactive protein, and prior use of high dose steroids and anti-cancer chemotherapeutic drugs. Furthermore, it was independently associated with in-hospital mortality (adjusted odds ratio, 2.36; 95% confidence interval, 1.23 to 4.54). Among different RVs, parainfluenza virus was more prevalent among patients who died in the hospital than among those who survived (11.5% vs. 3.5%, P = 0.027). Conclusions RV detection in the upper respiratory tract was relatively common in our cohort and was significantly associated with a poor prognosis. Thus, it can be used as a predictor of prognosis. Moreover, RV presence in the upper respiratory tract should be examined in patients who have previously been prescribed with high dose corticosteroids and anti-cancer drugs.
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Affiliation(s)
- Jongmin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Chan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaewoong Lee
- Department of Laboratory Medicine, Catholic Genetic Laboratory Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Gun Lee
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Divison of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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[Bone marrow transplantation patients in the intensive care unit]. Med Klin Intensivmed Notfmed 2021; 116:111-120. [PMID: 33564899 PMCID: PMC7871956 DOI: 10.1007/s00063-021-00782-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 10/31/2022]
Abstract
Allogeneic hematopoetic stem cell transplantation yields improved long-term survival for patients with high-risk malignant and non-malignant hematologic disease. However, it is associated with high morbidity and mortality. A proportion of patients need intensive care due to infectious, immunological and/or toxic complications. The utility of intensive care unit (ICU) treatments as mechanical ventilation and renal replacement therapy for these patients is uncertain since mortality is high. We describe the most frequent complications and the treatment options concerning the ICU in recipients of allogeneic hematopoetic stem cells.
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Legoff J, Zucman N, Lemiale V, Mokart D, Pène F, Lambert J, Kouatchet A, Demoule A, Vincent F, Nyunga M, Bruneel F, Contejean A, Mercier-Delarue S, Rabbat A, Lebert C, Perez P, Meert AP, Benoit D, Schwebel C, Jourdain M, Darmon M, Resche-Rigon M, Azoulay E. Clinical Significance of Upper Airway Virus Detection in Critically Ill Hematology Patients. Am J Respir Crit Care Med 2020; 199:518-528. [PMID: 30230909 DOI: 10.1164/rccm.201804-0681oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Noninvasive diagnostic multiplex molecular tests may enable the early identification and treatment of viral infections in critically ill immunocompromised patients. OBJECTIVES To assess the association between viral detection in nasopharyngeal swabs and ICU mortality in critically ill hematology patients. METHODS This was a post hoc analysis of a prospective cohort of critically ill hematology patients admitted to 17 ICUs. Nasal swabs sampled and frozen at ICU admission were tested using a multiplex PCR assay. Predictors of ICU mortality and assay positivity were identified. MEASUREMENTS AND MAIN RESULTS Of the 747 patients (447 with acute respiratory failure [ARF]), 21.3% had a virus detected (56.4% rhinovirus/enterovirus and 30.7% influenza/parainfluenza/respiratory syncytial viruses). Overall ICU and hospital mortality rates were 26% and 37%, respectively. Assay positivity was associated with lymphoproliferative disorders, hematopoietic stem cell transplantation, treatment with steroids or other immunosuppressants, ARF (25.5% vs. 16.3%; P = 0.004), and death in the ICU (28.9% vs. 19.3%; P = 0.008). The association with ICU mortality was significant for all viruses and was strongest for influenza/parainfluenza/respiratory syncytial viruses. In patients with ARF, detection of any respiratory virus was independently associated with ICU mortality (odds ratio, 2.07; 95% confidence interval, 1.22-3.50). CONCLUSIONS Respiratory virus detection in the upper airway by multiplex PCR assay is common in critically ill hematology patients. In patients with ARF, respiratory virus detection was independently associated with ICU mortality. Multiplex PCR assay may prove helpful for the risk stratification of hematology patients with ARF. Studies to understand whether respiratory tract viruses play a causal role in outcomes are warranted.
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Affiliation(s)
| | | | | | - Djamel Mokart
- 3 Intensive Care Unit, Paoli Calmette Institute, Marseille, France
| | - Frédéric Pène
- 4 Intensive Care Unit, AP-HP, Cochin Teaching Hospital, Paris, France
| | - Jérôme Lambert
- 5 Statistics Department, AP-HP, Saint Louis Teaching Hospital, Paris, France
| | | | - Alexandre Demoule
- 7 Intensive Care Unit, AP-HP, Pitié Salpêtrière Teaching Hospital, Paris, France
| | - François Vincent
- 8 Intensive Care Unit, AP-HP, Avicennes Teaching Hospital, Bobigny, France
| | - Martine Nyunga
- 9 Intensive Care Unit, Roubaix Regional Hospital Center, Roubaix, France
| | - Fabrice Bruneel
- 10 Intensive Care Unit, Versailles Teaching Hospital, Le Chesnay, France
| | | | | | - Antoine Rabbat
- 4 Intensive Care Unit, AP-HP, Cochin Teaching Hospital, Paris, France
| | - Christine Lebert
- 11 Intensive Care Unit, District Hospital Center, La Roche sur Yon, France
| | - Pierre Perez
- 12 Intensive Care Unit, Brabois Teaching Hospital, Nancy, France
| | | | - Dominique Benoit
- 14 Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - Carole Schwebel
- 15 Intensive Care Unit, Grenoble Teaching Hospital, Grenoble, France; and
| | - Mercé Jourdain
- 16 Intensive Care Unit, Regional Teaching Hospital, Lille, France
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Loubet P, Voiriot G, Neuville M, Visseaux B, Timsit JF. Virus respiratoires dans les pneumonies associées aux soins. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les pneumonies acquises à l’hôpital (PAH) sont fréquentes. À l’ère des techniques diagnostiques de biologie moléculaire (multiplex polymerase chain reaction), les rares données disponibles estiment que les virus respiratoires sont impliqués dans 22 à 32 % des épisodes. Les patients immunodéprimés constituent probablement la population la plus à risque. La présentation clinique et radiologique ne diffère pas entre pneumonies bactériennes, virales et mixtes (virus–bactérie). L’excrétion prolongée de virus respiratoires dans les voies aériennes a été rapportée chez les patients immunodéprimés. Elle pourrait promouvoir la co-infection bactérienne, associée à des durées d’hospitalisation prolongées. L’acquisition intrahospitalière a été démontrée chez tous les virus respiratoires. Elle encourage la mise en œuvre et le respect des mesures d’hygiène et de confinement, dans l’objectif de protéger soignants, visiteurs et patients. De nombreux points restent largement méconnus, relatifs aux interactions entre virus respiratoires et pathogènes non viraux, aux périodes d’incubation, ou encore aux durées d’excrétion virale. L’amélioration des techniques diagnostiques et l’accumulation de données épidémiologiques et cliniques devraient permettre de mieux appréhender le rôle des virus respiratoires dans les PAH. Cette meilleure connaissance aidera à rationaliser l’utilisation des tests de détection et facilitera l’interprétation de leurs résultats. Elle guidera aussi le clinicien dans l’utilisation future des nombreuses molécules antivirales actuellement en développement clinique chez l’homme.
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Moreau AS, Peyrony O, Lemiale V, Zafrani L, Azoulay E. Acute Respiratory Failure in Patients with Hematologic Malignancies. Clin Chest Med 2017; 38:355-362. [DOI: 10.1016/j.ccm.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Contejean A, Lemiale V, Resche-Rigon M, Mokart D, Pène F, Kouatchet A, Mayaux J, Vincent F, Nyunga M, Bruneel F, Rabbat A, Perez P, Meert AP, Benoit D, Hamidfar R, Darmon M, Jourdain M, Renault A, Schlemmer B, Azoulay E. Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study. Ann Intensive Care 2016; 6:102. [PMID: 27783381 PMCID: PMC5080277 DOI: 10.1186/s13613-016-0202-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 10/11/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology. METHODS This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders. RESULTS This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005). CONCLUSIONS In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132.
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Affiliation(s)
| | | | | | - Djamel Mokart
- Réanimation, Institut Paoli Calmettes, Marseille, France.,Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology And Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université Paris Diderot Sorbonne, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Frédéric Pène
- Réanimation médicale, Hôpital Cochin, APHP, Paris, France
| | - Achille Kouatchet
- Service de Reanimation Médicale et Médecine Hyperbare, CHU Angers, Angers, France
| | - Julien Mayaux
- Service de Pneumologie et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - François Vincent
- Réanimation polyvalente, Hôpital Avicenne, APHP, Bobigny, France
| | - Martine Nyunga
- Réanimation polyvalente, Hôpital V.Provo, Roubaix, France
| | - Fabrice Bruneel
- Réanimation polyvalente, Hôpital de Versailles, Le Chesnay, France
| | - Antoine Rabbat
- Réanimation médicale, Hôpital Cochin, APHP, Paris, France
| | - Pierre Perez
- Réanimation médicale, Hôpital Brabois, Nancy, France
| | - Anne-Pascale Meert
- Service des Soins Intensifs Medico-Chirurgicaux et Oncologie Thoracique, Institut Jules Bordet, Brussels, Belgium
| | | | | | - Michael Darmon
- Réanimation polyvalente, CHU de Saint-Etienne, Saint-Piest-en-Jarrez, France
| | | | - Anne Renault
- Réanimation et Urgences Médicales, CHU de la Cavale Blanche, Brest, France
| | | | - Elie Azoulay
- Réanimation médicale, Hôpital Saint Louis, APHP, Paris, France. .,Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology And Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université Paris Diderot Sorbonne, 1, Avenue Claude Vellefaux, 75010, Paris, France.
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Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis. Bone Marrow Transplant 2016; 51:1050-61. [PMID: 27042832 DOI: 10.1038/bmt.2016.72] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/16/2022]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.
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García‐Arroyo L, Prim N, Martí N, Roig MC, Navarro F, Rabella N. Benefits and drawbacks of molecular techniques for diagnosis of viral respiratory infections. Experience with two multiplex PCR assays. J Med Virol 2016; 88:45-50. [PMID: 26100363 PMCID: PMC7166422 DOI: 10.1002/jmv.24298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 11/08/2022]
Abstract
Molecular techniques have represented a major step forward in the diagnosis of viral respiratory infections. They are considered highly sensitive and specific compared to conventional techniques. In this study two nucleic acid amplification tests (NAATs) were compared to conventional methods (immunofluorescence and viral culture). The aim of this work was to discuss the clinical interpretation of the results obtained by NAATs on the basis of the two-decade experience of our group and the literature. Eighty nasopharyngeal aspirates were collected from children under six years attended for acute respiratory illness at the pediatric emergency room of a third level Hospital. Both NAATs tested (Seeplex(®) and Clart(®)) showed an overall higher performance regarding sensitivity (76% and 90%, respectively). Compared to Seeplex(®), the Clart(®) system tripled the number of multiple detections (8 by Seeplex(®) vs. 25 by Clart(®)). In some specimens both NAATs detected different viruses. Given these discrepancies and the fact that detection of viral nucleic acids is not necessarily related to the current clinical syndrome, the interpretation of molecular results may not always be so straightforward. The pros and cons of NAATs should always be taken into account when giving a result.
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Affiliation(s)
| | - Núria Prim
- Servei de Microbiologia, Hospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Neus Martí
- Servei de Microbiologia, Hospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Maria Carme Roig
- Servei de Microbiologia, Hospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Ferran Navarro
- Servei de Microbiologia, Hospital de la Santa Creu i Sant PauBarcelonaSpain
- Departament de Genètica i de MicrobiologiaUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Núria Rabella
- Servei de Microbiologia, Hospital de la Santa Creu i Sant PauBarcelonaSpain
- Departament de Genètica i de MicrobiologiaUniversitat Autònoma de BarcelonaBarcelonaSpain
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Steensels D, Reynders M, Descheemaeker P, Curran MD, Jacobs F, Denis O, Delforge ML, Montesinos I. Clinical evaluation of a multi-parameter customized respiratory TaqMan(®) array card compared to conventional methods in immunocompromised patients. J Clin Virol 2015; 72:36-41. [PMID: 26364158 PMCID: PMC7106552 DOI: 10.1016/j.jcv.2015.08.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Respiratory viral infections can cause significant morbidity and mortality in immunocompromised patients. Conventional tests routinely available at most institutions are limited by the number of detectable pathogens, by a poor sensitivity and/or a long turnaround time. OBJECTIVES To compare the performance of routine conventional testing with direct fluorescent antibody assays and viral culture to a customized TaqMan® array card (TAC) real-time PCR method, targeting 24 viruses, 8 bacteria and 2 fungi simultaneously. STUDY DESIGN We collected 143 respiratory samples from 120 symptomatic immunocompromised patients. Samples for which conventional and TAC results were discordant underwent further verification testing. RESULTS The TAC assay identified viral pathogens in more samples than did conventional testing (77/143 versus 27/143; McNemar P<0.0001), even when TAC results for viruses that could not be detected by conventional testing were excluded from analysis (59/143 versus 26/143; P<0.0001). In addition, the TAC assay identified 18 samples with non-viral pathogens. Verification testing confirmed positive TAC results for 50 out of 55 samples for which conventional testing was negative. Two out of three samples with a positive conventional test but negative TAC result were confirmed positive. A viral and a total pathogen co-infection rate of 5.6% and 11.8% were found, respectively. CONCLUSIONS The customized TAC assay resulted in a significantly increased identification of respiratory viruses. This study provides a practical real-life assessment of the performance of the TAC assay in a population for whom rapid and accurate diagnosis of viral and atypical pathogens is crucial for appropriate clinical management.
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Affiliation(s)
- Deborah Steensels
- Department of Clinical Microbiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Marijke Reynders
- Department of Clinical Microbiology, AZ St-Jan Brugge-Oostende Hospital, Brugge, Belgium
| | - Patrick Descheemaeker
- Department of Clinical Microbiology, AZ St-Jan Brugge-Oostende Hospital, Brugge, Belgium
| | - Martin D Curran
- Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Frédérique Jacobs
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Denis
- Department of Clinical Microbiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marie-Luce Delforge
- Department of Clinical Microbiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabel Montesinos
- Department of Clinical Microbiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Guigue N, Alanio A, Menotti J, Castro ND, Hamane S, Peyrony O, LeGoff J, Bretagne S. Utility of adding Pneumocystis jirovecii DNA detection in nasopharyngeal aspirates in immunocompromised adult patients with febrile pneumonia. Med Mycol 2014; 53:241-7. [PMID: 25550391 PMCID: PMC7107570 DOI: 10.1093/mmy/myu087] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Detection of viral and bacterial DNA in nasopharyngeal aspirates (NPAs) is now a routine practice in emergency cases of febrile pneumonia. We investigated whether
Pneumocystis jirovecii
DNA could also be detected in these cases by conducting retrospective screening of 324 consecutive NPAs from 324 adult patients (198 or 61% were immunocompromised) admitted with
suspected pulmonary infections during the 2012 influenza epidemic season, using a real-time quantitative polymerase chain reaction (PCR) assay (PjqPCR), which targets the
P. jirovecii
mitochondrial large subunit ribosomal RNA gene. These NPAs had already been tested for 22 respiratory pathogens (18 viruses and 4 bacteria), but we found that 16 NPAs (4.9%) were PjqPCR-positive, making
P. jirovecii
the fourth most prevalent of the 23 microorganisms in the screen. Eleven of the 16 PjqPCR-positive patients were immunocompromised, and five had underlying pulmonary conditions. Nine NPAs were also positive for another respiratory pathogen. Six had PjqPCR-positive induced sputa less than 3 days after the NPA procedure, and five were diagnosed with pneumocystis pneumonia (four with chronic lymphoproliferative disorders and one AIDS patient). In all six available pairs quantification of
P. jirovecii
DNA showed fewer copies in NPA than in induced sputum and three PjqPCR-negative NPAs corresponded to PjqPCR-positive bronchoalveolar lavage fluids, underscoring the fact that a negative PjqPCR screen does not exclude a diagnosis of pneumocystosis. Including
P. jirovecii
DNA detection to the panel of microorganisms included in screening tests used for febrile pneumonia may encourage additional investigations or support use of anti-pneumocystis pneumonia prophylaxis in immunocompromised patients.
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Affiliation(s)
- Nicolas Guigue
- Laboratoire de Parasitologie et de Mycologie, APHP, Hôpital Saint Louis Université Paris Diderot, Sorbonne Paris Cité
| | - Alexandre Alanio
- Laboratoire de Parasitologie et de Mycologie, APHP, Hôpital Saint Louis Université Paris Diderot, Sorbonne Paris Cité CNRS URA3012 Institut Pasteur, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Jean Menotti
- Laboratoire de Parasitologie et de Mycologie, APHP, Hôpital Saint Louis Université Paris Diderot, Sorbonne Paris Cité CNRS URA3012
| | - Nathalie De Castro
- Université Paris Diderot, Sorbonne Paris Cité Service de maladies infectieuses, APHP, Hôpital Saint Louis
| | - Samia Hamane
- Laboratoire de Parasitologie et de Mycologie, APHP, Hôpital Saint Louis
| | | | - Jérôme LeGoff
- Université Paris Diderot, Sorbonne Paris Cité Laboratoire de Microbiologie, APHP, Hôpital Saint Louis
| | - Stéphane Bretagne
- Laboratoire de Parasitologie et de Mycologie, APHP, Hôpital Saint Louis Université Paris Diderot, Sorbonne Paris Cité CNRS URA3012 Institut Pasteur, Unité de Mycologie Moléculaire, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
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Godet C, Le Goff J, Beby-Defaux A, Robin M, Raffoux E, Arnulf B, Roblot F, Frat JP, Maillard N, Tazi A, Bergeron A. Human metapneumovirus pneumonia in patients with hematological malignancies. J Clin Virol 2014; 61:593-6. [PMID: 25440914 PMCID: PMC7173302 DOI: 10.1016/j.jcv.2014.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/22/2014] [Accepted: 08/24/2014] [Indexed: 11/30/2022]
Abstract
25% of hematological patients with a positive HMPV test have pneumonia. HMPV pneumonia can occur in the course of several hematological conditions. HMPV can cause pneumonia as a single pathogen. Lung HRCT scan may be suggestive of HMPV pneumonia. The outcome of HMPV pneumonia is good despite no antiviral treatment.
Background Human metapneumovirus (HMPV) has recently emerged as a cause of respiratory infections in hematological patients. Clinical data are lacking to guide the management of HMPV pneumonias. Objectives To characterize the clinical and radiographic presentation and outcome of HMPV pneumonias diagnosed in hematological patients. Study design We screened the patients with a positive HMPV respiratory test in two French teaching hospitals between 2007 and 2011. Among them, the medical charts from the hematological patients who presented with HMPV pneumonia were reviewed. Results Among the 54 patients with several underlying hematological conditions who were positive for HMPV, we found 13 cases of HMPV pneumonias. HMPV could be the cause of pneumonia as a single pathogen without associated upper respiratory infection. Centrilobular nodules were constant on lung computed tomography scans. No patients died despite the absence of administration of antiviral treatments. Conclusions Our data provide further insights in the diagnosis and management of HMPV pneumonias in this setting.
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Affiliation(s)
- Cendrine Godet
- Service de Maladies Infectieuses et de Médecine Interne, CHU Poitiers, France
| | - Jérôme Le Goff
- Univ Paris Diderot, Sorbonne Paris Cité, Laboratoire de microbiologie, AP-HP, Hôpital Saint Louis, Paris, France
| | | | - Marie Robin
- Univ Paris Diderot, Sorbonne Cité, Service d'Hématologie-Greffe, AP-HP, Hôpital Saint Louis, Paris, France
| | - Emmanuel Raffoux
- Univ Paris Diderot, Sorbonne Cité, Maladies du sang, AP-HP, Hôpital Saint Louis, Paris, France
| | - Bertrand Arnulf
- Univ Paris Diderot, Sorbonne Cité, Service d'Immuno-Hématologie, AP-HP, Hôpital Saint Louis, Paris, France
| | - France Roblot
- Service de Maladies Infectieuses et de Médecine Interne, CHU Poitiers, France
| | | | | | - Abdellatif Tazi
- Biostatistics and Clinical Epidemiology Research Team (ECSTRA), UMR 1153 INSERM, Univ Paris Diderot, Sorbonne Paris Cité, France; AP-HP, Hôpital Saint-Louis, Service de Pneumologie, F-75010 Paris, France
| | - Anne Bergeron
- Biostatistics and Clinical Epidemiology Research Team (ECSTRA), UMR 1153 INSERM, Univ Paris Diderot, Sorbonne Paris Cité, France; AP-HP, Hôpital Saint-Louis, Service de Pneumologie, F-75010 Paris, France.
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Clajus C, Blasi F, Welte T, Greer M, Fuehner T, Mantero M. Therapeutic approach to respiratory infections in lung transplantation. Pulm Pharmacol Ther 2014; 32:149-54. [PMID: 25038552 PMCID: PMC7110868 DOI: 10.1016/j.pupt.2014.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/09/2014] [Indexed: 01/22/2023]
Abstract
Lung transplant recipients (LTRs) are at life-long risk for infections and disseminated diseases owing to their immunocompromised state. Besides organ failure and sepsis, infection can trigger acute and chronic graft rejection which increases mortality. Medical prophylaxis and treatment are based on comprehensive diagnostic work-up including previous history of infection and airway colonisation to reduce long-term complications and mortality. Common bacterial pathogens include Pseudomonas and Staphylococcus, whilst Aspergillus and Cytomegalovirus (CMV) are respectively the commonest fungal and viral pathogens. Clinical symptoms can be various in lung transplant recipients presenting an asymptomatic to severe progress. Regular control of infection parameters, daily lung function testing and lifelong follow-up in a specialist transplant centre are mandatory for early detection of bacterial, viral and fungal infections. After transplantation each patient receives intensive training with rules of conduct concerning preventive behaviour and to recognize early signs of post transplant complications. Early detection of infection and complications are important goals to reduce major complications after lung transplantation.
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Affiliation(s)
- Carolina Clajus
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
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Drieghe S, Ryckaert I, Beuselinck K, Lagrou K, Padalko E. Epidemiology of respiratory viruses in bronchoalveolar lavage samples in a tertiary hospital. J Clin Virol 2014; 59:208-11. [PMID: 24447853 PMCID: PMC7172540 DOI: 10.1016/j.jcv.2013.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 10/28/2013] [Accepted: 12/23/2013] [Indexed: 01/26/2023]
Abstract
Background The prevalence of respiratory viruses in adults is largely underexplored, as most studies focus on children. Additionally, in severely ill or immunocompromised adults, where respiratory infections are mostly attributed to bacteria and fungi; respiratory viruses can lead to severe complications. Objectives To evaluate the epidemiology of respiratory viruses in bronchoalveolar lavage fluid (BAL) specimens from patients with lower respiratory tract disease. The study population consisted of different groups including immunocompetent patients (control patients), solid organ transplant recipients, patients with haematological malignancies and other immunocompromised adults. Study design A total of 134 BAL fluid specimens collected during 2009–2011 were retrospectively assessed with the new commercial multiplex real-time PCR FTD Respiratory 21 Plus®, targeting 18 different viruses and 2 atypical bacterial pathogens. Results Viral or atypical bacterial pathogens were detected in 29.1% of BAL fluid specimens. Coronaviruses were most prevalent (13.4%), followed by rhinoviruses (5.2%), RSV (4.5%) and bocaviruses (3.7%). Comparing the total number of viruses detected, a statistically significant difference was observed between the control group and patients with haematological malignancies (27.5% vs. 57.1%, p < 0.05). Conclusion In conclusion, our study highlights the high prevalence of respiratory viruses in BAL fluid specimens from adult patients with lower respiratory tract disease. The methods to be used should be sensitive and cover a wide range of potential pathogens. The specific patient population can also influence the detection rates of respiratory viruses.
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Affiliation(s)
- Stefanie Drieghe
- Department of Clinical Chemistry, Microbiology and Immunology, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Inge Ryckaert
- Department of Clinical Chemistry, Microbiology and Immunology, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium
| | - Kurt Beuselinck
- Department of Microbiology & Immunology, KU Leuven and Clinical Department Laboratory Medicine University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology & Immunology, KU Leuven and Clinical Department Laboratory Medicine University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Elizaveta Padalko
- Department of Clinical Chemistry, Microbiology and Immunology, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium; School of Life Sciences, Hasselt University, Agoralaan Building D, 3590 Diepenbeek, Belgium.
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Community-acquired respiratory viral infections in lung transplant recipients. Curr Opin Infect Dis 2013; 26:302-8. [DOI: 10.1097/qco.0b013e3283630e85] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Vallières E, Renaud C. Clinical and economical impact of multiplex respiratory virus assays. Diagn Microbiol Infect Dis 2013; 76:255-61. [PMID: 23601453 PMCID: PMC7132665 DOI: 10.1016/j.diagmicrobio.2013.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 02/21/2013] [Accepted: 03/05/2013] [Indexed: 01/15/2023]
Abstract
During the last decade, a variety of molecular assays targeting respiratory viruses have been developed and commercialized. Therefore, multiplex PCR are increasingly used in everyday clinical practice. This improves our understanding of respiratory virus epidemiology and enhances our concerns about their clinical impact in specific patient populations. However, questions remain regarding cost-effectiveness of performing these diagnostic tests in routine and their real impact on patient care. This article will review available data and highlight unresolved questions about cost-effectiveness, infection control, clinical utility and public health impact of multiplex respiratory virus assays.
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Affiliation(s)
| | - Christian Renaud
- Département de Microbiologie et Immunologie, CHU Sainte-Justine, Université de Montréal, Montréal, Québec H3T 1C5, Canada
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