Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America

Effect of the PCV 10 vaccination on community-acquired pneumonia hospitalisations after four years of its introduction into the Polish National Immunisation Programme: Follow-up study

BACKGROUND

Vaccination against pneumococci is currently the most effective method of protection against pneumococcal infections. The aim of the study was to analyse changes in hospitalisations and in-hospital deaths due to pneumonia before (2009-2016) and after (2017-2020) the introduction of PCV 10 vaccinations in the National Immunisation Programme in Poland.

METHODS

Data on hospitalisations related to community acquired pneumonia (CAP) in the years 2009-2020 were obtained from the Nationwide General Hospital Morbidity Study. Analyses were made in the age groups: <2, 2-3, 4-5, 6-19, 20-59, 60+ years in 2009-2016 and 2017-2020.

RESULTS

Overall, there were 1,503,105 CAP-related hospitalisations in 2009-2020, 0.7% of which were caused by Streptococcus pneumoniae infections. Children <2 years of age were the most frequently hospitalised for CAP per 100,000 population, followed by patients aged 2-3, 4-5 and 60+ years. In the years 2009-2016, the percentage of CAP hospital admissions increased significantly, and after the year 2017, it decreased significantly in each of the age groups (p<0.001). In the years 2009-2016, a significant increase in hospitalisations for Streptococcus pneumoniae infections was observed in the age groups <2, 2-3 and 4-5 years (p<0.05). A significant reduction in hospitalisations was observed in the age groups <2, 20-59 and 60+ in 2017-2020 (p<0.05). In the years 2009-2020, there were 84,367 in-hospital deaths due to CAP, 423 (0.5%) of which due to Streptococcus pneumoniae, with patients mainly aged 60+.

CONCLUSIONS

Implementation of the PCV vaccination programme has effectively decreased the incidence of CAP hospitalisations, including children <2 years of age. The group that is most at risk of death are persons aged 60+. The results of our study can be useful in evaluating the vaccine efficacy and benefits, and they can be an essential part of public health policy. Effective prevention strategies for CAP should be implemented in different age groups.

Enhancing pneumonia prognosis in the emergency department: a novel machine learning approach using complete blood count and differential leukocyte count combined with CURB-65 score

BACKGROUND

Pneumonia poses a major global health challenge, necessitating accurate severity assessment tools. However, conventional scoring systems such as CURB-65 have inherent limitations. Machine learning (ML) offers a promising approach for prediction. We previously introduced the Blood Culture Prediction Index (BCPI) model, leveraging solely on complete blood count (CBC) and differential leukocyte count (DC), demonstrating its effectiveness in predicting bacteremia. Nevertheless, its potential in assessing pneumonia remains unexplored. Therefore, this study aims to compare the effectiveness of BCPI and CURB-65 in assessing pneumonia severity in an emergency department (ED) setting and develop an integrated ML model to enhance efficiency.

METHODS

This retrospective study was conducted at a 3400-bed tertiary medical center in Taiwan. Data from 9,352 patients with pneumonia in the ED between 2019 and 2021 were analyzed in this study. We utilized the BCPI model, which was trained on CBC/DC data, and computed CURB-65 scores for each patient to compare their prognosis prediction capabilities. Subsequently, we developed a novel Cox regression model to predict in-hospital mortality, integrating the BCPI model and CURB-65 scores, aiming to assess whether this integration enhances predictive performance.

RESULTS

The predictive performance of the BCPI model and CURB-65 score for the 30-day mortality rate in ED patients and the in-hospital mortality rate among admitted patients was comparable across all risk categories. However, the Cox regression model demonstrated an improved area under the ROC curve (AUC) of 0.713 than that of CURB-65 (0.668) for in-hospital mortality (p<0.001). In the lowest risk group (CURB-65=0), the Cox regression model outperformed CURB-65, with a significantly lower mortality rate (2.9% vs. 7.7%, p<0.001).

CONCLUSIONS

The BCPI model, constructed using CBC/DC data and ML techniques, performs comparably to the widely utilized CURB-65 in predicting outcomes for patients with pneumonia in the ED. Furthermore, by integrating the CURB-65 score and BCPI model into a Cox regression model, we demonstrated improved prediction capabilities, particularly for low-risk patients. Given its simple parameters and easy training process, the Cox regression model may be a more effective prediction tool for classifying patients with pneumonia in the emergency room.

Biological evaluation of levofloxacin and its thionated derivatives: antioxidant activity, aldehyde dehydrogenase enzyme inhibition, and cytotoxicity on A549 cell line

Levofloxacin (LVX) is among the fluoroquinolones antibiotics that has also been studied in vitro and in vivo for its anticancer effects. In this study, we used LVX and novel LVX thionated derivatives; compounds 2 and 3, to evaluate their antioxidant activity, aldehyde dehydrogenase (ALDH) enzymes activity inhibition, and anticancer activity. Combination treatments with doxorubicin (DOX) were investigated as well. The 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay was used to determine the antioxidant activity. The NADH fluorescence spectrophotometric activity assay was used to determine the ALDH inhibitory effects. Resazurin dye method was applied for cell viability assays. Molecular Operating Environment software was used for the molecular docking experiments. Compared to ascorbic acid, DPPH assay showed that compound 3 had the highest antioxidant activity among the tested compounds with approximately 35% scavenging activity. On ALDH enzymes, compound 3 showed a significant ALDH activity inhibition compared to compound 2 at 200 µM. The IC50 values for the tested compounds were approximately 100 µM on A549 cell line, a non-small cell lung cancer (NSCLC) cell line. However, significant enhancement of cytotoxicity and reduction of IC50 values were observed by combining DOX and synergism was achieved with LVX with a combination index value of 0.4. The molecular docking test showed a minimum binding energy with a good affinity for compound 3 towards ALDH enzymes. Thionated LVX derivatives, may be repurposed for NSCLC therapy in combination with DOX, taking into account the antioxidant activity, ALDH activity inhibition, and the molecular docking results of compound 3.

Real-World Experience of Ceftobiprole for Community- and Hospital-Acquired Pneumonia from a Stewardship Perspective

Ceftobiprole is a fifth-generation cephalosporin approved by European and American regulatory agencies for the treatment of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Ceftobiprole administration is useful in severe CAP as well as HAP where the potential is to save other β-lactams including carbapenems or linezolid/vancomycin in clinical practice. The aim of this study was to report the real-world evidence of ceftobiprole in patients with CAP and HAP in a single center. In this retrospective study, we included 159 patients with CAP or HAP: 105 (66%) had CAP and 54 (34%) had HAP. The median age was 70 years (IQR 60-77), the median Charlson Comorbidity Index was 5 (IQR 3-7.5) and baseline INCREMENT ESBL score was 8 (IQR 6-11). Ceftobiprole was mostly given as a combination treatment (77%) or as a carbapenem-sparing strategy (44%). There were no differences in mortality between shorter and longer duration of treatment (<7 days compared with ≥7 days (HR 1.02, C.I. 0.58-1.77, p = 0.93) or between first-line (HR 1.00, C.I. 0.46-2.17, p = 0.989) and second-line therapy. Ceftobiprole use in CAP or HAP in the real world is effective as a first- and second-line treatment as well as a carbapenem-sparing strategy. Further studies are needed to explore the full potential of ceftobiprole, including its real-world use in antimicrobial stewardship programs.

Bacterial Infections in Intensive Care Units: Epidemiological and Microbiological Aspects

Intensive care units constitute a critical setting for the management of infections. The patients' fragilities and spread of multidrug-resistant microorganisms lead to relevant difficulties in the patients' care. Recent epidemiological surveys documented the Gram-negative bacteria supremacy among intensive care unit (ICU) infection aetiologies, accounting for numerous multidrug-resistant isolates. Regarding this specific setting, clinical microbiology support holds a crucial role in the definition of diagnostic algorithms. Eventually, the complete patient evaluation requires integrating local epidemiological knowledge into the best practice and the standardization of antimicrobial stewardship programs. Clinical laboratories usually receive respiratory tract and blood samples from ICU patients, which express a significant predisposition to severe infections. Therefore, conventional or rapid diagnostic workflows should be modified depending on patients' urgency and preliminary colonization data. Additionally, it is essential to complete each microbiological report with rapid phenotypic minimum inhibitory concentration (MIC) values and information about resistance markers. Microbiologists also help in the eventual integration of ultimate genome analysis techniques into complicated diagnostic workflows. Herein, we want to emphasize the role of the microbiologist in the decisional process of critical patient management.

Radiographic Imaging of Community-Acquired Pneumonia: A Case-Based Review

The chest radiograph is the most common imaging examination performed in most radiology departments, and one of the more common indications for these studies is suspected infection. Radiologists must therefore be aware of less common radiographic patterns of pulmonary infection if they are to add value in the interpretation of chest radiographs for this indication. This review uses a case-based format to illustrate a range of imaging findings that can be associated with acute pulmonary infection and highlight findings that should prompt investigation for diseases other than community-acquired pneumonia to prevent misdiagnosis and delays in appropriate management.

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon

BACKGROUND

Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI.

METHODS AND RESULTS

We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR.

CONCLUSION

Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

Factors associated with an increased risk of developing pneumonia during acute ischemic stroke hospitalization

Stroke-associated pneumonia (SAP) is a common complication of acute ischemic stroke (AIS). This single-center retrospective observational study aimed to identify factors associated with SAP and predictors of poor outcomes in hospitalized patients with AIS. The study included patients admitted to Chumphon Khet Udomsakdi Hospital in Thailand within 7 days of the onset of AIS between July 2019 and July 2020. The patients were divided according to whether they were diagnosed with SAP during hospitalization into a pneumonia group and a non-pneumonia (control) group. Factors associated with SAP were identified. After 3 months, the patients with AIS were divided into those with a poor outcome (modified Rankin scale [mRS] score ≥4) and those with a non-poor outcome (mRS score <4). Factors associated with a poor outcome were sought. During the study period, 342 patients (mean age 65 years, 61% men) were admitted with AIS, of whom 54 (15.8%) developed SAP. Multivariate analysis identified a failed water-swallowing test (WST; adjusted odds ratio [aOR] 87.48, 95% confidence interval [CI] 21.00-364.51, p<0.001), endotracheal intubation with invasive mechanical ventilation (aOR 12.38, 95% CI 2.44-101.35, p = 0.001), and a retained Foley catheter (aOR 5.67, 95% CI 2.03-15.83, p = 0.001) to be associated with SAP. Of the 342 patients, 112 (32.7%) had a poor outcome at 3 months, predictors of which included having hypertension as a comorbidity (aOR 2.87, 95% CI 1.18-6.98, p = 0.020), a pre-stroke mRS score ≥2 (aOR 4.53, 95% CI 1.50-12.72, p = 0.007), an initial Barthel Index score <40 (aOR 3.35, 95% CI 1.57-7.16, p = 0.002), a failed WST (aOR 5.04, 95% CI 2.00-12.74, p = 0.001), and brain edema (aOR 20.67, 95% CI 2.10-203.26, p = 0.009). This study emphasized the association of SAP with a failed WST, endotracheal intubation with invasive mechanical ventilation, and a retained Foley catheter but also identified hypertension, a pre-stroke mRS score ≥2, an initial BI score <40, a failed WST, and brain edema as predictors of a poor outcome for patients 3 months after AIS.

Usefulness of a predictive model to hospitalize patients with low-risk community-acquired pneumonia

INTRODUCTION

A high proportion of patients with low-risk community-acquired pneumonia (CAP) (classes I-III of the Pneumonia Severity Index) are hospitalized. The purpose of this study was to determine whether validated severity scales are used in clinical practice to make admission decisions, identify the variables that influence this decision, and evaluate the potential predictive value of these variables.

MATERIALS AND METHODS

A prospective, observational study of patients ≥ 18 years of age with a diagnosis of low-risk CAP hospitalized or referred from the Emergency Department to outpatient consultations. A multivariate logistic regression predictive model was built to predict the decision to hospitalize a patient.

RESULTS

The study population was composed of 1,208 patients (806 inpatients and 402 outpatients). The severity of CAP was estimated in 250 patients (20.7%). The factors that determined hospitalization were "abnormal findings in complementary studies" (643/806: 79.8%; due to respiratory failure in 443 patients) and "signs of clinical deterioration" [64/806 (7.9%): hypotension (16/64, 25%); hemoptoic expectoration (12/64, 18.8%); tachypnea (10/64, 15.6%)]. In total, ambulatory management was not contraindicated in 24.7% of hospitalized patients (199). The predictive model built to decide about hospitalization had a good power of discrimination (AUC 0.876; 95%CI: 0.855-0.897).

CONCLUSIONS

Scales are rarely used to estimate the severity of CAP at the emergency department. The decision to hospitalize or not a patient largely depends on the clinical experience of the physician. Our predictive model showed a good power to discriminate the patients who required hospitalization. Further studies are warranted to validate these results.

A nomogram based on the expression level of angiopoietin-like 4 to predict the severity of community-acquired pneumonia

BACKGROUND

The morbidity and mortality of community-acquired pneumonia (CAP) remain high among infectious diseases. It was reported that angiopoietin-like 4 (ANGPTL4) could be a diagnostic biomarker and a therapeutic target for pneumonia. This study aimed to develop a more objective, specific, accurate, and individualized scoring system to predict the severity of CAP.

METHODS

Totally, 31 non-severe community-acquired pneumonia (nsCAP) patients and 14 severe community-acquired pneumonia (sCAP) patients were enrolled in this study. The CURB-65 and pneumonia severity index (PSI) scores were calculated from the clinical data. Serum ANGPTL4 level was measured by enzyme-linked immunosorbent assay (ELISA). After screening factors by univariate analysis and receiver operating characteristic (ROC) curve analysis, multivariate logistic regression analysis of ANGPTL4 expression level and other risk factors was performed, and a nomogram was developed to predict the severity of CAP. This nomogram was further internally validated by bootstrap resampling with 1000 replications through the area under the ROC curve (AUC), the calibration curve, and the decision curve analysis (DCA). Finally, the prediction performance of the new nomogram model, CURB-65 score, and PSI score was compared by AUC, net reclassification index (NRI), and integrated discrimination improvement (IDI).

RESULTS

A nomogram for predicting the severity of CAP was developed using three factors (C-reactive protein (CRP), procalcitonin (PCT), and ANGPTL4). According to the internal validation, the nomogram showed a great discrimination capability with an AUC of 0.910. The Hosmer-Lemeshow test and the approximately fitting calibration curve suggested a satisfactory accuracy of prediction. The results of DCA exhibited a great net benefit. The AUC values of CURB-65 score, PSI score, and the new prediction model were 0.857, 0.912, and 0.940, respectively. NRI comparing the new model with CURB-65 score was found to be statistically significant (NRI = 0.834, P < 0.05).

CONCLUSION

A robust model for predicting the severity of CAP was developed based on the serum ANGPTL4 level. This may provide new insights into accurate assessment of the severity of CAP and its targeted therapy, particularly in the early-stage of the disease.

Bayesian multitask learning for medicine recommendation based on online patient reviews

MOTIVATION

We propose a drug recommendation model that integrates information from both structured data (patient demographic information) and unstructured texts (patient reviews). It is based on multitask learning to predict review ratings of several satisfaction-related measures for a given medicine, where related tasks can learn from each other for prediction. The learned models can then be applied to new patients for drug recommendation. This is fundamentally different from most recommender systems in e-commerce, which do not work well for new customers (referred to as the cold-start problem). To extract information from review texts, we employ both topic modeling and sentiment analysis. We further incorporate variable selection into the model via Bayesian LASSO, which aims to filter out irrelevant features. To our best knowledge, this is the first Bayesian multitask learning method for ordinal responses. We are also the first to apply multitask learning to medicine recommendation. The sample code and data are made available at GitHub: https://github.com/thrushcyc-github/BMull.

RESULTS

We evaluate the proposed method on two sets of drug reviews involving 17 depression/high blood pressure-related drugs. Overall, our method performs better than existing benchmark methods in terms of accuracy and AUC (area under the receiver operating characteristic curve). It is effective even with a small sample size and only a few available features, and more robust to possible noninformative covariates. Due to our model explainability, insights generated from our model may work as a useful reference for doctors. In practice, however, a final decision should be carefully made by combining the information from the proposed recommender with doctors' domain knowledge and past experience.

AVAILABILITY AND IMPLEMENTATION

The sample code and data are publicly available at GitHub: https://github.com/thrushcyc-github/BMull.

The incidence of acute renal failure and high mortality rate in elderly patients hospitalized with community acquired pneumonia

Community acquired pneumonia is associated with high mortality and health care costs, especially in old age. The clinical presentation of pneumonia in the elderly may be asymptomatic or atypical. One of the known complication is an acute kidney injury. The purpose of our study was to estimate the incidence of this complication in elderly patients hospitalized with pneumonia in our geriatric hospital. From a group of 180 elderly patients hospitalized with community-acquired pneumonia 34.4 % developed acute kidney injury. In this group, 51.6 % of patients died compared to 14.4 % in the group of patients without acute kidney injury (p < 0.001). The lower level of e-GFR was significantly associated with mortality (p < 0.001): out of seven patients with e-GFR level of 15-29 mg/mmol, five patients died (71.4 %). Elderly patients with community-acquired pneumonia suffering acute kidney injury experienced worse in-hospital outcomes; mortality rate was significantly higher in our study. We found a relationship between low level of e-GFR and mortality. Clinicians should be alert for early detection and prevention of kidney injury in patients admitted with pneumonia.

Applications of microbiology to different forensic scenarios - A narrative review

In contrast to other forensic disciplines, forensic microbiology is still too often considered a "side activity" and is not able to make a real and concrete contribution to forensic investigations. Indeed, the various application aspects of this discipline still remain a niche activity and, as a result, microbiological investigations are often omitted or only approximated, in part due to poor report in the literature. However, in certain situations, forensic microbiology can prove to be extremely effective, if not crucial, when all other disciplines fail. Precisely because microorganisms can represent forensic evidence, in this narrative review all the major pathological forensic applications described in the literature have been presented. The goal of our review is to highlight the versatility and transversality of microbiology in forensic science and to provide a comprehensive source of literature to refer to when needed.

Antibiotic Treatment for Lower Respiratory Tract Infections in Primary Care: A Register-Based Study Examining the Role of Radiographic Imaging

When imaging (i.e., chest-x-ray or computed tomography) is used to differentiate between acute bronchitis and pneumonia, many patients are being prescribed antibiotics despite the absence of radiographic pneumonia signs. This study of lower respiratory tract infections (LRTIs) with negative chest imaging compares cases where antibiotics were prescribed and not prescribed to find characteristics that could explain the prescription. Data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for patients aged 18-79 years diagnosed with acute bronchitis or pneumonia and who had any chest radiologic imaging between 2007-2014. Of 696 cases without evidence of pneumonia on imaging, 55% were prescribed antibiotics. Age, sex, and co-morbidity did not differ between those with or without antibiotics. The median level of C-reactive protein was low in both groups but differed significantly (21 vs. 10 mg/L; p < 0.001). Resident physicians prescribed antibiotics more frequently than interns or specialists (p < 0.001). It is unclear what features prompted the antibiotic prescribing in those with negative imaging indicating overuse of antibiotics for LRTIs.

Guideline-Concordant Antibiotic Therapy for the Hospital Treatment of Community-Acquired Pneumonia and 1-Year All-Cause and Cardiovascular Mortality in Older Adult Patients Surviving to Discharge

BACKGROUND

Selection of empiric antibiotic treatment for community-acquired pneumonia (CAP) that is concordant with clinical practice guidelines has been associated with improved short-term outcomes of this infection, but whether it is also associated with longer-term outcomes is unknown.

RESEARCH QUESTION

Is guideline-concordance of the initial antibiotic treatment given to older adult patients hospitalized with CAP associated with the 1-year all-cause and cardiovascular mortality risk of those patients who survive hospitalization for this infection?

STUDY DESIGN AND METHODS

A total of 1,909 older (> 65 years of age) patients were identified who survived hospitalization for CAP at The Ottawa Hospital (Ontario, Canada) between 2004 and 2015. Linking patients' information to hospital and provincial data sets, this study analyzed whether the selection of the initial antibiotic therapy for their CAP was concordant with current clinical practice guidelines, and whether guideline-concordance was associated with 1-year all-cause and cardiovascular mortality following their index CAP hospitalization. Adjustments were made for the patients' overall 1-year expected death risk; CAP severity; and history of previous pneumonia admissions, myocardial infarction, heart failure, or cerebrovascular disease.

RESULTS

Selection of guideline-concordant antibiotic therapy was associated with a trend towards lower all-cause mortality at 1 year post-CAP (hazard ratio, 0.82; 95% CI, 0.65-1.04; P = .099). Furthermore, the use of guideline-concordant antibiotic therapy was associated with a significant almost 50% reduction in cardiovascular death risk 1 year following CAP admission (hazard ratio, 0.53; 95% CI, 0.34-0.80; P = .003).

INTERPRETATION

Use of guideline-concordant antibiotic therapy for CAP treatment in older hospitalized patients is associated with a significant reduction in the risk of cardiovascular death at 1 year post-CAP. This finding further supports current clinical practice guideline recommendations for CAP treatment.

Proton pump inhibitor-induced gut dysbiosis and immunomodulation: current knowledge and potential restoration by probiotics

Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for the treatment of non-erosive reflux disease (NERD), ulcers associated with non-steroidal anti-inflammatory drugs (NSAIDs), esophagitis, peptic ulcer disease (PUD), Zollinger-Ellison syndrome (ZES), gastroesophageal reflux disease (GERD), non-ulcer dyspepsia, and Helicobacter pylori eradication therapy. The drugs have the effect of inhibiting acid production in the stomach. According to research, PPIs can affect the composition of gut microbiota and modulate the immune response. Recently, there has been a problem with the over-prescription of such drugs. Although PPIs do not have many side effects, their long-term use can contribute to small intestinal bacterial overgrowth (SIBO) or C. difficile and other intestinal infections. Probiotic supplementation during PPIs therapy may provide some hope in the reduction of emerging therapy side effects. This review aims to present the most important effects of long-term PPI use and provides critical insights into the role of probiotic intervention in PPI therapy.

Acute organ injury and long-term sequelae of severe pneumococcal infections

Streptococcus pneumoniae (Spn) is a major public health problem, as it is a main cause of otitis media, community-acquired pneumonia, bacteremia, sepsis, and meningitis. Acute episodes of pneumococcal disease have been demonstrated to cause organ damage with lingering negative consequences. Cytotoxic products released by the bacterium, biomechanical and physiological stress resulting from infection, and the corresponding inflammatory response together contribute to organ damage accrued during infection. The collective result of this damage can be acutely life-threatening, but among survivors, it also contributes to the long-lasting sequelae of pneumococcal disease. These include the development of new morbidities or exacerbation of pre-existing conditions such as COPD, heart disease, and neurological impairments. Currently, pneumonia is ranked as the 9^th leading cause of death, but this estimate only considers short-term mortality and likely underestimates the true long-term impact of disease. Herein, we review the data that indicates damage incurred during acute pneumococcal infection can result in long-term sequelae which reduces quality of life and life expectancy among pneumococcal disease survivors.

Oral vs. parenteral antibiotic therapy in adult patients with community-acquired pneumonia: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Antibiotic therapy is widely used for patients with community-acquired pneumonia (CAP), and yet whether the efficacy of antibiotics differs based on the treatment mode remains unclear. This study aimed to summarize the evidence regarding the efficacy and safety of oral vs. parenteral administration of antibiotic therapy for the treatment of patients with CAP.

METHODS

The databases of PubMed, EmBase, and the Cochrane Central Register of Controlled Trials were systematically searched for eligible randomized controlled trials (RCTs) from inception until 11 December 2021. The effectiveness of oral vs. parenteral administration of antibiotic therapy was estimated using a random-effects model. Additional sensitivity, subgroup, and publication bias analyses were performed.

RESULTS

Of 912 identified articles, 12 RCTs involving 2158 patients with CAP were included in our pooled analysis. This mostly included trials with low certainty and some concerns regarding risk of bias, including lack of allocation concealment and blinding of participants and personnel. Overall, oral antibiotic therapy did not affect the incidence of clinical success at the end of treatment (relative risk [RR], 1.01; 95% confidence interval [CI], 0.98-1.05; P = 0.417), clinical success at follow-up (RR, 1.02; 95% CI, 0.98-1.06; P = 0.301), or adverse events (RR, 0.87; 95% CI, 0.56-1.35; P = 0.527). Moreover, oral antibiotic therapy had a beneficial effect on the risk of all-cause mortality (RR, 0.58; 95% CI, 0.35-0.96; P = 0.034).

CONCLUSIONS

Oral administration of antibiotics is associated with a reduced risk of all-cause mortality compared with parenteral therapy based on RCTs with low to moderate quality. This finding should be verified in further large-scale RCTs.

Risk factors for hyponatremia in acute exacerbation chronic obstructive pulmonary disease (AECOPD): a multicenter cross-sectional study

BACKGROUND

Hyponatremia is an independent predictor of poor prognosis, including increased mortality and readmission, in COPD patients. Identifying modifiable etiologies of hyponatremia may help reduce adverse events in patients with AECOPD. Therefore, the aim of this study was to explore the risk factors and underlying etiologies of hyponatremia in AECOPD patients.

METHODS

A total of 586 AECOPD patients were enrolled in this multicenter cross-sectional study. Finally, 323 had normonatremia, and 90 had hyponatremia. Demographics, underlying diseases, comorbidities, symptoms, and laboratory data were collected. The least absolute shrinkage and selection operator (LASSO) regression was used to select potential risk factors, which were substituted into binary logistic regression to identify independent risk factors. Nomogram was built to visualize and validate binary logistics regression model.

RESULTS

Nine potential hyponatremia-associated variables were selected by LASSO regression. Subsequently, a binary logistic regression model identified that smoking status, rate of community-acquired pneumonia (CAP), anion gap (AG), erythrocyte sedimentation rate (ESR), and serum magnesium (Mg²⁺) were independent variables of hyponatremia in AECOPD patients. The AUC of ROC curve of nomogram was 0.756. The DCA curve revealed that the nomogram could yielded more clinical benefits if the threshold was between 10% and 52%.

CONCLUSIONS

Collectively, our results showed that smoking status, CAP, AG, ESR, and serum Mg²⁺ were independently associated with hyponatremia in AECOPD patients. Then, these findings indicate that pneumonia, metabolic acidosis, and hypomagnesemia were the underlying etiologies of hyponatremia in AECOPD patients. However, their internal connections need further exploration.

TLRs Gene Polymorphisms Associated with Pneumonia before and during COVID-19 Pandemic

BACKGROUND

The progression of infectious diseases depends on the characteristics of a patient's innate immunity, and the efficiency of an immune system depends on the patient's genetic factors, including SNPs in the TLR genes. In this pilot study, we determined the frequency of alleles in these SNPs in a subset of patients with pneumonia.

METHODS

This study assessed six SNPs from TLR genes: rs5743551 (TLR1), rs5743708, rs3804100 (TLR2), rs4986790 (TLR4), rs5743810 (TLR6), and rs3764880 (TLR8). Three groups of patients participated in this study: patients with pneumonia in 2019 (76 samples), patients with pneumonia caused by SARS-CoV-2 in 2021 (85 samples), and the control group (99 samples).

RESULTS

The allele and genotype frequencies obtained for each group were examined using four genetic models. Significant results were obtained when comparing the samples obtained from individuals with pneumonia before the spread of SARS-CoV-2 and from the controls for rs5743551 (TLR1) and rs3764880 (TLR8). Additionally, the comparison of COVID-19-related pneumonia cases and the control group revealed a significant result for rs3804100-G (TLR2).

CONCLUSIONS

Determining SNP allele frequencies and searching for their associations with the course of pneumonia are important for personalized patient management. However, our results need to be comprehensively assessed in consideration of other clinical parameters.

Short-Term Exposure to Ciprofloxacin Reduces Proteoglycan Loss in Tendon Explants

Fluoroquinolone antibiotics are associated with increased risk of tendinopathy and tendon rupture, which can occur well after cessation of treatment. We have previously reported that the fluoroquinolone ciprofloxacin (CPX) reduced proteoglycan synthesis in equine tendon explants. This study aimed to determine the effects of CPX on proteoglycan catabolism and whether any observed effects are reversible. Equine superficial digital flexor tendon explant cultures were treated for 4 days with 1, 10, 100 or 300 µg/mL CPX followed by 8 days without CPX. The loss of [³⁵S]-labelled proteoglycans and chemical pool of aggrecan and versican was studied as well as the gene expression levels of matrix-degrading enzymes responsible for proteoglycan catabolism. CPX suppressed [³⁵S]-labelled proteoglycan and total aggrecan loss from the explants, although not in a dose-dependent manner, which coincided with downregulation of mRNA expression of MMP-9, -13, ADAMTS-4, -5. The suppressed loss of proteoglycans was reversed upon removal of the fluoroquinolone with concurrent recovery of MMP and ADAMTS mRNA expression, and downregulated TIMP-2 and upregulated TIMP-1 expression. No changes in MMP-3 expression by CPX was observed at any stage. These findings suggest that CPX suppresses proteoglycan catabolism in tendon, and this is partially attributable to downregulation of matrix-degrading enzymes.

Design and Synthesis of Thionated Levofloxacin: Insights into a New Generation of Quinolones with Potential Therapeutic and Analytical Applications

Levofloxacin is a widely used fluoroquinolone in several infectious diseases. The structure–activity relationship of levofloxacin has been studied. However, the effect of changing the carbonyl into thiocarbonyl of levofloxacin has not been investigated up to the date of this report. In this work, levofloxacin structure was slightly modified by making a thionated form (compound 3), which was investigated for its antibacterial activity, biocompatibility, and cytotoxicity, as well as spectroscopic properties. The antibacterial susceptibility testing against five different bacteria showed promising minimum inhibitory concentrations (MICs), particularly against B. spizizenii and E. coli, with an MIC value of 1.9 µM against both bacteria, and 7.8 µM against P. mirabilis. The molecular docking experiment showed similar binding interactions of both levofloxacin and compound 3 with the active site residues of topoisomerase IV. The biocompatibility and cytotoxicity results revealed that compound 3 was more biocompatible with normal cells and more cytotoxic against cancer cells, compared to levofloxacin. Interestingly, compound 3 also showed an excitation profile with a distinctive absorption peak at λ_max 404 nm. Overall, our results suggest that the thionation of quinolones may provide a successful approach toward a new generation with enhanced pharmacokinetic and safety profiles and overall activity as potential antibacterial agents.

Defining effective durations of antibiotic therapy for community-acquired pneumonia and urinary tract infections in hospitalized children

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) and urinary tract infections (UTI) are two common childhood infections often leading to hospital admission. National guidelines for CAP and UTI in children recommend durations of antibiotic therapy of 10 days and 7-14 days, respectively. Due to concerns of rising antimicrobial resistance and an increased awareness of harms associated with prolonged courses of antibiotics, there is a renewed emphasis on reevaluating commonly prescribed durations of antibiotic therapy across bacterial infections. We describe recent clinical trials and observational studies evaluating durations of therapy for CAP and UTI in adults and children and translate the findings to our suggested approach for selecting durations of antibiotic therapy in hospitalized children.

RECENT FINDINGS

There is a growing body of evidence, primarily in adults, that shorter durations of therapy than are commonly prescribed are just as effective as longer durations for CAP and UTIs.

SUMMARY

Combining clinical trial data from adults with available data in children, we believe it is reasonable to consider 5 days of therapy for CAP, 3-5 days of therapy for cystitis, and 7 days of therapy for pyelonephritis for most hospitalized children with uncomplicated infections.

Comparison between Ceftriaxone and Sulbactam-Ampicillin as Initial Treatment of Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis

Current guidelines recommend the use of ceftriaxone and sulbactam-ampicillin for the initial treatment of community-acquired pneumonia (CAP). However, there are no clear data on these guidelines. Therefore, this systematic review and meta-analysis aims to evaluate the effectiveness of ceftriaxone and sulbactam-ampicillin in the initial treatment of CAP. The Embase, Scopus, PubMed, Ichushi, and Cumulative Index to Nursing and Allied Health Literature databases were systematically searched from inception to July 2022. The studies included patients who received ceftriaxone or sulbactam-ampicillin as the initial antibiotic therapy for CAP. The mortality and clinical cure rates were evaluated. Of the 2152 citations identified for screening, four studies were included. Results of the pooled analysis indicated no significant differences in the mortality and clinical cure rates between patients treated with ceftriaxone and those treated with sulbactam-ampicillin (mortality, odds ratio [OR]: 1.85, 95% confidence interval [CI]: 0.57–5.96; clinical cure rate, OR: 1.08, 95% CI: 0.18–6.44). This study supports the guidelines for CAP treatment, though further studies are needed to obtain a deeper understanding.

Levofloxacin versus ceftriaxone and azithromycin for treating community-acquired pneumonia: a randomized clinical trial study

Background and Objectives

We compared two common antibiotic regimens for the treatment of mild to moderate CAP: levofloxacin versus β-lactam and macrolide combination; in terms of their efficacy and side effects.

Materials and Methods

Patients with mild to moderate CAP were randomized into two groups. Group I received a combination of 1 gram ceftriaxone daily and 500 mg azithromycin daily for 5-7 days. Group II received levofloxacin 750 mg daily for five days. The signs and symptoms, hospitalization length, and the side effects were investigated.

Results

There were 77 and 74 patients in groups I and II. The vital signs of group II were significantly better on the 3^rd day of admission, except for the temperature (P=0.09). The O₂ saturation of group II was markedly improved on the 5^th day of admission (P=0.0061). In terms of clinical symptoms and hospitalization length, group II was considerably better. However, the rate of side effects in both groups was similar (P=0.885).

Conclusion

Hospitalized patients with mild to moderate CAP might take more advantage of fluoroquinolone administration. It could improve the patients' signs and symptoms and reduce hospitalization length, compared with the combination of macrolide and cephalosporin, with the same rate of side effects.

Pneumococcal serotypes in adults hospitalized with community-acquired pneumonia in Greece using urinary antigen detection tests: the EGNATIA study, November 2017 - April 2019

Greece introduced a 13-valent pneumococcal conjugate vaccine (PCV13) into the infant national immunization program in 2010 (3 + 1 schedule until June 2019). Since 2015, PCV13 has been recommended for adults aged 19-64 years with comorbidities and adults ≥65 years sequentially with 23-valent pneumococcal polysaccharide vaccine (PPSV23). We examined pneumococcal serotype distribution among Greek adults aged ≥19 years hospitalized with community-acquired pneumonia (CAP) during November 2017-April 2019. This was an interim analysis of EGNATIA, a prospective study of adult hospitalized CAP in the cities of Ioannina and Kavala. Pneumococcus was identified using cultures, BinaxNow®, serotype-specific urinary antigen detection assays (UAD-1/2). Our analysis included overall 482 hospitalized CAP patients (mean age: 70.5 years; 56.4% male). 53.53% of patients belonged to the highest pneumonia severity index (PSI) classes (IV-V). Pneumococcus was detected in 65 (13.5%) patients, with more than half (57%) of cases detected only by UAD. Approximately two-thirds of pneumococcal CAP occurred in those aged ≥65 years (n = 40, 8.3% of CAP). More than half of pneumococcal CAP (n = 35, 53.8%) was caused by PCV13 serotypes. Most frequently detected PCV13 serotypes were 3, 19A, 23F, collectively accounting for 83% of PCV13 vaccine-type (VT) CAP and 6% of all-cause CAP. Overall, 82.9% of PCV13 VT CAP occurred among persons with an indication (age/risk-based) for PCV13 vaccination. Even with a mature PCV13 childhood immunization program, a persistent burden of PCV13 VT CAP exists in Greek adults. Strategies to increase PCV13 (and higher-valency PCVs, when licensed) coverage in adults should be implemented to reduce the disease burden.

Time-Dependent Increase in Susceptibility and Severity of Secondary Bacterial Infections During SARS-CoV-2

Secondary bacterial infections can exacerbate SARS-CoV-2 infection, but their prevalence and impact remain poorly understood. Here, we established that a mild to moderate infection with the SARS-CoV-2 USA-WA1/2020 strain increased the risk of pneumococcal (type 2 strain D39) coinfection in a time-dependent, but sex-independent, manner in the transgenic K18-hACE2 mouse model of COVID-19. Bacterial coinfection increased lethality when the bacteria was initiated at 5 or 7 d post-virus infection (pvi) but not at 3 d pvi. Bacterial outgrowth was accompanied by neutrophilia in the groups coinfected at 7 d pvi and reductions in B cells, T cells, IL-6, IL-15, IL-18, and LIF were present in groups coinfected at 5 d pvi. However, viral burden, lung pathology, cytokines, chemokines, and immune cell activation were largely unchanged after bacterial coinfection. Examining surviving animals more than a week after infection resolution suggested that immune cell activation remained high and was exacerbated in the lungs of coinfected animals compared with SARS-CoV-2 infection alone. These data suggest that SARS-CoV-2 increases susceptibility and pathogenicity to bacterial coinfection, and further studies are needed to understand and combat disease associated with bacterial pneumonia in COVID-19 patients.

Platelets, Bacterial Adhesins and the Pneumococcus

Systemic infections with pathogenic or facultative pathogenic bacteria are associated with activation and aggregation of platelets leading to thrombocytopenia and activation of the clotting system. Bacterial proteins leading to platelet activation and aggregation have been identified, and while platelet receptors are recognized, induced signal transduction cascades are still often unknown. In addition to proteinaceous adhesins, pathogenic bacteria such as Staphylococcus aureus and Streptococcus pneumoniae also produce toxins such as pneumolysin and alpha-hemolysin. They bind to cellular receptors or form pores, which can result in disturbance of physiological functions of platelets. Here, we discuss the bacteria-platelet interplay in the context of adhesin–receptor interactions and platelet-activating bacterial proteins, with a main emphasis on S. aureus and S. pneumoniae. More importantly, we summarize recent findings of how S. aureus toxins and the pore-forming toxin pneumolysin of S. pneumoniae interfere with platelet function. Finally, the relevance of platelet dysfunction due to killing by toxins and potential treatment interventions protecting platelets against cell death are summarized.

Predominance of Other Pathogenic Bacteria among Presumptive Tuberculosis Cases Attending Tuberculosis Clinics in Mwanza, Tanzania: A Cross-Sectional Laboratory-Based Study

This study was designed to determine the prevalence and co-infection of Mycobacterium tuberculosis and other pathogenic bacteria among presumptive cases of tuberculosis (TB) at selected hospitals in Mwanza, Tanzania. GeneXpert and conventional bacteriological culture and sensitivity were used for the detection of TB and other pathogenic bacteria, respectively. STATA version 13.0 was used for data analysis. The median (IQR) age of participants was 33 (19−51) years with males forming more than half (i.e., 59% (158/264)) of the participants. Microscopically, 29.5% (78/264) of the patients had polymorphonuclear leucocytes in the sputum samples. Approximately 7.2% (19/264), 16.3% (43/264), and 1.1% (3/264) of participants had TB, other pathogenic bacteria, and co-infections, respectively. One sample had growth of two other bacteria, resulting in a total of 44 isolated bacteria with the predominance of Gram-negative bacteria at 75.0% (33/44). The predominant species isolated was the Klebsiella pneumoniae complex at 52.3% (23/44). Overall, 27.3% (9/33) of GNB were resistant to third-generation cephalosporins, while Gram-positive bacteria were more resistant to erythromycin at 63.6% (7/11). Good quality sputa had a significantly higher yield of pathogenic bacteria than poor quality sputa (37.2% vs. 7.5%, p < 0.001). Presumptive TB cases were predominantly infected with other pathogenic bacteria than M. tuberculosis. Therefore, other pathogenic bacteria should be considered when attending presumptive TB cases to ensure favorable treatment outcomes.

Risk Factors for Length of Hospital Stay in Acute Exacerbation Chronic Obstructive Pulmonary Disease: A Multicenter Cross-Sectional Study

Background/Purpose

Patients and Methods

Results

Conclusion

Time-Dependent Increase in Susceptibility and Severity of Secondary Bacterial Infection during SARS-CoV-2 Infection.. [PMID: 35262077 PMCID: PMC8902874 DOI: 10.1101/2022.02.28.482305]

Secondary bacterial infections can exacerbate SARS-CoV-2 infection, but their prevalence and impact remain poorly understood. Here, we established that a mild to moderate SARS-CoV-2 infection increased the risk of pneumococcal coinfection in a time-dependent, but sex-independent, manner in the transgenic K18-hACE mouse model of COVID-19. Bacterial coinfection was not established at 3 d post-virus, but increased lethality was observed when the bacteria was initiated at 5 or 7 d post-virus infection (pvi). Bacterial outgrowth was accompanied by neutrophilia in the groups coinfected at 7 d pvi and reductions in B cells, T cells, IL-6, IL-15, IL-18, and LIF were present in groups coinfected at 5 d pvi. However, viral burden, lung pathology, cytokines, chemokines, and immune cell activation were largely unchanged after bacterial coinfection. Examining surviving animals more than a week after infection resolution suggested that immune cell activation remained high and was exacerbated in the lungs of coinfected animals compared with SARS-CoV-2 infection alone. These data suggest that SARS-CoV-2 increases susceptibility and pathogenicity to bacterial coinfection, and further studies are needed to understand and combat disease associated with bacterial pneumonia in COVID-19 patients.

Tenets of a holistic approach to drinking water-associated pathogen research, management, and communication

In recent years, drinking water-associated pathogens that can cause infections in immunocompromised or otherwise susceptible individuals (henceforth referred to as DWPI), sometimes referred to as opportunistic pathogens or opportunistic premise plumbing pathogens, have received considerable attention. DWPI research has largely been conducted by experts focusing on specific microorganisms or within silos of expertise. The resulting mitigation approaches optimized for a single microorganism may have unintended consequences and trade-offs for other DWPI or other interests (e.g., energy costs and conservation). For example, the ecological and epidemiological issues characteristic of Legionella pneumophila diverge from those relevant for Mycobacterium avium and other nontuberculous mycobacteria. Recent advances in understanding DWPI as part of a complex microbial ecosystem inhabiting drinking water systems continues to reveal additional challenges: namely, how can all microorganisms of concern be managed simultaneously? In order to protect public health, we must take a more holistic approach in all aspects of the field, including basic research, monitoring methods, risk-based mitigation techniques, and policy. A holistic approach will (i) target multiple microorganisms simultaneously, (ii) involve experts across several disciplines, and (iii) communicate results across disciplines and more broadly, proactively addressing source water-to-customer system management.

Prospective Evaluation of a Rapid Clinical Metagenomics Test for Bacterial Pneumonia

Background

The diagnosis of bacterial pathogens in lower respiratory tract infections (LRI) using conventional culture methods remains challenging and time-consuming.

Objectives

To evaluate the clinical performance of a rapid nanopore-sequencing based metagenomics test for diagnosis of bacterial pathogens in common LRIs through a large-scale prospective study.

Methods

We enrolled 292 hospitalized patients suspected to have LRIs between November 2018 and June 2019 in a single-center, prospective cohort study. Rapid clinical metagenomics test was performed on-site, and the results were compared with those of routine microbiology tests.

Results

171 bronchoalveolar lavage fluid (BAL) and 121 sputum samples were collected from patients with six kinds of LRIs. The turnaround time (from sample registration to result) for the rapid metagenomics test was 6.4 ± 1.4 hours, compared to 94.8 ± 34.9 hours for routine culture. Compared with culture and real-time PCR validation tests, rapid metagenomics achieved 96.6% sensitivity and 88.0% specificity and identified pathogens in 63 out of 161 (39.1%) culture-negative samples. Correlation between enriched anaerobes and lung abscess was observed by Gene Set Enrichment Analysis. Moreover, 38 anaerobic species failed in culture was identified by metagenomics sequencing. The hypothetical impact of metagenomics test proposed antibiotic de-escalation in 34 patients compared to 1 using routine culture.

Conclusions

Rapid clinical metagenomics test improved pathogen detection yield in the diagnosis of LRI. Empirical antimicrobial therapy could be de-escalated if rapid metagenomics test results were hypothetically applied to clinical management.

Microbiota of Bronchoalveolar Lavage Samples from Patients of Lower Respiratory Tract Infection – A Changing Trend

Bronchoalveolar lavage (BAL) is the saline wash of the bronchial tree, which aids in diagnosing various pulmonary pathologies. The present study was contemplated with an aim to know the clinical, microbiological profile of BAL samples along with its sensitivity pattern and to assess its utility as a diagnostic tool. This was a prospective observational study, carried over 90 patients presenting with lower respiratory tract infections. The total microbial recovery rate from BAL was 39 (43.3%). The sensitivity, specificity and positive predictive value of BAL were found to be 76.4%, 89.7% and 90.6% respectively. Maximum isolates were bacteria (25.5%) followed by Mycobacterium tuberculosis (MTB) (16.6%) and fungi (1.1%). Predominant bacterial isolates were Gram-negative (81.5%) compared to Gram-positive (18.5%). Multidrug resistance (MDR) in bacteria was seen in 59.2% of isolates. BAL is a valuable diagnostic tool to find not only bacterial but mycobacterial and fungal infections in patients with lower respiratory tract infection (LRTI). A trend towards LRTI with Gram-negative infections is on the rise and they tend to be multidrug-resistant. Hence checking susceptibility patterns is crucial to start evidence-based treatment.

Legionella Pneumonia in the ICU: A Tertiary Care Center Experience Over 10 Years

OBJECTIVES:

Few studies have reported the complications and outcomes of patients with Legionella pneumonia requiring ICU admission. The objective of our study is to report the clinical course, complications, and 30-day mortality of patients with Legionella pneumonia admitted to the critical care units at our medical center over a 10-year period.

DESIGN:

Retrospective observational study.

SETTING:

Tertiary care teaching hospital.

PATIENTS:

All adult (≥ 18 yr old) patients with Legionella pneumonia admitted to the ICUs from January 1, 2010, to December 31, 2019.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

A total of 88 patients with Legionella pneumonia were admitted to ICUs over the 10-year period. The majority of infections (n = 80; 90.9%) were community acquired. The median (interquartile range) age of patients was 60 years (51.5–71.0 yr); 58 (66%) were male, and 41 (46.6%) identified their race as Black. The median (interquartile range) Sequential Organ Failure Assessment score at ICU admission was 6 (3–9). The distribution of infections showed seasonal dominance with most cases (86%) occurring in the summer to early fall (May to October). Invasive mechanical ventilation was required in 62 patients (70.5%), septic shock developed in 57 patients (64.8%), and acute respiratory distress syndrome developed in 42 patients (47.7%). A majority of patients developed acute kidney injury (n = 69; 78.4%), with 15 (21.7%) receiving only intermittent hemodialysis and 15 (21.7%) requiring continuous renal replacement therapy. Ten patients required venovenous extracorporeal membrane oxygenation support; eight (80%) survived and were successfully decannulated. Overall 30-day mortality was 26.1% (n = 23). Advanced age, higher Sequential Organ Failure Assessment score at admission, and not receiving Legionella-specific antimicrobial therapy within 24 hours of hospital admission were predictors of 30-day mortality.

CONCLUSIONS:

Patients with Legionella pneumonia may require ICU admission and major organ support. Legionella-targeted antibiotics should be included in the empiric regimen for any patient with severe pneumonia. Outcomes of extracorporeal membrane oxygenation therapy in this population are encouraging.

Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis

Maternal sepsis is a leading cause of preventable maternal mortality that requires early recognition, expedient evaluation, and appropriate management.

Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a challenge as the normal physiologic changes of pregnancy may mask the signs and symptoms of sepsis. Bedside assessment tools may aid in the detection of maternal sepsis. Timely and targeted antibiotic therapy and fluid resuscitation are critical for survival in patients with suspected sepsis. Once diagnosed, a search for etiologies and early application of source control measures will further reduce harms. If the patient is in septic shock or not responding to initial treatment, multidisciplinary consultation and escalation of care is necessary. Health care professionals should be aware of the unique complications of sepsis in critically ill pregnant and postpartum patients, and measures to prevent poor outcomes in this population. Adverse pregnancy outcomes may occur in association with sepsis, and should be anticipated and prevented when possible, or managed appropriately when they occur. Using a standardized approach to the patient with suspected sepsis may reduce maternal morbidity and mortality.

Predictive Value of the Pneumonia Severity Score on Mortality due to Aspiration Pneumonia

Objective: Designing an efficient management strategy for aspiration is of high priority in our aging society because of its high incidence. We evaluated the prognostic value of both the A-DROP (age, dehydration, respiratory, disorientation, and pressure) and the modified A-DROP scoring systems (adding respiratory rate and comorbidity to A-DROP) in patients with aspiration pneumonia.Design: This is a retrospective study using electronic medical records at Saitama Medical University (SMU) hospital.Setting: A 965-bed university tertiary medical center in Japan.Participants: Data were extracted from the electronic medical records of patients from SMU hospital.Methods: In-hospital mortality was compared between two groups: (1) those with a 'severe' to 'advanced severe' A-DROP score; and (2) those with a 'low' to 'middle' A-DROP score. Area under the curve (AUC) for mortality for both the A-DROP and modified A-DROP scoring systems were compared.Results: The in-hospital mortality rates for patients with a high and a low A-DROP score were 28.6% and 9.0%, respectively. The mortality rates in the high modified A-DROP score group and in the low modified A-DROP score group were 28.2% and 9.9%, respectively. These differences in the mortality rates between the two groups were statistically significant for both the A-DROP and the modified A-DROP scoring systems. The AUC of the receiver operating characteristics curve for the A-DROP (0.700; 95% confidence interval, 0.608-0.779) was statistically significant.Conclusion: The A-DROP and modified A-DROP scoring systems are associated with in-hospital mortality in patients with aspiration pneumonia. The A-DROP scoring system is easy to use and may be a clinically valuable tool in the management of aspiration pneumonia.

Impact of acute kidney injury on in-hospital outcomes in Chinese patients with community acquired pneumonia

BACKGROUND

Acute kidney injury (AKI) is a frequent complication of community acquired pneumonia (CAP). However, the impact of AKI on in-hospital outcomes of patients with CAP in the Chinese population remains unclear.

METHODS

Patients diagnosed with CAP were evaluated in this retrospective observational study. Multiple Cox regression models were employed to identify the association between AKI and in-hospital mortality and 30-day mortality, respectively.

RESULTS

A total of 4213 patients were recruited; 950 (22.5%) patients were diagnosed with AKI. Independent risk factors for AKI were age, male gender, hypertension, cardiac dysfunction, diabetes, chronic kidney disease, acute respiratory failure, use of diuretics, use of vasoactive drugs, and CURB-65. Cox proportional hazards regression revealed AKI, use of angiotensin receptor blocker, hypertension, CURB-65, acute respiratory failure, and use of vasoactive drugs to be independent risk factors for both in-hospital and 30-day mortality. Compared to patients without AKI, those suffering AKI were found to have 1.31-fold (HR 1.31, 95% CI, 1.04-1.66; P = 0.023) and 1.29-fold (HR 1.29, 95% CI, 1.02-1.62; P = 0.033) increased in-hospital and 30-day mortality risks, respectively. In addition, patients with AKI were likely to require admission to intensive care unit (ICU) (42.9% versus 11.4%; P < 0.001), mechanical ventilation (33.8% versus 9.3%; P < 0.001), invasive mechanical ventilation (25.9% versus 5.8%; P < 0.001), non-invasive mechanical ventilation (25.4% versus 7.1%; P < 0.001), and experienced a longer duration of hospital stay (14 days versus 10 days; P < 0.001) than those without AKI. However, no significant difference in ICU stay (11 days versus 10 days; P = 0.099) and duration of mechanical ventilation (8 days versus 8 days; P = 0.369) between AKI and non-AKI groups was found.

CONCLUSION

AKI was common in Chinese patients with CAP. Patients with CAP who developed AKI had worse in-hospital outcomes.

Clinical Features of the 60 Years and Older Patients Infected with 2019 Novel Coronavirus: Can We Predict Mortality Earlier?

Introduction

The novel coronavirus (COVID-19), which has affected over 100 countries in a short while, progresses more mortally in elderly patients with comorbidities. In this study, we examined the epidemiological, clinical, and laboratory characteristics of the patients aged 60 and over who had been infected with COVID-19.

Methods

The data of the patients admitted to the hospital within 1 month from May 8, 2020 onwards and hospitalized for COVID-19 pneumonia were obtained from the hospital medical records, and the epidemiological, clinical, and laboratory parameters of the patients during the admission to the emergency department were examined. Patients were divided into 2 groups regarding the criteria of having in-hospital mortality (mortality group) and being discharged with full recovery (survivor group). The factors, which could have an impact on the mortality, were investigated using a univariate and multivariate logistic regression analysis.

Results

This retrospective study included 113 patients aged 60 years and older, with a confirmed diagnosis of COVID-19 pneumonia. The mean age of the patients was 70.7 ± 7.9, and 64.6% (n = 73) of them were male. The mortality rate was 19.4% (n = 22). Among the comorbid illnesses, only renal failure was significant in the mortality group (p = 0.04). A CURB-65score ≥3 or pneumonia severity index (PSI) class ≥4 manifested a remarkable discrimination ability to predict 30-day mortality (p < 0.001). When the laboratory parameters were considered, the value of neutrophil to lymphocyte ratio (NLR) was significant in predicting mortality in univariate and multivariate analysis (odds ratio [OR] = 1.11; 95% confidence interval [95% CI], 1.03–1.21; p = 0.006, and OR = 1.51; 95% CI, 1.11–2.39; p = 0.044, respectively).

Conclusion

In our study, NLR was determined to be an independent marker to predict in-hospital mortality among patients with COVID-19. PSI and CURB-65 revealed a considerably precise prognostic accuracy for the patients with COVID-19 in our study as well. Moreover, thanks to that NLR results in a very short time, it can enable the clinician to predict mortality before the scoring systems are calculated and hasten the management of the patients in the chaotic environment of the emergency room.

Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

C-reactive protein influences the doctor's degree of suspicion of pneumonia in primary care: a prospective observational study

BACKGROUND

In primary care, the diagnosis of pneumonia is often based on history and clinical examination alone. However, a previous study showed that the general practitioner's degree of suspicion correlates well with findings on chest X-ray, when the C-reactive protein (CRP) value is known.

OBJECTIVES

The present study aimed to investigate to what extent the physician's degree of suspicion is affected by the CRP level when community-acquired pneumonia is suspected in primary care.

METHODS

A prospective observational study was conducted at five primary health care centres in Sweden between October 2015 and December 2017. Adult patients (n = 266) consulting their health care centre with symptoms of lower respiratory tract infection, where the physician suspected pneumonia, were included consecutively. Anamnestic information and findings from clinical examination were documented in a case report form. All patients were tested for CRP. The physicians rated their degree of suspicion as 'unsure,' 'quite sure,' and 'sure' before and after the CRP result.

RESULTS

The degree of suspicion of pneumonia changed in 69% of the cases; most often to a lower degree (40%). In 28% of the cases, there was no longer any suspicion of pneumonia after CRP.

CONCLUSION

Our results indicate that CRP testing highly influences the physician's degree of suspicion of pneumonia in primary care and that it seems to be of most value when not sure of the diagnosis.

Cost-Effectiveness of Nusinersen and Universal Newborn Screening for Spinal Muscular Atrophy

OBJECTIVE

To evaluate the cost-effectiveness of nusinersen with and without universal newborn screening for infantile-onset spinal muscular atrophy (SMA).

STUDY DESIGN

A Markov model using data from clinical trials with US epidemiologic and cost data was developed. The primary interventions studied were nusinersen treatment in a screening setting, nusinersen treatment in a nonscreening setting, and standard care. Analysis was conducted from a societal perspective.

RESULTS

Compared with no screening and no treatment, the incremental cost-effectiveness ratio (ICER) for nusinersen with screening was $330 558 per event-free life year (LY) saved, whereas the ICER for nusinersen treatment without screening was $508 481 per event-free LY saved. For nusinersen with screening to be cost-effective at a willingness-to-pay (WTP) threshold of $50 000 per event-free LY saved, the price would need to be $23 361 per dose, less than one-fifth its current price of $125 000. Preliminary data from the NURTURE trial indicated an 85.7% improvement in expected LYs saved compared with our base results. In probabilistic sensitivity analysis, nusinersen and screening was a preferred strategy 93% of the time at a $500 000 WTP threshold.

CONCLUSION

Universal newborn screening for SMA provides improved economic value for payers and patients when nusinersen is available.

Clinical and microbiological profile of adult inpatients with community acquired pneumonia in Ilorin, North Central, Nigeria

Background

The optimal management of community acquired pneumonia (CAP) depends on the clinical and microbiological profile in the locality.

Objectives

To determine the clinical and microbiological profile of patients admitted with CAP in Ilorin, Nigeria.

Methods

One hundred and two consenting consecutively selected patients with clinical and radiologic confirmation of CAP were recruited in 12 months. The socio-demographic, physical examination and laboratory/radiologic parameters were documented in a questionnaire. Microbiological evaluation of their sputum was done and blood samples were taken for complete blood count, culture, serum urea and serological evaluation for atypical bacteria and some viral pathogens.

Results

CAP constituted 5.9% of the total medical admissions during the one-year study period. The mean age of the patients was 49 ± 22 years with the largest frequency in those aged 65 years and above. The commonest symptoms were shortness of breath (96.1%) and cough (94.1%), with a median duration of 3 days from symptom onset to admission. Systemic hypertension was the commonest comorbid illness (25/102; 24.5%). Klebsiella pneumoniae was the predominant pathogen isolated (20/102; 28.1%). The susceptible antibiotics were Imipenem, Ceftazidime and Ceftriaxone. Intra-hospital mortality was 17.6%. CURB – 65 score of ≥ 2 and the presence of complications of CAP were the independent predictors of mortality.

Conclusion

CAP constitutes a significant disease burden in Ilorin, Nigeria. Typical bacteria accounted for over half of the pathogens isolated from the patients with gram negative agents predominating. This highlights a possible shift in the microbiological profile which could guide empirical treatment.

Treatment of severe pneumonia by hinokitiol in a murine antimicrobial-resistant pneumococcal pneumonia model

Streptococcus pneumoniae is often isolated from patients with community-acquired pneumonia. Antibiotics are the primary line of treatment for pneumococcal pneumonia; however, rising antimicrobial resistance is becoming more prevalent. Hinokitiol, which is isolated from trees in the cypress family, has been demonstrated to exert antibacterial activity against S. pneumoniae in vitro regardless of antimicrobial resistance. In this study, the efficacy of hinokitiol was investigated in a mouse pneumonia model. Male 8-week-old BALB/c mice were intratracheally infected with S. pneumoniae strains D39 (antimicrobial susceptible) and NU4471 (macrolide resistant). After 1 h, hinokitiol was injected via the tracheal route. Hinokitiol significantly decreased the number of S. pneumoniae in the bronchoalveolar lavage fluid (BALF) and the concentration of pneumococcal DNA in the serum, regardless of whether bacteria were resistant or susceptible to macrolides. In addition, hinokitiol decreased the infiltration of neutrophils in the lungs, as well as the concentration of inflammatory cytokines in the BALF and serum. Repeated hinokitiol injection at 18 h intervals showed downward trend in the number of S. pneumoniae in the BALF and the concentration of S. pneumoniae DNA in the serum with the number of hinokitiol administrations. These findings suggest that hinokitiol reduced bacterial load and suppressed excessive host immune response in the pneumonia mouse model. Accordingly, hinokitiol warrants further exploration as a potential candidate for the treatment of pneumococcal pneumonia.

Prevalence of gram negative bacteria causing community acquired pneumonia among adults in Mwanza City, Tanzania

BACKGROUND

Community acquired pneumonia (CAP) in adults is still a common and serious illness in the sub-Saharan Africa. Identification of the pathogens is crucial in the management of CAP. This study was done to determine the common bacterial pathogens, treatment outcomes and associated factors for microbiological confirmed CAP among adults attending the Bugando Medical Centre and Sekou Toure hospital in the city of Mwanza, Tanzania.

METHODS

This was a hospital based cross sectional study involving patients with community acquired pneumonia attending Bugando Medical Centre and Sekou Toure regional Hospital. Demographic and other data were collected using standardized data collection tool. Sputum culture was done followed by identification of the isolates and antibiotics susceptibility testing.

RESULTS

A total of 353 patients were enrolled in the study. Out of 353 sputum samples, 265(75%) were of good quality. Of 353 non-repetitive sputum cultures, 72/353 (20.4, 95% CI: 16.2-24.6) were positive for the bacterial pathogens with five patients having more than one pathogen. Good quality sputa had significantly higher yield of pathogenic bacteria than poor quality sputa (26.1% vs.3.4%, P = 0.001). The majority 64 (83.1%) of the isolates were gram negative bacteria. Common bacteria isolated were Klebsiella pneumoniae 23/77(29.9%), Streptococcus pyogenes 10/77 (13.0%), Pseudomonas aeruginosa 9/77 (11.7%) and Escherichia coli 7/77 (9.1%). Of 23 K. pneumoniae isolates, 20/23 (87.0%) were resistant to ceftriaxone. Resistance to ceftriaxone was found to be associated with prolongation of CAP symptoms (p = 0.009).

CONCLUSION

Gram negative bacteria resistant to ampicillin, amoxicillin/clavulanic acid and ceftriaxone were most frequently isolated bacteria among adults' patients with CAP attending BMC and Sekou Toure hospital. Routine sputum culture should be performed to guide appropriate treatment of CAP among adults in developing countries.

Viral-bacterial (co-)occurrence in the upper airways and the risk of childhood pneumonia in resource-limited settings

OBJECTIVE

To examine the association between bacterial-viral co-occurrence in the nasopharynx and the risk of community acquired pneumonia (CAP) in young children living in resource-limited settings.

METHODS

A case-control study was conducted between January and December 2017 in Moshi, Tanzania. Children 2-59 months with CAP and healthy controls were enrolled. RSV and Influenza A/B were detected with a standardized polymerase chain reaction (PCR) method, and a simplified real-time quantitative PCR method, without sample pre-processing, was developed to detect bacterial pathogens in nasopharyngeal samples.

RESULTS

A total of 109 CAP patients and 324 healthy controls were enrolled. Co-detection of H. influenzae and S. pneumoniae in nasopharyngeal swabs was linked with higher odds of CAP (aOR=3.2, 95% CI=1.1-9.5). The majority of the H. influenzae isolated in cases and controls (95.8%) were non-typeable. Of the viruses examined, respiratory syncytial virus (RSV) was most common (n = 31, 7.2%) in cases and controls. Children with RSV had 8.4 times higher odds to develop pneumonia than healthy children (aOR=8.4, 95%CI= 3.2 - 22.1).

CONCLUSIONS

Co-occurence of H. influenzae and S. pneumoniae in the nasopharynx was strongly associated with CAP. The high prevalence of non-typeable H. influenzae might be a sign of replacement as a consequence of Haemophilus influenzae type b vaccination.