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Candel FJ, Salavert M, Estella A, Ferrer M, Ferrer R, Gamazo JJ, García-Vidal C, del Castillo JG, González-Ramallo VJ, Gordo F, Mirón-Rubio M, Pérez-Pallarés J, Pitart C, del Pozo JL, Ramírez P, Rascado P, Reyes S, Ruiz-Garbajosa P, Suberviola B, Vidal P, Zaragoza R. Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6526. [PMID: 37892664 PMCID: PMC10607368 DOI: 10.3390/jcm12206526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology and Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, Hospital Universitario y Politécnico La Fe, 46026 València, Spain
| | - Angel Estella
- Intensive Medicine Service, Hospital Universitario de Jerez, 11407 Jerez, Spain
- Departamento de Medicina, INIBICA, Universidad de Cádiz, 11003 Cádiz, Spain
| | - Miquel Ferrer
- UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic de Barcelona, IDIBAPS, CibeRes (CB06/06/0028), Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Ricard Ferrer
- Intensive Medicine Service, Hospital Universitario Valle de Hebrón, 08035 Barcelona, Spain;
| | - Julio Javier Gamazo
- Servicio de Urgencias, Hospital Universitario de Galdakao, 48960 Bilbao, Spain;
| | | | | | | | - Federico Gordo
- Intensive Medicine Service, Hospital Universitario del Henares, 28822 Coslada, Spain;
| | - Manuel Mirón-Rubio
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Torrejón, 28850 Torrejón de Ardoz, Spain;
| | - Javier Pérez-Pallarés
- Division of Respiratory Medicine, Hospital Universitario Santa Lucía, 30202 Cartagena, Spain;
| | - Cristina Pitart
- Department of Clinical Microbiology, ISGlobal, Hospital Clínic-University of Barcelona, CIBERINF, 08036 Barcelona, Spain;
| | - José Luís del Pozo
- Servicio de Enfermedades Infecciosas, Servicio de Microbiología, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Paula Ramírez
- Intensive Medicine Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Pedro Rascado
- Intensive Care Unit, Complejo Hospitalario Universitario Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Soledad Reyes
- Neumology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Borja Suberviola
- Intensive Medicine Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria IDIVAL, 39011 Santander, Spain;
| | - Pablo Vidal
- Intensive Medicine Service, Complexo Hospitalario Universitario de Ourense, 32005 Ourense, Spain;
| | - Rafael Zaragoza
- Intensive Care Unit, Hospital Dr. Peset, 46017 Valencia, Spain;
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Chen Y, Mao L, Lai D, Xu W, Zhang Y, Wu S, Yang D, Zhao S, Liu Z, Xiao Y, Tang Y, Meng X, Wang M, Shi J, Chen Q, Shu Q. Improved targeting of the 16S rDNA nanopore sequencing method enables rapid pathogen identification in bacterial pneumonia in children. Front Cell Infect Microbiol 2023; 12:1001607. [PMID: 36699719 PMCID: PMC9868273 DOI: 10.3389/fcimb.2022.1001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Objectives To develop a rapid and low-cost method for 16S rDNA nanopore sequencing. Methods This was a prospective study on a 16S rDNA nanopore sequencing method. We developed this nanopore barcoding 16S sequencing method by adding barcodes to the 16S primer to reduce the reagent cost and simplify the experimental procedure. Twenty-one common pulmonary bacteria (7 reference strains, 14 clinical isolates) and 94 samples of bronchoalveolar lavage fluid from children with severe pneumonia were tested. Results indicating low-abundance pathogenic bacteria were verified with the polymerase chain reaction (PCR). Further, the results were compared with those of culture or PCR. Results The turnaround time was shortened to 6~8 hours and the reagent cost of DNA preparation was reduced by employing a single reaction adding barcodes to the 16S primer in advance. The accuracy rate for the 21 common pulmonary pathogens with an abundance ≥ 99% was 100%. Applying the culture or PCR results as the gold standard, 71 (75.5%) of the 94 patients were positive, including 25 positive cultures (26.6%) and 52 positive quantitative PCRs (55.3%). The median abundance in the positive culture and qPCR samples were 29.9% and 6.7%, respectively. With an abundance threshold increase of 1%, 5%, 10%, 15% and 20%, the test sensitivity decreased gradually to 98.6%, 84.9%, 72.6%, 67.1% and 64.4%, respectively, and the test specificity increased gradually to 33.3%, 71.4%, 81.0%, 90.5% and 100.0%, respectively. Conclusions The nanopore barcoding 16S sequencing method can rapidly identify the pathogens causing bacterial pneumonia in children.
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Affiliation(s)
- Yinghu Chen
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China,Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Lingfeng Mao
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Dengming Lai
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China,Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Weize Xu
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China,Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Yuebai Zhang
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China
| | - Sihao Wu
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Di Yang
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Shaobo Zhao
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhicong Liu
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China
| | - Yi Xiao
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China
| | - Yi Tang
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Xiaofang Meng
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Min Wang
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Jueliang Shi
- Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China
| | - Qixing Chen
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China,Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China,*Correspondence: Qixing Chen, ; Qiang Shu,
| | - Qiang Shu
- The Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China,National Clinical Research Center for Child Health, Hangzhou, China,Joint Research Center for Molecular Diagnosis of Severe Infection in Children, Binjiang Institute of Zhejiang University, Hangzhou, China,*Correspondence: Qixing Chen, ; Qiang Shu,
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Garber B. Pneumonia Update for Emergency Clinicians. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022; 10:36-44. [PMID: 35874176 PMCID: PMC9296333 DOI: 10.1007/s40138-022-00246-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review
Many new concepts in diagnosis, management, and risk stratification of patients with pneumonia have been described recently. The COVID pandemic made importance of viruses as dangerous pathogens of pneumonia quite clear while several non-invasive measures for patients with respiratory failure gained a more wide-spread usage. Recent Findings Studies continue to examine feasibility of bedside ultrasound as a tool in accurate diagnosis of pneumonia in the emergency department, and several new antibiotics have been approved for treatment while others are in late-stage clinical trials. Additionally, the Infectious Diseases Society, American Thoracic Society, and their European counterparts published updated guidelines in recent years. For differences important to emergency medicine clinicians and new emphasis as compared to the prior guidelines, please see Table 1. Several new antibiotics have been approved recently but remain relatively unknown to emergency clinicians as their use is frequently restricted to infectious disease specialists.Differences important to emergency medicine clinicians and new emphasis [8, 16, 18, 19••, 30, 34] New recommendations | Difference with prior guidelines if any | Comment |
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Blood and sputum cultures recommended in severe disease and in inpatients treated for MRSA or P. aeruginosa | Similar from the ED perspective | Clinical gestalt performs as well as various decision instruments in deciding who needs blood cultures [13] | Obtaining procalcitonin level not recommended to guide antibacterial therapy | Was not covered in prior guidelines | | Recommend using validated risk factors to determine the need for P. aeruginosa or MRSA coverage instead of using hospital-acquired and ventilator-associated guidelines | Emphasized healthcare-associated pneumonia category | MDRO prevalence varies widely between communities challenging study interpretation [8] | Macrolide monotherapy conditional for outpatients based on local resistance patterns | Was strongly recommended | S. pneumonia is increasingly resistant to macrolides | Amoxicillin or doxycycline monotherapy for outpatients with no comorbidities or risk factors for MDRO. Amoxicillin/clavulanate or cephalosporin (cefuroxime or cefpodoxime) combined with a macrolide or doxycycline or monotherapy with a respiratory fluoroquinolone such as moxifloxacin for patients with comorbidities | Amoxicillin, amoxicillin/clavulanate, and doxycycline were not considered prominently in treatment regimens | The recommendation for including doxycycline in the treatment protocols is conditional and is based on weak evidence and is only recommended in patients with contraindications to both macrolides and fluoroquinolones. M. pneumonia is increasingly resistant to macrolides, and tetracyclines and respiratory fluoroquinolones are viable alternatives if a patient with a known M. pneumonia infection does not respond to a macrolide. In admitted patients, the addition of a macrolide to a b-lactam consistently lowers mortality [18]. Amoxicillin does not cover the atypicals | Do not give corticosteroids to pneumonia patients except in possibly decompensated refractory septic shock or known adrenal insufficiency | Was not considered | Note that in certain special forms of pneumonia (not considered CAP), such as Pneumocystis jirovecii pneumonia, corticosteroid therapy may still be necessary. Corticosteroids increase mortality in patients with influenza infection who develop pneumonia | When treating a patient with severe CAP b-lactam/macrolide combination preferred over b-lactam/fluoroquinolone combination, the use of anti-influenza therapy is recommended if influenza viral test is positive (expert recommendation) | B-lactam/macrolide combination OR b-lactam/fluoroquinolone combination; use of anti-influenza therapy was not considered | Influenza therapy in hospitalized patients has not been validated in a randomized controlled trial | Limiting the length of antibiotic therapy to 7–10 days including in ventilator-associated pneumonia | Recommended 14–21 days of therapy | In one study, CAP patients who received a single dose of intravenous ceftriaxone did just as well as patients who got it daily for 7 days [18]. Since that study compared ceftriaxone to daptomycin (that was later found to be inactivated by surfactant), this can be hypothesis generation only | Follow-up chest imaging after symptoms of pneumonia improve recommended only as necessary for lung cancer screening | Follow-up chest imaging was not addressed | |
Summary As the emergency physicians gain new tools to rapidly diagnose, treat, and appropriately disposition pneumonia cases that appear to become more complex as people unfortunately accumulate more comorbidities, we hope to offer better care and improve outcomes for our patients while allowing staff to enjoy coming to work.
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Affiliation(s)
- Boris Garber
- Metro Health Medical Center, Cleveland, USA
- CWRU School of Medicine, Cleveland, USA
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