Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association

Performance of various pneumonia severity models for predicting adverse outcomes in elderly inpatients with community acquired pneumonia

OBJECTIVE

We aimed to assess the performance of common pneumonia severity scores, including Pneumonia Severity Index (PSI), CURB-65, CRB-65, A-DROP and SMART-COP, in predicting adverse outcomes in an elderly community-acquired pneumonia (CAP) cohort and to determine the optimal scoring system for specific outcomes of interest.

METHODS

A total of 822 elderly inpatients were included in the retrospective cohort study. Clinical and laboratory results on admission were used to calculate above scores. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital mortality, need for mechanical ventilation (MV) and intensive care unit (ICU) admission. Model discrimination was evaluated by the area under receiver operating characteristic curves (AUCs).

RESULTS

The 30-day and in-hospital mortality rates were 6.8% (56/822) and 8.6% (71/822), respectively. One hundred and ninety-eight (24.0%) received MV and 111 (13.5%) were admitted to the ICU. All five scoring systems showed the same trend of increasing rates of each adverse outcome with increasing risk groups (all p<0.001). PSI had the highest AUC, sensitivity, and negative predictive value (NPV) in predicting 30-day mortality and in-hospital mortality. SMART-COP had the highest AUC for predicting the need for MV and ICU admission, but PSI had the highest sensitivity and NPV for these two outcomes.

CONCLUSIONS

PSI performed well in identifying elderly patients at risk for 30-day mortality and its high NPV is helpful in excluding patients who are not at risk. Considering the effectiveness and simplicity, SMART-COP and CURB-65 are easier to perform in clinical practice than PSI.

Enhancing pathogen description and antibiotic regimen selection in community-acquired pneumonia through RT-qPCR assays

Background

Adults with community-acquired pneumonia (CAP) in China suffer high morbidity. CAP is caused by a multitude of pathogens; however, pathogen-directed clinical symptoms are often lacking. Therefore, patients lacking an accurate microbiological diagnosis are administered with empirical antimicrobials.

Methods

We collected bronchoalveolar lavage fluid, as well as clinical and laboratory data from 650 adult patients with CAP admitted to three hospitals in Hubei, Sichuan, and Zhejiang provinces in China. Specimens were cultured and tested using real-time reverse transcription qPCR (RT-qPCR) assays for the presence of 42 respiratory bacteria and viruses. CAP was investigated with respect to regions, genders, and age and patterns of infections or co-infections. Employing clinical guidelines adapted for diagnosis, we assessed retrospectively the appropriate pathogen-directed therapy and compared it with the initial empirical therapies.

Results

Our study identified that 21.38% (139/650) of the patients were classified as having Severe CAP (S-CAP), with a higher prevalence among males, older adults, and during the warm season. Bacterial pathogens were detected in 35.53% (231/650) of cases. K. pneumoniae, H. influenzae, and S. aureus were the most prevalent bacteria across different demographics and regions. Viral pathogens were found in 48.76% (317/650) of patients Epstein-Barr, Human rhinovirus, and Cytomegalovirus were the most common viruses. Co-infections were present in 24.31% (158/650) of cases, with viral-bacterial co-infections being the most frequent. The RT-qPCR demonstrated significantly higher detection rates for key pathogens compared to standard culture methods. It showed potential in optimizing antimicrobial prescriptions by allowing for de-escalation in 18.30% (95/518) of patients, among which reducing the number of excessive antibiotics mainly comprised decreasing the use of 2nd or 3rd generation cephalosporins (5.79%, 30/518) and β-lactamase inhibitor combinations.

Conclusion

The study highlights the significant burden of S-CAP, particularly among specific demographics and seasons. The prevalence of bacterial and viral pathogens, along with the high rate of co-infections, emphasizes the need for comprehensive diagnostic approaches. The RT-qPCR assays emerge as a superior diagnostic tool, offering enhanced pathogen detection capabilities and facilitating more precise antimicrobial therapy. This could lead to improved patient outcomes and contribute to the rational use of antimicrobials, addressing the growing concern of antibiotic resistance.

Serum SOD1 level predicts the severity and prognosis of community-acquired pneumonia patients

BACKGROUND

Superoxide dismutase 1 (SOD1) is one of the most important participants of antioxidant enzyme system in biological system. Previous studies have found that SOD1 is associated with many inflammatory diseases. The goal of this study was to assess the associations of serum SOD1 with the severity and prognosis in community-acquired pneumonia (CAP) patients by a prospective cohort study.

METHODS

CAP patients were enrolled from the Second Affiliated Hospital of Anhui Medical University. Peripheral blood samples were gathered. The level of serum SOD1 was detected through enzyme linked immunosorbent assay (ELISA). Clinical characteristics and demographic information were analyzed.

RESULTS

The level of serum SOD1 was gradually upregulated with elevated CAP severity scores. Spearman correlation coefficient or Pearson rank correlation analyses indicated that serum SOD1 was strongly connected with many clinical parameters among CAP patients. Further linear and logistic regression analyses found that the level of serum SOD1 was positively associated with CRB-65, CURB-65, SMART-COP, and CURXO scores among CAP patients. Moreover, serum higher SOD1 at admission substantially increased the risks of ICU admission, mechanical ventilation, vasoactive agent usage, death, and longer hospital stays during hospitalization. Serum SOD1 level combination with CAP severity scores elevated the predictive abilities for severity and death compared with alone serum SOD1 and CAP severity scores in CAP patients during hospitalization.

CONCLUSION

The level of serum SOD1 is positively associated with the severity and poor prognosis in CAP patients, suggesting that SOD1 is implicated in the initiation and progression of CAP. Serum SOD1 may be regarded as a biomarker to appraise the severity and prognosis for CAP patients.

Microbiological Profile of Patients with Aspiration Pneumonia Identified by Combined Detection Methods

Purpose

Aspiration pneumonia (AP) challenges public health globally. The primary aim of this study was to ascertain the microbiological profile characteristics of patients with AP evaluated by combined detection methods, including conventional microbiological tests (CMTs), chips for complicated infection detection (CCID), and metagenomic next-generation sequencing (mNGS).

Patients and Methods

From June 2021 to March 2022, a total of thirty-nine patients with AP or community-acquired pneumonia with aspiration risk factors (AspRF-CAP) from 3 hospitals were included. Respiratory specimens, including bronchoalveolar lavage fluid (BALF), sputum, and tracheal aspirate, were collected for microorganism detection.

Results

Patients with AP were more inclined to be older, to have a shorter duration from illness onset to admission, to have a higher prevalence of different underlying diseases, particularly diabetes mellitus, chronic heart disease, and cerebrovascular disease, and to have a higher CURB-65 score (all P < 0.05). A total of 213 and 31 strains of microorganisms were detected in patients with AP and AspRF-CAP, respectively. The most common pathogens in AP were Corynebacterium striatum (17/213, 7.98%), Pseudomonas aeruginosa (15/213, 7.04%), Klebsiella pneumoniae (15/213, 7.04%), and Candida albicans (14/213, 6.57%). Besides, the most common pathogens in AspRF-CAP were Candida albicans (5/31, 16.13%), Pseudomonas aeruginosa (3/31, 9.68%) and Klebsiella pneumoniae (3/31, 9.68%). Moreover, Klebsiella pneumoniae (7/67, 10.45%) and Candida glabrata (5/67, 7.46%) were the most common pathogens among the 9 non-survived patients with AP.

Conclusion

The prevalent pathogens detected in cases of AP were Corynebacterium striatum, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida albicans. Early combined detection methods for patients with AP enhance the positive detection rate of pathogens and potentially expedites the initiation of appropriate antibiotic therapeutic strategies.

Subarachnoid hemorrhage with Takotsubo syndrome as the prominent manifestation: A case and literature review

Background

Takotsubo syndrome, which is often induced by physical or psychological stress, is typically a cardiac syndrome with transient left ventricular dysfunction in the absence of obstructive coronary artery disease. Subarachnoid hemorrhage with typical symptoms and signs is frequently reported, whereas the incidence of subarachnoid hemorrhage with Takotsubo syndrome as the prominent manifestation without a typical headache is rarely reported.

Case description

We present a rare case of a 63-year-old male patient with cough and fever as the first manifestations, accompanied by mild dizziness, headache, and mental discomfort; however, the patient was eventually diagnosed with atypical subarachnoid hemorrhage with Takotsubo syndrome. The patient underwent general anesthesia downwards stent-assisted spring coil embolization and was discharged from the hospital after postoperative treatment consisting of anti-cerebrovascular spasm, anti-platelet aggregation, and cerebrospinal fluid replacement.

Conclusion

This case demonstrates the association between Takotsubo syndrome and subarachnoid hemorrhage. When patients present with unexplained pulmonary edema with mild neurologic symptoms, clinicians should be alerted to subarachnoid hemorrhage and Takotsubo syndrome.

Detection of Macrolide-Resistant Streptococcus pneumoniae Genes and Its Clinical Outcomes in a Tertiary Teaching Hospital in Malaysia

Background

Streptococcus pneumoniae is one of the leading causes of mortality and morbidity worldwide. The dramatic increase in in-vitro resistance of antimicrobial agents, particularly beta-lactams and macrolides, makes pneumococcal infections difficult to treat. The aim of this study was to describe the drug resistance rate, assess the prevalence of macrolide-resistant genes and review the clinical complications of pneumococcal infections among patients presented to Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia.

Methods

This is a descriptive cross-sectional study. All S. pneumoniae isolates collected from clinical specimens within a 1-year period were subjected to selected antimicrobial susceptibility testing using E-test strips. Polymerase chain reaction (PCR) analysis was conducted to detect macrolide-resistant determinants. The patient's clinical data were obtained from clinical notes.

Results

A total of 113 patients with a positive growth of S. pneumoniae were included in the study. The most common predisposing factors among them were bronchopulmonary diseases (15.9%). The penicillin-resistant rate was 7.1%, with minimal inhibitory concentration (MIC) ranging between 0.012 μg/mL and >32 μg/mL, and the erythromycin-resistant rate was 26.5%, with a MIC range of 0.03 μg/mL-> 256 μg/mL. Most of the erythromycin-resistant isolates were found to have the mef(A) gene (50.4%) and the erm(B) gene (20%); 16.7% had a combination of genes mef(A) and erm(B), and 13.3% had none of the two genes. Community-acquired pneumonia is the predominant type of pneumococcal infection. There was no significant association between the presence of macrolide resistance determinants and mortality (P = 0.837) or complications (P > 0.999 for empyema and cardiac complication; P = 0.135 for subdural abscess).

Conclusion

The majority of erythromycin-resistant isolates were found to have the mef(A) gene, followed by the erm(B) gene and a combination of genes mef(A) and erm(B).

Assessment and clinical utility of metagenomic next-generation sequencing for suspected lower respiratory tract infections

OBJECTIVES

This study aims to compare the diagnostic efficacy of metagenomic next-generation sequencing (mNGS) to traditional diagnostic methods in patients with lower respiratory tract infections (LRTIs), elucidate the etiological spectrum of these infections, and explore the impact of mNGS on guiding antimicrobial therapy.

METHODS

We retrospectively analyzed data from 128 patients admitted to the Respiratory Department of Anqing 116 Hospital between July 2022 and July 2023. All patients had undergone both mNGS and conventional microbiological techniques (CMT) for LRTI diagnosis. We assessed the diagnostic performance of these methods and examined the influence of mNGS on antimicrobial decision-making.

RESULTS

Overall, mNGS demonstrated superior sensitivity (96.8%) and accuracy (96.8%) compared to CMT. For Mycobacterium tuberculosis detection, the accuracy and sensitivity of mNGS was 88.8% and 77.6%, which was lower than the 94.7% sensitivity of the T-spot test and the 79.6% sensitivity of CMT. In fungal pathogen detection, mNGS showed excellent sensitivity (90.5%), specificity (86.7%), and accuracy (88.0%). Bacteria were the predominant pathogens detected (75.34%), with Mycobacterium tuberculosis (41.74%), Streptococcus pneumoniae (21.74%), and Haemophilus influenzae (16.52%) being most prevalent. Bacterial infections were most common (62.10%), followed by fungal and mixed infections (17.74%). Of the 118 patients whose treatment regimens were adjusted based on mNGS results, 102 (86.5%) improved, 7 (5.9%) did not respond favorably, and follow-up was lost for 9 patients (7.6%).

CONCLUSIONS

mNGS offers rapid and precise pathogen detection for patients with suspected LRTIs and shows considerable promise in diagnosing Mycobacterium tuberculosis and fungal infections. By broadening the pathogen spectrum and identifying polymicrobial infections, mNGS can significantly inform and refine antibiotic therapy.

Utilizing metagenomic next-generation sequencing for pathogen detection and diagnosis in lower respiratory tract infections in real-world clinical practice

BACKGROUND

Infectious etiologies of lower respiratory tract infections (LRTIs) by the conventional microbiology tests (CMTs) can be challenging. Metagenomic next-generation sequencing (mNGS) has great potential in clinical use for its comprehensiveness in identifying pathogens, particularly those difficult-to-culture organisms.

METHODS

We analyzed a total of 205 clinical samples from 201 patients with suspected LRTIs using mNGS in parallel with CMTs. mNGS results were used to guide treatment adjustments for patients who had negative CMT results. The efficacy of treatment was subsequently evaluated in these patients.

RESULTS

mNGS-detected microorganisms in 91.7% (188/205) of the clinical samples, whereas CMTs demonstrated a lower detection rate, identifying microorganisms in only 37.6% (77/205) of samples. Compared to CMT results, mNGS exhibited a detection sensitivity of 93.5% and 95.4% in all 205 clinical samples and 180 bronchoalveolar lavage fluid (BALF) samples, respectively. A total of 114 patients (114/201; 56.7%) showed negative CMT results, among which 92 received treatment adjustments guided by their positive mNGS results. Notably, 67.4% (62/92) of patients demonstrated effective treatment, while 25% (23/92) experienced a stabilized condition. Subgroup analysis of cancer patients revealed that 41.9% (13/31) exhibited an effective response to treatment, and 35.5% (11/31) maintained a stable condition following medication adjustments guided by mNGS.

CONCLUSION

mNGS demonstrated great potential in identifying microorganisms of clinical significance in LRTIs. The rapid turnaround time and reduced susceptibility to the impact of antimicrobial administration make mNGS a valuable supplementary tool for diagnosis and treatment decision-making for suspected LRTIs in clinical practice.

Long-term outcomes of survivors with influenza A H1N1 virus-induced severe pneumonia and ARDS: a single-center prospective cohort study

Introduction

Systematic evaluation of long-term outcomes in survivors of H1N1 is still lacking. This study aimed to characterize long-term outcomes of severe H1N1-induced pneumonia and acute respiratory distress syndrome (ARDS).

Method

This was a single-center, prospective, cohort study. Survivors were followed up for four times after discharge from intensive care unit (ICU) by lung high-resolution computed tomography (HRCT), pulmonary function assessment, 6-minute walk test (6MWT), and SF-36 instrument.

Result

A total of 60 survivors of H1N1-induced pneumonia and ARDS were followed up for four times. The carbon monoxide at single breath (DLCO) of predicted values and the 6MWT results didn't continue improving after 3 months. Health-related quality of life didn't change during the 12 months after ICU discharge. Reticulation or interlobular septal thickening on HRCT did not begin to improve significantly until the 12-month follow-up. The DLCO of predicted values showed negative correlation with the severity degree of primary disease and reticulation or interlobular septal thickening, and a positive correlation with physical functioning. The DLCO of predicted values and reticulation or interlobular septal thickening both correlated with the highest tidal volume during mechanical ventilation. Levels of fibrogenic cytokines had a positive correlation with reticulation or interlobular septal thickening.

Conclusion

The improvements in pulmonary function and exercise capacity, imaging, and health-related quality of life had different time phase and impact on each other during 12 months of follow-up. Long-term outcomes of pulmonary fibrosis might be related to the lung injury and excessive lung fibroproliferation at the early stage during ICU admission.

Predictive Value of Lysophosphatidylcholine for Determining the Disease Severity and Prognosis of Elderly Patients with Community-Acquired Pneumonia

Purpose

To investigate the clinical value of serum lysophosphatidylcholine (LPC) as a predictive biomarker for determining disease severity and mortality risk in hospitalized elderly patients with community-acquired pneumonia (CAP).

Methods

This prospective, single-center study enrolled 208 elderly patients, including 67 patients with severe CAP (SCAP) and 141 with non-SCAP between November 1st, 2020, and November 30th, 2021 at the Qingdao Municipal Hospital, Shandong Province, China. The demographic and clinical parameters were recorded for all the included patients. Serum LPC levels were measured on day 1 and 6 after admission using ELISA. Propensity score matching (PSM) was used to balance the baseline variables between SCAP and non-SCAP patient groups. Receiver operative characteristic (ROC) curve analysis was used to compare the predictive performances of LPC and other clinical parameters in discriminating between SCAP and non-SCAP patients and determining the 30-day mortality risk of the hospitalized CAP patients. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors associated with SCAP. Cox proportional hazard regression analysis was used to determine if serum LPC was an independent risk factor for the 30-day mortality of CAP patients.

Results

The serum LPC levels at admission were significantly higher in the non-SCAP patients than in the SCAP patients (P = 0.011). Serum LPC level <24.36 ng/mL, and PSI score were independent risk factors for the 30-day mortality in the elderly patients with CAP. The risk of 30-day mortality in the elderly CAP patients with low serum LPC levels (< 24.36ng/mL) was >5-fold higher than in the patients with high serum LPC levels (≥ 24.36ng/mL).

Conclusion

Low serum LPC levels were associated with significantly higher disease severity and 30-day mortality in the elderly patients with CAP. Therefore, serum LPC is a promising predictive biomarker for the early identification of elderly CAP patients with poor prognosis.

Effectiveness of S100 calcium-binding protein A12 combined with modified early warning score in the clinical diagnosis of adult community-acquired pneumonia

Background

Recent studies have found that S100 serum calcium-binding protein A12 (S100A12) has important significance in the expression of acute infectious diseases, and has high clinical application value in the differential diagnosis, prognosis and other aspects of acute infectious diseases. The accuracy of modified early warning score (MEWS) in evaluating the disease risk level of critically ill patients is comparable to Acute Physiology and Chronic Health Evaluation (APACHE II).

Methods

Based on MEWS, 108 adult community-acquired pneumonia (CAP) patients were divided into the low-risk, intermediate-risk, and high-risk groups. The differences in invasive mechanical ventilation rate and mortality rate among each group were compared, and the differences of S100A12 in different levels of MEWS scores were compared through one-way analysis of variance. According to the prognosis after 30 days, the patients were divided into the death group and the survival group. Univariate and multivariate logistic regression analyses were used to study the influencing and independent factors of 30-day death in CAP patients. The sensitivity and specificity of S100A12, procalcitonin (PCT), and MEWS scores in predicting the 30-day death in CAP patients were evaluated using the receiver operating characteristic (ROC) curve, as well as the area under each indicator curve.

Results

The serum S100A12 concentration increased with the increase in the MEWS stratification, and the mechanical ventilation and mortality rates also increased significantly. Univariate and multivariate analyses were used to explore the factors influencing mortality in adult CAP patients after 30 days. The receiver-operating characteristics curve was used to analyze the sensitivity, specificity, and area under the curves of serum S100A12, PCT, and MEWS in predicting mortality in CAP patients after 30 days.

Conclusions

The serum S100A12, PCT, and MEWS can effectively predict the mortality risk in adult CAP patients after 30 days. Serum S100A12 combined with MEWS has a high clinical application value in evaluating the severity and prognosis of adult CAP.

The application of nanopore targeted sequencing for pathogen diagnosis in bronchoalveolar lavage fluid of patients with pneumonia: a prospective multicenter study

OBJECTIVE

To evaluate the value of nanopore targeted sequencing in diagnosing pneumonia pathogens.

METHODS

This large-scale multicentre prospective study performed in 8 hospitals across China from April to October 2022. Hospitalised patients with a diagnosis of pneumonia at admission were included. Complete clinical data were collected, and bronchoalveolar lavage fluid were obtained from each patient. These samples underwent simultaneous testing using conventional microbial testing, metagenomic next-generation sequencing, and nanopore targeted sequencing.

RESULTS

A total of 218 patients were included. Among the 168 cases of pulmonary infection, 246 strains of pathogens were confirmed. Nanopore targeted sequencing outperformed conventional microbial testing, identifying more pathogens with a sensitivity increase of 47.9% (77.2% vs. 29.3%). Metagenomic next-generation sequencing had a sensitivity of 82.9%. Total of 70.1% patients had consistent results in both metagenomic next-generation sequencing and nanopore targeted sequencing. Nanopore targeted sequencing exhibited significantly higher sensitivity in detecting Pneumocystis jiroveci, cytomegalovirus, Mycobacterium tuberculosis, Nontuberculous mycobacteria, Streptococcus pneumoniae, and Mycoplasma pneumoniae compared to conventional microbial testing. However, metagenomic next-generation sequencing demonstrated higher sensitivity than nanopore targeted sequencing for Aspergillus (88.5% vs. 53.8%). Regarding the detection of co-infections, nanopore targeted sequencing displayed significantly higher sensitivity than conventional microbial testing (76.7% vs. 28.7%) and was on par with metagenomic next-generation sequencing (76.7% vs. 82.9%).

CONCLUSION

Nanopore targeted sequencing performs equally well as metagenomic next-generation sequencing in bronchoalveolar lavage fluid for pathogen diagnosis in pneumonia, both methods showing higher sensitivity than conventional microbial testing. Nanopore targeted sequencing can be considered a reliable method for diagnosing pathogens in pneumonia.

Risk factors and predicting nomogram for the clinical deterioration of non-severe community-acquired pneumonia

BACKGROUND

Currently, there remains insufficient focus on non-severe community-acquired pneumonia (CAP) patients who are at risk of clinical deterioration, and there is also a dearth of research on the related risk factors. Early recognition of hospitalized patients at risk of clinical deterioration will be beneficial for their clinical management.

METHOD

A retrospective study was conducted in The First Affiliated Hospital of Wenzhou Medical University, China, spanning from January 1, 2018 to April 30, 2022, and involving a total of 1,632 non-severe CAP patients. Based on whether their condition worsened within 72 h of admission, patients were divided into a clinical deterioration group and a non-clinical deterioration group. Additionally, all patients were randomly assigned to a training set containing 75% of patients and a validation set containing 25% of patients. In the training set, risk factors for clinical deterioration in patients with non-severe CAP were identified by using LASSO regression analysis and multivariate logistic regression analysis. A nomogram was developed based on identified risk factors. The effectiveness of the nomogram in both the training and validation sets was assessed using Receiver Operating Characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

Age, body mass index (BMI), body temperature, cardiovascular comorbidity, respiratory rate, LDH level, lymphocyte count and D-dimer level were identified as risk factors associated with the clinical deterioration of non-severe CAP within 72 h of admission. The area under curve (AUC) value of the nomogram was 0.78 (95% CI: 0.74-0.82) in the training set and 0.75 (95% CI: 0.67-0.83) in the validation set. Furthermore, the calibration curves for both the training and validation sets indicated that the predicted probability of clinical deterioration aligned with the actual probability. Additionally, DCA revealed clinical utility for the nomogram at a specific threshold probability.

CONCLUSION

The study successfully identified the risk factors linked to the clinical deterioration of non-severe CAP and constructed a nomogram for predicting the probability of deterioration. The nomogram demonstrated favorable predictive performance and has the potential to aid in the early identification and management of non-severe CAP patients at elevated risk of deterioration.

Multi-omics analysis reveals overactive inflammation and dysregulated metabolism in severe community-acquired pneumonia patients

BACKGROUND

Severe community-acquired pneumonia (S-CAP) is a public health threat, making it essential to identify novel biomarkers and investigate the underlying mechanisms of disease severity.

METHODS

Here, we profiled host responses to S-CAP through proteomics analysis of plasma samples from a cohort of S-CAP patients, non-severe (NS)-CAP patients, diseases controls (DCs), and healthy controls (HCs). Then, typical differentially expressed proteins were then validated by ELISA in an independent cohort. Metabolomics analysis was further performed on both the cohort 1 and cohort 2. Then, the proteomic and metabolomic signatures were compared between the adult and child cohorts to explore the characteristics of severe pneumonia patients.

RESULTS

There were clear differences between CAP patients and controls, as well as substantial differences between the S-CAP and NS-CAP. Pathway analysis of changes revealed excessive inflammation, suppressed immunity, and lipid metabolic disorders in S-CAP cases. Interestingly, comparing these signatures between the adult and child cohorts confirmed that overactive inflammation and dysregulated lipid metabolism were common features of S-CAP patients, independent of age. The change proportion of glycerophospholipids, glycerolipids, and sphingolipids were obviously different in the adult and child S-CAP cases.

CONCLUSION

The plasma multi-omics profiling revealed that excessive inflammation, suppressed humoral immunity, and disordered metabolism are involved in S-CAP pathogenesis.

Omadacycline for the treatment of severe pneumonia caused by Chlamydia psittaci complicated with acute respiratory distress syndrome during the COVID-19 pandemic

Introduction

Chlamydia psittaci infection in humans is a rare cause that mainly present as community-acquired pneumonia. Severe Chlamydia psittaci pneumonia can lead to acute respiratory distress syndrome (ARDS), septic shock, or multiple organ dysfunction with a mortality rate of 15%-20% before accurate diagnosis and targeted treatment. Metagenomic next-generation sequencing (mNGS) has an advantage in achieving early diagnosis. In the study, omadacycline implementation was described to provide a better understanding of effectiveness in severe psittacosis pneumonia with ARDS.

Methods

Sixteen patients with severe psittacosis pneumonia with ARDS were selected between September 2021 and October 2022. They were diagnosed using mNGS and treated with omadacycline. Retrospective analysis of clinical manifestations, laboratory data, disease progression, diagnostic tool, treatment, and prognosis was summarized.

Results

Common symptoms included fever, dyspnea, and cough. All patients developed ARDS, accompanied by septic shock (43.7%) and pulmonary embolism (43.7%). Laboratory data showed normal leucocytes, increased creatine kinase isoenzyme, and decreased albumin with liver dysfunction in most patients. All patients had increased neutrophils, C-reactive protein, procalcitonin, and D-dimer with decreased lymphocytes. Airspace consolidation, ground glass opacity, and pleural effusion were found on chest CT. mNGS results were obtained in 24-48 h to identify the diagnosis of Chlamydia psittacosis. All patients received mechanical ventilation with omadacycline treatment. Fourteen patients experienced complete recovery, while the other two patients died from multidrug-resistant bacterial infection and renal failure.

Conclusion

mNGS has a significant value in the diagnosis of Chlamydia psittaci infection. Timely treatment of omadacycline can improve prognosis and provide a promising new option for the treatment of severe Chlamydia psittaci pneumonia with ARDS.

Diagnostic significance of HRCT imaging features in adult mycoplasma pneumonia: a retrospective study

Mycoplasma pneumoniae pneumonia (MPP) often overlaps with the clinical manifestations and chest imaging manifestations of other types of community-acquired pneumonia (CAP). We retrospectively analyzed the clinical and imaging data of a group of patients with CAP, summarized their clinical and imaging characteristics, and discussed the diagnostic significance of their certain HRCT findings. The HRCT findings of CAP researched in our study included tree-in-bud sign (TIB), ground-glass opacity (GGO), tree fog sign (TIB + GGO), bronchial wall thickening, air-bronchogram, pleural effusion and cavity. The HRCT findings of all cases were analyzed. Among the 200 cases of MPP, 174 cases showed the TIB, 193 showed the GGO, 175 showed the tree fog sign, 181 lacked air-bronchogram. In case taking the tree fog sign and lack of air-bronchogram simultaneously as an index to distinguish MPP from OCAP, the sensitivity was 87.5%, the specificity was 97.5%, the accuracy was 92.5%. This study showed that that specific HRCT findings could be used to distinguish MPP from OCAP. The combined HRCT findings including the tree fog sign and lacked air-bronchogram simultaneously would contribute to a more accurate diagnosis of MPP.

Applicability of Bronchoalveolar Lavage Fluid and Plasma Metagenomic Next-Generation Sequencing Assays in the Diagnosis of Pneumonia

Background

Metagenomic next-generation sequencing (mNGS) provides innovative solutions for predicting complex infections. A comprehensive understanding of its strengths and limitations in real-world clinical settings is necessary to ensure that it is not overused or misinterpreted.

Methods

Two hundred nine cases with suspected pneumonia were recruited to compare the capabilities of 2 available mNGS assays (bronchoalveolar lavage fluid [BALF] mNGS and plasma mNGS) to identify pneumonia-associated DNA/RNA pathogens and predict antibiotic resistance.

Results

Compared to clinical diagnosis, BALF mNGS demonstrated a high positive percent agreement (95.3%) but a low negative percent agreement (63.1%). Plasma mNGS revealed a low proportion of true negatives (30%) in predicting pulmonary infection. BALF mNGS independently diagnosed 65.6% (61/93) of coinfections and had a remarkable advantage in detecting caustic, rare, or atypical pathogens. Pathogens susceptible to invasive infection or bloodstream transmission, such as Aspergillus spp, Rhizopus spp, Chlamydia psittaci, and human herpesviruses, are prone to be detected by plasma mNGS. BALF mNGS tests provided a positive impact on the diagnosis and treatment of 128 (61.2%) patients. Plasma mNGS, on the other hand, turned out to be more suitable for diagnosing patients who received mechanical ventilation, developed severe pneumonia, or developed sepsis (all P < .01). BALF mNGS was able to identify resistance genes that matched the phenotypic resistance of 69.4% (25/36) of multidrug-resistant pathogens.

Conclusions

Our data reveal new insights into the advantages and disadvantages of 2 different sequencing modalities in pathogen identification and antibiotic resistance prediction for patients with suspected pneumonia.

The mortality and years of life lost for community-acquired pneumonia before and during COVID-19 pandemic in China

Background

Community-acquired pneumonia (CAP) is a leading cause of mortality worldwide, but disease burden of CAP is not clear so far. We aim to explore the spatial and temporal trends of mortality and years of life lost (YLL) due to CAP during 2013-2021 in mainland China, especially the mortality changes before and during COVID-19 pandemic due to COVID-19 related non-pharmaceutical interventions (NPIs).

Methods

We used data from the National Mortality Surveillance System to estimate the age-standardized rates of death and YLL of CAP at national and provincial level in China during 2013-2021. Monthly and provincial NPIs data were obtained from Oxford COVID-19 Government Response Tracker. The Average annual percentage change (AAPC) and mortality reduction were estimated by log-linear regression and interrupted time series, respectively.

Findings

In China, most CAP that caused deaths had no clear etiology, and bacterial pneumonia and viral pneumonia were the leading 2 causes among CAP deaths with determined etiology before and during COVID-19 pandemic. The age-standardized CAP mortality rate decreased from 11.18 per 100,000 in 2013 to 8.76 per 100,000 in 2019, and to 5.74 per 100,000 in 2021 (AAPC -4.51% vs -7.89%). Trends were similar in age-standardized rate of YLL. Both rates declined more for viral pneumonia, compared with bacterial pneumonia. After adjusting for NPIs at provincial level after 2020, the NPIs for COVID-19 was associated with significant reductions in CAP mortality (-0.34 per 100,000, -0.41 to -0.27; p < 0.0001), and provinces that economically developed and conducted strict regular NPIs against COVID-19 contributed the most reduction.

Interpretation

We observed a decreasing trend of age-standardized CAP mortality from 2013 to 2019, and a dramatical reduction during COVID-19 pandemic, especially for viral pneumonia. Our study provided the evidence for the effectiveness of regular NPIs on the significant reductions in CAP mortality.

Funding

This work has been supported by Beijing Municipal Science and Technology Project Z191100006619101, Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFMS 2021-I2M-1-048), CAMS Institute of Respiratory Medicine Grant for Young Scholars (2023-ZF-8) and the New Cornerstone Science Foundation.

Analysis of Correlation Between Serum Oncostatin-M and Disease Severity and Mortality in Hospitalized Patients with Community-Acquired Pneumonia

Purpose

The aim of this study was to investigate the level of serum tumor suppressor factor (Oncostatin-M, OSM) in patients with community-acquired pneumonia (CAP) and evaluate its predictive value for the severity and prognosis of pneumonia, so as to improve the ability to identify the risk of death in CAP patients.

Patients and Methods

A total of 110 patients with CAP admitted to the hospital from November 2020 to November 2021 were enrolled in this prospective study. Clinical data of all patients were collected. According to the 2016 edition of "Guidelines for the Diagnosis and Treatment of Community-acquired Pneumonia in Chinese Adults", the patients were divided into non-severe CAP (NSCAP)(n=55) and severe CAP (SCAP)(n=55). At the same time, they were divided into a survival group (n=96) and a death group (n=14) by tracking the survival of patients in the hospital. The OSM concentration of CAP patients on the first day after admission was determined by enzyme-linked immunosorbent assay. All clinical data were statistically and graphed using SPSS V23.0 and Grahpad Prim 8.

Results

Compared with NSCAP, patients with SCAP had higher serum OSM concentration on the day of admission, which was negatively correlated with LYM and positively correlated with WBC, NEU, CRP, IL-6, IL-8, IL-10, CURB-65 score, and PSI score. The level of OSM in the dead patient group was significantly higher than that in the surviving patient group. OSM and PSI scores were independent risk factors for in-hospital mortality in CAP patients. Kaplan-Meier survival curve showed that OSM≥76pg/mL was more advantageous in predicting mortality in patients with CAP.

Conclusion

The level of the OSM is closely related to the severity and prognosis of CAP and may be a new biomarker for the prognosis of CAP patients.

Metagenomic next-generation sequencing of bronchoalveolar lavage fluid in non-severe and severe pneumonia patients

Metagenomic next-generation sequencing (mNGS) is widely used as a more promising technology than conventional tests. However, its clinical utility in the context of bronchoalveolar lavage fluid (BALF) samples for discriminating between non-severe and severe pneumonia is not well established. Thus, this study aimed to investigate the diagnostic performance of mNGS on BALF samples from 100 individuals suspected of pneumonia, and compared it with conventional microbiological tests (CMT) of BALF samples and the final clinical diagnosis. Twenty-seven cases of non-severe pneumonia and 73 cases of severe pneumonia patients were finally clinically diagnosed. Among 100 cases, diagnostic performance of mNGS and culture showed a significant difference; 65 cases had the same sample types, of which 25 cases were diagnosed as positive by mNGS only (38.46%) and 1 was diagnosed as positive by culture only (1.54%). Moreover, 24 cases were diagnosed positive in both mNGS and culture (36.92%) and 15 cases tested negative in both mNGS and culture (23.08%). Among 35 cases, 28 out of 35 cases were diagnosed as positive by mNGS, while only 4 out of 35 cases were diagnosed as positive by the indirect immunofluorescence method (IIFT). In addition, the positive rate of mNGS was higher than that of culture in cases regardless of prior antibiotic exposure. Mixed pathogens were found to be significantly more prevalent in severe pneumonia patients than in non-severe pneumonia patients. Importantly, among 38 cases who were diagnosed solely by mNGS, 25 patients experienced an improved outcome after physicians changed the therapy according to the mNGS results. In conclusion, the results showed that mNGS of BALF represents a potentially effective tool for detection of mixed pathogens in severe pneumonia.

Clinical value of glucocorticoids for severe community-acquired pneumonia: A systematic review and meta-analysis based on randomized controlled trials

BACKGROUND

Severe community-acquired pneumonia (sCAP) is characterized by severe symptoms and a poor prognosis, especially with the recent global impact of novel coronavirus in recent years. The use of glucocorticoids in sCAP is currently a subject of debate. To evaluate the clinical efficacy and safety of glucocorticoids and provide guidance for their rational use in clinical practice, we conducted this study.

METHODS

We searched PubMed, Web of Science, and China National Knowledge Infrastructure using the following search terms: "pneumonia", "pneumonias", "Pulmonary Inflammation", "Pulmonary Inflammations", "Lung Inflammation", and "Lung Inflammations". The primary outcomes included mortality and the length of hospital stay. The secondary outcomes included the duration of mechanical ventilation, duration of vasoactive drug use, gastrointestinal bleeding, and multiple infections. The Cochrane Collaboration was used to assess the risk of bias of the included studies. Stata/MP14 was used for meta-analysis.

RESULTS

These studies contained information on 1252 patients who received glucocorticoids and 1280 patients who did not. Meta-analysis showed that there was no difference in terms of mortality [risk ratio (RR) = 0.93, 95% confidence interval (CI): 0.81-1.07, P  > .05], gastrointestinal bleeding (RR = 1.38, 95% CI: 0.83-2.30, P  <  .05), multiple infections (RR = 1.17, 95% CI: 0.90-1.53, P  > .05) and length of hospital stay (mean difference [MD] = -0.87, 95% CI: -2.35 to 0.61, P  > .05) between the hormonal and nonhormonal groups. However, there was a significant difference in the duration of mechanical ventilation (MD = -1.54; 95% CI, -1.89 to -1.12, P  <  .05) and the duration of use of vasoactive drugs (MD = -14.09, 95% CI: -15.72 to -12.46, P < .05).

CONCLUSION

Glucocorticoids reduced the duration of mechanical ventilation duration and vasoactive drug use in sCAP patients without increasing the risk of adverse events including hyperglycemia and multiple infections. However, there was no significant difference in mortality or length of hospital stay in sCAP patients between glucocorticoid and non-glucocorticoid groups. Glucocorticoids could be recommended for patients with sCAP with respiratory failure or hemodynamic instability.

Associations of Serum Clara Cell Protein 16 with Severity and Prognosis in Adults with Community-Acquired Pneumonia

Background

Clara cell protein 16 (CC16) has multiple functions, including antioxidant, anti-inflammatory, and immune regulation properties. Nevertheless, the concrete function of CC16 in adult patients with community-acquired pneumonia (CAP) remained blurred.

Methods

A total of 541 adult patients with CAP were recruited on admission. Peripheral blood specimens, clinical parameters, and demographic characteristics were collected. The concentration of serum CC16 was evaluated through ELISA. The relationships between serum CC16 and clinical parameters were appraised by Spearman or Pearson correlative analyses. The correlations of serum CC16 with severity and prognosis were assessed using linear or logistic regression models.

Results

The level of CC16 was gradually decreased across with the elevated severity scores system of CAP. After treatment, the level of serum CC16 was upregulated. Correlative analyses found that serum CC16 was negatively related to inflammatory cytokines. Additionally, multivariate linear and logistic regression models revealed that serum CC16 was inversely associated with severity scores system. In addition, reduced serum CC16 on admission elevated the risks of vasoactive agent usage, ICU admission, and death during hospitalization. We observed an almost discriminatory ability for severity and death between serum CC16 and severity scores system, and were all obviously elevated compared to routine inflammatory and infectious markers.

Conclusion

There are substantially inverse correlations between serum CC16 level on admission with severity scores and poorly prognostic outcomes, indicating that CC16 is involved in the pathophysiological process of CAP. This study is helpful for establishing the potential application of serum CC16 in risk evaluation and targeted treatment.

A score to predict Pseudomonas aeruginosa infection in older patients with community-acquired pneumonia

BACKGROUND

In Thailand, the incidence of community-acquired pseudomonal pneumonia among 60- to 65-year-olds ranges from 10.90% to 15.51%, with a mortality rate of up to 19.00%. Antipseudomonal agents should be selected as an empirical treatment for elderly patients at high risk for developing this infection. The purpose of this study was to identify risk factors and develop a risk predictor for Pseudomonas aeruginosa infection in older adults with community-acquired pneumonia (CAP).

METHODS

A retrospective data collection from an electronic database involved the elderly hospitalized patients with P. aeruginosa- and non-P. aeruginosa-causing CAP, admitted between January 1, 2016, and June 30, 2021. Risk factors for P. aeruginosa infection were analysed using logistic regression, and the instrument was developed by scoring each risk factor based on the beta coefficient and evaluating discrimination and calibration using the area under the receiver operating characteristic curve (AuROC) and observed versus predicted probability (E/O) ratio.

RESULTS

The inclusion criteria were met by 81 and 104 elderly patients diagnosed with CAP caused by P. aeruginosa and non-P. aeruginosa, respectively. Nasogastric (NG) tube feeding (odd ratios; OR = 40.68), bronchiectasis (B) (OR = 4.13), immunocompromised condition (I) (OR = 3.76), and other chronic respiratory illnesses (r) such as atelectasis, pulmonary fibrosis, and lung bleb (OR = 2.61) were the specific risk factors for infection with P. aeruginosa. The "60-B-r-I-NG" risk score was named after the 4 abbreviated risk variables and found to have good predicative capability (AuROC = 0.77) and accuracy comparable to or near true P. aeruginosa infection (E/O = 1). People who scored at least two should receive empirically antipseudomonal medication.

CONCLUSIONS

NG tube feeding before admission, bronchiectasis, immunocompromisation, atelectasis, pulmonary fibrosis and lung bleb were risk factors for pseudomonal CAP in the elderly. The 60-B-r-I-NG was developed for predicting P. aeruginosa infection with a high degree of accuracy, equal to or comparable to the existing P. aeruginosa infection. Antipseudomonal agents may be started in patients who are at least 60 years old and have a score of at least 2 in order to lower mortality and promote the appropriate use of these medications.

Mild Pulmonary Nocardiosis Caused by Nocardia terpenica in an Immunocompetent Patient

A 53-year-old immunocompetent man was admitted to our hospital because of paroxysmal cough with a low fever for more than 5 months. On admission, chest computed tomography showed multiple plaques and nodules, some with small central cavities, in both lungs and cystic and columnar bronchiectasis of the right middle bronchus. Treatment with various antibiotics was ineffective. Metagenomic next-generation sequencing of the bronchoalveolar lavage fluid showed Nocardia terpenica, and this organism was cultured from bronchoalveolar lavage fluid, resulting in a diagnosis of pulmonary nocardiosis. After administration of trimethoprim-sulfamethoxazole for 5 weeks, chest computed tomography showed a significant reduction in the lung lesions that had been detected on admission. Immunosuppressed patients are particularly prone to nocardiosis infection, which is usually severe. N. terpenica has rarely been detected in clinical samples, and its characteristics require further study with the accumulation of more clinical cases.

Clinical analysis of severe Chlamydia psittaci pneumonia: Case series study

The clinical characteristics and diagnosis of ten cases with severe Chlamydia psittaci pneumonia were analyzed. Ten patients had high fever, cough, or diarrhea, and all had a history of contact with birds or poultry. The white blood cell count of the patients was normal or slightly increased. The percentage of neutrophils (N%) and C reactive protein of the patients were significantly increased. Chest computer tomography showed patchy consolidation of both lungs, with one-sided lung lobes prominent, and bronchial inflation signs. All the patients were admitted to the intensive care unit due to respiratory failure. Nine patients needed ventilator-assisted ventilation therapy, and one patient needed high-flow oxygen therapy. All patients had sepsis, and five patients developed septic shock. The patients were diagnosed with severe C. psittaci pneumonia by clinical manifestations and contact history. After timely adjustment of tetracycline-based treatment, eight patients recovered and were discharged, and two patients died of septic shock and respiratory failure. Patients with poultry contact should be cautious toward C. psittaci pneumonia. A better method for the detection of C. psittaci is metagenomic next-generation sequencing. Its examination can shorten the diagnosis time. In a later stage, large-sample research is needed to guide clinical diagnosis and treatment.

CD4+ T cells related to disease severity in elderly and frailty community-acquired pneumonia patients: A retrospective cohort study

BACKGROUNDS

Elderly and frailty individuals show a more senescent immune system, which may relate to worse outcome in community-acquired pneumonia (CAP). This study aimed to explore prognostic factors related to immune.

METHODS

Sixty of elderly (≥65 years) and frailty (clinical frailty scale ≥5 scores) nonsevere CAP patients and 60 severe CAP (SCAP) patients were recruited at our center. Clinical and laboratory data, and several assessment scores were collected.

RESULTS

Compared with nonsevere CAP group, the elderly and frailty SCAP patients showed higher level of BMI, PaCO2 and lactate in arterial blood-gas, CURB-65 score, ICU admission, mechanical ventilation, shock accidence, and longer hospital stay using two-tailed t test. The SCAP group also showed increased CRP, IL-6, and PCT, and decreased CD3+ T cells, CD4+ T cells, and CD8+ T cells. Logistic regression analysis showed that CD4+ T cells, IL-6 and PCT were independent prognostic factors for SCAP. The area under the receiver operating characteristic (ROC) curve for CD4+ T cells combined with PCT was 0.771 (95% CI 0.683-0.859), and the sensitivity and specificity were both 76.7%. Paired t test analysis showed that low CD4+ T cells in SCAP patients increased after treatment.

CONCLUSIONS

CD4+ T cells decreased in elderly and frailty SCAP patients, and CD4+ T cells combined with PCT were relatively accurate in the prediction of elderly and frailty SCAP.

Psittacosis caused severe community-acquired pneumonia accompanied by acute hypoxic respiratory failure: a multicenter retrospective cohort study from China

INTRODUCTION

Psittacosis can cause severe community-acquired pneumonia (CAP). The clinical manifestations of psittacosis range from subclinical to fulminant psittacosis with multi-organ failure. It is essential to summarize the clinical characteristic of patients with severe psittacosis accompanied by acute hypoxic respiratory failure (AHRF).

METHODS

This retrospective study included patients with severe psittacosis caused CAP accompanied by AHRF from 19 tertiary hospitals of China. We recorded the clinical data, antimicrobial therapy, respiratory support, complications, and outcomes. Chlamydia psittaci was detected on the basis of metagenomic next-generation sequencing performed on bronchoalveolar lavage fluid samples. Patient outcomes were compared between the treatment methods.

RESULTS

This study included 45 patients with severe CAP and AHRF caused by psittacosis from April 2018 to May 2021. The highest incidence of these infections was between September and April. There was a history of poultry contact in 64.4% of the patients. The median PaO2/FiO2 of the patients was 119.8 (interquartile range, 73.2 to 183.6) mmHg. Four of 45 patients (8.9%) died in the ICU, and the median ICU duration was 12 days (interquartile range, 8 to 21) days. There were no significant differences between patients treated with fluoroquinolone initially and continued after the diagnosis, fluoroquinolone initially followed by tetracycline, and fluoroquinolone combined with tetracycline.

CONCLUSION

Psittacosis caused severe CAP seems not rare, especially in the patients with the history of exposure to poultry or birds. Empirical treatment that covers atypical pathogens may benefit such patients, which fluoroquinolones might be considered as an alternative.

Metabolomics Study Revealing Purines as Potential Diagnostic Biomarkers of Acute Respiratory Distress Syndrome in Patients with Community─Acquired Pneumonia

Community-acquired pneumonia (CAP) is a significant threat to human health and the leading cause of acute respiratory distress syndrome (ARDS). We aimed to reveal the metabolic profiling whether can be used for assessing CAP with or without ARDS (nARDS) and therapeutic effects on CAP patients after treatment. Urine samples were collected at the onset and recovery periods, and metabolomics was employed to identify robust biomarkers. 19 metabolites were significantly changed in the ARDS relative to nARDS, mainly involving purines and fatty acids. After treatment, 7 metabolites in the nARDS and 14 in the ARDS were found to be significantly dysregulated, including fatty acids and amino acids. In the validation cohort, we observed that the biomarker panel consisted of N2,N2-dimethylguanosine, 1-methyladenosine, 3-methylguanine, 1-methyladenosine, and uric acid exhibited better AUCs of 0.900 than pneumonia severity index and acute physiology and chronic health evaluation II (APACHE II) scores between the ARDS and nARDS. Combining L-phenylalanine, phytosphingosine, and N-acetylaspartylglutamate as biomarkers for discriminating the nARDS and ARDS patients after treatment exhibited good AUCs of 0.811 and 0.821, respectively. The metabolic pathway and defined biomarkers may serve as crucial indicators for predicting the development of ARDS in CAP patients and for assessing therapeutic effects.

Establishment of risk model for elderly CAP at different age stages: a single-center retrospective observational study

Community-acquired pneumonia (CAP) is one of the main reasons of mortality and morbidity in elderly population, causing substantial clinical and economic impacts. However, clinically available score systems have been shown to demonstrate poor prediction of mortality for patients aged over 65. Especially, no existing clinical model can predict morbidity and mortality for CAP patients among different age stages. Here, we aimed to understand the impact of age variable on the establishment of assessment model and explored prognostic factors and new biomarkers in predicting mortality. We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University. We used univariate and multiple logistic regression analyses to study the prognostic factors of mortality in each age-based subgroup. The prediction accuracy of the prognostic factors was determined by the Receiver Operating Characteristic curves and the area under the curves. Combination models were established using several logistic regressions to save the predicted probabilities. Four factors with independently prognostic significance were shared among all the groups, namely Albumin, BUN, NLR and Pulse, using univariate analysis and multiple logistic regression analysis. Then we built a model with these 4 variables (as ABNP model) to predict the in-hospital mortality in all three groups. The AUC value of the ABNP model were 0.888 (95% CI 0.854-0.917, p < 0.000), 0.912 (95% CI 0.880-0.938, p < 0.000) and 0.872 (95% CI 0.833-0.905, p < 0.000) in group 1, 2 and 3, respectively. We established a predictive model for mortality based on an age variable -specific study of elderly patients with CAP, with higher AUC value than PSI, CURB-65 and qSOFA in predicting mortality in different age groups (66-75/ 76-85/ over 85 years).

Factors Associated with Severe Adenovirus Pneumonia in Children: A Retrospective Study from Guangzhou, China (2017-2019)

BACKGROUND Adenovirus infections are prevalent in children, typically presenting with mild or asymptomatic symptoms. However, some children develop severe pneumonia necessitating hospitalization. This retrospective study aimed to identify risk factors associated with severe adenovirus pneumonia in children. MATERIAL AND METHODS We screened consecutive children admitted for community-acquired pneumonia at the Emergency Department of Guangzhou Women's and Children's Medical Center between 2017 and 2019. Adenovirus infection was confirmed through rapid respiratory virus assay, RT-PCR assay from respiratory secretions, or serum IgM antibodies. According to Chinese guidelines, patients with pneumonia were classified into severe and mild groups. We assessed risk factors for severe adenovirus pneumonia by comparing clinical features and laboratory indicators, then included differing factors between the 2 groups in a logistic regression analysis. Data analysis was performed using SPSS 26.0 software. RESULTS Our study included 173 children diagnosed with adenovirus pneumonia (117 severe, 56 mild). The median age was 40 months, with 64 male patients. Univariate analysis and binary logistic regression analysis revealed that pleural effusion (13.449 [1.226-147.510], p=0.033), electrolyte disturbances (15.149 [2.724-84.246], p=0.002), oxygen therapy (258.219 [20.684-3223.548], p<0.001), bronchoscopy (26.781 [6.088-117.805], p<0.001), and steroid administration (6.584 [1.497-28.953], p=0.013) were associated with the severity of adenovirus pneumonia. CONCLUSIONS This single-center retrospective study identified pleural effusion, the need for bronchoscopy, oxygen therapy, and steroid treatment, along with impaired serum electrolytes, as factors associated with severe adenovirus pneumonia in children.

Application of mNGS in the study of pulmonary microbiome in pneumoconiosis complicated with pulmonary infection patients and exploration of potential biomarkers

Background

Pneumoconiosis patients have a high prevalence of pulmonary infections, which can complicate diagnosis and treatment. And there is no comprehensive study of the microbiome of patients with pneumoconiosis. The application of metagenomic next-generation sequencing (mNGS) fills the gap to some extent by analyzing the lung microbiota of pneumoconiosis population while achieving accurate diagnosis.

Methods

We retrospectively analyzed 44 patients with suspected pneumoconiosis complicated with pulmonary infection between Jan 2020 and Nov 2022. Bronchoalveolar lavage fluid (BALF) specimens from 44 patients were collected and tested using the mNGS technology.

Results

Among the lung microbiome of pneumoconiosis patients with complicated pulmonary infection (P group), the most frequently detected bacteria and fungi at the genus level were Streptococcus and Aspergillus, at the species level were Streptococcus pneumoniae and Aspergillus flavus, respectively, and the most frequently detected DNA virus was Human gammaherpesvirus 4. There was no significant difference in α diversity between the P group and the non-pneumoconiosis patients complicated with pulmonary infection group (Non-P group) in pulmonary flora, while P< 0.01 for β diversity analysis, and the differential species between the two groups were Mycobacterium colombiense and Fusobacterium nucleatum. In addition, we monitored a high distribution of Malassezia and Pneumocystis in the P group, while herpes virus was detected in the majority of samples.

Conclusions

Overall, we not only revealed a comprehensive lung microbiome profile of pneumoconiosis patients, but also compared the differences between their microbiome and that of non-pneumoconiosis complicated with pulmonary infection patients. This provides a good basis for a better understanding of the relationship between pneumoconiosis and microorganisms, and for the search of potential biomarkers.

Neutrophil extracellular traps predict postoperative pulmonary complications in paediatric patients undergoing parental liver transplantation

BACKGROUND

Parental liver transplantation (PLT) improves long-term survival rates in paediatric hepatic failure patients; however, the mechanism of PLT-induced postoperative pulmonary complications (PPCs) is unclear.

METHODS

A total of 133 paediatric patients undergoing PLT were included. Serum levels of NET components, including circulating free DNA (cfDNA), DNA-histone complex, and myeloperoxidase (MPO)-DNA complex, were detected. The occurrence of PPCs post-PLT, prolonged intensive care unit (ICU) stay and death within one year were recorded as the primary and secondary outcomes.

RESULTS

The overall rate of PPCs in the hospital was 47.4%. High levels of serum cfDNA, DNA-histone complexes and MPO-DNA complexes were associated with an increased risk of PPCs (for cfDNA, OR 2.24; for DNA-histone complex, OR 1.64; and for MPO-DNA, OR 1.94), prolonged ICU stay (OR 1.98, 4.26 and 3.69, respectively), and death within one year (OR 1.53, 2.65 and 1.85, respectively). The area under the curve of NET components for the prediction of PPCs was 0.843 for cfDNA, 0.813 for DNA-histone complexes, and 0.906 for MPO-DNA complexes. During the one-year follow-up, the death rate was higher in patients with PPCs than in patients without PPCs (14.3% vs. 2.9%, P = 0.001).

CONCLUSIONS

High serum levels of NET components are associated with an increased incidence of PPCs and death within one year in paediatric patients undergoing PLT. Serum levels of NET components serve as a biomarker for post-PLT PPCs and a prognostic indicator.

Interventions to improve outcomes in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is a common infection associated with high morbimortality and a highly deleterious impact on patients' quality of life and functionality. We comprehensively review the factors related to the host, the causative microorganism, the therapeutic approach and the organization of health systems (e.g. setting for care and systems for allocation) that might have an impact on CAP-associated outcomes. Our main aims are to discuss the most controversial points and to provide some recommendations that may guide further research and the management of patients with CAP, in order to improve their outcomes, beyond mortality.

AREA COVERED

In this review, we aim to provide a critical account of potential measures to improve outcomes of CAP and the supporting evidence from observational studies and clinical trials.

EXPERT OPINION

CAP is associated with high mortality and a highly deleterious impact on patients' quality of life. To improve CAP-associated outcomes, it is important to understand the factors related to the patient, etiology, therapeutics, and the organization of health systems.

Epidemiological change of influenza virus in hospitalized children with acute respiratory tract infection during 2014-2022 in Hubei Province, China

PURPOSE

Influenza virus (IFV) causes acute respiratory tract infection (ARTI) and leads to high morbidity and mortality annually. This study explored the epidemiological change of IFV after the implementation of the universal two-child policy and evaluated the impact of coronavirus disease 2019 (COVID-19) pandemic on the detection of IFV.

METHODS

Hospitalized children under 18 years with ARTI were recruited from Hubei Maternal and Child Healthcare Hospital of Hubei Province from January 2014 to June 2022. The positive rates of IFV were compared among different periods by the implementation of the universal two-child policy and public health measures against COVID-19 pandemic.

RESULTS

Among 75,128 hospitalized children with ARTI, the positive rate of IFV was 1.98% (1486/75128, 95% CI 1.88-2.01). Children aged 6-17 years had the highest positive rate of IFV (166/5504, 3.02%, 95% CI 2.58-3.50). The positive rate of IFV dropped to the lowest in 2015, then increased constantly and peaked in 2019. After the universal two-child policy implementation, the positive rate of IFV among all the hospitalized children increased from 0.40% during 2014-2015 to 2.70% during 2017-2019 (RR 6.72, 95% CI 4.94-9.13, P < 0.001), particularly children under one year shown a violent increasing trend from 0.20 to 2.01% (RR 10.26, 95% CI 5.47-19.23, P < 0.001). During the initial outbreak of COVID-19, the positive rate of IFV decreased sharply compared to that before COVID-19 (0.35% vs. 3.37%, RR 0.10, 95% CI 0.04-0.28, P < 0.001), and then rebounded to 0.91%, lower than the level before COVID-19 (RR 0.26, 95% CI 0.20-0.36, P < 0.001).

CONCLUSION

IFV epidemiological pattern has changed after the implementation of the universal two-child policy. More attention should be emphasized to comprehend the health benefits generated by COVID-19 restrictions on IFV transmission in future.

Diagnostic and prognostic value of deregulated long non-coding RNA RPPH1 in patients with severe community-acquired pneumonia: a retrospective cohort study

BACKGROUND

Severe community-acquired pneumonia (SCAP) is one of the most common critical and acute diseases in the respiratory and acute medicine department. The expression and significance of lncRNA RPPH1 (RPPH1) in SCAP were assessed aiming to explore a biomarker assisting in the screening and management of SCAP.

METHODS

This study is a retrospective study enrolled 97 SCAP patients, 102 mild community-acquired pneumonia (MCAP) patients, and 65 healthy individuals. The serum expression of RPPH1 of study subjects was evaluated using PCR. The diagnostic and prognostic significance of RPPH1 in SCAP was evaluated by ROC and Cox analyses. Meanwhile, the correlation of RPPH1 with patients' clinicopathological features was evaluated by spearman correlation analysis to evaluate its role in assessing disease severity.

RESULTS

A significant downregulation of RPPH1 was observed in the serum of SCAP patients compared with MCAP and healthy individuals. RPPH1 was positively correlated with ALB (r = 0.74) and negatively correlated with C-reactive protein (r = -0.69), neutrophil-to-lymphocyte ratio (r = -0.88), procalcitonin (r = -0.74), and neutrophil (r = -0.84) of SCAP patients, which are associated with the development and severity of SCAP. Additionally, reduced RPPH1 was closely associated with the 28-day development-free survival of SCAP patients and served as an adverse prognostic indicator together with procalcitonin.

CONCLUSIONS

Downregulated RPPH1 in SCAP could act as a diagnostic biomarker screening SCAP from healthy and MCAP individuals and act as a prognostic biomarker predicting patients' disease conditions and outcomes. The demonstrated significance of RPPH1 in SCAP could assist the clinical antibiotic therapies of SCAP patients.

Prognostic significance of frailty in hospitalized elderly patients with community-acquired pneumonia: a retrospective cohort study

BACKGROUND

Frailty is associated with poor prognosis in a wide range of illnesses. However, its prognostic implications for older patients with community-acquired pneumonia (CAP) are not adequately addressed.

METHODS

In this study, patients were classified into 3 groups according to the frailty index based on standard laboratory tests (FI-Lab) score: robust (FI-Lab < 0.2), pre-frail (FI-Lab 0.2-0.35), and frail (FI-Lab ≥ 0.35). The relationships between frailty and all-cause mortality and short-term clinical outcomes (length of stay, duration of antibiotic therapy, in-hospital mortality) were examined.

RESULTS

Finally, 1164 patients were included, the median age was 75 years (interquartile range: 69, 82), and 438 patients (37.6%) were women. According to FI-Lab, 261(22.4%), 395(33.9%), and 508(43.6%) were robust, pre-frail, and frail. After adjustment for confounding variables, frailty was independently associated with prolonged antibiotic treatment (p = 0.037); pre-frailty and frailty were independently associated with longer inpatient days (p < 0.05 for both). The risk of in-hospital mortality was independently increased in frail patients (HR = 5.01, 95% CI = 1.51-16.57, p = 0.008) but not pre-frail patients (HR = 2.87, 95% CI = 0.86-9.63, p = 0.088) compared to robust patients. During a median follow-up of 33.9 months (interquartile range: 32.8 to 35.1 months), 408 (35.1%) patients died, of whom 29 (7.1%) were robust, 112 (27.5%) were pre-frail, and 267 (65.9%) were frail. Compared to robust patients, frail and pre-frail were significantly associated with increased risk for all-cause death (HR = 4.29, 95%CI: 1.78-10.35 and HR = 2.42 95%CI: 1.01-5.82, respectively).

CONCLUSIONS

Frailty is common among older patients with CAP and is strongly associated with increased mortality, longer length of stay, and duration of antibiotics. A routine frail assessment at the admission of elderly patients with CAP is necessary as the first step for appropriate multidisciplinary interventions.

Identification and comparison of Chlamydia psittaci, Legionella and Mycoplasma pneumonia infection

INTRODUCTION

Conventional etiological detection and pathogenic antibody methods make it challenging to identify the atypical pathogens among the community-acquired pneumonia (CAP). Metagenomic next-generation sequencing (mNGS) could rapidly detect all potentially infectious diseases and identifies novel or potential pathogens.

METHODS

Eighteen patients diagnosed with atypical CAP were enrolled in this retrospective study, including nine Chlamydia psittaci pneumonia (C. p), four Legionella pneumonia (L. p) and five Mycoplasma pneumonia (M. p). We simultaneously tested bronchoalveolar lavage fluid (BALF) samples for conventional microbiological methods and mNGS, and blood specimens were analysed. We also collected and compared baseline and clinical characteristics and treatment responses.

RESULTS

Patients with C. p and L. p had similar symptoms, including fever, cough, headache, dyspnoea, asthenia, shivering and headache, compared with M. p, whose symptoms were slight. C. p and L. p usually showed multiple lobar distributions with pleural effusion. Serologic testing indicated that L. p had higher levels of white blood cells (WBCs), neutrophils, C-reactive protein (CRP), procalcitonin (PCT), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and creatinine compared with M. p and L. p (p < 0.05). However, patients with C. p had lower levels of albumin (p < 0.05), and M. p had a minimum risk of cardiac volume loads (p < 0.05). CD4/CD8 ratio, lymphocytes, aspartate aminotransferase (AST), creatine kinase (CK), cell counting of BALF and coagulation had no difference (p < 0.05). Pathogenic IgM assay showed that 4/5 cases were positive for M. p and no positive detection for C. p and L. p infection. We timely adjusted the antibiotics according to the final mNGS results. Eventually, 16/18 patients recovered fully. Conditions of L. p patients were worse than those of C. p patients, and those of M. p patients were the least.

CONCLUSION

Early application of mNGS detection increased the atypical pathogenic identification, improved the prognosis and made up for the deficiency of conventional detection methods.

Prevalence and molecular characteristics of community-associated methicillin-resistant Staphylococcus aureus in the respiratory tracts of Chinese adults with community-acquired pneumonia

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an important pathogen causing healthcare-associated infections. In recent years, an increasing number of CA-MRSA clones have emerged and rapidly spread in the community and hospital settings in China.

OBJECTIVES

To investigate the molecular epidemiology and resistance of CA-MRSA in the respiratory tracts of Chinese adults with community-acquired pneumonia (CAP).

METHODS

A total of 243 sputum samples were collected from adult patients with CAP at the Nantong Hospital in China between 2018 and 2021. S. aureus was identified using PCR, and its susceptibility to 14 antimicrobials was tested using the broth dilution method. Genomic characterization of respiratory CA-MRSA and our previously collected intestinal CA-MRSA isolates was performed using whole-genome sequencing, and the evolutionary relationships of these isolates were assessed using phylogenetic analysis.

RESULTS

The CA-MRSA colonization rate among adults with CAP in China was 7.8 % (19/243). Antimicrobial resistance analysis revealed that the proportion of multidrug-resistant respiratory CA-MRSA isolates (100 %) was higher than that of intestinal CA-MRSA isolates (6.3 %). Among the 35 CA-MRSA isolates, 10 MLST types were identified and clustered into five clone complexes (CCs). CC5 (48.6 %) and CC88 (20 %) were predominant CA-MRSA clones. Notably, the CC5 clone ST764/ST6292-MRSA-II-t002 was identified as the major lineage causing respiratory tract infections in Chinese adults with CAP.

CONCLUSIONS

The prevalence of CA-MRSA among Chinese adults with CAP is high and often involves ST764/ST6292-MRSA-II-t002 as the causal pathogen.

Correlation analysis of the peripheral blood lymphocyte count and occurrence of pneumonia after lung transplantation

BACKGROUND

Infections are the most common complication in patients after lung transplantation and the main cause of death at all stages after transplantation; therefore, awareness regarding the occurrence of infectious pneumonia after lung transplantation is vital. This study aimed to explore the correlation between the absolute lymphocyte and T-lymphocyte subpopulation counts in the peripheral blood and the occurrence of pneumonia after lung transplantation and to predict the risk of pneumonia development after lung transplantation.

MATERIALS

Patients who underwent lung transplantation with long-term follow-up between June 2018 and December 2021 were prospectively included. The patients were divided into pneumonia and non-pneumonia groups. Demographic and clinical characteristics, and the levels of leukocytes, neutrophils, platelets, C-reactive protein (CRP), procalcitonin (PCT), serum albumin, peripheral blood T lymphocytes, and CD4+ and CD8+ T cells in the peripheral blood were measured in both groups.

RESULTS

We included 22 patients with post-lung transplants in the analysis. Of the 104 collected samples, 26 (56.5%) were pathogenically positive, 16 (61.5%) had bacterial infections, 7 samples (26.9%) had fungal infections, and 8 (30.8%) had viral infections. Patients with pneumonia had higher levels of peripheral blood neutrophils (P = 0.01), platelets (P = 0.03), and CRP (P < 0.001) than did those without pneumonia. Logistic regression analysis showed that the levels of peripheral blood neutrophils, total T lymphocytes, CRP, and PCT were associated with the development of pneumonia after transplantation (P < 0.05), as documented by their area under the curve (AUC) values of 0.702, 0.792, 0.899, and 0.789, respectively. The AUC for the combined receiver operating characteristic curve for predicting the development of pneumonia was 0.943, with a sensitivity of 91.3% and specificity of 93.1%. There was no significant difference in T-lymphocyte counts in patients with lung transplants between the pneumonia and non-pneumonia groups who were treated with two anti-rejection agents. In contrast, the absolute lymphocyte, total T-lymphocyte, and CD4+ and CD8+ T-cell counts in patients who developed pneumonia after treatment with three anti-rejection agents were lower than those in patients who did not develop pneumonia (P < 0.05).

CONCLUSION

Bacterial pneumonia is more common after lung transplantation than after fungal or viral infections. Peripheral blood T-lymphocyte counts combined with neutrophil, CRP, and PCT levels had good predictive value for the development of pneumonia after lung transplantation. Monitoring of patients should be strengthened by implementing peripheral blood T-lymphocyte counts to improve the early identification and prevention of pneumonia after lung transplantation.

Epidemiological features of Streptococcus pneumoniae in patients with acute respiratory tract infection in Beijing, China during 2009-2020

BACKGROUND

Streptococcus pneumoniae (S. pneumoniae) is one of the common pathogens causing acute respiratory tract infection (ARTI). The study aimed to investigate the prevalence of S. pneumoniae in patients with ARTI in Beijing, and to provide reference evidence for prevention and control of S. pneumoniae.

METHOD

The patients from the surveillance data of ARTI in Beijing from 2009 to 2020 were recruited in the study. All patients were tested for S. pneumoniae and other viral and bacterial pathogens. Logistic regression model was used to explore the epidemiological features of S. pneumoniae.

RESULTS

Totally, 4.63% (253/5468) of the ARTI patients were positive for S. pneumoniae. The age, case type and antibiotic therapy in one week before sampling affected the positive rate of S. pneumoniae in patients. No significant difference on the positive rate of S. pneumoniae between the mild and severe pneumonia. Patients infected with S. pneumoniae had a higher risk of pneumonia in adults and the elderly, but a lower risk in children. The leading bacterial and viral pathogens in patients positive for S. pneumoniae were Haemophilus influenzae (36.36%) and human rhinovirus (35.59%), respectively.

CONCLUSION

This study showed that the prevalence of S. pneumoniae in the patients with ARTI was at a low level in Beijing from 2009 to 2020, which was higher in elderly patients, outpatients and patients without antibiotic therapy. It is necessary to further explore the serotype of S. pneumoniae and PCVs vaccine coverage, and rationally develop vaccine manufacture and vaccination programs to reduce the burden of pneumococcal diseases.

Blood heparin-binding protein and neutrophil-to-lymphocyte ratio as indicators of the severity and prognosis of community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is particularly prevalent and has high mortality in severely ill patients, but the role of current biomarkers is limited. This study aimed to evaluate the importance of blood heparin-binding protein (HBP) and neutrophil-to-lymphocyte ratio (NLR) in assessing the severity and prognosis of CAP in adults.

METHODS

The clinical information of 206 CAP patients was retrospectively analyzed. Receiver operating characteristic (ROC) curves were created, and the accuracy of the diagnosis of severe pneumonia was evaluated by the area under the curve (AUC). Univariate and multivariate Cox regression analysis was used to examine independent factors affecting the 30-day prognosis. The Kruskal-Wallis test was utilized to contrast the variations among etiology.

RESULTS

Patients with severe pneumonia showed greater HBP and NLR compared to those with common pneumonia. The AUC of HBP was 0.723 (95% CI: 0.655-0.790) for the diagnosis of severe pneumonia, while NLR and HBP exhibited superior sensitivity (80.00%) and specificity (76.19%), respectively. Their combination boosted the diagnostic specificity (84.13%) while increasing the diagnostic sensitivity (86.25%) when combined with white blood cell (WBC) count. The 30-day mortality in CAP patients was independently predicted by HBP and NLR. However, there were no appreciable differences in HBP amongst patients with various etiologies.

CONCLUSION

HBP and NLR were also independent predictors of 30-day death in CAP patients and grew with increasing severity in these patients. Their combination opened up new possibilities. Furthermore, there is no connection between HBP and the etiology of CAP.

The relationship between frailty and community-acquired pneumonia in older patients

PURPOSES

To explore the relationship between frailty and community-acquired pneumonia (CAP) in older patients.

METHODS

A prospective observational study included 109 older patients(≥ 65 years) hospitalized with CAP in respiratory department of Fuxing hospital, Capital Medical University from June 2018 to December 2020. Frailty scores(Frail Scale, range 0-5) and pneumonia severity CURB-65 scale(mild = 1, modest = 2, and severe ≥ 3) were measured. We extracted clinical variables including white blood cell(WBC), neutrophil-to-lymphocyte ratio (NLR), C-reactive protein(CRP), hemoglobin, and albumin. Charlson Comorbidity Index(CCI) was calculated as well. The correlations between the variables and frailty scores were investigated, respectively. After adjusting for covariates, binomial logistic regression analysis was used to assess independent effect of frailty scores on the outcome(discharge or death/progression) in older CAP patients.

RESULTS

The subjects had a median age 87(interquartile range,8.5) years, 60.6% male, 45.9% pre-frail, and 32.1% frail. There were positive correlations between frailty scores and CURB-65 scale (p = 0.000, r = 0.542), CCI(p = 0.000, r = 0.359) and NLR(p = 0.005, r = 0.268). Negative correlations were observed between frailty scores and hemoglobin (p = 0.002, r = - 0.298), albumin (p = 0.000, r = - 0.465). In multivariable logistic regression analysis, the factors associated with discharge or death/progression of CAP were frailty scores (OR = 1.623, p = 0.037), NLR (OR = 1.086, p = 0.008) and albumin (OR = 0.869, p = 0.034).

CONCLUSIONS

Frailty is correlated with CURB-65 scale, CCI and hemoglobin, and albumin in older patients with CAP. Frailty is also a correlate of increased risk for death or progression in these older people.

Predictive Value of Annenxin A1 for Disease Severity and Prognosis in Patients with Community-Acquired Pneumonia

This prospective, single-center study evaluated the clinical utility of annenxin (Anx)A1 level as a biomarker for determining the severity of illness and predicting the risk of death in hospitalized patients with community-acquired pneumonia (CAP). A total of 105 patients (53 with severe [S]CAP, 52 with non-SCAP) were enrolled from December 2020 to June 2021. Demographic and clinical data were recorded. Serum AnxA1 concentration on days one and six after admission was measured by enzyme-linked immunosorbent assay. AnxA1 level at admission was significantly higher in SCAP patients than in non-SCAP patients (p < 0.001) irrespective of CAP etiology and was positively correlated with Pneumonia Severity Index and Confusion, Uremia, Respiratory Rate, Blood Pressure, and Age ≥ 65 Years score. AnxA1 level was significantly lower on day six after treatment than on day one (p = 0.01). Disease severity was significantly higher in patents with AnxA1 level ≥254.13 ng/mL than in those with a level <254.13 ng/mL (p < 0.001). Kaplan-Meier analysis of 30-day mortality showed that AnxA1 level ≤670.84 ng/mL was associated with a significantly higher survival rate than a level >670.84 ng/mL. These results indicate that AnxA1 is a useful biomarker for early diagnosis and prognostic assessment of CAP.

Clinical characteristics and outcomes of immunocompromised patients with severe community-acquired pneumonia: A single-center retrospective cohort study

Background

Immunocompromised patients with severe community-acquired pneumonia (SCAP) warrant special attention because they comprise a growing proportion of patients and tend to have poor clinical outcomes. The objective of this study was to compare the characteristics and outcomes of immunocompromised and immunocompetent patients with SCAP, and to investigate the risk factors for mortality in these patients.

Methods

We conducted retrospective observational cohort study of patients aged ≥18 years admitted to the intensive care unit (ICU) of an academic tertiary hospital with SCAP between January 2017 and December 2019 and compared the clinical characteristics and outcomes of immunocompromised and immunocompetent patients.

Results

Among the 393 patients, 119 (30.3%) were immunocompromised. Corticosteroid (51.2%) and immunosuppressive drug (23.5%) therapies were the most common causes. Compared to immunocompetent patients, immunocompromised patients had a higher frequency of polymicrobial infection (56.6 vs. 27.5%, P < 0.001), early mortality (within 7 days) (26.1 vs. 13.1%, P = 0.002), and ICU mortality (49.6 vs. 37.6%, P = 0.027). The pathogen distributions differed between immunocompromised and immunocompetent patients. Among immunocompromised patients, Pneumocystis jirovecii and cytomegalovirus were the most common pathogens. Immunocompromised status (OR: 2.043, 95% CI: 1.114-3.748, P = 0.021) was an independent risk factor for ICU mortality. Independent risk factors for ICU mortality in immunocompromised patients included age ≥ 65 years (odds ratio [OR]: 9.098, 95% confidence interval [CI]: 1.472-56.234, P = 0.018), SOFA score [OR: 1.338, 95% CI: 1.048-1.708, P = 0.019), lymphocyte count < 0.8 × 10⁹/L (OR: 6.640, 95% CI: 1.463-30.141, P = 0.014), D-dimer level (OR: 1.160, 95% CI: 1.013-1.329, P = 0.032), FiO₂ > 0.7 (OR: 10.228, 95% CI: 1.992-52.531, P = 0.005), and lactate level (OR: 4.849, 95% CI: 1.701-13.825, P = 0.003).

Conclusions

Immunocompromised patients with SCAP have distinct clinical characteristics and risk factors that should be considered in their clinical evaluation and management.

Longitudinal associations of serum survivin with the severity and prognosis of community-acquired pneumonia patients

BACKGROUND

Survivin is a member of apoptosis inhibitor proteins that evokes cellular proliferation and inhibits apoptosis. However, the role of survivin in community-acquired pneumonia (CAP) patients remains to be firmly established. The aim of this cohort study was to evaluate the correlations of serum survivin with the severity and prognosis of CAP patients.

METHODS

This research included 470 eligible CAP patients. Serum fasting samples were drawn from patients, and serum survivin was measured by enzyme-linked immunosorbent assay (ELISA). Meanwhile, demographic characteristics and clinical information were collected. The prognosis of CAP patients was tracked.

RESULTS

Serum survivin gradually decreased with elevated CAP severity scores. Additionally, the correlative analysis suggested that serum survivin was associated with many clinical characteristics. Furthermore, mixed linear and logistic regression models indicated that serum survivin was negatively associated with severity. After adjusting for confounding factors, logistic regression analyses found that lower serum survivin on admission elevated the risks of mechanical ventilation, vasoactive agent usage, longer hospital stays, ICU admission, and even death during hospitalization. Serum survivin in combination with CAP severity scores elevated the predictive capacities for severity and death in CAP patients compared with a single indicator.

CONCLUSION

On admission, there are inverse dose-response associations of serum survivin with severity and poor prognosis in CAP patients, demonstrating that serum survivin may be involved in the pathophysiology process of CAP. Serum survivin may serve as a potential biomarker for disease evaluation and prognosis in CAP patients.

Appropriateness of antimicrobial selection for treatment of pneumonia in selected public hospitals of Eastern Ethiopia: A cross-sectional study

Objective

Inappropriate antimicrobial use leads to drug resistance and poor clinical outcomes. Considering the lack of data regarding the drug use patterns in the treatment of pneumonia in selected study areas, the authors felt compelled to assess the appropriateness of antimicrobial usage in the treatment of pneumonia at Hiwot Fana Specialized Comprehensive University Hospital and Jugal Hospital from May 1 to 31, 2021.

Methods

A cross-sectional retrospective study was conducted using the medical cards of 693 admitted patients with pneumonia. The collected data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were used to identify the factors associated with an initial inappropriate antibiotic use. A p value of 0.05 was used to determine the statistical significance of the association using an adjusted odds ratio with 95% confidence interval.

Results

Of the total participants, 116 (16.74%, 95% confidence interval: 14.1-19.6) of them received an initial inappropriate antimicrobial regimen. Ceftriaxone plus azithromycin was the most prescribed antimicrobial agent. Patients who were younger than 5 years (adjusted odds ratio = 1.71; 95% confidence interval: 1.00-2.94), between 6 and 14 years (adjusted odds ratio = 3.14; 95% confidence interval: 1.64-6.00), and older than 65 years (adjusted odds ratio = 2.97; 95% confidence interval: 1.07-2.66), with comorbid conditions (adjusted odds ratio = 1.74; 95% confidence interval: 1.10-2.72) and prescribed by medical interns (adjusted odds ratio = 1.80; 95% confidence interval: 1.14-2.84) were associated with an initial inappropriate antimicrobial use.

Conclusion

Around one out of every six patients had received initial inappropriate treatments. Adherence to the recommendation of guidelines and attention to extreme-aged groups and comorbidity may improve antimicrobial use.

Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study

Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.

Myristoyl lysophosphatidylcholine is a biomarker and potential therapeutic target for community-acquired pneumonia

There is no gold standard for evaluating the severity of community-acquired pneumonia (CAP), and it is still based on a score. This study aimed to use the metabolomics method to find promised biomarkers in assessing disease severity and potential therapeutic targets for CAP. The result found that the metabolites in the plasma samples of CAP patients had significantly different between the acute phase and the remission phase, especially lysophosphatidylcholine (LPCs) in glycerophospholipids, whose levels are negatively linked to the severity of the disease. Subsequently, the two key metabolites of myristoyl lysophosphatidylcholine (LPC 14:0) and LPC 16:1 were screened. We analyzed the predictive performance of the two metabolites using Spearman-related analysis and ROC curves, and LPC14:0 showed more satisfactory diagnostic performance than LPC16:1. Then we explored the protective role and mechanism of LPC 14:0 in animal and cell models. The results showed that LPC 14:0 could inhibit the LPS-induced secretion of IL-1β, IL-6, and TNF-α, lower the ROS and MDA levels, and decreased the depletion of SOD and GSH, thereby reducing lung tissue and cell damage, such as down-regulating the protein level in BALF, lung W/D ratio, MPO activity, and apoptosis. We found that LPC 14:0 inhibited LPS-induced inflammatory response and oxidative stress, and the above protection was achieved by inhibiting LPS-induced activation of the NLRP3 inflammasome. LPC 14:0 may serve as a novel biomarker for predicting the severity of CAP. In addition, our exploration of the role of LPC 14:0 in animal and cellular models has reinforced its promise as a therapeutic target to improve the clinical efficacy for CAP.

Diagnostic and Prognostic Value of Dysregulated miR-10a-3p in Patients with Severe Pneumonia

PURPOSE

Previous studies have shown that microRNA is involved in regulating a variety of human inflammatory diseases. The purpose of this study was to investigate the expression of miR-10a-3p in the blood of patients with severe pneumonia and evaluate its value in the diagnosis and prognosis of severe pneumonia.

PATIENTS AND METHODS

Seventy patients with severe pneumonia and 75 healthy individuals were included in this study. Venous blood of all subjects was obtained for RT-qPCR analysis to obtain the relative expression level of miR-10a-5p. The diagnostic accuracy of miR-10a-5p for severe pneumonia was assessed by ROC curve. After standardized treatment, the prognosis of patients with severe pneumonia was analyzed by a 28-day follow-up method. Kaplan-Meier curve and multivariate Cox regression analysis were used to determine the basic factors influencing the prognosis of patients.

RESULTS

Compared with healthy control, serum miR-10a-3p expression in patients with severe pneumonia was distinctly upregulated (P < 0.001). Besides, ROC analysis showed that miR-10a-3p had high diagnostic accuracy for severe pneumonia, with an AUC of 0.881, sensitivity and specificity of 75.7% and 84.0%, respectively. Kaplan-Meier curve exhibited that high miR-10a-3p expression group had a higher probability of death than those with low miR-10a-3p expression. Multivariate Cox regression analysis demonstrated that miR-10a-3p and CRP were independent risk factors affecting the prognosis of patients.

CONCLUSION

The expression of miR-10a-3p was increased in patients with severe pneumonia, and abnormally expressed miR-10a-3p has the potential to be used as a diagnostic and prognostic marker for severe pneumonia, which provides a new biological direction for the early detection and risk assessment of severe pneumonia.

Effects of Juhongtanke oral solution on alleviating the symptoms of community-acquired pneumonia: A multicenter, prospective, randomized controlled trial

Introduction: The timely alleviation of symptoms is essential for managing community-acquired pneumonia (CAP). Juhongtanke oral solution is a traditional marketed Chinese patent medicine believed to ease CAP symptoms. The currently available evidence is based on a few retrospective studies of patients with various types of pneumonia, whereas robust randomized controlled trials (RCTs) that support this notion are lacking.

Material and methods: In this multi-center, prospective RCT, patients were randomly allocated to receive routine treatment alone or a combination of Juhongtanke oral solution (20 mL q8h) for 5 days and maintained for an additional 3-day safety observation period. The primary outcome was Breathlessness, Cough, and Sputum Scale (BCSS) score evaluated on day 5. Secondary outcomes included the evaluation of cough and dyspnea items in the Visual Analogue Scale (VAS) from days 1–5, remission rate in BCSS and VAS during the treatment course, and the length of hospitalization and in-hospital mortality.

Results: Of 272 patients assessed for eligibility, 240 were enrolled in the study (n =120 per group). The mean difference in BCSS evaluated on day 5 was a median 1 point [95%CI (1.00, 2.00)], significantly lower in the treatment group compared with the control group (p < 0.001). Similar results were observed in VAS on day 5, with statistics of a median 2 points [95%CI (1.40, 2.50)] in the cough item and a median 1 point [95%CI (0.50, 2.00)] in the dyspnea item, significantly lower in the treatment group compared with the control group (both p < 0.001). The treatment group had a favorable outcome in BCSS and VAS remission rate assessments compared with the control group, with 99.50% vs. 89.17% in BCSS (p = 0.01), 98.33% vs. 75% in the cough item of VAS (p < 0.001), and 88.33% vs. 62.50% in the dyspnea item of VAS (p < 0.001), respectively. No notable adverse effects were observed during the study. No differences were observed in the length of hospitalization between groups (with a median of 7 days for both groups, p = 0.871).

Conclusion: Juhongtanke oral solution may be considered to alleviate the clinical symptoms of CAP.