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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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Joo Park Y, Min Lee S, Sub Kang W. Empyema in a Patient with Schizophrenia Using Clozapine: A Case Report. PSYCHIAT CLIN PSYCH 2022; 32:184-187. [PMID: 38764862 PMCID: PMC11099640 DOI: 10.5152/pcp.2022.22314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/03/2022] [Indexed: 05/21/2024] Open
Abstract
Schizophrenia is associated with a high risk of thoracic infections and pneumonia. The use of atypical antipsychotics clozapine may also increase the risk of pulmonary infection. However, psychotic patients are less likely to report physical symptoms, and these dangerous conditions may go undetected. In this case report, we present 47-year-old woman with schizophrenia who had been using clozapine and did not complain of respiratory symptoms. After admission, she was diagnosed with streptococcus intermedius empyema. Although empyema has a high mortality rate, thanks to the timely admission and proper diagnosis, the patient recovered after 3 weeks of medical and surgical treatment.
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Affiliation(s)
- Young Joo Park
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Min Lee
- Department of Psychiatry, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Won Sub Kang
- Department of Psychiatry, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Govind R, de Freitas DF, Pritchard M, Khondoker M, Teo JT, Stewart R, Hayes RD, MacCabe JH. COVID-related hospitalization, intensive care treatment, and all-cause mortality in patients with psychosis and treated with clozapine. Eur Neuropsychopharmacol 2022; 56:92-99. [PMID: 35152033 PMCID: PMC8784620 DOI: 10.1016/j.euroneuro.2022.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 01/08/2023]
Abstract
Clozapine, an antipsychotic, is associated with increased susceptibility to infection with COVID-19, compared to other antipsychotics. Here, we investigate associations between clozapine treatment and increased risk of adverse outcomes of COVID-19, namely COVID-related hospitalisation, intensive care treatment, and death, amongst patients taking antipsychotics with schizophrenia-spectrum disorders. Using the clinical records of South London and Maudsley NHS Foundation Trust, we identified 157 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders, were taking antipsychotics (clozapine or other antipsychotics) at the time of COVID-19 pandemic in the UK and had a laboratory-confirmed COVID-19 infection. The following health outcomes were measured: COVID-related hospitalisation, COVID-related intensive care treatment and death. We tested associations between clozapine treatment and each outcome using logistic regression models, adjusting for gender, age, ethnicity, neighbourhood deprivation, obesity, smoking status, diabetes, asthma, bronchitis and hypertension using propensity scores. Of the 157 individuals who developed COVID-19 while on antipsychotics (clozapine or other antipsychotics), there were 28% COVID-related hospitalisations, 8% COVID-related intensive care treatments and 8% deaths of any cause during the 28 days follow-up period. amongst those taking clozapine, there were 25% COVID-related hospitalisations, 7% COVID-related intensive care treatments and 7% deaths. In both unadjusted and adjusted analyses, we found no significant association between clozapine and any of the outcomes. Thus, we found no evidence that patients with clozapine treatment at time of COVID-19 infection had increased risk of hospitalisation, intensive care treatment or death, compared to non-clozapine antipsychotic-treated patients. However, further research should be considered in larger samples to confirm this.
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Affiliation(s)
- Risha Govind
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Daniela Fonseca de Freitas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Mizanur Khondoker
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - James T Teo
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; King's College Hospital, Denmark Hill, London, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Richard D Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - James H MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom; National Psychosis Unit, South London and Maudsley NHS Foundation Trust, London, United Kingdom.
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Govind R, Fonseca de Freitas D, Pritchard M, Hayes RD, MacCabe JH. Clozapine treatment and risk of COVID-19 infection: retrospective cohort study. Br J Psychiatry 2021; 219:368-374. [PMID: 32713374 PMCID: PMC7417985 DOI: 10.1192/bjp.2020.151] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clozapine, an antipsychotic with unique efficacy in treatment-resistant psychosis, is associated with increased susceptibility to infection, including pneumonia. AIMS To investigate associations between clozapine treatment and increased risk of COVID-19 infection in patients with schizophrenia-spectrum disorders who are receiving antipsychotic medications in a geographically defined population in London, UK. METHOD Using information from South London and Maudsley NHS Foundation Trust (SLAM) clinical records, via the Clinical Record Interactive Search system, we identified 6309 individuals who had an ICD-10 diagnosis of schizophrenia-spectrum disorders and were taking antipsychotics at the time of the COVID-19 pandemic onset in the UK. People who were on clozapine treatment were compared with those on any other antipsychotic treatment for risk of contracting COVID-19 between 1 March and 18 May 2020. We tested associations between clozapine treatment and COVID-19 infection, adjusting for gender, age, ethnicity, body mass index (BMI), smoking status and SLAM service use. RESULTS Of 6309 participants, 102 tested positive for COVID-19. Individuals who were on clozapine had increased risk of COVID-19 infection compared with those who were on other antipsychotic medication (unadjusted hazard ratio HR = 2.62, 95% CI 1.73-3.96), which was attenuated after adjusting for potential confounders, including clinical contact (adjusted HR = 1.76, 95% CI 1.14-2.72). CONCLUSIONS These findings provide support for the hypothesis that clozapine treatment is associated with an increased risk of COVID-19 infection. Further research will be needed in other samples to confirm this association. Potential clinical implications are discussed.
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Affiliation(s)
- Risha Govind
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Daniela Fonseca de Freitas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Richard D. Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - James H. MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King's College London; and National Institute for Health Research (NIHR) Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London; and National Psychosis Unit, South London and Maudsley NHS Foundation Trust, London, UK
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Abstract
PURPOSE OF REVIEW Clozapine has recently been described as a novel cause of secondary antibody deficiency (SAD), associated with long-term therapy. Here we critically review the evidence linking clozapine use to an increased infection risk, describe immunological alterations, and discuss potential mechanisms. RECENT FINDINGS Individuals with schizophrenia are at two to five times more likely to develop pneumonia than the general population, in particular, when receiving clozapine. Delayed-onset distinguishes clozapine-associated hypogammaglobulinaemia from agranulocytosis or neutropenia that occur at lesser frequency. Biomarker searches in treatment-resistant schizophrenia highlight an immune signature associated with long-term clozapine use. This includes reduction in class-switched memory B cells, echoing common variable immunodeficiency. Recent identification of a role for dopamine in T follicular helper-B cell interactions may inform future clinical studies. SUMMARY The detrimental impact of the increased infection risk associated with clozapine necessitates a re-evaluation of the current monitoring strategies as well as further studies to better understand the underlying mechanisms of SAD in this setting. On the basis of available evidence, we suggest simple modifications to clozapine monitoring including integration of routine vaccination, smoking cessation, and assessment of humoral immunity. Further studies are required to understand the role of clozapine in neuroinflammation as well as other potentially autoantibody-mediated diseases.
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Supportive and palliative care for people with respiratory problems and preexisting serious mental illness. Curr Opin Support Palliat Care 2020; 14:190-196. [PMID: 32701857 DOI: 10.1097/spc.0000000000000510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW People living with serious mental illness are at a higher risk of developing respiratory problems that can lead to increased morbidity and early mortality. This review aimed to identify recent advances in care provision for people with respiratory problems and preexisting serious mental illness to ease symptom burden and reduce the risk of premature mortality. RECENT FINDINGS Intervention-based studies in this area are scarce. The evidence reviewed originated from observational studies. Concluding comments from the synthesis suggest there are specific needs for proactive screening of respiratory function as part of routine physical health checks across care settings for people living with serious mental illness, more stringent monitoring of comorbid chronic lung conditions and increased attention in reducing the frequency respiratory infections. Integrated services across care settings are needed to support people with serious mental illness to limit the impact of modifiable lifestyle factors known to be detrimental to respiratory health, such as smoking. SUMMARY Key priorities are identified to improve accessibility and inclusivity of respiratory care pathways for people living with serious mental illness to support early detection and proactive monitoring of respiratory problems to help reduce the risk of early mortality.
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Martínez-Alés G, López-Cuadrado T, Olfson M, Bouza C. Use and outcomes of mechanical ventilation for people with severe mental disorders admitted due to natural causes: A nationwide population-based study. Gen Hosp Psychiatry 2020; 65:15-20. [PMID: 32361660 DOI: 10.1016/j.genhosppsych.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/11/2020] [Accepted: 04/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To characterize temporal trends and outcomes of invasive mechanical ventilation (MV) for people with severe mental disorders (SMD) admitted due to natural causes. METHODS We identified all 224,507 hospitalizations of patients aged 15-69 who underwent MV in Spain between 2000 and 2015, excluding poisonings and injuries, and divided them by presence of an SMD diagnosis. We compared the two study groups regarding demographic and clinical characteristics and examined time trends in the incidence of MV and in-hospital mortality. RESULTS SMD patients were younger and had fewer comorbidities and lower in-hospital mortality than the non-SMD group. However, among patients admitted due to circulatory diseases, SMD patients had higher mortality risk (OR = 1.39; 95%CI = 1.22-1.59). In the SMD group, the increase in MV use quadrupled that of non-SMD patients (Average Annual Percent Change = 6.9%; 95%CI = 5.5-8.3 vs. 1.5%; 0.9-2.0, respectively). Overall in-hospital mortality declined similarly in both study groups. While the SMD group's circulatory-specific mortality also decreased, by 2015 it remained elevated in comparison to non-SMD patients (44% vs. 38%, respectively). CONCLUSION The increase in MV use due to natural causes among people with SMD outpaced that of non-SMD patients, with comparable decreasing trends in mortality. Although declining, SMD patients' higher circulatory-specific mortality risk requires further investigation.
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Affiliation(s)
- Gonzalo Martínez-Alés
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | | | - Mark Olfson
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, USA
| | - Carmen Bouza
- Health Technology Assessment Agency, Carlos III Health Institute, Madrid, Spain.
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