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Smits HH, Jochems SP. Diverging patterns in innate immunity against respiratory viruses during a lifetime: lessons from the young and the old. Eur Respir Rev 2024; 33:230266. [PMID: 39009407 PMCID: PMC11262623 DOI: 10.1183/16000617.0266-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/16/2024] [Indexed: 07/17/2024] Open
Abstract
Respiratory viral infections frequently lead to severe respiratory disease, particularly in vulnerable populations such as young children, individuals with chronic lung conditions and older adults, resulting in hospitalisation and, in some cases, fatalities. The innate immune system plays a crucial role in monitoring for, and initiating responses to, viruses, maintaining a state of preparedness through the constant expression of antimicrobial defence molecules. Throughout the course of infection, innate immunity remains actively involved, contributing to viral clearance and damage control, with pivotal contributions from airway epithelial cells and resident and newly recruited immune cells. In instances where viral infections persist or are not effectively eliminated, innate immune components prominently contribute to the resulting pathophysiological consequences. Even though both young children and older adults are susceptible to severe respiratory disease caused by various respiratory viruses, the underlying mechanisms may differ significantly. Children face the challenge of developing and maturing their immunity, while older adults contend with issues such as immune senescence and inflammaging. This review aims to compare the innate immune responses in respiratory viral infections across both age groups, identifying common central hubs that could serve as promising targets for innovative therapeutic and preventive strategies, despite the apparent differences in underlying mechanisms.
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Affiliation(s)
- Hermelijn H Smits
- Leiden University Center of Infectious Disease (LU-CID), Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Jochems
- Leiden University Center of Infectious Disease (LU-CID), Leiden University Medical Center, Leiden, The Netherlands
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Lawrence H, McKeever TM, Lim WS. Readmission following hospital admission for community-acquired pneumonia in England. Thorax 2023; 78:1254-1261. [PMID: 37524392 DOI: 10.1136/thorax-2022-219925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/28/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Readmission rates following hospital admission with community-acquired pneumonia (CAP) have increased in the UK over the past decade. The aim of this work was to describe the cohort of patients with emergency 30-day readmission following hospitalisation for CAP in England and explore the reasons for this. METHODS A retrospective analysis of cases from the British Thoracic Society national adult CAP audit admitted to hospitals in England with CAP between 1 December 2018 and 31 January 2019 was performed. Cases were linked with corresponding patient level data from Hospital Episode statistics, providing data on the primary diagnosis treated during readmission and mortality. Analyses were performed describing the cohort of patients readmitted within 30 days, reasons for readmission and comparing those readmitted and primarily treated for pneumonia with other diagnoses. RESULTS Of 8136 cases who survived an index admission with CAP, 1304 (15.7%) were readmitted as an emergency within 30 days of discharge. The main problems treated on readmission were pneumonia in 516 (39.6%) patients and other respiratory disorders in 284 (21.8%). Readmission with pneumonia compared with all other diagnoses was associated with significant inpatient mortality (15.9% vs 6.5%; aOR 2.76, 95% CI 1.86 to 4.09, p<0.001). A diagnosis of hospital-acquired infection was more frequent in readmissions treated for pneumonia than other diagnoses (22.1% vs 3.9%, p<0.001). CONCLUSION Pneumonia is the most common condition treated on readmission following hospitalisation with CAP and carries a higher mortality than both the index admission or readmission due to other diagnoses. Strategies to reduce readmissions due to pneumonia are required.
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Affiliation(s)
- Hannah Lawrence
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tricia M McKeever
- Academic Unit of Lifespan and Population Health, University of Nottingham, Nottingham, UK
- Nottingham Biomedical Research Centre, Nottingham, UK
| | - Wei Shen Lim
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Nottingham Biomedical Research Centre, Nottingham, UK
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3
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Malecki SL, Jung HY, Loffler A, Green MA, Gupta S, MacFadden D, Daneman N, Upshur R, Fralick M, Lapointe-Shaw L, Tang T, Weinerman A, Kwan JL, Liu JJ, Razak F, Verma AA. Identifying clusters of coexisting conditions and outcomes among adults admitted to hospital with community-acquired pneumonia: a multicentre cohort study. CMAJ Open 2023; 11:E799-E808. [PMID: 37669812 PMCID: PMC10482492 DOI: 10.9778/cmajo.20220193] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Little is known about patterns of coexisting conditions and their influence on clinical care or outcomes in adults admitted to hospital for community-acquired pneumonia (CAP). We sought to evaluate how coexisting conditions cluster in this population to advance understanding of how multimorbidity affects CAP. METHODS We studied 11 085 adults admitted to hospital with CAP at 7 hospitals in Ontario, Canada. Using cluster analysis, we identified patient subgroups based on clustering of comorbidities in the Charlson Comorbidity Index. We derived and replicated cluster analyses in independent cohorts (derivation sample 2010-2015, replication sample 2015-2017), then combined these into a total cohort for final cluster analyses. We described differences in medications, imaging and outcomes. RESULTS Patients clustered into 7 subgroups. The low comorbidity subgroup (n = 3052, 27.5%) had no comorbidities. The DM-HF-Pulm subgroup had prevalent diabetes, heart failure and chronic lung disease (n = 1710, 15.4%). One disease category defined each remaining subgroup, as follows: pulmonary (n = 1621, 14.6%), diabetes (n = 1281, 11.6%), heart failure (n = 1370, 12.4%), dementia (n = 1038, 9.4%) and cancer (n = 1013, 9.1%). Corticosteroid use ranged from 11.5% to 64.9% in the dementia and pulmonary subgroups, respectively. Piperacillin-tazobactam use ranged from 9.1% to 28.0% in the pulmonary and cancer subgroups, respectively. The use of thoracic computed tomography ranged from 5.7% to 36.3% in the dementia and cancer subgroups, respectively. Adjusting for patient factors, the risk of in-hospital death was greater in the cancer (adjusted odds ratio [OR] 3.12, 95% confidence interval [CI] 2.44-3.99), dementia (adjusted OR 1.57, 95% CI 1.05-2.35), heart failure (adjusted OR 1.66, 95% CI 1.35-2.03) and DM-HF-Pulm subgroups (adjusted OR 1.35, 95% CI 1.12-1.61), and lower in the diabetes subgroup (adjusted OR 0.67, 95% CI 0.50-0.89), compared with the low comorbidity group. INTERPRETATION Patients admitted to hospital with CAP cluster into clinically recognizable subgroups based on coexisting conditions. Clinical care and outcomes vary among these subgroups with little evidence to guide decision-making, highlighting opportunities for research to personalize care.
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Affiliation(s)
- Sarah L Malecki
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Hae Young Jung
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Anne Loffler
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Mark A Green
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Samir Gupta
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Derek MacFadden
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Nick Daneman
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Ross Upshur
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Michael Fralick
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Lauren Lapointe-Shaw
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Terence Tang
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Adina Weinerman
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Janice L Kwan
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Jessica J Liu
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Fahad Razak
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont
| | - Amol A Verma
- Department of Internal Medicine (Malecki), University of Toronto; Li Ka Shing Knowledge Institute (Jung, Loffler, Gupta, Razak, Verma), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Department of Geography & Planning (Green), University of Liverpool, Liverpool, UK; Division of Respirology (Gupta), Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (MacFadden); University of Ottawa (MacFadden), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Daneman, Weinerman); Division of Clinical Public Health (Upshur), Dalla Lana School of Public Health, University of Toronto; Sinai Health System (Fralick, Kwan); Department of Medicine (Fralick, Lapointe-Shaw, Tang, Weinerman, Kwan, Liu, Razak, Verma), University of Toronto; University Health Network (Lapointe-Shaw, Liu); Trillium Health Partners (Tang); Institute of Health Policy, Management and Evaluation (Razak, Verma), University of Toronto, Toronto, Ont.
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4
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Bacterial pneumonia and subsequent dementia risk: A nationwide cohort study. Brain Behav Immun 2022; 103:12-18. [PMID: 35390468 DOI: 10.1016/j.bbi.2022.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/17/2022] [Accepted: 04/01/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bacterial pneumonia is associated with an increased risk of dementia. However, the association between different pathogens of bacterial pneumonia and the risk of dementia remains unclear. METHODS Using the Taiwan National Health Insurance Research Database, we recruited 11,712 patients with bacterial pneumonia and 11,120 controls between 1997 and 2012 and followed them up until the end of 2013. A diagnosis of dementia, Alzheimer's disease (AD), vascular dementia (VaD), and unspecified dementia were identified during the follow-up period. Cox regression analyses were performed with adjustments for confounders. Sensitivity analysis was conducted to exclude patients with prodromal dementia. RESULTS Patients with bacterial pneumonia were more likely to develop dementia (hazard ratio [HR]: 2.83, 95% confidence interval [CI]: 2.53-3.18), AD (HR: 2.44, 95% CI: 1.65-3.61), VaD (HR: 4.15, 95% CI: 3.20-5.38), and unspecified dementia (HR: 2.62, 95% CI: 2.29-3.00) compared with controls after adjusting for potential confounders. Subgroup pathogen analyses showed that the HR of AD was 3.85 (1.66-8.96) for Hemophilus, and the HR of VaD was 5.40 for Staphylococcus. The risks of dementia and VaD were associated with repeated hospitalization due to bacterial pneumonia in a dose-dependent manner. Sensitivity analyses after exclusion of the first three years or first five years of observation and after exclusion case enrollment before 2010 or 2008 showed consistent findings. CONCLUSION Different pathogens are associated with different risks of AD, VaD, and unspecified dementia. Further studies are necessary to investigate the underlying mechanisms of bacterial pneumonia and dementia.
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Lin SF, Lin HA, Chuang HC, Tsai HW, Kuo N, Chen SC, Hou SK. Fever, Tachypnea, and Monocyte Distribution Width Predicts Length of Stay for Patients with COVID-19: A Pioneer Study. J Pers Med 2022; 12:jpm12030449. [PMID: 35330449 PMCID: PMC8953796 DOI: 10.3390/jpm12030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/04/2022] [Accepted: 03/11/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Our study investigated whether monocyte distribution width (MDW) could be used in emergency department (ED) settings as a predictor of prolonged length of stay (LOS) for patients with COVID-19. (2) Methods: A retrospective cohort study was conducted; patients presenting to the ED of an academic hospital with confirmed COVID-19 were enrolled. Multivariable logistic regression models were used to obtain the odds ratios (ORs) for predictors of an LOS of >14 days. A validation study for the association between MDW and cycle of threshold (Ct) value was performed. (3) Results: Fever > 38 °C (OR: 2.82, 95% CI, 1.13−7.02, p = 0.0259), tachypnea (OR: 4.76, 95% CI, 1.67−13.55, p = 0.0034), and MDW ≥ 21 (OR: 5.67, 95% CI, 1.19−27.10, p = 0.0269) were robust significant predictors of an LOS of >14 days. We developed a new scoring system in which patients were assigned 1 point for fever > 38 °C, 2 points for tachypnea > 20 breath/min, and 3 points for MDW ≥ 21. The optimal cutoff was a score of ≥2. MDW was negatively associated with Ct value (β: −0.32 per day, standard error = 0.12, p = 0.0099). (4) Conclusions: Elevated MDW was associated with a prolonged LOS.
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Affiliation(s)
- Sheng-Feng Lin
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
- School of Public Health, College of Public Health, Taipei Medical University, Taipei 110, Taiwan
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 110, Taiwan
| | - Han-Chuan Chuang
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan;
| | - Hung-Wei Tsai
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
| | - Ning Kuo
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
| | - Shao-Chun Chen
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei 110, Taiwan; (H.-A.L.); (H.-W.T.); (N.K.); (S.-C.C.)
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: ; Tel.: +886-2-2736-1661 (ext. 8107)
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6
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Faniyi AA, Hughes MJ, Scott A, Belchamber KBR, Sapey E. Inflammation, Ageing and Diseases of the Lung: Potential therapeutic strategies from shared biological pathways. Br J Pharmacol 2021; 179:1790-1807. [PMID: 34826882 DOI: 10.1111/bph.15759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/07/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022] Open
Abstract
Lung diseases disproportionately affect elderly individuals. The lungs form a unique environment: a highly elastic organ with gaseous exchange requiring the closest proximity of inhaled air containing harmful agents and the circulating blood volume. The lungs are highly susceptible to senescence, with age and "inflammageing" creating a pro-inflammatory environment with a reduced capacity to deal with challenges. Whilst lung diseases may have disparate causes, the burden of ageing and inflammation provides a common process which can exacerbate seemingly unrelated pathologies. However, these shared pathways may also provide a common route to treatment, with increased interest in drugs which target ageing processes across respiratory diseases. In this review, we will examine the evidence for the increased burden of lung disease in older adults, the structural and functional changes seen with advancing age and assess what our expanding knowledge of inflammation and ageing pathways could mean for the treatment of lung disease.
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Affiliation(s)
- A A Faniyi
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, U.K
| | - M J Hughes
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, U.K
| | - A Scott
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, U.K
| | - K B R Belchamber
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, U.K
| | - E Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, U.K
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Vyse A, Campling J, Czudek C, Ellsbury G, Mendes D, Reinert RR, Slack M. A review of current data to support decision making for introduction of next generation higher valency pneumococcal conjugate vaccination of immunocompetent older adults in the UK. Expert Rev Vaccines 2021; 20:1311-1325. [PMID: 34550850 DOI: 10.1080/14760584.2021.1984888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The burden of pneumococcal disease in older UK adults remains substantial. Higher valency pneumococcal conjugate vaccines (PCVs) are currently in development with adult formulations for two of these anticipated to become available in 2022. This article collates and reviews relevant candidate data now available that may be used to support cost effectiveness assessments of vaccinating immunocompetent UK adults aged ≥65-years with PCVs. AREAS COVERED This article uses published data from surveillance systems, randomized controlled trials and observational studies. It focuses on local data from the UK but where these are either limited or not available relevant global data are considered. EXPERT OPINION The body of relevant data now available suggests the UK is well placed to assess the cost effectiveness of vaccinating immunocompetent ≥65-year olds with new generation higher valency PCVs. Recent contemporary data provide important new and robust insights into the epidemiology of pneumococcal disease in older UK adults and help to address much of the uncertainty and data gaps associated with previous analyses. Using these data to make informed decisions about use of new higher valency PCVs for routine use in older adults will be important for public health in the UK.
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Affiliation(s)
- Andrew Vyse
- Medical Affairs, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK
| | - James Campling
- Medical Affairs, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK
| | - Carole Czudek
- Medical Affairs, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK
| | - Gillian Ellsbury
- Medical Affairs, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK
| | - Diana Mendes
- Health & Value, Pfizer Ltd, Walton Oaks, Tadworth, KT20 7NS, UK
| | | | - Mary Slack
- School of Medicine & Dentistry, Griffith University, Gold Coast Campus, Queensland 4222, Australia
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8
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Free RC, Richardson M, Pillay C, Hawkes K, Skeemer J, Broughton R, Haldar P, Woltmann G. Specialist pneumonia intervention nurse service improves pneumonia care and outcome. BMJ Open Respir Res 2021; 8:8/1/e000863. [PMID: 34348943 PMCID: PMC8340276 DOI: 10.1136/bmjresp-2020-000863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/07/2021] [Indexed: 11/09/2022] Open
Abstract
Background A specialist pneumonia intervention nursing (SPIN) service was set up across a single National Health Service Trust in an effort to improve clinical outcomes. A quality improvement evaluation was performed to assess the outcomes associated with implementing the service before (2011–2013) and after (2014–2016) service implementation. Results The SPIN service reviewed 38% of community-acquired pneumonia (CAP) admissions in 2014–2016. 82% of these admissions received antibiotic treatment in <4 hours (68.5% in the national audit). Compared with the pre-SPIN period, there was a significant reduction in both 30-day (OR=0.77 (0.70–0.85), p<0.0001) and in-hospital (OR=0.66 (0.60–0.73), p<0.0001) mortality after service implementation, with a review by the service showing the largest independent 30-day mortality benefit (HR=0.60 (0.53–0.67), p<0.0001). There was no change in length of stay (median 6 days). Conclusion Implementation of a SPIN service improved adherence to BTS guidelines and achieved significant reductions in CAP-associated mortality. This enhanced model of care is low cost, highly effective and readily adoptable in secondary care.
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Affiliation(s)
- Robert C Free
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Matthew Richardson
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | - Kayleigh Hawkes
- Respiratory Medicine Department, Glenfield Hospital, Leicester, UK
| | - Julie Skeemer
- Respiratory Medicine Department, Glenfield Hospital, Leicester, UK
| | - Rebecca Broughton
- Corporate Medical and Nursing, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Pranabashis Haldar
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Gerrit Woltmann
- Department of Respiratory Sciences, University of Leicester, Leicester, UK .,Respiratory Medicine Department, Glenfield Hospital, Leicester, UK
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9
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Serafim RB, Póvoa P, Souza-Dantas V, Kalil AC, Salluh JIF. Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review. Clin Microbiol Infect 2021; 27:47-54. [PMID: 33190794 PMCID: PMC7582054 DOI: 10.1016/j.cmi.2020.10.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients. METHODS We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection. RESULTS From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5-59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5-11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6-13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors. CONCLUSIONS This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.
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Affiliation(s)
- Rodrigo B Serafim
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil; Hospital Copa D'Or, Rio de Janeiro, Brazil; Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal; NOVA Medical School, CHRC, Universidade Nova de Lisboa, Lisboa, Portugal; Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| | | | - André C Kalil
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark; University of Nebraska Medical Center, Omaha, NE, USA
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10
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Lawrence H, Lim WS, McKeever TM. Variation in clinical outcomes and process of care measures in community acquired pneumonia: a systematic review. Pneumonia (Nathan) 2020; 12:10. [PMID: 32999854 PMCID: PMC7517805 DOI: 10.1186/s41479-020-00073-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/11/2020] [Indexed: 12/23/2022] Open
Abstract
Background Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence. Methods Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed. Results Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4–15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1–24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 h of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis. Conclusion There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence.
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Affiliation(s)
- H Lawrence
- Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - W S Lim
- Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre/Nottingham Clinical Research Facilities, Nottingham, UK
| | - T M McKeever
- Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre/Nottingham Clinical Research Facilities, Nottingham, UK
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11
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The Burden of Community-Acquired Pneumonia Requiring Admission to an ICU in the United States. Chest 2020; 158:841-843. [DOI: 10.1016/j.chest.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 11/20/2022] Open
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12
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Improved treatment of community-acquired pneumonia through tailored interventions: Results from a controlled, multicentre quality improvement project. PLoS One 2020; 15:e0234308. [PMID: 32525882 PMCID: PMC7289425 DOI: 10.1371/journal.pone.0234308] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is one of the leading causes of healthcare utilisation and death worldwide. Treatment according to evidence-based clinical guidelines can reduce mortality, antibiotic exposure and length of hospital stay related to CAP. Local problem Several studies, including a pilot study from one of our sites, indicate that physicians show a low grade of guideline adherence when managing patients with CAP. Methods To improve the guideline-based treatment of patients with CAP admitted to hospital, we designed a quality improvement study. Four process indicators were combined in a CAP care bundle: chest X-ray, CURB-65 severity score, lower respiratory tract samples and antibiotics within 8 hours from admission. After a 4-month baseline period, we applied multiple interventions at three hospitals during 8 months. Progression in our process indicators was measured continuously and compared with a control site without interventions. After the 8-month intervention period, we continued with a 4-month follow-up period to assess the sustainability of the improvements. Results The care bundle utilisation rate within 8 hours increased from 11% at baseline to 41% in the follow-up period at the intervention sites, whereas it remained below 3% at the control site. The most considerable improvements have been observed regarding documentation of CURB-65 (34% at baseline, 68% at follow-up) and the collection of lower respiratory tract samples (43% at baseline, 63% at follow-up). Conclusion Our study has demonstrated poor adherence to CAP guidelines at all sites at baseline. After implementing multiple tailored interventions, guideline adherence increased substantially. In conclusion, we recommend that CAP guidelines should be actively adapted in order to be followed in a daily routine.
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13
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Ferreira-Coimbra J, Sarda C, Rello J. Burden of Community-Acquired Pneumonia and Unmet Clinical Needs. Adv Ther 2020; 37:1302-1318. [PMID: 32072494 PMCID: PMC7140754 DOI: 10.1007/s12325-020-01248-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Indexed: 12/26/2022]
Abstract
Community-acquired pneumonia (CAP) is the leading cause of death among infectious diseases and an important health problem, having considerable implications for healthcare systems worldwide. Despite important advances in prevention through vaccines, new rapid diagnostic tests and antibiotics, CAP management still has significant drawbacks. Mortality remains very high in severely ill patients presenting with respiratory failure or shock but is also high in the elderly. Even after a CAP episode, higher risk of death remains during a long period, a risk mainly driven by inflammation and patient-related co-morbidities. CAP microbiology has been altered by new molecular diagnostic tests that have turned viruses into the most identified pathogens, notwithstanding uncertainties about the specific role of each virus in CAP pathogenesis. Pneumococcal vaccines also impacted CAP etiology and thus had changed Streptococcus pneumoniae circulating serotypes. Pathogens from specific regions should also be kept in mind when treating CAP. New antibiotics for CAP treatment were not tested in severely ill patients and focused on multidrug-resistant pathogens that are unrelated to CAP, limiting their general use and indications for intensive care unit (ICU) patients. Similarly, CAP management could be personalized through the use of adjunctive therapies that showed outcome improvements in particular patient groups. Although pneumococcal vaccination was only convincingly shown to reduce invasive pneumococcal disease, with a less significant effect in pneumococcal CAP, it remains the best therapeutic intervention to prevent bacterial CAP. Further research in CAP is needed to reduce its population impact and improve individual outcomes.
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Affiliation(s)
- João Ferreira-Coimbra
- Internal Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.
| | - Cristina Sarda
- Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research, Barcelona, Spain
- CIBERES-Centro de investigación en red de enfermedades respiratorias, Madrid, Spain
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14
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Corticosteroids for Community-Acquired Pneumonia: Overstated Benefits and Understated Risks. Chest 2019; 156:1049-1053. [PMID: 31287999 DOI: 10.1016/j.chest.2019.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/13/2023] Open
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15
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Pick HJ, Bolton CE, Lim WS, McKeever TM. Patient-reported outcome measures in the recovery of adults hospitalised with community-acquired pneumonia: a systematic review. Eur Respir J 2019; 53:13993003.02165-2018. [PMID: 30635298 DOI: 10.1183/13993003.02165-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/19/2018] [Indexed: 11/05/2022]
Abstract
Symptomatic and functional recovery are important patient-reported outcome measures (PROMs) in community-acquired pneumonia (CAP) that are increasingly used as trial end-points. This systematic review summarises the literature on PROMs in CAP.Comprehensive searches in accordance with the PRISMA statement were conducted to March 2017. Eligible studies included adults discharged from hospital following confirmed CAP and reporting PROMs.15 studies (n=5644 patients) were included; most were of moderate quality. Studies used a wide range of PROMs and assessment tools. At 4-6 weeks post-discharge, the commonest symptom reported was fatigue (45.0-72.6% of patients, three studies), followed by cough (35.3-69.7%) and dyspnoea (34.2-67.1%); corresponding values from studies restricted by age <65 years (two studies) were lower: fatigue 12.1-25.7%, cough 19.9-31.9% and dyspnoea 16.8-27.5%. Functional impairment 4 weeks post-discharge was reported in 18-51% of patients (two studies), while median time to return to normal activities was between 15 and 28 days (three studies).Substantial morbidity is reported by patients up to 6 weeks post-discharge. There is weak methodological consistency across existing studies. A core set of PROMs for use in future studies is suggested.
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Affiliation(s)
- Harry J Pick
- Dept of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, Nottingham, UK
| | - Wei Shen Lim
- Dept of Respiratory Medicine, Nottingham University Hospital NHS Trust, Nottingham, UK.,NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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16
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Feldman C, Shaddock E. Epidemiology of lower respiratory tract infections in adults. Expert Rev Respir Med 2018; 13:63-77. [DOI: 10.1080/17476348.2019.1555040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica Shaddock
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Misset B. [Steroids for community-acquired pneumonia: Should we go on searching or should we give up?]. Rev Mal Respir 2018; 35:781-783. [PMID: 30224211 DOI: 10.1016/j.rmr.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Affiliation(s)
- B Misset
- Médecine intensive et réanimation, université Rouen Normandie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France.
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18
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Soumagne T, Rabbat A. [Corticosteroids in community acquired pneumonia: Where are we in 2018?]. Rev Mal Respir 2018; 35:813-827. [PMID: 30217573 DOI: 10.1016/j.rmr.2018.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/23/2018] [Indexed: 12/15/2022]
Abstract
Community-acquired pneumonia (CAP) is a common infectious disease and one of the main causes of mortality worldwide. Despite an improvement in management globally, mortality remains high especially in severe forms of CAP. Adequate early antibiotics remain the cornerstone of the treatment but adjuvant corticosteroid administration is being considered to counterbalance the systemic inflammatory reaction and modulate the immune response. In the last ten years, several clinical trials and meta-analyses have been conducted in severe and non-severe CAP to assess the efficacy of corticosteroids. The benefits on the duration of hospitalization and the time to clinical stability are quite small and early mortality does not seem to be improved. Corticosteroids should not, therefore, be used routinely in patients with CAP, even in severe cases. However, new therapeutic trials are currently underway.
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Key Words
- Community acquired pneumonia, Severe, Corticosteroids, Mortality, Duration of hospitalization, Side effects
- Pneumopathie aiguë communautaire, Sévère, Corticostéroïdes, Mortalité, Durée d’hospitalisation, Effets secondaires
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Affiliation(s)
- T Soumagne
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France; Service de pneumologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France; Service de physiologie-explorations fonctionnelles, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon cedex, France.
| | - A Rabbat
- Service de pneumologie et soins intensifs respiratoires, hôpital Cochin, hôpitaux universitaires, Paris centre, AP-HP, 75679 Paris cedex 14, France
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Cillóniz C, Liapikou A, Martin-Loeches I, García-Vidal C, Gabarrús A, Ceccato A, Magdaleno D, Mensa J, Marco F, Torres A. Twenty-year trend in mortality among hospitalized patients with pneumococcal community-acquired pneumonia. PLoS One 2018; 13:e0200504. [PMID: 30020995 PMCID: PMC6051626 DOI: 10.1371/journal.pone.0200504] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is only limited information on mortality over extended periods in hospitalized patients with pneumococcal community-acquired pneumonia (CAP). We aimed to evaluate the 30-day mortality and whether is changed over a 20-year period among immunocompetent adults hospitalized with pneumococcal CAP. METHODS We conducted a retrospective observational study of data that were prospectively collected at the Hospital Clinic of Barcelona of all adult patients hospitalized with diagnosis of pneumococcal CAP over a 20-year period. To aid analysis, results were divided into four periods of 5 years each (1997-2001, 2002-2006, 2007-2011, 2012-2016). The primary outcome was 30-day mortality, but secondary outcomes included intensive care unit (ICU) admission, lengths of hospital and ICU-stays, ICU-mortality, and need of mechanical ventilation. RESULTS From a cohort of 6,403 patients with CAP, we analyzed the data for 1,120 (17%) adults with a diagnosis of pneumococcal CAP. Over time, we observed decreases in the rates of alcohol consumption, smoking, influenza vaccination, and older patients (age ≥65 years), but increases in admissions to ICU and the need for non-invasive mechanical ventilation. The overall 30-day mortality rate was 8% (95% confidence interval, 6%-9%; 84 of 1,120 patients) and did not change significantly between periods (p = 0.33). Although, we observed a decrease in ICU-mortality comparing the first period (26%) to the second one (10%), statistical differences disappeared with adjustment (p0.38). CONCLUSION Over time, 30-day mortality of hospitalized pneumococcal CAP did not change significantly. Nor did it change in the propensity-adjusted multivariable analysis. Since mortality in pneumococcal pneumonia has remained unaltered for many years despite the availability of antimicrobial agents with proven in vitro activity, other non-antibiotic strategies should be investigated.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Adamantia Liapikou
- Respiratory Department, Sotiria Chest Diseases Hospital, Mesogion, Athens, Greece
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Department of Clinical Medicine, Trinity College, Dublin, Ireland
| | | | - Albert Gabarrús
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Adrian Ceccato
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Daniel Magdaleno
- Superior Medical School of the National Polytechnic Institute Mexico City, Mexico City, Mexico
| | - Josep Mensa
- Department of Infectious Disease, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Francesc Marco
- Department of Microbiology, Biomedical Diagnostic Center (CDB), ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona—Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)—SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Daniel P, Rodrigo C, Bewick T, Sheppard C, Greenwood S, McKeever TM, Trotter C, Lim WS. 13-Valent vaccine serotype pneumococcal community acquired pneumonia in adults in high clinical risk groups. Vaccine 2018; 36:1614-1620. [DOI: 10.1016/j.vaccine.2018.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 01/29/2018] [Accepted: 02/01/2018] [Indexed: 11/24/2022]
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Dai RX, Kong QH, Mao B, Xu W, Tao RJ, Wang XR, Kong QY, Xu JF. The mortality risk factor of community acquired pneumonia patients with chronic obstructive pulmonary disease: a retrospective cohort study. BMC Pulm Med 2018; 18:12. [PMID: 29357862 PMCID: PMC5778745 DOI: 10.1186/s12890-018-0587-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in community acquired pneumonia (CAP) patients. We aimed to investigate the characteristics and mortality risk factors of COPD patients hospitalized with CAP. Methods A retrospective cohort study was conducted at Shanghai Pulmonary Hospital and Shanghai Dahua Hospital. Clinical and demographic data in patients diagnosed with CAP were collected between January 2015 and June 2016. Logistic regression analysis was performed to screen mortality risk factors of COPD patients hospitalized with CAP. Results Of the total 520 CAP patients, 230 (44.2%) patients had been diagnosed comorbid with COPD (COPD-CAP). CAP patients comorbid with COPD patients had higher rate of need for ICU admission (18.3% vs 13.1%) and need for NIMV (26.1% vs 1.4%) than without COPD (nCOPD-CAP). The PSI, CURB-65 and APACHE-II scores in COPD-CAP patients were higher than that in nCOPD-CAP patients (95 vs 79, P < 0.001; 1 vs 1, P < 0.001; 13 vs 8, P < 0.001, respectively). Logistic regression analysis indicated that aspiration, D-dimer > 2.0 μg/mL and CURB-65 ≥ 3 were risk factors associated with in-hospital mortality ((odd ratio) OR = 5.678, OR = 4.268, OR = 20.764, respectively) in COPD-CAP patients. The risk factors associated with 60-day mortality in COPD-CAP patients were comorbid with coronary heart disease, aspiration, need for NIMV (non-invasive mechanical ventilation) and CURB-65 ≥ 3 (OR = 5.206, OR = 7.921, OR = 3.974, OR = 18.002, respectively). Conclusions COPD patients hospitalized with CAP had higher rate of need for NIMV, need for ICU admission and severity scores than those without COPD. Aspiration, D-dimer > 2.0 μg/mL, comorbid with coronary heart disease, need for NIMV and CURB-65 ≥ 3 were mortality risk factors in CAP patients comorbid with COPD. Electronic supplementary material The online version of this article (10.1186/s12890-018-0587-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruo-Xuan Dai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Qing-Hua Kong
- Department of Respiratory and Critical Care Medicine, Shanghai Dahua Hospital, No. 901 Old Humin Road, Shanghai, China
| | - Bei Mao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Wen Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Ru-Jia Tao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China
| | - Xiao-Ru Wang
- Department of Respiratory and Critical Care Medicine, Shanghai Dahua Hospital, No. 901 Old Humin Road, Shanghai, China
| | - Qing-Yao Kong
- Department of Anesthesia and Critical Care, the University of Chicago, Chicago, IL, USA
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, China.
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Aston SJ. Pneumonia in the developing world: Characteristic features and approach to management. Respirology 2017; 22:1276-1287. [PMID: 28681972 DOI: 10.1111/resp.13112] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 01/22/2023]
Abstract
Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in adults worldwide, but its epidemiology varies markedly by region. Whilst in high-income countries, the predominant burden of CAP is in the elderly and those with chronic cardiovascular and pulmonary co-morbidity, CAP patients in low-income settings are often of working age and, in sub-Saharan Africa, frequently HIV-positive. Although region-specific aetiological data are limited, they are sufficient to highlight major trends: in high-burden settings, tuberculosis (TB) is a common cause of acute CAP; Gram-negative pathogens such as Klebsiella pneumoniae are regionally important; and HIV-associated opportunistic infections are common but difficult to diagnose. These differences in epidemiology and aetiological profile suggest that modified approaches to diagnosis, severity assessment and empirical antimicrobial therapy of CAP are necessary, but tailored individualized management approaches are constrained by limitations in the availability of radiological and laboratory diagnostic services, as well as medical expertise. The widespread introduction of the Xpert MTB/RIF platform represents a major advance for TB diagnosis, but innovations in rapid diagnostics for other opportunistic pathogens are urgently needed. Severity assessment tools (e.g. CURB65) that are used to guide early management decisions in CAP have not been widely validated in low-income settings and locally adapted tools are required. The optimal approach to initial antimicrobial therapy choices such as the need to provide early empirical cover for atypical bacteria and TB remain poorly defined. Improvements in supportive care such as correcting hypoxaemia and intravenous fluid management represent opportunities for substantial reductions in mortality.
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Affiliation(s)
- Stephen J Aston
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
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Wootton DG, Dickinson L, Pertinez H, Court J, Eneje O, Keogan L, Macfarlane L, Wilks S, Gallagher J, Woodhead M, Gordon SB, Diggle PJ. A longitudinal modelling study estimates acute symptoms of community acquired pneumonia recover to baseline by 10 days. Eur Respir J 2017; 49:49/6/1602170. [PMID: 28619956 PMCID: PMC5898948 DOI: 10.1183/13993003.02170-2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/22/2017] [Indexed: 12/14/2022]
Abstract
Our aims were to address three fundamental questions relating to the symptoms of community-acquired pneumonia (CAP): Do patients completely recover from pneumonia symptoms? How long does this recovery take? Which factors influence symptomatic recovery? We prospectively recruited patients at two hospitals in Liverpool, UK, into a longitudinal, observational cohort study and modelled symptom recovery from CAP. We excluded patients with cancer, immunosuppression or advanced dementia, and those who were intubated or palliated from admission. We derived a statistical model to describe symptom patterns. We recruited 169 (52% male) adults. Multivariable analysis demonstrated that the time taken to recover to baseline was determined by the initial severity of symptoms. Severity of symptoms was associated with comorbidity and was inversely related to age. The pattern of symptom recovery was exponential and most patients’ symptoms returned to baseline by 10 days. These results will inform the advice given to patients regarding the resolution of their symptoms. The recovery model described here will facilitate the use of symptom recovery as an outcome measure in future clinical trials. Severity of CAP symptoms is inversely related to age and resolution to baseline symptoms takes on average 10 dayshttp://ow.ly/dV0h30befE3
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Affiliation(s)
- Daniel G Wootton
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK .,Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Dickinson
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Henry Pertinez
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanne Court
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Odiri Eneje
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Lynne Keogan
- Dept of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Macfarlane
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Sarah Wilks
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Mark Woodhead
- Dept of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre and Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Stephen B Gordon
- Dept of Respiratory Research, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.,The Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Peter J Diggle
- CHICAS, Lancaster University Medical School, Lancaster University, Lancaster, UK
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Simonetti AF, van Werkhoven CH, Schweitzer VA, Viasus D, Carratalà J, Postma DF, Oosterheert JJ, Bonten MJM. Predictors for individual patient antibiotic treatment effect in hospitalized community-acquired pneumonia patients. Clin Microbiol Infect 2017; 23:774.e1-774.e7. [PMID: 28336384 DOI: 10.1016/j.cmi.2017.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Our objective was to identify clinical predictors of antibiotic treatment effects in hospitalized patients with community-acquired pneumonia (CAP) who were not in the intensive care unit (ICU). METHODS Post-hoc analysis of three prospective cohorts (from the Netherlands and Spain) of adult patients with CAP admitted to a non-ICU ward having received either β-lactam monotherapy, β-lactam + macrolide, or a fluoroquinolone-based therapy as empirical antibiotic treatment. We evaluated candidate clinical predictors of treatment effects in multiple mixed-effects models by including interactions of the predictors with empirical antibiotic choice and using 30-day mortality, ICU admission and length of hospital stay as outcomes. RESULTS Among 8562 patients, empirical treatment was β-lactam in 4399 (51.4%), fluoroquinolone in 3373 (39.4%), and β-lactam + macrolide in 790 (9.2%). Older age (interaction OR 1.67, 95% CI 1.23-2.29, p 0.034) and current smoking (interaction OR 2.36, 95% CI 1.34-4.17, p 0.046) were associated with lower effectiveness of fluoroquinolone on 30-day mortality. Older age was also associated with lower effectiveness of β-lactam + macrolide on length of hospital stay (interaction effect ratio 1.14, 95% CI 1.06-1.22, p 0.008). CONCLUSIONS Older age and smoking could influence the response to specific antibiotic regimens. The effect modification of age and smoking should be considered hypothesis generating to be evaluated in future trials.
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Affiliation(s)
- A F Simonetti
- Hospital Universitari de Bellvitge, Institut D'investigació Biomèdica de Bellvitge, Barcelona, Spain.
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - D Viasus
- Division of Health Sciences, Faculty of Medicine, Universidad del Norte, and Hospital Universidad del Norte, Barranquilla, Colombia
| | - J Carratalà
- Hospital Universitari de Bellvitge, Institut D'investigació Biomèdica de Bellvitge, Barcelona, Spain; Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - D F Postma
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J J Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M J M Bonten
- Departments of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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