Prevalence of atypical pathogens in patients with severe pneumonia: a systematic review and meta-analysis

OBJECTIVES

We aimed to summarise the prevalence of atypical pathogens in patients with severe pneumonia to understand the prevalence of severe pneumonia caused by atypical pathogens, improve clinical decision-making and guide antibiotic use.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Web of Science and Cochrane Library were searched through November 2022.

ELIGIBILITY CRITERIA

English language studies enrolled consecutive cases of patients diagnosed with severe pneumonia, with complete aetiological analysis.

DATA EXTRACTION AND SYNTHESIS

We conducted literature retrieval on PubMed, Embase, Web of Science and The Cochrane Library to estimate the prevalence of Chlamydia, Mycoplasma and Legionella in patients with severe pneumonia. After double arcsine transformation of the data, a random-effects model was used for meta-analyses to calculate the pooled prevalence of each pathogen. Meta-regression analysis was also used to explore whether the region, different diagnostic method, study population, pneumonia categories or sample size were potential sources of heterogeneity.

RESULTS

We included 75 eligible studies with 18 379 cases of severe pneumonia. The overall prevalence of atypical pneumonia is 8.1% (95% CI 6.3% to 10.1%) In patients with severe pneumonia, the pooled estimated prevalence of Chlamydia, Mycoplasma and Legionella was 1.8% (95% CI 1.0% to 2.9%), 2.8% (95% CI 1.7% to 4.3%) and 4.0% (95% CI 2.8% to 5.3%), respectively. We noted significant heterogeneity in all pooled assessments. Meta-regression showed that the pneumonia category potentially influenced the prevalence rate of Chlamydia. The mean age and the diagnostic method of pathogens were likely moderators for the prevalence of Mycoplasma and Legionella, and contribute to the heterogeneity of their prevalence.

CONCLUSIONS

In severe pneumonia, atypical pathogens are notable causes, especially Legionella. The diagnostic method, regional difference, sample size and other factors contribute to the heterogeneity of prevalence. The estimated prevalence and relative heterogeneity factors can help with microbiological screening, clinical treatment and future research planning.

PROSPERO REGISTRATION NUMBER

CRD42022373950.

Analysis of the association between atrial fibrillation with in-hospital mortality in people admitted for community-acquired pneumonia through an observational, nation-wide, sex-stratified study

We aimed to analyze the influence of atrial fibrillation (AF) prior to hospital admission (“prevalent”) and AF diagnosed during hospital admission (“incident”) on in-hospital mortality (IHM) in women and men admitted for community-acquired pneumonia (CAP) in Spain (2016–2019). We used the Spanish Register of Specialized Care‐Basic Minimum Database. We analyzed 519,750 cases of CAP in people ≥ 18 years (213,631 women (41.1%)), out of which people with prevalent AF represented 23.75% (N = 123,440), whereas people with incident AF constituted 0.60% (N = 3154). Versus no AF, crude IHM was significantly higher for prevalent AF (15.24% vs. 11.40%, p < 0.001) and for incident AF (23.84% vs. 12.24%, p < 0.001). After propensity score marching, IHM in women and men with prevalent AF neared IHM in women and men with no AF (15.72% vs. 15.52%, p = 0.425; and 14.90% vs. 14.99%, p = 0.631, respectively), but IHM in women and men with incident AF was higher than IHM in women and men with no AF (24.37% vs. 13.36%, p < 0.001; and 23.94% vs. 14.04%, p < 0.001, respectively). Male sex was associated with a higher IHM in people with prevalent AF (OR 1.06; 95% CI 1.02–1–10), but not in people with incident AF (OR 0.93; 95% CI 0.77–1–13). AF diagnosed during hospital admission was associated with a higher IHM, irrespectively of sex.

Cardiovascular Events After Community-Acquired Pneumonia: A Global Perspective with Systematic Review and Meta-Analysis of Observational Studies

Acute cardiovascular disease after community-acquired pneumonia is a well-accepted complication for which definitive treatment strategies are lacking. These complications share some common features but have distinct diagnostic and treatment approaches. We therefore undertook an updated systematic review and meta-analysis of observational studies reporting the incidence of overall complications, acute coronary syndromes, new or worsening heart failure, new or worsening arrhythmias and acute stroke, as well as short-term mortality outcomes. To set a framework for future research, we further included a holistic review of the interplay between the two conditions. From 1984 to 2019, thirty-nine studies were accrued, involving 92,188 patients, divided by setting (inpatients versus outpatients) and clinical severity (low risk versus high risk). Overall cardiac complications occurred in 13.9% (95% confidence interval (CI) 9.6-18.9), acute coronary syndromes in 4.5% (95% CI 2.9-6.5), heart failure in 9.2% (95% CI 6.7-12.2), arrhythmias in 7.2% (95% CI 5.6-9.0) and stroke in 0.71% (95% CI 0.1-3.9) of pooled inpatients. During this period, meta-regression analysis suggests that the incidence of overall and individual cardiac complications is decreasing. After adjusting for confounders, cardiovascular events taking place after community-acquired pneumonia independently increase the risk for short-term mortality (range of odds-ratio: 1.39-5.49). These findings highlight the need for effective, large trial based, preventive and therapeutic interventions in this important patient population.

Importance of Legionella pneumophila in the etiology of severe community-acquired pneumonia in Santiago, Chile

BACKGROUND

In US and European literature, Legionella pneumophila is reported as an important etiologic agent of severe community-acquired pneumonia (CAP), but in Chile this information is lacking. The aim of this study was to determine the incidence and identify predictors of severe CAP caused by L pneumophila in Santiago, Chile.

METHODS

A multicenter, prospective clinical study lasting 18 months was conducted; it included all adult patients with severe CAP admitted to the ICUs of four hospitals in Santiago. We excluded patients who were immunocompromised, had been hospitalized in the previous 4 weeks, or presented with another disease during their hospitalization. All data for the diagnosis of severe CAP were registered, and urinary antigens for L pneumophila serogroup 1 were determined.

RESULTS

A total of 104 patients with severe CAP were included (mean ± SD age, 58.3 ± 19.3 years; men, 64.4%; APACHE (Acute Physiology and Chronic Health Evaluation) II score, 16.7 ± 6.3; Sepsis-related Organ Failure Assessment score, 6.1 ± 3.2; Pitt Bacteremia Score, 3.4 ± 2.5; Pao2/Fio2, 170.8 ± 87.1). An etiologic agent was identified in 62 patients (59.6%), with the most frequent being Streptococcus pneumoniae (27 patients [26%]) and L pneumophila (nine patients [8.6%]). Logistic regression analysis showed that a plasma sodium level of ≤ 130 mEq/L was an independent predictor for L pneumophila severe CAP (OR, 11.3; 95% CI, 2.5-50.5; P = .002). Global mortality was 26% and 33% for L pneumophila. The Pitt bacteremia score and pneumonia score index were the best predictors of mortality.

CONCLUSIONS

We found that in Santiago, L pneumophila was second to S pneumoniae as the etiologic agent of severe CAP. Severe hyponatremia at admission appears to be an indicator for L pneumophila etiology in severe CAP.

Patients with acute exacerbation of chronic obstructive pulmonary disease feel safe when treated at home: a qualitative study

BACKGROUND

The design of new interventions to improve health care for patients with chronic obstructive pulmonary disease (COPD) requires knowledge about what patients with an acute exacerbation experience as important and useful. The objective of the study was to explore patients' experiences of an early discharge hospital at home (HaH) treatment programme for exacerbations in COPD.

METHODS

Six exacerbated COPD patients that were randomised to receiving HaH care and three patients randomised to receiving traditional hospital care were interviewed in semi-structured in-depth interviews. Four spouses were present during the respective patients' interviews. The interviews were audio-taped, transcribed and analysed by a four-step method for systematic text condensing.

RESULTS

Despite limited assistance from the health care service, the patients and their spouses experienced the HaH treatment as safe. They expressed that information that was adapted to specific situations in their daily lives and given in a familiar environment had positive impact on their self-management of COPD.

CONCLUSION

The results contribute to increased knowledge and awareness about what the patients experienced as important aspects of a HaH treatment programme. How adapted input from health services can make patients with exacerbation of COPD feel safe and better able to manage their disease, is important knowledge for developing new and effective health services for patients with chronic disease.

Effectiveness and cost-effectiveness of early assisted discharge for chronic obstructive pulmonary disease exacerbations: the design of a randomised controlled trial

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are the main cause for hospitalisation. These hospitalisations result in a high pressure on hospital beds and high health care costs. Because of the increasing prevalence of COPD this will only become worse. Hospital at home is one of the alternatives that has been proved to be a safe alternative for hospitalisation in COPD. Most schemes are early assisted discharge schemes with specialised respiratory nurses providing care at home. Whether this type of service is cost-effective depends on the setting in which it is delivered and the way in which it is organised.

METHODS/DESIGN

GO AHEAD (Assessment Of Going Home under Early Assisted Discharge) is a 3-months, randomised controlled, multi-centre clinical trial. Patients admitted to hospital for a COPD exacerbation are either discharged on the fourth day of admission and further treated at home, or receive usual inpatient hospital care. Home treatment is supervised by general nurses. Primary outcome is the effectiveness and cost effectiveness of an early assisted discharge intervention in comparison with usual inpatient hospital care for patients hospitalised with a COPD exacerbation. Secondary outcomes include effects on quality of life, primary informal caregiver burden and patient and primary caregiver satisfaction. Additionally, a discrete choice experiment is performed to provide insight in patient and informal caregiver preferences for different treatment characteristics. Measurements are performed on the first day of admission and 3 days, 7 days, 1 month and 3 months thereafter. Ethical approval has been obtained and the study has been registered.

DISCUSSION

This article describes the study protocol of the GO AHEAD study. Early assisted discharge could be an effective and cost-effective method to reduce length of hospital stay in the Netherlands which is beneficial for patients and society. If effectiveness and cost-effectiveness can be proven, implementation in the Dutch health care system should be considered.

TRIAL REGISTRATION

Netherlands Trial Register NTR1129.

Effects of acute renal failure on the pharmacokinetics of telithromycin in rats: negligible effects of increase in CYP3A1 on the metabolism of telithromycin

It was reported that the expression of CYP3A1 increased in rats with acute renal failure induced by uranyl nitrate (rat model of U-ARF) compared with controls. It was shown that telithromycin was mainly metabolized via CYP3A1/2 in rats in this study. Hence, the pharmacokinetic parameters of telithromycin were compared after both intravenous and oral administration at a dose of 50 mg/kg to control rats and a rat model of U-ARF. After intravenous administration of telithromycin to rats with U-ARF, the AUC and renal clearance (Cl(r)) were significantly greater (35.0% increase) and slower (99.1% decrease), respectively, than the controls. Unexpectedly, the nonrenal clearance (Cl(nr)) of telithromycin was comparable between the two groups of rats, suggesting that CYP3A isozyme responsible for the metabolism of telithromycin seemed not to be expressed considerably in the rat model of U-ARF. After oral administration of telithromycin to rats with U-ARF, the AUC was also significantly greater (127% increase) than the controls and the value, 127%, was considerably greater than 35.0% after intravenous administration of telithromycin. This may be due mainly to the decrease in the intestinal first-pass effect of telithromycin compared with controls in addition to significantly slower Cl(r) than controls.

[Pneumonia awareness year, 2004: scientific impact through publications in Archivos de Bronconeumología]

Pneumonia is a common and potentially serious infectious disease. Morbidity and mortality rates continue to be high in spite of major advances and steady progress in diagnosis and treatment. The economic impact of the disease is also great. It is therefore necessary to enlist the public, primary care and emergency physicians, and public policy administrators to join forces to treat and prevent pneumonia for the common good. The annual incidence of pneumonia in the population over the age of 14 years is 1.6 to 2.6 episodes/1000 inhabitants. The mortality rate is 14.1 per 100,000 inhabitants, and the associated costs are 115 million euros annually. The RESPIRA Foundation and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) declared 2004 to be pneumonia awareness year with the aim of coordinating efforts to raise awareness, distribute information, and foster debate.

Development and validation of a clinical prediction rule for severe community-acquired pneumonia

RATIONALE

Objective strategies are needed to improve the diagnosis of severe community-acquired pneumonia in the emergency department setting.

OBJECTIVES

To develop and validate a clinical prediction rule for identifying patients with severe community-acquired pneumonia, comparing it with other prognostic rules.

METHODS

Data collected from clinical information and physical examination of 1,057 patients visiting the emergency department of a hospital were used to derive a clinical prediction rule, which was then validated in two different populations: 719 patients from the same center and 1,121 patients from four other hospitals.

MEASUREMENTS AND MAIN RESULTS

In the multivariate analyses, eight independent predictive factors were correlated with severe community-acquired pneumonia: arterial pH < 7.30, systolic blood pressure < 90 mm Hg, respiratory rate > 30 breaths/min, altered mental status, blood urea nitrogen > 30 mg/dl, oxygen arterial pressure < 54 mm Hg or ratio of arterial oxygen tension to fraction of inspired oxygen < 250 mm Hg, age > or = 80 yr, and multilobar/bilateral lung affectation. From the beta parameter obtained in the multivariate model, a score was assigned to each predictive variable. The model shows an area under the curve of 0.92. This rule proved better at identifying patients evolving toward severe community-acquired pneumonia than either the modified American Thoracic Society rule, the British Thoracic Society's CURB-65, or the Pneumonia Severity Index.

CONCLUSIONS

A simple score using clinical data available at the time of the emergency department visit provides a practical diagnostic decision aid, and predicts the development of severe community-acquired pneumonia.

Prognosis in Patients With Pneumonia and Chronic Obstructive Pulmonary Disease

OBJECTIVE

To study the incidence, severity, and mortality rates of pneumonia in a cohort of chronic obstructive pulmonary disease (COPD) patients monitored over 3 years.

PATIENTS AND METHODS

A total of 596 patients diagnosed with COPD according to spirometric criteria were included in the study. The variables assessed were mortality and severity according to the Pneumonia Severity Index (PSI) for community-acquired pneumonia (CAP).

RESULTS

Of the 596 patients included in the study, 75 (12.6%) developed at least 1 episode of pneumonia during the 3 years of the study. The overall incidence of pneumonia was 55.1 per 1000 person-years. There were 88 episodes in 75 patients. COPD severity, evaluated based on percentage of predicted FEV1, was mild in 9 patients, moderate in 24, and severe in 42. Seventy-six (86.3%) episodes were CAP and 12 (13.6%) were acquired in hospital. Fourteen CAP cases corresponded to PSI group V, 28 to group IV, 20 to group III, and 14 to groups I and II. Overall mortality was 12.5% (11/88). The mortality rate was 41.7% (5/12) for nosocomial cases and 7.8% (6/76) for CAP cases (OR, 6.67; 95% confidence interval, 1.65-26.93). Assessing CAP mortality by level of severity, we found that the mortality rate was 35.7% (5/14) for group V and 3.5% (1/28) for group IV. No deaths occurred among patients in the other severity groups.

CONCLUSIONS

The incidence of pneumonia in COPD patients is high. More than half the cases of CAP (55.2%) in our COPD patients were classified in PSI risk groups IV and V.