Prediction model for pneumonia in primary care patients with an acute respiratory tract infection: role of symptoms, signs, and biomarkers

Prognostic value of chest computer tomography combined with serum platelet count, c-reactive protein levels and oxygenation index in severe community-acquired pneumonia

Objective

To investigate the prognostic value of chest computed tomography (CT), platelet count (PLT), serum C-reactive protein (CRP) level, and oxygenation index (OI) in patients with severe community-acquired pneumonia (CAP).

Methods

We conducted a retrospective analysis of clinical data collected from 226 patients with CAP who received treatment in Huzhou Central Hospital from February 2022 to November 2023. Patients were divided into two groups based on pneumonia severity: Severe group (patients with severe CAP, n=113) and Typical group (patients with typical pneumonia, n=113). Differences in CT score, PLT, CRP, and OI levels between the two groups were analyzed, as well as the prognostic value of the combined CT score, PLT, CRP, and OI levels in severe CAP.

Results

The CT Score and CRP level in the Severe group were significantly higher than those in the Typical group, whereas PLT and OI were significantly lower (P<0.05). Of 113 patients with severe pneumonia, 42 died and 71 survived. The CT Score and CRP level in the death group were significantly higher, whereas PLT and OI were lower compared to the survival group (P<0.05). The area under the ROC curve of the combined CT Score, PLT, CRP, OI for the prediction of death in patients with severe CAP was 0.970, sensitivity was 85.7, and specificity was 93.0, which was higher than that of each index alone.

Conclusions

The combined chest CT, PLT, CRP, and OI have high prognostic value for severe CAP.

Circulating markers of neutrophil activation and lung injury in pediatric pneumonia in low-resource settings

Diagnostic biomarkers for childhood pneumonia could guide management and improve antibiotic stewardship in low-resource settings where chest x-ray (CXR) is not always available. In this cross-sectional study, we measured chitinase 3-like protein 1 (CHI3L1), surfactant protein D (SP-D), lipocalin-2 (LCN2), and tissue inhibitor of metalloproteinases-1 (TIMP-1) in Ugandan children under the age of five hospitalized with acute lower respiratory tract infection. We determined the association between biomarker levels and primary end-point pneumonia, indicated by CXR consolidation. We included 89 children (median age 11 months, 39% female). Primary endpoint pneumonia was present in 22 (25%). Clinical signs were similar in children with and without CXR consolidation. Broad-spectrum antibiotics (ceftriaxone) were administered in 83 (93%). Levels of CHI3L1, SP-D, LCN2 and TIMP-1 were higher in patients with primary end-point pneumonia compared to patients with normal CXR or other infiltrates. All markers were moderately accurate predictors of primary end-point pneumonia, with area under receiver operator characteristic curves of 0.66-0.70 (p<0.05 for all markers). The probability of CXR consolidation increased monotonically with the number of markers above cut-off. Among 28 patients (31%) in whom all four markers were below the cut-off, the likelihood ratio of CXR consolidation was 0.11 (95%CI 0.015 to 0.73). CHI3L1, SP-D, LCN2 and TIMP-1 were associated with CXR consolidation in children with clinical pneumonia in a low-resource setting. Combinations of quantitative biomarkers may be useful to safely withhold antibiotics in children with a low probability of bacterial infection.

Antibiotic Treatment for Lower Respiratory Tract Infections in Primary Care: A Register-Based Study Examining the Role of Radiographic Imaging

When imaging (i.e., chest-x-ray or computed tomography) is used to differentiate between acute bronchitis and pneumonia, many patients are being prescribed antibiotics despite the absence of radiographic pneumonia signs. This study of lower respiratory tract infections (LRTIs) with negative chest imaging compares cases where antibiotics were prescribed and not prescribed to find characteristics that could explain the prescription. Data were extracted from the regional electronic medical record system in Kronoberg County, Sweden, for patients aged 18-79 years diagnosed with acute bronchitis or pneumonia and who had any chest radiologic imaging between 2007-2014. Of 696 cases without evidence of pneumonia on imaging, 55% were prescribed antibiotics. Age, sex, and co-morbidity did not differ between those with or without antibiotics. The median level of C-reactive protein was low in both groups but differed significantly (21 vs. 10 mg/L; p < 0.001). Resident physicians prescribed antibiotics more frequently than interns or specialists (p < 0.001). It is unclear what features prompted the antibiotic prescribing in those with negative imaging indicating overuse of antibiotics for LRTIs.

Pulse Oximetry as an Aid to Rule Out Pneumonia among Patients with a Lower Respiratory Tract Infection in Primary Care

Guidelines recommend chest X-rays (CXRs) to diagnose pneumonia and guide antibiotic treatment. This study aimed to identify clinical predictors of pneumonia that are visible on a chest X-ray (CXR+) which could support ruling out pneumonia and avoiding unnecessary CXRs, including oxygen saturation. A secondary analysis was performed in a clinical trial that included patients with suspected pneumonia in Swiss primary care. CXRs were reviewed by two radiologists. We evaluated the association between clinical signs (heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, abnormal auscultation, and oxygen saturation < 95%) and CXR+ using multivariate analysis. We also calculated the diagnostic performance of the associated clinical signs combined in a clinical decision rule (CDR), as well as a CDR derived from a large meta-analysis (at least one of the following: heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, or abnormal auscultation). Out of 469 patients from the initial trial, 107 had a CXR and were included in this study. Of these, 26 (24%) had a CXR+. We found that temperature and oxygen saturation were associated with CXR+. A CDR based on the presence of either temperature ≥ 37.8 °C and/or an oxygen saturation level < 95% had a sensitivity of 69% and a negative likelihood ratio (LR-) of 0.45. The CDR from the meta-analysis had a sensitivity of 92% and an LR- of 0.37. The addition of saturation < 95% to this CDR increased the sensitivity (96%) and decreased the LR- (0.21). In conclusion, this study suggests that pulse oximetry could be added to a simple CDR to decrease the probability of pneumonia to an acceptable level and avoid unnecessary CXRs.

Overruling of Procalcitonin-Guided Antibiotics for Lower Respiratory Tract Infections in Primary Care: Ancillary Study of a Randomized Controlled Trial

BACKGROUND

Lower respiratory tract infections (LRTIs) in primary care are a promising target for antibiotic stewardship. A clinical trial in Switzerland showed a large decrease in antibiotic prescriptions with procalcitonin guidance (cut-off < 0.25 µg/L) compared with usual care. However, one-third of patients with low procalcitonin at baseline received antibiotics by day 28.

AIM

To explore the factors associated with the overruling of initial procalcitonin guidance.

DESIGN AND SETTING

Secondary analysis of a cluster randomized trial in which patients with an LRTI were included.

METHOD

Using the characteristics of patients, their disease, and general practitioners (GPs), we conducted a multivariate logistic regression, adjusted for clustering.

RESULTS

Ninety-five out of 301 (32%) patients with low procalcitonin received antibiotics by day 28. Factors associated with an overruling of procalcitonin guidance were: a history of chest pain (adjusted OR [aOR] 1.81, 95% confidence interval 1.03-3.17); a prescription of chest X-ray by the GP (aOR 4.65, 2.32-9.34); a C-reactive protein measured retrospectively above 100 mg/L (aOR 7.48, 2.34-23.93, reference ≤ 20 mg/L); the location of the GP practice in an urban setting (aOR 2.27, 1.18-4.37); and the GP's number of years of experience (aOR per year 1.05, 1.01-1.09).

CONCLUSIONS

Overruling of procalcitonin guidance was associated with GPs' socio-demographic characteristics, pointing to the general behavioral problem of overprescription by physicians. Continuous medical education and communication training might support the successful implementation of procalcitonin point-of-care tests aimed at antibiotic stewardship.

The Role of CRP POC Testing in the Fight against Antibiotic Overuse in European Primary Care: Recommendations from a European Expert Panel

Tackling antibiotic resistance represents one of the major challenges in modern medicine, and limiting antibiotics' overuse represents the first step in this fight. Most antibiotics are prescribed in primary care settings, and lower respiratory tract infections (LRTIs) are one of the most common indications for their prescription. An expert panel conducted an extensive report on C-reactive protein point-of-care (CRP POC) testing in the evaluation of LRTIs and its usefulness to limit antibiotic prescriptions. The expert panel stated that CRP POC testing is a potentially useful tool to limit antibiotic prescriptions for LRTI in a community setting. CRP POC must be used in conjunction with other strategies such as improved communication skills and the use of other molecular POC testing. Potential barriers to the adoption of CRP POC testing are financial and logistical issues. Moreover, the efficacy in limiting antibiotic prescriptions could be hampered by the fact that, in some countries, patients may gain access to antibiotics even without a prescription. Through the realization of a better reimbursement structure, the inclusion in standardized procedures in local guidelines, and better patient education, CRP point-of-care testing can represent a cornerstone in the fight against antimicrobial resistance.

The Clinical Significance of Otolaryngology Manifestations in COVID-19 Pneumonia: A Single-center Retrospective Cohort Study

Objective Although the absence of a runny nose and sore throat, both ear-nose-throat (ENT) symptoms, suggests community-acquired pneumonia (CAP), the association between ENT symptoms and coronavirus disease 2019 (COVID-19) pneumonia remains unclear. We therefore investigated the association between ENT symptoms and COVID-19 pneumonia. Methods We retrospectively recruited consecutive confirmed COVID-19 inpatients with and without pneumonia admitted to a single institution from April 1, 2020, to July 31, 2021. After a descriptive analysis, we implemented univariable and multivariable regression analyses to assess the association between ENT symptoms and COVID-19 pneumonia. Results The present study included 385 patients. Pneumonia patients exhibited lower rates of positive runny nose and sore throat than non-pneumonia patients. Univariable analyses found mean odds ratios of 0.59 and 0.61 and 95% confidence intervals (CIs) of 0.30-1.16 and 0.32-1.17 for runny nose and sore throat, respectively, and multivariable analyses found mean odds ratios of 0.73 and 0.70 and 95% CIs of 0.34-1.56 and 0.34-1.46, respectively. Conclusion Our study found no statistically significant association between ENT symptoms and COVID-19 pneumonia. Clinicians should be aware that, unlike CAP, there is no correlation between ENT symptoms and pneumonia among patients with COVID-19, so it is necessary to consider the possibility of pneumonia even in the presence of ENT symptoms.

Prediction of ESBL-producing E coli for suspected urinary tract infection

Aim:

The widespread existence of extended-spectrum β-lactamase (ESBL) producing Escherichia coli ( E. coli) has become a critical threat in developed countries. Prediction rule for ESBL producing E. coli is relevant to see patients with suspected urinary tract infection.

Materials and methods:

We collected clinical and laboratory data and constructed multivariate logistic regression models to develop a clinical prediction rule in the derivation cohort with 1185 patients with urine cultures and validated the rule in the validation cohort with 516 patients.

Results:

ESBL-producing E. coli was found in 185 patients (16%) in the derivation cohort. When assigning 14 points for being female (odds ratio (OR): 4.2), six points for CRP >5 mg/dl (OR: 1.87), and four points for a history of urinary tract infection (OR: 1.52), the area under the curve (AUC) had 0.67 (95% confidence interval (CI): 0.63–0.70) in the derivation cohort and 0.64 (95% CI: 0.59–0.69] in the validation cohort.

Conclusions:

The developed prediction rule had moderate accuracy to predict ESBL-producing E. coli in patients with suspected urinary tract infection.

A pregnant woman with COVID-19 gives birth to premature triplets: A case report and literature review

To the best of our knowledge, no case report has been published to date concerning the novel coronavirus disease 2019 (COVID-19) treatment plan for pregnant women with triplets, as well as on the possibility of a vertical transmission to triplets delivered prematurely by a pregnant woman with COVID-19. The present study thus describes such as case. A 29-year-old local resident, a woman with COVID-19, who was pregnant with triplets, had not moved from her residence for the past 6 months. The main symptoms mentioned by the patient on the day of admission were the following: The patient was in the 28th week of pregnancy, 2019 novel coronavirus (2019-nCoV) nucleic acid positive test 13 h prior to admission. Additionally, the patient had a high fever and dyspnea after admission. The patient was treated with convalescent plasma from patients with COVID-19 and methylprednisolone, at the same time her anemia, anxiety and insomnia were treated. Subsequently, the patient's condition improved, and normal body temperature was restored. Cesarean section was performed due to severe intrahepatic cholestasis of pregnancy (ICP), and due to the fetuses being located in three chorionic and amniotic cavities, and due to the fact that each of the three infants was in a different position (cephalic, breech and transverse position). Following delivery, total bile acid values and liver function improved gradually, and the 2019-nCoV nucleic acid test was negative consecutively for two tests, and the woman was then discharged from the hospital. Each premature infant born by caesarean section was individually transported to a neonatal intensive care unit for isolation treatment, with the neonatal escorts and transport teams wearing secondary protective clothing. All three premature infants were transitioned gradually from parenteral intravenous nutrition to full oral feeding. 2019-nCoV nucleic acid test results were negative for all infants. 2019-nCoV IgM test results were negative and IgG were positive for all infants. The pregnant woman and the three premature infants were successfully treated and discharged after they felt no discomfort and were negative consecutively for two 2019-nCoV nucleic acid tests. The three premature infants were monitored for growth and development until December, 2021, and eye, lung, heart, brain, liver, kidney, intestine and other organ functions were normal. The present study reports on the treatment and delivery outcomes of a woman with COVID-19, who was pregnant with triplets. The present case report demonstrated that although the pregnant woman with triplets was suffering from COVID-19, all three premature infants delivered by cesarean section did not present with intrauterine vertical infection, and abnormal growth and development were not observed. The convalescent plasma of patients with COVID-19 and methylprednisolone were effective for the treatment of a continuously high fever, and the timely treatment of complications is helpful for the treatment of patients with COVID-19.

Comparison Analysis of Prediction Model for Respiratory Diseases

Millions of people around the world have one or many respiratory-related illnesses. Many chronic respiratory diseases like asthma, COPD, pneumonia, respiratory distress, etc. are considered to be a significant public health burden. To reduce the mortality rate, it is better to perform early prediction of respiratory disorders and treat them accordingly. To build an efficient prediction model for various types of respiratory diseases, machine learning approaches are used. The proposed methodology builds classifier model using supervised learning algorithms like random forest, decision tree, and multi-layer perceptron neural network (MLP-NN) for the detection of different respiratory diseases of ICU admitted patients. It achieves accuracy of nearly 99% by various machine learning approaches.

The value of biomarker-guided antibiotic therapy

INTRODUCTION

There is an increasing interest to individualize patient management and decisions regarding antibiotic treatment. Biomarkers may provide relevant information for this purpose.

AREAS COVERED

Despite a growing number of clinical trials investigating several biomarkers, there remain open questions regarding the best type of biomarker, timing or frequency of testing, and optimal cutoffs among others. The most promising results in regard to diagnosis of bacterial infection and therapy monitoring are found for procalcitonin (PCT), although some recent trials were not able to validate the promising earlier findings. Furthermore, less specific markers like C-reactive protein (CRP) and new prognostic biomarkers such as proadrenomedullin (MR-proADM) may improve the prognostic assessment of patients and proteomics may help shorten time to microbiological results. The aim of this review is to summarize the current concept of biomarker-guided management and provide an outlook of promising ongoing investigations.

EXPERT OPINION

'Antibiotic stewardship' is complex and needs more than just the measurement of one single biomarker. However, when integrated into the context of a thorough clinical examination, standard blood parameters and a well done risk stratification by clinical scores such as the SOFA-score, biomarkers have great potential to improve the diagnostic and prognostic assessment of patients.