1
|
Kang VJW, Huang YS, Chen MC, Chiang PY, Sheng WH, Wang HC, Wang TC, Chang YC. CT findings of 144 in-hospital patients with influenza pneumonia: A retrospective analysis. J Formos Med Assoc 2024; 123:381-389. [PMID: 37640653 DOI: 10.1016/j.jfma.2023.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/08/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND/PURPOSE Patients with influenza infection during their period of admission may have worse computed tomography (CT) manifestation according to the clinical status. This study aimed to evaluate the CT findings of in-hospital patients due to clinically significant influenza pneumonia with correlation of clinical presentations. METHODS In this retrospective, single center case series, 144 patients were included. All in-hospital patients were confirmed influenza infection and underwent CT scan. These patients were divided into three groups according to the clinical status of the most significant management: (1) without endotracheal tube and mechanical ventilator (ETTMV) or extracorporeal membrane oxygenation (ECMO); (2) with ETTMV; (3) with ETTMV and ECMO. Pulmonary opacities were scored according to extent. Spearman rank correlation analysis was used to evaluate the correlation between clinical parameters and CT scores. RESULTS The predominant CT manifestation of influenza infection was mixed ground-glass opacity (GGO) and consolidation with both lung involvement. The CT scores were all reach significant difference among all three groups (8.73 ± 6.29 vs 12.49 ± 6.69 vs 18.94 ± 4.57, p < 0.05). The chest CT score was correlated with age, mortality, and intensive care unit (ICU) days (all p values were less than 0.05). In addition, the CT score was correlated with peak lactate dehydrogenase (LDH) level and peak C-reactive protein (CRP) level (all p values were less than 0.05). Concomitant bacterial infection had higher CT score than primary influenza pneumonia (13.02 ± 7.27 vs 8.95 ± 5.99, p < 0.05). CONCLUSION Thin-section chest CT scores correlated with clinical and laboratory parameters in in-hospital patients with influenza pneumonia.
Collapse
Affiliation(s)
| | - Yu-Sen Huang
- Department of Medical Imaging, National Taiwan University, Taipei, Taiwan.
| | - Mei-Chi Chen
- Department of Medical Imaging, National Taiwan University, Taipei, Taiwan.
| | - Pin-Yi Chiang
- Department of Medical Imaging, National Taiwan University, Taipei, Taiwan.
| | - Wang-Huei Sheng
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University College of Medicine, Taiwan.
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University College of Medicine, Taiwan; Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Teh-Chen Wang
- Department Medical Imaging, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan.
| | - Yeun-Chung Chang
- Department of Medical Imaging, National Taiwan University, Taipei, Taiwan; Department of Radiology, National Taiwan University College of Medicine, Taipei, Taiwan.
| |
Collapse
|
2
|
Cao C, Wang S, Liu Y, Yue S, Wang M, Yu X, Ding Y, Lv M, Fang K, Chu M, Liao Z. Factors influencing C-reactive protein status on admission in neonates after birth. BMC Pediatr 2024; 24:89. [PMID: 38302903 PMCID: PMC10832075 DOI: 10.1186/s12887-024-04583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/21/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE To explore the factors influencing C-reactive protein (CRP) status in neonates on admission after birth. METHODS 820 newborns born and hospitalized at Xiangya Hospital of Central South University from Jan. 2020 to Dec. 2020 were retrospectively analyzed. Maternal medical history and medication use during pregnancy, neonatal demographic information and status at birth were collected through the electronic medical record system. Statistical software was used to analyze the possible relationship between perinatal factors and CRP on admission after birth. RESULTS A total of 820 neonates were analyzed, including 463 males and 357 females with a mean gestational age (GA) of 36.07 ± 3.30 weeks. (1) Multifactor Logistic regression analysis: larger GA (OR: 1.13, 95%CI: 1.00-1.28, P = 0.042), premature rupture of membranes (PROM) ≥ 18 h (OR: 2.39, 95%CI: 1.35-4.23, P = 0.003) and maternal autoimmune diseases (OR: 5.30, 95%CI: 2.15-13.07, P < 0.001) were independent risk factors for CRP ≥ 8 mg/L. Cesarean delivery (OR 0.40, 95%CI: 0.26-0.60, P < 0.001) was independent protective factor for CRP ≥ 8 mg/L. (2) Threshold effect analysis: A non-linear relationship was found between GA and CRP. When GA is less than 33.9 weeks, the risk of CRP ≥ 8 mg/L was reduced by 28% with one week increased (P < 0.001), and when GA is more than 33.9 weeks, the risk of CRP ≥ 8 mg/L was increased by 61% with one week increased (P < 0.001). CONCLUSIONS GA, PROM, maternal autoimmune diseases and cesarean delivery were all independent influences neonatal CRP ≥ 8 mg/L on admission, and there was a nonlinear relationship between GA and neonatal CRP ≥ 8 mg/L on admission.
Collapse
Affiliation(s)
- Chuanding Cao
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Shuo Wang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yang Liu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Shaojie Yue
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mingjie Wang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Xiaohe Yu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Ying Ding
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mei Lv
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Keren Fang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Meiyan Chu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Zhengchang Liao
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China.
| |
Collapse
|
3
|
Cassidy CA, Kabugho L, Kibaba G, Lin B, Hollingsworth B, Baguma E, Juliano JJ, Mulogo EM, Boyce RM, Ciccone EJ. Comparison of commercially available, rapid, point-of-care C-reactive protein assays among children with febrile illness in southwestern Uganda. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002727. [PMID: 38241274 PMCID: PMC10798459 DOI: 10.1371/journal.pgph.0002727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/21/2023] [Indexed: 01/21/2024]
Abstract
In Uganda, children with febrile illness are often treated with antibiotics even though most have self-limiting, likely viral, infections. C-reactive protein (CRP) measurement can help identify those who are more likely to have a bacterial infection and therefore need antibiotic treatment. Implementation of a CRP rapid diagnostic test (RDT) at the point-of-care in resource-constrained settings with minimal laboratory infrastructure could reduce unnecessary antibiotic use. In this study, we evaluated the performance of three semi-quantitative CRP RDTs (Actim, BTNX, Duo) against a reference CRP assay requiring an electrically powered analyzer (Afinion). While both tests demonstrated substantial agreement with Afinion, Actim had slightly higher agreement than BTNX. The sensitivity was higher for the BTNX test, whereas the Actim test had a higher specificity, at cut-offs of 40 mg/L and 80 mg/L. At a cut-off of 20 mg/L, Duo demonstrated substantial agreement with the Afinion test as well. Our results demonstrate the reliability of CRP RDTs when compared to a reference standard. CRP RDTs without the need for a laboratory-based analyzer are promising tools for optimizing antibiotic use in low-resource settings.
Collapse
Affiliation(s)
- Caitlin A. Cassidy
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Lydiah Kabugho
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Georget Kibaba
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bradley Lin
- Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Brandon Hollingsworth
- Department of Entomology, Cornell University, Ithaca, New York, United States of America
| | - Emmanuel Baguma
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan J. Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Edgar M. Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Emily J. Ciccone
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| |
Collapse
|
4
|
Wilkes C, Bava M, Graham HR, Duke T. What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review. J Glob Health 2023; 13:05003. [PMID: 36825608 PMCID: PMC9951126 DOI: 10.7189/jogh.13.05003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background Knowledge of the risk factors for and causes of treatment failure and mortality in childhood pneumonia is important for prevention, diagnosis, and treatment at an individual and population level. This review aimed to identify the most important risk factors for mortality among children aged under ten years with pneumonia. Methods We systematically searched MEDLINE, EMBASE, and PubMed for observational and interventional studies reporting risk factors for mortality in children (aged two months to nine years) in low- and middle-income countries (LMICs). We screened articles according to specified inclusion and exclusion criteria, assessed risk of bias using the EPHPP framework, and extracted data on demographic, clinical, and laboratory risk factors for death. We synthesized data descriptively and using Forest plots and did not attempt meta-analysis due to the heterogeneity in study design, definitions, and populations. Findings We included 143 studies in this review. Hypoxaemia (low blood oxygen level), decreased conscious state, severe acute malnutrition, and the presence of an underlying chronic condition were the risk factors most strongly and consistently associated with increased mortality in children with pneumonia. Additional important clinical factors that were associated with mortality in the majority of studies included particular clinical signs (cyanosis, pallor, tachypnoea, chest indrawing, convulsions, diarrhoea), chronic comorbidities (anaemia, HIV infection, congenital heart disease, heart failure), as well as other non-severe forms of malnutrition. Important demographic factors associated with mortality in the majority of studies included age <12 months and inadequate immunisation. Important laboratory and investigation findings associated with mortality in the majority of studies included: confirmed Pneumocystis jirovecii pneumonia (PJP), consolidation on chest x-ray, pleural effusion on chest x-ray, and leukopenia. Several other demographic, clinical and laboratory findings were associated with mortality less consistently or in a small numbers of studies. Conclusions Risk assessment for children with pneumonia should include routine evaluation for hypoxaemia (pulse oximetry), decreased conscious state (e.g. AVPU), malnutrition (severe, moderate, and stunting), and the presence of an underlying chronic condition as these are strongly and consistently associated with increased mortality. Other potentially useful risk factors include the presence of pallor or anaemia, chest indrawing, young age (<12 months), inadequate immunisation, and leukopenia.
Collapse
Affiliation(s)
- Chris Wilkes
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Mohamed Bava
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Hamish R Graham
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
| | | |
Collapse
|
5
|
Balanza N, Erice C, Ngai M, McDonald CR, Weckman AM, Wright J, Richard-Greenblatt M, Varo R, López-Varela E, Sitoe A, Vitorino P, Bramugy J, Lanaspa M, Acácio S, Madrid L, Baro B, Kain KC, Bassat Q. Prognostic accuracy of biomarkers of immune and endothelial activation in Mozambican children hospitalized with pneumonia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001553. [PMID: 36963048 PMCID: PMC10021812 DOI: 10.1371/journal.pgph.0001553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/24/2023] [Indexed: 02/25/2023]
Abstract
Pneumonia is a leading cause of child mortality. However, currently we lack simple, objective, and accurate risk-stratification tools for pediatric pneumonia. Here we test the hypothesis that measuring biomarkers of immune and endothelial activation in children with pneumonia may facilitate the identification of those at risk of death. We recruited children <10 years old fulfilling WHO criteria for pneumonia and admitted to the Manhiça District Hospital (Mozambique) from 2010 to 2014. We measured plasma levels of IL-6, IL-8, Angpt-2, sTREM-1, sFlt-1, sTNFR1, PCT, and CRP at admission, and assessed their prognostic accuracy for in-hospital, 28-day, and 90-day mortality. Healthy community controls, within same age strata and location, were also assessed. All biomarkers were significantly elevated in 472 pneumonia cases versus 80 controls (p<0.001). IL-8, sFlt-1, and sTREM-1 were associated with in-hospital mortality (p<0.001) and showed the best discrimination with AUROCs of 0.877 (95% CI: 0.782 to 0.972), 0.832 (95% CI: 0.729 to 0.935) and 0.822 (95% CI: 0.735 to 0.908), respectively. Their performance was superior to CRP, PCT, oxygen saturation, and clinical severity scores. IL-8, sFlt-1, and sTREM-1 remained good predictors of 28-day and 90-day mortality. These findings suggest that measuring IL-8, sFlt-1, or sTREM-1 at hospital presentation can guide risk-stratification of children with pneumonia, which could enable prioritized care to improve survival and resource allocation.
Collapse
Affiliation(s)
- Núria Balanza
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Michelle Ngai
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chloe R. McDonald
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M. Weckman
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julie Wright
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Richard-Greenblatt
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Pio Vitorino
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Miguel Lanaspa
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Sozinho Acácio
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Lola Madrid
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bàrbara Baro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Kevin C. Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ICREA, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| |
Collapse
|
6
|
Mahittikorn A, Kotepui KU, Mala W, Wilairatana P, Kotepui M. Procalcitonin as a Candidate Biomarker for Malarial Infection and Severe Malaria: A Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11389. [PMID: 36141662 PMCID: PMC9517210 DOI: 10.3390/ijerph191811389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/30/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
Procalcitonin (PCT), as a marker of malaria severity, remains to be investigated. The present study collated and compared the levels of PCT between patients with severe malaria, uncomplicated malaria, and control participants to assess their role in predicting malaria infection and disease severity. The systematic review was registered at PROSPERO with registration number CRD42021297243. The search for relevant studies that reported PCT in patients with malaria was performed in PubMed, Scopus, and Web of Science. The following meta-analyses were conducted; (1) the pooled mean PCT levels in patients with severe and uncomplicated malaria, and (2) the pooled mean difference in PCT levels between patients with severe and uncomplicated malaria. Fifteen studies were included for qualitative and quantitative syntheses. The meta-analysis results show that the pooled mean PCT levels in patients with uncomplicated malaria were 3.92 ng/mL (95% CI: 2.26-5.58 ng/mL, I2: 96.5, five studies), whereas the pooled mean PCT levels in patients with severe malaria were 14.13 ng/mL (95% CI: 8.75-19.5 ng/mL, I2: 92.6, six studies). The meta-analysis showed that patients with severe malaria had an equal mean of PCT compared to those with uncomplicated malaria when the random-effects model was used (p: 0.055, weighted mean difference: 6.93, 95% CI: -0.16-14.02, I2: 84.6%, four studies). There were probable correlations between the level of parasitemia, immunity level, and possibly bacterial or other parasitic co-infection that could affect the PCT level among different clinical severities of malaria. Therefore, the PCT level alone does not seem to be a suitable biomarker to discriminate the severe/uncomplicated or infected/uninfected cases. Further studies should investigate the increased PCT levels in combination with other markers in association with malaria infection and severity.
Collapse
Affiliation(s)
- Aongart Mahittikorn
- Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Kwuntida Uthaisar Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Wanida Mala
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Manas Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| |
Collapse
|
7
|
Ojuawo OB, Iroh Tam PY. Childhood Pneumonia Diagnostics in Sub-Saharan Africa: A Systematic Review. J Trop Pediatr 2022; 68:6604072. [PMID: 35674266 DOI: 10.1093/tropej/fmac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The prompt and accurate aetiological diagnosis of childhood pneumonia remains a challenge, especially in sub-Saharan Africa (SSA) because of limited resources for disease management. OBJECTIVE To review existing diagnostics for childhood pneumonia and potential modalities available to differentiate between bacterial and viral aetiologies in SSA. METHODS Online databases were searched for relevant articles published between January 2010 and December 2020 regarding childhood pneumonia diagnosis, conducted in SSA in children less than 18 years of age. The 2020 PRISMA checklist was utilized in appraising the selected studies and the QUADAS-2 tool was employed to assess the risk of bias in each of the studies selected. RESULTS A total of 1542 study titles and abstracts were screened following which 45 studies (39 on childhood pneumonia diagnostics and 6 on discriminating between bacterial and viral childhood pneumonia) were selected for review. Microbiological investigations (79.7%) constituted the most utilized index tests with blood-related specimen (32.8%) being the most utilized specimen. The most performed index diagnostic modality was polymerase chain reaction (PCR) (53.1%). The commonest reference gold standard technique was based on clinical diagnosis of the disease (46.2%). Only six studies in SSA attempted at using serum biomarkers, either singly or in combination to distinguish between aetiologies with use of combined biomarkers showing promise. CONCLUSION Microbiological investigations are the most employed diagnostic methods for childhood pneumonia in SSA. More studies are required to evaluate the potential use of serum biomarkers; either singly or in combination with the goal of discriminating bacterial and viral childhood pneumonia.
Collapse
Affiliation(s)
| | - Pui-Ying Iroh Tam
- Respiratory Department, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham B187QH, UK.,Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
8
|
A Mobile-based Application to Improve the Etiologic Diagnosis of Community-acquired Childhood Pneumonia: Another Brick in the Wall? Pediatr Infect Dis J 2022; 41:37-38. [PMID: 34711788 DOI: 10.1097/inf.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Wilairatana P, Mahannop P, Tussato T, Hayeedoloh IM, Boonhok R, Klangbud WK, Mala W, Kotepui KU, Kotepui M. C-reactive protein as an early biomarker for malaria infection and monitoring of malaria severity: a meta-analysis. Sci Rep 2021; 11:22033. [PMID: 34764364 PMCID: PMC8585865 DOI: 10.1038/s41598-021-01556-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023] Open
Abstract
This study investigated whether C-reactive protein (CRP) can be used as a marker for the early detection and monitoring of malaria severity. Potentially relevant studies were searched in Medline (PubMed), Scopus, and Web of Science. Differences in CRP between (1) severe malaria and uncomplicated malaria, (2) uncomplicated malaria and asymptomatic malaria, (3) uncomplicated malaria and febrile/healthy controls, and (4) asymptomatic malaria and febrile/healthy controls were estimated using random-effects models. Twenty-nine studies were included for meta-analysis. The results of meta-analysis demonstrated higher mean CRP levels in (1) patients with severe malaria compared with uncomplicated malaria (p < 0.001, standard mean difference [SMD]: 1.52, 95% confidence interval [CI]: 0.91-2.12, I2: 95.1%), (2) patients with uncomplicated malaria than in those with asymptomatic malaria (p: 0.001, SMD: 1.65, 95% CI: 0.67-2.62, I2: 96.7%), (3) patients with uncomplicated malaria compared with febrile/healthy controls (p < 0.001, SMD: 2.38, 95% CI: 1.37-3.40, I2: 98.5%), and (4) patients with asymptomatic malaria compared with febrile/healthy controls (p < 0.001, SMD: 2.55, 95% CI: 1.60-3.50, I2: 99.2%). This study demonstrated CRP levels are a biomarker for the early detection and monitoring of malaria severity.
Collapse
Affiliation(s)
- Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Praphassorn Mahannop
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Thanita Tussato
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - I-Mee Hayeedoloh
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Rachasak Boonhok
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Wiyada Kwanhian Klangbud
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Wanida Mala
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Kwuntida Uthaisar Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand
| | - Manas Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat, Thailand.
| |
Collapse
|
10
|
Samuels THA, Wyss R, Ongarello S, Moore DAJ, Schumacher SG, Denkinger CM. Evaluation of the diagnostic performance of laboratory-based c-reactive protein as a triage test for active pulmonary tuberculosis. PLoS One 2021; 16:e0254002. [PMID: 34252128 PMCID: PMC8274836 DOI: 10.1371/journal.pone.0254002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/17/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction A highly sensitive triage test that captures most symptomatic patients at increased likelihood of having pulmonary tuberculosis (PTB) would ‘rule-out’ lower-risk patients from expensive confirmatory testing. Although studies have assessed the diagnostic accuracy of a C-reactive protein (CRP) triage test for PTB in HIV+ patients, limited data are available from HIV- cohorts. Materials and methods In this retrospective case-control study, 765 serum samples were selected from FIND’s biobank. Each sample had been collected from an adult presenting with respiratory symptomatology to district hospitals in South Africa and referral hospitals in Cambodia, Peru, Georgia and Vietnam between 2007–2017. Serum CRP measurements were obtained using a laboratory-based assay. CRP cutoff-points of ≥8mg/L and ≥10mg/L were predefined as a positive triage test result. The PTB reference standard was two contemporaneously collected sputum liquid culture results. Results CRP demonstrated an overall sensitivity for PTB of 79.8% (95%CI 75.5–83.5) and 77.7% (95%CI 73.4–81.6) for cutoff-points of 8mg/L and 10mg/L respectively. Specificity was 62.8% (95%CI 57.8–67.6%) and 66.6% (95%CI 61.1–70.7) respectively. Area-under-the-curve using Receiver Operating Characteristic analysis was 0.77 (95%CI 0.74–0.81). Threshold analysis showed optimal CRP cutoff-points were higher in HIV+ than HIV- participants. An algorithm in which CRP triage was followed by confirmatory Xpert MTB/Rif testing achieved a sensitivity of 75.1% (95%CI 69.0–80.4%) whilst decreasing Xpert usage by 40.6%. Discussion CRP may not meet the challenge of a catch-all TB triage test. However, it shows promise in HIV+ individuals. Further research is required in a prospective study using point-of-care platforms to further evaluate its capabilities.
Collapse
Affiliation(s)
- Thomas H. A. Samuels
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Romain Wyss
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Stefano Ongarello
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - David A. J. Moore
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | | |
Collapse
|
11
|
Post A, Kaboré B, Bognini J, Diallo S, Lompo P, Kam B, Herssens N, van Opzeeland F, van der Gaast-de Jongh CE, Langereis JD, de Jonge MI, Rahamat-Langendoen J, Bousema T, Wertheim H, Sauerwein RW, Tinto H, Jacobs J, de Mast Q, van der Ven AJ. Infection Manager System (IMS) as a new hemocytometry-based bacteremia detection tool: A diagnostic accuracy study in a malaria-endemic area of Burkina Faso. PLoS Negl Trop Dis 2021; 15:e0009187. [PMID: 33647009 PMCID: PMC7951874 DOI: 10.1371/journal.pntd.0009187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/11/2021] [Accepted: 01/30/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND New hemocytometric parameters can be used to differentiate causes of acute febrile illness (AFI). We evaluated a software algorithm-Infection Manager System (IMS)-which uses hemocytometric data generated by Sysmex hematology analyzers, for its accuracy to detect bacteremia in AFI patients with and without malaria in Burkina Faso. Secondary aims included comparing the accuracy of IMS with C-reactive protein (CRP) and procalcitonin (PCT). METHODS In a prospective observational study, patients of ≥ three-month-old (range 3 months- 90 years) presenting with AFI were enrolled. IMS, blood culture and malaria diagnostics were done upon inclusion and additional diagnostics on clinical indication. CRP, PCT, viral multiplex PCR on nasopharyngeal swabs and bacterial- and malaria PCR were batch-tested retrospectively. Diagnostic classification was done retrospectively using all available data except IMS, CRP and PCT results. FINDINGS A diagnosis was affirmed in 549/914 (60.1%) patients and included malaria (n = 191) bacteremia (n = 69), viral infections (n = 145), and malaria-bacteremia co-infections (n = 47). The overall sensitivity, specificity, and negative predictive value (NPV) of IMS for detection of bacteremia in patients of ≥ 5 years were 97.0% (95% CI: 89.8-99.6), 68.2% (95% CI: 55.6-79.1) and 95.7% (95% CI: 85.5-99.5) respectively, compared to 93.9% (95% CI: 85.2-98.3), 39.4% (95% CI: 27.6-52.2), and 86.7% (95% CI: 69.3-96.2) for CRP at ≥20mg/L. The sensitivity, specificity and NPV of PCT at 0.5 ng/ml were lower at respectively 72.7% (95% CI: 60.4-83.0), 50.0% (95% CI: 37.4-62.6) and 64.7% (95% CI: 50.1-77.6) The diagnostic accuracy of IMS was lower among malaria cases and patients <5 years but remained equal to- or higher than the accuracy of CRP. INTERPRETATION IMS is a new diagnostic tool to differentiate causes of AFI. Its high NPV for bacteremia has the potential to improve antibiotic dispensing practices in healthcare facilities with hematology analyzers. Future studies are needed to evaluate whether IMS, combined with malaria diagnostics, may be used to rationalize antimicrobial prescription in malaria endemic areas. TRIAL REGISTRATION ClinicalTrials.gov (NCT02669823) https://clinicaltrials.gov/ct2/show/NCT02669823.
Collapse
Affiliation(s)
- Annelies Post
- Nijmegen Institute of International Health, Radboudumc, Nijmegen, the Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- * E-mail: (AP); (AvV)
| | - Berenger Kaboré
- Nijmegen Institute of International Health, Radboudumc, Nijmegen, the Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Joel Bognini
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Salou Diallo
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | | | - Basile Kam
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Natacha Herssens
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - Fred van Opzeeland
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Christa E. van der Gaast-de Jongh
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Jeroen D. Langereis
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Marien I. de Jonge
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Janette Rahamat-Langendoen
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Teun Bousema
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Heiman Wertheim
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Robert W. Sauerwein
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, the Netherlands
| | - Halidou Tinto
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
- Centre Muraz, Bobo-Dioulasso, Burkina Faso
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni de Bobo-Dioulasso, Burkina Faso
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM), Antwerp, Belgium
- Department of Microbiology and Immunology, University of Leuven (KU Leuven), Leuven, Belgium
| | - Quirijn de Mast
- Nijmegen Institute of International Health, Radboudumc, Nijmegen, the Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
| | - Andre J. van der Ven
- Nijmegen Institute of International Health, Radboudumc, Nijmegen, the Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
- * E-mail: (AP); (AvV)
| |
Collapse
|
12
|
Richard-Greenblatt M, Boillat-Blanco N, Zhong K, Mbarack Z, Samaka J, Mlaganile T, Kazimoto T, D'acremont V, Kain KC. Prognostic Accuracy of Soluble Triggering Receptor Expressed on Myeloid Cells (sTREM-1)-based Algorithms in Febrile Adults Presenting to Tanzanian Outpatient Clinics. Clin Infect Dis 2021; 70:1304-1312. [PMID: 31102510 DOI: 10.1093/cid/ciz419] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/17/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The inability to identify individuals with acute fever at risk of death is a barrier to effective triage and management of severe infections, especially in low-resource settings. Since endothelial and immune activation contribute to the pathogenesis of various distinct life-threatening infections, we hypothesized that measuring mediators of these pathways at clinical presentation would identify febrile adults at risk of death. METHODS Plasma concentrations of markers of endothelial (angiopoetin-1/2, soluble fms-like tyrosine kinase-1, soluble vascular cell adhesion molecule-1, soluble intercellular adhesion molecule-1) and immune (soluble triggering receptor expressed on myeloid cells [sTREM-1], interleukin-6, interleukin-8, chitinase-3-like protein-1, soluble tumor necrosis factor receptor-1, procalcitonin [PCT], C-reactive protein [CRP]) activation pathways were determined in consecutive adults with acute fever (≥38°C) at presentation to outpatient clinics in Dar es Salaam, Tanzania. We evaluated the accuracy of these mediators in predicting all-cause mortality and examined whether markers could improve the prognostic accuracy of clinical scoring systems, including the quick sequential organ failure assessment (qSOFA) and Glasgow coma scale (GCS). RESULTS Of 507 febrile adults, 32 died (6.3%) within 28 days of presentation. We found that sTREM-1 was the best prognostic marker for 28-day mortality (area under the receiver operating characteristic [AUROC] 0.87, 95% confidence interval [CI] 0.81-0.92) and was significantly better than CRP (P < .0001) and PCT (P = .0001). The prognostic accuracy of qSOFA and the GCS were significantly enhanced when sTREM-1 was added (0.80 [95% CI 0.76-0.83] to 0.91 [95% CI 0.88-0.94; P < .05] and 0.72 [95% CI 0.63-0.80] to 0.94 [95% CI 0.91-0.97; P < .05], respectively). CONCLUSIONS Measuring sTREM-1 at clinical presentation can identify febrile individuals at risk of all-cause febrile mortality. Adding severity markers such as sTREM-1 to simple clinical scores could improve the recognition and triage of patients with life-threatening infections in resource-limited settings.
Collapse
Affiliation(s)
| | | | - Kathleen Zhong
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada
| | - Zainab Mbarack
- Mwananyamala Hospita, Dar es Salaam, United Republic of Tanzanial
| | - Josephine Samaka
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Tarsis Mlaganile
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Thekla Kazimoto
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Valerie D'acremont
- Swiss Tropical and Public Health Institute, Basel.,University Centre of General Medicine and Public Health, Lausanne, Switzerland
| | - Kevin C Kain
- Tropical Disease Unit, Department of Medicine, University of Toronto, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Canada
| |
Collapse
|
13
|
Bassat Q. The Perks of Prognostic Biomarkers: A Paradigm Shift in the Triage of Sick Febrile Patients. Clin Infect Dis 2020; 70:1313-1315. [PMID: 31102517 DOI: 10.1093/cid/ciz420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023] Open
Affiliation(s)
- Quique Bassat
- Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Institució Catalana de Recerca i Estudis Avançats.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Spain
| |
Collapse
|
14
|
Akelew Y, Derbew A, Lemma M, Negash M, Bewket G, Belay G, Pollmann J, Adriaensen W, Adane A, Mohammed R, van Griensven J, Cnops L. Evaluation of C-reactive protein and myxovirus resistance protein A to guide the rational use of antibiotics among acute febrile adult patients in Northwest Ethiopia. Int J Infect Dis 2020; 101:276-282. [PMID: 33002622 DOI: 10.1016/j.ijid.2020.09.1444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/22/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES In low-resource settings, treatment is often given empirically without knowledge of the aetiology due to a lack of diagnostics. In the search for reliable rapid tests to guide treatment work-up, this study was performed to determine whether two biomarkers could differentiate bacterial from non-bacterial infections in acute febrile patients. METHODS Adults with acute fever were recruited at a referral hospital in Ethiopia. The QuikRead Go test was used to quantify C-reactive protein (qCRP) and the FebriDx test was used for combined qualitative detection of the bacterial CRP marker with myxovirus resistance protein A (MxA), a viral biomarker. RESULTS Of the 200 patients included in this study, most presented with 2-3 days of fever, headache, and joint pain. Antibiotics were prescribed for 83.5% and antimalarials for 36.5%, while a bacterial infection was only confirmed in 5% and malaria in 11%. The median qCRP level for confirmed bacterial infections was 128 mg/l. The FebriDx and QuikRead Go test had an overall agreement of 72.0%. CONCLUSIONS An over-prescription of antibiotics for febrile patients was observed, even for those with low CRP levels and without a confirmed bacterial infection. The added value of the FebriDx was limited, while the combined use of rapid tests for qCRP and malaria should be considered for the management of acute febrile illness and antibiotic stewardship.
Collapse
Affiliation(s)
- Yibeltal Akelew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia; Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Agegnehu Derbew
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia
| | - Mulualem Lemma
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Markos Negash
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Gezahegn Bewket
- Department of Immunology and Molecular Biology, College of Medicine and Health Sciences, University of Gondar, Debre Markos, Ethiopia
| | - Gizeaddis Belay
- Department of Medical Microbiology, University of Gondar, Debre Markos, Ethiopia
| | - Julia Pollmann
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Adriaensen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Aynishet Adane
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia
| | - Rezika Mohammed
- Department of Internal Medicine, University of Gondar, Debre Markos, Ethiopia; Leishmaniasis Research and Treatment Centre, University of Gondar, Debre Markos, Ethiopia
| | - Johan van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lieselotte Cnops
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| |
Collapse
|
15
|
van Griensven J, Cnops L, De Weggheleire A, Declercq S, Bottieau E. Point-of-Care Biomarkers to Guide Antibiotic Prescription for Acute Febrile Illness in Sub-Saharan Africa: Promises and Caveats. Open Forum Infect Dis 2020; 7:ofaa260. [PMID: 32818139 PMCID: PMC7423291 DOI: 10.1093/ofid/ofaa260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/26/2020] [Indexed: 01/21/2023] Open
Abstract
Empiric malaria treatment in Sub-Saharan Africa has significantly decreased with the scaling-up of malaria rapid diagnostic tests; this coincided with a pronounced increase in empiric antibiotic prescriptions. In high-income countries, guidance for antibiotic prescriptions using biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) has reduced antibiotic use while safe-guarding patient safety. Importantly, several low-cost point-of-care CRP/PCT tests are currently available. However, only a few studies on the role of CRP/PCT in differentiating bacterial vs viral infections in acute febrile illness have been conducted in Sub-Saharan Africa. Studies from Central and West Africa (most of which is malaria-endemic) are particularly scarce, and only 1 has included adults. The evidence base for point-of-care use of CRP/PCT biomarkers in acute fever in Sub-Saharan Africa should be urgently built. Before engaging in clinical trials to assess clinical impact, pilot studies should be conducted to address key knowledge gaps including recommended CRP/PCT cutoff values and the effect of malaria coinfection.
Collapse
|
16
|
Tillekeratne LG, Suchindran S, Ko ER, Petzold EA, Bodinayake CK, Nagahawatte A, Devasiri V, Kurukulasooriya R, Nicholson BP, McClain MT, Burke TW, Tsalik EL, Henao R, Ginsburg GS, Reller ME, Woods CW. Previously Derived Host Gene Expression Classifiers Identify Bacterial and Viral Etiologies of Acute Febrile Respiratory Illness in a South Asian Population. Open Forum Infect Dis 2020; 7:ofaa194. [PMID: 32617371 PMCID: PMC7314590 DOI: 10.1093/ofid/ofaa194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/21/2020] [Indexed: 01/21/2023] Open
Abstract
Background Pathogen-based diagnostics for acute respiratory infection (ARI) have limited ability to detect etiology of illness. We previously showed that peripheral blood-based host gene expression classifiers accurately identify bacterial and viral ARI in cohorts of European and African descent. We determined classifier performance in a South Asian cohort. Methods Patients ≥15 years with fever and respiratory symptoms were enrolled in Sri Lanka. Comprehensive pathogen-based testing was performed. Peripheral blood ribonucleic acid was sequenced and previously developed signatures were applied: a pan-viral classifier (viral vs nonviral) and an ARI classifier (bacterial vs viral vs noninfectious). Results Ribonucleic acid sequencing was performed in 79 subjects: 58 viral infections (36 influenza, 22 dengue) and 21 bacterial infections (10 leptospirosis, 11 scrub typhus). The pan-viral classifier had an overall classification accuracy of 95%. The ARI classifier had an overall classification accuracy of 94%, with sensitivity and specificity of 91% and 95%, respectively, for bacterial infection. The sensitivity and specificity of C-reactive protein (>10 mg/L) and procalcitonin (>0.25 ng/mL) for bacterial infection were 100% and 34%, and 100% and 41%, respectively. Conclusions Previously derived gene expression classifiers had high predictive accuracy at distinguishing viral and bacterial infection in South Asian patients with ARI caused by typical and atypical pathogens.
Collapse
Affiliation(s)
- L Gayani Tillekeratne
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA.,Infectious Diseases Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - Sunil Suchindran
- Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Emily R Ko
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA.,Program in Hospital Medicine, Duke Regional Hospital, Durham, North Carolina, USA
| | - Elizabeth A Petzold
- Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Champica K Bodinayake
- Duke Global Health Institute, Durham, North Carolina, USA.,Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - Ajith Nagahawatte
- Duke Global Health Institute, Durham, North Carolina, USA.,Department of Microbiology, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - Vasantha Devasiri
- Department of Pediatrics, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | | | | | - Micah T McClain
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Infectious Diseases Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Thomas W Burke
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Ephraim L Tsalik
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Infectious Diseases Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Ricardo Henao
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Geoffrey S Ginsburg
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| | - Megan E Reller
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA.,Infectious Diseases Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Christopher W Woods
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA.,Infectious Diseases Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.,Center for Applied Genomics and Precision Medicine, Durham, North Carolina, USA
| |
Collapse
|
17
|
Kortz TB, Nyirenda J, Tembo D, Elfving K, Baltzell K, Bandawe G, Rosenthal PJ, Macfarlane SB, Mandala W, Nyirenda TS. Distinct Biomarker Profiles Distinguish Malawian Children with Malarial and Non-malarial Sepsis. Am J Trop Med Hyg 2020; 101:1424-1433. [PMID: 31595873 DOI: 10.4269/ajtmh.18-0635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Presently, it is difficult to accurately diagnose sepsis, a common cause of childhood death in sub-Saharan Africa, in malaria-endemic areas, given the clinical and pathophysiological overlap between malarial and non-malarial sepsis. Host biomarkers can distinguish sepsis from uncomplicated fever, but are often abnormal in malaria in the absence of sepsis. To identify biomarkers that predict sepsis in a malaria-endemic setting, we retrospectively analyzed data and sera from a case-control study of febrile Malawian children (aged 6-60 months) with and without malaria who presented to a community health center in Blantyre (January-August 2016). We characterized biomarkers for 29 children with uncomplicated malaria without sepsis, 25 without malaria or sepsis, 17 with malaria and sepsis, and 16 without malaria but with sepsis. Sepsis was defined using systemic inflammatory response criteria; biomarkers (interleukin-6 [IL-6], tumor necrosis factor receptor-1, interleukin-1 β [IL-1β], interleukin-10 [IL-10], von Willebrand factor antigen-2, intercellular adhesion molecule-1, and angiopoietin-2 [Ang-2]) were measured with multiplex magnetic bead assays. IL-6, IL-1β, and IL-10 were elevated, and Ang-2 was decreased in children with malaria compared with non-malarial fever. Children with non-malarial sepsis had greatly increased IL-1β compared with the other subgroups. IL-1β best predicted sepsis, with an area under the receiver operating characteristic (AUROC) of 0.71 (95% CI: 0.57-0.85); a combined biomarker-clinical characteristics model improved prediction (AUROC of 0.77, 95% CI: 0.67-0.85). We identified a distinct biomarker profile for non-malarial sepsis and developed a sepsis prediction model. Additional clinical and biological data are necessary to further explore sepsis pathophysiology in malaria-endemic regions.
Collapse
Affiliation(s)
- Teresa B Kortz
- Department of Pediatrics, University of California, San Francisco, California.,Institute of Global Health Sciences, University of California, San Francisco, California
| | - James Nyirenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Pathology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Dumizulu Tembo
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Kristina Elfving
- Department of Infectious Diseases, Institution for Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, University of California, San Francisco, California.,Institute of Global Health Sciences, University of California, San Francisco, California
| | - Gama Bandawe
- Department of Biological Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Philip J Rosenthal
- Department of Medicine, University of California, San Francisco, California
| | - Sarah B Macfarlane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Wilson Mandala
- Department of Biological Sciences, Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi.,Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Tonney S Nyirenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Pathology, College of Medicine, University of Malawi, Blantyre, Malawi
| |
Collapse
|
18
|
Althaus T, Lubell Y, Maro VP, Mmbaga BT, Lwezaula B, Halleux C, Biggs HM, Galloway RL, Stoddard RA, Perniciaro JL, Nicholson WL, Doyle K, Olliaro P, Crump JA, Rubach MP. Sensitivity of C-reactive protein for the identification of patients with laboratory-confirmed bacterial infections in northern Tanzania. Trop Med Int Health 2020; 25:291-300. [PMID: 31808588 DOI: 10.1111/tmi.13358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Identifying febrile patients requiring antibacterial treatment is challenging, particularly in low-resource settings. In South-East Asia, C-reactive protein (CRP) has been demonstrated to be highly sensitive and moderately specific in detecting bacterial infections and to safely reduce unnecessary antibacterial prescriptions in primary care. As evidence is scant in sub-Saharan Africa, we assessed the sensitivity of CRP in identifying serious bacterial infections in Tanzania. METHODS Samples were obtained from inpatients and outpatients in a prospective febrile illness study at two hospitals in Moshi, Tanzania, 2011-2014. Bacterial bloodstream infections (BSI) were established by blood culture, and bacterial zoonotic infections were defined by ≥4 fold rise in antibody titre between acute and convalescent sera. The sensitivity of CRP in identifying bacterial infections was estimated using thresholds of 10, 20 and 40 mg/l. Specificity was not assessed because determining false-positive CRP results was limited by the lack of diagnostic testing to confirm non-bacterial aetiologies and because ascertaining true-negative cases was limited by the imperfect sensitivity of the diagnostic tests used to identify bacterial infections. RESULTS Among 235 febrile outpatients and 569 febrile inpatients evaluated, 31 (3.9%) had a bacterial BSI and 61 (7.6%) had a bacterial zoonosis. Median (interquartile range) CRP values were 173 (80-315) mg/l in bacterial BSI, and 108 (31-208) mg/l in bacterial zoonoses. The sensitivity (95% confidence intervals) of CRP was 97% (83%-99%), 94% (79%-98%) and 90% (74%-97%) for identifying bacterial BSI, and 87% (76%-93%), 82% (71%-90%) and 72% (60%-82%) for bacterial zoonoses, using thresholds of 10, 20 and 40 mg/l, respectively. CONCLUSION C-reactive protein was moderately sensitive for bacterial zoonoses and highly sensitive for identifying BSIs. Based on these results, operational studies are warranted to assess the safety and clinical utility of CRP for the management of non-malaria febrile illness at first-level health facilities in sub-Saharan Africa.
Collapse
Affiliation(s)
- Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Venance P Maro
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA
| | | | - Christine Halleux
- Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland
| | - Holly M Biggs
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Renee L Galloway
- Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robyn A Stoddard
- Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jamie L Perniciaro
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William L Nicholson
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kelly Doyle
- Intermountain Central Laboratory, Intermountain Healthcare, Murray, UT, USA
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland
| | - John A Crump
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA.,Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA.,Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Matthew P Rubach
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Duke Global Health Institute, Durham, NC, USA.,Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA.,Programme in Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore
| |
Collapse
|
19
|
Balanza N, Erice C, Ngai M, Varo R, Kain KC, Bassat Q. Host-Based Prognostic Biomarkers to Improve Risk Stratification and Outcome of Febrile Children in Low- and Middle-Income Countries. Front Pediatr 2020; 8:552083. [PMID: 33072673 PMCID: PMC7530621 DOI: 10.3389/fped.2020.552083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Fever is one of the leading causes for pediatric medical consultation and the most common symptom at clinical presentation in low- and middle-income countries (LMICs). Most febrile episodes are due to self-limited infections, but a small proportion of children will develop life-threatening infections. The early recognition of children who have or are progressing to a critical illness among all febrile cases is challenging, and there are currently no objective and quantitative tools to do so. This results in increased morbidity and mortality among children with impending life-threatening infections, whilst contributing to the unnecessary prescription of antibiotics, overwhelming health care facilities, and harm to patients receiving avoidable antimicrobial treatment. Specific fever origin is difficult to ascertain and co-infections in LMICs are common. However, many severe infections share common pathways of host injury irrespective of etiology, including immune and endothelial activation that contribute to the pathobiology of sepsis (i.e., pathogen "agnostic" mechanisms of disease). Importantly, mediators of these pathways are independent markers of disease severity and outcome. We propose that measuring circulating levels of these factors can provide quantitative and objective evidence to: enable early recognition of severe infection; guide patient triage and management; enhance post-discharge risk stratification and follow up; and mitigate potential gender bias in clinical decisions. Here, we review the clinical and biological evidence supporting the clinical utility of host immune and endothelial activation biomarkers as components of novel rapid triage tests, and discuss the challenges and needs for developing and implementing such tools.
Collapse
Affiliation(s)
- Núria Balanza
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Ngai
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,ICREA, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| |
Collapse
|
20
|
Lubell Y, Chandna A, Smithuis F, White L, Wertheim HFL, Redard-Jacot M, Katz Z, Dondorp A, Day N, White N, Dittrich S. Economic considerations support C-reactive protein testing alongside malaria rapid diagnostic tests to guide antimicrobial therapy for patients with febrile illness in settings with low malaria endemicity. Malar J 2019; 18:442. [PMID: 31878978 PMCID: PMC6933672 DOI: 10.1186/s12936-019-3059-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 12/08/2019] [Indexed: 11/16/2022] Open
Abstract
Malaria is no longer a common cause of febrile illness in many regions of the tropics. In part, this success is a result of improved access to accurate diagnosis and effective anti-malarial treatment, including in many hard-to-reach rural areas. However, in these settings, management of other causes of febrile illness remains challenging. Health systems are often weak and other than malaria rapid tests no other diagnostics are available. With millions of deaths occurring annually due to treatable bacterial infections and the ever increasing spread of antimicrobial resistance, improvement in the management of febrile illness is a global public health priority. Whilst numerous promising point-of-care diagnostics are in the pipeline, substantial progress can be made in the interim with existing tools: C-reactive protein (CRP) is a highly sensitive and moderately specific biomarker of bacterial infection and has been in clinical use for these purposes for decades, with dozens of low-cost devices commercially available. This paper takes a health-economics approach to consider the possible advantages of CRP point-of-care tests alongside rapid diagnostic tests for malaria, potentially in a single multiplex device, to guide antimicrobial therapy for patients with febrile illness. Three rudimentary assessments of the costs and benefits of this approach all indicate that this is likely to be cost-effective when considering the incremental costs of the CRP tests as compared with either (i) the improved health outcomes for patients with bacterial illnesses; (ii) the costs of antimicrobial resistance averted; or (iii) the economic benefits of better management of remaining malaria cases and shorter malaria elimination campaigns in areas of low transmission. While CRP-guided antibiotic therapy alone cannot resolve all challenges associated with management of febrile illness in remote tropical settings, in the short-term a multiplexed CRP and malaria RDT could be highly cost-effective and utilize the well-established funding and distribution systems already in place for malaria RDTs. These findings should spark further interest amongst industry, academics and policy-makers in the development and deployment of such diagnostics, and discussion on their geographically appropriate use.
Collapse
Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Arjun Chandna
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Frank Smithuis
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Lisa White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Heiman F L Wertheim
- Department of Medical Microbiology, Medical Center for Infectious Diseases, Radboud University, Radboudumc, Nijmegen, The Netherlands
| | - Maël Redard-Jacot
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Zachary Katz
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Arjen Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
| |
Collapse
|
21
|
Bottieau E, Mukendi D, Kalo JRL, Lutumba P, Barbé B, Ramadan K, Van Esbroeck M, Jacobs J, Yansouni CP, Chappuis F, Boelaert M, Winkler AS, Verdonck K. Potential usefulness of C-reactive protein and procalcitonin determination in patients admitted for neurological disorders in rural Democratic Republic of Congo. Sci Rep 2019; 9:15505. [PMID: 31664120 PMCID: PMC6820716 DOI: 10.1038/s41598-019-51925-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023] Open
Abstract
In low-resource hospitals of central Africa, neurological disorders are frequent and etiologies very diverse. The difficulty to identify invasive bacterial infections in this setting results in major antibiotic overuse. Biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) may help discriminate these conditions. We retrospectively determined the concentrations of CRP and PCT in the sera of patients consecutively enrolled from 2012 to 2015 in an etiological study on neurological disorders at the rural hospital of Mosango, Democratic Republic of Congo. Invasive bacterial infection had been diagnosed by the demonstration of a bacterial pathogen in cerebrospinal fluid or blood cultures or the presence of radiological pneumonia. Sera of 313 (89.2%) and 317 (90.3%) of the 351 enrolled participants were available for determination of CRP and PCT concentrations respectively. Areas under the receiver operating characteristic curves for invasive bacterial infection, diagnosed in 19 tested cases, were 94.3% for CRP and 91.7% for PCT. No single case had a normal CRP concentration (<10 mg/L). Our data, although limited, suggest that CRP or PCT concentrations may help discriminate invasive bacterial infections in patients with neurological disorders in tropical settings and that normal CRP values could assist in withholding antibiotics.
Collapse
Affiliation(s)
- Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Deby Mukendi
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
- Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jean-Roger Lilo Kalo
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Pascal Lutumba
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
- Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kadrie Ramadan
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Andrea S Winkler
- Department of Neurology, Technical University of Munich, Munich, Germany
- Centre for Global Health, University of Oslo, Oslo, Norway
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
22
|
High-Sensitivity C-Reactive Protein: A Potential Ancillary Biomarker for Malaria Diagnosis and Morbidity. DISEASE MARKERS 2019; 2019:1408031. [PMID: 31089391 PMCID: PMC6476067 DOI: 10.1155/2019/1408031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/21/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022]
Abstract
Background Malaria remains an important cause of morbidity and mortality in Africa. Previous studies that assessed C-reactive protein (CRP) have centered on the conventional method. This study evaluated the usefulness of high-sensitivity CRP (hs-CRP) in malaria diagnosis and morbidity in a pediatric population in Ghana. Methodology A total of 267 subjects (100 microscopically proven nonmalarial parasitaemics as controls and 167 plasmodium parasitaemic subjects as cases), between the ages of 7 months and 18 years, were recruited for this case-control study. Blood samples were collected for malaria parasite density by microscopic examination; full blood count, electrolytes, and liver function tests using an automated analyzer; and hs-CRP levels by sandwich ELISA method. Results The median hs-CRP concentration was lowest in the control group and increased significantly from low to high parasitaemia. The median hs-CRP level was significantly higher in high malaria parasitaemia compared to moderate and low malaria parasitaemia. Increasing hs-CRP cutoff (3.12-4.64 mg/L) presented with increasing specificity (79.3-93.1%) and sensitivity (96.4%-97.4%), except for moderate parasitaemia where a decline in sensitivity (80.9%) was observed. However, hs-CRP had relatively lower PPV but high NPV at low parasitaemia while both the PPV and NPV were moderate in moderate parasitaemia. Conclusion hs-CRP yielded a high sensitivity, specificity, and accuracy for low, moderate, and high-grade malaria, respectively, and thus may serve as an effective supplementary diagnostic and prognostic biomarker for Plasmodium parasite infection. However, hs-CRP might not be readily useful yet for diagnostic purposes in hospitals due to the relatively low PPV and NPV for low and moderate parasitaemia and thus necessitates further studies in larger cohorts.
Collapse
|
23
|
Use of procalcitonin in the diagnosis of tuberculosis in infants and preschool children. Eur J Pediatr 2018; 177:1377-1381. [PMID: 29374831 DOI: 10.1007/s00431-018-3099-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/11/2017] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Normal procalcitonin (PCT) levels have been reported in adult pulmonary tuberculosis (TB) but have not been previously investigated in children. We aimed to assess PCT levels at diagnosis of TB in young children in a low-burden setting. In a cross-sectional observational study in a referral pediatric center in Barcelona (Spain), we assessed the value of PCT and other inflammatory markers (leucocyte counts, C-reactive protein, and erythrocyte sedimentation rate) in the diagnosis of TB in pre-school children (< 6 years at diagnosis, n = 45), as compared with two control groups (pneumococcal pneumonia, n = 25; and healthy controls, n = 49). Normal PCT levels were observed at diagnosis of TB in most cases, while C-reactive protein values and leucocyte counts were slightly elevated when compared to healthy controls. All three inflammatory biomarkers were significantly higher in children with pneumococcal pneumonia. CONCLUSIONS In our study, PCT was not a useful diagnostic test for TB in young children. In a low-burden TB setting, PCT may be of some value in distinguishing pulmonary TB from pneumococcal pneumonia. What is Known: • Diagnosis of pediatric tuberculosis on clinical evidence is difficult, particularly in infants and small children. • Studies in adults with tuberculosis have mostly reported normal procalcitonin levels at diagnosis. What is New: • In pre-scholars with tuberculosis, erythrocyte sedimentation rate and white blood cell counts were higher than in healthy controls, but procalcitonin was not. • Procalcitonin may be useful in the differential diagnosis of intrathoracic tuberculosis and pneumococcal pneumonia.
Collapse
|
24
|
Sarfo BO, Hahn A, Schwarz NG, Jaeger A, Sarpong N, Marks F, Adu-Sarkodie Y, Tamminga T, May J. The usefulness of C-reactive protein in predicting malaria parasitemia in a sub-Saharan African region. PLoS One 2018; 13:e0201693. [PMID: 30080904 PMCID: PMC6078295 DOI: 10.1371/journal.pone.0201693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 07/22/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Malaria remains a leading cause of childhood mortality in sub-Saharan Africa. Identifying patients who are at risk for severe manifestations at presentation still remains challenging. This study examines whether a semi-quantitative test on C-Reactive Protein (CRP) could be useful for rapidly predicting the presence or absence of malarial parasitemia in febrile children. METHOD Data were collected from children with fever or a history of fever at the Agogo Presbyterian Hospital in the Ashanti Region of Ghana. Haematological measurements, microscopic detection of plasmodium species and semi-quantitative CRP measurements with a membrane-based immunoassay for whole blood were performed. CRP was classified as positive when the measured level was ≥ 10 mg/l. RESULTS During 548 visits, thick blood film results could be obtained from 541 patients, 270 (49.3%) yielded parasitemia with Plasmodium spp. Whereas malaria parasites were detected in only a few patients (7.1%) with normal CRP levels (< 10mg/l), more than a half of patients with an increased CRP concentration (≥ 10 mg/l) were parasite positive (OR 14.5 [CI 4.4-47.6], p<0.001). Patients with increased CRP levels had more than an eight-fold likelihood for parasitemia after correction for other parameters (adjusted OR 8.7 [CI 2.5-30.5], p<0.001). Sensitivity, specificity as well as positive predictive and negative predictive values of CRP for malaria were 99.3% (CI 96.2%-100%), 9.2% (CI 6.4%-12.8%), 31.7% (CI 27.4%-36.1%) and 97.0% (CI 84.2%-99.9%), respectively. CONCLUSION The semi-quantitative method of measuring CRP is cheap, rapid and easy to perform but not useful in predicting parasitemia and malaria. However, due to its high negative predictive value, it could have a role in identifying those patients unlikely to be presenting with clinical malaria.
Collapse
Affiliation(s)
| | - Andreas Hahn
- Institute for Microbiology, Charité Berlin University of Medicine, Berlin, Germany
| | | | - Anna Jaeger
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | | | - Yaw Adu-Sarkodie
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Juergen May
- Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
- University Medical Centre, Hamburg Eppendorf, Germany
- German Center for Infectious Disease Research (DZIF), Hamburg-Borstel-Lübeck, Germany
| |
Collapse
|
25
|
van Houten CB, de Groot JAH, Klein A, Srugo I, Chistyakov I, de Waal W, Meijssen CB, Avis W, Wolfs TFW, Shachor-Meyouhas Y, Stein M, Sanders EAM, Bont LJ. A host-protein based assay to differentiate between bacterial and viral infections in preschool children (OPPORTUNITY): a double-blind, multicentre, validation study. THE LANCET. INFECTIOUS DISEASES 2017; 17:431-440. [DOI: 10.1016/s1473-3099(16)30519-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/11/2016] [Accepted: 10/28/2016] [Indexed: 12/22/2022]
|
26
|
Abstract
Secondary bacterial pneumonia after viral respiratory infection remains a significant source of morbidity and mortality. Susceptibility is mediated by a variety of viral and bacterial factors, and complex interactions with the host immune system. Prevention and treatment strategies are limited to influenza vaccination and antibiotics/antivirals respectively. Novel approaches to identifying the individuals with influenza who are at increased risk for secondary bacterial pneumonias are urgently needed. Given the threat of further pandemics and the heightened prevalence of these viruses, more research into the immunologic mechanisms of this disease is warranted with the hope of discovering new potential therapies.
Collapse
Affiliation(s)
- Jason E Prasso
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, CHS 37-131, Los Angeles, CA 90095, USA
| | - Jane C Deng
- Division of Pulmonary and Critical Care Medicine, Veterans Affairs Healthcare System, University of Michigan, 2215 Fuller Road, 111G Pulmonary, Ann Arbor, MI 48105, USA.
| |
Collapse
|
27
|
Mahende C, Ngasala B, Lusingu J, Mårtensson T, Lushino P, Lemnge M, Mmbando B, Premji Z. Profile of C-reactive protein, white cells and neutrophil populations in febrile children from rural north-eastern Tanzania. Pan Afr Med J 2017; 26:51. [PMID: 28451028 PMCID: PMC5398868 DOI: 10.11604/pamj.2017.26.51.10264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/16/2016] [Indexed: 12/04/2022] Open
Abstract
Introduction C-reactive protein (CRP), white blood cell (WBC) and absolute neutrophil counts (ANC) are important inflammatory biomarkers in the early diagnosis of infections. However, little is known on their profile and usefulness in fever case management in children attending outpatient clinic in rural north-eastern Tanzania. Methods Patients aged between 2 and 59 months presenting with fever at Korogwe District Hospital were enrolled. Venous blood was collected for evaluation of serum CRP, WBC and ANC. Individual patient diagnosis was based on integrated management of childhood illness (IMCI) guidelines and laboratory investigations (blood and urine cultures). Results A total of 867 patients were enrolled, out of which 691 (79.7%) had complete clinical and laboratory data available for analysis. Acute upper respiratory tract infection 284 (41.1%), acute gastroenteritis 127 (18.4%) and pneumonia 100 (14.5%) were the most frequent diagnoses. The geometric mean levels of serum CRP, WBC and ANC were 10.4 (95% CI: 9.2 - 11.8), 11.5 (95% CI: 11.1 - 11.9) and 5.5 (95% CI: 5.2 - 5.8), respectively. CRP≤20, WBC≤15 (103cells/µL) and ANC≤10 103cells/µL) were observed in the majority of the patients with upper respiratory tract infection, pneumonia, acute gastroenteritis and non-specific febrile illness. Only serum CRP levels were positively correlated with positive blood cultures at a calculated cut-off value of 37.3 mg/L, giving a specificity of 77.8% and sensitivity of 74.2%. Conclusion CRP assessment together with IMCI guidelines may be useful in assisting the diagnosis and management of paediatric febrile infections in Tanzania.
Collapse
Affiliation(s)
- Coline Mahende
- Korogwe Research Station, Tanga Centre, National Institute for Medical Research, P. O. Box 5004, Tanga, Tanzania.,Department of Medical Entomology and Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania
| | - Billy Ngasala
- Department of Medical Entomology and Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania
| | - John Lusingu
- Korogwe Research Station, Tanga Centre, National Institute for Medical Research, P. O. Box 5004, Tanga, Tanzania.,Department of International Health, Microbiology and Immunology, University of Copenhagen, Denmark
| | - Thomas Mårtensson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Paminus Lushino
- Korogwe Research Station, Tanga Centre, National Institute for Medical Research, P. O. Box 5004, Tanga, Tanzania
| | - Martha Lemnge
- Korogwe Research Station, Tanga Centre, National Institute for Medical Research, P. O. Box 5004, Tanga, Tanzania
| | - Bruno Mmbando
- Korogwe Research Station, Tanga Centre, National Institute for Medical Research, P. O. Box 5004, Tanga, Tanzania
| | - Zul Premji
- Department of Medical Entomology and Parasitology, School of Public Health, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania
| |
Collapse
|
28
|
Dittrich S, Tadesse BT, Moussy F, Chua A, Zorzet A, Tängdén T, Dolinger DL, Page AL, Crump JA, D’Acremont V, Bassat Q, Lubell Y, Newton PN, Heinrich N, Rodwell TJ, González IJ. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus. PLoS One 2016; 11:e0161721. [PMID: 27559728 PMCID: PMC4999186 DOI: 10.1371/journal.pone.0161721] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/09/2016] [Indexed: 11/30/2022] Open
Abstract
Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result <10 min (but maximally <2 hrs); ii) storage conditions at 0–40°C, ≤90% non-condensing humidity with a minimal shelf life of 12 months; iii) operational conditions of 5–40°C, ≤90% non-condensing humidity; and iv) minimal sample collection needs (50–100μL, capillary blood). This expert approach to define assay requirements for a bacterial vs. non-bacterial assay should guide product development, and enable targeted and timely efforts by industry partners and academic institutions.
Collapse
Affiliation(s)
- Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- * E-mail:
| | - Birkneh Tilahun Tadesse
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland
- Hawassa University, College of Medicine and Health Sciences, Department of Pediatrics, Hawassa, Ethiopia
| | - Francis Moussy
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
| | - Arlene Chua
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anna Zorzet
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - Thomas Tängdén
- ReAct Europe, Uppsala University, Box 256, 751 05, Uppsala, Sweden
| | - David L. Dolinger
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
- World Health Organization, 20 Avenue Appia, 1211, Geneva 27, Switzerland
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anne-Laure Page
- Epidemiology and Population Health, Epicentre, Paris, France
| | - John A. Crump
- Centre for International Health, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
- Duke Global Health Institute, Box 90519, Duke University, Durham, NC, 27708, United States of America
- Division of Infectious Diseases and International Health, Box 102359, Duke University Medical Center, Durham, NC, 27710, United States of America
| | - Valerie D’Acremont
- Swiss Tropical and Public Health Institute, 4002 Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Bugnon 44, 1011, Lausanne, Switzerland
| | - Quique Bassat
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul N. Newton
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | - Norbert Heinrich
- Division for Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany; German Center for Infection Research, Munich partner site, Leopoldstr 5, D-80802, Munich, Germany
| | - Timothy J. Rodwell
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), 9 Chemin des Mines, 1202 Geneva, Switzerland
| |
Collapse
|
29
|
Kapasi AJ, Dittrich S, González IJ, Rodwell TC. Host Biomarkers for Distinguishing Bacterial from Non-Bacterial Causes of Acute Febrile Illness: A Comprehensive Review. PLoS One 2016; 11:e0160278. [PMID: 27486746 PMCID: PMC4972355 DOI: 10.1371/journal.pone.0160278] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/15/2016] [Indexed: 12/17/2022] Open
Abstract
Background In resource limited settings acute febrile illnesses are often treated empirically due to a lack of reliable, rapid point-of-care diagnostics. This contributes to the indiscriminate use of antimicrobial drugs and poor treatment outcomes. The aim of this comprehensive review was to summarize the diagnostic performance of host biomarkers capable of differentiating bacterial from non-bacterial infections to guide the use of antibiotics. Methods Online databases of published literature were searched from January 2010 through April 2015. English language studies that evaluated the performance of one or more host biomarker in differentiating bacterial from non-bacterial infection in patients were included. Key information extracted included author information, study methods, population, pathogens, clinical information, and biomarker performance data. Study quality was assessed using a combination of validated criteria from the QUADAS and Lijmer checklists. Biomarkers were categorized as hematologic factors, inflammatory molecules, cytokines, cell surface or metabolic markers, other host biomarkers, host transcripts, clinical biometrics, and combinations of markers. Findings Of the 193 citations identified, 59 studies that evaluated over 112 host biomarkers were selected. Most studies involved patient populations from high-income countries, while 19% involved populations from low- and middle-income countries. The most frequently evaluated host biomarkers were C-reactive protein (61%), white blood cell count (44%) and procalcitonin (34%). Study quality scores ranged from 23.1% to 92.3%. There were 9 high performance host biomarkers or combinations, with sensitivity and specificity of ≥85% or either sensitivity or specificity was reported to be 100%. Five host biomarkers were considered weak markers as they lacked statistically significant performance in discriminating between bacterial and non-bacterial infections. Discussion This manuscript provides a summary of host biomarkers to differentiate bacterial from non-bacterial infections in patients with acute febrile illness. Findings provide a basis for prioritizing efforts for further research, assay development and eventual commercialization of rapid point-of-care tests to guide use of antimicrobials. This review also highlights gaps in current knowledge that should be addressed to further improve management of febrile patients.
Collapse
Affiliation(s)
- Anokhi J. Kapasi
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Timothy C. Rodwell
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
- * E-mail:
| |
Collapse
|
30
|
Association between Subclinical Malaria Infection and Inflammatory Host Response in a Pre-Elimination Setting. PLoS One 2016; 11:e0158656. [PMID: 27386859 PMCID: PMC4936742 DOI: 10.1371/journal.pone.0158656] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/20/2016] [Indexed: 12/16/2022] Open
Abstract
Background Subclinical infections in endemic areas of Southeast Asia sustain malaria transmission. These asymptomatic infections might sustain immunity against clinical malaria and have been considered benign for the host, but if they are associated with chronic low-grade inflammation this could be harmful. We conducted a case-control study to explore the association between subclinical malaria and C-reactive protein (CRP), an established biomarker of inflammation. Methods Blood samples from asymptomatic villagers in Pailin, Western Cambodia were tested for malaria by high-volume ultra-sensitive polymerase chain reaction (uPCR) to determine the Plasmodium species. Plasma CRP concentration was measured in 328 individuals with parasitaemia (cases) and compared with: i) the same individual’s value at the first time point when they had no detectable parasites (n = 282); and ii) age- sex- and village-matched controls (n = 328) free of Plasmodium infection. Plasma CRP concentrations were compared against thresholds of 3mg/L and 10mg/L. Subgroup analysis was carried out for cases with P vivax and P falciparum mono-infections. Results Median plasma CRP level for all samples was 0.59mg/L (interquartile range: 0.24–1.64mg/L). CRP concentrations were higher in parasitaemic individuals compared with same-person-controls (p = 0.050); and matched-controls (p = 0.025). 4.9% of samples had CRP concentrations above 10mg/L and 14.6% were above 3mg/L. Cases were more likely to have plasma CRP concentrations above these thresholds than age/sex matched controls, odds ratio 3.5 (95%CI 1.5–9.8) and 1.8 (95%CI 1.1–2.9), respectively. Amongst cases, parasite density and CRP were positively correlated (p<0.001), an association that remained significant when controlling for age and fever. Individuals with P.vivax mono-infections had the highest plasma CRP concentrations with the greatest association with parasitaemia. Discussion In this setting persistent malaria infections in asymptomatic individuals were associated with moderately elevated plasma CRP concentrations; chiefly evident in cases with P.vivax mono-infections. As well as interrupting malaria transmission within the community, treatment of asymptomatic malaria infections, in particular radical cure of vivax malaria, may benefit the health of infected individuals.
Collapse
|
31
|
Tette EMA, Neizer M, Nyarko MY, Sifah EK, Nartey ET, Donkor ES. Changing Patterns of Disease and Mortality at the Children's Hospital, Accra: Are Infections Rising? PLoS One 2016; 11:e0150387. [PMID: 27045667 PMCID: PMC4821618 DOI: 10.1371/journal.pone.0150387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/12/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Millennium Development Goals (MDGs) have led to reductions in child mortality world-wide. This has, invariably, led to the changes in the epidemiology of diseases associated with child mortality. Although facility based data do not capture all deaths, they provide an opportunity to confirm diagnoses and insight into these changes which are relevant for further disease control. OBJECTIVE To identify changes in the disease pattern of children who died at the Princess Marie Louise Children's Hospital (PML) in Ghana from 2003-2013. METHODS A cross sectional review of mortality data was carried out at PML. The age, sex, duration of admission and diagnosis of consecutive patients who died at the hospital between 2003 and 2013 were reviewed. This information was entered into an Access database and analysed using Stata 11.0 software. RESULTS Altogether, 1314 deaths (3.6%) occurred out of a total of 37,012 admissions. The majority of the deaths, 1187 (90.3%), occurred in children under the age of 5 years. While deaths caused by malaria, malnutrition, HIV infection and diarrhoea decreased, deaths caused by pneumonia were rising. Suspected septicaemia and meningitis showed a fluctuating trend with only a modest decrease between 2012 and 2013. The ten leading causes of mortality among under-fives were malnutrition, 363 (30.6%); septicaemia, 301 (25.4%); pneumonia, 218 (18.4%); HIV infection, 183 (15.4%); malaria, 155 (13.1%); anaemia, 135 (11.4%); gastroenteritis/dehydration, 110 (9.3%); meningitis, 58 (4.9%); tuberculosis, 34 (2.9%) and hypoglycaemia, 27 (2.3%). For children aged 5-9 years, the leading causes of mortality were malaria, 42 (42.9%); HIV infection, 27 (27.6%); anaemia, 14 (14.3%); septicaemia, 12 (12.2%); meningitis, 10 (10.2%); malnutrition, 9 (9.2%); tuberculosis, 5 (5.1%); pneumonia, 4 (4.1%); encephalopathy, 3 (3.1%); typhoid fever, 3 (3.1%) and lymphoma, 3 (3.1%). In the adolescent age group, malaria, 8 (27.6%); anaemia, 6 (20.7%); HIV infection, 5 (17.2%); sickle cell disease, 3 (10.3%) and meningitis, 3 (10.3%) were most common. CONCLUSION There has been a decline in the under-five mortality at PML over the years; however, deaths caused by pneumonia appear to be rising. This highlights the need for better diagnostic services, wider HIV screening and clinical audits to improve outcomes in order to achieve further reductions in child mortality and maintain the gains.
Collapse
Affiliation(s)
- Edem M. A. Tette
- Department of Community Health, School of Public Health, University of Ghana, Legon, Ghana
- Princess Marie Louis Children’s Hospital, Accra, Ghana
- * E-mail:
| | | | | | - Eric K. Sifah
- Princess Marie Louis Children’s Hospital, Accra, Ghana
| | - Edmund T. Nartey
- Centre for Tropical Clinical Pharmacology and Therapeutics, School of Medicine and Dentistry, University of Ghana, Legon, Ghana
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Ghana
| | - Eric S. Donkor
- Department of Medical Microbiology, College of Health Sciences, University of Ghana, Legon, Ghana
| |
Collapse
|
32
|
Rubio M, Bassat Q, Estivill X, Mayor A. Tying malaria and microRNAs: from the biology to future diagnostic perspectives. Malar J 2016; 15:167. [PMID: 26979504 PMCID: PMC4793504 DOI: 10.1186/s12936-016-1222-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/09/2016] [Indexed: 12/21/2022] Open
Abstract
Symptoms caused by bacterial, viral and malarial infections usually overlap and aetiologic diagnosis is difficult. Patient management in low-resource countries with limited laboratory services has been based predominantly on clinical evaluation and syndromic approaches. However, such clinical assessment has limited accuracy both for identifying the likely aetiological cause and for the early recognition of patients who will progress to serious or fatal disease. Plasma-detectable biomarkers that rapidly and accurately diagnose severe infectious diseases could reduce morbidity and decrease the unnecessary use of usually scarce therapeutic drugs. The discovery of microRNAs (miRNAs) has opened exciting new avenues to identify blood biomarkers of organ-specific injury. This review assesses current knowledge on the relationship between malaria disease and miRNAs, and evaluates how future research might lead to the use of these small molecules for identifying patients with severe malaria disease and facilitate treatment decisions.
Collapse
Affiliation(s)
- Mercedes Rubio
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Carrer Rosselló 153 (CEK building), 08036, Barcelona, Spain
| | - Quique Bassat
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Carrer Rosselló 153 (CEK building), 08036, Barcelona, Spain.,Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Xavier Estivill
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology; CIBER in Epidemiology and Public Health (CIBERESP), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Experimental Genetics, Sidra Medical and Research Centre, Doha, Qatar
| | - Alfredo Mayor
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Carrer Rosselló 153 (CEK building), 08036, Barcelona, Spain. .,Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique.
| |
Collapse
|
33
|
Lubell Y, Blacksell SD, Dunachie S, Tanganuchitcharnchai A, Althaus T, Watthanaworawit W, Paris DH, Mayxay M, Peto TJ, Dondorp AM, White NJ, Day NPJ, Nosten F, Newton PN, Turner P. Performance of C-reactive protein and procalcitonin to distinguish viral from bacterial and malarial causes of fever in Southeast Asia. BMC Infect Dis 2015; 15:511. [PMID: 26558692 PMCID: PMC4642613 DOI: 10.1186/s12879-015-1272-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Poor targeting of antimicrobial drugs contributes to the millions of deaths each year from malaria, pneumonia, and other tropical infectious diseases. While malaria rapid diagnostic tests have improved use of antimalarial drugs, there are no similar tests to guide the use of antibiotics in undifferentiated fevers. In this study we estimate the diagnostic accuracy of two well established biomarkers of bacterial infection, procalcitonin and C-reactive protein (CRP) in discriminating between common viral and bacterial infections in malaria endemic settings of Southeast Asia. METHODS Serum procalcitonin and CRP levels were measured in stored serum samples from febrile patients enrolled in three prospective studies conducted in Cambodia, Laos and, Thailand. Of the 1372 patients with a microbiologically confirmed diagnosis, 1105 had a single viral, bacterial or malarial infection. Procalcitonin and CRP levels were compared amongst these aetiological groups and their sensitivity and specificity in distinguishing bacterial infections and bacteraemias from viral infections were estimated using standard thresholds. RESULTS Serum concentrations of both biomarkers were significantly higher in bacterial infections and malaria than in viral infections. The AUROC for CRP in discriminating between bacterial and viral infections was 0.83 (0.81-0.86) compared with 0.74 (0.71-0.77) for procalcitonin (p < 0.0001). This relative advantage was evident in all sites and when stratifying patients by age and admission status. For CRP at a threshold of 10 mg/L, the sensitivity of detecting bacterial infections was 95% with a specificity of 49%. At a threshold of 20 mg/L sensitivity was 86% with a specificity of 67%. For procalcitonin at a low threshold of 0.1 ng/mL the sensitivity was 90% with a specificity of 39%. At a higher threshold of 0.5 ng/ul sensitivity was 60% with a specificity of 76%. CONCLUSION In samples from febrile patients with mono-infections from rural settings in Southeast Asia, CRP was a highly sensitive and moderately specific biomarker for discriminating between viral and bacterial infections. Use of a CRP rapid test in peripheral health settings could potentially be a simple and affordable measure to better identify patients in need of antibacterial treatment and part of a global strategy to combat the emergence of antibiotic resistance.
Collapse
Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Stuart D Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Susanna Dunachie
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Ampai Tanganuchitcharnchai
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Wanitda Watthanaworawit
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Daniel H Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos. .,Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos.
| | - Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - François Nosten
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos.
| | - Paul Turner
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
| |
Collapse
|
34
|
Salih KMA, El-Samani EF, Bilal JA, Eldouch W, Ibrahim SA. Clinical and Laboratory Potential Predictors of Blood Culture Positivity in Under Five Children with Clinically Severe Pneumonia - Khartoum -Sudan. J Clin Diagn Res 2015; 9:SC04-7. [PMID: 26436013 DOI: 10.7860/jcdr/2015/13771.6377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 06/07/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Blood culture is necessary for appropriate management of clinically severe pneumonia in children under five years of age. However, in limited resource countries it might be unduly costly and waste of valuable time because of the high negative culture rate. OBJECTIVES This study aims to identify clinical and laboratory parameters that potentially predict a positive blood culture in cases of severe pneumonia. MATERIALS AND METHODS A hospital based study, enrolled 189 cases satisfying the WHO definition of severe pneumonia. Age, gender, clinical history, physical examination, temperature, complete blood count, C-reactive protein, blood culture and Chest X Ray for all the patients were recorded. RESULTS Forty one patients had positive blood culture giving a prevalence of 21.7%. All variables were used in a dichotomous manner. White Blood Count (WBC) more than 20 000, very high C-reactive protein (C-RP ≥8mg/L) and Temperature more than 40(o)C, had a positive predictive value of 46.1%, 44.3% and 40.0% respectively for a positive culture as well as a Negative Predictive Value of 91.1%, 91.6% and 91.7% respectively. The WBC more than 20 000 and temperature above 40(o)C had a significant association with a positive blood culture. Their adjusted Odds Ratios were 3.9 (95% CI: 1.4-10.90) and 3.1 (95% CI: 1.2-8.4) respectively. This was not the case for C-RP (Odds Ratio=2.2, 95% CI: 0.7-2.2) or positive Chest X Ray (Odds Ratio=1.5, 95% CI: 0.6-3.6). CONCLUSION AND RECOMMENDATION Temperature of more than 40(o)C, Very high C-RP and WBC of more than 20 000 are good indicators of a potential positive blood culture. It is therefore recommended that further research be undertaken to refine these predictors as screening tools before resorting to blood culture. It is also recommended that antibiotic treatment may be initiated on the basis of the high temperature and WBC, while waiting for the culture results.
Collapse
Affiliation(s)
- Karimeldin Mohamed Ali Salih
- Associate Professor, Deparment of Pediatrics, Bahri University, College of Medicine, Sudan and King Khalid University, College of Medicine , Abha, KSA
| | - El-Fatih El-Samani
- Professor, Deparment of Community Medicine & Epidemiology Department, Ahfad University for Women , Khartoum, Sudan
| | - Jalal Ali Bilal
- Assistant Professor, Deparment of Pediatrics, Qassim University, College of Medicine , Buraydah, KSA
| | - Widad Eldouch
- Consultant Pediatrician, Deparment of Pediatrics, Ministry of Health , Sudan
| | - Salah Ahmed Ibrahim
- Professor, Deparment of Pediatrics, University of Khartoum, Faculty of Medicine , Sudan
| |
Collapse
|
35
|
Erdman LK, D’Acremont V, Hayford K, Rajwans N, Kilowoko M, Kyungu E, Hongoa P, Alamo L, Streiner DL, Genton B, Kain KC. Biomarkers of Host Response Predict Primary End-Point Radiological Pneumonia in Tanzanian Children with Clinical Pneumonia: A Prospective Cohort Study. PLoS One 2015; 10:e0137592. [PMID: 26366571 PMCID: PMC4569067 DOI: 10.1371/journal.pone.0137592] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/18/2015] [Indexed: 11/30/2022] Open
Abstract
Background Diagnosing pediatric pneumonia is challenging in low-resource settings. The World Health Organization (WHO) has defined primary end-point radiological pneumonia for use in epidemiological and vaccine studies. However, radiography requires expertise and is often inaccessible. We hypothesized that plasma biomarkers of inflammation and endothelial activation may be useful surrogates for end-point pneumonia, and may provide insight into its biological significance. Methods We studied children with WHO-defined clinical pneumonia (n = 155) within a prospective cohort of 1,005 consecutive febrile children presenting to Tanzanian outpatient clinics. Based on x-ray findings, participants were categorized as primary end-point pneumonia (n = 30), other infiltrates (n = 31), or normal chest x-ray (n = 94). Plasma levels of 7 host response biomarkers at presentation were measured by ELISA. Associations between biomarker levels and radiological findings were assessed by Kruskal-Wallis test and multivariable logistic regression. Biomarker ability to predict radiological findings was evaluated using receiver operating characteristic curve analysis and Classification and Regression Tree analysis. Results Compared to children with normal x-ray, children with end-point pneumonia had significantly higher C-reactive protein, procalcitonin and Chitinase 3-like-1, while those with other infiltrates had elevated procalcitonin and von Willebrand Factor and decreased soluble Tie-2 and endoglin. Clinical variables were not predictive of radiological findings. Classification and Regression Tree analysis generated multi-marker models with improved performance over single markers for discriminating between groups. A model based on C-reactive protein and Chitinase 3-like-1 discriminated between end-point pneumonia and non-end-point pneumonia with 93.3% sensitivity (95% confidence interval 76.5–98.8), 80.8% specificity (72.6–87.1), positive likelihood ratio 4.9 (3.4–7.1), negative likelihood ratio 0.083 (0.022–0.32), and misclassification rate 0.20 (standard error 0.038). Conclusions In Tanzanian children with WHO-defined clinical pneumonia, combinations of host biomarkers distinguished between end-point pneumonia, other infiltrates, and normal chest x-ray, whereas clinical variables did not. These findings generate pathophysiological hypotheses and may have potential research and clinical utility.
Collapse
Affiliation(s)
- Laura K. Erdman
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valérie D’Acremont
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Kyla Hayford
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nimerta Rajwans
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mary Kilowoko
- Amana Regional Referral Hospital, Dar es Salaam, United Republic of Tanzania
| | - Esther Kyungu
- St-Francis Hospital, Ifakara, United Republic of Tanzania
| | | | - Leonor Alamo
- Department of Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - David L. Streiner
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
- Infectious Disease Service, University Hospital, Lausanne, Switzerland
| | - Kevin C. Kain
- Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| |
Collapse
|
36
|
Lanaspa M, Madrid L, Bassat Q. Biomarker discovery for childhood infections: paving the way for a diagnostic revolution in the developing world. Biomark Med 2015; 8:1057-60. [PMID: 25402575 DOI: 10.2217/bmm.14.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Miguel Lanaspa
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | | | | |
Collapse
|
37
|
Xiao X, Xue L, Sheng HL, Xiao ZH. Correlation between serum levels of C-reactive protein and infant pneumonia: A meta-analysis. Exp Ther Med 2015; 9:2331-2338. [PMID: 26136982 DOI: 10.3892/etm.2015.2417] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 03/31/2015] [Indexed: 01/11/2023] Open
Abstract
Experimental data imply that serum C-reactive protein (CRP) is a marker of general systemic inflammation, and inflammation may have a role in the development of pneumonia. The aim of the present study was to investigate the associations of serum CRP levels in infant patients with pneumonia by meta-analysis. The Science Citation Index, Cochrane Library, PubMed, Embase, CINAHL, Current Contents and two Chinese (CMB and CNKI) databases were searched. Studies were pooled and standard mean difference (SMD) and the corresponding 95% confidence interval (CI) were calculated. Subgroup analyses and publication bias detection were also conducted. The statistical analysis was conducted using Stata software version 12.0. Serum CRP levels were analyzed in 10 clinical case-control studies (652 infants with pneumonia and 845 healthy controls); significant differences in serum CRP levels were observed between infants with pneumonia and the healthy controls (SMD=4.41, 95% CI: 3.34-5.47, P<0.001). Ethnicity-stratified subgroup analysis detected that high levels of serum CRP may be the main risk factor for infant pneumonia in Asian, African and Caucasian populations (all P<0.05). Serum CRP levels were statistically higher in infants with pneumonia than in healthy infants, and thus serum levels of CRP may have independent diagnostic value for pneumonia in children.
Collapse
Affiliation(s)
- Xiao Xiao
- Neonatal Department, Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Long Xue
- Department of Neurosurgery, Yangpu Hospital of The Tongji University School of Medicine, Shanghai 200000, P.R. China
| | - Hui-Lin Sheng
- Department of Gynecology and Obstetrics, Putuo Maternity and Infant Hospital, Shanghai 200000, P.R. China
| | - Zhi-Hui Xiao
- Neonatal Department, Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| |
Collapse
|
38
|
Lanaspa M, Annamalay AA, LeSouëf P, Bassat Q. Epidemiology, etiology, x-ray features, importance of co-infections and clinical features of viral pneumonia in developing countries. Expert Rev Anti Infect Ther 2014; 12:31-47. [PMID: 24410617 PMCID: PMC7103723 DOI: 10.1586/14787210.2014.866517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pneumonia is still the number one killer of young children globally, accounting for 18% of mortality in children under 5 years of age. An estimated 120 million new cases of pneumonia occur globally each year. In developing countries, management and prevention efforts against pneumonia have traditionally focused on bacterial pathogens. More recently however, viral pathogens have gained attention as a result of improved diagnostic methods, such as polymerase chain reaction, outbreaks of severe disease caused by emerging pathogens, discovery of new respiratory viruses as well as the decrease in bacterial pneumonia as a consequence of the introduction of highly effective conjugate vaccines. Although the epidemiology, etiology and clinical characterization of viral infections are being studied extensively in the developed world, little data are available from low- and middle-income countries. In this paper, we review the epidemiology, etiology, clinical and radiological features of viral pneumonia in developing countries.
Collapse
Affiliation(s)
- Miguel Lanaspa
- Barcelona Center for International Health Research, Hospital Clinic, University of Barcelona, Rosello 132, 08036 Barcelona, Spain
| | | | | | | |
Collapse
|
39
|
Deng JC. Viral-bacterial interactions-therapeutic implications. Influenza Other Respir Viruses 2014; 7 Suppl 3:24-35. [PMID: 24215379 PMCID: PMC3831167 DOI: 10.1111/irv.12174] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2013] [Indexed: 01/09/2023] Open
Abstract
Viral and bacterial respiratory tract infections are a leading cause of morbidity and mortality worldwide, despite the development of vaccines and potent antibiotics. Frequently, viruses and bacteria can co‐infect the same host, resulting in heightened pathology and severity of illness compared to single infections. Bacterial superinfections have been a significant cause of death during every influenza pandemic, including the 2009 H1N1 pandemic. This review will analyze the epidemiology and global impact of viral and bacterial co‐infections of the respiratory tract, with an emphasis on bacterial infections following influenza. We will next examine the mechanisms by which viral infections enhance the acquisition and severity of bacterial infections. Finally, we will discuss current management strategies for diagnosing and treating patients with suspected or confirmed viral‐bacterial infections of the respiratory tract. Further investigation into the interactions between viral and bacterial infections is necessary for developing new therapeutic approaches aimed at mitigating the severity of co‐infections.
Collapse
Affiliation(s)
- Jane C Deng
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
40
|
Huang H, Ideh RC, Gitau E, Thézénas ML, Jallow M, Ebruke B, Chimah O, Oluwalana C, Karanja H, Mackenzie G, Adegbola RA, Kwiatkowski D, Kessler BM, Berkley JA, Howie SRC, Casals-Pascual C. Discovery and validation of biomarkers to guide clinical management of pneumonia in African children. Clin Infect Dis 2014; 58:1707-15. [PMID: 24696240 PMCID: PMC4036688 DOI: 10.1093/cid/ciu202] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Lipocalin 2 distinguishes severe and bacterial pneumonia from nonsevere and nonbacterial pneumonia with a high level of precision. The clinical impact of this biomarker requires large-scale clinical evaluation. Background. Pneumonia is the leading cause of death in children globally. Clinical algorithms remain suboptimal for distinguishing severe pneumonia from other causes of respiratory distress such as malaria or distinguishing bacterial pneumonia and pneumonia from others causes, such as viruses. Molecular tools could improve diagnosis and management. Methods. We conducted a mass spectrometry–based proteomic study to identify and validate markers of severity in 390 Gambian children with pneumonia (n = 204) and age-, sex-, and neighborhood-matched controls (n = 186). Independent validation was conducted in 293 Kenyan children with respiratory distress (238 with pneumonia, 41 with Plasmodium falciparum malaria, and 14 with both). Predictive value was estimated by the area under the receiver operating characteristic curve (AUC). Results. Lipocalin 2 (Lpc-2) was the best protein biomarker of severe pneumonia (AUC, 0.71 [95% confidence interval, .64–.79]) and highly predictive of bacteremia (78% [64%–92%]), pneumococcal bacteremia (84% [71%–98%]), and “probable bacterial etiology” (91% [84%–98%]). These results were validated in Kenyan children with severe malaria and respiratory distress who also met the World Health Organization definition of pneumonia. The combination of Lpc-2 and haptoglobin distinguished bacterial versus malaria origin of respiratory distress with high sensitivity and specificity in Gambian children (AUC, 99% [95% confidence interval, 99%–100%]) and Kenyan children (82% [74%–91%]). Conclusions. Lpc-2 and haptoglobin can help discriminate the etiology of clinically defined pneumonia and could be used to improve clinical management. These biomarkers should be further evaluated in prospective clinical studies.
Collapse
Affiliation(s)
| | - Readon C Ideh
- Child Survival Theme, Medical Research Council Unit, The Gambia
| | - Evelyn Gitau
- Liverpool School of Tropical Medicine, United Kingdom Kenya Medical Research Institute, Centre for Geographical Medicine Research (Coast), Kilifi
| | | | | | - Bernard Ebruke
- Child Survival Theme, Medical Research Council Unit, The Gambia
| | - Osaretin Chimah
- Child Survival Theme, Medical Research Council Unit, The Gambia
| | | | - Henri Karanja
- Kenya Medical Research Institute, Centre for Geographical Medicine Research (Coast), Kilifi
| | - Grant Mackenzie
- Child Survival Theme, Medical Research Council Unit, The Gambia
| | | | | | | | - James A Berkley
- Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford Kenya Medical Research Institute, Centre for Geographical Medicine Research (Coast), Kilifi
| | | | | |
Collapse
|
41
|
Houdouin V, Pouessel G, Angoulvant F, Brouard J, Derelle J, Fayon M, Ferroni A, Gangneux JP, Hau I, Le Bourgeois M, Lorrot M, Menotti J, Nathan N, Vabret A, Wallet F, Bonacorsi S, Cohen R, de Blic J, Deschildre A, Gandemer V, Pin I, Labbe A, Le Roux P, Martinot A, Rammaert B, Dubus JC, Delacourt C, Marguet C. Recommandations sur l’utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l’enfant de plus de trois mois. Arch Pediatr 2014; 21:418-23. [DOI: 10.1016/j.arcped.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/16/2013] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
|
42
|
Page AL, de Rekeneire N, Sayadi S, Aberrane S, Janssens AC, Dehoux M, Baron E. Diagnostic and prognostic value of procalcitonin and C-reactive protein in malnourished children. Pediatrics 2014; 133:e363-70. [PMID: 24446443 DOI: 10.1542/peds.2013-2112] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Early recognition of bacterial infections is crucial for their proper management, but is particularly difficult in children with severe acute malnutrition (SAM). The objectives of this study were to evaluate the accuracy of C-reactive protein (CRP) and procalcitonin (PCT) for diagnosing bacterial infections and assessing the prognosis of hospitalized children with SAM, and to determine the reliability of CRP and PCT rapid tests suitable for remote settings. METHODS From November 2007 to July 2008, we prospectively recruited 311 children aged 6 to 59 months hospitalized with SAM plus a medical complication in Maradi, Niger. Blood, urine, and stool cultures and chest radiography were performed systematically on admission. CRP and PCT were measured by rapid tests and by reference quantitative methods using frozen serum sent to a reference laboratory. RESULTS Median CRP and PCT levels were higher in children with bacteremia or pneumonia than in those with no proven bacterial infection (P < .002). However, both markers performed poorly in identifying invasive bacterial infection, with areas under the curve of 0.64 and 0.67 before and after excluding children with malaria, respectively. At a threshold of 40 mg/L, CRP was the best predictor of death (81% sensitivity, 58% specificity). Rapid test results were consistent with those from reference methods. CONCLUSIONS CRP and PCT are not sufficiently accurate for diagnosing invasive bacterial infections in this population of hospitalized children with complicated SAM. However, a rapid CRP test could be useful in these settings to identify children most at risk for dying.
Collapse
Affiliation(s)
- Anne-Laure Page
- Epidemiology and Population Health, Epicentre, Paris, France
| | | | | | | | | | | | | |
Collapse
|
43
|
Elevated inflammatory markers combined with positive pneumococcal urinary antigen are a good predictor of pneumococcal community-acquired pneumonia in children. Pediatr Infect Dis J 2013; 32:1175-9. [PMID: 23694836 DOI: 10.1097/inf.0b013e31829ba62a] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our objective was to evaluate procalcitonin (PCT) and C-reactive protein (CRP) as predictors of a pneumococcal etiology in community-acquired pneumonia (CAP) in hospitalized children. METHODS Children requiring hospitalization for CAP were prospectively enrolled. The following indices were determined: antibodies against pneumococcal surface proteins (anti-PLY, pneumococcal histidine triad D, pneumococcal histidine triad E, LytB and pneumococcal choline-binding protein A), viral serology, nasopharyngeal cultures and polymerase chain reaction for 13 respiratory viruses, blood pneumococcal polymerase chain reaction, pneumococcal urinary antigen, PCT and CRP. Presumed pneumococcal CAP (P-CAP) was defined as a positive blood culture or polymerase chain reaction for Streptococcus pneumoniae or as a pneumococcal surface protein seroresponse (≥2-fold increase). RESULTS Seventy-five patients were included from which 37 (49%) met the criteria of P-CAP. Elevated PCT and CRP values were strongly associated with P-CAP with odds ratios of 23 (95% confidence interval: 5-117) for PCT and 19 (95% confidence interval: 5-75) for CRP in multivariate analysis. The sensitivity was 94.4% for PCT (cutoff: 1.5 ng/mL) and 91.9% for CRP (cutoff: 100 mg/L). A value≤0.5 ng/mL of PCT ruled out P-CAP in >90% of cases (negative likelihood ratio: 0.08). Conversely, a PCT value≥1.5 ng/mL associated with a positive pneumococcal urinary antigen had a diagnostic probability for P-CAP of almost 80% (positive likelihood ratio: 4.59). CONCLUSIONS PCT and CRP are reliable predictors of P-CAP. Low cutoff values of PCT allow identification of children at low risk of P-CAP. The association of elevated PCT or CRP with a positive pneumococcal urinary antigen is a strong predictor of P-CAP.
Collapse
|
44
|
Abstract
Over the past two decades, the body of literature on the clinical usefulness of procalcitonin (PCT) in adults has grown rapidly. Although this approach has led to increased insight, it has also prompted debate regarding its potential use in diagnosis and management of severe infection. Clinicians, however, are less familiar with the use of PCT in pediatric populations. In this review, we examine PCT as a marker of severe clinical pediatric conditions including its role in systemic inflammation, infection, and sepsis.
Collapse
|
45
|
Díez-Padrisa N, Bassat Q, Morais L, O’Callaghan-Gordo C, Machevo S, Nhampossa T, Ibarz-Pavón AB, Quintó L, Alonso PL, Roca A. Procalcitonin and C-reactive protein as predictors of blood culture positivity among hospitalised children with severe pneumonia in Mozambique. Trop Med Int Health 2012; 17:1100-7. [DOI: 10.1111/j.1365-3156.2012.03035.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
46
|
Mtove G, Hendriksen IC, Amos B, Mrema H, Mandia V, Manjurano A, Muro F, Sykes A, Hildenwall H, Whitty CJM, Reyburn H. Treatment guided by rapid diagnostic tests for malaria in Tanzanian children: safety and alternative bacterial diagnoses. Malar J 2011; 10:290. [PMID: 21978238 PMCID: PMC3210100 DOI: 10.1186/1475-2875-10-290] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 10/06/2011] [Indexed: 11/10/2022] Open
Abstract
Background WHO guidelines for the treatment of young children with suspected malaria have recently changed from presumptive treatment to anti-malarial treatment guided by a blood slide or malaria rapid diagnostic test (RDT). However, there is limited evidence of the safety of this policy in routine outpatient settings in Africa. Methods Children 3-59 months of age with a non-severe febrile illness and no obvious cause were enrolled over a period of one year in a malaria endemic area of Tanzania. Treatment was determined by the results of a clinical examination and RDT result, and blood culture and serum lactate were also collected. RDT-negative children were followed up over 14 days. Results Over the course of one year, 965 children were enrolled; 158 (16.4%) were RDT-positive and treated with artemether-lumefantrine and 807 (83.4%) were RDT-negative and treated with non-anti-malarial medicines. Compared with RDT-positives, RDT-negative children were on average younger with a lower axillary temperature and more likely to have a history of cough or difficulty in breathing. Six (0.6%) children became RDT-positive after enrolment, all of whom were PCR-negative for Plasmodium falciparum DNA at enrolment. In addition, 12 (1.2%) children were admitted to hospital, one with possible malaria, none of whom died. A bacterial pathogen was identified in 9/965 (0.9%) children, eight of whom were RDT-negative and one was RDT-positive, but slide-negative. Excluding three children with Salmonella typhi, all of the children with bacteraemia were ≤12 months of age. Compared to double-read research slide results RDTs had a sensitivity of 97.8% (95%CI 96.9-98.7) and specificity of 96.3% (95%CI 96.3-98.4). Conclusions Use of RDTs to direct the use of anti-malarial drugs in young children did not result in any missed diagnoses of malaria although new infections soon after a consultation with a negative RDT result may undermine confidence in results. Invasive bacterial disease is uncommon in children with non-severe illness and most cases occurred in infants with a current fever.
Collapse
Affiliation(s)
- George Mtove
- 1National Institute for Medical Research, Amani Centre, Muheza, Tanga,Tanzania
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Song JY, Cheong HJ, Heo JY, Noh JY, Yong HS, Kim YK, Kang EY, Choi WS, Jo YM, Kim WJ. Clinical, laboratory and radiologic characteristics of 2009 pandemic influenza A/H1N1 pneumonia: primary influenza pneumonia versus concomitant/secondary bacterial pneumonia. Influenza Other Respir Viruses 2011; 5:e535-43. [PMID: 21682848 PMCID: PMC5780671 DOI: 10.1111/j.1750-2659.2011.00269.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Please cite this paper as: Song et al. (2011). Clinical, laboratory and radiologic characteristics of 2009 pandemic influenza A/H1N1 pneumonia: primary influenza pneumonia versus concomitant/secondary bacterial pneumonia. Influenza and Other Respiratory Viruses 5(6), e535–e543. Background Although influenza virus usually involves the upper respiratory tract, pneumonia was seen more frequently with the 2009 pandemic influenza A/H1N1 than with seasonal influenza. Methods From September 1, 2009, to January 31, 2010, a specialized clinic for patients (aged ≥15 years) with ILI was operated in Korea University Guro Hospital. RT‐PCR assay was performed to diagnose 2009 pandemic influenza A/H1N1. A retrospective case–case–control study was performed to determine the predictive factors for influenza pneumonia and to discriminate concomitant/secondary bacterial pneumonia from primary influenza pneumonia during the 2009–2010 pandemic. Results During the study period, the proportions of fatal cases and pneumonia development were 0·12% and 1·59%, respectively. Patients with pneumonic influenza were less likely to have nasal symptoms and extra‐pulmonary symptoms (myalgia, headache, and diarrhea) compared to patients with non‐pneumonic influenza. Crackle was audible in just about half of the patients with pneumonic influenza (38·5% of patients with primary influenza pneumonia and 53·3% of patients with concomitant/secondary bacterial pneumonia). Procalcitonin, C‐reactive protein (CRP), and lactate dehydrogenase were markedly increased in patients with influenza pneumonia. Furthermore, procalcitonin (cutoff value 0·35 ng/ml, sensitivity 81·8%, and specificity 66·7%) and CRP (cutoff value 86·5 mg/IU, sensitivity 81·8%, and specificity 59·3%) were discriminative between patients with concomitant/secondary bacterial pneumonia and patients with primary influenza pneumonia. Conclusions Considering the subtle manifestations of 2009 pandemic influenza A/H1N1 pneumonia in the early stage, high clinical suspicion is required to detect this condition. Both procalcitonin and CRP would be helpful to differentiate primary influenza pneumonia from concomitant/secondary bacterial pneumonia.
Collapse
Affiliation(s)
- Joon Y Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Vernet G, Saha S, Satzke C, Burgess D, Alderson M, Maisonneuve JF, Beall B, Steinhoff M, Klugman K. Laboratory-based diagnosis of pneumococcal pneumonia: state of the art and unmet needs. Clin Microbiol Infect 2011; 17 Suppl 3:1-13. [DOI: 10.1111/j.1469-0691.2011.03496.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|