Bacteriological and clinical profile of Community acquired pneumonia in hospitalized patients

Evaluating the Sputum Bacteriological Profile of Lower Respiratory Tract Infections With Bartlett Score Analysis in a Tertiary Care Hospital in Southern Karnataka

INTRODUCTION

Lower respiratory tract infections (LRTIs) are one of the most commonly encountered infections with significant mortality and morbidity. Sputum is the most frequently obtained sample for LRTI diagnosis. However, sputum samples carry the risk of being non-representative due to the risk of contamination with oral colonizers. To overcome the dilemma with respect to representative sampling, the use of a scoring system such as the Bartlett scoring system is emphasized. This study probes the bacterial profile of sputum samples among patients presenting with LRTIs and their antibiotic susceptibility profile in relation to the Bartlett scoring system.

METHODOLOGY

Retrospective data for a period of three years, comprising 4960 sputum samples from patients presenting with LRTI, were collected to study the bacterial profile and antibiogram in comparison with the sputum quality analyzed by the Bartlett scoring system.

RESULTS

Out of the 4960 sputum samples analyzed from patients with LRTI, 31.18% yielded the growth of bacterial pathogens, and 98.64% of the sputum samples yielding pathogenic growth had a significant Bartlett score.

CONCLUSION

Sputum samples are non-invasive representative samples of lower airway infective pathologies. Sputum quality assessment by Bartlett scoring serves as a proxy marker to rule out respiratory colonization and aid culture-based diagnosis.

Gingival Necrosis Related to Sepsis-Induced Agranulocytosis Due to Pseudomonas aeruginosa Bacteraemia: A Case Report

Background: There have been no reports of sepsis-induced agranulocytosis causing gingival necrosis in otherwise medically healthy patients to the authors' best knowledge. Even though there are several case reports of gingival necrosis secondary to medication-induced agranulocytosis, they have not systematically described the natural progression of agranulocytosis-related gingival necrosis. Methods: This paper presents a case report of a 29-year-old female Indian patient with generalised gingival necrosis and constitutive signs of intermittent fever, nausea, and vomiting. She also complained of abdominal pains. Blood counts showed agranulocytosis, and the patient was admitted for a workup of the underlying cause. Parenteral broad-spectrum antibiotics were administered, which brought about clinical resolution. Results: Her gingival necrosis was attributed to sepsis-induced agranulocytosis triggered by Pseudomonas aeruginosa bacteraemia, and upon clinical recovery, spontaneous exfoliation left behind exposed bone. Secondary healing over the exposed alveolar bone was noted after a year-long follow-up, albeit with some residual gingival recession. Conclusions: Oral manifestations of gingival necrosis, when present with concomitant constitutive symptoms, could indicate a serious underlying systemic condition that could be potentially life-threatening if left untreated. Dentists should be cognizant of this possibility so that timely intervention is not delayed.

Association of Serum Albumin and Copeptin with Early Clinical Deterioration and Instability in Community-Acquired Pneumonia

Background: There is a paucity of data on biomarkers for the early deterioration and clinical instability of patients in community-acquired pneumonia (CAP), as treatment failure occurs in the first seven days in 90% of patients. Aim: To evaluate serum albumin and copeptin with CURB-65, PSI scoring and ATS/IDSA minor criteria for the prediction of early mortality or ICU-admission (7 days) and clinical instability after 72 h. Methods: In 100 consecutive hospitalized adult CAP patients, PSI-scores, CURB-65 scores, ATS/IDSA 2007 minor criteria, copeptin and albumin on admission were evaluated. Univariate and multivariate Cox regression analysis was performed to assess independent risk factors for early combined mortality or ICU admission. Predictive powers of albumin and copeptin were tested with ROC curves and ICU-free survival probability was tested using Kaplan−Meier analysis. Results: Albumin was lower and copeptin higher in patients with short-term adverse outcomes (p < 0.05). Cox regression analysis showed that albumin [HR (95% CI): 0.41 (0.18−0.94, p = 0.034)] and copeptin [HR (95% CI): 1.94 (1.03−3.67, p = 0.042)] were independent risk factors for early combined mortality or ICU admission (7 days). The Kaplan−Meier analysis observed that high copeptin (>27.12 ng/mL) and low albumin levels (<2.85 g/dL) had a lower (p < 0.001) survival probability. The diagnostic accuracy of albumin was better than copeptin. The inclusion of albumin and copeptin into ATS/IDSA minor criteria significantly improved their predictive power. Conclusions: Both biomarkers serum albumin and copeptin can predict early deterioration and clinical instability in hospitalized CAP patients and increase the prognostic power of the traditional clinical scoring systems.

Systematic review and meta-analysis of comorbidities and associated risk factors in Indian patients of community-acquired pneumonia

Objective:

Comorbidities and risk factors have a major implication on incidence, complications, mortality, and management of community-acquired pneumonia complications and treatment outcomes. This study attempts to identify the same in the Indian population through a systematic review and meta-analysis.

Methods:

We screened observational studies (between January 1990 and February 2021) that reported potential comorbidities and other factors associated with increased risk of community-acquired pneumonia in the Indian population (⩾12 years) using PubMed, Google Scholar, and manual search. The risk of bias was identified using the Joanna Briggs Institute checklist for prevalence studies. Meta-analysis was conducted by using the random intercept logistic regression model.

Results:

Twenty-three studies were included in this analysis. The most prevalent comorbidities were chronic obstructive pulmonary disease (24.2%; 95% confidence interval: 16.4%–34.2%), hypertension (23.7%; 95% confidence interval: 13.6%–38.1%), and diabetes mellitus (16%; 95% confidence interval: 9.9%–24.7%). The prevalence of community-acquired pneumonia was high in patients with a current or previous history of smoking (51.4%; 95% confidence interval: 42.3%–61%) and advanced age ⩾50 years: (55.8%; 95% confidence interval: 48.4%–62%).

Conclusions:

Comorbid conditions like chronic obstructive pulmonary disease, hypertension, and diabetes mellitus and factors like advanced age and smoking history were common risk factors for community-acquired pneumonia in the Indian population.

Clinico-bacteriological profile and antibiotic resistance pattern in patients with acute exacerbation of COPD

Background

Repeated attacks of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have been attributed to bacterial infections. However, sputum microbiology for identifying the bacteriological profile is not performed usually and remains controversial. Thus, we performed a prospective, cross-sectional study to assess the clinico-bacteriological profile of the patients with AECOPD and antibiotic resistance pattern of bacteria isolated from sputum samples. The study involved 104 consecutive hospitalized patients, of either gender, aged 40–90 years, and diagnosed with AECOPD. Before initiating an empirical antibiotic therapy, the sputum samples of all the patients were collected and subjected to Gram staining, bacterial culture, and antibiotic sensitivity.

Results

The most common bacterial isolates were P. aeruginosa (30.7%) followed by K. pneumoniae (20.3%) and S. pneumoniae (8.6%). Both Gram-positive and Gram-negative bacteria were most sensitive to Meropenem (91%) followed by Amoxicillin-clavulanic acid (83%). However, these bacteria were most resistant to Cefoperazone-sulbactam (43%) followed by Levofloxacin (41%). P. aeruginosa and K. pneumoniae were most resistant to Cefoperazone-sulbactam (23%) followed by Fluoroquinolones (23–35%), while S. pneumoniae was most resistant to Ciprofloxacin (44%) followed by Amoxicillin-clavulanic acid (33%).

Conclusions

Isolation of P. aeruginosa, as the most common agent, further confirms its roles in severe attacks of AECOPD. The regularly used antibiotics were found to be resistant to most isolates, thereby suggesting that severity of AECOPD may be attributed to the prevalence of antibiotic-resistant strains.

Community-acquired bacterial pneumonia in adults: An update

Community-acquired pneumonia (CAP) is the prominent cause of mortality and morbidity with important clinical impact across the globe. India accounts for 23 per cent of global pneumonia burden with case fatality rates between 14 and 30 per cent, and Streptococcus pneumoniae is considered a major bacterial aetiology. Emerging pathogens like Burkholderia pseudomallei is increasingly recognized as an important cause of CAP in Southeast Asian countries. Initial management in the primary care depends on clinical assessment while the hospitalized patients require combinations of clinical scores, chest radiography and various microbiological and biomarker assays. This comprehensive diagnostic approach together with additional sampling and molecular tests in selected high-risk patients should be practiced. Inappropriate therapy in CAP in hospitalized patients lengthens hospital stay and increases cost and mortality. In addition, emergence of multidrug-resistant organisms poses tough challenges in deciding empirical as well as definitive therapy. Developing local evidence on the cause and management should be a priority to improve health outcomes in CAP.

Efficacy and safety of interferon on neonates with respiratory syncytial virus pneumonia

Respiratory syncytial virus (RSV) pneumonia is a leading cause of hospitalization and mortality among neonates worldwide, and there are currently no specific clinical treatments for RSV infection. Interferons (IFNs) possess broad-spectrum antiviral properties, and the present study aimed to evaluate the efficacy and safety of IFN-α1b for the treatment of neonatal RSV pneumonia. Neonates with RSV pneumonia were divided into the treatment (126 neonates) and control (160 neonates) groups, the former of which were treated with IFN. Aside from IFN administration, both groups received the same routine treatments. There were no significant differences in patient characteristics between the two groups. All neonates in the two groups displayed symptoms such as a cough (93.0%), tachypnea (90.1%), perilabial cyanosis (67.8%), choking on milk (62.9%) and moist rales (58.4%), and no significant differences in the occurrence of these symptoms were observed between the groups (P>0.05). The percentage of cases with bacterial co-infection was 66.8% (191/286), and the bacterial species in the spectrum primarily included Escherichia coli (21.5%), Klebsiella pneumonia (20.4%), Staphylococcus aureus (17.2%), Acihetobacter baumanii (13.1%) and Pseudomonas aeruginosa (9.9%). There were no significant differences in the co-infection rate or bacterial spectrum between the two groups. The remission time of cough, tachypnea, choking on milk, perilabial cyanosis, moist rales and oxygen inhalation in the treatment group was significantly lower compared with the control group (P<0.05). Although the hospitalization time in the treatment group was shorter compared with the control group, the difference was not significant. There were two patients in the treatment group that developed fever within 2-6 h after receiving IFN-α1b, though no other adverse effects were observed. In conclusion, IFN-α1b treatment improved the symptoms associated with neonatal RSV pneumonia with minimal adverse effects.

Community-Acquired Bacterial Pneumonia-Changing Epidemiology, Resistance Patterns, and Newer Antibiotics: Spotlight on Delafloxacin

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality both in the USA and globally. As the burden of CAP continues to increase due to several factors, the advances in its diagnosis, prevention, and treatment have taken on even greater interest and importance. The majority of CAP patients are treated empirically, and selection of appropriate antibiotic treatment is increasingly difficult because the epidemiology of CAP is changing, in part due to antimicrobial resistance, and the causative CAP pathogens differ between countries and regions. There is also an increasing prevalence of chronic co-morbid diseases among CAP patients. Treatment of CAP has become challenging because of these factors along with the varying safety profiles and efficacy of well-established antibiotics, as well as limited new therapeutic options. Recently, however, new antibiotics have been approved, which will expand the treatment options for CAP, particularly in those patients with underlying complications. Recently approved delafloxacin, an anionic fluoroquinolone, has a unique structure and distinct chemical characteristics; it demonstrated non-inferiority to moxifloxacin in a phase III clinical trial, but was shown to be superior to moxifloxacin at early clinical response in CAP patients who also have chronic obstructive pulmonary disease (COPD) or asthma as a co-morbidity, and in CAP patients who may have severe illness. Delafloxacin could offer an additional therapy against resistant isolates and among these difficult-to-treat patients. This review summarizes the development, latest research, and safety profile of the new antibiotic delafloxacin, and its potential future role in the treatment of CAP.

Prevalence of gram negative bacteria causing community acquired pneumonia among adults in Mwanza City, Tanzania

BACKGROUND

Community acquired pneumonia (CAP) in adults is still a common and serious illness in the sub-Saharan Africa. Identification of the pathogens is crucial in the management of CAP. This study was done to determine the common bacterial pathogens, treatment outcomes and associated factors for microbiological confirmed CAP among adults attending the Bugando Medical Centre and Sekou Toure hospital in the city of Mwanza, Tanzania.

METHODS

This was a hospital based cross sectional study involving patients with community acquired pneumonia attending Bugando Medical Centre and Sekou Toure regional Hospital. Demographic and other data were collected using standardized data collection tool. Sputum culture was done followed by identification of the isolates and antibiotics susceptibility testing.

RESULTS

A total of 353 patients were enrolled in the study. Out of 353 sputum samples, 265(75%) were of good quality. Of 353 non-repetitive sputum cultures, 72/353 (20.4, 95% CI: 16.2-24.6) were positive for the bacterial pathogens with five patients having more than one pathogen. Good quality sputa had significantly higher yield of pathogenic bacteria than poor quality sputa (26.1% vs.3.4%, P = 0.001). The majority 64 (83.1%) of the isolates were gram negative bacteria. Common bacteria isolated were Klebsiella pneumoniae 23/77(29.9%), Streptococcus pyogenes 10/77 (13.0%), Pseudomonas aeruginosa 9/77 (11.7%) and Escherichia coli 7/77 (9.1%). Of 23 K. pneumoniae isolates, 20/23 (87.0%) were resistant to ceftriaxone. Resistance to ceftriaxone was found to be associated with prolongation of CAP symptoms (p = 0.009).

CONCLUSION

Gram negative bacteria resistant to ampicillin, amoxicillin/clavulanic acid and ceftriaxone were most frequently isolated bacteria among adults' patients with CAP attending BMC and Sekou Toure hospital. Routine sputum culture should be performed to guide appropriate treatment of CAP among adults in developing countries.

Bacterial pathogens from lower respiratory tract infections: A study from Western Rajasthan

Respiratory tract infections are the most common diseases that are associated with social burden for the patient. Western Rajasthan has cases of Cystic fibrosis due to migrant population. The dry and dusty environment has led to prevalence of silicosis and COPD. As per IDSA (2018) guidelines, patients attending Out-Patient Department do not need microbiological investigations for lower respiratory tract infections (LRTI) except for influenza and tuberculosis.

Factors predicting in-hospital mortality among patients admitted with community acquired pneumonia at a tertiary care hospital Karachi, Pakistan

INTRODUCTION

Community Acquired Pneumonia (CAP) is associated with significant morbidity and mortality globally, but unfortunately there is limited data available from South East Asia.

OBJECTIVE

To determine the risk factors associated with in-hospital mortality in patients with CAP in a tertiary care hospital of Pakistan.

METHODS

A retrospective study was conducted on adult patients admitted with a diagnosis of CAP from January 2011 till December 2016. Their clinical records were reviewed and a multivariable analysis was done to determine the factors associated with in-hospital mortality.

RESULTS

A total of 1100 files were reviewed, of which 509 were included in the analysis. The mean age was 63.6 ± 16.5 years and 302 (52.16%) were males. The most Common isolated pathogen was Staphylococcus aureus (23%). Overall mortality was 10.8%. On univariate analysis factors associated with mortality were old age patients (P = 0.02); history of pneumonia in last 12 months (P = 0.008); CURB 65 score ≥ 3 (P < 0.001) and high dependency units as initial site of care (P < 0.001). On multivariable analysis CURB65 ≥ 3 score; high dependency unit as initial site of care; bedridden status; presence of bilateral infiltrates on chest X-ray and hemoglobin of 10.4 g/dL or less at the time of admission were key determinants of in-hospital mortality.

CONCLUSION

We found CURB65 ≥ 3 score; high dependency unit as initial site of care; bedridden status; bilateral infiltrates on chest X-ray and low hemoglobin (10.4 g/dL or less) at the time of admission as independent risk factors of in-hospital mortality. Staphylococcus aureus was the most common organism isolated in patients.

Clinical practice guidelines 2019: Indian consensus-based recommendations on pneumococcal vaccination for adults

Similar to the global scenario, pneumococcal diseases are a significant health concern in India. Pneumococcal diseases occur frequently among adults and are largely preventable through vaccines. Globally, several guidelines and recommendations are available for pneumococcal vaccination in adults. However, owing to wide variations in the disease burden, regulatory landscape, and health-care system in India, such global guidelines cannot be unconditionally implemented throughout the country. To address these gaps, the Indian Chest Society and National College of Chest Physicians of India jointly conducted an expert meeting in January 2019. The aim of the discussion was to lay down specific evidence-based recommendations on adult pneumococcal vaccination for the country, with a view to further ameliorate the disease burden in the country. This article presents an overview of the closed-door discussion by the expert members on clinical practice guidelines to be followed for adult pneumococcal vaccination in India.

Seasonal Incidence of Community-acquired Pneumonia: A Retrospective Study in a Tertiary Care Hospital in Kathmandu, Nepal

Introduction

Community-acquired pneumonia (CAP) is the major cause of death in adult and elderly persons with a variety of presentations. Seasonal variation in the incidence of the disease is essential for clinicians and epidemiologists who deal with such diseases. The study was aimed at analysing the clinical profile and outcomes of community-acquired pneumonia during different seasons of the year in a tertiary care hospital, Manmohan Memorial Teaching Hospital (MMTH), of Kathmandu, Nepal.

Method

The aetiology and clinical profile of 378 patients with CAP who were admitted to MMTH over a period of one year were taken into account in this retrospective cross-sectional hospital-based study. Data were retrieved from the hospital medical records section and the Department of Pathology. All patients with a primary diagnosis of CAP admitted to the hospital were included in the study. Monthly and seasonal trends, aetiology, comorbidities, and mortality rates were analysed.

Results 

Of 378 patients with CAP, 160 patients (42.3%) had associated chronic obstructive pulmonary disease (COPD), 92 patients (24.3%) had hypertension (HTN), 59 patients (15.6%) had diabetes, 12 patients (3.1%) had active pulmonary tuberculosis, seven patients (1.85%) had kidney disease, and the remaining 48 patients (12.6%) had only CAP. Seasonal variation of CAP was noted in 131 patients (35%) in the winter, 98 (26%) in autumn, 86 (23%) in spring, and 63 patients (16%) in summer seasons. None of the patients were vaccinated against influenza and pneumococcus. The most common organism isolated in CAP was Acinetobacter calcoaceticus baumannii (ACB) complex (4.7%), which was more distinguished in the winter season. The second most isolated organism was Pseudomonas aeruginosa (2.6%). The most common clinical presentation was fever (63%), followed by cough (47%) and shortness of breath (47%). Sputum culture was found to be positive in 51 cases (13.4%). Among 378 patients, 78 patients (20.6%) received treatment in the Intensive Care Unit (ICU) and the rest of the patients received treatment in the general medical ward. The mortality rate was found to be 6.6%.

Conclusion

An incidence of sputum-positive CAP was found in 51 cases (13.4%). The most common organism was ACB complex, followed by Pseudomonas aeruginosa, which were sensitive to polymyxins. Both of them were predominant in the winter and spring.

Streptococcus pneumoniae as a Cause of Community-Acquired Pneumonia in Indian Adolescents and Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Streptococcus pneumoniae is one of the primary cause of community-acquired pneumonia (CAP) worldwide. However, scant data are available on the prevalence of etiological organisms for CAP in adolescent and adult Indian population.

OBJECTIVE

We performed a systematic review and meta-analysis to determine the contribution of S. pneumoniae in the causation of CAP in Indian patients aged 12 years or above.

METHODOLOGY

We performed a systematic search of both indexed and non-indexed publications using PubMed, databases of National Institute of Science Communication and Information Resources (NISCAIR), Annotated Bibliography of Indian Medicine (ABIM), Google Scholar, and hand search including cross-references using key terms 'community acquired pneumonia AND India'. All studies, published between January 1990 and January 2017, that evaluated Indian patients aged above 12 years with a confirmed diagnosis of CAP were eligible for inclusion. Our search retrieved a total of 182 studies, of which only 17 and 12 qualified for inclusion in the systematic review of all etiological organisms, and meta-analysis of S. pneumonia, respectively.

RESULTS

A total of 1435 patients met the inclusion criteria. The pooled proportion of patients with S. pneumoniae infection was 19% (95% confidence interval [CI]: 12%-26%; I2 = 94.5% where I2 represents heterogeneity, P < .01). Other major etiological agents are Mycoplasma pneumoniae (15.5% [1.1%-35.5%]), Klebsiella pneumoniae (10.5% [1.6%-24.0%]), and Legionella pneumophila (7.3% [2.5%-23.8%]).

CONCLUSIONS

Analysis found approximately a one-fifth proportion of adult Indian patients of CAP with S. pneumoniae infection, suggesting it as a leading organism for causing CAP compared with other etiological organisms.

Bacteriology of community acquired pneumonia in adult patients at Felege Hiwot Referral Hospital, Northwest Ethiopia: a cross-sectional study

Background

Community acquired pneumonia (CAP) is reported as a common cause of lower respiratory tract infection worldwide. Bacterial pathogens and antimicrobial resistance (AMR) associated with this infection varied between geographical regions. Knowledge of the pathogens in a given area and their up-to-date AMR profile is essential for optimal management of patients. This study was aimed at assessing the type of bacterial isolates and their AMR among CAP adult patients at the Felege Hiwot Referral Hospital (FHRH), Northwest Ethiopia.

Methods

This cross-sectional study was conducted during 1 April to 30 July 2018. Demographic related data were collected from the study participants using a structured questionnaire. Sputum samples were collected and processed to identify pathogens using the conventional culture and biochemical tests as per the standard procedures. The Kirby Bauer disk diffusion method was implemented for the AMR testing. Descriptive and multivariable analysis was conducted using SPSS version 23.

Results

Among 414 presumptively diagnosed study participants for CAP, bacterial pathogens were identified from 167 (40.3%) participants. Among these, multidrug resistance (MDR) accounted for 127(76%) of the isolates. The predominant isolates were Streptococcus pneumoniae at 60(35.9%) and Klebsella pneumoniae at 30(18%). Overcrowded living conditions [AOR 1.579 (95%CI: 1.015–2.456)] and alcohol use [AOR 4.043 (95% CI, 2.537–6.443)] were found statistically associated with culture positive sputum.

Conclusions

The study showed high prevalence of mono- and multi-drug resistant isolates in the study area. Therefore, regular surveillance of the type of isolates and their AMR patterns should be considered. Interventions for reducing community acquired pneumonia should be integrated with lifestyle factors related to household and alcohol use.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

Comparative efficacy and safety analysis of CSE-1034: An open labeled phase III study in community acquired pneumonia

OBJECTIVE

CSE-1034 is a novel antibiotic adjuvant entity (AAE) with proven activity against broad range of multi-drug resistant (MDR) pathogens causing various bacterial infections. This phase 3 clinical trial was designed to evaluate the efficacy and safety of CSE-1034 therapy for the treatment of community-acquired pneumonia (CAP) patients of Pneumonia Outcomes Research Team (PORT) risk III-IV.

METHODS

In this multi-centric, controlled, open-labeled phase 3 trial, adult patients with PORT risk III-IV CAP were randomized to receive either intravenous CSE-1034 (3g every 12h) or Ceftriaxone (2g every 12h) for 3-10 days. The primary endpoint was clinical response in clinically-evaluable (CE) population and microbiological eradication in microbiologically-evaluable (ME) population at test of cure (TOC) visits. Secondary endpoints included verification of the primary endpoints across all other visits, treatment duration and safety of patients.

RESULTS

156 patients were screened at 5 study centers of which 93 subjects were enrolled in the study and randomized in CSE-1034 and Ceftriaxone treatment arms. In CE population (n=90), the clinical cure rates at TOC visit were 96% and 64% in CSE-1034 (n=46) and Ceftriaxone (n=44) treatment arms respectively (treatment difference: 32.0%; 95% CI, 15.8%-47.1%). The bacterial eradication in ME population of two treatment arms were 94% (n=36) and 56% (n=27) at TOC visit (treatment difference: 38.9%; 95% CI, 17.8%-57.6%). Overall, the total number of adverse events (AEs) reported in both groups were 21 (22.5%). The AEs rates reported in two treatment arms were 15.2% in CSE-1034 and 29.8% in Ceftriaxone group.

CONCLUSION

Overall assessment of clinical cure rate, microbiological eradication rate and safety assessment in this study has shown that CSE-1034 is an effective and safe option for the treatment of CAP patients of PORT risk III-IV. Moreover, the superiority of CSE-1034 over Ceftriaxone is also proven.

Association of high mortality with extended-spectrum β-lactamase (ESBL) positive cultures in community acquired infections

PURPOSE

Infections due to multidrug resistant organisms have become a serious health concern worldwide. The present study was conducted to investigate the spectrum of microbial resistance pattern in the community and their effects on mortality.

METHODS

A retrospective review and analysis of prospectively collected data was done of all patients admitted with diagnosis of sepsis in two tertiary care ICU's for a period of two years. Demographics, culture positivity, microbial spectrum, resistance pattern and outcome data were collected.

RESULTS

Out of 5309 patients enrolled; 3822 had suspected clinical infection on admission with 1452 patients growing positive microbial cultures. Among these, 201 bacterial strains were isolated from patients who had community acquired infections. 73% were Gram negative bacilli, commonest being E. coli (63%). 63.4% E. coli and 60.7% Klebsiella isolates were ESBL producers. The mortality in ESBL positive infections was significantly higher as compared to ESBL negative infections (Odds ratio 2.756). Moreover, ESBL positive patients empirically treated with Beta Lactams+Beta Lactamase inhibitors (BL+BLI) had significantly higher mortality as compared to patients treated with carbapenems. More data from multiple centres need to be gathered to formulate appropriate antibiotic policy for critically ill patients admitted from the community.

Mass gathering medicine (Hajj Pilgrimage in Saudi Arabia): The clinical pattern of pneumonia among pilgrims during Hajj

The planned annual Hajj to the holy shrines in Makkah, Saudi Arabia, is recognized as one of the largest recurring religious mass gatherings globally, and the outbreak of infectious diseases is of major concern. We aim to study the incidence, etiology, risk factors, length of hospital stay, and mortality rate of pneumonia amongst pilgrims admitted to Al-Ansar general hospital, Madinah, Saudi Arabia during the Hajj period of December 2004-November 2013. A retrospective analysis of all patients diagnosed and admitted as pneumonia was done. Patients were assessed according to the CURB-65 scoring system and admitted to the ward or intensive care unit accordingly. Throat and nasopharyngeal swabs, sputum, and blood culture were collected prior to antibiotic treatment. 1059 patients were included in the study (23% of total hospital admissions and 20% of ICU admissions). The mean age of participants was 56.8 years, the Male:Female ratio was 3:1, and the lengths of stay in the ward and intensive care units were 5 and 14.5 days, respectively. The main organisms cultured from sputum were Klebsiella Pneumoniae, Streptococcus Pneumoniae, Haemophilus Influenzae, Staphylococcus Aureus, Pseudomonas aeruginosa, and community-acquired MRSA. The mortality rate in the ward was 2.4%, while the rate in the ICU was 21.45%. The organisms which caused pneumonia were found to be different during Hajj. The usual standard guideline for the treatment of pneumonia was ineffective for the causative organisms. Therefore, specific adjustments in the guidelines are needed. All efforts should be made to determine the infectious agent. Healthcare workers and pilgrims should adhere to preventive measures.

Prevalence of LRTI in Patients Presenting with Productive Cough and Their Antibiotic Resistance Pattern

AIM

To find out the prevalence of Lower Respiratory Tract Infection (LRTI) such as bacterial, fungal, mycobacterial infections etc. in patients with productive cough of duration less than 15 days and to rule out the patients having previous history of tuberculosis or having treatment of tuberculosis.

MATERIALS AND METHODS

Outdoor and Indoor patients of Department of Medicine and Chest & TB, SRG hospital and Jhalawar Medical College, Jhalawar were included. After sample collection the specimens were sent to the Microbiology department, for processing of Gram staining, Acid fast staining, KOH mount and bacteriological culture and sensitivity.

RESULTS

A total of 200 samples were obtained from the outpatient and inpatient Department of Medicine and Chest & TB of which 66% were male and 34% were female. Seventy seven percent of samples were culture positive for both single pathogen and mixed infection of which 56.5% were male and 20.5% were female as males are more at risk for LRTI. Klebsiella pneumoniae was the most prevalent pathogen (71/193), followed by coagulase positive Staphylococci i.e. COPS (43/193). More resistant pattern was found in coagulase negative Staohylococci (CONS) showed 61.11% Methicillin Resistant Staohylococci (MRS) incidence compared to 41.86% in COPS, also regarding Extended Spectrum Beta Lactamase (ESBL) production Escherichia coli showed incidence of 36.36% as compared to other gram negative bacilli. Pseudomonas aeruginosa was the most resistant organism found based on the antibiotic susceptibility pattern while Proteus mirabilis was the most sensitive organism.

CONCLUSION

Lower respiratory tract infections can spread easily among community and indiscriminate use of antibiotics contributes to their therapeutic failure. Area-wise studies on antimicrobial susceptibility profiles are essential to guide policy on the appropriate use of antibiotics to reduce the morbidity and mortality and also to control the emergence of antimicrobial resistance in local area.

Changing bacteriological profile and mortality trends in community acquired pneumonia

There are very few and conflicting Indian data regarding the bacteriological etiology of community acquired pneumonia (CAP). Adding to this agony, there is no credible data from the eastern part of India. This is a cross-sectional study and descriptive in nature over a period of 1-year. Of the 464 cases of the study population, we could isolate aerobic bacteria in 149 patients (32.1%). Streptococcus pneumoniae has been identified as the most common organism causing CAP (68/149). Gram-negative bacilli (GNB) as a group exceeded marginally over S. pneumoniae (69/149). Among GNB, Pseudomonas aeruginosa was the most common organism (31/69), followed by Klebsiella pneumoniae (29/69). Staphylococcus aureus was identified in (12/149) cases. Co-amoxyclav is still the most sensitive drug for S. pneumoniae. P. aeruginosa was most sensitive to imipenam followed by piperacillin-tazobactam.

Efficacy and safety of moxifloxacin in community acquired pneumonia: a prospective, multicenter, observational study (CAPRIVI)

Background

Community acquired pneumonia (CAP) is a major cause of morbidity, hospitalization, and mortality worldwide. Management of CAP for many patients requires rapid initiation of empirical antibiotic treatment, based on the spectrum of activity of available antimicrobial agents and evidence on local antibiotic resistance. Few data exist on the severity profile and treatment of hospitalized CAP patients in Eastern and Central Europe and the Middle East, in particular on use of moxifloxacin (Avelox®), which is approved in these regions.

Methods

CAPRIVI (Community Acquired Pneumonia: tReatment wIth AVelox® in hospItalized patients) was a prospective observational study in 12 countries: Croatia, France, Hungary, Kazakhstan, Jordan, Kyrgyzstan, Lebanon, Republic of Moldova, Romania, Russia, Ukraine, and Macedonia. Patients aged >18 years were treated with moxifloxacin 400 mg daily following hospitalization with a CAP diagnosis. In addition to efficacy and safety outcomes, data were collected on patient history and disease severity measured by CRB-65 score.

Results

2733 patients were enrolled. A low severity index (i.e., CRB-65 score <2) was reported in 87.5% of CAP patients assessed (n = 1847), an unexpectedly high proportion for hospitalized patients. Moxifloxacin administered for a mean of 10.0 days (range: 2.0 to 39.0 days) was highly effective: 96.7% of patients in the efficacy population (n = 2152) improved and 93.2% were cured of infection during the study. Severity of infection changed from “moderate” or “severe” in 91.8% of patients at baseline to “no infection” or “mild” in 95.5% at last visit. In the safety population (n = 2595), 127 (4.9%) patients had treatment-emergent adverse events (TEAEs) and 40 (1.54%) patients had serious TEAEs; none of these 40 patients died. The safety results were consistent with the known profile of moxifloxacin.

Conclusions

The efficacy and safety profiles of moxifloxacin at the recommended dose of 400 mg daily are characterized in this large observational study of hospitalized CAP patients from Eastern and Central Europe and the Middle East. The high response rate in this study, which included patients with a range of disease severities, suggests that treatment with broader-spectrum drugs such as moxifloxacin is appropriate for patients with CAP who are managed in hospital.

Trial registration

ClinicalTrials.gov identifier: NCT00987792

Etiology of severe community-acquired pneumonia during the 2013 Hajj-part of the MERS-CoV surveillance program

Background

Pneumonia is the leading cause of hospital admission during the annual Islamic pilgrimage (Hajj). The etiology of severe pneumonia is complex and includes the newly emerged Middle East respiratory syndrome coronavirus (MERS-CoV). Since 2012, the Saudi Ministry of Health (MoH) has required screening for MERS-CoV for all cases of severe pneumonia requiring hospitalization. We aimed to screen Hajj pilgrims admitted to healthcare facilities in 2013 with severe community-acquired pneumonia (CAP) for MERS-CoV and to determine other etiologies.

Methods

Sputum samples were collected from all pilgrims admitted to 15 healthcare facilities in the cities of Makkah and Medina, Saudi Arabia, who were diagnosed with severe CAP on admission, presenting with bilateral pneumonia. The medical records were reviewed to collect information on age, gender, nationality, and patient outcome. Samples were screened for MERS-CoV by PCR, and a respiratory multiplex array was used to detect up to 22 other viral and bacterial respiratory pathogens.

Results

Thirty-eight patients met the inclusion criteria; they were predominantly elderly (mean age 58.6 years, range 25–83 years) and male (68.4%), and all were from developing countries. Fourteen of the 38 patients died (36.8%). MERS-CoV was not detected in any of the samples. Other respiratory pathogens were detected in 26 (68.4%) samples. Of these, bacterial pathogens were detected in 84.6% (22/26) and viruses in 80.7% (21/26). Twenty-one (80.7%) samples were positive for more than one respiratory pathogen and 17 (65.3%) were positive for both bacteria and viruses. The most common respiratory virus was human rhinovirus, detected in 57.7% of the positive samples, followed by influenza A virus (23.1%) and human coronaviruses (19.2%). Haemophilus influenzae and Streptococcus pneumoniae were the predominant bacteria, detected in 57.7% and 53.8%, respectively, of the positive samples, followed by Moraxella catarrhalis (36.4%).

Conclusions

MERS-CoV was not the cause of severe CAP in any of the hospitalized pilgrims investigated. However we identified a variety of other respiratory pathogens in the sputum of this small number of patients. This indicates that the etiology of severe CAP in Hajj is complex with implications regarding its management.

Microbiological Profile and Drug Sensitivity Pattern among Community Acquired Pneumonia Patients in Tertiary Care Centre in Mangalore, Coastal Karnataka, India

BACKGROUND

Community Acquired Pneumonia (CAP) is the most common respiratory tract infection in day to day practice. The knowledge of organism commonly causative of CAP helps in early empirical treatment initiation.

AIM

To study the microbiological profile of patients with community acquired pneumonia and to study drug sensitivity pattern.

METHODS

Hospital based cross sectional study among 100 patients with CAP was conducted in a tertiary care hospital of Southern India. Sputum culture showed that out of 100 patients 39 had an identifiable etiology with 12 patients having evidence of mixed infection.

RESULT

Micro-organisms isolated in sputum culture were Streptococcus pneumoniae (31%) followed by, Pseudomonas pyogens (15%), Klebsiella pneumoniae (13%). AFB smear was found to be positive in 6 patients. Organisms were found to be sensitive for piperacillin plus tazobactum (41%), aminoglycocides (amikacin-46%, gentamicin-31%), third generation cephalosporins (Cefotaxim-36%, Ceftriaxone-18%) and macrolides (Erythromicin-31%, Azithromycin-18%). Sensitivity to chloramphenicol was observed in 31% sputum culture positive patients. Ciprofloxacin sensitivity was seen among 49%.

CONCLUSION

Most of the organisms were found to be sensitive to monotherapy with extended spectrum beta lactamases, third generation cephalosporins, fluroquinolones, macrolides.

Population pharmacokinetic analysis of ciprofloxacin in the elderly patients with lower respiratory tract infections

The aims of the study were to develop a population pharmacokinetic model of ciprofloxacin (CPX) in the elderly patients and to examine the impact of patient-dependent variables on pharmacokinetic parameter values of this drug. The study was conducted in a group of 44 patients at the age of 44-96years, hospitalized due to pneumonia lobaris or bronchopneumonia. Patients received CPX at a dose of 200mg every 12h as a constant rate infusion over 0.5h. Concentrations of CPX in serum were measured by HPLC with UV detection. Population pharmacokinetic analysis revealed that CPX concentration versus time data were best described by a one-compartment model. The mean values of volume of distribution and clearance of CPX in the patients above 65years of age were 78.41±13.17L and 18.39±4.15L/h, respectively. The creatinine clearance influenced CPX clearance according to the equation: CLCPX (L/h)=8.0+0.21·CLCr, while the volume of distribution of CPX was dependent on the body weight of the patient as follows: VdCPX (L)=22.72+0.86·WT. In summary, the developed population model can be used to assess the pharmacokinetic parameters of CPX in the elderly patients and to select on the basis of these parameters and MIC values an optimal dosage regimen of this drug.

The bacterial aetiology of adult community-acquired pneumonia in Asia: a systematic review

BACKGROUND

Community-acquired pneumonia (CAP) is a major cause of adult mortality in Asia. Appropriate empirical treatment depends on knowledge of the pathogens commonly responsible. However, assessing the aetiological significance of identified organisms is often difficult, particularly with sputum isolates that might represent contamination with oropharyngeal flora.

METHODS

A systematic review of all adult CAP aetiology studies from Asia, excluding the Middle East, published in English between 1 January 1990 and 1 March 2012 was conducted. Forty-eight studies reporting on 10 423 patients were included, representing data from China, India, Indonesia, Japan, Malaysia, The Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam. Data from large parts of Asia were unavailable and there was substantial heterogeneity in methodology.

RESULTS

As in western studies, Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella spp. and Haemophilus influenzae were all significant pathogens. However, compared with western studies, S. pneumoniae was of less relative importance. Gram-negative bacilli and Mycobacterium tuberculosis were more important, and in northeast Thailand Burkholderia pseudomallei was a major pathogen.

CONCLUSION

These data have major implications for diagnostic strategies and empirical treatment. Narrow-spectrum antibiotics targeting S. pneumoniae may be inappropriate in many Asian settings, and agents active against TB may lead to partial response and delayed TB diagnosis.

Etiology and Anti-microbial Sensitivity of Organisms Causing Community Acquired Pneumonia: A Single Hospital Study

Objective:

The objective of this study was to identify the common etiological pathogens causing community acquired pneumonia (CAP) in our hospital and sensitivity patterns to the common antibiotics used.

Materials and Methods:

This study was undertaken in a 750 bedded multi-specialty referral hospital in Kerala catering to both urban and semi-urban populations. It is a prospective study of patients who attended the medical out-patient department and those admitted with a clinical diagnosis of CAP, during the year 2009. Data were collected based on detailed patient interview, clinical examination and laboratory investigations. The latter included sputum culture and sensitivity pattern. These were tabulated and percentage incidence of etiological pathogens calculated. The antimicrobial sensitivity pattern was also classified by percentage and expressed as bar diagram.

Results:

The study showed Streptococcus pneumoniae to be the most common etiological agent for CAP, in our hospital setting. The other organisms isolated in order of frequency were Klebsiella pneumoniae, Pseudomonas aeruginosa, Alpha hemolytic streptococci, Escherichia coli, Beta hemolytic streptococci and atypical coli. S. pneumoniae was most sensitive to linezolid, followed by amoxicillin-clavulanate (augmentin), cloxacillin and ceftriaxone. Overall, the common pathogens causing CAP showed highest sensitivity to amikacin, followed by ofloxacin, gentamycin, amoxicillin-clavulanate (augmentin), ceftriaxone and linezolid. The least sensitivity rates were shown to amoxicillin and cefoperazone.

Conclusion:

In a hospital setting, empirical management for cases of CAP is not advisable. The present study has shown S. pneumoniae as the most likely pathogen and either linezolid or amikacin as the most likely effective antimicrobial in cases of CAP, in our setting.

Etiology and outcome of severe community acquired pneumonia in immunocompetent adults

BACKGROUND

Community Acquired Pneumonia (CAP) is a commonly encountered disease, one third of which is Severe Community Acquired Pneumonia (SCAP) that can be potentially fatal. There is a paucity of data on etiology and outcome of patients with SCAP in South Asian Population.

METHODS

A retrospective cross-sectional study was conducted from March 2002 till December 2008 on patients of 16 years and above who were admitted with the diagnosis of SCAP in accordance to the criteria of American Thoracic Society Guidelines (2001). The patients underwent clinical and diagnostic evaluations to detect the severity of illness as well as the etiology and other risk factors influencing the eventual outcome of SCAP.

RESULTS

A total of 189 patients were included in the study. The mean age was 60 ± 18.0 years and 110 (58%) patients were males. The most common isolated pathogens were Staphylococcus aureus (15 patients), Streptococcus pneumoniae (14 patients) and Pseudomonas aeruginosa (9 patients). The highest mortality was seen in patients with Pseudomonas aeruginosa (89%) and Staphylococcus aureus (53%). Overall mortality rate was 51%. On univariate analysis, septic shock (p <0.001), prior antibiotic use (p = 0.04), blood urea nitrogen > 30 mg/dl (p = 0.03), hematocrit < 30% (p = 0.03) and Acute Physiology and Chronic Health Evaluation (APACHE) II score > 20 (p < 0.001) were significantly different between the patients who survived as compared to those who did not. On multivariate analysis, septic shock (p <0.001, OR: 4.70; 95% CI= 2.49-8.87) was found to be independently associated with mortality.

CONCLUSION

The microbes causing SCAP in our study are different from the usual spectrum. Staphylococcus aureus and Pseudomonas aeruginosa were the common causative pathogens and associated with high mortality. It is important to establish clinical guidelines for managing SCAP according to the etiologic organisms in our setting.

Regional epidemiology of invasive pneumococcal disease in Asian adults: epidemiology, disease burden, serotype distribution, and antimicrobial resistance patterns and prevention

OBJECTIVES

To summarize published data on the clinical and economic burden, epidemiology, antimicrobial resistance levels, serotype prevalence, and prevention strategies for pneumococcal disease among adults in Asia.

METHODS

We performed a systematic search of the PubMed database for relevant, peer-reviewed articles published between January 1995 and December 2011, covering China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam.

RESULTS

Taiwan and Thailand had the most comprehensive epidemiological data on adult pneumococcal disease. Very little relevant data were found for Indonesia, Pakistan, the Philippines, and Vietnam; surveillance is urgently needed in these countries. The emergence and spread of resistance emphasize the importance of vaccination to prevent infection in adults at increased risk for serious pneumococcal disease. Vaccination policies and opinions on the efficacy of vaccination vary widely in Asian countries, although a new option in the form of a pneumococcal conjugate vaccine is now available.

CONCLUSIONS

Increased awareness of the public health and economic benefits of pneumococcal vaccination is critically needed to help both the public and policymakers in making changes to vaccination policies in the region. Maximizing access to pneumococcal vaccines will decrease the number of hospitalizations, complications, and deaths associated with pneumococcal disease.

Lower Respiratory Tract Infections (LTRIs): An Insight into the Prevalence and the Antibiogram of the Gram Negative, Respiratory, Bacterial Agents

BACKGROUND

Community acquired respiratory tract infections are one of the commonest health issues globally, which demand frequent visits to the family practitioners. The emergence of antibiotic resistance in the frequently isolated pathogens has complicated the use of the empiric therapy with traditional agents.

AIM

This study was focused on obtaining a comprehensive insight into the microbial profile, its prevalence and the susceptibility patterns of the gram negative bacilli isolates in lower respiratory tract infections.

METHODS AND MATERIALS

Respiratory samples which were received from the patients at a Medical College Hospital in North Kerala, India were processed according to the standard protocol over a period of one year, from April 2011 to March 2012. The antimicrobial susceptibility was tested by the Kirby-Bauer disc diffusion method as per the CLSI guidelines. The data was interpreted by using the WHO Net antibiotic susceptibility surveillance soft ware Results: Out of 1750 respiratory samples, 298(17.03%) were culture positive for gram negative bacilli. The highest isolation rate was observed in the 61-80 years age group with a male preponderance and Klebsiella pneumoniae (41.95%) was found to be the predominant organism. The resistance pattern varied for different organisms. Among the different groups of antibacterial agents which were tested, levofloxacin was found to be an effective oral antibacterial against the pathogens which were isolated. The carbapenems (imipenem and meropenem), the betalactum/betalactamase inhibitors (piperacillin/tazobactum) and the aminoglycosides (amikacin) were effective among the parenteral antibacterials. The selection of the appropriate antibacterial therapy should be based on the organisms which are isolated and on the emerging resistance to the conventional therapies.

CONCLUSION

Owing to the increased concern which surrounds antibiotic resistance and the changing patterns of the bacterial pathogens, the ongoing surveillance of disease and a regular review of the management guidelines are critical.

Epidemiological investigation of a legionellosis outbreak in a Slovenian nursing home, August 2010

BACKGROUND

August 2010 marked the beginning of the largest outbreak of legionellosis in a Slovenian nursing home. This article presents our experiences with the outbreak investigation.

METHODS

In order to collect the necessary patient epidemiological data, we used individual epidemiological questionnaires. Samples were available from 15 patients and were subject to laboratory investigation. Urine and sputum samples were difficult to obtain due to the underlying diseases of the patients. Serological diagnostics constituted an important part of the epidemiological investigation. Sixty-four environmental samples were taken to identify the sources of infection. By genotyping, we assessed the affinity of the allelic profile of Legionella pneumophila serogroup 1 in environmental samples and in patient samples.

RESULTS

Legionnaires' disease was diagnosed in 10 patients based on a combination of various tests. Legionella pneumophila serogroup 1, Legionella pneumophila serogroups 2-14, and Legionella sp., in concentrations of < 10 to 61,000 CFU/l, were isolated from 51 out of 64 environmental samples. The source of the outbreak was confirmed by genotyping the isolates from patients and the isolates from the water supply system. The 2 isolates had identical allelic profiles corresponding to that of L. pneumophila serogroup 1 allelic profile 2,3,9,10,2,1,6, designated sequence type 23 (according to the European Working Group for Legionella Infections).

CONCLUSION

We describe a Legionella pneumophila serogroup 1 outbreak in a Slovenian nursing home. The source of infection was demonstrated using sequence-based typing. Water flow disturbances were determined as the most probable cause of Legionella growth. Overall, the risk of a Legionella outbreak is underestimated in Slovenia.