Aetiological spectrum of severe community-acquired pneumonia in HIV-positive patients from Pune, India

Severe community-acquired pneumonia at a tertiary academic hospital in Johannesburg, South Africa

PURPOSE

There is a paucity of data from sub-Saharan Africa describing Severe Community Acquired Pneumonia (SCAP), a condition with significant morbidity and mortality.

MATERIALS AND METHODS

This was a retrospective, single-centre, observational study of consecutive patients with SCAP admitted to the ICU at Charlotte Maxeke Johannesburg Academic Hospital, in South Africa between 1 July 2007 and 31 May 2019. Pneumonia was categorised as community-acquired if there had been no hospitalization in the preceding 2 weeks.

RESULTS

We identified 931 patients, (median age 37 [IQR 30-48] years), with the predominant co-morbidity being HIV co-infection (77.1 %). The median CURB-65 and APACHE II scores were 3 (IQR 2-3) and 18 (IQR 14-23) respectively, and most patients had multilobar consolidation on chest X-ray. Mycobacterium tuberculosis was the most common aetiology, followed by Streptococcus pneumoniae. The latter, and Pneumocystis jirovecii were more common amongst survivors and non-survivors, respectively. ICU mortality was 50.1 % and 85 % of patients required ventilation, mostly invasive mechanical ventilation. Ventilated patients and those requiring inotropic support and/or dialysis were more likely to die.

CONCLUSION

We have described a cohort of patients with SCAP, with a comprehensive overview of all putative microbiological causes, which to our knowledge, is the largest reported in the literature.

Alahmadi R, Raman G, Idhayadhulla A. Typical pneumonia among human immunodeficiency virus-infected patients in public hospitals in southern Ethiopia

BACKGROUND

Typical pneumonia is a pressing issue in the treatment of human immunodeficiency virus (HIV) patients, especially in Sub-Saharan Africa, where it remains a significant menace. Addressing this problem is crucial in improving health outcomes and the reduction of the burden of diseases in this vulnerable category of patients.

OBJECTIVE

To determine the prevalence of community-acquired typical pneumonia among HIV patients in Public Hospitals in southern Ethiopia.

METHODS

A cross-sectional study was done among 386 HIV patients clinically suspected of typical pneumonia attending the anti-retroviral therapy (ART) clinics of two hospitals from March to September 2022. A pretested structured questionnaire was employed to collect the demographic, clinical, and behavioral data. Sputum samples were collected and inspected for bacteria following standard procedures, and antimicrobial susceptibility testing was performed employing the Kirby-Bauer disk diffusion method. Besides, extended-spectrum β-lactamase (ESβL) and carbapenemase-producing Gram-negative bacteria were inspected by the double disk synergy test and modified carbapenem inactivation method. Descriptive and inferential statistical analyses were also done.

RESULTS

Overall, 39.1% (151/386) of sputum cultures (95% Confidence Interval: 32.4-44) were bacteriologically positive. A total of 151 bacteria were identified, comprising 72.8% (n = 110) of Gram-negative bacteria. The predominant isolate was Klebsiella pneumoniae (25.8%, n = 39), followed by Staphylococcus aureus (17.9%, n = 27); 59.6% (n = 90) of the entire isolates were multidrug-resistant (MDR). Forty percent (11/27) of S. aureus were methicillin-resistant S. aureus (MRSA), and 28.1% (n = 31) and 20.9% (n = 23) of Gram-negative bacteria were extended-spectrum beta-lactamases (ESBL) and carbapenemase producers, respectively. Occupational status, alcohol consumption, cluster of differentiation4 (CD4) Thymocyte cell count < 350, interruption of trimethoprim-sulfamethoxazole prophylaxis and antiretroviral treatment, and recent viral load ≥ 150 were found statistically significant.

CONCLUSION

The higher rates of MDR, MRSA, ESBL, and carbapenem-resistant Enterobacterales (CRE) indicate that bacterial pneumonia is a vexing problem among HIV patients and therefore it is advisable to implement an antimicrobial stewardship program in the study area.

A targeted likelihood estimation comparing cefepime and piperacillin/tazobactam in critically ill patients with community-acquired pneumonia (CAP)

Cefepime and piperacillin/tazobactam are antimicrobials recommended by IDSA/ATS guidelines for the empirical management of patients admitted to the intensive care unit (ICU) with community-acquired pneumonia (CAP). Concerns have been raised about which should be used in clinical practice. This study aims to compare the effect of cefepime and piperacillin/tazobactam in critically ill CAP patients through a targeted maximum likelihood estimation (TMLE). A total of 2026 ICU-admitted patients with CAP were included. Among them, (47%) presented respiratory failure, and (27%) developed septic shock. A total of (68%) received cefepime and (32%) piperacillin/tazobactam-based treatment. After running the TMLE, we found that cefepime and piperacillin/tazobactam-based treatments have comparable 28-day, hospital, and ICU mortality. Additionally, age, PTT, serum potassium and temperature were associated with preferring cefepime over piperacillin/tazobactam (OR 1.14 95% CI [1.01-1.27], p = 0.03), (OR 1.14 95% CI [1.03-1.26], p = 0.009), (OR 1.1 95% CI [1.01-1.22], p = 0.039) and (OR 1.13 95% CI [1.03-1.24], p = 0.014)]. Our study found a similar mortality rate among ICU-admitted CAP patients treated with cefepime and piperacillin/tazobactam. Clinicians may consider factors such as availability and safety profiles when making treatment decisions.

Critical illness due to infection in people living with HIV

People living with HIV comprise a substantial number of the patients admitted to intensive care. This number varies according to geography, but all areas of the world are affected. In lower-income and middle-income countries, the majority of intensive care unit (ICU) admissions relate to infections, whereas in high-income countries, they often involve HIV-associated non-communicable diseases diagnoses. Management of infections potentially resulting in admission to the ICU in people living with HIV include sepsis, respiratory infections, COVID-19, cytomegalovirus infection, and CNS infections, both opportunistic and non-opportunistic. It is crucial to know which antiretroviral therapy (ART) is appropriate, when is the correct time to administer it, and to be aware of any safety concerns and potential drug interactions with ART. Although ART is necessary for controlling HIV infections, it can also cause difficulties relevant to the ICU such as immune reconstitution inflammatory syndrome, and issues associated with ART administration in patients with gastrointestinal dysfunction on mechanical ventilation. Managing infection in people with HIV in the ICU is complex, requiring collaboration from a multidisciplinary team knowledgeable in both the management of the specific infection and the use of ART. This team should include intensivists, infectious disease specialists, pharmacists, and microbiologists to ensure optimal outcomes for patients.

HIV and COVID-19 Disease

Despite effective antiretroviral therapy (ART), HIV infected individuals throughout the world remain at significant risk of respiratory infections and non-communicable disease. Severe disease from SARS-CoV-2 is associated with a hyperinflammatory phenotype which manifests in the lungs as pneumonia and in some cases can lead to acute respiratory failure. Progression to severe COVID-19 is associated with comorbid disease such as obesity, diabetes mellitus and cardiovascular disease, however data concerning the associated risks of HIV coinfection are still conflicting, with large population studies demonstrating poorer outcomes, whilst smaller, case-controlled studies showing better outcomes. Furthermore, underlying immunopathological processes within the lungs and elsewhere, including interactions with other opportunistic infections (OI), remain largely undefined. Nonetheless, new and repurposed anti-viral therapies and vaccines which have been developed are safe to use in this population, and anti-inflammatory agents are recommended with the caveat that the coexistence of opportunistic infections is considered and excluded. Finally, HIV infected patients remain reliant on good ART adherence practices to maintain HIV viral suppression, and some of these practices were disrupted during the COVID-19 pandemic, putting these patients at further risk for acute and long-term adverse outcomes.

Bacteriology of community-acquired pneumonia, antimicrobial susceptibility pattern and associated risk factors among HIV patients, Northeast Ethiopia: cross-sectional study

Objective

Pneumonia is an opportunistic infection and it is a major cause of mortality and morbidity among human immunodeficiency virus/acquired immune deficiency syndrome-positive patients. Previous studies have shown the dominant pathogens bacterial isolates were K. pneumoniae 27.0%, S. aureus 20.8%, S. pneumoniae 18.8% and E. coli 8.3%. This study aimed to determine bacteriology of community-acquired pneumonia, antimicrobial susceptibility pattern and associated risk factors among human immunodeficiency virus patients in the Northeast Ethiopia: cross-sectional study.

Methods

A health facility-based cross-sectional study was conducted from January to April 2021 at six health facilities in Dessie Town. A total of 378 community-acquired pneumonia patients suspected to be human immunodeficiency virus-positive were recruited using a consecutive sampling technique. Sociodemographic and clinical data were collected using a structured questionnaire. A two-milliliter sputum specimen was collected aseptically from each study participant. Samples were cultivated on blood agar, chocolate agar and MacConkey agar to isolate bacterial pathogens. To identify bacteria pathogens Gram stain, colony morphology and biochemical tests were performed. The Kirby-Bauer Disc Diffusion method was used to perform the antimicrobial susceptibility test. Descriptive statistics, logistic regression analysis was carried out using Statistical package for social science version 25 software. p-value < 0.05 with a corresponding 95% confidence interval (CI) was considered for statistical significance.

Result

The overall prevalence of bacterial pneumonia was 175 (46.3%). Gram-negative bacteria accounted for 119 (68%) and the predominant isolates identified were Streptococcus pneumoniae 49 (28%) followed by Klebsiella pneumoniae 46 (26.3%), Pseudomonas aeruginosa 34 (19.4%). There were 148 (84.6%) multidrug-resistant bacteria overall. Statistically significant factors included viral load, cigarette smoking, cluster of differentiation 4 count, alcohol use, World Health Organization clinical stages III and IV and low white blood cell count.

Conclusion

The study found that both multidrug resistance and bacterial pneumonia were high. Thus, bacterial culture and antimicrobial susceptibility tests should be routinely performed in health facilities in order to prevent and control the spread of bacterial infection and concurrent drug resistance.

Imaging Approach to Pulmonary Infections in the Immunocompromised Patient

Pulmonary infections are the major cause of morbidity and mortality in immunocompromised patients and almost one-third of intensive care unit patients with pulmonary infections belong to the immunocompromised category. Multiple organisms may simultaneously infect an immunocompromised patient and the overwhelming burden of mixed infections further predisposes critically ill patients to acute hypoxemic respiratory failure. Notwithstanding that lung ultrasound is coming into vogue, the primary imaging investigation is a chest radiograph, followed by thoracic CT scan. This review based on our experience at tertiary care teaching hospitals provides insights into the spectrum of imaging features of various pulmonary infections occurring in immunocompromised patients. This review is unique as, firstly, the imaging spectrum described by us is categorized on basis of the etiological infective agent, comprehensively and emphatically correlated with the clinical setting of the patient. Secondly, a characteristic imaging pattern is emphasized in the clinical setting-imaging-pattern conglomerate, to highlight the most likely diagnosis possible in such a combination. Thirdly, the simulating conditions for a relevant differential diagnosis are discussed in each section. Fourthly, not only are the specific diagnostic and tissue sampling techniques for confirmation of the suspected etiological agent described, but the recommended pharmaco-therapeutic agents are also enumerated, so as to provide a more robust insight to the radiologist. Last but not the least, we summarize and conclude with a diagnostic algorithm, derived by us from the characteristic illustrative cases. The proposed algorithm, illustrated as a flowchart, emphasizes a diagnostic imaging approach comprising: correlation of the imaging pattern with clinical setting and with associated abnormalities in the thorax and in other organs/systems, which is comprehensively analyzed in arriving at the most likely diagnosis. Since a rapid evaluation and emergent management of such patients is of pressing concern not only to the radiologist, but also for the general physicians, pulmonologists, critical care specialists, oncologists and transplant surgery teams, we believe our review is very informative to a wide spectrum reader audience.

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.

Pulmonary tuberculosis and pneumocystis jirovecii concurrent pneumonia in HIV infected patients at a resource limited setting in Eastern India: A case series

Pneumocytis jirovecii pneumonia (PJP) and Pulmonary TB (PTB) both are common opportunistic infections among HIV infected individuals. But concurrent infections pose a diagnostic challenge owing to similar clinical features. Data suggests a high prevalence of such concurrent infections in developing countries but limited diagnostic modalities especially in resource constraint setup limits accurate diagnosis. At our centre we came across 6 newly diagnosed PTB patients among HIV infected ones had persistent shortness of breath (SOB) and hypoxia despite starting anti-tuberculous treatment (ATT). We excluded concomitant bacterial pneumonia by imaging, sputum examination and blood culture. Serum lactate dehydrogenase (LDH) was estimated and hypoxia by arterial blood gas (ABG). We found all 6 patients had elevated serum LDH, hypoxia and imaging suggestive of PJP were offered sputum for Geisma stain and standard treatment for PJP in form of Bactrim-double strength and steroid. 1 patient had PJ cysts in sputum. 5 patient's classical radiologic findings in form of ground glass opacities in lower lobes along with bilateral infiltrates and 1 had honeycombing. Serum LDH was elevated all 6 subjects. 5 were newly diagnosed HIV and 4 had CD4 count below 50 cells/mm³ and 2 had below 200 cells/mm³.1 patient had developed bilateral pneumothorax as complication. 4 patients responded to treatment and 2 (33.3%) died of respiratory failure during treatment. We were able to diagnose only severe PJP cases as concurrent infection with PTB as there was no availability of broncho alveolar lavage (BAL) as well as direct fluorescent antigen (DFA) test for PJ detection. A high index of suspicion for PJP even in PTB patients with low CD4 count will guide to appropriate therapy for both infections and eventually reduces morbidity and mortality.