Pneumonia最新文献

Background: Current guidelines recommend empiric antibiotic therapy for patients who require hospitalization for community-acquired pneumonia (CAP). We sought to determine whether clinical, imaging or laboratory features in patients hospitalized for CAP in whom PCR is positive for a respiratory virus enable exclusion of bacterial coinfection so that antibiotics can be withheld.

Methods: For this prospective study, we selected patients in whom an etiologic diagnosis was likely to be reached, namely those who provided a high-quality sputum sample at or shortly after admission, and in whom PCR was done to test for a respiratory virus. We performed quantitative bacteriologic studies on sputum to determine the presence of bacterial infection or coinfection and reviewed all clinical, imaging and laboratory studies.

Results: Of 122 CAP patients studied, 77 (63.1%) had bacterial infection, 16 (13.1%) viral infection, and 29 (23.8%) bacterial/viral coinfection. Underlying pulmonary disease and a history of smoking were more common in bacterial pneumonia. Upper respiratory symptoms were more common, and mean white blood cell (WBC) counts were lower viral pneumonia. Nevertheless, no clinical, laboratory or imaging findings allowed exclusion of bacterial coinfection in patients who tested positive for a respiratory virus. In fact, patients with bacterial/viral coinfection were sicker than those with bacterial or viral pneumonia; 30% were admitted required transfer to the ICU during their hospital course, compared to 17% and 19% of patients with bacterial or viral infection, respectively (p < .05). In this study, 64.4% of patients who tested positive for a respiratory virus had a bacterial coinfection.

Conclusions: If a test for a respiratory virus test is positive in a patient hospitalized for CAP, no sufficiently differentiating features exclude bacterial coinfection, thereby supporting the recommendation that empiric antibiotics be administered to all patients who are sufficiently ill to require hospitalization for CAP.

Background: Pneumococcal disease, caused by Streptococcus pneumoniae, imposes a significant global health burden, particularly affecting vulnerable groups such as the elderly and immunocompromised. The 23-valent pneumococcal polysaccharide vaccine (PPV23) is designed to protect against 23 serotypes of Streptococcus pneumoniae. However, there is ongoing debate about its effectiveness in reducing all-cause mortality. This systematic review and meta-analysis aimed to evaluate the efficacy of PPV23 in reducing all-cause and pneumonia-related mortality among adults.

Methods: A systematic search was conducted across PubMed, Embase, and Web of Science, focusing on studies that evaluated the mortality outcomes of adults vaccinated with PPV23 compared to non-vaccinated adults. Both randomized controlled trials (RCTs) and observational studies were included, while case reports, case series, and non-human studies were excluded. Data extraction and quality assessment were facilitated by Nested Knowledge software, using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for RCTs.

Results: The search yielded 826 records, with 19 studies meeting the inclusion criteria. The pooled analysis of four RCTs showed no significant reduction in all-cause mortality (RR = 1.030; 95% CI: 0.945, 1.122). However, analysis of pneumonia-related mortality across various studies indicated a significant reduction (HR = 0.504; 95% CI: 0.316, 0.693). Moderate to high heterogeneity was noted in mortality studies, and a potential publication bias was identified.

Conclusion: The findings suggest that while PPV23 may not significantly reduce all-cause mortality, it is effective in reducing pneumonia-related mortality among adults, particularly in those at higher risk. These results support the continued use of PPV23 in targeted adult populations, emphasizing the need for more primary studies to explore its effectiveness across diverse groups.

Background: Populations affected by humanitarian crises likely experience high burdens of pneumococcal disease. Streptococcus pneumoniae carriage estimates are essential to understand pneumococcal transmission dynamics and the potential impact of pneumococcal conjugate vaccines (PCV). Over 100 million people are forcibly displaced worldwide, yet here we present only the second pneumococcal carriage estimates for a displaced population.

Methods: In October 2019, we conducted a cross-sectional survey among internally displaced people (IDP) living in Digaale, a permanent IDP camp in Somaliland where PCV has not been implemented. We collected nasopharyngeal swab samples from 453 residents which were assessed for presence of pneumococci and serotyped using DNA microarray.

Results: We found that pneumococcal carriage prevalence was 36% (95%CI 31-40) in all ages, and 70% (95%CI 64-76) in children under 5. The three most common serotypes were vaccine serotypes 6B, 19F, and 23F. We estimated that the serotypes included in the 10-valent PNEUMOSIL vaccine were carried by 41% (95%CI 33-49) of all pneumococcal carriers and extrapolated that they caused 52% (95%CI 35-70) of invasive pneumococcal disease. We found some evidence that pneumococcal carriage was associated with recent respiratory symptoms, the total number of physical contacts made, and with malnutrition in children under 5. Through linking with a nested contact survey we projected that pneumococcal exposure of children under 2 was predominantly due to contact with children aged 2-5 (39%; 95%CI 31-48) and 6-14 (25%; 95%CI 17-34).

Conclusions: These findings suggest considerable potential for direct and indirect protection against pneumococcal disease in Digaale through PCV use in children and potentially adolescents.

Nucleic acid amplification tests (NAATs) greatly enhance the capacity to identify the etiology of pediatric complicated pneumonia. However, the use of pneumococcal conjugate vaccines could reduce the importance of Streptococcus pneumoniae in pediatric complicated pneumonia with the potential emergence of other bacterial agents. Using an expanded NAAT in culture negative pleural fluid or empyema samples collected in 2010-2024 (n = 554) in Portugal, we show that S. pneumoniae remains the most frequent agent despite decades of pneumococcal conjugate vaccine use and the COVID-19 pandemic. A rebound in pediatric complicated pneumonia occurred post-pandemic, including a rise in cases by Streptococcus pyogenes and Haemophilus influenzae. Empiric therapy of pediatric complicated pneumonia should still consider S. pneumoniae as the most likely cause, even in countries where the pneumococcal conjugate vaccine is in the national immunization program with a high uptake.

Background: Early prediction of non-invasive respiratory therapy (NIRT) failure is crucial to avoid needless prolongation of respiratory support and delayed endotracheal intubation. Data comparing the predictive value of oxygenation indices (OI) in COVID-19 receiving NIRT are scant. The aim of this monocentric retrospective study of prospectively collected data was to assess the effectiveness of different OI in predicting NIRT outcome at baseline (t0), 12 h (t12) and 24 h (t24) of treatment in hypoxemic patients with COVID-19-related pneumonia, managed in a Pulmonary Intermediate Care Unit (October 2020-June 2021).

Methods: We assessed the predictive value of SpO2/FiO2, PaO2/FiO2, standardised PaO2/FiO2 ratio (s-PaO2/FiO2), respiratory index (RI), arterial-alveolar oxygen gradient (a-ADO2), age adjusted arterial-alveolar oxygen ratio (adj-a-ADO2D). Receiver operating characteristics (ROC), AUC and best sensitivity-specificity cut-off values were calculated at t0, t12, t24. NIRT failure risk was adjusted for non-oxygenation predictors.

Results: Among 590 patients with COVID-19 infection, 368 met the eligibility criteria for inclusion in the study [mean (CI95%): PaO2/FiO2 214(206,8-221,9); PaCO2 mean 32,9 mmHg,(32,4-33,4)]. NIRT failure and hospital mortality rate were 23,4% and 19,6%, respectively. Older age, male gender, agitation/confusion, need for sedation, inability to tolerate prone positioning were independent predictors of NIRT failure. SpO2/FiO2, a-ADO2 and adj-aADO2 at t12 and t24, PaO2/FiO2 and RI at t24 were associated with NIRT failure. Prognostic predictivity of OI increased from t0 to t24. Greater ROC-AUC values were obtained with SpO2/FiO2 0,662 (0,60-0,72) (t0), PaO2/FiO2 0,697 (0,63-0,76) (t12) and s-PaO2/FiO2 0,769 (0,71-0,83) (t24). NIRT failure was independently predicted by PaO2/FiO2, s-PaO2/FiO2 and RI at any observation time and by SpO2/FiO2 and O2 gradients respectively at t0 and t24. SaO2/FiO2 ≤ 300 (t0), PaO2/FiO2 ≤ 151,7 (t12) and s-PaO2/FiO2 ≤ 160,4 (t24) turned out to be the best predictors of NIRT outcome.

Conclusions: OI showed different effectiveness in predicting NIRT failure within 24 h of treatment in COVID-19 related pneumonia. This may be due to the multi-factorial pathophysiology of hypoxemia. Our study empathises furthermore the role of non-oxygenation-related parameters in contributing to the outcome. These findings may be useful to build a predictive model also in no COVID-19 related hypoxemic pneumonia.

Background: Most Canadians receive their care in community hospitals, yet most clinical research is conducted in academic hospitals. This study aims to compare patients with community acquired pneumonia (CAP) treated in academic and community hospitals with respect to their demographics, clinical characteristics, treatments and outcomes.

Methods: This nested observational cohort substudy of the Community Acquired Pneumonia: Toward InnoVAtive Treatment (CAPTIVATE) trial included 1,329 hospitalized adults with CAP recruited between March 1st, 2018 and September 31st, 2023 from 15 Canadian hospitals. Unadjusted and adjusted analyses for age, sex and co-morbidities using logistic, Cox and censored quantile regressions were conducted.

Results: Patients in community hospitals were older (mean [SD] 75.0 [15.7] years vs. 68.3 [16.2] years; p < 0.001), were more likely to be female (49.7% vs. 41.0%, p = 0.002), and had more comorbidities (75.9% vs. 64.8%, p < 0.001). More patients in community hospitals received corticosteroids (49.2% vs. 37.4%, p < 0.001). Community hospital patients had a higher likelihood of developing acute respiratory distress syndrome (OR 3.13, 95% CI: 1.87, 5.24, p = < 0.001), and acute cardiac injury (OR 2.53, 95% CI: 1.33, 4.83, p = 0.005). In unadjusted and adjusted analyses, 28-day mortality difference did not meet statistical significance (OR 1.43, 95% CI: 0.98, 20.7, p = 0.062 and OR 1.23, 95% CI: 0.81, 1.87, p = 0.332, respective).

Conclusion: Patients with CAP in Canadian community and academic hospitals differed with respect to their age, clinical characteristics, treatments and outcomes, emphasizing the importance of including more community hospitals in clinical research studies to ensure the generalizability of results.

Background: Streptococcus pneumoniae is the most frequent causative pathogen of bacterial pneumonia in children worldwide. Bangladesh introduced the 10-valent pneumococcal conjugate vaccine (PCV10) in their national immunization program for infants in 2015. We assessed its potential coverage in under-fives with community-acquired pneumonia (CAP) in the years before PCV10 was introduced.

Methods: A total of 1502 childhood pneumonia cases (< 5 year olds living in the urban section Kamalapur, Dhaka) were enrolled between 2011 and 2013. Acute phase and late (convalescent) serum samples were collected from 1380 cases. Serotype-specific pneumococcal antibody concentrations were measured using a 25-plex immunoassay panel. Pneumococcal CAP was diagnosed based on a serotype-specific pneumococcal antibody response.

Results: S. pneumoniae was serologically identified as causative pathogen in 406/1380 (29%) cases. The five most prevalent serotypes were (in descending order) 11A, 22F, 3, 2 and 19F. Based on the percentage of pneumonia cases associated with PCV10 vaccine types, the potential PCV10 coverage was 29% (116/406).

Conclusions: In almost a third of the studied cases S. pneumoniae was identified as a causative pathogen. Because of the characteristics of the immunoassay, this might well be a gross underestimation. Nevertheless, the potential PCV10-coverage was low. Given the high serotype diversity, the region might benefit greatly from a higher-coverage PCV or recombinant protein vaccine.

Objective: The aim of this study was to describe the characteristics of patients admitted to the intensive care unit with severe pneumonia due to SARS-CoV-2, comparing them according to successive waves, and to identify prognostic factors for morbidity and mortality.

Materials and methods: This single-center retrospective observational descriptive study was conducted from March 10, 2020, to October 17, 2021. All adult patients admitted with SARS-CoV-2 pneumonia presenting acute respiratory failure were included. COVID 19 diagnosis was confirmed by RT-PCR testing of respiratory specimens. The primary endpoint was ICU mortality. Secondary endpoints were the occurrence of ventilator-associated pneumonia (VAP) or bronchopulmonary aspergillosis.

Results: Over the study period, 437 patients were included of whom 282 (65%) patients were ventilated for 9 [5;20] days. Among the studied population, 38% were treated for one or more episodes of VAP, and 22 (5%) for bronchopulmonary aspergillosis. ICU mortality was 26% in the first wave, then fell and stabilized at around 10% in subsequent waves (p = 0.02). Increased age, Charlson index, SOFA score and lactatemia on admission were predictive of mortality. Survival at 90 days was 85% (95% CI 82-88) and was unaffected by the presence of VAP. However, the occurrence of bronchopulmonary aspergillosis increased mortality to 36%.

Conclusion: In this study, we observed mortality in the lower range of those previously reported. Risk factors for mortality mainly included age and previous comorbidities. The prognosis of these critically ill Covid 19 patients improved over the four waves, underlining the likely beneficial effect of vaccination and dexamethasone.

Background: This study aimed to assess the diagnostic and prognostic value of Aspergillus-specific IgG (Asp-IgG) for invasive pulmonary aspergillosis (IPA) in non-neutropenic non-hematologic patients.

Methods: Between November 2019 and February 2022, we recruited 40 non-neutropenic, non-hematologic IPA patients from Taiwan and measured serum Asp-IgG levels using Phadia, Thermofisher. A positive Asp-IgG test was defined as a level > 40 mgA/L. We evaluated the association between Asp-IgG levels and overall survival, as well 90-day mortality rate of IPA patients.

Results: Of the 40 participants, 11 (27.5%) tested positive for Asp-IgG, while 16 (40%) had positive galactomannan antigen (optical density > 1). Higher Asp-IgG levels were associated with improved overall survival (HR: 0.22, 95% CI: 0.05-0.99, p = 0.035) in multivariable Cox regression. The overall 90-day mortality rate was 65% (26/40). We found that patients with low Asp-IgG levels (≤ 40 mgA/L) had a borderline higher 90-day mortality rate compared to patients with high Asp-IgG levels (OR: 3.15, 95% CI: 0.75-13.28, p = 0.118). Stratifying by serum galactomannan and Aspergillus IgG levels, patients with elevated serum GM and low Asp-IgG had the highest 90-day mortality (80%, 8/10), followed by patients with low serum GM and low Asp-IgG (68.4%, 13/19).

Conclusions: Asp-IgG was positive in approximately one-fourth of non-neutropenic IPA patients. Asp-IgG may hold potential as a clinical prognostic factor for IPA. Further studies are required to validate this finding.

Background: Patients with COVID-19 may experience a persistent increase in the blood urea nitrogen over creatinine ratio (PI-BUN/Cr). Its elevation could reflect multiple underlying pathophysiological processes beyond prerenal injury but also warrants nuanced interpretation due to its complex interplay with various factors, underscoring the importance of investigating its effects on mortality and acute kidney injury in this population.

Methods: We analized a retrospective and longitudinal cohort of patients admitted to a single center in Mexico City for patients with severe COVID-19. Between March 5, 2020 and August 25, 2021, we included patients with confirmed positive diagnosis for SARS-CoV-2, age > 18 years, disease severity was defined by clinical data of respiratory distress syndrome and a ratio of partial oxygen pressure to inspired oxygen fraction < 300 mmHg on admission. We excluded patients with End Stage Kidney Disease. Data was obtained from electronic medical records. PI-BUN/Cr was defined as an increase in the BUN/Cr ratio > 30 in more than 60% of measurements in the hospital. The outcomes included: risk factors to mortality and AKI in-hospital.

Results: The cohort included 3,007 patients with a median age of 54.6 ± 14.5 years. 35% of patients died; 44.6% developed PI-BUN/Cr ratio and 71.4% AKI. Mortality was associated with older age > 60 years [Hazard ratio (HR)] = 1.45, 95% CI: 1.28-1.65; p < 0.001); male (HR 1.25, 95% CI 1.09-1.44; p = 0.002) and AKI (HR 3.29, 95% CI 2.42-4.46; p < 0.001); PI-BUN/CR & Non-AKI (HR = 2.82, 95% CI: 1.61-4.93; p < 0.001); Non PI-BUN/CR & AKI (HR = 5.47, 95% CI: 3.54-8.44; p < 0.001); and PI-BUN/CR & AKI (HR = 4.26, 95% CI: 2.75-6.62, p < 0.001). Only hiperuricemia was a risk factor for AKI (HR = 1.71, 95% CI: 1.30-2.25, p < 0.001).

Conclusions: While PI-BUN/Cr alone may not directly associate with mortality, its capacity to sub-phenotype patients according to their AKI status holds significant promise in offering valuable insights into patient prognosis and outcomes. Understanding the nuanced relationship between PI-BUN/Cr and AKI enhances our comprehension of renal function dynamics. It equips healthcare providers with a refined tool for risk stratification and personalized patient management strategies.