Pneumonia最新文献

Introduction: COVID-19 severely impacted global health, especially older adults and those with comorbidities. Immunosuppressed patients are at high risk for severe outcomes, yet studies yield conflicting mortality rates for this group. This study examines the clinical characteristics and outcomes of immunosuppressed (IS) versus non-immunosuppressed (nIS) patients with COVID-19 in ICUs.

Methods: A multicenter, observational case-control study included 5,824 ICU patients with COVID-19 from the CIBERESUCICOVID study. Patients were categorized as IS or nIS based on history of transplantation, HIV, active neoplasia, and use of immunosuppressive drugs or corticosteroids. The primary outcome was 90-day mortality; secondary outcomes included in-hospital, 15-day, 30-day and 1-year mortality, ICU-free days, ventilator-free days, and hospital length of stay. Subgroup analyses examined vaccination status and tocilizumab treatment. Propensity score (PS) matching was used to obtain balance among the baseline variables in the two groups.

Results: IS patients (n = 689, 11.8%) were older, had more comorbidities, and higher APACHE-II scores. After PS matching, IS patients had higher 90-day mortality (39 vs. 33%; HR 1.30, 95% CI 1.04 to 1.62), as well as higher in-hospital (37 vs. 29%; sHR 1.35, 95% CI 1.08 to 1.69), 30-day (28 vs 23%; HR 1.31, 95% CI 1.01 to 1.69) and 1-year mortality (45 vs. 38%; HR 1.26, 95% CI 1.02 to 1.57). Among IS patients, transplant recipients had significantly higher 90-day mortality after matching (HR 4.45, 95% CI 1.46 to 13.58). Vaccinated IS patients showed higher mortality than vaccinated nIS patients, though differences were not significant after PS matching. Tocilizumab treatment in IS patients was associated with reduced mortality; multivariable analysis confirmed a significant decrease in in-hospital mortality (sHR 0.56, 95% CI 0.42 to 0.76).

Conclusion: Critical immunosuppressed patients with COVID-19 have higher mortality, particularly transplant recipients. Tocilizumab shows potential benefits for IS patients. These findings highlight the need for tailored therapeutic strategies for immunosuppressed individuals with severe COVID-19. Further research is needed to confirm these results in the current clinical context.

Background: Streptococcus pneumoniae is an important cause of pneumonia in older adults, however, serotyping and indirect impact information from low and middle-income countries is lacking. Mongolia has a childhood 13-valent pneumococcal conjugate vaccine (PCV13) program, but no adult pneumococcal vaccination program. We describe pneumococcal carriage rates, disease and serotype distribution among adults hospitalised with pneumonia, and explore changes over the COVID-19 pandemic period.

Methods: Adults (≥ 18 years) hospitalised with clinical pneumonia were enrolled over 3 years (March 2019-February 2022) into a prospective pneumonia surveillance program. Nasopharyngeal swabs were tested to detect pneumococci using lytA qPCR and molecular serotyping by DNA microarray and metagenomics. Pneumococcal pneumonia was identified using serotype-specific urinary antigen detection and BinaxNOW^® assays. Pneumococcal carriage and pneumonia prevalence were assessed over the COVID-19 period with log-binomial regression used to estimate prevalence and adjusted prevalence ratios (pre- versus early- and late-COVID-19 periods).

Results: Of 3,178 pneumonia cases, S. pneumoniae was identified in 12.1% (333/2,759) of swabs and 8.6% (253/2,925) of urine samples. PCV13 serotype carriage prevalence was 3.1% (82/2,663) and non-PCV13 serotype carriage prevalence 5.7% (152/2,663). In the late-COVID-19 period, pneumococcal carriage prevalence was reduced by 66% (aPR 0.34, 95%CI 0.25-0.46) and pneumococcal pneumonia by 82% (aPR 0.18, 95%CI 0.12-0.27) compared with the pre-COVID-19 transmission period.

Conclusion: Despite paediatric vaccination with high coverage, we identified some residual PCV13 serotypes with predominance of non-PCV13 serotypes carried and causing disease in adults. Direct adult vaccination which targets these serotypes will potentially reduce disease in adults in Mongolia.

The 2024 global redefinition of acute respiratory distress syndrome (ARDS) broadens diagnostic criteria to include patients on non-invasive respiratory support. While this inclusivity enhances early recognition, it also introduces heterogeneity in disease severity, inflammatory burden, and treatment responsiveness-complicating the use of corticosteroids. Although recent guidelines recommend corticosteroids for moderate-to-severe ARDS, they fall short of specifying optimal timing, dosing, and patient selection. The DEXA-ARDS trial showed that high-dose dexamethasone reduced mortality in moderate-to-severe ARDS regardless of etiology, but its generalizability to less severe or non-intubated patients remains unclear. Conversely, in severe community-acquired pneumonia (CAP), hydrocortisone regimens used in CAPE-COD and APROCCHSS trials demonstrated mortality benefits, suggesting a particular therapeutic niche for corticosteroids in non-viral, infection-associated ARDS. A recent network meta-analysis suggests that low-dose methylprednisolone may reduce ARDS mortality, though phenotype-specific efficacy is not well defined. Despite these encouraging signals, key questions persist: Which corticosteroid? At what dose? For which ARDS phenotype? As evidence accumulates unevenly across ARDS subtypes, guideline-endorsed recommendations may inadvertently mask the nuances required for individualized therapy. Until precision approaches are better defined, clinicians must balance empirical benefit with thoughtful restraint in applying corticosteroids to non-viral ARDS. This concise review summarizes current evidence, key limitations, and pragmatic phenotype-informed strategies for corticosteroid use in non-viral ARDS.

Background: Although pneumococcal conjugate vaccines (PCVs) have been used widely in many low and middle-income countries, residual vaccine-type (VT) carriage persists in these settings. We examined the role of specific age groups in transmission and as reservoirs of VT pneumococcal infection in The Gambia.

Methods: Between January and November 2022, we conducted a nested, population-based, cross-sectional social contact and pneumococcal carriage survey in the Central and Upper River Regions of The Gambia. Participants completed questionnaires on carriage risk factors and social contacts. Nasopharyngeal swabs were collected from selected household members across all age groups. Streptococcus pneumoniae was isolated and serotyped using standard methods. We analysed matched contact and pneumococcal carriage data and estimated the proportions of VT carriage attributable to contact with different age groups.

Results: A total of 1638 participants were enrolled, of which 67% were children aged 0-14 years. Pneumococcal carriage prevalence was 59.6% (95% CI: 53.9 - 65.1%) in 0-4 year-olds and 36.1% (95% CI: 29.6 - 43.1%) in 5-14 year-olds. PCV13 VT carriage prevalence was not significantly different (10-13%) between these age groups. Among pneumococcal carriers, the proportion of VT carriage was significantly higher in 5- 14-year-olds [35.7% (95% CI: 25.9 - 46.9%)] compared to 0-4-year-olds [17.8% (95% CI: 13.9 - 22.6%, p-value < 0.001)]. The odds of VT carriage were 10% higher [AOR = 1.10, 95% CI: 1.01-1.20] for each additional physical contact with a child aged 10-14 years. We estimated that children aged 5-14 years contributed about 63% to the overall risk of exposure to VT pneumococci in the population.

Conclusions: In rural Gambia, school-aged children, particularly those aged 5-9 years, are the main drivers of VT pneumococcal transmission. In the context of high coverage of routine PCV vaccination in infants, this suggests waning PCV protection by school entry. A booster dose for children at school entry may support better control of VT circulation in the population.

Introduction: Aspiration pneumonia (AP) in older persons is associated with oropharyngeal dysphagia (OD) and is estimated to account for 5-15% of cases of community-acquired pneumonia (CAP). Artificial Intelligence Massive Screening for OD (AIMS-OD) is an algorithm for identifying OD in older patients on hospital admission using data from electronic health records (EHR). We aimed to assess the prevalence of OD among older patients hospitalized with pneumonia and thus estimate the underdiagnosis of AP based on AIMS-OD.

Materials and methods: A retrospective observational study included 15,603 patients older than 65 years who were admitted for pneumonia to a general hospital between 2013 and 2022. Clinical data were obtained from EHR. AIMS-OD is an accurate diagnostic algorithm (AUCROC > 0.79, specificity 0.92, PPV 0.86, NPV 0.58) for OD using AI and machine learning.

Results: a) AP prevalence following traditional clinical practice (ICD-10 J69.0, AP codification) on discharge was 15.57% (n=2,430, 86.73±7.43 years); b) Estimated AP prevalence related to OD identified with AIMS-OD, was 25.32% (n=3,951, 85.11±8.78 years); c) AIMS-OD identified 84.77% (n=2,060, 87.17±7.09 years) of clinically diagnosed patients (ICD-10 J69.0), and 1,891 additional cases of AP (82.87±9.84 years) undetected by clinical practice, distinguishing them from pneumonia patients without OD in seconds.  CONCLUSION: The prevalence of AP following traditional clinical practice among older patients hospitalized with pneumonia was 15.57%. AIMS-OD revealed a potential prevalence of AP of 25.32%. AIMS-OD allows to increase by 62.6% the detection of AP related to OD versus traditional clinical practice among older patients hospitalized with pneumonia. AIMS-OD allows massive, immediate, and accurate identification of OD on hospital admission, from which AP cases can be identified, enabling early and specific treatment to improve the poor clinical outcomes of these unrecognized patients with AP and prevent its recurrence.