Pneumonia最新文献

Introduction: Legionella is the second cause of community-acquired pneumonia in Intensive Care Unit (ICU) patients. The aim of this study was to describe the epidemiology and outcome in patients with Legionella pneumonia (LP) in French ICUs.

Methods: A multi-center, retrospective, observational study in 12 French ICUs was performed between January 2014 and December 2019.

Results: LP was diagnosed in 162 patients during the study period. Invasive mechanical ventilation was required in 95 patients (58%), 73 (45%) of whom had acute respiratory distress syndrome (ARDS). Most of these patients were treated with a combination of antibiotics (128, patients; 79%). The most common combination consisted in a fluoroquinolone and a macrolide (118 patients). Median length of stay in an ICU was 11 [5; 11] days. At 28 days, 19 (12%) out of the 162 patients had not survived. In multivariate analyses, age (Incidence risk Ratio: IRR, 1.07; 95% CI, 1.01; 1.14) and a high Sequential Organ Failure Assessment (SOFA) score in the first 48 h (IRR, 1.47; 95% CI, 1.09; 2) were significantly associated with mortality.

Conclusion: In this French multicentric cohort, the LP prognosis in ICUs was apparently more favorable than in the literature, possibly because of the timely and improved LP management in ICUs.

Background: Community-acquired pneumonia (CAP) causes substantial morbidity and mortality, particularly in patients with chronic obstructive pulmonary disease (COPD). This study compares the microbial detections in CAP patients with and without COPD using culture based and molecular diagnostic methods.

Methods: This prospective study included 412 hospitalized pneumonia patients (136 with COPD). Lower respiratory tract samples were analysed with traditional cultures and a multiplex PCR panel (FilmArray Pneumonia Panel Plus). Multivariable Poisson regression identified predictors of Pseudomonas aeruginosa detection, and logistic regression estimated detection probability using the top predictors.

Results: Overall pathogen detection rates were similar between groups, but P. aeruginosa was significantly more common in COPD patients (12.5% vs. 3.1%; p < 0.001). In adjusted analyses, each additional year of age increased the risk of P. aeruginosa by 5% (RR 1.05; 95% CI 1.01-1.09), while advanced COPD (GOLD 3-4) conferred a four-fold higher risk (RR 4.29; 95% CI 1.94-9.46), diabetes mellitus a four-fold risk (RR 4.04; 95% CI 1.97-8.29), and prior P. aeruginosa detection a five-fold risk (RR 5.03; 95% CI 2.44-10.36). Inhaler use, bronchiectasis, and recent hospitalization were not independently associated.

Conclusion: Although overall microbial detection rates were comparable between groups, P. aeruginosa was disproportionately prevalent in high-risk COPD individuals. While most COPD patients with pneumonia can be managed with standard empirical antibiotics, empirical coverage for P. aeruginosa should be considered for selected high-risk patients. Prospective studies are warranted to evaluate targeted P. aeruginosa coverage to optimize antibiotic stewardship and improve outcomes.

Background: Legionnaires' disease (LD) is a severe form of primarily community-acquired pneumonia (CAP). To confirm a Legionella infection, microbiological testing is required. The Swiss and European guidelines recommend LD testing for all hospitalised CAP patients. However, the low positivity rate of such routine testing (1.5-3%) raises concerns about its cost-effectiveness and clinical utility. In a setting where routine testing is recommended, this multicentre study evaluated the impact of LD testing on the clinical management of the infection and antimicrobial prescribing.

Methods: Data from medical records of 195 community-acquired LD (CALD) patients from 20 Swiss hospitals (August 2022-March 2024) were analysed. We assessed the clinical management of CALD, focusing on the impact of microbiological testing on antibiotic prescribing. The appropriateness of antibiotic choice and duration of treatment was assessed using a standardised pathway analysis approach. Factors associated with unsupported antibiotic prescribing were assessed using mixed-effects logistic regression analysis.

Results: Microbiological testing was initiated promptly, with results available within 24 h after presenting to the hospital for 85.1% and within 48 h for 92.3% of patients. Antibiotics with Legionella coverage were initiated in 88.2% of patients within 24 h of admission. A positive Legionella test influenced antibiotic prescribing: 97.9% of patients received antibiotics active against Legionella spp., and 79.6% were prescribed appropriate and targeted monotherapy within 24 h of receiving the test result. Overall, 35.4% of patients were treated with antibiotics for a median of 4 days (IQR 3-4 days) longer than guidelines recommend (defined as > 10 days for immunocompetent or > 21 days for immunocompromised patients). Prolonged treatment was associated with CALD severity and antibiotic use > 2 days postdischarge (proxy for clinical stability reached). 38.5% of patients with impaired renal function received a suboptimal loading dose of levofloxacin.

Conclusion: Routine aetiological testing for LD has improved the clinical management of CALD by facilitating rapid detection of CALD cases and timely initiation of appropriate and targeted antibiotic therapy. Future antimicrobial stewardship efforts should sensitise physicians that a shorter duration of antibiotic treatment for CALD of 5 to 7 days according to the latest Swiss CAP guidelines is sufficient and safe.

Background: Respiratory syncytial virus (RSV) infection was originally considered to be simply a disease of childhood. However, it has increasingly been recognized that the virus may also cause infection in adults. Furthermore, great strides have been made in understanding the clinical manifestations, as well as aspects of its management and prevention, requiring the need for greater awareness of the various aspects of this infection in adults.

Main body: There are several potential reasons that RSV may have been overlooked in adults. Firstly, it was due to a lack of knowledge that this infection could occur in this age group. Secondly, there was infrequent testing for RSV infection in adults, both for this reason and because RSV antigen testing in adults is less sensitive than in children. Thirdly, RSV diagnosis, therefore, required the performance of polymerase chain reaction (PCR) testing, which is both expensive and underutilized. Finally, there was also the belief at that time that if the infection was due to RSV, there was little one could do to about it in terms of treatment and/or prevention. More recently, however, enormous advances have been made particularly in the management and prevention of this infection. This manuscript, which is an extensive literature review, describes the modern understanding of the burden of infection, the clinical presentation, risk factors, immunopathogenesis, management, and prevention of RSV infections in adults.

Conclusion: RSV virus is a common cause of respiratory tract infections in adults and advances in recent research have not only enhanced our knowledge of this infection but have led to the development of effective treatment and prevention of the infection.

Background: Computed tomography (CT) analysis of lung morphology has significantly advanced our understanding of acute respiratory distress syndrome (ARDS). During the Coronavirus Disease 2019 (COVID-19) pandemic, CT imaging was widely utilized to evaluate lung injury and was suggested as a tool for predicting patient outcomes. However, data specifically focused on patients with ARDS admitted to intensive care units (ICUs) remain limited.

Methods: This retrospective study analyzed patients admitted to ICUs between March 2020 and November 2022 with moderate to severe COVID-19 ARDS. All CT scans performed within 48 h of ICU admission were independently reviewed by three experts. Lung injury severity was quantified using the CT Severity Score (CT-SS; range 0-25). Patients were categorized as having severe disease (CT-SS ≥ 18) or non-severe disease (CT-SS < 18). The primary outcome was all-cause mortality at 90 days. Secondary outcomes included ICU mortality and medical complications during the ICU stay. Additionally, we evaluated a computer-assisted CT-score assessment using artificial intelligence software (CT Pneumonia Analysis^®, SIEMENS Healthcare) to explore the feasibility of automated measurement and routine implementation.

Results: A total of 215 patients with moderate to severe COVID-19 ARDS were included. The median CT-SS at admission was 18/25 [interquartile range, 15-21]. Among them, 120 patients (56%) had a severe CT-SS (≥ 18), while 95 patients (44%) had a non-severe CT-SS (< 18). The 90-day mortality rates were 20.8% for the severe group and 15.8% for the non-severe group (p = 0.35). No significant association was observed between CT-SS severity and patient outcomes.

Conclusion: In patients with moderate to severe COVID-19 ARDS, systematic CT assessment of lung parenchymal injury was not a reliable predictor of 90-day mortality or ICU-related complications.

Background: This real-world study aimed to assess the effectiveness of novel oral antiviral agents in managing COVID-19 among high-risk patients during the Omicron JN.1 subvariant wave.

Methods: Data from the TriNetX US network were analyzed using a multi-institutional propensity score matching (PSM) analysis. High-risk non-hospitalized adults with COVID-19 were included, and patients receiving oral antiviral agents (study group) were compared to those not receiving antiviral agents (control group). Primary outcomes included all-cause emergency department (ED) visits, hospitalizations, or death within 30 days.

Results: Among 67,495 high-risk patients identified, 17,852 received oral antiviral agents (study group) and 49,643 did not (control group). After PSM, two matched cohorts of 17,847 patients each were established. The study group receiving antiviral agents exhibited a significantly lower risk of primary composite outcome during the 30-day follow-up period compared to the control group (HR, 0.77; 95% CI, 0.72-0.84). Regarding the secondary outcomes, the study group consistently exhibited a significantly lower risk of all-cause ED visits (4.2% vs. 5.4%; HR, 0.78; 95% CI, 0.71-0.86), hospitalization (2.8% vs. 3.3%; HR, 0.86; 95% CI, 0.77-0.97), and mortality (0.1% vs. 0.3%; HR, 0.17; 95% CI, 0.08-0.35) than the control group. Subgroup analyses showed consistent benefits across various demographic and clinical characteristics, except in individuals with booster vaccination.

Conclusions: Oral antiviral agents significantly reduced the risk of adverse outcomes among high-risk COVID-19 patients during the Omicron JN.1 subvariant wave. These findings support the potential benefits of oral antiviral therapy in treating COVID-19, particularly in high-risk populations.

Background: Drainage of infected pleural fluid is pivotal in the management of pleural infections, either by chest tube drainage (CTD) or repeated therapeutic thoracocentesis (RTT), in association with the use of intrapleural fibrinolytic therapy (IPFT) and DNase.

Methods: The aim of this study was to compare the efficacy and the safety of these two methods of pleural drainage. We conducted a multicenter retrospective study, which included all the patients who was hospitalized for suspected pleural infection in three university hospitals between 2012 and 2021 drained by CTD or RTT. A propensity-score matching was performed to compare patients drained by RTT (RTT group) and by chest tube (CTD group) with adjunctive IPFT and DNase.

Results: Two hundred and twenty-nine patients with suspected pleural infection were included. After a propensity-score matching, 78 patients were included in the final analysis, divided in two groups of 39 patients each. Patients in RTT group had a reduced length of drainage (6 days [4.3-8] vs 9 [6.5-13], OR = 1.41, 95%CI [1.05-1.89]) and a reduced length of hospital stay (15 days [11.5-21.5] vs 21 [14-30.5], OR = 1.28, 95%CI [1.01-1.61]). There was no significant difference in mortality rates, surgical referral, relapse, and drainage-related complications between the two groups.

Conclusions: The management of pleural infections through RTT with IPFT and DNase appears to be as effective and as safe as CTD. Randomized controlled trials comparing RTT and CTD would be required to confirm these results.

Pleural infection is a key clinical challenge, especially in immunocompromised patients and in those with pulmonary comorbidities. Its incidence has increased owing to antibiotic resistance and aging of the population. While international guidelines recommend chest tube (CTD) placement for complicated parapneumonic effusions (CPPE), the optimal strategy for fluid drainage is debated. Repeated therapeutic thoracentesis (RTT) could be an alternative to help patient mobility and reduce infectious risk. Studies on RTT demonstrated efficacy similar to that of CTD, mainly when combined with intrapleural fibrinolytic therapy and DNase, whereas others showed higher treatment escalation rates. In the issue of the Journal, Charron et al. show that RTT, combined with IPFT and DNase, decreases both pleural drainage duration and hospital stay when compared with chest drainage, without increasing mortality, surgical referral, or complication rates. However, methodological concerns, including variability in pleural infection definition, retrospective design, and centre-dependent treatment strategies, might limit the generalizability. Large-scale randomized controlled trials are needed to definitively establish its role.