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      Bacterial etiology of community-acquired pneumonia in immunocompetent hospitalized patients and appropriateness of empirical treatment recommendations: an international point-prevalence study

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          Abstract

          An accurate knowledge of the epidemiology of community-acquired pneumonia (CAP) is key for selecting appropriate antimicrobial treatments. Very few etiological studies assessed the appropriateness of empiric guideline recommendations at a multinational level. This study aims at the following: (i) describing the bacterial etiologic distribution of CAP and (ii) assessing the appropriateness of the empirical treatment recommendations by clinical practice guidelines (CPGs) for CAP in light of the bacterial pathogens diagnosed as causative agents of CAP. Secondary analysis of the GLIMP, a point-prevalence international study which enrolled adults hospitalized with CAP in 2015. The analysis was limited to immunocompetent patients tested for bacterial CAP agents within 24 h of admission. The CAP CPGs evaluated included the following: the 2007 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA), the European Respiratory Society (ERS), and selected country-specific CPGs. Among 2564 patients enrolled, 35.3% had an identifiable pathogen. Streptococcus pneumoniae (8.2%) was the most frequently identified pathogen, followed by Pseudomonas aeruginosa (4.1%) and Klebsiella pneumoniae (3.4%). CPGs appropriately recommend covering more than 90% of all the potential pathogens causing CAP, with the exception of patients enrolled from Germany, Pakistan, and Croatia. The 2019 ATS/IDSA CPGs appropriately recommend covering 93.6% of the cases compared with 90.3% of the ERS CPGs ( p < 0.01). S. pneumoniae remains the most common pathogen in patients hospitalized with CAP. Multinational CPG recommendations for patients with CAP seem to appropriately cover the most common pathogens and should be strongly encouraged for the management of CAP patients.

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          BTS guidelines for the management of community acquired pneumonia in adults: update 2009.

          W Lim, S Baudouin, R C George … (2009)
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            Causes of severe pneumonia requiring hospital admission in children without HIV infection from Africa and Asia: the PERCH multi-country case-control study

            Katherine L O'Brien, Henry Baggett, W. Brooks … (2019)
            Summary Background Pneumonia is the leading cause of death among children younger than 5 years. In this study, we estimated causes of pneumonia in young African and Asian children, using novel analytical methods applied to clinical and microbiological findings. Methods We did a multi-site, international case-control study in nine study sites in seven countries: Bangladesh, The Gambia, Kenya, Mali, South Africa, Thailand, and Zambia. All sites enrolled in the study for 24 months. Cases were children aged 1–59 months admitted to hospital with severe pneumonia. Controls were age-group-matched children randomly selected from communities surrounding study sites. Nasopharyngeal and oropharyngeal (NP-OP), urine, blood, induced sputum, lung aspirate, pleural fluid, and gastric aspirates were tested with cultures, multiplex PCR, or both. Primary analyses were restricted to cases without HIV infection and with abnormal chest x-rays and to controls without HIV infection. We applied a Bayesian, partial latent class analysis to estimate probabilities of aetiological agents at the individual and population level, incorporating case and control data. Findings Between Aug 15, 2011, and Jan 30, 2014, we enrolled 4232 cases and 5119 community controls. The primary analysis group was comprised of 1769 (41·8% of 4232) cases without HIV infection and with positive chest x-rays and 5102 (99·7% of 5119) community controls without HIV infection. Wheezing was present in 555 (31·7%) of 1752 cases (range by site 10·6–97·3%). 30-day case-fatality ratio was 6·4% (114 of 1769 cases). Blood cultures were positive in 56 (3·2%) of 1749 cases, and Streptococcus pneumoniae was the most common bacteria isolated (19 [33·9%] of 56). Almost all cases (98·9%) and controls (98·0%) had at least one pathogen detected by PCR in the NP-OP specimen. The detection of respiratory syncytial virus (RSV), parainfluenza virus, human metapneumovirus, influenza virus, S pneumoniae, Haemophilus influenzae type b (Hib), H influenzae non-type b, and Pneumocystis jirovecii in NP-OP specimens was associated with case status. The aetiology analysis estimated that viruses accounted for 61·4% (95% credible interval [CrI] 57·3–65·6) of causes, whereas bacteria accounted for 27·3% (23·3–31·6) and Mycobacterium tuberculosis for 5·9% (3·9–8·3). Viruses were less common (54·5%, 95% CrI 47·4–61·5 vs 68·0%, 62·7–72·7) and bacteria more common (33·7%, 27·2–40·8 vs 22·8%, 18·3–27·6) in very severe pneumonia cases than in severe cases. RSV had the greatest aetiological fraction (31·1%, 95% CrI 28·4–34·2) of all pathogens. Human rhinovirus, human metapneumovirus A or B, human parainfluenza virus, S pneumoniae, M tuberculosis, and H influenzae each accounted for 5% or more of the aetiological distribution. We observed differences in aetiological fraction by age for Bordetella pertussis, parainfluenza types 1 and 3, parechovirus–enterovirus, P jirovecii, RSV, rhinovirus, Staphylococcus aureus, and S pneumoniae, and differences by severity for RSV, S aureus, S pneumoniae, and parainfluenza type 3. The leading ten pathogens of each site accounted for 79% or more of the site's aetiological fraction. Interpretation In our study, a small set of pathogens accounted for most cases of pneumonia requiring hospital admission. Preventing and treating a subset of pathogens could substantially affect childhood pneumonia outcomes. Funding Bill & Melinda Gates Foundation.
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              Etiology of Community-Acquired Pneumonia: Increased Microbiological Yield with New Diagnostic Methods

              Niclas Johansson, Mats Kalin, Annika Tiveljung-Lindell … (2010)
              Abstract Background The microbial etiology of community-acquired pneumonia (CAP) is still not well characterized. During the past few years, polymerase chain reaction (PCR)-based methods have been developed for many pathogens causing respiratory tract infections. The aim of this study was to determine the etiology of CAP among adults—especially the occurrence of mixed infections among patients with CAP—by implementing a new diagnostic PCR platform combined with conventional methods. Methods Adults admitted to Karolinska University Hospital were studied prospectively during a 12-month period. Microbiological testing methods included culture from blood, sputum, and nasopharyngeal secretion samples; sputum samples analyzed by real-time quantitative PCR for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; nasopharyngeal specimens analyzed by use of PCR; serological testing for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and viruses common in the respiratory tract; and urine antigen assays for detection of pneumococcal and Legionella pneumophila antigens. Results A microbial etiology could be identified for 67% of the patients (n = 124). For patients with complete sampling, a microbiological agent was identified for 89% of the cases. The most frequently detected pathogens were S. pneumoniae (70 patients [38]) and respiratory virus (53 patients [29]). Two or more pathogens were present in 43 (35%) of 124 cases with a determined etiology. Conclusions By supplementing traditional diagnostic methods with new PCR-based methods, a high microbial yield was achieved. This was especially evident for patients with complete sampling. Mixed infections were frequent (most commonly S. pneumoniae together with a respiratory virus).
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                Author and article information

                Contributors
                Manuela Carugati:
                ORCID: https://orcid.org/0000-0002-3187-5905
                ela.carugati@gmail.com
                Journal
                Journal ID (nlm-ta): Eur J Clin Microbiol Infect Dis
                Journal ID (iso-abbrev): Eur. J. Clin. Microbiol. Infect. Dis
                Title: European Journal of Clinical Microbiology & Infectious Diseases
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0934-9723
                ISSN (Electronic): 1435-4373
                Publication date (Electronic): 3 April 2020
                Pages: 1-13
                Affiliations
                [1 ]GRID grid.414818.0, ISNI 0000 0004 1757 8749, Internal Medicine Department, Division of Infectious Diseases, , Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, ; Milan, Italy
                [2 ]GRID grid.26009.3d, ISNI 0000 0004 1936 7961, Division of Infectious Diseases and International Health, , Duke University, ; Durham, USA
                [3 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Department of Pathophysiology and Transplantation, , Università degli Studi di Milano, ; Milan, Italy
                [4 ]GRID grid.414818.0, ISNI 0000 0004 1757 8749, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, , Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, ; Milan, Italy
                [5 ]GRID grid.11450.31, ISNI 0000 0001 2097 9138, Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, , University of Sassari, ; Sassari, Italy
                [6 ]Centre for Multidisciplinary Research in Health Science, Milan, Italy
                [7 ]GRID grid.84393.35, ISNI 0000 0001 0360 9602, Pneumology Service, , University and Polytechnic Hospital La Fe, ; Valencia, Spain
                [8 ]GRID grid.413126.3, ISNI 0000 0004 0621 0228, Clinic of Pulmonary Diseases, , Military Medical Academy, ; Sofia, Bulgaria
                [9 ]GRID grid.413448.e, ISNI 0000 0000 9314 1427, Department of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, CIBER de Enfermedades Respiratorias, , CIBERES, ; Bunyola, Spain
                [10 ]GRID grid.5808.5, ISNI 0000 0001 1503 7226, Serviço de Medicina, , Centro Hospitalar Universitario do Porto, ; Porto, Portugal
                [11 ]Emergency Medicine Department, University Hospital Hairmyres, Glasgow, Scotland
                [12 ]GRID grid.10776.37, ISNI 0000 0004 1762 5517, Pneumologia PROMISE, , University of Palermo, ; Palermo, Italy
                [13 ]GRID grid.413363.0, ISNI 0000 0004 1769 5275, Respiratory Diseases Clinic, , Policlinico di Modena, ; Modena, Italy
                [14 ]GRID grid.411142.3, ISNI 0000 0004 1767 8811, Respiratory Department, , Hospital del Mar - IMIM, DCEXS-UPF, CIBERES, BRN, ; Barcelona, Spain
                [15 ]GRID grid.411142.3, ISNI 0000 0004 1767 8811, Critical Care Department, , Hospital del Mar - IMIM, ; Barcelona, Spain
                [16 ]GRID grid.280682.6, ISNI 0000 0004 0420 5695, South Texas Veterans Health Care System and University of Texas Health San Antonio, ; San Antonio, USA
                Author information
                https://orcid.org/0000-0002-3187-5905
                Article
                Publisher ID: 3870
                DOI: 10.1007/s10096-020-03870-3
                PMC ID: 7222990
                PubMed ID: 32242314
                SO-VID: 20294061-79fa-4618-aaf7-71c979de1cf4
                Copyright © © Springer-Verlag GmbH Germany, part of Springer Nature 2020
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date received : 15 January 2020
                Date accepted : 18 March 2020
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: community-acquired pneumonia,antimicrobial treatment,guidelines,streptococcus pneumoniae
                Data availability:
                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: community-acquired pneumonia, antimicrobial treatment, guidelines, streptococcus pneumoniae

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