Bacteremic Pneumonia Research Articles

Clinical predictors and outcomes for Legionnaire's disease versus bacteremic pneumococcal pneumonia

BackgroundLegionnaires' disease (LD) is a serious sometimes fatal pneumonia caused by Legionella pneumophila. The clinical manifestations of LD may be similar to those by caused by Streptococcus pneumoniae. As both conditions can be serious illnesses but requiring different antimicrobial therapies, factors that can help differentiate these types of pneumonias can be helpful in the clinical management of hospitalized patients with bacterial pneumonia. This study aimed to compare clinical features and indicators of disease progression in hospitalized patients with community-acquired pneumonia caused by L. pneumophila and bacteremic S. pneumoniae. MethodsWe conducted a retrospective case comparison study of adult patients hospitalized with LD or S. pneumoniae. Data collected included demographic, clinical characteristics, and comorbidities, and outcomes. Data were analyzed using SPS vs 24.0. Multivariable analysis was done using logistic regression with a forward stepwise algorithm. ResultsA total of 106 patients met study criteria. The incidence of LD peaked in summer months and S. pneumoniae peaked in the winter quarter. From multivariable analysis predictors of LD were male gender (OR=21.6, p < 0.001), diarrhea (OR=4.5, p = 0.04), body mass index (BMI) (OR=1.13, p = 0.02), hyponatremia (OR=5.6, p = 0.03 and Charlson weighted index of comorbidity (CWIC) score (OR=0.61, p = 0.01). Patients with S. pneumoniae had higher rates of mechanical ventilation, septic shock, and death than those with LD. ConclusionsOur data suggests that variables that may distinguish LD from S. pneumoniae include male gender, diarrhea, hyponatremia, higher temperature on admission, higher BMI and fewer comorbidities. Bacteremic S. pneumoniae was associated with poorer outcomes than LD including higher rates of septic shock, mechanical ventilation, ICU admission, and death.

The first case of Francisella novicida infection in Taiwan: bacteraemic pneumonia in a haemodialysis adult

ABSTRACT Tularaemia is a zoonotic disease caused by Francisella tularensis (F. tularensis). Human infection is rare and can be life-threatening. F. tularensis subsp. novicida used to be a subspecies of F. tularensis, is now considered a different species, F. novicida. Though less virulent, F. novicida can cause morbidity and mortality among debilitated or immunocompromised patients. We reported that an adult with end-stage renal disease undergoing haemodialysis and a history of melioidotic aortic aneurysm developed F. novicida bacteraemic pneumonia, which was uneventfully treated by antimicrobial therapy. The microbiological confirmation of F. novicida infection relies on 16S rRNA sequencing. It is the first case of F. novicida infection in Taiwan.

Risk factors of methicillin-resistant Staphylococcus aureus bacteremic pneumonia in the emergency department

The infection rate of methicillin-resistant Staphylococcus aureus (MRSA) has increased worldwide and MRSA bacteremic pneumonia is associated with a high mortality rate. This is a retrospective study conducted at a university hospital in Korea involving adult patients diagnosed as bacteremic pneumonia caused by S. aureus in the ED between January 2009 and December 2019. We compared MRSA bacteremic pneumonia patients (n = 56) to methicillin-susceptible S. aureus bacteremic pneumonia patients (n = 49). Our study showed that that underlying hypertension (OR = 5.68; 95% CI = 2.00–16.11; p = 0.001) and cerebrovascular disease (OR = 3.54; 95% CI = 1.06–11.75; p = 0.038), recent intravenous therapy within 1 month (OR = 8.38; 95% CI = 2.88–24.38; p = 0.0001), and pleural effusion on chest radiography (OR = 5.77; 95% CI = 1.79–18.57; p = 0.003) were independent risk factors for MRSA bacteremic pneumonia presenting to the ED. Although MRSA infection has been more frequently derived from the community than before, inappropriate empiric antibiotic treatment was overwhelmingly observed in the majority of patients in our study. Considering the resistance of MRSA to the typical empiric regimen prescribed for community-acquired pneumonia, emergency physicians should pay attention to the predictors for MRSA bacteremic pneumonia including pleural effusion on chest radiography when deciding on the appropriate empiric antimicrobial therapy for pneumonia patients in the ED.

Decline in Pneumococcal Disease in Young Children During the Coronavirus Disease 2019 (COVID-19) Pandemic in Israel Associated With Suppression of Seasonal Respiratory Viruses, Despite Persistent Pneumococcal Carriage: A Prospective Cohort Study.

BackgroundThe incidence of invasive pneumococcal disease (IPD) declined during the COVID-19 pandemic. Previous studies hypothesized that this was due to reduced pneumococcal transmission resulting from non-pharmaceutical interventions. We used multiple ongoing cohort surveillance projects in children <5 years to test this hypothesis.MethodsThe first SARS-CoV-2 cases were detected in February-2020, resulting in a full lockdown, followed by several partial restrictions. Data from ongoing surveillance projects captured the incidence dynamics of community-acquired alveolar pneumonia (CAAP), non-alveolar lower respiratory infections necessitating chest X-rays (NA-LRI), nasopharyngeal pneumococcal carriage in non-respiratory visits, nasopharyngeal respiratory virus detection (by PCR), and nationwide invasive pneumococcal disease (IPD). Monthly rates (January-2020 through February-2021 vs. mean monthly rates 2016-2019 [expected rates]) adjusted for age and ethnicity, were compared.ResultsCAAP and bacteremic pneumococcal pneumonia were strongly reduced (incidence rate ratios, [IRRs] .07 and .19, respectively); NA-LRI and non-pneumonia IPD were also reduced, with a lesser magnitude (IRRs, .46 and .42, respectively). In contrast, pneumococcal carriage prevalence was only slightly reduced, and density of colonization and pneumococcal serotype distributions were similar to previous years. The decline in pneumococcus-associated disease was temporally associated with a full suppression of RSV, influenza viruses, and hMPV, often implicated as co-pathogens with pneumococcus. In contrast, adenovirus, rhinovirus, and parainfluenza activities were within or above expected levels.ConclusionsReductions in pneumococcal and pneumococcus-associated diseases occurring during the COVID-19 pandemic in Israel were not predominantly related to reduced pneumococcal carriage and density, but were strongly associated with the disappearance of specific respiratory viruses.

Pneumococcal serotypes causing non-invasive pneumonia in adults from a South Indian tertiary care hospital and the impact of the newer conjugate vaccines.

Background Streptococcus pneumoniae is the leading cause of community-acquired pneumonia (CAP) in adults. Ageing, chronic conditions and comorbidities are important risk factors for pneumococcal pneumonia.PurposeThere is lack of data on the pneumococcal serotypes causing non-invasive pneumonia in India. This study aims to determine the prevalent pneumococcal serotypes causing non-invasive pneumonia, the associated comorbidities, and the coverage of both the available pneumococcal vaccines in India and conjugate vaccines that are currently undergoing clinical trials.MethodsA total of 280 subjects (aged >16 years) who had clinical symptoms correlating with radiological findings for non-invasive bacteremic pneumonia and microbiological evidence of S. pneumoniae between 2018 and 2020 were included. The clinical, demographic, radiological and microbiological findings were retrieved from the Hospital Information System (HIS).ResultThe common serotypes in order of prevalence were 19F, 9V, 23F, 6B, 11A, 13, 34, 10A, 19A and 6A. The predominant non-vaccine serotypes were 13, 34, 35B, 31 and 16F. The associated radiological findings were pneumonic consolidation and multi-lobar involvement. Other coinfected bacterial pathogens included H. influenzae, S. aureus, K. pneumoniae and P. aeruginosa.ConclusionThe pneumococcal vaccines: PCV10/GSK, PCV10/SII, PCV13, PCV15, PCV20 and PPSV23 provide an overall serotype coverage of 36, 41, 47, 48, 61 and 69 %, respectively of S. pneumoniae causing non-invasive pneumonia in South India. Increasing catch-up vaccination using PCV10(SII) in pre-school children could have a more significant impact on reducing pneumococcal pneumonia in adults (>50 years) in terms of increased herd immunity at an affordable cost.

Streptococcus-Pneumoniae Diseases

Streptococcus pneumoniae is a Gram-positive encapsulated diplococcus. The capsule determines the ≥100 serotypes, is the relevant vaccine antigen and the main pathogenicity factor. Children &lt;5 years are the main reservoir and often spread S. pneumoniae to the elderly. Presence of an acute viral respiratory tract infection (ARI) may favor the development of mucosal pneumococcal infections, as theoretical, experimental, epidemiological, and clinical data indicate viral-bacterial synergy. Many risk factors like anatomical and immunological factors, underlying diseases, and environmental/behavioral factors favor development of invasive pneumococcal disease (IPD). Pneumococcal diseases can be treated with different groups of antibiotics, depending on the local resistance situation. Polysaccharide and polysaccharide-conjugate vaccines are used for pneumococcal disease prevention. The disadvantages of 23-valent pneumococcal polysaccharide vaccine (Pneumovax®) are: lack of memory cell induction, and thus no booster response, no reduction of carriage, and thus no herd protection, lack of IgG immune response in children &lt;2 years, only short-term and moderate protection rates in subjects ≥65 years against bacteremic pneumonia only. In contrast, pneumococcal conjugate vaccines (PCVs): generate a memory response in all ages, can reduce pneumococcal acquisition/colonization, reduce mucosal diseases (otitis media, non-bacteremic pneumonia, IPD), and there is long-term protection. Currently licensed and marketed PCVs are PCV10 (Synflorix®, not licensed in the USA; indicated only for children), PCV13 (Prevenar 13® [Europe]; Prevnar 13® [USA]) and PCV15 (Vaxneuvance®) which are both licensed in EU and USA for adults and children, and PCV20 (Prevnar 20® [USA]; Apexxnar® [Europe]) which is currently only licensed for use in adults.

Bacteraemic pneumococcal pneumonia and SARS-CoV-2 pneumonia: differences and similarities

ObjectiveTo analyse differences in clinical presentation and outcome between bacteraemic pneumococcal community-acquired pneumonia (B-PCAP) and sSvere Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pneumonia.MethodsThis observational multi-centre study was conducted on patients hospitalized with B-PCAP between 2000 and 2020 and SARS-CoV-2 pneumonia in 2020. Thirty-day survival, predictors of mortality, and intensive care unit (ICU) admission were compared.ResultsIn total, 663 patients with B-PCAP and 1561 patients with SARS-CoV-2 pneumonia were included in this study. Patients with B-PCAP had more severe disease, a higher ICU admission rate and more complications. Patients with SARS-CoV-2 pneumonia had higher in-hospital mortality (10.8% vs 6.8%; P=0.004). Among patients admitted to the ICU, the need for invasive mechanical ventilation (69.7% vs 36.2%; P<0.001) and mortality were higher in patients with SARS-CoV-2 pneumonia. In patients with B-PCAP, the predictive model found associations between mortality and systemic complications (hyponatraemia, septic shock and neurological complications), lower respiratory reserve and tachypnoea; chest pain and purulent sputum were protective factors in these patients. In patients with SARS-CoV-2 pneumonia, mortality was associated with previous liver and cardiac disease, advanced age, altered mental status, tachypnoea, hypoxaemia, bilateral involvement, pleural effusion, septic shock, neutrophilia and high blood urea nitrogen; in contrast, ≥7 days of symptoms was a protective factor in these patients. In-hospital mortality occurred earlier in patients with B-PCAP.ConclusionsAlthough B-PCAP was associated with more severe disease and a higher ICU admission rate, the mortality rate was higher for SARS-CoV-2 pneumonia and deaths occurred later. New prognostic scales and more effective treatments are needed for patients with SARS-CoV-2 pneumonia.

Comparison of prognostic factors between bacteraemic and non-bacteraemic critically ill immunocompetent patients in community-acquired severe pneumococcal pneumonia: a STREPTOGENE sub-study

BackgroundThe presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP.MethodsThis was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients.ResultsAmong 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone.ConclusionBacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors.

Clinical and bacterial characteristics of Pseudomonas aeruginosa affecting the outcome of patients with bacteraemic pneumonia

Few studies have assessed the clinical and bacterial characteristics of Pseudomonas aeruginosa (PA) bacteraemic pneumonia (BP) episodes. This study analysed all non-duplicate PA-BP episodes from a tertiary hospital in 2013–2017. Epidemiology, clinical data, antimicrobial therapy and outcomes were recorded. Whole-genome sequencing was performed on PA blood isolates. The impact on early and late overall mortality of host, antimicrobial treatment and pathogen factors was assessed by multivariate logistic regression analysis. Of 55 PA-BP episodes, 32 (58.2%) were caused by extensively drug-resistant (XDR) PA. ST175 (32.7%) and ST235 (25.5%) were the most frequent high-risk clones. β-Lactamases/carbapenemases were detected in 29 isolates, including blaVIM-2 (27.2%) and blaGES type (25.5%) [blaGES-5 (20.0%), blaGES-1 (3.6%) and blaGES-20 (1.8%)]. The most prevalent O-antigen serotypes were O4 (34.5%) and O11 (30.9%). Overall, an extensive virulome was identified in all isolates. Early mortality (56.4%) was independently associated with severe neutropenia (aOR = 4.64, 95% CI 1.11–19.33; P = 0.035) and inappropriate empirical antimicrobial therapy (aOR = 5.71, 95% CI 1.41–22.98; P = 0.014). Additionally, late mortality (67.3%) was influenced by septic shock (aOR = 8.85, 95% CI 2.00–39.16; P = 0.004) and XDR phenotype (aOR = 5.46, 95% CI 1.25–23.85; P = 0.024). Moreover, specific genetic backgrounds [ST235, blaGES, gyrA (T83I), parC (S87L), exoU and O11 serotype] showed significant differences in patient outcomes. Our results confirm the high mortality associated with PA-BP. Besides relevant clinical characteristics and inappropriate empirical therapy, bacteria-specific genetics factors, such as XDR phenotype, adversely affect the outcome of PA-BP.

Congenital Heart Disease Does Not Increase Risk of Bacteremia In Children With Pneumonia

Background: Pneumonia is a major cause of childhood morbidity and mortality worldwide. It can be complicated by bacteremia. Congenital heart diseases (CHD) that cause increased pulmonary blood flow are a common predisposing factor for pneumonia in children. Aim of the Work: We aimed to identify if children with pneumonia suffer from bacteremia and to identify the most common organisms causing bacteremia in cases of pneumonia with and without congenital heart disease and to study role of CHD in influencing type of bacteremia in pneumonia. Patients and Methods: We conducted a pilot prospective study at Pediatric Hospital, Cairo University on 55 children with pneumonia (group 1) and 55 children with pneumonia and CHD (group 2). They all underwent complete blood counts, blood cultures and chest x-ray. Results: The frequency of bacteremia was 56.4% in children with pneumonia and no CHD and 38.2% in those with pneumonia and CHD. In group with pneumonia and no CHD blood culture results showed no growth in 24 cases (43.6%), Klebsiella spp. growth 11 cases (20%), Coagulase negative staphylococci (CONS) in 6 cases (10.9%), Methicillin Resistant Staphylococcus aureus in 4 cases (7.3%), Candida albicans in 2 cases (3.6%) and Pseudomonas spp. in 2 cases (3.6%). While the blood cultures in the group with pneumonia and CHD showed no growth in 34 cases (61.8%), Klebsiella spp. in 10 cases (18.2%), CONS in 5 cases (9.1%) and Candida albicans in 3 cases (5.5%) and no statistically significant difference was found. Conclusion: Frequency of bacteremia in children with pneumonia with and without congenital heart disease were not significantly different, the most common organism causing bacteremia in cases of pneumonia with or without congenital heart disease is Klebsiella spp . and the most sensitive antibiotic is polymyxin.

Pyoverdine Inhibitors and Gallium Nitrate Synergistically Affect Pseudomonas aeruginosa.

ABSTRACTPseudomonas aeruginosa is a multidrug-resistant, opportunistic pathogen that frequently causes ventilator-associated pneumonia in intensive care units and chronic lung infections in cystic fibrosis patients. The rising prevalence of drug-resistant bacteria demands the exploration of new therapeutic avenues for treating P. aeruginosa infections. Perhaps the most thoroughly explored alternative is to use novel treatments to target pathogen virulence factors, like biofilm or toxin production. Gallium(III) nitrate is one such agent. It has been recognized for its ability to inhibit pathogen growth and biofilm formation in P. aeruginosa by disrupting bacterial iron homeostasis. However, irreversible sequestration by pyoverdine substantially limits its effectiveness. In this report, we show that disrupting pyoverdine production (genetically or chemically) potentiates the efficacy of gallium nitrate. Interestingly, we report that the pyoverdine inhibitor 5-fluorocytosine primarily functions as an antivirulent, even when it indirectly affects bacterial growth in the presence of gallium, and that low selective pressure for resistance occurs. We also demonstrate that the antibiotic tetracycline inhibits pyoverdine at concentrations below those required to prevent bacterial growth, and this activity allows it to synergize with gallium to inhibit bacterial growth and rescue Caenorhabditis elegans during P. aeruginosa pathogenesis.IMPORTANCE P. aeruginosa is one of the most common causative agents for ventilator-associated pneumonia and nosocomial bacteremia and is a leading cause of death in patients with cystic fibrosis. Pandrug-resistant strains of P. aeruginosa are increasingly identified in clinical samples and show resistance to virtually all major classes of antibiotics, including aminoglycosides, cephalosporins, and carbapenems. Gallium(III) nitrate has received considerable attention as an antipseudomonal agent that inhibits P. aeruginosa growth and biofilm formation by disrupting bacterial iron homeostasis. This report demonstrates that biosynthetic inhibitors of pyoverdine, such as 5-fluorocytosine and tetracycline, synergize with gallium nitrate to inhibit P. aeruginosa growth and biofilm formation, rescuing C. elegans hosts during pathogenesis.

Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

SummaryBackgroundStreptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are typically transmitted via respiratory droplets, are leading causes of invasive diseases, including bacteraemic pneumonia and meningitis, and of secondary infections subsequent to post-viral respiratory disease. The aim of this study was to investigate the incidence of invasive disease due to these pathogens during the early months of the COVID-19 pandemic.MethodsIn this prospective analysis of surveillance data, laboratories in 26 countries and territories across six continents submitted data on cases of invasive disease due to S pneumoniae, H influenzae, and N meningitidis from Jan 1, 2018, to May, 31, 2020, as part of the Invasive Respiratory Infection Surveillance (IRIS) Initiative. Numbers of weekly cases in 2020 were compared with corresponding data for 2018 and 2019. Data for invasive disease due to Streptococcus agalactiae, a non-respiratory pathogen, were collected from nine laboratories for comparison. The stringency of COVID-19 containment measures was quantified using the Oxford COVID-19 Government Response Tracker. Changes in population movements were assessed using Google COVID-19 Community Mobility Reports. Interrupted time-series modelling quantified changes in the incidence of invasive disease due to S pneumoniae, H influenzae, and N meningitidis in 2020 relative to when containment measures were imposed.Findings27 laboratories from 26 countries and territories submitted data to the IRIS Initiative for S pneumoniae (62 837 total cases), 24 laboratories from 24 countries submitted data for H influenzae (7796 total cases), and 21 laboratories from 21 countries submitted data for N meningitidis (5877 total cases). All countries and territories had experienced a significant and sustained reduction in invasive diseases due to S pneumoniae, H influenzae, and N meningitidis in early 2020 (Jan 1 to May 31, 2020), coinciding with the introduction of COVID-19 containment measures in each country. By contrast, no significant changes in the incidence of invasive S agalactiae infections were observed. Similar trends were observed across most countries and territories despite differing stringency in COVID-19 control policies. The incidence of reported S pneumoniae infections decreased by 68% at 4 weeks (incidence rate ratio 0·32 [95% CI 0·27–0·37]) and 82% at 8 weeks (0·18 [0·14–0·23]) following the week in which significant changes in population movements were recorded.InterpretationThe introduction of COVID-19 containment policies and public information campaigns likely reduced transmission of S pneumoniae, H influenzae, and N meningitidis, leading to a significant reduction in life-threatening invasive diseases in many countries worldwide.FundingWellcome Trust (UK), Robert Koch Institute (Germany), Federal Ministry of Health (Germany), Pfizer, Merck, Health Protection Surveillance Centre (Ireland), SpID-Net project (Ireland), European Centre for Disease Prevention and Control (European Union), Horizon 2020 (European Commission), Ministry of Health (Poland), National Programme of Antibiotic Protection (Poland), Ministry of Science and Higher Education (Poland), Agencia de Salut Pública de Catalunya (Spain), Sant Joan de Deu Foundation (Spain), Knut and Alice Wallenberg Foundation (Sweden), Swedish Research Council (Sweden), Region Stockholm (Sweden), Federal Office of Public Health of Switzerland (Switzerland), and French Public Health Agency (France).

Pharmacokinetic/pharmacodynamic evaluation of the antimicrobial therapy of pneumococcal invasive disease in adults in post-PCV13 vaccine period in Madrid, Spain.

The objective of our study was to evaluate by pharmacokinetic/pharmacodynamic (PK/PD) analysis, if the antimicrobials used for the treatment of invasive pneumococcal disease (IPD) in adults, including meningitis, are adequate considering the susceptibility profile of S. pneumoniae in Spain after the implantation of PVC13 vaccine. Pharmacokinetic parameters of benzylpenicillin and cefotaxime were obtained from the literature, and susceptibility data of invasive S. pneumoniae strains recovered in 2017 (post-PCV13 vaccination period) were provided by the Public Health Regional Laboratory of Madrid. We have also studied levofloxacin because it is used to treat pneumococcal pneumonia previously to be diagnosed as bacteremic pneumonia. Monte Carlo simulation was used to estimate the probability of target attainment (PTA) and the cumulative fraction of response (CFR). All doses of benzylpenicillin except 2 mU q6h provide a high probability of treatment success for MIC values ≤ 1 mg/L; 4 mU q4h is even useful for MIC values up to 4 mg/L. This high dose, used for the treatment of meningitis, also provides high probability of treatment success for MIC ≤ 0.5 mg/L. At the susceptibility EUCAST breakpoint (≤ 0.5 mg/L), cefotaxime provides a high rate of PD target achievement, even at the lowest dose (1 g q8h). For meningitis, 2 g q6h ensures probabilities of target attainment ≥90% for MIC up to 1 mg/L. Our study confirms that after the implementation of PCV13 vaccine, the treatment with benzylpenicillin and cefotaxime provides high probability of the therapy success of IPD, including meningitis.

Secondary infections in mechanically ventilated patients with COVID-19: An overlooked matter?

ABSTRACTIntroductionThe susceptibility to infection probably increases in COVID-19 patients due to a combination of virus and drug-induced immunosuppression. The reported rate of secondary infections was quite low in previous studies. The objectives of our study were to investigate the rate of secondary infections, risk factors for secondary infections and risk factors for mortality in COVID-19 critically ill patients.Material and methodsWe performed a single-center retrospective study in mechanically ventilated critically ill COVID-19 patients admitted to our Critical Care Unit (CCU). We recorded the patients’ demographic data; clinical data; microbiology data and incidence of secondary infection during CCU stay, including ventilator-associated pneumonia (VAP) and nosocomial bacteremia (primary and secondary).ResultsA total of 107 patients with a mean age 62.2 ± 10.6 years were included. Incidence of secondary infection during CCU stay was 43.0% (46 patients), including nosocomial bacteremia (34 patients) and VAP (35 patients). Age was related to development of secondary infection (65.2 ± 7.3 vs. 59.9 ± 12.2 years, p=0.007). Age ≥ 65 years and secondary infection were independent predictors of mortality (OR=2.692, 95% CI 1.068-6.782, p<0.036; and OR=3.658, 95% CI 1.385-9.660, p=0.009, respectively). The hazard ratio for death within 90 days in the ≥ 65 years group and in patients infected by antimicrobial resistant pathogens was 1.901 (95% CI 1.198-3.018; p= 0.005 by log-rank test) and 1.787 (95% CI 1.023-3.122; p= 0.036 by log-rank test), respectively.ConclusionsOur data suggest that the incidence of secondary infection and infection by antimicrobial resistant pathogens is very high in critically ill patients with COVID-19 with a significant impact on prognosis.

P0157 / #2124: IDENTIFYING THE RIGHT SOLUTION FOR THE RIGHT PROBLEM: THE CRITICALLY-ILL PEDIATRIC HEMATOLOGY-ONCOLOGY PATIENT

Aims & Objectives: To describe the clinical characteristics, epidemiology, management and outcome of unplanned transfers to the Pediatric Intensive Care Unit (PICU) from the Pediatric Hematology-Oncology Inpatient Unit (PHOIU). Methods: Retrospective descriptive study in a tertiary hospital including 34 non-elective PICU transfers from the PHOIU in 2019. Results: 20 patients (60% boys, mean age 7.7 years) required 34 PICU unplanned transfers (41.5% of the total PICU admissions from the PHOIU). 80% had malignancies, acute lymphoblastic leukemia being the most frequent (25%) and 55% had undergone a hematopoietic stem cell transplant. The majority were hospitalized for diagnosis confirmation (55%) or treatment initiation (40%). The median stay before PICU admission was 34.7 days. The median delay since the deterioration event to the intensivist’s evaluation and PICU transfer was 3.8 and 5.6 hours respectively. The median PICU stay was 4.4 days. During the first 24 hours of PICU stay, non-invasive ventilation was required in 11.5% of the episodes, invasive ventilation in 14.7% and vasoactive drugs in 17.6%. Upon admission, neutropenia was present in 47.1%, neurologic impairment in 20.1%, systemic inflammatory response syndrome in 38.2% and multiorgan failure in 35.3%. The most frequent diagnoses were sepsis/septic shock (35.6%), pneumonia (11.7%) and catheter-related bacteraemia (5.9%). Mortality rate was 15% during PICU stay. Conclusions: Morbimortality in pediatric hematology-oncology patients requiring an unplanned PICU admission is high. We decided to implement EVAT, an early warning system specific to the pediatric hematology-oncology patient for early detection and management of clinical deterioration in behalf of improving healthcare quality and survival.

Severe Necrotizing Pneumonia and Persistent Bacteremia in a Teenager with a History of Vaping

Severe Necrotizing Pneumonia and Persistent Bacteremia in a Teenager with a History of Vaping

Atypical presentation of Neisseria meningitidis serogroup W disease is associated with the introduction of the 2013 strain.

Since 2015, the incidence of invasive meningococcal disease (IMD) caused by serogroup W (MenW) has increased in Sweden, due to the introduction of the 2013 strain belonging to clonal complex 11. The aim of this study was to describe the clinical presentation of MenW infections, in particular the 2013 strain, including genetic associations. Medical records of confirmed MenW IMD cases in Sweden during the years 1995-2019 (n = 113) were retrospectively reviewed and the clinical data analysed according to strain. Of all MenW patients, bacteraemia without the focus of infection was seen in 44%, bacteraemic pneumonia in 26%, meningitis in 13% and epiglottitis in 8%, gastrointestinal symptoms in 48% and 4% presented with petechiae. Phylogenetic analysis was used for possible links between genetic relationship and clinical picture. The 2013 strain infections, particularly in one cluster, were associated with more severe disease compared with other MenW infections. The patients with 2013 strain infections (n = 68) were older (52 years vs. 25 years for other strains), presented more often with diarrhoea as an atypical presentation (P = 0.045) and were more frequently admitted for intensive care (P = 0.032). There is a risk that the atypical clinical presentation of MenW infections, with predominantly gastrointestinal or respiratory symptoms rather than neck stiffness or petechiae, may lead to delay in life-saving treatment.

Characteristics and outcomes of bacteremic pneumococcal pneumonia of patients with and without HIV infection in Argentina

Streptococcus pneumoniae is the main causative agent of pneumonia, with a 10 to 25 percent rate of isolation in blood cultures. Controversies exist regarding the prognostic impact of a history of human immunodeficiency virus (HIV) infection on community-acquired pneumonia. The aim of our work was to analyze and compare the clinical presentation, radiological findings and progression of pneumococcal pneumonia in patients infected with and not infected with HIV. We retrospectively analyzed adult patients with positive blood cultures for Streptococcus pneumoniae and clinical and radiological findings compatible with pneumonia in the period between January 2012 and May 2017. Age, sex, comorbidities, clinical and laboratory variables, radiological severity, progression and mortality were analyzed. Comparative analysis between HIV-positive and -negative patients was carried out. Receiver operating curves (ROC) for CURB-65 were performed to predict mortality in both groups. We included 107 patients (21 HIV-positive and 86 HIV-negative). HIV patients were on average younger (38 vs 58 years) with lower hematocrits (31.7 vs 36.5%) and fewer comorbidities (47 vs 72%). Overall mortality was 36 percent, and the area under the curve (AUC) of the CURB-65 ROC was 0.69 (95% confidence interval: 0.58–0.79) for all patients without differences between the two groups. Patients with a history of HIV infection had the same progression and mortality as the group of patients without that background.

Pharmaceutical Practice of Ceftazidime-avibactam Combined with High Dose Meropenem in XDR-Klebsiella Pneumoniae Bloodstream Infection

Background: The literature of ceftazidime-avibactam for bloodstream infections is limited, and whether meropenem (MIC ≥ 16 mg/L) can be used is also a perplexing issue for clinicians. Aim: To observe the clinical efficacy and safety of ceftazidime-avibactam combined with high dose meropenem in the treatment of extensively drug-resistant (XDR) klebsiella pneumonia (Kp) bacteremia. Methods: In 1 critically ill patient with XDR-Kp diagnosed through blood culture, tigecycline combined with cefoperazone-sulbactam and tigecycline combined with polymyxin B were successively given, and both showed poor anti-infection effects. The clinical pharmacists recommend ceftazidime-avibactam combined with high dose meropenem for anti-infection therapy. Through literature review, clinical pharmacists dynamically adjusted the dose according to the creatinine clearance rate of patients. Clinical pharmacists analyzed whether meropenem (MIC ≥ 16 mg/L) could be combined with ceftazidine-avibactam for XDR-Kp and recommended the dose of meropenem for 2g q8h and intravenous pumping for 4 hours. Results: Ceftazidime-avibactam combined with a large dose of meropenem pumped into the vein for a long time made XDR-Kp rapidly negative conversion, with clinical symptoms, signs and inflammatory indicators such as body temperature, PCT, and CRP significantly improved, without adverse reactions such as liver and kidney function. Conclusion: Ceftazidime-avibactam combined with high dose meropenem has a significant therapeutic effect on XDR-Kp and the efficacy is safe and reliable.

Twenty-Year Public Health Impact of 7- and 13-Valent Pneumococcal Conjugate Vaccines in US Children.

Pneumococcal conjugate vaccines (PCVs) have been used in the United States since 2000. To assess the cumulative 20-year effect of PCVs on invasive pneumococcal disease (IPD) incidence among children <5 years of age, we analyzed Active Bacterial Core Surveillance data, conducted a literature review, and modeled expected and observed disease. We found that PCVs have averted >282,000 cases of IPD, including ≈16,000 meningitis, ≈172,000 bacteremia, and ≈55,000 bacteremic pneumonia cases. In addition, vaccination has prevented 97 million healthcare visits for otitis media, 438,914–706,345 hospitalizations for pneumonia, and 2,780 total deaths. IPD cases declined 91%, from 15,707 in 1997 to 1,382 in 2019. Average annual visits for otitis media declined 41%, from 78 visits/100 children before PCV introduction to 46 visits/100 children after PCV13 introduction. Annual pneumonia hospitalizations declined 66%–79%, from 110,000–175,000 in 1997 to 37,000 in 2019. These findings confirm the substantial benefits of PCVs for preventing IPD in children.