Management Of Lower Respiratory Tract Infections Research Articles

Phage therapy in the management of respiratory and pulmonary infections: a systematic review.

Lower respiratory tract infections (LRTIs) pose a significant threat to global health, causing more than 2 million deaths worldwide. This menace is intensified by the alarming increase in drug resistance, which limits the availability of effective antibiotics for bacterial respiratory infections. Consequently, there is an urgent demand for alternative therapeutic options. Phage therapy (PT) has re-emerged as a promising therapeutic approach and as an adjunct to antibiotic treatment. This systematic review synthesises the application of PT for LRTIs in humans, providing unified and updated data on the evaluation of the safety and efficacy of PT for LRTIs. Systematic review. Following the PRISMA guidelines, a comprehensive search strategy was carried out (spanning January 2000 - February 2024) in four databases: PubMed, Scopus, ScienceDirect and Web of Science to retrieve published records of PT for LRTIs in humans only. The reference list of each included study was evaluated for possible inclusion of other relevant articles. Among the 18 records that fulfilled the inclusion criteria, 70 patients were administered PT. Microbiologically, 71.42% (n = 50/70) of the patients improved; with either the eradication of the pathogen or a decrease in bacterial load, whilst 15.71% (n = 11/70) did not record any improvement. About 5.71% (n = 4/70) recorded a partial/incomplete improvement, whilst 7.14% (n = 5/70) of the patients microbiological outcomes were unspecified. Clinically, up to 74.29% (n = 52/70) of the patients improved, whilst 10.00% (n = 7/70) of the patients showed no improvement. Another 2.86% (n = 2/70) recorded partial/incomplete improvement, whilst 12.86% (n = 9/70) were uncategorized. Phage titres that yielded positive outcomes ranged from 105 to 1012 PFU/mL. Studies that achieved a substantial phage titre at the site of infection frequently observed notable improvements. Regarding the safety of PT, 77.78% (N = 14/18) of the studies did not record any adverse effects after PT was administered, whilst 16.66% (n = 3/18) of the studies reported adverse effects. Based on recently published data originating mainly from observational studies, PT has shown considerable efficacy and safety in the treatment of LRTIs. However, there is a lack of uniform methodologies and protocols across different PT cases in the management of LRTIs. Consequently, there is a need for additional clinical studies to establish standardised pharmacokinetic elements and an overall protocol for PT. By doing so, we can fully unlock the potential of PT in effectively managing clinical bacterial infections, including LRTIs.

Bacterial Etiology of Lower Respiratory Tract Infection that Isolated from Tripoli University Hospital (TUH) Units in 2019

Introduction: Lower respiratory tract infection (LRTI) is one of the common major health problems, causing morbidity and mortality. Aims: The study was conducted to determine the current trends of bacterial etiology of LRTIs among patients who attended the University Teaching Hospital (UTH) and their antimicrobial susceptibility profile with special interest on drug resistance. Study Design: The study was a Cross sectional study. All patients’ files were selected as diagnosed with LRTIs and their demographic data, other illness, prescribed treatment /antibiotic used previously. Place and Duration of Study: This study is designed to collect data from files of lower respiratory tract infection patients following in units of university hospital in Tripoli. Methodology: The study was conducted between January to December 2019. at the unit in university hospital in Tripoli city in Libya. Sputum samples of 465 patients with suspected LRTIs were received, after obtaining patients' informed consent and ethical clearance from the UNTH. The samples were collected and processed according to standard laboratory procedures. Results: Of the total 465 sputum samples, 366 (78.7%) were positive for micro-organisms. Four main types of bacteria have been identified: acinetobacter spp. 25.6%, Klebsiellla pneumoniae 25.6%, P. saeroginosa (1.39%), Candida (9.03%). The distribution of lower respiratory tract infections within the hospital department indicated that the isolated strains revealed a higher infection rate of Gram-negative bacteria in the Pediatric Intensive Care Unit (PICU) and General Surgical Intensive Care Unit (GSICU) compared to other departments, with statistical significance. Notably, there was a significant difference in the infection rates of Pseudomonas in the Special Care Baby Unit (SCBU) with 7 cases, and in the Medical Intensive Care Unit (MICU) with 6 cases, as well as in the Neonatal Intensive Care Unit (NICU) with 2 cases. The infection rates for Candida and Streptococcus pneumoniae in the NICU were recorded at 2, 1, and 2, respectively, which were significantly different from those observed in other departments. The prevalence of antimicrobial resistance among Gram-negative and Gram-positive bacterial isolates indicated a very high resistance rate (98–100%) among Acinetobacter baumannii isolates to various antibiotics including AK, AMC, ATM, CAZ, CRO, CIP, GN, MEM, TOB, PRL, and CZ. However, for SXT, the isolate demonstrated the highest sensitivity, with a resistance rate of less than 53%. Conclusion: Understanding the variety of pathogens that cause lower respiratory tract infections (LRTIs) and their patterns of susceptibility to antibiotics, in addition to monitoring antibiotic resistance, is crucial for the effective management of LRTIs. This includes timely clinical and laboratory diagnoses, as well as the implementation of the appropriate treatment strategies.

Antibiogram Assessment of Gram-negative Bacterial Isolates of LRTI Suspected Patients Visiting Tertiary Care Hospital

Lower respiratory tract infection is a common cause of morbidity and mortality worldwide. A cross-sectional study was carried out with an objective to assess the antibiogram pattern of the Gram-negative bacterial isolates from LRTI suspected patients visiting tertiary care hospitals. The study was carried out in a tertiary care hospital laboratory from January 2022 to March 2022. A total of 108 sputum samples from LRTI suspected patients were processed for Gram-negative bacteria isolation. Out of 108 sputum samples, 17 (15.74%) showed significant growth for Gram- negative bacteria and 91 (84.26%) showed insignificant growth. Male suspected patients were more predominant over female suspected patients, showing (11)10% and (6)6% significant growth respectively. The most common bacterial pathogens among Lower respiratory tract infection (LRTI) suspected patients are Mycobacterium tuberculosis (47.05%) followed by Pseudomonas aeruginosa (17.64%), Klebsiella pneumoniae (17.64%), Escherichia coli (11.76%), and Klebsiella oxytoca (5.88%). Antibiotic susceptibility tests (AST) were done by the KirbyBauer disc diffusion method. The antibiotic susceptibility patterns of isolates revealed high resistivity against most of the used antibiotics whereas the isolates showed good in vitro activity against amikacin, ofloxacin and ceftriaxone. Therefore, Culture and Susceptibility tests are important for management of LRTI in patients.

Screening for Plasmid Mediated Antibiotic Resistance among Multi Drug Resistant Bacteria Isolated from Patients with Lower Respiratory Tract Infections Attending some Hospitals in Kano Metropolis

Study’s Novelty/Excerpt This study investigates the prevalence and plasmid-mediated resistance of multidrug-resistant (MDR) bacteria isolated from patients with lower respiratory tract infections (LRTIs), revealing significant findings pertinent to public health. The research demonstrates a high prevalence of MDR isolates (20%) and highlights the substantial role of plasmids, with 67.6% of MDR isolates containing plasmids, and 80% losing drug resistance post-plasmid curing. These results underscore the necessity for treatment options based on antibiotic susceptibility testing and continuous plasmid profiling to combat plasmid-mediated resistance effectively, marking a critical advancement in the management of LRTIs. Full Abstract Lower Respiratory tract infections (LRTIs) are among the serious infections in humans that have been worsening by the emergence of drug resistant bacteria and aggravated by plasmids transfer. The study aimed to screen Multidrug-resistant (MDR) bacteria isolated from patients with LRTIs for the presence of Plasmid. Sputum samples (400) were collected from patients with LRTIs and processed using standard microbiological procedures to isolate lower respiratory tract bacteria. The identified isolates were subjected to antibacterial susceptibility testing using the disc diffusion method. Multidrug resistant isolates were further subjected to plasmid curing using Acridine orange and the cured isolates were tested for loss of drug resistance. Among the 400 samples, 185 (46.2 %) harbored significant bacterial growth, with 83 (44.9%) Gram-positive and 102 (55.1%) Gram-negative bacteria. Bacteria isolated include Escherichia coli (29), Klebsiella pneumonia (46), Moraxella catarrhalis (13), Pseudomonas aerugonosa (14), Staphylococcus aureus(24) and Streptococcus pneumoniae (59). A higher infection rate was recorded in males (46.99%) and patients aged 41-50 (52.59%). The highest resistance was exhibited by Klebsiella pneumoniae (93%) against cefuroxime, followed by Streptococcus pneumoniae against oxacillin (75%). Of the 185 isolates, 37 (20%) were MDR, out of which 25 (67.6%) isolates had Plasmids. Following curing, 20 (80%) of the isolates were cured, and only 5 (20%) retained their plasmids. Most importantly, Escherichia coli and Klebsiella pneumonia were found to be sensitive to levofloxacin, gentamicin, and imipenem but retained their resistance to Cefuroxime, while Streptococcus pneumoniae was found to be sensitive to levofloxacin only with the highest resistance to oxacillin, doxycycline, and erythromycin. The study establishes a high prevalence of MDR isolates among LRTIs, with some exhibiting plasmid-mediated resistance, and therefore recommends treatment options to be solely based on antibiotic susceptibility testing and continuous plasmid profiling to detect plasmid-mediated resistance to enable appropriate drug administration.

Occurrence and management of lower respiratory tract infections in children at a Nigerian tertiary hospital

Objectives Infectious diseases such as pneumonia, diarrhea, and malaria are the major causes of child mortality, with pneumonia, a lower respiratory tract infection (LRTI), being the foremost of the three. Antimicrobial agents are required to treat LRTIs, such as pneumonia caused by bacteria, while those commonly caused by viruses, such as bronchiolitis, do not benefit from antimicrobial therapy unless laboratory tests indicate otherwise. When not shown, empirical management of patients using antimicrobials remains a risk factor for antimicrobial resistance in the management of LRTIs. This study aimed to determine the occurrence of LRTIs in children who presented with acute respiratory tract infections (RTIs) and evaluate their management in comparison with the guidelines. Material and Methods The study was a descriptive retrospective review of prescribing records for respiratory tract infections (RTIs) presented at the Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA), Ebonyi State, Nigeria. Data were collected through systematic sampling of the case folders of children aged five years and below who presented with RTIs from January to December 2021, using a data collection proforma. Collected data were cleaned and coded, and Statistical Package for Social Sciences (SPSS) Version 28 was used for analysis. Results There were 422 case folders containing diagnoses of RTIs. Of these, 36 (8.5%) were diagnosed with LRTIs and 28 (6.6%) had no comorbidity. Of the 28 cases without comorbidities, pneumonia (20;71.4%) and bronchiolitis (8;28.6%) were the only two LRTIs. Antibiotics were the most prescribed medications, followed by vitamins (8;28.6%) and antihistamines (7;25.0%). There were seven types and three combinations of antibiotic medications, the most being cefuroxime (10;35.7%) followed by amoxicillin/clavulanic acid (7; 25.0%). One case of pneumonia did not receive an antibiotic. Laboratory investigations were not conducted for the majority (25;89.3%) of the cases presented. Conclusion This study showed that the LRTIs presented were mostly managed using the recommended antibiotics for pneumonia. Antibiotics for bronchiolitis without confirmation by laboratory tests may not have been justified as most of them are of viral origin. Deviations from guidelines may be reduced if national protocols are developed in managing LRTIs.

Prevalence and Antimicrobial Resistance Trends among Lower Respiratory Tract Pathogens in Crete, Greece, 2017-2022.

Lower respiratory tract infections (LRTIs) are the most common infections in humans accounting for significant morbidity and mortality. Management of LRTIs is complicated due to increasing antimicrobial resistance. This study investigated the prevalence and trends of antimicrobial resistance for bacteria isolated from respiratory samples of patients with LRTIs. Sputum and bronchial washings were collected from patients of all ages hospitalized with LRTIs and were analyzed by the microbiological laboratory in the University Hospital of Heraklion, Crete, Greece, from January 2017 to December 2022. Identification of the bacterial isolates was performed by matrix-assisted laser desorption ionization-time of flight mass spectrometry and antimicrobial susceptibility testing by Vitek 2 system. A total of 4,008 strains were isolated from 3,427 respiratory samples. Acinetobacter baumannii was the most frequently isolated pathogen (23.1%), followed by Pseudomonas aeruginosa (20.0%), Staphylococcus aureus (10.6%) and Klebsiella pneumoniae (6.8%). The isolation rate of A. baumannii significantly increased during the study period, while there were lower increases in the isolation rates of P. aeruginosa, K. pneumoniae and S. aureus. A. baumannii and P. aeruginosa were more prevalent during summer, K. pneumoniae was more common during autumn, while for S. aureus higher incidence was noted during winter. A. baumannii exhibited high resistance rates (≥90.0%) to most of the antimicrobial agents tested, and extremely high multidrug-resistance (91.0%). P. aeruginosa showed the lowest rate of resistance for colistin (1.4%). Among β-lactams, resistance rates to piperacillin/tazobactam, ceftazidime, cefepime, imipenem and meropenem were 26.2%, 27%, 25.8%, 29.2% and 29.9%, respectively. A total of 162 (68.1%) meropenem-resistant P. aeruginosa were simultaneously resistant to ceftazidime and piperacillin/tazobactam. Regarding K. pneumoniae, high rates of resistance were observed for the third and fourth generation cephalosporins, namely cefotaxime, ceftriaxone, ceftazidime, and cefepime and the carbapenems, imipenem and meropenem ranging from 46.2% to 53.8%. Carbapenem-resistance was detected among 46.2% of the isolates. Among the 126 carbapenem-resistant K. pneumoniae isolates, 83 (65.9%), 30 (23.8%), 9 (7.2%), and 4 (4.2%) were positive for Klebsiella pneumoniae carbapenemase, New Delhi Metallo-β-lactamase, Verona Integron-Mediated Metallo-β-lactamase and OXA-48 carbapenemase, respectively. Of the total number of S. aureus, 37.2% were methicillin resistant. Low rates of resistance were detected in trimethoprim/sulfamethoxazole (3.3%), gentamicin (2.8%), and rifampicin (0.9%). All isolates were susceptible to linezolid, daptomycin, tigecycline, teicoplanin, and vancomycin. Regularly updated surveillance of local microbial prevalence and monitoring of antimicrobial resistance patterns is of paramount importance to guide the empiric treatment of LRTIs.

Cefotaxime: A Reappraisal in Lower Respiratory Tract Infections

Lower respiratory Tract Infection (LRTI) is one of the fourth most common cause of mortality across the globe, and constitutes to be a major portion in critically ill patients associated with prolonged hospitalisation. Apart from age factor, other risk factors which predispose to the LRTI include poor sanitization, severe malnutrition, and lack of breast feeding for infants, HIV infection, lack of immunization, chronic illness, family history of LRTI and exposure to tobacco smoke/air pollutants. The third generation cephalosporins are used in management and treatment of gram-negative and gram-positive organism. Common bacteria implicated in these infections include S. pneumoniae, H. influenzae, Chlamydia pneumoniae, and Staphylococcus aureus. Third generation cephalosporins also target respiratory ailments like acute bronchitis, pneumonia, acute exacerbation of chronic lung diseases (such as COPD or bronchiectasis). Cefotaxime and ceftriaxone have been widely recommended in guidelines to be used for many infections and diseases, but, some serious adverse effects have been seen in past few years with ceftriaxone like cholelithiasis, encephalopathy, memory impairment, tonic- clonic seizures, neurotoxicity and auto-immune haemolytic anaemia. This fact compels us to revisit the clinically safer and efficacious drug Cefotaxime which have been used since decades but have not developed any resistance till date. Cefotaxime has been found to be well tolerated and not associated with hypo-prothrombinemia/coagulopathies, disulfiram-like reactions, as with other cephalosporins. It can readily cross the blood-brain barrier when administered intravenously and may treat gram-negative infections resistant to previous generations of cephalosporins. Cefotaxime, demonstrates good efficacy and safety in the management of LRTIs including CAP, hospital acquired/nosocomial acquired pneumonia, acute exacerbation of pneumonia and acute bronchitis caused by both gram positive as well as gram negative bacteria. Keywords: LRTI, Cefotaxime, cephalosporins, CAP, pneumonia, respiratory tract

Bacteriological Profile and Antibiotic Susceptibility Patterns of Gram-negative Bacilli Isolated from Lower Respiratory Tract Infections

Background: Lower respiratory tract infections (LRTIs) are one of the most frequent infections seen in humans. Bacterial etiology of these infections is one of the major causes of morbidity and mortality. The emergence of drug resistance among bacteria is increasing throughout the world causing more severe infections because of their continuous mutation and multidrug resistance nature. Objectives: This study was focused on obtaining a comprehensive insight into the Gram-negative bacillary profile of LRTIs, their prevalence, and their antibiotic susceptibility patterns. Materials and Methods: The study was conducted for a duration of 6 months. Samples were obtained from patients of all ages and both sexes presenting with symptomatology suggestive of LRTIs. Following conventional culture, the isolated organisms were identified by various preliminary identification methods and biochemical tests. Antimicrobial sensitivity testing of Gram-negative isolates was performed by standard methods as recommended by CLSI 2019. Results: Out of the 1724 LRT specimens evaluated, 307 (17.80%) were culture positive. Our study showed that Gram-negative bacilli are the predominant cause (97.70%) of LRTIs with Klebsiella pneumoniae (42%) as the major pathogen followed by Escherichia coli (31.66%), Pseudomonas aeruginosa (25.33%), and Acinetobacter baumannii (1%). Extended-spectrum beta-lactamase production was detected in 3.33% and metallo-beta-lactamase in 2% of the total GNB pathogens. Conclusion: For effective management of LRTIs, an ultimate and detailed bacteriological diagnosis along with antimicrobial susceptibility testing is required to overcome the global problem of antibiotic resistance.

A COMPARATIVE STUDY OF AMOXICILLIN, ERYTHROMYCIN, CEFADROXIL, AND GATIFLOXACIN IN TREATMENT OF ACUTE LOWER RESPIRATORY TRACT INFECTIONS

Introduction: Community-acquired acute lower respiratory tract infection (LRTI) incorporates a spectrum of diseases from acute bronchitis, acute exacerbation of chronic obstructive pulmonary disease (COPD) and pneumonia. It is the most common cause for consulting general practice and OPD. This study was undertaken to compare older and newer antimicrobials in terms of clinical efficacy, tolerability and cost for the initial treatment for OPD management of LRTI in a government medical college setup. This randomized, prospective study was conducted in theMaterial And Methods: Medicine OPD of a government medical college, over a period of one year.Patients of either sex, aged between 16-60 yrs satisfying following definitions of acute bronchitis (with secondary bacterial infection), acute exacerbation of COPD and community acquired pneumonia were selected for the study. Patients were randomly assigned to one of the following treatment groups: Ÿ Group I- Amoxicillin 500 mg three times a day for 7 days. Ÿ Group II - Erythromycin 500mg four times a day for 7 days Ÿ Group III - Cefadroxil 500mg two times a day for 7 days Ÿ Group IV-Gatifloxacin 400mg once a day for 7 day Efficacy and safety of all antimicrobials were assessed and compared Results: Satisfactory clinical outcome as cure and improvement was obtained in 48 % and 36% in amoxicillin, 52% and 33% in erythromycin 49% and 38% in cefadroxil, 64% and 27% in gatifloxacin group respectively. Unsatisfactory clinical outcome as failure was recorded in 16%, 15%, 13% and 9% of amoxicillin, erythromycin, cefadroxil and gatifloxacin groups respectively. All the four drugs were equally effective with more than 80% efficacy in treatment ofConclusions: LRTI. The treatment groups did not differ in incidence of adverse events. All the adverse effects were mild and did not require cessation of therapy.

Lactate dehydrogenase to albumin ratio as a prognostic factor in lower respiratory tract infection patients.

To verify the role of lactate dehydrogenase to albumin (LDH/ALB) ratio as an independent prognostic factor for mortality due to the lower respiratory tract infection (LRTI) in the emergency department (ED). We reviewed the electronic medical records of patients who were admitted to the ED for the management of LRTI between January 2018 and December 2020. Initial vital signs, laboratory data, and patient severity scores in the ED were collected. The LDH/ALB ratio was compared to other albumin-based ratios (blood urea nitrogen to albumin ratio, C-reactive protein to albumin ratio, and lactate to albumin ratio) and severity scales (pneumonia severity index, modified early warning score, CURB-65 scores), which are being used as prognostic factors for in-hospital mortality. Multivariable logistic regression was performed to identify independent risk factors. The LDH/ALB ratio was higher in the non-survivor group than in the survivor group (median [interquartile range]: 217.6 [160.3;312.0] vs. 126.4 [100.3;165.1], p<0.001). In the comparison of the area under the receiver operating characteristic curve (AUC) for predicting in-hospital mortality, the AUC of the LDH/ALB ratio (0.808, 95% confidence interval: 0.757-0.842, p<0.001) was wider than other albumin-based ratios and severity scales, except the blood urea nitrogen to albumin ratio. In the multivariable logistic regression analysis, the LDH/ALB ratio independently affected in-hospital mortality. The LDH/ALB ratio may serve as an independent prognostic factor for in-hospital mortality in patients with LRTI.

Antibacterial Resistance in Lower Respiratory Tract Bacterial Pathogens: A Multicenter Analysis from Turkey.

This study aimed to evaluate the etiology of lower respiratory tract infections (LRTIs) and their antibiotic resistance. Bacterial culture results of LRT samples from 17 hospitals between 2016-2019 were included in the study. All isolates were identified and AST were performed by automated microbiology systems. AST was performed according to EUCAST. Non-duplicate 30,051 (26,890 HA and 3156 CA) isolates detected as causative pathogen. LRTIs are caused by 85.1% Gram-negative bacterial pathogens and 14.9% Gram-positive. The most common isolates among HA pathogens were Acinetobacter spp. (27.4%), P.aeruginosa (22.2%), K.pneumoniae (17.9%); among CA pathogen S.pneumoniae (19.9%), P. aeruginosa (18.9%), H.influenzae (14.6%). ESBL rate was 62.5% in K.penumoniae; 53.1% in E.coli; 19.1% in Klebsiella spp; 13.9% in Enterobacter spp.; 8.6% in Proteus spp.; 6.3% in Citrobacter spp.; and 4.3% in Serratia spp. Resistance rates to carbapenems and colistin were 92.8% and 12.8% in A baumannii, 39.8% and 7.5% in P.aeruginosa, 47.3% and 18.5% in K.penumoniae. Among staphylococci, 27.3% of S. aureus and 82.4% of CoNS were methicillin resistant. 7.6% of E.faecium and 0.9% of E.faecalis were vancomycin resistant. Linezolid resistant S. aureus, CoNS, E.faecalis and E.faecium rates were 0.3%, 2.9%, 0.0% and 4.6%. Inducible clindamycin resistant rate was 17.2% in S. aureus 38.2% in CoNS. Non-susceptible S.pneumoniae isolate rate to penicillin was 37.0%. 6.5% of S.maltophilia and 4.4% of B.cepacia isolates were resistant to trimethoprim/sulfamethoxazole. Antibiotic resistance was mainly observed among A.baumannii and K.pneumoniae and continuous surveillance of antimicrobial resistance patterns in the management of LRTIs is important.

Indoor microbiome and risk of lower respiratory tract infections among children under-five years: A meta-analysis.

We investigated whether exposure to microbiome within the indoor environment is associated with risk of lower respiratory tract infections (LRTI) among children under 5years of age. Electronic scientific repositories; PubMed, Scopus, Web of Science, GreenFILE, EMBASE, and Cochrane library were searched and screened through July 2019 for published reports for inclusion in the meta-analysis. Studies were eligible for inclusion if they reported an adjusted measure of risk for LRTI associated with IM exposure, including the relative risk (RR) or odds ratio (OR) and confidence interval (CI). The pooled OR was computed using the inverse of variance method for weighting. Sensitivity analysis was used to evaluate the effect of individual studies, while heterogeneity was evaluated by I2 statistics using RevMan 5.3. Seven studies were eligible for inclusion in our meta-analysis. Exposure to a higher concentration of IM was associated with an increased risk of LRTI [OR:1.20 (1.11, 1.33), P<.0001]. The risk was stronger with exposure to total fungal concentration [OR:1.27 (1.13, 1.44), P<.0001] than visible molds [OR:1.20 (1.07, 1.34, P=.001]. Under-five children exposed to higher IM concentration are likely at increased risk of LRTI. Interventions addressing IM exposure should be considered in the management of LRTI among under-five children.

Bacterial profile and antimicrobial susceptibility patterns of lower respiratory tract infection among patients attending selected health centers of Addis Ababa, Ethiopia

Background Respiratory tract infection is one of the most important infectious diseases worldwide, and it is the leading cause of morbidity and mortality in critically ill patients, especially in developing countries, and is usually contracted through air and by direct contact. Currently, antibiotic resistance among respiratory pathogens has seen a dramatic rise. In Ethiopia, there is limited information concerning lower respiratory tract infections (LRTI) burden and antimicrobial resistance pattern. Thus, the aim of this study was to assess bacteriological-confirmed burden, profile, and antibiotic susceptibility pattern of bacteria that leads LRTI. Patients and methods An institution-based cross-sectional study was performed in selected health centers of Kolfe Keraniyo Subcity, Addis Ababa, Ethiopia, from May to July, 2018, on 240 patients. Sputum samples were collected using convenient sampling technique and inoculated onto MacConkey, chocolate, and blood agar. In addition, biochemical and antimicrobial susceptibility testing was done. Data were entered and analyzed using Statistical Package for Social Sciences (SPSS), version 20. P values less than 0.05 were considered statistically significant. Results Of 240 samples processed, 77 (32.1%) showed growth of various species of bacteria. Among those, Klebsiella pneumoniae [32 (39.5%)] was a frequently isolated organism, followed by Streptococcus pneumoniae [15 (18.5%)], and Escherichia coli [13 (16%)]. Gram-negative bacilli were highly sensitive to meropenem (98%), tobramycin (94%), amikacin (94%), ceftazidime (84%), and cefuroxime (76%) and resistant to ampicillin (83%), tetracycline (52%), ciprofloxacin (35%), and trimethoprim-sulfamethoxazole (33%). Conclusion K. pneumoniae and S. pneumoniae are the most predominant pathogens that contribute to LRTI. In addition, most isolates showed a high level of antibiotic resistance. Therefore, culture and susceptibility tests have paramount importance for better management of LRTI and drug-resistant infections.

Effectiveness and safety evaluation of oral cefixime and moxifloxacin fixed dose combination in lower respiratory tract infections

Background: Scientific literature advocates the need for combination therapies in combatting lower respiratory tract infection (LRTI). Cefixime (400 mg) and moxifloxacin (400 mg) fixed dose combination (FDC) is currently approved in India for the management of LRTI, but data related to its real world usage is lacking. The present study was designed to understand the real world use (effectiveness and safety) of this FDC in LRTI.Methods: This retrospective study was conducted at out-patient departments of 5 hospitals between August 2018 and January 2019. After ethics committee approval, data of adults LRTI patients who received FDC of cefixime (400 mg) and moxifloxacin (400 mg) for at least 72 hours was collected. Improvement in LRTI symptoms (cough, sputum volume and purulence, fever, dyspnea, pleuritic chest pain, sleep disturbance, fatigue) were scored at baseline and follow-up using a 5-point severity scale. White blood cell (WBC) counts at baseline and end-of-treatment were compared.Results: Data of 190 patients having mean age 42.33+16.15 years was evaluated. Majority were males (61.58%), with commonest LRTI infection being community acquired pneumonia (CAP) (84.21%). Commonest clinical symptom reported (97.37%) was cough. All patients showed improvement in symptoms and significant improvement in all mean symptom scores were noted (p&lt;0.05). Of the 30 patients having WBC above normal range, 29 showed a decrease in count at end of treatment. No adverse events were reported.Conclusions: Oral FDC of cefixime (400 mg) and moxifloxacin (400 mg) was efficacious in improving all symptoms reported by LRTI patients without causing any adverse event.

Pharmacotherapy of Lower Respiratory Tract Infections in Elderly-Focused on Antibiotics.

Lower respiratory tract infections (LRTIs) refer to the inflammation of the trachea, bronchi, bronchioles, and lung tissue. Old people have an increased risk of developing LRTIs compared to young adults. The prevalence of LRTIs in the elderly population is not only related to underlying diseases and aging itself, but also to a variety of clinical issues, such as history of hospitalization, previous antibacterial therapy, mechanical ventilation, antibiotic resistance. These factors mentioned above have led to an increase in the prevalence and mortality of LRTIs in the elderly, and new medical strategies targeting LRTIs in this population are urgently needed. After a systematic review of the current randomized controlled trials and related studies, we recommend novel pharmacotherapies that demonstrate advantages for the management of LRTIs in people over the age of 65. We also briefly reviewed current medications for respiratory communicable diseases in the elderly. Various sources of information were used to ensure all relevant studies were included. We searched Pubmed, MEDLINE (OvidSP), EMBASE (OvidSP), and ClinicalTrials.gov. Strengths and limitations of these drugs were evaluated based on whether they have novelty of mechanism, favorable pharmacokinetic/pharmacodynamic profiles, avoidance of interactions and intolerance, simplicity of dosing, and their ability to cope with challenges which was mainly evaluated by the primary and secondary endpoints. The purpose of this review is to recommend the most promising antibiotics for treatment of LRTIs in the elderly (both in hospital and in the outpatient setting) based on the existing results of clinical studies with the novel antibiotics, and to briefly review current medications for respiratory communicable diseases in the elderly, aiming to a better management of LRTIs in clinical practice.

The inflamed sputum in lower respiratory tract infection: l-lactate levels are correlated to neutrophil accumulation.

Lower respiratory tract infections (LRTI) are common, but little is known about the response of biomarkers of inflammation in the lungs. Therefore, our primary aim was to compare the concentration of l‐lactate to the concentration of neutrophils in sputum and systemic markers of infection. Because it is difficult to differentiate viral and bacterial infection on the basis of clinical presentation in LRTI, our secondary aim was to evaluate if l‐ and d‐lactate may serve as markers of local inflammation as representatives of neutrophils and bacteria, respectively.MethodsPatients with acute LRTI were prospectively recruited. Sputum samples were collected and analysed for neutrophil count, l‐lactate and d‐lactate. We had data on pathogens from sputum cultures and polymerase chain reaction (PCR) (atypical bacteria, virus) and C‐reactive protein (CRP) from blood.ResultsIn 44 sputum samples from 32 patients, the median (interquartile range (IQR)) sputum neutrophil granulocyte count was 0.615 × 107 cells/mL (0.236–1.575). The sputum neutrophil granulocyte count was associated with sputum l‐lactate (p = 0.011) and CRP (p = 0.018), but not with d‐lactate (p = 0.177). There was a strong association between sputum d‐lactate and l‐lactate (p < 0.0001).ConclusionAs l‐lactate in sputum is closely correlated to sequestration of neutrophils in the lungs, l‐lactate is a marker for local inflammation in LRTI and a potential biomarker in clinical management of LRTI. On expectorated sputum, d‐lactate had no clinical relevance.

A Study on Analysis of the Sputum Gram Staining and Culture in Patients with Lower Respiratory Tract Infections Attending a Tertiary Care Hospital

Background: Microscopical examination of expectorated sputum samples is the most commonly followed method in the Microbiological laboratory for diagnosis of lower respiratory tract infections (LRTIs). Sputum sample is usually contaminated with normal resident floral organisms of the oropharynx. For the diagnosis and management of LRTIs, collection of sputum sample, sputum microscopy and culture is very important. The present study was conducted to analyse the importance of the microscopical examination of Gram stained sputum smears and the sputum culture in patients with LRTIs. Materials & Methods: The place of the study was in the department of Microbiology in a tertiary care hospital. The study period was for one year from Jan 2015 to Dec 2015. Gram staining and culture were done for all the 130 sputum samples. Gram stained sputum smears were observed under microscope for presence of organisms, pus cells and epithelial cells. Quality of expectorated sputum samples were assessed by using Bartlett’s grading system. By using standard protocols bacterial isolates were identified. Kirby Bauer disc diffusion method on Mueller Hinton agar was performed for antibiotic susceptibility testing. Results and conclusion: Out of 130 sputum samples, 72 (55.4%) samples were acceptable based on Bartlett’s screening system and 58(44.6%) samples were in the not acceptable category. Among acceptable category, 64(78.05%) samples were showed culture positivity. Among non-acceptable category, 18(21.95%) samples were showed culture positivity. Klebsiella pnemoniae-31.71% was the commonest isolated organism followed by Pseudomonas aeruginosa-14.63% and Staphylococcus aureus -13.41%.In this study authors recommended to receive good quality of sputum and do initial sputum screening for diagnosing clinically relevant LRTIs. Keywords: Bartlett’s grading system, Gram stain, Non-acceptable category, Sputum acceptable category, Sputum culture

The Use of Guidelines for Lower Respiratory Tract Infections in Tanzania: A Lesson from Kilimanjaro Clinicians.

Background:Evaluations of the guidelines for the management of Lower Respiratory Tract Infections (LRTI) Sub-Saharan Africa, particularly in Tanzania is scant.Aim:The aim of the study was to assess the usefulness of the current Tanzanian treatment guideline for the management lower respiratory tract infection.Subjects and Methods:A descriptive cross sectional study in 11 hospitals of different levels in the Kilimanjaro region Data were collected from May 2012 to July 2012 by semi-structured interview for clinicians using 2 dummy cases for practical assessment. Data were analyzed by STATA v11 (StataCorp, TX, USA). Qualitative narratives from the interviews were translated, transcribed then coded by colors into meaningful themes.Results:A variety of principles for diagnosing and managing LRTI were demonstrated by 53 clinicians of Kilimanjaro. For the awareness, 67.9% (36/53) clinicians knew their responsibility to use Standard Treatment Guideline for managing LRTI. The content derived from Standard Treatment Guideline could be cited by 11.3% of clinicians (6/53) however they all showed concern of gaps in the guideline. Previous training in the management of patients with LRTI was reported by 25.9% (14/53), majority were pulmonary TB related. Correct microorganisms causing different forms of LRTI were mentioned by 11.3% (6/53). Exact cause of Atypical pneumonia and Q fever as an example was stated by 13.0% (7/53) from whom the need of developing the guideline for LRTI was explicitly elaborated.Conclusion:The current guidelines have not been used effectively for the management of LRTI in Tanzania. There is a need to review its content for the current practical use.

"How Do You Feel about Antibiotics for This?" A Qualitative Study of Physician Attitudes towards a Context-Rich Communication Skills Method.

To explore experiences with and views of general practitioners (GPs) on a physician communication training method in primary care and its applicability and implementation in daily practice, we performed a semi-structured qualitative study of GPs’ experience of training in and implementing a communication skills training program for managing lower respiratory tract infection (LRTI) which included a seminar, simulated patient consultation together with providing and receiving feedback on ones own transcript, and a seminar in a structured approach to the LRTI consultation. Seventeen out of 20 eligible GPs who had participated in the IMPAC3T trial and were allocated to receiving enhanced physician communication training for managing lower respiratory tract infection participated. GPs’ experiences with the physician communication training method and its specific components were positive. The method gave GPs additional tools for managing LRTI consultations and increased their sense of providing evidence-based management. During the study, GPs reported using almost all communication items covered in the training, but some GPs stated that the communication skills diluted over time, and that they continued to use a selected set of the skills. The general communication items were most regularly used. Implementation of the method in daily practice helped GPs to prescribe fewer antibiotics in LRTI with the only perceived disadvantage being time-pressure. This study suggests that GPs felt positive about the physician communication training method for enhanced management of LRTI in primary care. GPs continued to use some of the communication items, of which general communication items were the most common. Furthermore, GPs believed that implementation of the communication skills in daily practice helped them to prescribe fewer antibiotics. The context-rich communication method could have wider application in common conditions in primary care.

Antibiotic Sensitivity Pattern of Bacterial Isolates from the Intensive Care Unit of a Tertiary Care Hospital in India

Purpose: To undertake an audit of the antimicrobial (AM) sensitivity pattern of bacterial isolates in the intensive care units (ICU) of a tertiary hospital of Bhavnagar, India. Methods: Retrospective analysis of the indoor case papers of ICUs from January 2010 to 31st March 2011 was carried out at Department of Pharmacology, Govt. Medical College and Sir Takhtsinhji General Hospital, Bhavnagar, India. Information collected include demographic data of the patient, admission unit, duration of hospital stay, diagnosis, type of infection, empirical treatment, indication of the use of the antimicrobials (AMs). Others include collected specimen, causative agent, sensitivity pattern, and treatment changes based on the sensitivity pattern in a case record form. AM sensitivity testing was performed by the modified Kirby Baur method as recommended by clinical and laboratory standard institute (CLSI). Internal and external quality control were maintained for culture and sensitivity method. Results: The most commonly isolated organisms were Klebsiella pneumoniae (28.6 %) and Pseudomonas aeruginosa (16.3 %). Lower respiratory tract infection (LRTI) was the most common infection. Imipenem, meropenem and levofloxacin were the most effective antimicrobials for Gramnegative isolates (GNIs) while vancomycin ciprofloxacin, and gentamicin were the most efficacious antimicrobials for Gram-positive isolates (GPIs). Widespread resistance to third generation cephalosporins and cloxacillin was noted for GNIs and GPIs, respectively. Meropenem (100 %) > levofloxacin (100 %) > sparfloxacin (94.4 %) > gentamicin (83.3 %) was the rank order of antimicrobial activity against LRTI. Conclusion: GNIs were the predominant cause of infection in ICUs. Third generation cephalosporinsresistant GNIs were the predominant resistant organisms. The study showed that fluoroquinolones and aminoglycosides could be used as first line AMs for the effective management of LRTI in a hospital setting.