Non-pneumonic Lower Respiratory Tract Infections Research Articles

South African guideline for the management of community-acquired pneumonia in adults.

CAP causes considerable morbidity and mortality throughout the world (1-3). Improving the care of patients with CAP in South Africa is particularly important because of the high burden of disease and the need to improve standards of antibiotic prescribing in the face of rising AMR (4). There are a number of important international guidelines including those of the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) (5) and the British Thoracic Society (BTS) (6). However, South Africa represents a unique environment with a high prevalence of both HIV infection and AMR such that guidelines must be locally applicable. Groups interested in approaches to the management of CAP in South Africa include the South African Thoracic Society (SATS) and the Federation of Infectious Diseases Societies of Southern Africa (FIDSSA). This guideline, under the auspices of SATS and FIDSSA, represents an update of the SATS CAP Guideline published in 2007 (7). Purpose and scope The purpose of this document is to update clinicians regarding important advances and controversies in the management of patients with CAP. South Africa has a high prevalence of HIV infection, which is a risk factor for a number of pulmonary infections with overlapping presentations including tuberculosis and Pneumocystis jirovecii pneumonia (PCP). This guideline seeks to provide practical advice on the approach to all adult patients with acute community-acquired infection of the lung parenchyma. These guidelines do not apply to the much larger group of adults with non-pneumonic lower respiratory tract infections (LRTI), including acute bronchitis, acute exacerbations of chronic obstructive pulmonary disease or illnesses labelled as ‘chest infections’. Pneumonia in non-ambulatory residents of nursing homes and other long-term care facilities epidemiologically mirrors healthcare-associated pneumonia (HCAP) and should be treated according to institutional HCAP guidelines.

S15 Clinical Characteristics Of Hospitalised Patients Misdiagnosed With Community-acquired Pneumonia

<h3>Background</h3> The diagnosis and treatment of patients hospitalised with community-acquired pneumonia (CAP) is predicated on an acutely abnormal chest radiograph.¹ Little is known about patients who present with infective respiratory symptoms with no consolidation, who have clinically significant non-pneumonic lower respiratory tract infection (LRTI). <h3>Methods</h3> A prospective observational cohort study of consecutive patients admitted to hospital with infective respiratory symptoms and treated for suspected CAP over winter 2013/14. Management was at the discretion of the admitting team. <h3>Results</h3> Of 628 patients admitted to hospital during the study, 304 (48.4%) did not have acute consolidation on chest radiograph; 166 were reported as clear, and 138 as either longstanding abnormality or not acute infection. Patients with LRTI had lower admission C-reactive protein levels (median 49 mg/l vs. 85 mg/l; p &lt; 0.01), were older (median 80.0 years vs. 76.3 years; p = 0.005), and were more likely to be managed on a non-respiratory ward (174/304 (57.2%) vs. 127/324 (39.1%); p &lt; 0.001). A higher proportion of patients with LRTI were care home residents, although this did not reach statistical significance (56/304 (18.4%) vs. 45/324 (13.9%); p = 0.12). A microbiological diagnosis was made in only 9/304 (3.0%) patients with LRTI compared with 45/324 (13.9%) with CAP (p &lt; 0.0001). CAP patients had a discharge clinical code of CAP (J12–18) in 247/324 (76.2%) cases; 121/304 (39.8%) patients with LRTI were miscoded as CAP. Thirty-day mortality was similar in both groups (48/324 (14.8%) vs. 43/304 (14.1%) p = 0.82), but median length of hospital stay was longer for patients with CAP (7.0 days vs. 5.6 days; p = 0.002). <h3>Conclusion</h3> Almost half patients treated for CAP were misdiagnosed and over-treated with broad spectrum antibiotics. Patients with non-pneumonic LRTI were older, with lower C-reactive protein levels, but similar 30-day mortality. Acute respiratory illness in this group may therefore be driven by decompensated comorbidity rather than an underlying inflammatory condition; broad spectrum antibiotics may not be useful. No national guidance currently exists on the optimal management of this group, and further study is required. <h3>Reference</h3> Lim WS <i>et al</i>. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. <i>Thorax</i><b>2009</b>,64 Suppl 3,iii1-ii55

Antibiotics in acute non-pneumonic lower-respiratory tract infection – Authors' reply

Antibiotics in acute non-pneumonic lower-respiratory tract infection – Authors' reply

Antibiotics in acute non-pneumonic lower-respiratory tract infection

We read with interest the study by Paul Little and colleagues1 that confirmed the findings of previous smaller studies2 and support the present recommendations that acute bronchitis should not be treated with antibiotics. Because the authors used a threshold of 1% for statistical significance, we wonder why one of the secondary outcomes—that fewer individuals experienced new or worsened symptoms in the amoxicillin group—was interpreted as significant (p=0·043). We think that, according to the methods of the authors, none of the primary or secondary outcomes reached statistical significance, which would further corroborate the authors' conclusions to discourage the use of antibiotics in patients with acute non-pneumonic lower-respiratory tract infection. Moreover, these data emphasise the need to develop strategies to identify which patients with lower-respiratory tract infections need antibiotic treatment and which do not. For example, the use of biomarkers such as procalcitonin has been suggested to provide such a discriminative method,3 and thus it might be interesting to know whether the patients included in the present study had low procalcitonin concentration.

The incidence and aetiology of hospitalised community-acquired pneumonia among Vietnamese adults: a prospective surveillance in Central Vietnam

BackgroundLower respiratory tract infection (LRTI) including Community-acquired pneumonia (CAP) is a common infectious disease that is associated with significant morbidity and mortality. The patterns of aetiological pathogens differ by region and country. Special attention must be paid to CAP in Southeast Asia (SEA), a region facing rapid demographic transition. Estimates burden and aetiological patterns of CAP are essential for the clinical and public health management. The purposes of the study are to determine the incidence, aetiological pathogens, clinical pictures and risk factors of community-acquired pneumonia (CAP) in the Vietnamese adult population.MethodsA prospective surveillance for hospitalised adult CAP was conducted in Khanh Hoa Province, Central Vietnam. All adults aged ≥15 years with lower respiratory tract infections (LRTI) admitted to a provincial hospital from September 2009 to August 2010 were enrolled in the study. Patients were classified into CAP and non-pneumonic LRTI (NPLRTI) according to the radiological findings. Bacterial pathogens were identified from sputum samples by the conventional culture and polymerase chain reaction (PCR) for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; 13 respiratory viruses were identified from nasopharyngeal specimens by PCR.ResultsOf all 367 LRTI episodes examined, 174 (47%) were CAP. Older age, the presence of underlying respiratory conditions, and higher index score of smoking were associated with CAP. The one-year estimated incidence of hospitalised adult CAP in our study population was 0.81 per 1,000 person years. The incidence increased considerably with age and was highest among the elderly. The case fatality proportion of hospitalised CAP patients was 9.8%. Among 286 sputum samples tested for bacterial PCR, 79 (28%) were positive for H. influenzae, and 65 (23%) were positive for S. pneumoniae. Among 357 samples tested for viral PCR, 73 (21%) were positive for respiratory viruses; influenza A (n = 32, 9%) was the most common.ConclusionsThe current adult CAP incidence in Vietnam was relatively low; this result was mainly attributed to the young age of our study population.

Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study

Objectives To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of...

Respiratory Viruses in Adults With Community-Acquired Pneumonia

BackgroundUse of nucleic acid amplification techniques has increased the identification of respiratory viruses (RVs) in adult patients with community-acquired pneumonia (CAP). The objectives of the present study were to identify RV in patients with CAP using three different sampling methods and to compare CAP virus proportions and types with two comparison groups.MethodsThe study population included 183 adult patients with CAP, 450 control subjects, and 201 patients with nonpneumonic lower respiratory tract infection (NPLRTI). Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washing, and the samples were tested for detection of 12 RVs by multiplex TaqMan Hydrolysis probe-based real-time polymerase chain reaction (Integrated DNA Technology; Coralville, IA).ResultsAt least one RV was identified in 58 patients with CAP (31.7%) compared with 32 (7.1%) in control subjects and 104 (51.7%) in patients with NPLRTI (P < .01 and P < .01, respectively). Coronaviruses were identified in 24 (13.1%) patients with CAP, compared with 17 (3.8%) in control subjects, and 21 (10.4%) patients with NPLRTI. Respiratory syncytial virus was identified in 13 (7.1%), four (0.9%), and seven (3.5%); rhinovirus in nine (4.9%), nine (2.0%), and 15 (7.5%); and influenza virus in eight (4.4%), two (0.4%), and 63 (31.3%) patients with CAP, control subjects, and patients with NPLRTI, respectively.ConclusionsThe proportion of RV involvement in CAP is higher than previously reported. The proportion of RV identified in healthy subjects is significantly lower than in CAP, but it is not zero and should be weighed when interpreting corresponding proportions among patients.

Prohormones for prediction of adverse medical outcome in community-acquired pneumonia and lower respiratory tract infections

IntroductionMeasurement of prohormones representing different pathophysiological pathways could enhance risk stratification in patients with community-acquired pneumonia (CAP) and other lower respiratory tract infections (LRTI).MethodsWe assessed clinical parameters and five biomarkers, the precursor levels of adrenomedullin (ADM), endothelin-1 (ET1), atrial-natriuretic peptide (ANP), anti-diuretic hormone (copeptin), and procalcitonin in patients with LRTI and CAP enrolled in the multicenter ProHOSP study. We compared the prognostic accuracy of these biomarkers with the pneumonia severity index (PSI) and CURB65 (Confusion, Urea, Respiratory rate, Blood pressure, Age 65) score to predict serious complications defined as death, ICU admission and disease-specific complications using receiver operating curves (ROC) and reclassification methods.ResultsDuring the 30 days of follow-up, 134 serious complications occurred in 925 (14.5%) patients with CAP. Both PSI and CURB65 overestimated the observed mortality (X2 goodness of fit test: P = 0.003 and 0.01). ProADM or proET1 alone had stronger discriminatory powers than the PSI or CURB65 score or any of either score components to predict serious complications. Adding proADM alone (or all five biomarkers jointly) to the PSI and CURB65 scores, significantly increased the area under the curve (AUC) for PSI from 0.69 to 0.75, and for CURB65 from 0.66 to 0.73 (P < 0.001, for both scores). Reclassification methods also established highly significant improvement (P < 0.001) for models with biomarkers if clinical covariates were more flexibly adjusted for. The developed prediction models with biomarkers extrapolated well if evaluated in 434 patients with non-CAP LRTIs.ConclusionsFive biomarkers from distinct biologic pathways were strong and specific predictors for short-term adverse outcome and improved clinical risk scores in CAP and non-pneumonic LRTI. Intervention studies are warranted to show whether an improved risk prognostication with biomarkers translates into a better clinical management and superior allocation of health care resources.Trial RegistrationNCT00350987.

Severe community-acquired pneumonia

Severe community-acquired pneumonia (CAP) is an increasingly common reason for admission to the intensive care unit (ICU). It is associated with significant morbidity, mortality, and utilization of health service resources. Inability to differentiate between CAP and nonpneumonic lower respiratory tract infections such as acute exacerbation of chronic obstructive pulmonary disease (COPD) has led to overtreatment, with a dramatic increase in the use of broad-spectrum antibiotics. This is associated with an increase in costs and side-effects, particularly Clostridium difficileassociated diarrhoea. A reduction in the frequency of Streptococcus pneumoniae infection has been associated with a simultaneous increase in the frequency of new pathogens such as Legionella, Chlamydia pneumoniae, and gram-negative bacillus such as Pseudomonas. 3

The patient with possible pneumonia

Abstract Community-acquired pneumonia (CAP) is part of a spectrum of lower respiratory tract infection (LRTI) and is commoner in the winter months and in more deprived populations. Despite modern antibiotics, pneumonia remains the second commonest cause of death in the UK after ischaemic heart disease. Streptococcus pneumoniae is the commonest confirmed microbiological cause of CAP, with Mycoplasma pneumoniae the second commonest during epidemic years. Although most patients with CAP will have lung crackles or bronchial breathing, distinguishing pneumonia from non-pneumonic LRTI can be difficult and chest X-ray confirmation is often required. All patients with CAP should undergo an initial severity assessment using the CURB-65 score before deciding on management, and respiratory rate is the most important clinical sign in assessing severity. Patients with severe pneumonia as defined by CURB-65 should receive broad spectrum intravenous antibiotics immediately, covering all suspected organisms, including Streptococcus pneumoniae . Those with no markers of severity can be treated safely at home with oral antibiotics. CRP should fall by 50% in 4 days; if not, reconsider the diagnosis and look for complications such as empyema. Clearance of the pneumonic consolidation takes on average 6 weeks and follow-up chest X-ray is usually unnecessary except in those at increased risk of malignancy, such as smokers and those aged over 65 years.

Naso- and oropharyngeal potential respiratory pathogens in adults with nonpneumonic lower respiratory tract infection

The objective of this prospective study was to determine positive isolation rates for potential respiratory pathogens (PRPs) in the naso- and oropharynx of adults hospitalized for nonpneumonic lower respiratory tract infection (NPLRTI), compared with patients with community-acquired pneumonia (CAP) and healthy controls. The study population was 315 non–chronic obstructive pulmonary disease adults hospitalized with febrile lower respiratory tract infection (158 NPLRTI and 157 CAP) and 450 control subjects. Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washings that were tested by conventional bacteriologic methods to identify PRP. At least 1 of the samples was positive for at least 1 of the 3 PRP bacteria in 55 NPLRTI patients (35%) compared with 51 CAP patients (33%) (NS) and 100 controls (22%) ( P = 0.003 compared with NPLRTI and P = 0.02 compared with CAP). Samples were positive for Streptococcus pneumoniae in 14 NPLRTI patients (9%) compared with 29 CAP patients (19%) ( P = 0.02) and 16 controls (4%) (NPLRTI P = 0.015, CAP P < 0.0001). The corresponding rates for Haemophilus influenzae were 23 (15%), 16 (10%), and 60 (13%) (NS for all 3 comparisons), and for Moraxella catarrhalis, 28 (18%), 25 (16%), and 48 (11%), respectively (NPLRTI versus controls, P = 0.03, NS other comparisons). We conclude that the rate of positive naso/oropharyngeal isolates for at least 1 of the 3 PRP bacteria in NPLRTI patients is similar to the corresponding rates for CAP patients and is higher in both groups than in controls.

Evaluation of Acute-phase Reactants, Immunologic Markers and other Clinical and Laboratory Parameters in Patients with Pneumonia and Non-pneumonic Lower Respiratory Tract Infections

More efficacious tools to distinguish pneumonia from other acute lower respiratory tract infections (OALRTI) in facilities where radiologic studies are not easily or rapidly available are desirable to select the patients who should undergo chest radiographs, to avoid unnecessary visits to the emergency wards of hospitals and to optimize health resources. To this end we analyzed the relevance of many clinical and laboratory parameters, including acute-phase reactants and immune activation markers, in 98 patients with pneumonia and 149 with OALRTI seen at the emergency ward of our hospital. Many clinical and laboratory parameters were associated with the diagnosis of pneumonia in the univariate analysis. Among them, C-reactive protein proved to be the most discriminant for the differentiation between the two conditions (area under the ROC curve 0.83, 95%CI 0.78-0.89, P<0.0001). A multivariate logistic regression analysis revealed that C-reactive protein, presence of suggestive auscultatory findings, lower age, presence of pleuritic pain and lower percent of eosinophils were independently associated with the diagnosis of pneumonia. A formula was derived from this analysis, which, for the most discriminant cut-off level, correctly classified pneumonic and non-pneumonic patients with a sensitivity of 88% and specificity 90%. The area under the ROC curve of this predictive model was 0.93 (95% CI 0.89-0.96, P<0.0001). C-reactive protein, especially if combined with other easily obtained parameters, constitutes a useful adjunct for the differentiation of pneumonia from OALRTI. Routine measurement of these parameters could result in a more adequate utilization of resources.

Infectious aetiologies in elderly patients hospitalised with non-pneumonic lower respiratory tract infection.

Objective: to identify the infectious aetiologies of non‐pneumonic lower respiratory tract infections in hospitalised elderly patients, and to characterise the patients in terms of demographic, clinical and therapeutic variables. Design: a prospective, non‐interventional, purely serologically based diagnostic study. Setting: a tertiary university hospital in southern Israel. Subjects: 133 elderly patients hospitalised for non‐pneumonic lower respiratory tract infections. Methods: paired sera were obtained for each of the hospitalisations and were tested using immunofluorescence or enzyme immunoassay methods to identify 13 different pathogens. Only significant changes in antibody titers or levels between the paired sera were considered diagnostic. Results: at least one infectious aetiology was identified in 77 patients (58%). At least one of seven viral aetiologies was identified in 52 patients (39%). A bacterial aetiology was identified in 27 patients (20%) including Streptococcus pneumoniae in 24 (18%). An atypical bacterium was found in 27 patients (20%) including Mycoplasma pneumoniae in 15 (11%) and Legionella spp. in nine (7%). More than one aetiology was found in 23 patients (17%). One hundred and twenty nine patients (96%) suffered from serious chronic co‐morbidity. One hundred and twenty one patients received antibiotics during their hospitalisation, 106 (80%) with a beta‐lactam and 42 (31%) with another antibiotic. Conclusions: non‐pneumonic lower respiratory tract infection is caused in hospitalised elderly patients by a broad spectrum of aetiological agents, primarily respiratory viruses with a significant, though lesser, prevalence of classical and atypical bacteria. Despite this distribution of aetiologies, most patients are treated with beta‐lactam antibiotics. The indication for antibiotic therapy in these patients and the choice of antibiotic preparation should be addressed in further studies.