Non-severe Pneumonia Research Articles

High utility of bronchoalveolar lavage fluid metagenomic next-generation sequencing approach for etiological diagnosis of pneumonia

BackgroundFor patients with pneumonia, the rapid detection of pathogens is still a major global problem in clinical practice because traditional diagnostic techniques for infection are time-consuming and insensitive. Metagenomic next-generation sequencing (mNGS) is a novel technique that has the potential to improve pathogen diagnosis. This study aimed to investigate the microbiological diagnostic ability of mNGS compared with conventional culture and to determine the optimal time to test patients for pneumonia.MethodsA prospective study using data from June 2020 to June 2021 was performed at a tertiary teaching hospital in China. We included 56 patients from all adult patients with a clinical diagnosis of pneumonia. Blood and bronchoalveolar lavage fluid (BALF) samples were taken for simultaneous mNGS and conventional culture testing.ResultsAll 56 patients underwent both conventional culture and mNGS. Of these patients, 37 were diagnosed with severe pneumonia and 17 were diagnosed with non-severe pneumonia. The top three pathogenic bacteria detected by mNGS were Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Enterococcus faecium was detected more frequently in the non-severe pneumonia group (4 vs. 0, p < 0.05). The findings revealed that the detection rate of mNGS (84%) was superior to that of conventional culture methods (48%). Notably, the percentage of mNGS-positive BALF samples (46/56, 82.14%) was significantly greater than that of blood samples (27/56, 48.21%). The etiological comparison demonstrated that mNGS-positive samples, which received clinical approval, tended to be associated with a more normalized temperature, lower PCO2 levels, and a higher SOFA score than mNGS-negative samples (p = 0.022, p = 0.0.028, and p = 0.038, respectively).ConclusionsIn this study, we discovered that the etiology of lung infections frequently involves multiple pathogens. The use of mNGS in BALF is instrumental for detecting nonviral pathogens associated with lung infections. Although the rate of positive blood NGS results is significantly influenced by various clinical factors, for patients suspected of having viral, Legionella, or tsutsugamushi infections, plasma mNGS could serve as a complementary diagnostic tool.

Factors associated with severe pneumonia among children

BackgroundPneumonia is one of the leading causes of infant mortality globally, particularly in sub-Saharan Africa. In Uganda, pneumonia was the fourth leading cause of death in children <5 years in 2018. Analysis of 2013–2022 data for children <5 years from the District Health Information System indicated a high incidence of severe pneumonia in Kasese District, Uganda. We investigated to identify factors associated with severe pneumonia among children <5 years in Kasese District to inform prevention and control strategies.MethodsWe conducted a 1:1 hospital-based case-control study among children aged 2–59 months presenting with pneumonia at five high-volume facilities in Kasese District from January to April 2023. A case was defined as pneumonia with ≥1 of the following danger signs: low oxygen saturation, central cyanosis, severe respiratory distress, feeding difficulties, altered consciousness, and convulsions. Controls were outpatient children aged 2–59 months with a diagnosis of non-severe pneumonia. We reviewed medical records at facilities and used an interviewer-administered questionnaire with caregivers to obtain information on socio-demographic and clinical characteristics. Logistic regression was used to identify factors associated with severe pneumonia.ResultsWe enrolled 199 cases and 174 controls. The odds of severe pneumonia were higher among children with diarrhoea only (adjusted odds ratio [aOR] = 2.9, 95%CI: 1.7–4.9), or malaria and diarrhoea (aOR = 3.4, 95%CI: 2.0-5.9), than those without a co-existing illness at the time of pneumonia diagnosis. Not being exclusively breastfed for ≥ 6 months (aOR = 2.0, 95%CI: 1.1–3.3) and exposure to indoor air pollution from cooking combustion sources (aOR = 2.9, 95%CI: 1.8–4.7) increased odds of severe pneumonia.ConclusionThe findings highlight the significance of comorbidities, lack of exclusive breastfeeding, and exposure to indoor air pollution in the development of severe pneumonia. Promoting exclusive breastfeeding for ≥ 6 months and advocating for the use of clean energy sources, could mitigate morbidity attributable to severe pneumonia in the region.

Epidemiological and clinical characteristics of respiratory syncytial virus infection among people aged 60 and above in Beijing City

Objective: To investigate the epidemiological and clinical characteristics of RSV among patients aged ≥60 years in Beijing from 2015 to 2023. Methods: Based on the respiratory pathogen surveillance system, samples of upper respiratory tract infections (URTI), non-severe community-acquired pneumonia (nsCAP) and severe community-acquired pneumonia (sCAP) among people aged ≥60 years were collected from 28 sentinel hospitals in 16 districts of Beijing from January 2015 to December 2023. Swab samples were collected from URTI within one week, and lower respiratory tract samples from nsCAP and sCAP were collected. Demographic and epidemiological data were also collected. Various respiratory pathogens including RSV were detected. Results: From January 2015 to December 2023, a total of 20 349 cases of acute respiratory infections aged ≥60 years were included, with the RSV-positive rate of 1.54% (313/20 349, 95%CI: 1.39%-1.68%). Among them, the total RSV-positive rates of older people during the pre-pandemic, pandemic, and post-pandemic periods of COVID-19 were 1.59% (207/13 006, 95%CI: 1.38%-1.81%), 0.82% (38/4 650, 95%CI: 0.56%-1.08%) and 2.53% (68/2 693, 95%CI: 1.93%-3.12%), respectively. The difference in RSV-positive rate was statistically significant (P<0.001). Based on the sampling time of cases, the RSV epidemic season for older people in Beijing was from October to March of the following year, with a peak period in December or January of the following year. In the post COVID-19 pandemic, there were very few RSV-positive cases detected in the elderly from April to June 2023, with only one positive case detected in May and one in June. The RSV-positive rate of older people increased significantly from October to December, reaching 11.75% (51/383) in December. Among 263 RSV-positive cases in the elderly, RSV-A, RSV-B and unclassified type accounted for 43.35% (114/263), 29.28% (77/263) and 27.38% (72/263), respectively. Since 2020, there has been a subtype conversion, with RSV-B being the main focus. Among 197 elderly cases that have complete clinical data, the main symptoms were cough (86.8%, 171/197), sputum (80.2%, 158/197) and fever (73.60%, 145/197). About 24.87% (49/197) of elderly cases experienced complications. The hospitalization mortality rate was 4.57% (9/197), and the hospitalization rate was 78.68% (155/197). The ICU occupancy rate was 1.99% (36/197). The mechanical ventilation usage rate was 13.32% (33/197), and the length of hospital stay [M (Q1, Q3)] was 12 (9, 16) days. Conclusion: In Beijing, the RSV infection rate is relatively low during the COVID-19 pandemic, and the prevalence of COVID-19 is relatively high. In 2023, there was no out-of-season outbreak of RSV infection among the elderly. Elderly RSV infection cases have multiple complications, severe diseases, and poor prognosis.

Antibiothérapie courte au cours de la pneumonie : PNEUMOSHORT

IntroductionPneumonia is one of the most common indications for antibiotic. Shortening the duration of antibiotic therapy should help reduce bacterial resistance. To date, three randomized control trials have shown non-inferiority of short courses of antibiotic therapy (3 days) compared with 7 days in non-severe pneumonia. The aim of this study was to assess this strategy in real life. MethodThis retrospective observational cohort study included all patients with pneumonia hospitalized in an internal medical ward from 11/01/2022 to 05/31/2023. We implemented the strategy based on early discontinuation of antibiotic therapy in patients with pneumonia who were clinically stable after 3 days of β-lactam treatment. ResultsAmong 49 patients included, median age was 72, median antibiotic duration was 4 days (IQR 3-6), and cure rate at D30 was 88 %. At day 30, we observed one death (2 %), four new antibiotic therapy (9 %), and two new hospitalisation (5 %), among five immunosuppressed patients. Among immunosuppressed patients (n=17; 35 %), failure rate was three times higher in case of short antibiotic courses (3/8; 38 %) than long antibiotic courses (1/7; 14 %). ConclusionStrategy based on early discontinuation of antibiotic therapy in immunocompetent patients with pneumonia who were clinically stable after 3 days of β-lactam treatment is safe, and easy to implement in a medical ward.

Levels of cardiac biomarkers and three-year survival rate in hospitalized patients with heart failure and community-acquired pneumonia

Aim. To evaluate the impact of community-acquired pneumonia (CAP) on the levels of cardiac biomarkers and long-term survival rate in patients with heart failure (HF).Material and methods. The prospective observational single-center study included 132 patients (73 men, 59 women); mean age — 72,3±12,1 years, consecutively hospitalized at Clinical Hospital № 4 of the I. M. Sechenov First Moscow State Medical University with decompensated heart failure in the period from March 2018 to December 2019. The main (n=40) and comparison group (n=92) included patients with and without clinical and CT signs of CAP, respectively.Results. Patients with HF and CAP and HF without CAP were comparable in sex, age, and severity of HF. CAP in most patients met the criteria for non-severe pneumonia (average CURB-65 score — 1,55±0,73). The levels of N-terminal probrain natriuretic peptide (NT-proBNP) in patients with HF with CAP (1188,9 [439; 2493] pg/ml) were insignificantly higher than in patients with HF without CAP (839,6 [413; 1900]) pg/ml (p&gt;0,05). A similar pattern was noted for the soluble growth stimulation expressed gene 2 (sST2) (30,85 [12,8; 59,6] ng/ml vs 22,8 [15,2; 44,7] ng/ml, p&gt;0,05). The haptoglobin level in patients with CAP was significantly lower (732 [315; 1312] ng/l), compared to the group without CAP (1270 [902; 2022] ng/l, p=0,0022). No differences in the concentrations of galectin-3, copeptin and hepcidin were detected. The one-year mortality rate of patients who underwent CAP was 27,3%, and without CAP — 7,2% (p&lt;0,001), while the three-year mortality rate was 44,9% and 21,4%, respectively (p=0,0004). Elevated levels of NT-proBNP and sST2, along with age over 75 years and left ventricular ejection fraction &lt;40%, are additional factors of poor prognosis in patients with HF and CAP.Conclusion. CAP in patients with HF does not have a significant effect on most cardiac biomarkers, but significantly worsens the prognosis. Independent factors of unfavorable prognosis in patients with HF and CAP are age over 75 years, left ventricular ejection fraction &lt;40%, increased NT-proBNP and sST2 levels.

Experience of using immunomodulatory therapy in the complex treatment of mild community-acquired pneumonia and its long-term results

A decrease of nonspecific body resistance, an imbalance of local and systemic immunity and a free-radical oxidation abnormality substantially contribute to the pathogenesis of community-acquired pneumonia (CAP).Purpose: To study the efficiency of including immunomodulators into the comprehensive treatment of nonsevere community-acquired pneumonia and assess the long-term effects of the treatment conducted.Patients (n = 55) with non-severe CAP (41 (31-48) years old, with CRB-65 score of 0.15 (0-1)) are included in the study. Group 1 (control) received only standard CAP therapy; the other two groups received immunomodulators concurrently with the standard therapy: bacterial lysate (BL) for group 2 and azoximer bromide (AzB) for group 3. TNFα and IL-6 concentration was determined on the day of visit, on day 13 and day 60 of follow-up. During 2 years, the incidence of low respiratory tract infections (LRTI) was studied in the same patients with CAP in past (n = 55). All patients (n = 55) had clinical signs of non-severe community-acquired pneumonia. The overall duration of all symptoms was lower in immunomodulators groups as compared to the control group: 12 (11-13) days in BL group (p &lt; 0.001) and 12 (11-12) days in AzB group (p &lt; 0.001) with no statistically significant difference between intervention groups (p = 0.36). During treatment, TNFα and IL-6 concentration decreased on day 13 and day 60 in all patients; in patients who received immunomodulators, TNFα and IL-6 were reliably lower as compared to the control. Changes of TNFα and IL-6 concentration in the groups on day 60 of the study as compared to the baseline showed a decrease in BL group by 85 (-89 – -82) % and 86 (-90 – -85) % (p &lt; 0.001; p = 0.001 and control); in AzB group by 82 (-86 – -80) % and 86 (-88 – -84) % (p = 0.002; p = 0.007 and control). Intensity of IL-6 concentration decrease on day 60 in BL and AzB groups did not differ (p = 0.72). Gender- and age-adjusted odds ratio for the development of low respiratory tract diseases (during 2 years after CAP) in AzB group was 0.15 (0.02-0.93) (p = 0.04) suggesting its protective effect. Inclusion of immunomodulators in basic treatment of non-severe community-acquired pneumonia reduces duration of symptoms and is associated with improvement of the proinflammatory cytokine profile. In 2 years of follow-up, long-term effects of the immunomodulatory therapy showed statistically significant lower incidence of low respiratory tract infections in AzB group only.

Predictors of Respiratory Syncytial Virus, Influenza Virus, and Human Metapneumovirus Carriage in Children Under 5 Years With WHO-Defined Fast-Breathing Pneumonia in Pakistan.

Pneumonia is a leading cause of morbidity and mortality in children < 5 years. We describe nasopharyngeal carriage of respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and influenza virus among children with fast-breathing pneumonia in Karachi, Pakistan. We performed a cross-sectional analysis of nasopharyngeal swabs from children aged 2-59 months with fast-breathing pneumonia, enrolled in the randomized trial of amoxicillin versus placebo for fast-breathing pneumonia (RETAPP) (NCT02372461) from 2014 to 2016. Swabs were collected using WHO standardized methods, processed at the Aga Khan University, Pakistan. Viral detection was performed using LUMINEX xTAG respiratory viral panel assay and logistic regression identified clinical and sociodemographic predictors. Of the 1000 children tested, 92.2% (n = 922) were positive for viral carriage. RSV, hMPV, and influenza virus were detected in 59 (6.4%), 56 (6.1%), and 58 (6.3%) children and co-infections in three samples (two RSV-hMPV and one influenza-hMPV). RSV carriage was common in infants (56%), we observed a higher occurrence of fever in children with hMPV and influenza virus (80% and 88%, respectively) and fast breathing in RSV (80%) carriage. RSV carriage was positively associated with a history of fast/difficulty breathing (aOR: 1.96, 95% CI 1.02-3.76) and low oxygen saturation (aOR: 2.52, 95% CI 1.32-4.82), hMPV carriage was positively associated with a complete vaccination status (aOR: 2.22, 95% CI 1.23-4.00) and body temperature ≥ 37.5°C (aOR: 2.34, 95% CI 1.35-4.04) whereas influenza viral carriage was associated with body temperature ≥ 37.5°C (aOR: 4.48, 95% CI 2.53-7.93). We observed a high nasopharyngeal viral carriage among children with WHO-defined fast-breathing pneumonia in Pakistan. Fever, difficulty in breathing, hypoxia and vaccination status areimportant clinical predictors for viral nonsevere community-acquired pneumonia.

Immediate vs. culture-initiated antibiotic therapy in suspected non-severe ventilator-associated pneumonia: a before–after study (DELAVAP)

BackgroundVentilator-associated pneumonia (VAP) is the leading nosocomial infection in critical care and is associated with adverse outcomes. When VAP is suspected, starting antibiotic therapy (AT) immediately after pulmonary sampling may expose uninfected patients to unnecessary treatment, whereas waiting for bacteriological confirmation may delay AT in infected patients. As no robust data exist to choose between these strategies, the decision must balance the pre-test diagnostic probability, clinical severity, and risk of antimicrobial resistance. The objective of this study in patients with suspected non-severe VAP was to compare immediate AT started after sampling to conservative AT upon receipt of positive microbiological results. The outcomes were antibiotic sparing, AT suitability, and patient outcomes.MethodsThis single-center, before–after study included consecutive patients who underwent distal respiratory sampling for a first suspected non-severe VAP episode (no shock requiring vasopressor therapy or severe acute respiratory distress syndrome). AT was started immediately after sampling in 2019 and upon culture positivity in 2022 (conservative strategy). The primary outcome was the number of days alive without AT by day 28. The secondary outcomes were mechanical ventilation duration, day-28 mortality, and AT suitability (active necessary AT or spared AT).ResultsThe immediate and conservative strategies were applied in 44 and 43 patients, respectively. Conservative and immediate AT were associated with similar days alive without AT (median [interquartile range], 18.0 [0–21.0] vs. 16.0 [0–20.0], p = 0.50) and without broad-spectrum AT (p = 0.53) by day 28. AT was more often suitable in the conservative group (88.4% vs. 63.6%, p = 0.01), in which 27.9% of patients received no AT at all. No significant differences were found for mechanical ventilation duration (median [95%CI], 9.0 [6–19] vs. 9.0 [6–24] days, p = 0.65) or day-28 mortality (hazard ratio [95%CI], 0.85 [0.4–2.0], p = 0.71).ConclusionIn patients with suspected non-severe VAP, waiting for microbiological confirmation was not associated with antibiotic sparing, compared to immediate AT. This result may be ascribable to low statistical power. AT suitability was better with the conservative strategy. None of the safety outcomes differed between groups. These findings would seem to allow a large, randomized trial comparing immediate and conservative AT strategies.

Comparison of Empiric Antibiotic Treatment Regimens for Hospitalized, Non-severe Community-acquired Pneumonia: A Retrospective, Multicenter Cohort Study

PurposeConsensus guidelines for hospitalized, non-severe community-acquired pneumonia (CAP) recommend empiric macrolide + β-lactam or respiratory fluoroquinolone monotherapy in patients with no risk factors for resistant organisms. In patients with allergies or contraindications, doxycycline + β-lactam is a recommended alternative. The purpose of this study was to compare differences in outcomes among guideline-recommended regimens in this population. MethodsThis retrospective, multicenter cohort study included patients ≥18 years of age with CAP who received respiratory fluoroquinolone monotherapy, empiric macrolide + β-lactam, or doxycycline + β-lactam. Major exclusion criteria included patients with immunocompromising conditions, requiring vasopressors or invasive mechanical ventilation within 48 hours of admission, and receiving less than 2 days of total antibiotic therapy. The primary outcome was in-hospital mortality. Secondary outcomes included clinical failure, 14- and 30-day hospital readmission, and hospital length of stay. Safety outcomes included incidence of new Clostridioides difficile infection and aortic aneurysm ruptures. FindingsOf 4685 included patients, 1722 patients received empiric respiratory fluoroquinolone monotherapy, 159 received empiric doxycycline + β-lactam, and 2804 received empiric macrolide + β-lactam. Incidence of in-hospital mortality was not observed to be significantly different among empiric regimens (doxycycline + β-lactam group: 1.9% vs macrolide + β-lactam: 1.9% vs respiratory fluoroquinolone monotherapy: 1.5%, P = 0.588). No secondary outcomes were observed to differ significantly among groups. ImplicationsWe observed no differences in clinical or safety outcomes among three guideline-recommended empiric CAP regimens. Empiric doxycycline + β-lactam may be a safe empiric regimen for hospitalized CAP patients with non-severe CAP, although additional research is needed to corroborate these observations with larger samples.

The Diagnostic Association of Radiological and Clinicopathological Parameters in Community-Acquired Pneumonia in Children: A Cross-Sectional Study.

Background Globally, pneumonia is one of the significant causes of death in children under the age of five years. Assessment of disease severity is essential for clinical decision-making. Clinicians in resource-limited settings use the WHO Integrated Management of Childhood Illness (IMNCI) guidelines to diagnose and treat pneumonia. Chest X-rays and blood biomarkers are frequently performed in children presenting with pneumonia, but their role in clinical decision-making is limited. Objective To evaluate the association of chest X-ray results, clinical parameters, and blood inflammatory biomarkers with the severity of community-acquired pneumonia (CAP) in children to decide which tests are helpful in accurately classifying the severity of pneumonia. Methods This cross-sectional, analytical study was conducted at the Combined Military Hospital, Lahore, among 421 children aged two months to five years who were admitted with complaints of cough and difficulty breathing and were COVID-19 negative. Data was collected through a structured questionnaire, including demographic information and clinical categorization of pneumonia severity using WHO criteria, SpO2 levels, chest X-rays, complete blood count (CBC), and C-reactive protein (CRP)levels obtained within 24 hours of admission. Statistical evaluation of 323 children was done using SPSS version 26, and analysis of variance (ANOVA), chi-square test, and Fisher's exact test were applied to determine statistical significance. p-Value <0.05 was considered significant. Results The median age of the study population was eight months (IQR: 3-20 months); 113 (33.1%) were girlsand 127 (37.2%) were underweight children. Eighteen (5.3%) patients had no pneumonia, 245 (71.8%) patients had non-severe pneumonia, and 78 (22.9%) patients had severe pneumonia. The clinical features of severe pneumonia were more common in children with radiologic findings of alveolarCAPthan non-alveolar CAP (36.2% and 20%, respectively, p: 0.05). A higher percentage of patients with alveolar CAP had CRP >6 mg/dL than non-alveolar CAP (69.9% and 35%, respectively, p < 0.001). Patients with undernutrition (WAZ <-2 SD), hypoxemia (SpO2<95%), and having CRP >6 mg/dL were associated with clinical features of severe pneumonia (46.1% vs. 33.8%, 100% vs 47.3%, and 67.9% vs 48.5%, respectively, p < 0.05). A significantly greater frequency of a bilateral multifocal distribution (p = 0.020), and the involvement of the right paracardiac region (p = 0.043) and the left lower lobe (p = 0.007) in those with severe pneumonia was observed. Conclusion Clinical diagnosis of pneumonia, along with the assessment of risk factors, including undernutrition and hypoxemia, should be adequate to diagnose pneumonia in children. Chest X-rays and CRP levels can be helpful in hospitalized children for whom physicians have difficulty deciding about antibiotic prescriptions, but their role in routinely classifying the severity of pneumonia in children is limited.

Risk factors and predicting nomogram for the clinical deterioration of non-severe community-acquired pneumonia

BackgroundCurrently, there remains insufficient focus on non-severe community-acquired pneumonia (CAP) patients who are at risk of clinical deterioration, and there is also a dearth of research on the related risk factors. Early recognition of hospitalized patients at risk of clinical deterioration will be beneficial for their clinical management.MethodA retrospective study was conducted in The First Affiliated Hospital of Wenzhou Medical University, China, spanning from January 1, 2018 to April 30, 2022, and involving a total of 1,632 non-severe CAP patients. Based on whether their condition worsened within 72 h of admission, patients were divided into a clinical deterioration group and a non-clinical deterioration group. Additionally, all patients were randomly assigned to a training set containing 75% of patients and a validation set containing 25% of patients. In the training set, risk factors for clinical deterioration in patients with non-severe CAP were identified by using LASSO regression analysis and multivariate logistic regression analysis. A nomogram was developed based on identified risk factors. The effectiveness of the nomogram in both the training and validation sets was assessed using Receiver Operating Characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).ResultsAge, body mass index (BMI), body temperature, cardiovascular comorbidity, respiratory rate, LDH level, lymphocyte count and D-dimer level were identified as risk factors associated with the clinical deterioration of non-severe CAP within 72 h of admission. The area under curve (AUC) value of the nomogram was 0.78 (95% CI: 0.74–0.82) in the training set and 0.75 (95% CI: 0.67–0.83) in the validation set. Furthermore, the calibration curves for both the training and validation sets indicated that the predicted probability of clinical deterioration aligned with the actual probability. Additionally, DCA revealed clinical utility for the nomogram at a specific threshold probability.ConclusionThe study successfully identified the risk factors linked to the clinical deterioration of non-severe CAP and constructed a nomogram for predicting the probability of deterioration. The nomogram demonstrated favorable predictive performance and has the potential to aid in the early identification and management of non-severe CAP patients at elevated risk of deterioration.

Neutrophil-lymphocyte ratio on first and third postoperative days: associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing surgeries.

Severe postoperative pneumonia can increase the risk of poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to explore the associations of preoperative or postoperative inflammatory markers calculated from blood cell counts with severe pneumonia. This retrospective study was conducted at the First Affiliated Hospital of Yangtze University from January 2019 to June 2023. The associations of neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammation response index (SIRI) with severe pneumonia were analyzed. There were 159 patients with pneumonia and 21 patients without pneumonia. There were 41 patients with severe pneumonia and 118 patients with non-severe pneumonia. The multivariate logistic regression analysis showed that NLR on the first postoperative (OR = 2.574, 95%CI: 1.035-6.403, p = 0.042) and third postoperative days (OR = 4.296, 95%CI: 1.699-10.860, p = 0.002) were associated with severe pneumonia in aSAH patients. Among patients ≥ 60years, SIRI on the preoperative day (OR = 7.430, 95%CI: 1.443-38.251, p = 0.016) and NLR on the third postoperative day (OR = 4.748, 95%CI: 1.286-17.801, p = 0.020) were associated with severe pneumonia. Among patients < 60years, NLR on the first postoperative day (OR = 24.149, 95%CI: 3.476-167.747, p = 0.001) was associated with severe pneumonia. The NLR on the first and third postoperative days were possibly associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing clipping or embolization surgeries. Dynamic detection of NLR during early perioperative period may help clinicians to predict the development of severe pneumonia.

Assessment of severity of community acquired pneumonia by paediatric infectious diseases society and clinical and radiological profile in 0-5 year age group

Background: The WHO estimates that ARI, mostly in the form of CAP, is the leading cause of death in children under five, killing over 2 million children annually. The present study's PEWS score and PIDS severity criteria were undertaken to know the clinical and radiological profile of patients with Pneumonia and to categorize these patients with PEWS score and PIDS criteria to redefine their severity and assess the management and outcomes. Methods: Patients aged between 0 to 5 years who presented with cough complaints and respiration difficulty were assessed. The criteria for ICU admission is the presence of more than 2 minor criteria or one of the major criteria. PIDS criteria for CAP recommends ICU admission or continuous monitoring for children in ED. Results: A prospective observational study of 104 children with CAP was included, and their pneumonia was evaluated using PIDS criteria. The patients were categorized for pneumonia according to PIDS criteria. 32.69% of children were classified as severe CAP (p value=0.02). This difference between non-severe and severe Pneumonia is considered to be statistically significant in which patients classified as severe CAP. Conclusions: The patients were categorized for Pneumonia according to PIDS criteria. 32.69% of children were classified as severe CAP (p value=0.02). This difference between non-severe and severe Pneumonia is considered to be statistically significant in which patients classified as severe CAP needed vigorous management in emergency department followed by ICU management.

Viral and bacterial microorganisms in Vietnamese children with severe and non-severe pneumonia

To investigate potential respiratory pathogens in children with community-acquired pneumonia (CAP) and risk factors for severe disease. This prospective study was conducted among 467 children at the Thai Binh Paediatric Hospital, Vietnam between 1 July 2020 and 30 June 2021. Clinical data and laboratory results were collected. Twenty-four respiratory microorganisms were tested from nasopharyngeal swabs using real-time PCR. Logistical regression was used to estimate a factor’s adjusted odd ratios of the severity of disease. Mean age of patients = 15.4 ± 13.3 months, 63.0% were male. Over 97% of patients had a positive PCR result. 87% of patients were positive for multiple (up to eight) microorganisms. Rhinovirus (46%), respiratory syncytial virus (RSV) (24%), enterovirus (17%), and parainfluenza viruses-3 (13%) were the most frequent viruses. H. influenzae (61%), S. pneumoniae (45%) and M. catarrhalis (30%) were the most common bacteria. 128 (27%) cases were classified as severe pneumonia. Presence of smokers at home (aOR 2.11, 95% CI 1.27–3.52, P value = 0.004), CRP level ≥ 50 mg/dL (aOR 6.11, 95% CI 3.86–9.68, P value < 0.0001), RSV (aOR 1.78, 95% CI 1.07–2.96, P value = 0.03) and H. influenzae (aOR 1.66, 95% CI 1.03–2.67, P value = 0.04) PCR detection associated with a higher risk of severe pneumonia; ,. Causative agents of pneumonia in children are complex. Children positive with RSV and H. influenzae need to be closely monitored to prevent severe pneumonia.

91. Implementation of a blood culture algorithm in emergency department patients as a diagnostic stewardship intervention

Abstract Background Blood cultures (BCx) are commonly ordered for patients at low risk of bacteremia. Liberal ordering can increase false-positive results due to contamination, along with increasing length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented an algorithm for appropriate blood culture obtainment (Figure 1) in an academic tertiary care emergency department (ED) and assessed the intervention’s impact on various operational, clinical, and safety metrics.Figure 1:ED Blood culture algorithm Methods We performed a prospective cohort study in the Duke University Hospital ED from 12/2022 to 3/2023 using historical controls from 12/2020-11/2022. The BCx algorithm was disseminated in-person, electronically, and accessible online. Weekly chart review of all eligible patients for algorithm adherence was completed by 7 ED clinicians with monthly feedback provided to all ED providers. We defined a BCx event as 1 or more BCx sets within 24 hours. We excluded patients &amp;lt; 18 years, absolute neutrophil count &amp;lt; 500 109/L, and heart and lung transplant recipients. We measured BCx order volume, indication, algorithm adherence, BCx positivity rate, antibiotic days of therapy (DOT), and 30-day hospital readmission. Results Average monthly BCx volume was 1387 pre-intervention compared to 1226 post-intervention (p= 0.046). An increase in culture positivity was see post-intervention with a rate of 13.9% compared to 11.23% in the pre-intervention group (Figure 2, p&amp;lt; 0.001). The majority of the 2168 BCx adhered to the algorithm. (Figure 3). The most common reasons for non-adherence were isolated fever or leukocytosis (29%), non-severe community-acquired pneumonia or healthcare-associated pneumonia (6.9%) and non-severe cellulitis (4%). No change in DOT (786 vs. 783 days of therapy per 1000 patient days, p-value 0.85) (Figure 4) or monthly 30-day hospital readmission (21.1% vs 19.6%, p-value 0.30) was observed.Figure 2:Blood cultures drawn per month and % appropriate pre/post-intervention (N=2168)Figure 3:Algorithm Adherent vs. Algorithm Non-Adherent blood cultures per month (N=2168)Figure 4:Emergency Department anti-bacterial days of antibiotic therapy per 1000 patient days Conclusion Introduction of a BCx algorithm in an academic tertiary care ED, resulted in a decrease in BCx volume, increase in BCx positivity rate, and no increase in DOT or readmission was observed. (Table 1)Table 1:Blood culture volume, positivity rate, days of antibiotic therapy, and 30-day readmission Disclosures Jessica Seidelman, MD, MPH, Uptodate: content editor for pelvic osteomyelitis page

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study.

Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO 2) < 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability. Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR). The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P<0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO 2 < 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO 2 < 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor. In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Systemic inflammation response index (SIRI) on the 3rd postoperative day are associated with severe pneumonia in cerebral hemorrhage patients: A single-center retrospective study.

Inflammatory response was involved in the progression of cerebral hemorrhage. We sought to explore the associations of easily obtained inflammatory indicators including blood cell counts and the ratios of different blood cells counts with pneumonia and severe pneumonia in cerebral hemorrhage patients. We carried 1 retrospective study including 200 patients with cerebral hemorrhage and surgeries. The associations of neutrophils, lymphocytes, monocytes, platelets, systemic immune inflammation index (SII), systemic inflammation response index (SIRI), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) with pneumonia and severe pneumonia in cerebral hemorrhage patients were estimated by univariate analysis and multivariate logistic regression model. Among the 200 patients included, there were a total of 163 (81.5%) had pneumonia after surgeries. Among 163 cerebral hemorrhage patients with pneumonia, 60 (36.8%) cases were evaluated as severe pneumonia. The level of SIRI on the 1st postoperative day in patients with severe pneumonia was higher than non-severe pneumonia (10.89 ± 12.10 × 109/L vs 7.14 ± 9.76 × 109/L, P = .003). The level of SIRI on the 3rd postoperative day in patients with severe pneumonia was more significantly higher (7.98 ± 7.46 × 109/L vs 4.10 ± 3.74 × 109/L, P < .001). The results of multivariate analysis showed that SIRI level on the 3rd postoperative day (>6.5 × 109/L) was associated with severe pneumonia in cerebral hemorrhage patients (OR: 4.409, 95% CI: 1.799-10.806, P = .001). SIRI was possibly a superior predictor for severe pneumonia in cerebral hemorrhage patients compared with other inflammatory indicators. On the one hand, we intend to validate the cutoff value of SIRI for predicting severe pneumonia in larger samples and multicenter studies. On the other hand, we also intend to use this index to guide the choice of antibacterial drugs in order to better benefit patients.

Metagenomic next-generation sequencing of bronchoalveolar lavage fluid in non-severe and severe pneumonia patients

Metagenomic next-generation sequencing (mNGS) is widely used as a more promising technology than conventional tests. However, its clinical utility in the context of bronchoalveolar lavage fluid (BALF) samples for discriminating between non-severe and severe pneumonia is not well established. Thus, this study aimed to investigate the diagnostic performance of mNGS on BALF samples from 100 individuals suspected of pneumonia, and compared it with conventional microbiological tests (CMT) of BALF samples and the final clinical diagnosis. Twenty-seven cases of non-severe pneumonia and 73 cases of severe pneumonia patients were finally clinically diagnosed. Among 100 cases, diagnostic performance of mNGS and culture showed a significant difference; 65 cases had the same sample types, of which 25 cases were diagnosed as positive by mNGS only (38.46%) and 1 was diagnosed as positive by culture only (1.54%). Moreover, 24 cases were diagnosed positive in both mNGS and culture (36.92%) and 15 cases tested negative in both mNGS and culture (23.08%). Among 35 cases, 28 out of 35 cases were diagnosed as positive by mNGS, while only 4 out of 35 cases were diagnosed as positive by the indirect immunofluorescence method (IIFT). In addition, the positive rate of mNGS was higher than that of culture in cases regardless of prior antibiotic exposure. Mixed pathogens were found to be significantly more prevalent in severe pneumonia patients than in non-severe pneumonia patients. Importantly, among 38 cases who were diagnosed solely by mNGS, 25 patients experienced an improved outcome after physicians changed the therapy according to the mNGS results. In conclusion, the results showed that mNGS of BALF represents a potentially effective tool for detection of mixed pathogens in severe pneumonia.

A nomogram based on the expression level of angiopoietin-like 4 to predict the severity of community-acquired pneumonia

BackgroundThe morbidity and mortality of community-acquired pneumonia (CAP) remain high among infectious diseases. It was reported that angiopoietin-like 4 (ANGPTL4) could be a diagnostic biomarker and a therapeutic target for pneumonia. This study aimed to develop a more objective, specific, accurate, and individualized scoring system to predict the severity of CAP.MethodsTotally, 31 non-severe community-acquired pneumonia (nsCAP) patients and 14 severe community-acquired pneumonia (sCAP) patients were enrolled in this study. The CURB-65 and pneumonia severity index (PSI) scores were calculated from the clinical data. Serum ANGPTL4 level was measured by enzyme-linked immunosorbent assay (ELISA). After screening factors by univariate analysis and receiver operating characteristic (ROC) curve analysis, multivariate logistic regression analysis of ANGPTL4 expression level and other risk factors was performed, and a nomogram was developed to predict the severity of CAP. This nomogram was further internally validated by bootstrap resampling with 1000 replications through the area under the ROC curve (AUC), the calibration curve, and the decision curve analysis (DCA). Finally, the prediction performance of the new nomogram model, CURB-65 score, and PSI score was compared by AUC, net reclassification index (NRI), and integrated discrimination improvement (IDI).ResultsA nomogram for predicting the severity of CAP was developed using three factors (C-reactive protein (CRP), procalcitonin (PCT), and ANGPTL4). According to the internal validation, the nomogram showed a great discrimination capability with an AUC of 0.910. The Hosmer–Lemeshow test and the approximately fitting calibration curve suggested a satisfactory accuracy of prediction. The results of DCA exhibited a great net benefit. The AUC values of CURB-65 score, PSI score, and the new prediction model were 0.857, 0.912, and 0.940, respectively. NRI comparing the new model with CURB-65 score was found to be statistically significant (NRI = 0.834, P < 0.05).ConclusionA robust model for predicting the severity of CAP was developed based on the serum ANGPTL4 level. This may provide new insights into accurate assessment of the severity of CAP and its targeted therapy, particularly in the early-stage of the disease.

44 Ceftriaxone Prescribing Patterns in an Outpatient Hospital Setting: A Quality Improvement Study

Abstract Background Ceftriaxone is a commonly administered antibiotic in paediatric medical day hospitals (MDH) for certain conditions where it may be considered first-line. Its long half-life permits once-daily dosing, thus potentially avoiding inpatient admission. However, administration of ceftriaxone requires intravenous line insertion, daily follow-up, and time spent by the family. There is a perception among healthcare providers in our tertiary hospital that ceftriaxone use is frequently inappropriate in the outpatient setting, and that more narrow-spectrum oral agents could be prescribed instead. Objectives Our primary objective was to evaluate the appropriateness of ceftriaxone use according to centre-specific first-line indications, in children between the ages of 3 months and 18 years in the MDH. Design/Methods Data were collected retrospectively for one winter season (Nov 2, 2019 to Jan 11, 2020) and one summer season (June 2, 2020 to Sept 25, 2020). All patients initially referred by the emergency department (ED) to the MDH were reviewed. Inclusion criteria included children (age 3 months to 18 years) who received ceftriaxone in the MDH or the ED. Patients with pre-existing immunodeficiency were excluded. Appropriateness was assessed according to the empiric antimicrobial guide available at our centre. In cases where ceftriaxone appropriateness was unclear, a detailed chart review was conducted by two parties including a resident and a staff trained in paediatric infectious diseases. Results Among eligible patients referred to the MDH from the ED (n=196), ceftriaxone was inappropriate in 113 cases (57.7%). Inappropriateness was more prevalent in the summer than the winter (76% vs 41.3%, p&amp;lt;0.0001). The most frequent inappropriate indications for ceftriaxone were: cellulitis with a skin portal of entry, including pre-septal cellulitis (54.0%); non-severe pneumonia (11.5%); and acute lymphadenitis (11.5%). Cellulitis was more prevalent in the summer (38.7% vs 16.3%), whereas pneumonia was more prevalent in the winter (20.2% vs 2.2%). Ceftriaxone was almost always initially prescribed in the ED (95.4%), and was continued in 164/187 (87.7%) of first MDH visits. An average of 2.9 doses of ceftriaxone was given per patient. Only one patient was documented to be initially unwell looking in the ED, and 50% were afebrile. Conclusion Ceftriaxone is overused in the MDH at our institution, largely due to skin and soft tissue infections and non-severe pneumonia. Targeted antimicrobial stewardship interventions to reduce ceftriaxone use in both the ED and MDH could improve the patient experience (less broad-spectrum antibiotics, less invasive procedures) and the efficient use of the MDH.