Viral community acquired pneumonia at the emergency department: Report from the pre COVID-19 age

Epidemiology and burden of respiratory syncytial virus in Italian adults: A systematic review and meta-analysis

OBJECTIVE

Respiratory syncytial virus (RSV) is a common respiratory pathogen not only in children, but also in adults. In view of a recent authorization of adult RSV vaccines in Italy, our research question was to quantify the epidemiology and burden of RSV in Italian adults.

METHODS

Observational studies on the epidemiology and clinical burden of laboratory-confirmed or record-coded RSV infection in Italian adults of any age were eligible. Studies with no separate data for Italian adults, modeling and other secondary publications were excluded. A literature search was performed in MEDLINE, Biological Abstracts, Global Health, Scopus and Web of Science on 22 November 2023. Critical appraisal was performed by means of a Joanna Briggs Institute checklist. Random-effects (RE) meta-analysis was performed to obtain pooled estimates and the observed heterogeneity was investigated by subgroup and meta-regression analyses. The protocol was prospectively registered (doi.org/10.17504/protocols.io.5qpvo32odv4o/v1).

RESULTS

Thirty-five studies were identified, most of which had at least one possible quality concern. RSV seasonal attack rates ranged from 0.8 ‰ in community-dwelling older adults to 10.9% in hematological outpatients. In the RE model, 4.5% (95% CI: 3.2-5.9%) of respiratory samples tested positive for RSV. This positivity prevalence was higher in older adults (4.4%) than in working-age adults (3.5%) and in outpatient (4.9%) than inpatient (2.9%) settings. According to the meta-regression, study location and sample size were also significant predictors of RSV detection frequency. The pooled estimate of in-hospital mortality was as high as 7.2% (95% CI: 4.7-10.3%). Data on other indicators of the diseases burden, such as complication and hospitalization rates, were unavailable.

CONCLUSION

RSV poses a measurable burden on Italian adults, especially those of older age and with some co-morbidities. However, several data on the natural history of RSV disease are missing and should be established by future large-scale studies.

Influenza vaccination in older adults and patients with chronic disorders: A position paper from the Portuguese Society of Pulmonology, the Portuguese Society of Diabetology, the Portuguese Society of Cardiology, the Portuguese Society of Geriatrics and Gerontology, the Study Group of Geriatrics of the Portuguese Society of Internal Medicine, and the Portuguese Society of Infectious Diseases and Clinical Microbiology

Influenza affects millions of people worldwide each year and can lead to severe complications, hospitalizations, and even death, especially among vulnerable populations such as older adults and those with chronic medical conditions. Annual vaccination is considered the most effective measure for preventing influenza and its complications. Despite the widespread availability of influenza vaccines, however, vaccination coverage rates remain suboptimal in several countries. Based on the latest scientific evidence and expert opinions on influenza vaccination in older people and patients with chronic disease, the Portuguese Society of Pulmonology (SPP), the Portuguese Society of Diabetology (SPD), the Portuguese Society of Cardiology (SPC), the Portuguese Society of Geriatrics and Gerontology (SPGG), the Study Group of Geriatrics of the Portuguese Society of Internal Medicine (NEGERMI-SPMI), and the Portuguese Society of Infectious Diseases and Clinical Microbiology (SPDIMC) discussed best practices for promoting vaccination uptake and coverage and drew up several recommendations to mitigate the impact of influenza. These recommendations focus on the efficacy and safety of available vaccines; the impact of influenza vaccination on older adults; patients with chronic medical conditions, namely cardiac and respiratory conditions, diabetes, and immunosuppressive diseases; and health care professionals, optimal vaccination timing, and strategies to increase vaccination uptake and coverage. The resulting position paper highlights the critical role that vaccinations play in promoting public health, raising awareness, and encouraging more people to get vaccinated.

[Community-acquired pneumonia]

RISK FACTORS FOR SEVERE COURSES

The CRB-65 score is recommended as a risk predictor, as well as consideration of unstable comorbidities and oxygenation.

GROUPING OF COMMUNITY-ACQUIRED PNEUMONIA

Community-acquired pneumonia is divided into 3 groups: mild pneumonia, moderate pneumonia, severe pneumonia. Whether there is a curative vs palliative treatment goal should be determined early.

DIAGNOSTIC RECOMMENDATION

An X-ray chest radiograph is recommended to confirm the diagnosis, also in the outpatient setting if possible. Sonography of the thorax is an alternative, asking for additional imaging if negative. Streptococcus pneumoniae remains the most common bacterial pathogen.

THERAPY

Community-acquired pneumonia continues to be associated with high morbidity and lethality. Prompt diagnosis and prompt initiation of risk-adapted antimicrobial therapy are essential measures. However, in times of COVID-19, as well as the current influenza and RSV epidemic, purely viral pneumonias must also be expected. At least with COVID-19, antibiotics can often be avoided. Antiviral and anti-inflammatory drugs are used here.

POST-ACUTE COURSE

Patients after community-acquired pneumonia have increased acute and long-term mortality due to cardiovascular events in particular. The focus of research is on improved pathogen identification, a better understanding of the host response with the potential of developing specific therapeutics, the role of comorbidities, and the long-term consequences of the acute illness.

Pneumonia Update for Emergency Clinicians

Purpose of Review

Many new concepts in diagnosis, management, and risk stratification of patients with pneumonia have been described recently. The COVID pandemic made importance of viruses as dangerous pathogens of pneumonia quite clear while several non-invasive measures for patients with respiratory failure gained a more wide-spread usage.

Recent Findings

Studies continue to examine feasibility of bedside ultrasound as a tool in accurate diagnosis of pneumonia in the emergency department, and several new antibiotics have been approved for treatment while others are in late-stage clinical trials. Additionally, the Infectious Diseases Society, American Thoracic Society, and their European counterparts published updated guidelines in recent years. For differences important to emergency medicine clinicians and new emphasis as compared to the prior guidelines, please see Table 1. Several new antibiotics have been approved recently but remain relatively unknown to emergency clinicians as their use is frequently restricted to infectious disease specialists.Table 1

Viral community acquired pneumonia at the emergency department: Report from the pre COVID-19 age

The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre‐coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and in‐hospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled‐up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co‐infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB‐65. All intra‐ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB‐65 score ≥2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one‐third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests.

This study stresses the incidence of viral pneumonia during the flu season and underlies the role of viral infection screening at the ED regardless of the current COVID‐19 pandemic.