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Lüthi-Corridori G, Roth AI, Boesing M, Jaun F, Tarr PE, Leuppi-Taegtmeyer AB, Leuppi JD. Diagnosis and Therapy of Community-Acquired Pneumonia in the Emergency Department: A Retrospective Observational Study and Medical Audit. J Clin Med 2024; 13:574. [PMID: 38276080 PMCID: PMC10816545 DOI: 10.3390/jcm13020574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Despite advances in therapy, community-acquired pneumonia (CAP) is still associated with significant morbidity and mortality. Several studies conducted in different countries have reported suboptimal adherence to the guidelines. However, there are currently no available data on adherence to CAP guidelines specifically in Switzerland. OBJECTIVES The aim of this study was to audit the quality of diagnosis and therapy of CAP at a Swiss general hospital. METHODS A retrospective, observational, single-center cohort study was conducted, including patients older than 18 years diagnosed with CAP and admitted to a medical ward throughout 2019 without prior antibiotic therapy prescribed by their general practitioner (GP). The baseline characteristics of the patients were analyzed, and the diagnostic workup and treatment were compared to the Swiss guidelines for CAP. RESULTS A total of 254 patients diagnosed with CAP were included in this study (median age 78 years, 51.6% males). Atypical pneumonia was diagnosed in 4% of patients, while an organism was identified in 33% of cases, with Streptococcus pneumoniae being the most frequently detected pathogen (57%). A chest image was taken in almost all patients. Documentation of respiratory rate was missing in 23% of cases. Procalcitonin was measured in 23.2% of cases. Pneumococcal and legionella urinary antigen testing was performed on approximately 90% of all patients and blood cultures were drawn in approximately 80% of patients. In 39% of cases, arterial blood gas analysis was performed. Guideline adherence for the administration of empiric antibiotics was documented/recorded in 75% of cases. Twelve different antibiotic regimens were administered, and they were mostly amoxicillin/clavulanate with or without macrolides, as suggested by the guidelines. In particular, the use of ceftriaxone was higher (19.7%) compared to the Swiss guidelines. The average length of antibiotic therapy was longer (8.2 days) compared to the guidelines (5-7 days). Oral steroid therapy was administered to 29.1% of patients, including to 75% of those diagnosed with COPD. CONCLUSION Overall, guideline adherence was moderately low, especially with regards to the assessment of respiratory rate, performance of arterial blood gas analysis, and sputum collection. Regarding antibiotic therapy, the use of ceftriaxone and the length of antibiotic therapy should be reduced. Further research is needed to identify the reasons for guideline non-adherence, and to find effective measures for the improvement of guideline adherence.
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Affiliation(s)
- Giorgia Lüthi-Corridori
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Andrea I. Roth
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Maria Boesing
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Fabienne Jaun
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Philip E. Tarr
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
- University Center for Internal Medicine, Infectious Diseases and Hospital Epidemiology Service, Cantonal Hospital Baselland, 4101 Bruderholz, Switzerland
| | - Anne B. Leuppi-Taegtmeyer
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
- Department of Patient Safety, Medical Directorate, University Hospital Basel, 4031 Basel, Switzerland
| | - Jörg D. Leuppi
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
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Cut TG, Mavrea A, Cumpanas AA, Novacescu D, Oancea CI, Bratosin F, Marinescu AR, Laza R, Mocanu A, Pescariu AS, Manolescu D, Dumache R, Enache A, Hogea E, Lazureanu VE. A Retrospective Assessment of Sputum Samples and Antimicrobial Resistance in COVID-19 Patients. Pathogens 2023; 12:pathogens12040620. [PMID: 37111506 PMCID: PMC10143659 DOI: 10.3390/pathogens12040620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Data on bacterial or fungal pathogens and their impact on the mortality rates of Western Romanian COVID-19 patients are scarce. As a result, the purpose of this research was to determine the prevalence of bacterial and fungal co- and superinfections in Western Romanian adults with COVID-19, hospitalized in in-ward settings during the second half of the pandemic, and its distribution according to sociodemographic and clinical conditions. The unicentric retrospective observational study was conducted on 407 eligible patients. Expectorate sputum was selected as the sampling technique followed by routine microbiological investigations. A total of 31.5% of samples tested positive for Pseudomonas aeruginosa, followed by 26.2% having co-infections with Klebsiella pneumoniae among patients admitted with COVID-19. The third most common Pathogenic bacteria identified in the sputum samples was Escherichia coli, followed by Acinetobacter baumannii in 9.3% of samples. Commensal human pathogens caused respiratory infections in 67 patients, the most prevalent being Streptococcus penumoniae, followed by methicillin-sensitive and methicillin-resistant Staphylococcus aureus. A total of 53.4% of sputum samples tested positive for Candida spp., followed by 41.1% of samples with Aspergillus spp. growth. The three groups with positive microbial growth on sputum cultures had an equally proportional distribution of patients admitted to the ICU, with an average of 30%, compared with only 17.3% among hospitalized COVID-19 patients with negative sputum cultures (p = 0.003). More than 80% of all positive samples showed multidrug resistance. The high prevalence of bacterial and fungal co-infections and superinfections in COVID-19 patients mandates for strict and effective antimicrobial stewardship and infection control policies.
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Affiliation(s)
- Talida Georgiana Cut
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Center for Ethics in Human Genetic Identifications, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Academy of Romanian Scientists, Splaiul Independentei, Nr. 54, 50085 Bucharest, Romania
| | - Adelina Mavrea
- Department VII, Internal Medicine II, Discipline of Cardiology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Alin Adrian Cumpanas
- Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Dorin Novacescu
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Academy of Romanian Scientists, Splaiul Independentei, Nr. 54, 50085 Bucharest, Romania
| | - Cristian Iulian Oancea
- Department XIII, Discipline of Pneumology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Center for Research and Innovation in Precision Medicine of Respiratory Diseases (CRIPMRD), Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Felix Bratosin
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Adelina Raluca Marinescu
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Ruxandra Laza
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Alexandra Mocanu
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Alexandru Silvius Pescariu
- Academy of Romanian Scientists, Splaiul Independentei, Nr. 54, 50085 Bucharest, Romania
- Department VII, Internal Medicine II, Discipline of Cardiology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Diana Manolescu
- Department XV, Discipline of Radiology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Raluca Dumache
- Center for Ethics in Human Genetic Identifications, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Department VIII, Discipline of Forensic Medicine, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Alexandra Enache
- Center for Ethics in Human Genetic Identifications, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Department VIII, Discipline of Forensic Medicine, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Elena Hogea
- Department XIV, Discipline of Microbiology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Voichita Elena Lazureanu
- Department XIII, Discipline of Infectious Diseases, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
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Clinical Characteristics and Microbial Profiles of Paediatric Patients with Methicillin-Resistant Staphylococcus aureus Pneumonia in China. Jundishapur J Microbiol 2023. [DOI: 10.5812/jjm-132894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Staphylococcus aureus can cause fatal pneumonia. The evolution of bacteria and the overuse of antibiotics have enhanced the drug resistance of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA). Objectives: This study aimed to recapitulate the microbiological profile and clinical characteristics of paediatric patients with MRSA. Methods: This retrospective study was conducted to investigate 1372 paediatric patients with S. aureus pneumonia from January 2017 to December 2021. Sputum specimens were collected and processed for performing bacterial culture and drug sensitivity tests. Medical records of patients were reviewed for clinical characteristics and laboratory examination results. Results: The MRSA and MSSA pneumonia mainly occurred in infants; however, comparisons of sex, age, and sampling time between patients with MRSA and MSSA pneumonia showed no significant differences (P > 0.05). The results of drug sensitivity in sputum culture revealed that all MRSA and MSSA isolates were susceptible to vancomycin, tigecycline, linezolid, teicoplanin, and ceftaroline. Methicillin-sensitive Staphylococcus aureus was completely sensitive to rifampicin and oxacillin. Methicillin-resistant Staphylococcus aureus was completely resistant to penicillin and oxacillin, while MSSA was less sensitive to penicillin. Methicillin-resistant Staphylococcus aureus and MSSA both maintained high sensitivity rates to gentamicin, sulfamethoxazole-trimethoprim, levofloxacin, and moxifloxacin, with the exception of clindamycin and erythromycin. According to our results, moreover, the sensitivity of MRSA to gentamicin and sulfamethoxazole-trimethoprim was significantly higher than that of MSSA (P < 0.05). The common symptoms of patients with S. aureus pneumonia were fever, cough, and wheezing. patients with MRSA pneumonia had significantly higher counts of white blood cells (WBCs), C-reactive protein (CRP), and procalcitonin (PCT) than patients with MSSA pneumonia (P < 0.05). Conclusions: The results of antimicrobial sensitivity test in sputum culture of MRSA and MSSA isolates can reflect the sensitivity of antibiotics and guide the use of clinical antibiotics. Infectious biomarkers can reflect the severity of infection and guide prognosis.
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Zhang J, Li D, Huang X, Long S, Yu H. The Distribution of K. pneumoniae in Different Specimen Sources and Its Antibiotic Resistance Trends in Sichuan, China From 2017 to 2020. Front Med (Lausanne) 2022; 9:759214. [PMID: 35242771 PMCID: PMC8885598 DOI: 10.3389/fmed.2022.759214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/24/2022] [Indexed: 11/27/2022] Open
Abstract
Objective We aim to analyze the distribution of Klebsiella pneumoniae in different specimen sources and its antibiotic resistance trends from the Antimicrobial Resistant Investigation Network of Sichuan Province (ARINSP) between 2017 and 2020. Methods According to the monitoring scheme, each participating hospital identified the bacteria and performed antimicrobial susceptibility tests using approved procedures. The data of non-repetitive isolates collected from outpatients and inpatients were submitted to ARINSP. The WHONET 5.6 software was used to analyze the results according to the Clinical and Laboratory Standards Institute (CLSI). Results Between 2017 and 2020, 833,408 non-repetitive clinical isolates of bacteria were isolated in total. The bacterial strains isolated from sputum and broncho-alveolar lavage accounted for 48.7, 56.4, 49.2, and 43.7% from 2017 to 2020 respectively, among all sources. The number of Klebsiella pneumoniae isolates from sputum and broncho-alveolar lavage increased from 18,809 in 2018, 19,742 in 2019, to 19,376 in 2020, playing a predominant role among all specimens. Meropenem-resistant K. pneumoniae occurrences (5.7% in 2017, 7.3% in 2018, 8.0% in 2019, and 7.5% in 2020) remained highest among carbapenems, and increased slightly over time. The resistance rate to tigecycline remained lowest, and declined from 2.4% in 2017, to 0.4% in 2018, and from 0.7% in 2019, to 0.6% in 2020. Conclusion The overall resistance rates of Klebsiella pneumoniae to carbapenems increased in Sichuan Province, giving a significant challenge to control K. pneumoniae related infections. Tigecycline has retained activity to against K. pneumoniae. Ongoing surveillance is essential. It can help for implementing intervention programs to reduce the occurrence of antimicrobial resistance and to provide with a rational use of antimicrobials.
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Affiliation(s)
- Jie Zhang
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Dan Li
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.,Department of Laboratory Medicine, Medical Center Hospital of Qionglai City, Chengdu, China
| | - Xiangning Huang
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Shanshan Long
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hua Yu
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Joseph S, Mathew J, Noyal S, Biju S, Jose A. Etiological profile, prescribing pattern of antibiotics and clinical outcomes of pneumonia patients in a tertiary care hospital in South India during 5-year period. MGM JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/mgmj.mgmj_205_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Wagner AP, Enne VI, Livermore DM, Craig JV, Turner DA. Review of health economic models exploring and evaluating treatment and management of hospital-acquired pneumonia and ventilator-associated pneumonia. J Hosp Infect 2020; 106:745-756. [PMID: 32971194 DOI: 10.1016/j.jhin.2020.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 09/08/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) is pneumonia that occurs ≥48 h after hospital admission; it is the most common hospital-acquired infection contributing to death. Ventilator-associated pneumonia (VAP) arises ≥48-72 h after intubation. Opinions differ on whether VAP is a subset of HAP; the same pathogens predominate in both. Compared with VAP-free controls, patients developing VAP are twice as likely to die and have significantly longer stays in intensive care units. Guidelines recommend that microbiological cultures should guide antibiotic treatment, but these lack sensitivity and take 48-72 h to process, meaning that initial therapy must be empiric, generally with broad-spectrum agents. Given increasing pressure to improve both antibiotic stewardship and patient outcomes, the National Institute for Health and Care Excellence and the Infectious Diseases Society of America recommend research into rapid molecular diagnostic tests to identify causative organisms and their antibiotic resistances. Ideally, these would supersede culture, being quicker and more sensitive. In the UK, the INHALE research programme, funded by the National Institute for Health Research, is exploring rapid molecular diagnostics to inform treatment of HAP/VAP and, given resource implications, incorporates a health economic component. AIM To identify previous economic modelling of HAP/VAP costs to inform this component. METHODS Literature review of HAP/VAP studies with economic modelling identified from three databases. FINDINGS Twenty studies were identified. Only one study specifically evaluated strategies to improve diagnosis; the remaining 19 studies omitted this important aspect. CONCLUSION HAP/VAP modelling would be improved by better awareness of long-term outcomes and treatment complexity. To the authors' knowledge, no similar literature reviews of economic modelling for HAP/VAP have been published.
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Affiliation(s)
- A P Wagner
- Norwich Medical School, University of East Anglia, Norwich, UK; National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK.
| | - V I Enne
- University College London, London, UK
| | - D M Livermore
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J V Craig
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - D A Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
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Vallecoccia MS, Dominedò C, Cutuli SL, Martin-Loeches I, Torres A, De Pascale G. Is ventilated hospital-acquired pneumonia a worse entity than ventilator-associated pneumonia? Eur Respir Rev 2020; 29:29/157/200023. [PMID: 32759376 PMCID: PMC9488552 DOI: 10.1183/16000617.0023-2020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/14/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Nosocomial pneumonia develops after ≥48 h of hospitalisation and is classified as ventilator-associated pneumonia (VAP) and hospital-acquired pneumonia (HAP); the latter may require mechanical ventilation (V-HAP) or not (NV-HAP). Main findings VAP and HAP affect a significant proportion of hospitalised patients and are characterised by poor clinical outcomes. Among them, V-HAP has the greatest 28-day mortality rate followed by VAP and NV-HAP (27.8% versus 18% versus 14.5%, respectively). However, no differences in terms of pathophysiology, underlying microbiological pathways and subsequent therapy have been identified. International guidelines suggest specific flow charts to help clinicians in the therapeutic management of such diseases; however, there are no specific recommendations beyond VAP and HAP classification. HAP subtypes are scarcely considered as different entities and the lack of data from the clinical scenario limits any final conclusion. Hopefully, recent understanding of the pathophysiology of such diseases, as well as the discovery of new therapies, will improve the outcome associated with such pulmonary infections. Conclusion Nosocomial pneumonia is a multifaced disease with features of pivotal interest in critical care medicine. Due to the worrisome data on mortality of patients with nosocomial pneumonia, further prospective studies focused on this topic are urgently needed. Due to the different mortality of each subtype of nosocomial pneumonia, including ventilator-associated pneumonia and hospital-acquired pneumonia requiring mechanical ventilation, new prospective studies are urgently neededhttps://bit.ly/3fFoZ6U
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Affiliation(s)
- Maria Sole Vallecoccia
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy.,Joint first authors
| | - Cristina Dominedò
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy.,Joint first authors
| | - Salvatore Lucio Cutuli
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ignacio Martin-Loeches
- Dept of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland.,Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gennaro De Pascale
- Dept of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy .,Università Cattolica del Sacro Cuore, Rome, Italy
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