Community-Acquired Pneumonia

A systematic review and meta-analysis of the efficacy and safety of glucocorticoids in the treatment of severe pneumonia

OBJECTIVES

To systematically evaluate the efficacy and superiority of glucocorticoids in the treatment of severe pneumonia.

METHOD

Randomized Controlled Trials (RCTs) on glucocorticoids in the treatment of severe pneumonia were retrieved from CNKI, CBM, China Science and Technology Journal Database (VIP), Wanfang Database, and PubMed as of January 1, 2017. The literature was independently and objectively screened, extracted, and evaluated by two researchers, and a meta-analysis of the extracted data was performed using Revman 5.3 software.

RESULTS

Ten studies that met the inclusion criteria were included, with a cumulative total of 1120 cases. The meta-analysis results confirmed that the observation group was superior to the control group in terms of efficacy rate, temperature recovery time, cough relief time, rale disappearance time, and serum CRP level. There was no statistically significant difference in terms of the incidence of adverse reactions, mortality rate, and reinfection rate between the two groups.

CONCLUSIONS

Glucocorticoids showed an obvious clinical efficacy in patients with severe pneumonia. However, due to the small number of included studies and the ambiguity of numerous bias risk assessments, high-quality and large-sample RCTs are still needed to provide corroborating evidence.

Clinical application of targeted next-generation sequencing utilizing bronchoalveolar lavage fluid in thoracic surgery ICU patients with suspected pulmonary infections

AIMS

The aim of this prospective study was to evaluate the diagnostic value of targeted next-generation sequencing (tNGS) in identifying pathogens from bronchoalveolar lavage fluid (BALF) in thoracic surgery ICU patients, offering additional diagnostic methods for clinical practice.

METHODS AND RESULTS

We collected clinical data from patients with suspected pulmonary infections in the thoracic surgery ICU of the Second Affiliated Hospital of Air Force Medical University. A total of 50 patients were enrolled in this study. Traditional pathogen detection (TPD), involving culture and loop-mediated isothermal amplification assays for 12 pathogens, along with tNGS, was employed for pathogen identification in BALF samples. Our findings demonstrated that the positive rate of tNGS was significantly greater than that of TPD (96% vs. 68%). Among the 50 samples analyzed, tNGS identified a total of 165 pathogens, whereas TPD detected only 48 pathogens. The TPD method primarily detected bacteria and fungi, whereas tNGS exhibited broader capabilities, identifying 104 cases with bacteria, 19 with fungi, 34 with DNA viruses, and 8 with RNA viruses. Notably, tNGS displayed enhanced efficiency in detecting atypical pathogens such as fungi, DNA viruses and RNA viruses. Furthermore, compared with TPD, tNGS demonstrated superior sensitivity (95.83% vs. 68.75%).

CONCLUSIONS

tNGS technology, characterized by its high sensitivity, specificity, and cost-effectiveness, holds great promise as a reliable diagnostic tool for assessing pulmonary infections in the thoracic surgery ICU patients.

Risk factors for drug-resistant pathogens in community-acquired pneumonia: systematic review and meta-analysis

INTRODUCTION

Community-acquired pneumonia (CAP) is a leading cause of death worldwide. Reducing inappropriate and excessive use of extended-spectrum antibiotics is essential for treating CAP effectively. Evaluating the risk of drug-resistant pathogens (DRPs) is crucial for determining initial antibiotic therapy in clinical settings.

METHODS

This systematic review and meta-analysis assessed the risk factors for DRPs in patients with CAP. CAP-DRPs were defined as pathogens resistant to commonly used antibiotics for CAP, including nonpseudomonal β-lactams such as ceftriaxone or sulbactam-ampicillin, macrolides and respiratory fluoroquinolones. The studies included were divided into two cohorts, namely an all-patient cohort, comprising both culture-positive and culture-negative patients, and a culture-positive pneumonia cohort, comprising patients with identified causative pathogens. The primary objective of this study was to evaluate the risk factors for CAP-DRPs in the all-patient cohort.

RESULTS

24 articles were included with 11 categorised into the all-patient cohort. The meta-analysis identified 11 significant risk factors for CAP-DRPs, namely prior DRP infection/colonisation, tracheostomy, severe respiratory failure requiring early induction of mechanical ventilation, prior use of antibiotics, chronic lung disease, COPD, wound care, neurological disorders, prior hospitalisation, nursing home residence and low activities of daily living.

CONCLUSION

To our knowledge, this is the first systematic review focused on CAP-DRP. Unlike previous reviews, the all-patient and culture-positive pneumonia cohorts were analysed separately. Findings from the all-patient cohort are particularly relevant for guiding initial antimicrobial selection in clinical practice. Furthermore, the abovementioned factors should be considered when developing prediction models for CAP-DRPs.

Hyaluronic Acid is Associated with Severity and Prognosis in Patients with Community-Acquired Pneumonia

Purpose

Hyaluronic acid (HA) is a novel inflammatory biomarker with a prognostic value for several infectious diseases. This study investigated the association of HA with severity and prognosis in hospitalized patients with community-acquired pneumonia (CAP).

Patients and Methods

We analyzed the differences of HA levels in different groups. Logistic regression analysis was performed to identify independent risk factors for severe CAP (SCAP). The predictive value of HA for SCAP was assessed using receiver operating characteristic (ROC) curves. Kaplan-Meier survival analysis was used to compare 30-day mortality between the high and low HA groups.

Results

Compared to healthy controls (49.2 ± 15.3 ng/mL), patients with CAP exhibited significantly elevated levels of HA (P < 0.001). In CAP patients, increased HA levels were more pronounced in those with SCAP (SCAP vs non-SCAP:135.6 ± 51 ng/mL vs 100.7 ± 47.8 ng/mL, P < 0.001). Compared to survivors (109.9 ± 48.7 ng/mL), HA levels in non-survivors were significantly higher (180.9 ± 67.8 ng/mL) (P < 0.001). HA was an independent predictor of SCAP [odds ratio (OR): 1.013, 95% confidence interval (CI): 1.003-1.022, P = 0.011] with high diagnostic accuracy [areas under the curve (AUC): 0.709, 95% CI: 0.622-0.797, P = 0.001]. Additionally, HA was independently associated with death risk in patients with CAP (OR: 1.022, 95% CI: 1.005-1.039, P = 0.010). Kaplan-Meier survival curves indicated that CAP patients in the high HA group exhibit a higher 30-day mortality rate compared to those in the low HA group (8.6% vs 1.5%, P = 0.008). Post hoc analysis indicated that our study possessed 98.857% statistical power.

Conclusion

In conclusion, High HA levels are associated with severity and mortality in patients with CAP, and HA could serve as a novel serum biomarker to predict the risk of CAP progression.

Prognostic value of the platelet, neutrophil, monocyte, basophil, and eosinophil to lymphocyte ratios in patients with severe community-acquired pneumonia (SCAP)

Severe community-acquired pneumonia (SCAP) is a serious respiratory inflammation disease with high morbidity and mortality. This study aimed to evaluate the prognostic value of the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), basophil-to-lymphocyte ratio (BLR) and eosinophil-to-lymphocyte ratio (ELR) in patients with SCAP. The study retrospectively included 554 patients with SCAP, and the clinical data were obtained from the electronic patient record (EMR) system. The primary outcome was in-hospital mortality, and the secondary outcomes included hospital length of stay (LOS), overall survival (OS), admission to ICU, ICU LOS, and ICU mortality. The results showed that both NLR and BLR were significant but not independent prognostic factors for in-hospital mortality; NLR was negatively correlated with hospital LOS while ELR was positively correlated with hospital LOS; both increased NLR and increased BLR were associated with reduced OS, while increased ELR was associated with improved OS; increased PLR, NLR, MLR, and BLR were all correlated with elevated ICU admission rates, while increased ELR was correlated with a reduced ICU admission rate; ELR was positively correlated with ICU LOS; both higher NLR and higher BLR were associated with increased ICU mortality. In summary, NLR and BLR were useful prognostic factors for clinical outcomes in patients with SCAP.

A Review on Risk Factors, Traditional Diagnostic Techniques, and Biomarkers for Pneumonia Prognostication and Management in Diabetic Patients

People of all ages can contract pneumonia, and it can cause mild to severe disease and even death. In addition to being a major cause of death for elderly people and those with prior medical conditions such as diabetes, it isthe world's biggest infectious cause of death for children. Diabetes mellitus is a metabolic condition with a high glucose level and is a leading cause of lower limb amputation, heart attacks, strokes, blindness, and renal failure. Hyperglycemia is known to impair neutrophil activity, damage antioxidant status, and weaken the humoral immune system. Therefore, diabetic patients are more susceptible to pneumonia than people without diabetes and linked fatalities. The absence of quick, precise, simple, and affordable ways to identify the etiologic agents of community-acquired pneumonia has made diagnostic studies' usefulness contentious. Improvements in biological markers and molecular testing techniques have significantly increased the ability to diagnose pneumonia and other related respiratory infections. Identifying the risk factors for developing severe pneumonia and early testing in diabetic patients might lead to a significant decrease in the mortality of diabetic patients with pneumonia. In this regard, various risk factors, traditional testing techniques, and pathomechanisms are discussed in this review. Further, biomarkers and next-generation sequencing are briefly summarized. Finding biomarkers with the ability to distinguish between bacterial and viral pneumonia could be crucial because identifying the precise pathogen would stop the unnecessary use of antibiotics and effectively save the patient's life.

Use of Parenteral Antibiotics in Emergency Departments: Practice Patterns and Class Concordance

Introduction

We aimed to assess antibiotic stewardship by quantifying the use of first-dose intravenous (IV) vs oral-only antibiotics and the frequency with which antibiotic class was changed for discharged patients. Secondary aims included the following: evaluation of the relative length of stay (LOS); differences in prescribing patterns between clinician types; differences between academic and community settings; assessment of prescribing patterns among emergency department (ED) diagnoses; and frequency of return visits for patients in each group.

Methods

This was a retrospective cohort study including patients presenting to EDs with infections who were discharged from our Midwest healthcare system consisting of 17 community hospitals and one academic center. We included infection type, antibiotic class and route of administration, type of infection, LOS, return visit within two weeks, clinician type, and demographics. Data were collected between June 1, 2018-December 31, 2021 and analyzed using descriptive statistics.

Results

We had 77,204 ED visits for patients with infections during the study period, of whom 3,812 received IV antibiotics during their visit. There were more women (62.4%) than men included. Of the 3,812 patients who received IV antibiotics, 1,026 (34.3%) were discharged on a different class of antibiotics than they received. The most common changes were from IV cephalosporin to oral quinolone or penicillin. Patients treated with IV antibiotics prior to discharge had a longer LOS in the ED (median difference of 102 minutes longer for those who received IV antibiotics). There was not a significant difference in the use of IV antibiotics between the academic center and community sites included in the study.

Conclusion

Administering IV antibiotics as a first dose prior to oral prescriptions upon discharge is common, as is shifting classes from the IV dose to the oral prescription. This offers an opportunity for intervention to improve antibiotic stewardship for ED patients as well as reduce cost and length of stay.

Serum SOD1 level predicts the severity and prognosis of community-acquired pneumonia patients

BACKGROUND

Superoxide dismutase 1 (SOD1) is one of the most important participants of antioxidant enzyme system in biological system. Previous studies have found that SOD1 is associated with many inflammatory diseases. The goal of this study was to assess the associations of serum SOD1 with the severity and prognosis in community-acquired pneumonia (CAP) patients by a prospective cohort study.

METHODS

CAP patients were enrolled from the Second Affiliated Hospital of Anhui Medical University. Peripheral blood samples were gathered. The level of serum SOD1 was detected through enzyme linked immunosorbent assay (ELISA). Clinical characteristics and demographic information were analyzed.

RESULTS

The level of serum SOD1 was gradually upregulated with elevated CAP severity scores. Spearman correlation coefficient or Pearson rank correlation analyses indicated that serum SOD1 was strongly connected with many clinical parameters among CAP patients. Further linear and logistic regression analyses found that the level of serum SOD1 was positively associated with CRB-65, CURB-65, SMART-COP, and CURXO scores among CAP patients. Moreover, serum higher SOD1 at admission substantially increased the risks of ICU admission, mechanical ventilation, vasoactive agent usage, death, and longer hospital stays during hospitalization. Serum SOD1 level combination with CAP severity scores elevated the predictive abilities for severity and death compared with alone serum SOD1 and CAP severity scores in CAP patients during hospitalization.

CONCLUSION

The level of serum SOD1 is positively associated with the severity and poor prognosis in CAP patients, suggesting that SOD1 is implicated in the initiation and progression of CAP. Serum SOD1 may be regarded as a biomarker to appraise the severity and prognosis for CAP patients.

Survival at 3, 6 and 12 months in patients diagnosed with community-acquired pneumonia in Colombia: a retrospective cohort study

BACKGROUND

The primary aim of this study is to assess the survival rates of individuals diagnosed with Community-Acquired Pneumonia (CAP) post-hospitalization in Colombia. Additionally, explore potential risk factors associated with decreased long-term survival.

METHODS

A retrospective cohort study was conducted in a hospital in Colombia, evaluating survival at 3, 6 and 12 months in CAP patients, using the Kaplan-Meier method. Stratifications were made by age, sex, comorbidity, and severity. The comparison of survival curves was performed using the Log-Rank test, a multivariate analysis with Cox regression was performed to study possible risk factors that affected 12-month survival in patients with CAP.

RESULTS

3688 subjects were admitted, with a mortality of 16.3 % per year. Survival at three, six, and twelve months was 92.9 % (95 % CI 92-93 %), 88.8 % (95 % CI 87-90 %), and 84.2 % (95 % CI 82-85 %), respectively. Analysis stratified by pneumonia severity index, 12-month survival was 98.7 % in Class I, 95.6 % in Class II, 87.41 % in Class III, 77.1 % in Class IV, and 65.8 % in class-V (p < 0.001). Cox-regression showed that being male (HR = 1.44; 95 % CI 1.22‒1.70; p < 0.001), an elevated pneumonia severity index (HR = 4.22; 95 % CI 1.89‒9.43; p < 0.001), a high comorbidity index (HR = 2.29; 95 % CI 1.89‒2.84; p < 0.001) and vasopressor requirement (HR = 2.22; 95 % CI < 0.001) were associated with a lower survival at twelve months of follow-up.

CONCLUSION

Survival in patients with CAP who require hospitalization decreases at 3, 6, and 12 months of follow-up, being lower in patients older than 65 years, men, high comorbidity, and in subjects with severe presentation of the disease.

A Study on the Etiology and Clinical Manifestations of Community-Acquired Pneumonia in Adults in Western India

BACKGROUND

 Community-acquired pneumonia (CAP) is an acute lung infection affecting the alveoli in individuals who have not had recent exposure to healthcare settings. It is characterized by newly detected pulmonary infiltration on a chest X-ray or computed tomography scan, accompanied by at least two of the following symptoms: a new or worsening cough, shortness of breath, increased sputum production, fever or hypothermia, pleuritic chest pain, hypoxia, confusion, or an abnormal WBC count (either leukopenia or leukocytosis). It is a major contributor to global mortality and morbidity, especially in elderly populations. This study aims to investigate the etiology of CAP in our region and analyze the clinical characteristics of patients diagnosed with CAP.

METHODOLOGY

 This prospective, hospital-based study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, a 2,011-bed multispecialty hospital. The study included 100 patients over 18 years old, diagnosed with CAP, and hospitalized between January 2023 and January 2024. All patients underwent a thorough clinical assessment, and sputum cultures were collected on the day of admission. Patients under 18 years old, those who had been hospitalized within the preceding two weeks, individuals with pneumonia caused by tuberculosis or aspiration pneumonia, patients with compromised immune systems, and pregnant women were excluded.

RESULTS

 The study included 100 patients with a mean age of 53.13 years (±18.31). The most common age group was 59-68 years, which included 25 (25%) cases, followed by the 69-78 year age group with 18 (18%) cases and the 18-28 year age group with 15 (15%) cases. The majority were male, with 61 (61%) cases. Common symptoms included fever in 78 cases (78%), chest pain in 69 cases (69%), dyspnea in 65 cases (65%), and cough in 51 cases (51%). Sputum cultures showed growth in 65 cases (65%), with Klebsiella pneumoniae being the most prevalent pathogen in 28 cases (43%), followed by Streptococcus pneumoniae in 18 cases (28%). Together, these two pathogens accounted for 46 out of 65 positive samples (70%).

CONCLUSIONS

 This study highlights the clinical profile and rising etiology of K. pneumoniae in CAP in adults in Western India, particularly in the elderly. These findings underscore the need for periodic updates on CAP etiology to inform empirical treatment strategies effectively. Future research should use advanced diagnostics and diverse samples to refine CAP management, with continuous monitoring to update treatment protocols.

Microbial variations in sputum cultures among hospitalized patients with community-acquired pneumonia: differences in sputum microbiota between asthma and COPD patients

OBJECTIVE

To assess differences in the sputum microbiota of community-acquired pneumonia (CAP) patients with either COPD or asthma, specifically focusing on a patient population in Turkey.

METHODS

This retrospective study included hospitalized patients > 18 years of age with a diagnosis of pneumonia between January of 2021 and January of 2023. Participants were recruited from two hospitals, and three patient groups were considered: CAP patients with asthma, CAP patients with COPD, and CAP patients without COPD or asthma.

RESULTS

A total of 246 patients with CAP were included in the study, 184 (74.8%) and 62 (25.2%) being males and females, with a mean age of 66 ± 14 years. Among the participants, 52.9% had COPD, 14.2% had asthma, and 32.9% had CAP but no COPD or asthma. Upon analysis of sputum cultures, positive sputum culture growth was observed in 52.9% of patients. The most commonly isolated microorganisms were Pseudomonas aeruginosa (n = 40), Acinetobacter baumannii (n = 20), Klebsiella pneumoniae (n = 16), and Moraxella catarrhalis (n = 8). CAP patients with COPD were more likely to have a positive sputum culture (p = 0.038), a history of antibiotic use within the past three months (p = 0.03), utilization of long-term home oxygen therapy (p < 0.001), and use of noninvasive ventilation (p = 0.001) when compared with the other patient groups. Additionally, CAP patients with COPD had a higher CURB-65 score when compared with CAP patients with asthma (p = 0.004).

CONCLUSIONS

This study demonstrates that CAP patients with COPD tend to have more severe presentations, while CAP patients with asthma show varied microbial profiles, underscoring the need for patient-specific management strategies in CAP.

Epidemiological and etiological characteristics of 1266 patients with severe acute respiratory infection in central China, 2018-2020: a retrospective survey

BACKGROUND

Severe acute respiratory infection (SARI), a significant global health concern, imposes a substantial disease burden. In China, there is inadequate data concerning the monitoring of respiratory pathogens, particularly bacteria, among patients with SARI. Therefore, this study aims to delineate the demographic, epidemiological, and aetiological characteristics of hospitalised SARI patients in Central China between 2018 and 2020.

METHODS

Eligible patients with SARI admitted to the First Affiliated Hospital of Zhengzhou University between 1 January 2018 and 31 December 2020 were included in this retrospective study. Within the first 24 h of admission, respiratory (including sputum, nasal/throat swabs, bronchoalveolar lavage fluid, thoracocentesis fluid, etc.), urine, and peripheral blood specimens were collected for viral and bacterial testing. A multiplex real-time polymerase chain reaction (PCR) diagnostic approach was used to identify human influenza virus, respiratory syncytial virus, parainfluenza virus, adenovirus, human bocavirus, human coronavirus, human metapneumovirus, and rhinovirus. Bacterial cultures of respiratory specimens were performed with a particular focus on pathogenic microorganisms, including S. pneumoniae, S. aureus, K. pneumoniae, P. aeruginosa, Strep A, H. influenzae, A. baumannii, and E. coli. In cases where bacterial culture results were negative, nucleic acid extraction was performed for PCR to assay for the above-mentioned eight bacteria, as well as L. pneumophila and M. pneumoniae. Additionally, urine specimens were exclusively used to detect Legionella antigens. Furthermore, epidemiological, demographic, and clinical data were obtained from electronic medical records.

RESULTS

The study encompassed 1266 patients, with a mean age of 54 years, among whom 61.6% (780/1266) were males, 61.4% (778/1266) were farmers, and 88.8% (1124/1266) sought medical treatment in 2020. Moreover, 80.3% (1017/1266) were housed in general wards. The most common respiratory symptoms included fever (86.8%, 1122/1266) and cough (77.8%, 986/1266). Chest imaging anomalies were detected in 62.6% (792/1266) of cases, and 58.1% (736/1266) exhibited at least one respiratory pathogen, with 28.5% (361/1266) having multiple infections. Additionally, 95.7% (1212/1266) of the patients were from Henan Province, with the highest proportion (38.3%, 486/1266) falling in the 61-80 years age bracket, predominantly (79.8%, 1010/1266) seeking medical aid in summer and autumn. Bacterial detection rate (39.0%, 495/1266) was higher than viral detection rate (36.9%, 468/1266), with the primary pathogens being influenza virus (13.8%, 175/1266), K. pneumoniae (10.0%, 127/1266), S. pneumoniae (10.0%, 127/1266), adenovirus (8.2%, 105/1266), P. aeruginosa (8.2%, 105/1266), M. pneumoniae (7.8%, 100/1266), and respiratory syncytial virus (7.7%, 98/1266). During spring and winter, there was a significant prevalence of influenza virus and human coronavirus, contrasting with the dominance of parainfluenza viruses in summer and autumn. Respiratory syncytial virus and rhinovirus exhibited higher prevalence across spring, summer, and winter. P. aeruginosa, K. pneumoniae, and M. pneumoniae were identified at similar rates throughout all seasons without distinct spikes in prevalence. However, S. pneumoniae showed a distinctive pattern with a prevalence that doubled during summer and winter. Moreover, the positive detection rates of various other viruses and bacteria were lower, displaying a comparatively erratic prevalence trend. Among patients admitted to the intensive care unit, the predominant nosocomial bacteria were K. pneumoniae (17.2%, 43/249), A. baumannii (13.6%, 34/249), and P. aeruginosa (12.4%, 31/249). Conversely, in patients from general wards, predominant pathogens included influenza virus (14.8%, 151/1017), S. pneumoniae (10.4%, 106/1017), and adenovirus (9.3%, 95/1017). Additionally, paediatric patients exhibited significantly higher positive detection rates for influenza virus (23.9%, 11/46) and M. pneumoniae (32.6%, 15/46) compared to adults and the elderly. Furthermore, adenovirus (10.0%, 67/669) and rhinovirus (6.4%, 43/669) were the primary pathogens in adults, while K. pneumoniae (11.8%, 65/551) and A. baumannii (7.1%, 39/551) prevailed among the elderly, indicating significant differences among the three age groups.

DISCUSSION

In Central China, among patients with SARI, the prevailing viruses included influenza virus, adenovirus, and respiratory syncytial virus. Among bacteria, K. pneumoniae, S. pneumoniae, P. aeruginosa, and M. pneumoniae were frequently identified, with multiple infections being very common. Additionally, there were substantial variations in the pathogen spectrum compositions concerning wards and age groups among patients. Consequently, this study holds promise in offering insights to the government for developing strategies aimed at preventing and managing respiratory infectious diseases effectively.

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

PURPOSE

Consensus 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.

METHODS

This 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.

FINDINGS

Of 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.

IMPLICATIONS

We 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.

Is the fluoroquinolone combination necessary for empirical antibiotic regimen in severe community-acquired pneumonia?

OBJECTIVES

This study aimed to assess whether superior clinical outcomes can be attained through piperacillin/tazobactam (TZP)+fluoroquinolone (FQ) combination therapy for severe community-acquired pneumonia (CAP) compared to TZP monotherapy.

METHODS

This retrospective study was conducted at a tertiary care hospital in Korea. Adult inpatients diagnosed with pneumonia within 48 hours of hospitalization were included. Severe CAP was defined as a CURB-65 score of ≥ 3 or based on the 2007 guidelines of the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) definition. Only patients who received either TZP and FQ combination or TZP as initial empirical therapy were included.

RESULTS

The final analysis included 145 patients; 57.9% received combination therapy and 42.1% received monotherapy. In the combination therapy group, body mass index (20.67 ± 3.28 vs. 22.26 ± 4.80, p = 0.030) and asthma prevalence (0 vs. 8.3%, p = 0.022) were significantly higher; initial symptoms, clinical severity, and causative pathogens were not significantly different between groups. White blood cell counts (12,641.64 ± 6,544.66 vs. 12,491.67 ± 10,528.24, p = 0.008), and C-reactive protein levels (18.78 ± 11.47 vs. 26.58 ± 14.97, p < 0.001) were significantly higher in the combination therapy group. Clinical outcomes, including all-cause in-hospital mortality rate (26.2 vs. 33.3%, p = 0.358), were not significantly different between the groups. Multivariate analysis identified no significant association between FQ combination and all-cause in-hospital mortality.

CONCLUSION

In patients with severe CAP, there were no differences in the clinical outcomes, including mortality, between the TZP and FQ combination therapy and TZP monotherapy. FQ combination was not significantly associated with in-hospital mortality.

Bacterial etiology of community-acquired pneumonia among adult patients in Ethiopia: A systematic review and meta-analysis

Background and objective

According to the Global Burden of Diseases, Injuries, and Risk Factors, lower respiratory infections cause more than 2.3 million deaths globally, with a majority occurring in sub-Saharan Africa, including Ethiopia.Community-acquired pneumonia (CAP) is a major contributor to global mortality and morbidity. Understanding the prevalence and common bacterial causes of CAP is crucial for clinicians to accurately diagnose and improve patient satisfaction. The purpose of this systematic review was to report the pooled prevalence and common bacterial etiologies of CAP among adult patients in Ethiopia.

Methods

This review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive search of the published articles between January 2000 and October 2022 was performed using open access electronic databases such as PUBMED, Science Direct, CINAHL, HINARI, Google Scholar, and local university repositories. Cochrane Q and I2 values were used to assess heterogeneity among the studies. Publication bias was assessed using funnel plots and Egger's test. The random-effects model was used to estimate the pooled prevalence.

Results and conclusions

Of all the publications that were thoroughly searched, 9 studies with 2496 participants met the criteria for analysis. All of the studies were cross-sectionally designed and most of the studies used convenient sampling techniques. The included studies consisted of two conducted among adult patients diagnosed with CAP and living with HIV/AIDS, while the remaining seven studies were conducted among adult patients diagnosed with CAP without HIV/AIDS. The combined prevalence of bacterial causes of community-acquired pneumonia (CAP) among adult patients was found to be 39.18% (CI 36.34-42.02), with an I2 of 52.6 and a P value of 0.032. The primary bacterial cause was Klebsiella pneumoniae (9.1%), followed by Streptococcus pneumoniae (8.11%), and Staphylococcus aureus (6.8%). Therefore, it is advisable to introduce a diagnostic tool for identifying specific causative agents and drug resistance, which could lead to improved treatment and better patient outcomes by reducing the need for empirical treatments.

Immunomodulatory Effects of Fluoroquinolones in Community-Acquired Pneumonia-Associated Acute Respiratory Distress Syndrome

Community-acquired pneumonia is reported as one of the infectious diseases that leads to the development of acute respiratory distress syndrome. The innate immune system is the first line of defence against microbial invasion; however, its dysregulation during infection, resulting in an increased pathogen load, stimulates the over-secretion of chemokines and pro-inflammatory cytokines. This phenomenon causes damage to the epithelial-endothelial barrier of the pulmonary alveoli and the leakage of the intravascular protein into the alveolar lumen. Fluoroquinolones are synthetic antimicrobial agents with immunomodulatory properties that can inhibit bacterial proliferation as well as exhibit anti-inflammatory activities. It has been demonstrated that the structure of fluoroquinolones, particularly those with a cyclopropyl group, exerts immunomodulatory effects. Its capability to inhibit phosphodiesterase activity leads to the accumulation of intracellular cAMP, which subsequently enhances PKA activity, resulting in the inhibition of transcriptional factor NF-κB and the activation of CREB. Another mechanism reported is the inhibition of TLR and ERK signalling pathways. Although the sequence of events has not been completely understood, significant progress has been made in comprehending the specific mechanisms underlying the immunomodulatory effects of fluoroquinolones. Here, we review the indirect immunomodulatory effects of FQs as an alternative to empirical therapy in patients diagnosed with community-acquired pneumonia.

Comparison of the thickness of the erector spinae muscles between aspiration pneumonia and bacterial pneumonia patients

BACKGROUND AND AIMS

Aspiration pneumonia is generally associated with deterioration of skeletal muscle mass, which is usually evaluated by the erector spinae muscle cross-sectional area (ESMCSA); however, no report has assessed ESMCSA in patients with aspiration pneumonia. Furthermore, erector spinae muscle thickness (ESMT) was developed to be easier to measure than ESMCSA. Therefore, this study investigated the relationship between ESMT and ESMCSA in aspiration pneumonia patients compared to bacterial pneumonia patients.

METHODS

We retrospectively collected data for 164 patients with aspiration pneumonia and 480 patients with bacterial pneumonia who were hospitalized at Fukujuji Hospital between September 2018 and May 2022. We assessed the correlations between ESMCSA and ESMT and compared the data between the two groups.

RESULTS

ESMT had a strong, proportional relationship with ESMCSA in all patients (r = 0.908, p < 0.001) and those with aspiration pneumonia (r = 0.896, p < 0.001). ESMCSA (median 671.8 mm2 [range 164.0-1636.7] vs. median 1057.0 mm2 [range 161.3-2412.5], p < 0.001) and ESMT (median 17.1 mm [range 6.95-34.4] vs. median 23.8 mm [range 6.95-43.7], p < 0.001) were significantly lower in patients with aspiration pneumonia. A multivariate analysis of aspiration pneumonia diagnosis showed significant independent differences from bacterial pneumonia in ESMCSA (odds ratio 0.998 [95% CI: 0.996-0.999], p = 0.001) and ESMT (odds ratio 0.90 [95% CI: 0.84-0.96], p = 0.002).

CONCLUSION

This study demonstrates a strong correlation between ESMCSA and ESMT. ESMT can be more easily used to evaluate skeletal muscle mass and can help in diagnosing aspiration pneumonia.

Population pharmacokinetic modeling of the influence of chronic and acute biofilm-forming Pseudomonas aeruginosa lung infection on ciprofloxacin free pulmonary and epithelial lining fluid concentrations

We previously reported that ciprofloxacin (CIP) free lung interstitial concentrations are decreased by biofilm-forming Pseudomonas aeruginosa pulmonary chronic (14 d) infection. To get a better understanding on the influence of infection on CIP lung distribution, in the present study free lung interstitial fluid and epithelial lining fluid (ELF) concentrations were determined by microdialysis in biofilm-forming P. aeruginosa acutely (2 d) and chronically infected (14 d) Wistar rats following CIP 20 mg/kg i.v. bolus dosing. A popPK model was developed, using NONMEM® (version 7.4.3) with FOCE+I, with plasma data described as a three-compartment model with first-order elimination. For lung data inclusion, the model was expanded to four compartments and ELF concentrations were described as a fraction of lung levels estimated as a distribution factor (ƒD). Acute infection had a minor impact on plasma and lung CIP distribution and both infection stages did not alter ELF drug penetration. Probability of target attainment of ƒAUC0-24/MIC ≥ 90 using 20 mg q8h, equivalent to 400 mg q8h in humans, showed that CIP free concentrations in plasma are adequate to successfully treat lung infections. However, lung and ELF free interstitial concentrations might be insufficient to result in efficacious treatment of biofilm-forming P. aeruginosa chronic infection. However, lung and ELF free interstitial concentrations might be insufficient to result in efficacious treatment of biofilm-forming P. aeruginosa chronic infection.

Can we recognize severe community-acquired pneumonia without pneumonia severity index? Use of modified qSOFA with procalcitonin

OBJECTIVE

The aim of this study is to analyze the diagnostic value of Quick Sequential Organ Failure Assessment (qSOFA), modified qSOFA, National Early Warning Score (NEWS) and NEWS + Lactate (NEWS + L) scores in the detection of severe community-acquired pneumonia (CAP).

METHODS

This research is a retrospective cohort study. Patients admitted to the Emergency Department (ED) with the diagnosis of CAP were divided into severe and mild pneumonia regarding their Pneumonia Severity Index (PSI) scores. The accuracies of lactate, procalcitonin (PCT) values, NEWS and qSOFA scores, as well as score combinations (NEWS + L and qSOFA + PCT) in predicting patients with severe CAP were analyzed.

RESULTS

Median qSOFA value in the severe CAP group (0 [IQR 0-1]) was found to be higher than median qSOFA value (0 [IQR 0-0]) in the mild CAP group (p < 0.001). The rate of qSOFA positivity (qSOFA ≥ 2) was significantly higher in the severe CAP group (17.1%, n = 21) compared to the mild CAP group (1.3%, n = 1) (p < 0.001). Median qSOFA + PCT for the severe CAP group (2 [IQR 1-2]) was higher than the mild CAP group (1 [IQR 0-1]) (p < 0.001). Mean NEWS score for severe CAP (4.95 ± 3.09) was found to be 1.69 (95% CI 0.92-2.46) higher than mean NEWS score of the mild CAP group (3.26 ± 2.39) (p < 0.001). The severe CAP NEWS + L score (6.97 ± 3.71) was higher than the mild CAP NEWS + L score (4.94 ± 2.48) (p < 0.001). Blood lactate level was not significant in the evaluation of severe CAP (p = 0.221). PCT (AUROC = 0.685 [95% CI 0.610-0.760]; p = 0.038), NEWS score (AUROC = 0.658 95% CI [0.582-0.733]; p < 0.001), qSOFA (AUROC = 0.686) were calculated to have adequate accuracy for the detection of severe CAP. [95% CI 0.613-0.759]; p = 0.037), NEWS + L score (AUROC = 0.665 [95% CI 0.589-0.740]; p = 0.038). The qSOFA + PCT score (AUROC = 0.758 [95% 0.691-0.825]; p = 0.034) was also found to be a highly accurate predictor of severe CAP.

CONCLUSION

In this study, we found a combination of qSOFA and PCT to be the most reliable method of detecting severe CAP.

Delayed diagnosis of pneumonia in the emergency department: factors associated and prognosis

Introduction

Whether a delayed diagnosis of community-acquired pneumonia (CAP) in the emergency department (ED) is associated with worse outcome is uncertain. We sought factors associated with a delayed diagnosis of CAP in the ED and those associated with in-hospital mortality.

Methods

Retrospective study including all inpatients admitted to an ED (Dijon University Hospital, France) from 1 January to 31 December 2019, and hospitalized with a diagnosis of CAP. Patients diagnosed with CAP in the ED (n = 361, early diagnosis) were compared with those diagnosed later, in the hospital ward, after the ED visit (n = 74, delayed diagnosis). Demographic, clinical, biological and radiological data were collected upon admission to the ED, as well as administered therapies and outcomes including in-hospital mortality.

Results

435 inpatients were included: 361 (83%) with an early and 74 (17%) with a delayed diagnosis. The latter less frequently required oxygen (54 vs. 77%; p < 0.001) and were less likely to have a quick-SOFA score ≥ 2 (20 vs. 32%; p = 0.056). Absence of chronic neurocognitive disorders, of dyspnea, and of radiological signs of pneumonia were independently associated with a delayed diagnosis. Patients with a delayed diagnosis less frequently received antibiotics in the ED (34 vs. 75%; p < 0.001). However, a delayed diagnosis was not associated with in-hospital mortality after adjusting on initial severity.

Conclusion

Delayed diagnosis of pneumonia was associated with a less severe clinical presentation, lack of obvious signs of pneumonia on chest X-ray, and delayed antibiotics initiation, but was not associated with worse outcome.

[Validation of a symptom scale for COVID-19 patients in ambulatory care]

Background

A symptom scale can be useful for the standardization of clinical evaluations and follow-up of COVID-19 patients in ambultaroy care. Scale development should be accompanied by an assessment of its reliablility and validity.

Objective

To develop and measure the psychometric characteristics of a COVID-19 symptom scale to be answered by either healthcare personnel or adult patients in ambulatory care.

Material and methods

The scale was developed by an expert panel using the Delphi method. We evaluated inter-rater reliability, where we defined a good correlation if Spearman's Rho was ≥ 0.8; test-retest, where we defined a good correlation if Spearman's Rho was ≥ 0.7; factor analysis using principal component methodology; and discriminant validity using Mann-Whitney's U test. A p < 0.05 was considered statistically significant.

Results

We obtained an 8 symptom scale, each symptom is scored from 0-4, with a total minimum score of 0 and a maximum of 32 points. Inter-rater reliability was 0.995 (n = 31), test-retest showed correlation of 0.88 (n = 22), factor analysis detected 4 factors (n = 40) and discriminant capacity of healthy versus sick adults was significant (p < 0.0001, n = 60).

Conclusions

We obtained a reliable and valid Spanish (from Mexico) symptom scale for COVID-19 ambulatory care, answerable by patients and health care staff.

Prevalence of respiratory pathogens and risk of developing pneumonia under non-pharmaceutical interventions in Suzhou, China

This study aims to evaluate the impact of non-pharmaceutical interventions (NPIs) on the prevalence of respiratory pathogens among hospitalised children with acute respiratory infections (ARIs) in Suzhou. Children with ARIs admitted to the Children's Hospital of Soochow University between 1 September 2021 and 31 December 2022 and subjected to 13 respiratory pathogen multiplex PCR assays were included in the study. We retrospectively collected demographic details, results of respiratory pathogen panel tests, and discharge diagnostic information of the participants, and described the age and seasonal distribution of respiratory pathogens and risk factors for developing pneumonia. A total of 10,396 children <16 years of age, including 5,905 males and 4,491 females, were part of the study. The positive rates of the 11 respiratory pathogen assays were 23.3% (human rhinovirus (HRV)), 15.9% (human respiratory syncytial virus (HRSV)), 10.5% (human metapneumovirus (HMPV)), 10.3% (human parainfluenza virus (HPIV)), 8.6% (mycoplasma pneumoniae (MP)), 5.8% (Boca), 3.5% (influenza A (InfA)), 2.9% (influenza B (InfB)), 2.7% (human coronavirus (HCOV)), 2.0% (adenovirus (ADV)), and 0.5% (Ch), respectively. Bocavirus and HPIV detection peaked during the period from September to November (autumn), and MP and HMPV peaked in the months of November and December. The peak of InfA detection was found to be in summer (July and August), whereas the InfB peak was observed to be in winter (December, January, and February). HRSV and HRV predominated in the <3 years age group. HRV and HMPV were common in the 3-6 years group, whereas MP was predominant in the ≥6 years group. MP (odds ratio (OR): 70.068, 95%CI: 32.665-150.298, P < 0.01), HMPV (OR: 6.493, 95%CI: 4.802-8.780, P < 0.01), Boca (OR: 3.300, 95%CI: 2.186-4.980, P < 0.01), and HRSV (OR: 2.649, 95%CI: 2.089-3.358, P < 0.01) infections were more likely to develop into pneumonia than the other pathogens. With the use of NPIs, HRV was the most common pathogen in children with ARIs, and MP was more likely to progress to pneumonia than other pathogens.

Predictive value of arterial blood lactate to serum albumin ratio for in-hospital mortality of patients with community-acquired pneumonia admitted to the Intensive Care Unit

OBJECTIVE

To investigate the predictive value of the arterial blood lactate to serum albumin ratio (LAR) on in-hospital mortality of patients with community-acquired pneumonia (CAP) admitted to the Intensive Care Unit (ICU).

METHODS

Clinical datasets of 1720 CAP patients admitted to ICU from MIMIC-IV database were retrospectively analyzed. Patients were randomly assigned to the training cohort (n=1204) and the validation cohort (n=516) in a ratio of 7:3. X-tile software was used to find the optimal cut-off value for LAR. The receiver operating curve (ROC) analysis was conducted to compare the performance between LAR and other indicators. Univariate and multivariate Cox regression analyses were applied to select prognostic factors associated with in-hospital mortality. Based on the observed prognostic factors, a nomogram model was created in training cohort, and the validation cohort was utilized to further validate the nomogram.

RESULTS

The optimal cut-off value for LAR in CAP patients admitted to ICU was 1.6 (the units of lactate and albumin were, respectively, 'mmol/L' and 'g/dL'). The ROC analysis showed that the discrimination abilities of LAR were superior to other indicators except Sequential Organ Failure Assessment score and Simplified acute physiology score (SAPSII), which had the same abilities. Age, mean arterial pressure, SpO2, heart rate, SAPSII score, neutrophil-to-lymphocyte ratio, and LAR were found to be independent predictors of poor overall survival in the training cohort by multivariate Cox regression analysis and were incorporated into the nomogram for in-hospital mortality as independent factors. The nomogram model, exhibiting medium discrimination, had a C-index of 0.746 (95% CI = 0.715-0.777) in the training cohort and 0.716 (95% CI = 0.667-0.765) in the validation cohort.

CONCLUSION

LAR could predict in-hospital mortality of patients with CAP admitted to ICU independently as a readily accessible biomarker. The nomogram that included LAR with other independent factors performed well in predicting in-hospital mortality.

CURB-65 and Long-Term Mortality of Community-Acquired Pneumonia: A Retrospective Study on Hospitalized Patients

Background Community-acquired pneumonia remains a significant factor in global mortality. Several clinical scoring models are used for predicting pneumonia severity and mortality, aiding in the clinical decision relative to the therapeutic approach, including the CURB-65 score. However, currently, no models exist to identify high-risk patients relative to long-term prognosis when recent evidence reveals a significantly higher mortality rate in the first year after community-acquired pneumonia (CAP) hospitalization. Purpose of the study The purpose of this study is to evaluate the application of the CURB-65 scoring model in our population and examine its potential to predict prognosis and subsequent mortality 6 months after hospitalization. Other potential factors influencing mortality during and after hospitalization were characterized: patient demographics, nosocomial infections, readmissions, and identified pathogens. Study design We conducted a retrospective observational study, enrolling 130 patients admitted with a diagnosis of CAP in the department of internal medicine of Centro Hospitalar Universitário Cova da Beira between January and December of 2018. Consultation of electronic medical records was used to calculate the CURB-65 score on admission at the first hospitalization by CAP, categorizing patients into five risk groups. Mortality and readmission were evaluated after 30, 90, and 180 days. Key results High-risk patients (CURB>2) accounted for 96.9% of our study population. Inpatient mortality of 13%, increasing to 21.5% after six months, was similar to previous studies and was correlated to the CURB-65 score on admission. A microbiologic agent was identified in 37% of cases, with 53% isolates of Streptococcus (S.) pneumoniae. Conclusions Identifying high-risk patients is important for more individualized healthcare and management. The CURB-65 score, only validated for a short-term (30 days) prediction, demonstrates a potential to also predict mortality and rehospitalization in the six-month period after hospitalization, as supported by our findings and previous studies.

Anti-inflammatory effect of chlorogenic acid in Klebsiella pneumoniae-induced pneumonia by inactivating the p38MAPK pathway

INTRODUCTION

Pneumonia is an inflammation-related respiratory infection and chlorogenic acid (CGA) possesses a wide variety of bioactive properties, such as anti-inflammation and anti-bacteria.

AIM

This study explored the anti-inflammatory mechanism of CGA in Klebsiella pneumoniae (Kp)-induced rats with severe pneumonia.

METHODS

The pneumonia rat models were established by infection with Kp and treated with CGA. Survival rates, bacterial load, lung water content, and cell numbers in the bronchoalveolar lavage fluid were recorded, lung pathological changes were scored, and levels of inflammatory cytokines were determined by enzyme-linked immunosorbent assay. RLE6TN cells were infected with Kp and treated with CGA. The expression levels of microRNA (miR)-124-3p, p38, and mitogen-activated protein kinase (MAPK)-activated protein kinase 2 (MK2) in lung tissues and RLE6TN cells were quantified by real-time quantitative polymerase chain reaction or Western blotting. The binding of miR-124-3p to p38 was validated by the dual-luciferase and RNA pull-down assays. In vitro, the functional rescue experiments were performed using miR-124-3p inhibitor or p38 agonist.

RESULTS

Kp-induced pneumonia rats presented high mortality, increased lung inflammatory infiltration and the release of inflammatory cytokines, and enhanced bacterial load, while CGA treatment improved rat survival rates and the above situations. CGA increased miR-124-3p expression, and miR-124-3p inhibited p38 expression and inactivated the p38MAPK pathway. Inhibition of miR-124-3p or activation of the p38MAPK pathway reversed the alleviative effect of CGA on pneumonia in vitro.

CONCLUSION

CGA upregulated miR-124-3p expression and inactivated the p38MAPK pathway to downregulate inflammatory levels, facilitating the recovery of Kp-induced pneumonia rats.

Metagenomics next-generation sequencing provides insights into the causative pathogens from critically ill patients with pneumonia and improves treatment strategies

Background

The metagenomics next-generation sequencing (mNGS) is a promising technique for pathogens diagnosis. However, whether the application of mNGS in critically ill patients with pneumonia could cause anti-infection treatment adjustment and thereby affect the prognosis of these patients has not been explored.

Methods

We retrospectively collected the clinical data of patients diagnosed with pulmonary infection in the ICU of the Affiliated Hospital of Qingdao University from January 2018 to January 2021. These patients with pneumonia were divided into mNGS group and no-mNGS group by whether being performed NGS or not. The clinical data, including demographics, illness history, APACHE II score, length of mechanical ventilation, length of stay in the hospital, length of stay in ICU and outcome, were collected. In addition, the data of pathogens and anti-infection treatment before and after NGS were also collected. Propensity score matching was performed to evaluate the mortality and deterioration rate between NGS group and non-NGS group.

Results

A total of 641 patients diagnosed with pneumonia were screened, and 94 patients were excluded based on exclusion criteria. Finally, 547 patients were enrolled, including 160 patients being performed NGS. Among these 160 patients, 142 cases had NGS-positive results. In addition, new pathogens were detected in 132 specimens by NGS, which included 82 cases with virus, 18 cases with fungus, 17 cases with bacteria, 14 cases with mycoplasma, and 1 case with mycobacterium tuberculosis. Anti-infection treatments were adjusted in some patients who performed NGS, including 48 anti-bacterial treatments, 20 antifungal treatments and 20 antiviral treatments. There were no significant differences in the mortality and deterioration rate between NGS and non-NGS group, but it exhibited a trend that the mortality and deterioration rate of NGS group was lower than non-NGS group after the propensity score matching analysis (15.8% vs 24.3%, P=0.173; 25.6% vs 37.8%, P=0.093).

Conclusion

NGS could affect the anti-infection treatments and had a trend of reducing the mortality and deterioration rate of critically ill patients with pneumonia.

An Unexpected Finding on Chest Radiograph: Cavitating Pneumonia

A pulmonary cavity is defined as a gas-filled space within a zone of pulmonary consolidation or within a mass or nodule. These cavities can be identified through imaging such as plain chest radiography and computed tomography. Pulmonary cavities arise from a variety of conditions that are infectious or noninfectious, leading to a broad range of differential diagnoses. One of the differential diagnoses is cavitary pneumonia, also referred to as necrotizing pneumonia; a rare complication related to community-acquired pneumonia. Infrequency of this complication can make this disease difficult to manage, leading to higher morbidity and mortality rates. This article provides an overview of a case of cavitary pneumonia that presented to an emergency department. This article discusses the history and physical, differential diagnoses/medical decision-making, management, and implications for the nurse practitioner for this patient.

Longitudinal associations of serum survivin with the severity and prognosis of community-acquired pneumonia patients

BACKGROUND

Survivin is a member of apoptosis inhibitor proteins that evokes cellular proliferation and inhibits apoptosis. However, the role of survivin in community-acquired pneumonia (CAP) patients remains to be firmly established. The aim of this cohort study was to evaluate the correlations of serum survivin with the severity and prognosis of CAP patients.

METHODS

This research included 470 eligible CAP patients. Serum fasting samples were drawn from patients, and serum survivin was measured by enzyme-linked immunosorbent assay (ELISA). Meanwhile, demographic characteristics and clinical information were collected. The prognosis of CAP patients was tracked.

RESULTS

Serum survivin gradually decreased with elevated CAP severity scores. Additionally, the correlative analysis suggested that serum survivin was associated with many clinical characteristics. Furthermore, mixed linear and logistic regression models indicated that serum survivin was negatively associated with severity. After adjusting for confounding factors, logistic regression analyses found that lower serum survivin on admission elevated the risks of mechanical ventilation, vasoactive agent usage, longer hospital stays, ICU admission, and even death during hospitalization. Serum survivin in combination with CAP severity scores elevated the predictive capacities for severity and death in CAP patients compared with a single indicator.

CONCLUSION

On admission, there are inverse dose-response associations of serum survivin with severity and poor prognosis in CAP patients, demonstrating that serum survivin may be involved in the pathophysiology process of CAP. Serum survivin may serve as a potential biomarker for disease evaluation and prognosis in CAP patients.

Vitamin A in children's pneumonia for a COVID-19 perspective: A systematic review and meta-analysis of 15 trials

BACKGROUND

To systematically review and meta-analyze the efficacy of vitamin A as an adjuvant therapy for pneumonia in children.

METHODS

We searched in PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure, WanFang Database and Chongqing VIP information network from libraries building to March 2022, screening randomized controlled trials (RCT) about vitamin A combined with conventional therapy for pneumonia in children. Two researchers used the Cochrane risk of bias tool to assess the quality of included studies dependently. Data analysis was conducted in the RevMan 5.3.

RESULTS

15 trials involving 3496 patients (treated group: 1898; control group: 1598) were analyzed in this study. The Meta-analysis showed that vitamin A combined with conventional therapy improved clinical efficacy (P < .05), shortened the duration of fever and cough, negative time of chest X-ray, and the hospitalization, lung rale disappearance, choking milk disappearance, shortness of breath disappearance and perilabial cyanosis disappearance (P < .05). However, vitamin A combined with conventional therapy did not reduce the mortality of pneumonia in children (P > .05).

CONCLUSION

Vitamin A contributes to relieve the clinical symptoms and signs, and also shorten the hospitalization.

Risk factors for mortality in aspiration pneumonia: a single-center retrospective observational study

Aspiration pneumonia (AP) is the leading cause of death among the elderly in Japan. The factors associated with the survival of elderly patients with AP are investigated in this retrospective observational study. Patients with AP over the age of 60 who were assessed for swallowing function in our hospital between April 2015 and March 2016 were eligible. Data on patients' body mass index (BMI), food consistency, and Karnofsky performance status were collected from medical records in hospital and again after recovery. Following hospital discharge, eligible patients were sent questionnaires containing information about their physical conditions, such as body weight and the Japanese version of the functional independence measure. Respondents were divided into two groups: those who died and those who survived, and the factors associated with patient mortality were investigated. There were 19 responses from 50 eligible patients, and seven patients died. The participants' average age was 81 years (SD 9.32). There were ten male participants (52.6%, p=1.00), and there were no significant differences in the mortality and survival groups. The most significant finding was that BMI was significantly lower in the patients who died (p=0.037, Cohen’s d=1.10). Fisher's exact tests clearly demonstrated that patients with a BMI <19.9 had a higher mortality rate (p=0.017). Lower BMI may be associated with increased mortality in elderly patients with a history of AP. In general practice, BMI is simple to measure and may allow for an easy assessment of the risk of AP-related mortality 

Validity of the ROX index in predicting invasive mechanical ventilation requirement in pneumonia

Background

The ROX index (Respiratory rate-OXygenation) has been described as a prediction tool to identify the need for invasive mechanical ventilation (IMV) in community-acquired pneumonia (CAP) with acute hypoxaemic respiratory failure treated with high-flow nasal cannula in order to avoid delay of a necessary intubation. However, its use in predicting the need for ventilatory support in hospitalised patients with CAP has not been validated.

Methods

This is a retrospective cohort study including subjects with CAP treated in the general ward, emergency service or intensive care unit of a third-level centre in Cundinamarca, Colombia, between January 2001 and February 2020. The ROX index was estimated as the ratio of oxygen saturation/fraction of inspired oxygen to respiratory rate.

Results

A total of 895 patients were included, of whom 93 (10%) required IMV. The ROX index proved to be a good predictor, presenting an area under the curve of receiver operating characteristics (AUROC) of 0.733 (95% CI 0.671 to 0.795, p<0.001) when determined by pulse oximetry and an AUROC of 0.779 (95% CI 0.699 to 0.859, p<0.001) when estimated by arterial blood gas (ABG) parameters, with an intraclass correlation of 0.894. The estimated cut-off point was 14.8; a score less than 14.8 indicates high risk of requiring IMV.

Conclusion

The ROX index is a good predictor of IMV in hospitalised patients with CAP. It presents good performance when calculated through pulse oximetry and can replace the one calculated by ABG.

Impact of Guideline Adherence on Outcomes in Patients Hospitalized with Community-Acquired Pneumonia (CAP) in Hungary: A Retrospective Observational Study

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. This retrospective observational study evaluated the antibiotic prescription patterns and associations between guideline adherence and outcomes in patients hospitalized with CAP in Hungary. Main outcome measures were adherence to national and international CAP guidelines (agent choice, dose) when using empirical antibiotics, antibiotic exposure, and clinical outcomes. Demographic and clinical characteristics of patients with CAP in the 30-day mortality and 30-day survival groups were compared. Fisher’s exact test and t-test were applied to compare categorical and continuous variables, respectively. Adherence to the national CAP guideline for initial empirical therapies was 30.61% (45/147) for agent choice and 88.89% (40/45) for dose. Average duration of antibiotic therapy for CAP was 7.13 ± 4.37 (mean ± SD) days, while average antibiotic consumption was 11.41 ± 8.59 DDD/patient (range 1−44.5). Adherence to national guideline led to a slightly lower 30-day mortality rate than guideline non-adherence (15.56% vs. 16.67%, p > 0.05). In patients aged ≥ 85 years, 30-day mortality was 3 times higher than in those aged 65−84 years (30.43% vs. 11.11%). A significant difference was found between 30-day non-survivors and 30-day survivors regarding the average CRP values on admission (177.28 ± 118.94 vs. 112.88 ± 93.47 mg/L, respectively, p = 0.006) and CCI score (5.71 ± 1.85 and 4.67 ± 1.83, p = 0.012). We found poor adherence to the national and international CAP guidelines in terms of agent choice. In addition, high CRP values on admission were markedly associated with higher mortality in CAP.

Emergent Virus Reactivation in SARS-CoV-2-Negative Community Acquired Pneumonia Patients During the COVID-19 Pandemic

Emergent viruses (namely, HSV-1, CMV, and EBV) reactivation were common in critically ill patients and/or immunosuppressed patients. This study aimed to understand the clinical manifestations and reactivation of the emergent viruses in SARS-CoV-2-Negative community acquired pneumonia (CAP) patients during the COVID-19 pandemic. We retrospectively reviewed the medical records of CAP patients from January to March 2020, in our university hospital in China. The patients were divided into two groups based on the presence or absence of emergent viruses. In all patients, the positive rates of EBV, HSV, and CMV were 23.43% (15/64), 22.06% (15/68), and 12.50% (8/64), respectively. The most common presenting symptoms were fever (98, 57.99%) and dry cough (55, 32.54%). The levels of albumin, hemoglobin, lymphocyte count, and CD4 + T lymphocyte count in emergent viruses positive group were lower than those of viruses negative group (P < 0.05). The initial chest CT features of these patients were diverse. The most common manifestations were ground-glass opacity (91/169, 53.85%) and pulmonary nodule (88/169, 52.07%). More emergent viruses positive patients have bilateral upper lobes involvement than emergent viruses negative patients (P < 0.05). A total of 80.47% patients (136/169) received empirical antimicrobial treatment. The most commonly used antibiotic regimen was fluoroquinolone monotherapy (80/169, 47.34%). The emergent viruses positive patients have poorer clinical outcome (P < 0.05). In conclusion, emergent viruses reactivation was common in SARS-CoV-2-Negative CAP patients. Emergent viruses positive patients have poorer cellular immune function, more severer conditions and poorer prognosis. Fluoroquinolones may be a therapeutic option for CAP patients.

Secondary streptococcal infection following influenza

Secondary bacterial infection following influenza A virus (IAV) infection is a major cause of morbidity and mortality during influenza epidemics. Streptococcus pneumoniae has been identified as a predominant pathogen in secondary pneumonia cases that develop following influenza. Although IAV has been shown to enhance susceptibility to the secondary bacterial infection, the underlying mechanism of the viral-bacterial synergy leading to disease progression is complex and remains elusive. In this review, cooperative interactions of viruses and streptococci during co- or secondary infection with IAV are described. IAV infects the upper respiratory tract, therefore, streptococci that inhabit or infect the respiratory tract are of special interest. Since many excellent reviews on the co-infection of IAV and S. pneumoniae have already been published, this review is intended to describe the unique interactions between other streptococci and IAV. Both streptococcal and IAV infections modulate the host epithelial barrier of the respiratory tract in various ways. IAV infection directly disrupts epithelial barriers, though at the same time the virus modifies the properties of infected cells to enhance streptococcal adherence and invasion. Mitis group streptococci produce neuraminidases, which promote IAV infection in a unique manner. The studies reviewed here have revealed intriguing mechanisms underlying secondary streptococcal infection following influenza. This article is protected by copyright. All rights reserved.

[Pulmonary nodules and pneumonia : A diagnostic guideline]

Hintergrund

Das konventionelle Röntgenbild zählt zu den am häufigsten durchgeführten radiologischen Untersuchungen. Seine Interpretation gehört zu den Grundkenntnissen jedes Radiologen.

Fragestellung

Ziel dieses Artikels ist es, häufige Zeichen und Muster der Pneumonie sowie Merkmale von Pseudoläsionen im konventionellen Röntgenbild zu erkennen und einen diagnostischen Leitfaden für junge Radiologen zu schaffen.

Methoden

Analyse aktueller Studien und Daten sowie eine Übersicht der häufigsten Zeichen und Muster im konventionellen Röntgenbild.

Ergebnisse

Die Kenntnis über häufige Zeichen und Muster im Röntgenbild bietet eine Hilfestellung in der Diagnostik und kann hinweisend für die Ursache einer Infektion sein. Häufig sind diese Zeichen jedoch unspezifisch und sollten daher immer in klinische Korrelation gesetzt werden. In der Detektion und Beurteilung von pulmonalen Rundherden gewinnt die Computertomographie (CT) durch ihre deutlich höhere Sensitivität in der Primärdiagnostik immer mehr an Bedeutung.

Schlussfolgerung

Das konventionelle Röntgenbild bildet weiterhin eine führende Rolle in der Primärdiagnostik; der Radiologe sollte jedoch die Limitationen des konventionellen Bildes kennen.

CURB-65 as a predictor of 30-day mortality in patients hospitalized with COVID-19 in Ecuador: COVID-EC study

Objective

This article aims to assess the utility of CURB-65 in predicting 30-day mortality in adult patients hospitalized with COVID-19.

Methods

This work is a cohort study conducted between March 1 and April 30, 2020 in Ecuador.

Results

A total of 247 patients were included (mean age 60 ± 14 years, 70% men, overall mortality 41.3%). Patients with CURB-65 ≥ 2 had a higher mortality rate (57 vs. 17%, p < .001) that was associated with other markers of risk: advanced age, hypertension, overweight/obesity, kidney failure, hypoxemia, requirement for mechanical ventilation, or onset of respiratory distress.

Conclusions

CURB-65  ≥ 2 was associated with higher 30-day mortality on the univariate (Kaplan–Meier estimator) and multivariate (Cox regression) analysis.

Influence of overweight and obesity on the mortality of hospitalized patients with community-acquired pneumonia

BACKGROUND

Obesity is associated with a better prognosis in patients with community-acquired pneumonia (the so-called obesity survival paradox), but conflicting results have been found.

AIM

To investigate the relationship between all-cause mortality and body mass index in patients with community-acquired pneumonia.

METHODS

This retrospective study included patients with community-acquired pneumonia hospitalized in the First Hospital of Qinhuangdao from June 2013 to November 2018. The patients were grouped as underweight (< 18.5 kg/m²), normal weight (18.5-23.9 kg/m²), and overweight/obesity (≥ 24 kg/m²). The primary outcome was all-cause hospital mortality.

RESULTS

Among 2327 patients, 297 (12.8%) were underweight, 1013 (43.5%) normal weight, and 1017 (43.7%) overweight/obesity. The all-cause hospital mortality was 4.6% (106/2327). Mortality was lowest in the overweight/obesity group and highest in the underweight group (2.8%, vs 5.0%, vs 9.1%, P < 0.001). All-cause mortality of overweight/obesity patients was lower than normal-weight patients [odds ratio (OR) = 0.535, 95% confidence interval (CI) = 0.334-0.855, P = 0.009], while the all-cause mortality of underweight patients was higher than that of normal-weight patients (OR = 1.886, 95%CI: 1.161-3.066, P = 0.010). Multivariable analysis showed that abnormal neutrophil counts (OR = 2.38, 95%CI: 1.55-3.65, P < 0.001), abnormal albumin levels (OR = 0.20, 95%CI: 0.06-0.72, P = 0.014), high-risk Confusion-Urea-Respiration-Blood pressure-65 score (OR = 2.89, 95%CI: 1.48-5.64, P = 0.002), and intensive care unit admission (OR = 3.11, 95%CI: 1.77-5.49, P < 0.001) were independently associated with mortality.

CONCLUSION

All-cause mortality of normal-weight patients was higher than overweight/ obesity patients, lower than that of underweight patients. Neutrophil counts, albumin levels, Confusion-Urea-Respiration-Blood pressure-65 score, and intensive care unit admission were independently associated with mortality in patients with community-acquired pneumonia.

Systemic Effects of Photobiomodulation on Blood Components in the Treatment of Community-Acquired Pneumonia

Background: The analysis of the complete blood count (CBC) of patients with community-acquired pneumonia (CAP) is an essential practice both for diagnosing the disease and for evaluating the patient's clinical evolution. It is proposed in the present study to analyze the hematological alterations resulting from photobiostimulation using near-infrared light-emitting diodes (LEDs) in patients with CAP. Methods: This was a clinical, prospective, blinded, and descriptive longitudinal study that involved 21 patients undergoing CAP treatment who were divided into two groups: LED, 11 patients who were treated with infrared LED and conventional treatment; and CON (control), 10 patients who received only conventional treatment (antibiotic therapy and physiotherapy). Physiotherapy was applied before LED irradiation in the LED group. The patients' CBCs were obtained before and after treatment, and erythrocyte counts, hemoglobin and hematocrit concentrations, and leukocyte and platelet counts were assessed. The phototherapy was performed with a vest with an array of 300 LEDs (940 nm) mounted on an area of 36 × 58 cm and positioned in the patient's anterior thoracic and abdominal regions. The total power was 6 W, with 15 min of irradiation time. The patients were treated daily for seven consecutive days. Statistical analyses of the intra- and intergroups of CBC data were done using Student's t-test and one-way ANOVA (analysis of variance), respectively, both at the significance level of α = 0.05. Results: There was a statistically significant recovery difference after treatment in the LED group compared with the CON group for erythrocytes, hemoglobin, leukocytes, segmented and band neutrophils, lymphocytes, and monocytes (p < 0.05). The greatest differences between the LED and CON groups were lymphocyte count reduction (60% vs. 16%), erythrocyte increase (86% vs. 35%), and leukocyte reduction (28% vs. 15%). Conclusions: The hematologic components of CAP patients recovered their normal values faster with conventional treatment associated with infrared LED therapy, thus indicating greater treatment efficiency when compared with the conventional therapy. This study was registered with the Brazilian Registry of Clinical Trials (ReBeC) under Universal Trial Number (UTN) U1111-1229-1296 (2019/06/05).

Acidic Glycosidases of Leukocytes in Patients with Community-acquired Pneumonia and Their Importance in the Course and Prognosis of the Disease

At present time pneumonia remains a significant medical and social problem, which is associated with disability and mortality throughout the world. Community-acquired pneumonia (CP) is one of the most common clinical conditions among the adult population and ranks 4th–5th in the world in the structure of causes of death after cardiovascular and oncological diseases, cerebrovascular pathology, trauma and poisoning, and among infectious diseases it ranks first. The search for biochemical markers of the different forms of pneumonia is of considerable interest both for diagnosis and prediction of the disease clinical course and timely treatment; however, the role of the acid glycosidases and their significance in CP has not been studied. The objective: the aim of the study: to analyze changes in the enzymatic protective systems of blood in practically healthy individuals (PHI) and patients with CP, to determine their role in diagnosis and prognosis of the disease. Materials and methods. 30 patients with CP aged 18 to 80 years were examined in Therapeutic Department of the City Clinical Hospital No. 25 in Kharkiv. The diagnosis of CP was established on the basis of epidemiological, clinical, laboratory, radiological data. The patients were with CP were compared with the group of PHI) and examined according to the Medical Standards of the National institute of phthisiology and pulmonology named after F.G. Yanovsky NMAS of Ukraine. Results. The study revealed that the activity of enzymes was significantly higher in CP patients compared to the PHI group (p<0.05). Significant changes were found in the activity of α- and β-glycosidases, as evidenced by an increase in the activity of β-galactosidase by 2.0 times, and β-glucuronidase – by 3.5 times. An increase in serum antiglucuronidase activity in CP patients can be considered as one of the possible protective mechanisms against the damage effect of β-glucuronidase. The development of the CP clinical picture was accompanied by changes in biochemical parameters of the blood serum. Results of the study of the serum total proteolytic activity found its increase by 1.4 times in CP patients during the entire study period compared to the PHI group. The level of the universal indicator of inflammation (total proteolytic activity) was significantly higher in the group of CP patients during the entire observation period, but its maximum increase was observed on the 5th and 10th days. In patients with severe CP, along with the intensification of proteolysis processes, activation of the lysosomal acid phosphatase enzyme in the blood serum waso fund. Conclusions. In patients with community-acquired pneumonia (CP) increase in the activity of leukocyte acid glycosidases is one of the biochemical markers of a favorable course and good prognosis of the disease. In patients with severe CP, along with the intensification of proteolysis processes, activation of the lysosomal acid phosphatase enzyme in the blood serum was found.

Activation and Functional Alteration of Mucosal-Associated Invariant T Cells in Adult Patients With Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) remains the significant infectious cause of morbidity and mortality worldwide. Although mucosal-associated invariant T cells (MAIT) play roles in the pathogenesis of children CAP and ICU-associated pneumonia, their roles in adult CAP are largely unexplored. In this study, we investigated the frequency, phenotype, and function of MAIT cells in peripheral blood and bronchoalveolar lavage fluid (BALF) of adult CAP patients. Our data indicate that MAIT-cell frequency is profoundly lower in the peripheral blood of CAP patients compared to that in healthy individuals. Furthermore, the circulatory MAIT cells express higher levels of CD69 and PD-1 compared to those in healthy individuals. In BALF of CAP patients, MAIT-cell frequency is higher and MAIT cells express higher levels of CD69 and PD-1 compared to their matched blood counterparts. Levels of IL-17A and IFN-γ are increased in BALF of CAP patients compared to those in BALF of patients with pulmonary small nodules. The IL-17A/IFN-γ ratio is significantly positively correlated with MAIT frequency in BALF of CAP patients, suggesting a pathogenic role of MAIT-17 cells in CAP. Of note, blood MAIT-cell frequency in CAP patients is strongly negatively correlated with high-sensitivity C-reactive protein (hsCRP) and neutrophil count percentage in blood. The ability of circulating MAIT cells in CAP patients to produce IFN-γ is significantly impaired compared to those in healthy individuals. In summary, our findings suggest the possible involvement of MAIT cells in the immunopathogenesis of adult CAP.

ΔRDW: A Novel Indicator with Predictive Value for the Diagnosis and Treatment of Multiple Diseases

Elevated red blood cell distribution width (RDW) is a powerful predictor of poor prognosis in a variety of diseases, but a single measurement of RDW cannot reflect the dynamic change of diseases. ΔRDW, as a risk stratification tool, can be used to record changes in RDW before and after treatment; also, it allows investigators to name the unit change of RDW in the studied population. So far, there have been few relevant studies on the predictive value of ΔRDW for different diseases; this article aims to review the studies and summaries of the current understandings on the correlation between ΔRDW and disease outcomes.

Epidemiologic and clinical characteristics of human bocavirus infection in infants and young children suffering with community acquired pneumonia in Ningxia, China

Background

Pneumonia has a high incidence rate and is a major cause of mortality in children, mostly community-acquired pneumonia (CAP). Human bocavirus (HBoV), since it first identified in 2005, has been repeatedly associated with respiratory tract infections. Nevertheless, the role and related information of HBoV as a pathogen of CAP has not been fulfilled. Here our study is to assess the epidemiological and clinical features in HBoV-positive children with CAP.

Methods

A total of 878 secretions of lower respiratory samples were obtained, multiplex PCR was used to detect HBoV and other respiratory viruses.

Results

Of all cases, HBoV was detected in 10.0%, with a peak incidence of infection among children < 2 year old, and predominantly noted in autumn and winter. Only 8 patients were HBoV single infection. Co-infection with other respiratory viruses was observed in 86.4%. Moreover, co-infection with bacteria occurred in 27.3% and with Mycoplasma pneumoniae (MP) in 33.0% of HBoV-positive patients. Among all HBoV-positive samples co-infected with bacteria, 87.5% are gram negative bacteria. Compared with HBoV-negative group, age (P = 0.048), wheezing (P = 0.015), tachypnea (P = 0.016), lactate dehydrogenase (P = 0.026) and severe pneumonia (P = 0.023) were statistically significant in HBoV-positive patients. Furthermore, HBoV-positive patients less than 1 year old were more likely to have co-infection with bacteria (P = 0.007).

Conclusions

HBoV can be detected alone in respiratory samples of children with CAP, maybe it is one of the causes of CAP in infants. The high incidence of severe pneumonia was found in HBoV-positive patients compared with HBoV-negative cases may indicate a relationship between severe pneumonia and HBoV.

Clinical and CT findings of adenovirus pneumonia in immunocompetent adults

INTRODUCTION

Adenovirus pneumonia is not uncommon in children and immunocompromised patients. However, the study of the clinical and computed tomography (CT) characteristics of Adenovirus pneumonia in immunocompetent adults is still limited.

OBJECTIVE

The objective of this study was to retrospectively observe the clinical and CT characteristics as well as their dynamic change of Adenovirus pneumonia in immunocompetent adults.

METHODS

Twenty patients (18 males, median age, 36 years old) with Adenovirus pneumonia were retrospectively included from January 2018 to December 2019. Clinical information and chest CT at admission of all patients were reviewed. Twelve patients underwent serial CT scans, and the temporal changes of CT findings were summarized. Pneumonia severity index (PSI) was calculated according to clinical information.

RESULTS

The median time interval from illness onset to admission was 6 days (interquartile range [IQR], 5-7.5 days). The clinical characteristics included the high fever (39.2 ± 0.8°C) with the normal white blood cell count, the decreased lymphocyte, and elevated C-reactive protein. Ten cases complicated with mycoplasma infection at admission. Thirteen patients were mechanically ventilated, and two patients died during hospitalization. Consolidation was a predominant pattern found during the first 2 weeks and then resolved to minimal consolidation after the fourth week. There was no significant correlation between CT score and PSI score (r = 0.15, p = 0.41).

CONCLUSIONS

Predominant radiological finding of Adenovirus pneumonia was consolidation. Multilobular involvement, higher CT scores, and pleural effusion were found in more severe patients. The abnormal opacity peaked in 2 weeks of illness onset and gradually resolved after the third week. The temporal changes of radiological score are consistent with clinical findings.

An integrated emergency department/hospital at home model in mild COVID-19 pneumonia: feasibility and outcomes after discharge from the emergency department

To evaluate the effectiveness of an integrated emergency department (ED)/hospital at home (HH) medical care model in mild COVID-19 pneumonia and evaluate baseline predictors of major outcomes and potential savings. Retrospective cohort study with patients evaluated for COVID-19 pneumonia in the ED, from March 3 to April 30, 2020. All of them were discharged home and controlled by HH. The main outcomes were ED revisit and the need for deferred hospital admission (protocol failure). Outcome predictors were analyzed by simple logistic regression model (OR; 95% CI). Potential savings of this medical care model were estimated. Of the 377 patients attended in the ED, 109 were identified as having mild pneumonia and were included in the ED/HH medical care model. Median age was 50.0 years, 52.3% were males and 57.8% had Charlson index ≥ 1. The median HH stay was 8 (IQR 3.7-11) days. COVID-19-related ED revisit was 19.2% (n = 21) within 6 days (IQR 3-12.5) after discharge from ED. Overall protocol failure (deferred hospital admission) was 6.4% (n = 7), without ICU admission. The ED/HH model provided potential cost savings of 77% compared to traditional stay, due to the costs of home care entails 23% of the expenses generated by a conventional hospital stay. 789 days of hospital stay were avoided by HH, rather than hospital admission. An innovative ED/HH model for selected patients with mild COVID-19 pneumonia is feasible, safe and effective. Less than 6.5% of patients requiring deferred hospital admission and potential savings were generated due to hospitalization.

Sex-specific differences in plasma levels of FXII, HK, and FXIIa-C1-esterase inhibitor complexes in community acquired pneumonia

Sex-dependent differences in immunity and coagulation play an active role in the outcome of community-acquired pneumonia (CAP). Contact phase proteins act at the crossroads between inflammation and coagulation thus representing a point of convergence in host defense against infection. Here, we measured the levels of factor XII (FXII), FXIIa-C1 esterase inhibitor (C1INH) complexes, and high molecular weight kininogen (HK) in plasma of CAP patients and correlated them to clinical disease severity. Levels of FXIIa-C1INH/albumin ratio were elevated, irrespective of sex, in plasma of CAP patients (n=139) as compared to age-matched donors (n=58). No simultaneous decrease in FXII levels, indicating its consumption, was observed. Stratification by sex revealed augmented FXII levels in plasma of CAP women as compared to sex-matched donors yet no apparent differences in men. This sex-specific effect was, however, attributable to lower FXII levels in female donors relative to men donors. Plasma estradiol levels mirrored those for FXII. Levels of HK/albumin ratio were decreased in CAP plasma as compared to donors, however, after stratification by sex, this difference was only observed in women and was related to higher HK/albumin values in female donors as opposed to male donors. Finally, strong negative correlation between plasma levels of HK/albumin ratio and CAP severity, as assessed by CRB65 score, in males and females was observed. Our study identifies sex-dependent differences in plasma levels of the contact phase proteins in elderly subjects that may contribute to specific clinical outcomes in CAP between men and women.

Examining the Effector Mechanisms of the Feishu Acupoint (BL13) in the Treatment of Pneumonia Based on Systematic Acupuncture and Moxibustion Research

Background

Pneumonia is a serious global health problem. In traditional Chinese medicine, acupuncture or moxibustion is used to directly stimulate select acupoints on the surface of the human body and produce physical stimulation to further stimulate regulatory functions in the body, strengthening bodily resistance, eliminating disease, and adjusting the viscera. However, this Chinese medicine knowledge does not include the specific mechanisms of action or targets of acupoints. Therefore, an in-depth research is needed.

Methods

An acupoint-element database was constructed, and the target elements of the Feishu point were screened. The UniProt-Swiss-Prot sublibrary was used to obtain correct gene name information. The National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (GEO) database and GEO2R were used to analyze differentially expressed genes in pneumonia. The STRING database was used to analyze interactions, construct a network of the Feishu point efficacy system in pneumonia, and elucidate the mechanisms of action.

Results

The Feishu point comprises 34 elements in total. The protein interaction analysis has 38 nodes and 115 edges. The Feishu point efficacy system-pneumonia system network shows that cytokine signaling in the immune system, signaling by interleukins (ILs), IL-4 and IL-13 signaling, and the immune system may be related to immunity and inflammation. The Feishu point efficacy system regulating pneumonia showed that FCER2, IL4R, FASLG, TGFB1, IL6R, STAT6, IL1B, CASP3, IL5RA, IL2RB, MYD88, SQSTM1, IL12RB1, IFNGR1, ADAM17, and CDH1 are the main targets.

Conclusion

From the perspective of systematic acupuncture and moxibustion, the Feishu point regulates cytokine signaling in the immune system, signaling by ILs, IL-4 and IL-13 signaling, and the immune system by targeting FCER2, IL4R, FASLG, TGFB1, IL6R, STAT6, IL1B, CASP3, IL5RA, IL2RB, MYD88, SQSTM1, IL12RB1, IFNGR1, ADAM17, and CDH1, thereby regulating pneumonia.

Evaluation of severity scoring systems in patients with severe community acquired pneumonia

BACKGROUND

The aim of this study was to evaluate the ability of severity scoring systems to predict 30-day mortality in patients with severe community-acquired pneumonia.

METHODS

The study included 98 patients aged ≥18 years with community acquired pneumonia hospitalized at the Intensive Care Unit of the University Clinic for Infectious Diseases in Skopje, Republic of North Macedonia, during a 3-year period. We recorded demographic, clinical and common biochemical parameters. Five severity scores were calculated at admission: CURB 65 (Confusion, Urea, Respiratory Rate, Blood pressure, Age ≥65 years), SCAP (Severe Community Acquired Pneumonia score), SAPS II (Simplified Acute Physiology Score), SOFA (Sequential Organ Failure Assessment Score) and MPM (Mortality Prediction Model). Primary outcome variable was 30-day in-hospital mortality.

RESULTS

The mean age of the patients was 59.08 ± 15.76 years, predominantly males (68%). The overall 30-day mortality was 52%. Charlson Comorbidity index was increased in non-survivors (3.72 ± 2.33) and was associated with the outcome. All severity indexes had higher values in patients who died, that showed statistical significance between the analysed groups. The areas under curve (AUC) values of the five scores for 30-day mortality were 0.670, 0.732, 0,726, 0.785 and 0.777, respectively.

CONCLUSION

Widely used severity scores accurately detected patients with pneumonia that had increased risk for poor outcome, but none of them individually demonstrated any advantage over the others.

NLRP6 modulates neutrophil homeostasis in bacterial pneumonia-derived sepsis

Bacterial pneumonia is a significant cause of morbidity, mortality, and health care expenditures. Optimum neutrophil recruitment and their function are critical defense mechanisms against respiratory pathogens. The nucleotide-binding oligomerization domain-like receptor (NLRP) 6 controls gut microbiota and immune response to systemic and enteric infections. However, the importance of NLRP6 in neutrophil homeostasis following lung infection remains elusive. To investigate the role of NLRs in neutrophil homeostasis, we used Nlrp6 gene-deficient (Nlrp6^-/-) mice in a model of Klebsiella pneumoniae-induced pneumonia-derived sepsis. We demonstrated that NLRP6 is critical for host survival, bacterial clearance, neutrophil influx, and CXC-chemokine production. Kp-infected Nlrp6^-/- mice have reduced numbers of hematopoietic stem cells and granulocyte-monocyte progenitors but increased retention of matured neutrophils in bone marrow. Neutrophil extracellular trap (NET) formation and NET-mediated bacterial killing were also impaired in Nlrp6^-/- neutrophils in vitro. Furthermore, recombinant CXCL1 rescued the impaired host defense, granulopoietic response, and NETosis in Kp-infected Nlrp6^-/- mice. Using A/J background mice and co-housing experiments, our findings revealed that the susceptible phenotype of Nlrp6^-/- mice is not strain-specific and gut microbiota-dependent. Taken together, these data unveil NLRP6 as a central regulator of neutrophil recruitment, generation, and function during bacterial pneumonia followed by sepsis.

Community-Acquired Pneumonia: A Focused Review

Community-acquired pneumonia (CAP) is a common cause for admission to the hospital and contributes significantly to patient morbidity and healthcare cost. We present a review of the epidemiology, pathophysiology, risk factors, symptoms, diagnosis, presentations, risk-stratification, markers, and management of CAP in the United States (US). The overall incidence of CAP is 16 to 23 cases per 1000 persons per year, and the rate increases with age. Some of the risk factors for CAP include comorbidities such as, chronic obstructive pulmonary disease (COPD), asthma, and heart failure. CAP symptoms vary, and typically include productive cough, dyspnea, pleuritic pain, abnormal vital signs (e.g., fever, tachycardia), and abnormal lung examination findings. A diagnosis can be made by radiography, which has the additional benefit of helping to identify patterns associated with typical and atypical CAP. There are risk-stratification calculators that can be used routinely by physicians to triage patients, and to determine adequate management. The Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) developed the Pneumonia Severity Index (PSI) which incorporates 20 risk factors to place patients into 5 classes correlated with mortality risk. In addition, the British Thoracic Society (BTS) established the original severity score CURB (confusion, uremia, respiratory rate, low blood pressure) to identify patients with CAP who may be candidates for outpatient vs. inpatient treatment. Inflammatory markers, such as procalcitonin (PCT), can be used to guide management throughout hospital stay. Antibiotic coverage will vary depending on whether outpatient vs. inpatient management is required.