Bacterial Pneumonia in Older Adults

Effectiveness and Safety of Oral Azvudine for Elderly Hospitalized Patients With COVID-19: A Multicenter, Retrospective, Real-World Study

Azvudine is recommended as a priority treatment for patients with Coronavirus Disease 2019 (COVID-19) during Omicron wave in China, but its efficacy and safety in elderly patients is unknown. In this multicenter, retrospective study, we identified 19763 elderly patients (aged over 60 years) with COVID-19 from nine hospitals in Henan Province, China. The primary outcome is all-cause death and the secondary outcome is composite disease progression. After propensity score matching, 4109 Azvudine recipients and 4109 matched controls is included, with average age of 75.15 years. Kaplan-Meier analysis reveales a notably survival and progression-free benefit in Azvudine treatment. The Cox analysis shows that compared with controls, Azvudine recipients have a 33% lower risk of all-cause death (95% confidence Interval (CI): 0.580-0.772, p < 0.001), but have no significant difference in composite disease progression (hazard ratio: 0.93, 95% CI: 0.833-1.046, p = 0.234). Subgroup analysis suggested Azvudine have a stronger protective effect in patients concomitant with antibiotics. Three sensitive analyses confirm the robustness of the findings. The safety of Azvudine in elderly patients is acceptable. These findings indicate that Azvudine therapy can reduce the rate of all-cause death in hospitalized elderly patients with COVID-19, and without obvious adverse events.

tesG expression as a potential clinical biomarker for chronic Pseudomonas aeruginosa pulmonary biofilm infections

BACKGROUND

Pseudomonas aeruginosa infections in the lungs affect millions of children and adults worldwide. To our knowledge, no clinically validated prognostic biomarkers for chronic pulmonary P. aeruginosa infections exist. Therefore, this study aims to identify potential prognostic markers for chronic P. aeruginosa biofilm lung infections.

METHODS

Here, we screened the expression of 11 P. aeruginosa regulatory genes (tesG, algD, lasR, lasA, lasB, pelB, phzF, rhlA, rsmY, rsmZ, and sagS) to identify associations between clinical status and chronic biofilm infection.

RESULTS

RNA was extracted from 210 sputum samples from patients (n = 70) with chronic P. aeruginosa lung infections (mean age; 29.3-56.2 years; 33 female). Strong biofilm formation was correlated with prolonged hospital stays (212.2 days vs. 44.4 days) and increased mortality (46.2% (18)). Strong biofilm formation is associated with increased tesG expression (P = 0.001), influencing extended intensive care unit (P = 0.002) or hospitalisation stays (P = 0.001), pneumonia risk (P = 0.006), and mortality (P = 0.001). Notably, tesG expression is linked to the modulation of systemic and sputum inflammatory responses and predicts biofilm biomass.

CONCLUSIONS

This study provides the first clinical dataset of tesG expression levels as a predictive biomarker for chronic P. aeruginosa pulmonary infections.

Predicting postoperative pulmonary infection in elderly patients undergoing major surgery: a study based on logistic regression and machine learning models

BACKGROUND

Postoperative pulmonary infection (POI) is strongly associated with a poor prognosis and has a high incidence in elderly patients undergoing major surgery. Machine learning (ML) algorithms are increasingly being used in medicine, but the predictive role of logistic regression (LR) and ML algorithms for POI in high-risk populations remains unclear.

METHODS

We conducted a retrospective cohort study of older adults undergoing major surgery over a period of six years. The included patients were randomly divided into training and validation sets at a ratio of 7:3. The features selected by the least absolute shrinkage and selection operator regression algorithm were used as the input variables of the ML and LR models. The random forest of multiple interpretable methods was used to interpret the ML models.

RESULTS

Of the 9481 older adults in our study, 951 developed POI. Among the different algorithms, LR performed the best with an AUC of 0.80, whereas the decision tree performed the worst with an AUC of 0.75. Furthermore, the LR model outperformed the other ML models in terms of accuracy (88.22%), specificity (90.29%), precision (44.42%), and F1 score (54.25%). Despite employing four interpretable methods for RF analysis, there existed a certain degree of inconsistency in the results. Finally, to facilitate clinical application, we established a web-friendly version of the nomogram based on the LR algorithm; In addition, patients were divided into three significantly distinct risk intervals in predicting POI.

CONCLUSIONS

Compared with popular ML algorithms, LR was more effective at predicting POI in older patients undergoing major surgery. The constructed nomogram could identify high-risk elderly patients and facilitate perioperative management planning.

TRIAL REGISTRATION

The study was retrospectively registered (NCT06491459).

Antibiotic susceptibility of pathogens isolated in respiratory tract samples of recently hospitalized patients

Community-acquired lower respiratory tract infections (CA-LRTIs) treatment is largely empirical as microbiologic testing is rarely performed. Here, we provide microbiologic data of severe CA-LRTI cases requiring hospitalization. We aim to describe the distribution and susceptibility patterns of pathogens causing severe CA-LRTI. We analyzed respiratory samples from recently admitted patients with CA-LRTIs to assess pathogen distribution and antibiotic susceptibility patterns. We divided patients into three groups: CA-LRTI and no prior healthcare exposure, CA-LRTI with healthcare exposure, and patients diagnosed with LRTI 48 to 7 days of hospital admission. In a sub-cohort, we assessed the bacteria's susceptibility to cefditoren. A total of 1,395, 2,212, and 2,760 samples were included in the three study groups. Gram-negative bacteria were the most common bacteria isolated. Streptococcus pneumoniae was over-represented in patients admitted to the intensive care unit (ICU) in the first two study groups, and was fully susceptible to penicillin in only ~50% of cases, and to fluoroquinolones and third-generation cephalosporins including cefditoren in >95% of cases. Susceptibility of Gram-negative bacteria to penicillins and to second-generation cephalosporins was lower than 50%. Age, admission to an ICU or surgical department, healthcare-associated infections, and infections with Gram-negative bacteria, Staphylococcus aureus, and Stenotrophomonas/Acinetobacter baumannii were associated with increased mortality. These results highlight pathogen diversity and concerning antibiotic susceptibility patterns in LRTI. These findings emphasize the importance of improving diagnostics and addressing antibiotic resistance in the effective management of LRTI.IMPORTANCEThis survey aims to describe the microbiologic aspects of community-acquired lower respiratory tract infections (CA-LRTI) in a large cohort of patients recently admitted to hospital. In a small sub-study, we assessed antibiotic susceptibility to cefditoren, an oral third-generation cephalosporin not used in Israel. By analyzing specimens from recently admitted patients with CA-LRTI, we aim to provide physicians with the relevant microbiologic data of the more severe CA-LRTI cases, i.e., those that resulted in hospital admission. Such microbiological data would provide primary care and emergency room physicians with additional insights as to the causative agents of severe CA-LRTI.

Benchmarking broad-spectrum antibiotic use in older adult pneumonia inpatients: a risk-adjusted smoothed observed-to-expected ratio approach

OBJECTIVE

Antimicrobial resistance is increased by antibiotic overuse, so it's crucial for stewardship programs to monitor and control their use. Pneumonia, particularly prevalent among older adults in Japan, is requiring higher rates of medical treatment. This study aimed to develop an improved method for benchmarking broad-spectrum antibiotic use in the empiric treatment of pneumonia in older adult inpatients by applying the "smoothed" observed-to-expected (O/E) ratio which adjusts for hospital-level variations and minimizes the effect of extreme values.

METHODS

Using nationwide data from the Diagnosis Procedure Combination research group, pneumonia patients between April 1st 2018 and March 31st 2020 were analyzed. The primary outcome was the smoothed O/E ratio of the broad-spectrum antibiotic use for hospitals. It was calculated from the predicted values of broad-spectrum antibiotic use that were obtained through multilevel logistic regression using patient characteristics as predictors from data clustered by hospitals. The analysis investigated the risk-adjusted use of broad-spectrum antibiotics among hospitals.

RESULTS

A total of 244,747 patients from 958 hospitals were included, with a mean age of 81 (±8.30) years. The proportion of broad-spectrum antibiotic use was 35.3% (n = 86,316). The prediction model showed a C-statistic of 0.722. There was a noticeable variation in the O/E ratio among hospitals with values ranging from 0.13 (95% CI: 0.09-0.20) to 2.81 (95% CI: 2.64-2.97).

CONCLUSIONS

Using a risk-adjusted smoothed O/E ratio, we assessed the use of broad-spectrum antibiotics across hospitals, identifying those with high O/E ratios that may indicate a need for improvement.

Phage Therapy in Bacterial Pneumonia Models: A Systematic Review and Meta-Analysis

BACKGROUND

Phage therapy could play an important role in the bacterial pneumonia. However, the exact role of phage therapy in bacterial pneumonia is unclear to date.

AIM

The current study aims to find out the role of phage therapy in preclinical models of bacterial pneumonia.

METHODS

The studies were searched in databases with proper MeSH terms along with Boolean operators and selected based on eligibility criteria as per the PRISMA guidelines. The Odd Ratio (OR) was calculated with a 95% confidence interval and the heterogeneity was also calculated. The funnel plot was used to conduct a qualitative examination of publication bias.

RESULTS

The OR was observed to be 0.11 (0.04, 0.27)] after 24 hrs, 0.11 [0.03, 0.34] after 7 days and 0.04 [0.01, 0.15] after 10 days that showed a significant role of phage therapy in reduction of deaths in the bacterial pneumonia models as compared to the placebo group. However, after 48hrs, a non-significant reduction was observed.

CONCLUSION

There was a significant role of phage therapy in the reduction of deaths in the bacterial pneumonia models.

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.

Sex-based difference in immune responses and efficacy of the pneumococcal conjugate vaccine

Vaccine-mediated protection and susceptibility to Streptococcus pneumoniae (pneumococcus) infections are influenced by biological sex. The incidence of invasive pneumococcal disease remains higher in males compared to females even after the introduction of the pneumococcal conjugate vaccine. However, sex-based differences in the immune response to this conjugate vaccine remain unexplored. To investigate those differences, we vaccinated adult male and female mice with pneumococcal conjugate vaccine and assessed cellular and humoral immune responses. Compared to females, male mice displayed lower levels of T follicular helper cells, germinal center B cells, and plasmablasts, which are all required for antibody production following vaccination. This was linked to lower IgG and IgM levels against pneumococci and lower isotype switching to IgG3 in vaccinated males. Due to lower antibody levels, sera of vaccinated male mice had lower efficacy in several anti-pneumococcal functions, including neutralization of bacterial binding to pulmonary epithelial cells as well as direct cytotoxicity against S. pneumoniae. Importantly, while the vaccine was highly protective in females, vaccinated males succumbed to infection more readily and were more susceptible to both lung-localized infection and systemic spread following S. pneumoniae challenge. These findings identify sex-based differences in immune responses to pneumococcal conjugate vaccine that can inform future vaccine strategies.

Longitudinal prevalence and co-carriage of pathogens associated with nursing home acquired pneumonia in three long-term care facilities

Nursing home acquired pneumonia (NHAP), and its subset - aspiration-associated pneumonia, is a leading cause of morbidity and mortality among residents in long-term care facilities (LTCFs). Understanding colonization dynamics of respiratory pathogens in LTCF residents is essential for effective infection control. This study examines the longitudinal trends in prevalence, persistence, bacterial load, and co-colonization patterns of five respiratory pathogens in three LTCFs in Phoenix, Arizona. Anterior nares and oral swabs were collected every other week and tested using qPCR for Haemophilus influenzae, Pseudomonas aeruginosa, Streptococcus pneumoniae, Staphylococcus aureus, and Chlamydia pneumoniae. Weekly average positivity rates were 17.75% for H. influenzae (0% - 39.39%), 9.95% for P. aeruginosa (0% - 37.74%), 31.89% for S. pneumoniae (1.79% - 41.67%), and for 28.00% for S. aureus (0% - 55.36%). C. pneumoniae was not detected. H. influenzae and S. pneumoniae predominantly colonized the oral cavity, while P. aeruginosa and S. aureus predominantly colonized the nasal cavity. S. pneumoniae and S. aureus colonizations were significantly more persistent than H. influenzae and P. aeruginosa, with persistence correlating with significantly higher bacterial loads. Co-colonization did occur in ~20% of positive samples, but appeared to be due to random chance. This study reveals distinct colonization patterns among respiratory pathogens in LTCF residents, highlighting differences in site-specific prevalence, persistence, and bacterial load. These findings underscore the importance of longitudinal monitoring to inform targeted infection control strategies in LTCFs.

Advancements and challenges in the management of pneumonia in elderly patients with COPD

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) significantly predisposes the elderly to pneumonia, presenting a complex interplay of pulmonary dysfunction and infection risk.

AREAS COVERED

This article reviews the substantial epidemiologic impact, elucidates the interlinked pathophysiology of COPD and pneumonia, and examines the microbial landscape shaping infection in these patients. It also evaluates management protocols and the multifaceted clinical challenges encountered during treatment.

EXPERT OPINION

Delving into the latest research, we underscore the criticality of preventive measures such as vaccination and present an integrated approach to managing Community-Acquired Pneumonia (CAP) in the COPD demographic. The review also proposes strategic directions for future investigations aimed at enhancing patient outcomes through a deeper understanding of the COPD-pneumonia nexus.

A systematic review of factors associated with poor prognosis despite appropriate antibiotics usage for pneumonia

Treatment with appropriate antibiotics does not seem to be associated with prognosis among elderly patients with pneumonia. Identifying factors associated with poor prognosis despite the use of appropriate antibiotics might help withhold aggressive antibiotic treatment in patients with pneumonia. This systematic review aims to identify the risk factors associated with unfavored outcomes despite using appropriate antibiotics for pneumonia. The PubMed database was searched for studies focusing on appropriate antibiotic use in patients with pneumonia (assessed on Aug 7, 2024). Appropriate antibiotics were defined as those sensitive to microorganisms isolated from patients. The risk of bias was evaluated using the Risk of Bias Assessment tool for nonrandomized Studies utilized for controlled observational studies. A total of 1563 studies were identified from the database, and eight observational studies were included in this review: ventilator-associated pneumonia (n = 4), community-onset pneumonia (n = 2), P. aeruginosa pneumonia (n = 1), and S. maltophilia pneumonia (n = 1). Advanced age was the most commonly evaluated factor associated with mortality. Additionally, high severity scores were related to the unfavored outcomes even after treatment with appropriate antibiotics. Advanced age and high severity scores may be associated with increased mortality despite appropriate antibiotic usage for pneumonia. Broad-spectrum antibiotics might not be indicated in elderly pneumonia patients with high severity status who do not wish to receive aggressive antibiotic treatments.

Quick Sequential Organ Failure Assessment (qSOFA) and Performance Status Scoring Systems as Prognostic Predictors in Pneumococcal Community-Acquired Pneumonia

Background and aim Streptococcus pneumoniae, or pneumococcus, is one of the most common pathogens responsible for community-acquired pneumonia (CAP), which can progress to sepsis and lead to severe illness. Several clinical scoring systems are widely used to assess the severity of CAP and sepsis. This study aims to evaluate the clinical factors that predict mortality in pneumococcal CAP (pCAP). Methods Patients eligible for this study were 16 years or older and diagnosed with pCAP at Yamagata Prefectural Central Hospital, Yamagata, Japan, between January 2012 and May 2018. pCAP was defined by the single isolation of S. pneumoniae from sputum or blood culture in patients with CAP. Patients were divided into two groups based on 60-day mortality: survivors and non-survivors. Clinical parameters, including performance status (PS), were assessed for both groups. Disease severity was evaluated using the A-DROP, CURB-65, and quick Sequential Organ Failure Assessment (qSOFA) scores. Statistical analysis was performed using JMP 11 software (JMP Statistical Discovery LLC, NC, USA). Results A total of 192 patients (135 men and 57 women) were enrolled in this study. The median age was 77 years (range: 21-97 years). Among them, 169 patients were survivors and 22 were non-survivors. S. pneumoniae was more frequently detected in the blood cultures of non-survivors than survivors (27.3% vs. 7.7%, respectively; p = 0.01, chi-square test). Non-survivors exhibited poorer PS (PS ≥3), higher A-DROP scores (A-DROP ≥3), and higher qSOFA scores (qSOFA ≥2) compared to survivors (p = 0.002, 0.02, and 0.0003, chi-square test, respectively). However, there was no significant difference in the CURB-65 score between the two groups. Multivariate analysis revealed that higher qSOFA scores and poor PS were independent risk factors for 60-day mortality in pCAP (OR 4.0 (95% CI: 1.3-13.3) and 4.0 (1.4-10.9), respectively). Conclusions The qSOFA and PS scoring systems may be useful in predicting the prognosis of pCAP.

Synthesis and evaluation of antibacterial and antibiofilm agents based on phenylamino-substituted 1,4-benzoquinones

Aim: This work describes the synthesis and antimicrobial evaluation of 6-aminated 1,4-benzoquinones (6-AQs) against seven resistant pathogens.Materials & methods: The 6-AQs, synthesized via a Michael addition reaction between bromoquinone and p-substituted anilines, were assessed for their antimicrobial activity through both in vitro and in silico analyses.Results: Bromoquinone and 6-AQs with electron-withdrawing groups demonstrated activity against Pseudomonas aeruginosa, with minimum inhibitory concentrations ranging from 16 to 128 μg/ml, comparable to standard antimicrobials. Two derivatives exhibited minimum inhibitory concentrations values against methicillin-resistant Staphylococcus aureus ranging from 64 to 128 μg/ml. These compounds demonstrated both bacteriostatic and bactericidal effects, and antibiofilm features.Conclusion: The 6-AQs 19g and 19f showed a promising antimicrobial profile, indicating their potential as new therapeutic options.

Vaccination Motivators and Deterrents Among Undervaccinated Older Adults in North Dakota

Despite increased risk of morbidity and mortality among older adults due to preventable infectious diseases such as influenza, shingles, pneumonia, and COVID-19, many forego receiving some, if not all, of these vaccinations. This study examines vaccination motivators and deterrents for undervaccinated older adults in North Dakota (ND). Adults aged 65+ in ND were mailed a survey (n = 901) with questions gauging vaccination behaviors and perceptions, with 132 of these indicating not receiving certain vaccinations. Further questions assessed reasons they have not been vaccinated against the following diseases: influenza, shingles, pneumonia, and COVID-19 (e.g., "Concerned about side effects", "Vaccines are dangerous", "I'm healthy and I do not need it") and what would make it more likely to get a vaccine (e.g., "More information", "Doctor recommendation", "Easy access to vaccines"). Reasons for remaining unvaccinated varied by vaccine. For influenza and pneumococcal vaccines, respondents were more likely to indicate they are healthy and do not need the vaccine. For shingles and COVID-19, respondents were more likely to indicate concerns about side effects. Factors reported to motivate increasing the likelihood of getting a vaccine were receiving a doctor recommendation, receiving more information, and having a vaccine provided at no cost. These results contribute to our understanding of vaccination behaviors among older adults and underscore specific issues around which to frame interventions tailored to increase vaccine uptake for this population.

Antibiotic Resistance in the Elderly: Mechanisms, Risk Factors, and Solutions

Antibiotic resistance presents a critical challenge in healthcare, particularly among the elderly, where multidrug-resistant organisms (MDROs) contribute to increased morbidity, mortality, and healthcare costs. This review focuses on the mechanisms underlying resistance in key bacterial pathogens and highlights how aging-related factors like immunosenescence, frailty, and multimorbidity increase the burden of infections from MDROs in this population. Novel strategies to mitigate resistance include the development of next-generation antibiotics like teixobactin and cefiderocol, innovative therapies such as bacteriophage therapy and antivirulence treatments, and the implementation of antimicrobial stewardship programs to optimize antibiotic use. Furthermore, advanced molecular diagnostic techniques, including nucleic acid amplification tests and next-generation sequencing, allow for faster and more precise identification of resistant pathogens. Vaccine development, particularly through innovative approaches like multi-epitope vaccines and nanoparticle-based platforms, holds promise in preventing MDRO infections among the elderly. The role of machine learning (ML) in predicting resistance patterns and aiding in vaccine and antibiotic development is also explored, offering promising solutions for personalized treatment and prevention strategies in the elderly. By integrating cutting-edge diagnostics, therapeutic innovations, and ML-based approaches, this review underscores the importance of multidisciplinary efforts to address the global challenge of antibiotic resistance in aging populations.

Severe aspiration pneumonia in the elderly

The global population is aging at an unprecedented rate, resulting in a growing and vulnerable elderly population in need of efficient comprehensive healthcare services that include long-term care and skilled nursing facilities. In this context, severe aspiration pneumonia, a condition that carries substantial morbidity, mortality, and financial burden, especially among elderly patients requiring admission to the intensive care unit, has attracted greater concern. Aspiration pneumonia is defined as a pulmonary infection related to aspiration or dysphagia in etiology. Prior episodes of coughing on food or liquid intake, a history of relevant underlying conditions, abnormalities on videofluoroscopy or water swallowing, and gravity-dependent shadow distribution on chest imaging are among the clues that suggest aspiration. Patients with aspiration pneumonia tend to be elderly, frail, and suffering from more comorbidities than those without this condition. Here, we comprehensively address the epidemiology, clinical characteristics, diagnosis, treatment, prevention, and prognosis of severe aspiration community-acquired pneumonia in the elderly to optimize care of this high-risk demographic, enhance outcomes, and minimize the healthcare costs associated with this illness. Emphasizing preventive measures and effective management strategies is vital in ensuring the well-being of our aging population.

A phage nucleus-associated protein from the jumbophage Churi inhibits bacterial growth through protein translation interference

Antibacterial proteins inhibiting Pseudomonas aeruginosa have been identified in various phages and explored as antibiotic alternatives. Here, we isolated a phiKZ-like phage, Churi, which encodes 364 open reading frames. We examined 15 early-expressed phage proteins for their ability to inhibit bacterial growth, and found that gp335, closely related to phiKZ-gp14, exhibits antibacterial activity. Similar to phiKZ-gp14, recently shown to form a complex with the P. aeruginosa ribosome, we predict experimentally that gp335 interacts with ribosomal proteins, suggesting its involvement in protein translation. GFP-tagged gp335 clusters around the phage nucleus as early as 15 minutes post-infection and remains associated with it throughout the infection, suggesting its role in protein expression in the cell cytoplasm. CRISPR-Cas13-mediated deletion of gp355 reveals that the mutant phage has a prolonged latent period. Altogether, we demonstrate that gp335 is an antibacterial protein of nucleus-forming phages that associates with the ribosomes at the phage nucleus.

Potential Impact of Higher-Valency Pneumococcal Conjugate Vaccines Among Adults in Different Localities in Germany

Next-generation pneumococcal conjugate vaccines (PCVs) have been approved for use. The serotype distribution of pneumococcal isolates can vary between regions. To understand the potential impacts of new PCVs, we evaluated trends in invasive pneumococcal disease (IPD) among adults in Germany at a local level using Bayesian hierarchical logistic regression. There was little spatial variation in IPD cases caused by 13-valent PCV serotypes, which dropped from 60% of IPD cases in 2006 to 30% in 2018. More than half of IPD cases in 2018 were attributable to serotypes covered by new PCVs (15-valent and 20-valent PCVs), which suggests they could further reduce the burden of IPD.

Post-marketing safety of lorlatinib: a real-world study based on the FDA adverse event reporting system

Background

Lorlatinib displays marked systemic and intracranial efficacy against anaplastic lymphoma kinase (ALK) positive non-small cell lung cancer (NSCLC). We aimed to establish the safety profile of lorlatinib based on the Food and Drug Administration Adverse Event Reporting System (FAERS).

Methods

Reports from the FAERS between 2019 and 2023 were collected to conduct the disproportionality analysis. Reporting odds ratio (ROR) was employed to detect the potential adverse events (AEs) related to lorlatinib. The clinical characteristics, age and gender differences, time to onset of AEs were also investigated.

Results

A total of 2,941 AE reports were found to be associated with lorlatinib among the 8,818,870 AE reports obtained from the FAERS database. 167 lorlatinib-related AE signals were identified. The frequently reported AEs including hypercholesterolemia, oedema, and cognitive disorder were in line with those observed in clinical trials and drug instruction. However, AEs such as interstitial lung disease and AV block indicated in the drug label require further evaluation. More attention should be paid to the new potential unexpected AEs including pulmonary arterial hypertension and radiation necrosis. Furthermore, we examined the specific high-risk AEs of different ages and genders. In addition, majority of AEs occurred within the first 2 months after lorlatinib initiation with a median onset time of 51 days.

Conclusion

Our study provides valuable insight into the post-marketing safety profile of lorlatinib, which can potentially benefit the rational and safe administration of lorlatinib in the clinic. Further prospective studies are needed to validate the associations between lorlatinib and the identified AEs.

ROS-Responsive Poly(α-l-lysine)-Based Nanoparticles Loaded with Doxycycline Combat Oxidative Stress and Bacterial Infection

Bacterial pneumonia is one of the major threats in clinical practice, and the reactive oxygen species (ROS) generated at the infection site can exacerbate the damage. Currently, conventional antibiotic therapies have low utilization, and their excessive use can result in substantial toxicity. Nanocarrier systems provide an ideal approach for treating bacterial infection by facilitating more efficient utilization of antibiotics. In this study, the ROS-responsive amphiphilic nanoparticles (NPs) are developed and used to encapsulate the antibiotic doxycycline (DOXY) to achieve antibacterial and antioxidant functionalities. The NPs are prepared from poly(α-l-lysine) (α-PLL) and phenylboronic acid pinacol ester simultaneously conjugated carbonyldiimidazole (abbreviated as CDIPB). The phenylboronic acid ester groups on CDIPB could react with excessive ROS to suppress oxidative damage at the infection site. The ROS-responsive degradation of CDIPB also facilitates the rapid release of internal DOXY, effectively killing the accumulated bacteria. Additionally, in vitro cell experiments demonstrate the good biocompatibility of the NPs. These results suggest that the ROS-responsive amphiphilic nanoparticles can serve as a novel nanoplatform for the treatment of bacterial pneumonia.

The prostaglandin D2 antagonist asapiprant ameliorates clinical severity in young hosts infected with invasive Streptococcus pneumoniae

Streptococcus pneumoniae (pneumococcus) remains a serious cause of pulmonary and systemic infections globally, and host-directed therapies are lacking. The aim of this study was to test the therapeutic efficacy of asapiprant, an inhibitor of prostaglandin D2 signaling, against pneumococcal infection. Treatment of young mice with asapiprant after pulmonary infection with invasive pneumococci significantly reduced systemic spread, disease severity, and host death. Protection was specific against bacterial dissemination from the lung to the blood but had no effect on pulmonary bacterial burden. Asapiprant-treated mice had enhanced antimicrobial activity in circulating neutrophils, elevated levels of reactive oxygen species (ROS) in lung macrophages/monocytes, and improved pulmonary barrier integrity indicated by significantly reduced diffusion of fluorescein isothiocyanate (FITC)-dextran from lungs into the circulation. These findings suggest that asapiprant protects the host against pneumococcal dissemination by enhancing the antimicrobial activity of immune cells and maintaining epithelial/endothelial barrier integrity in the lungs.

Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Reliance on sources of immunization information and vaccine uptake among older adults in a rural state: The mediating role of trust

Older adults are more vulnerable to the negative impacts of infectious diseases than younger individuals. However, regardless of the importance and effectiveness of vaccines to reduce morbidity and mortality, issues remain with vaccine hesitancy among this population. Older adults' sources of immunization information and their level of trust in those sources may play a role in their vaccination behaviors. This research aimed to better understand the role of information sources and related issues of trust as related to vaccine uptake among older adults. A community-based, cross-sectional survey was conducted with 901 older adults in North Dakota in May-July 2022. Measures included extent of reliance on specific sources of immunization information, levels of trust, and uptake for influenza, pneumonia, shingles, and COVID-19 vaccinations. Immunization information sources were grouped into medical experts, informal, and public outlets. Results indicated older adults were more likely to rely on medical experts than informal sources or public outlets for immunization information. Greater reliance on medical experts was associated with a greater likelihood of vaccine uptake for all vaccines, while reliance on public outlets was associated with a greater likelihood of vaccine uptake only for COVID primary series and boosters. Reliance on informal sources for immunization information was associated with a reduced likelihood of vaccine uptake for all vaccines except shingles. Nearly half of respondents were uncertain who to trust for vaccine information. Uncertainty who to trust for immunization information significantly mediated the associations between reliance on medical experts and uptake for most vaccines indicating that trust in medical experts fosters vaccine uptake. Increasing reliance on medical experts as sources of immunization information is vital to increasing vaccine uptake among older adults. Additionally, this population must be assisted in increasing their ability to successfully assess the trustworthiness of immunization information sources.

Carbapenem-resistant Acinetobacter baumannii and Ventilator-associated Pneumonia; Epidemiology, Risk Factors, and Current Therapeutic Approaches

Acinetobacter baumannii is one of the primary pathogens responsible for healthcare-associated infections. It is related to high rates of morbidity and mortality globally, mainly because of its high capacity to develop resistance to antimicrobials. Nowadays, carbapenem-resistant A. baumannii (CRAB) has increased and represents a significant concern among carbapenem-resistant organisms. It is also a key pathogen associated with ventilator-associated pneumonia. CRAB was placed on the critical group of the universal priority list of the World Health Organization for antibiotic-resistant bacteria, to mention the importance of research development and the urgency of new antibiotics. Patients with severe CRAB infections currently face significant treatment challenges. Some approaches have been taken to deal with CRAB, such as combination therapy and the synergistic effect of certain antibiotics, but the best antibiotic regimen is still unknown. In this narrative review, we attempt to clarify the issues, including epidemiology, risk factors, and current treatment options for CRAB.

Epidemiology of community-acquired pneumonia caused by S treptococcus pneumoniae in older adults: a narrative review

PURPOSE OF REVIEW

This review covers updated perspectives on different aspects of pneumococcal community-acquired pneumonia (pCAP), including the epidemiology, clinical presentation, risk factors, antibiotic treatment, and existing preventive strategies in older adults.

RECENT FINDINGS

pCAP remains the most prevalent condition among lower respiratory tract infections in the older adults according to Global Burden of Diseases 2019. Older adults can display atypical symptoms such as confusion, general clinical deterioration, new onset of and exacerbation of underlying illness that might trigger clinical suspicion of pCAP. Older adults with pCAP often experience increased disease severity and a higher risk of pulmonary complications compared with younger individuals, owing to age-related changes in immunity and a higher prevalence of comorbidities. Vaccination stands fundamental for prevention, emphasizing the need for effective immunization strategies, specifically tailored for older adults. There is a pressing need to reinforce efforts aimed at boosting pneumococcal vaccination rates.

SUMMARY

Despite a high morbidity and mortality, the burden of pCAP, in particular hospital admission and occurrence of invasive infections, among the elderly population is not sufficiently documented. This review findings emphasize the substantial burden of pCAP in this vulnerable population, driven by factors such as advancing age and underlying comorbidities. The emergence of antibiotic-resistant pneumococcal strains further complicates treatment decisions and highlights the importance of tailored approaches for managing pCAP in older adults.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol

BACKGROUND

Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions.

METHOD

We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat.

DISCUSSION

To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions.

TRIAL REGISTRATION

www.

CLINICALTRIALS

org NCT05546073 (Date of registration: September 19th, 2022).

Infection with multi‑drug resistant organisms in patients with limb fractures: Analysis of risk factors and pathogens

Infection with multi-drug resistant organisms (MDROs) has emerged as a global problem in medical institutions. Overuse of antibiotics is the main cause of drug resistance. Notably, the incidence of infection with MDROs increases in patients with limb fractures who have undergone invasive surgery. The present study aimed to analyze the risk factors for postoperative MDROs infection in a cohort of patients with limb fractures. A retrospective study was performed on the data of patients with fractures between January 2020 and August 2022. Postoperative surgical site infection occurred in 114 patients in total, of which 47 were infected with MDROs. Univariate logistic regression analysis and multivariate binary logistic regression were used to confirm the associations between independent risk factors and MDRO infection. A total of 155 bacteria were collected from patients with MDROs infection and patients with non-MDROs infection, of which 66.5% were gram-positive bacteria and 33.5% were gram-negative. Staphylococcus aureus accounted for 26.5% of the 155 pathogens. MDROs, such as methicillin-resistant S. aureus and extended-spectrum β-lactamases-positive gram-negative bacillus, were detected after antibiotic treatment. Univariate analysis indicated that the number of antibiotics administered, being bedridden, repeat infection, operative time and repeated operation were different in the two groups. In addition, univariate logistic analysis indicated that being bedridden (OR, 3.98; P=0.001), administration of >2 antibiotics (OR, 2.42; P=0.026), an operative time of >3 h (OR, 3.37; P=0.003), repeated infection (OR, 3.08; P=0.009) and repetition of procedures (OR, 2.25; P=0.039) were individual risk factors for MDRO infection. Multivariate analysis showed that being bedridden (OR, 2.66; P=0.037), repeated infection (OR, 4.00; P=0.005) and an operative time of >3 h (OR, 2.28; P=0.023) were risk factors of MDRO infection. In conclusion, constrained antibiotic use, shortened operative time and increased activity duration can effectively prevent surgical-site infection with MDROs in patients with fractures.

The Association between Statins Intake and Risk of Post Stroke Pneumonia: A Systematic Review and Meta-Analysis

AIM

This research aimed to examine the relationship between the intake of statins and the risk of post-stroke pneumonia in a systematic review and meta-analysis study.

METHODS

An extensive search of published articles on March 21st, 2023, was done in several databases, like Web of Science (ISI), PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. The Newcastle Ottawa Scale (NOS) checklist was employed to evaluate the quality of observational studies. Statistical tests (Chi-square test and I2) and graphical techniques (Forest plot) were used to determine whether heterogeneity existed in the meta-analysis studies. Funnel plots and Begg and Egger's tests were used to assess the publication bias.

RESULTS

Seven studies (5 cohort and 2 case-control studies) were retrieved to examine the association between statins and post-stroke pneumonia. The sample size of the studies compiled in the meta- analysis was obtained to be 68,966 participants. Meta-analysis demonstrated that the overall odds of post-stroke pneumonia in the statin group was equal to 0.87 (95% CI: 0.67 - 1.13; p-value 0.458). Subgroup analysis indicated that the odds of post-stroke pneumonia in the statin group was equal to 0.93 (95% CI: 0.73-1.18; p-value = 0.558) in the cohort studies, and equal to 0.92 (95% CI: 0.37-2.26; p-value = 0.857) in the case-control studies. The examination of the association between the intake of statins and post-stroke pneumonia showed no evidence of publication bias (Begg's test, p-value = 0.368; Eggers test, p-value = 0.282).

CONCLUSION

In this study, no relationship has been observed between receiving statins and the risk of post-stroke pneumonia.

Implementation of a centralized, web-based surveillance for healthcare associated infections among residents of long-term care facilities in Italy

Objective

The Italian National Action Plan to contrast AMR identified among its objectives the development and implementation of a national Healthcare-Associated Infection (HAI) surveillance system based on European Centre for Disease Prevention and Control (ECDC) indications, through point prevalence surveys (PPS) of HAIs and antibiotic use in acute-care hospitals and long-term care facilities (LTCFs). We aimed to assess feasibility and appropriateness of proposed tools for a national surveillance system of HAIs and antibiotic use in LTCFs.

Study design

Point prevalence survey.

Methods

A pilot PPS was conducted between May-June 2022, among 15 LTCFs of 7 Italian regions. Data were collected in a single day in each LTCF, at the LTCF, ward, and resident levels, using a web-based data collection tool developed ad hoc. Data collector teams of each facility were invited to complete a questionnaire investigating opinions on the proposed tools.

Results

Among 1025 included residents, the prevalence of residents with at least one HAI was 2.5% (95% CI 1.7%-3.7%) considering all HAIs and 2.2% (95% CI 1.3%-3%) without considering SARS-CoV-2 infections. The prevalence of antimicrobial use was 3% (95% CI 0.2%-4.3%). Overall, most respondents were satisfied with the web-based software, training and protocol, even though some difficulties were reported.

Conclusions

A national surveillance network was established, which will facilitate future surveillance efforts. Further studies are necessary to evaluate the impact of the pandemic on HAI transmission and antibiotic use in LTCFs.

A score to predict Pseudomonas aeruginosa infection in older patients with community-acquired pneumonia

BACKGROUND

In Thailand, the incidence of community-acquired pseudomonal pneumonia among 60- to 65-year-olds ranges from 10.90% to 15.51%, with a mortality rate of up to 19.00%. Antipseudomonal agents should be selected as an empirical treatment for elderly patients at high risk for developing this infection. The purpose of this study was to identify risk factors and develop a risk predictor for Pseudomonas aeruginosa infection in older adults with community-acquired pneumonia (CAP).

METHODS

A retrospective data collection from an electronic database involved the elderly hospitalized patients with P. aeruginosa- and non-P. aeruginosa-causing CAP, admitted between January 1, 2016, and June 30, 2021. Risk factors for P. aeruginosa infection were analysed using logistic regression, and the instrument was developed by scoring each risk factor based on the beta coefficient and evaluating discrimination and calibration using the area under the receiver operating characteristic curve (AuROC) and observed versus predicted probability (E/O) ratio.

RESULTS

The inclusion criteria were met by 81 and 104 elderly patients diagnosed with CAP caused by P. aeruginosa and non-P. aeruginosa, respectively. Nasogastric (NG) tube feeding (odd ratios; OR = 40.68), bronchiectasis (B) (OR = 4.13), immunocompromised condition (I) (OR = 3.76), and other chronic respiratory illnesses (r) such as atelectasis, pulmonary fibrosis, and lung bleb (OR = 2.61) were the specific risk factors for infection with P. aeruginosa. The "60-B-r-I-NG" risk score was named after the 4 abbreviated risk variables and found to have good predicative capability (AuROC = 0.77) and accuracy comparable to or near true P. aeruginosa infection (E/O = 1). People who scored at least two should receive empirically antipseudomonal medication.

CONCLUSIONS

NG tube feeding before admission, bronchiectasis, immunocompromisation, atelectasis, pulmonary fibrosis and lung bleb were risk factors for pseudomonal CAP in the elderly. The 60-B-r-I-NG was developed for predicting P. aeruginosa infection with a high degree of accuracy, equal to or comparable to the existing P. aeruginosa infection. Antipseudomonal agents may be started in patients who are at least 60 years old and have a score of at least 2 in order to lower mortality and promote the appropriate use of these medications.

The severity of pneumonia and its association with socio-demographic factors among children under five years old in Wasit governorate hospitals, Iraq

Background

Pneumonia is the leading infectious cause of death among children under five globally.

Objective

The study aims to determine socio-demographic factors associated with the severity of pneumonia among children under five in Wasit Governorate.

Methods

A cross-sectional study and convenience sampling (non-probability) were conducted among 477 children admitted to Wasit governorate hospitals. This sample was distributed throughout five hospitals selected using convenience sampling techniques, including AL-Zahra Hospital, AL-Numaniyah General Hospital, AL-Karama Teaching Hospital, Martyr Fairouz General Hospital, and AL-Kut Gynecology Hospital. It was conducted from October 1st, 2022, to May 1st, 2023. Through questionnaires, data were collected and analyzed through descriptive and inferential statistics.

Results

The results showed that the participants' distribution according to pneumonia severity was such that the majority of children (81%) included in the study suffered from pneumonia. 14% of children suffered from very severe pneumonia, and 5% suffered from severe pneumonia. The children at risk of developing pneumonia were within the age group of 1-11 months (55.6%), were male (60.6%), and resided in urban areas (63.7%). Both the mother and the father had completed their primary education (50.9% and 47.4%, respectively), and 99.4% and 97.5% of the mothers were married and housewives. More than half of the fathers, 59.5%, were self-employed, and 25.6% suffered from house overcrowding. In addition, 65% had low socioeconomic status. There was a significant relationship between pneumonia severity and the father's occupation and socioeconomic status.

Conclusions

This study concludes that pneumonia was the most common diagnosis at admission. Among the risk factors studied, low socioeconomic status and the father's occupation were significant risk factors for pneumonia in children.

Utility of the New Early Warning Score (NEWS) in combination with the neutrophil-lymphocyte ratio for the prediction of prognosis in older patients with pneumonia

OBJECTIVE

Predictors of prognosis are necessary for use in routine clinical practice for older patients with pneumonia, given the ageing of the population. Recently, the National Early Warning Score (NEWS), a comprehensive predictor of severity that consists solely of physiological indicators, has been proposed to predict the prognosis of pneumonia. The neutrophil/lymphocyte ratio (NLR) is a simple index of inflammation that may also be predictive of pneumonia. In the present study, we aimed to determine whether NEWS or a combination of NEWS and NLR predicts mortality in older patients with pneumonia.

DESIGN

A retrospective cohort study.

SETTING

A general hospital in Japan.

PARTICIPANTS

We collected data from patients aged ≥65 years with pneumonia who were admitted between 2018 and 2020 (n=282; age=85.3 (7.9)). Data regarding vital signs, demographics and the length of hospital stay, in addition to the NEWS and NLR, were extracted from the participants' electronic medical records.

INTERVENTION

The utility of the combination of NEWS and NLR was assessed using NEWS×NLR and NEWS+NLR.

MAIN OUTCOME MEASURES

Their predictive ability for 30-day mortality as the primary outcome was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

According to the NEWS classification, 80 (28.3%), 64 (22.7%) and 138 (48.9%) of the participants were at low, medium and high risk of mortality, respectively. The 30-day mortality for the entire cohort was 9.2% (n=26), and the mortality rate increased with the NEWS classification: low, 1.3%; medium, 7.8%; and high, 14.5%. The NLRs were 6.0 (4.2-9.8), 6.8 (4.8-10.4) and 14.6 (9.4-22.2), respectively (p<0.001). The areas under the ROC curves for 30-day mortality were 0.73 for the NEWS score, 0.84 for NEWS×NLR and 0.83 for NEWS+NLR, indicating that the combinations represent superior predictors of mortality to the NEWS alone. NEWS×NLR and NEWS+NLR tended to have better sensitivity, accuracy, positive predictive value and negative predictive value than NEWS alone (p=0.06).

CONCLUSIONS

A combination of the NEWS and NLR (NEWS×NLR or NEWS+NLR) may be superior to the NEWS alone for the prediction of 30-day mortality in older patients with pneumonia. However, further validation of these combinations for use in the prediction of prognosis is required.

The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study

BACKGROUND

Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU.

METHODS

This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes.

RESULTS

A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment.

CONCLUSIONS

The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.

COVID-19 in Adult Patients with Hematological Malignancies-Lessons Learned after Three Years of Pandemic

The COVID-19 pandemic is undoubtedly the most difficult health challenge of the 21st century with more than 600 million laboratory-confirmed SARS-CoV-2 infections and over 6.5 million deaths worldwide. The coronavirus pandemic contributed to rapid development of mRNA vaccines, which, along with new antiviral drugs, have been the subject of extensive research for many decades. Nevertheless, elderly, multi-morbid and immunocompromised patients continue to face a more severe clinical course and a higher risk of death from COVID-19, even now that the risk of COVID-19 in the general population is significantly reduced due to the introduction of global vaccination strategies. In this paper, we present the mechanisms of increased susceptibility to infectious complications and the evolution of the clinical course of COVID-19 in patients with hematological malignancies, taking into account the mutation of the virus and the introduction of vaccines and new antiviral drugs. We also present current recommendations for prophylactic and therapeutic management in patients with hematological malignancies.

Vaccine-Preventable Diseases in Older Adults

Older adults are at an increased risk of vaccine-preventable diseases partly because of physiologic changes in the immune and other body systems related to age and/or accumulating comorbidities that increase the vulnerability to infections and decrease the response to vaccines. Strategies to improve the response to vaccines include using a higher antigenic dose (such as in the high-dose inactivated influenza vaccines) as well as adding adjuvants (such as MF59 in the adjuvanted inactivated influenza vaccine).

Multidrug-resistant Gram-negative bacilli recovered from respiratory and blood specimens from adults: the ATLAS surveillance program in European hospitals, 2018-2020

The population of people ≥65 years of age is increasing in Europe. Pneumonia is a prominent cause of infection in this age group. These patients may be at heightened risk of infection caused by multidrug-resistant (MDR) organisms owing to their frequent and prolonged contact with healthcare facilities as well as frequent exposure to antimicrobials and medical devices. However, ATLAS surveillance data did not demonstrate any difference in the incidence of MDR Gram-negative pathogens among patients ≥65 years of age and those aged <65 years. Higher rates of carbapenem-resistant Enterobacterales (CRE) and MDR Pseudomonas aeruginosa were observed in patients aged 18-64 years (10.7% and 32.3%, respectively) than in patients aged ≥65 years (5.0% and 25.4%, respectively). Significant therapeutic gaps were identified for CRE, carbapenem-resistant Acinetobacter baumannii (65.9% of isolates tested) and MDR P. aeruginosa, which continue to be prevalent in European hospitals. Among the antimicrobials evaluated, only colistin provided >75% in vitro coverage for these pathogens.

Frailty and outcomes in lacunar stroke

BACKGROUND

Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described.

OBJECTIVE

To analyze the association between frailty and outcomes in LS.

METHODS

Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10^th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death.

RESULTS

Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU.

CONCLUSION

Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.

Effect of vaccine on prognosis and mortality in COVID-19

INTRODUCTION:The purpose of our study is to reveal the factors affecting the clinical course of the Covid-19 infection and mortality in the immunized and non-immunized 65-year-old and older patients. METHOD AND MATERIAL: The study was conducted by screening the files of 1,642 65-year-old and older Covid-19 cases in total.1337 cases enrolled in the study were categorized into two groups as follows: the patients vaccinated with the 2nd dose of CoronaVac but infected with Covid-19 after the 14-day period during which immunization is supposed to develop (Group I) and the patients who have never been vaccinated, who have been vaccinated with a single dose, or who have been infected with Covid-19 before the 14-day period is completed in spite of being vaccinated with the 2nd dose (Group II).The groups were compared with each other with regard to mortality and the factors affecting mortality. RESULTS: The length of ICU stay and the total length of hospital stay were significantly longer in Group II than Group I ( p

Association between IL-38 and inflammatory indicators in patients with bacterial pneumonia

BACKGROUND

IL-38, a recently discovered cytokine of IL-1 family, exerts immunoregulatory activities in multi-type inflammatory diseases. However, its expression level and underlying clinical importance for IL-38 in respiratory bacterial infections remain unknown.

METHODS

Thirty-five patients with bacterial pneumonia and twenty age- and gender- matched healthy individuals were enrolled in the study to determine serum IL-38 concentrations by ELISA. Then, the correlation between serum IL-38 levels and clinical features were analyzed and ROC curve was used to evaluate the potential diagnostic value for bacterial infections. In vitro, LPS-stimulated human respiratory epithelial cell model was employed to explore immunomodulatory mechanism of IL-38 in pulmonary infections.

RESULTS

Elevated serum levels of IL-38 were determined in patients with bacterial pneumonia when compared with healthy controls. In addition, serum IL-38 levels were negatively correlated with clinical inflammation parameters, including WBC count, CRP, PCT and proinflammatory IL-6 and IL-8. In vitro, we demonstrated that recombinant IL-38 was able to remarkably inhibit expression of proinflammatory IL-6, IL-8, IL-1β and TNF-α as well as adhesion molecule ICAM-1, which were partially mediated by attenuated activation of STAT3 and NF-κB signal cascades in BEAS-2B cells. Furthermore, we identified the diagnostic efficiency of IL-38 in discriminating patients with bacterial pneumonia from healthy individuals.

CONCLUSIONS

Our study indicates higher serum IL-38 levels in patients with bacterial pneumonia are involved in anti-inflammatory activities in respiratory infections revealing a critical role of IL-38 in attenuating excessive pulmonary inflammation against exogenous pathogens. More importantly, IL-38 exhibited a potential novel biomarker for bacterial pneumonia. Thus, our data may provide useful insights for both clinical and basic research for bacterial pneumonia diagnosis.

Nanomaterials for Delivering Antibiotics in the Therapy of Pneumonia

Bacterial pneumonia is one of the leading causes of death worldwide and exerts a significant burden on health-care resources. Antibiotics have long been used as first-line drugs for the treatment of bacterial pneumonia. However, antibiotic therapy and traditional antibiotic delivery are associated with important challenges, including drug resistance, low bioavailability, and adverse side effects; the existence of physiological barriers further hampers treatment. Fortunately, these limitations may be overcome by the application of nanotechnology, which can facilitate drug delivery while improving drug stability and bioavailability. This review summarizes the challenges facing the treatment of bacterial pneumonia and also highlights the types of nanoparticles that can be used for antibiotic delivery. This review places a special focus on the state-of-the-art in nanomaterial-based approaches to the delivery of antibiotics for the treatment of pneumonia.

Using the Oral Assessment Guide to Predict the Onset of Pneumonia in Residents of Long-Term Care and Welfare Facilities: A One-Year Prospective Cohort Study

Appropriate oral health care, depending on oral assessments, reduces the onset of pneumonia. However, the relationship between risk evaluation using an oral assessment tool and pneumonia in residents of long-term care facilities has not been fully elucidated. In the present study, we aim to examine the relationship between the total scores of the Oral Assessment Guide (OAG) and the incidence of pneumonia after a one-year baseline study of residents in long-term care facilities. The settings for sampling include nine long-term care facilities in Hokkaido. At baseline, there were 267 study subjects. A total of 72 individuals dropped out and 11 individuals met the exclusion criteria. Therefore, the subject sample included 184 individuals. Among the subjects included in our analyses, eight individuals developed pneumonia (six males and two females). A multiple logistic regression analysis was performed with the risk factors for developing pneumonia. Evaluations were performed based on the odds ratio (OR) and 95% confidence interval (CI). We observed that the OR for pneumonia onset was 2.29 (CI: 1.27-4.14) after being adjusted for pneumonia risk factors. Therefore, it was suggested that the total scores of the OAG could be used to screen for the risk of pneumonia onset in residents of long-term care and welfare facilities.

Exploration of prognostic factors for prediction of mortality in elderly CAP population using a nomogram model

Background

The incidence and mortality rate of community-acquired pneumonia (CAP) in elderly patients were higher than the younger population. The assessment tools including CURB-65 and qSOFA have been applied in early detection of high-risk patients with CAP. However, several disadvantages exist to limit the efficiency of these tools for accurate assessment in elderly CAP. Therefore, we aimed to explore a more comprehensive tool to predict mortality in elderly CAP population by establishing a nomogram model.

Methods

We retrospectively analyzed elderly patients with CAP in Minhang Hospital, Fudan University. The least absolute shrinkage and selection operator (LASSO) logistic regression combined with multivariate analyses were used to select independent predictive factors and established nomogram models via R software. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance.

Results

LASSO and multiple logistic regression analyses showed the age, pulse, NLR, albumin, BUN, and D-dimer were independent risk predictors. A nomogram model (NB-DAPA model) was established for predicting mortality of CAP in elderly patients. In both training and validation set, the area under the curve (AUC) of the NB-DAPA model showed superiority than CURB-65 and qSOFA. Meanwhile, DCA revealed that the predictive model had significant net benefits for most threshold probabilities.

Conclusion

Our established NB-DAPA nomogram model is a simple and accurate tool for predicting in-hospital mortality of CAP, adapted for patients aged 65 years and above. The predictive performance of the NB-DAPA model was better than PSI, CURB-65 and qSOFA.

INTRAPULMONARY TREATMENT WITH A NOVEL TLR4 AGONIST CONFERS PROTECTION AGAINST KLEBSIELLA PNEUMONIA

ABSTRACT

Objectives: Nosocomial pneumonia is a common complication in critically ill patients. The goal of this study was to examine the efficacy of the Toll-like receptor 4 agonist 3-deacyl phosphorylated hexacyl disaccharide (3D PHAD), in a clinically relevant murine model of pneumonia, and assess the cellular mechanisms that mediate the protective response. Design: Mice received intrapulmonary 3D PHAD (20 μg) or vehicle for 2 consecutive days before challenge with intrapulmonary Klebsiella pneumoniae (2.3 × 10 3 colony-forming units). Mice were followed for 14-day survival, pulmonary K. pneumoniae burden, lung leukocyte profile, leukocyte phagocytic capacity, and cytokine production. Pneumonia severity and leukocyte recruitment were further assessed by histological evaluation. Setting: Research laboratory. Subjects: Wild-type, male C57BL/6 J mice. Interventions: Intrapulmonary treatment with 20 μg 3D PHAD for 2 consecutive days. Measurements and main results: Intrapulmonary treatment with 3D PHAD decreased lung K. pneumoniae colony-forming units and pneumonia severity with an associated improvement in survival compared with mice treated with vehicle. The numbers of neutrophils, monocytes, and macrophages in the lungs of 3D PHAD-treated mice were higher than those in vehicle-treated mice before infection but were not significantly different from vehicle-treated mice at 48 h after K. pneumoniae challenge. Lung innate leukocytes from 3D PHAD-treated mice had increased phagocytic capacity. Treatment with 3D PHAD alone increased cytokines in the lungs but decreased cytokines in plasma during K. pneumoniae pneumonia as compared with control. Conclusions: Intrapulmonary treatment with 3D PHAD augments innate immunity in the lung and facilitates resistance to K. pneumoniae pneumonia.

Incidence of community acquired lower respiratory tract disease in Bristol, UK during the COVID-19 pandemic: A prospective cohort study

Background

The emergence of COVID-19 and public health measures implemented to reduce SARS-CoV-2 infections have both affected acute lower respiratory tract disease (aLRTD) epidemiology and incidence trends. The severity of COVID-19 and non-SARS-CoV-2 aLRTD during this period have not been compared in detail.

Methods

We conducted a prospective cohort study of adults age ≥18 years admitted to either of two acute care hospitals in Bristol, UK, from August 2020 to November 2021. Patients were included if they presented with signs or symptoms of aLRTD (e.g., cough, pleurisy), or a clinical or radiological aLRTD diagnosis.

Findings

12,557 adult aLRTD hospitalisations occurred: 10,087 were associated with infection (pneumonia or non-pneumonic lower respiratory tract infection [NP-LRTI]), 2161 with no infective cause, with 306 providing a minimal surveillance dataset. Confirmed SARS-CoV-2 infection accounted for 32% (3178/10,087) of respiratory infections. Annual incidences of overall, COVID-19, and non- SARS-CoV-2 pneumonia were 714.1, 264.2, and 449.9, and NP-LRTI were 346.2, 43.8, and 302.4 per 100,000 adults, respectively. Weekly incidence trends in COVID-19 aLRTD showed large surges (median 6.5 [IQR 0.7-10.2] admissions per 100,000 adults per week), while other infective aLRTD events were more stable (median 14.3 [IQR 12.8-16.4] admissions per 100,000 adults per week) as were non-infective aLRTD events (median 4.4 [IQR 3.5-5.5] admissions per 100,000 adults per week).

Interpretation

While COVID-19 disease was a large component of total aLRTD during this pandemic period, non- SARS-CoV-2 infection still caused the majority of respiratory infection hospitalisations. COVID-19 disease showed significant temporal fluctuations in frequency, which were less apparent in non-SARS-CoV-2 infection. Despite public health interventions to reduce respiratory infection, disease incidence remains high.

Funding

AvonCAP is an investigator-led project funded under a collaborative agreement by Pfizer.

Incidence of community acquired lower respiratory tract disease in Bristol, UK during the COVID-19 pandemic: A prospective cohort study

BACKGROUND

The emergence of COVID-19 and public health measures implemented to reduce SARS-CoV-2 infections have both affected acute lower respiratory tract disease (aLRTD) epidemiology and incidence trends. The severity of COVID-19 and non-SARS-CoV-2 aLRTD during this period have not been compared in detail.

METHODS

We conducted a prospective cohort study of adults age ≥18 years admitted to either of two acute care hospitals in Bristol, UK, from August 2020 to November 2021. Patients were included if they presented with signs or symptoms of aLRTD (e.g., cough, pleurisy), or a clinical or radiological aLRTD diagnosis.

FINDINGS

12,557 adult aLRTD hospitalisations occurred: 10,087 were associated with infection (pneumonia or non-pneumonic lower respiratory tract infection [NP-LRTI]), 2161 with no infective cause, with 306 providing a minimal surveillance dataset. Confirmed SARS-CoV-2 infection accounted for 32% (3178/10,087) of respiratory infections. Annual incidences of overall, COVID-19, and non- SARS-CoV-2 pneumonia were 714.1, 264.2, and 449.9, and NP-LRTI were 346.2, 43.8, and 302.4 per 100,000 adults, respectively. Weekly incidence trends in COVID-19 aLRTD showed large surges (median 6.5 [IQR 0.7-10.2] admissions per 100,000 adults per week), while other infective aLRTD events were more stable (median 14.3 [IQR 12.8-16.4] admissions per 100,000 adults per week) as were non-infective aLRTD events (median 4.4 [IQR 3.5-5.5] admissions per 100,000 adults per week).

INTERPRETATION

While COVID-19 disease was a large component of total aLRTD during this pandemic period, non- SARS-CoV-2 infection still caused the majority of respiratory infection hospitalisations. COVID-19 disease showed significant temporal fluctuations in frequency, which were less apparent in non-SARS-CoV-2 infection. Despite public health interventions to reduce respiratory infection, disease incidence remains high.

FUNDING

AvonCAP is an investigator-led project funded under a collaborative agreement by Pfizer.

Nanoparticles reduce monocytes within the lungs to improve outcomes after influenza virus infection in aged mice

Older people exhibit dysregulated innate immunity to respiratory viral infections, including influenza and SARS-CoV-2, and show an increase in morbidity and mortality. Nanoparticles are a potential practical therapeutic that could reduce exaggerated innate immune responses within the lungs during viral infection. However, such therapeutics have not been examined for effectiveness during respiratory viral infection, particular in aged hosts. Here, we employed a lethal model of influenza viral infection in vulnerable aged mice to examine the ability of biodegradable, cargo-free nanoparticles, designated ONP-302, to resolve innate immune dysfunction and improve outcomes during infection. We administered ONP-302 via i.v. injection to aged mice at day 3 after infection, when the hyperinflammatory innate immune response was already established. During infection, we found that ONP-302 treatment reduced the numbers of inflammatory monocytes within the lungs and increased their number in both the liver and spleen, without impacting viral clearance. Importantly, cargo-free nanoparticles reduced lung damage, reduced histological lung inflammation, and improved gas exchange and, ultimately, the clinical outcomes in influenza-infected aged mice. In conclusion, ONP-302 improves outcomes in influenza-infected aged mice. Thus, our study provides information concerning a practical therapeutic, which, if translated clinically, could improve disease outcomes for vulnerable older patients suffering from respiratory viral infections.

Incidence of acute lower respiratory tract disease hospitalisations, including pneumonia, among adults in Bristol, UK, 2019, estimated using both a prospective and retrospective methodology

OBJECTIVES

To determine the disease burden of acute lower respiratory tract disease (aLRTD) and its subsets (pneumonia, lower respiratory tract infection (LRTI) and heart failure) in hospitalised adults in Bristol, UK.

SETTING

Single-centre, secondary care hospital, Bristol, UK.

DESIGN

We estimated aLRTD hospitalisations incidence in adults (≥18 years) in Bristol, UK, using two approaches. First, retrospective International Classification of Diseases 10th revision (ICD-10) code analysis (first five positions/hospitalisation) identified aLRTD events over a 12-month period (March 2018 to February 2019). Second, during a 21-day prospective review (19 August 2019 to 9 September 2019), aLRTD admissions were identified, categorised by diagnosis and subsequently annualised. Hospital catchment denominators were calculated using linked general practice and hospitalisation data, with each practice's denominator contribution calculated based on practice population and per cent of the practices' hospitalisations admitted to the study hospital.

PARTICIPANTS

Prospective review: 1322 adults screened; 410 identified with aLRTD. Retrospective review: 7727 adult admissions.

PRIMARY AND SECONDARY OUTCOME MEASURES

The incidence of aLRTD and its subsets in the adult population of Southmead Hospital, Bristol UK.

RESULTS

Based on ICD-10 code analysis, annual incidences per 100 000 population were: aLRTD, 1901; pneumonia, 591; LRTI, 739; heart failure, 402. aLRTD incidence was highest among those ≥65 years: 65-74 (3684 per 100 000 adults), 75-84 (6962 per 100 000 adults) and ≥85 (11 430 per 100 000 adults). During the prospective review, 410/1322 (31%) hospitalised adults had aLRTD signs/symptoms and annualised incidences closely replicated retrospective analysis results.

CONCLUSIONS

The aLRTD disease burden was high, increasing sharply with age. The aLRTD incidence is probably higher than estimated previously due to criteria specifying respiratory-specific symptoms or radiological change, usage of only the first diagnosis code and mismatch between case count sources and population denominators. This may have significant consequences for healthcare planning, including usage of current and future vaccinations against respiratory infection.

Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions

Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.