The effect of focused lung ultrasonography on antibiotic prescribing in patients with acute lower respiratory tract infections in Danish general practice: study protocol for a pragmatic randomized controlled trial (PLUS-FLUS)

BACKGROUND

The use of antibiotics is a key driver of antimicrobial resistance and is considered a major threat to global health. In Denmark, approximately 75% of antibiotic prescriptions are issued in general practice, with acute lower respiratory tract infections (LRTIs) being one of the most common indications. Adults who present to general practice with symptoms of acute LRTI often suffer from self-limiting viral infections. However, some patients have bacterial community-acquired pneumonia (CAP), a potential life-threatening infection, that requires immediate antibiotic treatment. Importantly, no single symptom or specific point-of-care test can be used to discriminate the various diagnoses, and diagnostic uncertainty often leads to (over)use of antibiotics. At present, general practitioners (GPs) lack tools to better identify those patients who will benefit from antibiotic treatment. The primary aim of the PLUS-FLUS trial is to determine whether adults who present with symptoms of an acute LRTI in general practice and who have FLUS performed in addition to usual care are treated less frequently with antibiotics than those who only receive usual care.

METHODS

Adults (≥ 18 years) presenting to general practice with acute cough (< 21 days) and at least one other symptom of acute LRTI, where the GP suspects a bacterial CAP, will be invited to participate in this pragmatic randomized controlled trial. All participants will receive usual care. Subsequently, participants will be randomized to either the control group (usual care) or to an additional focused lung ultrasonography performed by the GP (+ FLUS). The primary outcome is the proportion of participants with antibiotics prescribed at the index consultation (day 0). Secondary outcomes include comparisons of the clinical course for participants in groups.

DISCUSSION

We will examine whether adults who present with symptoms of acute LRTI in general practice, who have FLUS performed in addition to usual care, have antibiotics prescribed less frequently than those given usual care alone. It is highly important that a possible reduction in antibiotic prescriptions does not compromise patients' recovery or clinical course, which we will assess closely.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06210282. Registered on January 17, 2024.

Short-term effects and economic burden of air pollutants on acute lower respiratory tract infections in children in Southwest China: a time-series study

BACKGROUND

There are few studies on the effects of air pollutants on acute lower respiratory tract infections (ALRI) in children. Here, we investigated the relationship of fine particulate matter (PM_2.5), inhalable particulate matter (PM₁₀), sulfur dioxide (SO₂), and nitrogen dioxide (NO₂) with the daily number of hospitalizations for ALRI in children in Sichuan Province, China, and to estimate the economic burden of disease due to exposure to air pollutants.

METHODS

We collected records of 192,079 cases of childhood ALRI hospitalization between January 1, 2017 and December 31, 2018 from nine municipal/prefecture medical institutions as well as the simultaneous meteorological and air pollution data from 183 monitoring sites in Sichuan Province. A time series-generalized additive model was used to analyze exposure responses and lagged effects while assessing the economic burden caused by air pollutant exposure after controlling for long-term trends, seasonality, day of the week, and meteorological factors.

RESULTS

Our single-pollutant model shows that for each 10 μg/m³ increase in air pollutant concentration (1 μg/m³ for SO₂), the effect estimates of PM_2.5, PM₁₀, SO₂, and NO₂ for pneumonia reached their maximum at lag4, lag010, lag010, and lag07, respectively, with relative risk (RR) values of 1.0064 (95% CI, 1.0004-1.0124), 1.0168(95% CI 1.0089-1.0248), 1.0278 (95% CI 1.0157-1.0400), and 1.0378 (95% CI, 1.0072-1.0692). By contrast, the effect estimates of PM_2.5, PM₁₀, SO₂, and NO₂ for bronchitis all reached their maximum at lag010, with RRs of 1.0133 (95% CI 1.0025-1.0242), 1.0161(95% CI 1.0085-1.0238), 1.0135 (95% CI 1.0025-1.0247), and 1.1133(95% CI 1.0739-1.1541). In addition, children aged 5-14 years were more vulnerable to air pollutants than those aged 0-4 years (p < 0.05). According to the World Health Organization's air quality guidelines, the number of ALRI hospitalizations attributed to PM_2.5, PM₁₀, and NO₂ pollution during the study period was 7551, 10,151, and 7575, respectively, while the incurring economic burden was CNY 2847.06, 3827.27, and 2855.91 million.

CONCLUSION

This study shows that in Sichuan Province, elevated daily average concentrations of four air pollutants lead to increases in numbers of childhood ALRI hospitalizations and cause a serious economic burden.

Viral etiology and outcome of severe lower respiratory tract infections among critically ill children admitted to the PICU

OBJECTIVE

To determine the viral etiology of severe lower respiratory tract infections (LRTIs), their clinical significance and prognosis among critically ill children.

DESIGN

A prospective descriptive study was carried out.

SETTING

Pediatric Intensive Care Unit (PICU) of Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey.

PATIENTS

A total of 115 patients hospitalized in the PICU were evaluated for inclusion in the study. Children with underlying comorbidities and those who did not require mechanical ventilation were excluded.

MAIN VARIABLES OF INTEREST

Demographic, clinical, laboratory test and radiographic data were recorded.

RESULTS

A total of 63 patients were eligible for the study. The most common diagnosis was bronchiolitis (57.1%). Respiratory syncytial virus (RSV) was the most frequent causal virus (36.5%). The most common complication was acute respiratory distress syndrome (ARDS) (28.6%). Multiple viral infection was identified in 20.6% of the patients, the most common in this subgroup being rhinovirus. Patients with bocavirus infection had a higher likelihood of needing invasive mechanical ventilation (IMV) at presentation. Children who died were likely to be <12 months old, have ARDS, hepatitis, pneumomediastinum, multiple viral infection, and required IMV support with an increased duration of MV. Additionally, they were found to have a high Pediatric Risk of Mortality III score, Predicted Death Rate and increased need for inotropic support at admission.

CONCLUSIONS

Our study showed critically ill children with LRTI without known risk factors to have high mortality when aged <12 months, in the presence of multiple agents and when certain complications (ARDS, hepatitis) and X-ray findings were identified.

Granulocyte-targeted therapies for airway diseases

The average respiration rate for an adult is 12-20 breaths per minute, which constantly exposes the lungs to allergens and harmful particles. As a result, respiratory diseases, which includes asthma, chronic obstructive pulmonary disease (COPD) and acute lower respiratory tract infections (LTRI), are a major cause of death worldwide. Although asthma, COPD and LTRI are distinctly different diseases with separate mechanisms of disease progression, they do share a common feature - airway inflammation with intense recruitment and activation of granulocytes and mast cells. Neutrophils, eosinophils, basophils, and mast cells are crucial players in host defense against pathogens and maintenance of lung homeostasis. Upon contact with harmful particles, part of the pulmonary defense mechanism is to recruit these cells into the airways. Despite their protective nature, overactivation or accumulation of granulocytes and mast cells in the lungs results in unwanted chronic airway inflammation and damage. As such, understanding the bright and the dark side of these leukocytes in lung physiology paves the way for the development of therapies targeting this important mechanism of disease. Here we discuss the role of granulocytes in respiratory diseases and summarize therapeutic strategies focused on granulocyte recruitment and activation in the lungs.

VIRAL ETIOLOGY AND OUTCOME OF SEVERE LOWER RESPIRATORY TRACT INFECTIONS AMONG CRITICALLY ILL CHILDREN ADMITTED TO THE PICU

OBJECTIVE

To determine the viral etiology of severe lower respiratory tract infections (LRTIs), their clinical significance and prognosis among critically ill children.

DESIGN

A prospective descriptive study was carried out.

SETTING

Pediatric Intensive Care Unit (PICU) of Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey.

PATIENTS

A total of 115 patients hospitalized in the PICU were evaluated for inclusion in the study. Children with underlying comorbidities and those who did not require mechanical ventilation were excluded.

MAIN VARIABLES OF INTEREST

Demographic, clinical, laboratory test and radiographic data were recorded.

RESULTS

A total of 63 patients were eligible for the study. The most common diagnosis was bronchiolitis (57.1%). Respiratory syncytial virus (RSV) was the most frequent causal virus (36.5%). The most common complication was acute respiratory distress syndrome (ARDS) (28.6%). Multiple viral infection was identified in 20.6% of the patients, the most common in this subgroup being rhinovirus. Patients with bocavirus infection had a higher likelihood of needing invasive mechanical ventilation (IMV) at presentation. Children who died were likely to be < 12 months old, have ARDS, hepatitis, pneumomediastinum, multiple viral infection, and required IMV support with an increased duration of MV. Additionally, they were found to have a high Pediatric Risk of Mortality III score, Predicted Death Rate and increased need for inotropic support at admission.

CONCLUSIONS

Our study showed critically ill children with LRTI without known risk factors to have high mortality when aged < 12 months, in the presence of multiple agents and when certain complications (ARDS, hepatitis) and X-ray findings were identified.

Multiplicative rates model for recurrent events in case-cohort studies

In large prospective cohort studies, accumulation of covariate information and follow-up data make up the majority of the cost involved in the study. This might lead to the study being infeasible when there are some expensive variables and/or the event is rare. Prentice (Biometrika 73(1):1-11, 1986) proposed the case-cohort study for time to event data to tackle this problem. There has been extensive research on the analysis of univariate and clustered failure time data, where the clusters are formed among different individuals under case-cohort sampling scheme. However, recurrent event data are quite common in biomedical and public health research. In this paper, we propose case-cohort sampling schemes for recurrent events. We consider a multiplicative rates model for the recurrent events and propose a weighted estimating equations approach for parameter estimation. We show that the estimators are consistent and asymptotically normally distributed. The proposed estimator performed well in finite samples in our simulation studies. For illustration purposes, we examined the association between prior occurrence of measles on acute lower respiratory tract infections (ALRI) among young children in Brazil.

Biodiversity and clinico-demographic characteristics of human rhinoviruses from hospitalized children with acute lower respiratory tract infections in Malaysia

Background

There is accumulating evidence that human rhinovirus (HRV) causes acute lower respiratory tract infections (ALRTI). Recently, HRV-C was identified as a new species of HRV, but its spectrum of clinical disease is not well understood.

Objectives

We investigated the molecular epidemiology, demographic and clinical characteristics of HRVs among hospitalized children with ALRIs.

Study design

One hundred and sixty-five nasopharangeal aspirates taken from children <5 years hospitalized with ALRTIs in Serdang Hospital, Malaysia, were subject to reverse transcriptase-PCR for HRV. Phylogenetic analysis on VP4/VP2 and 5′-NCR regions was used to further characterize HRV. Other respiratory viruses were also investigated using semi-nested multiplex RT-PCR assay. Clinical parameters were analyzed between HRV, RSV and IFV-A mono-infections and between HRV species.

Results

HRV was detected in 54 (33%) patients for both single (36 samples) and multiple (18 samples) infections, 61.1% (22/36) represents HRV-A strains while the remaining 14 HRV-C. Strain P51was the first reported representative of HRV98. The majority of the single HRV cases were in the second half of infancy; HRV-C occurred among older children compared with HRV-A. HRV children were admitted significantly earlier and less febrile than RSV and IFV-A infection. HRV-C infected children were more likely to have rhonchi and vomiting as compared to HRV-A. Pneumonia was the most common discharge diagnosis followed by bronchiolitis and post-viral wheeze in HRV patients.

Conclusion

Our study showed high prevalence of HRVs and detection of HRV-C among hospitalized children with ALRTIs in Malaysia. Analysis of clinical parameters suggested specific features associated with HRVs infections and specific HRV groups.