Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting.

OBJECTIVE: To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV. METHODS: Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported. RESULTS: Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44). CONCLUSION: Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Rate of dyslipidemia higher among women living with HIV: A comparison of metabolic and cardiovascular health in a cohort to study aging in HIV.

OBJECTIVES: Combination antiretroviral therapy has largely restored the lifespan of persons living with HIV. Data suggest early comorbidities of aging in this population. Past studies focused on men; limited data exist regarding the prevalence of dyslipidaemia in women living with HIV (WLWH). We investigated the prevalence of cardiometabolic abnormalities among WLWH and HIV-negative women in the Children and Women: Antiretrovirals and Markers of Aging (CARMA) cohort, and their relationships to cellular aging markers. METHODS: We conducted a cross-sectional analysis of nonpregnant female patients (156 WLWH and 133 HIV-negative controls, aged 12-69 years) enrolled in CARMA between 2013 and 2017. The Framingham risk score (FRS) and the prevalences of hypertension, diabetes, metabolic syndrome and dyslipideamia were determined using self-report, anthropometrics, chart review and laboratory data. Cellular aging was determined by assessing leukocyte telomere length and blood mitochondrial DNA content. Diagnoses were based on current Canadian guidelines and definitions. RESULTS: HIV-infected status was associated with dyslipidaemia [odds ratio (OR) 2.89; 95% confidence interval (CI) 1.69-5.01], but not diabetes, higher FRS, hypertension or metabolic syndrome. The median age was 43.5 [interquartile range (IQR) 36.8-50.9] years in WLWH and 46.2 (IQR 30.3-54.9) years in HIV-negative controls. WLWH were less likely to be menopausal or use alcohol, and more often had hepatitis C virus infection or a current or past smoking history. Lower mitochondrial DNA content was associated with metabolic syndrome; no other associations were noted between cardiometabolic abnormalities and markers of cellular aging. CONCLUSIONS: Despite their relatively young age, almost two-thirds of WLWH had dyslipidaemia, a significantly greater proportion than in controls. Strategies to address dyslipidaemia and decrease smoking rates may improve long-term outcomes among WLWH.

"Another thing to live for": Supporting HCV treatment and cure among Indigenous people impacted by substance use in Canadian cities.

BACKGROUND: Colonization and colonial systems have led to the overrepresentation of Indigenous people impacted by substance use and HCV infection in Canada. It is critical to ensure Indigenous people's equitable access to new direct acting antiviral HCV treatments (DAAs). Identifying culturally-safe, healing-centered approaches that support the wellbeing of Indigenous people living with HCV is an essential step toward this goal. We listened to the stories and perspectives of HCV-affected Indigenous people and HCV treatment providers with the aim of providing pragmatic recommendations for decolonizing HCV care. METHODS: Forty-five semi-structured interviews were carried out with Indigenous participants affected by HCV from the Cedar Project (n = 20, British Columbia (BC)) and the Canadian Coinfection Cohort (n = 25, BC; Ontario (ON); Saskatchewan (SK)). In addition, 10 HCV treatment providers were interviewed (n = 4 BC, n = 4 ON, n = 2 SK). Interpretive description identified themes to inform clinical approaches and public health HCV care. Themes and related recommendations were validated by Indigenous health experts and Indigenous participants prior to coding and re-contextualization. RESULTS: Taken together, participants' stories and perceptions were interpreted to coalesce into three overarching and interdependent themes representing their recommendations. First: treatment providers must understand and accept colonization as a determinant of health and wellness among HCV-affected Indigenous people, including ongoing cycles of child apprehension and discrimination within the healthcare system. Second: consistently safe attitudes and actions create trust within HCV treatment provider-patient relationships and open opportunities for engagement into care. Third: treatment providers who identify, build, and strengthen circles of care will have greater success engaging HCV-affected Indigenous people who have used drugs into care. CONCLUSION: There are several pragmatic ways to integrate Truth and Reconciliation as well as Indigenous concepts of whole-person wellness into the HCV cascade of care. By doing so, HCV treatment providers have an opportunity to create greater equity and support long-term wellness of Indigenous patients.

Cancer incidence among HIV-positive women in British Columbia, Canada: Heightened risk of virus-related malignancies.

OBJECTIVES: We used population-based data to identify incident cancer cases and correlates of cancer among women living with HIV/AIDS in British Columbia (BC), Canada between 1994 and 2008. METHODS: Data were obtained from a retrospective population-based cohort created from linkage of two province-wide databases: (1) the database of the BC Cancer Agency, a province-wide population-based cancer registry, and (2) a database managed by the BC Centre for Excellence in HIV/AIDS, which contains data on all persons treated with antiretroviral therapy in BC. This analysis included women (≥ 19 years old) living with HIV in BC, Canada. Incident cancer diagnoses that occurred after highly active antiretroviral therapy (HAART) initiation were included. We obtained a general population comparison of cancer incidence among women from the BC Cancer Agency. Bivariate analysis (Pearson χ(2) , Fisher's exact or Wilcoxon rank-sum test) compared women with and without incident cancer across relevant clinical and sociodemographic variables. Standardized incidence ratios (SIRs) were calculated for selected cancers compared with the general population sample. RESULTS: We identified 2211 women with 12 529 person-years (PY) of follow-up who were at risk of developing cancer after HAART initiation. A total of 77 incident cancers (615/100 000 PY) were identified between 1994 and 2008. HIV-positive women with cancer, in comparison to the general population sample, were more likely to be diagnosed with invasive cervical cancer, Hodgkin's lymphoma, non-Hodgkin's lymphoma and Kaposi's sarcoma and less likely to be diagnosed with cancers of the digestive system. CONCLUSIONS: This study observed elevated rates of cancer among HIV-positive women compared to a general population sample. HIV-positive women may have an increased risk for cancers of viral-related pathogenesis.

A case series of third-trimester raltegravir initiation: Impact on maternal HIV-1 viral load and obstetrical outcomes.

OBJECTIVE: To describe the impact of initiating raltegravir (RAL)-containing combination antiretroviral therapy (cART) regimens on HIV viral load (VL) in pregnant women who have high or suboptimal VL suppression late in pregnancy. METHODS: HIV-infected pregnant women who started RAL-containing cART after 28 weeks' gestation from 2007 to 2013 were identified in two university hospital centres. RESULTS AND DISCUSSION: Eleven HIV-infected women started RAL at a median gestational age of 35.7 weeks (range 31.1 to 38.0 weeks). Indications for RAL initiation were late presentation in pregnancy (n=4) and suboptimal VL suppression secondary to poor adherence or viral resistance (n=7). Mean VL at the time of RAL initiation was 73,959 copies/mL (range <40 to 523,975 copies/mL). Patients received RAL for a median of 20 days (range one to 71 days). The mean decline in VL from the time of RAL initiation to delivery was 1.93 log, excluding one patient who received only one RAL dose and one patient with undetectable VL at the time of RAL initiation. After eight days on RAL, 50% of the women achieved a VL <1000 copies/mL (the threshold for recommended Caesarean section to reduce the risk for perinatal transmission). There were no cases of perinatal HIV transmission. CONCLUSION: The present study provides preliminary data to support the use of RAL-containing cART to expedite HIV-1 VL reduction in women who have a high VL or suboptimal VL suppression late in pregnancy, and to decrease the risk of HIV perinatal transmission while avoiding Caesarean section. Further assessment of RAL safety during pregnancy is warranted.

OBJECTIF: Décrire les répercussions de l'amorce d'une antirétrovirothérapie prophylactique associative (ARPA) contenant du raltégravir (RAL) sur la charge virale (CV) du VIH chez les femmes enceintes dont la suppression de la CV est élevée ou sous-optimale en fin de grossesse. MÉTHODOLOGIE: Les chercheurs ont extrait le dossier des femmes enceintes infectées par le VIH qui avaient amorcé une ARAP contenant du RAL après 28 semaines de grossesse dans deux centres hospitaliers universitaires entre 2007 et 2013. RÉSULTATS ET EXPOSÉ: Onze femmes infectées ont entrepris un traitement de RAL à une médiane de 35,7 semaines de grossesse (plage de 31,1 à 38,0 semaines). Les indications pour entreprendre le RAL étaient une présentation tardive au suivi de grossesse (n=4) et une suppression sous-optimale de la CV en raison d'un mauvais respect du traitement ou d'une résistance virale (n=7). La CV moyenne au début du traitement au RAL était de 73 959 copies/mL (plage de moins de 40 copies/mL à 523 975 copies/mL). Les patientes ont pris du RAL pendant une médiane de 20 jours (plage de un à 71 jours). La diminution moyenne de la CV entre le début du RAL et l'accouchement était de 1,93 log, à l'exception d'une patiente qui n'a reçu qu'une dose de RAL et d'une patiente dont la CV n'était pas décelable au moment d'entreprendre le RAL. Au bout de huit jours de RAL, 50 % des femmes présentaient une CV inférieure à 1 000 copies/mL (le seuil pour recommander une césarienne afin de réduire le risque de transmission périnatale). Il n'y a d'ailleurs eu aucun cas de transmission périnatale du VIH. CONCLUSION: La présente étude fournit des données provisoires pour soutenir l'utilisation d'ARPA contenant du RAL afin d'accélérer la réduction de la CV du VIH-1 chez les femmes qui présentaient une CV élevée ou une suppression sous-optimale de leur CV pendant la grossesse, ainsi que pour réduire le risque de transmission périnatale du VIH tout en évitant une césarienne. Une évaluation plus approfondie de l'innocuité du RAL est justifiée pendant la grossesse.

HIV virological rebounds but not blips predict liver fibrosis progression in antiretroviral-treated HIV/hepatitis C virus-coinfected patients.

OBJECTIVES: Antiretroviral interruption is associated with liver fibrosis progression in HIV/hepatitis C virus (HCV) coinfection. It is not known what level of HIV viraemia affects fibrosis progression. METHODS: We evaluated 288 HIV/HCV-coinfected cohort participants with undetectable HIV RNA (<50 HIV-1 RNA copies/mL) on two consecutive visits while on combination antiretroviral therapy (cART) without fibrosis [aspartate aminotransferase to platelet ratio index (APRI) <1.5], end-stage liver disease or HCV therapy. An HIV blip was defined as a viral load of ≥ 50 and <1000 copies/mL, preceded and followed by undetectable values. HIV rebound was defined as: (i) HIV RNA ≥ 50 copies/mL on two consecutive visits, or (ii) a single HIV RNA measurement ≥ 1000 copies/mL. Multivariate discrete-time proportional hazards models were used to assess the effect of different viraemia levels on liver fibrosis progression (APRI ≥ 1.5). RESULTS: The mean age of the patients was 45 years, 74% were male, 81% reported a history of injecting drug use, 51% currently used alcohol and the median baseline CD4 count was 440 [interquartile range (IQR) 298, 609] cells/µL. Fifty-seven (20%) participants [12.4/100 person-years (PY); 95% confidence interval (CI) 9.2-15.7/100 PY] progressed to an APRI ≥ 1.5 over a mean 1.1 (IQR 0.6, 2.0) years of follow-up time at risk. Virological rebound [hazard ratio (HR) 2.3; 95% CI 1.1, 4.7] but not blips (HR 0.5; 95% CI 0.2, 1.1) predicted progression to APRI ≥ 1.5. Each additional 1 log10 copies/mL HIV RNA exposure (cumulative) was associated with a 20% increase in the risk of fibrosis progression (HR 1.2; 95% CI 1.0-1.3). CONCLUSIONS: Liver fibrosis progression was associated with HIV rebound, but not blips, and with increasing cumulative exposure to HIV RNA, highlighting the importance of achieving and maintaining HIV suppression in the setting of HIV/HCV coinfection.

Topical tacrolimus 0.1% ointment for treatment of cutaneous Crohn's Disease.

BACKGROUND: Cutaneous Crohn's Disease is a notoriously difficult condition to treat and causes significant morbidity, impacting heavily on quality of life. This is the first study in adults examining the effect of topical tacrolimus on the different cutaneous manifestations of Crohn's Disease. METHODS: This open label observational study of 20 patients with heterogeneous forms of cutaneous Crohn's disease used topical tacrolimus 0.1% ointment once daily to affected areas for 12 weeks with a maximal total dose of 90g. Therapy was stopped at 12 weeks to assess whether the condition relapsed. Thereafter relapsing patients optionally continued an open label extension of topical tacrolimus therapy and were observed for a total of 12 months. RESULTS: Of seventeen patients completing the twelve-week study, fifteen improved using a specifically designed physicians' global severity scale. One patient cleared, four showed a pronounced improvement (51-75%) and ten demonstrated a mild (1-25%) or moderate improvement (25-50%) in twelve weeks. Over twelve months eleven patients remained in the study, nine of which improved, one cleared and one showed no change. Perineal disease responded better with two out of twelve clearing, four showing pronounced benefit and four mild to moderate improvement. Long-term application of 0.1% tacrolimus applied to broken skin and mucosa was safe and serum levels of tacrolimus were undetectable in all subjects throughout the study. CONCLUSION: 0.1% tacrolimus ointment was safe and effective in treating cutaneous manifestations of Crohn's disease, particularly perineal disease and pyoderma gangrenosum, yet it seldom cleared the condition. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration System ID: 33000332.

HIV and hepatitis C virus coinfection in Canada: challenges and opportunities for reducing preventable morbidity and mortality.

OBJECTIVES: Hepatitis C virus (HCV) has emerged as an important health problem in the era of effective HIV treatment. However, very few data exist on the health status and disease burden of HIV/HCV-coinfected Canadians. METHODS: HIV/HCV-coinfected patients were enrolled prospectively in a multicentre cohort from 16 centres across Canada between 2003 and 2010 and followed every 6 months. We determined rates of a first liver fibrosis or endstage liver disease (ESLD) event and all-cause mortality since cohort enrolment and calculated standardized mortality ratios compared with the general Canadian population. RESULTS: A total of 955 participants were enrolled in the study and followed for a median of 1.4 (interquartile range 0.5-2.3) years. Most were male (73%) with a median age of 44.5 years; 13% self-identified as aboriginal. There were high levels of current injecting drug and alcohol use and poverty. Observed event rates [per 100 person-years; 95% confidence interval (CI)] were: significant fibrosis (10.21; 8.49, 12.19), ESLD (3.16; 2.32, 4.20) and death (3.72; 2.86, 4.77). The overall standardized mortality ratio was 17.08 (95% CI 12.83, 21.34); 12.80 (95% CI 9.10, 16.50) for male patients and 28.74 (95% CI 14.66, 42.83) for female patients. The primary causes of death were ESLD (29%) and overdose (24%). CONCLUSIONS: We observed excessive morbidity and mortality in this HIV/HCV-coinfected population in care. Over 50% of observed deaths may have been preventable. Interventions aimed at improving social circumstances, reducing harm from drug and alcohol use and increasing the delivery of HCV treatment in particular will be necessary to reduce adverse health outcomes among HIV/HCV-coinfected persons.

Upper extremity infections following common carp fish (cyprinus carpio) handling.

Upper extremity infection caused by aquatic pathogens on fish is a well recognized clinical entity. We report five consecutive cases of upper extremity infections, ranging from a simple localized reaction to a life-threatening systemic illness, which developed after handling common carp fish (Cyprinus carpio). In four cases, infection occurred following a penetrating injury by either the bones or the fin spines of the fish. Vibrio vulnificus was isolated from wound aspirates in four cases. Early broad-spectrum antibiotic therapy is mandatory. Deterioration in the clinical condition or a poor response to conservative treatment requires a meticulous surgical drainage and excision of both infected and necrotic tissues.

West Nile fever outbreak, Israel, 2000: epidemiologic aspects.

From August 1 to October 31, 2000, 417 cases of West Nile (WN) fever were serologically confirmed throughout Israel; 326 (78%) were hospitalized patients. Cases were distributed throughout the country; the highest incidence was in central Israel, the most populated part. Men and women were equally affected, and their mean age was 54+/-23.8 years (range 6 months to 95 years). Incidence per 1,000 population increased from 0.01 in the 1st decade of life to 0.87 in the 9th decade. There were 35 deaths (case-fatality rate 8.4%), all in patients >50 years of age. Age-specific case-fatality rate increased with age. Central nervous system involvement occurred in 170 (73%) of 233 hospitalized patients. The countrywide spread, number of hospitalizations, severity of the disease, and high death rate contrast with previously reported outbreaks in Israel.

Clinical characteristics of the West Nile fever outbreak, Israel, 2000.

West Nile (WN) virus is endemic in Israel. The last reported outbreak had occurred in 1981. From August to October 2000, a large-scale epidemic of WN fever occurred in Israel; 417 cases were confirmed, with 326 hospitalizations. The main clinical presentations were encephalitis (57.9%), febrile disease (24.4%), and meningitis (15.9%). Within the study group, 33 (14.1%) hospitalized patients died. Mortality was higher among patients >70 years (29.3%). On multivariate regressional analysis, independent predictors of death were age >70 years (odds ratio [OR] 7.7), change in level of consciousness (OR 9.0), and anemia (OR 2.7). In contrast to prior reports, WN fever appears to be a severe illness with high rate of central nervous system involvement and a particularly grim outcome in the elderly.

Inadequate protection against yellow fever of children visiting endemic areas.

The guidelines of the World Health Organization call for immunization against yellow fever at least 10 days before travel to endemic areas. The goal of this study was to determine whether these guidelines have been applied in 2 travel clinic settings in teaching hospitals in Israel and the United Kingdom specifically for children traveling to endemic areas. Two groups of children aged 9 months to 15 years (n = 98), who were planning to travel to yellow fever-endemic areas, were evaluated regarding characteristics related to the administration of yellow fever vaccine before travel. Overall, 19 children in both clinics (19.4%; 95% confidence interval, 12.1-28.6) had received their yellow fever vaccination < 10 days before departure (no interclinic difference). Eleven of these children received the vaccine < 7 days before departure. We found that the World Health Organization guidelines for yellow fever vaccination are frequently not followed. An initiative to explain to the public the importance of vaccination well before travel to endemic areas should be undertaken.

Ehrlichiosis associated vasculitis.

OBJECTIVE: To test the hypothesis that some cases of primary vasculitis are caused by ehrlichiosis. DESIGN: A retrospective case study and serological analysis of stored sera. SETTING: University hospital. SUBJECTS: Fifty-five patients discharged with any type of vasculitis over a 6-year period. MAIN OUTCOME MEASURES: Serology for human monocytic ehrlichiosis, and the human granulocytic ehrlichiosis agent, and polymerase chain reaction (PCR) analysis of biopsy specimens. RESULTS: Three patients (5.5%) had titres of 1 : 128 or higher against E. chaffeensis; none was positive for the human granulocytic ehrlichiosis agent. Skin biopsies of these patients showed lesions compatible with polyarteritis nodosa, allergic purpura and unspecified vasculitis. PCR analysis of the biopsies was unrevealing. CONCLUSIONS: Infection with human monocytic ehrlichiosis may underlie some forms of vasculitis. If confirmed, these findings may help identify patients with vasculitis who would benefit from antibiotic treatment.

Deep venous thrombosis associated with acute brucellosis--a case report.

Vascular complications, including arteries and veins associated with Brucella infection, have rarely been reported. To date, only three cases of deep venous thrombosis (DVT) of the lower extremities associated with brucellosis have been previously reported. The authors describe another case of DVT of the right leg in association with acute Brucella infection. Since infection with Brucella may be asymptomatic, and the manifestations of acute brucellosis are exceedingly nonspecific, and in view of the potential for Brucella to cause unexplained or unusual illness involving almost any organ including blood vessels, the authors' case and those previously reported suggest that brucellosis should be included among the causes and infections taken into account in patients suffering from DVT, particularly in those coming from Brucella-endemic areas.

[Intradermal hepatitis B vaccination in workers not responsive to intramuscular vaccination].

Health care workers are at continuous risk of hepatitis B infection. Currently recommended intramuscular vaccination confers immunity in only 85-90%. We examined the immunogenicity and safety of intradermal vaccination of hepatitis B vaccine in nonresponders. 400 hospital employees who had been immunized as recommended were screened for anti-HBs antibodies and 50 were found seronegative. Each received an intramuscular booster injection and antibody level was measured a month later. Excluded were 33 employees, including 24 late responders, 2 HbsAg carriers and 7 uncooperative employees. 17 employees (mean age 47.1 yrs) then received a series of 3 intradermal injections of Energix B, 0.25 ml in the forearm, 2-3 weeks apart. The mean number of previous intramuscular injections was 4.6 +/- 1.4. A month later there was a mean titer of 315.4 +/- 347.0 miu/ml of antibody in 16/17 workers. Side effects were minimal. Intradermal injection of hepatitis B vaccine for nonresponders seems effective for inducing seroconversion. Its cost-effectiveness for the health care system warrants assessment.

Primary Herpes Labialis Acquired during Scuba Diving Course.

Primary herpes infections usually require intimate contact of mucous membranes by either oral or sexual means.1,2 Infrequently, other types of contact have been described.3-5 Such was the case with an outbreak of herpes gladiatorum at a high-school wrestling camp, or a dental student who became infected from a patient.3,4 Reports charging fomites as vehicles of transmission of this virus seem anecdotal.6-8 Is it really that rare? We wish to present a hitherto unreported mode-of-transmission of primary herpes simplex virus (HSV) infection.

Pneumococcal community-acquired pneumonia in 148 hospitalized adult patients.

In a previous prospective study, Streptococcus pneumoniae was identified as the causative agent in 148 (42.8%) of 346 adult patients hospitalized over the course of one year with community-acquired pneumonia (CAP) in the Soroka Medical Center, Beer-Sheva, Israel. The present study characterizes those cases in which Streptococcus pneumoniae was the only pathogen and those in which additional etiological agents were identified. Pneumococcal CAP was diagnosed by standard blood cultures or positive serological tests by one of two laboratory methods. In 100 (67.6%) patients, at least one other etiological agent of CAP was identified in addition to Streptococcus pneumoniae. Compared with patients who were not infected by Streptococcus pneumoniae, patients with Streptococcus pneumoniae CAP were older and had a higher rate of comorbidity (39.5% vs. 29.8%). Streptococcus pneumoniae CAP had a more severe clinical course and a higher mortality rate, especially when Streptococcus pneumoniae was the only pathogen. Community-acquired pneumonia due to Streptococcus pneumoniae only was more similar in its clinical manifestations to classic typical pneumococcal pneumonia. When an additional etiological agent was identified, the clinical characteristics could not be distinguished from those of atypical pneumonia. It is concluded that Streptococcus pneumoniae remains the principal cause of CAP in this region. The frequency of additional etiological agents of CAP and the difficulty in differentiating clinically between cases due to Streptococcus pneumoniae only and those due to Streptococcus pneumoniae plus other organisms necessitates initial empirical treatment that covers Streptococcus pneumoniae as well as other causative agents of atypical pneumonia.