Seasonal predominance of atypical agents in adult community-acquired pneumonia in India's northeastern region: Is it the time to look again at empirical therapy guidelines?

Atypical agents such as Mycoplasma, Legionella, Chlamydia species, and Coxiella burnetii (Q-fever agent) are responsible for some adult community-acquired pneumonia (CAP). Insufficient studies on this topic can be blamed for the failure to include atypical pathogens in empirical management. We followed adult CAP cases for two years, and samples (respiratory and serum) were tested by culture, ELISA (IgM, IgG, and IgA), and PCR. A risk factor analysis was performed. Overall in 21.3% adult CAP patients, atypical agents found were Mycoplasma pneumoniae (51.5%), Legionella pneumophila (28.8%), and Chlamydophila pneumoniae (19.7%). However, amongst patients <60 years of age and in the summer season, the proportion of atypical agents increased significantly. There is thus a need to re-examine empirical antibiotic regimes.

Construction and verification of a nomogram prediction model of severe adult community-acquired pneumonia / 中华危重病急救医学

Objective:To construct and verify the nomogram prediction model based on inflammatory indicators, underlying diseases, etiology and the British Thoracic Society modified pneumonia score (CURB-65 score) in adults with severe community acquired pneumonia (CAP).Methods:The clinical data of 172 adult inpatients first diagnosed as CAP at Taikang Xianlin Drum Tower Hospital from January 2018 to December 2021 were divided into severe and non-severe diseases groups according to the severity of their conditions. The baseline conditions (including gender, age, past history, comorbidities and family history), clinical data (including chief symptoms, onset time, CURB-65 score), first laboratory results on admission (including whole blood cell count, liver and kidney function, blood biochemistry, coagulation function, microbiological culture results) and whether the antimicrobial therapy was adjusted according to the microbiological culture results were recorded in both groups. Univariate analysis was used to screen for differential indicators between severe and non-severe patients. After covariate analysis, multi-factor Logistic regression analysis was performed based on the Aakaike information criterion (AIC) forward stepwise regression method to rigorously search for risk factors for constructing the model. Based on the results of the multi-factor analysis, a nomogram prediction model was constructed, and the discriminatory degree and calibration degree of the model were assessed using the receiver operator characteristic curve (ROC curve) and calibration curve.Results:A total of 172 adult CAP patients were included, 48 in severe group and 124 in non-severe group. The median age was 74 (57, 83) years old, onset time was 5.0 (3.0, 10.0) days, total number of comorbidities was 3 (2, 5), including 58 cases (33.7%) with hypertension and 17 (9.9%) with heart failure, 113 (65.7%) with CURB-65 score≤1, 34 cases (19.8%) had a CURB-65 score = 2 and 25 cases (14.5%) had a CURB-65 score≥3. Univariate analysis showed that there were statistically significant differences between the two groups in age, smoking history, CURB-65 score, heart rate, onset time, total comorbidity, pathogenic microorganisms, fibrinogen (FIB), D-dimer, C-reactive protein (CRP), procalcitonin (PCT), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Multi-factor Logistic regression analysis showed that hypertension [odds ratio ( OR) = 3.749, 95% confidence interval (95% CI) 1.411 to 9.962], heart failure ( OR = 4.616, 95% CI was 1.116 to 19.093), co-infection ( OR = 2.886, 95% CI was 1.073 to 7.760), history of smoking ( OR = 8.268, 95% CI was 2.314 to 29.537), moderate to high CURB-65 score ( OR = 4.833, 95% CI was 1.892 to 12.346), CRP ( OR = 1.012, 95% CI was 1.002 to 1.022), AST ( OR = 1.015, 95% CI was 1.001 to 1.030) were risk factors for severe CAP (all P < 0.05). The filtered indicators were included in the nomogram model, and the results showed that the area under the ROC curve (AUC) for the model to identify patients with severe adult CAP was 0.896, 95% CI was 0.840 to 0.937 ( P < 0.05), and the calibration curve showed that the predicted probability of severe CAP was in good agreement with the observed probability (Hosmer-Lemeshow test: χ2 = 6.088, P = 0.665). Conclusions:The nomogram model has a good ability to identify patients with severe adult CAP and can be used as a comprehensive and reliable clinical diagnostic tool to provide a evidence for timely intervention in the treatment of adults with severe CAP.

High proportion of drug-resistant isolates in adult community-acquired pneumonia from Northeast India: A hospital-based study.

BACKGROUND: Empirical antibiotic therapy is the mainstay of management of adult community-acquired pneumonia (CAP) globally. Knowledge of prevalent pathogen (bacterial) profile and drug susceptibility pattern is very essential for appropriate management of CAP cases, which again calls for regular update of pathogen profile in a given locality. This study was to identify the bacterial etiology of CAP cases and their antibiotic susceptibility pattern. METHODS: This cross-sectional study was done on adult CAP patients from medicine, respiratory medicine, and intensive care unit area in our tertiary care hospital between May 1, 2015, and October 30, 2016. Subjects were enrolled continuously, and expectorated sputum, bronchoalveolar lavage fluid, and blood culture were performed. Urine antigen test was done for Streptococcus pneumoniae and Legionella pneumophila. Three types of ELISA (IgM, IgG, and IgA) were performed for atypical agents (Mycoplasma, Chlamydia, and Legionella) of CAP. Isolates obtained from culture of Sputum/BAL/Blood were further processed for antibiotic susceptibility testing - by disc diffusion as well as E-test method (latter for MIC i.e. minimum inhibitory concentration, determination). RESULTS: About 574 subjects were included, and in 266 (46.3%) cases, bacterial pathogen could be detected. Klebsiella pneumoniae (33.6%) and S. pneumoniae (32.9%) were the predominant agents identified. Atypical agents (Mycoplasma, Legionella, and Chlamydia) were at 15.1%. A high proportion of pneumococci isolates were multidrug resistant (52.6%). Resistance to beta-lactams, macrolide, and other agents was on the higher side, but fluoroquinolones were found to be less resistant (15.8%-21.1%). Extended-spectrum beta-lactamase (among Klebsiella isolates) and methicillin-resistant Staphylococcus aureus were also detected. CONCLUSION: A moderate-to-high degree of drug-resistant in adult CAP was evident, which is detrimental in effective empirical management of such cases. Urgent implementation of antibiotic stewardship scheme is the need of the hour.

Update of IDSA／ATS adult community-acquired pneumonia / 中华临床感染病杂志

The guideline for diagnosis and treatment of adult community-acquired pneumonia (CAP) (2007 edition) jointly formulated by the Infectious Diseases Society of America ( IDSA) and the American Thoracic Society ( ATS) has a great impact on the clinical management for CAP in China.In October 2019, the two societies revised and updated the guide again.Compared with the 2007 guideline, the new guideline is more concise ; some contents were deleted and some contents have been updated.The main updated points are obvious changes in the compiling mode , the reduced recommendation intensity for macrolides in CAP treatment ,and more emphasizing the relevance of diagnosis and treatment activities to the clinical practice.