scholarly journals 1484. Microbial Etiology of Community-acquired Pneumonia in Immunocompromised Patients

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S743-S744
Author(s):  
Abhishek Deshpande ◽  
Pei-Chun Yu ◽  
Michael Rothberg
Keyword(s):  
Panel Member ◽  
Positive Culture ◽  
Empiric Therapy ◽  
Community Acquired Pneumonia ◽  
Immunocompromised Patients ◽  
Viral Pathogens ◽  
Chest X Ray ◽  
Microbial Etiology ◽  
Almost All ◽  
Immunocompetent Patients

Abstract Background Community-acquired pneumonia (CAP) is a leading cause of infection related mortality. Few studies have specifically evaluated the microbial etiology of CAP in immunocompromised patients. Using a large national inpatient database, we compared the microbial etiology of CAP in immunocompromised patients compared to immunocompetent patients. Methods We included adult patients admitted with pneumonia from 2010-2015 to 176 US hospitals participating in Premier. Patients were identified as having CAP if they had a chest X-ray and were on antimicrobials on the first day. Immunocompromised was defined by the receipt of immunosuppressive medications or ICD-9 codes for neutropenia/ hematological malignancy/ organ transplantation or comorbidities with AIDS. For microbial etiology, patients were included if they had a positive culture or test collected by hospital day 0 through 3. Patients with identical bacteria in blood and urine were excluded. Results A total of 168,159 patients had a diagnosis of CAP with a culture/test performed on first 3 days. A pathogen was detected in 18.8% of patients. Among pathogen positive patients, 4,851 patients were identified as immunocompromised and 26,752 as immunocompetent. Almost all patients (99%) had at least one culture, blood (96%) and respiratory (51%). Among patients who were immunocompromised, the most common bacterial pathogens (compared to immunocompetent patients) were, S. pneumoniae (17.7% vs 19.0%), MRSA (13.1% vs 14.4%), MSSA (12.0% vs 11.8%), P. aeruginosa (12.0% vs 9.9%), E. coli (7.4% vs 6.4%), K. pneumoniae (5.8% vs 4.9%), H. influenzae (5.5% vs 5.5%), M. pneumoniae (3.0% vs 3.0%) and L. pneumophila (0.93% vs 1.2%). Among viral pathogens, while the most common were influenza virus (12.9% vs 14.1%) followed by rhinovirus (1.5% vs 0.89%), immunocompromised patients has a higher prevalence of noninfluennza viruses (3.42% vs 2.43%). Conclusion In a large US inpatient sample, the causative organisms in immunocompromised patients did not differ much from those in immunocompetent patients. CAP pathogens in immunocompromised patients were more likely to involve gram-negative bacilli such as P.aeruginosa and E.coli, than gram-positive cocci. These findings may have implications when deciding on empiric therapy in these patients. Disclosures Abhishek Deshpande, MD, PhD, Ferring Pharmaceuticals (Advisor or Review Panel member)Merck (Consultant)

scholarly journals 1027. Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S361-S362
Author(s):  
Timothy Shan ◽  
Sara J Gore ◽  
Caitlin M McCracken ◽  
Gregory B Tallman ◽  
Haley K Holmer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Positive Culture ◽  
Empiric Therapy ◽  
Community Acquired Pneumonia ◽  
University Hospital ◽  
Inappropriate Therapy ◽  
Definitive Therapy ◽  
Days Of Therapy ◽  
Risk Patients ◽  
The Impact

Abstract Background Current Infectious Disease Society of America guidelines recommend anti-methicillin-resistant Staphylococcus aureus(MRSA) agents for treatment of community-acquired pneumonia (CAP) only in specific high-risk patients. There are limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP. The objective of this study was to evaluate the use of vancomycin for CAP among inpatients. Methods We conducted a retrospective cohort study of inpatients at Oregon Health and Science University Hospital from August 1st, 2017 to July 31st, 2018 who received IV vancomycin and had a pneumonia encounter ICD-9 diagnosis code. Patients with hospital or ventilator-associated pneumonia were excluded. Appropriate therapy was defined as empiric therapy with known risk-factors, concordant therapy with no de-escalation option, or concurrent sepsis or febrile neutropenia. Vancomycin appropriateness was assessed based on medical history and microbiology for both empiric and definitive therapy. We characterized patients receiving inappropriate therapy and calculated the proportion of inappropriate days of therapy (DOT). Results We identified 52 patients with CAP who were treated with vancomycin for a median of 2 DOT (Interquartile Range (IQR): 1–3). Approximately 21% (11/52) of patients had risk factors warranting vancomycin empiric therapy and 42% (22/52) had concurrent sepsis. Nine CAP patients received inappropriate courses of vancomycin, median of 1 day (IQR: 1–2.25) of inappropriate therapy. The most common reason for classifying use as inappropriate was a positive culture for organisms other than MRSA. Patients receiving inappropriate therapy were more frequently transferred from another hospital (44% vs. 30%, P = 0.22). Overall, 16% (20/125) of vancomycin DOT were inappropriate. Conclusion In our study,CAP patients accounted for a small number of pneumonia patients who received vancomycin. The median inappropriate DOT was relatively short, possibly indicating that identification and de-escalation was performed quickly. Further work is required to determine the impact of these findings on patients. Disclosures All authors: No reported disclosures.

scholarly journals Approach to Pneumonia in Immunocompetent Patients

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Spandana Veeravalli ◽  
Safiya Soullane
Keyword(s):  
Decision Making ◽  
Lung Inflammation ◽  
Infectious Agent ◽  
Empiric Therapy ◽  
Community Acquired Pneumonia ◽  
Outpatient Management ◽  
Hospital Acquired Pneumonia ◽  
Hospital Acquired ◽  
Infectious Etiology ◽  
Immunocompetent Patients

Pneumonia is a leading cause of morbidity. Pneumonia is defined as a lung inflammation of infectious etiology. It can be subcategorized into Community Acquired Pneumonia, Hospital Acquired Pneumonia and Ventilator Acquired Pneumonia. Validated scores including the CRB-65, CURB-65 and PSI can guide decision-making between inpatient and outpatient management of pneumonia. While mild presentations can be managed through empiric treatment alone, more acute cases require identification of the infectious agent, initiation of empiric therapy, and subsequent de-escalation of treatment to the identified pathogen. This article aims to provide a framework for junior trainees to diagnose and manage pneumonia.

scholarly journals Comparison of pneumonia features in children caused by SARS-CoV-2 and other viral respiratory pathogens.

2021 ◽  
Author(s):  
Rut del Valle Pérez ◽  
Alvaro Ballesteros ◽  
Cristina Calvo ◽  
Talia Sainz ◽  
Ana Mendez Echevarría ◽  
...  
Keyword(s):  
Pediatric Intensive Care ◽  
Community Acquired Pneumonia ◽  
Hospitalized Children ◽  
Respiratory Pathogens ◽  
Viral Pathogens ◽  
X Ray ◽  
National Cohort ◽  
Chest X Ray ◽  
Viral Etiologies ◽  
Viral Respiratory

Pneumonia is a frequent manifestation of COVID-19 in hospitalized children. Methods The study involved 80 hospitals in the SARS-CoV-2 Spanish Pediatric National Cohort. Participants were children <18 years, hospitalized with SARS-CoV-2 community-acquired pneumonia (CAP). We compared the clinical characteristics of SARS-CoV-2-associated CAP with CAP due to other viral etiologies from 2012 to 2019. Results In total, 151 children with SARS-CoV-2-associated CAP and 138 with other viral CAP included. Main clinical features of SARS-CoV-2-associated CAP were cough 117/151(77%), fever 115/151(76%) and dyspnea 63/151(46%); 22/151(15%) patients were admitted to a pediatric intensive care unit (PICU), and 5/151(3%) patients died. Lymphopenia was found in 63/147(43%) patients. Chest X-ray revealed condensation (64/151[42%]) and other infiltrates (87/151[58%]). Compared with CAP from other viral pathogens, COVID-19 patients were older (8 vs.1 year; odds ratio [OR] 1.42 [95% confidence interval, CI 1.23;1.42]), with lower CRP levels (23 vs.48 mg/L; OR 1 [95%CI 0.99;1]), less wheezing (17 vs.53%; OR 0.18 [95%CI 0.11;0.31]) and greater need of mechanical ventilation, MV (7 vs.0.7%, OR 10.8 [95%CI 1.3;85). Patients with non-SARS-CoV-2-associated CAP had a greater need for oxygen therapy (77 vs.44%, OR 0.24 [95%CI 0.14;0.40]). There were no differences in the use of CPAP or HVF or PICU admission between groups. Conclusion SARS-CoV-2-associated CAP in children presents differently to other virus-associated CAP: children are older and rarely have wheezing or high CRP levels; they need less oxygen but more CPAP or MV. However, several features overlap, and differentiating the etiology may be difficult. The overall prognosis is good.

scholarly journals The virulence of the Cryptococcus neoformans VNIa-5 lineage is highly plastic and associated with isolate background

2020 ◽  
Author(s):  
Trieu Phan Hai ◽  
Thanh Lam Tuan ◽  
Duong Van Anh ◽  
Trinh Nguyen Mai ◽  
Lan Nguyen Phu Huong ◽  
...  
Keyword(s):  
Cryptococcus Neoformans ◽  
Culture Filtrate ◽  
Secreted Proteins ◽  
Immunocompromised Patients ◽  
Present Evidence ◽  
Sterile Culture ◽  
Virulence Phenotype ◽  
Almost All ◽  
Highly Virulent ◽  
Immunocompetent Patients

AbstractCryptococcus neoformans most frequently causes disease in immunocompromised patients. However, in Vietnam and east Asia, disease is frequently reported in apparently immunocompetent patients. We have previously shown that almost all such disease is due to a specific lineage of C. neoformans – VNIa-5. However, in HIV-infected patients, infections due to this lineage are not associated with worse outcomes. Here, we demonstrate that the VNIa-5 lineage presents different virulence phenotypes depending on its source. Isolates derived from immunocompetent patients are more virulent than those from HIV-infected patients or the environment. Moreover, the virulence phenotype is plastic – sterile culture filtrate from highly virulent VNIa-5 strains can induce increased virulence in less virulent VNIa-5 isolates, which in turn can then induce increased virulence in their low virulence states. We present evidence that this phenomenon is driven by secreted proteins associated with extra-cellular vesicles.

Other Respiratory Viruses as a Cause of Community-Acquired Pneumonia

2020 ◽  
Vol 41 (04) ◽  
pp. 579-591
Author(s):  
James M. Walter
Keyword(s):  
Pneumococcal Vaccination ◽  
Respiratory Viruses ◽  
Community Acquired Pneumonia ◽  
Nucleic Acid Amplification ◽  
Respiratory Pathogens ◽  
Viral Pathogens ◽  
Vaccination Programs ◽  
Syncytial Virus ◽  
Human Parainfluenza Virus ◽  
Immunocompetent Patients

AbstractCommunity-acquired pneumonia (CAP) is a major cause of morbidity and mortality worldwide. There is growing appreciation of the burden of noninfluenza viral pathogens in CAP. Due to multiple factors including pneumococcal vaccination programs, declining rates of cigarette smoking, an aging population, and increasingly sensitive diagnostic tests, respiratory viruses are now the most common pathogens detected in CAP, outpacing Streptococcus pneumoniae. Noninfluenza respiratory pathogens are widely accepted as causal pathogens in CAP including in immunocompetent patients. This review provides an overview of five noninfluenza respiratory viral pathogens commonly implicated in CAP pathogenesis: rhinovirus, human metapneumovirus, respiratory syncytial virus, human parainfluenza virus, and human adenoviruses. Nucleic acid amplification testing platforms and their impact on antimicrobial stewardship efforts are also considered.

scholarly journals Metagenomic Next-Generation Sequencing for Pathogenic Diagnosis and Antibiotic Management of Severe Community-Acquired Pneumonia in Immunocompromised Adults

2021 ◽  
Vol 11 ◽  
Author(s):  
Ting Sun ◽  
Xiaojing Wu ◽  
Ying Cai ◽  
Tianshu Zhai ◽  
Linna Huang ◽  
...  
Keyword(s):  
Next Generation Sequencing ◽  
Antibiotic Treatment ◽  
Community Acquired Pneumonia ◽  
Immunocompromised Patients ◽  
Next Generation ◽  
Days Of Therapy ◽  
Significant Difference ◽  
Severe Community Acquired Pneumonia ◽  
Generation Sequencing ◽  
Immunocompetent Patients

BackgroundMetagenomic next-generation sequencing (mNGS) is a promising technique for pathogens diagnosis. However, application of mNGS in immunocompromised adults with severe community-acquired pneumonia (SCAP) is relatively limited.MethodsWe retrospectively reviewed 23 immunocompromised and 21 immunocompetent SCAP patients with mNGS detection from April 2019 to December 2019. The performances of pathogenic diagnosis and subsequently antibiotic adjustment in immunocompromised SCAP patients were compared to immunocompetent SCAP patients. The defined by days of therapy (DOT) method was used for estimate daily antibiotic use.ResultsThere was a significant difference in the diagnostic positivity rate between mNGS and conventional test in both groups (P&lt;0.001). Compared to immunocompetent patients, more mixed pathogens in immunocompromised patients were found (P=0.023). Before the availability of mNGS, the DOTs in immunocompromise patients were higher than immunocompetent patients (3.0 [3.0, 4.0] vs. 3.0 [2.0, 3.0], P=0.013). Compared to immunocompetent patients, immunocompromised patients had fewer full pathogen covered empirical antibiotic therapy (14.7% vs. 57.1%, P=0.022), more adjustments of antibiotic treatment (87.0%) vs. 57.1%, P=0.027). More than a half (13 of 23) SCAP patients in immunosuppressed group had reduced or downgraded antibiotic adjustments based on the results.ConclusionsmNGS may be a useful technique for detecting mixed pathogens and personalized antibiotic treatment in immunocompromised SCAP patients.

Community acquired pneumonia-current scenario among immunocompromised patients in a tertiary care hospital

2016 ◽  
Vol 5 (01) ◽  
pp. 4715
Author(s):  
A. V. Sowmya* ◽  
G. Jayalakshmi ◽  
David Agatha
Keyword(s):  
Diabetes Mellitus ◽  
Antimicrobial Therapy ◽  
Tertiary Care ◽  
Community Acquired Pneumonia ◽  
Polymicrobial Infection ◽  
Resistance Pattern ◽  
Care Hospital ◽  
Immunocompromised Patients ◽  
Drug Resistant ◽  
Etiologic Agents

Pneumonia is a common illness accounting for majority of hospitalizations worldwide with significant mortality and morbidity. Antimicrobial therapy, being the main stay of treatment, the choices of antibiotics depends on the nature of the etiologic agents and the host factors. The current study was aimed to identify the bacterial & fungal etiologic agents of Community Acquired Pneumonia (CAP) in Immunocompromised (IC) patients, with their antimicrobial resistant pattern and to analyze the associated immunocompromised states. Various respiratory samples from study group of 75 immunocompromised patients with features of pneumonia were collected, processed and the isolates were identified with their antimicrobial susceptibility& resistance pattern according to CLSI guidelines. The results were analyzed statistically. Diabetes mellitus is the most common immunocompromised state (48%) associated with CAP. Monomicrobial and polymicrobial infection rates were 80.36% and 19.64% respectively. Gram negative pathogens and fungal pathogens were identified in 60% and 25.37% of culture positive cases respectively. Diabetes mellitus is commonly found in association with polymicrobial infection (19.44%) and fungal infection (16.66%). Drug resistant strains comprise about 75% of MRSA strains, 72.72 % of ESBL producers and 3.44% of Amp C producers. As the number of elderly people with associated IC state is on rise, with change in the pattern of microbial etiologic agents causing CAP, a prior knowledge of the host and microbial factors will help in formulating empirical antimicrobial therapy and proper treatment thereby curbing the spread of infections by drug resistant pathogens and the associated morbidity and mortality.

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia

2020 ◽  
pp. 1-9
Author(s):  
Michael Klompas ◽  
Peter B. Imrey ◽  
Pei-Chun Yu ◽  
Chanu Rhee ◽  
Abhishek Deshpande ◽  
...  
Keyword(s):  
Retrospective Cohort ◽  
Respiratory Virus ◽  
Respiratory Viruses ◽  
Community Acquired Pneumonia ◽  
Blood Cultures ◽  
Antibacterial Treatment ◽  
Viral Pathogens ◽  
Antimicrobial Utilization ◽  
Viral Testing ◽  
Virus Testing

Abstract Objective: Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization. Design: Retrospective cohort study. Setting: The study included 179 US hospitals. Patients: Adults admitted with pneumonia between July 2010 and June 2015. Methods: We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients. Results: Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001). Conclusions: A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.

scholarly journals 66. Impact of a Pharmacist-Driven Azithromycin De-escalation Protocol for Community-Acquired Pneumonia

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S52-S52
Author(s):  
Pegah Shakeraneh ◽  
Jeffrey Steele ◽  
Robert Seabury ◽  
Stephen J Thomas ◽  
Kristopher M Paolino ◽  
...  
Keyword(s):  
Legionella Pneumophila ◽  
Panel Member ◽  
Community Acquired Pneumonia ◽  
Hospital Length Of Stay ◽  
Post Intervention ◽  
Review Panel ◽  
Icu Patients ◽  
Significant Difference ◽  
Atypical Bacteria ◽  
Research Grant

Abstract Background Ceftriaxone and azithromycin are common empiric antibiotics for community-acquired pneumonia (CAP). Despite low suspicion for atypical infection, azithromycin is often continued for a full course. Negative laboratory data for atypical bacteria may assist with azithromycin de-escalation. Thus, a pharmacist-driven azithromycin de-escalation protocol was implemented for immunocompetent, non-intensive care unit (ICU) patients treated for CAP. The primary outcome was to compare azithromycin duration before and after protocol implementation. Secondary outcomes included hospital length of stay (LOS) and all-cause 30-day readmission. Methods This was a single-center, quasi-experimental study of hospitalized, non-ICU patients treated with azithromycin and a beta-lactam for CAP. The pre- and post-intervention cohorts were from 07/01/2018–04/30/2019 and 07/01/2019–04/30/2020, respectively. Patients were included if they were ≥18 years old, diagnosed with CAP, and had a negative Legionella pneumophila urinary antigen and negative nasopharyngeal swab PCR for Mycoplasma pneumoniae and Chlamydia pneumoniae. Patients were excluded if they were immunocompromised, admitted to an ICU, prescribed azithromycin for an alternative indication, or had evidence of atypical bacteria. Results After exclusion criteria were applied, 90 and 100 patients were included in the pre- and post-intervention cohorts, respectively. Demographic and clinical characteristics were mostly similar between cohorts. This initiative was associated with a statistically significant decrease in azithromycin duration (2 days (IQR 1–2.75) vs. 5 days (IQR 3–6), p &lt; 0.001) and hospital LOS (3 days (IQR 2–5) vs. 5 days (IQR 3–8.25), p &lt; 0.001). No statistically significant difference was observed for all-cause 30-day readmission (14 days (15.6%) vs 13 days (13.0%), p=0.614). Conclusion Implementation of a pharmacist-driven azithromycin de-escalation protocol for CAP was associated with reduced azithromycin duration and hospital LOS, but not all-cause 30-day readmission. Disclosures Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member) Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member)

scholarly journals High Intraspecific Genetic Diversity ofNocardia brasiliensis, a Pathogen Responsible for Cutaneous Nocardiosis Found in France: Phylogenetic Relationships by Usingsodandhsp65Genes

2018 ◽  
Vol 2018 ◽  
pp. 1-10
Author(s):  
D. Kosova-Maali ◽  
E. Bergeron ◽  
Y. Maali ◽  
T. Durand ◽  
J. Gonzalez ◽  
...  
Keyword(s):  
Phylogenetic Relationships ◽  
Genetic Characterization ◽  
Haplotype Diversity ◽  
Species Level ◽  
Genotype 1 ◽  
Tropical Regions ◽  
High Bootstrap ◽  
Almost All ◽  
A New Species ◽  
Immunocompetent Patients

This study aims at genetic characterization and phylogenetic relationships ofNocardia brasiliensisfocusing by using housekeepingrrs,hsp65,andsodAgenes.N. brasiliensisis the species responsible for 80% of cases of actinomycetoma, one form of cutaneous nocardiosis which occurs mainly in tropical regions reaching immunocompetent patients in which the disease can lead to amputation. We analyze 36 indigenous cases ofN. brasiliensisthat happened in France. Phylogenetic analysis targetingrrsgene showed no robustness at phylogenetic nodes level. However, the use of a concatenation ofhsp65andsodAgenes showed that the tested strains surprisingly ranked in 3 well-defined genotypes. Genotypes 2 and 3 were phylogenetically closer to each other and both diverged from genotype 1 sustained by a high bootstrap of 81%. This last genotype hosts all the cases of pulmonary forms (3), the sole cerebral form, and almost all the cases of immunocompromised patients (3 out of 4). Moreover, excepting one of them, all the strains belonging to this group present a susceptibility to imipenem which is not the case in the other genotypes that rarely count among them strains being susceptible to this drug. The haplotype diversity (Hd) ofhsp65(0.927) andsodA(0.885) genes was higher than that ofrrs(0.824). For this gene, we obtained 16 polymorphic sites whereas, forhsp65andsodAgenes, up to 27 and 29 were identified, respectively. This study reveals that these two genes have an important genetic discriminatory power for the evaluation of the intraspecies genetic variability ofN. brasiliensisand they may be useful for identification purposes at species level. This study also reveals the possible existence of a new species harbored by genotype 1.

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