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Different Microbiological and Clinical Aspects of Lower Respiratory Tract Infections Between China and European/American Countries

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Different Microbiological and Clinical Aspects of Lower Respiratory Tract Infections Between China and European/American Countries Original Article Different microbiological and clinical aspects of lower respiratory tract infections between China and European/American countries Xin Zhang1, Rui Wang2, Xiuzhen Di2, Bin Liu1, Youning Liu1 1Department of Respiratory Diseases, 2Department of Clinical Pharmacology, Chinese PLA General Hospital, Beijing 100853, China Corresponding to: Youning Liu, MD. Department of Respiratory Diseases, Chinese PLA General Hospital, Beijing 100853, China. Email: [email protected]. Background: National treatment/diagnosis guidelines for lower respiratory tract infections (LRTIs) are generally based on local epidemiological data. Etiology and drug-resistance patterns could differ between China and European/American countries, and simply following their respective guidelines might cause problems in clinical practice. Therefore, we need to summarize the microbiology and clinical manifestations of LRTIs in China and develop our own guidelines. Methods: Three major national multicenter epidemiology surveillance studies on LRTI were completed recently. The data were compared in detail with those from European/American studies. Results: Clinical and microbiological differences were observed in community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and pulmonary mycosis between our country and European/American countries. Conclusions: The microbiological and clinical characteristics of the major LRTIs in China differ in many respects from those in European/American countries. Patients should have personal treatment plans instead of simply following the guidelines from foreign countries Keywords: Pathogens; epidemiology; antimicrobial resistance; lower respiratory tract infections (LRTIs) Submitted Jun 21, 2013. Accepted for publication Jan 22, 2014. doi: 10.3978/j.issn.2072-1439.2014.02.02 Scan to your mobile device or view this article at: http://www.jthoracdis.com/article/view/2038/2701 Introduction research and epidemiological investigations. The most comprehensive and influential guidelines are currently Lower respiratory tract infection (LRTI) is one of the most presented by the American Thoracic Society (ATS), the common diseases in humans and a long-term global public Infectious Diseases Society of America (IDSA), and the health concern. Worldwide, it places considerably more British Thoracic Society (BTS). Compared with European/ strain on health budgets than do cancer, cardiovascular American countries, China has diverging socioeconomic diseases, and malaria (1). In the United States, the incidence models, different medicare systems, and varying LRTI of LRTI and its mortality rates are higher than for any etiology and drug-resistance patterns. Therefore, simply other infectious diseases. According to a 2002 WHO report, copying the existing European/American guidelines is LRTIs accounted for 6.9% of all deaths in that year (2). inappropriate and might cause serious problems in clinical High rates of LRTI incidence and the high medical cost practice. In recent years, large epidemiological investigations involved are found worldwide, and the importance of their of community-acquired pneumonia (CAP), hospital-acquired diagnosis and treatment is accordingly emphasized. Since pneumonia (HAP), and pulmonary mycosis were carried out the 1990s, European/American countries have developed in several large/middle-sized cities in China, and preliminary guidelines for diagnosis and treatment of LRTI. These data on LRTI were obtained. guidelines have been subject to regular evaluations and This paper summarized these results and discussed the revisions on the basis of repeated evidence-based medical differences in the microbiological and clinical features of © Pioneer Bioscience Publishing Company. All rights reserved. www.jthoracdis.com J Thorac Dis 2014;6(2):134-142 Journal of Thoracic Disease, Vol 6, No 2 February 2014 135 LP+Kpn 0.50% CP+SP LP+SP CP+Kpn SP+HI 0.50% 0.50% 0.50% 0.50% HI+LP MP+SA 0.70% Unkown 0.50% 46.81% MC MP+Kpn Others 0.80% Mixed infections 0.70% 2.10% PA 11.6% 0.80% MP+SP EC 2.00% 1.00% MP MP+HI 13.37% LP 2.10% 2.79% SP SA Kpn 6.09% three pathogens 2.79% 3.79% CP 0.80% 4.79% HI 5.39% MP+LP+Kpn+EC 0.20% Figure 1 The pathogen distribution of 610 adult CAP cases in China. Unknown, No detectable pathogens; SP, Streptococcus pneumonia; HI, Haemophilus influenza; Kpn, Klebsiella pneumonia; MP, Mycoplasma pneumoniae; LP, Legionella pneumophila; CP, Chlamydia pneumonia; EC, Escherichia coli; SA, Staphylococcus aureus; PA, Pseudomonas aeruginosa; MC, Moraxelle catarrhalis. LRTIs between China and European/American countries. cultured. (II) High resistance to macrolides among S. pneumoniae in China is another characteristic difference compared with CAP European/American countries. The Alexander Project CAP is one of the most common LRTIs. The overall Group showed that in European/American countries, incidence rate is 5-11 per 1,000 people per year, accounting rates of erythromycin resistance (resistant + intermediate for 5-12% of all LRTIs (3). The pathogens causing CAP resistance) in S. pneumoniae are <30%, with 6.9% in include viruses, bacteria, and other atypical pathogens. The Germany, 13.0% in the UK, and 28.8% in the USA (5). pathogen composition is complicated and varies according The resistance is mainly medicated by the mef(A) gene, to geographic area, population, and seasonal changes. The and the common resistance phenotype is M-type (low national pathogenic epidemiological investigation of CAP level resistance to 14- or 15-membered macrolides and in 2006 indicated the following major characteristics in susceptibility to 16-membered macrolides and clindamycin) China. (6,7) (Table 1). Therefore, in those countries, macrolide (I) The infection rate of Mycoplasma pneumoniae surpassed antibiotics are recommended as the first-line empirical that of Streptococcus pneumoniae and became the leading therapy in the clinic for CAP patients without risk factors (9). cause of adult CAP in our country. Whereas S. pneumonia In contrast, in our country, the level of macrolide resistance and Haemophilus influenzae are still two kinds of the most in S. pneumoniae is higher. For example, the rate of common CAP pathogens (Figure 1). A high proportion of azithromycin resistance is as high as 79.4%; mainly as adult cases of CAP are derived from mixed infection with constitutive resistance mediated by the erm(B) gene (cMLSB, bacteria and atypical pathogens (4). highly resistant to erythromycin) (8,10). Considering the Regular sputum sampling was done with most (590/610) high divergence in drug resistance to macrolides in different inpatients enrolled in the study, and blood samples were areas, the CAP guidelines from ATS/IDSA (2007 edition) taken if patients had a fever of >38.5 . Sputum was still recommended macrolides as the drug of first choice Gram-stained. Representative sputum originated from the for previously healthy patients. However, they also pointed ℃ lower respiratory tract was defined as that containing >25 out that in areas with high rates of macrolide resistance, granulocytes and <10 epithelial cells per low power field alternative antibiotics should be selected (11). microscopic view. Validated sputum and blood samples were (III) Many recent studies suggest that China has the © Pioneer Bioscience Publishing Company. All rights reserved. www.jthoracdis.com J Thorac Dis 2014;6(2):134-142 136 Zhang et al. Different characteristics of LRTIs between China and Western country Table 1 Comparative prevalences of erythromycin resistance in S. pneumoniae between China and European/American countries References The main resistance gene type and phenotype Country n, isolates (intermediate + resistant) Tiemei Z et al. (8) erm(B), cMLSB-phenotype China 149/192* Michael R et al. (5) mef(A), M-phenotype Germany 22/321 UK 31/238 USA 700/2,432 *, multiple comparisons of erythromycin resistance rates in S. pneumoniae isolates from different countries are based upon chi-square analog of Scheffé’s theorem. The rate of erythromycin resistance in S. pneumoniae isolates between China and any of other West countries are all significantly different (P≤0.05). Table 2 Comparative prevalences of macrolide resistance in M. pneumonia between China and European/American countries Country %, isolates (intermediate + resistant) References China 69.0* Cao B, et al. (17) Japan 30.6 Morozumi M, et al. (13) France 9.8 Peuchant O, et al. (14) USA 20.7 Dumke R, et al. (15) *, multiple comparisons of macrolide resistance rates in M. pneumoniae isolates from different countries are based upon chi-square analog of Scheffé’s theorem. The rate of macrolide resistance in M. pneumoniae isolates between China and any of the other three countries are of significances in statistics (P≤0.05). highest rates of macrolide resistance of M. pneumoniae. respiratory quinolones or tetracyclines can be used for adults. Since the first macrolide-resistant M. pneumoniae strain For adult patients with severe infection, respiratory quinolones was isolated from the lower respiratory tract of a Japanese alone or combined with other drugs can be used for initial child in 2001 (12), more macrolide-resistant strains have treatment. been obtained from other countries and the prevalence is (IV) CAP caused by methicillin-resistant Staphylococcus increasing annually. In 2006, this resistance rate in Japan was aureus (MRSA) is still rare in China. In 1993, the first 30.6% (13); from 2005 to 2007, it was 9.8% in France (14); community-acquired MRSA (19) was reported in Australia.
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