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Impact of Bacterial and Viral Coinfection in Community-Acquired Pneumonia in Adults

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Impact of Bacterial and Viral Coinfection in Community-Acquired Pneumonia in Adults Diagnostic Microbiology and Infectious Disease 94 (2019) 50–54 Contents lists available at ScienceDirect Diagnostic Microbiology and Infectious Disease journal homepage: www.elsevier.com/locate/diagmicrobio Impact of bacterial and viral coinfection in community-acquired pneumonia in adults Yong Kwan Lim a,c, Oh Joo Kweon b,c, Hye Ryoun Kim c,Tae-HyoungKimd,Mi-KyungLeec,⁎ a Department of Laboratory Medicine, Armed Forces Capital Hospital, Gyeonggi-do, Republic of Korea b Department of Laboratory Medicine, Aerospace Medical Center, Chungcheongbuk-do, Republic of Korea c Department of Laboratory Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea d Department of Urology, Chung-Ang University College of Medicine, Seoul, Republic of Korea article info abstract Article history: Bacterial and viral coinfected community-acquired pneumonia (CAP) is poorly characterized in adults. The aim of Received 27 June 2018 this study was to investigate the influence of bacterial and viral coinfection in patients with CAP. A total of 235 Received in revised form 14 November 2018 adults who requested molecular tests of pneumonia and were diagnosed with CAP were enrolled in this study. Accepted 17 November 2018 Microbiological tests included blood and sputum cultures, PCR for bacterial and viral pathogens, antigen test Available online 24 November 2018 for Streptococcus pneumoniae and the influenza virus, and antibody detection of Mycoplasma pneumonia.Ofthe 235 patients, 32 (13.6%) patients were coinfected with bacteria and virus. Among 64 severe CAP patients, the Keywords: fi fi Coinfection concurrent infections were con rmed in 14 patients (21.9%). The proportion of severe pneumonia was signi - Virus cantly higher in patients with coinfection, and they showed a significantly higher mortality rate. In conclusion, Bacteria bacterial and viral coinfection in CAP is not a rare occurrence in adults. Viral and bacterial coinfections have an Community-acquired pneumonia adverse impact on the severity of the pneumonia, and increase morbidity and mortality in patients with CAP. Severe pneumonia © 2018 Elsevier Inc. All rights reserved. Mortality 1. Introduction and viral coinfection, especially in adult patients with CAP are still lim- ited. Therefore, we retrospectively investigated adult, hospitalized pa- Pneumonia is an acute infectious disease, which is still one of the tients with CAP and analyzed the incidence, etiology, clinical features, most common causes of death in the world. In 2015, the World Health and outcomes of bacterial and viral coinfection in these patients. Organization (WHO) reported that lower respiratory infection caused 3.2 million deaths worldwide (World Health Organization (WHO), 2. Materials and methods 2017). In particular, pneumonia mortality rates are substantially higher in children under five and adults over 75 years of age. Community- 2.1. Subjects acquired pneumonia (CAP) is a type of pneumonia that develops in peo- ple with limited or no contact with the healthcare system. The incidence This study was a retrospective analysis of hospitalized patients with of CAP varies by age, country, and gender; however, the clinical impact of CAP who had been referred for molecular diagnosis of pneumonia using CAP is clear that patients with CAP often require hospitalization and CAP blood, sputum, or urine specimens in the Chung-Ang University Hospi- increases mortality (Welte et al., 2012; Wunderink and Waterer, 2014). tal from January 2015 to December 2015. This study was approved by CAP can be caused by various pathogens, such as bacteria, viruses, the Institutional Review Board of the Chung-Ang University Hospital fungus, or parasites, and most cases of CAP are caused by a single path- (C2016204 (1947)). ogen (Welte et al., 2012). Through development of diagnostic tech- Samples were collected from 3304 patients for molecular diagnosis niques, various pathogens can be effectively detected in clinical of pneumonia. These subjects were classified according to age, and the samples (Huijskens et al., 2013; Jennings et al., 2008), and the clinical medical records of 633 patients (18 years or older) were reviewed. Pa- characteristics of mixed infection in CAP have been described in several tients suspected as healthcare-associated pneumonia (HCAP) or reports (Chiu et al., 2015; Cilloniz et al., 2011; Jennings et al., 2008). A hospital-acquired pneumonia (HAP) were excluded from this study. possible correlation between mixed infection and the severity of dis- The HCAP and HAP patients were classified according to the Infectious eases was reported. However, data on the clinical features of bacterial Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines (ATS and IDSA, 2005). ⁎ Corresponding author. Tel.: +82-2-6299-2719; fax: +82-2-6298-8630. We confirmed 235 patients as diagnosed with CAP. CAP was defined E-mail address: [email protected] (M.-K. Lee). as pneumonia based on the British Thoracic Society (BTS) guidelines, https://doi.org/10.1016/j.diagmicrobio.2018.11.014 0732-8893/© 2018 Elsevier Inc. All rights reserved. Y.K. Lim et al. / Diagnostic Microbiology and Infectious Disease 94 (2019) 50–54 51 including clinical symptoms and signs were consistent with an acute as median with interquartile ranges for continuous variables and counts lower respiratory tract infection associated with new radiographic with percentages for categorical variables. To compare the continuous shadowing for which there was no other cause (Lim et al., 2009). In variables, the Mann–Whitney U-test was used. The Fisher's exact test the patients included in this study, CAP was the primary reason for hos- was performed to compare differences between categorical variables. pitalization, and it was managed as pneumonia. Subsequently, CURB-65 A P-value of less than 0.05 was considered as a significant difference. (Lim et al., 2003) and pneumonia severity index (PSI) (Fine et al., 1997) Multivariate logistic regression analysis was employed to identify risk were calculated and recorded at the time of admission for all subjects. factors for bacterial and viral coinfection. To select the final model, we Additionally, severe pneumonia patients were classified according to used stepwise backward selection with an entry probability of 0.05 the IDSA/ATS guidelines (Mandell et al., 2007). and a removal probability of 0.1. Baseline characteristics, such as phys- For subjects enrolled in this study, the following data were collected: ical findings, laboratory findings, or previous medical histories, were in- (1) basic patient information (age, sex, hospitalization period, and mor- cluded to analyze risk factors for dependent variable. In addition, similar tality rate), (2) past medical history with comorbid disease (any malig- statistical analysis was performed to identify independent variables as- nancy, congestive heart failure, cerebrovascular disease, renal disease, sociated with mortality. liver disease, chronic obstructive pulmonary disease (COPD), bronchiec- tasis, asthma, previous Mycobacteria infection history, and HIV (human 3. Results immunodeficiency virus) infection history), (3) physical findings (body temperature, heart rate, blood pressure, respiratory rate, and mental 3.1. Study populations and distributions of pathogens status), and (4) laboratory findings (bacterial culture results for any specimens, bacterial and viral antigen test, molecular test results of bac- Of the 3304 patients referred for pneumonia molecular testing, the terial and viral pathogens, antibody test for M. pneumoniae, HIV screen- majority of them (80.8%, 2671/3304) were pediatric patients, and 633 ing assay, arterial blood gas analysis (ABGA), complete blood cell count adult patients (19.2%, 633/3304) were enrolled in our study. With (CBC), blood nitrogen urea (BUN), sodium, glucose, C-reactive protein reviewing medical records, CAP diagnosis could be established in 235 (CRP), chest radiographic findings, mechanical ventilation, immuno- adult subjects (37.1%, 235/633). Among them, a total of 191 pathogens compromised status, and intensive care unit (ICU) admission). In addi- (121 bacterial pathogens and 70 viral pathogens) were confirmed and tion, chest computed tomography and bronchoscopy findings were also identified in 130 patients (55.3%, 130/235). The distribution of patho- collected when available. gens is summarized in Tables 1 and 2. The most commonly identified bacterial pathogens were Streptococcus pneumoniae (28.9%), Haemophi- 2.2. Microbiological examination lus influenza (25.6%), and Chlamydophila pneumoniae (17.4%). In addi- tion, two or more bacterial pathogens were isolated from 23 patients, At the time of hospitalization, blood, urine, sputum, and nasopha- of which 11 were found to be coinfected with viral pathogens. In the ryngeal swab specimens were collected for the microbiological exami- virus, the most frequently confirmed viruses were rhinovirus (18.6%), nation. Blood cultures were performed aerobically and anaerobically influenza A virus (17.1%), and adenovirus (12.9%). Infection with multi- using the BacT/Alert 3D blood culture system (bioMérieux Inc., Marcy- ple viruses was found in four patients, and all of them were coinfected l'Etoile, France). The Vitek 2 system (bioMérieux Inc.) was used for bac- with bacterial pathogens. The most frequently identified virus to cause terial identification. Sputum samples were Gram-stained and examined. bacterial and viral coinfection was RSV, resulting in concurrent infection Following, they were
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