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Objectives: Meropenem has become one of the most widely used antibiotics and is considered to be the drug of choice for empirical treatment in patients with pneumonia. The aim of this study is to evaluate factors associated with the use of Meropenem as a broad-spectrum antibiotic in a referral hospital in Makassar. Methods: In a retrospective observational study we conducted over one-month period (January- February 2024), adult patients diagnosed with pneumonia who received Meropenem were selected. We included data such as length of stay, admission to the intensive care unit, use of ventilator, basis of prescription (either empirical or culture-based), and laboratory profiles such as white blood cell count, procalcitonin levels, blood culture and resistance towards antibiotics. Results: Over one-month period, thirty patients admitted to our hospital with pneumonia were evaluated. Among these patients, several factors such as admission in intensive care unit, use of ventilator, and procalcitonin levels showed statically significance (p < 0,05) while blood culture and antibiotic resistance showed minimal impact towards utilization of Meropenem in patients with pneumonia. Conclusions: In conclusion, our study indicates that Meropenem usage for pneumonia treatment is significantly influenced by admission to the intensive care unit, use of ventilator, and specific laboratory parameters such as procalcitonin levels. Further research with larger scale is needed to evaluate utilization of Meropenem in clinical practices.
Introduction: Purulent pericarditis is defined as an infection in the pericardial space that produces macroscopically or microscopically purulent fluid. It was a rare but life-threatening condition. It may be primary or secondary to another infectious process. The diagnosis can only be confirmed by pericardiocentesis. Treatment must include drainage of the pericardial space combined with systemic antibiotics. This case report focuses on a critical and rare clinical scenario of purulent massive pericardial effusion in an 85- year-old male patient. This condition, characterized by an infectious or inflammatory accumulation of fluid in the pericardial cavity, presents significant diagnostic and therapeutic challenges, particularly in the context of multiple comorbidities. Case Description: The patient’s presentation, complicated by pneumonia, diabetes mellitus (DM), and heart failure, underscores the complexities in diagnosing and managing elderly patients with diverse medical backgrounds. The diagnosis of massive pericardial effusion was confirmed through echocardiography, which revealed the purulent fluid from pericardiocentesis procedure, a finding critical for guiding the diagnostic and management strategy. The source of infection wasn’t clear in patient with immunocompromised condition. Some examination performed to find the source of infection that led to a subdiaphragmatic suppurative focus. Infection management was good, but the patient ended with a constrictive that make his condition worse. The patient passed away on the 10th day of hospitalization. Conclusion: It is importance to recognize and promptly address purulent massive pericardial effusion in elderly patients with complex medical histories. The successful clinical outcome following the pericardiocentesis and the adaptive antimicrobial treatment approach provides valuable insights into the management of this severe condition.
Community-acquired bacterial pneumonia (CABP) contributes significantly to mortality and healthcare costs worldwide. The use of guideline-concordant antibiotic therapy for CABP is associated with improved outcomes.
Methods:
This was a retrospective cohort study of inpatients with CABP due to MRSA or P. aeruginosa in the All of Us database. The proportion of patients on guideline-concordant antibiotics or guideline-discordant antibiotics was compared within groups based upon patient age, sex, self-reported race, ethnicity, marital status, alcohol use, and tobacco use. Guideline concordance was determined using the 2019 IDSA/ATS CABP guidelines. Associations were further analyzed using multivariate logistic regression.
Results:
A total of 336 patients with CABP due to MRSA (152) or P. aeruginosa (184) were included. Guideline-concordant antibiotic therapy was prescribed to 70% of CABP-MRSA patients and for 57% of CABP-P. aeruginosa patients. Independently predictive factors of guideline-concordant antibiotic prescribing for CABP-P. aeruginosa patients were Non-Hispanic Black (NHB) vs. Non-Hispanic White (NHW) race (odds ratio = 0.30, 95% confidence interval = 0.12 – 0.75).
Conclusion:
In the All of Us database, the majority of CABP-MRSA and CABP-P. aeruginosa patients were prescribed guideline-concordant antibiotic therapy. Race was independently predictive of guideline-concordant antibiotic therapy for patients with CABP-P. aeruginosa, but not CABP-MRSA. NHB patients were less likely to receive guideline-concordant antibiotic therapy than NHW patients when treated for CABP-P. aeruginosa.
Dysphagia is a frequent symptom that has an impact on prognosis of the critically ill patient. Studies in unselected ICU patient populations revealed the presence of dyphagia in more than 50% of the patiente, and in patients on neurological ICUs dysphagia is thought to be present in even more than 90% of the patients. Dysphagia in critically ill patients is a significant predictor of complications, especially aspiration pneumonia, reintubation and mortality. Still, the access to adequate diagnostic and therapeutic procedures is often limited. This chapter offers a comprehensive overview of the pathophysiology and the diagnostic and therapeutic approach in neurogenic dysphagia.
Varicella zoster virus is a highly infectious virus that causes a vesicular rash and associated malaise, fever, and headaches. While the majority of the population has either had previous infection in childhood or vaccination, seronegative individuals are at risk of primary infection. Primary infection in pregnancy poses a risk of fetal transmission and congenital varicella syndrome, as well as risk of severe morbidity to the mother. Congenital varicella syndrome includes a conglomeration of anomalies such as cutaneous scarring, limb hypoplasia, microcephaly, and chorioretinitis. Seronegative mothers exposed to varicella should be treated with varicella immune globulin to reduce the risk of a primary varicella infection. If a pregnant woman develops varicella, oral acyclovir should be started to reduce the severity of infectious complications and the number of lesions. All women of reproductive age should be asked about their varicella status prior to conceiving. Varicella-naïve women should ideally complete the two-dose VARIVAX vaccine at least 4 weeks prior to conceiving.
Preoperative pneumonia in children with CHD may lead to longer stays in the ICU after surgery. However, research on the associated risk factors is limited. This study aims to evaluate the pre-, intra-, and postoperative risk factors contributing to extended ICU stays in these children.
Methods:
This retrospective cohort study collected data from 496 children with CHD complicated by preoperative pneumonia who underwent cardiac surgery following medical treatment at a single centre from 2017 to 2022. We compared the clinical outcomes of patients with varying ICU stays and utilised multivariate logistic regression analysis and multiple linear regression analyses to evaluate the risk factors for prolonged ICU stays.
Results:
The median ICU stay for the 496 children was 7 days. Bacterial infection, severe pneumonia, and Risk Adjustment for Congenital Heart Surgery-1 were independent risk factors for prolonged ICU stays following cardiac surgery (P < 0.05).
Conclusion:
CHD complicated by pneumonia presents a significant treatment challenge. Better identification of the risk factors associated with long-term postoperative ICU stays in these children, along with timely diagnosis and treatment of respiratory infections in high-risk populations, can effectively reduce ICU stays and improve resource utilisation.
The International Code of Marketing of Breast-Milk Substitutes is an important instrument to protect and promote appropriate infant and young child feeding and the safe use of commercial milk formulas. Ghana and Tanzania implemented the Code into national legislation in 2000 and 1994, respectively. We aimed to estimate the effects of the Code implementation on child mortality (CM) in both countries.
Setting:
The countries analysed were Ghana and Tanzania.
Participants:
For CM and HIV rates, data from the Institute for Health Metrics and Evaluation from up to 2019 were used. Data for income and skilled birth rates were retrieved from the World Bank, for fertility from the World Population Prospects, for vaccination from the Global Health Observatory and for employment from the International Labour Organization.
Design:
We used the synthetic control group method and performed placebo tests to assess statistical inference. The primary outcomes were CM by lower respiratory infections, mainly pneumonia, and diarrhoea and the secondary outcome was overall CM.
Results:
One-sided inference tests showed statistically significant treatment effects for child deaths by lower respiratory infections in Ghana (P = 0·0476) and Tanzania (P = 0·0476) and for diarrhoea in Tanzania (P = 0·0476). More restrictive two-sided inference tests showed a statistically significant treatment effect for child deaths by lower respiratory infections in Ghana (P = 0·0476). No statistically significant results were found for overall CM.
Conclusion:
The results suggest that the implementation of the Code in both countries had a potentially beneficial effect on CM due to infectious diseases; however, further research is needed to corroborate these findings.
Clozapine-induced inflammation, such as myocarditis and pneumonia, can occur during initial titration and can be fatal. Fever is often the first sign of severe inflammation, and early detection and prevention are essential. Few studies have investigated the effects of clozapine titration speed and concomitant medication use on the risk of clozapine-induced inflammation.
Aims
We evaluated the risk factors for clozapine-associated fever, including titration speed, concomitant medication use, gender and obesity, and their impact on the risk of fever and the fever onset date.
Method
We conducted a case-control study. The medical records of 539 Japanese participants with treatment-resistant schizophrenia at 21 hospitals in Japan who received clozapine for the first time between 2010 and 2022 were retrospectively investigated. Of these, 512 individuals were included in the analysis. Individuals were divided into three groups according to the titration rate recommended by international guidelines for East Asians: the faster titration group, the slower titration group and the ultra-slower titration group. The use of concomitant medications (such as antipsychotics, mood stabilisers, hypnotics and anxiolytics) at clozapine initiation was comprehensively investigated. Logistic regression analysis was performed to identify the explanatory variables for the risk of a fever of 37.5°C or higher lasting at least 2 days.
Results
Fever risk significantly increased with faster titration, male gender and concomitant use of valproic acid or quetiapine. No increased fever risk was detected with the use of other concomitant drugs, such as olanzapine, lithium or orexin receptor antagonists. Fever onset occurred significantly earlier with faster titration. Multivariate analysis identified obesity as being a factor that accelerated fever onset.
Conclusion
A faster titration speed and concomitant treatment with valproic acid and quetiapine at clozapine initiation increased the risk of clozapine-associated fever. Clinicians should titrate clozapine with caution and consider both the titration speed and concomitant medications.
This chapter details the epidemiology, route of spread, prevalence and incubation periods relating to the organisms which cause atypical pneumonia (M.pneumoniae, C.psittaci, C.burnetii, L.pneumophila). It gives information on symptoms, laboratory diagnosis, treatment, and outbreaks.
We report an outbreak of confirmed Mycoplasma pneumoniae community-acquired pneumonia (CAP) in Nord Franche-Comté Hospital, France, from 14 November 2023 to 31 January 2024. All 13 inpatients (11 adults with a mean age of 45.5 years and 2 children) were diagnosed with positive serology and/or positive reverse transcription polymerase chain reaction (RT-PCR) on respiratory specimens. All patients were immunocompetent and required oxygen support with a mean duration of oxygen support of 6.2 days. Two patients were transferred to the intensive care unit (ICU) but were not mechanically ventilated. Patients were treated with macrolides (n = 12, 92.3%) with recovery in all cases. No significant epidemiological link was reported in these patients.
Secondary pneumonia occurs in 8–24% of patients with Coronavirus 2019 (COVID-19) infection and is associated with increased morbidity and mortality. Diagnosis of secondary pneumonia can be challenging. The purpose of this study was to evaluate the use of plasma microbial cell free DNA sequencing (mcfNGS) in the evaluation of secondary pneumonia after COVID-19. We performed a single-center case series of patients with COVID-19 who underwent mcfNGS to evaluate secondary pneumonia and reported the organisms identified, concordance with available tests, clinical utility, and outcomes. In 8/13 (61%) cases, mcfNGS detected 1–6 organisms, with clinically significant organisms identified in 4 cases, including Pneumocystis jirovecii, and Legionella spp. Management was changed in 85% (11/13) of patients based on results, including initiation of targeted therapy, de-escalation of empiric antimicrobials, and avoiding contingent escalation of antifungals. mcfNGS may be helpful to identify pathogens causing secondary pneumonia, including opportunistic pathogens in immunocompromised patients with COVID-19. However, providers need to carefully interpret this test within the clinical context.
This study aims to evaluate the impact of non-pharmaceutical interventions (NPIs) on the prevalence of respiratory pathogens among hospitalised children with acute respiratory infections (ARIs) in Suzhou. Children with ARIs admitted to the Children’s Hospital of Soochow University between 1 September 2021 and 31 December 2022 and subjected to 13 respiratory pathogen multiplex PCR assays were included in the study. We retrospectively collected demographic details, results of respiratory pathogen panel tests, and discharge diagnostic information of the participants, and described the age and seasonal distribution of respiratory pathogens and risk factors for developing pneumonia. A total of 10,396 children <16 years of age, including 5,905 males and 4,491 females, were part of the study. The positive rates of the 11 respiratory pathogen assays were 23.3% (human rhinovirus (HRV)), 15.9% (human respiratory syncytial virus (HRSV)), 10.5% (human metapneumovirus (HMPV)), 10.3% (human parainfluenza virus (HPIV)), 8.6% (mycoplasma pneumoniae (MP)), 5.8% (Boca), 3.5% (influenza A (InfA)), 2.9% (influenza B (InfB)), 2.7% (human coronavirus (HCOV)), 2.0% (adenovirus (ADV)), and 0.5% (Ch), respectively. Bocavirus and HPIV detection peaked during the period from September to November (autumn), and MP and HMPV peaked in the months of November and December. The peak of InfA detection was found to be in summer (July and August), whereas the InfB peak was observed to be in winter (December, January, and February). HRSV and HRV predominated in the <3 years age group. HRV and HMPV were common in the 3–6 years group, whereas MP was predominant in the ≥6 years group. MP (odds ratio (OR): 70.068, 95%CI: 32.665–150.298, P < 0.01), HMPV (OR: 6.493, 95%CI: 4.802–8.780, P < 0.01), Boca (OR: 3.300, 95%CI: 2.186–4.980, P < 0.01), and HRSV (OR: 2.649, 95%CI: 2.089–3.358, P < 0.01) infections were more likely to develop into pneumonia than the other pathogens. With the use of NPIs, HRV was the most common pathogen in children with ARIs, and MP was more likely to progress to pneumonia than other pathogens.
Clozapine is a drug that can cause several side effects. Among the less commonly described is a drug-induced lung disease. Due to its non-specific clinical presentation, it represents a diagnostic challenge. The diagnosis is made based on: 1. Association of exposure to the agent and development of symptoms, 2. Pulmonary infiltration, 3. Exclusion of other causes, 4. Withdrawal of symptoms when the agent is excluded from therapy. To date, there have been only a few descriptions of this condition.
Objectives
Case report of rare side effect of clozapine.
Methods
Case report
Results
Case report: male patient (37) with schizophrenia, was hospitalized after a brutal suicide attempt. The PCR test for COVID-19 that was routinely performed on admission was negative. After the introduction of clozapine into therapy, the patient became febrile. There was a drop in oxygen saturation, a Lung CT scan showed inflammatory changes („ground-glass opacities“), and COVID-19 pneumonia was suspected. Due to the worsening of the mental state, the dose of clozapine was increased. The physical condition further deteriorated: febrile, sO2 declining. After repeated PCR tests for COVID-19 (all negative), interstitial pneumonia caused by clozapine was suspected, and clozapine was excluded from therapy. The physical condition started to improve. Quetiapine was introduced, and occasional episodes of agitation were relieved with intramuscular diazepam. In the following days, the patient’s mental state improved and he was discharged.
Conclusions
Despite its superiority over other antipsychotics, clozapine was with good rationale ranked third in treatment guidelines for schizophrenia.
As the population in the United States continues to age, familiarity with the clinical presentation, diagnosis, and management of the major serious infections of elderly individuals becomes an increasingly critical component of general medicine and primary care. While modern medicine has significantly reduced early death due to infection, diseases caused by infectious pathogens remain a major cause of illness and death among elderly persons. This chapter reviews the immunology of the elder host and environmental factors that make older adults uniquely vulnerable to infectious diseases. We propose an approach to the elderly patient with suspected infectious disease and highlight the differences in clinical presentation among older and younger patients, as well as addressing diagnosis and management of common and serious infectious diseases of older adults including urinary tract infection, bacterial pneumonia, influenza, herpes zoster, and Clostridioides difficile.
While incidence studies based on hospitalisation counts are commonly used for public health decision-making, no standard methodology to define hospitals' catchment population exists. We conducted a review of all published community-acquired pneumonia studies in England indexed in PubMed and assessed methods for determining denominators when calculating incidence in hospital-based surveillance studies. Denominators primarily were derived from census-based population estimates of local geographic boundaries and none attempted to determine denominators based on actual hospital access patterns in the community. We describe a new approach to accurately define population denominators based on historical patient healthcare utilisation data. This offers benefits over the more established methodologies which are dependent on assumptions regarding healthcare-seeking behaviour. Our new approach may be applicable to a wide range of health conditions and provides a framework to more accurately determine hospital catchment. This should increase the accuracy of disease incidence estimates based on hospitalised events, improving information available for public health decision making and service delivery planning.
The impact of influenza and pneumonia on individuals in clinical risk groups in England has not previously been well characterized. Using nationally representative linked databases (Clinical Practice Research Database (CPRD), Hospital Episode Statistics (HES) and Office for National Statistics (ONS)), we conducted a retrospective cohort study among adults (≥ 18 years) during the 2010/2011–2019/2020 influenza seasons to estimate the incidence of influenza- and pneumonia-diagnosed medical events (general practitioner (GP) diagnoses, hospitalisations and deaths), stratified by age and risk conditions. The study population included a seasonal average of 7.2 million individuals; approximately 32% had ≥1 risk condition, 42% of whom received seasonal influenza vaccines. Medical event incidence rates increased with age, with ~1% of adults aged ≥75 years hospitalized for influenza/pneumonia annually. Among individuals with vs. without risk conditions, GP diagnoses occurred 2–5-fold more frequently and hospitalisations were 7–10-fold more common. Among those with obesity, respiratory, kidney or cardiovascular disorders, hospitalisation were 5–40-fold more common than in individuals with no risk conditions. Though these findings likely underestimate the full burden of influenza, they emphasize the concentration of disease burden in specific age and risk groups and support existing recommendations for influenza vaccination.
Despite the growing body of evidence suggesting that alcohol consumption is associated with an increased risk of and poorer treatment outcomes from pneumonia, little is known about the association between alcohol control policy and pneumonia mortality. As such, this study aimed to assess the impact of three alcohol control policies legislated in 2008, 2017 and 2018 in Lithuania on sex-specific pneumonia mortality rates among individuals 15+ years of age. An interrupted time-series analysis using a generalised additive mixed model was performed for each policy. Of the three policies, only the 2008 policy resulted in a significant slope change (i.e. decline) in pneumonia mortality rates among males; no significant slope change was observed among females. The low R2 values for all sex-specific models suggest that other external factors are likely also influencing the sex-specific pneumonia mortality rates in Lithuania. Overall, the findings from this study suggest alcohol control policy's targeting affordability may be an effective way to reduce pneumonia mortality rates, among males in particular. However, further research is needed to fully explore their impact.
A 24-year-old gravida 1, para 0 female presents to the emergency department with a positive home pregnancy test and the acute onset of lower abdominal pain, right shoulder pain, and vaginal spotting. The pain is severe and woke her from sleep. She rates the pain as 8/10. She is a nurse and has stayed home from work the last three days due to fever, chills, and cough. She describes the cough as productive of yellow sputum. She has pain in her chest with coughing. She denies nausea, vomiting, or urinary symptoms. Her last menstrual period was six weeks ago.
1. Diagnosis and treatment of pneumonia should be based on the clinical picture.
2. The CURB-65 score is a clinical prediction tool that has been validated for predicting mortality in community-acquired pneumonia, and it is recommended by the British Thoracic Society for assessment of the severity of pneumonia.
3. Chest radiographs have historically been perceived as a reliable tool for diagnosing pneumonia; however, despite their availability and widespread use, they have their limitations.
4. Antibiotics should be used early.
5. Nationally accepted protocols and the local antibiogram should be utilised when treating pneumonia.
Adenovirus pneumonia can occur in immunocompetent youths and adults. We conducted a retrospective analysis on five immunocompetent patients (aged ⩾14 years) with adenovirus pneumonia who visited our fever clinic between 1 February 2020 and 29 February 2020. The symptoms at clinical onset were fever, with cough and phlegm production either absent or appearing several days after disease onset. One patient with severe disease exhibited dyspnoea and a rapid development of respiratory failure. A subset of patients had concurrent gastrointestinal symptoms. The results of blood tests revealed normal leukocyte counts, decreased lymphocyte counts and increased C-reactive protein levels. The imaging findings resembled those of bacterial pneumonia, and pleural effusions were present in some cases. Most patients had a good prognosis with symptomatic treatment and supportive care. However, one patient with severe disease and a MuLBSTA score of >12 had a poor prognosis and ultimately died. Immunocompetent youths and adults may develop adenovirus pneumonia, and severe cases are at the risk of death. Since no effective treatments for adenovirus pneumonia are currently known, the early diagnosis and provision of symptomatic treatment and supportive care should be adopted to prevent the development and progression of severe disease.