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Blood, sputum, BAL cultures, pleural fluid cultures and viral testing were more frequently obtained among patients undergoing invasive mechanical ventilation compared to patients not receiving invasive mechanical ventilation. In contrast, when ICU admission, vasopressor administration, or combined vasopressor and invasive mechanical ventilation administration were used as measures of disease severity, only blood cultures, BAL cultures and viral testing were significantly more common among patients with a severe disease table 3.
Of the diagnostic tests performed, Specifically, Bacteria, viruses and fungi accounted for Microbiological tests performed among adult inpatients with community-acquired pneumonia by disease severity.
ICU: intensive care unit. When the performance of diagnostic testing was compared among patients admitted at participating hospitals in North America, South America, Africa, Asia, Europe and Oceania, significant differences were identified table 4. Performance of at least one test ranged from Acute-phase serology for Chlamydophila pneumoniae , Mycoplasma pneumonia e and Legionella species was more common in Europe Microbiological tests performed among adult inpatients with community-acquired pneumonia by geographic area.
When the overall study population was analysed, over-testing and under-testing were reported in Over-testing and under-testing were documented in Among ERS-discordant patients, pneumococcal and Legionella urinary antigen tests performed without an indication accounted for the majority of over-testing, while under-testing was mainly due to the lack of obtaining blood cultures when indicated.
This international, multicentre, point-prevalence study provides a high-quality, real-life picture of diagnostic testing in patients hospitalised with CAP. At least one microbiological test was performed in the vast majority of patients hospitalised with CAP and led to an aetiological diagnosis in one-third of patients tested.
Geographic area and disease severity influenced testing frequency. Several crucial points could be raised by our findings. First, a pathogen was identified in one-third of adult inpatients with CAP. This pathogen-detection yield is similar to previously reported investigations [ 14 — 21 ] and consistent with the EPIC Etiology of Pneumonia in the Community study [ 1 ]. The low pathogen-detection yield reported in this and other CAP studies highlights how limited our understanding is of CAP aetiologies among adult inpatients and how current empirical antimicrobial recommendations are based on weak evidence.
Studies aimed at collecting as much data as possible to identify the aetiology using state-of-the-art diagnostic techniques and innovative pathogen-discovery approaches are urgently needed. Furthermore, aetiological studies should use novel analytical techniques in order to incorporate evidence from multiple specimens to account for the imperfect sensitivity and specificity of the diagnostic tests used [ 22 ].
Once a more accurate estimate of the aetiological distribution of CAP among adult inpatients is available, empirical antimicrobial recommendations should be updated. As a consequence, pneumonia severity was also associated with an increased probability of pathogen detection.
Exploring the true determinants of pathogen detection would have required a systematic and universal testing strategy and, for this reason, it was out of the scope of this study.
Thirdly, our study confirmed the differing diagnostic yield of various diagnostic tests. Specifically, only 6. In contrast, BAL cultures were characterised by a high diagnostic yield While impractical and potentially associated with complications, BAL cultures represent an effective diagnostic tool for patients with severe infections, who may benefit the most from a targeted antimicrobial regimen.
Indeed, a randomised trial by van der E erden et al. Fourthly, our analysis described a significant geographic variation in diagnostic testing strategies. We could speculate that the economical restraints of African health systems accounted for the reduced number of blood cultures and viral tests performed in this setting.
Laboratory infrastructure to support diagnostic microbiological testing is limited in most African countries: bacteriological culture or molecular techniques that form the mainstay of CAP diagnostics in well-resourced settings are often lacking in Africa [ 25 , 26 ]. In contrast, the seasonality and the epidemiological relevance of respiratory viruses, such as avian-origin influenza A and Middle East respiratory syndrome coronavirus, may have favoured the performance of viral testing in Asia [ 27 , 28 ].
Fifthly, our study is among the first to evaluate the concordance of real-life diagnostic testing with international guidelines. To the best of our knowledge, only J enkins et al. Discordance with ERS guidelines was mainly due to under-testing, as a result of the extensive testing approach recommended by these guidelines.
Over-testing was also identified as a cause of discordance with the ERS guidelines. This event was more frequently reported in Europe than in North America. Insurance and healthcare system-related factors may have shaped the diagnostic approach both of European and North American clinicians.
Finally, this study has important strengths and limitations. To our knowledge, GLIMP is the first study to enrol a large and diverse group of adult patients hospitalised with CAP across six continents, providing a detailed, real-world picture of CAP diagnostic testing around the world. Similarly, incomplete data regarding presence of pleural effusions and clinical and epidemiological determinants of Legionella infection limited the accuracy our findings, probably leading to an inflation of our over-testing estimates.
Finally, due to its cross-sectional design, our study did not provide CAP outcome data. In conclusion, our understanding of the aetiologies of CAP among hospitalised adults is scarce, limiting the accuracy of empirical antimicrobial regimens. Disease severity and geography are associated with differences in testing approaches.
GLIMP investigators: We would like to thank the following study contributors for their valuable collaboration. Dr Cazaux A.
India: Mohit Bhatia, S. Mahesh and B. Ireland: Vera M. Villegas, Hospital Universitario, Monterrey, Mexico. The Netherlands: E. UK: Devesh J. USA: Karen S. Dysart and Susan M. Kellie, Clement J. Holland and Stephen P. Soni, Julio Noda, Cecilia I. Hinojosa, Stephanie M. Levine, Luis F. Wunderink and Ray D. Conflict of interest: M. Carugati has nothing to disclose. Conflict of interest: S. Conflict of interest: L. Reyes has nothing to disclose. Conflict of interest: R. Franco Sadud has nothing to disclose.
Irfan has nothing to disclose. Conflict of interest: C. Prat has nothing to disclose. Conflict of interest: N. Soni has nothing to disclose. Conflict of interest: P. Faverio has nothing to disclose. Conflict of interest: A. Conflict of interest: F. Restrepo has nothing to disclose. Support statement: This project was not funded and relied solely on voluntary site and investigator participation.
ERJ Open Res. Published online Oct 8. Nilam J. Marcos I. Koul, P. Mahesh, B. Villegas, Milic Medenica, E. Dysart, Susan M. Kellie, Ricardo A. Holland, Stephen P. Angel, Antonio Anzueto, K. Wunderink, Ray D. Author information Article notes Copyright and License information Disclaimer. E-mail: ti. Received Jun 20; Accepted Aug This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.
Introduction Community-acquired pneumonia CAP is a leading cause of hospitalisation worldwide. Methods Study design, setting and participants We performed a secondary analysis of an international, multicentre, observational, prospective cohort study using the Global Initiative for Methicillin-resistant Staphylococcus aureus Pneumonia GLIMP database [ 13 ].
Open in a separate window. Statistical analysis Continuous variables were presented as medians with interquartile range. Results Among patients, TABLE 2 Baseline characteristics of adult inpatients with community-acquired pneumonia by testing status and by pathogen detection.
TABLE 3 Microbiological tests performed among adult inpatients with community-acquired pneumonia by disease severity. By using our site, you agree to our collection of information through the use of cookies. To learn more, view our Privacy Policy. To browse Academia. The main topics this article deals with are concerned with the novelty our exhibition brings in terms of the design concept, approach, and objects display, with our choices in exhibiting objects and our innovative display techniques, all of them employed in order to bring a selective and exigent public to the museum.
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Community-acquired pneumonia in sub-Saharan Africa. By using our site, you agree to our collection of information through the use of cookies.
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