Figures
- FIGURE 1
Discordance of diagnostic testing with the a) 2007 Infectious Diseases Society of America/American Thoracic Society (ATS) guidelines and b) 2011 European Respiratory Society (ERS) guidelines for community-acquired pneumonia by geographic area. Over: over-testing; under: under-testing; over/under: over-testing and under-testing.
Tables
- TABLE 1
Tests considered as recommended or not recommended by the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) and European Respiratory Society (ERS) guidelines
IDSA/ATS recommendations ERS recommendations Blood culture Recommended in case of ICU admission, leukopenia, alcohol abuse, chronic severe liver disease, asplenia, positive pneumococcal urinary antigen test and presence of pleural effusion Recommended in all patients hospitalised with CAP Sputum culture Recommended in case of ICU admission, alcohol abuse, severe obstructive or structural lung disease, positive Legionella urinary antigen test, positive pneumococcal urinary antigen test and presence of pleural effusion Recommended in case of purulent sputum sample Bronchoalveolar lavage culture Recommended in case of intubation Recommended in case of intubation Legionella urinary antigen test Recommended in case of ICU admission, alcohol abuse and presence of pleural effusion Recommended in all patients hospitalised with severe CAP Pneumococcal urinary antigen test Recommended in case of ICU admission, leukopenia, alcohol abuse, chronic severe liver disease, asplenia and pleural effusion Recommended in all patients hospitalised with severe CAP Acute-phase serology for Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella species Not recommended Not recommended ICU: intensive care unit; CAP: community-acquired pneumonia.
- TABLE 2
Baseline characteristics of adult inpatients with community-acquired pneumonia by testing status and by pathogen detection
Testing status Pathogen detection Not tested Tested p-value Not detected Detected p-value Patients 485 3217 2044 1173 Demographic characteristics Age 71.0 (54.0–81.0) 68.0 (54.0–80.0) 0.03 70.0 (55.0–81.0) 65.0 (50.0–77.0) <0.01 Male sex 255 (52.6) 1888 (58.7) 0.01 1173 (57.4) 715 (61.0) 0.04 Underweight 14 (5.2) 152 (7.4) 0.19 83 (6.5) 69 (8.8) 0.06 Obesity 64 (13.2) 513 (15.9) 0.12 314 (15.4) 199 (17.0) 0.23 Respiratory past medical history Active lung cancer 17 (3.5) 92 (2.9) 0.43 62 (3.0) 30 (2.6) 0.44 Asthma 26 (5.4) 235 (7.3) 0.12 149 (7.3) 86 (7.3) 0.97 Bronchiectasis 9 (1.9) 169 (5.3) <0.01 76 (3.7) 93 (7.9) <0.01 Chronic aspiration 39 (8.0) 218 (6.8) 0.31 137 (6.7) 81 (6.9) 0.83 COPD 96 (19.8) 840 (26.1) 0.01 517 (25.3) 323 (27.5) 0.16 Current or former smoker 121 (24.9) 1124 (34.9) <0.01 709 (34.7) 415 (35.4) 0.69 Interstitial lung disease 4 (0.8) 91 (2.8) 0.01 65 (3.2) 26 (2.2) 0.11 Obstructive sleep apnoea 7 (1.4) 123 (3.8) 0.01 78 (3.8) 45 (3.8) 0.98 Home oxygen therapy 14 (2.9) 210 (6.5) <0.01 123 (6.0) 87 (7.4) 0.12 Lung transplant 0 (0.0) 7 (0.2) 0.30 2 (0.1) 5 (0.4) 0.06 Tracheostomy 3 (0.6) 50 (1.6) 0.11 14 (0.7) 36 (3.1) <0.01 At least one respiratory comorbidity 235 (48.5) 1917 (59.6) <0.01 1434 (56.7) 718 (61.2) 0.01 Cardiovascular past medical history Arrhythmia 69 (14.2) 458 (14.2) 1.00 307 (15.0) 151 (12.9) 0.09 Coronary artery disease 69 (14.2) 528 (16.4) 0.22 325 (15.9) 203 (17.3) 0.30 Heart failure 64 (13.2) 421 (13.1) 0.95 270 (13.2) 151 (12.9) 0.79 Hypertension 201 (41.4) 1454 (45.2) 0.12 973 (47.6) 481 (41.0) <0.01 Stroke 55 (11.3) 251 (7.8) 0.01 168 (8.2) 83 (7.1) 0.25 Immunosuppressive conditions Active solid tumour 40 (8.2) 247 (7.7) 0.66 164 (8.0) 83 (7.1) 0.33 AIDS 8 (1.6) 57 (1.8) 0.85 24 (1.2) 33 (2.8) <0.01 Aplastic anaemia 1 (0.2) 13 (0.4) 0.51 8 (0.4) 5 (0.4) 0.88 Asplenia 0 (0.0) 12 (0.4) 0.18 5 (0.2) 7 (0.6) 0.12 Chemotherapy in the last 3 months 9 (1.9) 136 (4.2) 0.01 83 (4.1) 53 (4.5) 0.54 Haematological malignancy 11 (2.3) 151 (4.7) 0.02 93 (4.5) 58 (4.9) 0.61 HIV infection 16 (3.3) 107 (3.3) 0.98 56 (2.7) 51 (4.3) 0.01 Neutropenia 4 (0.8) 44 (1.4) 0.32 29 (1.4) 15 (1.3) 0.74 Steroids use 24 (4.9) 270 (8.4) 0.01 174 (8.5) 96 (8.2) 0.75 At least one immunosuppressive condition 74 (15.3) 591 (18.4) 0.09 356 (17.4) 235 (20.0) 0.07 Other chronic medical conditions Chronic renal failure 50 (10.3) 350 (10.9) 0.71 241 (11.8) 109 (9.3) 0.03 Cirrhosis 6 (1.2) 64 (2.0) 0.26 36 (1.8) 28 (2.4) 0.22 Diabetes mellitus 92 (19.0) 690 (21.4) 0.21 448 (21.9) 242 (20.6) 0.39 Haemodialysis 1 (0.2) 51 (1.6) 0.02 32 (1.6) 19 (1.6) 0.91 Liver disease 11 (2.3) 129 (4.0) 0.06 75 (3.7) 54 (4.6) 0.19 Mental illness 33 (6.8) 221 (6.9) 0.96 146 (7.1) 75 (6.4) 0.42 Dementia 74 (15.3) 334 (10.4) <0.01 228 (11.2) 106 (9.0) 0.06 Previous infections Prior ESBL 0 (0.0) 55 (1.7) <0.01 27 (1.3) 28 (2.4) 0.03 Prior MRSA 5 (1.0) 81 (2.5) 0.04 34 (1.7) 47 (4.0) <0.01 Prior mycobacterial disease 7 (1.4) 89 (2.8) 0.09 42 (2.1) 47 (4.0) <0.01 Prior Pseudomonas 4 (0.8) 97 (3.0) <0.01 32 (1.6) 65 (5.5) <0.01 Previous healthcare exposure# Lower respiratory tract infection 106 (21.9) 935 (29.1) <0.01 667 (26.4) 374 (31.9) <0.01 Emergency room admission 120 (24.7) 981 (30.5) 0.01 708 (28.0) 393 (33.5) <0.01 Hospitalisation 128 (26.4) 1035 (32.2) 0.01 771 (30.5) 392 (33.4) 0.07 Home antibiotic infusion therapy 21 (4.3) 141 (4.4) 0.96 94 (3.7) 68 (5.8) <0.01 Intravenous antibiotics 89 (18.4) 816 (25.4) <0.01 569 (22.5) 336 (28.6) <0.01 Oral antibiotics 166 (34.2) 1226 (38.1) 0.10 917 (36.3) 475 (40.5) 0.01 Current pneumonia episode ICU admission 33 (6.8) 601 (18.7) <0.01 275 (13.5) 326 (27.8) <0.01 Mechanical ventilation 28 (5.8) 634 (19.7) <0.01 312 (15.3) 322 (27.5) <0.01 Vasopressors 9 (1.9) 233 (7.2) <0.01 91 (4.5) 142 (12.1) <0.01 Data are presented as n, median (interquartile range) or n (%), unless otherwise stated. COPD: chronic obstructive pulmonary disease; ESBL: extended-spectrum β-lactamase; MRSA: methicillin-resistant Staphylococcus aureus; ICU: intensive care unit. #: in the previous 12 months. Bold indicates statistical significance at p<0.05.
- TABLE 3
Microbiological tests performed among adult inpatients with community-acquired pneumonia by disease severity
Total ICU Invasive mechanical ventilation and vasopressors No Yes p-value No Yes p-value Patients 3702 3068 634 3529 173 Blood culture 2633 (71.1) 2110 (68.8) 523 (82.5) <0.01 2477 (70.2) 156 (90.2) <0.01 Sputum culture 2287 (61.8) 1895 (61.8) 392 (61.8) 0.98 2182 (61.8) 105 (60.7) 0.76 Bronchoalveolar lavage culture 312 (8.4) 179 (5.8) 133 (21.0) <0.01 268 (7.6) 44 (25.4) <0.01 Pleural fluid culture 117 (3.2) 90 (2.9) 27 (4.3) 0.08 108 (3.1) 9 (5.2) 0.12 Pneumococcal urinary antigen 1110 (30.0) 939 (30.6) 171 (27.0) 0.07 1054 (29.9) 56 (32.4) 0.48 Legionella urinary antigen 1113 (30.1) 939 (30.6) 174 (27.4) 0.11 1051 (29.8) 62 (35.8) 0.09 Acute-phase serology 325 (8.8) 258 (8.4) 67 (10.6) 0.08 307 (8.7) 18 (10.4) 0.44 Viral testing 553 (14.9) 390 (12.7) 163 (25.7) <0.01 482 (13.7) 71 (41.0) <0.01 Data are presented as n or n (%), unless otherwise stated. ICU: intensive care unit. Bold indicates statistical significance at p<0.05.
- TABLE 4
Microbiological tests performed among adult inpatients with community-acquired pneumonia by geographic area
Continent Rest of the world p-value Blood culture North America 434 (82.0) 2199 (69.3) <0.01 South America 202 (92.7) 2431 (69.8) <0.01 Africa 65 (41.7) 2568 (72.4) <0.01 Asia 294 (70.8) 2339 (71.2) 0.89 Europe 1609 (68.6) 1024 (75.4) <0.01 Oceania 29 (72.5) 2604 (71.1) 0.85 Sputum culture North America 286 (54.1) 2001 (63.1) <0.01 South America 95 (43.6) 2192 (62.9) <0.01 Africa 92 (59.0) 2195 (61.9) 0.46 Asia 305 (73.5) 1982 (60.3) <0.01 Europe 1496 (63.8) 791 (58.2) <0.01 Oceania 13 (32.5) 2274 (62.1) <0.01 Bronchoalveolar lavage culture North America 68 (12.9) 244 (7.7) <0.01 South America 15 (6.9) 297 (8.5) 0.40 Africa 10 (6.4) 302 (8.5) 0.35 Asia 48 (11.6) 264 (8.0) 0.02 Europe 171 (7.3) 141 (10.4) <0.01 Oceania 0 (0.0) 312 (8.5) 0.05 Pleural fluid culture North America 13 (2.5) 104 (3.3) 0.32 South America 13 (6.0) 104 (3.3) 0.02 Africa 12 (7.7) 105 (3.0) <0.01 Asia 12 (2.9) 105 (3.2) 0.74 Europe 67 (2.9) 50 (3.7) 0.17 Oceania 0 (0.0) 117 (3.2) 0.25 Pneumococcal urinary antigen North America 55 (10.4) 1055 (33.2) <0.01 South America 17 (7.8) 1093 (31.4) <0.01 Africa 2 (1.3) 1108 (31.2) <0.01 Asia 22 (5.3) 1088 (33.1) <0.01 Europe 1014 (43.3) 96 (7.1) <0.01 Oceania 0 (0.0) 1110 (30.3) <0.01 Legionella urinary antigen North America 93 (17.6) 1020 (32.1) <0.01 South America 1 (0.5) 1112 (31.9) <0.01 Africa 1 (0.6) 1112 (31.4) <0.01 Asia 30 (7.2) 1083 (32.9) <0.01 Europe 988 (42.2) 125 (9.2) <0.01 Oceania 0 (0.0) 1113 (30.4) <0.01 Acute-phase serology North America 22 (4.2) 303 (9.5) <0.01 South America 11 (5.0) 314 (9.0) 0.04 Africa 9 (5.8) 316 (8.9) 0.18 Asia 17 (4.1) 308 (9.4) <0.01 Europe 263 (11.2) 62 (4.6) <0.01 Oceania 3 (7.5) 322 (8.8) 0.77 Viral testing North America 83 (15.7) 470 (14.8) 0.60 South America 25 (11.5) 528 (15.2) 0.14 Africa 2 (1.3) 551 (15.5) <0.01 Asia 78 (18.8) 475 (14.5) 0.02 Europe 361 (15.4) 192 (14.1) 0.30 Oceania 4 (10.0) 549 (15.0) 0.38 At least one test done North America 489 (92.4) 2728 (86.0) <0.01 South America 204 (93.6) 3013 (86.5) <0.01 Africa 128 (82.1) 3089 (87.1) 0.07 Asia 406 (97.8) 2811 (85.5) <0.01 Europe 1955 (83.4) 1262 (92.9) <0.01 Oceania 35 (87.5) 3182 (86.9) 0.91 Data are presented as n (%), unless otherwise stated. Bold indicates statistical significance at p<0.05.
Vol 4 Issue 4
Table of Contents
Microbiological testing of adults hospitalised with community-acquired pneumonia: an international study
