Viral community acquired pneumonia at the emergency department: Report from the pre COVID‐19 age

Abstract

The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre-coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and inhospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled-up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co-infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB-65. All intra-ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB-65 score ≥2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one-third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests. K E Y W O R D S community acquired pneumonia, emergency department, public health, viral infection This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Epidemiology and burden of respiratory syncytial virus in Italian adults: A systematic review and meta-analysis

“…Fourteen [32,38,40,41,44,46,48,51,53,58,61–66] out of 29 full-length articles were judged at low risk of bias, while the remaining 15 studies [30,33–37,42,49,50,52,54–56,59,60,64–66] had at least one possible source of bias (S5 Table). The most frequent criticalities concerned insufficient description of patients and setting, inappropriate sample frame and small sample size.…”

“…However, the study period was limited to one month only (from 15 January to 22 February 2019) [54]. As reported in Table 2, only the outcome of in-hospital mortality was reported in more studies [35,[63][64][65][66].…”

“…f All patients had cystic fibrosis; g Number imputed from the available percentages; ARI, Acute respiratory infection; CAP, community-acquired pneumonia; COPD, Chronic obstructive pulmonary disease; ED, Emergency department; HDR, Hospital discharge record; ICD, International Statistical Classification of Diseases and Related Health Problems; ICU, Intensive care unit; IFA, Immunofluorescence assay; ILI, Influenza-like illness; L, Lower respiratory tract specimens; LRTD, Lower respiratory tract disease; NA, Not available; RT-PCR, Reverse-transcription polymerase chain reaction; SARI, Severe Acute respiratory infection; U, Upper respiratory tract specimens; U/L, Upper and lower respiratory tract specimens; URTI, Upper respiratory tract infection.Fourteen[32,38,40,41,44,46,48,51,53,58,[61][62][63][64][65][66] out of 29 full-length articles were judged at low risk of bias, while the remaining 15 studies[30,[33][34][35][36][37]42,49,50,52,[54][55][56]59,60,[64][65][66] had at least one possible source of bias (S5 Table…”

Pneumonia Update for Emergency Clinicians

“…Hospital-acquired, and especially ventilator-associated pneumonia, and healthcare-associated pneumonia, as well as pneumonia developing after foreign travel to regions with unique endemic pathogens, in habitual intravenous drug users, or in patients with severe immunodeficiency may require a different diagnostic approach and initial antibiotic choice with more broad-spectrum coverage [ 19 ••, 28 , 34 ]. While Streptococcus pneumonia along with the atypical quartet ( Mycoplasma pneumoniae , Legionella spp., Chlamydia , and Moraxella catarrhalis ) remain the most common bacterial pathogens in CAP [ 8 , 18 ], the important roles of viruses as the cause, especially of Influenza group during seasonal outbreaks, RSV, metapneumoviruses [ 18 ], and recently coronaviruses, have evolved [ 5 , 33 ••]. Most cases of severe CAP are caused by S. pneumonia , Gram-negative, organisms, COVID-SARS-2, or have polymicrobial etiology [ 20 ].…”

“…It is well known that viral particles can persist in airways for weeks after the symptoms of infection have resolved [ 18 ]. Interestingly it appears that many respiratory viruses, especially Influenza, parainfluenza, and RSV, can modulate ACE receptors in upper airways predisposing the patient to subsequent SARS-COV-2 infection [ 5 ]. While aspiration is thought to be an important cause of CAP, the exact mechanism involved is unknown as up to 45% of population is documented to aspirate during sleep without any consequences [ 32 ••].…”