Invasive Pneumococcal Disease and Long-Term Mortality Rates in Adults, Alberta, Canada.

The relationship between increased short-term mortality rates after invasive pneumococcal disease (IPD) has been frequently studied. However, the relationship between IPD and long-term mortality rates is unknown. IPD patients in Alberta, Canada, had clinical data collected that were linked to administrative databases. We used Cox proportional hazards modeling, and the primary outcome was time to all-cause deaths. First IPD events were identified in 4,522 patients, who had a median follow-up of 3.2 years (interquartile range 0.8‒9.1 years). Overall all-cause mortality rates were consistently higher among cases than controls at 30 days (adjusted hazard ratio [aHR] 3.75, 95% CI 3.29-4.28), 30‒90 days (aHR 1.56, 95% CI 1.27‒1.93), and >90 days (aHR 1.43, 95% CI 1.33-1.54). IPD increases risk for short, intermediate, and long-term mortality rates regardless of age, sex, or concurrent conditions. These findings can help clinicians focus on postdischarge patient plans to limit long-term effects after acute IPD infection.

Invasive pneumococcal disease and long-term outcomes in children: A 20-year population cohort study.

Background: Although vaccination against Streptococcus pneumoniae infections (such as invasive pneumococcal disease (IPD)) are available, challenges remain in prevention efforts. Moreover, downstream sequelae in children is relatively unknown. Thus, we aimed to evaluate short and long-term health outcomes among children with IPD. Methods: Analysis of Streptococcus pneumoniae positive isolates from sterile body sites in children (0-17 years) in Alberta (Canada) from 1999 to 2019 was performed retrospectively (n=888). Cases were age and sex-matched to hospitalized population controls. Linkage to administrative health datasets was done to determine comorbidities and healthcare related outcomes. Cox proportional hazards were used to assess differences in time to mortality and hospitalisation between cases and controls in short (<30-day), intermediate (30-90 day), long-term (>90-day) follow-up. Findings: Proportionally more deaths occurred in cases (4.8 deaths/1000 person-years (PY)) than controls (2.7 deaths/1000 PY), leading to a significant adjusted hazard ratio (aHR) of 1.80 (95% CI 1.22-2.64). This increased risk of death was influenced primarily by short-term mortality (319 vs 36 deaths/1000 PY in cases vs controls respectively, aHR 8.78 [95% CI 3.33-23.18]), as no differences were seen in intermediate (14 vs 7 deaths/1000 PY; aHR 2.03, 95% CI 0.41-10.04) or long-term time intervals (2.4 vs 2.3 deaths/1000 PY, aHR 1.03, 95% CI 0.63-1.69). Interpretation: IPD continues to negatively impact survival in children despite vaccination. Although long-term impact on mortality and hospitalisations may not be substantial, the immediate effects of IPD are significant. Funding: This work was supported by grants-in-aid from Pfizer Canada and Wyeth Canada Inc all to GJT.

A 42-year-old man with nodular skin lesions.

Nodular skin lesions are infrequently reported among patients with syphilis. We describe a 42-year-old man with secondary syphilis who presented with a nodular cutaneous eruption involving his neck, upper chest, back, arms, and legs. Because there was uncertainty regarding the diagnosis at presentation, the patient underwent a punch biopsy of one of the lesions. Spirochetes were not seen with a Steiner silver stain, but they were visualized on subsequent immunohistochemical staining. The diagnosis was confirmed with serology, and the patient responded well to treatment with benzathine penicillin G. Given the current increase in syphilis cases across North America, it is critical that clinicians become familiar with some of the less common dermatologic manifestations of this infection so that the diagnosis is entertained and appropriate serologic testing is ordered in a timely fashion.

Les lésions nodulaires ne sont pas fréquentes chez les patients atteints de syphilis. Les auteurs décrivent le cas d'un homme de 42 ans atteint de syphilis secondaire qui a consulté à cause d'une éruption nodulaire lui touchant le cou, le haut du thorax, le dos, les bras et les jambes. Puisque le diagnostic était incertain, le patient a subi une biopsie à l'emporte-pièce de l'une des lésions. Aucunes spirochètes n'ont été observées au moyen d'une coloration à l'argent Steiner, mais elles ont été visualisées à la coloration immunohistochimique subséquente. La sérologie a confirmé le diagnostic, et le patient a bien répondu au traitement à la pénicille G benzathine. Étant donné l'augmentation des cas de syphilis en Amérique du Nord, il est essentiel que les cliniciens se familiarisent avec quelques manifestations dermatologiques plus rares de cette infection, afin que ce diagnostic soit envisagé et que le bon test sérologique soit effectué rapidement.

Invasive pneumococcal disease in Northern Alberta, not a Red Queen but a dark horse.

BACKGROUND: The consequences of the introduction of various pneumococcal protein conjugate vaccines (PCV) for children and adults is poorly understood. OBJECTIVE: We undertook a population-based cohort study of invasive pneumococcal disease (IPD) in Northern Alberta (Canada) from 2000 to 2014, years spanning pre-and early PCV (2000-2004) vs PCV-7 (2005-2009) vs PCV-13 (2010-2014) time periods. DESIGN: We collected clinical, laboratory, and Streptococcus pneumoniae serotype information on all patients from 2000 to 2014. We determined changes in presentation, outcomes, serotypes, and incidence in children and adults across time periods. SETTING: There were 509 cases of IPD in children, an 80% decrease over time. Rates of empyema (4.0-15.7%, p < 0.001), ICU admission (13.1-20%), and mortality (1.8-8.4%, p < 0.001) increased over time. There were 2417 cases of IPD in adults. Unlike children, incidence of IPD did not change nor did rates of empyema. ICU admissions increased (p = 0.004) and mortality decreased (18.7-16.5%, p = 0.002). The total number of serotypes causing IPD remained stable in children (22 vs 26 vs 20) while they decreased in adults (49 vs 47 vs 42). CONCLUSIONS AND RELEVANCE: For children, PCV vaccination strategies resulted in decreased overall rates of IPD and we observed increased rates of empyema and mortality; for adults, there was no change in IPD rates although disease severity increased while mortality decreased. On a population-wide basis, our results suggest that current PCV vaccination strategies are associated with an overall decrease in IPD but disease severity seems to be increasing in both children and adults.

Effect of Age on the Manifestations and Outcomes of Invasive Pneumococcal Disease in Adults.

BACKGROUND: Although a considerable amount is known about the effect of age on the manifestations and outcomes of pneumonia, the same is not true for invasive pneumococcal disease. METHODS: This was a prospective observational study of all cases (2435) of invasive pneumococcal disease in adults in Northern Alberta from 2000 to 2014. Rates of invasive pneumococcal disease per 100,000, sociodemographic variables, clinical characteristics, and invasive pneumococcal disease-related outcomes were compared for the following age groups: 17-54, 55-64, 65-74, and ≥75 years. RESULTS: The rate of invasive pneumococcal disease per 100,000 increased with increasing age. Although only 27.3% of the cases were in those aged ≥65 years, they accounted for 48% of the deaths. The case fatality rate increased with increasing age, from 9.6% for those aged 17-54 years to 31.7% for those aged ≥75 years. The rate of meningitis decreased with increasing age, as did admission to intensive care and use of mechanical ventilation. There was a marked reduction in the rate of invasive pneumococcal disease due to protein conjugate vaccine 7 and protein conjugate vaccine 13 serotypes in those aged ≥55 years but a much smaller decline in rates for those aged 17-54 years. Replacement with non-vaccine serotypes constituted approximately 50% of the cases. CONCLUSIONS: The rate of invasive pneumococcal disease is highest in the very elderly, and manifestations of invasive pneumococcal disease are influenced by age.

Rates of, and risk factors for, septic arthritis in patients with invasive pneumococcal disease: prospective cohort study.

BACKGROUND: There are many case reports of septic arthritis complicating invasive pneumococcal disease (IPD); however, no study has compared patients with IPD with septic arthritis to those who didn't develop septic arthritis Thus, we aimed to determine the rates of, and risk factors for, septic arthritis in patients with invasive pneumococcal disease (IPD). METHODS: Socio-demographic, clinical, and serological data were captured on all patients with IPD in Northern Alberta, Canada from 2000 to 2014. Septic arthritis was identified by attending physicians. Descriptive statistics and multivariate analyses were used to compare characteristics of those with septic arthritis and IPD to those who did not. RESULTS: Septic arthritis developed in 51 of 3251 (1.6%) of patients with IPD. Inability to walk independently, male sex, and underlying joint disease were risk factors for developing septic arthritis in patients with IPD. Capsular serotypes 22 and 12F were more common in patients with septic arthritis than those without. CONCLUSIONS: In patients with IPD, septic arthritis is uncommon. Certain risk factors such as walking with or without assistance and underlying joint disease make biological sense as damaged joints are more likely to be infected in the presence of bacteremia. TRIAL REGISTRATION: Not applicable.

Concurrent Infection with Hepatitis C Virus and Streptococcus pneumoniae.

Little is known about concurrent infection with hepatitis C virus (HCV) and Streptococcus pneumoniae, which causes invasive pneumococcal disease (IPD). We hypothesized that co-infection with HCV and S. pneumoniae would increase risk for death and complications. We captured sociodemographic and serologic data for adults with IPD in a population-based cohort study in northern Alberta, Canada, during 2000-2014. IPD patients infected with HCV were compared with IPD patients not infected with HCV for risk of in-hospital deaths and complications by using multivariable logistic regression. A total of 355 of 3,251 patients with IPD were co-infected with HCV. The in-hospital mortality rate was higher for IPD patients infected with HCV. Prevalence of most IPD-related complications (e.g., cellulitis, acute kidney injury, mechanical ventilation) was also higher in HCV-infected patients. Infection with HCV is common in patients with IPD, and HCV is independently associated with an increased risk for serious illness and death.

Risk of heart failure after community acquired pneumonia: prospective controlled study with 10 years of follow-up.

Objective To determine the attributable risk of community acquired pneumonia on incidence of heart failure throughout the age range of affected patients and severity of the infection.Design Cohort study.Setting Six hospitals and seven emergency departments in Edmonton, Alberta, Canada, 2000-02.Participants 4988 adults with community acquired pneumonia and no history of heart failure were prospectively recruited and matched on age, sex, and setting of treatment (inpatient or outpatient) with up to five adults without pneumonia (controls) or prevalent heart failure (n=23 060).Main outcome measures Risk of hospital admission for incident heart failure or a combined endpoint of heart failure or death up to 2012, evaluated using multivariable Cox proportional hazards analyses.Results The average age of participants was 55 years, 2649 (53.1%) were men, and 63.4% were managed as outpatients. Over a median of 9.9 years (interquartile range 5.9-10.6), 11.9% (n=592) of patients with pneumonia had incident heart failure compared with 7.4% (n=1712) of controls (adjusted hazard ratio 1.61, 95% confidence interval 1.44 to 1.81). Patients with pneumonia aged 65 or less had the lowest absolute increase (but greatest relative risk) of heart failure compared with controls (4.8% v 2.2%; adjusted hazard ratio 1.98, 95% confidence interval 1.5 to 2.53), whereas patients with pneumonia aged more than 65 years had the highest absolute increase (but lowest relative risk) of heart failure (24.8% v 18.9%; adjusted hazard ratio 1.55, 1.36 to 1.77). Results were consistent in the short term (90 days) and intermediate term (one year) and whether patients were treated in hospital or as outpatients.Conclusion Our results show that community acquired pneumonia substantially increases the risk of heart failure across the age and severity range of cases. This should be considered when formulating post-discharge care plans and preventive strategies, and assessing downstream episodes of dyspnoea.

Prognostic factors associated with mortality and major in-hospital complications in patients with bacteremic pneumococcal pneumonia: Population-based study.

Bacteremic pneumococcal pneumonia (BPP) causes considerable mortality and morbidity. We aimed to identify prognostic factors associated with mortality and major in-hospital complications in BPP.A prospective, population-based clinical registry of 1636 hospitalized adult patients (≥18 years) with BPP was established between 2000 and 2010 in Northern Alberta, Canada. Prognostic factors for mortality and major in-hospital complications (e.g., cardiac events, mechanical ventilation, aspiration) were evaluated using multivariable logistic regression.Average age was 54 (standard deviation 18) years, 57% males, and 59% had high case-fatality rate (CFR) serotypes. Overall, 14% (226/1636) of patients died and 22% (315/1410) of survivors developed at least 1 complication. Independent prognostic factors for mortality were age (adjusted odds ratio [aOR], 1.5 per decade; 95% confidence interval [CI], 1.3-1.7), nursing home residence (aOR, 3.7; 95% CI 1.8-7.4), community-dwelling dementia (aOR 3.7; 95% CI, 1.6-8.6), alcohol abuse (aOR, 2.2; 95% CI, 1.4-3.4), acid-suppressing drugs (aOR, 1.5; 95% CI, 1.0-2.3), guideline-discordant antibiotics (aOR, 3.4; 95% CI, 2.4-4.8), multilobe pneumonia (aOR, 2.6; 95% CI, 1.8-3.6), and high CFR serotypes (aOR, 1.8; 95% CI, 1.2-2.8). Similar prognostic factors were observed for major in-hospital complications. Pneumococcal vaccination was associated with reduced in-hospital mortality (aOR, 0.2; 95% CI, 0.05-0.9) but not major complications (P = 0.2).Older and frailer patients, and those who abuse alcohol or take acid-suppressing drugs, are at increased risk of BPP-related mortality and complications, as are those with high CFR serotypes. Beyond identifying those at highest risk, our findings demonstrate the importance of guideline-concordant antibiotics and pneumococcal vaccination in those with BPP.

Asplenic patients and invasive pneumococcal disease-how bad is it these days?

OBJECTIVES: Most are aware of pneumococcal infection as a complication of splenectomy and the increased risk of severe invasive pneumococcal disease (IPD) in asplenic patients. However little is known of the current status of this entity in a population with an active pneumococcal conjugate vaccine program for children. METHODS: All IPD cases reported from 2000 to 2014 in Northern Alberta, Canada were collected prospectively. Socio-demographic variables, clinical characteristics, and IPD-related outcomes were compared between patients with and without a spleen using the Student t-test, Chi-square test, or Fisher's exact test, as appropriate. RESULTS: Thirty-seven of 2435 patients with IPD (1.5%) were asplenic. Asplenic patients were significantly more likely to require mechanical ventilation or admission to the intensive care unit and had more complications (e.g., acute kidney injury). However, in-hospital mortality rates were similar in those with and without a spleen (19% vs. 16%, p=0.58). Pneumococcal serotype 22B was 33-fold higher in asplenic patients compared to those with a spleen. CONCLUSIONS: In patients with IPD, those who are asplenic have a more severe infection than those with a spleen; however, the mortality rate is not significantly different. The reason for the predominance of serotype 22B requires further investigation and if replicated may warrant attention to current vaccination strategies.

Bacterial Pneumonia in Older Adults.

Community-acquired pneumonia is common in the elderly person; its presentation in this population is often confounded by multiple comorbid illnesses, including those that result in confusion. Although severity-of-illness scoring systems might aid decision-making, clinical judgment following a careful assessment is key in deciding on the site of care and appropriate therapy.

Current Smoking and Reduced Mortality in Bacteremic Pneumococcal Pneumonia: A Population-Based Cohort Study.

BACKGROUND: Previous studies suggest that smoking is independently associated with decreased mortality in patients with pneumonia. We hypothesized that this is a result of acquiring differential pneumococcal serotypes (ie, smokers with pneumococcal pneumonia are more likely to experience bacteremia, with low case fatality rate (CFR) serotypes). We tested this hypothesis in a population-based cohort of patients with bacteremic pneumococcal pneumonia (BPP). METHODS: Our prospective population-based clinical registry included 1,636 adults (≥ 18 years) with BPP who were hospitalized between 2000 and 2010 in northern Alberta, Canada. Using multivariable logistic regression, we determined the adjusted risk of all-cause in-hospital mortality according to smoking status (current vs not current) and conducted stratified analyses by serotypes (low CFR vs all other CFRs) according to smoking status. RESULTS: The average patient age was 54 years, 57% were men, 49% were current smokers, and 41% had low-CFR serotypes. Overall, 62 of 809 current smokers died in the hospital vs 164 of 827 nonsmokers (8% vs 20%; adjusted OR, 0.52; 95% CI, 0.36-0.77; P = .001). Current smokers were more likely to have low-CFR-serotype isolates than were nonsmokers (53% vs 29%; adjusted OR, 1.67; 95% CI, 1.31-2.12; P < .001) and in models adjusted for low-CFR serotype, smoking remained independently associated with reduced mortality (P = .001). CONCLUSIONS: Compared with nonsmokers, current smokers with BPP had a decreased risk of in-hospital mortality and were more likely to experience bacteremia with low CFR serotypes. These findings, at least in part, may explain why previous studies showed that smoking was associated with lower mortality in patients with pneumonia.

Ten-Year Mortality after Community-acquired Pneumonia. A Prospective Cohort.

RATIONALE: Information on the long-term prognosis after community-acquired pneumonia (CAP) is limited. OBJECTIVES: To determine if CAP increases adverse long-term outcomes relative to a control population. METHODS: Between 2000 and 2002, 6,078 adults with CAP from six hospitals and seven emergency departments in Edmonton (AB, Canada) were prospectively recruited and matched on age, sex, and site of treatment with five control subjects without pneumonia (n = 29,402). Mortality, hospitalizations, and emergency department admissions through 2012 were evaluated using multivariable Cox proportional hazards analyses adjusted for socioeconomic status and comorbidities. MEASUREMENTS AND MAIN RESULTS: Average age was 59 years (2,682 [44%] ≥ 65 yr), 3,214 (53%) were men, and 3,425 (56%) were managed as outpatients. Over a median of 9.8 years, 2,858 patients with CAP died compared with 9,399 control subjects (absolute risk difference, 30 per 1,000 patient years [py]; adjusted hazard ratio [aHR], 1.65; 95% confidence interval, 1.57-1.73; P < 0.001). Patients with CAP who were younger than 25 years old had the lowest absolute rate difference for mortality (4 per 1,000 py; aHR, 2.40), and patients older than 80 years old had the highest absolute rate difference (92 per 1,000 py; aHR, 1.42). Absolute rates of all-cause hospitalization, emergency department visits, and CAP-related visits were all significantly higher in patients with CAP compared with control subjects (P < 0.001 for all comparisons). CONCLUSIONS: Our results indicate that an episode of CAP confers a high risk of long-term adverse events compared with the general population who have not experienced CAP, and this is irrespective of age.

Medication transitions and polypharmacy in older adults following acute care.

BACKGROUND/OBJECTIVE: Medication changes at transitions of care and polypharmacy are growing concerns that adversely impact optimal drug use. We aimed to describe transitions and patterns of medication use before and 1 year after older patients were hospitalized for community-acquired pneumonia, the second-most common reason for admission in North America. MATERIALS AND METHODS: This was an analysis of a population-based clinical registry of patients treated in any of the six hospitals or seven emergency departments in Edmonton, Alberta, Canada, comprising 2,105 patients 65 years and older with community-acquired pneumonia who had survived at least 1 year. The prevalence of polypharmacy (five or more unique prescription drugs), as well as new use and persistence of common drug classes were assessed. RESULTS: The mean age was 78 years (standard deviation 8 years), 50% were female, 62% were hospitalized, and 58% had severe pneumonia. Among the 2,105 patients, 949 (45%) were using five or more medications prior to hospitalization, increasing to 1,559 (74%) within 90 days postdischarge and remaining over 70% at 1 year. Overall, 1,690 (80%) patients newly started and 1,553 (74%) patients stopped at least one medication in the first 90 days of follow-up. The prevalence of the most common drug classes (ie, cardiovascular, alimentary/metabolism) remained stable, with the exception of anti-infective agents, whereby 25% of patients were dispensed an anti-infective agent 3 months to 1 year after hospitalization. CONCLUSION: Most older patients with pneumonia are subject to polypharmacy, and almost every patient had a medication started or stopped during 1-year follow-up, with 25% using antibiotics again. The period following an episode of pneumonia represents an opportunity potentially to optimize pharmacotherapy.

Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis.

OBJECTIVE: Some studies suggest better outcomes with macrolide therapy for critically ill patients with community-acquired pneumonia. To further explore this, we performed a systematic review of studies with mortality endpoints that compared macrolide therapy with other regimens in critically ill patients with community-acquired pneumonia. DATA SOURCES: Studies were identified via electronic databases, grey literature, and conference proceedings through May 2013. STUDY SELECTION: Using prespecified criteria, two reviewers selected studies; studies of outpatients and hospitalized noncritically ill patients were excluded. DATA EXTRACTION: Two reviewers extracted data and evaluated bias using the Newcastle-Ottawa Scale. Random effects models were used to generate pooled risk ratios and evaluate heterogeneity (I). DATA SYNTHESIS: Twenty-eight observational studies (no randomized control trials) were included. Average age ranged from 58 to 78 years and 14-49% were women. In our primary analysis of 9,850 patients, macrolide use was associated with statistically significant lower mortality compared with nonmacrolides (21% [846 of 4,036 patients] vs 24% [1,369 of 5,814]; risk ratio, 0.82; 95% CI, 0.70-0.97; p = 0.02; I = 63%). When macrolide monotherapy was excluded, the macrolide mortality benefit was maintained (21% [737 of 3,447 patients] vs 23% [1,245 of 5,425]; risk ratio, 0.84; 95% CI, 0.71-1.00; p = 0.05; I = 60%). When broadly guideline-concordant regimens were compared, there was a trend to improved mortality and heterogeneity was reduced (20% [511 of 2,561 patients] mortality with beta-lactam/macrolide therapy vs 23% [386 of 1,680] with beta-lactam/fluoroquinolone; risk ratio, 0.83; 95% CI, 0.67-1.03; p = 0.09; I = 25%). When adjusted risk estimates were pooled from eight studies, macrolide therapy was still associated with a significant reduction in mortality (risk ratio, 0.75; 95% CI, 0.58-0.96; p = 0.02; I = 57%). CONCLUSIONS: In observational studies of almost 10,000 critically ill patients with community-acquired pneumonia, macrolide use was associated with a significant 18% relative (3% absolute) reduction in mortality compared with nonmacrolide therapies. After pooling data from studies that provided adjusted risk estimates, an even larger mortality reduction was observed. These results suggest that macrolides be considered first-line combination treatment in critically ill patients with community-acquired pneumonia and support current guidelines.

Inhaled corticosteroids and risk of recurrent pneumonia: a population-based, nested case-control study.

BACKGROUND: Studies have suggested an increased risk of pneumonia with inhaled corticosteroid (ICS) use, although this association is inconsistent. We evaluated the risk of recurrent pneumonia associated with ICS use in a high-risk population of individuals who survived an episode of pneumonia. METHODS: Clinical and 5-year follow-up data were collected on all adults aged ≥ 65 years with pneumonia over a period of 2 years. Using a nested case-control design, first cases (patients with recurrent pneumonia ≥ 30 days after initial episode) and then controls (free of pneumonia and matched on age, sex, and chronic obstructive pulmonary disease [COPD]) were identified. ICS use was classified as never, past (remote, only before initial pneumonia), or current. Our primary outcome measure was recurrent pneumonia assessed using conditional multivariate logistic regression after adjustment of demographics and clinical data. RESULTS: During 5 years of follow-up, 653 recurrent pneumonia cases were matched with 6244 controls; mean age was 79 (SD, 8) years, 3577 (52%) were male, 2652 (38%) had COPD, and 2294 (33%) ever used ICS. Overall, 123 of 870 (14%) current ICS users had recurrent pneumonia compared to 395 of 4603 (9%) never-users (adjusted odds ratio, 1.90; 95% confidence interval, 1.45-2.50; P < .001; number need to harm = 20). Conversely, there was no association between past (remote) use of ICS and pneumonia: 9% of past users versus 9% never-users (P = .36). CONCLUSIONS: ICS use was associated with a 90% relative increase in the risk of recurrent pneumonia among high-risk pneumonia survivors. This should be considered when prescribing ICS and when deciding which patients might need more intensive follow-up.

Severe community-acquired pneumonia.

Severe community-acquired pneumonia necessitating intensive care unit admission is associated with high morbidity, mortality, and health-care cost. This review article serves to summarize the epidemiology, diagnosis, treatment, and prognosis of this common life-threatening condition. Current practice guidelines as well as the role of several scoring systems (such as the PSI, CURB-65, and IDSA/ATS criteria) used to predict CAP severity, prognosis, and site of care are reviewed. In addition, common complications and prevention strategies are discussed.

Diagnosis and management of Q fever--United States, 2013: recommendations from CDC and the Q Fever Working Group.

Q fever, a zoonotic disease caused by the bacterium Coxiella burnetii, can cause acute or chronic illness in humans. Transmission occurs primarily through inhalation of aerosols from contaminated soil or animal waste. No licensed vaccine is available in the United States. Because many human infections result in nonspecific or benign constitutional symptoms, establishing a diagnosis of Q fever often is challenging for clinicians. This report provides the first national recommendations issued by CDC for Q fever recognition, clinical and laboratory diagnosis, treatment, management, and reporting for health-care personnel and public health professionals. The guidelines address treatment of acute and chronic phases of Q fever illness in children, adults, and pregnant women, as well as management of occupational exposures. These recommendations will be reviewed approximately every 5 years and updated to include new published evidence.

Does empiric therapy for atypical pathogens improve outcomes for patients with CAP?

The present controversy regarding the need to cover atypical pathogens in the empiric therapy of community-acquired pneumonia is related to several issues, including the relevance of terminology, imprecise diagnostic methods, and perceived contradictory results of published evidence. Studies evaluating the time to clinical recovery and the use of earlier endpoints for evaluation suggest that appropriate therapy provides a benefit if an atypical pathogen is a pathogen. Because recent surveillance studies suggest these pathogens are common and until there is the availability of accurate, cost-effective, and easily interpreted laboratory tests to provide the etiologic diagnosis at the time of point of care, empiric therapy of atypical pathogens is supported.