Geographical and temporal variation in the frequency and antimicrobial susceptibility of bacteria isolated from patients hospitalized with bacterial pneumonia: results from 20 years of the SENTRY Antimicrobial Surveillance Program (1997-2016).

BACKGROUND: The SENTRY Antimicrobial Surveillance Program monitors the frequency of occurrence and antimicrobial susceptibility of organisms from various infection types worldwide. METHODS: A total of 102 995 bacterial isolates were consecutively collected (one per patient) in 1997-2016 from 258 medical centres in North America (n = 44 999; 113 centres), Europe (n = 30 988; 61 centres from 22 nations), the Asia-Pacific region (APAC; n = 16 503; 67 centres from 12 nations) and Latin America (n = 10 505; 17 centres from 7 nations). Organisms were isolated from respiratory tract specimens and tested for susceptibility by broth microdilution methods in a central laboratory. RESULTS: Staphylococcus aureus (n = 24 351) and Pseudomonas aeruginosa (n = 22 279) were the most common organisms overall. Klebsiella spp. (n = 10 565) ranked third in North America, Europe and APAC. The proportion of Gram-negatives increased from 70.0%-74.7% to 80.9%-82.6% in Europe, APAC and Latin America, and remained stable (65.5%-66.1%) in North America. Methicillin resistance rates decreased substantially in all four regions from 2005-06 to 2015-16 among S. aureus isolates. P. aeruginosa susceptibility to meropenem decreased overall in the initial years, but increased in the last years of the investigation. Among Klebsiella spp. isolates, susceptibility to ceftriaxone/meropenem decreased from 85.9%/99.3% to 58.6%/85.8% in Europe and from 91.8%/99.5% to 81.6%/93.9% in APAC during the study period. CONCLUSIONS: Rank order and susceptibility rates varied widely by geographical region and over time. The occurrence of some resistance phenotypes increased, though others decreased over the 20 years of the SENTRY Antimicrobial Surveillance Program.

Pneumonia-Specific Escherichia coli with Distinct Phylogenetic and Virulence Profiles, France, 2012-2014.

In a prospective, nationwide study in France of Escherichia coli responsible for pneumonia in patients receiving mechanical ventilation, we determined E. coli antimicrobial susceptibility, phylotype, O-type, and virulence factor gene content. We compared 260 isolates with those of 2 published collections containing commensal and bacteremia isolates. The preponderant phylogenetic group was B2 (59.6%), and the predominant sequence type complex (STc) was STc73. STc127 and STc141 were overrepresented and STc95 underrepresented in pneumonia isolates compared with bacteremia isolates. Pneumonia isolates carried higher proportions of virulence genes sfa/foc, papGIII, hlyC, cnf1, and iroN compared with bacteremia isolates. Virulence factor gene content and antimicrobial drug resistance were higher in pneumonia than in commensal isolates. Genomic and phylogenetic characteristics of E. coli pneumonia isolates from critically ill patients indicate that they belong to the extraintestinal pathogenic E. coli pathovar but have distinguishable lung-specific traits.

Prevalence of Nontuberculous Mycobacterial Pulmonary Disease, Germany, 2009-2014.

We analyzed routine statutory health insurance claim data to determine prevalence of nontuberculous mycobacterial pulmonary disease in Germany. Documented prevalence rates of this nonnotifiable disease increased from 2.3 to 3.3 cases/100,000 population from 2009 to 2014. Prevalence showed a strong association with advanced age and chronic obstructive pulmonary disease.

[Pneumonia in wounded].

Pneumonia is one of the common complications of wounds of any localization. Therapists are involved into the treatment of lung lesions in wounded in the ICU, in the surgical and if the patient arrives "on follow-up care,"--in the medical ward. The article analyzes the main statistical indicators reflecting the prevalence and clinical and pathogenetic characteristics of lung pathology in wounded during the Great Patriotic War, during the fighting Soviet troops in the Republic of Afghanistan, the 1st and 2nd Chechen campaign. Pneumonia as a manifestation of traumatic disease can occur in two ways. Primary pneumonia is in close connection with the pathogenetic traumatic injury. Secondary lung lesions complicate the injury at a later date and are due to the introduction of a nosocomial infection process flora. We describe the clinical picture of pneumonia in the affected, the basic pathogenesis, principles of therapy. Successful treatment of lung pathology in wounded depends on the performance of a complex of activities involving a wide range of doctors of various specialties.

Measles epidemics of variable lethality in the early 20th century.

Until the mid-20th century, mortality rates were often very high during measles epidemics, particularly among previously isolated populations (e.g., islanders), refugees/internees who were forcibly crowded into camps, and military recruits. Searching for insights regarding measles mortality rates, we reviewed historical records of measles epidemics on the Polynesian island of Rotuma (in 1911), in Boer War concentration camps (in 1900-1902), and in US Army mobilization camps during the First World War (in 1917-1918). Records classified measles deaths by date and clinical causes; by demographic characteristics, family relationships (for Rotuma islanders and Boer camp internees), and prior residences; and by camp (for Boer internees and US Army recruits). During the Rotuman and Boer War epidemics, measles-related mortality rates were high (up to 40%); however, mortality rates differed more than 10-fold across camps/districts, even though conditions were similar. During measles epidemics, most deaths among camp internees/military recruits were due to secondary bacterial pneumonias; in contrast, most deaths among Rotuman islanders were due to gastrointestinal complications. The clinical expressions, courses, and outcomes of measles during first-contact epidemics differ from those during camp epidemics. The degree of isolation from respiratory pathogens other than measles may significantly determine measles-related mortality risk.

Community-acquired pneumonia: 2012 history, mythology, and science.

Pneumonia remains one of the major disease entities practicing physicians must manage. It is a leading cause of infection-related morbidity and mortality in all age groups, and a leading cause of death in those older than 65 years of age. Despite its frequency and importance, clinical questions have remained in the therapy of community-acquired pneumonia including when to start antibiotics, when to stop them, who to treat, and what agents to use. Answers to these questions have involved historical practice, mythology, and science-sometimes good science, and sometimes better science. How clinical decisions are made for patients with community-acquired pneumonia serves as an illustrative model for other problem areas of medicine and allows for insight as to how clinical decisions have been made and clinical practice established.

"A startling new chemotherapeutic agent": pediatric infectious disease and the introduction of sulfonamides at Baltimore's Sydenham Hospital.

Using pediatric patient records from Baltimore's Sydenham Hospital, this article explores the adoption of sulfa drugs in pediatrics. It discusses how clinicians dealt with questions of dosing and side effects and the impact of the sulfonamides on two diagnoses in children: meningococcal meningitis and pneumonia. The care of infants and children with infectious diseases made demands on physicians and nurses that differed from those facing clinicians treating adult patients. The article demonstrates the need to distinguish between pediatric and adult medical history. It suggests that the new therapeutics demanded more intense bedside care and enhanced laboratory facilities, and as a result paved the way for the adoption of penicillin. Finally, it argues that patient records and the published medical literature must be examined together in order to gain a full understanding of how transformations in medical practice and therapeutics occur.

Pathogenic responses among young adults during the 1918 influenza pandemic.

Of the unexplained characteristics of the 1918-19 influenza pandemic, the extreme mortality rate among young adults (W-shaped mortality curve) is the foremost. Lack of a coherent explanation of this and other epidemiologic and clinical manifestations of the pandemic contributes to uncertainty in preparing for future pandemics. Contemporaneous records suggest that immunopathologic responses were a critical determinant of the high mortality rate among young adults and other high-risk subgroups. Historical records and findings from laboratory animal studies suggest that persons who were exposed to influenza once before 1918 (e.g., A/H3Nx 1890 pandemic strain) were likely to have dysregulated, pathologic cellular immune responses to infections with the A/H1N1 1918 pandemic strain. The immunopathologic effects transiently increased susceptibility to ultimately lethal secondary bacterial pneumonia. The extreme mortality rate associated with the 1918-19 pandemic is unlikely to recur naturally. However, T-cell-mediated immunopathologic effects should be carefully monitored in developing and using universal influenza vaccines.

Efficacy of whole-cell killed bacterial vaccines in preventing pneumonia and death during the 1918 influenza pandemic.

BACKGROUND: Most deaths in the 1918 influenza pandemic were caused by secondary bacterial pneumonia. METHODS: We performed a systematic review and reanalysis of studies of bacterial vaccine efficacy (VE) in preventing pneumonia and mortality among patients with influenza during the 1918 pandemic. RESULTS: A meta-analysis of 6 civilian studies of mixed killed bacterial vaccines containing pneumococci identified significant heterogeneity among studies and estimated VE at 34% (95% confidence interval [CI], 19%-47%) in preventing pneumonia and 42% (95% CI, 18%-59%) in reducing case fatality rates among patients with influenza, using random-effects models. Using fixed-effect models, the pooled VE from 3 military studies was 59% (95% CI, 43%-70%) for pneumonia and 70% (95% CI, 50%-82%) for case fatality. Military studies showed less heterogeneity and may provide more accurate results than civilian studies, given the potential biases in the included studies. Findings of 1 military study using hemolytic streptococci also suggested that there was significant protection. CONCLUSIONS: Despite significant methodological problems, the systematic biases in these studies do not exclude the possibilities that whole-cell inactivated pneumococcal vaccines may confer cross-protection to multiple pneumococcal serotypes and that bacterial vaccines may play a role in preventing influenza-associated pneumonia.

Secretory leukocyte protease inhibitor and elafin/trappin-2: versatile mucosal antimicrobials and regulators of immunity.

Elafin and secretory leukocyte protease inhibitor (SLPI) are pleiotropic molecules chiefly synthesized at the mucosal surface that have a fundamental role in the surveillance against microbial infections. Their initial discovery as anti-proteases present in the inflammatory milieu in chronic pathologies such as those of the lung suggested that they may play a role in keeping in check extracellular proteases released during the excessive activation of innate immune cells such as neutrophils. This soon proved to be a simplistic explanation, as other functions were also soon ascribed to these molecules (antimicrobial, modulation of innate and adaptive immunity, regulation of tissue repair). Data emanating from patients with chronic pathologies (in the lung and elsewhere) have shown that SLPI and elafin are often inactivated in inflammatory secretions, either through the action of host or microbial products, justifying attempts at antiprotease supplementation in clinical protocols. Although these have been sparse, proof of principle has been demonstrated, and future challenges will undoubtedly rest with improvements in methods of delivery in the context of tissue inflammation and in careful selection of patients more likely to benefit from SLPI/elafin augmentation.

Bacterial pneumonias during an influenza pandemic: how will we allocate antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.

Lobar pneumonia treated by Musgrave Park physicians.

In the decade 1935-45 the treatment of lobar pneumonia in the developed and warring world underwent a series of evolutions-anti-sera, specific anti-sera, refinement of sulpha drugs, sulpha and anti-sera, the introduction of penicillin for bacteriology, then ophthalmology, and then for penicillin-sensitive bacterial infections such as lobar pneumonia with its many Cooper types of Streptococcus pneumoniae. Penicillin for civilian use was essentially banned in World War II, a ban that early in 1941 two Musgrave Park physicians tried to circumvent. Strict secrecy on the details of penicillin production was enforced. The treatment option chosen by the Musgrave Park physicians in 1941, and the non-availability of penicillin led to sequelae affecting the post-Belfast careers of both patient and physicians.

Parapneumonic empyema deaths during past century, Utah.

Bacterial pneumonia with empyema is a serious complication of influenza and commonly resulted in death during the 1918 influenza pandemic. We hypothesize that deaths caused by parapneumonic empyema are increasing in Utah once again despite advances in critical care and the availability of antimicrobial drugs and new vaccines. In this study, we analyzed the historical relationship between deaths caused by empyema and influenza pandemics by using 100 years of data from Utah. Deaths caused by empyema have indeed increased from 2000-2004 when compared with the historic low death rates of 1950-1975. Vaccine strategies and antimicrobial drug stockpiling to control empyema will be important as we prepare for the next influenza pandemic.

Deaths from bacterial pneumonia during 1918-19 influenza pandemic.

Deaths during the 1918-19 influenza pandemic have been attributed to a hypervirulent influenza strain. Hence, preparations for the next pandemic focus almost exclusively on vaccine prevention and antiviral treatment for infections with a novel influenza strain. However, we hypothesize that infections with the pandemic strain generally caused self-limited (rarely fatal) illnesses that enabled colonizing strains of bacteria to produce highly lethal pneumonias. This sequential-infection hypothesis is consistent with characteristics of the 1918-19 pandemic, contemporaneous expert opinion, and current knowledge regarding the pathophysiologic effects of influenza viruses and their interactions with respiratory bacteria. This hypothesis suggests opportunities for prevention and treatment during the next pandemic (e.g., with bacterial vaccines and antimicrobial drugs), particularly if a pandemic strain-specific vaccine is unavailable or inaccessible to isolated, crowded, or medically underserved populations.

100 years of respiratory medicine: pneumonia.

In this review, we aim to lead the readers through the historical highlights of pathophysiological concepts and treatment of pneumonia. Understanding the aetiology, the risk factors and the pathophysiology influenced our management approaches to pneumonia. Pneumonia is still associated with significant morbidity and mortality, presents in a variety of healthcare settings and imposes a considerable cost to healthcare services. Guidelines have been issued by international and national scientific societies in order to spread the scientific knowledge on this important disease and to improve its management.