Respiratory Tract Infections

Kessler et al. prospectively collected BAL specimens for PCR and culture from 116 patients admitted to the hospital with a community-acquired pneumonia (40). Serology for M. pneumoniae was done on both acute- and convalescent-phase sera by the CF test. Twelve samples (10.3%) were PCR posi- tive, and 7 (6.0%) of these were subsequently confirmed by culture. The CF test showed seroconversion for these 12 pa- tients, and the results for all other patients remained negative. In contrast, in a comparison of PCR with serological methods, Menendez et al. (51) found their PCR assay to have a lower sensitivity than serology. Only 3 of 184 community-acquired pneumonia patients were found M. pneumoniae positive (51). M. pneumoniae infections seem to be rare in human immu- nodeficiency virus (HIV)-infected patients (82). Tarp et al., in a retrospective study, applied PCR to BAL fluids obtained from 103 episodes of pneumonia in 83 patients (66). M. pneu- moniae was found in two patients (2%). In both cases, M. pneumoniae was present as a coexisting pathogen. The re- searchers concluded that M. pneumoniae does not seem to play a major role in lower respiratory tract infections in HIV-in- fected adults and children.

Upper Respiratory Tract Infections To What Extent is the Management Evidence Based? ORIGINAL ARTICLE Upper Respiratory Tract Infections To What Extent is the Management Evidence Based? C L Teng, M Med[.]

Background: Acute lower respiratory tract infections (ALRI) are the major cause of morbidity and mortality in young children worldwide. Information on viral etiology in ALRI from India is limited. The aim of the present study was to develop a simple, sensitive, specific and cost effective multiplex PCR (mPCR) assay without post PCR hybridization or nested PCR steps for the detection of respiratory syncytial virus (RSV), influenza viruses, parainfluenza viruses (PIV1–3) and human metapneumovirus (hMPV). Nasopharyngeal aspirates (NPAs) were collected from children with ALRI ≤ 5 years of age. The sensitivity and specificity of mPCR was compared to virus isolation by centrifugation enhanced culture (CEC) followed by indirect immunofluorescence (IIF).

CRP is an acute-phase protein with levels quickly rising during inflammatory processes [2]. Relationship between CRP and infection of the lower respiratory tract was indi- cated by different studies in literature. High CRP levels were reported sensitive and specific to determine lower respira- tory diseases [13]. Almirres et al. reported that CRP levels have been shown to be also useful in confirming the diagno- sis, since they were significantly higher in patients with true pneumonia than in those in whom the diagnosis was not confirmed at follow up [14]. Macfarlane et al. in a study of lower respiratory tract infections in patients attending an outpatient setting, reported that 65% of patients with radio- graphically confirmed disease showed high serum CRP levels (above 5 mg/dL) compared with 40% in those with radiographic findings that were consistent with infection, and 11% in those who had no changes consistent with infection [1]. Melbye et al. showed that serum CRP level of above 5 mg/dL in patients with symptoms of re- spiratory infection who had been treated as outpatients had

Determining the viral etiology of respiratory tract infections (RTI) has been limited for the most part to specific primer PCR- based methods due to their increased sensitivity and specificity compared to other methods, such as tissue culture. However, specific primer approaches have limited the ability to fully understand the diversity of infecting pathogens. A pathogen chip sys- tem (PathChip), developed at the Genome Institute of Singapore (GIS), using a random-tagged PCR coupled to a chip with over 170,000 probes, has the potential to recognize all known human viral pathogens. We tested 290 nasal wash specimens from Fili- pino children <2 years of age with respiratory tract infections using culture and 3 PCR methods—EraGen, Luminex, and the GIS PathChip. The PathChip had good diagnostic accuracy, ranging from 85.9% (95% confidence interval [CI], 81.3 to 89.7%) for rhinovirus/enteroviruses to 98.6% (95% CI, 96.5 to 99.6%) for PIV 2, compared to the other methods and additionally identified a number of viruses not detected by these methods.

Abstract: Respiratory tract infections (RTIs) in children are one of the most common reasons for parents consulting health professionals. Most RTIs are self-limiting viral illnesses that will resolve with time and supportive management. However, it is important for the health professional to identify any RTI that may have more serious implications for the child and require medical intervention. Diagnosis can usually be made from the history and presenting symptoms such as cough, wheeze, tachypnea, fever, or stridor. Exclusion of “red flag” symptoms will enable health professionals to appropriately reassure parents and advise symptomatic management with antipyretics and adequate fluid administration. With the expanding role of nurses in ambu- latory settings, many children are now being seen by health professionals other than doctors, (eg, advanced nurse practitioners), some of whom are trained in pediatrics while others have limited knowledge of nursing sick children. It is therefore vital that these professionals remain aware of any risk factors and that they can recognize “red flags” in a sick child rapidly and escalate further management appropriately. Some children will require admission to hospital for respiratory support and other therapies, such as intravenous antibiotics and fluids. With advancement of the “non-medical prescriber” within the nursing profession, awareness of when to give or not give antibiotic therapy needs careful consideration, especially in light of the problems that may arise from overuse of antibiotic treatment. Nurses have a vital role, not only in administering medica- tions and supporting other medical interventions, but also in supporting the child and family over the period of illness. The education of the parents and the child, in some instances, about prevention and avoidance to reduce the risks of any further RTIs must be addressed, including immunization and smoking cessation.

vast majority of these infections. Warnings about antibiotic overuse from academic and particularly infectious disease specialists have been around since the advent of antibiotics. Yet, it has always seemed that as soon as a resistance problem became impor- tant, the pharmaceutical industry had a replacement agent available in the wings. Only now, as we ap- proach the new millennium, antibiotic discovery is no longer keeping pace with the emergence of bac- terial resistance. Realizing that inappropriate use of antibiotics should be reduced, there is now a search for ways to rein in overzealous prescribing habits. So, what are the barriers to reducing inappropriate antibiotic use for respiratory tract infections (RTIs)? In this issue of Pediatrics, Watson et al 7 describe

There is however a critical lack of data describing viral respiratory tract infections (RTIs) in young children with CF aged less than 2 years, when RTIs are particularly fre- quent and potentially more severe at this early period of life. Some studies conducted in the late 1980s and 1990s have drawn a pessimistic scenario of viral RTIs in this vulnerable population that is no longer observed. In these seminal studies, clinical manifestations were de- scribed as severe, frequently requiring hospitalization and prolonged oxygen supply or mechanical ventilation [16 – 18]. Some patients were described as acquiring pathogens such as PA in the weeks or months following RTI [18, 19]. At that time, respiratory syncytial virus (RSV) was found to be the most frequently recovered virus, but diagnostic tools were limited to immunological assays and viral culture, thus limiting the spectrum of virus that may be recovered. Recent studies have shown that RSV epidemics may be associated with the occur- rence of more pulmonary exacerbations [20], but RSV is rarely responsible for hospitalization because of respira- tory events in CF patients [21, 22].

There are limited data on the prevalence and clinical and molecular characterization of human respiratory syncytial virus (HRSV) in children with acute respiratory tract infections (ARTIs) in China. From December 2006 to March 2009, 894 nasopharyngeal aspirates (NPAs) were collected from children under 14 years of age with ARTIs. Samples were screened for HRSV and genotyped by reverse transcription-PCR (RT-PCR) and sequencing. Demographic and clinical information was recorded. A total of 38.14% (341/894) of samples were positive for HRSV. Phylogenetic analysis revealed that 60.4% of the selected 227 RSV strains were GA2, 34.4% were BA, 4.8% were GB2, and 0.4% were GB3. A total of 40.47% of all of the RSV-positive samples were coinfected with other respiratory viruses, and adenovirus was the most common additional respiratory virus. No statistical differences were found in the frequency of diagnosis and symptoms between the coinfection group and monoinfection group. Additionally, no statistical differences were found in epidemiological characteriza- tions or disease severity between genotype BA- and GA2-positive patients, except for a greater frequency of lower respiratory tract infections (LRTIs) (mostly bronchitis)with BA. HRSV is the most important viral pathogen in Chinese children with ARTIs. Four genotypes (i.e., GA2, BA, GB2, and GB3) circulate locally, and the predominant genotype may shift between seasons. Coinfection with other viruses does not affect disease severity. HRSV genotypes were not associated with different epidemiological characterizations or disease severity.

Rhinosinusitis (RS) is also extremely common in chil- dren, with 0.5–5 % of upper respiratory tract infections progressing to this condition [96]. A few years ago, a retrospective study evaluated serum 25(OH)D levels in children with allergic RS with or without nasal polyposis and found no difference in mean vitamin D3 levels be- tween controls and RS without polyposis, whereas the levels in children with allergic RS with polyposis were lower than the recommended levels [97]. Mullingan et al. confirmed these results in a study performed in adults [98]. In this study, the authors also wanted to de- termine the effect of cigarette smoke on vitamin D3 levels, conversion, and the regulation of inflammation. All the patients exposed to smoke had lower vitamin D3 levels, and the authors suggested that the reduction of vitamin D3 by cigarette smoke exposure is a novel mechanism through which cigarette smoke induces proinflammatory effects [98].

follows: 50 °C for 2 min, 95 °C for 10 min, followed by 40 cycles of 95 °C for 15 s, and 60 °C for 1 min. Samples with a cycle threshold (Ct) < 38 were regarded as positive. 10-fold serial dilutions of pMD18-T/Hexon plasmid from 10 10 to 10 0 copies per μL were prepared to establish a standard curve to measure the HAdV load. qPCR were performed using the Mx3005P qPCR System (Agilent Stratagene, USA). HAdV-positive samples were subsequently screened for the following pathogens: influenza A (FluA) and B (FluB) viruses, parainfluenza viruses (PIVs) 1–4, human metapneumovirus (HMPV), human rhinovirus (HRV), WU polyomavirus (WUPyV), respiratory syncytial virus (RSV) and human coronaviruses (HCoV) NL63, OC43, 229E, HKU1 and human bocavirus (HBoV), as described previously [13–15]. Additionally, mycoplasma pneumonia is determined by the detection of mycoplasma pneumoniae IgM antibody. As for bacterial pneumonia, it was con- firmed by sputum culture.

We report rates of hospitalization for severe LRTI among children in the United States, the fi rst reported rates for severe LRTI in the United States that we are aware of. The large data sets used to estimate our rates, MarketScan com- mercial and Medicaid databases, cover a wide geographic area and include children with private and government- sponsored insurance. During 2007 through 2011, young children had the highest rate of hospitalization for severe LRTI. Among children hospitalized for LRTI, children with underlying medical con- ditions were at greatest risk for severe LRTI. Given these fi ndings, prevention strategies to reduce LRTI among children should focus on young children (and people who may transmit infections to them), children with underlying med- ical conditions, and children in socio- economic settings requiring public insurance, including expanded cover- age for recommended vaccines to meet Healthy People 2020 goals. Pre- paredness planning for respiratory related emergencies should account for the large need for ICU and me- chanical ventilation among infants and young children.

We report rates of hospitalization for severe LRTI among children in the United States, the fi rst reported rates for severe LRTI in the United States that we are aware of. The large data sets used to estimate our rates, MarketScan com- mercial and Medicaid databases, cover a wide geographic area and include children with private and government- sponsored insurance. During 2007 through 2011, young children had the highest rate of hospitalization for severe LRTI. Among children hospitalized for LRTI, children with underlying medical con- ditions were at greatest risk for severe LRTI. Given these fi ndings, prevention strategies to reduce LRTI among children should focus on young children (and people who may transmit infections to them), children with underlying med- ical conditions, and children in socio- economic settings requiring public insurance, including expanded cover- age for recommended vaccines to meet Healthy People 2020 goals. Pre- paredness planning for respiratory related emergencies should account for the large need for ICU and me- chanical ventilation among infants and young children.

Upper respiratory tract infection (URTI) is mostly viral in aetiology, but patients presenting with such complaints are frequently prescribed antibiotics. This may result in increased development of antimicrobial resistance. The objectives of this study are to determine the choice and proportion of oral antibiotics prescribed in patients with URTI, in a Sarawak district hospital setting. All outpatient prescriptions received in July 2011 in 10 hospitals with relevant diagnoses were analysed. A total of 6747 URTI prescriptions met the inclusion criteria, and 64.8% (95% CI 63.7%, 65.9%) had antibiotic prescribed. Medical Assistants (MAs) were significantly more likely to prescribe antibiotics compared to Medical Officers (MOs) (p < 0.001). Prescribers were significantly influenced by the patient’s age and specific diagnosis when prescribing antibiotics for URTI (p < 0.001). Antibiotic choices differed between MOs and MAs, where some of the antibiotic choices were inappropriate. There is a need for multi-faceted interventions to improve antibiotic prescribing rate and choice.

Shandong locates in eastern China and lies near to Southern Korean and Japanese with 97 million popula- tions, which has a large transient population from differ- ent provinces and counties. The mixing of transient population may increase the transmission of respiratory viruses. Feng et al. [10] reported the viral etiology of hospitalized acute lower respiratory infection patients in 22 provinces of China, including Shandong province, but the findings didn’t include the data in this study. At the same time, HRV as the major infection pathogen was detected in the hospitalized ARIs, but Feng’s result didn’t describe HRV prevalence. Thus, our aim was to investigate the frequency and type of twelve common re- spiratory viral infections in hospitalized ARIs among chil- dren and adults in Shandong Province from 2011 to 2013.

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disorders (13.8%). Urinary tract infections and lower respiratory tract infections were the most common types of infections, occurring in 29.5% and 8.7% of the catheterized patients, followed by lower respiratory tract infections including bronchitis and bronchiolitis, occurring in 28.1% and17.7% of the patients who had mechanical ventilation or tracheostomy. 22.8% of the patients had blood stream infections and 4.5% of them were catheter associated. The nosocomial infections of surgical sites, skin and soft tissue were 8.2%. A majority of the patients with nosocomial infections had co-infection (24) or super infection (42) or both (31).

The high incidence of bronchitis (in Russia 75-200, in the USA 56 per 1000 children per year [7, 8]) cause 25-40% of all pediatric primary care visits [9]. Frightening for many parents manifestations (fever, cough, wheezing) raise the demand for antibiotics though practically all of them are caused by respiratory viruses [4]. Bacteria cause bronchitis in children in about 5% of cases (mostly in school age), they are mainly Mycoplasma pneumoniae and Chlamydia pneumoniae [6, 8, 10, 11]. Hence antibiotics have no place in the majority of bronchitis and bronchiolitis cases, and it is proven by a number of conclusive studies [10, 11], and recommendations to this effect are found in international and national guidelines [3, 5, 13]. Nevertheless antibiotics are widely used in bronchitis – in Europe in 40 – 67.5% [4, 5, 12, 13]. In the USA up to 1/3-1/2 of antibiotics in the lower respiratory tract infections considered to be used inappropriately [14, 15].

In addition, Kumar et al., found that metronidazole is the most prescribed 4 . The high prescribing of cephalosporins in this study could be attributed to their broad spectrum of activity against most gram-positive and gram-negative bacteria, including several strains resistant to other antibiotics, and recommended for serious infections caused by susceptible micro- organisms 6,26 . Metronidazole also prescribed in higher rate because it is the drug of choice in the treatment of anaerobic bacterial infections 26 . Although, ceftriaxone with fluoroquinolones and macrolides consider the preferred antimicrobials for respiratory tract infections that were the most diagnosis in the current study, this high prescribing rate of ceftriaxone reflected irrational prescribing of antimicrobials and it may be responsible on developing bacterial resistance. Moreover, there are many contributing factors for this irrational prescribing such as the wide available trade names of ceftriaxone in Yemeni market that leads to competition between pharmaceutical companies to distribute them, in addition to increasing the temptations to physicians to prescribing ceftriaxone 20,26 . The majority of the admitted patients received two or more antimicrobials in different combinations (63.54%). This prescribing is a practice commonly observed in Yemen as well as in other regions 6,20,26 . These findings are agreed with the study conducted in Nepal and other countries and also with the WHO guidelines 6,7 . The predominant use of a combination of antimicrobials may be due to the fact that physicians try to expand the possible spectrum of action to include all expected microbes by prescribing combination of antimicrobials. The other reasons to such practices were probably the availability of drugs, its costs