RESUMEN
BACKGROUND: It is hypothesised that community-acquired pneumonia (CAP) patients with more severe disease or inflammation might benefit more from adjunctive corticosteroid treatment. Neutrophil count, lymphocyte count and neutrophil-lymphocyte ratio (NLR) have been associated with inflammation and disease severity in CAP. We investigated the interaction between these parameters and adjunctive dexamethasone effects on clinical outcomes in CAP. METHODS: We conducted a post hoc analysis of the randomised placebo-controlled Santeon-CAP trial (n = 401), which showed a positive effect of adjunctive oral dexamethasone on length of stay (LOS) in CAP patients. White blood cell (WBC) count, neutrophil count, NLR (highest tertile vs. lowest two tertiles) and lymphocyte count (lowest tertile vs. highest two tertiles) were examined as potential effect modifiers of treatment with dexamethasone on LOS (primary outcome) and ICU-admission, 30-day mortality and hospital readmission. RESULTS: WBC differential counts were available for 354 patients. The effect of dexamethasone on LOS was more pronounced in high WBC count, high neutrophil count or high NLR subgroups (difference in median LOS of 2 days versus zero days in the reference subgroups, p for interaction < 0.05). There was no effect modification for the other outcomes. Patients with low WBC and low neutrophil counts did not benefit from dexamethasone, while hospital readmission rate was higher in those treated with dexamethasone (6% vs. 11%). CONCLUSIONS: WBC count and/or neutrophil might be easily available biomarkers to guide selection of CAP patients who are more likely to benefit from adjunctive dexamethasone treatment. Future prospective trials are needed to confirm this predictive potential.
Asunto(s)
Neutrófilos , Neumonía , Dexametasona/uso terapéutico , Humanos , Recuento de Leucocitos , Recuento de Linfocitos , Linfocitos , Neumonía/tratamiento farmacológico , Estudios RetrospectivosRESUMEN
Venous thromboembolism (VTE) seems to be an underdiagnosed complication in COVID-19 patients. We present three male patients, aged 67, 29 and 71 years, who were admitted to the hospital with COVID-19. They all showed deterioration in the course of their disease caused by VTE. In our hospital, VTE was diagnosed in 10% of COVID-19 patients admitted to the general ward (non-ICU patients) despite regular thromboprophylaxis. Deterioration in the course of COVID-19 has differential diagnoses such as progression of the infection itself, secondary bacterial pneumonia, left heart failure and in our experience not infrequently VTE. We therefore recommend to consider VTE in COVID-19 patients with a sudden clinical deterioration such as hypotension, tachycardia, unexplained hypoxaemia or insufficient clinical improvement and to perform CT-angiography if indicated. A high dose of thromboprophylaxis in COVID-19 patients may be considered because of increased coagulation activation.
Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/fisiopatología , Disnea/fisiopatología , Neumonía Viral/fisiopatología , Tromboembolia Venosa/fisiopatología , Adulto , Anciano , Anticoagulantes/uso terapéutico , COVID-19 , Infecciones por Coronavirus/complicaciones , Progresión de la Enfermedad , Disnea/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/complicaciones , Factores de Riesgo , SARS-CoV-2 , Tromboembolia Venosa/etiologíaRESUMEN
BACKGROUND: In 2006 a 7-valent pneumococcal conjugate vaccine (PCV7) was introduced in the immunisation programme for infants in The Netherlands and replaced by PCV10 in 2011. Limited data exist about the impact of PCV on the aetiology of CAP as a whole. The aim of the present study is to describe the overall changes in microbial aetiology, pneumococcal burden (including non-bacteraemic pneumococcal pneumonia) and its serotypes in adult community-acquired pneumonia (CAP) after the introduction of these PCVs. METHODS: Hospitalised adult CAP patients who participated in three consecutive trials were studied (2004-2006 (n=201), 2007-2009 (n=304) and 2012-2016 (n=300) and considered as pre-PCV7, PCV7 and PCV10 period). Extensive conventional microbiological testing was applied for all patients. In addition, patients with a serotype-specific pneumococcal antibody response were diagnosed with pneumococcal CAP. Changes in proportions of causative pathogens and distributions of pneumococcal serotypes were calculated. RESULTS: The proportion of pneumococcal CAP decreased from 37% (n=74/201) to 26% (n=77/300) comparing the pre-PCV7 period with the PCV10 period (p=0.01). For other pathogens, including Legionella spp., Mycoplasma pneumoniae, S. aureus, H. influenzae, and respiratory viruses, no sustained shifts were observed in their relative contribution to the aetiology of CAP. Within the pneumococcal CAP patients, we observed a decrease in PCV7 and an increase in non-PCV10 serotype disease. PCV10-extra type disease did not decrease significantly comparing the PCV10 period with the pre-PCV7 and PCV7 period, respectively. Notably, PCV7 type disease decreased both in bacteraemic and non-bacteraemic patients. CONCLUSIONS: Our findings confirm that PCV introduction in infants impact the microbial aetiology of adult CAP and suggest herd effects in adults with CAP after introduction of PCVs in children.