Out
Out
DOI 10.1007/s10096-005-1346-2
ARTICLE
Introduction
Community-acquired pneumonia (CAP) is a common acute
medical condition worldwide. It remains a major cause of
admission to hospital and mortality in developed countries
and is a large contributor to excessive healthcare resource
consumption and cost [14].
Most cases of CAP are probably caused by a single
pathogen, but dual or multiple infections have been reported increasingly in the literature [57], and there is
growing concern for the concurrent presence of a second
pathogen in a significant proportion of cases of CAP previously thought to be monomicrobial [5, 712]. The potential importance of mixed infections is highlighted by recent
retrospective studies showing that combined antimicrobial
therapy that includes a macrolide, given empirically, may
reduce mortality associated with bacteremic pneumococcal
pneumonia [1315].
The frequency of CAP of mixed etiology has varied
greatly between studies, probably depending on several
factors, including diagnostic methods and criteria used for
etiological diagnosis and the occurrence of epidemic outbreaks during some studies. Most of the studies reporting
data on the prevalence of CAP mixed infections have focused either on patients admitted to hospital or on outpatients [1622]. In addition, previous reports have provided
limited information on the characteristics of the patients,
and the clinical significance of mixed infections has not
been investigated.
The aim of the present report is to describe the prevalence, clinical characteristics, and outcome of mixed infections in a cohort of patients with a broad clinical spectrum
of CAP, including both patients admitted to hospital and
outpatients, in whom an extensive microbiological workup
was performed.
378
Statistical analysis
Descriptive statistics were computed by standard methods.
To detect differences between specified groups, we used
the chi-square test or Fishers exact test where appropriate
for categorical variables, and the Mann-Whitney U test or
the Students t test for continuous variables. A two-tailed
p value of 0.05 was considered significant. Statistical
precision of several test indices was determined by
calculating the 95% confidence interval (CI). Statistical
analyses were performed by means of the SPSS version
11 (SPSS Software, Chicago, IL, USA).
379
Results
Patient characteristics
161 (32.7)
109 (22.1)
87 (17.6)
136 (27.6)
308 (62.5)
111 (22.5)
63 (12.8)
3 (0.6)
60 (12.2)
227 (46)
99 (20.1)
98 (19.9)
52 (10.5)
26 (5.3)
21 (4.3)
20 (4.1)
17 (3.4)
114 (23.1%)
267 (54.2)
103 (20.9)
94 (19.1)
29 (5.9)
361 (73.2)
Monomicrobial pneumoniab
Streptococcus pneumoniae
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydophilia spp.c
Influenza virus
Pseudomonas spp.
Haemophilus influenzae
Gram-negative bacilli other than
Pseudomonas spp.d
Respiratory syncytial virus
Staphylococcus aureus
Moraxella catarralis
Coxiella burnetii
Adenovirus
Varicella-zoster viruse
Mixed pneumoniaf
Unknown
222 (45.0)
83 (16.8)
38 (7.7)
21(4.3)
30 (6.1)
14 (2.8)
11 (2.2)
9 (1.8)
5 (1.0)
4 (0.8)
2 (0.4)
1 (0.2)
2 (0.4)
1 (0.2)
1 (0.2)
28 (5.7)
243 (49.3)
380
Table 3 Distribution of the
causative microorganisms
identified in 28 patients with
community-acquired
pneumonia of mixed etiology
a
In one case, S. pneumoniae was
isolated from blood culture
b
Isolated from blood culture
c
Diagnosed by cutaneous
lesions consistent with
chickenpox and a fourfold rise
in antibody (complement
fixation test)
Microorganisms
Two organisms
Streptococcus pneumoniae plus other organism
S. pneumoniae, Legionella pneumophila
S. pneumoniae, Pseudomonas spp
S. pneumoniaea , Mycoplasma pneumoniae
S. pneumoniae, influenza virus
S. pneumoniae, Coxiella burnetii
S. pneumoniae, Klebsiella spp
S. pneumoniae, Moraxella spp
S. pneumoniae, Haemophilus spp
S. pneumoniae, Staphylococcus aureus
S. pneumoniae, Enterobacter spp
Two organisms other than S. pneumoniae
Chlamydophila pneumoniae, Legionella pneumophila
Mycoplasma pneumoniae, influenza virus
Mycoplasma pneumoniae, Haemophilus influenzae
Chlamydophila psitacci, Listeria monocytogenesb
Chlamydophila pneumoniae, Coxiella burnetti
Legionella pneumophila, influenza virus
Influenza virus, respiratory syncytial virus
Influenza virus, varicella-zoster virusc
Three organisms
S. pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae
S. pneumoniae, Mycoplasma pneumoniae, influenza virus
26 (92.9)
16 (57.1)
3 (10.7)
3 (10.7)
2 (7.1)
2 (7.1)
1
1
1
1
1
1
10 (35.7)
2 (7.1)
2 (7.1)
1
1
1
1
1
1
2 (7.1)
1
1
381
Table 4 Characteristics of
patients with mixed pneumonia
compared with those with
monomicrobial pneumonia
Characteristic
Mixed pneumonia
(n=28)a
Monomicrobial
pneumonia (n=222)a
p
value
Median age
Male sex
Predefined underlying conditionsb
Alcoholism or cigarette smoking
Either predefined underlying conditionsb
or alcoholism or cigarette smoking
Diabetes mellitus
Dementia
COPD
Previous antibiotic therapy
Mean PSI score
No. of patients admitted to hospital
Mean length of hospital stay SD
Pleural effusion
Empyema
Hypoxemia (PaO2 <60 mmHg)
Bacteremia
Combined therapy with a macrolide plus a
-lactam agent
Antibiotic therapy not including a macrolide
or a fluoroquinolone
Deaths
Deaths among bacteremic patients
58 years
20/28 (71.4)
18/27 (64.3)
12/28 (42.9)
23/27 (85.2)
60 years
139/222 (62.6)
100/221 (45.2)
58/221 (26.2)
134/221 (60.6)
0.5
0.4
0.04
0.076
0.01
1/28 (3.6)
7/28 (25)
8/28 (28.6)
6/28 (21.4)
70.5
23/28 (82.1)
10.216.66 days
7/28 (25)
0
12/23 (52.2)
2/19 (10.5)
11/28 (39.3)
49/221 (22.2)
22/221 (10.0)
41/221 (18.6)
47/218 (21.6)
63.0
156/221 (70.6)
9.5535 days
25/220 11.4
2/221 (0.9)
69/183 (37.7)
15/147 (10.2)
97/219 (44.3)
0.02
0.02
0.2
1.0
0.1
0.2
0.31
0.06
1.0
0.2
1.0
0.6
9/28 (32.1)
50/219 (22.8)
0.3
3/28 (10.7)
0/2
8/222 (3.6)
4/15 (26.6)
0.1
1.0
382
383
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