Respiratory viral infections are underdiagnosed in patients with suspected sepsis

European Journal of Clinical Microbiology & Infectious Diseases, May 2017

The study aim was to investigate the prevalence and clinical relevance of viral findings by multiplex PCR from the nasopharynx of clinically septic patients during a winter season. During 11 weeks of the influenza epidemic period in January–March 2012, consecutive adult patients suspected to be septic (n = 432) were analyzed with cultures from blood and nasopharynx plus multiplex PCR for respiratory viruses on the nasopharyngeal specimen. The results were compared with those from microbiology analyses ordered as part of standard care. During the winter season, viral respiratory pathogens, mainly influenza A virus, human metapneumovirus, coronavirus, and respiratory syncytial virus were clinically underdiagnosed in 70% of patients positive by the multiplex PCR assay. During the first four weeks of the influenza epidemic, few tests for influenza were ordered by clinicians, indicating low awareness that the epidemic had started. Nasopharyngeal findings of Streptococcus pneumoniae and Haemophilus influenzae by culture correlated to pneumonia diagnosis, and in those patients laboratory signs of viral co-infections were common but rarely suspected by clinicians. The role of respiratory viral infections in patients presenting with a clinical picture of sepsis is underestimated. Specific antiviral treatment might be beneficial in some cases and may reduce spread in a hospital setting. Diagnosing viral infections may promote reduction of unnecessary antibiotic use. It can also be a tool for decisions concerning patient logistics, in order to minimize exposure of susceptible patients and personnel.

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Respiratory viral infections are underdiagnosed in patients with suspected sepsis

European Journal of Clinical Microbiology & Infectious Diseases October 2017, Volume 36, Issue 10, pp 1767–1776 | Cite as Respiratory viral infections are underdiagnosed in patients with suspected sepsis AuthorsAuthors and affiliations L. R. LjungströmG. JacobssonB. E. B. ClaessonR. AnderssonH. Enroth Open Access Original Article First Online: 17 May 2017 4 Shares 1.4k Downloads 2 Citations Abstract The study aim was to investigate the prevalence and clinical relevance of viral findings by multiplex PCR from the nasopharynx of clinically septic patients during a winter season. During 11 weeks of the influenza epidemic period in January–March 2012, consecutive adult patients suspected to be septic (n = 432) were analyzed with cultures from blood and nasopharynx plus multiplex PCR for respiratory viruses on the nasopharyngeal specimen. The results were compared with those from microbiology analyses ordered as part of standard care. During the winter season, viral respiratory pathogens, mainly influenza A virus, human metapneumovirus, coronavirus, and respiratory syncytial virus were clinically underdiagnosed in 70% of patients positive by the multiplex PCR assay. During the first four weeks of the influenza epidemic, few tests for influenza were ordered by clinicians, indicating low awareness that the epidemic had started. Nasopharyngeal findings of Streptococcus pneumoniae and Haemophilus influenzae by culture correlated to pneumonia diagnosis, and in those patients laboratory signs of viral co-infections were common but rarely suspected by clinicians. The role of respiratory viral infections in patients presenting with a clinical picture of sepsis is underestimated. Specific antiviral treatment might be beneficial in some cases and may reduce spread in a hospital setting. Diagnosing viral infections may promote reduction of unnecessary antibiotic use. It can also be a tool for decisions concerning patient logistics, in order to minimize exposure of susceptible patients and personnel. KeywordsInfluenza Respiratory Syncytial Virus Respiratory Virus Viral Respiratory Infection Acute Lower Respiratory Infection  These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves. Electronic supplementary material The online version of this article (doi: 10.1007/s10096-017-2990-z) contains supplementary material, which is available to authorized users. Introduction Respiratory tract infections The respiratory tract is the most common focus of infection in septic patients. In adults with community-acquired pneumonia (CAP), a bacterial etiology can be established in about 25–50% of cases depending on definitions and methods used [1, 2]. S. pneumoniae is the most often found bacteria, followed by H. influenzae and Mycoplasma pneumoniae. More rarely found agents are Legionella pneumophila, Chlamydophila pneumoniae, and Coxiella burnetti [1, 3]. Several respiratory viruses may also cause severe respiratory disease, including CAP, mainly in children, but also in adults. This is well known for influenza A and B viruses, respiratory syncytial virus, coronavirus, human metapneumovirus, parainfluenza viruses types 1–3, adenovirus, enteroviruses, rhinovirus, and human bocavirus [3, 4, 5]. Indeed, viral infections are estimated to cause around 100 million annual cases of CAP worldwide [6]. Many of these viruses have seasonal variation patterns, causing epidemics, often with peaks during winter and early spring [7]. Viral respiratory infections may predispose for bacterial infections by damaging the respiratory epithelium as well as by viral-bacterial interactions. For example, influenza A virus can enhance the pathogenicity of S. pneumoniae, Staphylococcus aureus or H. influenzae. On the other hand it can inhibit the pathogenicity of others, such as M. pneumoniae and C. pneumoniae [8, 9, 10, 11]. Using molecular techniques it has become evident that viral infection is present in around 25% of CAP, regardless of severity [1, 12, 13]. Viral co-infections in CAP has been shown to increase both disease severity and length of stay in hospital [14]. In patients with pneumonia requiring intensive care, mixed viral-bacterial infections have demonstrated the highest mortality rate in at least one study [13]. Commercial multiplex tests are continuously being developed, allowing for rapid etiological diagnosis of a wide range of respiratory viruses and bacteria [4, 15, 16, 17, 18]. Diagnosing viral respiratory infections may help in reducing admissions, length of stay, use of antibiotic treatment and, in some cases, target antiviral treatment [14]. Testing is optimal during the first days of infection, when the viral load is high [19]. The clinical significance of a viral finding cannot always be determined. Some respiratory viruses, like rhinovirus, can persist in young children up to 6 weeks after a clin (...truncated)


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L. R. Ljungström, G. Jacobsson, B. E. B. Claesson, R. Andersson, H. Enroth. Respiratory viral infections are underdiagnosed in patients with suspected sepsis, European Journal of Clinical Microbiology & Infectious Diseases, 2017, pp. 1767-1776, Volume 36, Issue 10, DOI: 10.1007/s10096-017-2990-z