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Frequency, diagnosis and management of fungal respiratory infections

imagePurpose of reviewThis review highlights key recent advances in fungal respiratory infections, encompassing developments in epidemiology, diagnostics and management, focussing on Aspergillus, Pneumocystis and Cryptococcus as key pathogens. Recent findingsChronic pulmonary aspergillosis complicates existing lung diseases, particularly those associated with cavities or bullae, with a high global disease burden (prevalence estimate >1.1 million following tuberculosis) and significant under diagnosis (using Aspergillus IgG antibody). Several new treatment studies have been published (using caspofungin and voriconazole). Pneumocystis jirovecii demonstrates airborne transmission between infected and noninfected individuals necessitating isolation, and possibly identifying colonized patients. Early detection of serum cryptococcal antigenaemia in HIV may prevent development of meningitis, reducing morbidity and mortality, and routine testing of serum in community-acquired pneumonia cases in high endemicity areas may be helpful. Respiratory Aspergillus antigen and PCR testing is more sensitive than culture or serum testing. A new lateral flow antigen testing device may provide rapid bedside diagnosis of aspergillosis. Azole resistance to Aspergillus fumigatus is increasing across Europe. SummaryThe field of fungal respiratory infection continues to evolve and develop, with many recent key advances. Patients, and possibly colonized patients, with Pneumocystis require isolation in hospitals and preferably segregation in outpatients. Challenges remain in almost all areas, with further work needed to identify the true burden of Aspergillus disease and address the increasing problem of azole resistance.

Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management

imagePurpose of reviewThe recent evidence is reviewed on clinical epidemiology, trends in bacterial resistance, diagnostic tools and therapeutic options in hospital-acquired pneumonia (HAP), with a special focus on ventilator-associated pneumonia (VAP). Recent findingsThe current incidence of VAP ranges from two to 16 episodes for 1000 ventilator-days, with an attributable mortality of 3–17%. Staphylococcus aureus (with 50–80% of methicillin-resistant strains), Pseudomonas aeruginosa and Enterobacteriaceae represent the most frequent pathogens in HAP/VAP. The prevalence of carbapenemase-producing Gram-negative bacilli (GNB) and the emergence of colistin resistance are alarming. Procalcitonin seems to have a good value to monitor the response to treatment. Rapid molecular tests for the optimization of empirical therapy will be available soon. Recent studies support the use of a high-dosing regimen of colistin in HAP/VAP caused by extensively drug-resistant GNB. Linezolid may probably be preferred to vancomycin for a subset of methicillin-resistant S. aureus HAP/VAP. Given the scarcity of novel antimicrobial drugs, different approaches such as bacteriophage therapy or immunotherapy warrant further clinical evaluations. SummaryHAP/VAP is a major cause of deaths, morbidity and resources utilization, notably in patients with severe underlying conditions. The development of new diagnostic tools and therapeutic weapons is urgently needed to face the epidemic of multidrug-resistant pathogens.

Advances in antibiotic therapy for community-acquired pneumonia

imagePurpose of reviewCommunity-acquired pneumonia (CAP) is a major public health problem all over the world. The increasing number of antibiotic-resistant bacteria is a matter of concern for physicians when choosing antibiotic treatment in patients with CAP. This review focuses on the current recommendations of antibiotic treatment, recent information concerning antibiotic resistance of pathogens, and the advances in antibiotic therapy in the field of CAP. Recent findingsA significant increase in the frequency of resistance to the antibiotics commonly used against causative pathogens of CAP, such as β-lactams or macrolides, has been reported in recent years. At present, the prevalence of fluoroquinolone resistance in Streptococcus pneumoniae remains low. Community-acquired methicillin-resistant Staphylococcus aureus and influenza A(H1N1)pdm09 have been reported as causes of severe CAP. Several newly-developed antibiotics, including cepholosporins, ketolides and quinolones, present marked activity in vitro against the main causative pathogens of CAP. Many randomized controlled trials have demonstrated equivalent efficacy of the newer antibiotics compared with conventional antimicrobial therapy in mild-to-moderate CAP. SummaryAn increase of resistance to the antibiotics used in CAP has been documented over the years. Several new antibiotics have been developed for treating CAP, with promising results. However, data regarding their efficacy and safety in patients with severe CAP are lacking.

Diagnosis of pulmonary tuberculosis

imagePurpose of reviewThis review summarizes the recent literature on the developments in diagnostics for pulmonary tuberculosis (TB). Recent findingsA growing body of literature regarding the Xpert MTB/RIF assay confirms the high diagnostic accuracy in a range of clinical settings, including amongst inpatients, those with HIV coinfection and in children with culture-positive disease. Early experiences with operational implementation are now being reported from South Africa. Initial small-scale evaluations suggest that newer versions of line-probe assays have diagnostic accuracy similar to that of the Xpert MTB/RIF assay. Next-generation fully automated molecular assays that use isothermal amplification may in the future be more readily implemented at the point of care. The first low-cost, lateral-flow (strip-test) assay for lipoarabinomannan in urine shows promise as a rapid point-of-care test for TB amongst HIV-infected patients who have advanced immunodeficiency. A range of other diagnostic tools are also at various stages of development. SummaryThere is continued momentum and optimism regarding the developments in TB diagnostics. However, studies of clinical and programmatic impact and operational research are needed to guide implementation and scale-up of new assays in resource-limited settings. Further concerted efforts are needed to develop point-of-care assays which are desperately needed to accelerate progress in TB control.

Respiratory tract infections during the annual Hajj: potential risks and mitigation strategies

imagePurpose of reviewMass gatherings such as religious pilgrimages, sporting events and music concerts are becoming larger and more frequent. The scale and frequency of large-scale international events pose substantial risks to the spread of infectious diseases. The available literature on respiratory tract infections at the Hajj pilgrimage – annually attended by 3 million pilgrims from all over the globe – are reviewed. Recent findingsThe most common respiratory tract infection viruses are influenza and rhinovirus. Despite the occurrence of the Hajj during the 2009 H1N1 pandemic the available literature did not show an increased rate of infection. In hospitalized patients, pneumonia is a significant cause of admission accounting for 20–50% of such admissions. SummaryThe use of masks may reduce exposure to droplet nuclei, the main mode of transmission of most respiratory tract infections. The practice of social distancing, hand hygiene, and contact avoidance was associated with reduced risk of respiratory illness. In addition, utilizing the recommended vaccines would decrease the risk of acquiring respiratory tract pathogens.

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