Characteristics of community acquired pneumonia at a single center in central Sri Lanka during COVID-19 pandemic: A descriptive cross-sectional study
Dr. Anushika Luckmy Solanga Arachchige 1, Dushantha Madegedara 2
1 Post
graduate trainee in Respiratory Medicine, Postgraduate Insititute
of Medicine, Colombo, Sri Lanka
2 Chair
Professor of Medicine, Wayamba University of Sri Lanka and Consultant
Respiratory Physician, Respiratory Disease Treatment Unit, National Hospital,
Kandy, Sri Lanka
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ABSTRACT |
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Introduction
and Objective: Community acquired pneumonia (CAP)
is associated with increased mortality and morbidity. The disease severity is
multifactorial, co-morbid conditions and advanced age are the most important
risk factors. At present, there is a sparsity in published data on CAP in Sri
Lankan adults and adolescents. Aim of study to identify complications and
outcome of CAP. Methods: A single center descriptive prospective study was carried out in Respiratory Unit 11 in National Hospital-Kandy, Sri Lanka, among diagnosed CAP patients during six months from 1st of September 2020 to 28th of February 2021. Data were analyzed by SPSS (Statistical Package for Social Sciences) 21 package. Results: 105 cases were analyzed; of which 35.2% had complications. Parapenumonic effusion was the commonest complication, whilst pyothorax was the rarest complication. Nine patients (24%) had multiple complications. Prevalence of complications significantly correlated with CURB 65 score (pearson correlation coefficient 0.57, p value 0.001). 93.3% of patients survived with treatment, however 6.6% of them demised with male predominance and all had at least 2 preexisting diseases. Five deaths (71.4%) occurred in the intensive care unit. During follow up, 3.8% were diagnosed with bronchial malignancy, 5.7% pulmonary tuberculosis, 2.8% other chronic infections (melioidosis) and 1.9% chronic organizing pneumonia, respectively. Conclusion: CAP is a major health concern in central Sri Lanka during COVID-19 pandemic. Most CAP patients recovered completely. Mortality 6.6% with male predominance. Parapneumonic effusion was the commonest complication. Number of Complications had significant correlation with CURB 65 score. |
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Received 23 April 2023 Accepted 25 May 2023 Published 15 June 2023 Corresponding Author Dr. Anushika Luckmy Solanga Arachchige, mailto:saluckmy@gmail.com DOI 10.29121/granthaalayah.v11.i5.2023.5180 Funding: This research
received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors. Copyright: © 2023 The
Author(s). This work is licensed under a Creative Commons
Attribution 4.0 International License. With the
license CC-BY, authors retain the copyright, allowing anyone to download,
reuse, re-print, modify, distribute, and/or copy their contribution. The work
must be properly attributed to its author. |
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Keywords: Clinical Characteristics, Community
Acquired Pneumonia, Outcome |
1. INTRODUCTION
1.1.
BACKGROUND
Pneumonia
is an acute inflammation of lung parenchyma with inflammatory exudatives Fauci (1998). This is a still
common respiratory disease despite the presence of health facilities Murray and Lopez (2013). It is considered as
the 9th leading cause of death across the world since pneumonia carries a
significant morbidity and mortality in the population and it is the most common
infection causing deaths globally Wijesooriya et al. (2018).
Pneumonia
is an umbrella term which belongs to several subtypes owing to the acquisition
of disease. Out of all, community acquired pneumonia (CAP) is the commonest
type. Hospital acquired pneumonia, ventilator associated pneumonia and health
care associated pneumonia are other subtypes. The clinical spectrum of CAP is
diverse and ranging from very mild clinical symptoms to serious disease and
complications such as respiratory failure, cardiopulmonary compromise, sepsis, multi-organ
dysfunction and death.
Host
factors such as age, preexisting co-morbidities, underline pulmonary reserve,
coexisting pulmonary diseases, immune status, social circumstances
and behaviour are contributed to the severity of CAP.
Severity is also highly dependent on microbiological factors. CAP is caused by
different organisms. Streptococcus pneumonia is known as the main
bacterial aetiology followed by Haemophilus
influenza, Staphylococcus aureus, group A Streptococcus and numerous
other groups of bacteria Peto et al. (2014). There are many
types of respiratory viruses, also important as aetiology.
COVID-19 infection commonly overlaps with CAP which may mimic pneumonia. The
incidence of Streptococcus pneumonia has been declining in the
community, whereas other pathogens such as respiratory virus associated CAP is
an emerging global trend. Further,
another subset of CAP occurs due to atypical bacteria namely Mycoplasma
pneumonia, Legionella pneumonia and Chlamydia pneumophila.
Interestingly, pneumonia has numerous extra-pulmonary manifestations which
could easily be misrepresented Ishiguro et al. (2018) in clinical
practice.
Management
of pneumonia is based on the guidelines Ewig et al. (2016), Lim et al. (2009). However, pneumonia
management guidelines have not been recently updated globally. The treatment
modality of CAP is an appropriate antimicrobial therapy. The challenge is
emerging antimicrobial resistance with potential inadequate or zero therapeutic
response. Ideally, antibiotics are instituted depending on microbiological
clues. In terms of unavailability of necessary microbiological stains, cultures
and time lag are major drawbacks for moving to empirical antibiotics derived on
preexisting information in the medical literature and guidelines Mandell et al. (2007).
At
present, there is a sparsity of Sri Lankan research on CAP in on adult and
adolescents. Pneumonia research on Sri Lankan
paediatric age category is available Kudagammana et al. (2020). However, as per
available limited evidence, morbidity and mortality
due to CAP in our country is remarkably high Health Government (2023), Haniffa et al. (2009). Pneumonia related
hospital admissions were 26681 in Sri Lanka during the year 2018 Health Government (2023). Furthermore, 3842
deaths due to pneumonia had been reported during the same year. Thus, pneumonia
has been ranked as the seventh leading cause for in-hospital deaths Health Government (2023).
1.2. OBJECTIVES
The
global data on CAP is not precise to apply in Sri Lankan population due to
discrepancies in prevalence of co-morbidities, tropical infections, predominant
chronic infections (tuberculosis), environmental and socio-economic factors.
Therefore, it is a timely prerequisite to study on this entity and apply to
local patients with CAP which prompted us to identify this gap and carry out
this study.
We
aimed to ascertain factors and associations related to CAP in a sample of
patients treated in single center in Central Sri Lanka. Ultimately, the gain
was to contribute to the augmentation of the care of CAP, abate pneumonia
associated complications and lessen mortality.
2. METHODS
A
single-center descriptive cross-sectional study on CAP was carried out in
patients admitted in Respiratory Unit 11, National Hospital- Kandy, Sri Lanka
for a duration of 6 months from first of September 2020 to 28th
February 2021. The ethical and administrative approvals were granted by the
ethical review committee in National Hospital, Kandy and the Director of
National Hospital, Kandy correspondingly.
All
adult patients who met the diagnosis of CAP and gave informed written consent
were enrolled into the study. Parental consent was obtained for adolescents
under 18 years. Consecutive sampling methods were used to acquire study
subjects.
Exclusion
criteria were age less than 12 years, lack of informed written consent,
confirmed COVID-19 infection, hospital acquired pneumonia, noninfective
pneumonitis and cases treated in the community.
Standard
management and interventions were carried out according to guidelines. The
clinical, radiological and lab indices were monitored for satisfactory
response. Development of complications and outcome were identified accordingly.
Patients were reviewed at outpatient clinic and investigations were arranged
depending on the necessity.
3. DATA COLLECTION
Data
were collected at hospitalization with an interviewer administered
questionnaire.
4. STATISTICAL ANALYSIS
The
data were tabulated and analyzed with statistical package for Social Sciences
(SPSS) 21version. Subsequently, generated information was presented as numbers
and percentages in a tabulated format and as graphs.
Demographic
profile, symptomatology, investigation profile, management and outcome were analysed using descriptive analysis. Chi square test was
used to analyse significance of clinical features
between young adults (less than 55 years) and elderly (more than 55 years) aged
group with CAP. Associated factors for complications, gender and biomass
exposure were analysed using chi square test placing the p value
at 0.05 in 95% confidence interval. Pearson correlation was used to determine
bivariate correlation among complications and CRP along with severity index. A p
value of 0.05 was considered statistically significant.
5. RESULTS
5.1. Demographic profile
A
total of 105 subjects were enrolled. The median age was 60 years (SD 18.87),
and mean age was 54.8 years (SE 1.859), ranging from 14 to 88 years. The
majority (58.7%) of patients were above 55 years of age. The study included
58(55.2%) females and 47(44.8%) males Figure 1.
Almost
one third of total cases was housewives. About 16% of cases were service and
sales workers in contrast to 14.3% of elementary employees. Details of
occupations are summarized in Figure 2.
Figure 1
Figure 1 Gender Distribution of Patients |
Figure
2
Figure 2 Occupational Distribution of Patients |
5.2. Clinical presentation and
hospital stay
The
most common presenting symptom was cough 96 (91.4%). Out of which, 60.4% of
cases had cough with sputum production. In addition, fever and shortness of
breath were present in 82(78.1%) and 80(77.1%) patients respectively. Symptoms
were demonstrated in Figure 3. However,
overlapping symptoms were also encountered in study subjects.
The
mean duration of fever, dyspnea and cough at presentation was 4.1 days
(SE0.38), 6.5 days (SE0.68) and 10 days (SE9.27), respectively. The mean
hospital stay was 7 days (SE0.669).
Figure 3
Figure 3 Prevalence of Symptoms |
5.3. Co-morbidities and Risk
factors
Several
co-morbidities were identified among patients. Out of which, chronic lung
diseases were the most common in 42.9%; bronchial asthma 25.7, chronic
obstructive airway disease 9.6%, interstitial lung disease 3% and
bronchiectasis 4.6% respectively. Meanwhile 28.6% of cases were diabetics and
22.85% hypertension. In addition, rhinosinusitis was found in 17.1%. Multiple
co-morbidities were observed in a significant number of patients. Associated
co-morbidities were presented in Figure 4.
Figure 4
Figure 4 Co-Morbid Conditions Associated with Patients |
Out
of all cases, history of pneumonia was observed in 12.4%. Twenty-eight percent
and 30% of patients reported smoking and alcohol respectively. Many patients
(52.3%) had been exposed to domestic biomass fuels. 4.8% of patients reported
long distance travel within a period of 2 weeks. Furthermore, 3 pregnant
mothers with CAP were included in this study.
Figure 5
Figure 5 Predisposing and Associated Factors |
5.4. Clinical examination
The most common clinical sign was coarse
crepitation (86.6%). Out of all, 59.6% of patients had local in contrast to
generalized signs (40.43%). Bronchial breathing was detected only in 28.6% and
rhonchi was found in 47.6% of cases. Respiratory examination findings were
summarized in Figure 6 and Figure 7.
Figure 6
Figure 6 Presence of Respiratory Signs on Hospital Admission |
5.5. Investigation
profile
5.5.1. Radiology
Chest
radiography was performed on all patients. 22.8% of patients admitted with
chest radiographs while others subjected to chest radiography during first 24
hours of hospital admission. Almost 53.1% of patients had radiological changes
confined to a single zone in comparison with 46.9% of multizonal opacities.
Comparison of radiological findings were presented in Figure 7.
Figure 7
Figure 7 Location of Pathology According to Clinical Examination and Radiology |
5.5.2. Blood
investigations
The
mean white cell count was 11.63/cm3. C reactive protein had a median of 64 (SD
96.3, range 1.75 to 452) whilst median erythrocyte sedimentation rate remained
at 60 (SD 33.3, range 5 to 120). Although initial C reactive protein was
significantly correlating with occurrence of complications due to pneumonia (pearson correlation coefficient 0.758, p value
0.01), initial erythrocyte sedimentation rate and complications did not
illustrate statistically significant correlation (pearson
correlation coefficient 0.088, p value 0.42). Range of blood urea was
1.03 to 319(SD 62.9) with 4.94 of median.
Sputum
bacterial culture was carried out in 7.6% of cases and was positive in one case
that grew Pseudomonas aeurogenosa. Blood
culture was performed in 16.1% of cases and only two were positive for Streptococcus
pneumonia species. Procalcitonin was done in a minority of (11.4%) cases.
H1N1 testing was carried out in 6.6% patients while Mycoplasma antibodies were
performed in 2.9% of cases with a single case positivity.
5.6. Management and severity of
disease
Out
of cases with single lobar pneumonia, right side involvement was the commonest
in 62.09% of cases. The lower lobe was widely affected with 62.5% in contrast
to the other lobes. However, upper lobe was the least affected site (8.3%) in
this cohort. Lobar prediction was not recognized in 28.6% of total cases and a
minority of patients had interstitial pneumonia.
For
all, CURB65 score was calculated as the severity assessment tool. CURB65
indicated that 22 (20%) patients had moderately severe CAP and 8 (7.6%) had
severe CAP. In ward was the most common place of management accounting for
94.4%. The leading reason (70%) for intensive care admission was acute hypoxaemic respiratory failure compared to septic shock
(30%).
One third of the patients (33.3%) were exposed
to antibiotics prior to their admission, among which 43% of them were
prescribed with beta lactamase inhibitors. However, 10.5% of patients were
uncertain about receiving antibiotics. Cephalosporin was the predominant
antimicrobial agent (53.3%) during the time frame of in-hospital management
involved in this study. Nonetheless, 51.5% of cases were treated with
quinolones as well. Patients with moderate to severe complicated CAP and severe
CAP received more than one combination of antibiotics.
68%
of individuals had uncomplicated CAP in contrast to 35.2% of cases with
complications. Pleural effusion was the most common complication, accounted for
14.3% of
cases whilst pyothorax was the rarest complication. All the complications were
summarized in Figure 8. Nine subjects had
multiple complications.
Figure 8
Figure 8 Types of Complications |
There
was no significant association between diabetes mellitus and rate of
complications (chi value 0.117, p value 0.819). Also,
there was no significant association between smoking and complications due to
pneumonia. (Chi value 3.145, p value 0.10). However, prevalence of
complications significantly correlated with CURB 65 score( pearson
correlation coefficient 0.57, p value 0.001). Also, CURB 65 score did
not correlate with number of deaths as Pearson correlation coefficient 0.152, p
value 0.12.
5.7. Outcome
93.3%
of patients survived with treatment, however 6.6% of them demised. Complete
chest radiography clearance was noted at 1 month, 2 months and 3 months in 47%,
40% and 13% of recovered patients respectively. Out of all patients, 3.8% were
subsequently diagnosed with bronchial malignancy, pulmonary tuberculosis was
confirmed in 5.7% and chronic infections (melioidosis) apart from tuberculosis
was diagnosed in 2.8% accordingly. In addition, 1.9% developed post infectious
organizing pneumonia secondary to CAP and successfully managed with intensive
steroid therapy. Out of 7 deaths, 4 deaths were males. All demised patients had
more than 2 preexisting diseases. Five deaths occurred in the intensive care
unit.
6. DISCUSSION
CAP
is a leading infection in Southeast Asia including Sri Lanka which sharing
similar socio-economical statues Health Government (2023), Haniffa et al. (2009). The median age
range and mean age were equal to preexisting studies Lim et al. (2003), Mishra and Behera (2016), Myint et al. (2012), Partouche et al. (2015). There was a female
preponderance. However, this is an extraordinary feature in contrast to
comparable studies done in southeast Asian region other than a French study Partouche et al. (2015). 86% male
predominance was demonstrated in a study carried out by Aditya Bikram Peto et al. (2014). According to Lim WS
et al, 50.6% was males and the mean age was 65.4(19.6) years Lim et al. (2003), Mishra and Behera (2016). However, social
predisposing factors such as smoking and alcohol consumption were not
dominating in the present study since, these habits are not commonly seen among
Sri Lankan females.
Out
of all, housewives outnumbered remaining economically active population. The
most probable cause for this incidence could be the female preponderance in
this study sample. Also, field workers involved in service and sales were the
most affected economically active group by 16.2% in the study. In addition, 13.3% of patients was unemployed
as per employment characteristics of Sri Lanka according to the labour force survey in 2019 Sri Lanka Labour Force Annual
Report (2019). However, the
association between occurrence of CAP in unemployed personals was remained
unclear which needs to be further explored the future. Meanwhile, it was
obvious that poor socio-economical background and non-income generating
population were more susceptible for CAP in this study. Further, this fact was similar to the published data in the literature Jahanihashemi et al. (2018).
The
clinical profile was almost equivalent to the findings of published local and
international studies Lim et al. (2003), Mishra and Behera (2016), Partouche et al. (2015), Eekholm et al. (2020) amongst which cough
was the most common symptom. Also, cough had the longest duration at the
presentation which was around two times more than that of fever. Hence,
prolonged cough with recent onset of other respiratory symptoms may be a health
burden leading to catastrophic consequences due to CAP. Therefore, this
presentation requires early detection and simultaneous investigations. Cough
was present among all age groups without statistical significance between
elderly and young adults (Chi square value for cough was 2.776, p value
0.25.) which was true for fever. On contrary, dyspnoea
and pleuritic chest pain were more common in older population than young adults
and adolescents.
Predisposing
factors for adult CAP were evaluated and reported by Tor-res A et al which
revealed annual incidence inclined with age (14 per 100 person-years in adults
aged more than 65 years Torres et al. (2018). Solid epidemiological data is available in
terms of pulmonary infections that thrive in polluted environment circumstances
Torres-Duque et al. (2008). Biomass has been
profusely used in Sri Lankan households as a domestic fuel. This practice is
more prevalent in rural communities than in urban areas. Acute respiratory
tract infections in children who are associated with indoor biomass smoke was
strong evidence according to a review in 2008 Torres-Duque et al. (2008), Xing et al. (2016). As, housewives had an increased exposure to
solid substance combustion and a major proportion of CAP patients reported
obvious exposure, there was a significant association between gender and
biomass exposure (chi square 21.450, p value 0.001) in this study. This specific association could be attributed
to particulate matter (PM) 2.5 which is a noxious substance present in biomass
fuel. In addition, PM 2.5 has been recognized as a provoking factor for
infections in the human respiratory system Xing et al. (2016). Therefore, future
research in this area of interest is important.
Chronic
Obstructive Pulmonary Disease was the leading predisposed factor for CAP, in many
studies due to downgraded pulmonary immune mechanism Mishra and Behera (2016), Partouche et al. (2015), Eekholm et al. (2020). Also, prevalence of
bronchial asthma was 30% in this study. Diabetes mellitus and incidence of CAP
was variable among studies Eekholm et al. (2020), Ishiguro et al. (2013). A study published
in 2013 observed diabetes mellitus as a major risk factor for CAP Ishiguro et al. (2013). The present study
had more than one fourth of diabetes which was expeditiously higher than
similar studies despite direct comparison between these reports is not
reproducible. A Spanish study demonstrated occurrence of CAP was twofold high
in patients with history of pneumonia (OR 2.73) Sabatier et al. (2010).
In
terms of clinical signs, the presence of coarse
crepitations was the most sensitive sign in several studies as in this study Partouche et al. (2015). In addition,
rhonchi were noted to be a frequent finding in patients than other reports.
This observation was more likely due to underlying obstructive airway diseases
among the patients and movement of secretions which produced by pneumonia
exudates within the bronchial tree. Consolidation features on respiratory
examination was demonstrated in 68% of cases in an Indian study whereas our
study showed less features of consolidation Mishra and Behera (2016). This contradictory
finding was contributed by a significant proportion of antibiotic exposure at
the community level leading to an alteration of the distinct sequence of
disease process. Furthermore, clinical examination was notably disproportionate
to the radiology in some instances, a French study showed 36% of lack of signs
in contrast to 64% of positive chest radiographs for pneumonia Partouche et al. (2015). On the contrary, clinical signs could be
superior to chest radiography findings owing to the delayed onset of
radiological changes, atypical pathogens or poor
quality of radiographs. However, prehospitalization antibiotic administration
may be a provoking factor for minimal auscultation findings in CAP. The site of
pathology in chest radiography was almost constant in present and past results Mishra and Behera (2016). C reactive protein
value was a reliable indicator for predicting complications as there was a
statistically significant correlation between variables. Erythrocyte
sedimentation rate could not be a substitute for prediction of complications.
The
major drawback of microbiological confirmation of aetiology
was predominant in this cohort. Negligible positivity of sputum bacterial
culture was far inferior to the recent literature Torres et al. (2018), Shah et al. (2010), Self et al. (2017). The presumable
causes for culture negativity would be prior antibiotic administration,
sampling errors, technical constraints, atypical bacterial pathogens
and viruses. Additional serological investigations were not cost-effective
strategies for the present study. Procalcitonin is a crucial investigation in
clinical decision in severe CAP Shah et al. (2010). Nonetheless,
suboptimal performance of procalcitonin was a limitation throughout this study
period.
A
study carried out in France illustrated amoxicillin as the most preferred
antibiotic monotherapy prescribed by general practitioners in contrast to beta
lactamase inhibitors received by patients in the current study Partouche et al. (2015). Intravenous
cephalosporin together with quinolones were instituted for many patients which
was replaced by carbapenems depending on clinical deterioration. Therefore,
this combination of antibiotics was found to be more sensitive and effective in
managing hospitalized CAP in this center. However, this practice was dissimilar
to present management guidelines and a center policy had been established Lim et al. (2009). The percentage of
treatment escalation into intensive care facility was identical for this study
and recently published literature Mandell et al. (2007), Sabatier et al. (2010), Eshwara et al. (2020). Furthermore,
reasons for intensive care admissions were comparable to several descriptive
studies Mishra and Behera (2016), Partouche et al. (2015), Ishiguro et al. (2013), Mbata et al. (2013). Rate of
complications following CAP was nearly constant with preexisting studies along
with pleural effusion as the most frequent complication Eekholm et al. (2020), Xing et al. (2016), Sabatier et al. (2010), Eshwara et al. (2020). However, pleural
effusion was not a cause for mortality in the study group. As per previous research,
complications were dominant in severe CAP with a statistical significance (p
0.001) Lim et al. (2003), Partouche et al. (2015), Ishiguro et al. (2013), Shah et al. (2010). In this cohort, the
major proportion of patients was in less severe CAP according to CURBS65 score.
The minority had severe category of CAP and greater complication rate. On
contrary, mortality and severity score of CAP were
positively correlated without a statistical significance (p 0.121).
GC Mbata et al reported that 15% of mortality in their study
in Nigeria compared with 0.3% in a French study and zero in an Indian study
respectively [18, Mbata et al. (2013), Eshwara et al. (2020). This was 6.6% in
the present report indicating that mortality due to CAP was highly variable and
multifactorial possibly standards of health care also play a decisive role.
Since,
14.25% of patients did not respond to the treatment within the expected period
and later found to have an alternative aetiology or a
secondary cause. Mortality rates among poorly responded cases were reported to
be unprecedentedly high as 49% Mandell et al. (2007), Sabatier et al. (2010), Mbata et al. (2013). Hence, periodic
assessment after hospitalization is mandatory in terms of arranging prompt
investigations.
From
the present study, a set of recommendations would be suggested. Establishing a
definitive channel between community based preliminary treatment and hospital
setting with a proper system of referrals will be a necessary task. Further,
adhering to the clinical criteria on CAP would be crucial to improve the
outcome. Primary care physicians and emergency staff should be made aware of likelihood as well as common manifestations of CAP. If the
presentation is atypical and poorly resolving appropriate consultations should
be sought for the best interest of the patient. The policy of antibiotic stewardship
needs to be implemented and audits are encouraged for quality assurance.
Vulnerable groups such as older people and patients suffering from chronic lung
diseases should receive pneumococcal vaccination for prevention of CAP. Future
studies need to be planned to investigate female predominance in CAP with
possible associations with biomass exposure. Moreover, community-based CAP
management and health care accessibility to Sri Lankan population is another
potential area of interest.
The
major strength of this study was a prospective cross-sectional study which
selected a representative study setting of the whole country. Limitations were
the inadequate number of microbiological clues and absence of specific
investigations secondary to financial inferiority in the health sector.
Therefore, deficiency in aetiological diagnosis of
CAP is a significant restriction in contemporary study. In addition,
community-based CAP management was not considered since it was a hospital-based
study.
7. CONCLUSION
CAP
in adults and adolescents continues to be a significant health concern in Sri
Lanka even during COVID-19 pandemic which could have been overwhelmed. Outstanding incidence among females and
category of housewives was distinguishable to already published studies.
Meanwhile, the relationship between biomass fuel combustion and CAP needs to be
deeply elucidated in the future. As a result of aetiologic diagnosis of CAP
being a greater challenge, inappropriate antimicrobial administration would be
inevitable. Hence, potential threat of antibiotic resistance will be an
undeniable hazard in forthcoming years. Therefore, dissemination of
microbiology and ancillary laboratory services is a timely requirement at
present.
In
addition, clinical presentation has a similar pattern described in the
literature, therefore a high index of clinical suspicion is mandatory. Chest
radiography is the most accessible radiological investigation modality whilst
initial CRP is a predictor of complications. The prognosis is satisfactory with
timely management in this study although one third of cases was complicated
with 6.7% mortality which should be studied at national level and incorporated
into the management protocols in health institution with periodic updates along
the time frame.
CONFLICT OF INTERESTS
None.
ACKNOWLEDGMENTS
We would like to acknowledge Dr Achila Gahaliyadda, Postgraduate trainee in Emergency Medicine for helping us with data analysis.
REFERENCES
Eekholm, S., Ahlström, G., Kristensson, J., & Lindhardt, T. (2020). Gaps Between Current Clinical Practice and Evidence-Based Guidelines for Treatment and Care of Older Patients with Community Acquired Pneumonia: A Descriptive Cross-Sectional Study. BMC Infectious Diseases, 20(1), 73. https://doi.org/10.1186/s12879-019-4742-4
Eshwara, V. K., Mukhopadhyay, C., & Rello, J. (2020).
Community-Acquired Bacterial Pneumonia in Adults: An Update. Indian Journal of
Medical Research, 151(4), 287–302. https://doi.org/10.4103/ijmr.IJMR_1678_19
Ewig, S., Höffken, G., Kern, W. V., Rohde, G., Flick, H., Krause, R., Ott, S., Bauer, T., Dalhoff, K., Gatermann, S., Kolditz, M., Krüger, S., Lorenz, J., Pletz, M., de Roux, A., Schaaf, B., Schaberg, T., Schütte, H., & Welte, T. (2016). Behandlung Von Erwachsenen Patienten Mit Ambulant Erworbener Pneumonie und Prävention - Update 2016 [Management of Adult Community-acquired Pneumonia and Prevention - Update 2016]. Pneumologie (Stuttgart, Germany), 70(3), 151–200. https://doi.org/10.1055/s-0042-101873
Fauci, A. S. (Ed.). (1998). Harrison’s Principles of Internal Medicine. McGraw-Hill.
Haniffa, R., Ariyaratne, H., Fernando, S., & Rajapakse, S. (2009). Initial management of Patients With Community-Acquired Pneumonia in a Tertiary Hospital in Sri Lanka. Sri Lanka Journal of Critical Care, 1(1), 32–34. https://doi.org/10.4038/sljcc.v1i1.941
Ishiguro, T., Takayanagi, N., Yamaguchi, S., Yamakawa, H., Nakamoto, K., Takaku, Y., Miyahara, Y., Kagiyama, N., Kurashima, K., Yanagisawa, T., & Sugita, Y. (2013). Etiology and Factors Contributing to the Severity and Mortality of Community-Acquired Pneumonia. Internal Medicine (Tokyo, Japan), 52(3), 317–324. https://doi.org/10.2169/internalmedicine.52.8830
Ishiguro, T., Yoshii, Y., Kanauchi, T., Hoshi, T., Takaku, Y., Kagiyama,
N., Kurashima, K., & Takayanagi, N. (2018). Re-Evaluation of the
Etiology and Clinical and Radiological Features of Community-Acquired Lobar
Pneumonia in Adults. Journal of Infection and Chemotherapy: Official Journal of
the Japan Society of Chemotherapy, 24(6), 463–469. https://doi.org/10.1016/j.jiac.2018.02.001
Jahanihashemi, H., Babaie, M., Bijani, S., Bazzazan, M., & Bijani, B. (2018). Poverty as an Independent Risk Factor for in-Hospital Mortality in Community-Acquired Pneumonia: A Study in a Developing Country Population. International Journal of Clinical Practice, 72(5), e13085. https://doi.org/10.1111/ijcp.13085
Kudagammana, S. T., Karunaratne, R. R., Munasinghe, T. S., & Kudagammana, H. D. W. S. (2020). Community Acquired Paediatric Pneumonia; Experience from a Pneumococcal Vaccine- Naive Population. Pneumonia, 12, 8. https://doi.org/10.1186/s41479-020-00071-6
Lim, W. S., Baudouin, S. V., George, R. C., Hill, A. T., Jamieson, C., Le Jeune, I., Macfarlane, J. T., Read, R. C., Roberts, H. J., Levy, M. L., Wani, M., Woodhead, M. A., (2009). Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: Update 2009. Thorax, 64, Suppl. 3, iii1–ii55. https://doi.org/10.1136/thx.2009.121434
Lim, W. S., Van Der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining Community Acquired Pneumonia Severity on Presentation to Hospital: An International Derivation and Validation Study. Thorax, 58(5), 377–382. https://doi.org/10.1136/thorax.58.5.377
Mandell, L. A., Wunderink, R. G., Anzueto, A., Bartlett, J. G., Campbell, G. D., Dean, N. C., Dowell, S. F., File, T. M., Jr., Musher, D. M., Niederman, M. S., Torres, A., Whitney, C. G. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-Acquired Pneumonia in Adults. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 44, Suppl. 2(Suppl 2), S27–S72. https://doi.org/10.1086/511159
Mbata,
G., Chukwuka, C., Onyedum, C., Onwubere, B., & Aguwa, E. (2013). The
Role of Complications of Community Acquired Pneumonia on the Outcome of the
Illness: A Prospective Observational Study in a Tertiary Institution In Eastern
Nigeria. Annals of Medical and Health Sciences Research, 3(3), 365–369. https://doi.org/10.4103/2141-9248.117952
Mishra, A. B., & Behera,
G. B. (2016). Community Acquired Pneumonia, Detection and
Prevention-A Hospital Based Descriptive Study. International Journal of Contemporary
Medical Research, 3(4),
1127–1129.
Murray,
C. J. L., & Lopez, A. D. (2013). Measuring the Global Burden of Disease.
New England Journal of Medicine, 369(5), 448–457. https://doi.org/10.1056/NEJMra1201534
Myint, P. K., Kwok, C. S., Majumdar, S. R., Eurich, D. T., Clark, A. B.,
España, P. P., Man, S. Y., Huang, D. T., Yealy, D. M., Angus, D. C.,
Capelastegui, A., Rainer, T. H., Marrie, T. J., Fine, M. J., & Loke, Y. K.
(2012). The International Community-Acquired Pneumonia (CAP)
Collaboration Cohort (ICCC) Study: Rationale, Design and Description of Study
Cohorts and Patients. BMJ Open, 2(3), e001030. https://doi.org/10.1136/bmjopen-2012-001030
Partouche, H., Buffel du Vaure, C., Personne, V., Le
Cossec, C., Garcin, C., Lorenzo, A., Ghasarossian, C., Landais, P., Toubiana,
L., & Gilberg, S. (2015). Suspected Community-Acquired Pneumonia in
an Ambulatory Setting (CAPA): A French Prospective
Observational Cohort Study in General Practice. Npj Primary Care Respiratory
Medicine, 25, 15010. https://doi.org/10.1038/npjpcrm.2015.10
Peto, L., Nadjm, B., Horby, P., Ngan, T. T., van Doorn, R., Van Kinh, N., & Wertheim, H. F. (2014). The Bacterial Aetiology of Adult Community-Acquired Pneumonia in Asia: A Systematic Review. Transactions of the Royal Society of Tropical Medicine and Hygiene, 108(6), 326–337. https://doi.org/10.1093/trstmh/tru058
Sabatier, C., Peredo, R., Villagrá, A., Bacelar, N., Mariscal, D., Ferrer, R., Gallego, M., & Vallés, J. (2010). Neumonía Comunitaria Grave. Estudio Descriptivo De 7 Años y Utilidad de los Criterios de la Infectious Diseases Society of America y la American Thoracic Society 2007 en la identificación de los pacientes que requieren ingreso en una unidad de cuidados intensivos. Medicina Intensiva, 34(4), 237–245. https://doi.org/10.1016/j.medin.2009.11.008
Self,
W. H., Balk, R. A., Grijalva, C. G., Williams, D. J., Zhu, Y., Anderson, E. J.,
Waterer, G. W., Courtney, D. M., Bramley, A. M., Trabue, C., Fakhran, S.,
Blaschke, A. J., Jain, S., Edwards, K. M., & Wunderink, R. G. (2017).
Procalcitonin as a Marker of Etiology in Adults Hospitalized with Community-Acquired
Pneumonia. Clinical Infectious Diseases, 65(2), 183–190. https://doi.org/10.1093/cid/cix317
Sample Size Calculator (2023).
Shah, B. A., Singh, G., Naik, M. A., & Dhobi, G.
N. (2010). Bacteriological and Clinical Profile of Community Acquired
Pneumonia in Hospitalized Patients. Lung India:
Official Organ of Indian Chest Society, 27(2), 54–57.
https://doi.org/10.4103/0970-2113.63606
Sri Lanka Labour Force Annual Report (2019).
Torres, A., Cillóniz, C., Blasi, F., Chalmers, J. D.,
Gaillat, J., Dartois, N., Schmitt, H. J., & Welte, T. (2018). Burden
of Pneumococcal Community-Acquired Pneumonia in Adults Across Europe: A literature Review. Respiratory Medicine, 137,
6–13. https://doi.org/10.1016/j.rmed.2018.02.007
Torres-Duque, C., Maldonado, D., Pérez-Padilla, R., Ezzati, M., Viegi, G., (2008). Forum of International Respiratory Studies (FIRS) Task Force on Health Effects of Biomass Exposure. Biomass Fuels and Respiratory Diseases: A Review of the Evidence. Proceedings of the American Thoracic Society, 5(5), 577–590. https://doi.org/10.1513/pats.200707-100RP
Wijesooriya, L. I., Kok, T., Perera, J., Tilakarathne, Y., & Sunil-Chandra, N. P. (2018). Mycoplasma Pneumoniae DNA Detection and Specific Antibody class Response in Patients from Two Tertiary Care Hospitals in Tropical Sri Lanka. Journal of Medical Microbiology, 67(9), 1232–1242. https://doi.org/10.1099/jmm.0.000813
Xing, Y. F., Xu, Y. H., Shi, M. H., & Lian, Y. X. (2016). The Impact of PM2.5 on the Human Respiratory System. Journal of Thoracic Disease, 8(1), E69–E74. https://doi.org/10.3978/j.issn.2072-1439.2016.01.19
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