Yoğun bakım ihtiyacı olan pnömonili hastalarda atipik pnömoni ve viral pnömoni etkenlerinin araştırılması
Investigation of atypical and viral pneumonia in patients admitted tointensive care units
Yazar: AHMET DOĞAN
Danışman: PROF. DR. YASEMİN ERSOY
İnönü Üniversitesi / Tıp Fakültesi / Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2018
Konu: Klinik Bakteriyoloji ve Enfeksiyon Hastalıkları = Clinical Microbiology and Infectious Diseases
Dizin: Mortalite = Mortality ; Pnömoni = Pneumonia ; Pnömoni-viral = Pneumonia-viral ; Solunum sistemi = Respiratory system ; Yoğun bakım = Intensive care ; Yoğun bakım üniteleri = Intensive care units

Özet:
ÖZET

Yoğun Bakım İhtiyacı Olan Pnömonili Hastalarda Atipik Pnömoni ve Viral Pnömoni Etkenlerinin Araştırılması

	Giriş ve Amaç: Pnömoniler hem hastane kaynaklı hem de toplum kaynaklı enfeksiyonlar içerisinde önemli role sahiptir. Yoğun bakım ihtiyacı olan toplum kökenli ve hastane kökenli tüm pnömonili hastalarda amprik tedavi kritik öneme sahip olup, tedavi muhtemel etkenleri kapsamalıdır. Bakteriyel etkenlere yönelik çok sayıda çalışma olmasına karşın viral ve atipik etkenleri saptamaya yönelik ülkemizde az sayıda çalışma vardır. Bu çalışmada yoğun bakım ihtiyacı olan pnömonili hastalarda atipik pnömoni ve viral pnömoni etkenlerini belirlemeyi ve mortaliteye etkisini araştırmayı amaçladık.
	Gereç ve Yöntem: Çalışmaya prospektif olarak 1 Kasım 2016-30 Ekim 2017 tarihleri arasında hastanemiz Reanimasyon, Beyin Cerrahi, Nöroloji, Göğüs Hastalıkları ve Dahiliye yoğun bakım ünitelerine yatış esnasında klinik ve laboratuar bulguları ile toplumdan gelen pnömoni (TGP) tanısı konan veya yattıktan sonraki günlerde hastanede gelişen pnömoni (HGP) tanısı alan 18 yaş üzerindeki hastalardahil edildi. Hastalara ait klinik özellikler kaydedildi. Hastalardan balgam veya trakeal aspirat örnekleri standart bakteriyel kültür için gönderildi. Atipik pnömoni etkenlerinden olan Mycoplasma pneumoniae, Chlamydia pneumoniae ve Legionella pneumophiliae ve viral etkenlerin tespiti için trakeal aspirat veya balgam örnekleri alındı. L. pneumophiliae'nın tespiti amacıyla "Buffered Charcoal Yeast Extract (BCYE)" besiyerine ekim yapıldı. Ayrıca, aynı hastalardan viral pnömoni etkenlerinden respiratuvar sinsityal virüs (RSV), İnsan metapnömovirüs (HMPV), rinovirüs (RV), enterovirüs (EV), parainfluenza virüs (PIV), influenza A (InfA), influenza B (InfB), insan bokavirüs (HBoV), adenovirüs için nazofarinks sürüntü örneğinden in-house multipleks polimeraz zincir reaksiyonu (PZR) yöntemiyle spesifik DNA/RNA araştırıldı. 
	Bulgular: Çalışmaya 200 hasta dahil edildi. Hastaların 126'sı (%63) erkek, 74'ü (%37) kadındı. Hastaların 65'i (%32,5) TGP, 135'i (%67,5) HGP'idi.  Ateş hastaların %32,5'inde, dispne %61'inde, takipne %56'sında, pürülan balgam %95,5'inde, artan öksürük şikayeti %7,5'inde saptandı. Tüm hastaların akciğer radrografisinde infiltrasyon alanları mevcuttu. Hastaların 83'ünde (%41,5) bakteriyel bir veya daha fazla etken saptanırken, sekizinde (%4) ise M. pneumoniae tespit edildi. Otuzbir (%15,5) hastada bir viral etken,15 vakada ise (%7,5) bakteri-virüs karışık etken olduğu görüldü. Hem TGP hemde HGP olgularının %6'sında influenza saptandı. Hiçbir hastada Legionella üremesi olmadı. L. pneumoniae ve C. pneumoniae PZR tüm hastalarda negatif sonuçlandı.  Mortalite oranları TGP vakalarında %17, HGP vakalarında %29,6 bakteriyel etken saptanan vakalarda %27,5 viral etken saptanan vakalarda %25,8, bakteri-virüs karışık etken saptanan vakalarda %26,6 ve etken saptanmayan vakalarda %23,2 olarak gözlendi.	
Sonuç: Hastanede gelişen pnömoni ve TGP hastalarında atipik pnömoni etkenlerinden sadece M. pneumoniae az sayıda hastada saptanırken, viral etkenlerden amprik tedavide önemi olan influenza'nın nadir olduğu tespit edildi.
Anahtar kelimeler: Atipik pnömoni, viral pnömoni, toplumdan gelen pnömoni, hastanede gelişen pnömoni, yoğun bakım,

Abstract:
ABSTRACT

Investigation of Atypical Pneumonia and Viral Pneumonia in Patients with Intensive Care Pneumonia

Introduction and Aim: Pneumonia plays an important role in both hospital-acquired and community-acquired infections. Empirical treatment has critical prescription in all community-acquired and hospital-acquired pneumonia patients who need intensive care, and treatment should include possible factors. Despite the large number of studies on bacterial agents, few studies have been conducted in our country to detect viral and atypical agents. In this study, we aimed to determine the etiologies of atypical pneumonia and viral pneumonia in patients with pneumonia requiring intensive care and to investigate the effect of mortality.
Materials and Methods: We prospectively studied the clinical and laboratory findings and community-acquired pneumonia (TGP) during hospitalization in our hospital Reanimation, Brain Surgery,  Neurology, Chest Diseases and Internal Medicine intensive care units between 1 November 2016 and 30 October 2017, also patients over 18 years of age who were diagnosed with hospital acquired pneumonia (HGP) were included. Patients' clinical features were recorded. Sputum or tracheal aspirate samples taken from the patients were sent for standard bacterial culture. Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophiliae, which are atypical pneumonia, and tracheal aspirate or sputum samples were taken for the detection of viral agents. For the detection of L. pneumophiliae, the cultivation was carried out on "Buffered Charcoal Yeast Extract (BCYE)" medium. In addition, respiratory syncytial virus (RSV), human metapneumovirus (HMPV), rhinovirus (RV), enterovirus (EV), parainfluenza virus (PIV), influenzae (InfA), influenza B (InfB),  which are the agents of viral pneumonia taken from the same patients, specific DNA / RNA was investigated by in-house multiplex polymerase chain reaction (PZR) method for human bovavirus (HBoV), adenovirus, nasopharynx swab sample. 
Findings: 200 patients were included in the study. 126 (63%) of the patients were male and 74 (37%) were female. Sixty-five patients (32.5%) had TGP and 135 patients (67.5%) had HGP. 32.5% of the patients had fever, 61% had dyspnea, 56% had tachypnea, 95.5% had purulent sputum, and 7.5% had an increased cough. All patients had infiltration areas on the lung radiograph. One or more bacterial agents were detected in 83 (41.5%) of the patients and M. pneumoniae was detected in 8 (4%). Thirty-one (15.5%) patients were found to be a viral agent, while 15 cases (7.5%) were mixed bacterial-virus. Influenza was detected in 6% of both TGP and HGP cases. No patients had Legionella recurrence. L. pneumoniae and C. pneumoniae PZR were negative in all patients. Mortality rates were observed as 17% in TGP cases, 29.6% in HGP cases, 27.8% in case of detecting bacterial agent, 25.8% in case of detecting viral agent, 26.6% in cases of detecting bacterial-virus mixed agent and 23.2%. 
Conclusion: Of the atypical pneumonia agents in hospital-acquired pneumonia and TGP patients, only M. pneumoniae was detected in a small number of patients. Influenza, which is an important factor in empiric treatment of viral agents, was found to be rare. 
Key words: Atypical pneumonia, viral pneumonia, community-acquired pneumonia, hospital-acquired pneumonia, intensive care





ABSTRACT

Investigation of Atypical Pneumonia and Viral Pneumonia in Patients with Intensive Care Pneumonia

Introduction and Aim: Pneumonia plays an important role in both hospital-acquired and community-acquired infections. Empirical treatment has critical prescription in all community-acquired and hospital-acquired pneumonia patients who need intensive care, and treatment should include possible factors. Despite the large number of studies on bacterial agents, few studies have been conducted in our country to detect viral and atypical agents. In this study, we aimed to determine the etiologies of atypical pneumonia and viral pneumonia in patients with pneumonia requiring intensive care and to investigate the effect of mortality.
Materials and Methods: We prospectively studied the clinical and laboratory findings and community-acquired pneumonia (TGP) during hospitalization in our hospital Reanimation, Brain Surgery,  Neurology, Chest Diseases and Internal Medicine intensive care units between 1 November 2016 and 30 October 2017, also patients over 18 years of age who were diagnosed with hospital acquired pneumonia (HGP) were included. Patients' clinical features were recorded. Sputum or tracheal aspirate samples taken from the patients were sent for standard bacterial culture. Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophiliae, which are atypical pneumonia, and tracheal aspirate or sputum samples were taken for the detection of viral agents. For the detection of L. pneumophiliae, the cultivation was carried out on "Buffered Charcoal Yeast Extract (BCYE)" medium. In addition, respiratory syncytial virus (RSV), human metapneumovirus (HMPV), rhinovirus (RV), enterovirus (EV), parainfluenza virus (PIV), influenzae (InfA), influenza B (InfB),  which are the agents of viral pneumonia taken from the same patients, specific DNA / RNA was investigated by in-house multiplex polymerase chain reaction (PZR) method for human bovavirus (HBoV), adenovirus, nasopharynx swab sample. 
Findings: 200 patients were included in the study. 126 (63%) of the patients were male and 74 (37%) were female. Sixty-five patients (32.5%) had TGP and 135 patients (67.5%) had HGP. 32.5% of the patients had fever, 61% had dyspnea, 56% had tachypnea, 95.5% had purulent sputum, and 7.5% had an increased cough. All patients had infiltration areas on the lung radiograph. One or more bacterial agents were detected in 83 (41.5%) of the patients and M. pneumoniae was detected in 8 (4%). Thirty-one (15.5%) patients were found to be a viral agent, while 15 cases (7.5%) were mixed bacterial-virus. Influenza was detected in 6% of both TGP and HGP cases. No patients had Legionella recurrence. L. pneumoniae and C. pneumoniae PZR were negative in all patients. Mortality rates were observed as 17% in TGP cases, 29.6% in HGP cases, 27.8% in case of detecting bacterial agent, 25.8% in case of detecting viral agent, 26.6% in cases of detecting bacterial-virus mixed agent and 23.2%. 
Conclusion: Of the atypical pneumonia agents in hospital-acquired pneumonia and TGP patients, only M. pneumoniae was detected in a small number of patients. Influenza, which is an important factor in empiric treatment of viral agents, was found to be rare. 
Key words: Atypical pneumonia, viral pneumonia, community-acquired pneumonia, hospital-acquired pneumonia, intensive care





ABSTRACT

Investigation of Atypical Pneumonia and Viral Pneumonia in Patients with Intensive Care Pneumonia

Introduction and Aim: Pneumonia plays an important role in both hospital-acquired and community-acquired infections. Empirical treatment has critical prescription in all community-acquired and hospital-acquired pneumonia patients who need intensive care, and treatment should include possible factors. Despite the large number of studies on bacterial agents, few studies have been conducted in our country to detect viral and atypical agents. In this study, we aimed to determine the etiologies of atypical pneumonia and viral pneumonia in patients with pneumonia requiring intensive care and to investigate the effect of mortality.
Materials and Methods: We prospectively studied the clinical and laboratory findings and community-acquired pneumonia (TGP) during hospitalization in our hospital Reanimation, Brain Surgery,  Neurology, Chest Diseases and Internal Medicine intensive care units between 1 November 2016 and 30 October 2017, also patients over 18 years of age who were diagnosed with hospital acquired pneumonia (HGP) were included. Patients' clinical features were recorded. Sputum or tracheal aspirate samples taken from the patients were sent for standard bacterial culture. Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophiliae, which are atypical pneumonia, and tracheal aspirate or sputum samples were taken for the detection of viral agents. For the detection of L. pneumophiliae, the cultivation was carried out on "Buffered Charcoal Yeast Extract (BCYE)" medium. In addition, respiratory syncytial virus (RSV), human metapneumovirus (HMPV), rhinovirus (RV), enterovirus (EV), parainfluenza virus (PIV), influenzae (InfA), influenza B (InfB),  which are the agents of viral pneumonia taken from the same patients, specific DNA / RNA was investigated by in-house multiplex polymerase chain reaction (PZR) method for human bovavirus (HBoV), adenovirus, nasopharynx swab sample. 
Findings: 200 patients were included in the study. 126 (63%) of the patients were male and 74 (37%) were female. Sixty-five patients (32.5%) had TGP and 135 patients (67.5%) had HGP. 32.5% of the patients had fever, 61% had dyspnea, 56% had tachypnea, 95.5% had purulent sputum, and 7.5% had an increased cough. All patients had infiltration areas on the lung radiograph. One or more bacterial agents were detected in 83 (41.5%) of the patients and M. pneumoniae was detected in 8 (4%). Thirty-one (15.5%) patients were found to be a viral agent, while 15 cases (7.5%) were mixed bacterial-virus. Influenza was detected in 6% of both TGP and HGP cases. No patients had Legionella recurrence. L. pneumoniae and C. pneumoniae PZR were negative in all patients. Mortality rates were observed as 17% in TGP cases, 29.6% in HGP cases, 27.8% in case of detecting bacterial agent, 25.8% in case of detecting viral agent, 26.6% in cases of detecting bacterial-virus mixed agent and 23.2%. 
Conclusion: Of the atypical pneumonia agents in hospital-acquired pneumonia and TGP patients, only M. pneumoniae was detected in a small number of patients. Influenza, which is an important factor in empiric treatment of viral agents, was found to be rare. 
Key words: Atypical pneumonia, viral pneumonia, community-acquired pneumonia, hospital-acquired pneumonia, intensive care