Ward Ryan, Gonzalez Alejandro J, Kahla Justin A, Musher Daniel M
Baylor College of Medicine, Houston, USA.
Mayo Clinic College of Medicine and Science, School of Graduate Medical Education, Phoenix, USA.
Pneumonia (Nathan). 2025 Jan 5;17(1):1. doi: 10.1186/s41479-024-00153-9.
Current guidelines recommend empiric antibiotic therapy for patients who require hospitalization for community-acquired pneumonia (CAP). We sought to determine whether clinical, imaging or laboratory features in patients hospitalized for CAP in whom PCR is positive for a respiratory virus enable exclusion of bacterial coinfection so that antibiotics can be withheld.
For this prospective study, we selected patients in whom an etiologic diagnosis was likely to be reached, namely those who provided a high-quality sputum sample at or shortly after admission, and in whom PCR was done to test for a respiratory virus. We performed quantitative bacteriologic studies on sputum to determine the presence of bacterial infection or coinfection and reviewed all clinical, imaging and laboratory studies.
Of 122 CAP patients studied, 77 (63.1%) had bacterial infection, 16 (13.1%) viral infection, and 29 (23.8%) bacterial/viral coinfection. Underlying pulmonary disease and a history of smoking were more common in bacterial pneumonia. Upper respiratory symptoms were more common, and mean white blood cell (WBC) counts were lower viral pneumonia. Nevertheless, no clinical, laboratory or imaging findings allowed exclusion of bacterial coinfection in patients who tested positive for a respiratory virus. In fact, patients with bacterial/viral coinfection were sicker than those with bacterial or viral pneumonia; 30% were admitted required transfer to the ICU during their hospital course, compared to 17% and 19% of patients with bacterial or viral infection, respectively (p < .05). In this study, 64.4% of patients who tested positive for a respiratory virus had a bacterial coinfection.
If a test for a respiratory virus test is positive in a patient hospitalized for CAP, no sufficiently differentiating features exclude bacterial coinfection, thereby supporting the recommendation that empiric antibiotics be administered to all patients who are sufficiently ill to require hospitalization for CAP.
当前指南推荐对因社区获得性肺炎（CAP）而需住院治疗的患者进行经验性抗生素治疗。我们试图确定，因CAP住院且呼吸道病毒PCR检测呈阳性的患者，其临床、影像学或实验室特征能否排除细菌合并感染，从而避免使用抗生素。
在这项前瞻性研究中，我们选择了可能得出病因诊断的患者，即那些在入院时或入院后不久提供了高质量痰标本且进行了呼吸道病毒PCR检测的患者。我们对痰标本进行了定量细菌学研究，以确定是否存在细菌感染或合并感染，并回顾了所有临床、影像学和实验室检查结果。
在研究的122例CAP患者中，77例（63.1%）有细菌感染，16例（13.1%）有病毒感染，29例（23.8%）有细菌/病毒合并感染。细菌性肺炎患者中潜在肺部疾病和吸烟史更为常见。上呼吸道症状在病毒性肺炎中更为常见，且平均白细胞（WBC）计数较低。然而，对于呼吸道病毒检测呈阳性的患者，没有任何临床、实验室或影像学表现能够排除细菌合并感染。事实上，细菌/病毒合并感染的患者比细菌性或病毒性肺炎患者病情更重；30%的患者在住院期间需要转入重症监护病房（ICU），而细菌性或病毒感染患者的这一比例分别为17%和19%（p < 0.05）。在本研究中，呼吸道病毒检测呈阳性的患者中有64.4%存在细菌合并感染。
对于因CAP住院且呼吸道病毒检测呈阳性的患者，没有足够的鉴别特征能够排除细菌合并感染，因此支持对所有病情严重到需要因CAP住院治疗的患者使用经验性抗生素的建议。
