Transcript Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Influenza Virus: A Significant Etiology in Adult Patients Hospitalized with Lower Respiratory
Tract Infections in Jefferson County, Kentucky
Swetha Kadali, MD, Rehab Abdelfattah, MD, MPH, Martin Gnoni, MD, Francisco Fernandez, MD, Jorge Perez, MD, Colleen Jonsson, PhD, James
Summersgill, PhD, Robert Kelley, PhD, Timothy Wiemken, PhD,MPH, Paula Peyrani, MD
ABSTRACT
INTRODUCTION: Acute Lower Respiratory Tract Infections (ALRTIs) are
responsible for more morbidity and mortality than any other infectious
disease in the United States. A considerable proportion of these ALRTIs are
attributable to influenza. The objective of this study is to discover how
frequently Influenza virus is isolated in adult patients hospitalized with
Acute Bronchitis, Acute Exacerbation of COPD (AECOPD), Community
Acquired Pneumonia (CAP), and Health Care Associated Pneumonia
(HCAP), in the Jefferson County area.
MATERIALS AND METHODS: This was a secondary data analysis of the
Rapid Empiric Treatment with Oseltamivir Study(RETOS) database. Patients
from the database with LRTIs were included in the study and classified as
having acute bronchitis, AECOPD, CAP, HCAP. The frequency of influenza
virus isolation for patients with each classification was calculated.
RESULTS: A total of 1,256 patients were included in the study. Of these,
109 patients had Acute bronchitis (9%), 346 AECOPD (27%), 531 CAP
(42%), and 270 HCAP (22%). Influenza was found in 45 of the acute
bronchitis patients (41%), 52 of AECOPD patients (15%), 80 of the CAP
patients (15%), and 32 of the HCAP patients (12%).
CONCLUSION: The data indicate that during flu season in the Jefferson
county area, influenza is frequently found in all categories of ALRTIs but
especially in acute bronchitis. These findings suggest that influenza should
be strongly suspected in patients presenting with any subtype of ALRTI
during the flu season and early empiric antiviral treatment with oseltamivir
may improve clinical outcomes.
INTRODUCTION
- Acute lower respiratory tract infections (ALRTIs) can be classified as 1)
Acute Bronchitis, 2) Acute Exacerbation of Chronic Obstructive Pulmonary
Disease, 3) Community Acquired Pneumonia, and 4) Health-care Associated
Pneumonia.
-Acute Lower respiratory Tract Infections are responsible for more
morbidity and mortality than any other infectious disease in the United
States (1, 2).
-This is especially significant due to the growing number of elderly in the
community in whom respiratory infections are more prevalent and severe
(1, 2).
-Patients with ALRTIs infections can be treated in an ambulatory setting or
may require hospitalization.
-Mortality, poor outcomes, and health-care costs are higher among patients
who are hospitalized for ALRTIs.
MATERIALS AND METHODS
Study Design and Population
Figure 1
This was a secondary data analysis of the Rapid Empiric Treatment with
Oseltamivir Study (RETOS) database. All patients admitted with acute lower
respiratory tract infections to nine hospitals in Jefferson County, Kentucky
during 3 consecutive Influenza seasons between December 2010 to April
2013 were included in the study. Patients were classified as acute
bronchitis, acute exacerbation of chronic obstructive pulmonary disease,
community acquired pneumonia and health-care associated pneumonia
and the frequency of influenza virus isolation for each subtype was
calculated. Informed consent was obtained from all participating patients.
 Acute Bronchitis: Presence of one of 3 criteria: 1) new or increased
cough with/without sputum, 2) fever(>37 degrees Celsius) or
hypothermia (<35.6 degrees Celsius), and 3) changes in
WBC(leukocytosis or leukopenia) along with an absence of new
infiltrates on imaging (chest X-ray/CT-Scan) and absence of prior history
of Chronic Obstructive Pulmonary Disease.
 Acute Exacerbation of Chronic Obstructive Pulmonary Disease
(AECOPD): Presence of at least one of three criteria- 1)new or increased
cough with/without sputum, 2) fever(>37 degrees Celsius) or
hypothermia (<35.6 degrees Celsius), and 3) changes in WBC
(leukocytosis or leukopenia) along with presence of prior history of
Chronic Obstructive Pulmonary Disease and absence of new infiltrate on
imaging (chest X-ray/CT-Scan).
 Community Acquired Pneumonia (CAP): Evidence of new infiltrate on
imaging (chest X-ray/CT-Scan) plus at least one of three criteria- 1) new
or increased cough with/without sputum, 2) fever(>37 degrees Celsius)
or hypothermia (<35.6 degrees Celcius), and 3) changes in WBC
(leukocytosis or leukopenia)
 Health-care Associated Pneumonia (HCAP): All criteria for diagnosis of
CAP plus presence of at least one of the following risk factors- 1) Nursing
home resident, 2) Hospitalized for 2 days or more in the prior 90 days, 3)
IV antibiotic therapy in the prior 90 days, 4) Home infusion therapy
(including ABT and chemotherapy), 5) Chronic dialysis within prior 30
days, or 6) Home wound care.
-Despite poor outcomes and mortality being of greater concern among
hospitalized patients with ALRTIs, most studies in the past have dealt with
patient populations only in an ambulatory setting.
-Although the influenza virus is a well-recognized cause of ALRTIs there is
limited evidence in the literature describing the role of influenza as an
etiology in different subtypes of ALTRIs among hospitalized patients.
- The objective of this study is to determine how frequently influenza virus
is isolated in adult patients hospitalized with Acute Bronchitis, Acute
Exacerbation of Chronic Obstructive Pulmonary Disease, Community
Acquired Pneumonia, and Health Care Associated Pneumonia in the
Jefferson county area.
CONCLUSIONS
 These data indicate that during flu season in the Jefferson county area,
influenza virus was isolated most frequently in patients diagnosed with
Acute Bronchitis.
 Influenza virus was also commonly isolated in patients hospitalized with
Acute Exacerbation of Chronic Obstructive Pulmonary Disease,
Community Acquired Pneumonia and Health-care Associated
Pneumonia.
 The results suggest that for patients hospitalized with any subtype of
ALRTI during the influenza season, an etiology of influenza virus should
be strongly suspected while ordering the microbiological work-up.
 Early detection of influenza virus and empiric antiviral therapy may
improve clinical outcomes in patients hospitalized with Acute Lower
Respiratory Tract Infections.
Study Definitions:
 Timely intervention with specific therapy in patients infected with
influenza can also reduce the risk of complications and control the
spread of virus to contacts (6).
 Definitive microbiological diagnosis of Influenza infection in all patients
with ALRTIs enables a more accurate measurement of the effect of
seasonal and epidemic influenza for public health purposes (6).
 The unexpectedly high frequency of influenza in patients hospitalized
with Health-care associated pneumonia in our study implies the
increased circulation of the virus among individuals living in long term
care facilities and those frequently exposed to health care settings.
 In contrast to bacterial etiology which differs considerably among HCAP
and CAP patients, viruses causing HCAP in a population are similar to
those circulating within the community (7).
Figure 2
 The relatively high incidence of influenza infection among patients with
HCAP in our study population emphasizes the need for implementing
more effective protective and preventative measures in healthcare
facilities in order to prevent transmission of the virus among healthcare
workers and contacts.
REFERENCES
Laboratory Methods:
Nasopharyngeal Swab was obtained at the time of hospitalization and the
specimen was tested for influenza A and/or B by Luminex RT-PCR at the
University of Louisville Division of Infectious Disease Research Laboratory.
-A considerable proportion of these ALRTIs are attributable to influenza
virus (3-5).
-Approximately 5-20% of the population in the United States is affected by
Influenza each year leading to an average of 226,000 hospitalizations and
36,000 deaths (7).
RESULTS
RESULTS
A total of 1,256 patients were enrolled in the study, consisting of 109
patients with Acute Bronchitis, 346 Acute Exacerbation of Chronic
Obstructive Pulmonary Disease, 531 Community Acquired Pneumonia, and
270 Health-care Associated Pneumonia (shown in figure 1). Of these
Influenza virus was isolated in 45 of the acute bronchitis patients (41%), 52
of Acute Exacerbation of COPD patients (15%), 80 of the CAP patients
(15%), and 32 of the HCAP patients (12%).(shown in figure 2)
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