Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries

doi:10.1016/j.cmi.2018.02.004

. 2018 Nov;24(11):1158-1163.

doi: 10.1016/j.cmi.2018.02.004. Epub 2018 Feb 12.

Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries

M Ieven¹, S Coenen², K Loens³, C Lammens³, F Coenjaerts⁴, A Vanderstraeten³, B Henriques-Normark⁵, D Crook⁶, K Huygen⁷, C C Butler⁶, T J M Verheij⁸, P Little⁹, K Zlateva¹⁰, A van Loon⁴, E C J Claas¹⁰, H Goossens³; GRACE consortium

Affiliations

¹ Department of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium; Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium. Electronic address: greet.ieven@uza.be.
² Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium; Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Antwerp, Belgium.
³ Department of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium; Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.
⁴ Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵ Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.
⁶ Nuffield Department of Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁷ Department of Communicable and Infectious Diseases, Scientific Institute of Public Health, Brussels, Belgium.
⁸ Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁹ University of Southampton, Southampton, UK.
¹⁰ Leiden University Medical Centre, Leiden, The Netherlands.

PMID: 29447989
PMCID: PMC7129248
DOI: 10.1016/j.cmi.2018.02.004

Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries

M Ieven et al. Clin Microbiol Infect. 2018 Nov.

. 2018 Nov;24(11):1158-1163.

doi: 10.1016/j.cmi.2018.02.004. Epub 2018 Feb 12.

Authors

Affiliations

¹ Department of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium; Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium. Electronic address: greet.ieven@uza.be.
² Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium; Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Antwerp, Belgium.
³ Department of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium; Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.
⁴ Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵ Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.
⁶ Nuffield Department of Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
⁷ Department of Communicable and Infectious Diseases, Scientific Institute of Public Health, Brussels, Belgium.
⁸ Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁹ University of Southampton, Southampton, UK.
¹⁰ Leiden University Medical Centre, Leiden, The Netherlands.

PMID: 29447989
PMCID: PMC7129248
DOI: 10.1016/j.cmi.2018.02.004

Abstract

Objectives: To describe the role of bacteria (including bacterial resistance), viruses (including those recently described) and mixed bacterial-viral infections in adults presenting to primary care with lower respiratory tract infection (LRTI).

Methods: In all, 3104 adults with LRTI were enrolled, of whom 141 (4.5%) had community-acquired pneumonia (CAP), and 2985 matched controls in a prospective study in 16 primary care networks in Europe, and followed patients up at 28-35 days. We detected Streptococcus pneumoniae and Haemophilus influenzae and assessed susceptibility, atypical bacteria and viruses.

Results: A potential pathogen was detected in 1844 (59%) (in 350 (11%) bacterial pathogens only, in 1190 (38%) viral pathogens only, and in 304 (10%) both bacterial and viral pathogens). The most common bacterial pathogens isolated were S. pneumoniae (5.5% overall, 9.2% in CAP patients) and H. influenzae (5.4% overall, 14.2% in CAP patients). Less than 1% of S. pneumoniae were highly resistant to penicillin and 12.6% of H. influenzae were β-lactamase positive. The most common viral pathogens detected were human rhinovirus (20.1%), influenza viruses (9.9%), and human coronavirus (7.4%). Influenza virus, human parainfluenza viruses and human respiratory syncytial virus as well as human rhinovirus, human coronavirus and human metapneumovirus were detected significantly more frequently in LRTI patients than in controls.

Conclusions: A bacterial pathogen is identified in approximately one in five adult patients with LRTI in primary care, and a viral pathogen in just under half, with mixed infections in one in ten. Penicillin-resistant pneumococci and β-lactamase-producing H. influenzae are uncommon. These new findings support a restrictive approach to antibiotic prescribing for LRTI and the use of first-line, narrow-spectrum agents in primary care.

Keywords: Aetiology; Lower respiratory tract infection; Respiratory.

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Figures

**Fig. 1**
Venn diagrams of percentages (numbers) of patients with no, a bacterial, a viral or a mixed bacterial and viral aetiology detected in (a) 3104 patients with lower respiratory tract infections (LRTI) and in (b) 141 patients with community-acquired pneumonia (CAP) in primary care.

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References

1. Woodhead M., Blasi F., Ewig S., Garau J., Huchon G., Ieven M. Guidelines for the management of adult lower respiratory tract infections–full version. Clin Microbiol Infect. 2011;17(Suppl. 6):E1–E59. - PMC - PubMed
1. Little P., Stuart B., Moore M., Coenen S., Butler C.C., Godycki-Cwirko M. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013;13:123–129. - PubMed
1. Moore M., Stuart B., Coenen S., Butler C.C., Goossens H., Verheij T.J. Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract. 2014;64:e75–80. - PMC - PubMed
1. Butler C.C., Hood K., Verheij T., Little P., Melbye H., Nuttall J. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242. - PMC - PubMed
1. Malhotra-Kumar S., Van Heirstraeten L., Coenen S., Lammens C., Adriaenssens N., Kowalczyk A. Impact of amoxicillin therapy on resistance selection in patients with community-acquired lower respiratory tract infections: a randomized, placebo-controlled study. J Antimicrob Chemother. 2016;71:3258–3267. - PubMed

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[1] Woodhead M., Blasi F., Ewig S., Garau J., Huchon G., Ieven M. Guidelines for the management of adult lower respiratory tract infections–full version. Clin Microbiol Infect. 2011;17(Suppl. 6):E1–E59. - PMC - PubMed

[2] Woodhead M., Blasi F., Ewig S., Garau J., Huchon G., Ieven M. Guidelines for the management of adult lower respiratory tract infections–full version. Clin Microbiol Infect. 2011;17(Suppl. 6):E1–E59. - PMC - PubMed

[3] Little P., Stuart B., Moore M., Coenen S., Butler C.C., Godycki-Cwirko M. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013;13:123–129. - PubMed

[4] Little P., Stuart B., Moore M., Coenen S., Butler C.C., Godycki-Cwirko M. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013;13:123–129. - PubMed

[5] Moore M., Stuart B., Coenen S., Butler C.C., Goossens H., Verheij T.J. Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract. 2014;64:e75–80. - PMC - PubMed

[6] Moore M., Stuart B., Coenen S., Butler C.C., Goossens H., Verheij T.J. Amoxicillin for acute lower respiratory tract infection in primary care: subgroup analysis of potential high-risk groups. Br J Gen Pract. 2014;64:e75–80. - PMC - PubMed

[7] Butler C.C., Hood K., Verheij T., Little P., Melbye H., Nuttall J. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242. - PMC - PubMed

[8] Butler C.C., Hood K., Verheij T., Little P., Melbye H., Nuttall J. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242. - PMC - PubMed

[9] Malhotra-Kumar S., Van Heirstraeten L., Coenen S., Lammens C., Adriaenssens N., Kowalczyk A. Impact of amoxicillin therapy on resistance selection in patients with community-acquired lower respiratory tract infections: a randomized, placebo-controlled study. J Antimicrob Chemother. 2016;71:3258–3267. - PubMed

[10] Malhotra-Kumar S., Van Heirstraeten L., Coenen S., Lammens C., Adriaenssens N., Kowalczyk A. Impact of amoxicillin therapy on resistance selection in patients with community-acquired lower respiratory tract infections: a randomized, placebo-controlled study. J Antimicrob Chemother. 2016;71:3258–3267. - PubMed

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Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries

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Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries

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