Thursday, November 30, 2023
|
Characteristics |
Total, n = 130 |
C. striatum, n = 27 |
MRSA, n = 103 |
p value |
|---|---|---|---|---|
| Sex | ||||
| M | 92 (70.8) | 18 (66.7) | 74 (71.8) | 0.60 |
| F | 38 (29.2) | 9 (33.3) | 33 (32.0) | |
| Median age (interquartile range) | 71.0 (63.8–77.0) | 72.0 (66.0–80.0) | 71.0 (63.0–76.0) | 0.17 |
| Underlying disease or condition† | ||||
| Solid cancer | 32 (24.6) | 4 (14.8) | 28 (27.2) | 0.18 |
| Diabetes mellitus | 30 (23.1) | 6 (22.2) | 24 (23.3) | 0.91 |
| Structural lung disease | 24 (18.5) | 4 (14.8) | 20 (19.4) | 0.78 |
| Chronic obstructive lung disease | 12 (9.2) | 3 (11.1) | 9 (8.7) | 0.71 |
| Interstitial lung disease | 5 (3.8) | 0 | 5 (4.9) | 0.58 |
| Bronchiectasis | 4 (3.1) | 0 | 4 (3.9) | 0.58 |
| Destroyed lung due to tuberculosis | 1 (0.8) | 0 | 1 (1.0) | 1.00 |
| Pneumoconiosis | 1 (0.8) | 0 | 1 (1.0) | 1.00 |
| Bronchiolitis obliterans | 1 (0.8) | 1 (3.7) | 0 | 0.21 |
| Hematologic malignancy | 13 (10.0) | 5 (18.5) | 8 (7.8) | 0.14 |
| Liver cirrhosis | 11 (8.5) | 2 (7.4) | 9 (8.7) | 1.00 |
| End-stage renal disease | 7 (5.4) | 2 (7.4) | 5 (4.9) | 0.64 |
| Chronic renal failure | 6 (4.6) | 3 (11.1) | 3 (2.9) | 0.10 |
| Congestive heart failure | 3 (2.3) | 1 (3.7) | 2 (1.9) | 0.51 |
| Alcoholism | 2 (1.5) | 0 | 2 (1.9) | 1.00 |
| Cerebrovascular attack | 12 (9.2) | 5 (18.5) | 7 (6.8) | 0.13 |
| Solid organ transplantation | 2 (1.5) | 0 | 2 (1.9) | 0.63 |
| Hematopoietic stem cell transplantation | 3 (2.3) | 2 (7.4) | 1 (1.0) | 0.11 |
| Immunocompromised state‡ | 41 (31.5) | 14 (51.9) | 27 (26.2) | 0.01 |
| Recent chemotherapy | 23 (17.7) | 7 (25.9) | 16 (15.5) | 0.26 |
| Recent surgery, ≤1 mo | 19 (14.6) | 2 (7.4) | 17 (16.5) | 0.36 |
| Active smoker | 10 (7.7) | 1 (3.7) | 9 (8.7) | 0.69 |
| Neutropenia, <500 cells/mL | 8 (6.2) | 4 (14.8) | 4 (3.9) | 0.06 |
| Category of pneumonia | ||||
| Community-acquired | 6 (4.6) | 1 (3.7) | 5 (4.9) | 1.00 |
| Healthcare-associated | 37 (28.5) | 4 (14.8) | 33 (32.0) | 0.08 |
| Hospital-acquired | 63 (48.5) | 19 (70.4) | 44 (42.7) | 0.01 |
| Ventilator-associated | 24 (18.5) | 3 (11.1) | 21 (20.4) | 0.40 |
Table 1. Characteristics of adult patients with severe pneumonia caused by Corynebacterium striatum, Seoul, South Korea, 2014–2019*
*Values are no. (%) except as indicated. MRSA, methicillin-resistant Staphylococcus aureus.
†Patients could have ≥1 underlying disease or condition.
‡Defined as ≥1 of the following conditions: daily receipt of immunosuppressants, including corticosteroids; HIV infection; solid organ or hematopoietic stem cell transplant recipient; receipt of chemotherapy for underlying malignancy during the previous 6 months; or underlying immune deficiency disorder.
|
Pathogens identified |
No. (%) patients |
p value* |
|||
|---|---|---|---|---|---|
|
2014–2015, n = 200 |
2016–2017, n = 180 |
2018–2019, n = 185 |
Total, n = 565 |
||
| Total | 88 (44.0) | 66 (36.7) | 75 (40.5) | 229 (40.5) | 0.35 |
| Staphylococcus aureus | 27 (13.5) | 15 (8.3) | 8 (4.3) | 50 (8.8) | <0.01 |
| Methicillin-susceptible | 3 (1.5) | 0 | 3 (1.6) | 6 (1.1) | 0.24 |
| Methicillin-resistant | 24 (12.0) | 15 (8.3) | 5 (2.7) | 44 (7.8) | <0.01 |
| Corynebacterium striatum | 2 (1.0) | 7 (3.9) | 10 (5.4) | 19 (3.4) | 0.05 |
| Streptococcus pneumoniae | 4 (2.0) | 2 (1.1) | 1 (0.5) | 7 (1.2) | 0.43 |
| Legionella pneumophila | 1 (0.5) | 1 (0.6) | 0 | 2 (0.4) | 0.61 |
| Moraxella catarrhalis | 0 | 0 | 1 (0.5) | 1 (0.2) | 0.36 |
| Streptococcus pyogenes | 0 | 1 (0.6) | 0 | 1 (0.2) | 0.34 |
| Nocardia species | 0 | 0 | 1 (0.5) | 1 (0.2) | 0.36 |
| Enteric gram-negative bacilli | 18 (9.0) | 22 (12.2) | 20 (10.8) | 60 (10.6) | 0.59 |
| Klebsiella pneumoniae | 13 (6.5) | 14 (7.8) | 16 (8.6) | 43 (7.6) | 0.73 |
| Escherichia coli | 4 (2.0) | 4 (2.2) | 3 (1.6) | 11 (1.9) | 0.92 |
| Enterobacter cloacae | 1 (0.5) | 3 (1.7) | 2 (1.1) | 6 (1.1) | 0.54 |
| Citrobacter freundii | 1 (0.5) | 2 (1.1) | 0 | 3 (0.5) | 0.34 |
| Klebsiella oxytoca | 0 | 0 | 2 (1.1) | 2 (0.4) | 0.13 |
| Hafnia alvei | 0 | 0 | 1 (0.5) | 1 (0.2) | 0.36 |
| Nonenteric gram-negative bacilli | 47 (23.5) | 22 (12.2) | 37 (20.0) | 106 (18.8) | 0.02 |
| Acinetobacter baumannii | 24 (12.0) | 13 (7.2) | 23 (12.4) | 60 (10.6) | 0.20 |
| Pseudomonas aeruginosa | 19 (9.5) | 6 (3.3) | 11 (5.9) | 36 (6.4) | 0.047 |
| Stenotrophomonas maltophilia | 4 (2.0) | 2 (1.1) | 7 (3.8) | 13 (2.3) | 0.22 |
| Burkholderia cepacia | 0 | 0 | 1 (0.5) | 1 (0.2) | 0.36 |
| Acinetobacter lwoffii | 0 | 1 (0.6) | 0 | 1 (0.2) | 0.34 |
| Chryseobacterium indologenes | 0 | 1 (0.6) | 0 | 1 (0.2) | 0.34 |
| Chryseobacterium meningosepticum | 1 (0.5) | 0 | 0 | 1 (0.2) | 0.40 |
| Chlamydia pneumoniae | 1 (0.5) | 0 | 0 | 1 (0.2) | 0.40 |
Table 2. Bacterial pathogens detected among 565 adult patients with severe hospital-acquired pneumonia, Seoul, South Korea, 2014–2019
*p value based on χ2 test for trend.
|
Pathogens |
No. (%) co-infecting pathogens |
p value* |
||
|---|---|---|---|---|
|
Total, n = 130 |
C. striatum, n = 27 |
MRSA, n = 103 |
||
| Any | 50 (38.5) | 13 (48.1) | 37 (35.9) | 0.25 |
| Other bacteria | 28 (21.5) | 2 (7.4) | 26 (25.2)† | 0.045 |
| Pseudomonas aeruginosa | 7 | 0 | 7 | |
| Acinetobacter baumannii | 6 | 0 | 6 | |
| Klebsiella pneumoniae | 5 | 0 | 5 | |
| Escherichia coli | 4 | 1 | 3 | |
| Haemophilus influenzae | 2 | 0 | 2 | |
| Streptococcus pneumoniae | 2 | 0 | 2 | |
| Citrobacter freundii | 1 | 0 | 1 | |
| Enterobacter cloacae | 1 | 1 | 0 | |
| Elizabethkingia meningosepticum | 1 | 0 | 1 | |
| Klebsiella aerogenes | 1 | 0 | 1 | |
| Stenotrophomonas maltophilia | 1 | 0 | 1 | |
| Virus | 24 (18.5) | 9 (33.3)‡ | 15 (14.6)§ | 0.047 |
| Influenza virus | 8 | 4 | 4 | |
| Influenza virus A | 3 | 3 | 0 | |
| Influenza virus B | 1 | 1 | 1 | |
| Parainfluenza virus type 3 | 4 | 1 | 3 | |
| Rhinovirus | 3 | 1 | 2 | |
| Adenovirus | 3 | 1 | 2 | |
| Respiratory syncytial virus | 2 | 1 | 1 | |
| Respiratory syncytial virus A | 1 | 1 | 0 | |
| Respiratory syncytial virus B | 1 | 0 | 1 | |
| Human coronavirus | 2 | 1 | 1 | |
| 229E | 1 | 1 | 0 | |
| OC43/HKU1 | 1 | 0 | 1 | |
| Human metapneumovirus | 2 | 1 | 1 | |
| Bocavirus | 1 | 0 | 1 | |
| Enterovirus | 1 | 0 | 1 | |
| Fungus | 4 (3.1) | 4 (14.8)¶ | 0 | <0.01 |
| Aspergillus species | 4 (3.1) | 4 (14.8) | 0 | |
| Pneumocystis jirovecii | 1 (0.8) | 1 (3.7) | 0 | |
Table 3. Additional pathogens detected among adult patients with severe Corynebacterium striatum pneumonia and methicillin-resistant Staphylococcus aureus pneumonia, Seoul, South Korea, 2014–2019*
*Categories of co-infection were not mutually exclusive; some cases were associated with ≥2 categories of pathogens.
†Three patients were co-infected with 2 bacteria: H. influenzae and S. pneumoniae; E. coli and K. pneumoniae; and A. baumannii and K. pneumoniae.
‡One patient was co-infected with influenza A virus and human metapneumovirus.
§One patient was co-infected with bocavirus and rhinovirus.
¶One patient was co-infected with Aspergillus species and P. jirovecii.
|
Characteristics |
Total, n = 130 |
C. striatum, n = 27 |
MRSA, n = 103 |
p value |
|---|---|---|---|---|
| Clinical manifestation | ||||
| Dyspnea | 106 (81.5) | 25 (92.6) | 81 (78.6) | 0.16 |
| Fever, temperature >38°C | 103 (79.2) | 18 (66.7) | 85 (82.5) | 0.07 |
| Sputum | 92 (70.8) | 16 (59.3) | 76 (73.8) | 0.14 |
| Cough | 57 (43.8) | 11 (40.7) | 46 (44.7) | 0.72 |
| Altered mental status | 46 (35.4) | 10 (37.0) | 36 (35.0) | 0.84 |
| Diarrhea | 4 (3.1) | 2 (7.4) | 2 (1.9) | 0.19 |
| Septic shock at ICU admission | 81 (62.3) | 12 (44.4) | 69 (67.0) | 0.03 |
| Mechanical ventilation | 127 (97.7) | 27 (100) | 100 (97.1) | 1.00 |
| APACHE II score, mean (SD) | 25.6 (8.1) | 26.4 (11.9) | 26.0 (7.0) | 0.72 |
| SOFA score, mean (SD) | 9.5 (3.7) | 9.5 (3.4) | 9.5 (3.7) | 0.99 |
| Bacteremia | 19 (14.6) | 1 (3.7) | 18 (17.5) | 0.12 |
| Laboratory findings, median (IQR) | ||||
| Leukocyte count, cells/mL | 10,950 (7,800–15,625) | 11,600 (4,800–15,900) | 10,700 (8,400–15,600) | 0.26 |
| Platelets, × 103/mL | 159 (81–242) | 123 (55–230) | 171 (102–245) | 0.14 |
| C-reactive protein, mg/dL | 11.3 (5.5–19.3) | 13.6 (8.0–19.8) | 10.8 (5.4–18.6) | 0.61 |
| Procalcitonin, ng/mL | 1.1 (0.3–3.9) | 0.3 (0.1–1.3) | 1.8 (0.4–4.2) | <0.01 |
Table 4. Clinical and laboratory characteristics of patients with severe Corynebacterium striatum pneumonia and methicillin-resistant Staphylococcus aureus pneumonia, Seoul, South Korea, 2014–2019*
*Values are no. (%) except as indicated APACHE, acute physiology and chronic health evaluation; BAL, bronchoalveolar lavage; ICU, intensive care unit; IQR, interquartile range; MRSA, methicillin-resistant Staphylococcus aureus; SOFA, sequential organ failure assessment.
|
Outcome |
Total, n = 130 |
C. striatum, n = 27 |
MRSA, n = 103 |
p value |
|---|---|---|---|---|
| Death | ||||
| Total | n = 103 | n = 27 | n = 103 | NA |
| 30 days | 41 (31.5) | 11 (40.7) | 30 (29.1) | 0.25 |
| 60 days | 57 (43.8) | 14 (48.1) | 44 (42.7) | 0.61 |
| 90 days | 68 (52.3) | 16 (59.3) | 52 (50.5) | 0.42 |
| In-hospital | 73 (56.2) | 19 (70.4) | 54 (52.4) | 0.09 |
| Death among patient categories | ||||
| Nonimmunocompromised patients | n = 89 | n = 13 | n = 76 | NA |
| 30 days | 21 (23.6) | 5 (38.5) | 16 (21.1) | 0.18 |
| 60 days | 31 (34.8) | 5 (38.5) | 26 (34.2) | 0.76 |
| 90 days | 40 (44.9) | 7 (53.8) | 33 (43.4) | 0.49 |
| In-hospital | 40 (44.9) | 7 (53.8) | 33 (43.4) | 0.49 |
| Immunocompromised patients | n = 41 | n = 14 | n = 27 | NA |
| 30 days | 20 (48.8) | 6 (42.9) | 14 (51.9) | 0.59 |
| 60 days | 26 (63.4) | 8 (57.1) | 18 (66.7) | 0.55 |
| 90 days | 28 (68.3) | 9 (64.3) | 19 (70.4) | 0.73 |
| In-hospital | 33 (80.5) | 12 (85.7) | 21 (77.8) | 0.69 |
| Median ICU stay, d (IQR) | 14.0 (8.0–26.3) | 14.0 (9.0–27.0) | 14.0 (8.0–26.0) | 0.33 |
| Median hospital stay after ICU admission, d (IQR) | 29.5 (14.0–57.0) | 30.0 (16.0–81.0) | 29.0 (14.0–55.0) | 0.48 |
Table 5. Outcomes of adult patients with severe Corynebacterium striatum and methicillin-resistant Staphylococcus aureus pneumonia, Seoul, South Korea, 2014–2019*
*Values are no. (%) except as indicated. ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus; NA, not applicable.
This activity is intended for infectious disease clinicians, pulmonologists, internists, hospitalists, intensivists, and other clinicians who treat and manage patients with or at risk for severe Corynebacterium striatum pneumonia.
The goal of this activity is for learners to be better able to describe the proportion, clinical characteristics, and outcomes of severe Corynebacterium striatum hospital-acquired pneumonia (HAP) in adults compared with those of severe methicillin-resistant Staphylococcus aureus HAP, based on a retrospective study of 27 severe Corynebacterium striatum pneumonia cases during 2014 to 2019 in Seoul, South Korea.
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This study is part of an ongoing prospective observational study on severe pneumonia in critically ill adult (≥16 years of age) patients at Asan Medical Center, a 2,700-bed tertiary referral center in Seoul, South Korea. Since March 2010, we have prospectively identified all adult patients admitted to the 28-bed medical intensive care unit (ICU) who were clinically suspected of having severe pneumonia and monitored them until hospital discharge[7–10]. We collected data on patient demographics; underlying diseases or conditions; category of pneumonia; initial clinical manifestations; laboratory, microbiologic, and radiologic findings; treatment; complications; and mortality rates. For this study, we investigated patients with severe C. striatum pneumonia who were admitted to the medical ICU during January 2014–December 2019. This study was approved by the institutional review board of Asan Medical Center (IRB no. 2010–0079), which waived the need for informed consent due to the observational nature of the study.
We defined and categorized pneumonia as previously stated[11–13]. We defined severe pneumonia as the necessity for mechanical ventilation or having septic shock at ICU admission[12]. We defined sepsis and septic shock according to Sepsis-3 criteria[14]. We defined immunocompromised state as described previously[15].
We cultured sputum specimens on a 5% sheep blood plate and MacConkey agar (Synergy Innovation, http://www.synergyinno.com). When coryneform gram-positive bacilli were isolated, we identified and performed antimicrobial susceptibility testing for specimens that were urea positive or from the ICU[16]. We quantitatively cultured bronchoalveolar lavage specimens on chocolate agar and identified and performed susceptibility testing were conducted when coryneform gram-positive bacilli exclusively grew at ≥104 CFU/mL[16]. Until August 2015, our facility used the triple sugar iron, motility, API Coryne (bioMérieux-Vitek, https://www.biomerieux.com) system to identify coryneform gram-positive rods. In September 2015, our facility began using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (Bruker Daltonik, https://www.bruker.com). We determined antimicrobial susceptibility profiles by ETEST (bioMérieux-Vitek) with MHF medium (Mueller-Hinton agar with 5% horse blood + 20 mg/L β-NAD; bioMérieux-Vitek). We used the Clinical and Laboratory Standards Institute M45 guideline for interpreting susceptibility test results[17] and defined multidrug resistance as resistance to ≥3 antimicrobial drug families.
We compared patient demographics, underlying diseases and conditions, and clinical and laboratory parameters between the C. striatum group and the MRSA group. We used χ2 or Fisher exact test to compare categorical variables and Student t-test or Mann-Whitney U test to compare continuous variables. We analyzed changes in the proportions of pneumonic pathogens over time by using a χ2 test for trend. We performed all analyses in SPSS Statistics 24.0 (IBM Corp., https://www.ibm.com) and considered p<0.05 statistically significant.
