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Diagnostic accuracy of pneumonia in Hospital Tuanku Ja'afar Seremban, a tertiary hospital

Poh KW, Cheok LH, Liow JH, Mat Soom MA, Azlina S, Nadiah MN, et al.

Med J Malaysia, 2020 01;75(1):7-11.
PMID: 32008012

OBJECTIVES: The primary objective of this study was to describe the accuracy of pneumonia diagnosis, both community-acquired pneumonia (CAP) and hospitalacquired pneumonia (HAP). Secondary objectives were describing the choice of antibiotics used, pathogens isolated, and predictive parameters in diagnosing pneumonia.
METHODS: This was a prospective cross-sectional study to determine the accuracy of the diagnosis of CAP and HAP admitted to Hospital Tuanku Ja'afar. All patients aged ≥12 years admitted to the general medical ward with the diagnosis of CAP or HAP were included in the study. Chest radiograph interpretation was done by certified radiologists. An accurate diagnosis of pneumonia was defined by clinical signs and symptoms of pneumonia supported by radiographical evidence.
RESULTS: A total of 159 patients were enrolled into the study from January 2018 to February 2018. Of these only 59(37.1%) cases were accurately diagnosed as pneumonia. Amongst those with pneumonia diagnosis made by the emergency department, medical officers and specialists of medical department; 65.4%, 60% and 47.3% respectively were not pneumonia. Amoxicillin with clavulanate and azithromycin were amongst the most common first choice of antibiotic used (46.5%). In this study, pathogens were isolated either by blood culture or sputum culture in only 20 (12.6%) patients. There was no significant predictive parameter identified in this study, which included white cell counts, Creactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and Pao2/FiO2 ratio.
CONCLUSION: About two-thirds of patients diagnosed with pneumonia did not have a compatible radiological finding. Better tools and systems are needed to aid in the diagnosis of pneumonia.

Matched MeSH terms: Community-Acquired Infections/diagnosis*
Misdiagnosis of community-acquired pneumonia in patients admitted to respiratory wards, Penang General Hospital

Ang CS, Kelvin Beh KM, Yeang LJ, Chin YQ, Khor IS, Yoon CK, et al.

Med J Malaysia, 2020 07;75(4):385-390.
PMID: 32723999

INTRODUCTION: Pneumonia continues to be as one of the top causes of hospitalisations and deaths in Malaysia despite the advancement in prevention and treatment of pneumonia. One of the possible explanations is the frequent misdiagnosis of pneumonia which had been reported elsewhere but such data is not available locally.
OBJECTIVES: This is an audit project aiming to evaluate the proportion of misdiagnosis among hospitalised communityacquired pneumonia (CAP) patients in the Respiratory wards of Penang General Hospital based on their initial presentation data, and their associated outcomes.
METHODS: We reviewed the medical notes and initial chest radiographs of 188 CAP patients who were admitted to respiratory wards. Misdiagnosis was defined as cases which lack suggestive clinical features and/or chest radiograph changes. In-hospital mortality and length of stay (LOS) were the outcomes of interest.
RESULTS: The study found that 38.8% (n=73) of the hospitalised CAP patients were misdiagnosed. The most common alternative diagnosis was upper respiratory tract infection (32.8%, n=24). There was no statistical difference between misdiagnosis and CAP patients in the demographic and clinical variables collected. In terms of outcomes, misdiagnosed patients were discharged earlier (mean LOS= 3.5±3.28 days vs. 7.7±15.29 days, p=0.03) but the in-hospital mortality difference was not statistically significant (p=0.07).
CONCLUSIONS: One third of our CAP admissions were misdiagnosed. Although initial misdiagnosis of CAP in our study did not show any increase in mortality or morbidity, a proper diagnosis of CAP will be helpful in preventing inappropriate prescription of antibiotics and unnecessary admission.

Matched MeSH terms: Community-Acquired Infections/diagnosis*
Fulltext The bacterial aetiology of adult community-acquired pneumonia in Asia: a systematic review

Peto L, Nadjm B, Horby P, Ngan TT, van Doorn R, Van Kinh N, et al.

Trans R Soc Trop Med Hyg, 2014 Jun;108(6):326-37.
PMID: 24781376 DOI: 10.1093/trstmh/tru058

Community-acquired pneumonia (CAP) is a major cause of adult mortality in Asia. Appropriate empirical treatment depends on knowledge of the pathogens commonly responsible. However, assessing the aetiological significance of identified organisms is often difficult, particularly with sputum isolates that might represent contamination with oropharyngeal flora.

Matched MeSH terms: Community-Acquired Infections/diagnosis
Fulltext Clinical features of Malaysian children hospitalized with community-acquired seasonal influenza

Sam IC, Abdul-Murad A, Karunakaran R, Rampal S, Chan YF, Nathan AM, et al.

Int J Infect Dis, 2010 Sep;14 Suppl 3:e36-40.
PMID: 20153233 DOI: 10.1016/j.ijid.2009.10.005

OBJECTIVES: The clinical impact of seasonal influenza is understudied in tropical countries. The aim of this study was to describe the clinical features and seasonal pattern of influenza in children hospitalized in Malaysia, and to identify predictors of severe disease.
METHODS: Children hospitalized with community-acquired, laboratory-confirmed influenza at a teaching hospital in Kuala Lumpur, Malaysia during 2002-2007 were identified retrospectively. Clinical data were collected, and predictors of severe disease were identified by multivariate logistic regression. All influenza cases from 1982 to 2007 were also analyzed for seasonal patterns.
RESULTS: A total of 132 children were included in the study, 48 (36.4%) of whom had underlying medical conditions. The mean age was 2.5 years and 116 (87.9%) were <5 years old. The most common presenting features were fever or history of fever, cough, rhinitis, vomiting, and pharyngitis. Severe influenza was seen in 16 patients (12.1%; nine previously healthy), including 12 (9.1%; eight previously healthy) requiring intensive care. There were three (2.3%) deaths. Severe disease was associated with age <12 months, female sex, and absence of rhinitis on admission. Influenza was seen year-round, with peaks in November-January and May-July.
CONCLUSIONS: Seasonal influenza has a considerable impact on children hospitalized in Malaysia, in both the healthy and those with underlying medical conditions.

Study site: University Malaya Medical Centre (UMMC)

Matched MeSH terms: Community-Acquired Infections/diagnosis
Fulltext Community-acquired pneumonia in Malaysian patients: addition of macrolide and the use of BTS "curb" index to assess severity

Loh LC

Med J Malaysia, 2006 Mar;61(1):128-30.
PMID: 16708753

Sir, I read with interest the elegantly written CME article by Liam C K recently!. The choice of empiric antibiotic(s) in treating hospitalized adult patients with communityacquired pneumonia (CAP) is important as it can influence clinical outcomes 2. As correctly pointed out by the author, patients with CAP requiring hospitalization should, in addition to a ~-lactam stable antibiotic, be covered with a macrolide, to combat atypical pathogens such as Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydia pneumoniae. Such is the recommendation from most foreign guidelines 3. 4. Here I wish to add our own observation based on a prospective study conducted between 2002 and 2004 of 141 adult patients with CAP hospitalized in Seremban Hospital in which we studied the clinical outcomes of patients treated empirically with and without a macrolide added to their ~-lactam stable antibiotic, recently published in Respirology 5.

Matched MeSH terms: Community-Acquired Infections/diagnosis
Mycoplasma Pneumoniae infection in Malaysian children admitted with community acquired pneumonia

Chan PW, Lum LC, Ngeow YF, Yasim MY

Southeast Asian J Trop Med Public Health, 2001 Jun;32(2):397-401.
PMID: 11556595

Mycoplasma pneumoniae is increasingly recognized as an important cause of community acquired pneumonia (CAP) in children. We determined the importance of M. pneumoniae as a causative agent in 170 children aged 1 month to 15 years who were hospitalized with CAP over a 6-month period. The diagnosis of M. pneumoniae infection was based on serological evidence obtained by a particle agglutination test (SERODIA-MYCO II). A positive serological diagnosis was made if the acute phase serum titer was more than 1:160 or paired samples taken 2-4 weeks apart showed a four-fold or greater rise in the serum titer. M. pneumoniae was identified as the causative agent in 40 (23.5%) children. Children with M. pneumoniae infection were more likely to be older than 3 years (OR 4.0 95%CI 1.8-9.1, p<0.001), Chinese (OR 4.3 95%CI 2.0-8.9, p<0.001), have a duration of illness longer than 7 days prior to admission (OR 6.0 95%CI 2.7-13.5, p<0.001) and have perihilar interstitial changes on chest X-ray (OR 4.6 95%CI 2.2-9.9, p<0.001). A significant number of hospital admissions for CAP in Malaysian children can be attributed to M. pneumoniae. It is important to identify these children so as to administer the most appropriate antibiotic treatment.

Matched MeSH terms: Community-Acquired Infections/diagnosis
Fulltext Acute haematogenous community-acquired methicillin-resistant Staphylococcus aureus osteomyelitis in an adult: case report and review of literature

Dhanoa A, Singh VA, Mansor A, Yusof MY, Lim KT, Thong KL

BMC Infect Dis, 2012;12:270.
PMID: 23098162 DOI: 10.1186/1471-2334-12-270

Methicillin-resistant Staphylococcus aureus (MRSA) has of late emerged as a cause of community-acquired infections among immunocompetent adults without risk factors. Skin and soft tissue infections represent the majority of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clinical presentations, whilst invasive and life-threatening illness like necrotizing pneumonia, necrotizing fasciitis, pyomyositis, osteomyelitis and sepsis syndrome are less common. Although more widely described in the pediatric age group, the occurrence of CA-MRSA osteomyelitis in adults is an uncommonly reported entity.

Matched MeSH terms: Community-Acquired Infections/diagnosis*
Selective media and real-time PCR improves diagnosis of melioidosis in community-acquired pneumonia in a low-incidence setting in Kuala Lumpur, Malaysia

Subakir H, Chong YM, Chan YF, Hasan MS, Jamaluddin MFH, Pang YK, et al.

J Med Microbiol, 2020 Jan;69(1):49-51.
PMID: 31750812 DOI: 10.1099/jmm.0.001108

Introduction.Burkholderia pseudomallei (melioidosis) is an important cause of community-acquired pneumonia (CAP) in the tropics. Selective medium is recommended for laboratory diagnosis with non-sterile respiratory samples, while PCR is not routinely used due to variable reported performance. The effectiveness of these diagnostic modalities varies by site.Aim. To compare selective media and real-time PCR (qPCR) with routine media in detecting B. pseudomallei in CAP respiratory samples in a low-incidence setting in Kuala Lumpur, Malaysia.Methodology. Respiratory samples were routinely cultured on blood, chocolate and MacConkey agar (RESP-ROUTINE), and compared to culture on selective Ashdown medium (RESP-SELECTIVE) and qPCR. The gold standard was routine culture of B. pseudomallei from any site (ALL-ROUTINE).Results.B. pseudomallei was detected in 8/204 (3.9 %) samples. Overall sensitivity rates differed (P=0.03) for qPCR (100%), RESP-SELECTIVE (87.5%) and RESP-ROUTINE (50%). There was a trend towards lower median days to positive culture for RESP-SELECTIVE (1 day) compared to RESP-ROUTINE (2 days, P=0.08) and ALL-ROUTINE (2 days, P=0.06). Reagent costs for each additional detection were USD59 for RESP-SELECTIVE and USD354 for PCR.Conclusions. In a low-incidence setting, selective culture of respiratory samples on Ashdown was more sensitive and allowed quicker identification than routine media, at reasonable cost. Blood cultures are critical, confirming four cases missed by routine respiratory culture. Selective medium is useful in early pneumonia (pre-sepsis) and resource-limited settings where blood cultures are infrequently done. Real-time PCR is costly, but highly sensitive and useful for high-risk patients with diabetes, cancer or immunosuppressants, or requiring ventilation or intensive care.

Matched MeSH terms: Community-Acquired Infections/diagnosis
Fulltext The use of multiplex real-time PCR improves the detection of the bacterial etiology of community acquired pneumonia

Mustafa MI, Al-Marzooq F, How SH, Kuan YC, Ng TH

Trop Biomed, 2011 Dec;28(3):531-44.
PMID: 22433882 MyJurnal

Community-acquired pneumonia (CAP) is still a major cause of morbidity and mortality especially to children and compromised hosts, such as the old and those with underlying chronic diseases. Knowledge of pathogens causing CAP constitutes the basis for selection of antimicrobial treatment. Previous data have shown that etiological agents can be identified in only up to 50% of patients, but this figure can be improved by using polymerase chain reaction (PCR). This study was designed to evaluate multiplex real-time PCR as a method for rapid differential detection of five bacterial causes of CAP (Streptococcus pneumoniae, Burkholderia pseudomallei and atypical bacterial pathogens namely Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila) in CAP patients attending Hospital Tengku Ampuan Afzan (HTAA)/ Kuantan, Pahang, Malaysia. Two previously developed multiplex real-time PCR assays, duplex for the differential detection of S. pneumoniae and B. pseudomallei and triplex for the atypical bacterial pathogens, were used to detect a bacterial cause of CAP in blood and respiratory samples. Thus, 46 blood and 45 respiratory samples collected from 46 adult CAP patients admitted to HTAA were analysed by multiplex real-time PCR assays and conventional methods. The microbial etiology of CAP could be established for 39.1% (18/46) of CAP patients by conventional methods and this was increased to 65.2% (30/46) with the additional use of real-time PCR. The most frequently detected pathogens were S. pneumoniae (21.7% - all by PCR alone), Klebsiella pneumoniae (17.3%), B. pseudomallei (13% - 83% of them positive by PCR alone and 17% by both culture and PCR), Pseudomonas aeruginosa (6.5%), M. pneumoniae (6.5% - all by serology), C. pneumoniae (4.3% - all positive by both PCR and serology), L. pneumophila (2.1% - all by PCR alone), Escherichia coli (4.3%). Haemophilus infuenzae, Acinetobacter lwoffii and Acinetobacter baumannii were detected by conventional methods (2.1% for each).

Matched MeSH terms: Community-Acquired Infections/diagnosis*
Fulltext Pneumonia in the tropics: Report from the Task Force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Nor MBM, Richards GA, McGloughlin S, Amin PR, Council of the World Federation of Societies of Intensive and Critical Care Medicine

J Crit Care, 2017 Dec;42:360-365.
PMID: 29129538 DOI: 10.1016/j.jcrc.2017.11.004

The aetiology of community acquired pneumonia varies according to the region in which it is acquired. This review discusses those causes of CAP that occur in the tropics and might not be readily recognizable when transplanted to other sites. Various forms of pneumonia including the viral causes such as influenza (seasonal and avian varieties), the coronaviruses and the Hantavirus as well as bacterial causes, specifically the pneumonic form of Yersinia pestis and melioidosis are discussed.

Matched MeSH terms: Community-Acquired Infections/diagnosis*
Pulmonary tuberculosis presenting as community-acquired pneumonia

Liam CK, Pang YK, Poosparajah S

Respirology, 2006 Nov;11(6):786-92.
PMID: 17052309

The aims of this study were to investigate the frequency of Mycobacterium tuberculosis as a cause of community-acquired pneumonia (CAP) requiring hospitalization in Malaysia, and to define the clinical features of pulmonary tuberculosis (PTB) that distinguish it from non-TB CAP.

Matched MeSH terms: Community-Acquired Infections/diagnosis
An Asian study on the prevalence of atypical respiratory pathogens in community-acquired pneumonia

Ngeow YF, Suwanjutha S, Chantarojanasriri T, Wang F, Saniel M, Alejandria M, et al.

Int J Infect Dis, 2005 May;9(3):144-53.
PMID: 15840455

In many parts of Asia, the inaccessibility and high cost of diagnostic tests have hampered the study of community-acquired pneumonia (CAP) caused by atypical respiratory pathogens.

Matched MeSH terms: Community-Acquired Infections/diagnosis
Fulltext Development of multiplex real-time PCR for the rapid detection of five bacterial causes of community acquired pneumonia

Al-Marzooq F, Imad MA, How SH, Kuan YC

Trop Biomed, 2011 Dec;28(3):545-56.
PMID: 22433883 MyJurnal

Establishing a microbial diagnosis for patients with community-acquired pneumonia (CAP) is still challenging and is often achieved in only 30-50% of cases. Polymerase chain reaction (PCR) has been shown to be more sensitive than conventional microbiological methods and it could help to increase the microbial yield for CAP patients. This study was designed to develop, optimize and evaluate multiplex real-time PCR as a method for rapid differential detection of five bacterial causes of CAP namely Streptococcus pneumoniae, Burkholderia pseudomallei and atypical bacterial pathogens, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila. Duplex and triplex real-time PCR assays were developed using five sets of primers and probes that were designed based on an appropriate specific gene for each of the above CAP pathogens. The performance of primers for each organism was tested using SYBR Green melt curve analysis following monoplex realtime PCR amplification. Monoplex real-time PCR assays were also used to optimize each primers-probe set before combining them in multiplex assays. Two multiplex real-time PCR assays were then optimized; duplex assay for the differential detection of S. pneumoniae and B. pseudomallei, and triplex assay for the atypical bacterial pathogens. Both duplex and triplex real-time PCR assays were tested for specificity by using DNA extracted from 26 related microorganisms and sensitivity by running serial dilutions of positive control DNAs. The developed multiplex real-time PCR assays shall be used later for directly identifying CAP causative agents in clinical samples.

Matched MeSH terms: Community-Acquired Infections/diagnosis*

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