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What are the latest developments in the diagnosis and treatment of lung infections? Professor Qu Jieming fully summarized

 Last Update: 2023-01-06
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These 4 lung infections are the deadliest infectious diseases to understand

pneumonia and other lower respiratory tract infections, according to the WHO's 2019 global ten leading death factors, lower respiratory tract infections ranked fourth in terms of
deaths.
Through global efforts, infectious diseases have been effectively controlled
.
However, while traditional infectious diseases have been controlled, many problems have not been solved through breakthroughs, such as drug resistance
.
And these problems are becoming
more and more serious.

From October 22 to 23 this year, the 14th Ruijin Respiratory Disease Academic Forum was held in Shanghai through live
webcasting, jointly organized by the Department of Respiratory and Critical Care Medicine of Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine and Shanghai Key Laboratory of Emergency Prevention and Control of Respiratory Infectious Diseases.
Professor Qu Jieming from Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine led us to see the progress of lung infection diseases, let's take a look together~

COVID-19

At present, the number of patients infected with the new coronavirus pneumonia has exceeded 500 million worldwide, so the number of people who have lost their lives has exceeded 6 million
.
The COVID-19 variant Omicron (B.
1.
1.
529) was classified as VOC
by WHO in November 2021.
In February 2022, Omicron has replaced Delta as the dominant circulating strain
worldwide.
It can be seen that the mutation of the entire new coronavirus at this stage is constantly and rapidly developing
.
Professor Qu Jieming believes that the COVID-19 variant is becoming more and more
distant from the original strain.

Compared with the original strain, Omicron embodies 4 characteristics:
(1) there are 30 spike protein mutations;
(2) 15 receptor binding domain mutations, which are related to decreased antibody binding;
(3) mutations in furin S1/S2 locus, which can increase furin binding and increase infectivity;
(4) Mutation in amino acid terminal structure
.

Compared with BA.
1, BA.
2 has 8 unique spike protein mutations and 13 spike protein mutations, and BA.
3 has no specific mutations, but shares 10 mutations of BA.
1 and 2 mutations of BA.
2
.
Compared with Delta, Omicron infection has a lower risk of serious outcomes, and the more severe the outcome, the lower the risk
.
At the same time, we also found that severe patients are usually the elderly, immunocompromised people, tumor patients, etc.
, with serious conditions, rapid progression, and difficult treatment, so we must pay attention to this group [1].

We also found less lower respiratory tract involvement, lower hospitalizations, and an increased
risk of sore throat and hoarseness after Omicron infection.

Regarding the new coronavirus vaccines, they are now divided into five categories: inactivated vaccines, adenovirus vector vaccines, recombinant protein vaccines, nucleic acid vaccines (including mRNA and DNA vaccines) and attenuated vaccines
.
196 vaccines are in preclinical trials and 153 are in clinical trials
.

For the treatment of COVID-19 pneumonia, the COVID-19 Drug Treatment Dynamic Guidelines are constantly updated
as the new coronavirus condition changes.
According to the severity of the patient's condition, it can be divided into 3 categories: (1) non-heavy: does not have the characteristics of severe or critical disease; (2) Heavy: oxygen saturation <90% when breathing air, signs of pneumonia, severe respiratory distress; (3) Critical: requires vital sign support, acute respiratory distress syndrome, sepsis, septic shock<b21>.
Different types of patients use different treatment options
.

In addition, the 9th edition of our COVID-19 guidelines has also been updated as follows:

Community-acquired pneumonia (CAP)

What do the CAP guidelines and specifications say?
In 2016, the Chinese Medical Association updated the guidelines, and in 2019, ATS/IDSA issued the Guidelines for the Diagnosis and Treatment of Adult Community-acquired Pneumonia, which brought important guidance to clinical diagnosis and treatment
.

According to the "Application of CAP Guidelines under COVID-19", 5 recommendations are made:
(1) for CAP patients with undiagnosed COVID-19, empirical coverage of bacterial pathogens is recommended;
(2) recommend that patients with COVID-19 and pneumonia use the same empirical antibiotics;
(3) When it comes to multidrug-resistant pathogens, sputum culture and blood culture testing are most useful;
(4) procalcitonin surveillance may help limit the overuse of antibiotics in patients with COVID-19-related pneumonia;
(5) Immunomodulatory therapy
is not recommended for pneumonia patients at present.
How to choose CAP drugs?
1) Professor Qu Jieming of omacycline
tosylate believes that in the treatment of community-acquired bacterial pneumonia in adults, omacycline tosylate plays a significant effect, no less than moxifloxacin
。 This is a new once-daily aminomethylcycline antibiotic that can be given intravenously or orally, at high concentrations in lung tissue, and is active against common pathogens of community-acquired bacterial pneumonia [2].

2) Professor Qu Jieming of β-lactam
believes that in the antibiotic treatment of hospitalized patients with community-acquired pneumonia, short-course treatment is beneficial to reduce the consumption of antibiotics, which can reduce bacterial drug resistance, adverse events and treatment costs
.
In studies that met the criteria for clinical stability, discontinuation of B-lactam therapy after three days in hospitalized patients with CAP was no less effective than that of 8 days [3].

3) Professor Qu Jieming of Dexamethasone
believes that in adult patients hospitalized with CAP, intravenous corticosteroid adjuvant therapy can shorten the length of
hospital stay.
Oral dexamethasone has been shown to reduce hospitalization and ICU admissions in adults hospitalized with CAP
.
However, it is not clear which patients have the best risk-benefit ratio [4].

Hospital-acquired pneumonia (HAP)

What do the HAP guidelines and specifications say?
1) The "Clinical Practice Guidelines for the Management of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Adults (2016 Edition)" published by the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) 6 recommendations:

2) Guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults in China (2018 edition) 8 recommendations:
how to choose HAP drugs?
1) Ceftadime-avibactam has been studied to have more advantages in the efficacy and safety of ceftazidime-avibactam
in patients with hospital-acquired pneumonia, including ventilator-associated pneumonia, compared with meropenem [5].

2) Professor Ceftolozane/tazobactam
Qu Jieming believes that nosocomial pneumonia caused by drug-resistant pathogens is associated with
high mortality.
High-dose Ceftolozane/tazobactam is an effective and well-tolerated drug
for the treatment of G-hospital-acquired pneumonia in mechanically ventilated patients.
Studies have shown that Ceftolozane/tazobactam has a more significant efficacy and good safety profile in the treatment of G-hospital-acquired pneumonia compared with meropenem [6].

3) Compared with high-dose, prolonged infusion of meropenem, cefdidil
is more effective and safe
in adult patients with hospital-acquired pneumonia.
Professor Qu Jieming believes that cefdom is a potential choice for HAP patients [7].

In addition, there are studies that have shown that combination therapy is not superior to monotherapy
.
Colistin + meropenem does not improve efficacy compared with colistin alone [8].

tuberculosis

According to data from the Global TB Report 2021, the cause of death from TB as a single source of infection fell to second place in 2020 due to the pandemic, and the global TB case fatality rate was 15% in 2020, up from 14%
in 2019.
Regarding tuberculosis diagnosis, Professor Qu Jieming believes that effective identification of tuberculosis and latent tuberculosis infection (LTBI) is of great significance
for controlling tuberculosis epidemics.
According to the Expert Consensus on the Clinical Application of Recombinant Mycobacterium tuberculosis fusion protein (EC), EC is recommended for LTBI screening and epidemiological diagnosis
.

For the treatment of tuberculosis, there are currently two new drugs, namely:
(1) bedaquiline
, a novel mycobacterial ATP synthetase inhibitor, which can prevent bacteria from using ATP to produce energy and exert anti-tuberculosis effects
。 As part of the combination treatment of MDR-TB, this new mechanism of drugs has the potential to shorten the course of
treatment for drug-sensitive TB patients.

(2) Delamani
is a nitrodihydroimidazole derivative with a novel mechanism of action, by inhibiting mycobacterial synthesis, interfering with Mycobacterium tuberculosis (MTB) cell wall metabolism, thereby inhibiting the activity
of anti-drug resistant strains.

small

knot

Finally, Professor Qu Jieming concluded that facing the new discipline development process and facing the current situation of the new crown virus epidemic, the new generation of Ruijin Respiratory is fully committed to facing the challenge, so as to better promote the long-term development of
Ruijin Respiratory Discipline.
It is expected that Ruijin Respiratory Science will make greater contributions
to the respiratory community in China and even the world in the future development.

Expert profile
: Professor Qu Jieming, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Secretary of the Party Committee of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
Chief physician, professor, doctoral supervisor
Chairman of the Respiratory Disease Branch of the Chinese Medical Association
Leader of the Pulmonary Infection Group of the Respiratory Disease Branch of the Chinese Medical Association
Vice President of Respiratory Physician Branch of Chinese Medical Doctor Association
President of Respiratory Medicine Branch of Shanghai Medical Doctor Association
Standing Director of Shanghai Medical Doctor Association
Chairman of the 10th Respiratory Society of Shanghai Medical Association
Vice President of Shanghai Medical Association

References:

[1] Lancet 2022:399（10335）:1618-1624.

[2] The New England Journal of medicine vol.
380.
5(2019):517-527.
doi:10.
1056/NEJMoa1800201.

[3] Lancet vol.
397,10280(2021):1195-1203.
doi:10.
1016/S0140-6736(21)00313-5.

[4] Eur Respir J.
2021 Aug 12:58（2）:2002535.

[5] Lancet Infect Dis.
2018 Mar.
18（3）:285-295.

[6] Lancet Infect Dis.
2019 Dec; 19（12）:1299-1311.

[7] Lancet Infect Dis.
2021 Feb; 21（2）:213-225.

[8] Lancet Infect Dis.
2018; 18（4）:391-400.

Source: Medical Respiratory Channel Author: Qu Jieming Song Qiuyi Review of this article: Professor Qu JiemingRuijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine Responsible Editor: Peng Jianping Dai Dai
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