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Diagnosis of severe respiratory infections in immunocompromised patients

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Abstract

An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.

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Authors and Affiliations

  1. Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France

    Elie Azoulay, Virginie Lemiale & Adrien Mirouse

  2. Université de Paris, Paris, France

    Elie Azoulay & Adrien Mirouse

  3. Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark

    Lene Russell

  4. Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA

    Andry Van de Louw

  5. Department of Critical Care, King’s College Hospital NHS Foundation Trust, London, UK

    Victoria Metaxa

  6. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA

    Philippe Bauer

  7. Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal

    Pedro Povoa

  8. Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain

    José Garnacho Montero

  9. Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James’s Hospital, St James Street, Dublin 8, Ireland

    Ignacio Martin Loeches

  10. Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada

    Sangeeta Mehta

  11. Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK

    Kathryn Puxty

  12. Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria

    Peter Schellongowski

  13. Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain

    Jordi Rello

  14. CRIPS Department, Vall d’Hebron Institut of Research (VHIR), Barcelona, Spain

    Jordi Rello

  15. Critical Care Department, Institut Paoli Calmettes, Marseille, France

    Djamel Mokart

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Conflict of interest

EA has received fees for lectures from Gilead, Pfizer, Baxter, and Alexion. His research group has been supported by Ablynx, Fisher & Payckle, Jazz Pharma, and MSD. IML reports personal fees from MSD and Gilead. PV has received consultation fees from Orion, Pfizer, and Technofage. PS received honoraria from Astellas, Basilea, Fisher & Paykel, Getinge, Gilead, Hill-Rom, Jazz Pharmaceuticals, Kite, Merck, Orion, Pfizer Rokitan, and Shire. He also declares research support from Amgen, Astellas, Astro-Pharma, and Baxter. JR served a consultant or in the speakers bureau for Merck, Anchoagen, Pfizer, ROCHE and in the speakers bureau for Pfizer and MSD. JGM has received fees for lectures from Gilead. All other authors have no conflict of interest to disclose.

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Azoulay, E., Russell, L., Van de Louw, A. et al. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 46, 298–314 (2020). https://doi.org/10.1007/s00134-019-05906-5

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