ERS 2019 - Prevention and management of respiratory infections in primary care.

  • Eliana Mesa
  • Conference Reports
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Community-acquired pneumonia, economic aspects on vaccinations for respiratory disease, and the importance of phenotyping in COPD infections were covered in this session.

Three important issues can be highlighted:

Clinical aspects of community acquired pneumonia, have been reviewed, focusing on microorganisms frequently implicated, differential diagnoses and management. Once pneumonia has been diagnosed, largely based on clinical symptoms and chest x-ray, the severity has to be assessed. When the severity is high, the patient should be referred to a hospital. In a case of low severity (CRB65=0), antibiotic treatment has to be initiated early, preferably with betalactam and avoiding fluorquinolone or dual antibiotic therapy. The treatment has to be maintained 5 days, only considering prolonging this treatment in cases where no improvement is seen.  It is also recommended that steroids are not used, except where the patient has a concomitant condition (eg. COPD, asthma).

In the case of vaccines, the strategies employed between different countries for respiratory disease prevention has been stressed. Its cost-effectiveness has been demonstrated and this should be taken into account when designing vaccination programs. In the case of influenza vaccine, the cost-effectiveness of the high-dose versus standard-dose in terms of hospitalisations due to underlying cardio-respiratory disease has been demonstrated, even in low- and middle-income countries. The influenza vaccine for COPD patients is often well established, although new influenza and pneumococcal vaccines and strategies can be optimised.

Phenotyping COPD has been another interesting topic. Different markers can be observed to define each COPD type and, considering these characteristics, it is possible to predict the type of exacerbation. The colour of the sputum and CRP are useful markers of bacterial infection. Blood eosinophils are a good marker of eosinophilic exacerbation. Patients can be stratified to low or high risk by considering the obstruction (post-bronchodilatation), the dyspnoea grade (by mMRC scale) and the number of exacerbations in the previous year. A high number of previous exacerbations predict a high risk of future exacerbations. Another important factor is the profile of the lung microbiota. There is a relationship between high levels of eosinophils in the blood and a high diversity of the microbiota, both of which are related to eosinophilic exacerbations and less bacterial exacerbations.  This should be considered in the treatment with antibiotics and systemic steroids. Patients with an eosinophilic pattern and low bacterial load will not benefit from antibiotics, and steroids should not be used in patients with a bacterial pattern.