Aetiology of lower respiratory tract infection in adults in primary care: A prospective study in 11 European Countries

Abstract

Objectives: To describe the role of bacteria (including bacterial resistance), viruses (including those recently described), and mixed bacterial-viral infections in adults presenting to primary care with lower respiratory tract infection (LRTI). 
Methods: We enrolled 3104 adults with LRTI, 141 (4.5%) of whom had community-acquired pneumonia (CAP), and 2985 matched controls in a prospective study in 16 primary care networks in Europe, and followed patients up at 28-35 days. We detected S. pneumoniae and H. influenzae and assessed susceptibility, atypical bacteria and viruses. 
Results: A potential pathogen was detected in 1844 (59%) (in 350 (11%) bacterial pathogens only, in 1190 (38%) viral pathogens only, and in 304 (10%) both bacterial and viral pathogens). The most common bacterial pathogens isolated were S. pneumoniae (5.5% overall, 9.2% in CAP patients) and H. influenzae (5.4% overall, 14.2% in CAP patients). <1% of S. pneumoniae were highly resistant to penicillin and 12.6% of H. influenzae were beta-lactamase positive. The most common viral pathogens detected were human rhinovirus (HRV; 20.1%), influenza viruses (FLU; 9.9%), and human coronavirus (HCoV; 7.4%). FLU, human parainfluenzaviruses and human respiratory syncytial virus as well as HRV, HCoV, human metapneumovirus were detected significantly more frequently in LRTI patients than in controls. 
Conclusions: A bacterial pathogen is identified in approximately one in five adult patients with LRTI in primary care, and a viral pathogen in just under half, with mixed infections in one in ten. Penicillin resistant pneumococci and beta-lactamase producing H. influenzae are uncommon. These new findings support a restrictive approach to antibiotic prescribing for LRTI and the use of first-line, narrow spectrum agents in primary care.

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