title: Clinical differences between respiratory viral and bacterial mono- and dual pathogen detected among Singapore military servicemen with febrile respiratory illness.
abstract: BACKGROUND
  Although it is known that febrile respiratory illnesses (FRI) may be caused by multiple respiratory pathogens, there are no population-level studies describing its impact on clinical disease.
  
  
  METHODS
  Between May 2009 and October 2012, 7733 FRI patients and controls in the Singapore military had clinical data and nasal wash samples collected prospectively and sent for PCR testing. Patients with one pathogen detected (mono-pathogen) were compared with those with two pathogens (dual pathogen) for differences in basic demographics and clinical presentation.
  
  
  RESULTS
  In total, 45.8% had one pathogen detected, 20.2% had two pathogens detected, 30.9% had no pathogens detected, and 3.1% had more than two pathogens. Multiple pathogens were associated with recruits, those with asthma and non-smokers. Influenza A (80.0%), influenza B (73.0%) and mycoplasma (70.6%) were most commonly associated with mono-infections, while adenovirus was most commonly associated with dual infections (62.9%). Influenza A paired with S. pneumoniae had higher proportions of chills and rigors than their respective mono-pathogens (P = 0.03, P = 0.009). H. influenzae paired with either enterovirus or parainfluenzae had higher proportions of cough with phlegm than their respective mono-pathogens. Although there were observed differences in mean proportions of body temperature, nasal symptoms, sore throat, body aches and joint pains between viral and bacterial mono-pathogens, there were few differences between distinct dual-pathogen pairs and their respective mono-pathogen counterparts.
  
  
  CONCLUSIONS
  A substantial number of FRI patients have multiple pathogens detected. Observed clinical differences between patients of dual pathogen and mono-pathogen indicate the likely presence of complex microbial interactions between the various pathogens.
authors.affiliation: HQ Medical Corps, Singapore Armed Forces, Singapore.
authors.forename: Zheng Jie Marc
authors.initials: ZJ
authors.lastname: Ho
authors.affiliation: Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors.forename: Xiahong
authors.initials: X
authors.lastname: Zhao
authors.affiliation: Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors.forename: Alex R
authors.initials: AR
authors.lastname: Cook
authors.affiliation: DSO National Laboratories, Singapore.
authors.forename: Jin Phang
authors.initials: JP
authors.lastname: Loh
authors.affiliation: DSO National Laboratories, Singapore.
authors.forename: Sock Hoon
authors.initials: SH
authors.lastname: Ng
authors.affiliation: DSO National Laboratories, Singapore.
authors.forename: Boon Huan
authors.initials: BH
authors.lastname: Tan
authors.affiliation: HQ Medical Corps, Singapore Armed Forces, Singapore.|Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors.forename: Vernon J
authors.initials: VJ
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D000328:Adult; D001419:Bacteria / Q000235:genetics / Q000302:isolation & purification; D001424:Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D005334:Fever / Q000453:epidemiology* / Q000382:microbiology / Q000821:virology; D006801:Humans; D007251:Influenza, Human / Q000453:epidemiology* / Q000821:virology; D008297:Male; D008875:Middle Aged; D008889:Military Personnel / Q000706:statistics & numerical data*; D012141:Respiratory Tract Infections / Q000453:epidemiology* / Q000382:microbiology / Q000821:virology; D012846:Singapore / Q000453:epidemiology; D014780:Viruses / Q000235:genetics / Q000302:isolation & purification; D055815:Young Adult
keywords: epidemiology; military personnel; respiratory infections; surveillance
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