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Both bacterial and viral pneumonia are well accepted entities; however, with evolving diagnostics there has been increasing interest in the pathogenesis, epidemiology, presentation, and prognosis of viral pneumonias. In addition, the concept of viral and bacterial co-infections in pneumonia is an area of growing research and may be best recognized among patients with influenza who develop secondary bacterial infections; there was particular interest in this after the 2009 pandemic [1–4]. However, in the setting of increasing molecular diagnostics, particularly multiplex PCR platforms, there is an opportunity to better define the epidemiology of co-infections and their impact on clinical diagnosis and patient outcomes [5, 6]. There is some evidence that dual infection may worsen patient outcome, including severity of disease and mortality [1, 2]. With this in mind, the article by Voiriot et al. [7], “Viral–bacterial coinfection affects the presentation and alters the prognosis of severe community-acquired pneumonia”, adds to our expanding knowledge base in this arena. Prior studies have focused on community-acquired pneumonia (CAP) with multiplex pathogen panels, and rates of positivity for concurrent viral detection have ranged up to approximately half of patients; however, detecting a virus does not necessarily imply the virus is directly affecting the patient’s current clinical illness [1, 3, 4, 8]. The study by Voiriot et al. is a single center, retrospective study of critically ill patients admitted to an ICU between October 2011 and June 2015 for community-acquired pneumonia who also had a multiplex retrograde pathogen panel completed within 72 h of admission to the ICU. Patients were categorized based on pathogen, including bacterial, viral, mixed viral and bacterial pathogens, and no etiology based on microbiologic data obtained. The primary endpoint was to identify specific features regarding presentation and prognosis of mixed viral bacterial coinfected patients. Clinical course was evaluated via a composite criterion of “complicated course” including hospital death or utilization of mechanical ventilation for greater than 7 days. The study included 174 patients that were predominantly male and of old age. Patients with microbiologic documentation of infection included 144 patients: 52.3% had at least one bacterium identified and 56.3% had at least one virus identified. Of these, 45 had a mixed bacterial and viral pneumonia per the investigators’ criteria; 15 were influenza and 14 were picornavirdae. In the analyses, the composite “complicated course” achieved statistical significance, with higher rates in the mixed group. Presentations were also altered, with increased groundglass opacities radiographically and increased severity of illness among those with mixed infection. It is of note, however, that radiographic findings for bacterial and viral pneumonia may have significant overlap and have historically not been particularly predictive of single entity, dual, or mixed infection [1]. This retrospective study has several potential limitations (e.g., selection bias, confounding by indication of ordering or not the multiplex PCR panel) but the results, limited as they may be, demonstrate that over half of patients admitted to an ICU with presumed communityacquired pneumonia have detectable virus at the time of presentation, consistent with other studies noted above. In the study by Voiriot et al., dual infection with mixed * Correspondence: akalil@unmc.edu Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA

Viral and bacterial co-infection in pneumonia: do we know enough to improve clinical care?