ANTECEDENTES: Este estudio tuvo como objetivo comparar la evolución de los pacientes con neumonía adquirida en la comunidad grave (SCAP) tratados con la combinación de cualquiera de β-lactámicos-quinolona (βQ) o (βM) antibióticos β-lactámicos, macrólidos.
Métodos: Se estudiaron retrospectivamente una cohorte de pacientes con SCAP tratados entre enero de 2000 diciembre de 2010 a una unidad de cuidados intensivos de nivel universitario mixto (UCI). APACHE II, la gravedad SCAP evaluada por puntaje IDSA / ATS, primer tratamiento antibiótico iniciado durante las primeras 24 h del ingreso, la UCI y la estancia hospitalaria (LOS), y en la UCI, hospital, 30 y mortalidad de 60 días se evaluaron.
RESULTADOS: En total, se analizaron 210 pacientes con SCAP, 104 en el brazo βQ y 106 en el brazo βM. La mediana de las puntuaciones APACHE II al ingreso fueron mayores en el grupo βM (22 vs 18, p = 0,003). Más pacientes en el grupo βQ requieren ventilación mecánica (63,1% vs. 42,5%, p = 0,004) y cumplen los criterios de la IDSA / ATS SCAP (n = 87; 83,7%) que los del grupo de βM (n = 73; 68,9%; P = 0,015). Treinta y mortalidad día fue de 16,3% en el grupo βQ y 24,5% en el grupo βM (P = 0,17), y con la mortalidad shock séptico fue 19,6% y 32,6%, respectivamente (P = 0,16). El APACHE II y la IDSA / ATS SCAP puntuación de análisis de regresión logística multivariante ajustado, el grupo βM tenía una razón de probabilidad ligeramente mayor pero no significativa (OR) para una mortalidad a los 30 días en comparación con el grupo βQ (OR 1,4; IC del 95%, 0,62 -3,0; P = 0,44).
CONCLUSIÓN: la tasa de mortalidad Treinta días de los pacientes SCAP no difirió si fueron tratados con βQ o combinación βM.
Few patients with community-acquired pneumonia (CAP) require admission to the intensive care unit (ICU-CAP). However, they represent the most severe form of the disease. An understanding of the etiologic agents of ICU-CAP may lead to better treatment decisions and patient outcomes. The objective of this study was to determine the incidence of respiratory viruses in patients with ICU-CAP. This was an observational study conducted in six Kentucky hospitals from December 2008 through October 2011. A case of ICU-CAP was defined as a patient admitted to an ICU with the diagnosis of CAP. The Luminex xTAG multiplex polymerase chain reaction (PCR) assay was used for viral identification. A total of 468 adult and pediatric patients with ICU-CAP were enrolled in the study. A total of 92 adult patients (23 %) and 14 pediatric patients (19 %) had a respiratory virus identified. Influenza was the most common virus identified in adults and the second most common in pediatric patients. This study suggests that respiratory viruses may be common etiologic agents of pneumonia in patients with ICU-CAP. The Centers for Disease Control and Prevention (CDC) recommend empiric anti-influenza therapy during the winter for hospitalized patients with CAP. This study supports this recommendation in patients with ICU-CAP.
BACKGROUND: Lower respiratory tract infection (LRTI) including Community-acquired pneumonia (CAP) is a common infectious disease that is associated with significant morbidity and mortality. The patterns of aetiological pathogens differ by region and country. Special attention must be paid to CAP in Southeast Asia (SEA), a region facing rapid demographic transition. Estimates burden and aetiological patterns of CAP are essential for the clinical and public health management. The purposes of the study are to determine the incidence, aetiological pathogens, clinical pictures and risk factors of community-acquired pneumonia (CAP) in the Vietnamese adult population.
METHODS: A prospective surveillance for hospitalised adult CAP was conducted in Khanh Hoa Province, Central Vietnam. All adults aged ≥15 years with lower respiratory tract infections (LRTI) admitted to a provincial hospital from September 2009 to August 2010 were enrolled in the study. Patients were classified into CAP and non-pneumonic LRTI (NPLRTI) according to the radiological findings. Bacterial pathogens were identified from sputum samples by the conventional culture and polymerase chain reaction (PCR) for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; 13 respiratory viruses were identified from nasopharyngeal specimens by PCR.
RESULTS: Of all 367 LRTI episodes examined, 174 (47%) were CAP. Older age, the presence of underlying respiratory conditions, and higher index score of smoking were associated with CAP. The one-year estimated incidence of hospitalised adult CAP in our study population was 0.81 per 1,000 person years. The incidence increased considerably with age and was highest among the elderly. The case fatality proportion of hospitalised CAP patients was 9.8%. Among 286 sputum samples tested for bacterial PCR, 79 (28%) were positive for H. influenzae, and 65 (23%) were positive for S. pneumoniae. Among 357 samples tested for viral PCR, 73 (21%) were positive for respiratory viruses; influenza A (n = 32, 9%) was the most common.
CONCLUSIONS: The current adult CAP incidence in Vietnam was relatively low; this result was mainly attributed to the young age of our study population.
OBJETIVO: Streptococcus pneumoniae (SP) representa un patógeno importante en la neumonía. El impacto de la azitromicina sobre la mortalidad en la neumonía SP sigue siendo poco clara. Preocupaciones de seguridad con respecto a la azitromicina recientes han elevado la alarma sobre el papel de este agente con neumonía. Hemos tratado de aclarar la relación entre la supervivencia y el uso de azitromicina en la neumonía SP.
Diseño: cohorte retrospectivo.
Emplazamiento hospital académico Urbano.
PARTICIPANTES: Los adultos con un diagnóstico de neumonía SP (enero-diciembre de 2010). El diagnóstico de la neumonía requiere un síndrome clínico compatible y evidencia radiográfica de un infiltrado.
INTERVENCIÓN: Ninguno.
MEDIDAS DE RESULTADO PRIMARIAS Y SECUNDARIAS: mortalidad hospitalaria sirvieron como la variable principal, y se compararon los pacientes que recibieron azitromicina con los no tratados con esto. Las covariables de interés incluyen la demografía, la gravedad de la enfermedad, las comorbilidades y las características relacionadas con la infección (por ejemplo, la adecuación del tratamiento inicial, bacteriemia). Se empleó la regresión logística para evaluar el impacto independiente de azitromicina en la mortalidad hospitalaria.
Resultados: La cohorte incluyó 187 pacientes (: 67,0 ± 8,2 años, 50,3% hombres, 5,9% ingresados en la unidad de cuidados intensivos edad media). Los antibióticos macrólidos no utilizados más frecuentemente incluyen: ceftriaxona (n = 111), cefepima (n = 31) y moxifloxacino (n = 22). Aproximadamente dos tercios de la cohorte recibieron azitromicina. Bruta de mortalidad fue menor en las personas dadas azitromicina (5,6% vs 23,6%, p <0,01). El modelo de supervivencia final incluyó cuatro variables: edad, necesidad de ventilación mecánica, la terapia inicial adecuada y el uso de azitromicina. La OR ajustada para la mortalidad asociada con azitromicina igualado (IC del 95%: 0,08 a 0,80, p = 0,018) 0,26.
Conclusiones: La neumonía SP generalmente permanece asociada con la mortalidad sustancial mientras que el tratamiento con azitromicina se asocia con tasas de supervivencia significativamente más altos. El impacto de la azitromicina es independiente de múltiples factores de confusión potenciales.
BACKGROUND: Modern molecular techniques reveal new information on the role of respiratory viruses in community-acquired pneumonia. In this study, we tried to determine the prevalence of respiratory viruses and bacteria in patients with community-acquired pneumonia who were admitted to the hospital.
METHODS: Between April 2008 and April 2009, 408 adult patients (aged between 20 and 94 years) with community-acquired pneumonia were tested for the presence of respiratory pathogens using bacterial cultures, real-time PCR for viruses and bacteria, urinary antigen testing for Legionella and Pneumococci and serology for the presence of viral and bacterial pathogens.
RESULTS: Pathogens were identified in 263 (64·5%) of the 408 patients. The most common single organisms in these 263 patients were Streptococcus pneumoniae (22·8%), Coxiella burnetii (6·8%) and influenza A virus (3·8%). Of the 263 patients detected with pathogens, 117 (44·5%) patients were positive for one or more viral pathogens. Of these 117 patients, 52 (44·4%) had no bacterial pathogen. Multiple virus infections (≥2) were found in 16 patients.
CONCLUSION: In conclusion, respiratory viruses are frequently found in patients with CAP and may therefore play an important role in the aetiology of this disease.
BACKGROUND: Adult community-acquired pneumonia (CAP) is a relevant worldwide cause of morbidity and mortality, however the aetiology often remains uncertain and the therapy is empirical. We applied conventional and molecular diagnostics to identify viruses and atypical bacteria associated with CAP in Chile.
METHODS: We used sputum and blood cultures, IgG/IgM serology and molecular diagnostic techniques (PCR, reverse transcriptase PCR) for detection of classical and atypical bacteria (Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumoniae) and respiratory viruses (adenovirus, respiratory syncytial virus (RSV), human metapneumovirus, influenza virus, parainfluenzavirus, rhinovirus, coronavirus) in adults >18 years old presenting with CAP in Santiago from February 2005 to September 2007. Severity was qualified at admission by Fine's pneumonia severity index.
RESULTS: Overall detection in 356 enrolled adults were 92 (26%) cases of a single bacterial pathogen, 80 (22%) cases of a single viral pathogen, 60 (17%) cases with mixed bacterial and viral infection and 124 (35%) cases with no identified pathogen. Streptococcus pneumoniae and RSV were the most common bacterial and viral pathogens identified. Infectious agent detection by PCR provided greater sensitivity than conventional techniques. To our surprise, no relationship was observed between clinical severity and sole or coinfections.
CONCLUSIONS: The use of molecular diagnostics expanded the detection of viruses and atypical bacteria in adults with CAP, as unique or coinfections. Clinical severity and outcome were independent of the aetiological agents detected.
INTRODUCTION: Determining the cause of community-acquired pneumonia (CAP) remains problematic. In this observational study, we systematically applied currently approved diagnostic techniques in patients hospitalized for CAP in order to determine the proportion in which an etiological agent could be identified.
METHODS: All patients admitted with findings consistent with CAP were included. Sputum and blood cultures, urine tests for pneumococcal and Legionella antigens, nasopharyngeal swab for viral PCR, and serum procalcitonin were obtained in nearly every case. Admission-related electronic medical records were reviewed in entirety.
RESULTS: By final clinical diagnosis, 44 patients (17.0%) were uninfected. A causative bacterium was identified in only 60 (23.2%) cases. PCR identified a respiratory virus in 42 (16.2%), 12 with documented bacterial coinfection. In 119 (45.9%), no cause for CAP was found; 69 (26.6%) of these had a syndrome indistinguishable from bacterial pneumonia. Procalcitonin was elevated in patients with bacterial infection and low in uninfected patients or those with viral infection, but with substantial overlap.
CONCLUSIONS: Only 23.2% of 259 patients admitted with a CAP syndrome had documented bacterial infection; another 26.6% had no identified bacterial etiology, but findings closely resembled those of bacterial infection. Nevertheless, all 259 received antibacterial therapy. Careful attention to the clinical picture may identify uninfected patients or those with viral infection, perhaps with reassurance by a non-elevated procalcitonin. Determining an etiologic diagnosis remains elusive. Better discriminators of bacterial infection are sorely needed.
OBJECTIVES: To determine the aetiology, clinical features and prognosis of CAP during the first post-pandemic influenza season. We also assessed the factors associated with severe disease and tested the ability of a scoring system for identifying influenza A (H1N1)pdm09-related pneumonia.
METHODS: Prospective cohort study carried out at 10 tertiary hospitals of Spain. All adults hospitalised with CAP from December 01, 2010 to March 31, 2011 were analysed.
RESULTS: A total of 747 adults with CAP required hospitalisation. The aetiology was determined in 315 (42.2%) patients, in whom 154 (21.9%) were due to bacteria, 125 (16.7%) were due to viruses and 36 (4.8%) were mixed (due to viruses and bacteria). The most frequently isolated bacteria were Streptococccus pneumoniae. Among patients with viral pneumonia, the most common organism identified were influenza A (H1N1)pdm09. Independent factors associated with severe disease were impaired consciousness, septic shock, tachypnea, hyponatremia, hypoxemia, influenza B, and influenza A (H1N1)pdm09. The scoring system evaluated did not differentiate reliably between patients with influenza A (H1N1)pdm09-related pneumonia and those with other aetiologies.
CONCLUSIONS: The frequency of bacterial and viral pneumonia during the first post-pandemic influenza season was similar. The main identified virus was influenza A (H1N1)pdm09, which was associated with severe disease. Although certain presenting clinical features may allow recognition of influenza A (H1N1)pdm09-related pneumonia, it is difficult to express them in a reliable scoring system.
ANTECEDENTES: La neumonía adquirida en la comunidad (NAC) causa una considerable mortalidad en todo el mundo, pero los datos limitados comparar la mortalidad en diferentes regiones del mundo. Nuestro objetivo fue determinar si había una diferencia en la mortalidad entre los pacientes hospitalizados con NAC en tres regiones continentales del mundo.
MÉTODOS: Se realizó un estudio de cohortes de pacientes hospitalizados por neumonía entre noviembre de 2001 y diciembre de 2011 de 70 instituciones en 16 países de los Estados Unidos / Canadá, Europa y América Latina; la Organización de la Comunidad Neumonía Adquirida (CAPO) base de datos internacional. El resultado primario fue la mortalidad y los factores de interés incluye las regiones del mundo, los procesos de atención, la gravedad de la enfermedad, agente patógeno asociado, comorbilidades específicas, y la terapia antimicrobiana. Regresión logística multivariante se realizó para ajustar para efectos de confusión sobre las diferencias en la mortalidad entre las regiones. Los pacientes se analizaron por separado en función de su estatus de admisión unidad de cuidados intensivos.
RESULTADOS: Un total de 6.371 pacientes fueron revisados. América Latina tuvo el mayor mortalidad (13,3%), seguido de Europa (9,1%) y los EE.UU. / Canadá (7,3%) (p <0,001 para diferencias entre regiones). Variables de confusión importantes incluyen comorbilidades (es decir, la insuficiencia cardíaca congestiva, enfermedad cerebrovascular), el nivel de nitrógeno de urea en sangre elevada, el tratamiento antimicrobiano (macrólido o el uso de fluoroquinolonas), y si el paciente tenía vacunaciones anteriores (influenza, neumococo). Tras ajustar por variables de confusión, las diferencias estimadas en la mortalidad entre las tres regiones se redujeron de manera significativa tanto para los pacientes en la UCI y la sala.
CONCLUSIONES: Hubo una discrepancia observada en la mortalidad de la PAC entre tres regiones del mundo. Factores identificados que han contribuido a estas diferencias incluyen la incidencia de la infección por H1N1, BUN elevado, enfermedad cerebrovascular, el uso de macrólidos, el uso de fluoroquinolonas y las vacunas. Régimen de tratamiento (uso de fluoroquinolonas y los macrólidos) y las medidas de prevención (vacunas) fueron las variables que pueden ser modificados para ayudar a aliviar las diferencias.