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1.
Eur Respir J ; 2024 Oct 03.
Artículo en Inglés | MEDLINE | ID: mdl-39362667

RESUMEN

Fungal lung disease encompasses a wide spectrum of organisms and associated clinical conditions presenting a significant global health challenge with type and severity determined by underlying host immunity and infecting fungal strain. The most common group of diseases are associated with the filamentous fungus Aspergillus spp. and include allergic bronchopulmonary aspergillosis (ABPA), sensitization, aspergilloma, and chronic and invasive pulmonary aspergillosis. Fungal lung disease remains epidemiologically heterogenous and is influenced by geography, environment, and host comorbidities. Diagnostic modalities continue to evolve and now include novel molecular assays and biomarkers, however, persisting challenges include achieving rapid and accurate diagnosis, particularly in resource-limited settings and in differentiating fungal infection from other pulmonary conditions. Treatment strategies for fungal lung diseases rely mainly on antifungal agents, however, the emergence of drug-resistant strains poses a substantial global threat and adds complexity to existing therapeutic challenges. Emerging antifungal agents and increasing insight into lung mycobiome via may offer fresh and personalized approaches to diagnosis and treatment, while innovative methodologies are required to mitigate drug resistance and adverse effects of treatment. This state-of-the-art review describes the current landscape of fungal lung disease, highlighting key clinical insights, current challenges, and emerging approaches for its diagnosis and treatment.

2.
Semin Respir Crit Care Med ; 44(4): 468-476, 2023 08.
Artículo en Inglés | MEDLINE | ID: mdl-37429296

RESUMEN

Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.


Asunto(s)
Empiema , Derrame Pleural , Neumonía , Humanos , Anciano , Estudios Prospectivos , Derrame Pleural/complicaciones , Fibrinolíticos , Empiema/tratamiento farmacológico , Exudados y Transudados , Neumonía/tratamiento farmacológico
3.
Am J Respir Crit Care Med ; 205(9): 1093-1101, 2022 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-35081010

RESUMEN

Rationale: Pleural effusion commonly complicates community-acquired pneumonia and is associated with intense pleural inflammation. Whether antiinflammatory treatment with corticosteroids improves outcomes is unknown. Objectives: To assess the effects of corticosteroids in an adult population with pneumonia-related pleural effusion. Methods: The STOPPE (Steroid Therapy and Outcome of Parapneumonic Pleural Effusions) trial was a pilot, multicenter, double-blinded, placebo-controlled, randomized trial involving six Australian centers. Patients with community-acquired pneumonia and pleural effusion were randomized (2:1) to intravenous dexamethasone (4 mg twice daily for 48 h) or placebo and followed for 30 days. Given the diverse effects of corticosteroids, a comprehensive range of clinical, serological, and imaging outcomes were assessed in this pilot trial (ACTRN12618000947202). Measurements and Main Results: Eighty patients were randomized (one withdrawn before treatment) and received dexamethasone (n = 51) or placebo (n = 28). This pilot trial found no preliminary evidence of benefits of dexamethasone in improving time to sustained (>12 h) normalization of vital signs (temperature, oxygen saturations, blood pressure, heart, and respiratory rates): median, 41.0 (95% confidence interval, 32.3-54.5) versus 27.8 (15.4-49.5) hours in the placebo arm (hazard ratio, 0.729 [95% confidence interval, 0.453-1.173]; P = 0.193). Similarly, no differences in C-reactive protein or leukocyte counts were observed, except for a higher leukocyte count in the dexamethasone group at Day 3. Pleural drainage procedures were performed in 49.0% of dexamethasone-treated and 42.9% of placebo-treated patients (P = 0.60). Radiographic pleural opacification decreased over time with no consistent intergroup differences. Mean duration of antibiotic therapy (22.4 [SD, 15.4] vs. 20.4 [SD, 13.8] d) and median hospitalization (6.0 [interquartile range, 5.0-10.0] vs. 5.5 [interquartile range, 5.0-8.0] d) were similar between the dexamethasone and placebo groups. Serious adverse events occurred in 25.5% of dexamethasone-treated and 21.4% of placebo-treated patients. Transient hyperglycemia more commonly affected the dexamethasone group (15.6% vs. 7.1%). Conclusions: Systemic corticosteroids showed no preliminary benefits in adults with parapneumonic effusions. Clinical trial registered with www.anzctr.org.au (ACTRN12618000947202).


Asunto(s)
Infecciones Comunitarias Adquiridas , Derrame Pleural , Neumonía , Corticoesteroides/uso terapéutico , Adulto , Australia , Infecciones Comunitarias Adquiridas/complicaciones , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Dexametasona/uso terapéutico , Humanos , Proyectos Piloto , Derrame Pleural/tratamiento farmacológico , Neumonía/complicaciones , Esteroides/uso terapéutico
5.
Curr Opin Infect Dis ; 34(2): 175-179, 2021 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-33492003

RESUMEN

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19) has produced an extraordinary amount of literature in a short time period. This review focuses on what the new literature has provided in terms of more general information about the management of community-acquired pneumonia (CAP). RECENT FINDINGS: Measures taken to reduce the spread of COVID-19 have caused a significant drop in influenza worldwide. Improvements in imaging, especially ultrasound, and especially in the application of rapid molecular diagnosis are likely to have significant impact on the management of CAP. Therapeutic advances are so far limited. SUMMARY: COVID-19 has taught us that we can do far more to prevent seasonal influenza and its associated mortality, morbidity and economic cost. Improvements in imaging and pathogen diagnosis are welcome, as is the potential for secondary benefits of anti-COVID-19 therapies that may have reach effect on respiratory viruses other than severe acute respiratory syndrome coronavirus 2. As community-transmission is likely to persist for many years, recognition and treatment of severe acute respiratory syndrome coronavirus 2 will need to be incorporated into CAP guidelines moving forward.


Asunto(s)
COVID-19/diagnóstico , COVID-19/prevención & control , COVID-19/epidemiología , COVID-19/terapia , Técnicas de Laboratorio Clínico , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/prevención & control , Infecciones Comunitarias Adquiridas/terapia , Diagnóstico por Imagen , Humanos , Control de Infecciones , Neumonía/diagnóstico , Neumonía/prevención & control , Neumonía/terapia , SARS-CoV-2
6.
Curr Opin Pulm Med ; 26(3): 203-207, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32084039

RESUMEN

PURPOSE OF REVIEW: The American Thoracic Society and Infectious Diseases Society of America recently released their joint guideline for the diagnosis and treatment of adults with community-acquired pneumonia (CAP). The co-chairs of the guideline committee provide a summary of the guideline process, key recommendations from the new guideline and future directions for CAP research. RECENT FINDINGS: The guideline committee included 14 experts from the two societies. Sixteen questions for the guideline were selected using the PICO format. The GRADE approach was utilized to review the available evidence and generate recommendations. The recommendations included expanded microbiological testing for patients suspected of drug-resistant infections, empiric first-line therapy recommendations for outpatients and inpatients including use of beta-lactam monotherapy for uncomplicated outpatients, elimination of healthcare-associated pneumonia as a treatment category, and not recommending corticosteroids as routine adjunct therapy. SUMMARY: CAP is a major cause of morbidity and mortality. Effective antibiotic therapy is available and remains largely empirical. New diagnostic tests and treatment options are emerging and will lead to guideline updates in the future.


Asunto(s)
Antibacterianos/uso terapéutico , Neumonía/diagnóstico , Neumonía/tratamiento farmacológico , Corticoesteroides/uso terapéutico , Adulto , Programas de Optimización del Uso de los Antimicrobianos , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Farmacorresistencia Bacteriana , Humanos , Guías de Práctica Clínica como Asunto
8.
Am J Respir Crit Care Med ; 200(7): e45-e67, 2019 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-31573350

RESUMEN

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.


Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/tratamiento farmacológico , Adulto , Atención Ambulatoria , Antígenos Bacterianos/orina , Cultivo de Sangre , Infecciones por Chlamydophila/diagnóstico , Infecciones por Chlamydophila/tratamiento farmacológico , Infecciones por Chlamydophila/metabolismo , Técnicas de Cultivo , Quimioterapia Combinada , Infecciones por Haemophilus/diagnóstico , Infecciones por Haemophilus/tratamiento farmacológico , Infecciones por Haemophilus/metabolismo , Hospitalización , Humanos , Legionelosis/diagnóstico , Legionelosis/tratamiento farmacológico , Legionelosis/metabolismo , Macrólidos/uso terapéutico , Infecciones por Moraxellaceae/diagnóstico , Infecciones por Moraxellaceae/tratamiento farmacológico , Infecciones por Moraxellaceae/metabolismo , Neumonía por Mycoplasma/diagnóstico , Neumonía por Mycoplasma/tratamiento farmacológico , Neumonía por Mycoplasma/metabolismo , Neumonía Neumocócica/diagnóstico , Neumonía Neumocócica/tratamiento farmacológico , Neumonía Neumocócica/metabolismo , Neumonía Estafilocócica/diagnóstico , Neumonía Estafilocócica/tratamiento farmacológico , Neumonía Estafilocócica/metabolismo , Radiografía Torácica , Índice de Severidad de la Enfermedad , Esputo , Estados Unidos , beta-Lactamas/uso terapéutico
10.
Clin Infect Dis ; 68(12): 2026-2033, 2019 05 30.
Artículo en Inglés | MEDLINE | ID: mdl-30265290

RESUMEN

BACKGROUND: Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated. METHODS: We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. RESULTS: Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%) and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%) and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. CONCLUSIONS: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.


Asunto(s)
Antígenos Bacterianos/orina , Infecciones Comunitarias Adquiridas/diagnóstico , Pruebas Inmunológicas , Enfermedad de los Legionarios/diagnóstico , Neumonía Neumocócica/diagnóstico , Anciano , Anciano de 80 o más Años , Biomarcadores , Infecciones Comunitarias Adquiridas/inmunología , Infecciones Comunitarias Adquiridas/microbiología , Estudios Transversales , Femenino , Humanos , Pruebas Inmunológicas/métodos , Enfermedad de los Legionarios/inmunología , Enfermedad de los Legionarios/microbiología , Masculino , Persona de Mediana Edad , Neumonía Neumocócica/inmunología , Neumonía Neumocócica/microbiología , Vigilancia en Salud Pública , Sensibilidad y Especificidad , Urinálisis/métodos
11.
N Engl J Med ; 373(5): 415-27, 2015 Jul 30.
Artículo en Inglés | MEDLINE | ID: mdl-26172429

RESUMEN

BACKGROUND: Community-acquired pneumonia is a leading infectious cause of hospitalization and death among U.S. adults. Incidence estimates of pneumonia confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS: We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among adults 18 years of age or older in five hospitals in Chicago and Nashville. Patients with recent hospitalization or severe immunosuppression were excluded. Blood, urine, and respiratory specimens were systematically collected for culture, serologic testing, antigen detection, and molecular diagnostic testing. Study radiologists independently reviewed chest radiographs. We calculated population-based incidence rates of community-acquired pneumonia requiring hospitalization according to age and pathogen. RESULTS: From January 2010 through June 2012, we enrolled 2488 of 3634 eligible adults (68%). Among 2320 adults with radiographic evidence of pneumonia (93%), the median age of the patients was 57 years (interquartile range, 46 to 71); 498 patients (21%) required intensive care, and 52 (2%) died. Among 2259 patients who had radiographic evidence of pneumonia and specimens available for both bacterial and viral testing, a pathogen was detected in 853 (38%): one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%). The most common pathogens were human rhinovirus (in 9% of patients), influenza virus (in 6%), and Streptococcus pneumoniae (in 5%). The annual incidence of pneumonia was 24.8 cases (95% confidence interval, 23.5 to 26.1) per 10,000 adults, with the highest rates among adults 65 to 79 years of age (63.0 cases per 10,000 adults) and those 80 years of age or older (164.3 cases per 10,000 adults). For each pathogen, the incidence increased with age. CONCLUSIONS: The incidence of community-acquired pneumonia requiring hospitalization was highest among the oldest adults. Despite current diagnostic tests, no pathogen was detected in the majority of patients. Respiratory viruses were detected more frequently than bacteria. (Funded by the Influenza Division of the National Center for Immunizations and Respiratory Diseases.).


Asunto(s)
Hospitalización/estadística & datos numéricos , Neumonía/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Chicago/epidemiología , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Femenino , Humanos , Incidencia , Pulmón/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Neumonía/clasificación , Neumonía/microbiología , Vigilancia de la Población , Radiografía , Factores de Riesgo , Estaciones del Año , Índice de Severidad de la Enfermedad , Tennessee/epidemiología , Adulto Joven
12.
Am J Respir Crit Care Med ; 196(5): 609-620, 2017 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-28614669

RESUMEN

RATIONALE: Up to one-third of patients hospitalized with pneumococcal pneumonia experience major adverse cardiac events (MACE) during or after pneumonia. In mice, Streptococcus pneumoniae can invade the myocardium, induce cardiomyocyte death, and disrupt cardiac function following bacteremia, but it is unknown whether the same occurs in humans with severe pneumonia. OBJECTIVES: We sought to determine whether S. pneumoniae can (1) translocate the heart, (2) induce cardiomyocyte death, (3) cause MACE, and (4) induce cardiac scar formation after antibiotic treatment during severe pneumonia using a nonhuman primate (NHP) model. METHODS: We examined cardiac tissue from six adult NHPs with severe pneumococcal pneumonia and three uninfected control animals. Three animals were rescued with antibiotics (convalescent animals). Electrocardiographic, echocardiographic, and serum biomarkers of cardiac damage were measured (troponin T, N-terminal pro-brain natriuretic peptide, and heart-type fatty acid binding protein). Histological examination included hematoxylin and eosin staining, immunofluorescence, immunohistochemistry, picrosirius red staining, and transmission electron microscopy. Immunoblots were used to assess the underlying mechanisms. MEASUREMENTS AND MAIN RESULTS: Nonspecific ischemic alterations were detected by electrocardiography and echocardiography. Serum levels of troponin T and heart-type fatty acid binding protein were increased (P < 0.05) after pneumococcal infection in both acutely ill and convalescent NHPs. S. pneumoniae was detected in the myocardium of all NHPs with acute severe pneumonia. Necroptosis and apoptosis were detected in the myocardium of both acutely ill and convalescent NHPs. Evidence of cardiac scar formation was observed only in convalescent animals by transmission electron microscopy and picrosirius red staining. CONCLUSIONS: S. pneumoniae invades the myocardium and induces cardiac injury with necroptosis and apoptosis, followed by cardiac scarring after antibiotic therapy, in an NHP model of severe pneumonia.


Asunto(s)
Cardiotoxicidad/etiología , Miocardio/patología , Neumonía Neumocócica/complicaciones , Streptococcus pneumoniae/patogenicidad , Animales , Antibacterianos/uso terapéutico , Western Blotting , Cardiotoxicidad/sangre , Modelos Animales de Enfermedad , Ecocardiografía , Electrocardiografía , Proteínas de Unión a Ácidos Grasos/sangre , Femenino , Corazón/microbiología , Masculino , Papio , Neumonía Neumocócica/sangre , Neumonía Neumocócica/tratamiento farmacológico , Troponina T/sangre
13.
Turk J Med Sci ; 48(4): 730-736, 2018 Aug 16.
Artículo en Inglés | MEDLINE | ID: mdl-30119147

RESUMEN

Background/aim: The optimal empiric antibiotic regimen for patients with community-acquired pneumonia (CAP) remains unclear. This study aimed to evaluate the clinical cure rate, mortality, and length of stay among patients hospitalized with community- acquired pneumonia in nonintensive care unit (ICU) wards and treated with a ß-lactam, ß-lactam and macrolide combination, or a fluoroquinolone. Materials and methods: This prospective cohort study was performed using standardized web-based database sheets from January 2009 to September 2013 in nine tertiary care hospitals in Turkey. Results: Six hundred and twenty-one consecutive patients were enrolled. A pathogen was identified in 78 (12.6%) patients. The most frequently isolated bacteria were S. pneumoniae (21.8%) and P. aeruginosa (19.2%). The clinical cure rate and length of stay were not different among patients treated with ß-lactam, ß-lactam and macrolide combination, and fluoroquinolone. Forty-seven patients (9.2%) died during the hospitalization period. There was no difference in survival among the three treatment groups. Conclusion: In patients admitted to non-ICU hospital wards for CAP, there was no difference in clinical outcomes between ß-lactam, ß-lactam and macrolide combination, and fluoroquinolone regimens.


Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Fluoroquinolonas/uso terapéutico , Tiempo de Internación , Macrólidos/uso terapéutico , Neumonía/tratamiento farmacológico , beta-Lactamas/uso terapéutico , Anciano , Anciano de 80 o más Años , Infecciones Comunitarias Adquiridas/microbiología , Infecciones Comunitarias Adquiridas/mortalidad , Quimioterapia Combinada , Femenino , Departamentos de Hospitales , Mortalidad Hospitalaria , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Neumonía/microbiología , Neumonía/mortalidad , Estudios Prospectivos , Pseudomonas aeruginosa/crecimiento & desarrollo , Streptococcus pneumoniae/crecimiento & desarrollo , Resultado del Tratamiento , Turquía/epidemiología
14.
Clin Infect Dis ; 64(11): 1564-1572, 2017 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-28329167

RESUMEN

BACKGROUND.: Annual influenza vaccine is recommended for those at greatest risk of severe influenza infection. Recent reports of a negative impact of serial influenza vaccination on vaccine effectiveness (VE) raises concerns about the recommendation for annual influenza vaccines, particularly in persons at greatest risk. METHODS.: The Influenza Complications Alert Network (FluCAN) is an Australian hospital-based sentinel surveillance program. In this observational study, cases were defined as subjects aged >9 years admitted with influenza confirmed by polymerase chain reaction. Controls were subjects with acute respiratory illness testing negative for influenza. Propensity scores were used to adjust for the likelihood of being vaccinated. VE was calculated as 1 - adjusted odds ratio of vaccination in cases compared with test-negative controls. RESULTS.: Over 2010-2015, 6223 cases and 6505 controls were hospitalized with confirmed influenza and influenza test-negative acute respiratory illness, respectively. Following stratification by quintile of propensity score, site, and year, VE was estimated to be 43% (95% confidence interval [CI], 37%-49%) overall. VE was estimated to be 51% (95% CI, 45%-57%) in those vaccinated in both the current and previous season, compared with 33% (95% CI, 17%-47%) vaccinated in the current season only and 35% (95% CI, 21%-46%) in the previous season only. Similar results were observed for influenza A/H1N1, influenza A/H3N2, and influenza B strains. CONCLUSIONS.: Vaccination in both the current and previous seasons was associated with a higher VE against hospitalization with influenza than vaccination in either single season. These findings reinforce current recommendations for annual influenza vaccination, particularly those at greatest risk of influenza disease.


Asunto(s)
Hospitalización , Vacunas contra la Influenza/administración & dosificación , Gripe Humana , Potencia de la Vacuna , Adolescente , Adulto , Anciano , Australia/epidemiología , Estudios de Casos y Controles , Niño , Femenino , Humanos , Subtipo H1N1 del Virus de la Influenza A/genética , Subtipo H1N1 del Virus de la Influenza A/inmunología , Subtipo H1N1 del Virus de la Influenza A/aislamiento & purificación , Subtipo H3N2 del Virus de la Influenza A/genética , Subtipo H3N2 del Virus de la Influenza A/inmunología , Subtipo H3N2 del Virus de la Influenza A/aislamiento & purificación , Virus de la Influenza B/genética , Virus de la Influenza B/inmunología , Virus de la Influenza B/aislamiento & purificación , Vacunas contra la Influenza/efectos adversos , Gripe Humana/diagnóstico , Gripe Humana/epidemiología , Gripe Humana/prevención & control , Gripe Humana/virología , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Reacción en Cadena de la Polimerasa , Factores de Riesgo , Estaciones del Año , Vigilancia de Guardia , Factores de Tiempo , Vacunación , Adulto Joven
15.
Clin Infect Dis ; 65(2): 183-190, 2017 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-28407054

RESUMEN

BACKGROUND: Recent trials suggest procalcitonin-based guidelines can reduce antibiotic use for respiratory infections. However, the accuracy of procalcitonin to discriminate between viral and bacterial pneumonia requires further dissection. METHODS: We evaluated the association between serum procalcitonin concentration at hospital admission with pathogens detected in a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia. Systematic pathogen testing included cultures, serology, urine antigen tests, and molecular detection. Accuracy of procalcitonin to discriminate between viral and bacterial pathogens was calculated. RESULTS: Among 1735 patients, pathogens were identified in 645 (37%), including 169 (10%) with typical bacteria, 67 (4%) with atypical bacteria, and 409 (24%) with viruses only. Median procalcitonin concentration was lower with viral pathogens (0.09 ng/mL; interquartile range [IQR], <0.05-0.54 ng/mL) than atypical bacteria (0.20 ng/mL; IQR, <0.05-0.87 ng/mL; P = .05), and typical bacteria (2.5 ng/mL; IQR, 0.29-12.2 ng/mL; P < .01). Procalcitonin discriminated bacterial pathogens, including typical and atypical bacteria, from viral pathogens with an area under the receiver operating characteristic (ROC) curve of 0.73 (95% confidence interval [CI], .69-.77). A procalcitonin threshold of 0.1 ng/mL resulted in 80.9% (95% CI, 75.3%-85.7%) sensitivity and 51.6% (95% CI, 46.6%-56.5%) specificity for identification of any bacterial pathogen. Procalcitonin discriminated between typical bacteria and the combined group of viruses and atypical bacteria with an area under the ROC curve of 0.79 (95% CI, .75-.82). CONCLUSIONS: No procalcitonin threshold perfectly discriminated between viral and bacterial pathogens, but higher procalcitonin strongly correlated with increased probability of bacterial pathogens, particularly typical bacteria.


Asunto(s)
Biomarcadores/sangre , Calcitonina/sangre , Infecciones Comunitarias Adquiridas/sangre , Infecciones Comunitarias Adquiridas/diagnóstico , Neumonía Bacteriana/sangre , Neumonía Viral/sangre , Anciano , Programas de Optimización del Uso de los Antimicrobianos , Infecciones Comunitarias Adquiridas/microbiología , Infecciones Comunitarias Adquiridas/virología , Enterobacteriaceae/clasificación , Enterobacteriaceae/genética , Enterobacteriaceae/aislamiento & purificación , Femenino , Hospitalización , Humanos , Inmunoensayo , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/microbiología , Neumonía Viral/diagnóstico , Reacción en Cadena de la Polimerasa , Estudios Prospectivos , Curva ROC , Sensibilidad y Especificidad , Virus/clasificación , Virus/genética , Virus/aislamiento & purificación
17.
Clin Infect Dis ; 63(5): 575-82, 2016 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-27521441

RESUMEN

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.


Asunto(s)
Infección Hospitalaria/diagnóstico , Infección Hospitalaria/terapia , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/terapia , Neumonía Asociada al Ventilador/diagnóstico , Neumonía Asociada al Ventilador/terapia , Adulto , Antibacterianos/uso terapéutico , Técnicas Bacteriológicas , Farmacorresistencia Bacteriana Múltiple , Humanos , Guías de Práctica Clínica como Asunto , Estados Unidos
18.
Clin Infect Dis ; 63(3): 300-9, 2016 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-27161775

RESUMEN

BACKGROUND: Prevalence of Staphylococcus aureus community-acquired pneumonia (CAP) and its clinical features remain incompletely understood, complicating empirical selection of antibiotics. METHODS: Using a multicenter, prospective surveillance study of adults hospitalized with CAP, we calculated the prevalence of methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) among all CAP episodes. We compared the epidemiologic, radiographic, and clinical characteristics of S. aureus CAP (per respiratory or blood culture) with those of pneumococcal (per respiratory or blood culture or urine antigen) and all-cause non-S. aureus CAP using descriptive statistics. RESULTS: Among 2259 adults hospitalized for CAP, 37 (1.6%) had S. aureus identified, including 15 (0.7%) with MRSA and 22 (1.0%) with MSSA; 115 (5.1%) had Streptococcus pneumoniae Vancomycin or linezolid was administered to 674 (29.8%) patients within the first 3 days of hospitalization. Chronic hemodialysis use was more common among patients with MRSA (20.0%) than pneumococcal (2.6%) and all-cause non-S. aureus (3.7%) CAP. Otherwise, clinical features at admission were similar, including concurrent influenza infection, hemoptysis, multilobar infiltrates, and prehospital antibiotics. Patients with MRSA CAP had more severe clinical outcomes than those with pneumococcal CAP, including intensive care unit admission (86.7% vs 34.8%) and in-patient mortality (13.3% vs 4.4%). CONCLUSIONS: Despite very low prevalence of S. aureus and, specifically, MRSA, nearly one-third of adults hospitalized with CAP received anti-MRSA antibiotics. The clinical presentation of MRSA CAP overlapped substantially with pneumococcal CAP, highlighting the challenge of accurately targeting empirical anti-MRSA antibiotics with currently available clinical tools and the need for new diagnostic strategies.


Asunto(s)
Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas/epidemiología , Neumonía Estafilocócica/epidemiología , Staphylococcus aureus/efectos de los fármacos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Centers for Disease Control and Prevention, U.S. , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/microbiología , Monitoreo Epidemiológico , Femenino , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Persona de Mediana Edad , Neumonía Estafilocócica/diagnóstico , Neumonía Estafilocócica/microbiología , Prevalencia , Estudios Prospectivos , Estados Unidos/epidemiología , Adulto Joven
19.
Clin Infect Dis ; 63(5): e61-e111, 2016 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-27418577

RESUMEN

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.


Asunto(s)
Infección Hospitalaria/diagnóstico , Infección Hospitalaria/terapia , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/terapia , Neumonía Asociada al Ventilador/diagnóstico , Neumonía Asociada al Ventilador/terapia , Adulto , Antibacterianos/uso terapéutico , Técnicas Bacteriológicas , Farmacorresistencia Bacteriana Múltiple , Humanos , Estados Unidos
20.
Cytokine ; 88: 267-273, 2016 12.
Artículo en Inglés | MEDLINE | ID: mdl-27701021

RESUMEN

OBJECTIVE: To determine if serum levels of endothelial adhesion molecules were associated with the development of multiple organ failure (MOF) and in-hospital mortality in adult patients with severe sepsis. DESIGN: This study was a secondary data analysis of a prospective cohort study. SETTING: Patients were admitted to two tertiary intensive care units in San Antonio, TX, between 2007 and 2012. PATIENTS: Patients with severe sepsis at the time of intensive care unit (ICU) admission were enrolled. Inclusion criteria were consistent with previously published criteria for severe sepsis or septic shock in adults. Exclusion criteria included immunosuppressive medications or conditions. INTERVENTIONS: None. MEASUREMENTS: Baseline serum levels of the following endothelial cell adhesion molecules were measured within the first 72h of ICU admission: Intracellular Adhesion Molecule 1 (ICAM-1), Vascular Cell Adhesion Molecule-1 (VCAM-1), and Vascular Endothelial Growth Factor (VEGF). The primary and secondary outcomes were development of MOF (⩾2 organ dysfunction) and in-hospital mortality, respectively. MAIN RESULTS: Forty-eight patients were enrolled in this study, of which 29 (60%) developed MOF. Patients that developed MOF had higher levels of VCAM-1 (p=0.01) and ICAM-1 (p=0.01), but not VEGF (p=0.70) compared with patients without MOF (single organ failure only). The area under the curve (AUC) to predict MOF according to VCAM-1, ICAM-1 and VEGF was 0.71, 0.73, and 0.54, respectively. Only increased VCAM-1 levels were associated with in-hospital mortality (p=0.03). These associations were maintained even after adjusting for APACHE and SOFA scores using logistic regression. CONCLUSIONS: High levels of serum ICAM-1 was associated with the development of MOF. High levels of VCAM-1 was associated with both MOF and in-hospital mortality.


Asunto(s)
Mortalidad Hospitalaria , Molécula 1 de Adhesión Intercelular/sangre , Insuficiencia Multiorgánica , Sepsis , Molécula 1 de Adhesión Celular Vascular/sangre , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/sangre , Insuficiencia Multiorgánica/mortalidad , Sepsis/sangre , Sepsis/mortalidad , Índice de Severidad de la Enfermedad , Factor A de Crecimiento Endotelial Vascular/sangre
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