RESUMEN
Severe COVID-19 is associated with a systemic inflammatory response and progressive CD4+ T-cell lymphopenia and dysfunction. We evaluated whether platelets might contribute to CD4+ T-cell dysfunction in COVID-19. We observed a high frequency of CD4+ T cell-platelet aggregates in COVID-19 inpatients that inversely correlated with lymphocyte counts. Platelets from COVID-19 inpatients but not from healthy donors (HD) inhibited the upregulation of CD25 expression and tumour necrosis factor (TNF)-α production by CD4+ T cells. In addition, interferon (IFN)-γ production was increased by platelets from HD but not from COVID-19 inpatients. A high expression of PD-L1 was found in platelets from COVID-19 patients to be inversely correlated with IFN-γ production by activated CD4+ T cells cocultured with platelets. We also found that a PD-L1-blocking antibody significantly restored platelets' ability to stimulate IFN-γ production by CD4+ T cells. Our study suggests that platelets might contribute to disease progression in COVID-19 not only by promoting thrombotic and inflammatory events, but also by affecting CD4+ T cells functionality.
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Antígeno B7-H1 , COVID-19 , Antígeno B7-H1/metabolismo , Plaquetas/metabolismo , Linfocitos T CD4-Positivos , Humanos , Interferón gammaRESUMEN
Chagas disease reactivation in HIV-positive people is an opportunistic infection with 79 to 100% mortality. It commonly involves the central nervous system (CNS). Early treatment with trypanocidal drugs such as benznidazole (BNZ) is crucial for this severe manifestation of Trypanosoma cruzi infection. However, limited BNZ clinical pharmacology data are available, especially its concentration in the CNS. We report a series of HIV-positive patients undergoing treatment for T. cruzi meningoencephalitis, their clinical response, and cerebrospinal fluid (CSF) and plasma BNZ concentrations. Measurements were carried out using leftover samples originally obtained for routine medical care. A high-performance liquid chromatography/tandem mass spectrometry bioanalytical method designed for BNZ plasma measurements was adapted and validated for CSF samples. Six patients were enrolled in this study from 2015 to 2019. A total of 6 CSF and 19 plasma samples were obtained. Only three of the CSF samples had detectable BNZ levels, all under 1 µg/ml. Fifteen plasma samples had detectable BNZ, and 13 were above 2 µg/ml, which is the putative trypanocidal level. We observed BNZ concentrations in human CSF and plasma. CSF BNZ concentrations were low or not measurable in all patients, suggesting that the usual BNZ doses may be suboptimal in HIV-positive patients with T. cruzi meningoencephalitis. While drug-drug and drug-disease interactions may be in part responsible, the factors leading to low CSF BNZ levels remain to be studied in detail. These findings highlight the potential of therapeutic drug monitoring in BNZ treatment and suggest that the use of higher doses may be useful for Chagas disease CNS reactivations.
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Enfermedad de Chagas , Infecciones por VIH , Meningoencefalitis , Nitroimidazoles , Tripanocidas , Trypanosoma cruzi , Enfermedad de Chagas/tratamiento farmacológico , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Humanos , Meningoencefalitis/tratamiento farmacológico , Nitroimidazoles/uso terapéutico , Tripanocidas/uso terapéuticoRESUMEN
A 31-year-old woman, with signs of HIV infection (oral thrush, weight loss, asthenia) presented to our hospital with dyspnea and fever. A rapid HIV test yielded a positive result, and cryptococcal capsular antigen was detected in serum. In the mycological study of the clinical respiratory samples, yeasts compatible with Cryptococcus were observed under light microscope in a wet mount; structures compatible with Pneumocystis jirovecii were also observed in Giemsa stain. Treatment for both pathologies was prescribed but, unfortunately, the patient died 7 days after. The finding of two etiologic agents in the same clinical picture is rare but not exceptional, and it always must be considered in immunocompromised hosts.
Asunto(s)
Infecciones por VIH , Pneumocystis carinii , Neumonía por Pneumocystis , Adulto , Femenino , Humanos , Huésped Inmunocomprometido , MicologíaRESUMEN
Introducción: En COVID-19 grave, identificar pacientes con mayor riesgo de ventilación mecánica (VM) ayuda a optimizar el manejo. Materiales y métodos: Análisis retrospectivo de características clínico-epidemiológicas de pacientes con COVID-19 ingresados a UTI entre marzo/septiembre 2020. Se utilizó estadística descriptiva, análisis univariado (p significativa <0.05) y multivariado (variables significativas en el univariado).Resultados: Ingresaron 114 pacientes, 91 (79,8%) hombres, edad promedio 54,6 ±14,8 años. 66 (57,9%) eran obesos, 44 (38,6%) ≥ 60 años, 38 (33,3%) hipertensos (33,3%) y 28 (24,6%) diabéticos. 39 (23%) tenían ferritina elevada, 62 (76,5%) linfopenia y 33 (41,3%) LDH aumentada. Mortalidad global 34%. 72 pacientes (63,1%) requirieron VM. Los predictores independientes de requerimiento de VM en el análisis multivariado fueron sexo masculino, edad ≥60 años, diabetes, linfopenia y ferritina y LDH aumentadas. Conclusiones: En pacientes con COVID-19 grave, los predictores independientes de necesidad de VM fueron sexo masculino, edad ≥ 60 años, diabetes, niveles elevados de ferritina y LDH y linfopenia
Introduction: In severe COVID-19, identifying patients with a higher risk of mechanical ventilation (MV) helps to optimize management.Materials and methods: Retrospective analysis of clinical-epidemiological characteristics of patients with COVID-19 admitted to ICU between March / September 2020. Descriptive statistics, univariate and multivariate analysis were used. Results: 114 patients were admitted, 91 (79.8%) were men, mean age 54.6 ± 14.8 years. 66 (57.9%) were obese, 44 (38.6%) ≥60 years, 38 (33.3%) were hypertensive (33.3%) and 28 (24.6 %) diabetics. 39 (23%) had elevated ferritin, 62 (76.5%) had lymphopenia, and 33 (41.3%) had increased LDH. Overall mortality 34%. 72 patients (63.1%) required MV. The independent predictors of MV requirement in the multivariate analysis were male sex, age ≥60 years, diabetes, lymphopenia, and increased ferritin and LDH.Conclusions: In patients with severe COVID-19, the independent predictors of the need for MV were male sex, age ≥ 60 years, diabetes, elevated levels of ferritin and LDH, and lymphopenia
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Humanos , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Terapia por Inhalación de Oxígeno , Respiración Artificial , Análisis Multivariante , Estudios Retrospectivos , Medición de Riesgo , Prueba de COVID-19 , COVID-19/terapia , Unidades de Cuidados IntensivosRESUMEN
En diciembre de 2019 se identificó en Wuhan, China, un nuevo coronavirus denominado SARS-CoV-2, agente causal de la epidemia de neumonía atípica COVID-2019, que el 11 de marzo de 2020 fue declarada pandemia por la OMS.Hasta el 30 de septiembre de 2020, en Argentina fueron confirmados 751.001 casos y más de 16.937 muertes.La frecuencia y el impacto de las coinfecciones que afectan a los pacientes infectados por SARS-Cov-2 se ha estudiado junto con el avance de la pandemia. Entre las debidas a hongos se encuentran las fungemias por Candida sp, la aspergilosis invasora, las micosis sistémicas endémicas y la neumocistosis. Presentamos las distintas coinfecciones micosis-COVID-19 que fueron asistidas en nuestra institución entre abril y septiembre de 2020, y se realiza un análisis de las características de estas infecciones en pacientes con y sin sida. En este período se internaron 2837 pacientes, 2287 tuvieron diagnóstico confirmado de COVID-19. La coinfección de COVID-19 con micosis pulmonares o sistémicas fue menor al 1%.Dieciocho pacientes presentaron infecciones fúngicas pulmonares o sistémicas. Ocho padecieron candidemias, cinco criptococosis meningeas, dos histoplasmosis, dos aspergilosis invasoras agudas probables y una aspergilosis pulmonar crónica. La estadía prolongada en terapia intensiva facilitó las fungemias por Candida sp, los casos de histoplasmosis y criptococosis parecen relacionarse con la enfermedad avanzada por VIH y no con COVID-19. Los enfermos con un componente inflamatorio basal alto con neumonía grave por coronavirus se relacionan más con micosis invasoras que los enfermos VIH positivos con niveles bajos de LTCD4+
On December 2019 a new coronavirus (SARS-CoV2) result in atypical pneumonía epidemic, it was identified in Wuhan China and it was called COVID-19. Then on March 11 was declared pandemic by the WHO.Until September 30, 2020 in Argentina 751,001 cases and more than 16,937 deaths have been confirmed. The frequency and impact of co-infections affecting SARS-Cov2 infected patients has been studied with the advance of the pandemic. Among those due to fungi are Candida sp fungemias, invasive aspergillosis, endemic systemic mycoses, and pneumocystosis.We present the different mycosis-COVID-19 co-infections that were assisted in F. J. Muñiz Hospital between April and September of this year and review the characteristics of these infections in patients with and without AIDS is carried out.In this period, 2,837 patients were admitted in the Muñiz hospital, 2,287 had a confirmed diagnosis of COVID-19.Co-infection of COVID-19 with pulmonary or systemic mycoses was less than 1%.Eighteen patients had pulmonary or systemic fungal infections. Eight suffered from candidemia, five meningeal cryptococcosis, two histoplasmosis, two probable acute invasive aspergillosis, and one chronic pulmonary aspergillosis.Prolonged stay in intensive care facilitated fungemia due to Candida sp. Histoplasmosis and cryptococcosis cases seem to be related to advanced HIV disease and not to COVID-19.Patients with a high baseline inflammatory component with severe coronavirus pneumonia are more associated with invasive mycoses than HIV-positive patients with low levels of LTCD4 +
Asunto(s)
Humanos , Epidemiología Descriptiva , Estudios Retrospectivos , Aspergilosis Pulmonar Invasiva/microbiología , Candidemia/microbiología , Coinfección , Enfermedades Pulmonares Fúngicas/microbiologíaRESUMEN
ntroducción: Aunque la incidencia de neumonía adquirida en la comunidad (NAC) por Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMR-AC) es inferior al 10%, por su elevada mortalidad debe considerarse en los pacientes graves.Objetivo: Identificar factores de riesgo asociados con SAMR-AC en pacientes con NAC grave. Material y métodos: Estudio observacional, retrospectivo, que analizó pacientes con NAC con diagnóstico etiológico ingresados en terapia intensiva en un hospital público entre 2006 y 2017.Resultados: Se incluyeron 250 episodios de NAC, 53 por SAMR-AC y 197 por otros agentes. Los pacientes con SAMR fueron más jóvenes (35,6±13,4 vs 43,1±12,4, p<0,001) y mostraron mayores tasas de infecciones de piel y estructuras relacionadas (IPER) (58,4% vs 2,0%, p<0,001), empiema (15,9% vs 5,0%, p=0,006), compromiso radiológico bilateral (81,1% vs 36,0%, p<0,001), promedio de score APACHE II basal (16,7±3,8 vs 13,2±4,3, p<0,001) y requerimiento de ventilación mecánica (VM) (33,9 vs 17,6 p=0,009). La tasa de mortalidad fue significativamente mayor para los pacientes con SAMR-AC (35,8% vs 11,1%, p<0,001). Las variables que se asociaron con SAMR-AC fueron IPER (OR 67,99, IC 5% 21,94-210,65), compromiso radiológico bilateral (OR 7,63, IC 95% 3,67-16,11), scoreAPACHE II ≥ 15 (OR 4,37, IC 95% 2,08-9,16), edad ≤ 35 años RESUMENTRABAJO COMPLETO(OR 3,60, IC 95% 1,77-7,29), empiema (OR 3,32, IC 95% 1,24-8,10) y VM (OR 2,85, IC 95% 1,36-5,86). Conclusión: En pacientes con NAC grave, la presencia de IPER, compromiso radiológico bilateral, score APACHE II ≥ 15, edad ≤ 35 años, empiema y VM se asociaron significativamente con mayor probabilidad de infección por SAMR-AC
ntroduction: Despite the incidence of community-acquired pneumonia (CAP) due to community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) being less than 10%, its presence should be considered in critical patients because of its high rate of mortality.Objectives: To identify risk factors associated with CA-MRSA in patients with severe CAP.Materials and method: A retrospective, observational study analysed episodes of etiological diagnosis in patients admitted in Intensive Care Unit in a public hospital between 2006 and 2017.Results: 250 episodes of NAC were included, among which 53 were caused by SAMR-AC and 197 by other agents. Patients with MRSA were the youngest (35.6±13.4 vs 43.1±12.4, p<0.001), and showed higher rates of skin and skin-structure infections (SSSI) (58.4% vs 2.0%, p<0.001), empyema (15.9% vs 5.0%, p=0.006), bilateral radiological compromise (81.1% vs 36.0%, p<0.001), average base-line APACHE II score (16.7±3.8 vs 13.2±4.3, p<0.001) and mechanical ventilation requirement rate (MV) (33.9 vs 17.6 p=0.009). The mortality rate was significantly higher than the one in CA-MRSA patients (35.8% vs 11.1%, p<0.001). The variables associated with CA-MRSA were SSSI (OR 67.99, IC 5% 21.94-210.65), bilateral radiological compromise (OR 7.63, IC 95% 3.67-16.11), APACHE II score ≥ 15 (OR 4.37, IC 95% 2.08-9.16), age ≤35 years (OR 3.60, IC 95% 1.77-7,29), empyema (OR 3.32, IC 95% 1.24-8.10) and MV (OR 2.85, IC 95% 1.36-5.86).Conclusion: The presence of SSSI, bilateral radiological compromise, APACHE II score ≥ 15, age ≤35 years, empyema and MV in patients with severe CAP was largely associated with higher probability of CA-MRSA infection
Asunto(s)
Humanos , Adulto , Neumonía/diagnóstico , Staphylococcus aureus/inmunología , Factores Epidemiológicos , Factores de Riesgo , Infecciones Comunitarias Adquiridas/diagnóstico , APACHE , Staphylococcus aureus Resistente a Meticilina , Estudio Observacional , Hospitales PúblicosRESUMEN
BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is now the most common cause of skin and skin structure infections (SSSI) in several world regions. In Argentina prospective, multicenter clinical studies have only been conducted in pediatric populations. OBJECTIVE: PRIMARY: describe the prevalence, clinical and demographic characteristics of adult patients with community acquired SSSI due to MRSA; secondary: molecular evaluation of CA-MRSA strains. Patients with MRSA were compared to those without MRSA. MATERIALS AND METHODS: Prospective, observational, multicenter, epidemiologic study, with molecular analysis, conducted at 19 sites in Argentina (18 in Buenos Aires) between March 2010 and October 2011. Patients were included if they were ≥ 14 years, were diagnosed with SSSI, a culture was obtained, and there had no significant healthcare contact identified. A logistic regression model was used to identify factors associated with CA-MRSA. Pulse field types, SCCmec, and PVL status were also determined. RESULTS: A total of 311 patients were included. CA-MRSA was isolated in 70% (218/311) of patients. Clinical variables independently associated with CA-MRSA were: presence of purulent lesion (OR 3.29; 95%CI 1.67, 6.49) and age <50 years (OR 2.39; 95%CI 1.22, 4.70). The vast majority of CA-MRSA strains causing SSSI carried PVL genes (95%) and were SCCmec type IV. The sequence type CA-MRSA ST30 spa t019 was the predominant clone. CONCLUSIONS: CA-MRSA is now the most common cause of SSSI in our adult patients without healthcare contact. ST30, SCCmec IV, PVL+, spa t019 is the predominant clone in Buenos Aires, Argentina.
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Infecciones Comunitarias Adquiridas/epidemiología , Staphylococcus aureus Resistente a Meticilina/fisiología , Piel/microbiología , Infecciones Cutáneas Estafilocócicas/diagnóstico , Infecciones Cutáneas Estafilocócicas/epidemiología , Adulto , Argentina/epidemiología , Infecciones Comunitarias Adquiridas/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Introducción: La incidencia creciente de infecciones invasivas por Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMR-AC) obliga a considerar a este patógeno como posible agente etiológico de la neumonía adquirida en la comunidad (NAC). Es importante reconocer variables específicas que se asocien con un mayor riesgo de padecer esta enfermedad, a fin de mejorar la terapia antibiótica empírica y limitar el tratamiento anti-SAMR. Objetivos: Identificar factores de riesgo asociados a SARM-AC en pacientes con NAC hospitalizados en Unidades de Cuidados Intensivos (UCI). Materiales y métodos: Se analizaron de manera retrospectiva todos los episodios de NAC ingresados en la UCI de un hospital público entre los años 2006 y 2014 en los que se logró identificar el agente etiológico. Se dividió a la población en dos grupos según el agente causal: SAMR-AC (NAC-S) o no SAMR-AC (NAC- no S). Se compararon diferentes variables demográficas, epidemiológicas y clínicas entre ambos grupos (análisis univariado). Para identificar factores de riesgo asociados con NAC por SAMR-AC se realizó análisis de regresión logística de las variables que resultaron significativamente diferentes en el análisis univariado. Para valorar diferencias entre ambos grupos se utilizó estadística descriptiva, test de Fisher y análisis de regresión logística. Se utilizó el software EPIcalc-2000. Se consideró significativo un valor de p<0.05. Resultados: Se incluyeron 239 episodios de NAC, de las cuales 39 fueron causadas por SAMR-AC, y 200 por otros agentes, con la siguiente distribución:niae 6 (3%), H1N1 5 (2,5%), Mycoplasma pneunoniae 4 (2%), Moraxella catharralis 3 (1,5%), SAMS 3 (1,5%), otros 6 (3%). Los pacientes del grupo NAC-S fueron significativamente más jóvenes (edad promedio 35.7 años ± 13.0 vs 43.2 ±12.4, p<0.0001), tuvieron en menor proporción infección por virus de la inmunodeficiencia humana (VIH) (23.1% vs 56.0%, p<0.0001) y presentaron con mayor frecuencia requerimiento de ventilación mecánica (VM) en las primeras 24 horas (38.5% vs 18.0%, p=0.008). Los pacientes del grupo NAC-S mostraron un promedio de score de APACHE II significativamente mayor al ingreso (17.0 ±5.3 vs 13.3 ±4.4, p<0.0001). La mortalidad fue significativamente más elevada en el grupo de NAC-S (35.9% vs 11.0%, p=0.0002). En el resto de las variables analizadas no se observaron diferencias significativas. El análisis de regresión logística mostró que las variables que se asociaron con NAC-S fueron edad ≤35 años (OR 3.60, IC 95% 1.77-7.29), score de APACHE II ≥ 15 (OR 4.37, IC 95% 2.08-9.16) y requerimiento de VM (OR 2.85, IC 95% 1.36-5.86). En cambio, la infección por VIH fue una variable que se asoció con menor probabilidad de desarrollar NAC-S (OR 0.24, IC 95% 0.11-0.52). Conclusión: En los pacientes con NAC que ingresan en una UCI, la edad ≤35 años, el score de APACHE II ≥ 15 y la necesidad de VM se asociaron significativamente con mayor probabilidad de infección por SAMR-AC Streptococcus pneumoniae 113 (56,5%); Haemophillus influenzae 39 (19,5%), Chlamydia psitacii 13 (6,5%), Pseudomonas aeruginosa 8 (4%), Klebsiella pneumo
Risk factors associated with methicillin resistant Staphylococcus aureus community acquired pneumonia in patients assisted at Intensive Care Units Introduction: The increasing incidence of invasive infections by Community Acquired methicilin-resistant Staphylococcus aureus (CA-MRSA) makes it necessary to consider this pathogen as a possible etiological agent in Community Acquired Pneumonia (CAP). It is important to recognize specific variables that are associated with an increased risk of this disease, in order to improve empirical antibiotic therapy and to limit anti-MRSA treatment. Objectives: To identify risk factors associated with CA-MRSA in patients with CAP hospitalized in Intensive Care Units (ICUs). Material and methods: We analyse retrospectively all CAP episodes admitted to the ICU of a public hospital between 2006 and 2014 in which the etiologic agent was identified. The population was divided in two groups, according the etiological agent: CA-MRSA (CAP-MRSA) o not CA-MRSA (CAP-no MRSA). Different demographic, epidemiological and clinical variables were compared between both groups (univariate analysis). Logistic regression analysis of variables that were significantly different in the univariate analysis was performed to identify risk factors associated with CAP by CA-MRSA. Descriptive statistic was used, Fisher´s test was performed to assess differences between both groups and logistic regression test was made to know risks factors associated. EPIcalc-2000 software was used. A value of p <0.05 was considered significant. Results: 239 CAP episodes were includes; 39 were caused by CA-MRSA and 200 by others agents. The etiological distribution was: Streptococcus pneumoniae 113 (56,5%); Haemophillus influenzae 39 (19,5%), Chlamydia psitacii 13 (6,5%), Pseudomona aeruginosa 8 (4%), Klebsiella pneumoniae 6 (3%), H1N1 5 (2,5%), Mycoplasma pneunoniae 4 (2%), Moraxella catharralis 3 (1,5%), MSSA 3 (1,5%), others 6 (3%). Patients in the CAP-MRSA group were significant younger (mean age 35.7 years old ± 13.0 vs 43.2 ±12.4, p<0.0001), had a lower proportion of HIV infections (23.1% vs 56.0%, p<0.0001) and needed of mechanical ventilation (MV) in the first 24 hours with higher frequency (38.5% vs 18.0%, p=0.008). Patients in the CAP-MRSA showed a significantly higher APACHE II score on admission (17.0 ±5.3 vs 13.3 ±4.4, p<0.0001). Mortality rate was significantly higher in CAP-MRSA group (35.9% vs 11.0%, p=0.0002). In the other analysed variables, no significant range differences were observed. Logistic regression analysis showed that the variables that were associated with CAP by MRSA were age ≤35 years (OR 3.60, 95% CI 1.77-7.29), APACHE II score ≥ 15 (OR 4.37, CI 95% 2.08-9.16) and MV requirement (OR 2.85, 95% CI 1.36-5.86). HIV infection was associated with lower probability to have CAP-MSA (OR 0.24, CI 95% 0.11-0.52). Conclusion: In patients with CAP who entered an ICU, age ≤35 years, APACHE II score ≥15 and the need for MV were significantly associated with a greater likelihood of CAP-MRSA infection.
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Humanos , Adulto , Persona de Mediana Edad , Neumonía/terapia , Infecciones Estafilocócicas/terapia , Distribución de Chi-Cuadrado , Factores de Riesgo , Mortalidad , APACHE , Staphylococcus aureus Resistente a Meticilina/inmunología , Unidades de Cuidados IntensivosRESUMEN
Las infecciones por Staphylococcus aureus meticilino re-sistente adquirido en la comunidad (SAMR-AC) constituyen un pro-blema emergente debido a su elevada virulencia y gran capacidad de diseminación. Para las infecciones invasivas, las recomendaciones publicadas sugieren vancomicina como droga de elección. Sin em-bargo, no está claro si otras alternativas pudieran ser mejores en de-terminadas situaciones, o si el uso de combinaciones de antibióticos sería beneficioso. No se han realizado trabajos que sugieran que al-guna alternativa terapéutica sea preferible a otra para el tratamiento de pacientes con infecciones invasivas por SAMR-AC, por lo que las decisiones a tomar se basan en la extrapolación de datos de estudios realizados en otros contextos o en la opinión de expertos. Por tal mo-tivo, se presenta esta revisión, con el objeto de poner en manos de los infectólogos y otros especialistas la evidencia disponible, a fin de intentar encontrar las mejores alternativas de tratamiento para estas infecciones
Infections caused to community-acquired methicillin-resistant Staphylococcus aureus ( CA-MRSA ) is an emerging problem due to its high virulence and large capacity of spread. For invasive infections, published recommendations suggest vancomycin as the drug of choice. However, it is unclear whether other alternatives might be better in certain situations, or if the use of combinations of antibiotics would be beneficial. No studies has been done to suggest that any therapeutic alternative is better than another for the treatment of patients with invasive CA-MRSA infections, so the decisions you make are based on extrapolation of data from studies in other contexts or expert opinion. Therefore, this review is presented, in order to put in the hands of infectologist and others specialists the available evidence, in order to find the best treatment options for these infections
Asunto(s)
Humanos , Masculino , Femenino , Infecciones Estafilocócicas/terapia , Infecciones Comunitarias Adquiridas/terapia , Staphylococcus aureus Resistente a Meticilina/inmunologíaRESUMEN
Objetivos: Conocer la frecuencia de Staphylococcus aureus meticilino resistente adquirido en la comunidad (SAMR-AC) en neumonía adquirida en la comunidad (NAC); examinar sus características clínicas - evolutivas y analizar factores de riesgo. Pacientes, material y métodos: Estudio retrospectivo, descriptivo, observacional, realizado en una unidad de cuidados intensivos respiratorios entre 2006 y 2012. Resultados: Se evaluaron 180 pacientes con NAC con diagnóstico etiológico. Etiologías más frecuentes: Streptococcus pneumoniae (50.5%), Haemophillus influenzae (18.3%) ySAMR-AC (12.2%, 22 casos). La neumonía por SAMR-AC se presentó en individuos jóvenes, mayoritariamente hombres. En el 81.8% de los casos el foco primario fue infección de piel y estructuras relacionadas (IPER), 95.4% presentó criterios clínicos de sepsis, 72.7% tuvo compromiso radiológico bilateral y 45.5% desarrolló derrame pleural. El 40.9% requirió ventilación mecánica y el 45.4% utilizó drogas vasoactivas. El 81.8% de los pacientes no alcanzó criterios de estabilidad clínica al cabo de la primer semana y la mortalidad fue del 36.3%, significativamente superior al resto de los microorganismos (8.8%, p<0,001). Los factores clínicos asociados con mayor riesgo de SAMR-AC fueron la presencia de IPER concomitante, compromiso radiológico bilateral, presencia de criterios clínicos de sepsis, edad inferior a 30 años y requerimiento de drogas vasoactivas. Los factores que se asociaron con mortalidad en NAC fueron la etiología por SAMR-AC y el compromiso radiológico bilateral. Conclusiones: La neumonía por SAMR-AC es una patología emergente, asociada a elevada morbimortalidad. Debe ser considerada en pacientes jóvenes, con presencia concomitante de IPER, compromiso radiológico bilateral, criterios clínicos de sepsis o necesidad de drogas vasoactivas.
Objectives: To know the incidence of Community Acquired Pneumonia (CAP) caused by Methicillin Resistant Sthaphylococcus aureus (MRSA), to examine their clinical and developmental characteristics and to analyze risk factors. Materials and Methods: Retrospective, descriptive and observational study carried out at a Respiratory Intensive Care Unit, between 2006 and 2012. Results: 180 patients with etiologic diagnosis of CAP were evaluated. The most common causes were Streptococcus pneumoniae (50.5%), Haemophillus influenzae (18.3%) and MRSA (12.2%, 22 cases). Community Acquired MRSA (CA-MRSA) pneumonia was present in young people, especially in male. In 81.8% of the cases, skin and related structure infections (SRSI) were the primary focus, 95.4% presented clinical criteria of sepsis, 72.7% had bilateral radiology involvement and 45.5% developed pleural effusion. 40.9% needed mechanical ventilation and 45.4% used vasoactive drugs. Clinical stability at the first week was not reached in 81.8% and mortality rate was 36.6%, significantly higher than for pneumonia caused by other microorganisms (8.8% p<0,001). Clinical factors related with high risk of CA-MRSA pneumonia were the concomitant presence of SRSI, bilateral radiology involvement, clinical criteria of sepsis, age <30 years old and need for vasoactive drugs. Factors related to CAP mortality were CA-MRSA aetiology and bilateral radiology involvement. Conclusions: CA-MRSA pneumonia is an emergent disease with high morbidity and mortality. It must be considered in young patients, with SRSI, bilateral radiology involvement, clinical criteria of sepsis or intake of vasoactive drugs.
Asunto(s)
Humanos , Adulto , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/etiología , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/terapia , Neumonía Estafilocócica/microbiología , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Antibacterianos/administración & dosificación , Estudios de Cohortes , Factores de RiesgoRESUMEN
Las infecciones por Staphylococcus aureus meticilino resistente adquirido en la comunidad (SAMR-AC) constituyen un problema emergente debido a su elevada virulencia y gran capacidad de diseminación. Para las infecciones invasivas, las recomendaciones publicadas sugieren vancomicina como droga de elección. Sin embargo, no está claro si otras alternativas pudieran ser mejores en determinadas situaciones, o si el uso de combinaciones de antibióticos sería beneficioso. No se han realizado trabajos que sugieran que alguna alternativa terapéutica sea preferible a otra para el tratamiento de pacientes con infecciones invasivas por SAMR-AC, por lo que las decisiones a tomar se basan en la extrapolación de datos de estudios realizados en otros contextos o en la opinión de expertos. Por tal motivo, se presenta esta revisión, con el objeto de poner en manos de los infectólogos y otros especialistas la evidencia disponible, a fin de intentar encontrar las mejores alternativas de tratamiento para estas infecciones...
Infections caused to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging problem due to its high virulence and large capacity of spread. For invasive infections, published recommendations suggest vancomycin as the drug of choice. However, it is unclear whether other alternatives might be better in certain situations, or if the use of combinations of antibiotics would be beneficial. No studies has been done to suggest that any therapeutic alternative is better than another for the treatment of patients with invasive CA-MRSA infections, so the decisions you make are based on extrapolation of data from studies in other contexts or expert opinion. Therefore, this review is presented, in order to put in the hands of infectologist and others specialists the available evidence, in order to find the best treatmente options for these infections...