Protocolo clínico de atendimento de pneumonia adquirida na comunidade para Pronto-Socorro Infantil do Hospital do Servidor Público Municipal de São Paulo / Clinical protocol for community-acquired pneumonia care for the Children's Emergency Room of the Hospital do Servidor Público Municipal de São Paulo

A pneumonia adquirida na comunidade (PAC) é a infecção aguda do parênquima pulmonar que ocorre no meio comunitário. A PAC representa a maior causa de morbidade e mortalidade em todo o mundo em crianças abaixo de cinco anos. Nesta faixa etária, a etiologia viral é a mais comum; porém, dentre as causas bacterianas, o Streptoccocus pneumoniae é o mais prevalente. As manifestações clínicas variam de acordo com o patógeno, hospedeiro e da gravidade da doença, sendo geralmente descrita com tosse, febre e desconforto respiratório. A PAC complicada é a pneumonia que, apesar do uso de antibióticos, evolui com complicações locais ou sistêmicas. Nos pacientes hospitalizados, as hemoculturas devem ser consideradas para auxiliar no diagnóstico etiológico e planejamento terapêutico. O tratamento inicial deve ser iniciado empiricamente com antibióticos. Caso haja necessidade de hospitalização, hemoculturas devem ser consideradas para auxiliar na propedêutica. Após implementação das vacinas pneumocócicas, principalmente após introdução da vacina pneumocócica 13 valente (PCV 13), houve redução significativa dos casos de pneumonia bacteriana e também da necessidade hospitalização. Diante de tal realidade, a elaboração do trabalho possui como objetivo a melhora dos procedimentos e a padronização dos atendimentos da população pediátrica com um quadro clínico sugestivo pneumonia adquirida na comunidade, que procura o serviço de Pronto Atendimento Infantil do Hospital do Servidor Público Municipal de São Paulo (HSPM), ao construir um protocolo clínico de atendimento específico para a doença. O presente trabalho objetiva elaborar um protocolo clínico de atendimento de pneumonia adquirida na comunidade no Hospital do Servidor Público Municipal de São Paulo, contribuindo na assistência médica dos pacientes pediátricos. Apesar do grande avanço com a introdução das vacinas pneumocócicas, a PAC ainda representa uma importante causa de mortalidade na população infantil, sendo fundamental a elaboração de protocolos clínicos para abordar corretamente os pacientes que recorrem a um Pronto Socorro Infantil. Protocolos clínicos são diretrizes fundamentadas nas melhores práticas para a abordagem e tratamento de determinadas doenças, baseadas em evidência científica. O presente trabalho objetiva a melhora dos procedimentos e a uniformização dos atendimentos da população pediátrica com pneumonia, que procura o serviço de Pronto Atendimento Infantil do Hospital do Servidor Público Municipal de São Paulo (HSPM), com a construção de um protocolo clínico de atendimento específico para a doença, a partir da revisão de literatura atualizada, cujo período de vigência seguirá os progressos científicos sobre o tema. Palavras-chave: Pneumonia Adquirida da Comunidade. Protocolos clínicos. Pediatria. Serviços Médicos de Emergência. Vacinas Pneumocócicas

Burden of pneumococcal pneumonia requiring ICU admission in France: 1-year prognosis, resources use, and costs.

BACKGROUND: Community-acquired pneumonia (CAP), especially pneumococcal CAP (P-CAP), is associated with a heavy burden of illness as evidenced by high rates of intensive care unit (ICU) admission, mortality, and costs. Although well-defined acutely, determinants influencing long-term burden are less known. This study assessed determinants of 28-day and 1-year mortality and costs among P-CAP patients admitted in ICUs. METHODS: Data regarding all hospital and ICU stays in France in 2014 were extracted from the French healthcare administrative database. All patients admitted in the ICU with a pneumonia diagnosis were included, except those hospitalized for pneumonia within the previous 3 months. The pneumococcal etiology and comorbidities were captured. All hospital stays were included in the cost analysis. Comorbidities and other factors effect on the 28-day and 1-year mortality were assessed using a Cox regression model. Factors associated with increased costs were identified using log-linear regression models. RESULTS: Among 182,858 patients hospitalized for CAP in France for 1 year, 10,587 (5.8%) had a P-CAP, among whom 1665 (15.7%) required ICU admission. The in-hospital mortality reached 22.8% at day 28 and 32.3% at 1 year. The mortality risk increased with age > 54 years, malignancies (hazard ratio (HR) 1.54, 95% CI [1.23-1.94], p = 0.0002), liver diseases (HR 2.08, 95% CI [1.61-2.69], p < 0.0001), and the illness severity at ICU admission. Compared with non-ICU-admitted patients, ICU survivors remained at higher risk of 1-year mortality. Within the following year, 38.2% (516/1350) of the 28-day survivors required at least another hospital stay, mostly for respiratory diseases. The mean cost of the initial stay was €19,008 for all patients and €11,637 for subsequent hospital stays within 1 year. One-year costs were influenced by age (lower in patients > 75 years old, p = 0.008), chronic cardiac (+ 11% [0.02-0.19], p = 0.019), and respiratory diseases (+ 11% [0.03-0.18], p = 0.006). CONCLUSIONS: P-CAP in ICU-admitted patients was associated with a heavy burden of mortality and costs at one year. Older age was associated with both early and 1-year increased mortality. Malignant and chronic liver diseases were associated with increased mortality, whereas chronic cardiac failure and chronic respiratory disease with increased costs. TRIAL REGISTRATION: N/A (study on existing database).

Assessment of an Antibody-in-Lymphocyte Supernatant Assay for the Etiological Diagnosis of Pneumococcal Pneumonia in Children.

New diagnostic tests for the etiology of childhood pneumonia are needed. We evaluated the antibody-in-lymphocyte supernatant (ALS) assay to detect immunoglobulin (Ig) G secretion from ex vivo peripheral blood mononuclear cell (PBMC) culture, as a potential diagnostic test for pneumococcal pneumonia. We enrolled 348 children with pneumonia admitted to Patan Hospital, Kathmandu, Nepal between December 2015 and September 2016. PBMCs sampled from participants were incubated for 48 h before harvesting of cell culture supernatant (ALS). We used a fluorescence-based multiplexed immunoassay to measure the concentration of IgG in ALS against five conserved pneumococcal protein antigens. Of children with pneumonia, 68 had a confirmed etiological diagnosis: 12 children had pneumococcal pneumonia (defined as blood or pleural fluid culture-confirmed; or plasma CRP concentration ≥60 mg/l and nasopharyngeal carriage of serotype 1 pneumococci), and 56 children had non-pneumococcal pneumonia. Children with non-pneumococcal pneumonia had either a bacterial pathogen isolated from blood (six children); or C-reactive protein <60 mg/l, absence of radiographic consolidation and detection of a pathogenic virus by multiplex PCR (respiratory syncytial virus, influenza viruses, or parainfluenza viruses; 23 children). Concentrations of ALS IgG to all five pneumococcal proteins were significantly higher in children with pneumococcal pneumonia than in children with non-pneumococcal pneumonia. The concentration of IgG in ALS to the best-performing antigen discriminated between children with pneumococcal and non-pneumococcal pneumonia with a sensitivity of 1.0 (95% CI 0.73-1.0), specificity of 0.66 (95% CI 0.52-0.78) and area under the receiver-operating characteristic curve (AUROCC) 0.85 (95% CI 0.75-0.94). Children with pneumococcal pneumonia were older than children with non-pneumococcal pneumonia (median 5.6 and 2.0 years, respectively, p < 0.001). When the analysis was limited to children ≥2 years of age, assay of IgG ALS to pneumococcal proteins was unable to discriminate between children with pneumococcal pneumonia and non-pneumococcal pneumonia (AUROCC 0.67, 95% CI 0.47-0.88). This method detected spontaneous secretion of IgG to pneumococcal protein antigens from cultured PBMCs. However, when stratified by age group, assay of IgG in ALS to pneumococcal proteins showed limited utility as a test to discriminate between pneumococcal and non-pneumococcal pneumonia in children.

The efficacy of high-dose penicillin G for pneumococcal pneumonia diagnosed based on initial comprehensive assessment at admission: an observational study.

OBJECTIVES: High-dose penicillin therapy is effective in approximately 90% of pneumococcal pneumonia cases diagnosed based on urinary pneumococcal antigen tests or Gram staining at admission. The efficacy of high-dose penicillin therapy for pneumococcal pneumonia diagnosed based on an initial comprehensive assessment comprising a syndromic approach, Gram staining of sputum and urinary pneumococcal antigen testing was investigated. RESULTS: Seventy adult patients diagnosed with pneumococcal pneumonia based on an initial comprehensive assessment and treated with high-dose penicillin G at admission were included. The median patient age was 76.5 years, and 37.1% of the patients were women. The urinary pneumococcal antigen test was positive in 67.1% of all patients, and Gram staining of sputum showed that gram-positive cocci were dominant in 58.6% of the patients. The primary outcome was treatment success based on vital signs until day 6. Treatment with high-dose penicillin G was effective in 87.1% of the patients (95% CI 79.1-95.2%), and the proportion of patients who received other antibiotics because of treatment failure with penicillin G was only 5.7%. The efficacy of high-dose penicillin G treatment for pneumococcal pneumonia diagnosed based on a comprehensive assessment at admission may be comparable to that in previous reports.

Evaluating the accuracy and economic value of a new test in the absence of a perfect reference test.

BACKGROUND: Streptococcus pneumoniae (SP) pneumonia is often treated empirically as diagnosis is challenging because of the lack of a perfect test. Using BinaxNOW-SP, a urinary antigen test, as an add-on to standard cultures may not only increase diagnostic yield but also increase costs. OBJECTIVE: To estimate the sensitivity and specificity of BinaxNOW-SP and subsequently estimate the cost-effectiveness of adding BinaxNOW-SP to the diagnostic work-up. DESIGN: We fit a Bayesian latent-class meta-analysis model to obtain estimates of BinaxNOW-SP accuracy that adjust for the imperfect accuracy of culture. Meta-analysis results were combined with information on prevalence of SP pneumonia to estimate the number of patients who are correctly classified under competing diagnostic strategies. Taking into consideration the cost of antibiotics, we determined the incremental cost of adding BinaxNOW-SP to the work-up per case correctly diagnosed. RESULTS: The BinaxNOW-SP test had a pooled sensitivity of 0.74 (95% credible interval [CrI], 0.67-0.83) and a pooled specificity of 0.96 (95% CrI, 0.92-0.99). An overall increase in diagnostic accuracy of 6.2% due to the addition of BinaxNOW-SP corresponded to an incremental cost per case correctly classified of $582 Canadian dollars. CONCLUSIONS: The methods we have described allow us to evaluate the accuracy and economic value of a new test in the absence of a perfect reference test using an evidence-based approach.

Prospective, population-based surveillance of the burden of Streptococcus pneumoniae in community-acquired pneumonia in older adults, Chrzanów County, Poland, 2010 to 2012.

INTRODUCTION: Community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae is a substantial cause of morbidity and mortality among older adults. This study estimated incidences of CAP, chest x-ray-confirmed CAP (CXR+CAP), S pneumonia- positive CAP, S pneumonia-positive CXR+CAP, and S. pneumoniae serotype distribution among 46,000 at-risk adults aged ≥ 50 years residing in Chrzanów County, Poland. MATERIAL AND METHODS: From January 2010 to January 2012, all facilities providing ambulatory and inpatient care enrolled all consenting resident patients with suspicion of CAP. Chest x-rays, urine, blood, and sputum samples were analyzed. Annualized incidence rates were determined. Presence of S pneumonia-positive CAP and/or S. pneumoniae serotype distribution was determined using the urine antigen detection assay (capable of detecting the serotypes in the 13-valent pneumococcal conjugate vaccine [PCV13]), BinaxNOW®, and/or microbiology cultures. RESULTS: Among 5055 enrolled patients, 1195 (23.7%) were diagnosed with CAP and 1166 (23.4%) had CXR+CAP. S. pneumoniae was detected in 144 (12.1%) and 131 (11.2%) patients from the CAP and CXR+CAP cohorts, respectively. Annualized incidence rates of CAP, CXR+CAP, S pneumonia-positive CAP, and S. pneumonia-positive CXR+CAP were 12.8, 12.5, 1.6, and 1.4 per 1000 residents, respectively. Among CXR+CAP patients, 39.7% were aged 50 to 64 years and 60.3% were aged ≥ 65 years. Incidence rates generally increased with age. The most common serotypes in S. pneumoniae-positive CXR+CAP patients were 3 (n = 15), 23F (n = 10), 18C (n = 9), and 9V (n = 6). CONCLUSIONS: CAP due to PCV13 serotypes is a source of morbidity among adults >50 years and may be reduced by greater access to pneumococcal vaccines.

Usefulness of pneumococcal antigen urinary testing in the intensive care unit?

OBJECTIVES: The use of pneumococcal antigen urinary tests is substantially increasing and is associated with a significant cost. The relevant use of this test in the intensive care unit (ICU) should be better defined. Our aim was to define the role of this test in relation to other microbiological tests. We described a series of patients admitted to the ICU for an invasive pneumococcal disease (IPD). PATIENTS AND METHODS: We conducted a retrospective and descriptive study of the microbiological tests used to diagnose IPD in patients admitted to the ICU of the University Hospital in Bordeaux. Our aim was to measure the sensitivity of these bacteriological tests and of the BinaxNOWS. pneumoniae test. RESULTS: Between 2009 and 2013, 148 patients were admitted for an IPD. A lower respiratory tract infection was diagnosed in 96.6% of them (143 patients). The overall ICU case fatality rate was 17.6%. The sensitivity of the pneumococcal antigen urinary test, sputum bacteriological examination, and blood cultures was respectively 83%, 37.6%, and 29.7%. S. pneumoniae was isolated from at least one bacteriological sample in 48.6% of patients, but in 51.4%, the diagnosis was only based on the results of the pneumococcal antigen urinary test. CONCLUSION: We suggest performing a pneumococcal antigen urinary test when an IPD is suspected, only if the bacteriological tests are still negative after 48hours. This strategy would result in a substantial cost saving. Patients would not face any additional risks as the result of the pneumococcal antigen urinary test does not have any impact on the initially prescribed antibiotic therapy.

Clinical burden of pneumonia, meningitis and septicemia in Norway 2 years after 7-valent pneumococcal conjugate vaccine introduction.

AIMS: This population-based, retrospective study quantified the rates of all-cause and pneumococcal pneumonia, meningitis and septicemia in Norway from 2008 to 2009 and determined the proportions of cases caused by pneumococcal vaccine serotypes. METHODS: Data on patients with all-cause and pneumococcal pneumonia, meningitis and septicemia were obtained from the Norwegian Patient Registry, which collects hospitalization data from all Norwegian public hospitals based on International Classification of Diseases codes. Norwegian Patient Registry case records linked to the Norwegian Surveillance System for Communicable Diseases provided serotype data for invasive pneumococcal disease in patients with microbiological cultures. RESULTS: In 2008 and 2009, hospitalization rates were relatively stable for all-cause pneumonia (5.28 and 5.35, respectively, per 1000), meningitis (10.70 and 9.67, respectively, per 100,000), and septicemia (from 171.81 to 161.46 per 100,000). In contrast, rates decreased for International Classification of Diseases-10 diagnosed pneumococcal pneumonia (from 13.66 to 10.52 per 100,000), although these cases may be under-reported because of inclusion in all-cause pneumonia. Rates also decreased in diagnosed pneumococcal meningitis (from 1.60 to 1.19 per 100,000) and diagnosed pneumococcal septicemia (from 9.08 to 7.94 per 100,000). Diagnosed pneumococcal disease rates were highest in younger children and older adults, peaking at ⩾ 60 years old. Pneumococcal pneumonia, meningitis and septicemia caused by serotypes included in the 7-valent pneumococcal conjugate vaccine decreased substantially during the study period, with corresponding serotype replacement by non-7-valent pneumococcal conjugate vaccine serotypes. CONCLUSIONS: From 2008 to 2009, International Classification of Diseases-10 diagnosed pneumococcal pneumonia, meningitis and septicemia decreased in most age groups but remained greatest among subjects aged 0-1 and ⩾ 60 years.

Pneumococcal lower respiratory tract infections in adults: an observational case-control study in primary care in Belgium.

BACKGROUND: Serious lower respiratory tract infections (SLRTIs), especially Streptococcus pneumoniae (SP)-related pneumonia cause considerable morbidity and mortality. Chest imaging, sputum and blood culture are not routinely obtained by general practitioners (GPs). Antibiotic therapy is usually started empirically. The BinaxNOW® and Urine Antigen Detection (UAD) assays have been developed respectively to detect a common antigen from all pneumococcal strains and the 13 pneumococcal serotypes present in the vaccine Prevenar 13® (PCV13). METHODS: OPUS-B was a multicentre, prospective, case-control, observational study of patients with SLRTI in primary care in Belgium, conducted during two winter seasons (2011-2013). A urine sample was collected at baseline for the urine assays. GPs were blinded to the results. All patients with a positive BinaxNOW® test and twice as much randomly selected BinaxNOW® negative patients were followed up. Recorded data included: socio-demographics, medical history, vaccination history, clinical symptoms, CRB-65 score, treatments, hospitalization, blood cultures, healthcare use, EQ-5D score. The objectives were to evaluate the percentage of SP SLRTI within the total number of SLRTIs, to assess the percentage of SP serotypes and to compare the burden of disease between pneumococcal and non-pneumococcal SLRTIs. RESULTS: There were 26 patients with a BinaxNOW® positive test and 518 patients with a BinaxNOW® negative test. The proportion of pneumococcal SLRTI was 4.8 % (95 % CI: 3.1 %-7.2 %). Sixty-eight percent of positive cases showed serotypes represented in PCV13. In the BinaxNOW-positive patients, women were more numerous, there was less exposure to young children, seasonal influenza vaccination was less frequent, COPD was more frequent, the body temperature and the number of breaths per minute were higher, the systolic blood pressure was lower, the frequency of sputum, infiltrate, chest pain, muscle ache, confusion/disorientation, diarrhoea, pneumonia and exacerbations of COPD was more frequent, EQ-5D index and VAS scale were lower, the number of visits to the GP, of working days lost and of days patients needed assistance were higher. CONCLUSIONS: SP was responsible for approximately 5 % of SLRTIs observed in primary care in Belgium. Pneumococcal infection was associated with a significant increase in morbidity. Sixty-eight percent of serotypes causing SLRTI were potentially preventable by PCV13.

Positive urinary antigen tests for Streptococcus pneumoniae in community-acquired pneumonia: a 7-year retrospective evaluation of health care cost and treatment consequences.

A positive pneumococcal urinary antigen test (PUAT) for Streptococcus pneumoniae allows an early switch from empiric to targeted treatment in hospitalised community-acquired pneumonia (CAP) patients. The economic and treatment consequences of this widespread implemented test are, however, unknown. We retrospectively evaluated all tests performed since its introduction in two teaching hospitals. Data on patient characteristics, treatment, admission and outcome were retrieved from the electronic patient files. Test benefits were expressed as the number of days that targeted therapy (i.e. penicillin) was administered to hospitalised CAP patients due to a positive PUAT. This calculation was based on the timing of the PUAT and the initiation of targeted therapy. Subsequently, we performed two direct cost analyses from a hospital perspective, first including tests performed for CAP only, and second including costs of all (excessive) tests. Between 2005 and 2012, 3,479 PUATs were performed, of which 1,907 (55 %) were for CAP. A total of 1,638 PUATs (86 %) were negative and 269 (14 %) were positive. Fifty-two (19 %) positive tests were excluded. In 75 (35 %) of the 217 remaining positive tests, a positive PUAT led to targeted treatment during 293 cumulative admission days. Testing costs for CAP only were €131 per targeted treatment day. These costs were €257 if local protocol dictated PUAT use for all CAP cases, as opposed to €72 if the test was reserved for severe cases only. When including all tests, PUAT costs were €254 per targeted treatment day. Therefore, improving the selective use of the PUAT in hospitalised CAP patients may lead to increased (cost-)efficiency.

The burden of pneumococcal pneumonia - experience of the German competence network CAPNETZ.

BACKGROUND: Pneumococcal pneumonia is still an important cause of mortality. The objective of this study was to compare frequency, clinical presentation, outcome and vaccination status of patients with pneumococcal community-acquired pneumonia (CAP) to CAP due to other or no detected pathogen based on data of the German Network for community-acquired pneumonia (CAPNETZ). METHODS: Demographic, clinical and diagnostic data were recorded using standardized web-based data acquisition. Standardized microbiological sampling and work-up were conducted in each patient. RESULTS: 7400 patients with CAP from twelve clinical centers throughout Germany were included. In 2259 patients (32 %) a pathogen was identified, Streptococcus pneumonia being the most frequent (n = 676, 30 % of all patients with identified pathogens). Compared to those with non-pneumococcal pneumonia, patients with pneumococcal pneumonia were more frequently admitted to hospital (80 % vs. 66 %, p < 0.001), had higher CURB score values on admission, had more frequently pleural effusion (19 % vs. 14 %, p = 0.001) and needed more frequently oxygen insufflation (58 % vs. 44 %, p < 0.001). There was no relevant difference in overall mortality. CONCLUSIONS: Pneumococcal pneumonia was associated with a more severe clinical course demanding more medical resources as compared to non-pneumococcal pneumonia.

Prospective, randomised study to compare empirical treatment versus targeted treatment on the basis of the urine antigen results in hospitalised patients with community-acquired pneumonia.

BACKGROUND: Recommendations for diagnostic testing in hospitalised patients with community-acquired pneumonia remain controversial. The aim of the present study was to evaluate the impact of a therapeutic strategy based on the microbiological results provided by urinary antigen tests for Streptococcus pneumoniae and Legionella pneumophila. METHODS: For a 2-year period, hospitalised patients with community-acquired pneumonia were randomly assigned to receive either empirical treatment, according to international guidelines, or targeted treatment, on the basis of the results from antigen tests. Outcome parameters, monetary costs and antibiotic exposure levels were compared. RESULTS: Out of 194 enrolled patients, 177 were available for randomisation; 89 were assigned to empirical treatment and 88 were assigned to targeted treatment. Targeted treatment was associated with a slightly higher overall cost (euro 1657.00 vs euro 1617.20, p=0.28), reduction in the incidence of adverse events (9% vs 18%, p=0.12) and lower exposure to broad-spectrum antimicrobials (154.4 vs 183.3 defined daily doses per 100 patient days). No statistically significant differences in other outcome parameters were observed. Oral antibiotic treatment was started according to the results of antigen tests in 25 patients assigned to targeted treatment; these patients showed a statistically significant higher risk of clinical relapse as compared with the remaining population (12% vs 3%, p=0.04). CONCLUSIONS: The routine implementation of urine antigen detection tests does not carry substantial outcome-related or economic benefits to hospitalised patients with community-acquired pneumonia. Narrowing the antibiotic treatment according to the urine antigen results may in fact be associated with a higher risk of clinical relapse.

[Assessment of the contribution of the immunochromatographic pneumococcal urinary antigen test to the etiological diagnosis of pneumonia in hospitalized adults]. / Bilan de la contribution de l'antigénurie pneumocoque par test immunochromatographique au diagnostic étiologique des pneumonies chez l'adulte hospitalisé.

AIM OF THE STUDY: To assess the usefulness and prescription practices of the Binax Now Streptococcus pneumoniae urinary antigen test in hospitalized adults. PATIENTS AND METHODS: The results of the pneumococcal urinary antigen tests (UAT) performed from January 2002 to September 2004 were related to that of microbiological cultures, and in positive patients to radiographic findings and C-reactive protein (CRP) levels. The evolution of the number of prescriptions and positivity rate in 2007 versus 2002-2004 was analyzed. RESULTS: The pneumococcal UAT was positive in 32 of the 278 patients included from 2002 to 2004 (11.5%). Results were concordant with that of microbiological cultures in 90% of the 247 documented cases. Pneumococcal etiology was considered to be definite in 19 patients (isolation of S. pneumoniae from blood, 17 patients; or pleural fluid, two patients), of whom 15 had a positive UAT (sensitivity: 79%); to be probable in 22 patients (positive UAT, 17 patients and/or isolation of S. pneumoniae from respiratory samples, six patients), and was retained in 39 of the 41 patients (positive predictive value: 93.7%). CRP was greater than 100mg/L in 34 of 39 documented patients and lobar alveolar radiographic opacities observed in 25 of 28 documented patients. In 2007, the dramatic increase in the number of UAT prescriptions and the diversification of prescribing units were associated to a decreased positivity rate (8.1%). CONCLUSION: Whereas the pneumococcal UAT clearly increases etiological diagnosis, pneumococcal pneumonia cannot be ruled out if negative. Indications for its use need to be refined to improve the cost-effectiveness of this test.

Pathogenesis, treatment, and prevention of pneumococcal pneumonia.

Pneumococcus remains the most common cause of community-acquired pneumonia worldwide. Streptococcus pneumoniae is well adapted to people, and is a frequent inhabitant of the upper airways in healthy hosts. This seemingly innocuous state of colonisation is a dynamic and competitive process in which the pathogen attempts to engage the host, proliferate, and invade the lower airways. The host in turn continuously deploys an array of innate and acquired cellular and humoral defences to prevent pneumococci from breaching tissue barriers. Discoveries into essential molecular mechanisms used by pneumococci to evade host-sensing systems that are designed to contain the pathogen provide new insights into potential treatment options. Versatility of the genome of pneumococci and the bacteria's polygenic virulence capabilities show that a multifaceted approach with many vaccine antigens, antibiotic combinations, and immunoadjuvant therapies will be needed to control this microbe.

Assessment of the usefulness of sputum Gram stain and culture for diagnosis of community-acquired pneumonia requiring hospitalization.

BACKGROUND: The usefulness of sputum Gram stain and culture in guiding microbiological diagnosis of community-acquired pneumonia (CAP) is controversial. We evaluated the role of sputum examination at a university teaching hospital. MATERIAL/METHODS: Three hundred forty-seven adult patients with CAP were enrolled in this study. Before administering antibiotic therapy, sputum was collected and its quality evaluated. Samples were gram stained and those of good quality were assessed for a predominant morphotype. RESULTS: Sputum samples were obtained from 216 patients (62%), and of these 124 (57%) samples were good quality and 80 (65%) showed a predominant morphotype. Sputum culture yielded a causative organism in 70 (88%) of the 80 samples with a predominant morphotype. In the cases of patients who had received previous antibiotic treatment, a good quality samples showing a predominant morphotype and positive culture was less frequently obtained from than from those who had not (p<0.0001). The sensitivity and specificity of the gram-positive diplococci identification in the sputum culture of S. pneumoniae were 68.2% and 93.8%, respectively, and the sensitivity and specificity of the gram-negative coccobacilli identification in the sputum culture of H. influenzae were 76.2% and 100%, respectively. CONCLUSIONS: Gram stain of sputum samples was useful in guiding microbiological diagnosis of CAP in 23% of patients. The Gram stain and culture of sputum samples obtained from patients who have received antibiotic treatment was unreliable. The presence of gram-positive diplococci and gram-negative coccobacilli was highly specific for the culture of S. pneumoniae and H. influenzae, respectively.

The clinical and public health value of non-culture methods in the investigation of a cluster of unexplained pneumonia cases.

During 2003, a cluster of initially unexplained pneumonia cases (two fatal) occurred in patients aged <50 years in a British city. Routine culture tests were inconclusive, however, pneumococcal infection was suspected and the putative outbreak was investigated using non-culture methods. Clinical samples from ten patients were tested by pneumococcal polymerase chain reaction (PCR) and multi-locus sequence typing (MLST), or Binax NOW pneumococcal urine antigen test and serotype-specific enzyme-linked immunosorbent assay (ELISA). Lung samples from the deceased patients were PCR positive and yielded different MLST types. Two patients in one family group were serotype 1 pneumococcal antigen positive. Two further patients were serotype 1 antigen positive, and one serotype 4 positive. Two antigen-positive cases were also serum PCR positive. Non-culture methods confirmed the disease aetiology in six cases. Serotype and MLST results showed no single outbreak, but a family cluster of cases in a high background of pneumococcal pneumonia, providing important epidemiological data that would not otherwise have been available.

[Preliminary assessment of Streptococcus pneumoniae, pneumonia, economical and clinical burden in Romania]. / Impactul medical si economic al pneumoniei pneumococice in România: evaluare preliminara.

BACKGROUND: In Romania there is a significant number of persons at-risk to develop pneumococcal diseases, especially the elderly over 65 years old. Costs of health care for these patients both for inpatient and outpatient facilities are high, due to increased Streptococcus pneumoniae drug resistance and due to additionally co morbidities these patients usually have. However, the real burden of pneumococcal disease in Romania remains unknown. OBJECTIVE: To assess the epidemiological and economical burden of pneumococcal pneumonia in Romania. MATERIAL AND METHOD: Epidemiological data reported over the past 5 years by the' Centrul de Calcul, Statistica Sanitara si Documentare Medicala,' were analyzed (1999-2004). A retrospective analysis was performed by M. Nasta Institute from Bucharest and Pneumology Hospital in Iasi, based on data from medical records and costs registered for a representative sample of patients treated in both inpatient facilities and on a survey conducted among physicians in outpatient facilities. RESULTS: It has been estimated that during 2004, there were registered 10,000 pneumococcal pneumonia cases that needed hospitalization and 38,200 patients that were treated in outpatient facilities. The global cost estimated for health care of pneumococcal pneumonia were 30 millions RON (8.3 millions) 86% were spent for hospitalized cases and 14% for ambulatory care. CONCLUSIONS: This first assessment reveal that the Pneumococcal pneumonia the Romanian Health Care System and for the National Insurance House, as well. The use of antipneumococcal vaccine can be an effective tool for decreasing the costs related to Streptococcus pneumoniae respiratory infections health care. However, further cost- analysis assessments are needed (strongly recommended).

Assessment of analysis of urinary pneumococcal antigen by immunochromatography for etiologic diagnosis of community-acquired pneumonia in adults.

The limitations of conventional microbiologic methods (CMM) for etiologic diagnosis of community pneumococcal pneumonia have made faster diagnostic techniques necessary. Our aim was to evaluate the usefulness of the immunochromatography (ICT) technique for detecting urinary Streptococcus pneumoniae antigen in the etiologic diagnosis of community-acquired pneumonias (CAP). This was a prospective study on in-patients with CAP in a tertiary hospital conducted from October 2000 to March 2004. Apart from using CMM to reach an etiologic diagnosis, we determined pneumococcal antigen in concentrated urine by ICT. We also determined the urinary pneumococcal antigen (UPA) content in patients from two control groups to calculate the specificity of the technique. One group was comprised of in-patients diagnosed with chronic obstructive pulmonary disease (COPD) or asthma, with respiratory infection, and without pneumonia; the other group included fractures. We studied 959 pneumonia patients and determined UPA content in 911 (95%) of them. We diagnosed the etiology of 253 cases (28%) using CMM; S. pneumoniae was the most common etiologic agent (57 cases). ICT analysis was positive for 279 patients (31%). Using this technique, the percentage of diagnoses of pneumococcal pneumonias increased by 26%, while the overall etiologic diagnosis increased from 28 to 49%. The technique sensitivity was 81%; the specificity oscillated between 80% in CAP with nonpneumococcal etiology and 99% for patients with fractures without infections. Determination of UPA is a rapid, simple analysis with good sensitivity and specificity, which increased the percentage of etiologic diagnoses. Positive UPA may persist in COPD patients with probable pneumococcal colonization or recent pneumococcal infections.