Neumonía adquirida en la comunidad / Community-acquired pneumonia

La neumonía adquirida en la comunidad ocurre en pacientes previamente sanos y su principal etiología es viral. Dentro de las etiologías bacterianas la principal en el recién nacido es el S. agalactiae y en los mayores es S. pneumoniae. Es la principal causa de muerte en niños menores de 5 años de edad en el mundo. Su diagnóstico se basa en la anamnesis y los hallazgos clínicos clásicos, pudiendo complementarse el estudio con radiografía de tórax e identificación viral con métodos rápidos. Su manejo depende de la etiología, y se indica antibioticoterapia (de elección amoxicilina v.o. o ampicilina e.v.) solo frente a la sospecha fundada de etiología bacteriana. Además se debe dar soporte según los requerimientos del paciente, incluyendo la hospitalización si cumple los criterios para ésta. La necesidad de cirugía está restringida principalmente para el manejo de empiemas.

Community acquired pneumonia occurs in previously healthy children and its ethnology is viral. Bacterial ethnology are S. agalactiaein neonates and S. pneumoniaein the olders. Is the main cause of death in children under 5 years of age. Diagnosis is made base on clinical features and chest X ray. Treatment depends on the etiology and antibiotics, preference oral amoxicilin or iv ampiciline, are indicated when a bacterial ethnology is suspected.

Predictores clínicos de bacteriemia en adultos inmunocompetentes hospitalizados por neumonía adquirida en la comunidad / Clinical predictors of bacteremia in immunocompetent adult patients hospitalized for community-acquired pneumonia

Background: The clinical usefulness of blood cultures in the management of patients hospitalized with community-acquired pneumonia (CAP) is controversial. Aim: To determine clinical predictors of bacteremia in a cohort of adult patients hospitalized for community-acquired pneumonia. Material and Methods: A prospective cohort of 605 immunocompetent adult patients aged 16 to 101 years (54% male) hospitalized for CAP was studied. The clinical and laboratory variables measured at admission were associated with the risk of bacteremia by univariate and multivariate analysis using logistic regression models. Results: Seventy seven percent of patients had comorbidities, median hospital stay was 9 days, 7.6% died in hospital and 10.7% at 30 days. The yield of the blood cultures was 12.6% (S. pneumoniae in 69 patients, H. influenzae in 3, Gram negative bacteria in three and S. aureus in one). These results modified the initial antimicrobial treatment in one case (0.2%). In a multivariate analysis, clinical and laboratory variables associated with increased risk of bacteremia were low diastolic blood pressure (Odds ratio (OR): 1.85, 95% confidence intervals (CI) 1.02 to 3.36, p < 0.05), leukocytosis e" 15,000/mm³ (OR: 2.18, 95% CI 1.22 to 3.88, p < 0.009), serum urea nitrogen e" 30 mg/dL (OR: 2.23, 95% CI 1.22 to 4.05, p < 0.009) and serum C-reactive protein e" 30 mg/dL (OR: 2.20, 95% CI 1.22 to 3.97, p < 0.01). Antimicrobial use before hospital admission significantly decreased the blood culture yield (OR: 0.14, 95% CI 0.04 to 0.46, p < 0.002). Conclusions: Blood cultures do not contribute significantly to the initial management of patients hospitalized for community-acquired pneumonia. The main clinical predictors of bacteremia were antibiotic use, hypotension, renal dysfunction and systemic inflammation.

Fatores associados às complicações em crianças pré-escolares com pneumonia adquirida na comunidade / Factors associated with complications of community-acquired pneumonia in preschool children

OBJETIVO: Identificar os fatores socioeconômicos e clínicos associados à evolução para complicações em crianças internadas com pneumonia adquirida na comunidade (PAC). MÉTODOS: Estudo longitudinal prospectivo em crianças diagnosticadas com PAC (12-59 meses de idade) internadas em enfermarias gerais de pediatria de dois hospitais na região de Campinas (SP). Os critérios de exclusão foram ter fibrose cística, cardiopatia, malformação pulmonar, neuropatias e doenças genéticas. PAC foi diagnosticada por características clínicas e radiológicas. Os dados foram coletados dos prontuários médicos e por um questionário semiestruturado. Os sujeitos foram divididos em dois grupos (PAC complicada e não complicada). Foram comparadas variáveis socioeconômicas e clínicas, e foi realizada análise de regressão logística multivariada. RESULTADOS: Das 63 crianças incluídas, 29 e 34, respectivamente, apresentaram PAC não complicada e PAC complicada. Não houve diferenças estatisticamente significantes entre os grupos quanto a idade na admissão, idade gestacional, peso ao nascer, gênero ou variáveis socioeconômicas. Houve diferenças significantes entre os grupos em relação a pneumonia anterior (p = 0,03), antibioticoterapia prévia (p = 0,004), tempo de início da doença (p = 0,01), duração da febre antes da internação (p < 0,001), duração da antibioticoterapia (p < 0,001) e tempo de internação (p < 0,001). Na análise multivariada, somente permaneceu no modelo a duração da febre antes da internação (OR = 1,97; IC95%: 1,36-2,84; p < 0,001). CONCLUSÕES: Variáveis biológicas, com destaque para o tempo de febre anterior à internação, parecem estar associadas com a evolução para complicação em crianças com PAC.

OBJECTIVE: To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). METHODS: This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. RESULTS: Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). CONCLUSIONS: Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.

A case of community-acquired Acinetobacter junii-johnsonii cellulitis / Celulitis por Acinetobacter junii-johnsonii adquirida en la comunidad: una presentación de caso

Acinetobacter skin and soft tissue infection outside of the traumatic wound setting are rare occurrences. The majority of cases occur in the presence of significant comorbilities and by Acinetobacter baumanii. Herein a case is reported of community-onset, health-care-associated, non-traumatic cellulitis caused by Acinetobacter, species junii-johnsonii with bacteremia. This is the first reported case of Acinetobacter junii-johnsonii skin and soft tissue infection. Hemorrhagic bullae might be one of the clinical features of Acinetobacter cellulitis.

La infección de piel y tejidos blandos por Acinetobacter no relacionada con trauma es una presentación inusual. La mayoría de los casos descritos presentan enfermedades concomitantes y son causados por Acinetobacter baumanii. Se describe un caso de celulitis no traumática por A. junii-johnsonii con bacteriemia, de inicio en la comunidad y asociado con el tratamiento médico. De acuerdo con nuestro conocimiento, éste sería el primer caso reportado de infección de tejidos blandos y piel por A. junii-johnsonii. La vesícula hemorrágica podría ser una característica clínica de celulitis por Acinetobacter.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study / Esquemas de tratamiento antibiótico para la neumonía extrahospitalaria muy grave en niños: estudio clínico aleatorizado

OBJECTIVE: To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP). METHODS: A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion). RESULTS: The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 ± 2.2 versus 5.8 ± 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 ± 6.2 versus 14.4 ± 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion. CONCLUSIONS: Both treatment plans are effective in treating very severe CAP in 2-month-to 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea.

OBJETIVO: Comparar la respuesta clínica al tratamiento empírico inicial con oxacilina más ceftriaxona frente a amoxicilina más ácido clavulánico en niños hospitalizados con diagnóstico de neumonía extrahospitalaria muy grave. MÉTODOS: Se llevó a cabo un estudio clínico prospectivo aleatorizado en niños de 2 meses a 5 años de edad con diagnóstico de neumonía extrahospitalaria muy grave en la sala de pediatría del Hospital Universitario del Estado de São Paulo en Botucatu, São Paulo, Brasil, entre abril del 2007 y mayo del 2008. Los pacientes se dividieron aleatoriamente en dos grupos según el tratamiento administrado: un grupo recibió oxacilina/ceftriaxona (n = 48) y otro amoxicilina/ácido clavulánico (n = 56). Los criterios de valoración analizados fueron el tiempo hasta la mejoría clínica (de la fiebre y la taquipnea), el tiempo de administración de oxigenoterapia, la duración de la internación, la necesidad de ampliar el espectro antibiótico y las complicaciones (como el derrame pleural). RESULTADOS: Los dos grupos no presentaban diferencias estadísticas con respecto a la edad, el sexo, la duración de los síntomas antes de la internación o el tratamiento previo con antibióticos. El tiempo hasta la mejoría de la taquipnea fue menor en los pacientes tratados con amoxicilina/ácido clavulánico que en los que recibieron oxacilina/ceftriaxona (4,8 ± 2,2 días frente a 5,8 ±2,4 días, respectivamente; P = 0,028), y también fue menor la duración de la internación (11,0 ± 6,2 días frente a 14,4 ± 4,5 días, respectivamente; P = 0,002). No hubo diferencias estadísticamente significativas entre los dos grupos en relación con el tiempo hasta la mejoría de la fiebre, el tiempo de administración de oxigenoterapia, la necesidad de ampliar el espectro antibiótico ni la frecuencia de derrame pleural. CONCLUSIONES: Ambos esquemas de tratamiento son eficaces para tratar la neumonía extrahospitalaria muy grave en niños de 2 meses a 5 años de edad hospitalizados. El único criterio de valoración analizado que favoreció el tratamiento con amoxicilina/ ácido clavulánico fue el tiempo hasta la mejoría de la taquipnea.

Neumonía de difícil control / Difficult pneumonia

Community Acquired Pneumonia (CAP) is an important cause of morbimortality in children. Even when the study and management of such pathology are standarized enough and the success rate of treatments is very high, we all have faced a case of CAP which is not-responding to the treatment as we expected. The objective of this article is to describe how to face this situation and communicate part of this personal experience.

La neumonía adquirida en la comunidad (NAC) es causa importante de morbimortalidad en pediatría. Si bien el estudio y manejo de esa patología están suficientemente estandarizados (1,2) y la tasa de éxito de los tratamientos aplicados es muy elevada, todos nos hemos enfrentado alguna vez a una NAC que no responde al tratamiento como esperábamos. El objetivo de este artículo es describir la forma de enfrentar esa situación y transmitir parte de una experiencia personal en la materia.

Estado nutricional y mortalidad en neumonía de la comunidad / Nutritional status and mortality in community acquired pneumonia

Las neumonías constituyen una causa mayor de morbimortalidad, y entre los factores de riesgo se incluye el estado nutricional. En el presente estudio se analizó la relación entre malnutrición y mortalidad en Neumonía Aguda de la Comunidad (NAC) y se utilizó la Escala de Evaluación Global Subjetiva (EGS) como método de valoración del estado nutricional de los pacientes con NAC. En este estudio prospectivo observacional se incluyeron en forma consecutiva 98 pacientes con NAC que requirieron hospitalización, de octubre de 2004 a septiembre de 2006. Se registraron características clínicas, bacteriológicas y de laboratorio y se evaluó nutricionalmente a cada paciente utilizando la EGS. El seguimiento se realizó hasta el alta médica, derivación o muerte. La persistencia de tos o fiebre, la presencia de derrame pleural, neoplasias o larga hospitalización se asociaron a peor pronóstico. La mortalidad aumentó proporcionalmente con el grado de desnutrición. Treinta y dos pacientes (32.65%) fueron clasificados como categoría EGS-A; 44 (44.90%) como EGS-B, y 22 (22.45%) como EGS-C. Fallecieron 3 de 32 EGS-A (9.37%), 8 de 44 EGS-B (18.18%) y 10 de 22 EGS-C. El riesgo de muerte fue significativamente mayor en el grupo EGS-C que en el EGS-A; OR = 6.085 (CI95% 1.071- 34.591) p = 0.042. Considerando la muerte como variable de egreso, la categoría EGS-A mostró el mayor valor predictivo negativo (0.906), y EGS-C el mayor valor predictivo positivo (0.455). La EGS realizada al ingreso fue un instrumento útil para identificar el estado nutricional y un buen pronosticador de riesgo de muerte en NAC.

Pneumonias are a major cause of morbidity and mortality and their prognosis depends on many factors including nutritional status. This study analyzed the relationship between malnutrition and the risk of death in Community Acquired Pneumonia (CAP) patients. This is a prospective observational study. The Subjective Global Assessment (SGA) was used as a screening tool to appraise the nutritional status. Ninety-eight patients with CAP requiring hospitalization were included consecutively from October 2004 to September 2006. The clinical, bacteriological and laboratory features were recorded. Patient's nutritional condition was assessed using the SGA. The monitoring was performed until discharge, death or shunt. Persistent cough or fever, the presence of pleural effusion, malignancies or long hospitalization were associated with worse prognosis. Mortality increased in proportion to the degree of malnutrition. Thirty two CAP patients (32.65%) were classified as SGA-category A; 44 (44.90%) as SGA-B, and 22 (22.45%) as SGA-C. Pneumonia resulted in death in 3/32 SGA-A (9.37%), 8/44 SGA-B (18.18%) and 10/ 22 SGA-C patients. SGA-C patients showed significantly higher odds ratios for death in comparison to SGA-A patients (OR = 6.085, CI95%: 1.071-34.591; p = 0.042). Considering death as the outcome variable, SGA-A class had the highest negative predictive value (0.906), while SGA-C class showed the highest positive predictive value (0.455). These results link the nutritional status to the NAC evolution prognostic. SGA provides a simple estimation of the nutritional status and it is a good predictor of the risk of death in CAP patients.

Clinical Significance of Serum Procalcitonin in Patients with Community-acquired Lobar Pneumonia / 대한진단검사의학회지

BACKGROUND: Community-acquired pneumonia (CAP) is a common respiratory disorder in children, which necessitates hospitalization. Bacterial pneumonia, especially lobar pneumonia and parapneumonic effusions, is associated with considerably severe clinical course and extensive alveolar infiltrates. Serum procalcitonin (PCT) level has been used to distinguish bacterial from viral infections, but its usefulness is disputed. The diagnostic accuracy and usefulness of PCT, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count were determined by comparing their values in the patients with CAP with those in healthy controls. METHODS: The serum PCT levels, as well as CRP level, ESR, and WBC counts, were measured in 76 hospitalized patients with CAP (lobar pneumonia, 16; bronchopneumonia, 60) and 18 healthy controls. Serum PCT level was measured using VIDAS(R) BRAHMS PCT (Biomerieux, France), and ROC curve analysis was performed to evaluate its diagnostic accuracy. RESULTS: Serum PCT levels were higher in the patients with CAP than in healthy controls, especially in the patients with lobar pneumonia than in those with bronchopneumonia. Serum CRP level was also significantly elevated in the patients with CAP, especially in those with lobar pneumonia. The diagnostic accuracy of serum PCT level for the diagnosis of lobar pneumonia was better than those of serum CRP level and ESR. The serum PCT level was significantly correlated with the CRP level, ESR, and WBC count. CONCLUSIONS: Serum PCT level was a better marker than CRP level or ESR for the diagnosis of lobar pneumonia in children with CAP.

Empyema thoracis; possible factors for predicting this complication in children with community acquired bacterial pneumonia

Empyema as a complication of community acquired pneumonia [CAP] is relatively common occurrence in developing countries. Prospective study. 4 year Jan 2001- Dec 2004. Department of Pediatric surgery the Children's hospital Lahore. A total of 114 cases of empyema thoracic secondary to CAP were dealt with during this period, while in the same duration a total of 1768 cases of pneumonia were treated at the Children's hospital Lahore. Majority of the patients with CAP [59.61%] were below one year of age whereas the patients who developed empyema, were mainly [45.67%] between 2 to 5 years of age. Patients above 5 years of age having CAP [31.70%] and having repeated attacks of respiratory tract infection were most susceptible to develop empyema. Staphylococcus aureus was the most common organism found [40.35%] in this series. Vaccination, poverty and gender did not significant affected the development of empyema among the patients of CAP. Antibiotic resistance had no role in the development of empyema. Ibuprofen may be a risk factor. All the patients were initially managed with tube thoracostomy and antibiotics. Forty-eight patients [42.10%] needed subsequently operative management. Three patients [2.63%] had fatal course in this series same as seen in patients of CAP [2%]. Immunization against causative organism and modification of out patient treatment may affect the incidence of empyema in children and should be studied prospectively

La experiencia clínica con tigeciclina: Una breve revisión / Clinical experience with tygecicline: A brief review

The available clinical experience with tigecycline is analyzed under the perspective of a systematic review of the hterature, related to the already approved indications reported in the recent hterature. The safety profile is checked in the above mentioned clinical trials. The available information allows supporting tigecycline efficiency in the managing of complicated skin and soft tissues infections, complicated intrabdominales infections and in community acquired pneumonias.

Se analiza, bajo la perspectiva de una revisión sistemática de la literatura médica, la experiencia clínica con tigeciclina, en las indicaciones ya aprobadas por las entidades reguladoras reportadas en la literatura reciente. Se revisa el perfil de seguridad y tolerabilidad en dichos ensayos clínicos. La información disponible permite avalar su eficacia en el manejo de infecciones de piel y tejidos blandos complicadas, infecciones intra-abdominales complicadas y neumonías adquiridas en la comunidad.

Use of non-invasive ventilation in a pregnant woman with acute respiratory distress syndrome due to pneumonia.

Utility of non-invasive ventilation (NIV) in patients with acute respiratory distress syndrome (ARDS) is not proven. We report a case of a 28-year-old primigravida female with ARDS due to community-acquired severe pneumonia in whom non-invasive ventilation was instituted in an attempt to improve oxygenation and avoid intubation. This lead to an improvement in arterial oxygenation and reduction in respiratory rate of the patient and gradual disappearance of fetal distress.

Empiema y efusión pleural en niños / Empyema and pleural efussion in children

Introducción: El empiema pleural (EP) es una complicación grave de la neumonía adquirida en la comunidad (NAC). Objetivos: Describir las características de los pacientes hospitalizados por EP en el Servicio de Pediatría del Hospital de la Universidad Católica durante el período 2000-2005. Se identificaron 86 hospitalizaciones por NAC con efusión pleural, practicándose en 59 (70 por ciento), al menos una toracocentesis. Se consideró EP a la presencia de pus, tinción de Gram con bacterias, cultivo positivo o pH < 7,10 en el líquido pleural, siendo las efusiones para-neumónicas los controles. Resultados: Se analizaron 24 EP y 25 controles [promedio 2,9 años (rango: 8 meses - 14,3 años)], 78 por ciento de edad inferior a 5 años con diferencia entre los grupos EP y controles [1,6 vs 3,3 años, respectivamente (p = 0,01)]. El promedio global (días) de síntomas previo al ingreso en los EP fue 7 (rango: 2-21), siendo los más frecuentes fiebre (100 por ciento) y tos (96 por ciento). Se identificó algún microorganismo en 15/24 EP, Streptococcus pneumoniae fue el más frecuente (n: 9). En 48 niños, el manejo inicial fue conservador, requiriéndose cuatro rescates quirúrgicos luego del cuarto día. El promedio (días) de hospitalización fue significativamente superior en el grupo EP vs controles [15 (rango: 5-38) vs 9 (rango: 3-16) (p < 0,01)]. Requirieron drenaje pleural 83 por ciento del grupo EP y 36 por ciento de los controles (p = 0,002). No hubo diferencia en el número de días de empleo de oxígeno [6 vs 4,5 (p = 0,36)] o drenaje pleural [3 vs 2,5 (p = 0,29)]. No se registraron fallecidos. Conclusión: El EP en niños fue una condición respiratoria aguda que se asoció a estadías hospitalarias prolongadas, especialmente en los de menor edad, no requiriéndose, en la mayoría, una intervención quirúrgica de rescate.

Introduction: Pleural empyema (PE) is a serious complication of community-acquired pneumonia (CAP). Objectives: To describe the clinical profile of hospitalized patients with PE in the pediatric ward of the Catholic University Hospital between 2000-2005. Patients y methods: Retrospectively, all pediatric admission due to CAP and pleural effusion (86 children) were identified. In 59 (70 percent) children > 1 thoracocentesis were performed. We considered PE as the presence in the pleural effusion of pus, and/or a positive gram strain and/ or positive culture, and/or a pH < 7.10. Children with effusions not meeting any criteria were used as controls. Results: Twenty four PE and 25 controls were identified, with a global mean age of 2.9 years (range: 8 months to 14.3 years); 78 percent were < 5 years, with a significant difference between PE and controls [1.6 vs 3.3 years (p = 0.01)]. The mean duration of symptoms in PE patients before admission was 7 days (range: 2-21), and the most frequent symptoms were fever (100 percent) and cough (96 percent). In 15/24 cases a microorganism was identified being Streptococcus pneumoniae (n = 9) the most common. In 48 patients management was conservative and in 4 surgical procedures were required. The mean duration of hospitalization was significantly higher in the PE group vs controls group: 15 (range: 5-38) vs 9 days (range 3-16) (p < 0.01). A chest tube was inserted in 83 percent of children with EP compared with 36 percent in the control group (p = 0.002). There were no difference in number of days of oxygen use [6 vs 4.5 (p = 0.36)] or number of chest tubes per child [3 vs 2.5 (p = 0.29)]. No deaths were reported. Conclusion: PE in children represented an acute respiratory event associated with more prolonged hospitalization especially at younger ages; the majority of cases did not require surgical intervention.

Outcomes and Prognostic Factors for Severe Community-Acquired Pneumonia that Requires Mechanical Ventilation

BACKGROUND: Community-acquired pneumonia (CAP) remains a common and serious condition worldwide. The mortality from severe CAP remains high, and this has reached 50% in some series. This study was conducted to determine the mortality and predictors that contribute to in-hospital mortality for patients who exhibit CAP and acute respiratory failure that requires mechanical ventilation. METHODS: We retrospectively reviewed the medical records of 85 patients with severe CAP as a primary cause of acute respiratory failure, and this required mechanical ventilation in a setting of the medical intensive care unit (ICU) of a tertiary university hospital between 2000 and 2003. RESULTS: The overall in-hospital mortality was 56% (48/85). A Cox-proportional hazard model revealed that the independent predictive factors of in-hospital mortality included a PaCO2 of less than 45 mmHg (p<0.001, relative risk [RR]: 4.73; 95% confidence interval [CI]: 2.16-10.33), a first 24-hour urine output of less than 1.5 L (p=0.006, RR: 2.46, 95% CI: 1.29-4.66) and a high APACHE II score (p=0.004, RR: 1.09, 95% CI: 1.03-1.16). CONCLUSIONS: Acute respiratory failure caused by severe CAP and that necessitates mechanical ventilation is associated with a high mortality rate. Initial hypercapnia and a large urine output favored survival, whereas a high APACHE II score predicted mortality.

Derrame pleural parapneumônico e empiema / Parapneumonic effusion and empyema

O derrame infeccioso, uma das causas mais freqüentes de derrame pleural obervados na pratica clinica, é um sinal de complicação do quadro pneumônico. O reconhecimento precoce do derrame parapneumônico é fundamental para determinar a melhor forma de tratamento, reduzindo o risco de morbidade e mortalidade. A evolução dos métodos diagnósticos e a experiência dos diversos estudos publicados na literatura permitiram estabelecer diretrizes baseadas em evidencias que orientam a conduta de abordagem terapêutica do derrame parapneumônico e empiema.

The infectious effusion, one of the most frequent causes of pleural effusions in the clinical practice, is a sign of complication of the pneumonic disease. The early recognition of the parapneumonic effusion is crucial to determine the best treatment form and reduce the risk of morbidity and mortality. The evolution in the diagnostic methods and the contribution of several studies published in the literature allowed to establish evidence-based guidelines that are used to guide the treatment of the parapneumonic pleural effusion and empyema.

A fatal case of community acquired methicillin resistant Staphylococcus aureus brain abscess in a previously healthy adolescent / Un Caso Fatal de Estafilococo Dorado Resistente a la Meticilina, Adquirido en la Comunidad, por una Adolescente Previamente Sana

A 16-year-old adolescent presented with fever, lethargy and vomiting associated with mild dehydration. This was followed less than 24-hours later by loss of consciousness, seizures and clinical brain death. She had no prior medical illness, no hospital or frequent antibiotic exposure. There was no evidence of soft tissue or skin infection. Management included intravenous fluids, ampicillin and cefotaxime parenterally, dexamethasone, endotracheal intubation and mechanical ventilation. Her neurologic examination remained unchanged with areflexia, flaccid paralysis and fixed pupils. Post-mortem examination revealed an eight-centimetre right fronto-parietal lobe brain abscess. Cultures were positive for methicillin resistant Staphylococcus aureus. Although formerly a nosocomial pathogen affecting debilitated patients in the hospital setting, S aureus that is methicillin resistant is emerging as a community acquired pathogen affecting previously well patients.

Una adolescente de 16 años de edad se presentó con fiebre, letargia y vómitos, asociados con deshi-dratación ligera. Estos síntomas fueron seguidos en menos de 24 horas por pérdida de conciencia, ataques y muerte clínica del cerebro. Con anterioridad, la paciente no había tenido enfermedad médica, ni hospitalización, ni tratamiento frecuente con antibióticos. No había evidencia de tejidos blandos o infección de la piel. El tratamiento incluyó líquidos intravenosos, ampicilina y cefotaxima de forma parenteral, dexametasona, entubación endotraqueal, y ventilación mecánica. El examen neurológico permaneció invariable con areflexia, parálisis flácida, y pupilas fijas. El examen post-mortem reveló un absceso cerebral de ocho centímetros en el lóbulo fronto-parietal derecho. Los cultivos resultaron positivos al Staphylococcus aureus resistente a la meticilina. Aunque visto an-teriormente como un patógeno nosocomial que afecta a los pacientes debilitados en el entorno hos-pitalario, el S aureus resistente a la meticilina está surgiendo como un patógeno extrahospitalario (ie adquirido en la comunidad) y afecta a pacientes previamente sanos. 1Equivalente acuñado aquí para el término inglés caseness, a saber, criterios que definen el estatus de caso sobre la base de la presencia de sintomatologia clinicamente significativa.

Hiponatremia como factor de riesgo de muerte en pacientes internados por neumonia adquirida en la comunidad / Hyponatremia as a risk factor of death in patients with community-acquired pneumonia requiring hospitalization

Investigamos si la hiponatremia es un factor de riesgo de muerte en pacientes internados por neumoníaadquirida en la comunidad (NAC) y estimamos el peso relativo de otros factores de riesgo de muerte por NAC, en un estudio de cohorte, prospectivo, multicéntrico, en 5 Servicios de Clínica Médica del Area Metropolitana de Buenos Aires. Evaluamos adultos con NAC ingresados entre 21 de marzo de 2000 y 21 de diciembre del mismo año. Los factores de riesgo que mostraron asociación con evolución por análisis univariado, fueron sometidos a análisis de regresión logística, con un nivel de significación de α de 0.05. En 9 meses seinternaron 238 pacientes con NAC: 150 (63%) varones y 88 (36%) mujeres, con edades medias 52.99 (±20.35)y 55.06 (±20.94) años, respectivamente. Fallecieron 25/238 (10.5%). En análisis multivariado, se asociaron significativamente con evolución: enfermedad vascular encefálica (EVE) (B: 2.614, p<0.001, RRE: 13.6, IC 95%: 3.7-49.6); hiponatremia al ingreso o durante la internación (B: 1.994, p<0.001, RRE: 7.3, IC 95%: 2.5-20.8); urea plasmática elevada (B: 0.016, p= 0.003, RRE: 1.016, IC 95%: 1.005-1.02). Desarrollamos una fórmula deprobabilidad de fallecer por NAC: P (óbito)= 1/1+ exp. – (-4.03 + 2.61x1 + 1.99x2 + 0.016x3), donde: x1= EVE(sí =1/no =0); x2= hiponatremia (sí =1/no =0); x3 = urea plasmática (mg/dl). La predictibilidad fue 91.1%. Elriesgo de fallecer por NAC fue significativamente mayor entre quienes presentaron EVE, hiponatremia y ureaplasmática elevada

We investigated whether hyponatremia is a risk factor of death in patients hospitalized with community-acquired pneumonia (CAP) and estimated the relative risk of death by CAP of otherrisk factors. The design was prospective multicentre cohort study. In 5 centers in Buenos Aires, Argentina, westudied adults hospitalized with CAP between March 21, 2000 and December 21, 2000. Using stepwise logisticregression, we analyzed risk factors that showed a univariate association with mortality; α significance level was0.05. During a 9-month period, 238 patients were admitted with CAP: 150 (63%) male and 88 (36%) female,mean age 52.99 (±20.35) and 55.06 (±20.94), respectively. Mortality was 10.5% (25/238). By multivariate analysis, the following variables were statistically associated with evolution: cerebrovascular disease (CD) (B: 2.614,p<0.001, RRE: 13.6, IC 95%: 3.7-49.6); hyponatremia at admission or during hospitalization (B: 1.994, p<0.001, RRE: 7.3, IC 95%: 2.5-20.8); and elevated blood urea (B: 0.016, p= 0.003, RRE: 1.016, IC 95%: 1.005-1.02). We developed a formula to predict mortality by CAP: P (death) = 1/1+ exp – (-4.03 + 2.61x1 + 1.99x2 + 0.016x3), where: x1= CD (yes=1/no =0); x2= hyponatremia (yes=1/no =0); x3 = blood urea (mg/dl). The predictability was 91.1%. The mortality risk by CAP was statistically higher in patients with CD, hyponatremia and elevated blood urea

Prognostic Significance of Infection Acquisition Sites in Spontaneous Bacterial Peritonitis: Nosocomial versus Community Acquired

Spontaneous bacterial peritonitis (SBP) is an ascitic fluid infection as a complication of end stage liver disease. The outcome is related to the severity of hepatorenal function, gastrointestinal bleeding, and many others; however it is not well known whether the infection acquisition sites have an effect on the prognosis of SBP. In order to identify the prognostic significance of the acquisition sites, we studied 106 patients who were diagnosed as culture positive SBP between October 1998 and August 2003. Thirty-two episodes were nosocomial and 74 were community acquired. Gramnegative bacilli such as Escherichia coli were dominant in both of the nosocomial and community-acquired SBPs. Despite significantly higher resistance to cefotaxime in nosocomial isolates compared to community-acquired isolates (77.8% vs. 13.6%, p=0.001), no difference was found regarding short or long term prognosis. Infection acquisition sites were not related to short or long term prognosis either. Shock, gastrointestinal bleeding and renal dysfunction were related to short term prognosis. Only Child-Pugh class C was identified as an independent prognostic factor of long-term survival.

Antimicrobial resistance to newer quinolones of bacterial strains isolated from community-acquired pneumonia and acute exacerbations of chronic bronchitis

Resistance to some routine antimicrobial agents in respiratory tract pathogens causes therapy of lower respiratory tract infections difficult. New agents such as new fluoroquinolones are extensively studied and were found successful in bacterial eradication and decrease in relapse rate. Therefore in this study we evaluated the antimicrobial resistance in bacterial strains isolated from cases of lower respiratory tract infection against newer quinolones. Sputum samples from 97 patients with a diagnosis of community acquired pneumonia [CAP] or acute exacerbations of chronic bronchitis [AECB] were sent to Istanbul University Istanbul Faculty of Medicine, Department of Microbiology and Clinical Microbiology by the Department of Pulmonology. The resistance of isolated microorganisms to the new fluoroquinolones levofloxacin, gatifloxacin and moxifloxacin was determined by E-test strips. Results: Among 97 patients, there were 25 patients of CAP and 72 patients of AECB. 1 strain each of S. pneumoniae, and M. catarrhalis were in 25 CAP patients. There were 4 strains of S.pneumoniae, 8 strains of H.influenzae and 2 strains of M. catarrhalis in 72 AECB patients. Except in 2 P.aeruginosa strains, none of the other strains was found resistant to the new fluoroquinolones. There is a need for development of new agents due to the increasing resistance to antibiotics in respiratory tract pathogens. Our results showed that there is minimal antimicrobial resistance to newer quinolones and these seem to be a promising alternate option in this era of antimicrobial resistance

Neumonía neumocócica adquirida en la comunidad en adultos hospitalizados / Community acquired pneumococcal pneumonia in hospitalized adult patients

BACKGROUND: S pneumoniae is the most common cause of community-acquired pneumonia. AIM: To evaluate the clinical characteristics, antibiotic resistance, management and prognostic factors in pneumococcal pneumonia. METHODS: Prospective evaluation in 46 adults (age +/- sd: 68 +/- 17 years) hospitalized with pneumococcal pneumonia confirmed by sputum, blood or pleural fluid cultures. Clinical and radiographic variables, risk factors for antibiotic resistance, and hospital mortality rate were recorded. RESULTS: Heart disease (39 per cent), COPD/asthma (25 per cent), and diabetes mellitus (18 per cent) were the most frequent underlying diseases. None of the patients had previously received pneumococcal vaccine. Only 17 per cent of the patients had the classic triad of chills, fever and productive cough. At admission, interestingly, 17 per cent presented with congestive heart failure. Resistance of pneumococci to penicillin, cefotaxime or erythromycin was 15 per cent, 6 per cent and 11 per cent, respectively. Antibiotic use prior to admission was significantly associated with antibiotic resistance (OR = 6; CI 95 per cent = 1.1-32; p < 0.05). Fifty per cent of the patients were admitted to intermediate or intensive care units, 15 per cent were mechanically ventilated, 20 per cent developed septic shock, 20 per cent developed acute renal failure and 13 per cent died in the hospital. Clinical factors significantly associated with higher mortality were systolic hypotension (< or = 90 mmHg), ICU admission and BUN > 30 mg per dL. CONCLUSIONS: Our data suggest that pneumococcal pneumonia is still a severe infection with high mortality; hence, efforts should be made at prevention using pneumococcal immunization.