Diferencias y similitudes clínicas y epidemiológicas de la neumonía viral en dos pandemias / Clinical and epidemiological differences and similarities of viral pneumonias in two pandemics

BACKGROUND: In a decade, we faced two pandemic viruses, influenza A H1N1pdm09 and SARS CoV-2, whose most serious manifestation is pneumonia. AIM: To compare the clinical, epidemiological and management aspects of pneumonias caused by each pandemic virus in adults requiring hospitalization. Material and Methods: Comparative, observational study carried out at a regional Chilean hospital, including 75 patients with influenza A H1N1pdm09 prospectively studied in 2009 and 142 patients with SARS-CoV-2 studied in 2020. RESULTS: Patients with SARS-CoV-2 pneumonia were older (56 and 39.7 years respectively, p < 0.01) and had significantly more comorbidities. Cough, fever and myalgias were more frequent in influenza. Dyspnea was more frequent in COVID-19. Patients with COVID-19 had more extensive lung involvement and a longer hospitalization (13.6 and 8.6 days respectively, p = 0.01). There was no difference on ICU admission requirements and mortality attributable to pneumonia. Patients with influenza had greater APACHE scores and a higher frequency of a PaO2/FiO2 ratio ≤ 200. During COVID-19pandemic chest sean replaced x-ray examination. Also high-flow nasal cannulas and awake prone position ventilation were added as treatments. Conclusions: COVID-19 patients were older, had fewer classic flu symptoms but more dyspnea and longer hospitalization periods than patients with influenza.

Factores de riesgo socio-demográficos del síndrome cardiopulmonar por hantavirus / Sociodemographic risk factors of hantavirus cardiopulmonary syndrome

Resumen Introducción: El síndrome cardiopulmonar por hantavirus (SCPH) es causado en Chile y en el sur de Argentina por el Andes hantavirus (ANDV), el que es endémico en esta zona. La enfermedad causada por ANDV produce un aumento de permeabilidad vascular y filtración de plasma con una alta tasa de letalidad (35%), debido principalmente a insuficiencia respiratoria por edema pulmonar y al desarrollo en los casos graves de compromiso miocárdico, hipoperfusión y shock. Aunque se sabe que los factores socio-demográficos del hospedero pueden influir en el curso y el resultado de la enfermedad, estos no se han caracterizado previamente en la población chilena. Objetivo: Evaluar la relación entre los factores socio-demográficos y la gravedad del SCPH. Pacientes y Métodos: Período de análisis 2004-20013, pacientes atendidos en ocho centros colaboradores, diagnóstico etiológico serológico o por biología molecular, se comparan SCPH leve y grave. Se analizaron 139 pacientes chilenos, 64 (46%) con enfermedad grave, entre los cuales 12 murieron (19%). Resultados: La etnia europea tuvo un riesgo 5,1 veces mayor de desarrollar un SCPH grave que la etnia amerindia, gravedad mayor que también se asoció a una residencia urbana. Conclusiones: Se observó una asociación estadísticamente significativa entre etnia, lugar de residencia y evolución de SCPH. Se discuten hipótesis que expliquen estos hallazgos.

Background: Hantavirus cardiopulmonary syndrome (HCPS) is caused by new world hantaviruses, among which Andes hantavirus (ANDV) is endemic to Chile and Southern Argentina. The disease caused by ANDV produces plasma leakage leading to enhanced vascular permeability and has a high case fatality rate (35%), mainly due to respiratory failure, pulmonary edema and myocardial dysfunction, hypoperfusion and shock. Host sociodemographic and genetic factors might influence the course and outcome of the disease. Yet, they have not been thoroughly characterized. Aim: To evaluate sociodemographic factors as risk factors in severity of HCPS. Patients and Methods: Study period: 2004-20013, attending in eight collaborative centers, etiological diagnosis was performed by serology or molecular biology, mild and severe HCPS were compared.139 Chilean patients were analyzed, 64 (46%) with severe disease among which 12 (19 %) died. Results: European ethnicity had 5,1 times higher risk than Amerindian ethnic group to develop a severe HCPS, greater seriousness that was also associated with an urban residence. Conclusion: It was observed that ethnicity and type of residence were significant risk factors for HCPS severity. Hypotheses explaining these findings are discussed.

Impacto de la tuberculosis en el hospital de Puerto Montt / Impact of tuberculosis in Puerto Montt hospital, Chile

Resumen Objetivo: Dimensionar la demanda de atención y/u hospitalización de la tuberculosis (TBC) en el Hospital de Puerto Montt (HPM). Método: Revisión retrospectiva de los registros de TBC del Servicio de Salud del Reloncaví (SSDR) y del HPM entre los años 2011 y 2015. Se incluyeron todos los casos de TBC activa vistos en forma ambulatoria u hospitalizada en el HPM. Resultados: Se diagnosticaron en el SSDR 298 casos de TBC, y de ellos un 64% (192/298) fue pesquisado en el HPM. Se presentan datos socioeconómicos, epidemiológicos, clínicos, de laboratorio y forma de diagnóstico de 180 casos, que cumplieron criterios de inclusión: varones 62%, edad media 44 ± 19 años. El 72% correspondieron al estrato social de menores ingresos, 4% indigentes, solo 14% poseía enseñanza media completa, 11% analfabetos, ruralidad 19%. Las principales co-morbilidades fueron alcoholismo (17%), VIH (12%), Diabetes (10%). En aquellos con TBC pulmonar o pleural (128) el tiempo con síntomas con frecuencia era prolongado (15% > 90 días) y la radiología mostraba enfermedad avanzada: infiltrados bilaterales 73%, compromiso > 3 lóbulos 55%, una o más cavitaciones 34%. Se hospitalizó el 71% (126/180), 50% por necesidad de estudio, 48%por gravedad. El 8% necesitó Unidad de Paciente Crítico (UPC). Fallecieron 24 pacientes (13%). Se asoció significativamente a mortalidad el analfabetismo y necesidad de UPC. Conclusiones: En el SSDR la TBC es un problema sanitario que afecta principalmente a poblaciones más pobres y vulnerables.

Backgroud: Tuberculosis (TB) is still a problem that impacts on hospitals of high complexity. Aim: To assess demand for care and/or hospitalization because of TB in Puerto Montt Hospital (PMH), located in the southern of Chile. Patients and Methods: Retrospective study of all Reloncaví Health Service (RHS) and PMH clinical records, between 2011 and 2015. We include all ambulatory or hospitalized cases of active TB registered in PMH during the period of the study. Results: In RHS there were 298 cases of TB and 64% of them (192/298) was detected in HPM. We present social, economic, epidemiological, clinical, laboratory studies, and specific type of diagnosis of 180 cases that met inclusion criteria: men 62%, mean age 45 ± 19 years-old. The population with lower income was 72%, 4% homeless, 14% with complete high school, 11% illiterate and 19% lived at country side. Main co-morbidities were alcoholism 17%, HIV 12%, Diabetes Mellitus 10%. In the specific group of lung/pleural TB (128 cases) the time with symptoms was often prolonged (15% > 90 days) and imagen studies showed advanced pathology: bilateral infiltrates 73%>, affecting three or more lobes 55%, cavitations 34%. 71% (126/180) were hospitalized, because of necessity of more study (50%) or severity (48%), 8% required to enter to the Critical Care Unit (CCU). Twenty-four patients died (13%). Illiteracy and the need for CCU were associated with mortality. Conclusions: In RHS TB is a sanitary problem that affects principally the most poor and vulnerable populations.

Neumonía neumocócica bacteriémica en adultos en hospital regional de Chile / Bacteremic pneumococcal pneumonia in adults admitted to a general hospital: experience in 60 cases

Background: Bacteremic pneumococcal pneumonia (BPP) is a preventable disease with high morbimortality. Aim: To evaluate clinical aspects and mortality on BPP patients admitted to a Chilean regional hospital. Patients and Methods: We looked for adult patients with Streptococcus pneumoniae isolated from blood cultures between 2010 and 2014 years and reviewed clinical records of those who were admitted with pneumonia. Results: We identified 70 BPP patients: 58% were men, mean age was 56 years, 30% were > 65 years, 70% with basic public health insurance, 26% were alcoholics, 86% had comorbidities. Only two patients were vaccinated against S. pneumoniae. CURB-65 severity index for community acquired pneumonia was > 3 in 37% of patients. Twenty-four patients were admitted to ICU, twenty required mechanical ventilation and twenty-four died (34%). Mortality was associated with an age over 65 years, presence of comorbidities and complications of pneumonia. A total of 22 serotypes of S. pneumoniae were identified, five of them (1,3,7F,14 y 9V) were present in 57% of cases. Conclusions: Elevated mortality of our BNN patients was associated with comorbidities and possibly with socio economic factors, which conditioned a late access to medical care.

Etiología viral en la neumonía del adulto adquirida en la comunidad en un hospital del sur de Chile / Viral etiology of community acquired pneumonia among adults admitted to a general hospital

Background: There is paucity of information about viral etiology of community acquired pneumonia in adults. Aim: To investigate the viral etiology of pneumonia among hospitalized patients. Material and Methods: All adults with pneumonia that were hospitalized were prospectively enrolled at Puerto Montt hospital. A microbiological and viral assessment was carried out. Viral assessment included direct immunofluorescence of nasopharyngeal aspirates for influenza A and B virus and serum samples obtained during the acute phase of the disease and during convalescence for Hanta virus. Results: Between April 1 2005 and March 31 2006,159 adults aged 62 ± 20 years (58 % males), were admitted to the hospital for pneumonia. Mean hospital stay was 11.9 ± 8.6 days. Four patients had Hantavirus acute infection. Other viruses were identified in twelve patients (7.7%). Nine had influenza A, one syncytial respiratory virus, one syncytial and influenza A virus and one varicella zoster virus. Excluding patients with Hantavirus, no significant differences in age, clinical presentation, chest X ray findings, laboratory results and mortality were observed between patients with bacterial or viral etiology of the pneumonia. Conclusions: Viral etiology was confirmed in 10% of adult patients hospitalized with community acquired pneumonia.

Impacto clínico de la influenza A H1N1 pandémica en el hospital de Puerto Montt, Chile / Clinical impact of pandemic influenza A H1N1 in a Chilean regional hospital

Background: Pandemic flu (H1N1 ) strongly affected southern Chile during2009. Aim: To report the logistic and organizational changes implemented at a regional hospital to face the pandemic. Material and Methods: All patients with flu like disease that were hospitalized, were prospectively enrolled at the Puerto Montt hospital. A nasopharyngeal aspirate was obtained in all for influenza virus A and B direct immunofluorescence and polymerase chain reaction (PCR). All epidemiological and clinical data of patients were recorded. Results: Between May 29 and July 7, 2009, 184 adults were admitted to the hospital and in 117patients aged 41 ± 18 years (56 percent females ), direct immunofluorescence was positive for influenza. In 67 of these patients PCR did not confirm the disease. These unconfirmed patients had a mean age of 49 ± 19 years (p < 0.01, compared with confirmed cases) and had a lower frequency of fever, rhinorrhea and chills. No significant differences in the incidence of community acquired pneumonia or chest X ray findings were observed between confirmed and unconfirmed cases. Hospital stay was over 15 days in 14 percent of confirmed cases and 5 percent of unconfirmed cases (p = 0.03). Fifteen patients, aged 53 ± 18 years, died. Conclusions: Low sensibility of direct immunofluorescence and delay in obtaining PCR confirmation of influenza posed a problem for the management of these patients.

Hantavirus asociado a sepsis estafilocócica: caso clínico / Hantavirus infection associated to a staphylococcal sepsis: report of one case

We report a previously healthy 36-year-old mole who developed a pulmonary syndrome caused by Hantavirus infection. He was admitted to an intensive care unit in shock and respiratory failure and died four hours after admission. Blood cultures were positive for Staphylococcus aureus. This patient could be an index case that shows, for the first time, an association of Hantavirus Pulmonary Syndrome with Staphylococcus aureus infection similar to what happens with other viruses.

Neumonía adquirida en la comunidad en el anciano hospitalizado: aspectos clínicos y nutricionales / Community-acquired pneumonia in the elderly: clinical and nutritional aspects

Community acquired pneumonia (CAP) in the elderly has unique features and there is little information about the effects of nutrition status on its outcome. Aim: To assess the clinical manifestations and prognostic factors of CAP in immunocompetent elderly patients requiring hospitalization. Patients and methods: Prospective study of all patients with CAP, admitted to Puerto Montt Hospital, Chile over one year. Epidemiológica! and clinical information and laboratory results were recorded. A nutritional assessment was also performed. Outcomes of elderly (>65 years) and young patients were compared. Results: Two hundred patients aged 63± 19 years were studied. Of these, 109 were older than 65 years (78.4±8 years) and 91 were younger than 65years (45.5±11 years). Multiple associated diseases, altered mental status, absence of fever, malnutrition and mortality were more common in the older group. Suspected aspiration pneumonia was more common in younger patients, probably related to alcoholism. Malnutrition was associated with longer hospital stay and mortality at any age. An univariate analysis showed that a low serum albumin (<3.4 g/dl) and a mid arm muscle circumference below the 25th percentile were associated with higher mortality. Conclusions: CAP in the elderly has specific features and malnutrition is associated with a worse prognosis in young and elderly patients.

Experiencia de un Programa de Control de Asma Bronquial en Puerto Montt, Chile / Report of a bronchial asthma control program in Puerto Montt, Chile

Asthma is a disease with a variable clinical behaviour and usually insufficiently treated and managed. Methods: An Asthma Control Program was implemented in Puerto Montt, Chile, with the out patient participation of the primary medical care system. This Program classifies the asthmatic patients by using preestablished criteria of severity. We analyzed the evolution of 135 patients through six quarterly medical controls covering 18 months of follow up. Results: Patients diminished progressively and significantly their severity levels and their daily and nocturnal symptoms. Besides a significant increase of physical capacity (p = 0.001) and peak expiratory flow (PEF) (p = 0.0001) was observed. A series of severe asthmatic patients (12.5 percent) was identified. This group concentrated most of the emergency consultations and hospitalizations. Conclusions: An organized management of asthmatic patients has allowed us to show objectively clinical improvements in these patients after entering to this program

El asma es una patología de comportamiento clínico variable y generalmente sub tratada. Material y métodos: En Puerto Montt se implementó un Programa de Control de Asma Bronquial integrado con el nivel primario de atención, que clasifica los pacientes usando criterios de gravedad. Se analizó la evolución de 135 asmáticos en 6 controles trimestrales cubriendo 18 meses de seguimiento. Resultados: Hubo disminución progresiva y significativa de los niveles de severidad, de síntomas diurnos y nocturnos, aumento de la capacidad de ejercicio (p = 0,001) y del flujo espiratorio máximo (PEF) (0,0001). Se identificó un subgrupo de asmáticos graves (12,5 por ciento) responsables de la gran mayoría de las consultas en urgencia y de las hospitalizaciones. Conclusiones: El manejo organizado de los pacientes asmáticos permitió obtener ventajas clínicas objetivables

Etiologíay factores pronósticos de la neumonía adquirida en la comunidad en el adulto hospitalizado, Puerto Montt, Chile / Etiology and prognostics factors of community-acquired pneumonia among adults patients admitted to a regional hospital in Chile

Background: Community-acquired pneumonia (CAP) is a common and serious illness in Chile. Aim: To evaluate the etiology, severity, prognostic factors and blood culture yield of CAP requiring hospitalization in Puerto Montt in Southern, Chile. Patients and methods: All non immunocompromised adults with CAP admitted at Puerto Montt Hospital during one year, were prospectively studied. Clinical and radiological assessment was done in all patients. Blood and sputum cultures were obtained and serology for atypical agents was determined. Results: We studied 200 patients, aged 63±19 years (109 males). The prognostic factors associated with mortality were an age over 65 years, an altered mental status, shock and acute renal failure. Etiology was demonstrated in 29% of patients. The most frequent pathogens were Streptococcus pneumoniae (40.7%), Haemophilus influenzae (23.7%) and Chlamydia pneumoniae (16.9%). Mixed infections were found in 17%. Fifteen atypical pathogens were identified in 12 patients. Of these only two received a specific treatment but no one died and their length hospital stay was similar than in the rest of the patients. Overall, blood cultures were positive in 12.5% of patients, but among alcoholics, 58% were positive. In only one percent of cases, positive cultures motivated therapeutic changes among clinicians. Eight percent of S pneumoniae strains were penicillin resistant. Conclusions: Atypical agents were a common cause of CAP in this group of patients, but their pathogenic role and treatment requirements are debatable. Focusing blood cultures on specific groups could improve their yield. The rate of Penicillin resistance for S pneumoniae was low.

Susceptibilidad a penicilina en cepas de Streptococcus pneumoniae aisladas en el Hospital de Puerto Montt, 1995-2003 / Penicillin susceptibility in Streptococcus pneumoniae strains isolated at Puerto Montt Hospital between 1995 and 2003

Background: The emergence and dissemination of resistance to penicillin among Streptococcus pneumoniae changed the approach to empiric antimicrobial therapy. Aim: To evaluate the in vitro susceptibility to penicillin in all S. pneumoniae strains isolated in Puerto Montt Hospital between 1995 and 2003. Material and methods: We revised all Microbiology Laboratory files of this period. Identification and antimicrobial susceptibility study methods for S pneumoniae did not change during the study period. Results: Six hundred eighteen S pneumoniae strains were identified. Of these, 66% came from adults and 48% from invasive diseases. Only 1.9% of strains were penicillin resistant and 7.6% had intermediate sensibility. Strains isolated from children and those isolated from non sterile sources had non significantly higher resistance levels. The susceptibility did not change along the years of the study. Conclusions: Among S pneumoniae strains isolated at Puerto Montt Hospital, the prevalence of penicillin resistance is low.

Etiología de la neumonía adquirida en la comunidad en el adulto inmunocompetente / Etiology of comuunity-acquired pneumonia in immunocompetent adults

In an ideal clinical setting, empiric antimicrobial treatment prescribed in adult community acquired pneumonia (CAP) should be based on national etiological surveillance and in vitro susceptibility assays. Available information about etiology in ambulatory patients and intensive care unit (ICU) patients is scarce, compared to information obtained in hospitalized patients. In studies designed to explore the etiology of pneumonia, no microorganism is detected in 40-50% of patients, a fact that represents limited yields in diagnostic methods. In all settings, Streptococcus pneumoniae is the main respiratory pathogen recovered in adults CAP, being responsible of about 16% of cases among ambulatory patients and about 22% of those admitted to hospital and ICU. About one third of cases are caused by a small group of microorganisms: Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, respiratory viruses, Staphylococcus aureus, gramnegative bacillus, Legionella sp; each one is isolated in less than 10% of cases. In general, microorganism distribution varies scarcely in the following attending settings: ambulatory patients, common wards and ICU. An exception is represented by a higher frequency of gram negative bacillus, S. aureus and Legionella sp in ICU, and of C. pneumoniae in the ambulatory setting. In Chile, CAP etiology in hospitalized adult patients is similar to foreign reports; no systematic information has been collected about the etiology in neither ambulatory patients nor in severe CAP.

En la situación clínica ideal, el tratamiento antimicrobiano empírico prescrito en la neumonía del adulto adquirida en la comunidad (NAC) debería estar basado en el resultado de los estudios microbiológicos realizados en el medio nacional. La información disponible sobre la etiología en el medio ambulatorio y la UCI es relativamente escasa, en comparación con la referida al medio intrahospitalario. En los estudios diseñados específicamente para estudiar los agentes causales, en 40-50% de los casos no se identifica el patógeno respiratorio, lo que pone de manifiesto las dificultades de los métodos diagnósticos. En todos los escenarios de atención, Streptococcus pneumoniae es el principal patógeno respiratorio aislado en la NAC del adulto, siendo responsable de 16% de los casos tratados en el medio ambulatorio y de alrededor de 22% de los casos admitidos al hospital y la UCI. Aproximadamente un tercio de los casos son causados por un conjunto de varios microorganismos: Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, virus respiratorios, Staphylococcus aureus, bacilos gramnegativos y Legionella sp, siendo cada uno responsable de menos de 10% de los casos. En general, la distribución de los microorganismos varía escasamente en los tres entornos de atención: ambulatorio, sala de cuidados generales y UCI. Entre las excepciones destaca una mayor frecuencia de infección por bacilos gramnegativos, S. aureus y Legionella sp en la UCI, y de C. pneumoniae en el medio ambulatorio. En Chile, la etiología de la NAC en el adulto hospitalizado es similar a la comunicada en estudios extranjeros, y no se dispone de información específica sobre la NAC de manejo ambulatorio y de la que cursa en forma grave.

Neumonía neumocócica bacterémica en 45 adultos inmunocompetentes hospitalizados: cuadro clínico y factores pronósticos / Bacteremic pneumococcal pneumonia in 45 hospitalized adults

Background: The presence of bacteremia during a pneumococcal pneumonia is a sign of bad prognosis. Aim: To report a clinical experience with bacteremic pneumococcal pneumonia. Patients and methods: We reviewed the clinical and laboratory data from 45 adults (36 male, aged 17 to 97 years) with community acquired pneumonia (CAP) and Streptococcus pneumoniae bacteremia, hospitalized between January 1997 and August 2002 at the Puerto Montt Hospital (Southern Chile). Results: Eighty four percent of patients had underlying aggravating conditions, mainly alcoholism (40 percent), chronic obstructive lung disease (17.8 percent) and renal failure (17.8 percent). Seven percent were homeless. Fever, cough, dyspnea and sputum were the most common presenting symptoms. Five patients had pleural involvement. Four strains (8.9 percent) of S. pneumoniae had diminished susceptibility to penicillin. Nine patients died (case-fatality rate of 20 percent), but mortality was attributed to pneumonia in only three of them. Main factors associated with a higher mortality were renal failure, absence of cough, an arterial pH <7.3 on admission, ICU hospitalization, shock, mechanical ventilation and an APACHE score >16. Conclusions: The high death rate of these patients could be explained mainly by underlying conditions. ICU management and higher cost preventive measures could reduce this rate (Rev MÚd Chile 2004; 132: 588-94).