[Community-acquired pneumonia requiring hospitalization in immunocompetent elderly patients: clinical features, prognostic factors and treatment]. / Neumonía adquirida en la comunidad en el anciano inmunocompetente que requiere hospitalización. Cuacro clínico, factores pronósticos y tratamiento.

BACKGROUND: Community-acquired pneumonia (CAP) is the leading cause of death from infectious disease among the elderly. This study was carried out to examine the clinical manifestations, etiology, prognostic factors and treatment of CAP in immunocompetent elderly patients requiring hospitalization. RESULTS: A total of 306 elderly (80 +/- 7 years) patients were evaluated: 54% were male, 89% had concurrent diseases (principally cardiovascular and neurological disease, chronic obstructive lung disease and diabetes), and 97% were treated with second-or third-generation cephalosporins. Mean hospital stay was 10 days, and mortality was approximately 10% in hospital and around 13% on follow up at 30 days. As compared to younger CAP patients, multiple comorbidity, altered mental status, hypoxemia, high serum urea nitrogen on hospital admission were more frequent in the elderly. Intermediate care and intensive care unit admissions were also more frequent in the elderly. Hospital length of stay as well as mortality in the hospital and at 30 days were higher in elderly patients. The pathogen was identified as part of routine care in around 25% of cases. The most frequent pathogens were Streptococcus pneumoniae (10.5%), enteric Gram negative bacilli (5.2%), Staphylococcus aureus (4.2%) and Haemophilus influenzae (3.9%). In multivariate analysis the prognostic factors on admission associated with in-hospital mortality were advanced age (> 83 years), absence of cough, low blood pressure and hyperphosphatemia. CONCLUSION: CAP in elderly patients is a prevalent disease with specific clinical and epidemiological characteristics, clinical course and prognosis.

Neumonía adquirida en la comunidad en el anciano inmunocompetente que requiere hospitalización. Cuadro clínico, factores pronósticos y tratamiento / Community-acquired pneumonia requiring hospitalization in immunocompetent elderly patients: clinical features, prognostic factors and treatment

FUNDAMENTO Y OBJETIVOS: La neumonía adquirida en la comunidad (NAC) es la principal causa de muerte de origen infeccioso en el anciano. Realizamos este trabajo con el propósito de examinar el cuadro clínico, la etiología, los factores pronósticos y el tratamiento de la NAC en el anciano inmunocompetente que requiere hospitalización. Diseño: estudio clínico prospectivo descriptivo observacional. RESULTADOS: Se evaluó a 306 pacientes (80 ñ 7 años), un 54 por ciento de ellos eran varones, el 89 por ciento presentaba comorbilidad (especialmente cardiovascular, neurológica, enfermedad pulmonar obstructiva crónica, diabetes) y el 97 por ciento fue tratados con cefalosporinas de segunda o tercera generación. La estancia promedio en el hospital fue de 10 días, aproximadamente el 10 por ciento de los pacientes falleció en el hospital y alrededor del 13 por ciento en el seguimiento a los 30 días. En la NAC del anciano, comparada con la del adulto joven, fue más frecuente la presencia de comorbilidad múltiple, estado mental alterado, hipoxemia y nitrógeno ureico sérico elevado en la admisión, así como la necesidad de ingreso en la unidad de cuidado intensivo. Además, la estancia y la mortalidad en el hospital y en el seguimiento a los 30 días fueron más elevadas en la población senescente. En la práctica clínica habitual, la etiología microbiana se estableció en aproximadamente el 25 por ciento de los casos. Los patógenos aislados con mayor frecuencia fueron Streptococcus pneumoniae (10,5 por ciento), bacilos gramnegativos entéricos (5,2 por ciento), Staphylococcus aureus (4,2 por ciento) y Haemophilus influenzae (3,9 por ciento). En el análisis multivariado, los factores medidos en la admisión asociados con mayor riesgo de morir en el hospital fueron la edad avanzada (> 83 años), ausencia de tos, hipotensión arterial e hiperfosfemia. CONCLUSIÓN: La NAC en el anciano es una enfermedad prevalente que presenta características clinicoepidemiológicas, evolución y pronóstico particulares (AU)

[Community-acquired pneumonia in the elderly requiring hospitalization. Clinical features and prognosis]. / Neumonía adquirida en la comunidad en ancianos que requieren internación. Cuadro clínico y pronostico.

We evaluated retrospectively 96 patients older than 64 years admitted with the diagnosis of Community Acquired Pneumonia (CAP) in order to describe the clinical features, evaluate severity and assess prognostic factors. During an 18-month period 100 cases of CAP were included. Average age was 82.3 years +/- 8.3 (+/- SD). By the time of admission, cough and fever were found in 35% of cases and 48% had altered mental status. Fourteen per cent needed mechanical ventilation. Etiology was determined in 21% of cases. Most common pathogens were S. pneumoniae (38.1%), S. aureus (19%) and H. infuenzae (14.3%). Overall mortality was 29%. The most commonly present criteria of severity were tachypnea (respiratory rate > 30) and a PaO2/FIO2 ratio < 250. Severe pneumonia was found in 60% of patients and mortality in that group was 40%. Multivariate analysis demonstrated that some independent prognostic factors were associated with higher mortality: requirement of vasopressors (Odds Ratio [OR] = 22.0; 95% confidence interval [CI] = 1.9-249.5), oliguria (OR = 9.9; CI = 1.5-66.2), previous neurologic disease (OR = 8.2; CI = 1.8-36.6), PaCO2 > 44 mm/Hg (OR = 6.9; CI = 1.1-43.2), and creatinine > 1.4 mg/dl (OR = 4.7; CI = 1.2-19.1). We conclude that CAP features in elderly patients requiring hospitalization are atypical, severe presentations are frequent and mortality is high. Prognostic factors as found in this study can help the evaluating physician to identify those who require special care.

Neumonía adquirida en la comunidad en ancianos que requieren internación. Cuadro clínico y pronostico. / [Community-acquired pneumonia in the elderly requiring hospitalization. Clinical features and prognosis]

We evaluated retrospectively 96 patients older than 64 years admitted with the diagnosis of Community Acquired Pneumonia (CAP) in order to describe the clinical features, evaluate severity and assess prognostic factors. During an 18-month period 100 cases of CAP were included. Average age was 82.3 years +/- 8.3 (+/- SD). By the time of admission, cough and fever were found in 35

of cases and 48

had altered mental status. Fourteen per cent needed mechanical ventilation. Etiology was determined in 21

of cases. Most common pathogens were S. pneumoniae (38.1

), S. aureus (19

) and H. infuenzae (14.3

). Overall mortality was 29

. The most commonly present criteria of severity were tachypnea (respiratory rate > 30) and a PaO2/FIO2 ratio < 250. Severe pneumonia was found in 60

of patients and mortality in that group was 40

. Multivariate analysis demonstrated that some independent prognostic factors were associated with higher mortality: requirement of vasopressors (Odds Ratio [OR] = 22.0; 95

confidence interval [CI] = 1.9-249.5), oliguria (OR = 9.9; CI = 1.5-66.2), previous neurologic disease (OR = 8.2; CI = 1.8-36.6), PaCO2 > 44 mm/Hg (OR = 6.9; CI = 1.1-43.2), and creatinine > 1.4 mg/dl (OR = 4.7; CI = 1.2-19.1). We conclude that CAP features in elderly patients requiring hospitalization are atypical, severe presentations are frequent and mortality is high. Prognostic factors as found in this study can help the evaluating physician to identify those who require special care.

[Cholestasis associated with ticlopidine]. / Colestasis asociada a ticlopidina.

The case of a 56-years-old male with cholestasis associated with ticlopidine is presented. Cholestasis is an infrequent adverse effect of this drug. The patient was admitted to hospital because of jaundice, choluria, and itching of one month of evolution. The patient had taken ticlopidine twice a day for 3 months up to one week prior to admission for peripheral arteriopathy. Biopsy was performed showing acinar cholestasis and portal inflammatory infiltrate compatible with cholestasis due to hypersensitivity. Ticlopidine was discontinued by the patient himself one week prior to admission. The drug was not readministered and the evolution of the clinical and biochemical parameters of cholestasis decreased. The patient was asymptomatic and laboratory data were normal 4 months later.