Appropriateness and delay to initiate therapy in ventilator-associated pneumonia.

Inappropriate therapy (IT) and delayed initiation of appropriate therapy (DIAT) result in inadequate therapy in patients with ventilator-associated pneumonia (VAP). The aim of the current study was to assess the impact of DIAT in VAP. A total of 76 mechanically ventilated patients with bacteriologically confirmed VAP were prospectively evaluated in the intensive care unit of six hospitals in Buenos Aires, Argentina. Appropriate therapy was defined as coverage of all the identified pathogens by the antimicrobial therapy administered at the time of VAP clinical diagnosis. The clinical pulmonary infection score was measured during the 3 days before, at the onset and during the days which followed the onset of VAP. A total of 24 patients received adequate therapy; mortality was 29.2%. The remaining 52 patients received either IT (n = 16) or DIAT (n = 36); the mortality was 63.5% combined, and 75.0 and 58.3% for IT and DIAT, respectively (statistically significant compared with adequate therapy). Inappropriate therapy and delayed initiation of appropriate therapy increased the mortality of ventilator-associated pneumonia. Patients with inappropriate therapy and/or delayed initiation of appropriate therapy had a more gradual increase in clinical pulmonary infection score than those receiving adequate therapy, and this increase was found to occur prior to the time of the clinical diagnosis. In conclusion, these findings might provide the rationale for a trial of earlier initiation of therapy, based on clinical grounds in an effort to improve the outcome of patients with ventilator-associated pneumonia.

Neumonia por Legionella pneumophila. Experiencia en un Hospital Universitario de Buenos Aires / Pneumonia due to Legionella pneumophila. Experience gathered in a University Hospital in Buenos Aires

Legionnaires' disease is a well recognized cause of community acquired pneumonia (CAP) all around the world. In Latin America its incidence remains unknown. This study analyzed a cohort of 9 patients with CAP due to Legionella pneumophila observed from 1997 to 2001, in the Hospital de Clínicas José de San Martin, University of Buenos Aires. Clinical history included recent illnesses, work exposure, physical exam, prior antibiotic use and severity of illness criteria. None of the 9 patients had a history of recent travels, and 4 of them required admission in intensive care unit (ICU). Seven patients had a cigarette smoking history, four of them also had COPD, and one patient had a non-Hodgkin lymphoma. This study confirms the low specificity of clinical and general laboratory criteria to predict this etiology. Legionella isolation is difficult, and serological testing allows retrospective diagnosis but takes several weeks, while urinary antigen test gives a bed-side diagnosis. When Legionella appears in isolated cases, as happens in Argentina, it should be necessary to have a high index of suspicion to successfully arrive at an etiological diagnosis. Legionella pneumophila is a pathogen causing CAP in our area. A surveillance should be established preferably focused on selected populations including severe CAP, immunocompromised hosts and patients with chronic obstructive pulmonary disease.

La enfermedad de los legionarios es una causa de neumonía adquirida en la comunidad (NAC)reconocida en todo el mundo. En Latinoamérica su incidencia es desconocida. En este estudiose analizó a 9 pacientes con NAC por Legionella pneumophila atendidos entre 1997 y 2001 en el Hospital deClínicas José de San Martín de la Universidad de Buenos Aires. Se registraron datos de antecedentes, enfermedad actual, contactos, exposición laboral, examen físico, pruebas de laboratorio y uso previo de antibióticos, y se tomó en cuenta la presencia de criterios de gravedad. Nueve pacientes presentaron diagnóstico de NAC por Legionella, ninguno refirió antecedentes de viajes recientes; cuatro de ellos debieron ser internados en unidades de cuidado intensivo. Siete pacientes tenían antecedentes de tabaquismo, 4 tenían EPOC y un paciente linfoma no-Hodgkin. Nuestra casuística corrobora la baja especificidad de la clínica y estudios complementarios para predecir esta etiología. El aislamiento de Legionella es dificultoso, la seroconversión permite eldiagnóstico retrospectivo y requiere plazos prolongados y el antígeno urinario aporta un diagnóstico inmediato.Cuando la legionelosis aparece en casos aislados, como ocurriría en Argentina, si no se piensa en esta etiologíano se llegará al diagnóstico. Legionella pneumophila es un patógeno de NAC en nuestro medio, debe buscarsemejor, particularmente en pacientes graves, inmunodeprimidos y en fumadores con enfermedad pulmonarobstructiva crónica (EPOC).

Neumonia por Legionella pneumophila. Experiencia en un Hospital Universitario de Buenos Aires / Pneumonia due to Legionella pneumophila. Experience gathered in a University Hospital in Buenos Aires

Legionnaires disease is a well recognized cause of community acquired pneumonia (CAP) all around the world. In Latin America its incidence remains unknown. This study analyzed a cohort of 9 patients with CAP due to Legionella pneumophila observed from 1997 to 2001, in the Hospital de Clínicas José de San Martin, University of Buenos Aires. Clinical history included recent illnesses, work exposure, physical exam, prior antibiotic use and severity of illness criteria. None of the 9 patients had a history of recent travels, and 4 of them required admission in intensive care unit (ICU). Seven patients had a cigarette smoking history, four of them also had COPD, and one patient had a non-Hodgkin lymphoma. This study confirms the low specificity of clinical and general laboratory criteria to predict this etiology. Legionella isolation is difficult, and serological testing allows retrospective diagnosis but takes several weeks, while urinary antigen test gives a bed-side diagnosis. When Legionella appears in isolated cases, as happens in Argentina, it should be necessary to have a high index of suspicion to successfully arrive at an etiological diagnosis. Legionella pneumophila is a pathogen causing CAP in our area. A surveillance should be established preferably focused on selected populations including severe CAP, immunocompromised hosts and patients with chronic obstructive pulmonary disease.(AU)

La enfermedad de los legionarios es una causa de neumonía adquirida en la comunidad (NAC)reconocida en todo el mundo. En Latinoamérica su incidencia es desconocida. En este estudiose analizó a 9 pacientes con NAC por Legionella pneumophila atendidos entre 1997 y 2001 en el Hospital deClínicas José de San Martín de la Universidad de Buenos Aires. Se registraron datos de antecedentes, enfermedad actual, contactos, exposición laboral, examen físico, pruebas de laboratorio y uso previo de antibióticos, y se tomó en cuenta la presencia de criterios de gravedad. Nueve pacientes presentaron diagnóstico de NAC por Legionella, ninguno refirió antecedentes de viajes recientes; cuatro de ellos debieron ser internados en unidades de cuidado intensivo. Siete pacientes tenían antecedentes de tabaquismo, 4 tenían EPOC y un paciente linfoma no-Hodgkin. Nuestra casuística corrobora la baja especificidad de la clínica y estudios complementarios para predecir esta etiología. El aislamiento de Legionella es dificultoso, la seroconversión permite eldiagnóstico retrospectivo y requiere plazos prolongados y el antígeno urinario aporta un diagnóstico inmediato.Cuando la legionelosis aparece en casos aislados, como ocurriría en Argentina, si no se piensa en esta etiologíano se llegará al diagnóstico. Legionella pneumophila es un patógeno de NAC en nuestro medio, debe buscarsemejor, particularmente en pacientes graves, inmunodeprimidos y en fumadores con enfermedad pulmonarobstructiva crónica (EPOC).(AU)