Utilidad de la proteína C reactiva sérica en el diagnóstico y tratamiento del adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Immunocompetent adults hospitalized for a community-acquired pneumonia: Serum C-reactive protein as a prognostic marker

Background: C-reactive protein (CRP) is used to monitor patients' response during treatment of infectious diseases. Morbidity and mortality associated with community-acquired pneumonia (CAP) is high, particularly in hospitalized patients. Better risk prediction during hospitalization could improve management and ultimately reduce mortality rates. Aim: To evaluate CRP measured at admission and the third day of hospitalization as a predictor for adverse events in CAP. Material and Methods: A prospective cohort study of adult patients hospitalized with CAP at an academic hospital. Major adverse outcomes were admission to ICU, mechanical ventilation, prolonged hospital length of stay, hospital complications and 30-day mortality. Predictive associations between CRP (as absolute levels and relative decline at third day) and adverse events were analyzed. Results: Eight hundred and twenty-three patients were assessed, 19% were admitted to ICU and 10.6% required mechanical ventilation. The average hospital stay was 8.8 ± 8.2 days, 42% had nosocomial complications and 8.1% died within 30 days. Ninety eight percent of patients had elevated serum CRP on admission to the hospital (18.1 ± 14.1 mg/dL). C-reactive protein measured at admission was associated with the risk of bacterial pneumonia, bacteremic pneumonia, septic shock and use of mechanical ventilation. Lack of CRP decline within three days of hospitalization was associated with high risk of complications, septic shock, mechanical ventilation and prolonged hospital stay. Conclusions: CRP responses at third day of hospital admission was a valuable predictor of adverse events in hospitalized CAP adult patients.

Mortalidade e custos da pneumonia pneumocócica em adultos: um estudo transversal / Mortality and costs of pneumococcal pneumonia in adults: a cross-sectional study

RESUMO Objetivo A pneumonia pneumocócica é uma causa significativa de morbimortalidade entre adultos. Desta maneira, o objetivo principal deste estudo foi avaliar a mortalidade intra-hospitalar e os custos relacionados à doença adquirida em adultos. Métodos Este estudo transversal utilizou prontuários de pacientes adultos com pneumonia pneumocócica internados em um hospital universitário no Brasil, de outubro de 2009 a abril de 2017. Todos os pacientes com idade ≥ 18 anos e diagnosticados com pneumonia pneumocócica foram incluídos. Dados como os fatores de risco, a internação em unidade de terapia intensiva, o tempo de internação, a mortalidade hospitalar e os custos diretos e indiretos foram analisados. Resultados No total, 186 pacientes foram selecionados. A taxa média de mortalidade intra-hospitalar foi de 18% para adultos com idade < 65 anos e 23% para os idosos (≥ 65 anos). A pneumonia pneumocócica bacterêmica acometeu 20% dos pacientes em ambos os grupos, principalmente por doença respiratória crônica (OR ajustada: 3,07; IC95%: 1,23‐7,65; p < 0,01). Após levantamento das internações ocorridas no período de sete anos de tratamento, verificou-se que os custos diretos e indiretos totais anuais foram de US$ 28.188 para adultos < 65 anos (US$ 1.746 per capita) e US$ 16.350 para os idosos (US$ 2.119 per capita). Conclusão A pneumonia pneumocócica continua sendo uma importante causa de morbimortalidade entre adultos, afetando significativamente os custos diretos e indiretos. Esses resultados sugerem a necessidade de estratégias de prevenção para todos os adultos, especialmente para pacientes com doenças respiratórias crônicas.

ABSTRACT Objective Pneumococcal pneumonia is a significant cause of morbidity and mortality among adults. The study's main aim was to evaluate the in-hospital mortality and related costs of community-acquired pneumococcal pneumonia in adults. Methods This cross-sectional study used medical records of adult patients with pneumococcal pneumonia hospitalized in a university hospital in Brazil from October 2009 to April 2017. All patients aged ≥ 18 years diagnosed with pneumococcal pneumonia were included. Risk factors, intensive care unit admission, length of hospital stay, in-hospital mortality, and direct and indirect costs were analyzed. Results In total, 186 patients were selected. The mean in-hospital mortality rate was 18% for adults aged < 65 years and 23% for the elderly (≥ 65 years). Bacteremic pneumococcal pneumonia affected 20% of patients in both groups, mainly through chronic respiratory disease (adjusted OR: 3.07, 95% CI: 1.23-7.65, p < 0.01). Over 7 years, annual total direct and indirect costs were USD 28,188 for adults < 65 years (USD 1,746 per capita) and USD 16,350 for the elderly (USD 2,119 per capita). Conclusion Pneumococcal pneumonia remains an important cause of morbidity and mortality among adults, significantly affecting direct and indirect costs. These results suggest the need for prevention strategies for all adults, especially for patients with chronic respiratory diseases.

Lower long-term mortality in obese patients with community-acquired pneumonia: possible role of CRP

OBJECTIVE: The present study aimed to investigate the relationship between obesity and mortality in patients with community-acquired pneumonia (CAP) in China. METHODS: In total, 909 patients with CAP were recruited for this study from January 2010 to June 2015. All patients were selected and divided into 4 groups according to their body mass index (BMI) values. All patients' clinical information was recorded. The associations among mortality; BMI; the 30-day, 6-month and 1-year survival rates for different BMI classes; the etiology of pneumonia in each BMI group; and the risk factors for 1-year mortality in CAP patients were analyzed. RESULT: With the exception of the level of C-reactive protein (CRP), no other clinical indexes showed significant differences among the different BMI groups. No significant differences were observed among all groups in terms of the 30-d and 6-month mortality rates (p>0.05). There was a significantly lower risk of 1-year mortality in the obese group than in the nonobese group, (p<0.05). Logistic regression analysis showed that there were seven independent risk factors for 1-year mortality in CAP patients, namely, age, cardiovascular disease, cerebrovascular disease, obesity, APACHE II score, level of CRP and CAP severity. CONCLUSION: Compared with nonobese patients with CAP, obese CAP patients may have a lower mortality rate, especially with regard to 1-year mortality, and CRP may be associated with the lower mortality rate in obese individuals than in nonobese individuals.

Do N-terminal pro-brain natriuretic peptide levels determine the prognosis of community acquired pneumonia? / Os níveis de pró-peptídeo natriurético cerebral N-terminal determinam o prognóstico de pneumonia adquirida na comunidade?

ABSTRACT Objective: Pneumonia is a leading cause of mortality worldwide, especially in the elderly. The use of clinical risk scores to determine prognosis is complex and therefore leads to errors in clinical practice. Pneumonia can cause increases in the levels of cardiac biomarkers such as N-terminal pro-brain natriuretic peptide (NT-proBNP). The prognostic role of the NT-proBNP level in community acquired pneumonia (CAP) remains unclear. The aim of this study was to evaluate the prognostic role of the NT-proBNP level in patients with CAP, as well as its correlation with clinical risk scores. Methods: Consecutive inpatients with CAP were enrolled in the study. At hospital admission, venous blood samples were collected for the evaluation of NT-proBNP levels. The Pneumonia Severity Index (PSI) and the Confusion, Urea, Respiratory rate, Blood pressure, and age ≥ 65 years (CURB-65) score were calculated. The primary outcome of interest was all-cause mortality within the first 30 days after hospital admission, and a secondary outcome was ICU admission. Results: The NT-proBNP level was one of the best predictors of 30-day mortality, with an area under the curve (AUC) of 0.735 (95% CI: 0.642-0.828; p < 0.001), as was the PSI, which had an AUC of 0.739 (95% CI: 0.634-0.843; p < 0.001), whereas the CURB-65 had an AUC of only 0.659 (95% CI: 0.556-0.763; p = 0.006). The NT-proBNP cut-off level found to be the best predictor of ICU admission and 30-day mortality was 1,434.5 pg/mL. Conclusions: The NT-proBNP level appears to be a good predictor of ICU admission and 30-day mortality among inpatients with CAP, with a predictive value for mortality comparable to that of the PSI and better than that of the CURB-65 score.

RESUMO Objetivo: A pneumonia é uma das principais causas de mortalidade no mundo, especialmente em idosos. O uso de escores de risco clínico para determinar o prognóstico é complexo e, portanto, leva a erros na prática clínica. A pneumonia pode causar aumento nos níveis de biomarcadores cardíacos, como o N-terminal pro-brain natriuretic peptide (NT-proBNP, pró-peptídeo natriurético cerebral N-terminal). O papel prognóstico do nível de NT-proBNP na pneumonia adquirida na comunidade (PAC) continua incerto. O objetivo deste estudo foi avaliar o papel prognóstico do nível de NT-proBNP em pacientes com PAC, bem como sua correlação com escores de risco clínico. Métodos: Pacientes consecutivos internados com PAC foram incluídos no estudo. Na internação hospitalar, foram coletadas amostras de sangue venoso para avaliação dos níveis de NT-proBNP. Foram calculados o Pneumonia Severity Index (PSI, Índice de Gravidade de Pneumonia) e o escore Confusão mental, Ureia, frequência Respiratória, Blood pressure (pressão arterial) e idade ≥ 65 anos (CURB-65). O desfecho primário de interesse foi mortalidade por todas as causas nos primeiros 30 dias após a admissão hospitalar, e um desfecho secundário foi admissão na UTI. Resultados: O nível de NT-proBNP foi um dos melhores preditores de mortalidade em 30 dias, com uma área sob a curva (ASC) de 0,735 (IC95%: 0,642-0,828; p < 0,001), assim como o PSI, que teve uma ASC de 0,739 (IC95%: 0,634-0,843; p < 0,001), enquanto CURB-65 teve uma ASC de apenas 0,659 (IC95%: 0,556-0,763; p = 0,006). O nível de corte do NT-proBNP que mostrou ser o melhor preditor de admissão na UTI e de mortalidade em 30 dias foi de 1.434,5 pg/ml. Conclusões: O nível de NT-proBNP parece ser um bom preditor de admissão na UTI e de mortalidade em 30 dias entre pacientes internados com PAC, com um valor preditivo para mortalidade comparável ao do PSI e superior ao do CURB-65.

Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia in a public hospital in the interior of Brazil / Perfil clínico, epidemiológico e etiológico de pacientes internados com pneumonia adquirida na comunidade em um hospital público do interior do Brasil

ABSTRACT Objective: To describe the patient profile, mortality rates, the accuracy of prognostic scores, and mortality-associated factors in patients with community-acquired pneumonia (CAP) in a general hospital in Brazil. Methods: This was a cohort study involving patients with a clinical and laboratory diagnosis of CAP and requiring admission to a public hospital in the interior of Brazil between March 2014 and April 2015. We performed multivariate analysis using a Poisson regression model with robust variance to identify factors associated with in-hospital mortality. Results: We included 304 patients. Approximately 70% of the patients were classified as severely ill on the basis of the severity criteria used. The mortality rate was 15.5%, and the ICU admission rate was 29.3%. After multivariate analysis, the factors associated with in-hospital mortality were need for mechanical ventilation (OR: 3.60; 95% CI: 1.85-7.47); a Charlson Comorbidity Index score > 3 (OR: 1.30; 95% CI: 1.18-1.43); and a mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) score > 2 (OR: 1.46; 95% CI: 1.09-1.98). The mean time from patient arrival at the emergency room to initiation of antibiotic therapy was 10 h. Conclusions: The in-hospital mortality rate of 15.5% and the need for ICU admission in almost one third of the patients reflect the major impact of CAP on patients and the health care system. Individuals with a high burden of comorbidities, a high CURB-65 score, and a need for mechanical ventilation had a worse prognosis. Measures to reduce the time to initiation of antibiotic therapy may result in better outcomes in this group of patients.

RESUMO Objetivo: Descrever o perfil dos pacientes, taxas de mortalidade, acurácia de escores prognósticos e fatores associados à mortalidade em pacientes com pneumonia adquirida na comunidade (PAC) em um hospital geral no Brasil. Métodos: Estudo de coorte envolvendo pacientes com diagnóstico clínico e laboratorial de PAC e necessidade de internação hospitalar entre março de 2014 e abril de 2015 em um hospital público do interior do Brasil. Foi realizada a análise multivariada mediante o modelo de regressão de Poisson com variância robusta para avaliar os fatores associados com mortalidade intra-hospitalar. Resultados: Foram incluídos 304 pacientes. Aproximadamente 70% dos pacientes foram classificados como graves de acordo com os critérios de gravidade utilizados. A taxa de mortalidade foi de 15,5% e a de necessidade de internação em UTI foi de 29,3%. Após a análise multivariada, os fatores associados à mortalidade intra-hospitalar foram necessidade de ventilação mecânica (OR = 3,60; IC95%: 1,85-7,47); Charlson Comorbidity Index > 3 (OR = 1,30; IC95%: 1,18-1,43); e mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) > 2 (OR = 1,46; IC95%: 1,09-1,98). A média do tempo entre a chegada do paciente na emergência e o início da antibioticoterapia foi de 10 h. Conclusões: A taxa de mortalidade intra-hospitalar de 15,5% e a necessidade de internação em UTI em quase um terço dos pacientes demonstram o grande impacto da PAC nos pacientes e no sistema de saúde. Indivíduos com maior carga de comorbidades prévias, CURB-65 elevado e necessidade de ventilação mecânica apresentaram pior prognóstico. Ações para reduzir o tempo até o início da antibioticoterapia podem resultar em melhores desfechos nesse grupo de pacientes.

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.

Evaluación de los índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Adverse event prediction in immunocompetent adult patients hospitalized with community-acquired pneumonia

Background: Community-acquired pneumonia (CAP) causes significant morbidity and mortality in adults. Aim: To compare the accuracy of four validated rules for predicting adverse outcomes in patients hospitalized with CAP. Patients and Methods: We compared the pneumonia severity index (PSI), British Thoracic Society score (CURB-65), SMART-COP and severe CAP score (SCAP) in 659 immunocompetent adult patients aged 18 to 101 years, 52% male, hospitalized with CAP. Major adverse outcomes were: admission to ICU, need for mechanical ventilation (MV), in-hospital complications and 30-day mortality. Mean hospital length of stay (LOS) was also evaluated. The predictive indexes were compared based on sensitivity, specificity, and area under the curve of the receiver operating characteristic curve. Results: Of the studied patients, 77% had comorbidities, 23% were admitted to the intensive care unit and 12% needed mechanical ventilation. The rate of all adverse outcomes and hospital LOS increased directly with increasing PSI, CURB-65, SMART-COP and SCAP scores. The sensitivity, specificity and area under the curve of the prognostic indexes to predict adverse events were: Admission to ICU (PSI: 0.48, 0.84 and 0.73; SMART-COP: 0.97, 0.23 and 0.75; SCAP: 0.57, 0.81 and 0.76); use of MV (PSI: 0.44, 0.84 and 0.75; SMART-COP: 0.96, 0.35 and 0.84; SCAP: 0.53, 0.87 and 0.78); 30-days mortality (PSI: 0.45, 0.97 and 0.83; SMART-COP: 0.94, 0.29 and 0.77; SCAP: 0.53, 0.95 and 0.81). CURB-65 had a lower discriminatory power compared to the other indices. Conclusions: PSI score and SCAP were more accurate and specific and SMART-COP was more sensitive to predict the risk of death. SMART-COP was more sensitive and SCAP was more specific in predicting the use of mechanical ventilation.

Predictores clínicos de eventos adversos serios en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Clinical predictors of serious adverse events in immunocompetent adult patients hospitalized with community-acquired pneumonia

Introducción: La neumonía adquirida en la comunidad (NAC) ocasiona morbilidad y mortalidad significativa en la población adulta. Objetivos: Examinar las variables clínicas y de laboratorio medidas en la admisión al hospital que permiten predecir los eventos adversos clínicamente relevantes en pacientes adultos hospitalizados por neumonía comunitaria. Métodos: Evaluamos las variables clínicas y de laboratorio asociadas a eventos adversos serios en una cohorte de adultos hospitalizados por NAC. Los eventos adversos examinados fueron la admisión a UCI, necesidad de ventilación mecánica, shock séptico, complicaciones cardiovasculares y generales y estadía prolongada en el hospital y mortalidad a 30 días. Las variables predictoras fueron sometidas a análisis univariado y multivariado en un modelo de regresión logística. Resultados: Se evaluaron 659 pacientes, edad: 67 ± 18 años, 52% varones, 77% tenía comorbilidad, 23% fueron admitidos a la UCI, 12% requirieron ventilación mecánica, 31% presentaron complicaciones en el hospital, la estadía media en el hospital fue 9 días y 9,9% fallecieron en el seguimiento a 30 días. Las comorbilidades, inestabilidad hemodinámica y disfunción renal se asociaron con la admisión a UCI, riesgo de complicaciones y estadía prolongada en el hospital. El uso de ventilación mecánica y shock séptico fue más frecuente en pacientes con inestabilidad hemodinámica y disfunción renal. La edad avanzada, enfermedades cardiovasculares y respiratorias crónicas, sospecha de aspiración, taquipnea y disfunción renal se asociaron al riesgo de eventos cardiovasculares en el hospital. Conclusión: Las variables clínicas y de laboratorio medidas en la admisión al hospital permiten predecir el riesgo de eventos adversos serios en el adulto hospitalizado por neumonía.

Introduction: Community-acquired pneumonia (CAP) causes significant morbidity and mortality in adult population. Objectives: To assess clinical and laboratory variables measured at hospital admission associated to clinically relevant adverse outcomes in patients hospitalized with community-acquired pneumonia. Methods: We prospectively assessed clinical and laboratory variables associated to serious adverse events in a cohort of CAP hospitalized adult patients. Major adverse outcomes were admission to ICU, need for mechanical ventilation, septic shock, prolonged hospital stay, cardiovascular and in-hospital complications and 30-day mortality. The clinical and laboratory variables measured at hospital admission associated to serious adverse events were assessed by univariate and multivariate analysis using logistic regression models. Results: 659 CAP hospitalized immunocompetent adult patients were assessed, mean age: 67 years, 52% were male, 77% had comorbidities, 23% were admitted to the intensive care unit (ICU), 12% needed mechanical ventilation, 31% had hospital complication, mean hospital length of stay was 9 days and 9.9% died at 30-days follow up. Comorbidities, hemodynamic instability and renal dysfunction were associated with ICU admission, risk of complications, and prolonged hospital stay. Mechanical ventilation requirement and septic shock were more frequent in patients with hemodynamic instability and renal dysfunction. Advanced age, chronic cardiovascular and respiratory diseases, aspiration pneumonia, tachypnea, and renal dysfunction were associated with high risk of cardiovascular events in the hospital. Conclusion: The clinical and laboratory variables measured at hospital admission allow us to predict the risk of serious adverse events in CAP hospitalized adult patients.

In-hospital mortality risk factors in community acquired pneumonia: evaluation of immunocompetent adult patients without comorbidities / Fatores de risco para mortalidade intra-hospitalar em pneumonia adquirida em comunidade: avaliação de pacientes imunocompetentes sem comorbidades

Summary Objective: several scores were developed in order to improve the determination of community acquired pneumonia (CAP) severity and its management, mainly CURB-65 and SACP score. However, none of them were evaluated for risk assessment of in-hospital mortality, particularly in individuals who were non-immunosuppressed and/or without any comorbidity. In this regard, the present study was carried out. Methods: we performed a cross-sectional study in 272 immunocompetent patients without comorbidities and with a diagnosis of CAP. Performance of CURB- 65 and SCAP scores in predicting in-hospital mortality was evaluated. Also, variables related to death were assessed. Furthermore, in order to design a model of in-hospital mortality prediction, sampled individuals were randomly divided in two groups. The association of the variables with mortality was weighed and, by multiple binary regression, a model was constructed in one of the subgroups. Then, it was validated in the other subgroup. Results: both scores yielded a fair strength of agreement, and CURB-65 showed a better performance in predicting in-hospital mortality. In our casuistry, age, white blood cell counts, serum urea and diastolic blood pressure were related to death. The model constructed with these variables showed a good performance in predicting in-hospital mortality; moreover, only one patient with fatal outcome was not correctly classified in the group where the model was constructed and in the group where it was validated. Conclusion: our findings suggest that a simple model that uses only 4 variables, which are easily accessible and interpretable, can identify seriously ill patients with CAP .

Resumo Objetivo: diversos escores de gravidade da pneumonia adquirida em comunidade (PAC) foram desenvolvidos com o intuito de melhorar o manejo clínico, em especial os escores CURB-65 e SCAP. Contudo, nenhum dos dois foi avaliado para determinar o risco de morte intra- hospitalar, principalmente em pacientes imunocompetentes e/ou sem comorbidades. Diante disso, propusemo- nos a analisar a utilidade dos escores para prever a mortalidade intra-hospitalar e estudar as variáveis associadas ao desfecho fatal. Métodos: desenvolvemos um trabalho transversal com 272 pacientes imunocompetentes, sem comorbidades e com diagnóstico de PAC. Foi avaliada a eficácia dos escores CURB-65 e SCAP em prever a mortalidade durante a internação. Foram estudadas as variáveis relacionadas a este desfecho. Por fim, a amostra foi dividida em dois subgrupos com o objetivo de desenvolver um modelo de avaliação do risco de morte em um subgrupo, validando-o no outro. Resultados: ambos os escores apresentaram pobre concordância de classificação da gravidade para PAC. O escore CURB-65 mostrou melhor desempenho na avaliação do risco de morte. Em nossa amostra, idade, contagem de glóbulos brancos, ureia sérica e pressão arterial diastólica foram as variáveis que se associaram à mortalidade. O modelo desenvolvido com essas variáveis mostrou eficácia muito boa para prever o desfecho fatal. Inclusive, somente um paciente no grupo de desenvolvimento do modelo e outro no grupo de validação foram classificados de modo incorreto. Conclusão: nossos resultados sugerem que com um modelo de quatro variáveis, de fácil acesso e interpretação, foi possível identificar pacientes gravemente enfermos com PAC. .

Hospitalización diurna como modelo de atención de salud en pacientes adultos inmunocompetentes con neumonía adquirida en la comunidad / Respiratory day hospital care for immunocompetent adult patients with community-acquired pneumonia

Background: Day hospitals can reduce health care costs without increasing the risks of patients with lower respiratory tract infection. Aim: To report the experience of a respiratory day hospital care delivered to adult patients with community-acquired pneumonia (CAP) in a public hospital. Material and Methods: During the fall and winter of 2011 and 2012, adult patients with CAP of intermediate risk categories were assessed in the emergency room, their severity was stratified according to confusion, respiratory rate, blood pressure, 65 years of age or older (CRB-65) score and the Chilean CAP Clinical Guidelines, and were admitted to the respiratory day hospital. Results: One hundred seventeen patients aged 67 ± 16 years, (62% females) with CAP were attended in the respiratory day hospital. Ninety percent had comorbidities, especially chronic obstructive pulmonary disease in 58%, heart disease in 32%, diabetes in 16% and asthma in 13%. Their most important risk factors were age over 65 years in 60%, comorbidities in 88%, failure of antibiotic treatment in 17%, loss of autonomy in 21%, vital sign abnormalities in 60%, mental confusion in 5%, multilobar CAP in 23%, pleural effusion in 15%, hypoxemia in 41% and a serum urea nitrogen over 30 mg/dL in 16%. Patients stayed an average of seven days in the day hospital with oxygen, hydration, chest physiotherapy and third-generation cephalosporins (89%) associated with quinolones (52%) or macrolides (4%). Thirteen patients required noninvasive ventilation, eight patients were hospitalized because of clinical deterioration and three died in hospital. Conclusions: Day hospital care reduced hospital admission rates of patients with lower respiratory tract infections.

Lethality by pneumonia and factors associated to death / Letalidade por pneumonia e fatores associados ao óbito

OBJECTIVE: To describe the case-fatality rate (CFR) and risk factors of death in children with community-acquired acute pneumonia (CAP) in a pediatric university hospital. METHOD: A longitudinal study was developed with prospective data collected from 1996 to 2011. Patients aged 1 month to 12 years were included in the study. Those who left the hospital against medical orders and those transferred to ICU or other units were excluded. Demographic andclinical-etiological characteristics and the initial treatment were studied. Variables associated to death were determined by bivariate and multivariate analysis using logistic regression. RESULTS: A total of 871 patients were selected, of whom 11 were excluded; thus 860 children were included in the study. There were 26 deaths, with a CFR of 3%; in 58.7% of these, penicillin G was the initial treatment. Pneumococcus was the most common pathogen (50.4%). From 1996 to 2000, there were 24 deaths (93%), with a CFR of 5.8% (24/413). From 2001 to 2011, the age group of hospitalized patients was older (p = 0.03), and the number of deaths (p = 0.02) and the percentage of disease severity were lower (p = 0.06). Only disease severity remained associated to death in the multivariate analysis (OR = 3.2; 95%CI: 1.2-8.9; p = 0.02). CONCLUSION: When the 1996-2000 and 2001-2011 periods were compared, a significant reduction in CFR was observed in the latter, as well as a change in the clinical profile of the pediatric in patients at the institute. These findings may be related to the improvement in the socio-economical status of the population. Penicillin use did not influence CFR. .

OBJETIVO: Descrever a taxa de letalidade (TL) e os fatores de risco de óbito em crianças com pneumonia grave adquirida na comunidade (CAP) em um hospital universitário pediátrico. MÉTODO: Foi desenvolvido um estudo longitudinal com dados prospectivos coletados de 1996 a2011. Foram incluídos no estudo pacientes com idade entre 1 mês e 12 anos de idade. Foram excluídos aqueles que deixaram o hospital desconsiderando as recomendações médicas e aqueles transferidos para UTI ou outras unidades. Foram estudadas as características demográficas, clínicas e etiológicas e o tratamento inicial. As variáveis associadas a óbito foram determinadas por análise bivariada e multivariada utilizando regressão logística. RESULTADOS: Foi selecionado um total de 871 pacientes, dos quais 11 foram excluídos; assim, foram incluídas no estudo 860 crianças. Houve 26 óbitos, com uma TL de 3%; em 58,7% desses, penicilina G foi o tratamento inicial. Pneumococo foi o patógeno mais comum (50,4%). De 1996 a 2000, houve 24 óbitos (93%), com uma TL de 5,8% (24/413). De 2001 a 2011, a faixa etária de pacientes internados foi mais velha (p = 0,03) e o número de óbitos (p = 0,02) e o percentual de gravidade das doenças foram menores (p = 0,06). Apenas a gravidade das doenças continuou associada a óbito na análise multivariada (RC = 3,2; IC de 95%: 1,2-8,9; p = 0,02). CONCLUSÃO: Quando os períodos de 1996-2000 e 2001-2011 foram comparados, foi observada uma redução significativa na TL no último período, bem como uma alteração no perfil clínico dos pacientes hospitalizados no instituto. Esses achados podem estar relacionados à melhora na situação socioeconômica da população. O uso de penicilina não influenciou a TL. .

Sobrevida a largo plazo en adultos inmunocompetentes mayores de 60 años hospitalizados por neumonía adquirida en la comunidad / Long-term survival of immunocompetent patients older than 60 years hospitalized for community-acquired pneumonia

Background: A reduction in long-term survival of adult patients hospitalized with community-acquired pneumonia (CAP), especially older people with múltiple comorbidities, has been reported. Aim: To examine the clinical variables associated to mortality at 72 months of adult patients older than 60 years hospitalized with CAP and compare their mortality with a control group matched for age, gender and place of admission. Material and Methods: Prospective assessment of 465 immunocompetent patients aged 61 to 101 years, hospitalized for CAP in a teaching hospital. Hospital and 30 day mortality was obtained from medical records. Seventy two months survival ofthe 424 patients who were discharged olive, was compared with a group of 851 patients without pneumonia paired for gender and age. Mortality at 72 months was obtained from death certificates. Results: Eighty seven percent of patients had comorbidity. The median hospital length ofstay was 10 days, 8.8% died in the hospital, 29.7% at one year follow-up and 61.9%o at 6 years. The actuarial survival at six years was similar in the cohort of adults hospitalized with CAP and the control group matched for age, gender and site of care. In a multivariate analysis, the clinical variables associated with increased risk of dying during long-term follow-up were older age, chronic cardiovascular and neurological diseases, malignancy, absence of fever, low C-reactive protein at hospital admission and high-risk parameters of the Fine índex. Conclusions: Advanced age, some specific comorbidities, poor systemic inflammatory response at admission and high risk parameters of the Fine Index were associated to increased risk of dying on long-term follow-up among older adults hospitalized for CAP.

Predictores clínicos de mortalidad en el seguimiento a mediano plazo en pacientes adultos inmunocompetentes hospitalizados por neumonía adquirida en la comunidad / Predictors of one year mortality among immunocompetent adults hospitalized for community-acquired pneumonia

Background: Mortality increases in adults, especially in older adults, after recovery from an episode of community-acquired pneumonia (CAP). Aim: To analyze survival and predictors of death at one year follow up of a cohort of adult patients hospitalized with CAP. Material and Methods: Immunocompetent patients admitted to a clinical hospital for an episode of CAP were included in the study and were assessed according to a standardized protocol. One year mortality after admission was assessed using death records of the National Identification Service. Clinical and laboratory variables measured at hospital admission associated with risk of death at one year follow up were subjected to univariate and multivariate analysis by a logistic regression model. Results: We evaluated 659 patients aged 68 ± 19 years, 52% were male, 77% had underlying conditions (especially cardiovascular, neurological and respiratory diseases). Mean hospital length of stay was 9 days, 7.1% died during hospital stay and 15.8% did so during the year of follow-up. A causal agent was identified in one third of cases. The main pathogens isolated were Streptococcus pneumoniae (12.9%), Haemophilus influenzae (4.1%), respiratory viruses (6.5%) and Gram-negative bacilli (6.5%). In multivariate analysis, the clinical variables associated with increased risk of dying during the year of follow-up were older age, chronic neurological disease, malignancies, lack of fever at admission and prolonged hospital length of stay. Conclusions: Age, specific co-morbidities such as chronic neurological disease and cancer, absence of fever at hospital admission and prolonged hospital length of stay were associated with increased risk of dying during the year after admission among adult patients hospitalized with community-acquired pneumonia.

Comparison of clinical characteristics between healthcare-associated pneumonia and community-acquired pneumonia in patients admitted to secondary hospitals

BACKGROUND: Since healthcare-associated pneumonia (HCAP) is heterogeneous, clinical characteristics and outcomes are different from region to region. There can also be differences between HCAP patients hospitalized in secondary or tertiary hospitals. This study aimed to evaluate the clinical characteristics of HCAP patients admitted into secondary community hospitals. METHODS: This was a retrospective study conducted in patients with HCAP or community-acquired pneumonia (CAP) hospitalized in two secondary hospitals between March 2009 and January 2011. RESULTS: Of a total of 303 patients, 96 (31.7%) had HCAP. 42 patients (43.7%) resided in a nursing home or long-term care facility, 36 (37.5%) were hospitalized in an acute care hospital for > 2 days within 90 days, ten received outpatient intravenous therapy, and eight attended a hospital clinic or dialysis center. HCAP patients were older. The rates of patients with CURB65 scores of 3 or more (22.9% vs. 9.1%; p = 0.001) and PSI class IV or more (82.2% vs. 34.7%; p < 0.001) were higher in the HCAP group. Drug-resistant pathogens were more frequently detected in the HCAP group (23.9% vs. 0.4%; p < 0.001). However, Streptococcus pneumoniae was the most common pathogen in both groups. The rates of antibiotic change, use of inappropriate antibiotics, and failure of initial antibiotic therapy in the HCAP group were significantly higher. Although the overall survival rate of the HCAP group was significantly lower (82.3% vs. 96.8%; p < 0.001), multivariate analyses failed to show that HCAP itself was a prognostic factor for mortality (p = 0.826). Only PSI class IV or more was associated with increased mortality (p = 0.005). CONCLUSIONS: HCAP should be distinguished from CAP because of the different clinical features. However, the current definition of HCAP does not appear to be a prognostic for death. In addition, the use of broad-spectrum antibiotics for HCAP should be reassessed because S. pneumoniae was most frequently identified even in HCAP patients.

Impacto de la bacteriemia en una cohorte de pacientes con neumonía neumocócica / Impact of bacteremia in a cohort of patients with pneumococcal pneumonia

OBJETIVO: Bacteriemia es la forma invasiva más común de neumonía adquirida en la comunidad (NAC) por Streptococcus pneumoniae. Investigamos si la bacteriemia en NAC neumocócica empeora los resultados y si ella guarda relación con la vacunación antineumocócica (VAN). MÉTODOS: Análisis secundario de una cohorte de pacientes con NAC neumocócica confirmada por cultivo de sangre o esputo o antígeno urinario. Se registraron datos demográficos, clínicos, radiográficos y de laboratorio, escores Acute Physiology and Chronic Health Evaluation II (APACHE II) y pneumonia severity index (PSI), comorbilidades y antecedente de VAN. Se compararon pacientes con NAC neumocócica bacteriémica (NNB) vs. no bacteriémica (NNNB). RESULTADOS: Cuarenta y siete pacientes tenían NNB y 71 NNNB (45 por cultivo de esputo y 26 por antígeno urinario); 107 tenían alguna indicación de VAN. Ningún paciente con NNB, pero 9 con NNNB, habían recibido VAN (p = 0,043). Los pacientes con NNB eran mayores (76,4 ± 11,5 vs. 67,5 ± 20,9 años), tenían mayor APACHE II (16,4 ± 4,6 vs. 14,1 ± 6,5) y PSI (129,5 ± 36 vs. 105,2 ± 45), más frecuentemente cardiopatía e insuficiencia renal crónica e internación en UTI (42,5% vs. 22,5%) y menor hematocrito (35,7 ± 5,8 vs. 38,6 ± 6,7%) y sodio plasmático (133,9 ± 6,0 vs. 137,1 ± 5,5 mEq/L). La mortalidad fue similar (29,8% vs. 28,2%). CONCLUSIONES: Los niveles de VAN (8,4%) en esta población con alto riesgo de NAC por S. pneumoniae fueron extremadamente bajos. Los pacientes con NNB estaban más graves, pero la mortalidad fue similar entre los dos grupos. La VAN reduce la incidencia de NNB y es razonable incrementar el nivel de vacunación de la población en riesgo.

OBJECTIVE: Bacteremia is the most common presentation of invasive disease in community-acquired pneumonia (CAP) due to Streptococcus pneumoniae. We investigated whether bacteremia in pneumococcal CAP worsens outcomes and whether it is related to pneumococcal vaccination (PV). METHODS: Secondary analysis of a cohort of patients with pneumococcal CAP confirmed by blood culture, sputum culture, or urinary antigen testing. Demographic, clinical, radiographic, and biochemical data were collected, as were Acute Physiology and Chronic Health Evaluation II (APACHE II) and pneumonia severity index (PSI) scores, comorbidities, and PV history. We drew comparisons between patients with bacteremic pneumococcal CAP (BPP) and those with non-bacteremic pneumococcal CAP (NBPP). RESULTS: Forty-seven patients had BPP, and 71 had NBPP (confirmed by sputum culture in 45 and by urinary antigen testing in 26); 107 had some indication for PV. None of the BPP patients had received PV, compared with 9 of the NBPP patients (p = 0.043). Among the BPP patients, the mean age was higher (76.4 ± 11.5 vs. 67.5 ± 20.9 years), as were APACHE II and PSI scores (16.4 ± 4.6 vs. 14.1 ± 6.5 and 129.5 ± 36 vs. 105.2 ± 45, respectively), as well as the rate of ICU admission for cardiopathy or chronic renal failure (42.5% vs. 22.5%), whereas hematocrit and plasma sodium levels were lower (35.7 ± 5.8 vs. 38.6 ± 6.7% and 133.9 ± 6.0 vs. 137.1 ± 5.5 mEq/L, respectively), although mortality was similar (29.8% vs. 28.2%). CONCLUSIONS: In this population at high risk for CAP due to S. pneumoniae, the PV rate was extremely low (8.4%). Although BPP patients were more severely ill, mortality was similar between the two groups. Because PV reduces the incidence of BPP, the vaccination rate in at-risk populations should be increased.

Adesão a diretrizes e impacto nos desfechos em pacientes hospitalizados por pneumonia adquirida na comunidade em um hospital universitário / Adherence to guidelines and its impact on outcomes in patients hospitalized with community-acquired pneumonia at a university hospital

OBJETIVO: Avaliar a concordância entre os critérios de hospitalização utilizados para a admissão de pacientes com pneumonia adquirida na comunidade (PAC) e aqueles da Sociedade Brasileira de Pneumologia e Tisiologia e avaliar a associação dessa concordância com a taxa de mortalidade em 30 dias. Secundariamente, avaliar a associação da concordância entre o tratamento instituído e as recomendações dessas diretrizes com duração da internação hospitalar, investigação microbiológica, mortalidade em 12 meses, complicações, internação em UTI, ventilação mecânica e mortalidade em 30 dias. MÉTODOS: Estudo retrospectivo que incluiu pacientes adultos internados entre 2005 e 2007 no Hospital das Clínicas da Universidade Federal de Minas Gerais, na cidade de Belo Horizonte (MG). Foram revisados prontuários e radiografias de tórax. RESULTADOS: Dentre os 112 pacientes incluídos, os critérios de internação e de tratamento foram concordantes com as diretrizes em 82 (73,2%) e 66 (58,9%), respectivamente. A taxa de mortalidade em 30 dias e em 12 meses foi de 12,3% e 19,4%, respectivamente. Pacientes com escore de CRP-65 (Confusão mental, frequência Respiratória, Pressão arterial e idade > 65 anos) de 1-2 e com antibioticoterapia concordante com as diretrizes foram associados a menor mortalidade em 30 dias (p = 0,01). Doença cerebrovascular e tratamento antibiótico adequado apresentaram associações independentes com mortalidade em 30 dias. Houve uma tendência de associação entre antibioticoterapia concordante e menor duração da internação hospitalar. CONCLUSÕES: Na população estudada, os critérios de hospitalização e de antibioticoterapia concordantes com as diretrizes associaram-se a desfechos favoráveis do tratamento de pacientes hospitalizados com PAC. Doença cerebrovascular, como fator de risco, e antibioticoterapia concordante, como fator protetor, associaram-se à mortalidade em 30 dias.

OBJECTIVE: To evaluate the agreement between the criteria used for hospitalization of patients with community-acquired pneumonia (CAP) and those of the Brazilian Thoracic Association guidelines, and to evaluate the association of that agreement with 30-day mortality. Secondarily, to evaluate the agreement between the treatment given and that recommended in the guidelines with length of hospital stay, microbiological profile, 12-month mortality, complications, ICU admission, mechanical ventilation, and 30-day mortality. METHODS: This was a retrospective study involving adult patients hospitalized between 2005 and 2007 at the Federal University of Minas Gerais Hospital das Clínicas, located in Belo Horizonte, Brazil. Medical charts and chest X-rays were reviewed. RESULTS: Among the 112 patients included in the study, admission and treatment criteria were in accordance with the guidelines in 82 (73.2%) and 66 (58.9%), respectively. The 30-day and 12-month mortality rates were 12.3% and 19.4%, respectively. The 30-day mortality rate was lower for patients in whom the CRB-65 (mental Confusion, Respiratory rate, Blood pressure, and age > 65 years) score was 1-2 and the antibiotic therapy was in accordance with the guidelines (p = 0.01). Cerebrovascular disease and appropriate antibiotic therapy showed independent associations with 30-day mortality. There was a trend toward an association between guideline-concordant antibiotic therapy and shorter hospital stay. CONCLUSIONS: In the population studied, admission and treatment criteria that were in accordance with the guidelines were associated with favorable outcomes in hospitalized patients with CAP. Cerebrovascular disease, as a risk factor, and guideline-concordant antibiotic therapy, as a protective factor, were associated with 30-day mortality.

Implementação de uma diretriz para pneumonia adquirida na comunidade em um hospital público no Brasil / Implementation of community-acquired pneumonia guidelines at a public hospital in Brazil

OBJETIVO: Implementar uma diretriz para pneumonia adquirida na comunidade (PAC) em um hospital público no Brasil e avaliar seu impacto na qualidade da assistência à saúde. MÉTODOS: Estudo quasi-experimental com delineamento antes e depois que incluiu os pacientes adultos diagnosticados com PAC e internados na enfermaria geral do Hospital das Clínicas da Faculdade de Medicina de Marília, na cidade de Marília (SP), entre julho de 2007 e outubro de 2008. RESULTADOS: Durante o período do estudo, 68 pacientes foram diagnosticados com PAC: 48 antes da implementação da diretriz e 20 após sua implementação. Após a implementação da diretriz, 85 por cento dos casos foram tratados em conformidade com a diretriz, e houve um aumento significativo no uso de antibioticoterapia para germes atípicos nos casos de PAC grave (6,3 por cento vs. 75,0 por cento; p < 0,001). Houve uma tendência de diminuição da mortalidade (35,4 por cento vs. 15,0 por cento; p = 0,09) e de aumento do registro de SpO2 nos prontuários dos pacientes (18 por cento vs. 30 por cento; p = 0,42) após a implementação da diretriz. Durante o período do estudo, não houve registros da avaliação da gravidade nos prontuários da maioria dos pacientes. Além disso, o início da antibioticoterapia seguiu um esquema de horário pré-estabelecido, independentemente da gravidade do quadro infeccioso. CONCLUSÕES: Este estudo mostrou que a elaboração e a implementação da diretriz para PAC promoveu a otimização da escolha terapêutica, mas não houve diferenças significativas quanto à avaliação de gravidade, registro de SpO2 ou no início da antibioticoterapia, evidenciando que as variáveis que se relacionam ao processo de trabalho médico e de enfermagem exigem estratégias mais efetivas para serem modificadas.

OBJECTIVE: To implement community-acquired pneumonia (CAP) guidelines at a public hospital in Brazil and to evaluate the impact of these guidelines on health care quality. METHODS: A quasi-experimental study, with a before-and-after design, involving adult patients diagnosed with CAP and hospitalized between July of 2007 and October of 2008 in the general ward of the Marília School of Medicine Hospital das Clínicas, located in the city of Marília, Brazil. RESULTS: During the study period, 68 patients were diagnosed with CAP: 48 before the implementation of the guidelines and 20 after their implementation. After the implementation of the guidelines, 85 percent of the cases were treated in accordance with the guidelines, and there was a significant increase in the use of antibiotic therapy for atypical bacteria in patients with severe CAP (6.3 percent vs. 75.0 percent; p < 0.001). Comparing the pre-implementation and post-implementation periods, we observed a trend toward a decrease in the mortality (35.4 percent vs. 15.0 percent; p = 0.09) and toward an increase in the recording of SpO2 in the medical charts of the patients (18 percent vs. 30 percent; p = 0.42). During the study period, the degree of severity was not recorded on the medical charts of most patients. In addition, the initiation of antibiotic therapy followed a pre-established schedule, regardless of the severity of the infection. CONCLUSIONS: This study showed that, although the development and implementation of CAP guidelines promoted the optimization of the treatment, there were no significant differences regarding the assessment of severity, SpO2 recording, or the initiation of antibiotic therapy. Therefore, strategies that are more effective are needed in order to modify variables related to the work of physicians and nurses.

Factores asociados a mortalidad en neumonía grave adquirida en la comunidad, periodo 2005-2010 / Predictor factors of mortality in severe community acquired pneumonia between 2005-2010

La neumonía grave adquirida en la comunidad (NAC) representa 10 por ciento-30 por ciento del total de esta patología. La morbilidad y la mortalidad son elevadas. Objetivo: Dilucidar factores predictores de mortalidad en NAC. A través de sus historias clínicas, se obtuvieron antecedentes de 121 pacientes (100 por ciento) que ingresaron con este diagnóstico, durante 2005-2010. Resultados: Media de edad de 59,2 +/- 19,1 años, 61,1 por ciento sexo masculino y 79,3 por ciento con comorbilidad; 74,3 por ciento con CURB-65 entre 3 y 5 y 64,4 por ciento con al menos 2 criterios mayores ATS modificados. Media de puntaje de APACHE II de ingreso de 20,3 +/- 7,7 puntos y media de puntaje SOFA de8,5 +/- 3,9 puntos. Mortalidad global del grupo de 31,1 por ciento. Pacientes no fallecidos versus fallecidos con puntaje CURB-65 mayor a 3 en 66,6 por ciento versus 89,4 por ciento, respectivamente (p=0,08), puntaje APACHE II de 18,1 +/- 6,7 versus 25 +/- 7,8 puntos, respectivamente (p<0,0001) y puntaje SOFA de 7,7+/- 4 versus 10 +/- 3,1 puntos, respectivamente (p= 0,003). Mortalidad en relación al ingreso precoz a UCI (antes de 24 horas de evolución) 24,6 por ciento versus 42,2 por ciento cuando fue tardío (p= 0,035). Se observó tendencia a menor mortalidad (26,9 por ciento) en quienes tuvieron cobertura para gérmenes atípicos versus 35,5 por ciento sin cobertura (p= 0,09). El score SOFA y APACHE II en general tienen una buena correlación en relación a mortalidad, sin embargo, la mayor influencia en este punto lo tienen el ingreso precoz a una Unidad de Cuidados Intensivos, los protocolos de reanimación precoz y la cobertura para gérmenes atípicos.

Severe community acquired pneumonia represents 10 –30 percent of this disease. High morbidity and mortality. In this review, we pretend found some predictor factors of mortality in this type of pneumonia. We realize a retrospective study of 121 adult patients admitted at ICU with diagnosis of severe community acquired pneumonia, between 2005-2010. Results: The patients was an average of age of 59,2 +/- 19,1 years, 61,1 percent were male and 79,3 percent with comorbidity; 74,3 percent with CURB – 65 score between 3 – 5 and 64,4 percent with at least 2 major criteria ATS modified. At admission: average of APACHE II score of 20,3 +/- 7,7 points and average of SOFA socre of 8,5 +/- 3,9 points. Global mortality of 31,1 percent. Survivor patients versus patients who died because of the disease, with CURB-65 score up to 3 points in 66,6 percent versus 89,4 percent, respectively (p=0,08), APACHEII score of 18,1 +/- 6,7 versus 25 +/- 7,8 points, respectively (p<0,0001) and SOFA score of 7,7 +/- 4 versus 10 +/- 3,1 points, respectively (p=0,003); 24,6 percent versus 42,2 percent of mortality in early admission to ICU (before 24 hours of evolution) and delayed admission, respectively (p=0,035). Tendence to minor mortality in patients who recived atypical bacteria treatment (26,9 percent versus 35,5 percent, p=0,09). The SOFA and APACHE II score with good correlation with mortality, however, the most important point is the early admission to ICU, early reanimation protocols and atypical bacteria treatment.

Invasive pneumococcal disease in a third level pediatric hospital in Mexico City: epidemiology and mortality risk factors / Enfermedad neumocócica invasora en un hospital pediátrico de tercer nivel en la Ciudad de México: características epidemiológicas y factores de riesgo asociados con mortalidad

Objective. To assess the epidemiologic characteristics of invasive pneumococcal diseases (IPD) among a population in a pediatric hospital in Mexico City and analyze mortality-related risk factors, serotype distribution and antibiotic susceptibility related to S.pneumoniae. Material and Methods. We performed a retrospective review of IPD cases at a third level pediatric hospital between 1997-2004. Results. A total of 156 patients were included. The mortality rate was 27.5 percent and was associated with six pneumococcal serotypes: 14, 6B, 23F, 6A, 19F and 19A. There was no relationship between mortality and antimicrobial susceptibility pattern. A total of 28.2 percent of isolates were resistant to penicillin and 24.6 percent were resistant to cefotaxime. A statistically significant relationship was observed between mortality and previous underlying disease (CI 95 percent; 2.5-18.3; p< 0.05) using a multivariate logistic regression model. Conclusions. Our outcomes show that IPD mortality in our population is closely related to underlying disease and to six serotypes, five of which are included in the 7-valent pneumococcal conjugate vaccine.

Objetivo. Conocer la epidemiología de la enfermedad neumocócica invasora (ENI) en un hospital pediátrico y analizar los factores de riesgo relacionados con la mortalidad, la distribución de serotipos y el patrón de susceptibilidad de S. pneumoniae. Material y métodos. Revisión retrospectiva de los casos de ENI en un hospital pediátrico de tercer nivel, entre 1997 y 2004. Resultados. En 156 pacientes la mortalidad fue de 27.5 por ciento. Los serotipos de neumococo más frecuentemente relacionados con la mortalidad fueron: 14, 6B, 23F, 6A, 19F y 19A; no hubo relación de mortalidad con la resistencia a antibióticos. El 28.2 por ciento mostró resistencia a penicilina y 24.6 por ciento a cefotaxima. A través del modelo multivariado, se encontró una relación estadísticamente significativa entre la mortalidad y enfermedad previa (IC 95 por ciento; 2.5-18.3; p<0.05). Conclusiones. La mortalidad asociada a la ENI tuvo relación significativa con antecedente de una enfermedad previa y con seis serotipos, cinco incluidos en la vacuna neumocócica conjugada 7-valente.

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.