Nonsevere community-acquired pneumonia: correlation between cause and severity or comorbidity.

BACKGROUND: Community-acquired pneumonia frequently constitutes a nonsevere infection manageable at home. However, for these low-risk episodes, the epidemiological features have not been carefully analyzed. OBJECTIVES: To determine the cause of nonsevere community-acquired pneumonia and to investigate if a correlation exists between cause and severity or comorbidity. METHODS: During a 3-year period, all patients with nonsevere community-acquired pneumonia, according to the Pneumonia Patient Outcome Research Team prognostic classification (patients in groups 1-3), were included in the study. Causes were investigated through the following procedures: cultures of blood, sputum, and pleural fluid; serologic tests; and polymerase chain reaction methods to detect Streptococcus pneumoniae DNA in whole blood or Mycoplasma pneumoniae and Chlamydia pneumoniae DNA in throat swab specimens. RESULTS: Of 317 initially included patients, 247 were eligible for the study. A microbial diagnosis was obtained in 162 patients (66%), and the main pathogens detected were S pneumoniae (69 patients [28%]), M pneumoniae (40 patients [16%]), and C pneumoniae (28 patients [11%]). For the 58 patients in prognostic group 1, M pneumoniae was the most prevalent cause, and atypical microorganisms constituted 40 (69%) of the isolated agents. In contrast, for patients in prognostic groups 2 and 3, S pneumoniae was the leading agent, and a significant reduction of M pneumoniae cases and a greater presence of other more uncommon pathogens were observed. The existence of comorbid conditions was not a determining factor for particular causes. CONCLUSIONS: Among low-risk patients with community-acquired pneumonia, there was a certain correlation between severity and cause. In contrast, the existence of a comorbidity did not have a predictive causative value.

Is Streptococcus pneumoniae the leading cause of pneumonia of unknown etiology? A microbiologic study of lung aspirates in consecutive patients with community-acquired pneumonia.

PURPOSE: Although a wide variety of recognized pathogens can cause community-acquired pneumonia, in many patients the etiology remains unknown after routine diagnostic workup. The aim of this study was to identify the causal agent in these patients by obtaining lung aspirates with transthoracic needle aspiration. SUBJECTS AND METHODS: During a 15-month period, all consecutive patients with community-acquired pneumonia who were eligible for transthoracic needle aspiration were enrolled in the study. In addition to conventional microbial methods (culture of blood and sputum, serologic studies), we performed cultures and genetic and antigen tests for common respiratory pathogens in lung aspirates. RESULTS: The study group consisted of 109 patients. Conventional microbial studies identified an etiology in 54 patients (50%), including Mycoplasma pneumoniae in 19 patients, Chlamydia pneumoniae in 9 patients, and Streptococcus pneumoniae in 9 patients. Among the remaining 55 patients, study of the lung aspiration provided evidence of the causal agent in 36 (65%). In 4 additional patients with a single microbial diagnosis by conventional methods, the lung sample provided evidence of an additional microorganism. The new pathogens detected by lung aspiration were S. pneumoniae in 18 patients, Haemophilus influenzae in 6 patients, Pneumocystis carinii in 4 patients, and C. pneumoniae in 3 patients; other organisms were identified in 4 patients. CONCLUSIONS: In our study, S. pneumoniae was the leading cause of community-acquired pneumonia, accounting for 25% of all cases, including about one-third of the cases the cause of which could not be ascertained with routine diagnostic methods.

Transthoracic needle aspiration in the study of pulmonary infections in patients with HIV.

STUDY OBJECTIVE: To evaluate the safety and efficacy of transthoracic aspiration with an ultrathin needle in the microbiologic diagnosis of pulmonary infections in HIV-infected patients. DESIGN: Retrospective review of cases. SETTING: A 500-bed teaching hospital in Lleida, Spain. PATIENTS: Forty-five HIV-infected patients admitted between March 1989 and March 1993 with clinical and roentgenographic evidence of pulmonary infection and without contraindications for transthoracic needle aspiration (TNA). INTERVENTIONS: Forty-seven TNAs were performed in the emergency room (20) or during hospitalization (27). The TNA procedures were done without premedication and without fluoroscopic guidance. Specimens were processed using routine microbiologic and cytologic techniques; in addition, polymerase chain reaction (PCR) for Pneumocystis carinii was carried out since March 1992. Development of adverse effects was carefully evaluated. RESULTS: The TNA was effective in 29 (62 percent) out of 47 procedures. The diagnosis was obtained for 14 of 15 patients with P carinii pneumonia, 8 out of 14 patients with bacterial pneumonia, and 4 out of 12 patients with tuberculosis. Other pathogens recovered were Nocardia asteroides, Cryptococcus neoformans, Rhodococcus equi, and Mycobacterium avium. No false-positive results were obtained. Pneumothorax developed in eight (17 percent) procedures, but only one procedure resulted in a pleural drainage; the incidence of other adverse effects was low and clinically irrelevant. CONCLUSION: Our study suggests that TNA can be a useful technique in establishing the etiologic diagnosis of pulmonary infections in HIV-infected patients, with a good sensitivity, high specificity, and relatively low incidence of serious complications, with TNA appearing as a reliable alternative to more uncomfortable methods.

Community-acquired pneumonia: development of a bedside predictive model and scoring system to identify the aetiology.

Although initial presentation has been commonly used to select empirical therapy in patients with community-acquired pneumonia (CAP), few studies have provided a quantitative estimation of its value. The objective of this study was to analyse whether a combination of basic clinical and laboratory information performed at bedside can accurately predict the aetiology of pneumonia. A prospective study was developed among patients admitted to the Emergency Department University Hospital Arnau de Vilanova, Lleida, Spain, with CAP. Informed consent was obtained from patients in the study. At entry, basic clinical (age, comorbidity, symptoms and physical findings) and laboratory (white blood cell count) information commonly used by clinicians in the management of respiratory infections, was recorded. According to microbiological results, patients were assigned to the following categories: bacterial (Streptococcus pneumoniae and other pyogenic bacteria), virus-like (Mycoplasma pneumoniae, Chlamydia spp and virus) and unknown pneumonia. A scoring system to identify the aetiology was derived from the odds ratio (OR) assigned to independent variables, adjusted by a logistic regression model. The accuracy of the prediction rule was tested by using receiver operating characteristic curves. One hundred and three consecutive patients were classified as having virus-like (48), bacterial (37) and unknown (18) pneumonia, respectively. Independent predictors related to bacterial pneumonia were an acute onset of symptoms (OR 31; 95% CI, 6-150), age greater than 65 or comorbidity (OR 6.9; 95% CI, 2-23), and leukocytosis or leukopenia (OR 2; 95% CI, 0.6-7). The sensitivity and specificity of the scoring system to identify patients with bacterial pneumonia were 89% and 94%, respectively. The prediction rule developed from these three variables classified the aetiology of pneumonia with a ROC curve area of 0.84. Proper use of basic clinical and laboratory information is useful to identify the aetiology of CAP. The prediction rule may help clinicians to choose initial antibiotic therapy.

Rapid detection of pneumococcal antigen in lung aspirates: comparison with culture and PCR technique.

Detection of pneumococcal antigen has been used to increase the rate of diagnosis of pneumococcal pneumonia. The present study was designed to determine the value of rapid detection of pneumococcal antigen in samples obtained by transthoracic needle aspiration (TNA) from patients with community-acquired pneumonia (CAP) in a comparative analysis with culture and polymerase chain reaction (PCR). Pneumococcal antigen was detected by latex agglutination. One hundred and ten consecutive patients diagnosed with CAP underwent TNA. Patients were grouped, according to PCR, culture and serological results, into pneumococcal pneumonia (n = 18), other known aetiology (n = 67) and unknown aetiology (n = 25). In patients with pneumococcal pneumonia, antigen was detected in 17 (94.4%) cases. Antigen was detected in one and nine patients with pneumonia of other known or unknown aetiologies, respectively, yielding a specificity of 89.1%. In conclusion, detection of pneumococcal antigen on samples obtained by TNA from patients with CAP provides a sensitive and specific diagnosis of Streptococcus pneumoniae infection. Furthermore, its rapid results would reduce the dependence on empirical treatments.

[Value of transthoracic aspiration puncture in the etiologic diagnosis of nosocomial pneumonia in patients not admitted to the ICU]. / Valor de la punción transtorácica aspirativa en el diagnóstico etiológico de la neumonía nosocomial de los pacientes no ingresados en UCI.

The aim of this study was to determine the etiologic diagnosis of nosocomial pneumonia in hospitalized patients outside the intensive care unit. The study was carried out prospectively at the University Hospital Arnau de Vilanova in Lerida (Spain) from 1 May 1994 through 28 February 1996, during which 103 cases were diagnosed. Transthoracic needle aspiration (TNA) was chosen as the most useful diagnostic procedure, given its high specificity and low rate of complications. Sixty-seven TNA procedures were carried out; 10 (14.9%) were positive. Sputum was cultured for 62 patients and true positives were observed in 6 (9.7%). Pleural liquid was cultured for 35 patients and germs were isolated for 2 (5.7%). Bronchial brushing with a telescoping catheter was performed in 4 patients and brush culture provided 2 additional positives. Blood samples from 51 patients were cultured provided 4 additional diagnoses (7.8%). The most commonly found germs were P. aeruginosa (13.33%), S. aureus (13.3%), C. pneumoniae (10%) and L. pneumophila (10%). Disease was polymicrobial in 33.3%. Complications were observed, in the form of pneumothorax, in 2 cases (3%), one of which required drainage. We conclude that TNA, which is highly specific and has a low rate of complication, is a useful procedure for diagnosing nosocomial pneumonia in patients who are not being mechanically ventilated.

[Eosinophilic gastroenteritis: review of the published cases in Spain and comparison with foreign literature]. / Gastroenteritis eosinofílica: revisión de los casos publicados en España y comparación con la literatura extranjera.

We review the Spanish literature on Eosinophilic Gastroenteritis. The data are compared with those of several foreign series. Abdominal pain, vomiting, diarrhea, and abdominal distension due to ascites were the most frequent clinical manifestations. In our country most cases had ascites. A history of allergy was reported by less than on half of patients. Peripheral eosinophilia with otherwise normal laboratory findings is the rule. However, peripheral eosinophilia was not essential for diagnosis, since it was absent in one quarter of patients. Small intestine barium studies were abnormal almost always, but the findings were not specific. The diagnosis is based on the endoscopic and/or peroral gastrointestinal biopsy. However, a false negative diagnosis can occur, since the disease can take up a patchy distribution, or a more profound involvement of the gastrointestinal layers without mucosal disease. The treatment of choice is corticosteroids, with a spectacular therapeutic response. Complete studies with biopsies taken at multiple levels of the gastrointestinal tract, are necessary to ascertain the extent and depth of the disease. The etiology is unknown, and although allergy causes can be elicited in some cases, they are absent in the majority of them. We encounter no essential differences in the eosinophilic gastroenteritis characteristics in our country in relation to other countries.

[Epidemiology of acute cerebrovascular disease in Lleida from 1996 to 1997. Predictive factors of mortality at short and medium term]. / Epidemiología de la enfermedad cerebrovascular aguda en la provincia de Lleida durante el período 1996-1997. Factores predictivos de mortalidad a corto y medio plazo.

INTRODUCTION: Given the great clinical relevance of the cerebrovascular disease, the incidence, nosology, vascular risk factors and factors predicting short and medium-term survival after stroke were evaluated in Lleida (Spain). PATIENTS AND METHODS: Five hundred forty-five consecutive patients with an acute stroke admitted to the Hospital Universitario Arnau de Vilanova during the period 1996-1997 were evaluated. A descriptive epidemiological study and a multivariate logistic regression analysis of predictive factors of mortality at 1-month and 1-year after the stroke were made. The latter provided a clinical scoring system for predicting survival. RESULTS: The incidence rate of stroke was 138.3/100,000 inhabitants. Significant risk factors were hypertension and peripheral vasculopathy. There were 80.1% of ischemic and 19.9% of hemorrhagic strokes (p < 0.001). A Glasgow scale < or = 7, hemianopsia and hemorraghic stroke were significant predictors of 1-month mortality, whereas age > or = 70 years, diabetes, atrial fibrillation and limb weakness decreased survival at 1 year. CONCLUSIONS: The incidence rate of stroke in Lleida is low respect to other studies in Spain. Simple clinical measures may help to establish a prognosis at short and medium-term.

[Risk factors of non-ICU nosocomial pneumonia]. / Factores de riesgo de la neumonía nosocomial no UCI.

OBJECTIVE: To know the incidence and risk's factors of nosocomial pneumonia (NN) in patient entered in hospital with age more of 14 years-old. The study was not performed in patients of Unit Care. Also, morbility and mortality are showed and the relation between bacterial agent and inmunologic answer of the patients. By other hand, we reported about specific clinical predictors for NN. MATERIALS AND METHODS: During a period of twenty-two months, 103 cases of NN were diagnosed what supposed 0.34% of the patients entered in this period of time. The study has been carried out in the University Arnau of Vilanova Hospital in Lleida (HUAV), with a capacity of 435 beds. Factors of the patients' risk of NN were valued. Multivariate analysis has been carried out by means of the pattern Cox's regression for proportional risks. RESULTS: About 66.99% of the patients had followed previous antibiotic treatment to the pneumonia episode, but only were significants those that had been treated with amoxicillin-clavulanic acid (28.15%, p = 0.0191). Blocking of the channels of the calcium were administered to 14.56% (p = 0.0030), and treatment with sedative drugs in 27.18% (p = 0.0397). Aerosol therapy was performed in 29 patients (28.15%, p = 0.0030). Nasogastric tube was performed in 19.41% of the patients (p = 0.0132). Creatinine was elevated in 31.42% (p < 0.05). The attributable mortality to the NN was of 33.9%, having a rate of higher mortality that the patients without NN. The agent etiologic was isolated in 23.3% of cases. The NN was polymicrobial in 8 cases with P. aeruginosa and S. aureus as the most frequents. CONCLUSION: In patients with several pathologies and treatments could be changed the immunologic answer and these patients are more predisposed to suffer NN. The mortality is associate to the age and others illness of the patient.

[Survival and disease progression in 251 patients with HIV-1 infection. Study of p24 antigen and viral burden as prognosis makers. Their value at 4 years of follow-up]. / Supervivencia y progresión de la enfermedad en 251 pacientes con infección por el VIH-1. Estudio del antígeno p24 y de la carga viral como marcadores pronóstico. Su valor a los 4 años de seguimiento.

BACKGROUND: Prospective study of survival and AIDS or death progression in a cohort of 251 HIV infected patients whose seroconversion time is unknown, with a main objective: To analyse p24 antigen plasmatic levels and viral load as surrogate markers. PATIENTS: 251 patients were included, most of them undergoing antiretroviral therapy, and were followed-up consecutively in the HIV/AIDS Unity of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova in Lleida. METHODS: We made clinical and analytical baseline studies and every 3 months thereafter. Related to p24 antigen 3 group were established: group I, < 20 pg/mL, group 2, 20-39 pg/mL, group 3, 40 or more pg/mL. We studied survival and progression according to baseline levels over 4 year period. Regard to viral load, we just compared this with p24 antigen in the last phase of the study (third and fourth year) for technical reasons. Survival analysis was made by Kaplan-Meier estimation. Relative risk was calculated by Cox's proportional hazards model. RESULTS: During the 48 months of follow-up 55 patients died. AIDS progression risk or death was 4.8 times higher for the p24 antigen > = 40 pg/mL group than for the p24 antigen < 20 pg/mL one; the relative risk of patients with p24 antigen between 20-39 pg/mL was 2.5 times higher than those included in the group of p24 antigen < 20 pg/mL. Related to progression study, 34 patients progressed. AIDS progression risk or death for p24 antigen > = 40 pg/mL group was 7.69 times higher compared with group 2 (p24 antigen levels between 20-39 pg/mL). The comparison with viral load by PCR determination shows controversial results. CONCLUSIONS: p24 antigen plasma level is a good survival and AIDS progress or death surrogate markers in HIV infected patients, and it is useful for 4 years or more. An isolated value < 20 pg/mL is a sign of good prognosis. Parallelism between p24 antigen plasmatic level and viral load has not been observed.

[Value of quantification of p24 antigen in plasma as a prognostic marker of survival in a cohort of 251 HIV-positive patients]. / Valor de la cuantificacion plasmática del antígeno p24 como marcador pronóstico de supervivencia en una cohorte de 251 pacientes VIH +.

OBJECTIVE: To analyse plasma p24 antigen as a marker of survival in a cohort of HIV-infected patients whose time of seroconversion is unknown. DESIGN: Prospective cohort study. SETTING: AIDS Unit in a teaching hospital. PATIENTS: 251 patients were studied, most on antiretroviral therapy. Mean initial CD4 cell counts were 376 x 106/ 1 (range: 0.8-1350). 51 cases had been diagnosed previously with AIDS. METHODS: Analysis of survival, according to initial plasma p24 antigen was performed by Kaplan-Meier test. Relative risks were calculated by Cox's proportional hazards model. RESULTS: During a follow-up period of 24 months, 46 patients died. Relative risk (RR) of death related to the group with p24 antigen = < 40 pg/ml was 3.32 when p24 antigen > 40 pg/ml (p = 0.0001). CD4+ cell levels adjusting, the result was 2.47 (CI 95% 1.37-4.46) (p = 0.0027). CONCLUSIONS: Plasma levels of p24 antigen is useful as a marker of the risk of death and it behaves as a independent prognostic marker in our patients. P24 antigen = < 40 pg/ml is associated with a better prognosis.

[The prognostic markers of HIV infection progression. A study of the p24 antigen in a cohort of 251 patients]. / Marcadores pronóstico de progresión en la infección por VIH. Estudio del antígeno p24 en una cohorte de 251 pacientes.

BACKGROUND: Prospective study of AIDS or death progression in a cohort of 251 HIV infected patients whose time of seroconversion is unknown, with 2 main objectives: 1. To analyse plasma level p24 antigen as a marker of progression. 2. To evaluate stability of plasma levels of p24 antigen as a marker of progression. PATIENTS AND METHODS: 251 patients were studied, most on antiretroviral therapy, who were attended at HIV/AIDS Unit of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova de Lleida. Mean initial CD4 cell count were 376 x 10(6)/L (range: 0.8-1350) 51 cases had been diagnosed previously with AIDS, their were therefore excluded. Analysis of survival, according to initial plasma p24 antigen and Cd4 cell count as well as the stability of plasma level p24 antigen was performed by Kaplan-Meier test. Relative risk were calculate by Cox's proportional hazard model. RESULTS: During a follow-up period of 24 months, 38 patients progressed to AIDS or died. Relative risk (RR) of progression to AIDS or death related to the group with p24 antigen < 40 pg/ml was 5.48 when p24 antigen => 40 pg/ml (p < 0.0005). Relative risk of progression to AIDS or death for the patients with unstable plasmatic level of p24 antigen related to the group with stable plasmatic level was 4.25 (p < 0.0005). CONCLUSIONS: Plasma level and stability of p24 antigen are useful as a markers of risk of AIDS progression or death and they behaves as an independent prognostic markers in our patients. p24 antigen < 40 pg/ml is associated with a better prognosis.

[The prognostic markers of survival and progression in HIV-1 infection. A study of CD4+ lymphocytes, antigen p24 and viral load during 3 years in a cohort of 251 patients]. / Marcadores pronóstico de supervivencia y de progresión en la infección por el VIH-1. Estudio de linfocitos CD4+, antígeno p24 y carga viral durante 3 años en una cohorte de 251 pacientes.

BACKGROUND: Prospective study of survival and AIDS or death progression in a cohort of 251 HIV infected patients whose seroconversion time is unknown, with 1 main objective: To analyse CD4+ lymphocytes count, p24 antigen plasmatic levels and viral load as surrogate markers. PATIENTS AND METHODS: 251 patients were included, most of them undergoing antiretroviral therapy, followed consecutively in the HIV/AIDS Unity of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova in Lleida. We made clinical and analytical baseline studies and every 3 months thereafter. In relation to CD4+ lymphocytes, 3 groups were established: group I, 500 or more cells/mL; group II, 200-499 cells/mL and group III, < 200 cells/mL. In the same way, with p24 antigen we established 3 group: group I, < 20 pg/mL, group II, 20-39 pg/mL, group III 40 or more pg/mL. We studied survival in relation to baseline levels and stability, the latter being understood as persistent levels in the initial group, or better, over 3 year period. Survival analysis was made by Kaplan-Meier estimation. Relative risk was calculated by Cox's proportional hazards model. RESULTS: During the 36 months of follow-up 53 patients died. AIDS progression risk or death was 4.8 times higher for the p24 antigen > = 40 pg/mL group than for the p24 antigen < 20 pg/mL one; patients with p24 antigen between 20-39 pg/mL relative risk was 2.5 times higher than those included in p24 antigen < 20 pg/mL group. These results emphasize that if we take into account the p24 antigen stability during these 36 months. In relation to progression study, 36 patients progressed. AIDS progression risk or death for p24 antigen > = 40 pg/mL group was 7.69 times higher in relation to that with p24 antigen levels between 20-39 pg/mL. The bivariable study shows that CD4 lymphocytes counts and p24 antigen level have quite an independent value. The comparison with viral load by PCR determination makes manifest discrepancy, difficult to explain. CONCLUSIONS: p24 antigen plasma level is a good survival and AIDS progress or death surrogate markers in HIV infected patients, and it is useful for 3 years or more. An isolated value < 20 pg/mL and, furthermore, the stability in successive controls under this concentration is a sign of good prognosis. Its value is emphasized with CD4+ lymphocytes count. It seem necessary that more comparative studies with viral load are required.