Alejandro Díaz F

Neumonía adquirida en la comunidad en el adulto hospitalizado: Cuadro clínico y factores pronósticos

Background: Community-acquired pneumonia (CAP) is a serious health problem in Chile. Aim: To study prognostic factors on admission and outcome of CAP, in immune competent adult patients, hospitalized in the Catholic University Clinical Hospital. Patients and methods: All adult patients admitted with a CAP in a period of 2 years were prospectively studied. Patients with immunodeficiency, solid tumors or receiving oral adrenal steroids were excluded from the study. Results: In the study period, 463 patients (69±19 years, 55% male) were evaluated. Ninety four percent were treated with 2nd or 3rd generation cephalosporins. Mean hospital length of stay was 10 days. Mortality during hospital stay was 8% and in the ensuing 30 days, it was 12%. Bacterial etiology was established in 25% of cases. The most frequent pathogens isolated were Streptococcus pneumoniae (10.2%), Haemophilus influenzae (3.7%), Staphylococcus aureus (2.8%) and Gram negative bacilli (5.2%). Admission prognostic factors associated with hospital mortality were: an age over 65 years, presence of comorbidity, chronic neurological and hepatic disease, suspicion of aspiration, duration of symptoms for less than 3 days, presence of dyspnea and altered mental status, absence of cough, fever and chills; low blood pressure, tachypnea, metabolic acidosis, hypoxemia, high blood urea nitrogen, hypernatremia, hyperkalemia, hyperphosphatemia, hypoalbuminemia, multilobar radiographic pulmonary infiltrates, bacteremia, high risk categories of the Fine Index (IV and V), and admission to Intermediate Care Unit or ICU. Conclusions: The features of community acquired pneumonia of these patients are similar to those reported abroad (Rev Med Chile 2002; 130: 1373-82).

Utilidad clínica de los hemocultivos en pacientes hospitalizados por neumonía adquirida en la comunidad

Background: The clinical role of blood cultures (BC) in the management of hospitalized patients with community-acquired pneumonia (CAP) is controversial. Aim: To evaluate the clinical usefulness of blood cultures in CAP. Material and methods: We prospectively studied 244 immunocompetent adults with two or more BC obtained at admission. The diagnostic yield of BC and its impact on antibiotic therapy were assessed. Results: Mean age (x±sd) of patients was 67±20 years, 80% had underlying diseases and 29% received antibiotics prior to admission. Hospital length of stay was 10.4±10 days and global mortality was 7%. The diagnostic yield of BC was only 8.2% (20 patients). Mortality was significantly higher in patients with positive BC (20%) than in those with negative BC (5.8%). In only one of the 20 patients with positive BC (0.4% of total study population), attending physicians changed empiric antimicrobial therapy based on these results. Conclusions: This study confirms that the diagnostic yield of BC in CAP hospitalized patients is low, that mortality in bacteremic patients is high and suggests that clinical usefulness of BC to guide changes on empiric antimicrobial therapy is limited, in part because attending physicians seldom use such information (Rev Med Chile 2002; 130: 993-1000).

Susceptibilidad a antimicrobianos de Streptococcus pneumoniae en poblacion infantil y adulta de Santiago. Periodo 1997-2003

Background: In Chile, the emergence of drug-resistant strains of Streptococcus pneumoniae has complicated treatment decisions and may lead to treatment failures. Aim: to examine antimicrobial resistance trends among pneumococcal isolates from the Catholic University Hospital between 1997 and 2003. Material and methods: During a seven-year period, we examined 901 strains of S. pneumoniae isolated from sterile and non-sterile samples from adult and pediatric population. Results: Overall, 20% of isolates showed intermediate resistance to penicillin (MIC: 0.12-1 µg/ml) y 10.8% high level of resistance to penicillin (MIC ³ 2 µg/ml). Pneumococcal resistance to penicillin did not change significantly during the study period, but it was more common in pediatric patients and isolates from non-sterile samples. No isolate had a MIC ³ 8 µg/ml for penicillin. Twenty one percent of pneumococcal strains were resistant to erythromycin, 41.6% to trimethoprim-sulfamethoxazole and 3.6% to chloramphenicol. Macrolides resistance tended to increase between 1997 and 2003. Fourteen percent of strains showed intermediate resistance (MIC: 1 µg/ml) and 2.5%, a high level of resistance to cefotaxime (MIC: ³ 2 µg/ml). No isolate had a CIM ³ 4 µg/ml for cefotaxime. Among those isolates with intermediate or high level of resistance to penicillin, there were significantly more isolates highly resistant to erythromycin, trimethoprim-sulfamethoxazole and cefotaxime. Conclusions: Multidrug-resistant pneumococci are common and are increasing in our country, particularly in pediatric population, probably associated to indiscriminate ambulatory prescription of antimicrobials (Rev Med Chile 2005; 133: 42-49)

Etiología de la neumonía adquirida en la comunidad en adultos hospitalizados en Santiago, Chile: implicancias para las guías clínicas

RESUMEN Fundamento: Hay escasos estudios que examinen la etiologia de la neumoniaadquirida en la comunidad (NAC) en poblacion adulta chilena. Objetivo: Identifi-car la etiologia de la NAC en adultos inmunocompetentes hospitalizados. Metodo: Estudiamos, prospectiva y consecutivamente durante 16 meses, a 130 pacientes(edad promedio ± DS: 68 ± 18 anos; letalidad en el hospital: 6,2%). La evaluacionmicrobiologica incluyo cultivo de expectoracion y hemocultivos para bacterias; * Departamento de Enfermedades Respiratorias, Pontificia Universidad Catolica de Chile.** Servicio de Urgencias, Pontificia Universidad Catolica de Chile.*** Estudiantes de Medicina de tercer ano de la Pontificia Universidad Catolica de Chile.**** Estudiantes de Medicina de cuarto ano de la Pontificia Universidad Catolica de Chile. Financiamiento: Fondo de Investigacion de la Sociedad Chilena de Enfermedades Respiratorias (2002) y fondo de laDireccion de Investigacion de la Pontificia Universidad Catolica de Chile (DIPUC 2003/10E).

Diseño de un índice pronóstico clínico para el manejo de la neumonía del adulto adquirida en la comunidad

2 days, altered mental status, absence of cough, fever and chills; low bloodpressure, tachypnea, hypoxemia and multilobar radiographic pulmonary infiltrates. A clinicalprognostic index derived from a logistic regression analysis including five independent variablesassociated with mortality (confusion, comorbidity, low systolic blood pressure, temperature <37.5

Valor predictivo de la historia clínica y examen físico en el diagnóstico de neumonía del adulto adquirida en la comunidad

Thirty-four percent of the patients had pneumonia.The clinical diagnosis of pneumonia before X-ray examination was variable among emergencyphysicians (positive likelihood ratio: 1.5-4.8) and showed only moderate sensitivity (79%) and specificity(66%). The clinical variables significantly associated with the presence of pneumonia were: advancedage (over 75 years), cardiovascular disease, fever, chills, sputum production, orthopnea, altered mentalstatus, cyanosis, dullness on percussion, bronchial breath sounds, crackles, any abnormal vital sign(heart rate

Neumonía neumocócica adquirida en la comunidad en adultos hospitalizados

Background: S pneumoniae is the most common cause of community-acquired pneumonia. Aim: To evaluate the clinical characteristics, antibiotic resistance, management and prognostic factors in pneumococcal pneumonia. Methods: Prospective evaluation in 46 adults (age ± sd: 68±17 years) hospitalized with pneumococcal pneumonia confirmed by sputum, blood or pleural fluid cultures. Clinical and radiographic variables, risk factors for antibiotic resistance, and hospital mortality rate were recorded. Results: Heart disease (39%), COPD/asthma (25%), and diabetes mellitus (18%) were the most frequent underlying diseases. None of the patients had previously received pneumococcal vaccine. Only 17% of the patients had the classic triad of chills, fever and productive cough. At admission, interestingly, 17% presented with congestive heart failure. Resistance of pneumococci to penicillin, cefotaxime or erythromycin was 15%, 6% and 11%, respectively. Antibiotic use prior to admission was significantly associated with antibiotic resistance (OR=6; CI 95% = 1.1-32; p 30 mg per dL. Conclusions: Our data suggest that pneumococcal pneumonia is still a severe infection with high mortality; hence, efforts should be made at prevention using pneumococcal immunization (Rev Med Chile 2003; 131: 505-14).

Manejo ambulatorio de la neumonía comunitaria del adulto en las unidades de emergencia: Servicio de Salud Viña del Mar-Quillota de la V Región

22 years (152 males), were evaluated. Patients with class I CAP (40% of cases) were treatedwith Clarithromycin (71.8%) or Amoxicillin (26.6%) for 10 days. Patients with class II CAP(60%) were treated with Amoxicillin-clavulanate (80.7%) or Levofloxacin (18.2%) for 10 days.Three hundred eight patients (99%) were cured without need of hospital admission; threepatients (1%) were subsequently hospitalized because of clinical failure of ambulatorytreatment. Overall, three patients (1%) died; all deaths occurred during or immediately afterhospitalization and were related to the severity of lung infection but not to the choice ofantibiotic treatment.

Tratamiento de la neumonía del adulto adquirida en la comunidad

Appropriate antibiotic treatment reduces the duration of symptoms associated to pneumonia, the risk of complications and mortality. In most cases, it is not possible to identify the etiologic agent so antibiotic treatment is empirically prescribed. In Chile, one third of Streptococcus pneumoniae strain isolates has diminished susceptibility to penicillin; in-vitro erythromycin resistance is about 10-15% and cefotaxime resistance 2-10%. It is recommended to classify patients with community acquired pneumonia in four risk categories: Group 1: patients under 65 years without co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin 1 g TID, 7 days. Group 2: patients over 65 years and / or co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days. Group 3: patients admitted to general wards with criteria of moderate severity. Treatment: ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days. Group 4: patients with severe CAP that must be interned into ICU. Treatment: ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days. In the presence of allergy to or treatment failure with betalactam drugs and/or positive serology for Mycoplasma, Chlamydia or Legionella sp it is recommended to add: erythromycin 500 mg QID, IV or oral, oral clarithromycin 500 mg BID, or oral azythromycin 500 mg once a day

Utilidad clínica del tratamiento antibiótico de la guía de la Sociedad Chilena de Enfermedades Respiratorias para la neumonía comunitaria en adultos hospitalizados

The Chilean Society of Respiratory Diseases (SER) developed guidelines for the empirical treatment of community acquired pneumonia (CAP). Aim: To evaluate the degree of adherence to antibiotic treatment recommended by SER guidelines and its influence on medical outcomes. Patients and Methods: We prospectively evaluated 453 consecutive immunocompetent adults (mean age±SD: 69±19 years) hospitalized for CAP. Patients were stratified according to the Pneumonia Severity Index (PSI), and initial antibiotic regimen was classified as being consistent or inconsistent with the SER guidelines. Rate of medical complications, switch therapy rate, length of stay (LOS), and 30 days mortality were compared between those treated consistently or inconsistently with the SER guidelines. Results: Adherence to SER guidelines was 46%. Patients treated consistently with the SER guidelines were older (mean age±SD: 72±16 v/s 65±20 years), had more comorbidities (84 v/s 69%) and a higher proportion belonged to the high-risk PSI categories (69 v/s 49%). There were no significant differences in medical complication rate, switch therapy rate or LOS between both groups. Adherence to SER guidelines did not affect mortality after adjusting for PSI and for prognostic factors associated with 30 days mortality by multivariate analysis. Conclusions: The degree of adherence to antibiotic treatment recommended by SER guidelines was moderate and they were applied mainly in patients with high risk CAP. This fact can explain the lack of evidence of improved medical outcome in patients treated according to SER guidelines (Rev Med Chile 2003; 131: 847-56)