Antônio Carlos Moreira Lemos

III Diretrizes para Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia

New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations on TB have been evaluated, discussed by all of the members of the BTA Committee on TB and of the TB Work Group, and highlighted. The first version of the present Guidelines was posted on the BTA website and was available for public consultation for three weeks. Comments and critiques were evaluated. The level of scientific evidence of each reference was evaluated before its acceptance for use in the final text.

Diretrizes brasileiras para pneumonia adquirida na comunidade em adultos imunocompetentes - 2009

Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.

Prevalência de TB ativa e TB latente em internos de um hospital penal na Bahia

OBJECTIVE To determine the prevalence of latent and active TB among detainees in a prison hospital in Bahia, Brazil. METHODS A cross-sectional study with prospective data collection was carried out comprising 237 inmates in the Bahia State Prison Hospital between July 2003 and April 2004. A standardized questionnaire was applied and completed by medical students. The detainees were systematically submitted to the following tests: tuberculin skin test, chest X-ray (anteroposterior), sputum smear microscopy and culture for mycobacteria. The events of interest were active TB and latent TB. RESULTS The mean age of the participants was 36.6 years, and 89.9% were male. Smoking and alcohol consumption were reported by 70.0% and 43.9% of the inmates, respectively. A history of treatment for TB was reported by 11.3% of the inmates. Of the inmates evaluated, 36.3% reported cough and 31.4% reported expectoration. Other less common symptoms were asthenia (in 26.2%), weight loss (in 23.1%), loss of appetite (in 17.7%), fever (in 11.3%) and hemoptysis (in 6.7%). Of the 86 inmates tested, none presented positive HIV serology. The prevalence of latent TB was 61.5% (96 of the 156 inmates submitted to tuberculin skin tests), whereas that of active TB was 2.5% (6 of the 237 inmates evaluated). The presence of cough was a determinant of active TB (prevalence ratio = 8.8; 95% CI: 1.04-73.9; p = 0.025). CONCLUSIONS Active and latent TB are highly prevalent among inmates hospitalized in the Bahia State Prison Hospital. Our findings justify the need to implement public policies specifically directed towards the control of TB in this population.

Risk of tuberculosis among household contacts in Salvador, Bahia

UNLABELLED Tuberculosis is one of the most important infectious diseases in the world. Only 68% of the estimated new tuberculosis (TB) cases in Brazil are diagnosed. Our aim was to determine the risk of infection among household contacts. STUDY DESIGN Cohort of tuberculin-negative household contacts followed for 12 months. METHODS Household contacts of randomly selected index acid-fast bacilli (AFB)-positive TB cases were evaluated through clinical examination, thorax X-ray, tuberculin, AFB smear and culture. Contacts with a negative response to the tuberculin test (less than 10 mm diameter) were retested after 90 days. Tuberculin reversal (used as a parameter of infection risk) was defined as an increase of at least 10 mm from the last measurement. RESULTS 269 household contacts were followed. The prevalence of disease in this population was 3.7%. The prevalence of infection after the 12-month follow-up period was 63.9%. The risk of infection was 31.1% within 120 +/- 48 days. CONCLUSION Household contacts of AFB positive tuberculosis patients have a very high prevalence and risk of tuberculosis infection. TB preventive or therapeutic measures directed towards this group should be implemented in Brazil.

Nontuberculosis mycobacteria at a multiresistant tuberculosis reference center in Bahia: clinical epidemiological aspects

OBJECTIVE Examine the prevalence and clinical/epidemiological aspects of patients with nontuberculous mycobacteria (NTM) isolated from sputum provided by an outpatient clinic specializing in the treatment of multiresistant tuberculosis (MRTB) in Bahia, Brazil. METHODS All patients followed at the MRTB outpatient clinic of the Octávio Mangabeira Specialized Hospital (HEOM) were evaluated retrospectively from July 1998 to July 2003. All patients underwent direct examinations and cultures to identify the mycobacteria species found during initial and subsequent evaluations. The following variables were recorded: age, gender, clinical symptoms and signs, pre-existing lung disease, prior TB treatment, HIV serology, and NTM species. Categorical and quantitative variables were respectively characterized using proportions and measures +/- SD. RESULTS NTM were isolated in 19 of 231 patients (8.2%; 95%CI: 5.2%-12.3%), with the following species distribution: 58% (11/19) M. chelonae/abscessus; 16% (3/19) M. avium-intracellular complex; 16% (3/19) M. kansasii; and 11% (2/19) M. fortuitum. HIV serology was positive for just one patient (5%), from whom M. chelonae/abscessus was isolated. Productive coughing was observed in all cases. American Thoracic Society (ATS) diagnostic criteria for NTM lung disease were observed in 14 patients (74%). CONCLUSION The prevalence of NTM isolated from patients referred to the MRTB outpatient clinic in Bahia was 8.2% (CI 95%: 5.2%-12.3%); rapid-growth mycobacteria (M. chelonae/M. fortuitum) were the most frequently isolated (68%).

Prevalence of pathogens in cystic fibrosis patients in Bahia, Brazil

INTRODUCTION Recurrent respiratory infections account for most of the morbidity and mortality of cystic fibrosis patients. MATERIALS AND METHODS The objective was to determine the prevalence of pathogens isolated from lower respiratory tract secretions in cystic fibrosis patients. In this descriptive observational study, data from 69 patients was collected from medical records. RESULTS The microorganisms that were identified included 36.2 P. aeruginosa, 28.9% S. Aureus, 4.3% K. pneumoniae, 1.5% H. influenzae, 1.5% E. coli, 1.5% S. maltoophilia, and in 27.5% the flora was normal. The prevalence of P. aeruginosa was 83% in patients under two years of age, demonstrating early colonization. CONCLUSION P. aeruginosa and S. aureus were the most prevalent pathogens; there was also early infection/colonization by P. aeruginosa. This information will contribute to improved therapeutic measures for patients of the Bahia Cystic Fibrosis Reference Center.

Fibrose cística em adultos: aspectos clínicos e espirométricos

INTRODUCTION: Cystic Fibrosis is usually diagnosed in childhood. In Brazil, few studies have approached CF diagnosed in adulthood. OBJECTIVE: The aim of this study was to describe demographic and clinical characteristics and spirometric data of patients with CF diagnosed in adulthood (over 16 years of age) in Bahia, Brazil. METHODS: Twenty-eight patients with cystic fibrosis diagnosed in adulthood were evaluated at the Reference Center of Cystic Fibrosis of the state of Bahia. Variables of interest were age, gender, race, body mass index (BMI), sputum culture, presence of sinusitis and bronchiectasis, spirometric tests with the best values performed for forced expiratory volume in the first second (% FEV1), forced vital capacity (FVC) and response to bronchodilators. RESULTS: Mean age of diagnosis was 31.1 ± 12.4 years. Of the patients, 53.4% were black and mulattos and the mean BMI was 18.7 ± 3.0 kg/m2. P. aeruginosa was present in 12 (43%) of the total patients. The mean percentages ± SD of FVC and FEV1 were 58.9 ± 21.6% and 44.1 ± 23%, respectively. In the group of patients with presence of P. aeruginosa in the sputum cultures mean of the spirometry parameters were lower than those of the P. aeruginosa-free group. However, this difference achieved a statistically significant difference (p = 0.0007) only in FVC. CONCLUSIONS: In agreement with many authors, this study strengthen the point of view that CF must be investigated in patients with recurrent infections, sinusitis and bronchiectasis even in adulthood. Values of the percentages of FVC and FEV1 in relation to those foreseen were lower in patients bearers of P.aeruginosa thereby showing a higher deterioration of the pulmonary function.

Avaliação de atopia em portadores de DPOC

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood.OBJETIVO: Determinar a prevalencia de atopia e avaliar o perfil clinico, laboratorial e radiologico de pacientes com DPOC. METODOS: Estudo de corte transversal com pacientes ambulatoriais portadores de DPOC estavel (definida pela historia clinica e relacao VEF1/CVF < 70% do previsto apos broncodilatador). Os pacientes responderam um questionario clinico e de atopia e foram submetidos a citologia de lavado nasal, teste cutâneo de alergia, radiografia de torax, hemogasometria arterial e dosagem de IgE total. RESULTADOS: Dos 149 individuos avaliados, 53 (35,6%), 49 (32,8%) e 88 (59,1%), respectivamente, apresentavam eosinofilia no lavado nasal, teste cutâneo positivo e sintomas de rinite alergica. A analise de correspondencia confirmou esses achados, evidenciando dois perfis distintos de doenca: a presenca de atopia em pacientes com estagios mais leves de DPOC, e a ausencia de caracteristicas de atopia em pacientes com aspectos de doenca mais grave (VEF1 reduzido e hiperinsuflacao). Houve uma associacao estatisticamente significante entre eosinofilia no lavado nasal e prova farmacodinâmica positiva. CONCLUSOES: Este estudo identificou uma alta frequencia de atopia em pacientes com DPOC, utilizando ferramentas simples e reprodutiveis. A monitorizacao inflamatoria de vias aereas parece ser uma ferramenta util para avaliar as doencas respiratorias em idosos, assim como em pacientes com sobreposicao de asma e DPOC, entidade clinica ainda pouco compreendida.

Anti-tuberculosis drug resistance in strains of Mycobacterium tuberculosis isolated from patients in a tertiary hospital in Bahia

Anti-tuberculosis drug resistance, particularly multiresistance, is a crucial issue in the control of tuberculosis (TB). This study estimated the prevalence of primary and acquired anti-tuberculosis drug resistance in strains of Mycobacterium tuberculosis isolated from hospitalized patients, to identify the risk factors for resistance, and to evaluate the its impact on hospital mortality for tuberculosis. Strains of Mycobacterium tuberculosis from 217 patients hospitalized for TB were analyzed. Subjects were recruited sequentially at a TB reference hospital in Salvador, Bahia, Brazil from July 2001 to July 2003. Multiresistant (MR) strains were defined as strains resistant to rifampicin and isoniazid. Of a total of 217 strains isolated, 41 (19.0%, 95%CI: 14.1-24.5%) were resistant to at least one drug. Prevalence of primary resistance was 7.0% (10/145), while a prevalence of 43.1% (31/72) was found for acquired resistance. Primary resistance to one drug alone was found in 2.1% (3/145) and acquired monoresistance in 5.6% (4/72). Prevalence of MR strains in general was 14.3% (31/217), of which 4.2% (6/145) consisted of primary MR and 34.7% (25/72) of acquired MR. Three strains showed resistance to more than one drug, but were not classified as MR. In the multivariate analysis, abandoning treatment remained strongly associated with resistance (adjusted OR: 7.21; 95%CI: 3.27-15.90; p<0.001) following adjustment for 3 potential confounders (gender, alcohol dependence and HIV-infection). An association was found between resistance and mortality from tuberculosis, even after adjustment for HIV status, age, sex and alcohol dependence (adjusted OR: 7.13; 95%CI: 2.25-22.57; p<0.001). High prevalences of resistance, principally acquired resistance including MR, were found in patients hospitalized for TB in Bahia. This finding was strongly associated with having abandoned treatment, and confirmed the need to standardize the procedure for requesting sensitivity tests in this population at the time of hospital admission.

A asma e a DPOC na visão do pneumologista

OBJECTIVE: To evaluate how pulmonologists view the impact that asthma and COPD has on their patients, as well as how they treat these diseases. METHODS: Survey including 227 pulmonologists participating in the VI Brazilian Asthma Conference, II Brazilian COPD Conference and II Brazilian Smoking Conference, all of which were held in 2007. RESULTS: According to the answers given by the pulmonologists, COPD is a public health problem of equal or greater importance than asthma, and COPD causes various disruptions in the lives of patients and their family members. When prescribing an inhalation device, pulmonologists feel that simplicity of use is more important than is the cost. There was a slight preference for the Aeroliser® and Diskus® systems. The budesonide-formoterol combination was the therapeutic regimen most often cited for the continued treatment of the symptomatic asthma, whereas tiotropium bromide was the most often cited medication for the treatment of patients with COPD. Selection of the therapeutic regimen for asthma and COPD is primarily influenced by the results of therapeutic trials published in the literature. CONCLUSIONS: The opinions of pulmonologists on the topics under study are in concordance with data in the specialized literature.