Antonio Torres

Prospective Study of Prognostic Factors in Community-Acquired Bacteremic Pneumococcal Disease in 5 Countries

To define the influence of prognostic factors in patients with community-acquired pneumococcal bacteremia, a 2-year prospective study was performed in 5 centers in Canada, the United States, the United Kingdom, Spain, and Sweden. By multivariate analysis, the independent predictors of death among the 460 patients were age >65 years (odds ratio [OR], 2.2), living in a nursing home (OR, 2.8), presence of chronic pulmonary disease (OR, 2.5), high acute physiology score (OR for scores 9-14, 7.6; for scores 15-17, 22; and for scores >17, 41), and need for mechanical ventilation (OR, 4.4). Of patients with meningitis, 26% died. Of patients with pneumonia without meningitis, 19% of those with >/=2 lobes and 7% of those with only 1 lobe involved (P=.0016) died. The case-fatality rate differed significantly among the centers: 20% in the United States and Spain, 13% in the United Kingdom, 8% in Sweden, and 6% in Canada. Differences of disease severity and of frequencies and impact of underlying chronic conditions were factors of probable importance for different outcomes.

Molecular Epidemiology of Streptococcus pneumoniae Causing Invasive Disease in 5 Countries

A multicenter study was done during 1993-1995 to investigate prospectively the influence of several prognostic factors for predicting the risk of death among patients with pneumococcal bacteremia. Five centers located in Canada, the United Kingdom, Spain, Sweden, and the United States participated. Clinical parameters were correlated to antibiotic susceptibility and serotyping of the 354 invasive pneumococcal isolates collected and to molecular typing of 173 isolates belonging to the 5 most common serotypes (14, 9V, 23F, 3, and 7F). Serotype 14 was the most common among all isolates, but serotype 3 dominated in fatal cases and in isolates from Spain and the United States, the countries with the highest case-fatality rates. Fewer different patterns were found among the type 3 isolates, which suggests a closer clonal relationship than that among isolates belonging to other serotypes. Of type 3 isolates from fatal cases, 1 clone predominated. Other penicillin-susceptible invasive clones were also shown to spread in and between countries.

Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study

BACKGROUND Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. METHODS We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. FINDINGS Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001). INTERPRETATION This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia. FUNDING None.

Normativa SEPAR: neumonía nosocomial

a Unidad de Cuidados Intensivos Respiratorios, Hospital Clínic Universitari, Valencia, Spain b Neumología, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain c Pulmonary/Critical Care Medicine, South Texas Veterans Health Care System, Audie L. Murphy Division; University of Texas Health Science Center at San Antonio, San Antonio, TX, USA d Unidad de Vigilancia Intensiva e Intermedia Respiratoria, Servicio de Neumología, Instituto del Tórax, Hospital Clinic, IDIBAPS, Barcelona, Spain e Neumología, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain f UCI, Hospital Universitari Vall d’Hebron, VHIR Universitat Autonòma Barcelona, CibeRes, Barcelona, Spain g Neumología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain

Statement of the Fourth International Consensus Conference in critical care on ICU-acquired pneumonia

Scientific Advisors Christian Brun Bruisson (Paris, France), Waldemar Johanson (New Jersey, USA); International Consensus Conference Committee ATS: Catherine Sassoon (Long Beach, CA, USA), Brian Kavanagh (Toronto, Canada); ERS: Marc Elliott (Leeds, UK) ESICM: Graham Ramsay (Maastricht, Netherlands), Marco Ranieri (Turino, Italy); SRLF: Didier Dreyfuss (Paris, France), Jordi Mancebo (Barcelona, Spain). Scientific Experts: Edward Abraham; (Denver, USA), Massimo Antonelli, (Roma, Italy), Robert P Baughman; Cincinnati, USA, Marc Bonten; Utrecht, Netherland, Lucca Brazzi; Italy, Jean Chastre; Paris, France, Deborah Cook; Hamilton, Canada, Donald E Craven; Boston, USA, Lisa L, Dever; New Jersey, USA, Didier Dreyfuss; Colombes, France, Mahmoud Eltorky, Memphis, USA, Jean-Yves Fagon; Paris, France, Jesse Hall; Chicago, USA, Alan M Fein; Manhasset, USA, Dean Hess; Boston, USA, Steven H Kirtland; Seattle, USA, Marin H Kollef; St. Louis, USA, Lionel A Mandell; Hamilton, Canada, Charles H Marquette; Lille, France, Thomas R Martin; Seattle, USA, C Glen Mayhall; Galveston, USA, G Umberto Meduri; Memphis, USA, Dominique L Monnet; Copenhagen, Denmark, Michael S Niederman; Mineola, USA, Jerome Pugin; Geneva, Switzerland, Theodore J Standiford; Michigan, USA, Jordi Rello; Tarragona, Spain, Jean-Francois Timsit; Paris, France, Antonio Torres; Barcelona, Spain, Robert Weinstein; Chicago, USA, Richard Wunderink; Memphis, USA. On May 23-24, 2002, in Chicago Illinois, a jury of eleven intensivists heard expert testimony that was intended to answer five specific questions: 1) What is the epidemiology of ICU-Acquired pneumonia; 2) What are the pathophysiological characteristics and pathogenesis of ICU-acquired pneumonia; 3) What are the Risk Factors and Effective Preventive Measures for ICU-Acquired Pneumonia; 4) What is the best means to establish a Diagnosis of ICU-Acquired Pneumonia; and 5) What are the Optimal Therapeutic Approaches to ICU-Acquired Pneumonia. The following is a synopsis of the expert testimony, the jury’s interpretation of the testimony and their recommendations.