Beatriz Rosón

Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics, and outcomes.

We performed an observational analysis of pro-spectively collected data on 1,474 adult patients who were hospitalized for community-acquired pneumonia; 1,169 patients were under 80 years of age and 305 (21%) patients were over 80 years (“very elderly”). Mean patient ages were 60 years in the former group and 85 years in the latter group. Severely immunosuppressed patients and nursing-home residents were not included. Comorbidities significantly associated with older age were chronic obstructive pulmonary disease, chronic heart disease, and dementia. The most common causative organism was Streptococcus pneumoniae (23% in both groups). Aspiration pneumonia was more frequent in the very elderly (5% in younger patients versus 10% in the very elderly);Legionella pneumophila (8% in younger patients versus 1% in the very elderly) and atypical agents (7% in younger patients versus 1% in the very elderly) were rarely recorded in the very elderly. While very elderly patients complained less frequently of pleuritic chest pain, headache, and myalgias, they were more likely to have absence of fever and altered mental status on admission. No significant differences were observed between groups as regards incidence of classic bacterial pneumonia syndrome (60% versus 59%) in 343 patients with pneumococcal pneumonia. The development of inhospital complications (26% in younger versus 32% in very elderly patients) as well as early mortality (2% in younger versus 7% in very elderly patients) and overall mortality (6% in younger versus 15% very elderly patients) were significantly higher in very elderly patients. Acute respiratory failure and shock/multiorgan failure were the most frequent causes of death, especially of early mortality. Factors independently associated with 30-day mortality in the very elderly were altered mental status on admission (odds ratio, 3.69), shock (odds ratio, 10.69), respiratory failure (odds ratio, 3.50), renal insufficiency (odds ratio, 5.83), and Gram-negative pneumonia (odds ratio, 20.27).

Contribution of a Urinary Antigen Assay (Binax NOW) to the Early Diagnosis of Pneumococcal Pneumonia

We evaluated the usefulness of a rapid urinary antigen test (Binax NOW; Binax) to detect Streptococcus pneumoniae for the early diagnosis of community-acquired pneumococcal pneumonia (PP) in 220 nonseverely immunosuppressed adults. We compared results of this test with those of sputum Gram staining. The rapid urinary antigen test showed limited sensitivity (65.9%; 95% confidence interval [CI], 51.4-80.4) but high specificity (100%; 95% CI, 99.7-100) for diagnosing PP. The test was more sensitive for patients with versus those without high-risk pneumonia (94% vs. 63%; P<.001) and for patients without versus those with demonstrative results of a sputum Gram stain (97% vs. 55%; P<.001), and it tended to be more sensitive for patients with versus those without bacteremic PP (92% vs. 74%; P=NS). Rapid urinary antigen testing permitted early diagnosis of PP in 26% more patients than did Gram staining but missed 22% of the rapid diagnoses initially identified by Gram staining. On the basis of our results, a sequential approach is proposed, with reservation of urinary antigen testing for high-risk patients for whom demonstrative results of a sputum Gram stain are unavailable.

Prospective Study of the Usefulness of Sputum Gram Stain in the Initial Approach to Community-Acquired Pneumonia Requiring Hospitalization

From February 1995 through May 1997, we prospectively studied 533 patients with community-acquired pneumonia requiring hospitalization in order to assess the current usefulness of sputum Gram stain in guiding the etiologic diagnosis and initial antibiotic therapy when applied routinely. Sputum samples of good quality were obtained in 210 (39%) patients, 175 of whom showed a predominant morphotype. Sensitivity and specificity of Gram stain for the diagnosis of pneumococcal pneumonia were 57% and 97%, respectively; the corresponding values for Haemophilus influenzae pneumonia were 82% and 99%. Patients with a predominant morphotype were more frequently treated with monotherapy than were patients without a demonstrative sputum sample (89% vs. 75%; P<.001). Analysis of our data shows that a good-quality sputum sample can be obtained from a substantial number of patients with community-acquired pneumonia. Gram stain was highly specific for the diagnosis of pneumococcal and H. influenzae pneumonia and may be useful in guiding pathogen-oriented antimicrobial therapy.

Etiology, Reasons for Hospitalization, Risk Classes, and Outcomes of Community-Acquired Pneumonia in Patients Hospitalized on the Basis of Conventional Admission Criteria

We performed an observational analysis of prospectively collected data on 533 nonseverely immunosuppressed adult patients who were hospitalized for community-acquired pneumonia on the basis of conventional admission criteria. For this population, we correlated etiology, reasons for admission, and outcomes using the Pneumonia Severity Index (PSI), to identify major discrepancies between the PSI risk class and the conventional criteria for deciding the site of care. PSI classes and corresponding mortality rates were as follows: class I, 51 patients (0%); class II, 62 (2%); class III, 117 (3%); class IV, 198 (10%); and class V, 105 (29%). We identified significant discrepancies between both methods. Overall, 230 patients (40%) who were hospitalized according to conventional criteria were assigned to low-risk classes. Of these 230 patients, 137 (60%) needed supplementary oxygen or had pleural complications; for the remaining patients, there were no irrefutable reasons for admission. This latter group deserves prospective evaluation in randomized studies that compare ambulatory and in-hospital management.

Factors Associated with Complications and Mortality in Adult Patients Hospitalized for Infectious Cellulitis

The aim of this study was to analyze medical outcomes, including risks for complications and mortality, in 332 adult patients hospitalized for cellulitis. The infection was documented microbiologically in 128 cases (39%). Staphylococcus aureus (46 cases) and Streptococcus pyogenes (22 cases) were the most frequent causative pathogens. Overall, 63 patients (19%) were discharged early (≤4 days) and 166 patients (50%) were hospitalized for more than 4 days without developing any complications. One hundred three patients (31%) had one or more complications or died. Of these, 78 required surgical debridement, 10 required plastic surgery, 7 underwent amputation, and 15 had shock on presentation. When comparing the three study groups (patients discharged early, patients hospitalized for ≤4 days without complications, and patients who developed 1 or more complication or who died), patients who were discharged early (low risk) were more frequently female and were less likely to have multiple comorbid conditions, hypoalbuminemia, renal insufficiency, and/or cutaneous necrosis at presentation. Overall mortality (<30 days) was 5% (16/332 patients). Factors associated with death were male sex, presence of multiple comorbid conditions, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency, shock, and Pseudomonas aeruginosa cellulitis. These findings can be used to stratify patients with acute cellulitis according to risks for complications and mortality and may be helpful when deciding the most appropriate means of care, i.e. outpatient treatment or hospitalization.

Usefulness of betalactam therapy for community-acquired pneumonia in the era of drug-resistant Streptococcus pneumoniae: a randomized study of amoxicillin-clavulanate and ceftriaxone

Empirical antibiotic therapy of community-acquired pneumonia (CAP) has been complicated by the worldwide emergence of penicillin resistance among Streptococcus pneumoniae. The impact of this resistance on the outcome of patients hospitalized for CAP, empirically treated with betalactams, has not been evaluated in a randomized study. We conducted a prospective, randomized trial to assess the efficacy of amoxicillin-clavulanate (2 g/200 mg/8 hr) and ceftriaxone (1 g/24 hr) in a cohort of patients hospitalized for moderate-to-severe CAP. Three-hundred seventy-eight patients were randomized to receive amoxicillin-clavulanate (184 patients) or ceftriaxone (194 patients). Efficacy was assessed on Day 2, after completion of therapy and at long term follow-up. There were no significant differences in outcomes between treatment groups, both in intention-to-treat and per-protocol analysis. Overall mortality was 10.3% for amoxicillin-clavulanate and 8.8% for ceftriaxone (NS). There were 116 evaluable patients with proven pneumococcal pneumonia. Rates of high-level penicillin resistance (MIC of penicillin > or = 2 microg/mL) were similar in the two groups (8.2 and 10.2%). Clinical efficacy at the end of therapy was 90.6% for amoxicillin-clavulanate and 88.9% for ceftriaxone (95% C.I. of the difference: -9.3 to +12.7%). No differences in outcomes were attributable to differences in penicillin susceptibility of pneumococcal strains. Sequential i.v./oral amoxicillin-clavulanate and parenteral ceftriaxone were equally safe and effective for the empirical treatment of acute bacterial pneumonia, including penicillin and cephalosporin-resistant pneumococcal pneumonia. The use of appropriate betalactams in patients with penumococcal pneumonia and in the overall CAP population, is reliable at the current level of resistance.

Clinical Diagnosis of Legionella Pneumonia Revisited: Evaluation of the Community-Based Pneumonia Incidence Study Group Scoring System

This prospective case-control study sought to identify differences in presentation between Legionella pneumonia (LP) diagnosed by urinary antigen and bacteremic pneumococcal pneumonia (PP), with the aim of assessing the ability of physicians to recognize such differences at admission and validating the Community-Based Pneumonia Incidence Study (CBPIS) Group scoring system for LP diagnosis. Significant differences in presentation were found: male sex, previous receipt of beta-lactam therapy, and temperature >39 degrees C were positively associated with LP; purulent sputum, pleuritic chest pain, and previous upper respiratory tract infection were negatively associated with LP. Physicians considered Legionella to be the most likely diagnosis in 52 (64%) of 81 LP cases and in 8 (6%) of 136 PP cases. Initial administration of a macrolide and rifampin and requests for urinary antigen testing for Legionella at admission were significantly more frequent among patients with LP. Overall, the CBPIS score did not differentiate reliably between LP and PP. Although certain presenting clinical features may allow recognition of LP, it is difficult to express them in a reliable scoring system.

Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality.

BACKGROUND Prognostic factors of mortality in elderly patients with dementia with aspiration pneumonia (AP) are scarcely known. We determined the mortality rate and prognostic factors in old patients with dementia hospitalized due to AP. METHODS We prospectively studied 120 consecutive patients aged ≥ 75 years with dementia admitted with AP to two tertiary university hospitals. We collected data on demographic and clinical variables and comorbidities. Oropharyngeal swallowing was assessed by the water swallow test. RESULTS Sixty-one (50.8%) patients were female, and mean age was 86 ± 9 years. The swallow test was performed in 68 patients, revealing aspiration in 92.6%. Patients with repeat AP (28.3%) were more-frequently taking thickeners (61.8% vs.11.6%, p<0.0001) and were less-frequently prescribed angiotensin-converting-enzyme (ACE) inhibitors (8.8% vs. 27.9%, p<0.001) than patients with a first episode. Hospital mortality was 33.3%; these patients had lower lymphocyte counts and higher percentage of multilobar involvement. In the multivariate model, involvement of ≥ 2 pulmonary lobes was associated with hospital mortality (OR 3.051, 95% CI 1.248 to 7.458, p<0.01). Six-month mortality was 50.8%; these patients were older and had worse functional capacity and laboratory data indicative of malnutrition. In the multivariate model, lower albumin levels were associated with six-month mortality (OR 1.129, 95% CI 1.008 to 1.265, p<0.03). CONCLUSION In-hospital and 6-month mortality were high (one-third and one-half patients, respectively). Multilobar involvement and lower lymphocyte counts were associated with hospital mortality, and older age, greater dependence and malnutrition with six-month mortality.

Prevalence and routine assessment of unhealthy alcohol use in hospitalized patients.

OBJECTIVES To determine the prevalence of alcohol misuse among medical inpatients and the methods used by medical staff to evaluate alcohol consumption. METHODS Multicenter, prospective, observational, cross-sectional study performed at 21 hospitals in Spain. All adult patients hospitalized in internal medicine wards on 12 March 2008 were eligible for study. Alcohol consumption was evaluated with the Alcohol Use Disorders Identification Test (AUDIT-C and AUDIT) and the Systematic Inventory of Alcohol Consumption questionnaire. Drinking patterns were determined according to clinical evaluation using ICD-10 criteria. Medical records were reviewed to gather information on the recording of alcohol use. RESULTS We assessed 1039 inpatients, of whom 123 (12%) had unhealthy alcohol drinking patterns. Alcohol misuse was more frequent among males (odds ratio 5.20), younger patients (odds ratio, 14.17), median age patients (odds ratio, 2.99), and South Region (odds ratio, 1.77). Alcohol use during hospitalization was recorded in 603 inpatients (59%); quantitative records were performed in 28% of hazardous and harmful drinkers and in 41% of dependent patients. Lack of alcohol use recording was more frequent among females (odds ratio 1.73), median and older age groups (odds ratios 1.44 and 1.73, respectively), Northwest Regions (odds ratios 3.46). Patients from the East Region (odds ratio 0.47) had more frequently assessed the question in their medical records. CONCLUSIONS Prevalence of alcohol misuse was higher in hospitalized patients than in the general population. Adequate quantitative recording was infrequent. We stress the need to implement measures to increase and improve the detection and recording of alcohol use.

Geriatric assessment and chronic kidney disease in the oldest old: The Octabaix study

BACKGROUND The prevalence of chronic kidney disease (CKD) in older people is increasing. We determine the proportion of CKD in a sample of 321, 85-year-old community-dwelling subjects, and assess the association of socio-demographic data, global geriatric assessment data and comorbidity with CKD according to the estimated glomerular filtration rate (eGFR) of subjects. METHODS Serum creatinine, eGFR (derived in ml/min/1.73 m(2) using the Modification of Diet in Renal Disease formula), socio-demographic variables, the Barthel Index (BI), the Spanish version of the Mini-Mental State Examination (MEC), the Mini Nutritional Assessment (MNA), the Charlson Index, the Gait Rating Scale, social risk, quality of life and prevalent chronic diseases were collected. RESULTS CKD prevalence was 56.7% for eGFR < 60 ml/min/1.73 m(2), 19.9% for eGFR < 45 ml/min/1.73 m(2) and 6.6% for GFR < 30 ml/min/1.73 m(2). Multiple logistic regression analysis showed that a prior diagnosis of hypertension was associated with an eGFR < 60 ml/min/1.73 m(2) (p<0.008, OR 2.134, 95% CI 1.216-3.744). A diagnosis of heart failure (p<0.001, OR 3.610, 95% CI 1.677-7.771) and a poor score on the quality of life measure (p<0.008, OR 0.9660, 95% CI 0.966-0.995) were associated with an eGFR < 45 ml/min/1.73 m(2). CONCLUSIONS More than half of the oldest old in this study had an eGFR < 60 ml/min/1.73 m(2). A history of hypertension was associated with CKD. The group of patients with an eGFR < 45 ml/min/1.73 m(2) was associated with a diagnosis of heart failure and a worse quality of life.