Pere Tudela

Prospective Study of Community-Acquired Pneumonia of Bacterial Etiology in Adults

Abstract The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age ≥60 years (28% vs 13%, P=0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs 9%, P=0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests.

Hospital-Acquired Legionnaires Disease in a University Hospital: Impact of the Copper-Silver Ionization System

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

Error diagnóstico en urgencias: relación con el motivo de consulta, mecanismos y trascendencia clínica

BACKGROUND AND OBJECTIVE: We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications. PATIENTS AND METHOD: We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences. RESULTS: We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases. CONCLUSIONS: Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed.

Análisis de los avisos internos al equipo de guardia del área médica en un hospital general

Fundamento Valorar la frecuencia y caracteristicasde las urgencias internas. Pacientes y metodos Se recogen los avisosdiarios al equipo de guardia durante unmes, analizando las caracteristicas clinicasy epidemiologicas. Resultados Se documentaron 341 avisos,con una media diaria superior en dias festivos.Se trata de problemas fundamentalmenteclinicos (78%), variables segun elservicio. Se realizaron exploraciones complementariasal 44% de los pacientes, y seindicaron modificaciones terapeuticas en el77%. Conclusiones Las urgencias internas suponenun apartado importante de la laborasistencial de los equipos de guardia, yplantean importantes valoraciones diagnosticasy terapeuticas.

Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los últimos 10 años

BACKGROUND AND OBJECTIVE To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution. PATIENTS AND METHOD We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance. RESULTS We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period. CONCLUSIONS In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF.Sabado 1 Diciembre 2007. Volumen 129 - Numero 20 p. 770 - 772 Texto completo Descargar PDF Buscar en medline articulos de: Pere Tudela Josep Maria Modol Montserrat Gimenez Cristina Prat Blanca Vilaseca Jordi Tor Buscar: en Medicina Clinica en Vol. 129, Num. 20 Busqueda avanzada Originales breves Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los ultimos 10 anos Pere Tudelaa Josep Maria Modola Montserrat Gimenezb Cristina Pratb Blanca Vilasecac Jordi Tord aUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. bServicio de Microbiologia. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. cUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. dServicio de Medicina Interna. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. Fundamento y objetivo: Conocer la incidencia anual de bacteriemia en pacientes no hospitalizados (BPNH), analizar sus caracteristicas clinicas y epidemiologicas, asi como sus tendencias evolutivas. Pacientes y metodo: Se analizo un periodo de 10 anos, durante el cual se contabilizaron el porcentaje de hemocultivos positivos y, de estos, el porcentaje de BPNH. Se recogieron los siguientes parametros: ano, mes, edad, sexo, diagnostico inicial, factores de riesgo para la bacteriemia, microorganismo, diagnostico final, concordancia entre ambos y necesidad de ingreso. Se clasificaron en: infeccion urinaria, respiratoria, abdominal, de cateter venoso (ICV), cutanea, endocarditis, bacteriemia sin focalidad aparente (BSFA) y un grupo miscelanea. Se compararon las variables edad, sexo, ano y mes entre los grupos con y sin diagnostico concordante. Resultados: Se registraron 283 episodios. El porcentaje de hemocultivos positivos se mantuvo constante, mientras que el de BPNH tendio a descender. El microorganismo mas frecuente fue Escherichia coli (56,5%), y los principales focos, el urinario (59,7%) y la BSFA (19,7%). Los diagnosticos inicial y final no eran concordantes en el 37,1% de los casos. Preciso ingreso el 30,3%. Se detecto infeccion urinaria en el 93,5% de los casos, ICV solo en el 6,2% y ninguna BSFA. La presencia de los principales factores de riesgo para la bacteriemia a lo largo de los anos mostro un descenso de la infeccion por el virus de la inmunodeficiencia humana, mientras que se advertia un ascenso de las enfermedades neoplasicas. Conclusiones: La BPNH, en nuestra experiencia, tiende a un descenso progresivo. La de origen urinario no parece preocupante, mientras que es mejorable la sospecha de ICV. La BSFA constituye el grupo mas preocupante y supone un reto diagnostico para el futuro

Análisis clínico de la tromboembolia pulmonar no sospechada en el servicio de urgencias

Fundamento Valorar la sospecha diagnosticade tromboembolia pulmonar (TEP) en elarea de urgencias. Pacientes Y Metodos Se analizan los casosde dos anos, y se compara el grupo A (sospechade TEP) con el grupo B (sin sospechade TEP). Resultados De 57 casos, no se sospechoTEP en 14 (25%). Hubo diferencias significativasen los signos de trombosis venosaprofunda (mayor frecuencia en el grupo A),insuficiencia cardiaca y derrame pleural(mayor frecuencia en el grupo B). Los diagnosticosalternativos fueron insuficienciacardiaca y neumonia. Conclusiones Los pacientes con TEP nosospechada no presentan un perfil clinicodiferencial. La TEP se confunde con insuficienciacardiaca y neumonia.

Estudio de la concordancia diagnóstica entre el área médica de urgencias y la de hospitalización en un hospital general

Fundamento Conocer la concordancia diagnosticaentre urgencias y hospitalizacion, analizandoel indice de error, sus caracteristicasepidemiologicas y motivos fundamentales. Pacientes y metodo Se analizaron los ingresosen el area medica, estableciendo tres nivelesde concordancia: coincidente (A), sindromica(B) y erronea (C). Se compararon lasvariables edad, sexo, horario y estancia, enlos grupos A + B y C. En el grupo C se determinoel motivo fundamental del error. Resultados La concordancia fue nivel A enel 88,1%, B en el 7,3% y C en el 4,6%. Nohubo diferencias significativas en la distribucionde las variables analizadas. Los motivosde error mas frecuentes fueron una valoracionclinica insuficiente (50%) y la interpretacionde la radiografia de torax (28,6%). Conclusiones La concordancia diagnosticafue mayoritaria, con un indice de error inferioral 5%. No hallamos un perfil epidemiologiconi clinico caracteristico del error. Elmotivo mas frecuente de error fue una insuficientevaloracion clinica.

Correlation of inflammatory and cardiovascular biomarkers with pneumonia severity scores

PURPOSE To assess the correlation of procalcitonin (PCT), C-reactive protein (CRP), neopterin, mid-regional pro-atrial natriuretic peptide (MR-proANP), and mid-regional pro-adrenomedullin (MR-proADM) with severity risk scores: severe CAP (SCAP) and SMART-COP in patients with community-acquired pneumonia (CAP), as well as short term prognosis and to determine the correlation with mortality risk scores. METHODS Eighty-five patients with a final diagnosis of pneumonia were consecutively included during a two month period. Epidemiological, clinical, microbiological, and radiological data were recorded. Patients were stratified according to the PSI, CURB-65, SCAP and SMART-COP. Complications were defined as respiratory failure/shock, need of ICU, and death. Plasma samples were collected at admission. RESULTS MR-proANP and MR-proADM showed significantly higher levels in high risk SCAP group in comparison to low risk. When considering SMART-COP none of the biomarkers showed statistical differences. MR-proADM levels were high in patients with high risk of needing intensive respiratory or vasopressor support according to SMRT-CO. Neopterin and MR-proADM were significantly higher in patients that developed complications. PCT and MR-proADM showed significantly higher levels in cases of a definite bacterial diagnosis in comparison to probable bacterial, and unknown origin. MR-proANP and MR-proADM levels increased statistically according to PSI and CURB-65. CONCLUSIONS Biomarker levels are higher in pneumonia patients with a poorer prognosis according to SCAP and SMART-COP indexes, and to the development of complications.

Indicaciones y rendimiento diagnóstico de la punción lumbar en urgencias

Fundamento Conocer la frecuencia con que se realizala puncion lumbar (PL) en urgencias y susindicaciones, asi como su rendimiento diagnosticoen la sospecha de infeccion del sistema nerviosocentral (ISNC). Pacientes y metodo Se analizaron las puncionespracticadas durante dos anos en un servicio de urgencias,comparando las caracteristicas clinicasde los casos en que la PL confirmo o no la sospechade infeccion. Se revisaron los casos de ISNCno sospechados en urgencias. Resultados En el 0,4% de las urgencias medicasse practico un PL. En el 76% la indicacion fuesospecha de ISNC, de las cuales se confirmaron el30%. Fiebre, cefalea, rigidez de nuca y antecedentesde otitis o sinusitis cronica fueron las variablesasociadas a ISNC. Un 11% de las ISNC nose sospecharon en urgencias, y de ellas el 80%tenian el antecedente de infeccion por el VIH. Conclusiones La PL se realiza frecuentemente enurgencias, fundamentalmente por sospecha deISNC, que se confirma en un tercio de los casos.La ISNC no sospechada en urgencias correspondemayoritariamente a meningitis subagudas en pacientescon infeccion por el VIH.

Hypercalcemic Encephalopathy in a Patient with Hepatocellular Carcinoma

Cirrhotic patients with hepatocellular carcinoma (HCC) frequently develop hepatic encephalopathy. Metabolic etiology of encephalopathy is less often considered in these patients. Although paraneoplastic hypercalcemia may be associated with several malignant tumors, it has also been described in HCC [1–4], and may cause neurologic disturbances. We present a case of hypercalcemic encephalopathy in a patient with hepatic cirrhosis and underlying HCC in whom first diagnostic was hepatic encephalopathy.