Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series / Pneumonia por Streptococcus pneumoniae complicada por pericardite purulenta: uma série de casos

AbstractObjective: In the antibiotic era, purulent pericarditis is a rare entity. However, there are still reports of cases of the disease, which is associated with high mortality, and most such cases are attributed to delayed diagnosis. Approximately 40-50% of all cases of purulent pericarditis are caused by Gram-positive bacteria, Streptococcus pneumoniae in particular.Methods: We report four cases of pneumococcal pneumonia complicated by pericarditis, with different clinical features and levels of severity.Results: In three of the four cases, the main complication was cardiac tamponade. Microbiological screening (urinary antigen testing and pleural fluid culture) confirmed the diagnosis of severe pneumococcal pneumonia complicated by purulent pericarditis.Conclusions: In cases of pneumococcal pneumonia complicated by pericarditis, early diagnosis is of paramount importance to avoid severe hemodynamic compromise. The complications of acute pericarditis appear early in the clinical course of the infection. The most serious complications are cardiac tamponade and its consequences. Antibiotic therapy combined with pericardiocentesis drastically reduces the mortality associated with purulent pericarditis.

ResumoObjetivo:Na era dos antibióticos, a pericardite purulenta é uma entidade rara. Entretanto, ainda há relatos de casos da doença, associados a alta mortalidade, muitos deles atribuídos ao diagnóstico tardio. Aproximadamente 40-50% de todos os casos de pericardite purulenta são causados por bactérias gram-positivas, particularmente Streptococcus pneumoniae.Métodos:Relatamos quatro casos de pneumonia pneumocócica complicada por pericardite, com diferentes características clínicas e níveis de gravidade.Resultados:Em três dos quatro casos, a principal complicação foi tamponamento cardíaco. A pesquisa microbiológica (teste de antígeno urinário e cultura de líquido pleural) confirmou o diagnóstico de pneumonia pneumocócica grave complicada por pericardite purulenta.Conclusões:Em casos de pneumonia pneumocócica complicada por pericardite, o pronto diagnóstico é de extrema importância para evitar comprometimento hemodinâmico grave. As complicações da pericardite aguda aparecem no início do curso clínico da infecção. As complicações mais graves são tamponamento cardíaco e suas consequências. A antibioticoterapia com pericardiocentese reduz sobremaneira a mortalidade associada à pericardite purulenta.

Fluoroquinolonas respiratorias como antibiótico de primera línea en neumonia adquirida en la comunidad, posición a favor / Respiratory fluoroquinolones as first-line antibiotic in community acquired pneumonia, a supporting opinion

Las fluoroquinolonas de cuarta generación disponibles son levofloxacina y moxifloxacina.Tienen buena penetración en el interior de las bacterias y alta biodisponibilidad que permite el tratamiento por vía oral y el rápido pasaje de la vía parenteral a oral. Streptococcus pneumoniae es el patógeno más frecuente y que produce mayor número de muertes enneumonía adquirida en la comunidad (NAC), los llamados ®atípicos¼, Mycoplasma pneumoniae, Chlamydophyla pneumoniae y Legionella pneumophila son agentes comunes.Estos antibióticos tiene actividad frente a los gérmenes mencionados y a otros como H. influenzae, Staphylococcus aureus meticilino sensible, otros gram-positivos y gram-negativos, incluyendo Pseudomonas aeruginosa, y enterobacterias y anaerobios. La resistencia del neumococo a penicilina ocurre en todo el mundo, pero está creciendo también para otros antibióticos, en macrólidos puede llegar al 35%. Según la guía Infectious Diseases Society of America/American Thoracic Society la monoterapia con fluoroquinolonas es de primera línea en pacientes con riesgo de neumococo resistente, ambulatorios mayores ocon comorbilidades y hospitalizados en sala general, en un mismo plano a la combinación beta lactámico/macrólido. Si bien como monoterapia no parecen inferiores, se recomiendan en combinación con otros antibióticos en la neumonía grave en terapia intensiva.

Levofloxacin and moxifloxacin are the available fourth generation fluroquinolones. Their penetration into the pathogens and high bioavailability favor their use by the oral route andtheir rapid switch from the parenteral route. Streptococcus pneumoniae, the most frequently involved microorganism also has the higher fatality rate in community acquired pneumonia(CAP); the so called atypical Mycoplasma pneumoniae, Chlamydophyla pneumoniae andLegionella pneumophila are very common. These antimicrobials are active against the mentioned microorganisms and other pathogens as H. influenzae, methicillin susceptible Staphylococcus aureus, and other gram-positive and gram-negative organisms, includingPseudomonas aeruginosa, enteric bacteria and anaerobes. Penicillin resistance happens all over the world, also resistance to other antimicrobials is growing, for macrolides it is ashigh as 35%. According with the Infectious Diseases Society of America/American Thoracic Society guideline, fluoroquinolone monotherapy is in the first line in patients at risk forresistant pneumococcus, elderly or with comorbid illnesses outpatients and in those hospitalized not in the ICU, in the same level as the beta-actam/macrolide combination. Two different studies demonstrated that in patients with severe CAP admitted to the ICUfluoroquinolone monotherapy was not inferior to combination therapy; however the guideline recommends its use in combination with other antimicrobial.