Utilidad de la proteína C reactiva sérica en el diagnóstico y tratamiento del adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Immunocompetent adults hospitalized for a community-acquired pneumonia: Serum C-reactive protein as a prognostic marker

Background: C-reactive protein (CRP) is used to monitor patients' response during treatment of infectious diseases. Morbidity and mortality associated with community-acquired pneumonia (CAP) is high, particularly in hospitalized patients. Better risk prediction during hospitalization could improve management and ultimately reduce mortality rates. Aim: To evaluate CRP measured at admission and the third day of hospitalization as a predictor for adverse events in CAP. Material and Methods: A prospective cohort study of adult patients hospitalized with CAP at an academic hospital. Major adverse outcomes were admission to ICU, mechanical ventilation, prolonged hospital length of stay, hospital complications and 30-day mortality. Predictive associations between CRP (as absolute levels and relative decline at third day) and adverse events were analyzed. Results: Eight hundred and twenty-three patients were assessed, 19% were admitted to ICU and 10.6% required mechanical ventilation. The average hospital stay was 8.8 ± 8.2 days, 42% had nosocomial complications and 8.1% died within 30 days. Ninety eight percent of patients had elevated serum CRP on admission to the hospital (18.1 ± 14.1 mg/dL). C-reactive protein measured at admission was associated with the risk of bacterial pneumonia, bacteremic pneumonia, septic shock and use of mechanical ventilation. Lack of CRP decline within three days of hospitalization was associated with high risk of complications, septic shock, mechanical ventilation and prolonged hospital stay. Conclusions: CRP responses at third day of hospital admission was a valuable predictor of adverse events in hospitalized CAP adult patients.

Evaluación de los índices predictores de eventos adversos en el adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Adverse event prediction in immunocompetent adult patients hospitalized with community-acquired pneumonia

Background: Community-acquired pneumonia (CAP) causes significant morbidity and mortality in adults. Aim: To compare the accuracy of four validated rules for predicting adverse outcomes in patients hospitalized with CAP. Patients and Methods: We compared the pneumonia severity index (PSI), British Thoracic Society score (CURB-65), SMART-COP and severe CAP score (SCAP) in 659 immunocompetent adult patients aged 18 to 101 years, 52% male, hospitalized with CAP. Major adverse outcomes were: admission to ICU, need for mechanical ventilation (MV), in-hospital complications and 30-day mortality. Mean hospital length of stay (LOS) was also evaluated. The predictive indexes were compared based on sensitivity, specificity, and area under the curve of the receiver operating characteristic curve. Results: Of the studied patients, 77% had comorbidities, 23% were admitted to the intensive care unit and 12% needed mechanical ventilation. The rate of all adverse outcomes and hospital LOS increased directly with increasing PSI, CURB-65, SMART-COP and SCAP scores. The sensitivity, specificity and area under the curve of the prognostic indexes to predict adverse events were: Admission to ICU (PSI: 0.48, 0.84 and 0.73; SMART-COP: 0.97, 0.23 and 0.75; SCAP: 0.57, 0.81 and 0.76); use of MV (PSI: 0.44, 0.84 and 0.75; SMART-COP: 0.96, 0.35 and 0.84; SCAP: 0.53, 0.87 and 0.78); 30-days mortality (PSI: 0.45, 0.97 and 0.83; SMART-COP: 0.94, 0.29 and 0.77; SCAP: 0.53, 0.95 and 0.81). CURB-65 had a lower discriminatory power compared to the other indices. Conclusions: PSI score and SCAP were more accurate and specific and SMART-COP was more sensitive to predict the risk of death. SMART-COP was more sensitive and SCAP was more specific in predicting the use of mechanical ventilation.

Hospitalización diurna como modelo de atención de salud en pacientes adultos inmunocompetentes con neumonía adquirida en la comunidad / Respiratory day hospital care for immunocompetent adult patients with community-acquired pneumonia

Background: Day hospitals can reduce health care costs without increasing the risks of patients with lower respiratory tract infection. Aim: To report the experience of a respiratory day hospital care delivered to adult patients with community-acquired pneumonia (CAP) in a public hospital. Material and Methods: During the fall and winter of 2011 and 2012, adult patients with CAP of intermediate risk categories were assessed in the emergency room, their severity was stratified according to confusion, respiratory rate, blood pressure, 65 years of age or older (CRB-65) score and the Chilean CAP Clinical Guidelines, and were admitted to the respiratory day hospital. Results: One hundred seventeen patients aged 67 ± 16 years, (62% females) with CAP were attended in the respiratory day hospital. Ninety percent had comorbidities, especially chronic obstructive pulmonary disease in 58%, heart disease in 32%, diabetes in 16% and asthma in 13%. Their most important risk factors were age over 65 years in 60%, comorbidities in 88%, failure of antibiotic treatment in 17%, loss of autonomy in 21%, vital sign abnormalities in 60%, mental confusion in 5%, multilobar CAP in 23%, pleural effusion in 15%, hypoxemia in 41% and a serum urea nitrogen over 30 mg/dL in 16%. Patients stayed an average of seven days in the day hospital with oxygen, hydration, chest physiotherapy and third-generation cephalosporins (89%) associated with quinolones (52%) or macrolides (4%). Thirteen patients required noninvasive ventilation, eight patients were hospitalized because of clinical deterioration and three died in hospital. Conclusions: Day hospital care reduced hospital admission rates of patients with lower respiratory tract infections.

Evolución clínica y pronóstico del paciente hospitalizado por neumonía adquirida en la comunidad según lugar de admisión / Clinical evolution and prognosis of the hospitalized patient by community-acquired pneumonia according to admission place

La evaluación de la gravedad del paciente con neumonía comunitaria (NAC) permite decidir el lugar de manejo, la extensión del estudio microbiológico y elección del tratamiento antimicrobiano. Objetivos: Describir la evolución clínica y pronóstico del adulto inmunocompetente hospitalizado por neumonía comunitaria según lugar de admisión. Resultados: Durante el período 1999-2001, se evaluaron 463 adultos con NAC en el servicio de urgencia de un hospital docente, 55 por ciento eran varones, 76 por ciento tenía comorbilidad, un tercio había recibido antibióticos antes del ingreso y 75 por ciento correspondían a las categorías de riesgo elevado de Fine (Clases III-V). De acuerdo a su gravedad, cerca del 40 por ciento de los pacientes fueron admitidos a la Unidad de Cuidados Intermedios (UTIM)o UCI. La etiología fue establecida en 25 por ciento de los casos, especialmente en aquellos internados en unidades especializadas. Los patógenos más frecuentes aislados fueron Streptococcus pneumoniae (10,2 por ciento), Haemophilus influenzae (3,7 por ciento), Staphylococcus aureus (2,8 por ciento) y bacilos Gram negativos entéricos (5,2 por ciento). En la admisión al hospital, la edad avanzada, presencia de comorbilidad, disnea, taquipnea, confusión mental, hipotensión, hipoxemia, acidosis metabólica, nitrógeno ureico elevado, hiperglicemia y compromiso radiográfico multilobar fueron más prevalentes en los pacientes admitidos a las unidades especializadas. La neumonía bacterémica, la infección por bacilos gram negativos entéricos y S aureus y la estadía prolongada en el hospital fueron más frecuentes en los pacientes admitidos a UTIM y UCI. El riesgo de complicaciones en el hospital y la letalidad en el hospital y seguimiento a 30 días también fueron más frecuentes en los pacientes admitidos a las unidades especializadas. Conclusión: El cuadro clínico, la evolución, riesgo de complicaciones y la letalidad del adulto inmunocompetente hospitalizado por neumonía comunitaria varía según el lugar de admisión al hospital.