Neumonía en el paciente crítico: diagnóstico sindrómico rápido de PCR múltiple en un hospital general de agudos / Pneumonia in the critically ill patient: rapid syndromic diagnosis by multiplex PCR in a general hospital for acute care

Está demostrado en diversos estudios que los avances en el diagnóstico microbiológico reducen el tiempo de entrega de resultados y poseen un impacto clínico eviden-te. Hoy en día, las técnicas basadas en amplificación de ácidos nucleicos nos permiten hacer diagnóstico direc-tamente de la muestra y sumar la posibilidad de detectar más de un agente. Esto impacta tanto en el control de la multiresistencia (MR) como en el inicio de una terapéuti-ca apropiada. La implementación de un sistema de PCR múltiple rápido para neumonía puede ser útil en áreas crí-ticas, donde son frecuentes las infecciones respiratorias agudas (IRA) y el tiempo es un condicionante del éxito terapéutico. El objetivo de nuestro proyecto fue evaluar la implementación del diagnóstico sindrómico rápido por PCR múltiple para neumonía en el manejo del tratamiento de IRA en una unidad de cuidados intensivos. La con-ducta terapéutica fue la variable relevante. Este nuevo diagnóstico nos proporcionó una herramienta ágil, con un tiempo de respuesta de tres a cuatro horas. La ausencia o presencia de genes de resistencia y el microorganismo identificado fueron lo que condujo a la conducta terapéuti-ca acertada en el 75% de los casos. Constituyó una herra-mienta importante para el control de la multirresistencia bacteriana y aumentó la oportunidad de éxito terapéutico

It has been shown in various studies that advances in microbiological diagnosis reduce the delivery time of results and have an evident clinical impact. Today, techniques based on nucleic acid amplification allow us to diagnose directly from the sample and add the possibility of detecting more than one agent. This impacts both the control of MR and the initiation of appropriate therapy. The implementation of a rapid multiplex PCR system for pneumonia can be useful in critical areas where acute respiratory infections (ARI) are frequent and time is a determining factor for therapeutic success. The objective of our project was to evaluate the implementation of rapid syndromic diagnosis by multiple PCR for pneumonia in the management of ARI treatment in an Intensive Care Unit. The therapeutic behavior was the relevant variable. This new diagnosis provided us with an agile tool, with a response time of 3 to 4 hours. The absence or presence of resistance genes and the identified microorganism was what led to the correct therapeutic approach in 75% of the cases. It constituted an important tool for the control of bacterial multiresistance and increased the opportunity for therapeutic success.

Neumonía redonda unilateral en pediatría: informe de caso y revisión de la literatura / Unilateral round pneumonia in pediatrics: case report and review of the literature

Antecedentes: La neumonía redonda es una enfermedad que se presenta comúnmente en niños menores de 8 años, Streptococcus pneumoniae es el agente más frecuente que causa este tipo característico de neumonía. Tiene una incidencia que representa menos del 1% de las lesiones de monedas. Este es el primer caso documentado de neumonía redonda en Honduras. Descripción del caso clínico: Se reporta el caso de una paciente preescolar con historia de 7 días de presentar tos húmeda sin predominio de horario, acompañada de fiebre de 5 días de evolución, por lo que solicita atención médica en la Sala de Emergencia del Hospital de Occidente. Al examen físico: paciente en buen estado general, con frecuencia respiratoria 32 respiraciones por minuto, saturación de oxígeno 95%, sin dificultad respiratoria y pulmones bien ventilados. Fue ingresada a Sala de Pediatría, ya que presentaba un hemograma con leucocitosis y neutrofilia. En radiografía de tórax se observó radiopacidad homogénea en lóbulo inferior en pulmón izquierdo, motivo por el cual se decidió realizar tomografía computarizada de tórax en la cual se concluyó diagnóstico de neumonía redonda. Posteriormente después de terapia antibiótica con ampicilina se realizó radiografía control donde se observó resolución del consolidado neumónico. Conclusiones: El conocimiento de esta patología permitirá al médico reconocer que se trata de una enfermedad que tiene un curso benigno. Se recomienda siempre sospecharla en el contexto de un cuadro indicativo de infección respiratoria más un consolidado neumónico esférico de bordes definidos para evitar pruebas diagnósticas innecesarias...(AU)

A case of acute severe cryptogenic organic pneumonia with secondary hemophilia / 中南大学学报(医学版)

Cryptogenic organic pneumonia (COP) refers to organic pneumonia that has not been identified a clear cause by current medical methods. A small proportion of COP can exhibit severe and progressive characteristics, while severe COP can cause systemic inflammatory storms and can be secondary to hemophilia. This article reported a case of acute severe COP secondary to hemophilia. A 67-year-old male patient was admitted to the hospital due to cough, shortness of breath, and fever. At first, he was misdiagnosed as severe pneumonia, but failed to receive anti infection treatments. Sputum pathogenetic examination and Macrogene testing of alveolar lavage fluid were performed, and no etiology was found to explain the patient's condition. The condition was gradually worsened and hemophilia occurred to explain, suggesting that acute severe COP was relevant. After receiving hormone treatment, the condition gradually relieved and the absorption of lung lesions improved. Hemophilia secondary to COP is rare, and the specific mechanism needs further study.

Advances in epidemiology, etiology, and treatment of community-acquired pneumonia / 中华预防医学杂志

Community-acquired pneumonia (CAP) is the third leading cause of death worldwide and one of the most commonly infectious diseases. Its epidemiological characteristics vary with host and immune status, and corresponding pathogen spectrums migrate over time and space distribution. Meanwhile, with the outbreak of COVID-19, some unconventional treatment strategies are on the rise. This article reviewed the epidemiological characteristics, pathogen spectrum and treatment direction of CAP in China over the years, and aimed to provide guidance for the diagnosis and treatment of CAP in clinical practice.

Utilidad del panel de PCR multiplex en el diagnóstico microbiológico temprano y adecuación antimicrobiana en pacientes críticos con neumonía / Usefulness of the multiplex PCR panel in the early microbiological diagnosis and antimicrobial suitability in critical patients with pneumonia / Utilidade do painel de PCR multiplex no diagnóstico microbiológico precoce e adequação antimicrobiana em pacientes críticos com pneumonia

Resumen: Introducción: el inicio temprano de la antibioticoterapia adecuada en infecciones graves se asocia con reducción de la mortalidad. La identificación precoz del microorganismo es fundamental para realizar un tratamiento dirigido y disminuir la terapéutica inicial inapropiada. Objetivo: valorar la utilidad de una técnica de biología molecular por amplificación de ácidos nucleicos mediante reacción en cadena de polimerasa en tiempo real para diagnóstico microbiológico temprano y adecuación de la antibioticoterapia en pacientes con neumonías graves. Metodología: estudio retrospectivo observacional llevado a cabo en la unidad de cuidados intensivos del Hospital Maciel. Se analizaron muestras respiratorias de pacientes con diagnóstico o sospecha de neumonía. Se compararon los resultados microbiológicos obtenidos por técnicas convencionales y por biología molecular multiplex (panel neumonía). Resultados: se incluyeron 53 muestras obtenidas de 51 pacientes. El multiplex detectó al menos un microorganismo en 38 (71,7%) muestras frente a 30 (56.6%) desarrollos en cultivos tradicionales. La mayoría de las muestras se obtuvieron bajo antibioticoterapia previa (86.8%). El panel neumonía mostró un porcentaje de concordancia positiva combinado de 100% y un porcentaje de concordancia negativa del 94% para la identificación bacteriana en comparación con los métodos microbiológicos tradicionales. En 27 (51%) casos el resultado del panel de neumonía determinó un cambio en la conducta terapéutica. Conclusiones: la técnica de PCR permite la identificación temprana de microorganismos causantes de neumonía optimizando la terapéutica empírica inicial y racionalizando el uso de antimicrobianos. Un panel negativo aleja el planteo de infección respiratoria a gérmenes habituales y permite considerar diagnósticos diferenciales en cuanto a foco y/o etiología.

Summary: Introduction: the early initiation of the adequate antibiotic therapy in severe infections is associated to a reduction in mortality. Early identification of the microorganism is essential to define directed therapy and decrease the initial inadequate treatment. Objective: to assess usefulness of a molecular biology technique by nucleic acid amplification through a polymerase chain reaction in real time for an early microbiological diagnosis and correction of the antibiotic therapy in patients with severe pneumonias. Method: retrospective, observational study conducted in the intensive care unit of Maciel Hospital. The respiratory samples of patients with a diagnosis of pneumonia or suspicious to have pneumonia were analyzed. The microbiological results obtained were compared using conventional techniques and multiplex molecular biology (pneumonia panel). Results: 53 samples obtained from 51 patients were included in the study. Multiplex detected at least one microorganism in 38 (71.7%) samples compared to 30 (56.6%) in traditional cultures. Most samples were obtained under the previous antibiotic therapy (86.8%). The pneumonia panel showed a combined positive agreement percentage of 100% and a negative agreement of 94% for the identification of bacteria when compared to the traditional microbiological methods. In 27 cases (51%) the pneumonia panel results determined changing the therapeutic behavior. Conclusions: the PCR technique allows for the early identification of microorganisms causing pneumonia, thus optimizing initial empirical therapy and rationalizing the use of antibiotics. A negative panel reduces the suspicion of a respiratory infection caused by the usual germs and enables considering differential diagnosis in terms of etiology or cause.

Resumo: Introdução: o início precoce da antibioticoterapia adequada em infecções graves está associado à redução da mortalidade. A identificação precoce do microrganismo é essencial para realizar o tratamento dirigido e reduzir o uso inicial inadequado de antimicrobianos. Objetivo: avaliar a utilidade de uma técnica de biologia molecular para amplificação de ácidos nucleicos por reação em cadeia da polimerase em tempo real para diagnóstico microbiológico precoce e adequação da antibioticoterapia em pacientes com pneumonia grave. Metodologia: estudo observacional retrospectivo realizado na unidade de terapia intensiva do Hospital Maciel. Amostras respiratórias de pacientes com diagnóstico ou suspeita de pneumonia foram analisadas. Os resultados microbiológicos obtidos por técnicas convencionais e por biologia molecular multiplex (painel de pneumonia) foram comparados. Resultados: foram incluídas 53 amostras obtidas de 51 pacientes. O multiplex detectou pelo menos um microrganismo em 38 (71,7%) amostras em comparação com 30 (56,6%) usando culturas tradicionais. A maioria das amostras foi obtida com antibioticoterapia prévia (86,8%). O painel de pneumonia mostrou uma concordância percentual positiva combinada de 100% e uma concordância percentual negativa de 94% para identificação bacteriana em comparação com métodos microbiológicos tradicionais. Em 27 (51%) casos, o resultado do painel de pneumonia determinou mudança no comportamento terapêutico. Conclusões: a técnica de PCR permite a identificação precoce de microrganismos causadores de pneumonia, otimizando a terapia empírica inicial e racionalizando o uso de antimicrobianos. Um painel negativo afasta a suspeita de infecção respiratória pelos germes usuais e permite considerar diagnósticos diferenciais em termos de foco e/ou etiologia.

Analysis of clinical features and risk factors of necrotizing pneumonia in children / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinical characteristics and risk factor analysis of necrotizing pneumonia in children.@*METHODS@#A retrospective study was used to analyze the case data of 218 children with severe pneumonia hospitalized in the Department of Respiratory Medicine, Children's Hospital of Capital Institute of Pediatrics from January 2016 to January 2020, and they were divided into 96 cases in the necrotizing pneumonia group (NP group) and 122 cases in the non-necrotizing pneumonia group (NNP group) according to whether necrosis of the lung occurred. The differences in clinical characteristics (malnutrition, fever duration, hospitalization time, imaging performance, treatment and regression follow-up), laboratory tests [leukocytes, neutrophil ratio, platelet (PLT), C-reactive protein (CRP), procalcitonin (PCT), D-dimer, and lactate dehydrogenase (LDH)] and bronchoscopic performance between the two groups were compared, and Logistic regression analysis of clinical risk factors associated with necrotizing pneumonia was performed to further determine the maximum diagnostic value of each index by subject operating characteristic curve (ROC). The critical value of each index was further determined by the ROC.@*RESULTS@#The differences in age, gender, pathogenic classification, and bronchoscopic presentation between the two groups of children were not statistically significant (P>0.05); whereas the imaging uptake time of the children in the NP group was higher than that in the NNP group (P < 0.05). The differences in malnutrition, fever duration, length of stay, white blood cell count, neutrophil ratio, CRP, PCT, and D-dimer were statistically significant between the two groups (P < 0.05). The imaging uptake time was lower in children under 6 years of age than in those over 6 years of age, and the imaging uptake time for bronchoalveolar lavage within 10 d of disease duration was lower than that for those over 10 d; the imaging uptake time was significantly longer in the mixed infection group than that in the single pathogen infection group. Logistic regression analysis of the two groups revealed that the duration of fever, hospital stay, CRP, PCT, and D-dimer were risk factors for secondary pulmonary necrosis (P < 0.001, P < 0.001, P < 0.001, P=0.013, P=0.001, respectively). The ROC curves for fever duration, CRP, PCT, and D-dimer were plotted and found to have diagnostic value for predicting the occurrence of pulmonary necrosis when fever duration >11.5 d, CRP >48.35 mg/L, and D-dimer > 4.25 mg/L [area under ROC curve (AUC)=0.909, 0.836, and 0.747, all P < 0.001].@*CONCLUSION@#Children with necrotizing pneumonia have a longer heat course and hospital stay, and the imaging uptake time of mixed pathogenic infections is significantly longer than that of single pathogenic infections. Children with necrotizing pneumonia under 6 years of age have more advantageous efficacy of electronic bronchoscopic alveolar lavage within 10 d of disease duration compared with children in the group over 6 years of age and children in the group with disease duration >10 d. Inflammatory indexes CRP, PCT, and D-dimer are significantly higher. The heat course, CRP, PCT, and D-dimer are risk factors for secondary lung necrosis in severe pneumonia. Heat course >11.5 d, CRP >48.35 mg/L, and D-dimer >4.25 mg/L have high predictive value for the diagnosis of necrotizing pneumonia.

Clinical characteristics of influenza pneumonia in the elderly and relationship between D-dimer and disease severity / 北京大学学报(医学版)

OBJECTIVE@#To clarify the clinical characteristics of influenza pneumonia in the elderly patients and the relationship between D-dimer and the severity of influenza pneumonia.@*METHODS@#In the study, 52 hospitalized patients older than 65 years with confirmed influenza pneumonia diagnosed in Peking University People's Hospital on 5 consecutive influenza seasons from 2014 were retrospectively analyzed. General information, clinical symptoms, laboratory data, treatment methods and prognosis of the patients were collected. The relationship between D-dimer and pneumonia severity was analyzed, and receiver operating characteristic (ROC) curve was used to evaluate the predictive value of D-dimer.@*RESULTS@#Among the 52 patients, 31 were male (31/52, 59.6%), the average age was (77.1±7.4) years, and 19 of them (36.5%) were diagnosed with severe pneumonia. About 70% patients presenting with fever. In the severe group, the patients were more likely to complain of dyspnea than in the non-severe group (14/19, 73.7% vs. 10/33, 30.3%, P=0.004), severe pneumonia group had higher level of CURB-65 (confusion, urea, respiratory rate, blood pressure, and age>65), pneumonia severity index (PSI), C-reactive protein, urea nitrogen, lactate dehydrogenase, fasting glucose, and D-dimer (P value was 0.004, < 0.001, < 0.001, 0.003, 0.038, 0.018, and < 0.001, respectively), albumin was lower than that in the non-severe group [(35.8±5.6) g/L vs. (38.9±3.5) g/L, t=-2.348, P=0.018]. There was a significant positive correlation between the D-dimer at the first admission and PSI score (r=0.540, 95%CI: 0.302 to 0.714, P < 0.001), while a significant negative correlation with PaO2/FiO2 (r=-0.559, 95%CI: -0.726 to -0.330, P < 0.001). Area under the curve of D-dimer was 0.765 (95%CI: 0.627 to 0.872). Area under the curve of PSI was 0.843 (95%CI: 0.716 to 0.929). There was no statistically significant difference in test efficacy between the two (Z=2.360, P=0.174). D-dimer level over 1 225 μg/L had a positive predict value for influenza pneumonia in hospital death with a sensitivity of 76.92% and a specificity of 74.36%.@*CONCLUSION@#Influenza pneumonia in the elderly always has atypical symptoms, dyspnea is a prominent feature in severe cases, D-dimer level is associated with the severity of influenza pneumonia, and greater than 1 200 μg/L has a good predictive value for in-hospital death in the elderly.

Recomendaciones para el manejo de las infecciones respiratorias agudas bajas en menores de 2 años. Actualización 2021 / Recommendations for the management of acute lower respiratory infections in children under 2 years of age. Update 2021

Las infecciones respiratorias agudas bajas (IRAB) continúan representando una importante causa de morbimortalidad en nuestro medio. El manejo normatizado de casos constituye una valiosa herramienta para enfrentarlas.Además de los aspectos relacionados con el diagnóstico y tratamiento de estas enfermedades, el análisis de factores de riesgo (tanto biológicos como socioambientales), desde una perspectiva local y actual, permitie implementar medidas efectivas de control y/o prevención, así como identificar aquellos pacientes susceptibles de presentar formas graves o complicaciones.Desde 1996 la Sociedad Argentina de Pediatría asumió el desafío de generar un documento que guíe el manejo integral de los pacientes con IRAB. En esta cuarta actualización se incluyen los últimos adelantos en el tema.

Acute lower respiratory infections (ARI) continue being an important cause of morbidity and mortality in our region. Standardized case management is a valuable tool to deal with them.In addition to aspects related to the diagnosis and treatment of these diseases, the analysis of risk factors (both biological and socio-environmental) from a local and current perspective, allows the implementation of effective control and/or prevention measures, as well as identifying those patients susceptible to presenting serious forms or complications.Since 1996, the Sociedad Argentina de Pediatría asumed the challenge of generating a document that guides the comprehensive management of patients with ARI. This fourth update includes the latest advances on the subject.

Estudio multicéntrico argentino sobre la utilidad del panel de neumonía de FilmArray® / Argentine multicenter study on the utility of the FilmArray® pneumonia panel

Resumen Las infecciones de las vías respiratorias inferiores se encuentran entre aquellas en las que el uso inadecuado de antimicrobianos es frecuente, por lo que es fundamental contar con una prueba diagnóstica rápida, sensible y específica. El sistema de FilmArray es un análisis de PCR múltiple con un panel de neumonía que incluye 26 microorganismos y 7 marcadores de resistencia antimicrobiana. Los objetivos de este estudio fueron: a) establecer la correlación entre los cultivos cuantitativos para agentes bacterianos de muestras de vías respiratorias inferiores (MRVB) y la detección fenotípica de mecanismos de resistencia con los correspondientes resultados de FilmArray; b) determinar el cambio terapéutico generado con el informe del resultado inmediato. Se incluyó un total de 194 MRVB correspondientes a 191 pacientes con neumonía y se documentaron 277 bacterias. FilmArray identificó 253/277 (91%) bacterias y 161/277 (58%) se aislaron del cultivo, 58 (23%) coincidieron con el mismo recuento, 116 (46,7%) dieron mayores recuentos con FilmArray y 72 (28,9%) fueron detectadas por este método pero el cultivo fue negativo. Se detectaron marcadores de resistencia antimicrobiana en 63 aislados, pero solo 28 fueron confirmados por métodos fenotípicos. Estos resultados podrían haber provocado cambios en el tratamiento antibiótico en el 74,6% (174/194). FilmArray es una herramienta útil para optimizar el tratamiento antimicrobiano en pacientes con neumonía.

Abstract Lower respiratory tract infections are among those in which the inappropriate use of antimicrobials is common, so it is essential to have a rapid, sensitive and specific diagnostic test. The FilmArray system is a multiplex PCR assay with a pneumonia panel that includes 26 microorganisms and 7 antibiotic resistance markers. The objectives of this study were: a) to establish the correlation between quantitative cultures for bacterial agents from lower respiratory tract samples (MRVB) and the phenotypic detection of resistance mechanisms with the corresponding results of FilmArray b) to determine the therapeutic change generated with the immediate result report. A total of 194 MRVB corresponding to 191 patients with pneumonia were included and 277 bacterial strains were documented. FilmArray identified 253/277 (91%) bacteria and 161/277 (58%) were isolated from culture, 58 (23%) matched the same count, 116 (46.7%) yielded higher counts with FilmArray, and 72 (28.9%) with negative culture were detected by this method. Antibiotic resistance markers were detected in 63 strains, but only 28 were confirmed by phenotypic methods. These results may cause changes in the antimicrobial treatment in 74.6% (174/194). FilmArray is a useful tool to optimize antimicrobial therapy in patients with pneumonia.

Resumo As infecções do trato respiratório inferior estão entre aquelas em que o uso inadequado de antimicrobianos é comum, por isso é essencial um teste diagnóstico rápido, sensível e específico. O sistema FilmArray é um ensaio de PCR multiplo com um painel de pneumonia que inclui 26 microrganismos e 7 marcadores de resistência antimicrobiana. Os objetivos deste estudo foram: a) estabelecer a correlação entre as culturas quantitativas de agentes bacterianos de amostras do trato respiratório inferior (MRVB) e a detecção fenotípica de mecanismos de resistência com os resultados correspondentes do FilmArray b) determinar a alteração terapêutica gerada com o relatório de resultado imediato. Um total de 194 MRVB correspondendo a 191 pacientes com pneumonia foram incluídos e 277 cepas bacterianas foram documentadas. FilmArray identificou 253/277 (91%) bactérias e 161/277 (58%) foram isoladas da cultura, 58 (23%) coincidiram com mesma contagem, 116 (46,7%) deram contagens mais altas com FilmArray e 72 (28,9%) foram detectados por este método, mas a cultura foi negativa. Marcadores de resistência antimicrobiana foram detectados em 63 cepas, mas apenas 28 foram confirmados por métodos fenotípicos. Esses resultados puderam causar alterações no tratamento antibiótico em 74,6% (174/194). FilmArray é uma ferramenta útil para otimizar a terapia antimicrobiana em pacientes com pneumonia..

Ubicación intrahospitalaria y tratamiento antimicrobiano inicial en pacientes con neumonía adquirida en la comunidad y su relación con la frecuencia y calidad del proceso de estratificación / Intrahospitalary location and antimicrobial initial treatment in patients with acquired pneumonia in the community and their relationship with the frequency and quality of the stratification process

La importancia de la evaluación inicial de la gravedad del paciente con neumonía es una acción diagnóstica de importancia bien establecida. El objetivo del trabajo fue evaluar la relación entre la frecuencia y calidad del proceso de estratificación de pacientes con neumonía, y el cumplimiento de las sugerencias de ubicación intrahospitalaria y de tratamiento antimicrobiano inicial de un instrumento de estratificación. Se realizó un estudio descriptivo sobre una población de 1,809 pacientes hospitalizados durante 10 años. Se analizó el comportamiento de los índices de ubicación intrahospitalaria y tratamiento antimicrobiano inicial acorde a la sugerencia de un instrumento de estratificación utilizado; en el análisis estadístico se utilizó el Odds ratio y el estadígrafo X2, con un nivel de significación de 95%. En los resultados se destacan que la ubicación intrahospitalaria estuvo acorde a la sugerencia del instrumento en el 96%, con el valor más bajo en los pacientes con neumonía grave y altas probabilidades de recuperación (82%, p<,05). Se constató mayor frecuencia de ubicación intrahospitalaria acorde a la sugerencia del instrumento en los pacientes bien estratificados (p<,05), fundamentalmente en los pacientes con neumonía grave y altas probabilidades de recuperación. La correspondencia del tratamiento antimicrobiano inicial con la propuesta del instrumento fue del 61%; el estrato IIIA mostró el valor más elevado (80%, p<,05). Como conclusiones del estudio se constató un elevado desempeño en el cumplimiento de la sugerencia de ubicación intrahospitalaria del instrumento de estratificación, no así en el cumplimiento de la sugerencia de tratamiento antimicrobiano inicial. Se demostró la existencia de una relación entre el proceso de estratificación y el cumplimiento de la ubicación intrahospitalaria sugerida por el instrumento empleado.

The initial evaluation of the patient's condition with pneumonia is a very important assistance action. The objective was evaluate the relationship between the frequency and quality of the stratification process of the patient with pneumonia, and the execution of suggestions of intrahospitalary location and the initial antimicrobial treatment of stratification instrument. A descriptive study was done on a population of 1,809 patients hospitalized during 10 years. The indexes of intrahospitalary location and of antimicrobian initial treatment were analized according to the suggestions of the instrument; in the statistical analysis it was used the odds ratio and the statistician X2, with a significant level of 95%. The intrahospitalary location was in agreement with the suggestion of the instrument in 96% of the cases, with the lowest value in patients with serious pneumonia and high recovery probabilities (82%, p <,05). The frequency of intrahospitalary location was bigger and veryfied with the suggestion of the instrument in the termed well stratified patients (p <,05), fundamentally in the patients with serious pneumonia and high recovery probabilities. The correspondence of the initial antimicrobial treatment with the proposal of the instrument was of 61%; the stratum IIIA showed the highest value (80%, p <,05). As conclusions, a high performance in the execution of the suggestion of the intrahospitalary location has been one of the characteristics of the process, although as a negative element it stands out the frequent non-fulfillment of the suggestion of the initial antimicrobial treatment. There was a relationship between the stratification process and the execution of the suggestion of the intrahospitalary location.

Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study

ABSTRACT BACKGROUND: Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. OBJECTIVES: To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. DESIGN AND SETTING: Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. METHODS: PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. RESULTS: One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CONCLUSIONS: CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.

Neumonía adquirida en la comunidad en una Unidad de Cuidados Intensivos Pediátrica / Community-acquired pneumonia in the pediatric intensive care unit / Pneumonia adquirida na comunidade em uma unidade de terapia intensiva pediátrica

RESUMEN Introducción: En el Hospital Pediátrico Docente "Pedro Agustín Pérez" de Guantánamo no se ha caracterizado la neumonía grave adquirida en la comunidad. Objetivo: Identificar el perfil de esta enfermedad en la Unidad de Cuidados Intensivos del citado hospital en el periodo 2016-2019. Método: Se realizó un estudio descriptivo, longitudinal y retrospectivo. El universo estuvo constituido por todos los ingresados en este periodo (N=153). Se estudió el sexo, edad, diagnóstico microbiológico, terapéutica antimicrobiana, aplicación de ventilación mecánica, procederes realizados, complicaciones, estadía, estado al egreso y causa directa de muerte. Los resultados se presentaron en tablas y se resumieron mediante frecuencias absolutas y acumuladas. Resultados: La mayor proporción de los pacientes fueron varones con edad entre 1 y 4 años de edad (30,7 %). El Streptococcus pneumoniae fue el más común (38,5 %). Las cefalosporinas fueron los fármacos más prescritos (36,0 %). El 16,3 % requirió ventilación mecánica y el 22,9 % presentó alguna complicación, la más común fue el derrame pleural paraneumónico (21,5 %). El 96,4 % egresó vivo y la principal causa de muerte fue el choque séptico (57,2 %). Conclusiones: La neumonía continúa siendo una patología frecuente en la edad pediátrica al igual que el predominio del sexo masculino. Después de la introducción de la vacunación, el Streptococcus pneumoniae ha emergido como el principal patógeno bacteriano a cualquier edad, con un predominio importante en los menores de 5 años.

ABSTRACT Introduction: Severe community-acquired pneumonia has not been characterized at the Pediatric Teaching Hospital ¨Pedro Agustín Pérez¨ in Guantanamo. Objective: To profile this affection at the Intensive Care Unit of the already cited institution in the period 2016-2019. Method: A descriptive, longitudinal and retrospective study was carried out. The study population was made out of all the patients in the intensive care unit in that period of time (N=153). The variables analyzed were: gender, age, microbiological diagnosis, antimicrobial therapy, mechanical ventilation application, medical procedures applied, complications, in-hospital stay, state at the time of discharge and cause of death. Results were presented in tables and were summed up in absolute and cumulative frequencies. Results: Most patients were male, ranging from 1 to 4 years of age (30.7%). Streptococcus pneumoniae was the most common infection (36.0%). 16.3% if the cases required mechanical ventilation and the 22.9% presented some complication, the most common being the parapneumonic pleural effusion (22.5%). 96.4% of the patients were discharged alive, and the main cause of death was septic shock (57.2%). Conclusions: Pneumonia remains a frequent pathology in patients in pediatric age; and prevails in male patients as well. After vaccination campaigns started, the Streptococcus pneumoniae emerged as the main bacterial pathogen to cause infections at any age, especially in patients below the 5 years of age.

RESUMO Introdução: No Hospital Pediátrico Docente "Pedro Agustín Pérez" de Guantánamo, pneumonia grave adquirida na comunidade não foi caracterizada. Objetivo: Identificar o perfil desta doença na Unidade de Terapia Intensiva do referido hospital no período 2016-2019. Método: Foi realizado um estudo descritivo, longitudinal e retrospectivo. O universo era composto por todos os admitidos neste período (N=153). Foram estudadas sexo, idade, diagnóstico microbiológico, terapia antimicrobiana, aplicação de ventilação mecânica, procedimentos realizados, complicações, permanência, estado na alta e causa direta do óbito. Os resultados foram apresentados em tabelas e resumidos por meio de frequências absolutas e cumulativas. Resultados: A maior proporção de pacientes eram homens entre 1 e 4 anos (30,7%). Streptococcus pneumoniae foi o mais comum (38,5%). As cefalosporinas foram os medicamentos mais prescritos (36,0%). 16,3% necessitaram de ventilação mecânica e 22,9% apresentaram alguma complicação, sendo a mais comum o derrame pleural parapneumônico (21,5%). 96,4% tiveram alta com vida e a principal causa de morte foi choque séptico (57,2%). Conclusões: A pneumonia continua sendo uma patologia frequente na idade pediátrica, assim como a predominância do sexo masculino. Após a introdução da vacinação, Streptococcus pneumoniae surgiu como o principal patógeno bacteriano em qualquer idade, com predomínio significativo em crianças menores de 5 anos.

Usefulness of blood cultures in COVID-19 pneumonia / Utilidad de los hemocultivos en la neumonía por COVID-19

Abstract The Coronavirus Disease 2019 (COVID-19) pandemic has strained the world's health systems, highlighting the need to optimize its clinical management and treatment. The usefulness of blood cultures in patients with COVID-19 pneumonia has not been proved. We aim to describe the diagnostic yield of early blood cultures in patients with COVID-19 pneumonia in a public hospital in Buenos Aires City. This descriptive observational study included all adult patients with COVID-19 pneumonia admitted to the Internal Medicine ward of Hospital Durand between April 1, 2020 and July 30, 2020, who had blood cultures drawn within 5 days from hospital admission. Among 267 patients hospitalized with COVID-19 pneumonia, 38 had early blood cultures drawn. No clinically relevant microorganism was isolated from blood and contaminant microorganisms were recovered in 7 (18.4%) patients. This study found no evidence of bacteremia in patients with COVID-19 pneumonia. Furthermore, the rate of contaminated blood cultures nearly doubles the reported in patients with community acquired pneumonia (10%), which may be explained by unfamiliarity of additional personal protective equipment worn by healthcare workers. Our results advocate against the routine indication of blood cultures upon admission to the Internal Medicine Ward of patients with COVID-19 pneumonia. We suggest that blood cultures could only be useful in case of clinical deterioration or suspected hospital-acquired infection.

Resumen La pandemia por COVID-19 ha puesto en jaque a los sistemas de salud del mundo, priorizando la necesidad de optimizar su manejo clínico. Aunque los protocolos de varios hospitales de nuestro país para COVID-19 incluyen hemocultivo al ingreso, no se ha demostrado su utilidad en pacientes con neumonía por COVID-19. Nuestro objetivo fue describir el rédito diagnóstico de los hemocultivos tempranos en pacientes con neumonía por COVID-19 en un hospital público de la Ciudad de Buenos Aires. Este estudio observacional descriptivo incluyó todos los pacientes adultos ingresados en la sala de Clínica Médica del Hospital Durand entre el 1 de abril y el 30 de julio de 2020, con neumonía por COVID-19 y hemocultivos realizados dentro de los 5 días del ingreso. De los 267 pacientes con neumonía por COVID-19, a 38 se les realizó hemocultivos tempranos. No se aisló ningún microorganismo clínicamente relevante en ninguno de ellos y se recuperaron microorganismos contaminantes en 7 (18.4%). Este estudio no encontró evidencia de bacteriemia en pacientes con neumonía por COVID-19. Además, la tasa de hemocultivos contaminados casi duplicó la tasa en pacientes con neumonía adquirida en la comunidad, lo que probablemente se deba a la falta de familiaridad de equipos de protección personal adicional utilizado por el personal de salud. Nuestros resultados abogan en contra de la realización rutinaria de hemocultivos al ingreso de pacientes con neumonía por COVID-19. Sugerimos que los hemocultivos solo sean utilizados ante el deterioro clínico o la sospecha de infección intrahospitalaria.

Depresión en ancianos graves con neumonía adquirida en la comunidad / Depression in seriously-ill elder people with community-acquired pneumonia

RESUMEN Introducción: aquellos países con alto grado de envejecimiento poblacional muestran asociaciones importantes con diferentes enfermedades, por ejemplo, la neumonía adquirida en la comunidad y la depresión en los ancianos. Objetivos: relacionar la depresión con la mortalidad y evaluar efectos de los antidepresivos, en los pacientes con neumonía adquirida en la comunidad, ingresados en la Unidad de Cuidados Intensivos del Hospital Militar Central "Dr. Carlos J. Finlay". Materiales y métodos: se realizó un estudio analítico, longitudinal prospectivo, con todos los pacientes con neumonía adquirida en la comunidad, ingresados en la Unidad de Cuidados Intensivos Emergentes, del Hospital Militar "Dr. Carlos J. Finlay". Periodo correspondiente a enero del 2018 hasta abril del 2019 que cumplieron con los criterios de inclusión. El universo lo constituyó 160 pacientes. Resultados: existieron 55 pacientes con síntomas de depresión previos al ingreso, (34 %). El 78 % de fallecidos presentaron depresión al ingreso. La edad media de los no deprimidos fue de 74, la más alta de los deprimidos fue de 80,80. No presentaron signos de depresión 93 pacientes vivos y 43 que la presentaron y fallecieron con una gran significación estadística p 0,000. RR 6,8. Se observó una marcada relación entre la mortalidad y el no recibir tratamiento para la depresión, (37) p 0,000. Conclusiones: la neumonía y la depresión son enfermedades que tienen una relación íntima. Esta asociación cuenta con una elevada mortalidad, así como el impacto del tratamiento antidepresivo en la evolución del paciente es definitorio en el ámbito de los cuidados intensivos (AU).

ABSTRACT Introduction: those countries with a high level of population ageing show important associations to different diseases, for example, community acquired pneumonia and depression in elder people. Objectives: to establish the relationship of depression with mortality and to evaluate the effect of antidepressants in patients with community-acquired pneumonia admitted in the Intensive Care Unit of the Central Military Hospital "Dr. Carlos J. Finlay". Materials and methods: a prospective, longitudinal, analytic study was carried out with all patients with community-acquired pneumonia, admitted in the Intensive Care Unit of the Central Military Hospital "Dr. Carlos J. Finlay" in the period from January 2018 until April 2019, who fulfilled the inclusion criteria. The universe were 160 patients. Results: there were 55 patients with depression symptoms before the admission. 78 % of the deceased showed depression at the admittance. The medium age of the non-depressed ones was 74 years; the highest age of the depressed ones was 80.80 years. 93 living patients did not present depression signs, and 43 presented them and died with a great statistical significance p: 0.000 RR: 6.8. A remarked relation was observed between mortality and not receiving treatment for depression (37) p 0,000. Conclusions: pneumonia and depression are diseases having a tight relationship. This association yields a high mortality, and the impact of the anti-depression treatment on the patient's evolution is defining in the intensive care settings (AU).

Validación externa del modelo predictivo de mortalidad en ancianos con neumonía adquirida en la comunidad / External validation of the predictive model of mortality in elder people with community-acquired pneumonia

RESUMEN Introducción: la neumonía adquirida en la comunidad es la enfermedad infecciosa que conlleva una mayor mortalidad en los países desarrollados. El diagnóstico pasa por varios momentos, el cuadro clínico, la analítica y las imágenes. Objetivos: realizar la validación externa de un modelo matemático predictivo de mortalidad en pacientes ingresados por neumonía grave adquirida en la comunidad. Material y métodos: estudio longitudinal prospectivo (cohorte) con un grupo, con todos los pacientes que ingresaron en la Unidad de Cuidados intensivos emergentes con el diagnóstico de neumonía adquirida en la comunidad en el Hospital Militar Dr. Carlos J. Finlay, de febrero de 2018 hasta marzo del 2019. El universo estuvo constituido por 160 pacientes y no se tomó muestra alguna. Resultados: índice de Kappa K=1. Test Hosmer Lemenshow 0,650 con elevado ajuste. Resultados del modelo con sensibilidad= 79%. Especificidad: 91% con (VPP): 80 y (VPN)= 91. RR: 9,1. Área bajo la Curva = 0997. Porcentaje de aciertos en la regresión logística de 88,4 %. Conclusiones: el modelo propuesto constituyo una herramienta útil en la detección temprana de pacientes con riesgo de muerte a corto plazo. Permitió unificar en una sola variable el resultado de otras que aparentemente no tienen relación entre ellas; con lo que se hace más fácil la interpretación de los resultados, toda vez que este refleja, el conjunto y no la individualidad (AU).

SUMMARY Introduction: community-acquired pneumonia is the infectious disease leading to higher mortality in developed countries. The diagnosis goes through several moments, clinical symptoms, analytics, and images. Objective: to perform the external validation of a predictive mathematical model of mortality in patients admitted by serious community-acquired pneumonia. Methods: longitudinal prospective (cohort) study with a group formed with all patients who were admitted to the Emergent Intensive Care Unit in the Military Hospital ¨Dr. Carlos Juan Finlay¨ with the diagnosis of community-acquired pneumonia, from February 2018 to March 2019. The universe was formed by 160 patients and no sample was chosen. Results: Kappa index K= 1. Hosmer Lemenshow test= 0.650 with a high adjustment. Result of the model with sensibility= 79 %. Specificity= 91 % with (APV) = 80 and (NPV) = 91. RR= 9.1. Area under the curve= 0997. Percentage of correctness in logistic regression of 88.4 %. Conclusions: The proposed model was a useful tool in the early detection of patients at near-term death risk. It allowed to unite in an only variant the result of others that apparently are not related one to another, making it easier the interpretation of the results, since it reflects the whole and not the individuality (AU).

Neumonía por COVID19: Valoración por imagen, lo básico / COVID­19 pneumonia: Imaging evaluation, the basics

La pandemia de COVID­19 ha resultado en una emergencia de salud global. Los estu­dios de imagen utilizados en esta enfermedad son la radiografía de tórax (RX) y la to­mografía computarizada (TC). Ambas modalidades tienen sus hallazgos descritos, pero no son específicos dado que muchas enfermedades pueden producir patrones simila­res, particularmente las neumonías virales. Los RX de tórax muestra hallazgos consis­tentes en opacidades alveolares las cuales son múltiples, periféricas, bilaterales y basales, mientras que la tomografía de tórax sus hallazgos más frecuentes son presen­cia de patrón en vidrio deslustrado, consolidaciones, engrosamiento septal, patrón en empedrado, dilatación bronquial y engrosamiento peri bronquial, broncograma, patrón de halo invertido y patrón de neumonía organizada. Los hallazgos por imagen depen­den del tiempo de evolución de la enfermedad ya que en etapas tempranas puede ser normal tanto en la RX como la TC. El riesgo de trombo embolismo pulmonar es alto y más frecuente que en pacientes con COVID­19 negativo

The COVID­19 pandemic has resulted in a global health emergency. The imaging stu­dies used in this disease are chest radiography (CXR) and computed tomography (CT). Both imaging modalities findings have had their findings. These findings described are not specific since many diseases can produce similar patterns. CXR shows somewhat consistent findings consisting of alveolar opacities which are multiple, peripheral, bilate­ral and basal, while CT the most frequent findings are the presence of grounded glass pattern, consolidations, septal thickening, crazy paving pattern, bronchial dilation and peribronchial thickening, air bronchograms, inverted halo sign and organized pneumo­nia. Imaging findings depends on the evolution time of the disease since in the early sta­ges both chest radiography and tomography may be normal. The risk for pulmonary embolism is high and more frequent than in patients with negative COVID­19

Community-acquired pneumonia among children: the latest evidence for an updated management / Pneumonia adquirida na comunidade em crianc¸as: as evidências mais recentes para um manejo atualizado

Abstract Objective To provide cutting-edge information for the management of community-acquired pneumonia in children under 5 years, based on the latest evidence published in the literature. Data source A comprehensive search was conducted in PubMed, by using the expressions: "community-acquired pneumonia" AND "child" AND "etiology" OR "diagnosis" OR "severity" OR "antibiotic". All articles retrieved had the title and the abstract read, when the papers reporting the latest evidence on each subject were identified and downloaded for complete reading. Data synthesis In the era of largely implemented bacterial conjugate vaccines and widespread use of amplification nucleic acid techniques, respiratory viruses have been identified as the most frequent causative agents of community-acquired pneumonia in patients under 5 years. Hypoxemia (oxygen saturation ≤96%) and increased work of breathing are signs most associated with community-acquired pneumonia. Wheezing detected on physical examination independently predicts viral infection and the negative predictive value (95% confidence interval) of normal chest X-ray and serum procalcitonin <0.25 ng/dL was 92% (77-98%) and 93% (90-99%), respectively. Inability to drink/feed, vomiting everything, convulsions, lower chest indrawing, central cyanosis, lethargy, nasal flaring, grunting, head nodding, and oxygen saturation <90% are predictors of death and can be used as indicators for hospitalization. Moderate/large pleural effusions and multilobar infiltrates are predictors of severe disease. Orally administered amoxicillin is the first line outpatient treatment, while ampicillin, aqueous penicillin G, or amoxicillin (initiated initially by intravenous route) are the first line options to treat inpatients. Conclusions Distinct aspects of childhood community-acquired pneumonia have changed during the last three decades.

Resumo Objetivo Fornecer informações de ponta para o manejo de crianças menores de cinco anos com pneumonia adquirida na comunidade, com base nas evidências mais recentes publicadas na literatura. Fonte de dados Uma pesquisa abrangente foi feita no PubMed, com as expressões: "community-acquired pneumonia" + "child" + "etiology" ou "diagnosis" ou "severity" ou "antibiotic". Todos os artigos encontrados tiveram o título e o resumo lidos e os artigos que relatavam as evidências mais recentes sobre cada assunto foram identificados e recuperados para leitura completa. Síntese dos dados Na era das vacinas bacterianas conjugadas amplamente usadas e do uso difundido de técnicas de amplificação de ácidos nucléicos, os vírus respiratórios foram identificados como os agentes causadores mais frequentes de pneumonia adquirida na comunidade em pacientes com menos de cinco anos. A hipoxemia (saturação de oxigênio ≤ 96%) e o aumento do esforço respiratório são os sinais mais associados à pneumonia adquirida na comunidade. A sibilância detectada ao exame físico prediz de forma independente a infecção viral e o valor preditivo negativo (intervalo de confiança de 95%) da radiografia de tórax normal e a procalcitonina sérica < 0,25 ng/dL foi de 92% (77-98%) e 93% (90-99%), respectivamente. Incapacidade de beber e se alimentar, vomitar todo o alimento, convulsões, retração torácica subcostal, cianose central, letargia, aleteo nasal, estridor e saturação de oxigênio < 90% são preditores de óbito e podem ser usados como indicadores de hospitalização. Derrames pleurais moderados/grandes e infiltrados multilobulares são preditores de doença grave. A amoxicilina administrada por via oral é a opção de primeira linha para tratar pacientes ambulatoriais e a ampicilina ou penicilina cristalina G ou amoxicilina (administrada inicialmente por via intravenosa) são as opções de primeira linha para tratar pacientes hospitalizados. Conclusões Aspectos distintos da pneumonia adquirida na comunidade durante a infância mudaram durante as últimas três décadas.