Pneumonia tuberculosa: relato de caso / Tuberculous pneumonia: case report / Neumonía tuberculosa: reporte de caso

A tuberculose é uma doença infecciosa causada pelo Mycobacterium tuberculosis muito disseminada no Brasil. Tem preferência pelo acometimento pulmonar, embora vários outros órgãos possam ser afetados, como vasos linfáticos, trato geniturinário, ossos, articulações, sistema nervoso central, trato gastrointestinal e pericárdio. A pneumonia tuberculosa é uma forma rara, que se apresenta com consolidação alveolar, principalmente em lobo superior, podendo mimetizar um quadro de pneumonia pneumocócica. O objetivo deste ensaio é relatar o caso clínico de um indivíduo do sexo masculino com diagnóstico de pneumonia tuberculosa no Hospital Geral Roberto Santos (HGRS) e fazer uma breve revisão da literatura sobre o tema. O método utilizado para isso será o relato de caso clínico, com informações obtidas por meio de revisão de dados contidos em prontuário médico. Os resultados obtidos foram: paciente do sexo masculino, 19 anos, previamente hígido, não tabagista, natural de Recife, procedente de Salvador, admitido em agosto de 2019 no serviço de emergência do HGRS, com história de tosse produtiva de secreção amarelada, febre não mensurada e calafrios. O relato de caso descrito mostra uma apresentação atípica, rara e pouco comum de pneumonia tuberculosa/tuberculose pulmonar. A procura por diagnósticos diferenciais em quadros com resposta ruim à terapêutica inicialmente instituída é fundamental para evitar atrasos entre a realização do diagnóstico correto e a introdução das devidas medidas terapêuticas.

Tuberculosis is a highly prevalent infectious disease in Brazil, caused by Mycobacterium tuberculosis. Despite mostly affecting the lungs, it may also affect other organs, such as lymphatic vessels, genitourinary tract, bones, joints, central nervous system, gastrointestinal tract, and pericardium. A rare form of the disease, tuberculous pneumonia presents with alveolar consolidation, especially in the upper lobe, possibly mimicking pneumococcal pneumonia. This study sought to report the clinical case of a male individual diagnosed with Tuberculous Pneumonia at the Hospital Geral Roberto Santos, as well as to perform a brief literature review of subject. The study was conducted with data collected from the medical records of a male patient aged 19 years old, previously healthy, non-smoker, born in Recife and living in Salvador, admitted in August 2019 to the emergency service of Hospital Geral Roberto Santos with a history of productive cough yellowish sputum, unmeasured fever, and chills. The case report here described shows an atypical, rare, and uncommon presentation of Tuberculous Pneumonia/Pulmonary Tuberculosis. To avoid delays between the correct diagnosis and the introduction of the respective therapeutic measures, health professionals should search for differential diagnoses in conditions with poor response to the initially instituted therapy.

La tuberculosis es una enfermedad infecciosa causada por Mycobacterium tuberculosis muy prevalente en Brasil. Tiene preferencia por la afectación pulmonar, aunque pueden estar implicados muchos otros órganos, como vasos linfáticos, tracto genitourinario, huesos, articulaciones, sistema nervioso central, tracto gastrointestinal y pericardio. La neumonía tuberculosa es una forma rara, que se presenta con consolidación alveolar, especialmente en el lóbulo superior, que puede simular un cuadro de neumonía neumocócica. El objetivo de este ensayo es informar el caso clínico de un varón diagnosticado de Neumonía Tuberculosa en el Hospital Geral Roberto Santos y realizar una breve revisión de la literatura sobre el tema. El método utilizado para ello será elreporte de caso clínico con información obtenida mediante revisión de datos contenidos en historias clínicas. Los resultados obtenidos fueron: paciente varón de 19 años, previamente sano, no fumador, nacido en Recife, residente en Salvador, ingresado en agosto de 2019 en el servicio de urgencias del Hospital Geral Roberto Santos, con antecedente de tos productiva amarillenta, fiebre no medida y escalofríos. El reporte de caso aquí descrito muestra una presentación atípica, rara y poco común de neumonía tuberculosa/tuberculosis pulmonar. La búsqueda de diagnósticos diferenciales en condiciones con mala respuesta a la terapia inicialmente instituida es fundamental para evitar retrasos entre el diagnóstico correcto y la introducción de las respectivas medidas terapéuticas.

Protocolo clínico de diagnóstico y tratamiento de pacientes con neumonía adquirida en la comunidad que ingresan a la Unidad de Cuidados Intensivos / Clinical protocol for diagnosis and treatment of patients with community-acquired pneumonia admitted to the Intensive Care Unit

La neumonía es una infección frecuente que se presenta en todas las edades, en cualquier tipo de pacientes y a nivel co-munitario u hospitalario. La neumonía que se origina en la comunidad afecta a los pacientes con comorbilidades y en los extremos de la vida. La mortalidad de la neumonía comunitaria (NC) per-manece elevada, los sistemas de salud deben implementar estrategias para diagnosticar y tratar de forma rápida a estos pacientes. Cuando un paciente con neumonía comunitaria es ingresado en la emergencia de cualquier hospital se debe categorizar su estado para que reciba el mejor tratamiento posible. La Unidad de Cuidados Intensivos (UCI) participa en la detección de los pacientes con neu-monía adquirida en la comunidad grave, con el objetivo de priorizar su atención para lograr las metas de manejo lo más rápido posible y disminuir la mortalidad de estos pacientes.

Pneumonia is a common infection that occurs in all ages, in any type of patient and at the community or hospital level. Community-originating pneumonia affects patients with comorbidities and at the ex-tremes of life. Mortality from commu-nity pneumonia remains high, health sys-tems must implement strategies to quickly diagnose and treat these patients. When a patient with community pneumonia is admitted to any hospital emergency, their condition must be categorized so that they receive the best possible treat-ment. The Intensive Care Unit (ICU) participates in the detection of patients with severe community-acquired pneu-monia, with the objective of prioritizing their care to achieve management goals as quickly as possible and reduce the mortality of these patients.

Neumonía adquirida en la comunidad en pacientes que requirieron hospitalización / Community acquired pneumonia in patients requiring hospitalization

Resumen La neumonía adquirida en la comunidad (NAC) representa un importante problema sanitario y ~20% de los pacientes requiere hospitalización. El objetivo principal del trabajo fue determinar las características clínico-imagenológicas de los episodios de NAC que requirieron internación. Los objetivos secundarios fueron determinar el rédito diagnóstico de los estudios microbiológicos e identificar las complicaciones. Realizamos un estudio analítico retrospectivo en un hospital de tercer nivel durante el período 2017-2019, en adultos admitidos por NAC, excluyendo embarazadas. Identificamos 340 episodios en 321 pacientes, la mediana de edad fue 75 años (rango intercuartil 57-85). Los factores de riesgo más frecuentes fueron inmunocompromiso (30%), enfermedad neurológica (22%) y enfermedad renal crónica (17%). Según tres scores pronósticos de gravedad, CURB65, qSOFA y PSI/PORT, 216 (63.5%), 290 (85.3%) y 130 (38%) episodios fueron identificados como de bajo riesgo, respectivamente. Del total de los episodios, 49 (14.4%) requirieron internación en unidad de cuidados intensivos, 39 (11.5%) ventilación mecánica y se registraron 30 (8.8%) muertes durante la hospitalización. Los patrones de imagen más frecuentes fueron consolidativo en 134 (39.4%), intersticio-alveolar en 98 (28.8%) y mixto entre ambos patrones en 67 (19.7%) episodios. Identificamos el agente causal en 79 (23.2%) episodios. Los microorganismos aislados más frecuentemente fueron influenza en 37 (10.9%) y Streptococcus pneumoniae en 11 (3.2%). La mayoría de los episodios afectaron pacientes ancianos y el principal patrón radiológico fue el consolidativo. El agente causal se pudo identificar en uno de cada cuatro episodios y el método con mayor rédito diagnóstico fue el test para influenza.

Abstract Community-acquired pneumonia (CAP) represents a major health issue and ~20% of the patients require in-hospital attention. The main objective of the study was to determine clinical-imaging features of CAP episodes requiring hospitalization. The secondary objectives were to determine the diagnostic yield of microbiological analyses and the medical complications. A retrospective analytical study was conducted on adults admitted due to CAP in a third-level hospital in the period 2017-2019. Pregnant women were excluded. A total of 340 CAP episodes were identified in 321 patients; the median age was 75 years old (interquartile range 57-85). The most frequent risk factors were immunocompromise 102 (30%), neurological disease 75 (22%), and chronic kidney disease 58 (17%). According to three prognostic scores, CURB65, qSOFA and PSI/PORT, 216 (63.5%), 290 (83.5%) and 130 (38%) patients were identified as low risk, respectively. A total of 49 (14.4%) episodes required admission at the critical care unit and 39 (11.5%) required mechanical ventilation; 30 patients (8.8%) died during hospitalization. The radiologic patterns most frequently found were consolidation in 134 (39.4%), interstitial-alveolar pattern in 98 (28.8%), and the combination of both patterns in 67 (19.7%) episodes. Identification of the causal agent was achieved in 79 (23.2%) episodes. The most frequently isolated microorganisms were influenza virus in 37 (10.9%) episodes and Streptococcus pneumoniae in 11 (3.2%). Most of the hospitalized CAP patients were elderly with consolidative radiological patterns. The causal agent could be identified in less than a quarter of the patients, with the influenza test being the method with the highest diagnostic yield.

Frecuencia de Streptococcus pneumoniae aislados de enfermedad invasiva en Paraguay, serotipos y perfil de sensibilidad (2010-2018) / Frequency of Streptococcus pneumoniae isolated from invasive disease in Paraguay, serotypes and sensitivity profile (2010-2018)

Streptococcus pneumoniae sigue siendo una de las causas más importantes de morbilidad y mortalidad en niños y adultos alrededor del mundo. El objetivo del estudio fue describir la frecuencia de aislamiento de S. pneumoniae en enfermedad invasiva, distribución de serotipos y sensibilidad antimicrobiana en Paraguay (2010-2018). Se estudiaron 793 cepas de S. pneumoniae aisladas de pacientes de todas las edades con enfermedad invasiva en Paraguay, provenientes de los diferentes centros centinelas y colaboradores en el marco de la vigilancia de meningitis y neumonías, durante el periodo 2010-2018. La frecuencia general según diagnóstico resultó 74.9% de neumonías (n=594), 18.4% de meningitis (n=146) y 6.7% de sepsis (n=53). El serotipo 14 fue más frecuente con 174 aislamientos (22.0%), seguido del serotipo 19A con 84 aislamientos (10.6%), el serotipo 3 con 66 aislamientos (8.3%) y el 6A con 37 aislamientos (4.7%). En meningitis se registró una frecuencia general de resistencia a penicilina del 32,2% y de ceftriaxona del 1,4%. En los casos de no meningitis la resistencia a penicilina fue del 0,8% y ceftriaxona del 0,3%. Los resultados de serotipos y sensibilidad antimicrobiana proporcionarán información necesaria para la implementación de estrategias de prevención y tratamiento de la enfermedad neumocócica en nuestro país, por lo que es necesaria una vigilancia continua para evaluar la carga de enfermedad, los serotipos circulantes y el aumento de la resistencia a los antibióticos

Streptococcus pneumoniae remains one of the most important causes of morbidity and mortality in children and adults worldwide. The objective of the study was to describe the frequency of isolation of S. pneumoniae in invasive disease, serotype distribution and antimicrobial susceptibility in Paraguay (2010-2018). We studied 793 strains of S. pneumoniae isolated from patients of all ages with invasive disease in Paraguay, from different sentinel centers and collaborators in the framework of meningitis and pneumonia surveillance during the period 2010-2018. The general frequency according to diagnosis was 74.9% of pneumonia (n = 594), 18.4% of meningitis (n = 146) and 6.7% of sepsis (n = 53). Serotype 14 was more frequent with 174 isolates (22.0%), followed by serotype 19A with 84 isolates (10.6%), serotype 3 with 66 isolates (8.3%) and 6A with 37 isolates (4.70%). In meningitis, there was a general frequency of penicillin resistance of 32.2% and ceftriaxone of 1.4%. In cases of non-meningitis, penicillin resistance was 0.8% and ceftriaxone 0.3%. The results of serotypes and antimicrobial sensitivity will provide necessary information for the implementation of prevention strategies and treatment of pneumococcal disease in our country, therefore it is necessary to continue monitoring in order to assess the burden of the disease, circulating serotypes and increased antibiotic resistance

Hemolytic uremic syndrome associated with streptococcus pneumoniae in pediatrics: a case series / Síndrome hemolítico-urêmica associada com streptococcus pneumoniae em pediatria: série de casos

ABSTRACT Objective: To describe a case series of four (4) patients with hemolytic uremic syndrome due to Streptococcus pneumoniae in a level four complexity institution in the city of Bogotá, D.C., Colombia. Cases description: We describe cases of four patients who presented respiratory symptoms and fever. All four patients were in regular conditions on hospital admission, after which they required intensive care and ventilatory support. Upon admission, three cases showed evidence of pleuropulmonary complication. Penicillin-sensitive Streptococcus pneumoniae was isolated in all cases. All patients presented anemia, severe thrombocytopenia, schistocytes on peripheral blood smear, and hyperazotemia. They required blood transfusion and renal replacement therapy during their hospitalization. The patients were diagnosed with hemolytic uremic syndrome due to S. pneumoniae. Three of the four patients had a progressive recovery of the renal function and were discharged after an average of 36 days of hospital stay. The remaining patient had two amputations in the extremities due to thrombotic vascular complications and was discharged after 99 days of hospital stay, requiring hemodialysis every other day. Comments: Hemolytic uremic syndrome due to Streptococcus pneumoniae is a rare but severe complication of invasive pneumococcal disease. Complicated pneumonia is the main condition associated with this entity. It is noteworthy the short period in which these cases were presented, considering the low annual incidence of the disease.

RESUMO Objetivo: Descrever uma série de casos de quatro pacientes com síndrome hemolítico-urêmica por pneumococo em uma instituição de referência em Bogotá, Colômbia. Descrição dos casos: Descrevemos os casos de quatro pacientes que apresentaram sintomas respiratórios e febre. Todos estavam em estado geral regular à admissão hospitalar e necessitaram de cuidados intensivos e suporte ventilatório. Na admissão, em três dos casos foi evidenciada a complicação pleuropulmonar. Isolamento de Streptococcus pneumoniae sensível à penicilina foi realizado em todos os casos. Os quatro pacientes precisaram de transfusão sanguínea e terapia de reposição renal durante a hospitalização. Nos testes laboratoriais, observou-se anemia, trombocitopenia grave, presença de esquizócitos em esfregaço de sangue periférico e hiperazotemia. Com esse quadro, o diagnóstico foi de síndrome hemolítico-urêmica associada à infecção por S. pneumoniae. Houve recuperação progressiva da função renal em três dos quatro pacientes, que tiveram alta após 36 dias de internação hospitalar, em média. Um paciente teve complicações vasculares trombóticas, resultando em duas amputações nas extremidades, e teve alta após 99 dias de internação, com necessidade de hemodiálise em dias alternados. Comentários: A síndrome hemolítico-urêmica por Streptococcus pneumoniae é uma complicação rara, mas grave, da doença invasiva pneumocócica. A pneumonia complicada é a principal condição associada a essa entidade. Destaca-se o curto período em que esses casos foram apresentados, levando em conta a baixa incidência anual de síndrome hemolítico-urêmica.

Estudio Observacional: Uso de Antimicrobianos en la Unidad de Cuidados Intensivos del Hospital SOLCA Guayaquil-Ecuador Publicaciones del Proyecto de Optimización de Uso de Antibióticos en Latinoamérica (PROA) / Observational Study: Use of Antimicrobials in the Intensive Care Unit of the SOLCA-Guayaquil Hospital

Introducción: Los programas de optimización del uso de antimicrobianos (PROA) surgen ante la necesidad de disminuir el porcentaje de infecciones por microorganismos resistentes a los antimicrobianos, lo cual beneficiaria con mejores resultados clínicos, disminuyendo efectos adversos y reduciendo el gasto que involucra el uso de los mismos. Este programa se implementó en la unidad de cuidados intensivos del hospital oncológico SOLCA Guayaquil, durante un año. Es objetivo del presente estudiofueestablecer la tasa de uso de antimicrobianos en una Unidad de Cuidados Intensivos(UCI) el porcentaje de descalamiento y la epidemiología de las infecciones en UCI. Métodos: En este estudio observacional prospectivo, con muestra no probabilística se incluyeron todos los casos ingresados en la UCIdel Instituto Oncológico Nacional Dr. Juan Tanca Marengo de la ciudad de Guayaquil, en el período julio 2018 a junio 2019. Las variablesfueron prevalencia del uso de antibióticos, tipo de antibiótico usado, descalamiento de antibioterapia, adherencia del personal a las guías clínicas y dosis diarias definidas (DDD) y el índice días-paciente mes por área de internación. Resultados: Se incluyeron 246 pacientes; el 81% se encontraba recibiendo antibióticos, con un máximo de dos antibióticos por paciente; la profilaxis quirúrgica se mantuvo dentro de las primeras 24 horas en el 50% de la veces y el 25.66% la recibió por un periodo mayor a 24 horas; 57.25% tuvo un decalamiento mantenido, en el 20.75% de tipo escalado y el13.66% de tipo descalado. Entre los patógenos aislados están las enterobacterias productoras de beta lactamasas de espectro extendido positivas (BLEE+) con un 57% y las enterobacterias resistentes a los carbapenémicos con un 32%. El mayor consumo fue de carbapenémicos con 625.24g. seguidos de los inhibidores de betalactamasas con 402.94 g. La tasa de tratamientos empíricos del 49.58% vs el 26.41% de tratamientos dirigidos; y mortalidad bruta del 22.76%. Conclusión:La tasa de uso de antibióticos en UCI es alta, el porcentaje de descalamiento fue aceptable comparada con las tasas reportadas regionalmente, la epidemiología de gérmenes reportados más frecuentes son las enterobacterias productoras de beta lactamasa espectro extendido.

Introduction: Antimicrobial use optimization programs (PROA) arise due to the need to decrease the percentage of infections by antimicrobial resistant microorganisms, which would benefit from better clinical results, reducing adverse effects and reducing the expense involved in the use of the same. This program was implemented in the intensive care unit of the SOLCA Guayaquil cancer hospital for one year. The objective of the present study was to establish the rate of use of antimicrobials in an Intensive Care Unit (ICU), the percentage of descaling and the epidemiology of infections in the ICU. Methods:In this prospective observational study, with a non-probability sample, all the cases admitted to the ICU of the Dr. Juan Tanca Marengo National Oncological Institute in the city of Guayaquil, in the period July 2018 to June 2019 were included. The variables were prevalence of the antibiotic use, type of antibiotic used, antibiotics displacement, staff adherence to clinical guidelines and defined daily doses (DDD) and the patient-day-month index by hospitalization area. Results:246 patients were included; 81% were receiving antibiotics, with a maximum of two antibiotics per patient; Surgical prophylaxis was maintained within the first 24 hours 50% of the time and 25.66% received it for a period greater than 24 hours; 57.25% had a sustained offset, in 20.75% the scaled type and 13.66% the bare type. Isolated pathogens include 57% positive extended spectrum beta lactamase-producing enterobacteriaceae (ESBL +) and 32% carbapenem-resistant enterobacteriaceae. The highest consumption was of carbapenems with 625.24 g. followed by beta-lactamase inhibitors with 402.94 g. The empirical treatment rate of 49.58% vs. 26.41% of targeted treatments; and gross mortality of 22.76%. Conclusion:The rate of use of antibiotics in the ICU is high, the percentage of descaling was acceptable compared to the rates reported regionally, the epidemiology of the most frequent reported germs are the extended spectrum beta lactamase-producing enterobacteriaceae.

Clinical and microbiological characteristics of community-acquired pneumonia associated with Streptococcus pneumoniae in adult patients in Mexico / Características clínicas y microbiológicas de la neumonía adquirida en la comunidad asociada con Streptococcus pneumoniae en pacientes adultos en México

The aim of this study was to assess the risk factors and clinical and microbiological characteristics of community-acquired pneumonia (CAP) in adult patients in Mexico. Streptococcus pneumoniae classified as the causative agent of CAP in adult patients and patients with invasive S. pneumoniae isolates presented to three tertiary teaching hospitals during the 15-year study period were selected. Serotyping and susceptibility testing were performed for all included isolates. Clinical and demographic data were recorded. A total of 96 patients infected with S. pneumoniae (71 with CAP, 25 with invasive disease) were included. The CAP group involved more males (74.6%) than the invasive disease group (p = 0.03). Head trauma was more common in the CAP group (21.1%) than in the invasive disease group (4.0%; p = 0.03). The most prevalent serotype was 19A, followed by serotypes 3 and 23F. After the introduction of the heptavalent conjugated pneumococcal vaccine (PCV7), the prevalence of included serotypes declined significantly; no such change was found after the introduction of the PCV13 vaccine, including in the prevalence of serotype 19A. Susceptibility to all antimicrobials tested except vancomycin declined over the study period. In conclusion, head trauma was the most common comorbidity in the CAP group. The most prevalent serotype was 19A. Decreased susceptibility to most antimicrobials tested was observed.

El objetivo de este estudio fue evaluar los factores de riesgo y las características clínicas y microbiológicas de la neumonía adquirida en la comunidad (NAC) en pacientes adultos en México. Se seleccionaron pacientes adultos con NAC con Streptococcus pneumoniae como agente causal y pacientes con aislamientos invasivos de S. pneumoniae que concurrieron a tres hospitales de enseñanza de tercer nivel durante el período de estudio de 15 anos (2000-2015). Se realizaron pruebas de serotipificación y sensibilidad con todos los aislados incluidos. Se colectaron los datos clínicos y demográficos. Se incluyeron en total 96 pacientes infectados con S. pneumoniae (71 con NAC y 25 con enfermedad invasiva). El grupo con NAC incluía más varones (74,6%) que el grupo de enfermedad invasiva (p = 0,03). El traumatismo craneoencefálico fue más frecuente en el grupo NAC (21,1%) queen el grupo con enfermedad invasiva (4,0%; p = 0,03). El serotipo más frecuente fue 19A, seguido de los serotipos 3 y 23F. Después de la introducción de la vacuna antineumocócica conjugada heptavalente (PCV7), la prevalencia de los serotipos incluidos en aquella disminuyó significativamente; no sucedió lo mismo después de la introducción de la PCV13, incluso en relación con la prevalencia del serotipo 19A. La sensibilidad a todos los antimicrobianos evaluados, excepto la vancomicina, disminuyó durante el período de estudio. En conclusión, el traumatismo craneoencefálico fue la comorbilidad más frecuente en el grupo con NAC. El serotipo más frecuente fue el 19A, y se observó disminución de la sensibilidad a la mayoría de los antimicrobianos probados a lo largo del período considerado.

Postinfectious Glomerulonephritis Associated with Pneumococcus and Influenza A Virus Infection in a Child: a Case Report and Literature Review

Postinfectious glomerulonephritis (PIGN) is most commonly caused by Streptococcus pyogenes in children, but PIGN associated with other pathogens has been described in the literature. A previously healthy 6-year-old boy was admitted with complaints of cough, fever, and right chest pain. The patient was diagnosed with pneumococcal bacteremia and influenza A virus infection and treated with antibiotics and antiviral agent. During hospitalization, generalized edema, hematuria, proteinuria, and increased blood pressure were observed; therefore, we started administering diuretics. The boy was discharged with gross hematuria, and even microscopic hematuria disappeared 14 weeks after discharge. We report a case of PIGN associated with bacteremic pneumococcal pneumonia and influenza A virus infection in children. A urine test and blood pressure measurement should be considered for the early detection of PIGN in children with pneumococcal or influenza A virus infection when they present with nephritic symptoms.

Mortalidade e custos da pneumonia pneumocócica em adultos: um estudo transversal / Mortality and costs of pneumococcal pneumonia in adults: a cross-sectional study

RESUMO Objetivo A pneumonia pneumocócica é uma causa significativa de morbimortalidade entre adultos. Desta maneira, o objetivo principal deste estudo foi avaliar a mortalidade intra-hospitalar e os custos relacionados à doença adquirida em adultos. Métodos Este estudo transversal utilizou prontuários de pacientes adultos com pneumonia pneumocócica internados em um hospital universitário no Brasil, de outubro de 2009 a abril de 2017. Todos os pacientes com idade ≥ 18 anos e diagnosticados com pneumonia pneumocócica foram incluídos. Dados como os fatores de risco, a internação em unidade de terapia intensiva, o tempo de internação, a mortalidade hospitalar e os custos diretos e indiretos foram analisados. Resultados No total, 186 pacientes foram selecionados. A taxa média de mortalidade intra-hospitalar foi de 18% para adultos com idade < 65 anos e 23% para os idosos (≥ 65 anos). A pneumonia pneumocócica bacterêmica acometeu 20% dos pacientes em ambos os grupos, principalmente por doença respiratória crônica (OR ajustada: 3,07; IC95%: 1,23‐7,65; p < 0,01). Após levantamento das internações ocorridas no período de sete anos de tratamento, verificou-se que os custos diretos e indiretos totais anuais foram de US$ 28.188 para adultos < 65 anos (US$ 1.746 per capita) e US$ 16.350 para os idosos (US$ 2.119 per capita). Conclusão A pneumonia pneumocócica continua sendo uma importante causa de morbimortalidade entre adultos, afetando significativamente os custos diretos e indiretos. Esses resultados sugerem a necessidade de estratégias de prevenção para todos os adultos, especialmente para pacientes com doenças respiratórias crônicas.

ABSTRACT Objective Pneumococcal pneumonia is a significant cause of morbidity and mortality among adults. The study's main aim was to evaluate the in-hospital mortality and related costs of community-acquired pneumococcal pneumonia in adults. Methods This cross-sectional study used medical records of adult patients with pneumococcal pneumonia hospitalized in a university hospital in Brazil from October 2009 to April 2017. All patients aged ≥ 18 years diagnosed with pneumococcal pneumonia were included. Risk factors, intensive care unit admission, length of hospital stay, in-hospital mortality, and direct and indirect costs were analyzed. Results In total, 186 patients were selected. The mean in-hospital mortality rate was 18% for adults aged < 65 years and 23% for the elderly (≥ 65 years). Bacteremic pneumococcal pneumonia affected 20% of patients in both groups, mainly through chronic respiratory disease (adjusted OR: 3.07, 95% CI: 1.23-7.65, p < 0.01). Over 7 years, annual total direct and indirect costs were USD 28,188 for adults < 65 years (USD 1,746 per capita) and USD 16,350 for the elderly (USD 2,119 per capita). Conclusion Pneumococcal pneumonia remains an important cause of morbidity and mortality among adults, significantly affecting direct and indirect costs. These results suggest the need for prevention strategies for all adults, especially for patients with chronic respiratory diseases.

Neumonía neumocócica bacteriémica en adultos en hospital regional de Chile / Bacteremic pneumococcal pneumonia in adults admitted to a general hospital: experience in 60 cases

Background: Bacteremic pneumococcal pneumonia (BPP) is a preventable disease with high morbimortality. Aim: To evaluate clinical aspects and mortality on BPP patients admitted to a Chilean regional hospital. Patients and Methods: We looked for adult patients with Streptococcus pneumoniae isolated from blood cultures between 2010 and 2014 years and reviewed clinical records of those who were admitted with pneumonia. Results: We identified 70 BPP patients: 58% were men, mean age was 56 years, 30% were > 65 years, 70% with basic public health insurance, 26% were alcoholics, 86% had comorbidities. Only two patients were vaccinated against S. pneumoniae. CURB-65 severity index for community acquired pneumonia was > 3 in 37% of patients. Twenty-four patients were admitted to ICU, twenty required mechanical ventilation and twenty-four died (34%). Mortality was associated with an age over 65 years, presence of comorbidities and complications of pneumonia. A total of 22 serotypes of S. pneumoniae were identified, five of them (1,3,7F,14 y 9V) were present in 57% of cases. Conclusions: Elevated mortality of our BNN patients was associated with comorbidities and possibly with socio economic factors, which conditioned a late access to medical care.

Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

The changes of prevalence and etiology of pediatric pneumonia from National Emergency Department Information System in Korea, between 2007 and 2014 / 소아과

PURPOSE: Understanding changes in pathogen and pneumonia prevalence among pediatric pneumonia patients is important for the prevention of infectious diseases. METHODS: We retrospectively analyzed data of children younger than 18 years diagnosed with pneumonia at 117 Emergency Departments in Korea between 2007 and 2014. RESULTS: Over the study period, 329,380 pediatric cases of pneumonia were identified. The most frequent age group was 1–3 years old (48.6%) and the next was less than 12 months of age (17.4%). Based on International Classification of Diseases, 10th revision diagnostic codes, confirmed cases of viral pneumonia comprised 8.4% of all cases, pneumonia due to Mycoplasma pneumoniae comprised 3.8% and confirmed cases of bacterial pneumonia 1.3%. The prevalence of confirmed bacterial pneumonia decreased from 3.07% in 2007 and 4.01% in 2008 to 0.65% in 2014. The yearly rate of pneumococcal pneumonia also decreased from 0.47% in 2007 to 0.08% in 2014. A periodic prevalence of M. pneumoniae pneumonia (MP) was identified. CONCLUSION: The increased number of patients with pneumonia, bacterial pneumonia, pleural effusion, and empyema in 2011 and 2013–2014 resulted from an MP epidemic. We provide evidence that the frequency of confirmed cases of bacterial pneumonia and pneumococcal pneumonia has declined from 2007 to 2014, which can simultaneously reflect the effectiveness of the pneumococcal conjugate vaccine.

Síndrome de Austrian: reporte de caso / Austrian syndrome: report of one case

Austrian syndrome is a triad characterized by pneumonia, meningitis and endocarditis, as a result of a Streptococcus pneumoniae bacteremia. We report a previously healthy 49 year-old male, who consulted at the emergency care unit with a history of one week of pleuritic pain, fever leading to an altered level of consciousness and seizures. A diagnosis of community-acquired pneumonia and meningitis was reached, isolating Streptococcus pneumoniae in the cerebrospinal fluid and blood cultures. Antibiotic treatment was started but the patient had an unsatisfactory response. During hospitalization a new heart murmur was found in the physical examination. An echocardiography was performed and a massive aortic valve insufficiency was found along with vegetations and a perforation of the same valve. The valve was replaced by a prosthetic one and the patient responded satisfactorily to the surgical and antibiotic treatment, without complications.

Uso de la Escala Clínica de Infección Pulmonar para valorar pacientes con ventilación mecánica asistida / Use of the Clinical Pulmonary Infection Score to patients with mechanical ventilation

AbstractIntroduction: Ventilator-associated pneumonia (VAP) is a lung infection that occurs 48 hours or more after endotracheal intubation in patients undergoing mechanical ventilation.Objective: To use the Clinical Pulmonary Infection Score (CPIS) in order to identify the presence of VAP in patients with endotracheal intubation.Methods: Descriptive, cross-sectional study, which included 53 patients with mechanical ventilation, out of which only 11 met the selection criteria. Patients were assessed with the CPIS, as well as with their results of blood count, chest X-ray, and culture of endotracheal aspirates.Results: 81.9% were male, with a mean age of 65.09 ± 13.4 years, weight 75.7 ± 13.5 kg, height 1.61 ± 0.21 cm. The main cause of mechanical ventilation was neurological in 36.4%, and pulmonary in 27.3%. Of all the microorganisms isolated, the one with the highest estimated rate was Pseudomonas aeruginosa. Enterobacter cloacae and Pseudomonas aeruginosa showed drug resistance to all antibiotics.Conclusion: The use of the scale for evaluating patients with mechanical ventilation helps to identify the presence of ventilator-associated pneumonia.

Hospitalizaciones por neumonía adquirida en la comunidad / Hospitalizations for community-acquired pneumonia

Introducción: Streptoccocus pneumoniae es la causa más frecuente de neumonía bacteriana adquirida en la comunidad en la edad pediátrica. Objetivo: estimar la proporción de casos hospitalizados y defunciones por neumonía, así como describir la utilización de servicios de atención al paciente grave en niños con neumonía y sepsis. Métodos: se realizó un estudio retrospectivo de series de casos de niños entre 1 mes a 18 años, 2002-2013, así como datos de ingreso por neumonía (confirmada radiológicamente) y sepsis, en la Unidad de Terapia Intensiva 2011-2013, del Hospital Pediátrico Centro Habana. Resultados: se registraron un total de 5 672 ingresos por neumonía, para una media de 469 casos anuales, más frecuente en varones (53,2 por ciento) y niños entre 1 a 4 años (55,1 por ciento). Se registraron 14 fallecidos (0,25 por ciento del total), de los cuales 9 fueron del sexo masculino (64,3 por ciento). Entre 2011-2013, el 6 a 9 por ciento de los niños con neumonía requirieron ingreso en unidades de atención al grave, con predominio también de preescolares. Conclusiones: los datos obtenidos pueden aportar evidencia indirecta de la magnitud de la enfermedad neumocócica en un hospital pediátrico(AU)

Introduction: Streptococcus pneumoniae is the most common cause of community-acquired bacterial pneumonia at pediatric ages. Objective: to estimate the ratio of hospitalized cases and deaths of pneumonia as well as to describe the use of services to severely-ill patients in children with pneumonia and sepsis. Methods: retrospective case-series study performed in children aged one to 18 years from 2002 to 2013 and of hospitalization data for pneumonia (X ray-confirmed) and sepsis in the intensive care unit from 2011 to 2013 in Centro Habana pediatric hospital. Results: a total number of 5 672 admissions for pneumonia were registered, for a mean of 469 cases yearly, more frequent in males (53.2 percent) and children aged one to four years (55.1 percent). There were 14 deaths (0.25 percent of total number) and nine of them were males (64.3 percent). From 2011 to 2013, six to nine percent of children with pneumonia required admission to the severely-ill patient care unit with predominance of pre-school children. Conclusions: the collected data may provide indirect evidence for analysis of the magnitude of pneumococcal disease in a pediatric hospital(AU)

Impact of the pneumococcal 10-valent vaccine on reducing hospitalization for community-acquired pneumonia in children / Impacto da vacina antipneumocócica 10-valente na redução de hospitalização por pneumonia adquirida na comunidade em crianças

Abstract Objective: To describe and analyze the occurrence of hospitalizations for community-acquired pneumonia in children before and after the pneumococcal 10-valent conjugate vaccine implementation into the National Immunization Program. Methods: This is an ecological study that includes records of children younger than one year old, vaccinated and not vaccinated with the pneumococcal 10-valent conjugate vaccine in the periods pre- and post-inclusion of the vaccine in the National Immunization Program in the area covered by the Regional Health Superintendence of Alfenas, state of Minas Gerais, Brazil. Vaccination was considered as the exposure factor and hospitalization for community-acquired pneumonia as the endpoint, using secondary annual data by municipality. The prevalence ratio and its 95% confidence interval (95%CI) were used to verify the association between variables. The Z test was used to calculate the difference between proportions. Results: Considering the 26 municipalities of the Regional Health Superintendence of Alfenas, there was a significant reduction in hospitalizations for community-acquired pneumonia in children younger than one year of age, with prevalence ratio (PR)=0.81 (95%CI: 0.74-0.89; p<0.05), indicating a 19% lower prevalence of hospitalization for community-acquired pneumonia in the post-vaccination period. Conclusions: The results suggest the effectiveness of the pneumococcal 10-valent conjugate vaccine in preventing severe cases of community-acquired pneumonia in children younger than one year of age.

Resumo Objetivo: Descrever e analisar a ocorrência de internações por pneumonia adquirida na comunidade em crianças antes e após a implantação, no Programa Nacional de Imunização, da vacina pneumocócica 10-valente (conjugada). Métodos: Trata-se de um estudo ecológico que incluiu registros de crianças menores de um ano, vacinadas e não vacinadas com a vacina antipneumocócica 10-valente conjugada, no período pré e pós-inclusão da vacina no Programa Nacional de Imunização na área de abrangência da Superintendência Regional de Saúde de Alfenas, MG, Brasil. A vacinação foi considerada como fator de exposição e a hospitalização por pneumonia adquirida na comunidade como desfecho, com o uso de dados anuais secundários por município. Para verificar a associação entre as variáveis foi empregada a razão de prevalência e seu intervalo de confiança 95% (IC95%). Para o cálculo de diferença entre proporções empregou-se o teste Z. Resultados: Considerando os 26 municípios da Superintendência Regional de Saúde de Alfenas, houve redução significativa do número de hospitalização por pneumonia adquirida na comunidade em crianças abaixo de um ano, com razão de prevalência (RP)=0,81 (IC95% 0,74-0,89; p<0,05), o que indica uma prevalência de internação por pneumonia adquirida na comunidade 19% menor no período pós-vacinal. Conclusões: Os resultados sugerem a efetividade da vacina pneumocócica 10-valente (conjugada) na prevenção de casos graves da pneumonia adquirida na comunidade em crianças menores de um ano.