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.

Distribution and Characterization of Airborne Respiratory Pathogens in Public Facilities

Respiratory infections, which are caused by airborne pathogens, are the most common disease of all ages worldwide. This study was conducted to characterize the airborne respiratory pathogens in the public facilities in Busan, South Korea. A total of 260 public facilities were investigated in 2017, 52 seasonal indoor air from 2 hospitals and 208 indoor air samples from 208 randomly selected daycare centers. Among respiratory pathogen, 8 viral pathogens including human adenovirus (HAdV), human bocavirus (HBoV), human rhinovirus (HRV), human parainfluenza virus (HPIV), human respiratory syncytial virus (HRSV), human metapneumovirus (HMPV), human coronavirus (HCoV) and influenza virus (IFV), and 3 bacterial pathogens including Mycoplasma pneumoniae, Bordetella pertussis, and Chlamydophila pneumoniae, were investigated by multiplex real-time reverse transcription polymerase chain reaction. Pathogens were detected in 9 cases (3.4%). Among 9 positive samples, 6 (2.3%) cases were positive for HBoV and 3 (1.2%) cases were positive for IFV. All the positive cases were detected in daycare centers. Additionally, the concentration of HBoV was determined. In HBoV-positive samples, the cycle threshold (Ct) values of HBoV were 29.73~36.84, which are corresponding to the viral concentration of 4.91 × 10⁰ ~ 9.57 × 10² copies/ml. Serotype distribution of isolated HBoV was analyzed by sequencing of VP1/VP2 gene. All of the HBoV isolates were identified as HBoV type 1 with a high similarity among the isolates (>97%). No bacterial pathogen was identified in indoor air samples. Although virus concentration was not high in public facilities (daycare center), the presence of respiratory viral pathogens has been identified. Effective ventilation and air purification strategies are needed to reduce the indoor concentration of respiratory pathogens. A long-term and ongoing surveillance plan for respiratory pathogen management should be established.

Evaluation of EuDx™-PN MLC Detection Kit for Detection of Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila in Respiratory Specimens / 대한임상미생물학회지

BACKGROUND: Infection by the intracellular bacteria Mycoplasma pneumoniae, Chamydophila pneumoniae, and Legionella pneumophila are common causes of community-acquired pneumonia (CAP). This study describes the evaluation of a new multiplex real-time PCR test, EuDx™-PN MLC Detection Kit (EUDIPIA), which allows the simultaneous detection of M. pneumoniae, C. pneumoniae, and L. pneumophila in respiratory samples. METHODS: A total of 353 samples were tested using three PCR kits: multiplex PCR (Seeplex PneumoBacter ACE Detection Kit) and two multiplex real-time PCR (EuDx™-PN MLC Detection Kit and Anyplex™ II RB5 Detection Kit). The results were considered true positives (expanded standard) for M. pneumoniae, C. pneumoniae, and L. pneumophila if they were positive according to any of the three tests. RESULTS: The sensitivity and specificity of EuDx™-PN MLC Detection Kit were 93.3–100% and 100%, respectively. The agreement rate and Cohen's kappa coefficient (value) between EuDx™-PN MLC Detection Kit and Anyplex™ II RB5 Detection Kit for M. pneumoniae, C. pneumoniae, and L. pneumophila were 70–100% and 0.82–1, respectively. CONCLUSION: These results demonstrate that the EuDx™-PN MLC Detection Kit is a sensitive, specific, and useful screening tool for the detection of atypical pathogens in respiratory samples and can be helpful in selecting appropriate antimicrobial therapy for patients with respiratory infection.

Chlamydia trachomatis: um importante agente de infecções respiratórias em lactentes de famílias de baixa renda / Chlamydia trachomatis: a major agent of respiratory infections in infants from low-income families

OBJETIVOS: Determinar a prevalência de infecção do trato respiratório inferior (ITRI) por Chlamydia trachomatis em lactentes internados e descrever as características clínicas, laboratoriais e radiológicas da doença. MÉTODOS: Este foi um estudo do tipo corte transversal, realizado durante um período de 12 meses. Foram incluídos todos os lactentes de até 6 meses internados consecutivamente no Centro Pediátrico Professor Hosannah de Oliveira da Universidade Federal da Bahia, em Salvador, BA, com diagnóstico clínico ou clínico-radiológico de ITRI. O diagnóstico de infecção por C. trachomatis foi realizado através da pesquisa de anticorpos da classe IgM, utilizando-se o ensaio imunoenzimático (ELISA). A prevalência de ITRI por C. trachomatis foi determinada, e foram calculadas as razões de prevalência para essa infecção e variáveis clínicas e laboratoriais. RESULTADOS: Cento e cinquenta e um lactentes realizaram sorologia para C. trachomatis, das quais 15 (9,9%) foram positivas. A infecção por C. trachomatis ocorreu unicamente entre os menores de 5 meses, principalmente naqueles menores de 2 meses. Três crianças com infecção por C. trachomatis nasceram de parto cesáreo. Conjuntivite e eosinofilia ocorreram em 33,3% dos casos. As radiografias de tórax se mostraram alteradas em 92% dos casos. Demonstrou-se associação da infecção por C. trachomatis com duração de internação superior a 15 dias (p = 0,0398) e com oxigenoterapia (p = 0,0484). CONCLUSÕES: Houve alta prevalência de ITRI por C. trachomatis na população estudada. A infecção por esta bactéria foi associada a uma forma mais grave da doença, demonstrando a importância de se investigar essa infecção na gestante de forma a evitar o adoecimento de recém-nascidos.

OBJECTIVES: To determine the prevalence of lower respiratory tract infection (LRTI) due to Chlamydia trachomatis in newborn infants and to describe the clinical, laboratory, and radiological characteristics of the disease. METHODS: A cross-sectional study carried out over a 12-month period. All infants up to 6 months of age admitted consecutively at the Centro Pediátrico Professor Hosannah de Oliveira of the Universidade Federal da Bahia in Salvador, Brazil, and diagnosed with LRTI according to clinical and/or radiological criteria were included in the study. C. trachomatis infection was diagnosed by the enzyme-linked immunosorbent assay (ELISA) for the detection of IgM-class antibodies. The prevalence of LRTI by C. trachomatis was determined and the prevalence ratios for the infection and clinical or laboratory variables were calculated. RESULTS: One hundred and fifty-one infants were submitted to serology for C. trachomatis and 15 (9.9%) tested positive. Chlamydial infection was found only in infants under 5 months of age, mainly in those aged under 2 months. Three of the infants with C. trachomatis infection were born by cesarean section. Conjunctivitis and eosinophilia had occurred in 33.3% of the cases. Chest X rays were abnormal in 92.0% of cases. There was an association between C. trachomatis infection and the duration of hospitalization exceeding 15 days (p = 0.0398) and oxygen therapy (p = 0.0484). CONCLUSIONS: There was a high prevalence of C. trachomatis respiratory infection in the population studied. The infection was associated with a more severe form of the disease, emphasizing the importance of testing pregnant women for this infection to avoid infection in the newborn infant.

Comparison of Sputum and Nasopharyngeal Aspirates for Molecular Detection of Community-Acquired Pneumonia Pathogens / 임상검사와정도관리

BACKGROUND: Community-acquired pneumonia (CAP) is a leading cause of infectious diseases and mortality. CAP is primarily treated by administration of adequate antibiotics against the causative pathogens. Because detection of some pathogens by the conventional culture method is difficult, the use of molecular diagnostic methods is increasing. Although an optimal specimen type is very important for proper testing, there is no consensus on the optimal specimen type for detecting CAP pathogens. In this study, we compared sputum specimens and nasopharyngeal aspirates (NPAs) for molecular detection of 4 CAP-causing bacterial species. METHODS: From September 2011 to January 2012, we collected sputum specimens and NPAs from CAP patients on the first or second day of hospitalization. The specimens were tested for Mycoplasma pneumoniae, Streptococcus pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila by using commercial real-time PCR. RESULTS: We collected 63 sputum specimens and 96 NPAs from 109 patients and found positive results for 38.1% (24/63) and 28.1% (27/96), respectively (P = 0.251). There were no significant differences in the positive rates obtained for sputum specimens of different quality. CONCLUSIONS: The results obtained using NPAs and sputum specimens for the molecular detection of CAP pathogens were comparable.

Mycoplasma pneumoniae Pneumonia Unresponsive to Macrolide Treatment

We present a case of community-acquired pneumonia (CAP) that developed in a previously healthy young woman. She was diagnosed with Mycoplasma pneumoniae pneumonia, but did not respond to macrolide treatment. The pathogens of CAP was examined using chest radiographs, computed tomography, and various laboratory tests including Mycoplasma IgG and IgM antibodies, blood and sputum cultures, and PCR for M. pneumoniae, Legionella pneumophila, and Chlamydophila pneumoniae. In this study, differential diagnosis of the pathogens and analysis of the mechanisms underlying their resistance to macrolide treatment were performed, and the results were discussed. After changing the antimicrobial to quinolone, the patients' clinical symptoms and radiographic findings improved, and she was discharged after 8 days.

Chlamydophila pneumoniae enhances secretion of VEGF, TGF-beta and TIMP-1 from human bronchial epithelial cells under Th2 dominant microenvironment

PURPOSE: Chlamydophila pneumoniae infection in the airways is thought to be associated with the pathogenesis of asthma, especially in non-atopic severe asthma with irreversible airway obstruction that may be related to airway remodeling. Here, we investigated whether C. pneumoniae infection enhances the secretion of critical chemical mediators for airway remodeling, such as VEGF, TGF-beta, and TIMP-1, in human bronchial epithelial cells (BECs) in a Th2-dominant microenvironment. METHODS: Human bronchial epithelial cells (BEAS-2B cells) were infected with C. pneumoniae strain TW183 and cultured in both a Th1-dominant microenvironment with INF-gamma and a Th2-dominant microenvironment with IL-4 or IL-13 added to the culture medium. The VEGF, TGF-beta, and TIMP-1 levels in the culture supernatants were measured using enzyme-linked immunosorbent assays (ELISA). The activation of NF-kappaB in each experimental condition was determined using an electrophoretic mobility shift assay. RESULTS: Chlamydophila pneumoniae-infected BECs showed enhanced secretion of VEGF, TGF-beta, and TIMP-1 compared with non-infected BECs. The levels of cytokines secreted from BECs were increased more when IL-13 was added to the culture medium. C. pneumoniae-infected BECs also showed increased NF-kappaB activation. CONCLUSIONS: These results suggest that C. pneumoniae plays a role in the pathogenesis of airway remodeling in asthma, revealing a Th2-dominant immune response. Further studies are required to clarify the precise mechanism of C. pneumoniae infection in airway remodeling.

Comparison of Collagen-coated Polyethylene Terephthalate Disc Plate and Shell Vial Culture Method for the Isolation of Chlamydophila pneumoniae / 대한임상미생물학회지

BACKGROUND: Chlamydophila pneumoniae is one of the major respiratory infectious pathogens and can be accurately diagnosed by cell culturing. The author performed this study to compare the usefulness of the collagen-coated polyethylene terephthalate (PET) disc culture method and that of the shell vial method. METHODS: Twenty-nine sputums and 17 blood specimens collected from 46 patients for C. pneumoniae culture were inoculated into HeLa-229 cell monolayers cultured in shell vials and polyester plates. After incubation, they were stained using the indirect immunofluorescent method with genus-specific FITC-conjugated anti-chlamydia antibody. When both results were inconsistent, microimmunofluorescence results were used. RESULTS: HeLa-229 cells successfully formed monolayers in shell vials and collagen-coated PET plates in all cases. Positive inclusion bodies in HeLa-229 cells of shell vials and PET plates for C. pneumoniae culture were similarly stained with the indirect immunofluorescent method. Both methods showed consistent results with 20 positive and 22 negative cases. The total agreement between the PET plate and shell vial was excellent (91.3%, k=0.826). CONCLUSION: The collagen-coated PET disc culture method showed highly consistent results with that of the shell vial method, and no technical differences were experienced between the two methods. Therefore, the author concluded that the shell vial method could be replaced by the PET plate method for detection of C. pneumoniae.

Clinical Evaluation of the Multiplex PCR Assay for the Detection of Bacterial Pathogens in Respiratory Specimens from Patients with Pneumonia / 대한임상미생물학회지

BACKGROUND: Community-acquired pneumonia (CAP) is a major infectious disease with significant morbidity and mortality worldwide. Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila, and Bordetella pertussis are common pathogens of CAP; however, the conventional methods used to detect these agents, including culturing, lack sensitivity and are time-consuming. We evaluated a recently developed multiplex PCR assay which can test these agents simultaneously. METHODS: One hundred patients with pneumonia and 99 healthy adults were tested using the Seeplex Pneumobacter ACE Detection assay (Seegene, Inc., Seoul, Korea). Culture and urinary antigen tests were also performed. RESULTS: In patients with pneumonia, the positive detection rates of PCR for S. pneumoniae and H. influenzae were 52.0% (52/100) and 30.0% (30/100), respectively, those of M. pneumoniae and L. pneumophila were 2.0% (2/100) and 1.0% (1/100), respectively, and B. pertussis and C. pneumoniae were not detected. In healthy adults, the detection rates of S. pneumoniae and H. influenzae revealed similar results, 53.5% (53/101) and 40.4% (40/101), respectively, and the other four pathogens were not detected. The sensitivity and specificity of PCR for S. pneumoniae in pneumonia patients were 100% (95% confidence interval [CI], 87.9~100%) and 65.7% (95% CI, 55.2~76.5%), respectively, according to the urinary antigen test and cultures of the respiratory samples and blood. CONCLUSION: Differentiating S. pneumoniae and H. influenzae colonization from infection was difficult using the PCR assay. Therefore, the use of this assay is inappropriate for the diagnosis of pneumonia due to these agents, although multiplex PCR assay would be useful for the detection of M. pneumoniae and L. pneumophila.

Development of Protein Chip for Diagnosis of Chlamydophia Pneumoniae / 결핵및호흡기질환

BACKGROUND: The diagnosis of chlamydial infection is based on serology. The current gold standard of diagnosis is MIF(microimmunofluorescence), but this modality is subjective and time-consuming. Protein microarray with using a SPR(surface plasmon resonance) sensor has recently been suggested as a method for detecting infection. For developing a protein chip to diagnose chlamydial infection, EBs(elementary bodies) were immobilized on a gold chip and the interaction between an antibody for Chlamydophila pneumoniae and the EBs(elementary bodies) immobilized on the surface of the gold chip was measured by using an SPR sensor. METHODS: For the surface antigen, the EBs of Chlamydophila pneumoniae LKK1 were purified. Charged arrays were prepared by using PDDA(polydiallyldimethylammonium chloride) which has a positive charge. After immobilization of the chlamydial EBs on the PDDA surface, the investigation of the surface was done with using atomic force microscopy. After the antibody for C. pneumoniae was applied on chip, we monitored the SPR wavelength-shift to detect any antigen-antibody interaction with using a self-assembled SPR sensor. RESULTS: The chlamydial EBs on the positively charged PDDA were visible on the surface with using atomic force microscopy. The SPR wavelength increased after interaction of antibody for C. pneumoniae with the EBs immobilized on charged gold surface. The wavelength-shift was correlated with the concentration of antigens. CONCLUSION: The surface immobilization of EBs on the gold surface with the charged arrays was identified and the antigen-antibody interaction on the gold chip was detected via the SPR sensor. Further investigations are needed to apply this technique to the clinical field.

Association of Myocardial Infarction and Chlamydophila pneumoniae Infection / 대한임상미생물학회지

BACKGROUND: Although there are growing evidences linking Chlamydophila pneumoniae infection to myocardial infarction, it remains controversial. The authors intended to assess whether C. pneumoniae infection is associated with myocardial infarction. METHODS: Sera and peripheral mononuclear cells (PMNCs) were collected from 54 cases of acute myocardial infarction (MI), 33 cases of old MI, and 60 normal controls. Anti-C.pneumoniae IgG and IgM antibodies were measured using a microimmunofluorescence (mIF) method, and C.pneumoniae DNA was detected using polymerase chain reaction (PCR). RESULTS: Seropositivity of anti-C.pneumoniae IgM antibody by mIF was shown 5.0% in control group, 29.6% (OR=8.00) in the acute MI and 6.1% (OR=1.23) in old MI group. Seropositivity of anti C.pneumoniae IgG antibody were 60.0 % in control group, 92.6% (OR=8.33) in the acute MI and 87.9% (OR= 4.83) in old MI group. The antibody titers in the acute MI and old MI group tended to be higher compared to those in control group. No C.pneumoniae DNA was detected in any case by PCR. CONCLUSION: The seropositivity and antibody titers were significantly higher in the acute MI and old MI group than in control group, suggesting that C.pneumoniae infection may be a risk factor for myocardial infarction.

Association of Chlamydophila pneumoniae, Cytomegalovirus, Helicobacter pylori and HIV Infections with Myocardial Infarction / 대한임상미생물학회지

BACKGROUND: There is some evidence linking the infections with common organisms such as Chlamydophila pneumoniae, cytomegalovirus (CMV), Helicobacter pylori and HIV to myocardial infarction (MI). We had performed a serologic study to assess whether C.pneumoniae, CMV, H. pylori and HIV infections are associated with MI. METHODS: Serum samples were obtained from 54 cases of acute MI, 33 cases of old MI, and 60 normal controls. C-reactive protein (CRP) as an inflammation marker was measured and antibodies to C.pneumoniae, CMV, H.pylori and HIV were assayed by ELISA. Odds ratios (OR) were calculated against control group. RESULTS: CRP was significantly higher in the acute MI and old MI group. ORs of C.pneumoniae infection increased considerably in the acute MI (IgM 1.57, IgG 4.80) and old MI group (IgM 2.42, IgG 5.18). ORs of CMV infection were 3.30 in the acute MI and 5.12 in old MI group. ORs of H. pylori infection showed below 1 in the acute MI and old MI. Anti-HIV antibody showed all negative result in three groups, so OR could not be calculated. CONCLUSION: C.pneumoniae and CMV infections appear to be risk factors for MI.

Detection of Chlamydophila pneumoniae in Acute Myocardial Infarction / 대한임상미생물학회지

BACKGROUND: There is growing evidence linking infection with Chlamydophila pneumoniae with vascular diseases, such as atherosclerosis and myocardial infarction. However, the data remain inconclusive and the clinical importance of C. pneumoniae as vasculopathic is unclear. So, we intend to detect C. pneumoniae in acute myocardial infarction patients by microimmunofluorescence (mIF) and polymerase chain reaction (PCR). METHODS: Blood and peripheral mononuclear cells (PMNCs) of 24 myocardial infarction patients and 100 normal controls were collected. Serum were used in mIF and PMNCs in PCR. PMNC sample were tested for C. pneumoniae by 'touchdown 'nested PCR. The first round PCR amplified DNA from both C. pneumoniae and Chlamydophila psittaci, while the second round specially targeted C. pneumoniae allowing the two species to be differentiated. RESULTS: Seropositivity of IgG and IgM anti-Chlamydophila pneumoniae antibody titers were 95.8% and 25% in myocardial infarction patients and 61% and 16% in control group, respectively. Positive rates of PCR of PMNCs were 8.3% in the patients and 15% in control group. CONCLUSION: The results of mIF show that mIF positive rate in myocardial infarction was much higher than control group. So an association between C. pneumoniae and myocardial infarction can be concluded. But the opposite results of PCR of PMNCs needed further studies.

Clinical Strudy of chlamydial Pneumonia in Early Infants

No abstract available.