Uma rara apresentação de plexopatia braquial por empiema de necessidade / A rare presentation of brachial plexopathy due to need empyema

Contexto: O empiema tem aumentado sua incidência ao longo das últimas décadas e ainda é a complicação mais comum de pneumonias. Apesar dos avanços no tratamento clínico, o acometimento do tecido pleural por infecções pode levar a sequelas irreparáveis e ainda apresenta uma alta mortalidade. Descrição do caso: Paciente do sexo masculino, 55 anos de idade, relatou queixa de dor em hemitórax e ombro esquerdos e parestesia difusa em membro ipsilateral há três dias. Tomografia de tórax revelou empiema pleural em lobo superior esquerdo e eletroneuromiografia evidenciou plexopatia braquial. Foi feita a punção guiada do empiema que demonstrou infecção por Staphylococcus aureus sensível à meticilina. Após drenagem do abscesso e antibioticoterapia, o paciente apresentou melhora progressiva dos sintomas. Discussão: O empiema de necessidade raramente se apresenta secundário a uma infecção bacteriana aguda, sendo geralmente causado por longas efusões pneumônicas tuberculosas. Sua manifestação clínica mais comum é a presença de massa dolorosa na região anterior do tórax, com exames de imagem mostrando alterações inflamatórias. A terapêutica preconizada se constitui de drenagem e antibioticoterapia. Conclusão: O diagnóstico de empiema de necessidade foi poucas vezes descrito na literatura e deve ser suspeitado em quadros infecciosos pulmonares com repercussão neurológica em plexo braquial.

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.

Prevalencia de Neumonía Complicada en Pacientes Pediátricos Hospitalizados en el Hospital José Carrasco Arteaga. Enero del 2014 a Diciembre del 2017 / Prevalence of Complicated Pneumonia in Hospitalized Pediatric Patients at Hospital José Carrasco Arteaga. January 2014 to December 2017

Introducción: La neumonía complicada representa un problema de salud en la población pediátrica, forma parte de las enfermedades respiratorias agudas, siendo la principal causa de morbimortalidad hospitalaria, siendo necesario el diagnóstico y tratamiento oportuno. El objetivo del estudio fue determinar la prevalencia de neumonía complicada en los pacientes hospitalizados del servicio de pediatría del Hospital "José Carrasco Arteaga" de la ciudad de Cuenca de enero del 2014 a diciembre del 2017. Metodología: Estudio descriptivo transversal en pacientes del área de Pediatría y Cuidados Intensivos Pediátricos desde enero del 2014 a diciembre del 2017. Para el análisis se utilizó la estadística descriptiva, los datos fueron tabulados en el programa SPSS v.15 Resultados: La prevalencia de neumonía complicada es de 28,8%. Hubo predominio del sexo masculino con 56.4%, así como del grupo etario de 0 a 3 años con 43.6% y la población proviene en su mayoría de la zona urbana en 58,9%. Se encontró desnutrición en el 51.1%, las comorbilidades más comunes fueron las respiratorias con 12.4%. La mayoría requirió hospitalización por 5-9 días representando 54.6%, los antibióticos más utilizados fueron los betaláctamicos en el 85.8% de los casos. La complicación más frecuente fue la bacteremia en 43.2% y la mortalidad alcanzó el 8.1%. Conclusiones: La prevalencia de la neumonía complicada es elevada, con predominio de la bacteremia, en el sexo masculino, en menores de 3 años, con desnutrición, el antibiótico que más se utilizó fueron los betalactámicos

Introduction: Complicated pneumonia represents a health problem in the pediatric population, it is part of acute respiratory diseases, being the main cause of hospital morbidity and mortality, requiring timely diagnosis and treatment. The objective of the study was to determine the prevalence of complicated pneumonia in hospitalized patients of the Pediatric service of the Hospital "José Carrasco Arteaga" in the city of Cuenca from January 2014 to December 2017. Methodology: Cross-sectional descriptive study in patients in the area of Pediatrics and Pediatric Intensive Care from January 2014 to December 2017. Descriptive statistics were used for the analysis, the data were tabulated in the SPSS v.15 program. Results: The prevalence of complicated pneumonia is 28.8%. There was a predominance of males with 56.4%, as well as the age group from 0 to 3 years with 43.6% and the population comes mostly from the urban area in 58.9%. Malnutrition was found in 51.1%, the most common comorbidities were respiratory with 12.4%. Most required hospitalization for 5-9 days, representing 54.6%, the most widely used antibiotics were betalactamic in 85.8% of the cases. The most frequent complication was bacteremia in 43.2% and mortality reached 8.1%. Conclusions: The prevalence of complicated pneumonia is high, with a predominance of bacteremia, in males, in children under 3 years of age, with malnutrition, the antibiotic that was used the most were beta-lactams

Neumonía estafilocócica complicada en un paciente pediátrico: a propósito de un caso clínico / Stafilocócica pneumony complicated in a pediatric patient: on the purpose of a clinical case

La neumonía es definida por la Organización Mundial de Salud (OMS) como una infección respiratoria aguda que afecta a los alvéolos pulmonares, dificultando la respiración y absorción de oxígeno afectando a la población infantil. Por eso se propuso analizar la neumonía estafilocócica complicada con enfoque clínico, radiológico y tratamiento en el paciente pediátrico para establecer elementos que ayuden a la elaboración de protocolos de diagnóstico y tratamiento. Se realizó un estudio de tipo documental, observacional y analítico mediante la entrevista directa con el paciente y familiares y el análisis clínico de los signos y síntomas presentados por el paciente. Mediante la valoración clínico, radiológico y oportuno tratamiento en el paciente pediátrico con neumonía estafilocócica complicada, se logró establecer elementos que podrán ayudar a la elaboración de un protocolo de diagnóstico y tratamiento de dicha patología(AU)

Pneumonia is defined by the World Health Organization (WHO) as an acute respiratory infection that affects the pulmonary alveoli, making it difficult to breathe and absorb oxygen, affecting the child population. Therefore, it was proposed to analyze complicated staphylococcal pneumonia with a clinical, radiological and treatment approach in the pediatric patient to establish elements that help to develop diagnostic and treatment protocols. A documentary, observational and analytical study was conducted through a direct interview with the patient and family members and the clinical analysis of the signs and symptoms presented by the patient. By means of the clinical, radiological evaluation and timely treatment in the pediatric patient with complicated staphylococcal pneumonia, it was possible to establish elements that may help to elaborate a protocol for the diagnosis and treatment of said pathology(AU)

Effectual components of Polygonum ciliinerve protects against Staphylococcus aureus infection with immunomodulatory functions in C57BL/6 mice

Abstract Purpose: To investigate the efficacy and mechanisms of root tuber of Polygonum ciliinerve (Nakai) ohwi (rPC) which has been used to treat bacterial infection in traditional Chinese medicine. Methods: With the mouse model of Staphylococcus aureus (S. aureus) pneumonia, the phenotype of rPC treated mice, including body weight, mortality, lung slices and bacterial burden were evaluated. Furthermore, inflammatory factors in bronchoalveolar lavage (BAL) were determined by ELISA and the distribution of T cells in lung was assessed by immunofluorescence assay. Results: rPC treatment could dose-dependently reduce weight loss and mortality in S. aureus-infected mice. Upon 10 mg/ml rPC treatment, S. aureus-infected mice showed about 8 grams increase in body weight (P<0.001) and 50% enhancement in mortality. The integrity of lung tissue and bacterial burden were also improved by rPC treatment. Moreover, rPC was found to modulate the immune response in infection. Conclusion: rPC has therapeutic potential for S. aureus infections and pneumonia with immunomodulatory functions.

Elucidation of Bacterial Pneumonia-Causing Pathogens in Patients with Respiratory Viral Infection / 결핵및호흡기질환

BACKGROUND: Bacterial pneumonia occurring after respiratory viral infection is common. However, the predominant bacterial species causing pneumonia secondary to respiratory viral infections other than influenza remain unknown. The purpose of this study was to know whether the pathogens causing post-viral bacterial pneumonia vary according to the type of respiratory virus. METHODS: Study subjects were 5,298 patients, who underwent multiplex real-time polymerase chain reaction for simultaneous detection of respiratory viruses, among who visited the emergency department or outpatient clinic with respiratory symptoms at Ulsan University Hospital between April 2013 and March 2016. The patients' medical records were retrospectively reviewed. RESULTS: A total of 251 clinically significant bacteria were identified in 233 patients with post-viral bacterial pneumonia. Mycoplasma pneumoniae was the most frequent bacterium in patients aged <16 years, regardless of the preceding virus type (p=0.630). In patients aged ≥16 years, the isolated bacteria varied according to the preceding virus type. The major results were as follows (p<0.001): pneumonia in patients with influenza virus (type A/B), rhinovirus, and human metapneumovirus infections was caused by similar bacteria, and the findings indicated that Staphylococcus aureus pneumonia was very common in these patients. In contrast, coronavirus, parainfluenza virus, and respiratory syncytial virus infections were associated with pneumonia caused by gram-negative bacteria. CONCLUSION: The pathogens causing post-viral bacterial pneumonia vary according to the type of preceding respiratory virus. This information could help in selecting empirical antibiotics in patients with post-viral pneumonia.

Prior oropharyngeal colonization and ventilator-associated pneumonia

This study evaluated the relationship between previous colonization of the oropharynx and development of ventilator-associated pneumonia through the classification of genomic fingerprint pattern by pulsed-field gel electrophoresis of both oxacillin-resistant and oxacillin-susceptible Staphylococcus aureus isolates obtained from hospitalized patients in an intensive care unit.

Success stories about severe pneumonia caused by Panton-Valentine leucocidin-producing Staphylococcus aureus

We describe three cases of community-acquired necrotizing pneumonia which were caused by Panton-Valentine leucocidin-producing strains of Staphylococcus aureus (one of them methicillin sensitive). All cases were successfully treated without any sequelae for the patients due to the prompt initiation of adequate antimicrobial therapy. High suspicion toward this fatal pathogen was the key to the successful outcome of the patients.

Infección grave por Staphylococcus aureus en tres unidades de cuidados intensivos pediátricos. Análisis de los casos de neumonía necrotizante / Severe Staphylococcus aureus infection in three pediatric intensive care units. Analysis of cases of necrotizing pneumonia

El Staphylococcus aureus afecta frecuentemente al ser humano. Dentro de las manifestaciones clínicas, la neumonía necrotizante se asocia a una alta mortalidad. Nuestro objetivo es describir la evolución de las infecciones graves por Staphylococcus aureus en tres unidades de terapia intensiva pediátricas y analizar los casos de neumonía necrotizante en el período del 01-2011 al 03-2013. Se analizaron 43 pacientes; 76,7% presentaron infección adquirida en la comunidad, y en 31 fue por Staphylococcus aureus resistente a la meticilina adquirido en la comunidad. El principal motivo de ingreso fue la claudicación respiratoria. Se documentó bacteriemia en el 55,8% de los casos. El 86% de los ingresos requirieron asistencia respiratoria mecánica y 27 pacientes desarrollaron shock séptico. La estadía en la unidad de terapia intensiva fue de 13 (5-25) días, y la mortalidad, del 14%. La neumonía necrotizante estuvo presente en el 51% de los casos. Conclusión. Se identificó una alta proporción de infección adquirida en la comunidad. La neumonía necrotizante se asociócon una peor evolución.

Staphylococcus aureus frequently affects human beings. Among clinical manifestations, necrotizing pneumonia is associated with a high mortality rate. Our objective is to describe the progress of severe Staphylococcus aureus infections in three intensive care units and analyze cases of necrotizing pneumonia in the period ranging from January 2011 to March 2013. Forty- three patients were studied, 76.7% had a community-acquired infection, and 31 had community-acquired methicillin-resistant Staphylococcus aureus. The main reason for admission was respiratory failure. Bacteremia was confirmed in 55.8% of cases. Mechanical ventilation was required in 86% of admitted patients, while 27 patients developed septic shock. The length of stay in the intensive care unit was 13 (5-25) days, and the mortality rate was 14%. Necrotizing pneumonia was observed in 51% of cases. Conclusion. A high rate of community-acquired infection was identified. Necrotizing pneumonia was associated with a worse clinical course.

Clinical features of inhaled and blood-borne Staphylococcus aureus pneumonia and analysis of antibiotic resistance of the pathogen in children / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To compare the clinical manifestations between inhaled and blood-borne Staphylococcus aureus pneumonia (SAP) and the antibiotic resistance between the isolates of inhaled and blood-borne Staphylococcus aureus.</p><p><b>METHODS</b>The clinical data of 44 pediatric SAP cases in the Children′s Hospital, Chongqing Medical University from January 2008 to December 2013 were retrospectively analyzed. Twenty-four cases were identified as inhaled SAP, and 20 cases as blood-borne SAP.</p><p><b>RESULTS</b>Inhaled SAP was more common in children younger than 3 years of age, while blood-borne SAP was more prevalent in children older than 6 years of age. Patients with inhaled SAP had significantly higher incidence rates of cough, wheeze, moist rales, dyspnea and empyema than those with blood-borne SAP (P<0.05). The patients with blood-borne SAP were more vulnerable to severe fever, unconsciousness, dysfunction of liver and kidney, pyogenic osteomyelitis, septic arthritis, sepsis, and abscess of skin and soft tissues (P<0.05). Inhaled SAP isolates had significantly higher rates of resistance to amoxicillin/clavulanic acid, oxacillin, and cefoxitin than blood-borne SAP isolates (P<0.05), while the latter had a higher rate of resistance to cotrimoxazole (P<0.05).</p><p><b>CONCLUSIONS</b>Inhaled SAP often occurs in children younger than 3 years of age, and the respiratory manifestations are commonly seen. Blood-borne SAP often occurs in children older than 6 years of age, with the infectious-toxic symptoms that result in multiple organ infection and dysfunction. The isolates of inhaled and blood-borne SAP have different antibiograms.</p>

Analysis of serum vancomycin concentration after administration of different doses in children with Staphylococcus aureus pneumonia / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To analyze serum vancomycin concentration after administration of different therapeutic doses in children with Staphylococcus aureus pneumonia (SAP) in order to determine the appropriate dose of vancomycin in clinical administration.</p><p><b>METHODS</b>The clinical data of 35 children who were diagnosed with SAP and treated with vancomycin from January 2008 to December 2013 were retrospectively analyzed.</p><p><b>RESULTS</b>Among the 35 SAP cases with vancomycin therapy, 22 cases (63%) had serum vancomycin trough concentration monitored. The numbers of cases with vancomycin at 10, 12.5, and 15 mg/(kg·dose) × every 6 hours (q6h) were 11, 4 and 7, respectively. The mean serum trough concentration of vancomycin in the 15 mg/(kg·dose) group was 14.98 mg/L, which was significantly higher than in the 10 mg/(kg·dose) and 12.5 mg/(kg·dose) groups (4.97 and 8.00 mg/L respectively; P<0.05). The percentage of cases that reached the expected trough concentration in the 15 mg/(kg·dose) group (71%) was significantly higher than that in the 10 mg/(kg·dose) group (9%), but there was no significant difference in this percentage between the 15 mg/(kg·dose) and 12.5 mg/(kg·dose) groups (71% vs 25%).</p><p><b>CONCLUSIONS</b>The reasonable dosage of vancomycin for the treatment of pediatric SAP is 15 mg/(kg·dose) × q6h or 60 mg/(kg·d).</p>

Pneumonia comunitária causada por Staphylococcus aureus MRSA – cepa positiva para Leucocidina de Panton-Valentine / Community-acquired pneumonia by MRSA Staphylococcus aureus – Panton-Valentine Leukocidine positive strain

Staphylococcus aureus resistente à meticilina (MRSA) é considerado um germe tipicamente hospitalar, entretanto, nos últimos anos, vários casos de MRSA têm sido descritos como causa de infecções de comunidade em vários sítios. O presente relato descreve um caso de um adulto jovem com pneumonia necrosante adquirida na comunidade em que isolou-se MRSA, cepa positiva para leucocidina Panton-Valentine, sem fatores de risco associados para pneumonia estafilocócica. Ressalta-se a importância da suspeição diagnóstica dessa entidade em pacientes com pneumonia adquirida na comunidade que apresentem hemoptise e cavitações na radiografia de tórax, especialmente pela necessidade de uso precoce de glicopeptídeos, recomendação não descrita nos consensos atuais que versam sobre o tema.

Methicillin-resistant staphylococcus aureus (MRSA) is considered as a typically hospital germ, but in recent years several cases of MRSA have been reported to cause community infections in various sites. This report describes the case of a young adult with necrotizing pneumonia acquired in the community in which a Panton-Valentine leukocidine positive strain of MRSA was isolated without associated risk factors for staphylococcal pneumonia. We highlight the importance of diagnostic suspicion of this entity in patients with community-acquired pneumonia presenting hemoptysis and cavitations on chest X-ray, especially because of the need for early use of glycopeptides, a recommendation that is not described in the current consensus dealing with the topic.

A Case of Acute Cerebral Aspergillosis Complicating Influenza A/H1N1pdm 2009

Invasive aspergillosis is a rare complication in patients with influenza infection. Several cases of invasive pulmonary aspergillosis accompanying influenza infections were reported during the influenza A/H1N1pdm 2009. We encountered a case of acute cerebral aspergillosis in a patient with influenza A/H1N1pdm 2009 infection. A 24-year-old man with uncontrolled diabetes was diagnosed with influenza A/H1N1pdm 2009 infection. Initial evaluation indicated methicillin-sensitive Staphylococcus aureus pneumonia and diabetic ketoacidosis along with influenza. During his hospital course, multiple new rim-enhancing mass lesions not evident in the initial evaluation developed in the fronto-parietal cortical and subcortical white matter and right cerebellum. Pathology and culture results confirmed the presence of Aspergillus fumigatus. Surgical drainage combined with a total of 18 weeks of antifungal therapy resulted in complete resolution of the infection. This case demonstrates that cerebral aspergillosis can present alongside influenza in patients with diabetes or those under intensive care. Clinical suspicion of invasive aspergillosis is required for a definite diagnosis and better prognosis in such cases.

Staphylococcus aureus meticilino resistente adquirido en la comunidad: una nueva amenaza / Community acquired methicillin-resistant Staphylococcus: A new threat

Objetivos: Conocer la frecuencia de Staphylococcus aureus meticilino resistente adquirido en la comunidad (SAMR-AC) en neumonía adquirida en la comunidad (NAC); examinar sus características clínicas - evolutivas y analizar factores de riesgo. Pacientes, material y métodos: Estudio retrospectivo, descriptivo, observacional, realizado en una unidad de cuidados intensivos respiratorios entre 2006 y 2012. Resultados: Se evaluaron 180 pacientes con NAC con diagnóstico etiológico. Etiologías más frecuentes: Streptococcus pneumoniae (50.5%), Haemophillus influenzae (18.3%) ySAMR-AC (12.2%, 22 casos). La neumonía por SAMR-AC se presentó en individuos jóvenes, mayoritariamente hombres. En el 81.8% de los casos el foco primario fue infección de piel y estructuras relacionadas (IPER), 95.4% presentó criterios clínicos de sepsis, 72.7% tuvo compromiso radiológico bilateral y 45.5% desarrolló derrame pleural. El 40.9% requirió ventilación mecánica y el 45.4% utilizó drogas vasoactivas. El 81.8% de los pacientes no alcanzó criterios de estabilidad clínica al cabo de la primer semana y la mortalidad fue del 36.3%, significativamente superior al resto de los microorganismos (8.8%, p<0,001). Los factores clínicos asociados con mayor riesgo de SAMR-AC fueron la presencia de IPER concomitante, compromiso radiológico bilateral, presencia de criterios clínicos de sepsis, edad inferior a 30 años y requerimiento de drogas vasoactivas. Los factores que se asociaron con mortalidad en NAC fueron la etiología por SAMR-AC y el compromiso radiológico bilateral. Conclusiones: La neumonía por SAMR-AC es una patología emergente, asociada a elevada morbimortalidad. Debe ser considerada en pacientes jóvenes, con presencia concomitante de IPER, compromiso radiológico bilateral, criterios clínicos de sepsis o necesidad de drogas vasoactivas.

Objectives: To know the incidence of Community Acquired Pneumonia (CAP) caused by Methicillin Resistant Sthaphylococcus aureus (MRSA), to examine their clinical and developmental characteristics and to analyze risk factors. Materials and Methods: Retrospective, descriptive and observational study carried out at a Respiratory Intensive Care Unit, between 2006 and 2012. Results: 180 patients with etiologic diagnosis of CAP were evaluated. The most common causes were Streptococcus pneumoniae (50.5%), Haemophillus influenzae (18.3%) and MRSA (12.2%, 22 cases). Community Acquired MRSA (CA-MRSA) pneumonia was present in young people, especially in male. In 81.8% of the cases, skin and related structure infections (SRSI) were the primary focus, 95.4% presented clinical criteria of sepsis, 72.7% had bilateral radiology involvement and 45.5% developed pleural effusion. 40.9% needed mechanical ventilation and 45.4% used vasoactive drugs. Clinical stability at the first week was not reached in 81.8% and mortality rate was 36.6%, significantly higher than for pneumonia caused by other microorganisms (8.8% p<0,001). Clinical factors related with high risk of CA-MRSA pneumonia were the concomitant presence of SRSI, bilateral radiology involvement, clinical criteria of sepsis, age <30 years old and need for vasoactive drugs. Factors related to CAP mortality were CA-MRSA aetiology and bilateral radiology involvement. Conclusions: CA-MRSA pneumonia is an emergent disease with high morbidity and mortality. It must be considered in young patients, with SRSI, bilateral radiology involvement, clinical criteria of sepsis or intake of vasoactive drugs.

A severe pneumonia due to methicillin resistant Staphylococcus aureus clone USA 300: implications of vertical transmission / Pulmonía severa debido al clon USA 300 del estafilococo dorado resistente a la meticilina: implicaciones de la transmisión vertical

Staphylococcus aureus is an important pathogen in both community and healthcare associated pneumonia. We describe a case of severe pneumonia caused by the methicillin resistant Staphylococcus aureus (MRSA) clone USA 300 in a 44-year old post-partum woman and the subsequent vertical transmission of this virulent organism to her neonate.

El estafilococo dorado (Staphylococcus aureus) es un patógeno importante tanto en la atención a las comunidades como en el cuidado de la salud en relación con la pulmonía. Se describe un caso de pneumonia severa causada por el clon USA 300 del estafilococo dorado resistente a la meticilina (EDRM) en una mujer de 44 anos en periodo de post-parto, y la posterior transmisión vertical de este virulento organismo a su neonato.

Post-influenza Pneumonia Caused by the USA300 Community-Associated Methicillin-Resistant Staphylococcus aureus in Korea

Panton-Valentine leukocidin (PVL)-positive USA300 clone has been the most successful community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) clone spreading in North America. In contrast, PVL-negative ST72-CA-MRSA has been predominant in Korea, and there has been no report of infections by the USA300 strain except only one case report of perianal infection. Here, we describe the first case of pneumonia caused by the USA300 strain following pandemic influenza A (H1N1) in Korea. A 50-year-old man was admitted with fever and cough and chest radiograph showed pneumonic consolidation at the right lower lung zone. He received a ventilator support because of respiratory failure. PCR for pandemic influenza A (H1N1) in nasopharyngeal swab was positive, and culture of sputum and endotracheal aspirate grew MRSA. Typing of the isolate revealed that it was PVL-positive, ST 8-MRSA-SCCmec type IV. The analysis of the PFGE patterns showed that this isolate was the same pulsotype as the USA300 strain.

The Difference in Clinical Presentations between Healthcare-Associated and Community-Acquired Pneumonia in University-Affiliated Hospital in Korea

PURPOSE: Healthcare-associated pneumonia (HCAP) has been proposed as a new category of pneumonia. However, epidemiological studies for HCAP in South Korea are limited. This study aimed to reveal the differences between HCAP and community-acquired pneumonia (CAP), especially in elderly patients, in university-affiliated hospital in South Korea. MATERIALS AND METHODS: We conducted a retrospective observational study of patients with HCAP and CAP (older than 60 years old) who were hospitalized between January 2007 and December 2008. We compared the baseline characteristics, comorbidities, severity, pathogen distribution, antibiotics, and clinical outcomes. RESULTS: A total of 210 patients were evaluated, including 35 patients with HCAP (17%) and 175 with CAP (83%). The most common causative organism was Streptococcus pneumoniae in CAP (33.3%), whereas, Staphylococcus aureus was most common pathogen in HCAP (40.0%). Initial inappropriate antibiotics (6.3% vs. 22.9%; p < 0.005) and initial treatment failure (15.4% vs. 31.4%; p = 0.018) were more frequent in HCAP than CAP. However, mortality (11.4% vs. 5.7%; p = 0.369) was not different between the two groups. CONCLUSION: The present study provides additional evidence that HCAP should be distinguished from CAP, even in elderly patients, in South Korea. Physicians should consider S. aureus and MDR pathogens in selecting initial empirical antibiotics of HCAP in South Korea.

Pneumonia necrosante em crianças submetidas à toracoscopia por empiema pleural: incidência, tratamento e evolução clínica / Necrotizing pneumonia in children submitted to thoracoscopy due to pleural empyema: incidence, treatment and clinical evolution

OBJETIVO: Analisar a incidência de pneumonia necrosante (PN) em crianças submetidas a toracoscopia e comparar pacientes com e sem PN em relação às diferentes apresentações e evolução clínica. MÉTODOS: Estudo retrospectivo de crianças portadoras de empiema e submetidas a toracoscopia. A toracoscopia foi realizada em pacientes não submetidos a drenagem torácica prévia e evidência de derrame septado ou pneumotórax, assim como naqueles submetidos previamente a drenagem torácica e pneumotórax persistente ou febre e secreção purulenta. Baseado na presença de PN durante a toracoscopia, os pacientes foram divididos em dois grupos: com PN e sem PN. RESULTADOS: Participaram do estudo 52 pacientes. Dos 24 pacientes com PN, 19 (79 por cento) foram submetidos a drenagem torácica anterior à toracoscopia, 11 (46 por cento) apresentaram pneumotórax, e 16 (67 por cento) evoluíram com fístula broncopleural. Neste grupo, as medianas do tempo de drenagem e de hospitalização foram, respectivamente, 18 e 19 dias. Dos 28 pacientes sem PN, 10 (36 por cento) foram submetidos a drenagem torácica anterior à toracoscopia, 9 (32 por cento) apresentaram pneumotórax, e 5 (18 por cento) evoluíram com fístula broncopleural. Neste grupo, as medianas do tempo médio de drenagem e de hospitalização foram, respectivamente, 6 e 10 dias. CONCLUSÕES: A PN deve ser suspeitada na presença de pneumotórax. A toracoscopia precoce pode ser uma opção terapêutica de grande valor na PN da infância, pois acelera a recuperação quando comparada ao tratamento médico isolado e evita ressecções pulmonares extensas da toracotomia tardia.

OBJECTIVE: To assess the incidence of necrotizing pneumonia (NP) in children submitted to thoracoscopy, comparing patients with and without NP in terms of the presentation and clinical evolution. METHODS: A retrospective study of children with pleural empyema submitted to thoracoscopy. Thoracoscopy was performed in patients not previously submitted to thoracic drainage and in whom there was evidence of loculated effusion or pneumothorax, as well as in those previously submitted to thoracic drainage and in whom there was persistent pneumothorax or fever with purulent discharge. On the basis of the thoracoscopy findings, patients were distributed into two groups: those with NP (NP group) and those without (no-NP group). RESULTS: The study sample comprised 52 patients. Of the 24 patients with NP, 19 (79 percent) had undergone thoracic drainage prior to thoracoscopy, 11 (46 percent) presented with pneumothorax, and 16 (67 percent) developed bronchopleural fistula. In the NP group, the median drainage time and the median length of hospital stay were 18 and 19 days, respectively. Of the 28 patients without NP, 10 (36 percent) had undergone thoracic drainage prior to thoracoscopy, 9 (32 percent) presented pneumothorax, and 5 (18 percent) developed bronchopleural fistula. In the no-NP group, the median drainage time and the median length of hospital stay were 6 and 10 days, respectively. CONCLUSIONS: Pneumothorax should raise the suspicion of NP. Early thoracoscopy can be a valuable treatment option for NP in children because it hastens recovery in comparison with the medical treatment alone and avoids extensive late thoracotomy lung resections.

Neumonía necrosante por Staphylococcus aureus extrahospitalario resistente a la meticilina: reporte de dos casos en Colombia / Necrotizing pneumonia by community-acquired, methicillin-resistant Staphylococcus aureus in Colombia

En los últimos años se ha informado la aparición de Staphylococcus aureus resistente a la meticilina como causa de infecciones extrahospitalarias graves. En Colombia, en el 2006, se publicó el primer reporte de S. aureus como causa de infección de piel y tejidos blandos; en esta ocasión, presentamos el primer reporte de neumonía necrosante con etiología por S. aureus, en dos pacientes adultos que se caracterizaron por presentar progresión clínica rápida, estancia prolongada en cuidados intensivos y complicación de la neumonía con aparición de empiema. Ambos desarrollaron falla renal aguda, por lo que fueron manejados con linezolide, con adecuada respuesta clínica. Con la caracterización molecular de los aislamientos se confirmó la presencia del gen mecA que porta el casete SCCmec tipo IV y la producción de la toxina leucocidina Panton-Valentine.

The emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) as a cause of severe infections has been described in the recent years. In 2006, the first report of skin and soft tissue infection by CA-MRSA was published in Colombia. Herein, two additional cases of CA-MRSA are reported with a clinical course characterized by rapid progression, prolonged stay in the intensive care unit and complication of pneumonia with the onset of empyema. Both adult patients developed acute renal failure, and were treated with linezolide; the subsequent clinical response showed adequate treatment response. Molecular characterization of the isolates indicated the presence of the mecA gene carrying the cassette SCCmec type IV and the production of the toxin panton-valentine leukocidin.

Sepse por Staphylococus aureus resistente à meticilina adquirida na comunidade no sul do Brasil / Sepsis due to community-acquired methicillin-resistant Staphylococcus aureus in southern Brazil

Staphylococcus aureus resistente à meticilina foi inicialmente descrito como um típico microrganismo adquirido em infecções nosocomiais. No entanto, nos últimos anos Staphylococcus aureus resistente à meticilina adquirido na comunidade é causa de infecções de pele e tecidos moles, mas infecções graves como pneumonia e sepse podem ocorrer. Este relato descreve um caso de sepse em criança, complicado com pneumonia secundária a lesão em partes moles por Staphylococcus aureus resistente à meticilina adquirido na comunidade no Sul do Brasil. O paciente foi atendido em Unidade de Emergência com história de ferimento provocado por trauma em membro inferior que evoluiu para celulite, pneumonia e sepse.

Methicillin-resistant Staphylococcus aureus was initially described as a typical microorganism acquired in nosocomial infections. However, over recent years, community-acquired methicillin-resistant Staphylococcus aureus has been a cause of skin and soft-tissue infections. Serious infections such as pneumonia and sepsis can also occur. This report describes a case of sepsis in a child that was complicated by pneumonia secondary to soft tissue lesions that were due to community-acquired methicillin-resistant Staphylococcus aureus in southern Brazil. The patient was attended at the Emergency Unit with a history of injury caused by lower-limb trauma that evolved to cellulitis, pneumonia and sepsis.