Impacto de la vacuna neumocócica conjugada 13-valente en la incidencia de neumonía consolidante en menores de 5 anos en el partido de Pilar, Buenos Aires: estudio de base poblacional / Impact of the 13-valent pneumococcal conjugate vaccine on the incidence of consolidated pneumonia in children younger than 5 years old in Pilar, Buenos Aires: A population-based study

Introducción. En enero de 2012, en Argentina, fue introducida la vacuna neumocócica conjugada 13-valente (13-Valent Pneumococcal Conjugate Vaccine; PCV13, por sus siglas en inglés) en el Calendario Nacional, en menores de 2 anos. La cobertura en el partido de Pilar en 2012 fue > 90% para las primeras 2 dosis y 60% para la tercera. Objetivo. Medir la efectividad de la PCV13 en la reducción de la incidencia de neumonías consolidantes (NC), durante los dos anos siguientes a su introducción en el Calendario. Métodos. Estudio prospectivo debase poblacional en Pilar. Se incluyeron todos los menores de 5 anos con signos clínicos de neumonía atendidos en hospitales de referencia (ambulatorios y hospitalizados) en los primeros 2 anos de la incorporación (2012-2013). Se comparó la incidencia anual de NC con el período basal 2003-2005. Evaluación clínica-radiológica, según criterio de la Organización Mundial de la Salud. Resultados. Se incluyeron 666 pacientes con sospecha clínica de neumonía. Se diagnosticó NC en 309 pacientes; 52,1% de mujeres, 70,2% menores de 2 anos y 56,4% vacunado con PCV13; 4,5% (14/309) con bacteriología confirmada (S. pneumoniae: 4; N. meningitidis: 4; S. aureus: 2; otros: 4). Se observó una reducción significativa en la incidencia de NC (por 100000 niños menores de 5 anos) entre los períodos pre y posvacunal de 750 (204/27209) a 561 (171/30 475) en 2012 y 453 (138/30 475) en 2013; efectividad de 25,2% y 39,6%, respectivamente. Reducción en menores de 1 año: 33,9% en 2012 y 44,6% en 2013; y en niños de 12-23 meses: 57,9% en 2013. No se observaron diferencias significativas en las incidencias en edades mayores. Conclusiones. Luego de la introducción de la PCV13 en el Calendario de Vacunación en Argentina, se observó una reducción rápida y significativa en la incidencia de NC, principalmente en menores de 1 año en 2012 y menores de 2 anos en 2013.

Introduction. In January 2012, Argentina introduced the 13-valent pneumococcal conjugate vaccine (PCV13) in its immunization schedule for children younger than 2 years old. Coverage in Pilar in 2012 reached>90% for the first two doses and 60% for the third dose. Objective. To measure the effectiveness of PCV13 to reduce the incidence of consolidated pneumonia (CP)in the two-year period following its introduction in the immunization schedule. Methods. Prospective, population-based study conducted in Pilar. All children younger than 5 year sold with clinical signs of pneumonia assisted at the reference hospitals (both inpatients and utpatients) in the first two years since the vaccine introduction (2012-2013) were included. The annual incidence of CP was compared to the 2003-2005 baseline period. Clinical and radiological assessments were done as per the World Health Organization's criteria. Results. Six hundred and sixty-six patients with clinical suspicion of pneumonia were included. CP was diagnosed in 309 patients; 52.1% were girls, 70.2% were younger than 2 years old, and 56.4% had been immunized with the PCV13; 4.5% (14/309) had bacteriological confirmation (S. pneumoniae: 4; N. meningitidis: 4; S. aureus: 2; others: 4). A significant reduction in the incidence of CP (per 100 000 children younger than 5 years old) was observed between the pre- and postimmunization periods, from 750 (204/27209) to 561 (171/30 475) in 2012 and to 453 (138/30 475) in 2013; effectiveness accounted for 25.2% and 39.6%, respectively. Reduction in infants younger than 1 year old: 33.9% in 2012 and 44.6% in 2013; and in children aged 12-23 months old: 57.9% in 2013. No significant differences were observed in the incidence of CP at an older age. Conclusions. Following the introduction of PCV13 in Argentina's immunization schedule, a fast and significant reduction in the incidence of CP was observed, mainly in infants younger than 1 year old in 2012 and in children younger than 2 years old in 2013.

Incidencia de egresos por neumonía en niños menores de 24 meses antes y después de la implementación de la vacuna conjugada antineumocócica 10-valente en el Programa Nacional de Inmunizaciones de Chile / Incidence of admissions due to pneumonia in children under 24 months old before and after the introduction of the 10-valent pneumococcal conjugate vaccine into the National Immunization Program of Chile

Introducción: Streptococcus pneumoniae es la primera causa de neumonía bacteriana en niños, principalmente en hospitalizados. La vacuna antineumocócica 10-valente fue introducida al Programa Nacional de Inmunizaciones de Chile el año 2011. El objetivo de este estudio fue determinar la incidencia de egresos por neumonía en niños < 24 meses en el Hospital Dr. Luis Calvo Mackenna, Santiago, Chile, antes y después de la implementación de vacuna antineumocócica 10-valente en el Programa Nacional de Inmunizaciones. Pacientes y método: Estudio de vigilancia pasiva; se estudiaron los pacientes < 24 meses egresados desde el Hospital Dr. Luis Calvo Mackenna entre los años 2009-2013 con diagnóstico de neumonía bacteriana. Los datos fueron obtenidos desde el Servicio de Estadística del Hospital Dr. Luis Calvo Mackenna. Se evaluó la incidencia de neumonía durante el período prevacuna (2009-2010) y posvacuna (2012-2013). Resultados: Durante el período de estudio se observó un promedio de 4.321 egresos/año en niños < 24 meses (rango: 3.587-4.702), con una disminución significativa desde el período pre- al posvacuna (4.644 versus 4.013; p < 0,001). La incidencia media de egresos por neumonía varió de 3,4/100.000 a 1,5/100.000 en el período pre- y posvacuna, respectivamente (p = 0,009), con un promedio anual de casos de neumonía de 157 en el primer período y de 62 en el segundo (p < 0,001) y una disminución de incidencia entre ambos períodos del 56%. Conclusión: Este estudio corrobora la información obtenida en otros países, mostrando una disminución en la incidencia de neumonía al implementar la vacuna antineumocócica a nivel poblacional. Es necesaria una vigilancia permanente para evaluar si este efecto se mantiene en el tiempo y se expande a poblaciones de mayor edad.

Introduction: Streptococcus pneumoniae is the leading cause of bacterial pneumonia in children, especially in the hospitalized population. The 10-valent pneumococcal vaccine was included in the National Immunization Program of Chile in 2011. This study aims to evaluate the incidence of pneumonia in hospitalized children < 24 months of age in the Luis Calvo Mackenna Hospital before and after the introduction of the pneumococcal vaccine into the National Immunization Program. Patients and methods: Passive surveillance study. Patients < 24 months with discharge diagnosis of bacterial pneumonia from Luis Calvo Mackenna Hospital were studied between 2009 and 2013. Data were obtained from the Luis Calvo Mackenna Hospital's Statistical Service. The incidence of pneumonia was evaluated in the pre-vaccination period (2009-2010) and in the post-vaccination period (2012-2013). Results: During the study period, an average of 4,321 discharges/year was observed in children < 24 months (range: 3,587-4,702), with a significant decrease from pre- to post-vaccination vaccine period (4,644 vs 4,013, P < .001). The average incidence of pneumonia ranged from 3.4/100,000 to 1.5/100,000 in the pre- and post-vaccine period, respectively (P = .009), with an annual mean of 157 cases of pneumonia in the pre-vaccine period, and 62 cases in the postvaccine period (P < .001) and a decrease in incidence between the two periods of 56%. Conclusion: This study confirms information previously obtained in other countries, which show a decrease in the incidence of pneumonia associated with the implementation of a pneumococcal vaccine at the population level. Ongoing surveillance is required to evaluate if this effect is maintained over time and expands to older populations.

Neumonía adquirida en la comunidad en niños y adolescentes / Community-acquired pneumonia in children and adolescents

La neumonía tiene una alta morbilidad y mortalidad en países en desarrollo y en Cuba sigue siendo un problema de salud importante. El propósito de este trabajo es ofrecer información actualizada a los profesionales de la atención primaria de salud acerca de la neumonía en los primeros años de vida. La neumonía adquirida en la comunidad ocurre en sujetos que conviven en ella, por un fallo en los mecanismos de defensa a nivel de las vías aéreas frente diversos agentes infecciosos que difieren según la edad del paciente, siendo Streptococcus pneumoniae el más importante en la infancia. Su diagnóstico es fundamentalmente clínico y la taquipnea es el mejor signo predictor en niños menores de 5 años; las pruebas de laboratorio no son estrictamente necesarias en la atención primaria, donde tampoco están indicados estudios microbiológicos y la radiografía de tórax no debe hacerse de forma rutinaria. Ante complicaciones y otros criterios, el paciente debe ser hospitalizado para su tratamiento y control. Se recomienda tratamiento antibiótico en todos los casos, en función de la edad del paciente. La prevención es de vital importancia en el control de esta enfermedad. Se trata de una enfermedad curable que puede ser fatal, sobre todo en niños, por lo que resulta necesario conocer su importancia como problema de la salud pública y tener un conocimiento actualizado acerca de su etiología, patogenía, diagnóstico y las estrategias para su tratamiento y prevención.

Pneumonia brings high morbidity and mortality to developing countries and it is still a substantial health problem in Cuba. The objective of this paper was to provide the primary health care professionals with updated information about pneumonia in the childhood. Community-acquired pneumonia appears in individuals living in the community as a result of a failure in the mechanisms of defense at airways against the action of infective agents that vary with the patient's age. Streptococcus pneumonia is the most significant in childhood. The diagnosis is basically clinical whereas tachypnea found in children under 5 years of age is the main predictive signal. Neither lab tests nor microbiological studies are strictly indispensable at primary health care level; furthermore, X-rays should not be made as part of a routine. In the face of complications and other criteria, the patient must be admitted to the hospital for treatment and monitoring. It is recommended to apply antibiotics in all the cases, depending on the patient's age. Prevention is vital to control the disease. Pneumonia is a typically curable disease, but it is often deadly, particularly in children; therefore, it is necessary to keep the perception on the weight of pneumonia as a public health problem and to have clear and updated knowledge about the etiology, the pathogenesis and the diagnosis of this disease, as well as the strategies to be pursued to prevent, to manage and to treat it.

Multi-center surveillance for pneumonia & meningitis among children (<2 yr) for Hib vaccine probe trial preparation in India.

Background & objectives: Severe clinical pneumonia and meningitis caused by Haemophilus influenzae type b in children less than 5 yr old is preventable by use of Hib vaccine. However, data on Hib burden in India are limited. To support an evidence-based decision for Hib vaccine introduction in India, a vaccine probe study was planned. This paper presents the results of the preparatory phase for such a study, which aimed to determine the feasibility of conducting a randomized vaccine probe study and to estimate the incidence of all causes of pneumonia and meningitis. The preparatory study included population-based, hospital-based and carriage surveillance. Methods: Children aged 18-24 months and were enrolled at PGIMER, Chandigarh, CMC, Vellore and NICED, Kolkata, from July 2005 to December 2006. At the time of enrollment, parents were informed about the signs and symptoms of pneumonia and meningitis, and were encouraged to take the child to study hospitals for treatment. Hospitalized children less than two years of age suspected of having pneumonia and/or meningitis were enrolled in study hospitals, whether or not they were from the cohort population. Patients were examined clinically and received chest radiograph for suspected cases of pneumonia or lumbar puncture for suspected cases of meningitis. Blood culture was done for both pneumonia and meningitis patients. Cerebrospinal fluid (CSF) was tested for biochemistry, culture, latex agglutination test and polymerase chain reaction. Nasopharyngeal swabs were collected from healthy children less than 2 yr of age at immunization clinics to estimate Hib carriage. Results: A cohort of 17,951 children were recruited for the population-based arm. The incidence of severe clinical pneumonia ranged from 2717 to 7890 per 100,000 child-years of observation; suspected meningitis ranged from 1971 to 2433 per 100,000 child-years of observation. In the hospital-based study 7/90 (7.8%), 29/98 (29.6%) and 38/181 (21.0%) of CSF samples with cell count ≥100 WBCs/mm3 were purulent at Chandigarh, Kolkata and Vellore respectively. Of these purulent CSF samples, Hib was detected in 2, 6 and 11 cases, respectively. The Hib nasopharyngeal carriage prevalence ranged from 6.0 - 7.6 per cent. Interpretation & conclusions: Incidence of severe clinical pneumonia is comparable with other studies from India but that of suspected meningitis is higher. Although rates of Hib meningitis cannot be calculated from a hospital-based study, there is evidence of Hib meningitis in these study settings. Hib carriage prevalence indicates that Hib is present and circulating in these study areas. There is a significant burden of pneumonia and meningitis among children in India. Continued strengthening of laboratory capacity and bacterial surveillance systems are necessary.

Diretrizes brasileiras para pneumonia adquirida na comunidade em adultos imunocompetentes - 2009 / Brazilian guidelines for community-acquired pneumonia in immunocompetent adults - 2009

A pneumonia adquirida na comunidade mantém-se como a doença infecciosa aguda de maior impacto médico-social quanto à morbidade e a custos relacionados ao tratamento. Os grupos etários mais suscetíveis de complicações graves situam-se entre os extremos de idade, fato que tem justificado a adoção de medidas de prevenção dirigidas a esses estratos populacionais. Apesar do avanço no conhecimento no campo da etiologia e da fisiopatologia, assim como no aperfeiçoamento dos métodos propedêuticos e terapêuticos, inúmeros pontos merecem ainda investigação adicional. Isto se deve à diversidade clínica, social, demográfica e estrutural, que são tópicos que não podem ser previstos em sua totalidade. Dessa forma, a publicação de diretrizes visa agrupar de maneira sistematizada o conhecimento atualizado e propor sua aplicação racional na prática médica. Não se trata, portanto, de uma regra rígida a ser seguida, mas, antes, de uma ferramenta para ser utilizada de forma crítica, tendo em vista a variabilidade da resposta biológica e do ser humano, no seu contexto individual e social. Esta diretriz constitui o resultado de uma discussão ampla entre os membros do Conselho Científico e da Comissão de Infecções Respiratórias da Sociedade Brasileira de Pneumologia e Tisiologia. O grupo de trabalho propôs-se a apresentar tópicos considerados relevantes, visando a uma atualização da diretriz anterior. Evitou-se, tanto quanto possível, uma repetição dos conceitos considerados consensuais. O objetivo principal do documento é a apresentação organizada dos avanços proporcionados pela literatura recente e, desta forma, contribuir para a melhora da assistência ao paciente adulto imunocompetente portador de pneumonia adquirida na comunidade.

Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.

Recurrent pneumonia caused by genetic immunodeficiency: a prophylactic and rehabilitative approach

Recurrent infections are a consequence of a series of genetic diseases characterized by deficiency in the immunological response. One of these diseases is the agammaglobulinemia, which is characterized by the basic defect in the maturation of lymphocytes B. The carrier of this kind of immunodeficiency, which is linked to the X (XLA) chromosome, has had primary pneumonias that have evolved into secondary pneumonias (chronic lungs with sequelae) after the third or fourth year of life. The clinical and rehabilitative quest for prophylaxis against the XLA immunodeficiency is accomplished in order to avoid the evolution of the bacterial infection into sequelae and loss of pulmonary function, which propitiates the recurrence of the disease and deteriorates the life quality of the patient. Forty cases of recurrent respiratory infections were studied. Some of them were associated with primary respiratory diseases without investigation of serum immunoglobulins and some were not. Casuistics was performed according to data from medical records with pertinent treatments collected from January 1997 to September 2004 at the Specialized Physiotherapy Center. Age average was 2.7 years of life. It is statistically impossible to precise results concerning only the immunosuppressed patients due to the lack of specific diagnosis. That is explained by the fact that recurrent XLA pneumonias may be attributed to the gastroesophageal reflux disease or to bronchial asthma. However, the improved results showed by the pulmonary function as preventive strategy were attributed to the respiratory physiotherapy, since intravenous immunoglobulin replacement therapies were not performed. Respiratory physiotherapy acts as a supportive factor in the healing process and occupies a fundamental role in the prophylaxis against recurrent respiratory clinical features, especially those of obstructive and secretionary characteristics.

Potentially serious infections in the aging person: diagnosis, treatment and prevention

Infections in the elderly patient are a challenge, since the classical signs of infection are absent or ill defined. The present paper describes the presentation, diagnosis, clinical manifestations and treatment for a selected group of potential serious infections including influenza, bacterial pneumonia, urinary tract infections as well as infections caused by multiresistant bacteria, like vacomycin-resistant enterococcus and methicillin resistant S. aureus. We conclude with the need for prevention in the older person with the use of vaccines, specifically the influenza and pneumococcal vaccine as well as the prevention of urinary infections. Influenza is a significant cause of morbidity, whose ill effects can be prevented in many older persons with the use of a vaccine. The use in prophylaxis and treatment of antiviral agents like amantadine, rimatadine, and oseltamivir is presented. Bacterial pneumonia is one of the leading causes of death in the USA among the older persons. The emergence of drug resistant Streptococcus pneumoniae leads to the consideration as empiric therapy the newer fluoroquinolones or the use of third or fourth generation cephalosporis. Of importance is the use of pneumococcal vaccine among people age 60 or above. The frequency of urinary tract infections among the elderly is of primary although in many instances important do not require treatment. When infection of the urinary tract is diagnosed, most authors use a fluoroquinolone as empiric theraphy. The emergence of multiresistant bacteria like methicillin resistant S. aureus and or vancomycin resistant enterococci leads to the need to consider new agents like quinipristin-dalfopristin, linezolid and deptomycin in the management of such patients.

Neumonía asociada a ventilación mecánica: enfoque actual / Pneumonia associated with mechanical ventilation: current approach

La neumonía asociada a la ventilación mecánica (NAVM) es la complicación infecciosa más importante que afecta a los pacientes conectados a ventilación mecánica con una mortalidad que fluctúa entre 30 a 70 por ciento. La falta de especificidad del diagnóstico clínico puede inducir a un sobretratamiento de la NAVM, de modo que es imprescindible la toma de muestras respiratorias para cultivo y que éste debe ser cuantitativo, resultados por debajo de los límites sugeridos no descartan necesariamente el diagnóstico pero lo hacen menos probable y permite ajustar el tratamiento antibiótico e incluso acortar los plazos de antibioterapia. Muchos factores han sido asociados a una mayor mortalidad de la NAVM, no obstante, el tratamiento antibiótico inadecuado y el retraso en su inicio son los únicos factores que pueden ser modificados para reducir su mortalidad. El tratamiento antibiótico debe ser empírico y tradicionalmente se basa en los días de ventilación mecánica, considerándola precoz si ocurre los primeros cuatro días. Este enfoque puede ocasionar hasta 30 por ciento de tratamientos antibióticos inadecuados. Por este motivo se ha introducido el concepto de terapia de desescalamiento que implica un esquema antibiótico empírico de amplio espectro que se ajusta posteriormente de acuerdo a los hallazgos microbiológicos.

Fatiga del material de los sistemas de ventilación mecanica como factor de riesgo en neumonía asociada a ventilación mecanica / Waste of material employed in mechanical ventilator systems as a risk factor for ventilator-associated pneumonia

La neumonía asociada a ventilación mecanica (NAVM) en Chile, es una de las infecciones intrahospitalarias (IIH) mas frecuentes y de mayor impacto en morbimortalidad. A pesar de las medidas habituales de prevención de IIH aplicadas en nuestro hospital, se presentó en el año 2002 un aumento en la tasa de NAVM, junto al aislamiento de un mayor porcentaje de Acinetobacter baumannii, cepa endémica en nuestro hospital. Con el fin de identificar posibles nichos de microorganismos nosocomiales, se realizó un plan de estudio, que involucró al paciente (secreción traqueal) y los sistemas de ventilación, humidificadores, tubo endotraqueal, tubo en Y, mangueras del sistema de ventilación. Se estudió por microscopia de barrido las mangueras de ventilación para precisar características del material. Se observó, al cabo de 7 días, tiempo de recambio establecido por el Comité Nacional de IIH, colonización por A. baumannii, Pseudomonas aeruginosa y Klebsiella pneumoniae, agentes asociados a NAVH en 2 pacientes. Se estudió el circuito de ventilación mecanica perteneciente a un paciente con NAVM tanto preesterilización como postesterilización, aislandose en ambos cultivos microorganismos multiresistentes. Al analizar porciones del circuito por microscopia de barrido se observó un desgaste de las mangueras con múltiples grietas con formas cocoides y bacilares incluidas en la trama. Al estudiar diferentes circuitos pre y posesterilización, se observó en 2 circuitos cultivos positivos con posterioridad a la esterilización en oxido de etileno. Nuestros datos dan enfasis a la necesidad de incorporar en forma rutinaria dentro de las normas de control de IIH las relacionadas a material reutilizable.

Neumonía asociada a la ventilación. Estrategia empírica precoz versus estrategia específica en el tratamiento antibiótico. Datos preliminares / Ventilator associated pneumonia. Early empirical strategy versus specific strategy in antibiotic therapy. Preliminary data

La mejor estrategia terapéutica para el manejo de la neumonía asociada a la ventilación (NAV) permanece controvertida. Los objetivos de este trabajo fueron: 1)comparar la estrategia empírica precoz (EEP) versus estrategia específica (EE); 2)identificar qué grupo de pacientes se beneficia con el inicio precoz de una terapia antimicrobiana y cuál grupo podría esperar un tratamiento específico. Material y método: el estudio fue realizado entre setiembre del año 2000 y enero del 2002 en la Unidad de Cuidados Intensivos (UCI) del Hospital Pasteur y la UCI del Hospital Policial. Se incluyeron todos los pacientes ventilados por un período 48 horas que tuvieron sospecha de estar desarrollando una NAV. Tipo de estudio: prospectivo, observacional.Resultados: 123 pacientes fueron enrolados por tener sospecha clínica de NAV; de éstos se analizaron finalmente 69 NAV confirmadas de las cuales 36 se manejaron con EEP y 33 con EE. Los dos grupos fueron comparados a través de 20 variables. La mortalidad atribuible con EEP fue de 17,5 por ciento y para la EE de 26,4 por ciento. La mortalidad cruda con EEP fue de 44 por ciento (n=16) y con EE 57 por ciento (n=19) (p=NS). No encontramos diferencias significativas con las dos estrategias al analizar estadía en la unidad, duración de la ARM, complicaciones, no curación y falla terapéutica. Se utilizaron 12 variables para un análisis univariado, valorando EEP y EE en dos grupos: los que presentaron buena evolución y mala evolución encontrando una asociación significativa entre el grupo con EE que tuvo mala evolución con la demora mayor a las 48 horas en iniciar un antibiótico (p=0,034). El shock séptico se asoció con mala evolución en ambos grupos, EE vs EEP (p=0,0036 y p= 0,046 respectivamente). El APACHE II mayor de 18 al diagnóstico de la neumonía, se asoció en el análisis de regresión logística con mayor mortalidad. Conclusiones: nuestros resultados sugieren que no hay diferencias entre EEP y EE en cuanto a mortalidad y resultados secundarios. Si se demora más de 48 horas en instaurar un tratamiento antibiótico los pacientes van a tener peor evolución. Pensamos que la EE puede ayudar a minimizar el uso innecesario de antimicrobianos sin agregar mortalidad al enfermo