Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review.

Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.

Biomarkers of stable and decompensated phases of heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a disorder related to patient comorbidities and aging. Whether mitochondrial dysfunction is present during HFpEF decompensation versus the stable phase is largely unknown. The aim of the present study was to identify mitochondrial and cell metabolism blood biomarkers in older patients with acute and stable HFpEF. METHODS: Peripheral blood biomarkers were investigated in a group of eight to 12 patients aged 80-96 years and diagnosed with HFpEF first when they were in decompensated phase and then at least three months later in stable phase. Their data were compared to two control groups with an equal number of participants and sex proportions. One group was age matched and the other included individuals aged between 22 and 44 years. RESULTS: Decompensated patients experienced an increased mitochondrial superoxide production and mitochondrial mass, lower mitochondrial DNA copy number and LDHB expression, and higher lactate level compared to the stable stage. The stable phase was characterized by a sharp reduction in formate level. Multivariate analysis indicated that formate, lactate, and histidine can distinguish both of the HFpEF phases. Many of these parameters, including LDHB, lactate, formate, and mitochondrial mass, followed an age-related pattern, with acute HFpEF at its apex or nadir, suggesting that it represents an exacerbation of an aging-related process. CONCLUSIONS: We identified distinct blood biomarkers of chronic and decompensated HFpEF phases. The data underlined the relationship between HFpEF and aging. These findings could be used to monitor patients and might be therapeutically targeted.

Ceftolozane-tazobactam in nosocomial pneumonia

Ceftolozane is a potent antimicrobial against Pseudomonas aeruginosa, including carbapenem-resistant andmultidrug-resistant strains, and is also active against Enterobacteriaceae. It MIC (minimal inhibitory concentration) andMPC (mutant preventive concentration) are close together,allowing to avoid the mutant selection window specificallyin the treatment of Pseudomonas aeruginosa infection. Themolecule is time-dependent and stable when reconstituted atroom temperature, facilitating safe and effective dosage optimization in frail and critically ill patients. It has been shown tobe non-inferior to meropenem in the treatment of nosocomial infection in the ASPECT-NP study but superior in post-hocstudies in the subgroup of patients with ventilator-associatedpneumonia, without the emergence of resistance during treatment. It is FDA approved at a dose of 3 g every 8 hours in thetreatment of nosocomial pneumonia (HABP/VABP) in adults. (AU)

Fungal infections following treatment with monoclonal antibodies and other immunomodulatory therapies / Infecciones fúngicas como consecuencia de tratamientos con anticuerpos monoclonales y otras terapias inmunomoduladoras

Tumor necrosis factor (TNF) is a proinflammatory cytokine involved in a wide range of important physiologic processes and has a pathologic role in some diseases. TNF antagonists (infliximab, adalimumab, etanercept) are effective in treating inflammatory conditions. Antilymphocyte biological agents (rituximab, alemtuzumab), integrin antagonists (natalizumab, etrolizumab and vedolizumab), interleukin (IL)-17A blockers (secukinumab, ixekizumab) and IL-2 antagonists (daclizumab, basiliximab) are widely used after transplantation and for gastroenterological, rheumatological, dermatological, neurological and hematological disorders. Given the putative role of these host defense elements against bacterial, viral and fungal agents, the risk of infection during a treatment with these antagonists is a concern. Fungal infections, both opportunistic and endemic, have been associated with these biological therapies, but the causative relationship is unclear, especially among patients with poor control of their underlying disease or who are undergoing steroid therapy. Potential recipients of these drugs should be screened for latent endemic fungal infections. Cotrimoxazole prophylaxis could be useful for preventing Pneumocystis jirovecii infection in patients over 65 years of age who are taking TNF antagonists, antilymphocyte biological agents or who have lymphopenia and are undergoing concomitant steroid therapy. As with other immunosuppressant drugs, TNF antagonists and antilymphocyte antibodies should be discontinued for patients with active infectious disease

El factor de necrosis tumoral (TNF) es una citocina proinflamatoria involucrada en una amplia gama de procesos fisiológicos importantes y desarrolla un papel en la patogenia de algunas enfermedades. Los antagonistas del TNF (infliximab, adalimumab, etanercept) son efectivos en el tratamiento de afecciones inflamatorias. Los agentes biológicos antilinfocitarios (rituximab, alemtuzumab), los antagonistas de la integrina (natalizumab, etrolizumab y vedolizumab), de la interleucina 17A (secukinumab, ixekizumab) o los antagonistas de la IL-2 (daclizumab, basiliximab) se usan ampliamente después del trasplante y en trastornos gastroenterológicos, reumatológicos, dermatológicos, neurológicos y hematológicos. Dado el papel relevante de estos elementos de defensa del huésped contra agentes bacterianos, virales y fúngicos, el riesgo de infección durante el tratamiento con estos antagonistas genera preocupación. Las infecciones por hongos, tanto oportunistas como endémicos, se han asociado con estas terapias biológicas, pero la relación causal no está clara, especialmente entre los pacientes con un control deficiente de su enfermedad subyacente o que están recibiendo terapia con esteroides. Los pacientes en tratamiento con estos medicamentos deben ser examinados para detectar infecciones micóticas endémicas latentes. La profilaxis con cotrimoxazol podría ser útil para prevenir la infección por Pneumocystis jirovecii en pacientes mayores de 65 años que estén tomando antagonistas de TNF, agentes biológicos antilinfocitarios, o tengan linfopenia y estén en tratamiento concomitante con esteroides. Al igual que con otros fármacos inmunosupresores, deben suspenderse los antagonistas de TNF y los anticuerpos antilinfocitarios en pacientes con enfermedad infecciosa activa hasta su control

Fungal infections following treatment with monoclonal antibodies and other immunomodulatory therapies.

Tumor necrosis factor (TNF) is a proinflammatory cytokine involved in a wide range of important physiologic processes and has a pathologic role in some diseases. TNF antagonists (infliximab, adalimumab, etanercept) are effective in treating inflammatory conditions. Antilymphocyte biological agents (rituximab, alemtuzumab), integrin antagonists (natalizumab, etrolizumab and vedolizumab), interleukin (IL)-17A blockers (secukinumab, ixekizumab) and IL-2 antagonists (daclizumab, basiliximab) are widely used after transplantation and for gastroenterological, rheumatological, dermatological, neurological and hematological disorders. Given the putative role of these host defense elements against bacterial, viral and fungal agents, the risk of infection during a treatment with these antagonists is a concern. Fungal infections, both opportunistic and endemic, have been associated with these biological therapies, but the causative relationship is unclear, especially among patients with poor control of their underlying disease or who are undergoing steroid therapy. Potential recipients of these drugs should be screened for latent endemic fungal infections. Cotrimoxazole prophylaxis could be useful for preventing Pneumocystis jirovecii infection in patients over 65 years of age who are taking TNF antagonists, antilymphocyte biological agents or who have lymphopenia and are undergoing concomitant steroid therapy. As with other immunosuppressant drugs, TNF antagonists and antilymphocyte antibodies should be discontinued for patients with active infectious disease.

Update in infectious diseases 2019

The IX Course of Antimicrobials and Infectious Diseases update included a review of the main issues in clinical microbiology, epidemiology and clinical aspects for a current approach of infectious pathology. The present introduction summarizes about the most important meetings related to infectious diseases during 2018 (ECCMID, IAS, ASM and ID Week). In addition, the course provides a practical information to focus on nosocomial infection models, with immunosuppressed patients or complex multidrug-resistant pathogens. The closing lecture of this year reviewed the infection during donation process

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Update in Infectious Diseases 2018 / Actualización en patología infecciosa 2018

VIII Updating Course of Antimicrobials and Infectious Diseases has reviewed useful microbiological, epidemiological and clinical aspects for a current approach of infectious pathology. Present manuscript summarizes a chronicle about the main infection related meetings during 2017 (ECCMID, IAS, ASM and ID Week). In addition, the course proposed a practical approach for understanding different type of pathogens and our selected topics this year were the epidemiology of bacterial nosocomial infection, a practical approach to Clostridium difficile infection patients, a two year selection of the top ten papers about fungal infection and an update in fungal biofilms. Finally, proffesors made a practical approach by main clinical syndromes like sepsis, infections in oncohematological patients, CNS infections in immunosuppressed patients and reviewed the top ten papers in transplant infectious diseases and infection control during the last two years

El VIII Curso de Actualización en Patología Infecciosa y Antimicrobianos de Uso Clínico revisó aspectos microbiológicos, epidemiológicos y clínicos útiles para un enfoque actual de la patología infecciosa. El manuscrito actual resume una crónica sobre las principales reuniones relacionadas con la infección durante 2017 (ECCMID, IAS, ASM y la Semana de identificación). Además, el curso propuso un enfoque práctico para comprender diferentes tipos de patógenos y nuestros temas seleccionados este año fueron la epidemiología de la infección nosocomial bacteriana, un enfoque practico en pacientes con infección por Clostridium difficile, una selección de los diez mejores artículos sobre infección fungica en los ultimos dos años y una actualización en biofilm fungicos. Finalmente, los profesores realizaron un abordaje de práctico por síndromes clínicos principales como sepsis, las infecciones en pacientes oncolohematológicos, las infecciones del sistema nervioso central en pacientes inmunosuprimidos y revisaron los diez articulos mas importantes en enfermedades infecciosas de trasplantes y control de infecciones en los ultimos 2 años

Update on management of invasive candidiasis / Actualización del tratamiento de la candidiasis invasiva

Given the growing incidence of invasive candidiasis in critically ill and haemato-oncological patients and its poor outcomes, an early diagnosis and treatment are need for get a better prognosis. This document reviews the current approaches that help in diagnosis of invasive candidiasis based on culture-independent microbiological tests. The combination of clinical prediction scores with fungal serological markers could facilitate the approach in antifungal therapy, optimizing it. This article also reviews the epidemiology and primary risk factors for invasive candidiasis in these patients, updating the therapeutic approach algorithms in both clinical contexts based on the main evidence and international guidelines (AU)

Dada la creciente incidencia de candidiasis invasiva en pacientes críticos y hematooncológicos y sus malos resultados, es necesario un diagnóstico y tratamiento precoz para obtener un mejor pronóstico. Este documento revisa los enfoques actuales que ayudan en el diagnóstico de candidiasis invasiva basado en pruebas microbiológicas independientes del cultivo. La combinación de puntuaciones de predicción clínica con marcadores serológicos fúngicos podría facilitar el enfoque en la terapia antifúngica, optimizándola. Este artículo también revisa la epidemiología y los principales factores de riesgo de candidiasis invasiva en estos pacientes, actualizando los algoritmos de abordaje terapéutico en ambos contextos clínicos basados en la evidencia publicada y en las guías internacionales (AU)

Update in Infectious Diseases 2017 / Actualización en patología infecciosa 2017

Antimicrobial resistance in complex models of continuous infection is a current issue. The update 2017 course addresses about microbiological, epidemiological and clinical aspects useful for a current approach to infectious disease. During the last year, nosocomial pneumonia approach guides, recommendations for management of yeast and filamentous fungal infections, review papers on the empirical approach to peritonitis and extensive guidelines on stewardship have been published. HIV infection is being treated before and more intensively. The implementation of molecular biology, spectrometry and inmunology to traditional techniques of staining and culture achieve a better and faster microbiological diagnosis. Finally, the infection is increasingly integrated, assessing non-antibiotic aspects in the treatment (AU)

La resistencia a los antimicrobianos en modelos cada vez más complejos de infección continúa siendo actualidad. El curso de actualización de este año 2017 trata aspectos microbiológicos, epidemiológicos y clínicos útiles para un abordaje actual de la patología infecciosa. Durante el último año se han publicado guías de aproximación a la neumonía nosocomial, recomendaciones sobre el manejo de la infección fúngica por levaduras y filamentosos, documentos de revisión sobre el abordaje empírico de la peritonitis y una extensas guías sobre stewardship. En la infección por el VIH, cada vez se trata antes y más intensamente. La implementación de la biología molecular, la espectrometría y la inmunología a las técnicas tradicionales de tinción y cultivo consiguen un diagnóstico microbiológico mejor y más rápido. Por último, la infección se aborda de forma cada vez más integral, valorando aspectos no antibióticos en el tratamiento (AU)

[Duration of antimicrobial therapy]. / Duración del tratamiento antibiótico.

The management of infectious diseases is always complex, not only because of its high incidence and mortality, but the difficulty of designing effective treatments that minimize the development of bacterial resistance in the clinical setting. One of the most important options is the reduction of exposure to antibiotic treatment, optimizing by desescalation and shortening the duration of therapy.

La duración del tratamiento antibiótico / Duration of antimicrobial therapy

El manejo de las enfermedades infecciosas es siempre complejo, no sólo por su elevada incidencia y mortalidad, sino por la dificultad de diseñar tratamientos eficaces, que minimicen el desarrollo de las resistencias bacterianas en el escenario clínico. Una de las opciones más importantes es la reducción de la exposición al tratamiento antibiótico optimizando mediante la desescalada y el acortamiento de la duración del mismo (AU)

The management of infectious diseases is always complex, not only because of its high incidence and mortality, but the difficulty of designing effective treatments that minimize the development of bacterial resistance in the clinical setting. One of the most important options is the reduction of exposure to antibiotic treatment, optimizing by desescalation and shortening the duration of therapy (AU)