Vacunación frente a la neumonía adquirida en la comunidad del adulto. Posicionamiento del Grupo de Neumoexpertos en Prevención / Vaccination against community acquired pneumonia in adult patients. A position paper by Neumoexpertos en Prevención

Introducción. La neumonía adquirida en la comunidad (NAC) es una causa importante de morbimortalidad en adultos. La incidencia anual de NAC en adultos en España varía entre 3 y 14 casos por 1.000 habitantes. Las guías clínicas actuales se centran básicamente en el abordaje terapéutico de la NAC más que en su prevención. El objetivo de este estudio es desarrollar y proponer una guía práctica de prevención de la NAC mediante vacunación en España en función de las vacunas y las evidencias disponibles. Métodos. Revisión bibliográfica y opinión de expertos. Resultados. Las vacunas contra el neumococo y la gripe son las principales herramientas preventivas disponibles frente a la NAC. La edad, las enfermedades crónicas y la inmunosupresión son factores de riesgo para la neumonía, por lo que estas poblaciones deben ser objetivo prioritario de vacunación. Además, se considera recomendable la vacunación antigripal y antineumocócica tanto en el adulto sano de menos de 60 años como en cualquier persona de cualquier edad con condición de riesgo para NAC. La vacuna de la gripe se administrará estacionalmente, mientras que la vacunación antineumocócica podrá administrarse en cualquier momento del año. Conclusiones. La vacunación frente a neumococo y gripe en el adulto puede contribuir a disminuir la carga de enfermedad por NAC y sus complicaciones asociadas. La evidencia disponible avala las indicaciones prioritarias establecidas en esta guía, y sería recomendable tratar de lograr una difusión e implementación amplia en la práctica de estas recomendaciones (AU)

Introduction. Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in adults. The annual incidence of CAP in adults in Spain ranges from 3 to 14 cases per 1,000 inhabitants. Current clinical guidelines primarily focus on the therapeutic approach to CAP rather than its prevention. The aim of this study is to develop and propose a practical guide for CAP prevention through vaccination in Spain according to available vaccines and evidence. Methods. A literature review and expert opinion. Results. Pneumococcal and influenza vaccines are the main preventive tools available against CAP. Age, chronic diseases, and immunosuppression are risk factors for pneumonia, so these populations should be a priority for vaccination. In addition, influenza and pneumococcal vaccination is considered advisable in healthy adults under 60 years of age, and anyone with risk condition for CAP, irrespective of age. The influenza vaccine will be administered seasonally, while pneumococcal vaccination can be administered at any time of the year. Conclusions. Vaccination against pneumococcus and influenza in adults can help to reduce the burden of CAP and its associated complications. The available evidence supports the priority indications set out in this guide, and it would be advisable to try to achieve a wide circulation and practical implementation of these recommendations (AU)

[Vaccination against community acquired pneumonia in adult patients. A position paper by Neumoexpertos en Prevención]. / Vacunación frente a la neumonía adquirida en la comunidad del adulto. Posicionamiento del Grupo de Neumoexpertos en Prevención.

INTRODUCTION: Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in adults. The annual incidence of CAP in adults in Spain ranges from 3 to 14 cases per 1,000 inhabitants. Current clinical guidelines primarily focus on the therapeutic approach to CAP rather than its prevention. The aim of this study is to develop and propose a practical guide for CAP prevention through vaccination in Spain according to available vaccines and evidence. METHODS: A literature review and expert opinion. RESULTS: Pneumococcal and influenza vaccines are the main preventive tools available against CAP. Age, chronic diseases, and immunosuppression are risk factors for pneumonia, so these populations should be a priority for vaccination. In addition, influenza and pneumococcal vaccination is considered advisable in healthy adults under 60 years of age, and anyone with risk condition for CAP, irrespective of age. The influenza vaccine will be administered seasonally, while pneumococcal vaccination can be administered at any time of the year. CONCLUSIONS: Vaccination against pneumococcus and influenza in adults can help to reduce the burden of CAP and its associated complications. The available evidence supports the priority indications set out in this guide, and it would be advisable to try to achieve a wide circulation and practical implementation of these recommendations.

[Is the breath test reliable in primary care diagnosis of Helicobacter pylori infection?]. / ¿Es fiable el test del aliento para el diagnóstico de infección por Helicobacter pylori en atención primaria?

OBJECTIVE: To evaluate the reliability of the breath test urea 13C in the primary care for the diagnosis of Helicobacter pylori (Hp) infection. DESIGN: Descriptive, prospective and multicentric.Location. Urban area belonging to the Health Center Actur Sur of Zaragoza with participation of Miguel Servet Hospital. PARTICIPANTS: 87 patients with clinical diagnosis of functional dispepsia. In all of them was made a breath test with 13C urea as well as a gastroscopy with taking of samples for histology and ureasa fast test. MAIN MEASUREMENTS: Age, sex and the presence of positivity or negativity of infection by Hp were valued in the histology, ureasa test and in the breath test, considering the histology and the ureasa test like gold tests for this measurement, reason why it was demanded that the positive or outside negative result in both considering it nonambiguous. RESULTS: Two cases were excluded by ambiguous results. The 77.6% (66/85) were positive by histology and ureasa test, and these, 92.4% (61/66) were positives to the breath test. The sensitivity of this test was 92% and the specificity 100%. CONCLUSIONS: The breath test in primary care has a high value diagnosis of Hp infection, being able to avoid, in some cases, another invasives techniques like gastroscopy.

¿Es fiable el test del aliento para el diagnóstico de infección por Helicobacter pylori en atención primaria? / Is the breath test reliable in primary care diagnosis of Helicobacter pylori infection?

Objetivo. Evaluar la fiabilidad del test del aliento con urea 13C en atención primaria para el diagnóstico de infección por Helicobacter pylori (Hp).Diseño. Estudio descriptivo, prospectivo y multicéntrico. Emplazamiento. Área urbana perteneciente al Centro de Salud Actur Sur de Zaragoza, con participación del Hospital Miguel Servet. Participantes. Se incluyó a 87 pacientes con diagnóstico clínico de dispepsia funcional. A todos ellos se les realizó un test de aliento con urea 13C, así como una gastroscopia con toma de muestras para histología y test de ureasa rápida. Mediciones principales. Se valoraron edad, sexo y la presencia de positividad o negatividad de infección por Hp en la histología, el test de ureasa y el test del aliento, considerando la histología y el test de ureasa pruebas gold standard para esta medición, por lo que se exigía que el resultado en ambas fuera positivo o negativo para considerarlo no equívoco. Resultados. Se excluyeron 2 casos por resultados equívocos. El 77,6 per cent (66/85) fue positivo por histología y test de ureasa, de los que un 92,4 per cent (61/66) resultó positivo al test del aliento. La sensibilidad de esta prueba fue del 92 per cent y la especificidad del 100 per cent. Conclusiones. El test del aliento en atención primaria tiene un alto valor diagnóstico de infección por Hp, pudiendo evitar así en algunos casos la realización de técnicas más invasivas como la gastroscopia (AU)

[Failure of rapid serology for Helicobacter pylori as diagnostic method in primary care consultation]. / Fracaso de la serología rápida para Helicobacter pylori como método diagnóstico en la consulta de atención primaria.

OBJECTIVE: To evaluate the validity of a rapid serology test for diagnosing Helicobacter pylori infection in our area. DESIGN: Longitudinal, prospective study. SETTING: Urban primary care centre. MEASUREMENTS: As reference tests for defining the presence/absence of Helicobacter pylori, histology and the urease gastric mucous membrane test (Jatrox(R) test) were used. Both tests can be either positive or negative, without intermediate values. RESULTS: 47 consecutive patients were included. Histology (confirmed with the urease test) showed infection in 38 cases (80.85% prevalence). The results of rapid serology (95% CI) were: sensitivity 0.66 (0.51-0.81), specificity 1 (1-1), positive predictive value 1 (1-1), and negative predictive value 0.41 (0.2-0-61). CONCLUSIONS: In a population with high prevalence of infection, a positive in the rapid serology test confirms infection. However, a negative does not discount infection, which significantly reduces the test's overall diagnostic value. This confirms in the primary care context the findings of hospital-based studies.

Fracaso de la serología rápida para Helicobacter pylori como método diagnóstico en la consulta de atención primaria / Failure of rapid serology for helicobacter pylori as diagnostic method in the primary care clinic

Objetivo. Evaluar la validez de una prueba de serología rápida para el diagnóstico de infección por Helicobacter pylori en nuestro medio. Diseño. Estudio prospectivo, longitudinal. Emplazamiento. Centro de atención primaria urbano. Mediciones. Como pruebas de referencia para definir la presencia/ausencia de Helicobacter pylori se utilizan la histología y el test de ureasa de mucosa gástrica (Jatroxtest®). Ambos tests pueden ser positivos o negativos sin valores intermedios. Se comparan con el test de referencia, calculándose sensibilidad, especificidad y valores predictivos. Resultados. Se incluyeron 47 pacientes consecutivos. La histología (confirmada con test de ureasa) demostró infección en 38 casos (prevalencia, 80,85 por ciento). Los resultados de la serología rápida con intervalos de confianza del 95 por ciento son: sensibilidad, 0,66 (0,51-0,81); especificidad, 1 (1-1); valor predictivo positivo, 1 (1-1), y valor predictivo negativo, 0,41 (0,2-0,61). Conclusiones. En una población con alta prevalencia de infección, el test de serología rápida positivo confirma la infección. Sin embargo, un test negativo no la descarta, lo que disminuye significativamente el valor diagnóstico global, confirmando en el medio primario los resultados de estudios hospitalarios. (AU)

[Cost-effectiveness analysis of 2 strategies of Helicobacter pylori eradication: results of a prospective and randomized study in primary care]. / Análisis coste-efectividad de dos estrategias de erradicación de Helicobacter pylori: resultados de un estudio prospectivo y aleatorizado en atención primaria.

BACKGROUND: To analyze cost-effectiveness of two different strategies to treat H. pylori infection in peptic ulcer in the primary care setting. PATIENTS AND METHODS: Consecutive patients with endoscopic diagnosis of peptic ulcer were randomized to one of two strategies: a) treatment during 7 days with omeprazole, tetracycline, metronidazole and bismuth subcitrate ("quadruple" therapy) and if failure second-line treatment with omeprazole, amoxycillin and clarithromycin during 7 days (OCA7), and b) initial treatment with OCA7 and if failure treatment with "quadruple therapy". End point was eradication 8 weeks after last treatment dose. Direct and indirect costs were estimated (euros, 1997) and a cost-effectiveness analysis using a decision-tree model was undertaken after real clinical data. 95% confidence intervals are given. RESULTS: After screening 255 patients, 97 were finally included. 48 patients were given strategy a and 49 strategy b. Eradication was obtained (intention-to-treat) in 72.9% (CI 95%: 58.2-84.7) in group a versus 91.8% (CI 95%: 80.4-97.7) (p < 0.05) in group b. Mean cost per case treated was lower in group a (237 versus 268 euros) but cost per case eradicated was lower in group b (320 versus 296 euros). The cost was primarily determined by efficacy. CONCLUSIONS: Treatment with OCA7 followed by rescue with "quadruple" therapy if failure is more efficient in our area that the inverse strategy. Efficiency is mostly determined by efficacy.

Eradication of helicobacter pylori among patients from a primary care practice.

BACKGROUND: The eradication of Helicobacter pylori is becoming the therapy of choice for peptic ulcers, if the infection is present. Published data from primary care settings are, however, limited. METHODS: An open-ended, prospective study was undertaken that included 31 patients with active peptic ulcer demonstrated by endoscopy and H pylori infection confirmed by urease and histologic tests. After a 14-day period of treatment with omeprazole, bismuth, tetracycline, and metronidazole, healing and H pylori status were evaluated by repeat endoscopy done at least 28 days after the last treatment dose. Eradication is defined as absence of H pylori in at least four (two from the fundus and two from the antrum) samples taken from the gastric mucosa and a negative urease test. Drug side effects and patient compliance were monitored in all cases. RESULTS: Twenty-eight patients completed the protocol. Healing was obtained in all cases, and eradication was accomplished in 25 (89%). Side effects were common (69%) but mild. Compliance was good. After a mean follow-up of 300 days (range, 180 to 400), one ulcer recurrence was observed in an H pylori-positive patient and none in H pylori-negative patients. CONCLUSIONS: The treatment of H pylori infection is an effective way of healing peptic ulcers, and can be applied in primary care settings. Further studies with more patients and with shorter and easier therapies should be undertaken to confirm our findings.

[The value of symptoms in the diagnosis of peptic ulcer: an approximation to the primary care medium]. / Valor de los síntomas en el diagnóstico de la úlcera péptica: una aproximación al medio primario.

GOAL: To evaluate which clinical data are useful to select those patients with peptic ulcers in primary care most likely to benefit from complementary studies. METHODS: This is a prospective study done on 101 patients evaluated in a period of a year in a Primary Care Center. In all patients an endoscopy was done when a peptic ulcer was considered a possibility. In all cases a standardized questionnaire was completed before endoscopy and the patient evaluated by his primary care physician. The final diagnosis was defined according to endoscopy, done by expert endoscopists within seven days of the clinical evaluation. Statistical analysis was undertaken with SPSS software. RESULTS: An active peptic ulcer was found in 45 (44.5%) cases. A high-grade MALT lymphoma was diagnosed in one case. Male sex, smoking status, number of cigarettes, smoking-index, and a previous history of ulcer complications were significantly associated with the diagnosis, as well as severe diurnal or nocturnal pain. Mean age was lower in ulcer patients. However no clinical data in individual or combined form did show any predictive value. CONCLUSIONS: Clinical data do not permit to obviate endoscopy as the key initial procedure to diagnosis, even in primary care.