Correction to: Atypical pathogens in hospitalized patients with community-acquired pneumonia: a worldwide perspective.

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International prevalence and risk factors evaluation for drug-resistant Streptococcus pneumoniae pneumonia.

OBJECTIVE: Streptococcus pneumoniae is the most frequent bacterial pathogen isolated in subjects with Community-acquired pneumonia (CAP) worldwide. Limited data are available regarding the current global burden and risk factors associated with drug-resistant Streptococcus pneumoniae (DRSP) in CAP subjects. We assessed the multinational prevalence and risk factors for DRSP-CAP in a multinational point-prevalence study. DESIGN: The prevalence of DRSP-CAP was assessed by identification of DRSP in blood or respiratory samples among adults hospitalized with CAP in 54 countries. Prevalence and risk factors were compared among subjects that had microbiological testing and antibiotic susceptibility data. Multivariate logistic regressions were used to identify risk factors independently associated with DRSP-CAP. RESULTS: 3,193 subjects were included in the study. The global prevalence of DRSP-CAP was 1.3% and continental prevalence rates were 7.0% in Africa, 1.2% in Asia, and 1.0% in South America, Europe, and North America, respectively. Macrolide resistance was most frequently identified in subjects with DRSP-CAP (0.6%) followed by penicillin resistance (0.5%). Subjects in Africa were more likely to have DRSP-CAP (OR: 7.6; 95%CI: 3.34-15.35, p<0.001) when compared to centres representing other continents. CONCLUSIONS: This multinational point-prevalence study found a low global prevalence of DRSP-CAP that may impact guideline development and antimicrobial policies.

Atypical pathogens in hospitalized patients with community-acquired pneumonia: a worldwide perspective.

BACKGROUND: Empirical antibiotic coverage for atypical pathogens in community-acquired pneumonia (CAP) has long been debated, mainly because of a lack of epidemiological data. We aimed to assess both testing for atypical pathogens and their prevalence in hospitalized patients with CAP worldwide, especially in relation with disease severity. METHODS: A secondary analysis of the GLIMP database, an international, multicentre, point-prevalence study of adult patients admitted for CAP in 222 hospitals across 6 continents in 2015, was performed. The study evaluated frequency of testing for atypical pathogens, including L. pneumophila, M. pneumoniae, C. pneumoniae, and their prevalence. Risk factors for testing and prevalence for atypical pathogens were assessed through univariate analysis. RESULTS: Among 3702 CAP patients 1250 (33.8%) underwent at least one test for atypical pathogens. Testing varies greatly among countries and its frequency was higher in Europe than elsewhere (46.0% vs. 12.7%, respectively, p < 0.0001). Detection of L. pneumophila urinary antigen was the most common test performed worldwide (32.0%). Patients with severe CAP were less likely to be tested for both atypical pathogens considered together (30.5% vs. 35.0%, p = 0.009) and specifically for legionellosis (28.3% vs. 33.5%, p = 0.003) than the rest of the population. Similarly, L. pneumophila testing was lower in ICU patients. At least one atypical pathogen was isolated in 62 patients (4.7%), including M. pneumoniae (26/251 patients, 10.3%), L. pneumophila (30/1186 patients, 2.5%), and C. pneumoniae (8/228 patients, 3.5%). Patients with CAP due to atypical pathogens were significantly younger, showed less cardiovascular, renal, and metabolic comorbidities in comparison to adult patients hospitalized due to non-atypical pathogen CAP. CONCLUSIONS: Testing for atypical pathogens in patients admitted for CAP in poorly standardized in real life and does not mirror atypical prevalence in different settings. Further evidence on the impact of atypical pathogens, expecially in the low-income countries, is needed to guidelines implementation.

Serum levels of immunoglobulins and severity of community-acquired pneumonia.

INSTRUCTION: There is evidence of a relationship between severity of infection and inflammatory response of the immune system. The objective is to assess serum levels of immunoglobulins and to establish its relationship with severity of community-acquired pneumonia (CAP) and clinical outcome. METHODS: This was an observational and cross-sectional study in which 3 groups of patients diagnosed with CAP were compared: patients treated in the outpatient setting (n=54), patients requiring in-patient care (hospital ward) (n=173), and patients requiring admission to the intensive care unit (ICU) (n=191). RESULTS: Serum total IgG (and IgG subclasses IgG1, IgG2, IgG3, IgG4), IgA and IgM were measured at the first clinical visit. Normal cutpoints were defined as the lowest value obtained in controls (≤680, ≤323, ≤154, ≤10, ≤5, ≤30 and ≤50 mg/dL for total IgG, IgG1, IgG2, IgG3, IgG4, IgM and IgA, respectively). Serum immunoglobulin levels decreased in relation to severity of CAP. Low serum levels of total IgG, IgG1 and IgG2 showed a relationship with ICU admission. Low serum level of total IgG was independently associated with ICU admission (OR=2.45, 95% CI 1.4 to 4.2, p=0.002), adjusted by the CURB-65 severity score and comorbidities (chronic respiratory and heart diseases). Low levels of total IgG, IgG1 and IgG2 were significantly associated with 30-day mortality. CONCLUSIONS: Patients with severe CAP admitted to the ICU showed lower levels of immunoglobulins than non-ICU patients and this increased mortality.

Mortality among methicillin-resistant Staphylococcus aureus carriers in long-term care facilities / Mortalidad entre los portadores de Staphylococcus aureus resistente a la meticilina en centros sociosanitarios

Introduction. Little is known about the natural course of patients with chronic stable illnesses colonized with methicillin-resistant Staphylococcus aureus (MRSA). The aim is to determine the impact of MRSA colonization in mortality among long-term health care facility (LTHCF) residents. Method. A multicenter, prospective, observational study was designed. Residents in 4 LTHCFs were classified according to MRSA carriage status and followed for 12 months. Treatment consisted of 5 days of nasal mupirocin in MRSA carriers. Results. Ninety-three MRSA-carriers among 413 residents were identified. Thirty-one MRSA-colonized patients died during the study period, 11 of whom from an infectious disease. Independent predictors of their higher mortality rates included heart failure, current neoplasm, MRSA carriage and COPD at 3 months and these same factors plus stroke, Barthel index (AU)

Introducción. La evolución natural de los pacientes con enfermedades crónicas y estables que son colonizados con Staphylococcus aureus resistente a la meticilina (SARM) es poco conocida. El objetivo es determinar el impacto de la colonización por SARM en la mortalidad entre los residentes de centros sociosanitarios (CSS). Métodos. Se diseñó un estudio multicéntrico, prospectivo y observacional. Los residentes de 4 CSS tras ser clasificados según su estado de portador de SARM, fueron sometidos a seguimiento durante 12 meses. Los portadores fueron tratados 5 días con mupirocina nasal. Resultados. Entre 413 residentes se identificaron 93 portadores. Durante el período de estudio murieron 31 colonizados, 11 de los cuales por infección. Predictores independientes de mortalidad incluyeron, a los 3 meses: insuficiencia cardíaca, neoplasia activa, colonización por SARM y enfermedad pulmonar obstructiva crónica; a los 12 meses incluyeron estos mismos factores y además: ictus, índice de Barthel (AU)

Prevalence and risk factors for meticillin-resistant Staphylococcus aureus in an acute care hospital and long-term care facilities located in the same geographic area / Prevalencia y factores de riesgo de Staphylococcus aureus resistente a meticilina en un hospital de agudos y cuatro centros sociosanitarios de una misma área geográfica

To determine the prevalence and risk factors (RF) for methicillin-resistant Staphylococcus aureus (MRSA) during stay in 1 acute care hospital (ACH) and 4 long-term care facilities (LTCF). After obtaining the informed consent, nasal and skin ulcer swabs were taken and a survey was conducted to determine RF for MRSA. Six hundred and ninety nine patients were included, 413 LTCF and 286 ACH patients and MRSA prevalence were 22.5% and 7.3% respectively. MRSA was located in the nares, skin ulcers, and in both in 61.4%, 21.1%, and 17.5%. Among MRSA carriers, 81% of the ACH and 66.7% of the LTCF patients were only colonized. The multivariate analysis for the ACH revealed the following factors to be associated with MRSA: referral from an LTCF (OR 4.84), pressure ulcers (OR 4.32), a Barthel score < 60 (OR 2.60), and being male (OR 5.21). For the LTCF: urinary catheterisation (OR 3.53), pressure ulcers (OR 2.44), other skin lesions (OR 2.64), antibiotic treatment in ≤ 6 months, (OR 2.23), previous MRSA colonization (OR 2.15), and a Barthel score <20 (OR 1.28). Molecular typing identified 2 predominant clones Q, P, present in all centres. No relationship was found between clones and antibiotic susceptibility. In conclusion: MRSA prevalence is high in all centres but is 3 times greater in LTCF. The risk factors most strongly associated with MRSA were pressure ulcers and a stay in an LTCF. We propose preventive isolation in these cases (AU)

El objetivo de este estudio es determinar la prevalencia y factores de riesgo de Staphylococcus aureus resistente a meticilina (SARM) en 1 hospital de agudos y 4 centros socio sanitarios (CSS) de la misma área geográfica. Después de obtener el consentimiento informado de los pacientes se efectuó un frotis nasal y de úlceras cutáneas a los pacientes ingresados en las 5 instituciones. Al mismo tiempo se pasó un cuestionario para establecer los factores de riesgo de SARM. Se estudiaron 699 enfermos, 413 en los CSS y 286 en el hospital. La prevalencia de SARM en los CSS fue del 22,5% y del 7,3% en el hospital. Las localizaciones fueron nasal 61,4%, úlceras de decúbito 21,1% y ambas localizaciones 17,5%. El 81% de los portadores de SARM en el hospital y el 66,7% en los CSS estaban exclusivamente colonizados. El análisis multivariado en el hospital mostró que eran factores independientemente asociados a SARM: proceder de un CSS o residencia (OR 4,84), tener úlceras de decúbito (OR 4,32), un índice de Barthel <60 (OR 2,60) y ser varón (OR 5,21). En los CSS los factores independientemente asociados a SARM eran el sondaje urinario (OR 3,53), las úlceras de decúbito (OR 2,44) y otras lesiones cutáneas (OR 2,64), haber tomado antibióticos en los últimos 6 meses (OR 2,23), la colonización previa por SARM (OR 2,15) y un índice de Barthel < 20 (OR 1,28). Mediante tipificación molecular se han identificado 2 clones epidémicos predominantes Q y P distribuidos en todos los centros. No se ha observado relación entre los genotipos y la sensibilidad antibiótica. Conclusión: La prevalencia de SARM es alta en los 5 centros, siendo en los CSS tres veces superior a la del hospital. Las úlceras de decúbito y proceder de un CSS son los factores más fuertemente asociados a SARM por lo que proponemos que un aislamiento preventivo en estos pacientes (AU)

Influencia del medio y del ejercicio físico sobre las inmunoglobulinas séricas durante una carrera de trineos de nieve en montaña / Influence of environmental conditions and exercise on serum inmunoglobulin levels in a mushing race

Intencionalidad: El frío, la altitud y el ejercicio durante las actividades de montaña pueden alterar el sistema inmunitario humano según revisión de la literatura. Además, se ha observado un déficit transitorio del nivel de inmunoglobulinas plasmáticas (Ig) durante la fase aguda en neumonías adquiridas en la comunidad (NAC) en adultos. Los autores del presente trabajo tienen la intención de verificar estas apreciaciones en un grupo de deportistas de montaña. Objetivo: Confirmar la hipótesis que los niveles de Ig disminuyen con el ejercicio mantenido en un ambiente de frío en alta montaña. El objetivo secundario es estudiar su implicación en las infecciones respiratorias del deportista en la nieve. Metodología: Estudio observacional y prospectivo de los participantes en una carrera de trineos de tiro con perros. Se estudiaron los concursantes (casos, subdivididos en corredores de trineo/esquís de tiro y en cuidadores de perros) y el personal de la organización (controles). Se obtuvieron datos demográficos y dos muestras sanguíneas para determinar niveles de Ig: una al inicio y otra durante la segunda semana de competición. Se compararon los niveles sucesivos de Ig, inter e intraindividuales, con pruebas no paramétricas: Kruskal Wallis, rangos de Wilcoxon, U de Mann-Whitney. Resultados: Se reclutaron 47 sujetos, de los que 14 eran concursantes y 33 personas de apoyo u organización. Se obtuvo información epidemiológica de 31 individuos. En la determinación basal los niveles de IgA e IgM fueron inferiores en el grupo de corredores respecto al grupo control (176 vs 245 mg/dL, p=0,02; y 94 vs 125 mg/dL, p=0,045 respectivamente), independientemente de la edad, género, entrenamiento previo o lugar de residencia. En la segunda determinación no se obtuvieron diferencias significativas en ninguna de las Ig, incluso tras estratificación por grupos (corredores/organizadores) o nivel de entrenamiento previo. Conclusiones: La concentración de IgA tiende a ser menor en personas que practican ejercicio en altitud. No se pudo verificar la influencia del déficit de Ig en infecciones respiratorias y hacen falta más estudios con mayor número de participantes para definir mejor la relación entre ejercicio, variables ambientales, déficit inmunológico y el desarrollo de infección. Esta información puede ayudar a elaborar recomendaciones para las personas que practican deporte en altura, con intención de minimizar el riesgo de infección

Background: It is well known that cold, altitude and exercise during mountain activities can impair the human immune system. Moreover, a transient decrease in plasma immunoglobulins (Ig) levels during the acute phase of adults’ community acquired pneumonia (CAP) has been observed. The authors intend to verify these statements in a group of mountain athletes. Objective: Our main objective was to confirm that serum Ig levels decrease after sustained exercise in a cold environment at high altitude. The secondary objective is to study their role in winter sportsperson’s respiratory tract infections. Methods: A prospective observational study was done, enrolling participants of a mushing race: contestants (cases, divided into mushers/skijörers and handlers) and organization staff (controls). Demographical data and a blood sample were collected at the beginning and a second blood sample during the second week of the competition. Ig levels in each sample levels were determined and comparisons were done with non-parametric tests: Kruskal Wallis, Wilcoxon signed-rank, Mann-Whitney U. Results: Information from 31 individuals and plasma Ig levels from 47 was available for analysis, studying 14 cases and 33 controls. IgA and IgM levels were decreased in the fi rst sample when participants in the race and supporting staff were compared (176 vs 245 mg/dL, p=0.02; and 94 vs 125 mg/dL, p=0.045), irrespective of age, gender, previous physical activity or place of residence. In the second sample no significant differences in any Ig class were disclosed, even after stratification by groups (case/control) or previous training level. Conclusions: IgA levels tend to be decreased in people who exercise at high altitude, but further studies with a greater number of participants are needed to better define the relationship between exercise, environmental variables, immunological deficit, and the development of infections. Influence of low levels of Ig on respiratory tract infections could not be verified. This information could help in the development of recommendations to people practicing sports at high altitude, in order to minimize the risk of infection

Serum immunoglobulins in the infected and convalescent phases in community-acquired pneumonia.

BACKGROUND: A population-based case-control study was designed to assess changes of serum levels of immunoglobulins and IgG subclasses between infected and convalescent phase in community-acquired pneumonia (CAP). METHODS: Over a 2-year period, all subjects who were >14 years of age living in the Maresme region (Barcelona, Spain) diagnosed of CAP were registered. Controls were healthy subjects selected from the municipal census. Prognostic factors were assessed and serum levels of total IgG, IgA, IgM, and IgG subclasses were measured at diagnosis and 1 month later (cases). RESULTS: We studied 171 patients with CAP and 90 controls. All immunoglobulins were significantly lower in cases than in controls. At diagnosis, 42.7% of cases showed low levels of some immunologic parameter, mainly total IgG and IgG2. Low immunoglobulin levels at diagnosis were more frequent in patients requiring in-patient care and in those with pneumonia of other etiology than Streptococcus pneumoniae. In the convalescent phase, 26 (23.6%) patients normalized immunological levels. In 27 (24.5%) cases, some parameter with low levels persisted especially in patients with etiology of CAP other than S. pneumoniae. CONCLUSIONS: Low serum levels of immunoglobulins particularly total IgG and IgG2 were a common finding in patients with CAP compared to healthy controls. Low immunoglobulin levels may be related to CAP prognosis and persisted in the convalescent phase in one-fourth of cases.