Community-acquired pneumonia in immunocompromised older patients: incidence, causative organisms and outcome.

The number of elderly patients in the community with immunosuppressive conditions has increased progressively over recent decades. We sought to determine the incidence, causative organisms and outcome of community-acquired pneumonia (CAP) occurring in immunocompromised older patients. We prospectively compared cases of CAP in immunocompromised and non-immunocompromised patients admitted to five public hospitals in three Spanish regions. Of 320 cases studied, 115 (36%) occurred in immunocompromised patients, including: solid or hematological malignancy (97), corticosteroids or other immunosuppressive drugs (44), solid organ or stem cell transplant (five), and other conditions (eight). The etiology was established in 44% of immunocompromised patients vs. 32% of non-immunocompromised patients (p 0.03). Streptococcus pneumoniae was the most common causative organism in both groups (29% vs. 21%; p 0.08), followed by Legionella pneumophila (3% vs. 6%; p 0.01). Gram-negative bacilli were more frequent among immunocompromised patients (5% vs. 0.5%; p <0.01), particularly Pseudomonas aeruginosa (3% vs. 0%; p 0.04). Nocardiosis was only observed in immunocompromised patients (two cases). Bacteremia occurred similarly in the two groups. No significant differences were found with respect to ICU admission (8%, in both groups) or the length of stay (12.5 vs. 10.4 days). The early (<48 h) (3.5 vs. 0.5%; p 0.04) and overall case-fatality rates (12% vs. 3%; p <0.01) were higher in immunocompromised patients. In conclusion, a substantial number of older patients hospitalized for CAP are immunocompromised. Although relatively uncommon, CAP due to gram-negative bacilli, including P. aeruginosa, is more frequent among these patients. CAP occurring in immunocompromised patients causes significant morbidity and mortality.

Effectiveness of the pneumococcal polysaccharide vaccine in preventing pneumonia in the elderly.

The objective of our study was to evaluate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV) in preventing hospital admission for community-acquired pneumonia (CAP) in people ≥65 yrs of age. We conducted a matched case-control study in patients with CAP admitted to five Spanish hospitals. Cases were persons aged ≥65 yrs admitted to hospital through the emergency department, who presented a clinical and radiological pattern compatible with pneumonia, assessed using established criteria. We matched each case with three control subjects by sex, age (±5 yrs), date of hospitalisation (±30 days) and underlying disease. The study period was May 1, 2005 to January 31, 2007. The PPV immunisation status of cases and controls was investigated. Adjusted ORs for vaccination were calculated using logistic regression analysis. A total of 489 cases and 1,467 controls were included in the final analysis. The overall adjusted vaccination effectiveness for all patients was 23.6% (95% CI 0.9-41.0). The adjusted vaccination effectiveness for immunosuppressed patients was 21.0% (95% CI -18.7-47.5). Our results suggest that the PPV may potentially reduce hospitalisations for pneumonia in the elderly and supports vaccination programmes in this age group.

[Diagnosis and prevention of tuberculosis in hemodialysis patients. a new old problem?]. / Detección y prevención del desarrollo de tuberculosis en pacientes en hemodiálisis. Un antiguo problema actual?

Patients with chronic renal failure undergoing hemodialysis are at increased risk of developing tuberculosis because of impaired cellular immunity. Most cases are due to reactivation of disease and are known to develop the complication of extrapulmonary tuberculosis more frequently than the general population, and this makes the disease difficult to diagnose, delaying the establishment of appropiate therapy. We evaluated 39 patients undergoing hemodialysis treatment in the course of a 3 year period, therewere. Tuberculosis control program was developed to evaluate all patients newly admitted to the renal dialysis program. All of the patients were skin-tested initially with use 2 U.I. tuberculin PPD RT23, and 16 patients had positive results. Three cases of tuberculosis -registered that developed in patients, and in exposed patients, 3 patients with negative test result 2 months later had positive test. No relationship was found between the results of the tests and age, sex, renal disease, other pathologies or previous tuberculosis and albumin figures. However, positive patients had higher levels of total leukocytes. The period from undergoing hemodialysis until mantoux testing was performed was lower in those patients who resulted positive: 9.4+/-13.6 months versus 32.9+/-39 months in negative patients. The use of mantoux testing is important as a sieve system in hemodialysis patients as long as is associated with other diagnosis techniques, detecting that way those cases at risk of developing tuberculosis and latting perform further studies and isoniacida prophylaxis. Establishing isoniacida prevention in hemodialysis patients can avoid the development of tuberculosis in patients at risk as well as prompt detection makes easier the establishment of right therapy.

Detección y prevención del desarrollo de tuberculosis en pacientes en hemodiálisis. ¿Un antiguo problema actual? / Tuberculosis in hemodialysis patients. A new old problem?

El paciente con insuficiencia renal crónica en tratamiento con hemodiálisis tiene incrementado el riesgo de desarrollar enfermedad tuberculosa. La escasez de síntomas, su posible confusión con sintomatología propia de su insuficiencia renal, y la circunstancia de tratarse en muchos casos de reactivaciones de enfermedad antigua con alta incidencia de formas extrapulmonares, dificultan el diagnóstico y retrasan la adopción de medidas terapéuticas. Durante un período de tres años se valora la incidencia de enfermedad tuberculosa en una unidad de hemodiálisis, mediante la aplicación y el establecimiento de un programa de detección, prevención y tratamiento precoces, que incluye la realización de mantoux al inicio de tratamiento sustitutivo y quimioprofilaxis en pacientes susceptibles de padecer la enfermedad. El estudio incluye 39 pacientes con insuficiencia renal crónica que han recibido tratamiento con hemodiálisis en nuestro centro. El test de mantoux fue positivo en 19 pacientes: en 16 casos el test cutáneo fue inicialmente positivo de los cuales dos casos desarrollaron enfermedad tuberculosa, y 3 pacientes más evidenciaron positivización del mantoux tras una exposición. No se encontró relación entre la positividad o negatividad del mantoux y edad, sexo, patología renal de base, patologías concomitantes, antecedentes de tuberculosis antigua o cifras de albúmina, pero existía una cifra ligeramente más elevada de leucocitos totales en los pacientes con test cutáneo positivo. El tiempo que habían permanecido en hemodiálisis hasta la realización del mantoux era inferior en los pacientes con positividad: 9,4 +/- 13,6 meses frente a 32,9 +/- 39 meses en los pacientes con negatividad. La utilidad del mantoux como sistema de cribaje es de utilidad en el paciente en hemodiálisis cuando se valora con otras técnicas diagnósticas, detectando los casos con posibilidad de desarrollar tuberculosis y permitiendo valorar la indicación de más estudios y de quimioprofilaxis con isoniacida. El mantenimiento de un sistema de vigilancia y control profiláctico con isoniacida en las unidades de hemodiálisis puede evitar el desarrollo de enfermedad tuberculosa en pacientes susceptibles y su detección precoz facilita la instauración de medidas terapéuticas (AU)

[Tuberculosis in hemodialysis patients and evaluation of exposures]. / Tuberculosis en hemodiálisis: casos coincidentes en el tiempo y valoración de contactos.

Three cases of tuberculosis in hemodialysis patients are described. All of them had an insidious presentation: a pulmonary form, a pleural form and a lymphadenitis form of the disease. The three cases presented risk factors associated and in two out of the three the detection of the team was achieved during the first three months of hemodialysis therapy (one had to undertake hemodialysis again, after disfunction of renal transplant). The three teams happened within two months. Owing to this, an evaluation of exposure was carried out in patients, staff and collective transport personnel making tuberculin test conversion clear in all three groups and establishing chemoprophylaxis afterward. Isoniacide prophylaxis eliminates a possible need for multidrug therapy for active tuberculosis at a future date, but decisions to institute preventive therapy are always difficult. To successfully combat the spread of tuberculosis, timely identification and treatment of high-risk populations is essential.