Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala.

BACKGROUND: Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged ≥18 years hospitalized with ARI in Guatemala. METHODS: We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and ≥ 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician's discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases. RESULTS: Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults ≥18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases. CONCLUSIONS: Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality.

Incidence of Hospitalized Pneumococcal Pneumonia among Adults in Guatemala, 2008-2012.

BACKGROUND: Streptococcus pneumoniae is a leading cause of pneumonia worldwide. However, the burden of pneumococcal pneumonia among adults in low- and middle-income countries is not well described. METHODS: Data from 2008-2012 was analyzed from two surveillance sites in Guatemala to describe the incidence of pneumococcal pneumonia in adults. A case of hospitalized pneumococcal pneumonia was defined as a positive pneumococcal urinary antigen test or blood culture in persons aged ≥ 18 years hospitalized with an acute respiratory infection (ARI). RESULTS: Among 1595 adults admitted with ARI, 1363 (82%) had either urine testing (n = 1286) or blood culture (n = 338) performed. Of these, 188 (14%) had pneumococcal pneumonia, including 173 detected by urine only, 8 by blood culture only, and 7 by both methods. Incidence rates increased with age, with the lowest rate among 18-24 year-olds (2.75/100,000) and the highest among ≥65 year-olds (31.3/100,000). The adjusted incidence of hospitalized pneumococcal pneumonia was 18.6/100,000 overall, with in-hospital mortality of 5%. CONCLUSIONS: An important burden of hospitalized pneumococcal pneumonia in adults was described, particularly for the elderly. However, even adjusted rates likely underestimate the true burden of pneumococcal pneumonia in the community. These data provide a baseline against which to measure the indirect effects of the 2013 introduction of the pneumococcal conjugate vaccine in children in Guatemala.

Using Standardized Interpretation of Chest Radiographs to Identify Adults with Bacterial Pneumonia--Guatemala, 2007-2012.

BACKGROUND: Bacterial pneumonia is a leading cause of illness and death worldwide, but quantifying its burden is difficult due to insensitive diagnostics. Although World Health Organization (WHO) protocol standardizes pediatric chest radiograph (CXR) interpretation for epidemiologic studies of bacterial pneumonia, its validity in adults is unknown. METHODS: Patients (age ≥ 15 years) admitted with respiratory infections to two Guatemalan hospitals between November 2007 and March 2012 had urine and nasopharyngeal/oropharyngeal (NP/OP) swabs collected; blood cultures and CXR were also performed at physician clinical discretion. 'Any bacterial infection' was defined as a positive urine pneumococcal antigen test, isolation of a bacterial pneumonia pathogen from blood culture, or detection of an atypical bacterial pathogen by polymerase chain reaction (PCR) of nasopharyngeal/oropharyngeal (NP/OP) specimens. 'Viral infection' was defined as detection of viral pathogens by PCR of NP/OP specimens. CXRs were interpreted according to the WHO protocol as having 'endpoint consolidation', 'other infiltrate', or 'normal' findings. We examined associations between bacterial and viral infections and endpoint consolidation. FINDINGS: Urine antigen and/or blood culture results were available for 721 patients with CXR interpretations; of these, 385 (53%) had endpoint consolidation and 253 (35%) had other infiltrate. Any bacterial infection was detected in 119 (17%) patients, including 106 (89%) pneumococcal infections. Any bacterial infection (Diagnostic Odds Ratio [DOR] = 2.9; 95% confidence Interval (CI): 1.3-7.9) and pneumococcal infection (DOR = 3.4; 95% CI: 1.5-10.0) were associated with 'endpoint consolidation', but not 'other infiltrate' (DOR = 1.7; 95% CI: 0.7-4.9, and 1.7; 95% CI: 0.7-4.9 respectively). Viral infection was not significantly associated with 'endpoint consolidation', 'other infiltrate,' or 'normal' findings. INTERPRETATION: 'Endpoint consolidation' was associated with 'any bacterial infection,' specifically pneumococcal infection. Therefore, endpoint consolidation may be a useful surrogate for studies measuring the impact of interventions, such as conjugate vaccines, against bacterial pneumonia.

[Phenotypical determinants of stem cell subpopulations derived from human umbilical cord blood]. / Determinación fenotípica de subpoblaciones de células madre derivadas de sangre de cordón umbilical.

INTRODUCTION: Human umbilical cord blood (HUCB) is a common source of hematopoietic progenitor cells; however, coexpression of CD34, CD38 and HLA DR antigens and of embryonic antigens (SSEA-4 and CD13) have not been described in HUCB. OBJECTIVE: The current study attempted to identify in HUCB the presence of these antigens. MATERIALS AND METHODS: Cord blood samples were obtained from 80 women with normal pregnancies, who were attending the gynecology-obstetrics service of the San Ignacio Hospital, Bogotá (Colombia). The antigens were identified with a FACS Calibur BDO flow cytometer and a cocktail of monoclonal antibodies. RESULTS: The population of CD34+ cells in HUCB was higher than 0.2% (p = 0.001). The levels of additional cell subpopulations were as follows: CD34+/CD38-/HLA-DR--0.015%-0.023%, CD34+/CD38+/HLA-DR--0.019%-0.30%, CD34+/CD38-/HLA-DR(+)--0.043%-0.068% and CD34+/CD38+/HLA-DR--0.24%-0.51%. Eight samples of the eighty were positive for embryonic markers. The most frequent phenotype in HUCB was CD34+ CD38+ HLA DR+. CONCLUSION: This is the first time that SSEA-4 and CD13 antigens have been reported in human umbilical cord blood cells.

Determinación fenotípica de subpoblaciones de células madre derivadas de sangre de cordón umbilical / Phenotypical determinants of stem cell subpopulations derived from human umbilical cord blood

Introducción. La sangre de cordón umbilical humana es una alternativa para la obtención de células madre hematopoyéticas; sin embargo, no es clara la expresión conjunta de los antígenos CD34, CD38 y HLA-DR, ni de antígenos embrionarios asociados con este tipo de muestra. Objetivos. Determinar la expresión en membrana de los antígenos CD34, CD38 y HLA-DR, así como de los antígenos embrionarios SSEA-4 (Specific Stage Embryonic Antigen–4) y CD13. Materiales y métodos. El estudio se realizó en muestras de sangre de cordón umbilical obtenidas de ochenta mujeres en estado de gravidez normal a término que asistieron al servicio de ginecobstetricia del Hospital Universitario San Ignacio. Los antígenos se determinaron mediante citometría de flujo. Resultados. El rango de células CD34+ presentes en sangre de cordón umbilical humana fue mayor al 0,2 por ciento (p=0,0010): a partir de esta población el rango de CD34+/ CD38-/ HLA-DR- fue de 0,0153 por ciento a 0,0234 por ciento, de CD34+/CD38+/HLA-DR- fue de 0,0191 por ciento a 0,296 por ciento, de CD34+/CD38-/HLA-DR+ fue de 0,0427 por ciento a 0,0676 por ciento, y de CD34+/CD38+/HLA-DR+ fue de 0,2427 por ciento a 0,5117 por ciento. La expresión de los antígenos embrionarios SSEA-4 y CD13 se determinó con el mismo método y se encontraron ocho muestras positivas para la expresión de estos antígenos. Conclusiones. El fenotipo que se expresa con mayor frecuencia en sangre de cordón umbilical corresponde a CD34+ CD38+ HLA DR+; además, el hallazgo de antígenos embrionarios podría indicar que en sangre de cordón umbilical humana existen poblaciones celulares con fenotipos similares a los progenitores celulares adultos multipotentes (Multipotent Adult Progenitor Cells) descritos en médula ósea.