Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis

Introduction: The frequency and clinical significance of polymicrobial aetiology in community-acquired pneumonia (CAP) patients admitted to the ICU have been poorly studied. The aim of the present study was to describe the prevalence, clinical characteristics and outcomes of severe CAP of polymicrobial aetiology in patients admitted to the ICU. Methods: The prospective observational study included 362 consecutive adult patients with CAP admitted to the ICU within 24 hours of presentation; 196 (54%) patients had an established aetiology. Results: Polymicrobial infection was present in 39 (11%) cases (20% of those with defined aetiology): 33 cases with two pathogens, and six cases with three pathogens. The most frequently identified pathogens in polymicrobial infections were Streptococcus pneumoniae (n = 28, 72%), respiratory viruses (n = 15, 39%) and Pseudomonas aeruginosa (n = 8, 21%). Chronic respiratory disease and acute respiratory distress syndrome criteria were independent predictors of polymicrobial aetiology. Inappropriate initial antimicrobial treatment was more frequent in the polymicrobial aetiology group compared with the monomicrobial aetiology group (39% vs. 10%, P < 0.001), and was an independent predictor of hospital mortality (adjusted odds ratio = 10.79, 95% confidence interval = 3.97 to 29.30; P < 0.001). The trend for higher hospital mortality of the polymicrobial aetiology group compared with the monomicrobial aetiology group (n = 8, 21% versus n = 17, 11%), however, was not significantly different (P = 0.10). Conclusions: Polymicrobial pneumonia occurs frequently in patients admitted to the ICU. This is a risk factor for inappropriate initial antimicrobial treatment, which in turn independently predicts hospital mortality

Acute respiratory distress syndrome in mechanically ventilated patients with community-acquired pneumonia

Our aim was to assess the incidence, characteristics, aetiology, risk factors and mortality of acute respiratory distress syndrome (ARDS) in intensive care unit (ICU) patients with community-acquired pneumonia (CAP) using the Berlin definition. We prospectively enrolled consecutive mechanically ventilated adult ICU patients with CAP over 20 years, and compared them with mechanically ventilated patients without ARDS. The main outcome was 30-day mortality. Among 5334 patients hospitalised with CAP, 930 (17%) were admitted to the ICU and 432 required mechanical ventilation; 125 (29%) cases met the Berlin ARDS criteria. ARDS was present in 2% of hospitalised patients and 13% of ICU patients. Based on the baseline arterial oxygen tension/inspiratory oxygen fraction ratio, 60 (48%), 49 (40%) and 15 (12%) patients had mild, moderate and severe ARDS, respectively. Streptococcus pneumoniae was the most frequent pathogen, with no significant differences in aetiology between groups. Higher organ system dysfunction and previous antibiotic use were independent risk factors for ARDS in the multivariate analysis, while previous inhaled corticosteroids were independently associated with a lower risk. The 30-day mortality was similar between patients with and without ARDS (25% versus 30%, p=0.25), confirmed by propensity-adjusted multivariate analysis. ARDS occurs as a complication of CAP in 29% of mechanically ventilated patients, but is not related to the aetiology or mortality

Desarrollo de una aplicación web multiplataforma según el patrón Modelo Vista Controlador

Memoria del desarrollo de una aplicación web siguiendo el patrón de diseño Modelo Vista Controlador, desde la planificación a la implementación. Tecnologías utilizadas: MySQL, Java2EE, HTML5, Struts2, jQuery, jQueryMobile, JSP, ESAPI, Jasypt, XML.Memòria del desenvolupament d'una aplicació web seguint el patró de disseny Model Vista Controlador, des de la planificació a la implementació. Tecnologies utilitzades: MySQL, Java2EE, HTML5, Struts2, jQuery, jQueryMobile, JSP, ESAPI, Jasypt, XML

A multiplex real-time PCR assay for identification of Pneumocystis jirovecii, Histoplasma capsulatum, and Cryptococcus neoformans/Cryptococcus gattii in samples from AIDS patients with opportunistic pneumonia

A molecular diagnostic technique based on real-time PCR was developed for the simultaneous detection of three of the most frequent causative agents of fungal opportunistic pneumonia in AIDS patients: Pneumocystis jirovecii, Histoplasma capsulatum, and Cryptococcus neoformans/Cryptococcus gattii. This technique was tested in cultured strains and in clinical samples from HIV-positive patients. The methodology used involved species-specific molecular beacon probes targeted to the internal transcribed spacer regions of the rDNA. An internal control was also included in each assay. The multiplex real-time PCR assay was tested in 24 clinical strains and 43 clinical samples from AIDS patients with proven fungal infection. The technique developed showed high reproducibility (r(2) of >0.98) and specificity (100%). For H. capsulatum and Cryptococcus spp., the detection limits of the method were 20 and 2 fg of genomic DNA/20 μl reaction mixture, respectively, while for P. jirovecii the detection limit was 2.92 log(10) copies/20 μl reaction mixture. The sensitivity in vitro was 100% for clinical strains and 90.7% for clinical samples. The assay was positive for 92.5% of the patients. For one of the patients with proven histoplasmosis, P. jirovecii was also detected in a bronchoalveolar lavage sample. No PCR inhibition was detected. This multiplex real-time PCR technique is fast, sensitive, and specific and may have clinical applications

O diagnóstico clínico da pneumonia associada ao ventilador revisitado: validação comparativa usando biópsias pulmonares post-mottem imediatas

RESUMO: Efectuou-se um estudo prospectivo que englobou 25 doentes submetidos a ventilação mecânica e quevieram a falecer, com o objectivo de avaliar o valor diagnóstico dos criterios clínicos e o impacto dos testes microbiológicos na correcta determinação do diagnóstico de pneumonia associada ao ventilador (PAV). Forarn colhidas, logo após a morte, múltiplas amostras de biópsias de ambos os pulmões (16 amostras por doente), que foram submetidas a exame histológico e culturas quantitativas. O teste de referênda foi baseado na presença de pneumonia identificada histologicamente e, simultâneamente, numa cultura pulmonar positiva. A presença de infiltrados na radiografia de tórax e de dois de três critérios clínicos (leucocitose, secreções purulentas e febre)- critérios de Johanson revelaram uma sensibilidade de 69% e uma especificidade de 75%. Os valores correspondentes, quando se utilizou o âclinical pulmonary infection scoreâ (CPIS), foram de 77% e 42%. Os resultados das amostras colhidos quer por técnicas invasivas, quer por técnicas não invasivas apresentaram valores comparáveis. Com a combinação de todas as técnicas obteve-se uma sensibilidade de 85% e uma especificidade de 50%, não se alterando estes valores apesar da terapêutica prévia com antibióticos. Quando os resultados microbiológicos foram acrescentados aos critérios clínicos, a adequação dos diagnósticos com base nos resultados microbiológicos que corrigiram os resultados clínicos falsos positivos e falsos negativos (n=5), foram contrabalançãdos por uma proporção idêntica de diagnósticos inadequados (n=6). Conclusõe5: Os critérios clínicos revelaram valores diagnósticos razoáveis, não exibindo os critérios do CPIS valores superiores aos critérios clínicos convencionais. As técnicas não-invasivas e invasivas revelaram valores diagnósticos comparáveis aos critérios clínicos. Um algoritmo orientado exclusivamente pelos resultados microbiológicos na terapêutica antibiótica não aumenta a precisão diagnóstica global e conduz ao risco de subtratamento. COMENTÃRIO: A abordagem diagnóstica da P AV permanece controversa não se conseguindo ainda encontrar um algoritrno definitivo para o estabelecimento de um diagnóstico preciso. Os critérios clínicos têm sido referidos como inapropriados para o diagnóstico de PAV, apontando vários estudos para os beneficios da colheita de amostras bacteriológicas quer por métodos invasivos, como os broncoscópicos, quer não invasivos, com determinação de culturas quantitativas. Os vários estudos efectuados, têm revelado alguma controvérsia quer em relação à escolha do melhor metoda, quer à sua eficácia, sendo ainda, algumas destas técnicas, dificilmente acessíveis nalgumas instituições, não sendo também isentas de alguma morbilidade e mortalidade.Um problema metodológico importante diz respeito à escolha e exactidão do teste de referênda utilizado nos vários estudos. Neste trabalho, foi escolhida para validação dos resultados, a presençã histológica de pneumonia associada à positividade da cultura quantitativa de tecido pulmonar, reflectindo deste modo, segundo os autores, a presença de pneumonia clinicamente sintomática.Neste estudo, os critérios clínicos apresentaram uma sensibilidade e especificidade razoáveis, não mostrando os critérios do CPIS resultados superiores aos critérios de Johanson. Por outro Iado, a colheita de amostras utilizando quer métodos invasivos, quer não invasivos, não revelou resultados superiores aos clínicos na precisão diagnóstica, salientando-se mesmo, que, em vários casos, a colheita efectuada por estes métodos falhou o diagnóstico, que, no entanto, os critérios clínicos tinham estabelecido correctamente. Se a decisão na administração ou paragem do antibiótico fosse baseada no resultado dos critérios microbiológicos, ter-se-ia corrido o risco de vários doentes não terem sido tratados apesar do diagnóstico baseado nos critérios clínicos ter sido correcto. Oeste modo, o risco para o doente da não utilização do antibi6tico seria certamente maior do que a utilização abusiva do antibiótico.Neste trabalho, é pois sugerido, que os parâmetros clfnicos são razoavelmente satisfatórios no diagnóstico de PAV, sendo também o critéria mais importante na orientação diagnóstica. Os autores concluem que o ponto-chave na prática clínica, é encontrar um equilíbrio entre a informação fomecida pelo raciocínio clínico e o resultado micribiológico das vias aéreas inferiores e não suspender a antibioterapia se o diagnóstico de PAV fôr clinicamente suspeito. Palavras-chave: Pneumonia associada ao ventilador, pneumonia nosocomial, diagnóstico clínico, Key-words: ventilated-associated pneumonia, hospital-acquired pneumonia, clinical diagnosi

Pulmonary Infiltrates in Immunosuppressed Patients: Analysis of a Diagnostic Protocol

A diagnostic protocol was started to study the etiology of pulmonary infiltrates in immunosuppressed patients. The diagnostic yields of the different techniques were analyzed, with special emphasis on the importance of the sample quality and the role of rapid techniques in the diagnostic strategy. In total, 241 patients with newly developed pulmonary infiltrates within a period of 19 months were included. Noninvasive or invasive evaluation was performed according to the characteristics of the infiltrates. Diagnosis was achieved in 202 patients (84%); 173 patients (72%) had pneumonia, and specific etiologic agents were found in 114 (66%). Bronchoaspirate and bronchoalveolar lavage showed the highest yields, either on global analysis (23 of 35 specimens [66%] and 70 of 134 specimens [52%], respectively) or on analysis of each type of pneumonia. A tendency toward better results with optimal-quality samples was observed, and a statistically significant difference was found in sputum bacterial culture. Rapid diagnostic tests yielded results in 71 of 114 (62.2%) diagnoses of etiological pneumonia