Publications (14)62.21 Total impact
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Dataset: Global Perspective on CAP
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Dataset: Systemic steroids and CAP Torres
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Article: Systemic corticosteroids for Community Acquired Pneumonia: reasons for use and lack of benefit on outcome.
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ABSTRACT: SUMMARY AT A GLANCE: Despite the lack of a clear benefit, systemic corticosteroids are frequently administered in community-acquired-pneumonia. We investigated clinical reasons for steroid prescription and the impact on major outcomes, showing no correlation with mortality or clinical stability independent of severity and cumulative steroid dosage, but an increase in length of hospital stay. ABSTRACT: Background and Objective: Although the benefits of systemic corticosteroids in community-acquired pneumonia (CAP) are not clear, their use is frequent in clinical practice. We sought to describe the frequency of this practice, patients' characteristics and its clinical impact. Methods: We investigated 3257 adult CAP patients diagnosed between June 1997 and January 2008. Results: 260 patients received systemic corticosteroids (8%) with a mean daily dose of 45(33) mg (median, 36mg/ day). Patients receiving corticosteroids were older (74(13) vs. 65(19) years), had more comorbidities (respiratory, 59% vs. 38%, cardiac, 29% vs. 16%), higher Pneumonia Severity Index (Fine IV-V, 76% vs. 50%) and had received inhaled corticosteroids (36% vs. 15%) and previous antibiotics (31% vs. 23%) more frequently (p<0.01). Predictors of corticosteroid administration were: Chronic Obstructive Pulmonary Disease (OR: 1.91; 95%CI, 1.34-2.74), fever (OR, 0.59; 95%CI, 0.40-0.88), expectoration (OR: 1.59; 95%CI, 1.07-2.26), creatinine (+1mg/dl, OR: 0.92; 95%CI, 1.02-1.39), SaO(2) ≥92% (OR, 0.46; 95%CI, 0.33-0.65), C-Reactive Protein (+5 mg/dL; OR, 0.92; 95%CI, 0.86-0.99) and cardiac failure (OR:1.76; 95%CI, 1.21-2.58). Mortality (6% vs. 7%; p=0.43) and time to clinical stability (4[3-6] vs. 5[3-7] days; p=0.11) did not differ between two groups, while length-of-hospital-stay was longer for the steroid group (9[6-14.¡] vs. 6[3-9] days; p<0.01). Conclusions: The main reasons for administering systemic steroids were the presence of chronic respiratory comorbidity or severe clinical presentation but therapy did not influence mortality or clinical stability; by contrast, steroids administration was associated with prolonged length of stay. Yet, the steroid group did not show an increased mortality as was expected based on the initial Pneumonia Severity Index score. Influence of steroids on outcomes of CAP need to be further investigated through randomized clinical trial. © 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.Respirology 11/2012; · 2.42 Impact Factor -
Article: Implications of endotracheal tube biofilm in ventilator-associated pneumonia response: a state of concept.
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ABSTRACT: INTRODUCTION: Biofilm in endotracheal tubes (ETT) of ventilated patients has been suggested to play a role in the development of ventilator-associated pneumonia (VAP). Our purpose was to analyze the formation of ETT biofilm and its implication in the response and relapse of VAP. METHODS: We performed a prospective, observational study in a medical intensive care unit. Patients mechanically ventilated for more than 24 hours were consecutively included. We obtained surveillance endotracheal aspirates (ETA) twice weekly and, at extubation, ETTs were processed for microbiological assessment and scanning electron microscopy. RESULTS: Eighty-seven percent of the patients were colonized based on ETA cultures. Biofilm was found in 95% of the ETTs. In 56% of the cases, the same microorganism grew in ETA and biofilm. In both samples the most frequent bacteria isolated were Acinetobacter baumannii and Pseudomonas aeruginosa. Nineteen percent of the patients developed VAP (N = 14), and etiology was predicted by ETA in 100% of the cases. Despite appropriate antibiotic treatment, bacteria involved in VAP were found in biofilm (50%). In this situation, microbial persistence and impaired response to treatment (treatment failure and relapse) were more frequent (100% vs 29%, P = 0.021; 57% vs 14%, P = 0.133). CONCLUSIONS: Airway bacterial colonization and biofilm formation on ETTs are early and frequent events in ventilated patients. There is microbiological continuity between airway colonization, biofilm formation and VAP development. Biofilm stands as a pathogenic mechanism for microbial persistence, and impaired response to treatment in VAP.Critical care (London, England) 05/2012; 16(3):R93. · 4.61 Impact Factor -
Article: The impact of guidelines on the outcomes of community-acquired and ventilator-associated pneumonia.
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ABSTRACT: The correct implementation of the current guidelines for the management of community-acquired pneumonia is associated with less mortality, faster clinical stabilization, and lower costs in these patients. By contrast, implementing the current guidelines for the management of hospital-acquired pneumonia has been followed by an increase in initially adequate antibiotic treatment but has not been accompanied by a consistently improved outcome in patients.Clinics in chest medicine 09/2011; 32(3):491-505. · 2.51 Impact Factor -
Article: Diagnostic implications of soluble triggering receptor expressed on myeloid cells-1 in patients with acute respiratory distress syndrome and abdominal diseases: a preliminary observational study.
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ABSTRACT: Patients admitted to the intensive care unit (ICU) because of acute or decompensated chronic abdominal disease and acute respiratory failure need to have the potential infection diagnosed as well as its site (pulmonary or abdominal). For this purpose, we measured soluble triggering receptor expression on myeloid cells-1 (sTREM-1) in alveolar and peritoneal fluid. Consecutive patients (n = 21) with acute or decompensated chronic abdominal disease and acute respiratory failure were included. sTREM was measured in alveolar (A-sTREM) and peritoneal (P-sTREM) fluids. An infection was diagnosed in all patients. Nine patients had a lung infection (without abdominal infection), 5 had an abdominal infection (without lung infection) and seven had both infections. A-sTREM was higher in the patients with pneumonia compared to those without pneumonia (1963 ng/ml (1010-3129) vs. 862 ng/ml (333-1011); P 0.019). Patients with abdominal infection had an increase in the P-sTREM compared to patients without abdominal infection (1941 ng/ml (1088-3370) vs. 305 ng/ml (288-459); P < 0.001). A cut-off point of 900 pg/ml of A-sTREM-1 had a sensitivity of 81% and a specificity of 80% (NPV 57%; PPV 93%, AUC 0.775) for the diagnosis of pneumonia. In abdominal infections, a cut-off point for P-sTREM of 900 pg/ml had the best results (sensitivity 92%; specificity 100%; NPV 90%, PPV 100%, AUC = 0.903). sTREM-1 measured in alveolar and peritoneal fluids is useful in assessing pulmonary and peritoneal infection in critical-state patients-A-sTREM having the capacity to discriminate between a pulmonary and an extra-pulmonary infection in the context of acute respiratory failure.Critical care (London, England) 02/2011; 15(1):R50. · 4.61 Impact Factor -
Article: Validation and comparison of SCAP as a predictive score for identifying low-risk patients in community-acquired pneumonia.
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ABSTRACT: (1) To validate the Severe Community Acquired Pneumonia (SCAP) score in predicting 30-day mortality. (2) To validate its ability to identifying patients at low risk of death. (3) To compare it against the Pneumonia Severity Index (PSI), and the British Thoracic Society's CURB-65 rules. The SCAP score was validated to predict 30-day mortality in an internal validation cohort of consecutive adult patients seen in one hospital. Consecutive inpatients from other three hospitals were used to externally validate the score and compare the SCAP with the PSI and CURB-65. The discriminatory power of these rules to predict 30-day mortality was tested by the Area under Curve (AUC), and their predictive accuracy with the sensitivity, specificity and predictive values. The 30-day mortality rate increased directly with increasing SCAP score (class 0: 0.5%, to class 4: 66.5% risk) in the internal validation cohort, and from 1.3% to 29.2% in external cohort (P<0.001) with an AUC of 0.83 and 0.75, respectively (P=0.024). The SCAP score identified 62.4% (95% IC 58.8-66.0) low-risk patients, 52.5% (95% IC 48.8-56.2) the PSI and 46.2% (95% CI 42.5-49.9) the CURB-65 in the external cohort. Patients classified as low risk by the three rules had similar 30-day mortality (SCAP: 2.5%, PSI: 1.6% and CURB-65: 2.7%). The SCAP is valid to predict 30-day mortality among low-risk patients and identifies a larger proportion of patients as low-risk than the other studied rules.The Journal of infection 12/2009; 60(2):106-13. · 4.13 Impact Factor -
Article: Systemic inflammatory response and increased risk for ventilator-associated pneumonia: a preliminary study.
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ABSTRACT: Inflammatory markers have been assessed for the diagnosis and follow-up of ventilator-associated pneumonia (VAP), but their potential role in predicting the risk for VAP is unknown. We prospectively assessed the evolution of cytokines in mechanically ventilated patients and their predictive and diagnostic role for VAP. Prospective observational study. Medical intensive care unit. Mechanically ventilated patients. Exclusion criteria were active infection at admission and subsequent extrapulmonary infection. None. Sequential measurements of interleukin (IL)-1, IL-6, IL-8, IL-10, and tumor necrosis factor-alpha were done in 44 ventilated patients. VAP was suspected in 20 cases and microbiologically confirmed in nine. At admission, demographics, severity scores, and clinical and standard laboratory values did not discriminate patients with and without VAP, but the median (interquartile range) serum levels of IL-6 were higher in patients who subsequently developed VAP, compared with those without VAP (235 [141-803] vs. 113 [60-170] pg/mL, p = 0.015). The sensitivity and specificity of IL-6 to predict VAP was 71% and 78%, respectively, using 198 pg/mL as optimal cutoff, with relative risk (95% confidence interval) 8.9 (1.4-56.3). When VAP was suspected, serum levels of IL-6 were higher in patients with confirmed compared with nonconfirmed VAP (1131 [496-1987] vs. 236 [115-357] pg/mL, p = 0.016). The sensitivity and specificity to discriminate between confirmed and nonconfirmed VAP was 71% and 89%, respectively, using 620 pg/mL as optimal cutoff, with relative risk (95% confidence interval) 15.0 (1.2-185.2). IL-6 at admission is an early and accurate indicator of patients at increased risk for VAP. IL-6 is also accurate in discriminating patients with VAP from other causes of pulmonary infiltrates. Extrapolation of these results to the overall population of critically ill patients is limited by the small number of patients.Critical care medicine 04/2009; 37(5):1691-5. · 6.37 Impact Factor -
Article: Development of a prognostic index for 90-day mortality in patients discharged after admission to hospital for community-acquired pneumonia.
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ABSTRACT: Although patients admitted to hospital for community-acquired pneumonia (CAP) experience substantial short-term mortality following hospital discharge, few studies have focused on identifying factors that predict mortality after admission to hospital in this population. The objective of this study was to develop and validate a prognostic index for 90-day mortality after hospital discharge among patients with CAP. The prognostic index was derived in 1117 adult patients discharged between 2003 and 2007 from a general hospital following admission for CAP. It was validated in 646 consecutive patients with CAP discharged from three other hospitals between 1 November 2005 and 31 July 2006. Risk factors evaluated included host-related factors, severity upon admission, in-hospital management and bacteriology. In the derivation cohort, three factors were independently associated with 90-day mortality: pre-illness functional status, Charlson index (composite measure of co-morbid illnesses) and severity on admission. Mortality at 90 days was 0.7% in the low-risk group, 3.5% in the intermediate-risk group and 17.2% in the high-risk group. In the validation cohort, 90-day mortality in the three groups was 0.6%, 3.9% and 19.6%, respectively. Compared with the low-risk group, the odds ratio for mortality was 43.5 for the high-risk group. The risk categories showed an area under the receiver operating characteristic curve of 0.79 in the derivation cohort and 0.82 in the validation cohort. The prognostic index accurately stratifies patients admitted to hospital for CAP into low-, intermediate- and high-risk groups for 90-day mortality on discharge. The use of this index could help clinicians improve outcomes in this vulnerable population by targeting specific interventions to each group.Thorax 03/2009; 64(6):496-501. · 6.84 Impact Factor -
Article: Severe community-acquired pneumonia: validation of the Infectious Diseases Society of America/American Thoracic Society guidelines to predict an intensive care unit admission.
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ABSTRACT: The recent Infectious Disease Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia (CAP) in adults defined a predictive rule to identify patients with severe CAP to determine the need for intensive care unit (ICU) admission. We clinically validated this rule. We analyzed 2102 episodes of CAP in consecutively hospitalized patients over a 7-year period. The predictive rule consists of at least 1 of 2 major severity criteria (septic shock and invasive mechanical ventilation) or at least 3 of 9 minor severity criteria. We assessed the association of the predictive rule with ICU admission and mortality. A total of 235 episodes of CAP (11%) occurred in patients who were admitted to the ICU, whereas the predictive rule identified 397 (19%) of 2102 episodes as severe CAP. The predictive rule and the decision for ICU admission agreed in 1804 (86%) of the episodes (kappa coefficient, 0.45), with a sensitivity of 71% and a specificity of 88%, similar to the 2001 American Thoracic Society guidelines (sensitivity, 66%; specificity, 90%) in predicting ICU admission. Severe CAP criteria had higher sensitivity (58% vs. 46%) and similar specificity (88% vs. 90%), compared with the 2001 American Thoracic Society guidelines in predicting hospital mortality. Invasive mechanical ventilation was the main determinant for ICU admission, followed by septic shock. In the absence of major criteria, ICU admission was not related to survival of patients with minor severity criteria. The predictive rule to identify severe CAP is accurate for ICU admission and improved the prediction of mortality, compared with the previous American Thoracic Society guidelines. The need for ICU admission derived from minor severity criteria alone is uncertain and deserves further investigation.Clinical Infectious Diseases 02/2009; 48(4):377-85. · 9.15 Impact Factor -
Article: Prospective comparison of severity scores for predicting clinically relevant outcomes for patients hospitalized with community-acquired pneumonia.
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ABSTRACT: The comparative accuracy and discriminatory power of three validated rules for predicting clinically relevant outcomes other than mortality in patients hospitalized with community-acquired pneumonia (CAP) are unknown. We prospectively compared the newly developed severe community-acquired pneumonia (SCAP) score, pneumonia severity index (PSI), and the British Thoracic Society confusion, urea > 7 mmol/L, respiratory rate > or = 30 breaths/min, BP < 90 mm Hg systolic or < 60 mm Hg diastolic, age > or = 65 years (CURB-65) rule in an internal validation cohort of 1,189 consecutive adult inpatients with CAP from one hospital and an external validation cohort of 671 consecutive adult inpatients from three other hospitals. Major adverse outcomes were admission to ICU, need for mechanical ventilation, progression to severe sepsis, or treatment failure. Mean hospital length of stay (LOS) was also evaluated. The rules were compared based on sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic. The rate of all adverse outcomes and hospital LOS increased directly with increasing SCAP, PSI, or CURB-65 scores (p < 0.001) in both cohorts. Patients classified as high risk by the SCAP score showed higher rates of adverse outcomes (ICU admission, 35.8%; mechanical ventilation, 16.4%; severe sepsis, 98.5%; treatment failure, 22.4%) than PSI and CURB-65 high-risk classes. The discriminatory power of SCAP, as measured by AUC, was 0.75 for ICU admission, 0.76 for mechanical ventilation, 0.79 for severe sepsis, and 0.61 for treatment failure in the external validation cohort. AUC differences with PSI or CURB-65 were found. The SCAP score is as accurate or better than other current scoring systems in predicting adverse outcomes in patients hospitalized with CAP while helping classify patients into different categories of increasing risk for potentially closer monitoring.Chest 01/2009; 135(6):1572-9. · 5.25 Impact Factor -
Article: Treatment failure in community-acquired pneumonia.
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ABSTRACT: Treatment failure (TF) is defined as a clinical condition with inadequate response to antimicrobial therapy. Clinical response should be evaluated within the first 72 h of treatment, whereas infiltrate images may take up to 6 weeks to resolve. Early failure is considered when ventilatory support and/or septic shock appear within the first 72 h. The incidence of treatment failure in community-acquired pneumonia is 10 to 15%, and the mortality is increased nearly fivefold. Resistant and unusual microorganisms and noninfectious causes are responsible for TF. Risk factors are related to the initial severity of the disease, the presence of comorbidity, the microorganism involved, and the antimicrobial treatment implemented. Characteristics of patients and factors related to inflammatory response have been associated with delayed resolution and poor prognosis. The diagnostic approach to TF depends on the degree of clinical impact, host factors, and the possible cause. Initial reevaluation should include a confirmation of the diagnosis of pneumonia, noninvasive microbiological samples, and new radiographic studies. A conservative approach of clinical monitoring and serial radiographs may be recommended in elderly patients with comorbid conditions that justify a delayed response. Invasive studies with bronchoscopy to obtain protected brush specimen and BAL are indicated in the presence of clinical deterioration or failure to stabilize. BAL processing should include the study of cell patterns to rule out other noninfectious diseases and complete microbiological studies. The diagnostic yield of imaging procedures with noninvasive and invasive samples is up to 70%. After obtaining microbiological samples, an empirical change in antibiotic therapy is required to cover a wider microbial spectrum.Chest 11/2007; 132(4):1348-55. · 5.25 Impact Factor -
Article: A worldwide perspective of atypical pathogens in community-acquired pneumonia.
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ABSTRACT: Controversy still exists in the international literature regarding the need to use antimicrobials covering atypical pathogens when initially treating hospitalized patients with community-acquired pneumonia (CAP). In different regions of the world, monotherapy with a beta-lactam antimicrobial is common. We sought to correlate the incidence of CAP due to atypical pathogens in different regions of the world with the proportion of patients treated with an atypical regimen in those same regions. In addition, we sought to compare clinical outcomes of patients with CAP treated with and without atypical coverage. A secondary analysis was performed using two comprehensive international databases. World regions were defined as North America (I), Europe (II), Latin America (III), and Asia and Africa (IV). Time to reach clinical stability, length of hospital stay, and mortality were compared between patients treated with and without atypical coverage. The incidence of CAP due to atypical pathogens from 4,337 patients was 22, 28, 21, and 20% in regions I-IV, respectively. The proportion of patients treated with atypical coverage from 2,208 patients was 91, 74, 53, and 10% in regions I-IV, respectively. Patients treated with atypical coverage had decreased time to clinical stability (3.7 vs. 3.2 d, p < 0.001), decreased length of stay (7.1 vs. 6.1 d, p < 0.01), decreased total mortality (11.1 vs. 7%, p < 0.01), and decreased CAP-related mortality (6.4 vs. 3.8%, p = 0.05). The significant global presence of atypical pathogens and the better outcomes associated with antimicrobial regimens with atypical coverage support empiric therapy for all hospitalized patients with CAP with a regimen that covers atypical pathogens.American Journal of Respiratory and Critical Care Medicine 05/2007; 175(10):1086-93. · 11.08 Impact Factor -
Article: New Biological Markers of Ventilator-Associated Pneumonia
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ABSTRACT: The signs and symptoms indicating the possible presence of ventilator-associated pneumonia (VAP) have a low specificity and sensitivity. Moreover, microbiological confirmation may be delayed up to 3 days and influenced by the previous use of antibiotics. However, VAP is one of the most frequent infectious complications in patients admitted to intensive care units and it is, therefore, necessary to improve the diagnostic arsenal for this infection. Consequently, there have been attempts to use biological markers in the diagnosis of VAP; the ideal substance would be one with correct sensitivity and specificity that could also be analyzed quickly and at a moderate cost. The previously used biological markers have not been, for different reasons, converted into a commonly used technique in clinical practice. Currently, the products derived from the inflammatory response, whether local or systemic, are being widely studied. Serum C-reactive protein (CRP) is a widely used technique of low economic cost but easily influenced by other inflammatory circumstances. Serum procalcitonin may be a good marker of VAP, but further studies are required to corroborate this quite economically viable technique. Although promising, the clinical use of s-TREM needs more evidence. Despite the increasing number of studies using cytokines in VAP, results are discordant.Clinical Pulmonary Medicine 02/2007; 14(2):93-98.
Top co-authors
Top Journals
Institutions
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2011
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Southern Medical Clinic
San Fernando, San Fernando, Trinidad and Tobago
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2007–2011
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Hospital Universitari i Politècnic la Fe
- Servicio de Neumología
Valencia, Valencia, Spain
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2009
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Institut d’Investigacions Biomèdiques August Pi i Sunyer
Barcelona, Catalonia, Spain
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