Publications (26)139.79 Total impact
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Article: Impact of Age and Comorbidity on Etiology and Outcome in Community-Acquired Pneumonia.
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ABSTRACT: ABSTRACT BACKGROUND: Prolonged life expectancy has currently increased the proportion of the very elderly among patients with community-acquired pneumonia (CAP). The aim of this study was to determine the influence of age and comorbidity on microbial patterns in CAP patients over 65 years of age. METHODS: Prospective observational study of adult CAP patients (excluding nursing home) over a 12-year period. We compared patients aged 65-74 years, 75-84 years and >85 years for potential differences in clinical presentation, comorbidities, severity on admission, microbial investigations, etiologies, antimicrobial treatment, and outcomes. RESULTS: We studied a total of 2149 patients: 759 (35.3%) patients aged 65-74 years, 941 (43.7%) aged 75-84 years, and 449 (20.8%) patients aged >85 years. At least one comorbidity was present in 1710 (79.6%) patients. Streptococcus pneumoniae was the most frequent pathogen in all age groups, regardless of comorbidity. Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa accounted for 9.1% of isolates and Haemophilus influenzae, 6.4%. All these pathogens were isolated only in patients with ≥1 comorbidity. Mortality increased with age (65-74 y, 6.9%; 75-84 y, 8.9%; >85 y, 17.1%; p<0.001) and was associated with increased comorbidities (neurological, OR: 2.1, 95% CI: 1.5-2.1), PSI IV-V (OR: 3.2, 95% CI: 1.8-6.0), bacteremia (OR: 1.7, 95% CI: 1.1-2.7), the presence of a potential MDR pathogen (S. aureus, P. aeruginosa, Enterobacteriaceae; OR: 2.4, 95% CI: 1.3-4.3) and ICU admission (OR: 4.2, 95% CI: 2.9-6.1) on multivariate analysis. CONCLUSIONS: Age does not influence microbial etiology itself, while comorbidities are associated with specific etiologies such as H. influenzae and potential MDR pathogens. Mortality in the elderly is mainly driven by the presence of comorbidities and potential MDR.Chest 05/2013; · 5.25 Impact Factor -
Article: Influence of Previous Use of Inhaled Corticoids on the Development of Pleural Effusion in Community-Acquired Pneumonia.
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ABSTRACT: Rationale: Previous use of inhaled corticosteroids in patients with chronic obstructive pulmonary disease has been associated with increased risk of community-acquired pneumonia. However, inhaled corticosteroids have been associated with fewer pneumonia complications and decreased risk of pneumonia-related mortality. Objectives: The objective of the study was to assess the influence of previous use of inhaled corticosteroids on the incidence of parapneumonic effusion in patients with different baseline respiratory disorders. Methods: We conducted a single-centre cohort study of 3612 consecutively collected patients diagnosed with community-acquired pneumonia. We assessed clinical, radiographic and pleural-fluid chemistry and microbiological variables. Patients were classified according to whether they received prior inhaled corticosteroid treatment or not. Measurements and main results: 633 patients (17%) were treated with corticosteroids before the diagnosis of pneumonia (COPD, 54%; Asthma, 13%). Incidence of parapneumonic effusion was lower in patients with ICS use compared to non-ICS patients (5% vs 12%, p < 0.001). After matching according to propensity scores (n=640), prior treatment with corticosteroids was still significantly associated with a lower incidence of parapneumonic effusion (OR 0.40 [95% CI, 0.23-0.69], p=0.001) compared to patients without corticosteroid treatment. Prior inhaled corticosteroid treatment was associated with higher levels of glucose (p=0.003) and pH (p=0.02), and lower levels of protein (p=0.01) and lactic acid dehydrogenase (p=0.007) in the pleural fluid. Conclusions: Prior treatment with inhaled corticosteroids in a population of patients with different respiratory chronic disorders who develop pneumonia is associated with lower incidence of parapneumonic effusion.American Journal of Respiratory and Critical Care Medicine 04/2013; · 11.08 Impact Factor -
Article: [Multidisciplinary guidelines for the management of community-acquired pneumonia.]
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ABSTRACT: Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2011. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system:Medicina Clínica 12/2012; · 1.38 Impact Factor -
Article: Systemic Inflammatory Pattern of Community-Acquired Pneumonia (CAP) Patients With and Without Chronic Obstructive Pulmonary Disease (COPD).
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ABSTRACT: ABSTRACT BACKGROUND Several clinical studies have evaluated the role of chronic obstructive pulmonary disease (COPD) in community-acquired pneumonia (CAP) patients. We investigated the systemic inflammatory response of CAP patients with (CAP+COPD) and patients without associated COPD (CAP only). METHODS Clinical, microbiological and immunological data were collected from 367 prospective patients on admission to hospital during a 3-year period. Comparative analyses were performed between CAP+COPD (n=117) and CAP only patients (n=250) and between patients with and without domiciliary use of inhaled (ICS) and oral corticosteroids. RESULTS Detailed characteristics of clinical severity and prognosis (mortality on hospitalization, at 30 days and at 90 days) were similar between CAP+COPD and CAP only patients. The re-admission rate and the frequency of a previous pneumonia were higher in the group of CAP+COPD patients.On day 1 (admission to hospital) CAP+COPD patients had significantly lower serum levels of tumour necrosis factor (TNF) α, interleukin (IL) 1 and IL-6 compared with CAP only patients; the remaining inflammatory biomarkers (C-reactive protein, procalcitonin, IL-8 and IL-10) were similar at days 1 and 3. The exclusion of patients with domiciliary use of ICS and oral corticosteroids confirms lower levels of TNF-α on day 1 in CAP+COPD patients. Finally, lower levels of IL-6 were found only among those COPD patients who were currently using ICS. CONCLUSION Our prospective study demonstrates a different, disease-specific early inflammatory pattern between CAP patients with and without associated COPD; these finding are not completely corticosteroid-mediated.1Department of Pulmonary Rehabilitation, Ospedale Villa Pineta - University of Modena and Reggio Emilia, Modena, Italy. ecrisafulli@pneumonet.it, enrico.clini@unimore.it2Servicio de Neumología, Hospital Universitario y politecnico La Fe, CIBERES, Valencia, Spain, rosmenend@gmail.com, rasmartinez@hotmail.com, gelina82@comv.es3Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona (UB) - Supported by: 2009 SGR 911, Ciber de Enfermedades Respiratorias (Ciberes CB06/06/0028), Pneumonia Corporate Research Program (CRP). The Ciberes is an initiative of the ISCIII. SGR: Support to research groups of Catalunya - Barcelona, Spain. ahuerta@clinic.ub.es, ATORRES@clinic.ub.esCORRESPONDENCE: Prof. Antoni Torres - Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic, Villarroel 170. 08036 Barcelona, Spain. E-mail: ATORRES@clinic.ub.esFunding/Support: This manuscript was supported by a grant from Marato TV3 - Spain.Chest 09/2012; · 5.25 Impact Factor -
Article: Thrombocytosis is a marker of poor outcome in community-acquired pneumonia.
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ABSTRACT: ABSTRACT BACKGROUND: Thrombocytosis, often considered a marker of normal inflammatory reaction of infections, has been recently associated with increased mortality in hospitalized patients with community-acquired pneumonia (CAP). We assessed the characteristics and outcomes of patients with CAP and thrombocytosis (platelet count ≥4x105/mm3), compared with thrombocytopenia (platelet count <105/mm3) and normal platelet count. METHODS: We prospectively analyzed 2,423 consecutive hospitalized patients with CAP. We excluded patients with immunosuppression, neoplasm, active tuberculosis or hematological disease. RESULTS: Fifty-three patients (2%) presented thrombocytopenia, 204 (8%) thrombocytosis and 2,166 (90%) had normal platelet count. Patients with thrombocytosis were younger (p<0.001) while those with thrombocytopenia had more frequently chronic heart and liver disease (p<0.001 both). Patients with thrombocytosis presented more frequently respiratory complications such as complicated pleural effusion and empyema (p<0.001), whereas those with thrombocytopenia presented more often severe sepsis (p<0.001), septic shock (p=0.009), need for invasive mechanical ventilation (p<0.001) and intensive care unit admission (p=0.011). Patients with thrombocytosis and thrombocytopenia had longer hospital stay (p=0.004), higher 30-day mortality (p=0.001) and readmission rate (p=0.011) than those with normal platelet count. Multivariate analysis confirmed a significant association between thrombocytosis and 30-day mortality (OR 2.720, 95% CI 1.589-4.657; p<0.001). Adding thrombocytosis to the CRB-65 score slightly improved the accuracy to predict mortality (area under the ROC curve increased from 0.634 to 0.654 p=0.049). CONCLUSION: Thrombocytosis in patients with CAP is associated with poor outcome, complicated pleural effusion and empyema. The presence of thrombocytosis in CAP should encourage ruling out respiratory complication and could be considered for severity evaluation.1Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Spain.2Emergency Medicine Department, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.3Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain.4Respiratory Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil.5Servicio de Enfermedades Infecciosas, Hospital Clínic, IDIBAPS, Barcelona, Spain.6Servicio de Neumologia, Hospital Universitario La Fe,Valencia, Spain.Correspondence: Dr. Miquel Ferrer. UVIR, Servei de Pneumologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain. E-mail: miferrer@clinic.ub.esFunded By: This work was supported by Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), 2009 SGR 911, PII de infecciones respiratorias of SEPAR, and IDIBAPS.Chest 09/2012; · 5.25 Impact Factor -
Article: Biomarkers and community-acquired pneumonia: tailoring management with biological data.
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ABSTRACT: Community-acquired pneumonia (CAP) is the leading cause of death from infectious diseases worldwide, with an incidence of 0.3 to 0.5% in the adult population. A new diagnostic and prognostic approach relies on evaluation of biomarkers as an expression of the host's inflammatory response against the microorganism. C-reactive protein (CRP), procalcitonin (PCT), and cytokines are the most frequently studied, whereas pro-adrenomedullin (pro-ADM), pro-vasopressin (pro-VNP), and others are currently obtaining promising results. Their usefulness for diagnosis is limited, although PCT has been successfully used to guide prescription of antibiotics in patients with suspected CAP. Nevertheless, the accuracy of PCT in distinguishing between bacterial or viral infection and safely withholding antibiotics in CAP is the subject of debate. Analysis of systemic biomarkers in addition to clinical scores [Pneumonia Severity Index (PSI) or CURB-65 (confusion, urea, respiratory, blood pressure, >65 years)/CRB-65 (confusion, respiratory, blood pressure)] has been shown to improve 30 day mortality prediction and absence of severe complications. Pro-ADM is probably the biomarker that correlates most strongly with mortality prediction. During treatment, ~15% of hospitalized CAP patients develop treatment failure, and almost 6% may manifest rapidly progressive pneumonia. Initially increased and persistent raised levels of biomarkers and cytokines have been shown to identify patients at risk of treatment failure, thereby aiding clinical management. Data from the literature appear to support the use of biomarkers in routine clinical practice to improve the decision making in CAP.Seminars in Respiratory and Critical Care Medicine 06/2012; 33(3):266-71. · 2.43 Impact Factor -
Article: Bacterial co-infection with H1N1 infection in patients admitted with community acquired pneumonia.
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ABSTRACT: Bacterial co-infection is an important contributor to morbidity and mortality during influenza pandemics .We investigated the incidence, risk factors and outcome of patients with influenza A H1N1 pneumonia and bacterial co-infection. Prospective observational study of consecutive hospitalized patients with influenza A H1N1 virus and community-acquired pneumonia (CAP). We compared cases with and without bacterial co-infection. The incidence of influenza A H1N1 infection in CAP during the pandemic period was 19% (n, 667). We studied 128 patients; 42(33%) had bacterial co-infection. The most frequently isolated bacterial pathogens were Streptococcus pneumoniae (26, 62%) and Pseudomonas aeruginosa (6, 14%). Predictors for bacterial co-infection were chronic obstructive pulmonary disease (COPD) and increase of platelets count. The hospital mortality was 9%. Factors associated with mortality were age ≥ 65 years, presence of septic shock and the need for mechanical ventilation. Although patients with bacterial co-infection presented with higher Pneumonia Severity Index risk class, hospital mortality was similar to patients without bacterial co-infection (7% vs. 11%, respectively, p = 0.54). Bacterial co-infection was frequent in influenza A H1N1 pneumonia, with COPD and increased platelet count as the main predictors. Although associated with higher severe scales at admission, bacterial co-infection did not influence mortality of these patients.The Journal of infection 04/2012; 65(3):223-30. · 4.13 Impact Factor -
Article: Compliance with guidelines-recommended processes in pneumonia: impact of health status and initial signs.
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ABSTRACT: Initial care has been associated with improved survival of community-acquired pneumonia (CAP). We aimed to investigate patient comorbidities and health status measured by the Charlson index and clinical signs at diagnosis associated with adherence to recommended processes of care in CAP. We studied 3844 patients hospitalized with CAP. The evaluated recommendations were antibiotic adherence to Spanish guidelines, first antibiotic dose <6 hours and oxygen assessment. Antibiotic adherence was 72.6%, first dose <6 h was 73.4% and oxygen assessment was 90.2%. Antibiotic adherence was negatively associated with a high Charlson score (Odds ratio [OR], 0.91), confusion (OR, 0.66) and tachycardia ≥100 bpm (OR, 0.77). Delayed first dose was significantly lower in those with tachycardia (OR, 0.75). Initial oxygen assessment was negatively associated with fever (OR, 0.61), whereas tachypnea ≥30 (OR, 1.58), tachycardia (OR, 1.39), age >65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing <6 hours was negatively associated with confusion (OR, 0.69) and a high Charlson score (OR, 0.92) adjusting for severity and hospital effect, whereas age was not an independent factor. Deficient health status and confusion, rather than age, are associated with lower compliance with antibiotic therapy recommendations and timing, thus identifying a subpopulation more prone to receiving lower quality care.PLoS ONE 01/2012; 7(5):e37570. · 4.09 Impact Factor -
Article: Cytokine activation patterns and biomarkers are influenced by microorganisms in community-acquired pneumonia.
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ABSTRACT: The inflammatory response in community-acquired pneumonia (CAP) depends on the host and on the challenge of the causal microorganism. Here, we analyze the patterns of inflammatory cytokines, procalcitonin (PCT), and C-reactive protein (CRP) in order to determine their diagnostic value. This was a prospective study of 658 patients admitted with CAP. PCT and CRP were analyzed by immunoluminometric and immunoturbidimetric assays. Cytokines (tumor necrosis factor-α [TNF-α], IL-1β, IL-6, IL-8, and IL-10) were measured using enzyme immunoassay. The lowest medians of CRP, PCT, TNF-α, and IL-6 were found in CAP of unknown cause, and the highest were found in patients with positive blood cultures. Different cytokine profiles and biomarkers were found depending on cause: atypical bacteria (lower PCT and IL-6), viruses (lower PCT and higher IL-10), Enterobacteriaceae (higher IL-8), Streptococcus pneumoniae (high PCT), and Legionella pneumophila (higher CRP and TNF-α). PCT ≥ 0.36 mg/dL to predict positive blood cultures showed sensitivity of 85%, specificity of 42%, and negative predictive value (NPV) of 98%, whereas a cutoff of ≤ 0.5 mg/dL to predict viruses or atypicals vs bacteria showed sensitivity of 89%/81%, specificity of 68%/68%, positive predictive value of 12%/22%, and NPV of 99%/97%. In a multivariate Euclidean distance model, the lowest inflammatory expression was found in unknown cause and the highest was found in L pneumophila, S pneumoniae, and Enterobacteriaceae. Atypical bacteria exhibit an inflammatory pattern closer to that of viruses. Different inflammatory patterns elicited by different microorganisms may provide a useful tool for diagnosis. Recognizing these patterns provides additional information that may facilitate a broader understanding of host inflammatory response to microorganisms.Chest 12/2011; 141(6):1537-45. · 5.25 Impact Factor -
Article: Inflammatory biomarkers and prediction for intensive care unit admission in severe community-acquired pneumonia.
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ABSTRACT: Increased inflammatory response is related to severity and outcome in community-acquired pneumonia, but the role of inflammatory biomarkers in deciding intensive care unit admission is unknown. We assessed the relationship between inflammatory response, prediction for intensive care unit admission, delayed intensive care unit admission, and outcome in patients with community-acquired pneumonia. Prospective clinical study. Intensive care units of two university hospitals. We included 627 ward and 58 intensive care unit patients with community-acquired pneumonia, 36 with direct and 22 with delayed intensive care unit admission. Serum levels of C-reactive protein, procalcitonin, tumor necrosis factor-α, interleukin-1, interleukin-6, interleukin-8, and interleukin-10 at admission. We assessed the prediction for intensive care unit admission of biomarkers and the Infectious Diseases Society of America/American Thoracic Society guidelines minor criteria for severe community-acquired pneumonia. Procalcitonin (p=.001), C-reactive protein (p=.005), tumor necrosis factor-α (p=.042), and interleukin-6 (p=.003) levels were higher in intensive care unit-admitted patients; however, the Infectious Diseases Society of America/American Thoracic Society guidelines minor severity criteria predicted better intensive care unit admission (odds ratio, 12.03; 95% confidence interval, 5.13-28.20; p<.001). No patient with severe community-acquired pneumonia by three or more minor severity criteria and procalcitonin levels below the optimal cutoff (0.35 ng/mL) needed intensive care unit admission compared with 14 (23%) with levels above the cutoff (p=.032). In patients initially admitted to wards, procalcitonin (p=.012) and C-reactive protein (p=.039) were higher in those 22 patients subsequently transferred to the intensive care unit after adjusting for age, comorbidities, and Pneumonia Severity Index risk class. Despite initially admitted to wards, 14 (64%) patients with delayed intensive care unit admission had already criteria for severe community-acquired pneumonia at admission compared with 73 (12%) ward patients (p<.001). Inflammatory biomarkers identified patients needing intensive care unit admission, including those with delayed intensive care unit admission. Patients with severe community-acquired pneumonia by minor criteria and low levels of procalcitonin may be safely admitted to wards. Correctly applying the Infectious Diseases Society of America/American Thoracic Society guidelines would reduce substantially delayed intensive care unit admission.Critical care medicine 06/2011; 39(10):2211-7. · 6.37 Impact Factor -
Article: [Community acquired pneumonia. New guidelines of the Spanish Society of Chest Diseases and Thoracic Surgery (SEPAR)].
Archivos de Bronconeumología 10/2010; 46(10):543-58. · 2.17 Impact Factor -
Article: Meeting the old man's friend.
Thorax 12/2009; 64(12):1016-7. · 6.84 Impact Factor -
Article: Improving outcomes in elderly patients with community-acquired pneumonia by adhering to national guidelines: Community-Acquired Pneumonia Organization International cohort study results.
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ABSTRACT: To define whether elderly patients hospitalized with community-acquired pneumonia (CAP) had better outcomes if they were treated with empirical antimicrobial therapy adherent to the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines for CAP. This was a secondary analysis of the CAPO International Cohort Study database, which contained data from a total of 1725 patients aged 65 years or older who were hospitalized with CAP. Data from June 1, 2001, until January 1, 2007, were analyzed from 43 centers in 12 countries including North America (n = 2), South America (n = 4), Europe (n = 4), Africa (n = 1), and Southeast Asia (n = 1). Initial empirical therapy for CAP was evaluated for guideline compliance according to the 2007 IDSA/ATS guidelines for CAP. Time to clinical stability, length of stay (LOS), total in-hospital mortality, and CAP-related mortality for each group were calculated. Comparisons between groups were made using cumulative incidence curves and competing risks regression. Among the 1649 patients with CAP, aged 65 years or older, 975 patients were given antimicrobial regimens adherent to the IDSA/ATS for CAP guidelines, while 660 patients were treated with nonadherent regimens (465 patients were "undertreated"; 195 were "overtreated"). Adherence to guidelines was associated with a statistically significant decreased time to achieve clinical stability compared with nonadherence: the proportion of patients who reached clinical stability by 7 days was 71% (95% confidence interval [CI], 68%-74%) and 57% (95% CI, 53%-61%) (P < .01), respectively. Guideline adherence was also associated with shorter LOS (median adherence LOS, 8 days; interquartile range [IQR], 5-15 days; median nonadherence LOS, 10 days; IQR, 6-24 days) (P < .01) and decreased overall in-hospital mortality (8%; 95% CI, 7%-10% vs 17%; 95% CI, 14%-20%) (P < .01). Implementation of national guidelines at the local hospital level will improve not only mortality and LOS of elderly patients hospitalized with CAP but also time to clinical stability.Archives of internal medicine 09/2009; 169(16):1515-24. · 11.46 Impact Factor -
Article: Stability in community-acquired pneumonia: one step forward with markers?
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ABSTRACT: Biological markers as an expression of systemic inflammation have been recognised as useful for evaluating the host response in community-acquired pneumonia (CAP). The objective of this study was to evaluate whether the biological markers procalcitonin (PCT) and C-reactive protein (CRP) might reflect stability after 72 h of treatment and the absence of subsequent severe complications. A prospective cohort study was performed in 394 hospitalised patients with CAP. Clinical stability was evaluated using modified Halm's criteria: temperature <or=37.2 degrees C; heart rate <or=100 beats/min; respiratory rate <or=24 breaths/min; systolic blood pressure >or=90 mm Hg; oxygen saturation >or=90%; or arterial oxygen tension >or=60 mm Hg. PCT and CRP levels were measured on day 1 and after 72 h. Severe complications were defined as mechanical ventilation, shock and/or intensive care unit (ICU) admission, or death after 72 h of treatment. 220 patients achieved clinical stability at 72 h and had significantly lower levels of CRP (4.2 vs 7 mg/dl) and of PCT (0.33 vs 0.48 ng/ml). Regression logistic analyses were performed to calculate several areas under the ROC curve (AUC) to predict severe complications. The AUC for clinical stability was 0.77, 0.84 when CRP was added (p = 0.059) and 0.77 when PCT was added (p = 0.45). When clinical stability was achieved within 72 h and marker levels were below the cut-off points (0.25 ng/ml for PCT and 3 mg/dl for CRP), no severe complications occurred. Low levels of CRP and PCT at 72 h in addition to clinical criteria might improve the prediction of absence of severe complications.Thorax 09/2009; 64(11):987-92. · 6.84 Impact Factor -
Article: A prediction rule for estimating the risk of bacteremia in patients with community-acquired pneumonia.
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ABSTRACT: We endeavored to construct a simple score based entirely on epidemiological and clinical variables that would stratify patients who require hospital admission because of community-acquired pneumonia into groups with a low or high risk of developing bacteremia. Derivation and internal validation cohorts were obtained by retrospective analysis of a database that included 3116 consecutive patients with community-acquired pneumonia from 2 university hospitals. Potential predictive factors were determined by means of a multivariate logistic regression equation applied to a cohort consisting of 60% of the patients. Points were assigned to significant parameters to generate the score. It was then internally validated with the remaining 40% of patients and was externally validated using an independent multicenter cohort of 1369 patients. The overall rates of bacteremia were 12%-16% in the cohorts. The clinical probability estimate of developing bacteremia was based on 6 variables: liver disease, pleuritic pain, tachycardia, tachypnea, systolic hypotension, and absence of prior antibiotic treatment. For the score, 1 point was assigned to each predictive factor. In the derivation cohort, a cutoff score of 2 best identified the risk of bacteremia. In the validation cohorts, rates of bacteremia were <8% for patients with a score 1 (43%-49% of patients), whereas blood culture results were positive in 14%-63% of cases for patients with a score 2. This clinical score, based on readily available and objective variables, provides a useful tool to predict bacteremia. The score has been internally and externally validated and may be useful to guide diagnostic decisions for community-acquired pneumonia.Clinical Infectious Diseases 06/2009; 49(3):409-16. · 9.15 Impact Factor -
Article: Impact of guidelines on outcome: the evidence.
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ABSTRACT: Pneumonia continues to be the main cause of death due to infection in the world, and it produces a high consumption of healthcare resources. The guidelines established by the scientific societies improve the care of patients with pneumonia. One way of evaluating the effect of the guidelines is to analyze their impact on the prognosis of the infection. To evaluate this effect, cohort studies have been performed using before-after, observational, cost-effectiveness, and, to a lesser degree, randomized designs. The most recent studies show that the implementation of the guidelines is accompanied by an increase in the process of care percentage and a lower inpatient hospital mortality rate- including the first 48 hours and after 30 days. These findings are consistent across various studies, and they have been confirmed in patients admitted to the intensive care unit. Clinical stability is also reached earlier in patients hospitalized for community-acquired pneumonia (CAP) when the antibiotic treatment is begun early and complies with the recommendations. Finally, the choice of antibiotics that adhere to the guidelines is cost-effective in CAP requiring hospitalization, which is responsible for 80% of the total cost of this disease.Seminars in Respiratory and Critical Care Medicine 05/2009; 30(2):172-8. · 2.43 Impact Factor -
Article: Biomarkers improve mortality prediction by prognostic scales in community-acquired pneumonia.
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ABSTRACT: Prognostic scales provide a useful tool to predict mortality in community-acquired pneumonia (CAP). However, the inflammatory response of the host, crucial in resolution and outcome, is not included in the prognostic scales. The aim of this study was to investigate whether information about the initial inflammatory cytokine profile and markers increases the accuracy of prognostic scales to predict 30-day mortality. To this aim, a prospective cohort study in two tertiary care hospitals was designed. Procalcitonin (PCT), C-reactive protein (CRP) and the systemic cytokines tumour necrosis factor alpha (TNFalpha) and interleukins IL6, IL8 and IL10 were measured at admission. Initial severity was assessed by PSI (Pneumonia Severity Index), CURB65 (Confusion, Urea nitrogen, Respiratory rate, Blood pressure, > or = 65 years of age) and CRB65 (Confusion, Respiratory rate, Blood pressure, > or = 65 years of age) scales. A total of 453 hospitalised CAP patients were included. The 36 patients who died (7.8%) had significantly increased levels of IL6, IL8, PCT and CRP. In regression logistic analyses, high levels of CRP and IL6 showed an independent predictive value for predicting 30-day mortality, after adjustment for prognostic scales. Adding CRP to PSI significantly increased the area under the receiver operating characteristic curve (AUC) from 0.80 to 0.85, that of CURB65 from 0.82 to 0.85 and that of CRB65 from 0.79 to 0.85. Adding IL6 or PCT values to CRP did not significantly increase the AUC of any scale. When using two scales (PSI and CURB65/CRB65) and CRP simultaneously the AUC was 0.88. Adding CRP levels to PSI, CURB65 and CRB65 scales improves the 30-day mortality prediction. The highest predictive value is reached with a combination of two scales and CRP. Further validation of that improvement is needed.Thorax 02/2009; 64(7):587-91. · 6.84 Impact Factor -
Article: [Respiratory infections research: a perspective from the tuberculosis and respiratory infections area (TIR)].
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ABSTRACT: The scientific production of the TIR Area of SEPAR during 2008 is reviewed. In pneumonias, studies on C-reactive protein, procalcitonin and the cytokines as predictive markers of treatment failure are noteworthy, as well as research into the genetic predisposition of the host (polymorphisms of mannose binding lectin) in the prognosis. Among the different activities on tuberculosis in the SEPAR year, was the publication of the new SEPAR guidelines for the . The studies into tuberculosis have been on, the tuberculosis infection, the new in vitro techniques for detecting interferon gamma, new non-bacillary tuberculosis diagnostic committees, and treatment schemes without rifampicin and isoniazid. In COPD,we have highlighted new aspects in the indications for antibiotic treatment in the Consensus Document for the antibiotic treatment of acute exacerbations of COPD, and in the SEPAR-ALAT Clinical Guidelines. In the field of cystic fibrosis (CF), we highlight 3 studies: a) association between colonising- Pseudomonas aeruginosa induced chronic infection and bronchial hyperreactivity; b) serum immunoglobulins response to Aspergillus fumigatus and Candida albicans in the colonising of the lower respiratory tract and its clinical significance; and c) prevalence of environmental mycobacteria in these patients. In the chapter on bronchiectasis, a study on the relationship between systemic inflammation and severity parameters is highlighted, and finally, the main contributions of the new SEPAR guidelines on the diagnosis and treatment of bronchiectasis.Archivos de Bronconeumología 01/2009; 45 Suppl 1:11-5. · 2.17 Impact Factor -
Article: Risk Factors for Multidrug-Resistant Pneumococcal Pneumonia
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ABSTRACT: Background: Several patient-related factors for acquisition of penicillin/erythromycin-resistant pneumococcal community-acquired pneumonia (CAP) have been reported. However, risk factors associated with CAP caused by multidrug-resistant Streptococcus pneumoniae (MDRSP) have not been extensively studied. Methods: From January 1999 to April 2000, a prospective-multicenter study was conducted in 35 Spanish hospitals to determine the risk factors associated with CAP caused by MDRSP. Pneumococci resistant to multiple antimicrobial agents were defined by the presence of intermediate or high-level resistance to penicillin plus intermediate resistance/resistance to ≥2 non-β-lactam agents (erythromycin, tetracycline, vanco mycin, chloramphenicol, or respiratory quinolones). Results: One hundred forty-two of 638 isolates were found to be MDRSP. The 30-day survival probability was 79.5 and 86.6 for MDRSP-CAP and non-MDRSP-CAP, respectively (P = 0.059). Using multivariate survival analysis, only shock (hazard ratio: 16.4) showed an association with 30-day mortality in MDRSP-CAP. Multivariate analysis showed that asthma (odds ratio [OR], 2.17), HIV infection (OR, 1.97), previous hospital admission (OR, 1.75), nursing home residence (OR, 2.94), and Pneumonia Severity Index (PSI) classes ≥ III (PSI-III, P = 0.008; PSI-IV, P = 0.022; PSI-V, P = 0.005) were significantly associated with MDRSP-CAP. Conclusions: Pneumonia Severity Index score, asthma, HIV infection, previous hospital admission, and nursing home residence are risk factors for MDRSP in CAP patient.Infectious Disease in Clinical Practice 10/2008; 16(6):368-375. -
Article: [Hospital admission in community-acquired pneumonia].
Medicina Clínica 08/2008; 131(6):216-7. · 1.38 Impact Factor
Top co-authors
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Institutions
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2013
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Centro de Investigación Biomédica en Red de Enfermedades Raras
Valencia, Valencia, Spain
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2012
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University of Barcelona
Barcelona, Catalonia, Spain
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2002–2012
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Hospital Universitari i Politècnic la Fe
- • Servicio de Neumología
- • Service of Pneumology
Valencia, Valencia, Spain
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2009
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Hospital Universitari Arnau de Vilanova
Lleida, Catalonia, Spain
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