Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Tratamiento de la NAC:
importancia de los factores de riesgo
1
XXV Curso de Avances en Neumología
DR. JORDI ROIG
Pneumolog...
Enf cardiaca isquémica
Enf cerebrovascular
Infección respiratoria
Enf diarreicas
Trast perinatales
EPOC
Tuberculosis
Saram...
Neumonía comunitaria: Mortalidad
Bodi M et al CID 2005;41:1709; Rello J et al ICM 2002;28:1030; BTS Thorax 2001;56
(suppl ...
S.pneumoniae
S.aureus
Legionella
PA
H.influenzae
Enterobac.
Community Acquired Pneumonia:
Etiology
Angus DC et al . Am J R...
¿Es S. pneumoniae la causa principal de
neumonía de etiología desconocida?
Ruiz-Gonzalez A. A microbiologic study with lun...
Edad  50 años
o
comorbilidad
o
anomalias en signos
vitales
calcular PSI score
http://pda.ahqr.gov/
Male age (yrs)
Female ...
Fine MJ.NEJM 1997; 336:243 Pneumonia Severity Index PSI
Definition of SCAP: PSI Score
Fine MJ et al NEJM 1997; 336:243
COPD?
Prevalencia España
En España 1.300.000 personas entre 40 y 69 años padecen una
EPOC. El 78% no estaba diagnosticado.
Leves...
La EPOC en la NAC
que ingresa en UCI
supone mayor
mortalidad (OR 1.58)
10
Rello J et al . Eur Respir J 2006; 27: 1210-6
Cillóniz C et al.
Microbial aetiology of community-acquired
pneumonia and its relation to severity.
Thorax. 2011 Jan 21. [...
Cillóniz C et al.
Microbial aetiology of community-acquired
pneumonia and its relation to severity.
Thorax. 2011 Jan 21. [...
46,2
10,1 8,8 8,2 7,6
59,3
4,3
7,6 5,9 8,4
0
10
20
30
40
50
60
70
S.pneumoniae S.aureus L.pneumophila P.aeruginosa H.influ...
Factores que aumentan el riesgo de
infección por S.pneumoniae resistente
-Edad:>65 años o <2 años
-Beta-lactámicos en los ...
Risk factors for multidrug-resistant
pneumococcal pneumonia
Pneumonia Severity Index (PSI) score
Asthma
HIV infection
Prev...
RESISTENCIA NEUMOCOCO
• Historia de antibióticos utilizados
recientemente
– Terapia previa con beta-lactámicos,
macrólidos...
Ho et al. Risk factors for acquisition of levofloxacin
resistant Streptococcus pneumoniae: a case-control
study. Clin Infe...
Puntos clave: resistencia y etiología
• La selección de cepas resistentes se
asocia fuertemente a tratamientos
antimicrobi...
30,1%
21,4%
0%
5%
10%
15%
20%
25%
30%
35%
COPD Non COPD
Mortalityrate(%)
p=0.05
n=176
n=252
COPD (%) Non-COPD(%)
Streptococcus
pneumoniae
52 (54.1) 68 (51.5)
P. aeruginosa 13 (13.5) 1 (0.8)
Haemophillus
influenzae
...
Risk factors for infection with P. aeruginosa
Structural lung disease
Corticosteroid therapy (> 10 mg/d)
Use of broad-spec...
Risk factors for infection with enteric gram-
negative organisms
Nursing home residence
Cardiopulmonary disease
Multiple c...
0%
10%
20%
30%
40%
50%
60%
Inappropriate Appropriate
COPD PATIENTS WITH SCAP:
MORTALITY RATE / EMPIRIC ATB TREATMENT
Rello...
RISK FACTORS OF TREATMENT FAILURE IN
CAP / MORTALITY RATE
Menéndez R et al. Thorax 2004;59:960
0%
5%
10%
15%
20%
25%
30%
F...
¿Es importante la administración
precoz de antibióticos?
• Meehan TP. Quality of care, process, and
outcomes in elderly pa...
Tratamiento de la CAP grave
• Escoger apropiadamente antibiótico inicial
9,2%
15,5%
9,9%
16,5%
0%
2%
4%
6%
8%
10%
12%
14%
...
Early recognition of LD leads to prompt
therapy and low mortality
• Symptoms > 5 days: higher mortality1 in
severe cases
•...
COPD PATIENTS: ICU MORTALITY RATE
RISK FACTORS (Cox proportional regression
analysis)
Rello J, Rodriguez A, Torres A, Roig...
DEVELOPMENT OF SHOCK: Risk Factors
CAPUCI Study
.2 .3 .4 .5 .6 .7 .8 .9 1 2 3 4 5
OR
0.3
Previous ATB
APACHE II score >20
...
Normativa SEPAR de Neumonia
Adquirida en la Comunidad:
actualización de septiembre de 2010.
R. Menéndez, A. Torres, J. Asp...
Características del antibiótico ideal
• Alta actividad contra patógenos
potenciales
• Perfil farmacodinámico adecuado (bue...
Efecto de los antibióticos en la
mortalidad en bacteremia por
neumococo
0
10
20
30
40
50
60
70
80
90
100
0
2
4
6
8
10
12
1...
Penicillin vs Placebo RT
0
20
40
60
80
100
Mortality
All cases Very Severe
Age Group
Penicillin
None
N=200
Evans and Brim ...
Mortalidad: neumonía por
neumococo
0
5
10
15
20
25
30
35
40
45
50
1920
1926
1932
1938
1944
1950
1956
1962
1968
1974
1980
1...
Antibioterapia combinada es mejor que
monoterapia en neumonía neumocócica
bacteriémica
18,2%
20,0%
55,3%
23,4%
4,3%
6,9%
0...
Tipo de Combinación / Mortalidad
OR: 2.7
Mortensen EM et al. Crit Care 2006;10:R8 p=0.004
20-year longitudinal study of Bacteremic pneumococcal
pneumonia in Huntington, West Virginia
0
2
4
6
8
10
12
14
16
18
20
1...
806040200
DAYS
1,0
0,8
0,6
0,4
0,2
0,0
CumulatedSurvival
MONOTHERAPY-
censured
COMBINED-
censured
MONOTHERAPY
COMBINED RX
...
HRCT in patients with dyspnea, fever of unknown origin
and normal X-ray
Brown MJ. Acute lung disease in the immunocompromi...
Epidemiological features
• Travel or residence in high-risk areas for
some pathogens: rickettsiosis, fungal
infection, vir...
Acinetobacter as causative agent of SCAP
•Marik PE. The clinical features of SCAP
presenting as septic shock. Norasept II ...
S. aureus infection in healthy patients
•Gillet Y. Association between S. aureus strains
carrying gene for Panton-Valentin...
221.200
Mercè Agustí
Jordi Roig
157.200
165.138
73.800 40.000
231.468
Jordi Almirall
Eugènia Carandell
Imma Hospital
Pilar...
269/267
353/376
232/230
129/127 79/80
159/171
115/75
N: 1336/1326
OR P
DENTISTA 0.69 0.02
VACUNA NEUMOCOCO 0.54 0.003
PREVIA NAC 1.48 0.001
TABAQUISMO
<150 paq/año
>150 paq/año
1.01
1.46
0...
OR P
CORTICOIDES INH 7.44 0.05
BETA-2 1.17 0.45
IPRATROPIO 2.30 0.002
OXIGENOTERAPIA 5.04 0.014
INHALADORES
Con cámara
Sin...
Prevención de la CAP
Vacunación antigripal
Vacuna antineumocócica:
Johnstone J.Effect of pneumococcal vaccination
in hospi...
FUMADOR
ACTIVO
Pacientes
n (%)
Controles OR
ajustada
p
Nº cig
0/ dia 92 (42) 224 (76) 1.0
1-14/dia 48 (22) 39 (13) 2.3 (1....
No
FUMADOR
Pacientes
n (%)
Controles OR
ajustada
p
No
exposición
40 (59) 125 (80) 1.0
1-4h /dia 16 (24) 25 (16) 2.4 (0.9-
...
Effect of nicotine on L. pneumophila growth
in alveolar macrophages024
control nicotine 0.1 nicotine 1 nicotine 10
24h aft...
Estudio TORCH
6.112 pacientes EPOC y
FEV1<60%
Salmeterol+fluticasona
Fluticasona
Salmeterol
Placebo
52
Calverley P et al. ...
Estudio TORCH
NEUMONÍA
Salmeterol+fluticasona 19.6%
Fluticasona 18.3%
Placebo 12.3%
(P<0.001)
53
Calverley P et al. N Engl...
Inhaled drugs as risk factors for
community-acquired pneumonia
J. Almirall, I. Bolíbar, M. Serra-Prat, E. Palomera, J. Roi...
COPD OR p
Upper respiratory tract infection in the
past month
2.25 (0.84–6.01) 0.107
Oxygen therapy 1.18 (0.19–7.39) 0.863...
Table 3– Association between inhaled drug treatments and the risk of CAP adjusted for
respiratory comorbidity and its seve...
5,81
0,73
4,52
3,02
1,19
5,16
0
1
2
3
4
5
6
7
Biologic Adoptive
Infection
Vascular
Cancer
Sorenson TI et al N Engl J Med 1...
Sorenson et al N Engl J Med 1988
Pathogen coverage Timely initiation
Correct dose Correct route
Optimal
therapy
Increased survival
Pea F et al. Clin Infect...
Pneumonia risk factors
Upcoming SlideShare
Loading in …5
×

Pneumonia risk factors

342 views

Published on

Tratamiento de la NAC: Importancia de los factores de riesgo

Published in: Health & Medicine
  • Be the first to comment

Pneumonia risk factors

  1. 1. Tratamiento de la NAC: importancia de los factores de riesgo 1 XXV Curso de Avances en Neumología DR. JORDI ROIG Pneumologia
  2. 2. Enf cardiaca isquémica Enf cerebrovascular Infección respiratoria Enf diarreicas Trast perinatales EPOC Tuberculosis Sarampión Accidentes de tráfico Cáncer de pulmón 3ª Cáncer gástrico SIDA Suicidio 1990 2020 Murray CJ & Lopez AD. Lancet 1997 Mortalidad Global Prevista 4ª
  3. 3. Neumonía comunitaria: Mortalidad Bodi M et al CID 2005;41:1709; Rello J et al ICM 2002;28:1030; BTS Thorax 2001;56 (suppl IV) 1-64; Fine JM et al NEJM 1997;336:243; Marik PE. J Crit Care 2000;15:85 1% 5% 40% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% No Hospitalizada Hospitalizada UCI Mortalitat
  4. 4. S.pneumoniae S.aureus Legionella PA H.influenzae Enterobac. Community Acquired Pneumonia: Etiology Angus DC et al . Am J Respir Crit Care Med 2002;166:717-723 “S.pneumoniae is the principal microorganism responsible of CAP” “The etiologic pattern was similar in both ICU and non-ICU patients”.
  5. 5. ¿Es S. pneumoniae la causa principal de neumonía de etiología desconocida? Ruiz-Gonzalez A. A microbiologic study with lung aspirates in consecutive patients with CAP. Am J Med 1999. • n= 109 • Conventional microbial work-up + in 54 cases (50%) 9 of them S. pneumoniae • Lung aspiration in remaining 55 provided diagnosis in 36: – S. pneumoniae 18 – H. influenzae 6
  6. 6. Edad  50 años o comorbilidad o anomalias en signos vitales calcular PSI score http://pda.ahqr.gov/ Male age (yrs) Female - 10 Nursing home + 10 cardiac + 10 hepatic + 20 renal + 10 CNS + 10 neoplasia + 20 HR  125/bpm + 10 RR  30/min + 20 SBP < 90 mmHg + 20 Temp. < 35 or  40 C + 15 Confusion + 20 pH < 7.35 + 30 Blood urea nitrogen  30 mg/dl + 20 Sodium < 130 mmol/l + 20 Glucose  250 mg/dl + 10 Hemotocrit < 30% + 10 PaO2 < 60 mmHg + 10 Pleural effusion + 10
  7. 7. Fine MJ.NEJM 1997; 336:243 Pneumonia Severity Index PSI
  8. 8. Definition of SCAP: PSI Score Fine MJ et al NEJM 1997; 336:243 COPD?
  9. 9. Prevalencia España En España 1.300.000 personas entre 40 y 69 años padecen una EPOC. El 78% no estaba diagnosticado. Leves: 38.3% Mod.: 39.7% Graves: 22% Sobradillo V et al. Chest. 2000 Oct;118(4):981-9.
  10. 10. La EPOC en la NAC que ingresa en UCI supone mayor mortalidad (OR 1.58) 10 Rello J et al . Eur Respir J 2006; 27: 1210-6
  11. 11. Cillóniz C et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax. 2011 Jan 21. [Epub ahead of print] AETIOLOGY PSI I-III n= 659 (%) PSI IV n=500 (%) PSI V n=301 (%) TOTAL n=1460 (%) p value St. pneumoniae 276 (42) 205 (41) 132 (44) 613 (42) 0.728 H. influenzae 27 (4) 28 (6) 15 (5) 70 (5) 0.488 Atypical bacteria Legionella Mycoplasma Chlamydia Coxiella 163 (25) 54 (8) 51 (8) 31 (5) 27 (4) 77 (15) 50 (10) 12 (2) 13 (3) 2 (0.4) 23 (8) 14 (5) 2 (1) 6 (2) 1 (0.3) 263 (18) 118 (8) 65 (4) 50 (3) 30 (2) <0.001 0.027 <0.001 0.046 <0.001 Virus 62 (9) 57 (11) 29 (10) 148 (10) 0.511 Mixed 84 (13) 73 (15) 51 (17) 208 (14) 0.217
  12. 12. Cillóniz C et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax. 2011 Jan 21. [Epub ahead of print] AETIOLOGY PSI I-III n= 659 (%) PSI IV n=500 (%) PSI V n=301 (%) TOTAL n=1460 (%) p value St. pneumoniae 276 (42) 205 (41) 132 (44) 613 (42) 0.728 H. influenzae 27 (4) 28 (6) 15 (5) 70 (5) 0.488 Moraxella cath. S. aureus MSSA MRSA GNEnterobact 2 (0.3) 9 (1) 5 (1) 4 (1) 7 (1) 2 (0.4) 10 (2) 5 (1) 5 (1) 9 (2) 1 (0.3) 6 (2) 4 (1) 2 (1) 11 (4) 5 (0.3) 25 (2) 14 (1) 11 (1) 27 (2) 0.961 0.651 0.697 0.731 0.022 Pseudomonas 9 (1) 17(3) 23 (8) 49 (3) <0.001 Others 20 (3) 22 (4) 10 (3) 52 (4) 0.448
  13. 13. 46,2 10,1 8,8 8,2 7,6 59,3 4,3 7,6 5,9 8,4 0 10 20 30 40 50 60 70 S.pneumoniae S.aureus L.pneumophila P.aeruginosa H.influenzae Shock No Shock CAP: Etiology (CAPUCI Study) “The etiologic pattern was similar in both shock and non- shock patients”. Bodí M (CAPUCI study). CID 2005
  14. 14. Factores que aumentan el riesgo de infección por S.pneumoniae resistente -Edad:>65 años o <2 años -Beta-lactámicos en los últimos 3 meses -Alcoholismo -Inmunosupresión -Comorbilidades -Contacto con niños en guarderías - Hospitalización reciente o actual CAP ATS/IDSA Guidelines 2005
  15. 15. Risk factors for multidrug-resistant pneumococcal pneumonia Pneumonia Severity Index (PSI) score Asthma HIV infection Previous hospital admission Nursing home residence Shock associated with 30-day mortality Aspa J, Rajas O, et al. Infect Dis Clin Pract 2008.
  16. 16. RESISTENCIA NEUMOCOCO • Historia de antibióticos utilizados recientemente – Terapia previa con beta-lactámicos, macrólidos y quinolonas favorece resistencia al mismo agente • Escoger un antibiótico diferente al indicado la última vez aunque haya habido éxito terapéutico
  17. 17. Ho et al. Risk factors for acquisition of levofloxacin resistant Streptococcus pneumoniae: a case-control study. Clin Infect Dis 2001 • Case-control study: 27 with levo-Resist pneumococci: 10 AECB, 11 pneumonia, 6 colonized; 54 controls (levo-Sens pneumococci) • Risks for resistance in logistic regression: nursing home residence (OR= 7.4), COPD (OR=10.3), nosocomial (OR=16.2), recent hospitalization (OR= 4.6), prior quinolones within 12 months (OR= 10.7), prior beta-lactam within 6 weeks (OR=14.7) • 11/14 got prior quinolones (8 with levofloxacin) for COPD.
  18. 18. Puntos clave: resistencia y etiología • La selección de cepas resistentes se asocia fuertemente a tratamientos antimicrobianos subóptimos • Las pautas de tratamiento cortas ayudan a reducir la aparición de bacterias multiresistentes Rello J & Roig J. In: Respiratory infections. Chapter 40; Hodder Arnold Pub, London, 2006.
  19. 19. 30,1% 21,4% 0% 5% 10% 15% 20% 25% 30% 35% COPD Non COPD Mortalityrate(%) p=0.05 n=176 n=252
  20. 20. COPD (%) Non-COPD(%) Streptococcus pneumoniae 52 (54.1) 68 (51.5) P. aeruginosa 13 (13.5) 1 (0.8) Haemophillus influenzae 11 (11.4) 7 (5.3) Legionella spp. 4 (4.1) 15 (11.4) Staphylococcus aureus 3 (3.1) 12 (9.0) Enterobacteriaceae 3 (3.1) 9 (6.8) Microorganismos aislados en pacientes inmunocompetentes con y sin EPOC con CAP grave Rello J, Rodriguez A, Torres A, Roig J. ERJ 2006
  21. 21. Risk factors for infection with P. aeruginosa Structural lung disease Corticosteroid therapy (> 10 mg/d) Use of broad-spectrum antibiotics Malnutrition Leukopenic immunosuppression Previous hospital admission Malignancy Rapid X-ray spread Weyers CM. Clin Chest Med 2005; Arancibia F. Arch Intern Med 2002; Bodí M (CAPUCI, CID 2005)
  22. 22. Risk factors for infection with enteric gram- negative organisms Nursing home residence Cardiopulmonary disease Multiple co-morbidities Recent antibiotic use Previous hospital admission Probable aspiration Weyers CM. Clin Chest Med 2005. Arancibia F. Arch Intern Med 2002
  23. 23. 0% 10% 20% 30% 40% 50% 60% Inappropriate Appropriate COPD PATIENTS WITH SCAP: MORTALITY RATE / EMPIRIC ATB TREATMENT Rello J, Rodriguez A, Torres A, Roig J et al. ERJ 2006 p<0.05
  24. 24. RISK FACTORS OF TREATMENT FAILURE IN CAP / MORTALITY RATE Menéndez R et al. Thorax 2004;59:960 0% 5% 10% 15% 20% 25% 30% Failure No Failure p<0.001
  25. 25. ¿Es importante la administración precoz de antibióticos? • Meehan TP. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA 1997; 278: 2080-84 • Houck PM. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with CAP. Arch Intern Med; 2004; 164: 637-644 8 Horas 4 Horas
  26. 26. Tratamiento de la CAP grave • Escoger apropiadamente antibiótico inicial 9,2% 15,5% 9,9% 16,5% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Hospital 30-days <4 hs > 4 hs Houck PM et al. Arch Intern Med 2004;164:637-644 p = 0.04 p = 0.03
  27. 27. Early recognition of LD leads to prompt therapy and low mortality • Symptoms > 5 days: higher mortality1 in severe cases • Adequate Rx < 24 h ICU: 78% survival vs 54% (p=0.005)2 • Fatality rate11% in outbreaks if delayed recognition3 • Lower fatality rates (<2%) if early recognition, as reported in Australia and Murcia, Spain (n=449)3,4 1Gacouin 2002; 2Lettinga 2002; 3Navarro, Eurosurveillance Weekly 2001; 4Garcia-Fulgueiras 2003
  28. 28. COPD PATIENTS: ICU MORTALITY RATE RISK FACTORS (Cox proportional regression analysis) Rello J, Rodriguez A, Torres A, Roig J et al. ERJ 2006
  29. 29. DEVELOPMENT OF SHOCK: Risk Factors CAPUCI Study .2 .3 .4 .5 .6 .7 .8 .9 1 2 3 4 5 OR 0.3 Previous ATB APACHE II score >20 3.4 4.4 Rapid X-rays spread
  30. 30. Normativa SEPAR de Neumonia Adquirida en la Comunidad: actualización de septiembre de 2010. R. Menéndez, A. Torres, J. Aspa, A. Capelastegui, C. Prat, F. Rodríguez de Castro Sociedad Española de Neumología y Cirugía Torácica; www. separ.es
  31. 31. Características del antibiótico ideal • Alta actividad contra patógenos potenciales • Perfil farmacodinámico adecuado (buena penetración tisular) • Perfil de seguridad bueno • Posología fácil • Relación coste/beneficio favorable
  32. 32. Efecto de los antibióticos en la mortalidad en bacteremia por neumococo 0 10 20 30 40 50 60 70 80 90 100 0 2 4 6 8 10 12 14 16 18 20 22 Days of illness Austrian and Gold Ann Int Med 1964 Penicillin (298) Serum (93) Untreated (384)
  33. 33. Penicillin vs Placebo RT 0 20 40 60 80 100 Mortality All cases Very Severe Age Group Penicillin None N=200 Evans and Brim Lancet 1938; 2: 14-19
  34. 34. Mortalidad: neumonía por neumococo 0 5 10 15 20 25 30 35 40 45 50 1920 1926 1932 1938 1944 1950 1956 1962 1968 1974 1980 1986 1992 1998 2004 USA data compiled from published studies and Vital Statistics Reports %mortality MORTALITY(%)
  35. 35. Antibioterapia combinada es mejor que monoterapia en neumonía neumocócica bacteriémica 18,2% 20,0% 55,3% 23,4% 4,3% 6,9% 0% 10% 20% 30% 40% 50% 60% Waterer Martinez Baddour Monoth. Combo (1) Waterer GW et al. Arch Intern Med 2001;161:1837-42 (2) Martínez JA et al. CID 2003;36:389-395 (3) Baddour LM et al. Am J Respir Crit Care Med 2004; 170:440-444 Mortality rate
  36. 36. Tipo de Combinación / Mortalidad OR: 2.7 Mortensen EM et al. Crit Care 2006;10:R8 p=0.004
  37. 37. 20-year longitudinal study of Bacteremic pneumococcal pneumonia in Huntington, West Virginia 0 2 4 6 8 10 12 14 16 18 20 1978-1982 1983-1987 1988-1992 1993-1997 Pen alone Pen+Mac Mufson MA & Stanek RJ. Am J Med 1999 p<0.001
  38. 38. 806040200 DAYS 1,0 0,8 0,6 0,4 0,2 0,0 CumulatedSurvival MONOTHERAPY- censured COMBINED- censured MONOTHERAPY COMBINED RX Severe LD(Capuci): Kaplan – Meier survival curve P=0.203 (Log Rank)
  39. 39. HRCT in patients with dyspnea, fever of unknown origin and normal X-ray Brown MJ. Acute lung disease in the immunocompromised host: CT and pathologic findings. Radiology 1994 Ramila E. Bronchoscopy guided by HRCT for the diagnosis of pulmonary infections in patients with hemathologic malignancies and normal plain chest X-rays. Haematologica 2000 • Immunocompromise, severe emphysema • May detect an unsuspected alveolar infiltrate or a subtle interstitial pattern • Guide for FOB techniques ► better yield
  40. 40. Epidemiological features • Travel or residence in high-risk areas for some pathogens: rickettsiosis, fungal infection, viral hemorrhagic pneumonia • Occupational risk: F. tularensis, Coxiella burnetti, Leptospira, Adenovirus • Family illness: Mycoplasma, C. pneumoniae • Bioterrorism setting • Close contact (schools,…): H1N1
  41. 41. Acinetobacter as causative agent of SCAP •Marik PE. The clinical features of SCAP presenting as septic shock. Norasept II Study Investigators. J Crit Care 2000; 15:85-90. •Anstey NM. Community-acquired bacteremic Acinetobacter pneumonia in tropical Australia is caused by diverse strains of A. baumannii, with carriage in the throat in at-risk groups. J Clin Microbiol 2002; 40: 685-686. •Lee K. Novel acquired metallo-β-lactamase gene, in a class 1 integron from A. baumannii clinical isolates from Korea. AAC 2005; 49: 4485-4491. •Leung W. Fulminant A. baumannii CAP as a distinct clinical syndrome. Chest 2006; 129:102-9.
  42. 42. S. aureus infection in healthy patients •Gillet Y. Association between S. aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002;359:753- 59. •Boussaud V. Life-threatening hemoptysis in adults with CAP due to PV leukocidin-secreting S. aureus. Intensive Care Med 2003;29:1840-3. •Francis J. Severe Community-onset pneumonia in healthy adults caused by methicillin-resistant S. aureus carrying the PV leukocidin genes. CID 2005; 40: 100-7.
  43. 43. 221.200 Mercè Agustí Jordi Roig 157.200 165.138 73.800 40.000 231.468 Jordi Almirall Eugènia Carandell Imma Hospital Pilar Ayuso Andreu Estela Población diana: 888.806 habitantes Almirall J et al. New evidence of risk factors for CAP: a population-based study. PACAP group. Eur Respir J 2008
  44. 44. 269/267 353/376 232/230 129/127 79/80 159/171 115/75 N: 1336/1326
  45. 45. OR P DENTISTA 0.69 0.02 VACUNA NEUMOCOCO 0.54 0.003 PREVIA NAC 1.48 0.001 TABAQUISMO <150 paq/año >150 paq/año 1.01 1.46 0.006 BRONQUITIS CRÓNICA 1.81 0.006 OXÍGENO 2.42 0.01 INHALADORES 1.57 0.03 HALADORES New evidence of risk factors for CAP: a population-based study Almirall J et al. PACAP group. Eur Respir J 2008
  46. 46. OR P CORTICOIDES INH 7.44 0.05 BETA-2 1.17 0.45 IPRATROPIO 2.30 0.002 OXIGENOTERAPIA 5.04 0.014 INHALADORES Con cámara Sin cámara 2.28 1.39 0.01 ANÁLISIS MULTIVARIANTE (tratamiento) casos n=473; controles n=235
  47. 47. Prevención de la CAP Vacunación antigripal Vacuna antineumocócica: Johnstone J.Effect of pneumococcal vaccination in hospitalized adults with CAP. Arch Intern Med 2007. OR of death or ICU was 0.62 Tabaco ↑ riesgo adquisición y muerte. Nuorti JP. Cigarette smoking and invasive pneumococcal dis. NEJM2000 Control odontólogo  riesgo de adquisición Cambio brusco Tª ↑ riesgo
  48. 48. FUMADOR ACTIVO Pacientes n (%) Controles OR ajustada p Nº cig 0/ dia 92 (42) 224 (76) 1.0 1-14/dia 48 (22) 39 (13) 2.3 (1.3- 4.3) 0.006 15-24/dia 41 (19) 19 (6) 3.7 (1.8- 7.8) <0.001 > 25/dia 37 (17) 13 (4) 5.5 (2.5- 12.9) <0.001 Nuorti JP. Cigarrette smoking and invasive pneumococcal disease. NEJM 2000
  49. 49. No FUMADOR Pacientes n (%) Controles OR ajustada p No exposición 40 (59) 125 (80) 1.0 1-4h /dia 16 (24) 25 (16) 2.4 (0.9- 6.3) 0.08 > 4h /dia 12 (18) 7 (4) 3.9 (1.0- 16) 0.05 Nuorti JP. Cigarrette smoking and invasive pneumococcal disease. NEJM 2000
  50. 50. Effect of nicotine on L. pneumophila growth in alveolar macrophages024 control nicotine 0.1 nicotine 1 nicotine 10 24h after infection 48h after infection Matsunaga K et al. J Immunol 2001
  51. 51. Estudio TORCH 6.112 pacientes EPOC y FEV1<60% Salmeterol+fluticasona Fluticasona Salmeterol Placebo 52 Calverley P et al. N Engl J Med 2007; 356: 775-789
  52. 52. Estudio TORCH NEUMONÍA Salmeterol+fluticasona 19.6% Fluticasona 18.3% Placebo 12.3% (P<0.001) 53 Calverley P et al. N Engl J Med 2007; 356: 775-789
  53. 53. Inhaled drugs as risk factors for community-acquired pneumonia J. Almirall, I. Bolíbar, M. Serra-Prat, E. Palomera, J. Roig, I. Hospital, E. Carandell, M. Agustí, P. Ayuso, A. Estela, A. Torres and the Community-Acquired Pneumonia in Catalan Countries (PACAP) Eur Respir J 2010; 36: 1080–1087
  54. 54. COPD OR p Upper respiratory tract infection in the past month 2.25 (0.84–6.01) 0.107 Oxygen therapy 1.18 (0.19–7.39) 0.863 Inhaled steroids 3.26 (1.07–9.98) 0.038 Inhaled β-agonists 0.68 (0.23–2.02) 0.483 Inhaled anticholinergics 1.19 (0.39–3.63) 0.757 Asthma 1.00 (0.38–2.62) 0.998 Oral corticosteroids 1.30 (0.31–5.47) 0.718 Smoking history pack-yrs 0 1 0.081 1–150 4.23 (1.07–16.7) 0.039 >150 2.44 (0.83–7.21) 0.105 Influenza vaccine 0.39 (0.12–1.27) 0.118 Table 3– Association between inhaled drug treatments and the risk of CAP adjusted for respiratory comorbidity and its severity, respiratory treatments and other non-respiratory risk factors, by strata of patients with specific respiratory diseases
  55. 55. Table 3– Association between inhaled drug treatments and the risk of CAP adjusted for respiratory comorbidity and its severity, respiratory treatments and other non-respiratory risk factors, by strata of patients with specific respiratory diseases Asthma alone OR p Upper respiratory tract infection in the past month 1.46 (0.92–2.30) 0.105 Inhaled steroids 1.10 (0.40–3.00) 0.857 Inhaled β-agonists 1.24 (0.58–2.67) 0.582 Inhaled anticholinergics 8.80 (1.02–75.7) 0.048 Influenza vaccine 0.67 (0.42–1.08) 0.096 Pneumococcal vaccine at any time of life 0.35 (0.14–0.84) 0.020 N-Acetylcysteine 0.23 (0.03–1.87) 0.168 Depression 0.70 (0.40–1.21) 0.200
  56. 56. 5,81 0,73 4,52 3,02 1,19 5,16 0 1 2 3 4 5 6 7 Biologic Adoptive Infection Vascular Cancer Sorenson TI et al N Engl J Med 1988 Dying from infection is hereditary
  57. 57. Sorenson et al N Engl J Med 1988
  58. 58. Pathogen coverage Timely initiation Correct dose Correct route Optimal therapy Increased survival Pea F et al. Clin Infect Dis. 2006;42:1764-1771; Rello J et al. Chest. 2006;130:938 Tratamiento “OPTIMO” Inmunomodulación?

×