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Legionellosis is the infection caused by bacteria of the genus Legionella, including a non-pneumonic influenza-like syndrome, and Legionnaires' disease is a more serious illness characterized by pneumonia. Legionellosis is becoming increasingly important as a public health problem throughout the world; although it is an underreported disease, studies have consistently documented a high incidence. In addition, health costs associated with the disease are high. Diagnosis of Legionnaires' disease is based mainly on the detection of Legionella pneumophila serogroup 1 antigen in urine. However, there have been advances in detection tests for patients with legionellosis. New methodologies show greater sensitivity and specificity, detect more species and serogroups of Legionella spp., and have the potential for use in epidemiological studies. Testing for Legionella spp. is recommended at hospital admission for severe community-acquired pneumonia, and antibiotics directed against Legionella spp. should be included early as empirical therapy. Inadequate or delayed antibiotic treatment in Legionella pneumonia has been associated with a worse prognosis. Either a fluoroquinolone (levofloxacin or moxifloxacin) or a macrolide (azithromycin preferred) is the recommended first-line therapy for Legionnaires' disease; however, little information is available regarding adverse events or complications, or about the duration of antibiotic therapy and its association with clinical outcomes. Most published studies evaluating antibiotic treatment for Legionnaires' disease are observational and consequently susceptible to bias and confounding. Well-designed studies are needed to assess the usefulness of diagnostic tests regarding clinical outcomes, as well as randomized trials comparing fluoroquinolones and macrolides or combination therapy that evaluate outcomes and adverse events.

Introducción: Un número significativo de pacientes con COVID-19 requieren ingreso en la unidad de cuidados intensivos (UCI). Sin embargo, la mortalidad varía entre los estudios. Objetivos: Determinar las características clínicas y el pronóstico de los adultos con COVID-19 ingresados en UCI en Colombia durante la primera ola de la pandemia. Materiales y métodos: Este estudio retrospectivo multicéntrico se realizó en 8 hospitales. Se incluyeron pacientes con infección confirmada por SARS-CoV-2, de marzo a julio de 2020. Resultados: Durante el período de estudio, 229 adultos con COVID-19 ingresaron en las UCI. La mayoría de los pacientes (54,5%) tenían más de 65 años. Se documentaron comorbilidades en 146 (64%) pacientes, principalmente hipertensión arterial y diabetes mellitus. La mediana de la puntuación SOFA al ingreso en UCI fue de 5 (rango intercuartílico, 2-12). En cuanto a las complicaciones, 118 (51,5%) requirieron ventilación mecánica, 51 (22,4%) terapia de reemplazo renal y 85 (35%) uso de vasopresores. La mortalidad fue 38,4% (88 de 219 pacientes). La mortalidad aumentó con la edad (20% en menores de 40 años y 54,1% en mayores de 65 años; p

Chikungunya virus (CHIKV) infection is an emerging arboviral disease that has spread geographically to many previously unaffected areas. Although severe cases of acute CHIKV infection have been documented, little is known about its pathogenesis. We aimed to determine the levels of cardiovascular biomarkers in fatal and non-fatal patients with acute CHIKV infection. This study included fatal and non-fatal patients with CHIKV reported to National System for Public Health Surveillance and laboratory-confirmed by the Colombian National Institute of Health. Each fatal patient was matched to 2 non-fatal patients for age (± 10 years). Blood samples were processed for cardiovascular biomarkers by multiplex immunoassays. Twenty-five cases of fatal CHIKV infection and 50 patients of non-fatal CHIKV infection were included. Nearly 20% of the population were under 10 years old and 52% were over 60. The median serum levels of endocan-1 (p = 0.000), creatine kinase MB isoenzyme (p = 0.000), oncostatin (p = 0.000), fatty-acid-binding protein 3 (p = 0.000) and fatty-acid-binding protein 4 (p = 0.000) were significantly higher in fatal CHIKV infection cases than in non-fatal patients. Troponin I tended to be higher in fatal CHIKV infection cases than in non-fatal CHIKV infection patients (p = 0.063). Among fatal patients, no significant differences were found in serum levels of cardiovascular biomarkers among younger (50 years-old) and older (≥ 50 years-old) patients. We found high serum levels of cardiovascular biomarkers in fatal CHIKV infection. These results promote the fact that endothelial and cardiac damage can occurs and may be significant factors related organ failure and death in these patients.

Malnutrition comprises two groups of conditions: undernutrition and overweight or obesity. It has been associated with a high risk of contracting infectious diseases and with elevated mortality rates. Community-acquired pneumonia (CAP) is one of the most common infectious diseases worldwide and its prognosis is affected by a large number of recognizable risk factors. This narrative review updates the information on the impact of malnutrition, including both undernutrition and obesity, on the risk and prognosis of adults with CAP. Studies of CAP that have evaluated undernutrition have applied a variety of definitions when assessing the nutritional status of patients. Undernutrition has been associated with unfavorable clinical outcomes, such as prolonged hospital stay, need for intensive care unit admission, and mortality; in contrast, most published studies have found that increased body mass index is significantly associated with higher survival in patients with CAP. However, some authors have presented divergent results, mainly in relation to the etiology of CAP (bacterial versus viral). Influenza infection, caused by influenza A (H1N1) pdm09, has been associated with worse prognosis in obese patients. The current data underscore the need for larger studies to examine the physiological mechanisms that explain the differential impact of malnutrition on outcomes. Achieving a better understanding may help to guide the design of new interventions to improve prognosis.

We report the high frequency of early mortality in COVID‐19 patients (48.6% of 72 deaths). Early deaths were not explained by differences in age, sex and comorbidities, but they had a more severe disease at hospital admission compared with late deaths. These data highlight the importance of outpatient monitoring for the early identification of COVID‐19 patients who require hospital admission.

To describe the characteristics of COVID-19-associated deaths in Barranquilla, Colombia, a city with a high mortality rate, and their changes between pandemic waves.The local Health Department obtained information on all laboratory-confirmed COVID-19 deaths reported from March 2020 to May 2021. Data were collected using national surveillance reports and death certificates.Four thousand nine hundred and sixty-three COVID-19-associated deaths were documented for a mortality rate of 389.4 deaths per 100,000 population. Sixty-two percent of all deaths occurred in people aged ≥65 years and 58% in males. Only 7 COVID-19-associated deaths in children were reported. Comorbidities were found in 47.9% of cases. The number of deaths among people aged 50-64 years increased significantly during the pandemic waves (from 25% to 29%). Conversely, the frequency of male sex (from 64.6% to 53.9%) and deaths with comorbidities (from 60.9% to 39.6%) decreased significantly between the waves of pandemic. Early mortality, defined as death within 48 h after hospital admission, was higher during the first pandemic wave than in the others (29.5%, 9.7% and 10.5%), and time from hospital admission to death increased during waves (from 9 to 14 days).The COVID-19-associated mortality rate was high and mainly affects older people, with comorbidities and male sex. Early mortality was higher during the first wave. Women and healthy people without comorbidities died more frequently after the first pandemic wave.

Introduction Studies have suggested that an inappropriate inflammatory response is a major cause of treatment failure and mortality in patients with community-acquired pneumonia (CAP). We aimed to determine the effect of age and comorbidities on serum inflammatory markers in CAP. Methods We performed a prospective cohort study of adults hospitalized with CAP. For the purposes of this study, we compared patients according to comorbidities and age. Inflammatory markers were measured at hospital admission, focusing on acute phase proteins, cytokines, and monocyte human leukocyte antigen DR (mHLA-DR) expression. Results In patients with chronic pulmonary disease (COPD), serum cytokines had significantly decreased levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and mHLA-DR expression, as well as the C-reactive protein (CRP), compared with patients who had no comorbidities. Similarly, patients with chronic heart disease had a significantly reduced CRP levels and mHLA-DR expression, whereas patients with chronic kidney disease had significantly higher serum levels of procalcitonin and TNF-α. Lower procalcitonin, IL-6, and IL-10 levels, as well as mHLA-DR expression, were documented in older patients, but with no significant differences compared to younger patients. Multimorbidity in older patients was associated with significant lower levels of CRP and mHLA-DR expression. Conclusions The circulating inflammatory markers to CAP have profiles that differ with age and underlying comorbidities. Multimorbidity in the elderly is also associated with lower serum levels of some inflammatory markers. Our findings suggest that inflammatory markers in CAP should be interpreted after considering age and comorbid conditions.

Background: Studies have suggested that an inappropriate inflammatory response is a major cause of treatment failure and mortality in patients with community-acquired pneumonia (CAP). We aimed to determine the effect of comorbidities and age on serum inflammatory markers in CAP.Methods: We performed a prospective cohort study of adults hospitalized with CAP. For the purposes of this study, we compared patients according to comorbidities and age. Inflammatory markers were measured at hospital admission, focusing on acute phase proteins, cytokines, and monocyte human leukocyte antigen DR (mHLA-DR) expression.Results: In patients with chronic pulmonary disease (COPD), serum cytokines had significantly decreased levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and mHLA-DR expression, as well as the C-reactive protein (CRP), compared with patients who had no comorbidities. Similarly, patients with chronic heart disease had a significantly reduced CRP levels and mHLA-DR expression, whereas patients with chronic kidney disease had significantly higher serum levels of procalcitonin and TNF-α. Lower procalcitonin, IL-6, and IL-10 levels, as well as mHLA-DR expression, were documented in older patients, but with no significant differences compared to younger patients. Multimorbidity in older patients was associated with significant lower levels of CRP and mHLA-DR expression.Conclusions: The circulating inflammatory markers to CAP have profiles that differ with age and underlying comorbidities. Multimorbidity in the elderly is also associated with lower serum levels of some inflammatory markers. These findings suggest that age and comorbidities have much more of an impact than to simply reduce physiological reserve and can cause variations in the inflammatory response in CAP.

Worse outcomes of coronavirus disease 2019 (COVID-19) have been documented in older patients with comorbidities, especially in those with diabetes mellitus (DM). However, the clinical picture and risk factors of COVID-19 in DM is still emerging. Here, we report four cases of severe COVID-19 patients with acute diabetic ketoacidosis (DKA) without respiratory symptoms, with viral and bacterial coinfection, and poor clinical outcomes. Higher monitoring of patients with DM and COVID-19 is advised, as well as rapid and accurate diagnostic tests and treatment.

Chikungunya virus (CHIKV), a mosquito-borne alphavirus of the Togaviridae family, is part of a group of emergent diseases, including arbovirus, constituting an increasing public health problem in tropical areas worldwide. CHIKV causes a severe and debilitating disease with high morbidity. The first Colombian autochthonous case was reported in the Colombian Caribbean region in September 2014. Within the next two to three months, the CHIKV outbreak reached its peak. Although the CHIKV pattern of clinical symptomatology has been documented in different epidemiological studies, understanding of the relationship between clinical symptomatology and variation in phenotypic response to CHIKV infection in humans remains limited. We performed a cross sectional study following 1160 individuals clinically diagnosed with CHIKV at the peak of the Chikungunya outbreak in the Colombian Caribbean region. We examined the relationship between symptomatology and diverse phenotypic responses. Latent Class Cluster Analysis (LCCA) models were used to characterize patients’ symptomatology and further identify subgroups of individuals with differential phenotypic response. We found that most individuals presented fever (94.4%), headache (73.28%) and general discomfort (59.4%), which are distinct clinical symptoms of a viral infection. Furthermore, 11/26 (43.2%) of the categorized symptoms were more frequent in women than in men. LCCA disclosed seven distinctive phenotypic response profiles in this population of CHIKV infected individuals. Interestingly, 282 (24.3%) individuals exhibited a lower symptomatic “extreme” phenotype and 74 (6.4%) patients were within the severe complex “extreme” phenotype. Although clinical symptomatology may be diverse, there are distinct symptoms or group of symptoms that can be correlated with differential phenotypic response and perhaps susceptibility to CHIKV infection, especially in the female population. This suggests that, comparatively to men, women are a CHIKV at-risk population. Further study is needed to validate these results and determine whether the distinct LCCA profiles are a result of the immune response or a mixture of genetic, lifestyle and environmental factors. Our findings could contribute to the development of machine learning approaches to characterizing CHIKV infection in other populations. Preliminary results have shown prediction models achieving up to 92% accuracy overall, with substantial sensitivity, specificity and accuracy values per LCCA-derived cluster., Author summary The Chikungunya virus (CHIKV) infection is a mosquito-borne virus of the Togaviridae family, part of the arbovirus group of mosquito-transmitted pathogens. CHIKV causes a severe and debilitating disease with high morbidity. In this study, we comprehensively analysed clinical data from 1160 individuals from the Colombian Caribbean, who were diagnosed with CHIKV infection during the 2014 epidemic peak and before the Zika epidemic (registered back in 2015). Further, the presence of latent classes and predictors of CHIKV susceptibility and severity of the CHIKV infection were analysed. Although it is well known that people respond differently to infection, our results showed that these differences are not arbitrary and may come from the specific orchestration of our immune response and specific genetic makeup. For example, we identified that females infected with CHIKV exhibited significant and heterogeneous phenotypic response patterns compared to men. Overall, these results inform about potential predictors and outlining strategies to study the natural history of CHIKV infection. Future studies assessing the contribution of demographic, immunological and genetic factors to symptom co-occurrence could shed some light on the severity of the clinical symptomatology and, ultimately, lead to more accurate, more efficient and differential diagnosis. These results could contribute to the development of machine learning approaches to characterizing CHIKV infection in other populations and provide more accurate and differential diagnosis.

Legionellaceae are Gram-negative bacilli, of which Legionella pneumophila is the principal cause of human infections. Their natural habitats are freshwater streams, lakes, thermal springs, moist soil, and mud, but the principal source for large outbreaks of legionellosis is cooling systems used for air conditioning and other cooling equipment. Legionella spp. are principally transmitted to humans through contaminated water aerosols. Middle-aged men, smokers, regular alcohol drinkers, and those with comorbidity are most at risk. Aside from supportive care, the first-choice antibiotics are macrolides (mainly azithromycin) and/or fluoroquinolones (especially levofloxacin). Case fatality is 5–15% in previously well adults, but much higher in those who are immunocompromised or develop respiratory failure. Prognosis is improved by early administration of effective anti-legionella antibiotic therapy. Prevention is by the correct design, maintenance, and monitoring of water systems.

Community-acquired pneumonia (CAP) is an increasing problem in the elderly that is associated with elevated morbidity and mortality. Given the expected increased life expectancy, this problem is only likely to worsen, so it has been considered that treatment effects must be examined separately in elderly adults with CAP. Areas covered: In this narrative review, we give an update of the available data of antibiotics for elderly patients with CAP. Clinical features, drug pharmacokinetics and pharmacodynamics, adverse effects, and outcomes differ in CAP depending on patient age. Older age, for example, can affect the effect of specific antibiotic regimens on important CAP clinical outcomes. Current guidelines do not offer specific recommendations for the management of CAP in elderly patients. Expert opinion: Most of our knowledge about the treatment of CAP in elderly patients has been gained from studies in young populations. However, elderly patients with CAP deserve special attention because there are several factors in this population that could influence their response to antibiotic regimens in CAP.

Objectives To assess risk factors for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infection in neutropenic patients. Methods Single-centre retrospective analysis of consecutive bloodstream infection (BSI) episodes (2004–2017, Barcelona). Two multivariate regression models were used at BSI diagnosis and P. aeruginosa detection. Significant predictors were used to establish rules for stratifying patients according to MDR-PA BSI risk. Results Of 661 Gram-negative BSI episodes, 190 (28.7%) were caused by P. aeruginosa (70 MDR-PA). Independent factors associated with MDR-PA among Gram-negative organisms were haematological malignancy (OR 3.30; 95% CI 1.15–9.50), pulmonary source of infection (OR 7.85; 95% CI 3.32–18.56), nosocomial-acquired BSI (OR 3.52; 95% CI 1.74–7.09), previous antipseudomonal cephalosporin (OR 13.66; 95% CI 6.64–28.10) and piperacillin/tazobactam (OR 2.42; 95% CI 1.04–5.63), and BSI occurring during ceftriaxone (OR 4.27; 95% CI 1.15–15.83). Once P. aeruginosa was identified as the BSI aetiological pathogen, nosocomial acquisition (OR 7.13; 95% CI 2.87–17.67), haematological malignancy (OR 3.44; 95% CI 1.07–10.98), previous antipseudomonal cephalosporin (OR 3.82; 95% CI 1.42–10.22) and quinolones (OR 3.97; 95% CI 1.37–11.48), corticosteroids (OR 2.92; 95% CI 1.15–7.40), and BSI occurring during quinolone (OR 4.88; 95% CI 1.58–15.05) and β-lactam other than ertapenem (OR 4.51; 95% CI 1.45–14.04) were independently associated with MDR-PA. Per regression coefficients, 1 point was assigned to each parameter, except for nosocomial-acquired BSI (3 points). In the second analysis, a score >3 points identified 60 (86.3%) out of 70 individuals with MDR-PA BSI and discarded 100 (84.2%) out of 120 with non-MDR-PA BSI. Conclusions A simple score based on demographic and clinical factors allows stratification of individuals with bacteraemia according to their risk of MDR-PA BSI, and may help facilitate the use of rapid MDR-detection tools and improve early antibiotic appropriateness.

Community-acquired pneumonia (CAP) continues to be associated with significant mortality and morbidity. As with other infectious diseases, in recent years there has been a marked increase in resistance to the antibiotics commonly used against the pathogens that cause CAP. Antimicrobial stewardship denotes coordinated interventions to improve and measure the appropriate use of antibiotics by encouraging the selection of optimal drug regimens. Areas covered: Several elements can be applied to antibiotic stewardship strategies for CAP in order to maintain or improve patient outcomes. In this regard, antibiotic de-escalation, duration of antibiotic treatment, adherence to CAP guidelines recommendations about empirical treatment, and switching from intravenous to oral antibiotic therapy may each be relevant in this context. Antimicrobial stewardship strategies, such as prospective audit with intervention and feedback, clinical pathways, and dedicated multidisciplinary teams, that have included some of these elements have demonstrated improvements in antimicrobial use for CAP without negatively affecting clinical outcomes. Expert commentary: Although there are a limited number of randomized clinical studies addressing antimicrobial stewardship strategies in CAP, there is evidence that antibiotic stewardship initiatives can be securely applied, providing benefits to both healthcare systems and patients.

At the end of 2013, the Pan American Health Organization issued an epidemiological alert due to the detection of the first local cases of Chikungunya in the Americas. By August 2015, autochthonous transmissions were detected in 33 countries and territories of the Americas. Latin America has reported nearly one million cases; only Colombia has issued a report of >200,000 cases during the first 4 months of 2015. In some Latin American and Caribbean countries, Chikungunya becomes a major public health problem. The disease commonly exhibits a self-limited course of arthritis, usually lasting for a few days or that may be prolonged to weeks; however, in 10–60 % of cases, joint pain may become chronic and persist for up to 3–5 years. Human-caused environmental changes, such as climate change, the globalization of international exchange, and disordered urban growth, are some factors that aid in its emergence and dissemination. Outbreaks of Chikungunya comprise a challenge for health care systems and rheumatologists because of the high attack rate on the population and the anticipated development of post-Chikungunya chronic rheumatism. This review emphasizes the rheumatologic clinical manifestations reported in the American continent and highlights the challenges that health care systems face in the absence of an effective vaccine and specific treatment to fight Chikungunya.

Community-acquired pneumonia (CAP) continues to be a leading cause of hospitalization and mortality worldwide. Streptococcus pneumoniae and Legionella pneumophila remain the major etiological agents and are responsible for a significant proportion of CAP mortality. Among diagnostic tests for CAP, urine antigen detection of S. pneumoniae and L. pneumophila is widely accepted due to the simplicity of collection and the rapidity of the test results. Areas covered: This comprehensive review outlines the urinary antigen tests available, discusses their sensitivity and specificity, and assesses the usefulness of their results as the basis for targeted therapy. Expert commentary: There have been advances in urine antigen detection tests for patients with CAP. New methodologies show greater sensitivity, detect S. pneumoniae and L. pneumophila in a single test, and also detect pneumococcal serotypes. In addition, urine antigen detection tests have shown a high specificity, which means that a positive result practically indicates the causative pathogen of CAP. Therefore, a positive result can lead to a targeted therapy that is likely to improve patient outcomes and reduce the risk of resistance and adverse events. However, well-designed studies are needed to evaluate the usefulness of urine antigen detection tests with regard to clinical outcomes.

Our objective was to determine the frequency of zika (ZIKV), chikungunya (CHIKV) and dengue (DENV) virus coinfection and describe the mortality cases that occurred during the epidemiologic surveillance of the ZIKV epidemic in Colombia. We analysed all cases of suspected ZIKV infection that were reported to the National Institute of Health (October 2015–December 2016). DENV, CHIKV and ZIKV RNA were detected in serum or tissue samples using polymerase chain reaction assay. Medical records of the fatal cases were reviewed. We identified that 23 871 samples were processed. The frequency of viral agents was 439 (1.84%) for DENV, 257 (1.07%) for CHIKV and 10118 (42.38%) for ZIKV. Thirty-four (0.14%) cases of coinfection were identified. The CHIKV–ZIKV coinfection was present in 28 cases (82.3%), DENV–CHIKV in three (8.8%) and DENV–ZIKV in three (8.8%). Seven (20.6%) coinfection cases were fatal (two DENV–CHIKV cases and five CHIKV–ZIKV cases). Two cases were foetal deaths and the others were related to neurological syndrome and sepsis. In conclusion, the frequency of arbovirus coinfection during epidemic of ZIKV was low, and CHIKV–ZIKV coinfection was the most common. Mortality was high among coinfection patients. The role of each virus in the mortality cases of coinfection warrants further studies.

HIV infection has a tremendous impact on the immune system’s proper functioning. The mucosa-associated lymphoid tissue (MALT) is significantly disarrayed during HIV infection. Compositional changes in the gut microbiota might contribute to the mucosal barrier disruption, and consequently to microbial translocation. We performed an observational, cross-sectional study aimed at evaluating changes in the fecal microbiota of HIV-infected individuals from Colombia. We analyzed the fecal microbiota of 37 individuals via 16S rRNA gene sequencing; 25 HIV-infected patients and 12 control (non-infected) individuals, which were similar in body mass index, age, gender balance and socioeconomic status. To the best of our knowledge, no such studies have been conducted in Latin American countries. Given its compositional nature, microbiota data were normalized and transformed using Aitchison’s Centered Log-Ratio. Overall, a change in the network structure in HIV-infected patients was revealed by using the SPIEC-EASI MB tool. Genera such as Blautia, Dorea, Yersinia, Escherichia-Shigella complex, Staphylococcus, and Bacteroides were highly relevant in HIV-infected individuals. Differential abundance analysis by both sparse Partial Least Square-Discriminant Analysis and Random Forest identified a greater abundance of Lachnospiraceae-OTU69, Blautia, Dorea, Roseburia, and Erysipelotrichaceae in HIV-infected individuals. We show here, for the first time, a predominantly Lachnospiraceae-based signature in HIV-infected individuals.

Publicaciones recientes han desafiado la visión convencional sobre la naturaleza benigna de la infección por el virus de Chikungunya (VCHIK). Las manifestaciones clínicas son muy variables y pueden ser graves en algunos casos. Los estudios sugieren que la forma grave de la infección por el VCHIK puede ser asociada con disfunción orgánica múltiple, hepatitis, meningitis, nefritis, encefalitis, dermatitis ampollosa, miocarditis, arritmias cardiacas, entre otras. La fisiopatología subyacente para algunas de las complicaciones de la enfermedad por el VCHIK sigue siendo poco clara. Sin embargo, de acuerdo con las características clínicas de los casos graves o atípicos descritos a la fecha, el desarrollo de complicaciones podría agruparse principalmente en tres categorías: la exacerbación de condiciones médicas subyacentes, el deterioro de un trastorno no reconocido previamente y la respuesta inmunológica inadecuada a la infección. Se ha encontrado asociación entre las manifestaciones graves de la infección, niveles elevados de citoquinas y algunas secuencias genómicas específicas del VCHIK. La inmunoterapia pasiva puede constituir una estrategia eficaz en el tratamiento de individuos expuestos al VCHIK con riesgo de infección grave. Actualmente no existe evidencia clínica que soporte el uso de antivirales en la prevención o tratamiento de la infección por el VCHIK. Recent publications have challenged the conventional view of the benign nature of the Chikungunya virus (CHIKV) infection. The clinical manifestations are highly variable and can be severe in some cases. Studies suggest that the severe form of CHIKV infection may be associated with multiple organ failure, hepatitis, meningitis, nephritis, encephalitis, bullous dermatitis, myocarditis, cardiac arrhythmias, among others. The underlying pathophysiology for some of these complications remains unclear. However, according to the clinical characteristics of severe or atypical cases reported to date, the development of complications could be grouped into three main categories, such as exacerbation of underlying medical conditions, deterioration of a previously unrecognized condition and inadequate immune response to infection. Some studies have found association between severe manifestations of infection and high levels of cytokines or some specific genomic sequences CHIKV. Experimental studies suggest that passive immunotherapy can be an effective strategy for the management of individuals at risk of severe CHIKV infection. Currently there is no clinical evidence to support antiviral drug use in the prevention or treatment of the disease.

Objective Our objective was to identify clinical predictors of antibiotic treatment effects in hospitalized patients with community-acquired pneumonia (CAP) who were not in the intensive care unit (ICU). Methods Post-hoc analysis of three prospective cohorts (from the Netherlands and Spain) of adult patients with CAP admitted to a non-ICU ward having received either β-lactam monotherapy, β-lactam + macrolide, or a fluoroquinolone-based therapy as empirical antibiotic treatment. We evaluated candidate clinical predictors of treatment effects in multiple mixed-effects models by including interactions of the predictors with empirical antibiotic choice and using 30-day mortality, ICU admission and length of hospital stay as outcomes. Results Among 8562 patients, empirical treatment was β-lactam in 4399 (51.4%), fluoroquinolone in 3373 (39.4%), and β-lactam + macrolide in 790 (9.2%). Older age (interaction OR 1.67, 95% CI 1.23–2.29, p 0.034) and current smoking (interaction OR 2.36, 95% CI 1.34–4.17, p 0.046) were associated with lower effectiveness of fluoroquinolone on 30-day mortality. Older age was also associated with lower effectiveness of β-lactam + macrolide on length of hospital stay (interaction effect ratio 1.14, 95% CI 1.06–1.22, p 0.008). Conclusions Older age and smoking could influence the response to specific antibiotic regimens. The effect modification of age and smoking should be considered hypothesis generating to be evaluated in future trials.

Background Information regarding physiopathology and complications in fatal cases of chikungunya virus (CHIKV) is scarce. Objectives The aim of this study was to describe the frequency and severity of renal complications in fatal cases associated with CHIKV infection based on the clinical and histopathological features from post-mortem tissue biopsies. Study design This retrospective study included fatal cases associated with CHIKV infection occurring from September 2014 through October 2015, reported to National System for Public Health Surveillance (SIVIGILA) and laboratory-confirmed by the National Institute of Health of Colombia. Medical records from 13 patients were available. Information was collected on history, physical examination, and haematological, biochemical, radiological, and virologic investigation reports. Results Diagnosis of CHIKV infection was performed by positive CHIKV-PCR on post-mortem tissue in 10 cases, positive CHIKV-PCR in serum in 6 cases and anti-CHIKV virus IgM in 2 cases. Only 3 cases were children (≤5 years old). Four cases had underlying diseases, mainly systemic arterial hypertension. The median value of creatinine at admission was 2.8 mg/dL (interquartile range 1.52–4.51). During hospitalization, 9 cases required ICU admission, 8 vasopressor support and 6 mechanical ventilation. Kidney histopathological findings were mainly acute interstitial nephritis (11 cases), congestion/oedema glomerular (10 cases) and acute tubular necrosis (5 cases). Conclusions Renal impairment in fatal cases of CHIKV infection is frequent and related mainly to acute interstitial nephritis. These data demonstrate evidence of acquired kidney injuries during CHIKV infection.

Summary Objective To identify the incidence, causes, timing and risk factors associated with 1-year mortality in CAP patients after hospital discharge. Methods Adult patients with CAP who were admitted to a tertiary hospital from 2007 to 2011 were prospectively recruited and followed up for 1 year after hospital discharge. Results Of the 1284 patients discharged, 93 (7.2%) died within 1-year of leaving hospital. Sixty eight (73.1%) patients died in the first six months. The main reasons for 1-year mortality after hospital discharge were infectious diseases, mainly pneumonia, followed by acute cardiovascular events. Mortality from infectious diseases was higher during the first 6 months (86.1%), while the number of deaths from cardiovascular causes was stable throughout the months of follow-up. After adjustment for confounders, chronic obstructive pulmonary disease, diabetes mellitus, cancer, dementia, rehospitalization within 30 days of hospital discharge and nursing home were independently associated with 1-year mortality. The incidence of long-term mortality increased >50% when ≥4 risk factors were present ( P Conclusions Patients mainly died from infectious diseases and acute cardiovascular events in the first six months after leaving hospital for an acute CAP episode. Certain features may help to identify the risk of long-term mortality in CAP patients.

Introduction The aim of this study is to describe the epidemiological and clinical features, treatment and prognosis of community-acquired pneumonia (CAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in two different geographic regions where community-acquired MRSA (CA-MRSA) infections have different frequencies. Methods Observational study of patients admitted to two hospitals (one in Argentina, the other in Spain) between March 2008 and June 2012. Results We documented 16 cases of CAP caused by MRSA. MRSA accounted for 15 of 547 (2.7%) cases of CAP in Hospital Rodolfo Rossi and 1 of 1258 (0,08%) cases at the Hospital Universitari de Bellvitge (P ≤ .001). Most patients were young and previously healthy. Multilobar infiltrates, cavitation and skin and soft tissue involvement were frequent. All patients had positive blood cultures. Five patients required admission to the intensive care unit. Early mortality (≤ 48 hours) was 19%, and overall mortality (≤ 30 days) was 25%. Conclusion CAP caused by MRSA causes high morbidity and mortality rates. It should be suspected in areas with a high prevalence of CA-MRSA infections, and especially in young and healthy patients who present with multilobar pneumonia with cavitation. Mortality is mainly related to septic shock and respiratory failure and occurs early in most cases.

Summary Objectives To determine the aetiology, clinical features and prognosis of CAP during the first post-pandemic influenza season. We also assessed the factors associated with severe disease and tested the ability of a scoring system for identifying influenza A (H1N1)pdm09-related pneumonia. Methods Prospective cohort study carried out at 10 tertiary hospitals of Spain. All adults hospitalised with CAP from December 01, 2010 to March 31, 2011 were analysed. Results A total of 747 adults with CAP required hospitalisation. The aetiology was determined in 315 (42.2%) patients, in whom 154 (21.9%) were due to bacteria, 125 (16.7%) were due to viruses and 36 (4.8%) were mixed (due to viruses and bacteria). The most frequently isolated bacteria were Streptococccus pneumoniae. Among patients with viral pneumonia, the most common organism identified were influenza A (H1N1)pdm09. Independent factors associated with severe disease were impaired consciousness, septic shock, tachypnea, hyponatremia, hypoxemia, influenza B, and influenza A (H1N1)pdm09. The scoring system evaluated did not differentiate reliably between patients with influenza A (H1N1)pdm09-related pneumonia and those with other aetiologies. Conclusions The frequency of bacterial and viral pneumonia during the first post-pandemic influenza season was similar. The main identified virus was influenza A (H1N1)pdm09, which was associated with severe disease. Although certain presenting clinical features may allow recognition of influenza A (H1N1)pdm09-related pneumonia, it is difficult to express them in a reliable scoring system.

To investigate whether serum albumin levels within 24 h of admission correlate with outcomes in community-acquired pneumonia (CAP).Observational analysis of a prospective cohort of adults with CAP requiring hospitalization from 1995 through 2011. Serum albumin level was the independent variable. The primary end point was 30-day mortality.During the study period, 3463 patients with CAP required hospitalization. The median value of albumin was 31 g/L (IQR 28-35). As levels of serum albumin decrease, the risk of complications significantly increases (P.001). Decreased albumin levels were also associated with prolonged time to reach clinical stability (P.001), prolonged hospital stay (P.001), ICU admission (P.001), the need for mechanical ventilation (P.001), and 30-day mortality (P.001). After adjusting for potential confounders in a multivariate logistic regression analysis, serum albumin levels at admission (-5 g/L decrease) were independently associated with a higher risk of 30-day mortality (OR 2.11, 95% CI 1.73-2.56). For predicting primary end point, hypoalbuminemia (30 g/L) significantly increased the area under ROC curves of PSI and CURB-65 scores (P ≤ .02), and identified those patients with higher risk of complications classified into low- and high-risk groups by these scores.Serum albumin level within 24 h of admission is a good prognostic marker in CAP. Physicians should consider albumin level when evaluating the severity of illness in patients with CAP.