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Background and objectiveThe objective of this study was to evaluate the effect of age and comorbidities, smoking and alcohol use on microorganisms in patients with community-acquired pneumonia (CAP). MethodsA prospective multicentre study was performed with 4304 patients. We compared microbiological results, bacterial aetiology, smoking, alcohol abuse and comorbidities in three age groups: young adults (65years). ResultsBacterial aetiology was identified in 1522 (35.4%) patients. In seniors, liver disease was independently associated with Gram-negative bacteria (Haemophilus influenzae and Enterobacteriaceae), COPD with Pseudomonas aeruginosa (OR=2.69 (1.46-4.97)) and Staphylococcus aureus (OR=2.8 (1.24-6.3)) and neurological diseases with S. aureus. In adults, diabetes mellitus (DM) was a risk factor for Streptococcus pneumoniae and S. aureus, and COPD for H. influenzae (OR=3.39 (1.06-10.83)). In young adults, DM was associated with S. aureus. Smoking was a risk factor for Legionella pneumophila regardless of age. Alcohol intake was associated with mixed aetiology and Coxiella burnetii in seniors, and with S. pneumoniae in young adults. ConclusionIt should be considered that the bacterial aetiology may differ according to the patient's age, comorbidities, smoking and alcohol abuse. More extensive microbiological testing is warranted in those with risk factors for infrequent microorganisms. We report patterns of rare causative organisms for community-acquired pneumonia related to comorbidities such as liver disease, COPD, neurological illness diabetes, smoking and alcohol abuse in three age groups: young adults (65years).

RATIONALE: Detection of the C-polysaccharide of Streptococcus pneumoniae in urine by an immune-chromatographic test is increasingly used to evaluate patients with community-acquired pneumonia. OBJECTIVES: We assessed the sensitivity and specificity of this test in the largest series of cases to date and used logistic regression models to determine predictors of positivity in patients hospitalized with community-acquired pneumonia. METHODS: We performed a multicenter, prospective, observational study of 4,374 patients hospitalized with community-acquired pneumonia. MEASUREMENTS AND MAIN RESULTS: The urinary antigen test was done in 3,874 cases. Pneumococcal infection was diagnosed in 916 cases (21%); 653 (71%) of these cases were diagnosed exclusively by the urinary antigen test. Sensitivity and specificity were 60 and 99.7%, respectively. Predictors of urinary antigen positivity were female sex; heart rate>/=125 bpm, systolic blood pressure/=30 mg/dl. With at least six of all these predictors present, the probability of positivity was 52%. With only one factor present, the probability was only 12%. CONCLUSIONS: The urinary antigen test is a method with good sensitivity and excellent specificity in diagnosing pneumococcal pneumonia, and its use greatly increased the recognition of community-acquired pneumonia due to S. pneumoniae. With a specificity of 99.7%, this test could be used to direct simplified antibiotic therapy, thereby avoiding excess costs and risk for bacterial resistance that result from broad-spectrum antibiotics. We also identified predictors of positivity that could increase suspicion for pneumococcal infection or avoid the unnecessary use of this test.

BACKGROUND: Active smoking increases the risk of developing community-acquired pneumonia (CAP) and invasive pneumococcal disease, although its impact on mortality in pneumococcal CAP outcomes remains unclear. The aim of this study was to investigate the influence of current smoking status on pneumococcal CAP mortality. METHODS: We performed a multicenter, prospective, observational cohort study in 4,288 hospitalized patients with CAP. The study group consisted of 892 patients with pneumococcal CAP: 204 current smokers (22.8%), 387 nonsmokers (43.4%), and 301 exsmokers (33.7%). RESULTS: Mortality at 30 days was 3.9%: 4.9% in current smokers vs 4.3% in nonsmokers and 2.6% in exsmokers. Current smokers with CAP were younger (51 years vs 74 years), with more alcohol abuse and fewer cardiac, renal, and asthma diseases. Current smokers had lower CURB-65 (confusion, uremia, respiratory rate, BP, age >= 65 years) scores, although 40% had severe sepsis at diagnosis. Current smoking was an independent risk factor (OR, 5.0; 95% CI, 1.8-13.5; P = .001) for 30-day mortality of pneumococcal CAP aft er adjusting for age (OR, 1.06; P = .001), liver disease (OR, 4.5), sepsis (OR, 2.3), antibiotic adherence to guidelines, and first antibiotic dose given, 6 h. The independent risk effect of current smokers remained when compared only with nonsmokers (OR, 4.0; 95% CI, 1.3-12.6; P = .015) or to exsmokers (OR, 3.9; 95% CI, 1.09-4.95; P = .02). CONCLUSIONS: Current smokers with pneumococcal CAP oft en develop severe sepsis and require hospitalization at a younger age, despite fewer comorbid conditions. Smoking increases the risk of 30-day mortality independently of tobacco-related comorbidity, age, and comorbid conditions. Current smokers should be actively targeted for preventive strategies.

Healthcare-associated pneumonia (HCAP) is actually considered a subgroup of hospital-acquired pneumonia due to the reported high risk of multidrug-resistant pathogens in the USA. Therefore, current American Thoracic Society/Infectious Diseases Society of America guidelines suggest a nosocomial antibiotic treatment for HCAP. Unfortunately, the scientific evidence supporting this is contradictory.

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 65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing

Introducción: El riesgo de tuberculosis (TB) está aumentado en pacientes con insuficiencia renal crónica y en diálisis. La prueba de la tuberculina (PT) es el test de cribado clásico en estos pacientes, a pesar de su baja sensibilidad. En los últimos años se han desarrollado nuevos métodos diagnósticos que se basan en la producción de interferón gamma tras la estimulación con antígenos de M. tuberculosis. El objetivo de este estudio fue evaluar si el Quantiferon® TB-gold In Tube (QFT-GIT) puede contribuir en el diagnóstico de la infección tuberculosa en pacientes en diálisis peritoneal (DP). Pacientes y métodos: Se incluyeron 54 pacientes en DP. Se valoró la posibilidad de infección tuberculosa latente mediante el QFT-GIT, la PT y la valoración clinicorradiológica por parte de un neumólogo experto. Se estudiaron las concordancias entre los tests. Resultados: La prevalencia de un resultado positivo para el test de la tuberculina fue del 29,6% para el primer test y del 31,5% para el segundo (valorando el efecto booster). Una radiografía de tórax positiva aumentaba la detección de infección tuberculosa latente hasta un 42,6% y la del neumólogo hasta un 44,4%. El nivel de correlación entre el QFT-GIT y la PT fue moderado (kappa = 0,36; p = 0,006), al igual que entre la PT y la valoración del neumólogo (kappa = 0,257, p = 0,06). Conclusiones: El QFT-GIT aporta algunas ventajas en el diagnóstico de la infección tuberculosa en pacientes con insuficiencia renal crónica en DP, y puede complementar a la prueba de la tuberculina. Objective: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferon-gamma have been developed. The aim of this study was to evaluate if Quantiferon® TB-gold In Tube (QFT-GIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). Patients and methods: Fifty-four patients on PD were included in the study. They were evaluated for latent tuberculosis with QFT-GIT, TST and an assessment by an expert pulmonologist using patient's medical history and x-rays. Agreement between test results was determined. Results: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest x-ray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFT-GIT and TST was fair (κ=0.36; P=.006), as it was between TST and expert physician's evaluation (κ=0.257; P=.06). Conclusions: According to our experience QFT-GIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST.

Introducción: El riesgo de tuberculosis (TB) está aumentado en pacientes con insuficiencia renal crónica y en diálisis. La prueba de la tuberculina (PT) es el test de cribado clásico en estos pacientes, a pesar de su baja sensibilidad. En los últimos años se han desarrollado nuevos métodos diagnósticos que se basan en la producción de interferón gamma tras la estimulación con antígenos de M. tuberculosis. El objetivo de este estudio fue evaluar si el Quantiferon® TB-gold In Tube (QFT-GIT) puede contribuir en el diagnóstico de la infección tuberculosa en pacientes en diálisis peritoneal (DP). Pacientes y métodos: Se incluyeron 54 pacientes en DP. Se valoró la posibilidad de infección tuberculosa latente mediante el QFT-GIT, la PT y la valoración clinicorradiológica por parte de un neumólogo experto. Se estudiaron las concordancias entre los tests. Resultados: La prevalencia de un resultado positivo para el test de la tuberculina fue del 29,6% para el primer test y del 31,5% para el segundo (valorando el efecto booster). Una radiografía de tórax positiva aumentaba la detección de infección tuberculosa latente hasta un 42,6% y la del neumólogo hasta un 44,4%. El nivel de correlación entre el QFT-GIT y la PT fue moderado (kappa = 0,36; p = 0,006), al igual que entre la PT y la valoración del neumólogo (kappa = 0,257, p = 0,06). Conclusiones: El QFT-GIT aporta algunas ventajas en el diagnóstico de la infección tuberculosa en pacientes con insuficiencia renal crónica en DP, y puede complementar a la prueba de la tuberculina.

Some studies highlight the association of better clinical responses with adherence to guidelines for empiric treatment of community-acquired pneumonia (CAP), but little is known about factors that influence this adherence.

The natural history of the resolution of infectious parameters in patients with community-acquired pneumonia (CAP) is not completely known. The aim of our study was to identify those factors related to host characteristics, the severity of pneumonia, and treatment that influence clinical stability.

Objectives Pharmacokinetically enhanced co-amoxiclav 2000/125 mg was designed to achieve high serum concentrations of amoxicillin over the 12 h dosing interval to eradicate Streptococcus pneumoniae with amoxicillin MICs of at least 4 mg/L. Methods This randomized, double-blind, double-dummy, multicentre study compared the efficacy and safety of oral co-amoxiclav 2000/125 mg twice daily versus co-amoxiclav 875/125 mg three times daily, for 7 or 10 days, in the treatment of community-acquired pneumonia (CAP). Results The per-protocol (PP) population at follow-up (Days 18-39) comprised 114 patients receiving co-amoxiclav 2000/125 mg and 116 receiving co-amoxiclav 875/125 mg. Clinical success at follow-up (primary efficacy endpoint) in the clinical PP population was 94.7% (108/114) for co-amoxiclav 2000/125 mg versus 88.8% (103/116) for co-amoxiclav 875/125 mg [treatment difference (TD) = 5.9%, 95% CI: 1.1, 13.0]. Bacteriological success in the bacteriology PP population at follow-up was 85.0% (17/20) for co-amoxiclav 2000/125 mg versus 77.3% (17/22) for co-amoxiclav 875/125 mg (TD = 7.7%, 95% CI: 15.8, 31.2). Penicillin-resistant S. pneumoniae (PRSP) were isolated in three patients (including two with bacteraemia) in the co-amoxiclav 2000/125 mg group (amoxicillin MICs 8 mg/L, penicillin MICs 4 mg/L) and one in the comparator group; all were clinical and bacteriological successes. Co-amoxiclav 2000/125 mg and co-amoxiclav 875/125 mg were associated with adverse events leading to withdrawal in 6.3% and 6.2% of patients, respectively. Conclusions Co-amoxiclav 2000/125 mg twice daily was at least as effective clinically as co-amoxiclav 875/125 mg three times daily in the treatment of CAP. Although few patients in this study had PRSP infection, 3/3 were successfully treated with co-amoxiclav 2000/125 mg.

We studied 162 patients with community-acquired pneumonia admitted for hospital treatment, in order to determine the utility of clinical and ancillary examinations for predicting etiology and guiding the most appropriate empirical treatment. Acute first appearance of symptoms, purulent expectoration, chest sounds indicating lung condensation, pleuritic chest pain and leukocytosis over 12,500/ml were statistically significant in differentiating typical pneumonias from those with atypical behavior patterns. The last two features were the most relevant according to multivariate analysis. We conclude that careful taking of case histories and basic blood testing continue to be relevant and must not be considered anachronistic for the differential diagnosis of community-acquired pneumonias.

par L. Molinos et C. Pronnier, Textband: VIII, 340 S., [1] Bl. ; Tafelband: [2] Bl., 27 Tafeln

Community-acquired pneumonia (CAP) is a serious infection that may occasionally rapidly evolve provoking organ dysfunctions. We aimed to characterize CAP presenting with organ dysfunctions at the emergency room, with regard to host factors and causative microorganisms, and its impact on 30-day mortality. 460 of 4070 (11.3%) CAP patients had >= 2 dysfunctions at diagnosis, with a 30-day mortality of 12.4% vs. 3.4% in those with one or no dysfunctions. Among them, the most frequent causative microorganisms were Streptococcus pneumoniae, gram-negatives and polymicrobial etiology. Independent host risk factors for presenting with >= 2 dysfunctions were: liver (OR 2.97) and renal diseases (OR 3.91), neurological disorders (OR 1.86), and COPD (OR 1.30). Methicillin-resistant Staphylococcus aureus (OR 6.41) and bacteraemic episodes (OR 1.68) had the higher independent risk among microorganisms. The number of organ dysfunctions vs. none increased at 30-day mortality: three organs (OR 11.73), two organs (OR 4.29), and one organ (OR 2.42) whereas Enterobacteria (OR 3.73) were also independently related to mortality. The number of organ dysfunctions was the strongest 30-day mortality risk factor while Enterobacteriaceae was also associated with poorer outcome. The assessment of organ dysfunctions in CAP should be implemented for management, allocation and treatment decisions on initial evaluation. (C) 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

PII (Programme of research of SEPAR) in respiratory infection; CIBERES (Centro de investigacion en red de enfermedades respiratorias) an initiative of ISCIII (Instituto de Salud Carlos III); Beca Fis [PI04/1150]; Beca SEPAR (Sociedad Espanola de Neumologia y Cirugia toracica) [2006/0237]; Beca de la Conselleria Sanitat Comunidad Valenciana [2007/0059], Montull, B., Menéndez, R., Torres, A., Reyes, S., Méndez, R., Zalacaín, R., Capelastegui, A., Rajas, O., Borderías, L., Martin-Villasclaras, J., Bello, S., Alfageme, I., De Castro, F.R., Rello, J., Molinos, L., Ruiz-Manzano, J., Aspa, J.

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 65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing, This work was supported by CIBERES (Centro de investigación en red de enfermedades respiratorias) an initiative of ISCIII (Instituto de Salud Carlos III); Beca Fis (PI 041150); Beca SEPAR (Sociedad Española de Neumología y Cirugía torácica) (2006/0237); Beca de la Consellería Sanitat Comunidad Valenciana (2007/0059) and PII (Programme of research of SEPAR) in respiratory infections