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To construct a prediction model for bacteraemia in patients with pneumococcal community-acquired pneumonia (P-CAP) based on variables easily obtained at hospital admission.This prospective observational multicentre derivation-validation study was conducted in patients hospitalised with P-CAP between 2000 and 2020. All cases were diagnosed based on positive urinary antigen tests in the emergency department and had blood cultures taken on admission. A risk score to predict bacteraemia was developed.We included 1783 patients with P-CAP (1195 in the derivation and 588 in the validation cohort). A third (33.3%) of the patients had bacteraemia. In the multivariate analysis, the following were identified as independent factors associated with bacteraemia: no influenza vaccination the last year, no pneumococcal vaccination in the last 5 years, blood urea nitrogen (BUN) ≥30 mg/dL, sodium130 mmol/L, lymphocyte count800/µl, C-reactive protein ≥200 mg/L, respiratory failure, pleural effusion and no antibiotic treatment before admission. The score yielded good discrimination (AUC 0.732; 95% CI: 0.695-0.769) and calibration (Hosmer-Lemeshow p-value 0.801), with similar performance in the validation cohort (AUC 0.764; 95% CI:0.719-0.809).We found nine predictive factors easily obtained on hospital admission that could help achieve early identification of bacteraemia. The prediction model provides a useful tool to guide diagnostic decisions.

After SARS-CoV-2 infection, the molecular phenoreversion of the immunological response and its associated metabolic dysregulation are required for a full recovery of the patient. This process is patient-dependent due to the manifold possibilities induced by virus severity, its phylogenic evolution and the vaccination status of the population. We have here investigated the natural history of COVID-19 disease at the molecular level, characterizing the metabolic and immunological phenoreversion over time in large cohorts of hospitalized severe patients (n = 886) and non-hospitalized recovered patients that self-reported having passed the disease (n = 513). Non-hospitalized recovered patients do not show any metabolic fingerprint associated with the disease or immune alterations. Acute patients are characterized by the metabolic and lipidomic dysregulation that accompanies the exacerbated immunological response, resulting in a slow recovery time with a maximum probability of around 62 days. As a manifestation of the heterogeneity in the metabolic phenoreversion, age and severity become factors that modulate their normalization time which, in turn, correlates with changes in the atherogenesis-associated chemokine MCP-1. Our results are consistent with a model where the slow metabolic normalization in acute patients results in enhanced atherosclerotic risk, in line with the recent observation of an elevated number of cardiovascular episodes found in post-COVID-19 cohorts.

Leukocyte differential present certain features in COVID 19 patients. RE-LYMP (reactive lymphocytes) is an extended inflammation parameter (EIP) reported by XN analyzer (Sysmex Corporation, Kobe, Japan) reflect the activation of lymphocytes triggered by infections. We aimed to assess the clinical utility of these parameters as biomarkers for the rapid detection of COVID 19.The study group included 200 COVID 19 and 167 patients with other infections at admission. Differences of leukocyte differential, neutrophil/lymphocyte ratio (NLR) and EIP among groups were assessed with the Kruskal-Wallis test; parameters statiscally different in the groups were tested with Receiver operating characteristic (ROC) curve analysis to assess their diagnostic performance in distinguishing SARS-CoV-2 infections. The reliability of the selected parameters was evaluated in a validation group of 347 patients (160 COVID 19 and 187 other infections).NLR performed well to discard viral infections, area under curve (AUC) 0.988 (95%CI 0.973 - 0.991) and RE-LYMP was useful to distinguish COVID 19 and bacterial infections AUC 0.920 (95%CI 0.884 - 0.948); the two conditions NLR3.3 RE-LYMP0.6% was applied to the validation group and 153 out of 160 COVID 19 patients were correctly distinguished (95.6%).Early diagnosis of SARS-CoV-2 infection is critical for better caring of patients and to reduce the threat of nosocomial infection for professionals. Leukocyte differential and RE-LYMPH could assist in a preliminary differential diagnosis of the disease.

Background Spain introduced the 13-valent pneumococcal conjugate vaccine (PCV13) in the childhood National Immunization Program in 2015–2016 with coverage of 3 doses of 94.8% in 2018. We assessed the evolution of all pneumococcal, PCV13 vaccine type (VT), and experimental PCV20-VT (PCV13 + serotypes 8, 10A, 11A, 12F, 15B, 22F, 33F) hospitalized community-acquired pneumonia (CAP) in adults in Spain from 2011–2018. Methods A prospective observational study of immunocompetent adults (≥18 years) admitted to 4 Spanish hospitals with chest X-ray–confirmed CAP between November 2011 and November 2018. Microbiological confirmation was obtained using the Pfizer serotype-specific urinary antigen detection tests (UAD1/UAD2), BinaxNow test for urine, and conventional cultures of blood, pleural fluid, and high-quality sputum. Results Of 3107 adults hospitalized with CAP, 1943 were ≥65 years. Underlying conditions were present in 87% (n = 2704) of the participants. Among all patients, 895 (28.8%) had pneumococcal CAP and 439 (14.1%) had PCV13-VT CAP, decreasing from 17.9% (n = 77) to 13.2% (n = 68) from 2011–2012 to 2017–2018 (P = .049). PCV20-VT CAP occurred in 243 (23.8%) of those included in 2016–2018. The most identified serotypes were 3 and 8. Serotype 3 accounted for 6.9% (n = 215) of CAP cases, remaining stable during the study period, and was associated with disease severity. Conclusions PCV13-VT caused a substantial proportion of CAP in Spanish immunocompetent adults 8 years after introduction of childhood PCV13 immunization. Improving direct PCV13 coverage of targeted adult populations could further reduce PCV13-VT burden, a benefit that could be increased further if PCV20 is licensed and implemented.

The main aim of this study was to assess the utility of differential white cell count and cell population data (CPD) for the detection of COVID-19 in patients admitted for community-acquired pneumonia (CAP) of different etiologies.This was a multicenter, observational, prospective study of adults aged ≥18 years admitted to three teaching hospitals in Spain from November 2019 to November 2021 with a diagnosis of CAP. At baseline, a Sysmex XN-20 analyzer was used to obtain detailed information related to the activation status and functional activity of white cells.The sample was split into derivation and validation cohorts of 1065 and 717 patients, respectively. In the derivation cohort, COVID-19 was confirmed in 791 patients and ruled out in 274 patients, with mean ages of 62.13 (14.37) and 65.42 (16.62) years, respectively (p0.001). There were significant differences in all CPD parameters except MO-Y. The multivariate prediction model showed that lower NE-X, NE-WY, LY-Z, LY-WY, MO-WX, MO-WY, and MO-Z values and neutrophil-to-lymphocyte ratio were related to COVID-19 etiology with an AUC of 0.819 (0.790, 0.846). No significant differences were found comparing this model to another including biomarkers (p=0.18).Abnormalities in white blood cell morphology based on a few cell population data values as well as NLR were able to accurately identify COVID-19 etiology. Moreover, systemic inflammation biomarkers currently used were unable to improve the predictive ability. We conclude that new peripheral blood biomarkers can help determine the etiology of CAP fast and inexpensively.

To assess the incidence, related factors, timing and duration of new- onset atrial fibrillation in a cohort of consecutive patients diagnosed with pneumococcal pneumonia.Observational study including all immunocompetent adults hospitalized for pneumococcal pneumonia. Patients were classified by time (atrial fibrillation recognized on emergency room arrival or developed during hospitalization) and duration (paroxysmal or persistent). Patients were followed-up for 6 months after discharge.We included 1092 patients, of whom 109 (9.9%) had new-onset atrial fibrillation. An early event was documented in 87 (79.8%) cases. Arrhythmia was classified as paroxysmal in 78 patients. Older age, heavy drinking, respiratory rate ≥ 30/minute, leukopenia, severe inflammation and bacteremia were independent risk factors for developing new-onset atrial fibrillation on admission. Overall, 48 (4.4%) patients died during hospitalization, the rate being higher in those patients who developed new-onset arrhythmia (17.9% vs 2.9% p0.001). Among patients with events recognized at admission, in-hospital mortality was higher in those with persistent arrhythmia (34.8% vs 6.3%, p = 0.002) and 6-month survival was better among those who developed paroxysmal event.The development of new-onset atrial fibrillation was associated with pneumonia severity, and higher in-hospital mortality. Bacteremia and severe systemic inflammation were factors associated with its development.

Introduction Community-acquired pneumonia increases the risk of cardiovascular events (CVE). The objective of this study was to analyze host, severity, and etiology factors associated with the appearance of early and late events and their impact on mortality. Method Prospective multicenter cohort study in patients hospitalized for pneumonia. CVE and mortality rates were collected at admission, 30-day follow-up (early events), and one-year follow-up (late events). Results In total, 202 of 1967 (10.42%) patients presented early CVE and 122 (6.64%) late events; 16% of 1-year mortality was attributed to cardiovascular disease. The host risk factors related to cardiovascular complications were: age ≥ 65 years, smoking, and chronic heart disease. Alcohol abuse was a risk factor for early events, whereas obesity, hypertension, and chronic renal failure were related to late events. Severe sepsis and Pneumonia Severity Index (PSI) ≥ 3 were independent risk factors for early events, and only PSI ≥ 3 for late events. Streptococcus pneumoniae was the microorganism associated with most cardiovascular complications. Developing CVE was an independent factor related to early (OR 2.37) and late mortality (OR 4.05). Conclusions Age, smoking, chronic heart disease, initial severity, and S. pneumoniae infection are risk factors for early and late events, complications that have been related with an increase of the mortality risk during and after the pneumonia episode. Awareness of these factors can help us make active and early diagnoses of CVE in hospitalized CAP patients and design future interventional studies to reduce cardiovascular risk.

Resumen Introduccion La neumonia adquirida en la comunidad se asocia al desarrollo de eventos cardiovasculares (ECV). El objetivo del estudio fue analizar los factores relativos al huesped, la gravedad y la etiologia que se asocian con la aparicion de estos eventos, tempranos y tardios, y su impacto en la mortalidad. Metodo Estudio prospectivo de cohortes multicentrico en pacientes ingresados por neumonia. Se recogieron ECV durante el ingreso, a los 30 dias (tempranos) y al ano (tardios) y la mortalidad. Resultados Doscientos dos de 1.967 (10,42%) pacientes presentaron ECV tempranos y 122 (6,64%) tardios. El 16% de la mortalidad al ano se atribuyo a complicaciones cardiovasculares. Los factores del huesped relacionados con complicaciones cardiovasculares fueron: edad ≥ 65 anos, abuso de alcohol, tabaquismo y cardiopatia cronica en los tempranos y obesidad, HTA e insuficiencia renal cronica en los tardios. La presencia de sepsis grave y Pneumonia Severity Index (PSI) ≥ 3 fueron factores de riesgo independiente de eventos tempranos y, unicamente, el PSI ≥ 3 de los tardios. Streptococcus pneumoniae fue el microorganismo con mayor riesgo de complicaciones cardiovasculares. Desarrollar un ECV fue factor independiente de mortalidad temprana (OR 2,37) y tardia (OR 4,05). Conclusiones La edad, el tabaquismo, la cardiopatia, la gravedad inicial y el S. pneumoniae son factores de riesgo de presentar ECV tempranos y tardios, lo que conlleva mayor mortalidad durante y tras el episodio agudo de neumonia. Conocer estos factores puede ser de utilidad para desarrollar estrategias activas de diagnostico precoz de eventos y/o disenar ensayos dirigidos a reducir las complicaciones cardiovasculares.

Q fever is a zoonotic infectious disease caused by the Coxiella burnetii bacterium. It is an obligate intracellular pathogen with a high infection capacity that proliferates exclusively in an acidified medium, forming a lysosome-like vacuole. It presents a peculiar phenomenon called “antigenic phase variation,” produced by a modification in the complexity of the membrane lipopolysaccharides. Q fever can be found worldwide and presents variable clinical features and geographical distribution. It mostly affects people in rural areas who are in contact with animals. The most common type of transmission to humans is via the inhalation of aerosols containing the pathogen, especially those formed from placental derivatives. Wild animals, domestic animals, and ticks are the principal reservoirs.Diagnosis is mainly made by indirect methods such as serology or by direct methods such as microbiological cultures or tests that detect the specific DNA. Typically, there are two clinical presentations: the acute disease, which is more frequent and often asymptomatic, and a persistent focalized infection in 4 to 5% of patients, generally with a poor evolution. Treatment of the acute form in both children and adults consists of administering doxycycline, while persistent focalized infection should be treated with at least two antibiotics, such as doxycycline and hydroxychloroquine. Several measures should be undertaken to minimize exposure among people working with animals or handling birth products. Different vaccines have been developed to prevent infection, though few data are available.

The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.

Background. Factors related to an adverse evolution in COVID19 infection are needed for proper decision making. We try to identify factors related to hospitalization, ICU admission, and mortality related to the infection. Methods. Retrospective cohort study of patients with SARS-CoV-2 infection from March 1st 2020 to January 9th 2022. The sample was randomly divided into two subsamples, for the purposes of derivation and validation of the prediction rule, until omicron variant appearance and afterwards, respectively. Data collected for this study included sociodemographic data, baseline comorbidities and treatments, and other background data. Multivariable logistic regression models using Lasso logistic regression were used . Results. In the multivariable models, older age, male, peripheral vascular disease, heart failure, heart disease, cerebrovascular, dementia, liver, kidney, diabetes, hemiplegia, interstitial pulmonary disease, cystic fibrosis, malignant tumors, as well as diuretics and the chronic systemic use of steroids were common predictive factors of death. Similar predictors, except liver disease, plus arterial hypertension, were also related to adverse evolution. Similar predictors to the previous, including liver disease, plus dyslipidemia, inflammatory bowel disease, respiratory diseases, and the basal prescription of NSAIDs, heparin, bronchodilators, or immunosuppressants were related to hospital admission. All risk scores developed had AUCs from 0.79 (hospital admission) to 0.94 (death) in the validation in the omicron sample. Conclusions. We propose three risk scales for adverse outcomes and hospital admission easy to calculate and with high predictive capacity, which also work with the current omicron variant, which can help manage patients in primary, emergency, and hospital care.

Introduction: The new coronavirus causing COVID-19 has spread worldwide, leading to a shortage of ICU and ward beds, thereby prompting the need to triage mild vs severe pneumonia. The objective of our study is to identify patients with low-risk COVID-19 pneumonia who do not require ICU admission and/or do not die during hospitalization, based on analytical and clinical data obtained in the initial evaluation. Methods: To this end, a multicenter cohort was defined in 4 hospitals with 1274 hospitalized patients. The cohort was stratified into two groups: (1) low-risk patients (hospitalized pneumonia that does not require ICU admission or die during hospitalization) and (2) severe pneumonia (direct or subsequent ICU admission and/or death). Demographic variables, analytics, and lower ATS/IDSA criteria were collected. A univariate study was conducted and, the variables found as significant, were introduced in a multivariate analysis of logistic regression. Results: Five independent associated factors were identified as predictors of no ICU requirement and/or death: 450 (OR 0.23, 0.15-0.36), CRP 723 cells/mL (OR 0.54, 0.36-0.81) and urea Conclusions: In conclusion, early identification of low-risk SARS-CoV-2 pneumonia is feasible based on initial biochemical findings and using lower ATS/IDSA criteria. This is useful for the quickly decision of hospital admission when there are different hospitalization alternatives. Funding: Instituto de Salud Carlos III (COV20/00385).

To assess survival and identify predictors of survival more than 30-days after discharge in a cohort of consecutive patients diagnosed with pneumococcal pneumonia.Observational study including all consecutive immunocompetent adult patients surviving more than 30-days after hospitalization. The bacteriological diagnosis was based on the results of urinary antigen testing and/or blood culture. Life expectancy was calculated for each patient considering their sex, age and date of discharge.We included 1114 patients that survived more than 30- days after discharge. Of them, 431 (38.6%) died during follow-up (median follow-up of 6.7 years). Age, history of cancer, liver disease, chronic renal disease, chronic obstructive pulmonary disease, cerebrovascular disease, atrial arrhythmia and coronary disease, red cell distribution width (RDW)15%, positive blood culture, hematocrit30% and living in a nursing home were independent risk factors for reduced long-term survival after hospital discharge. Cumulative 1-, 3- and 5-year survival rates were 93.9%, 85.3% and 76%, respectively. Among non-survivors, 361 (83.8%) died earlier than expected given their life expectancy.Survival after hospital discharge is mainly associated with age and comorbidities. The findings of bacteremia and elevated RDW on admission could help identify patients at high risk of long-term mortality.

Young and middle-aged adults are the largest group of patients infected with SARS-CoV-2 and some of them develop severe disease. Objective: To investigate clinical manifestations in adults aged 18-65 years hospitalized for COVID-19 and identify predictors of poor outcome. Secondary objectives: to explore potential differences compared to the disease in elderly patients and the suitability of the commonly used community-acquired pneumonia prognostic scales in younger populations. Methods: Multicenter prospective registry of consecutive patients hospitalized for COVID-19 pneumonia aged 18-65 years between March and May 2020. We considered a composite outcome of “poor outcome” including intensive care unit admission and/or use of noninvasive ventilation, continuous positive airway pressure or high flow nasal cannula oxygen therapies and/or death. Results: We identified 513 patients

Objective: Analyze the role of a new-onset atrial arrhythmia (AA) in the prognosis of pneumococcal pneumonia(PP). Methods: Prospective observational study, including immunocompetent adults hospitalized for PP in 2 hospitals for a 18 year period. The bacteriological diagnosis was based on the result of urinary antigen test and/or blood culture. We evaluated patients with PP who presented a new-onset AA during hospitalization and classified them according to the time (early AA -on hospital admission- or late- 24h after admission) and the duration of the AA (paroxysmal or persistent). All survived patients were followed-up for 6- months period after discharged. Patients with stable or exacerbated chronic AA were excluded. Survival was analyzed using the Kaplan-Meier method. Results: 1092 patients included. Of them 109 had a new-onset AA. An early AA was documented in 87 patients and late onset in 22. AA was persistent in 31 patients and paroxysmal in 78.Figure 1:demographics and in-hospital outcomes.Figure 2: Kaplan-Meier survival curve for patients according to time and duration of the AA (p Conclusions: 1.Nearly 8.3% of patients had a new AA during their hospitalization for PP. 2.New onset AA was associated with worst outcome and higher mortality. 3. Late and persistent new-onset AA were associated with worse prognosis.

Purpose: Nowadays, most cases of pneumococcal community-acquired pneumonia (PCAP) are diagnosed by positive urinary antigen. Our aims were to analyse process of care in patients hospitalised with non-bacteremic PCAP (NB-PCAP) and identify factors associated with poor outcome (PO) in this population. Methods: We conducted a prospective study, including patients hospitalised for NB-PCAP (positive urinary antigen and negative blood culture) over a 15 year period. We performed multivariate analysis of predisposing factors for PO, defined as need for mechanical ventilation and/or shock and/or in-hospital death. Results: Of the 638 patients included, 4.1% died in hospital and 12.8% had PO. Host-related factors were similar in patients with and without PO, but patients with PO had higher illness severity on admission. Adjusted analysis revealed the following independent factors associated with PO: being a nursing home resident (OR: 6.156; 95% CI: 1.827–20.750; p = .003), respiratory rate ≥30 breaths/min (OR: 3.030; 95% CI: 1.554–5.910; p = .001), systolic blood pressure p = .001), diastolic blood pressure p = .007), pulse rate ≥125 beats/min (OR: 3.476; 95% CI: 1.607–7.518; p = .002), pH p p p = .009). The area under the curve for predicting PO was 0.890 (95% CI: 0.851–0.929). Conclusions: Since patients with PO seem different and had worse in-hospital course, we identified eight independent risk factors for PO measurable on admission.

Transbronchial lung cryobiopsy (TBLC) is an emerging technique for the diagnosis of interstitial lung disease (ILD), but its risk benefit ratio has been questioned. The objectives of this research were to describe any adverse events that occur within 90 days following TBLC and to identify clinical predictors that could help to detect the population at risk.We conducted an ambispective study including all patients with suspected ILD who underwent TBLC. Data were collected concerning the safety profile of this procedure and compared to various clinical variables.Overall, 257 TBLCs were analysed. Complications were observed in 15.2% of patients; nonetheless, only 5.4% of all patients required hospital admission on the day of the procedure. In the 30 and 90 days following the TBLC, rates of readmission were 1.3% and 3.5% and of mortality were 0.38%, and 0.78% respectively. Two models were built to predict early admission (AUC 0.72; 95% CI 0.59-0.84) and overall admission (AUC 0.76; 95% CI 0.67-0.85).Within 90 days after TBLC, 8.9% of patients suffered a complication serious enough to warrant hospital admission. Modified MRC dyspnoea score ≥2, FVC50%, and a Charlson Comorbidity Index score ≥2 were factors that predicted early and overall admission.

Introduction: Consensed and objective criteria to identify IPF patients with palliative needs are mising. The Danish Respiratory Society(DRS) recently published some recommendations. Objective: Assess the usefulness of DRS palliative criteria in a cohort of IPF patients. Methodology: Retrospective descriptive study of patients with IPF attended at hospital ILD unit and diagnosed since 2012. Sociodemographic, functional data, hospital admission, and the DRS criteria were assessed. Results: In a cohort of 68 patients diagnosed with IPF,25(37.3%)died during the follow-up. Patient characteristics at diagnosis and palliative criteria results are summarized in figure1. Using DRS criteria we would have identified 20 patients(80%) of the deceased. Sensitivity(S), specificity (Sp), positive predictive value(PPV), negative predictive value(NPV) and accuracy index ( AI) were 0,80; 0,88; 0,80 ;0,88 and respectively. Adding DLCO less than 35% of reference or inability to perform it, in the lung function section of the previous criteria, the S,Sp, PPV, NPV, AI increased to 0,96;0,88;0,97; 0,92; 0,91 respectively and we identified 24 patients(96%) in palliative status. Conclusions: The SDR palliative criteria would have identified 80% of our patients with IPF as palliative. Adding DLCO value to previous criteria the S, E, AI increased. The proposed new criteria would have identified 96% of patients one year before death.

Background Community-acquired pneumonia (CAP) increases the risk of cardiovascular complications during and following the episode. The goal of this study was to determine the usefulness of cardiovascular and inflammatory biomarkers for assessing the risk of early (within 30 days) or long-term (1-year follow-up) cardiovascular events. Methods A total of 730 hospitalized patients with CAP were prospectively followed up during 1 year. Cardiovascular (proadrenomedullin [proADM], pro-B-type natriuretic peptide (proBNP), proendothelin-1, and troponin T) and inflammatory (interleukin 6 [IL-6], C-reactive protein, and procalcitonin) biomarkers were measured on day 1, at day 4/5, and at day 30. Results Ninety-two patients developed an early event, and 67 developed a long-term event. Significantly higher initial levels of proADM, proendothelin-1, troponin, proBNP, and IL-6 were recorded in patients who developed cardiovascular events. Despite a decrease at day 4/5, levels remained steady until day 30 in those who developed late events. Biomarkers (days 1 and 30) independently predicted cardiovascular events adjusted for age, previous cardiac disease, Pa o 2/F io 2 Conclusions Cardiac biomarkers are useful for identifying patients with CAP at high risk for early and long-term cardiovascular events. They may aid personalized treatment optimization and for designing future interventional studies to reduce cardiovascular risk.

Community-acquired pneumonia increases the risk of cardiovascular events (CVE). The objective of this study was to analyze host, severity, and etiology factors associated with the appearance of early and late events and their impact on mortality.Prospective multicenter cohort study in patients hospitalized for pneumonia. CVE and mortality rates were collected at admission, 30-day follow-up (early events), and one-year follow-up (late events).In total, 202 of 1,967 (10.42%) patients presented early CVE and 122 (6.64%) late events; 16% of 1-year mortality was attributed to cardiovascular disease. The host risk factors related to cardiovascular complications were: age ≥65 years, smoking, and chronic heart disease. Alcohol abuse was a risk factor for early events, whereas obesity, hypertension, and chronic renal failure were related to late events. Severe sepsis and Pneumonia Severity Index (PSI) ≥3 were independent risk factors for early events, and only PSI ≥3 for late events. Streptococcus pneumoniae was the microorganism associated with most cardiovascular complications. Developing CVE was an independent factor related to early (OR 2.37) and late mortality (OR 4.05).Age, smoking, chronic heart disease, initial severity, and S. pneumoniae infection are risk factors for early and late events, complications that have been related with an increase of the mortality risk during and after the pneumonia episode. Awareness of these factors can help us make active and early diagnoses of CVE in hospitalized CAP patients and design future interventional studies to reduce cardiovascular risk.

We sought to evaluate the usefulness of biomarkers-procalcitonin (PCT), C-reactive protein (CRP) and proadrenomedullin (pro-ADM)-combined with prognostic scales (PSI, CURB-65 and SCAP score) for identifying adverse outcomes in patients with community-acquired pneumonia (CAP) attending at an Emergency Department (ED).Prospective observational study in a teaching hospital among patients with CAP. In addition to collecting data for the prognostic scales, samples were taken at the ED for assessing PCT, CRP and pro-ADM levels. We compared the prognostic accuracy of these biomarkers with severity scores to predict pneumonia related complications, using the area under the receiver operating characteristics curves (AUC), which evaluates how well the model discriminate between patients who had a pneumonia related complication or not.A total of 491 patients with CAP were enrolled, 256 being admitted to the hospital and 235 treated as outpatients. Admitted patients had higher biomarker levels than outpatients (p 0.001). The SCAP score and pro-ADM level had the best AUCs for predicting pneumonia related complications (0.83 and 0.84, respectively). Considering SCAP score plus pro-ADM level, the AUC increased significantly to 0.88. SCAP score class 0 or 1 with a pro-ADM level0.5 ng/mL was the best indicator for selecting patients for outpatient care.A new risk score combining SCAP score with pro-ADM level is useful to classify severity risk in CAP patients and hence supporting decision-making on hospital admission.

The introduction of pneumococcal conjugate vaccines (PCV7 and PCV13) in children has led to a change in the pattern of pneumococcal serotypes causing pneumococcal disease in adults. The aim of this study is to analyze the distribution of pneumococcal serotypes in adults with bacteremic pneumococcal community-acquired pneumonia (BPP) after the introduction of PCVs in childhood, and the impact of age and comorbidity on this distribution. We conducted an observational study of all adults hospitalized with BPP between 2001 and 2014, in two tertiary hospitals. Overall, we identified 451 cases of BPP (2001–2005: 194, 2006–2010: 134, 2011–2014: 123). The rate of appearance of new cases decreased over the study period. In 70% of the cases, the serotypes found were among those included in PCV13. The most prevalent serotypes were 3 (23.1%), 7F (14.6%), 19A (8.4%) and 1 (7.5%). There was a significant trend to decrease in the percentage of BPP cases due to PCV7 from period 2001–2005 to 2011–2014 (p = 0.0166) and a significant trend to increase in the six serotypes added to form PCV 13 (p = 0.0003). Serotype 3 was the most frequent in patients who developed complications during hospitalization. We did not detect a significant increase in cases caused by non-PCV13 serotypes. The most frequent non-PCV13 serotype was 22F. In conclusion, a significant proportion of adults continue to develop BPP with vaccine serotypes despite infant pneumococcal vaccination. There is a need for further strategies to reduce the current burden of this disease on adults.

Introduction: Frequently there is an important delay in the admission to the Respiratory Intermediate Care Units (RICUs), which may have a negative impact. Objective: To assess the impact of misclassification of the severity at the time of entry in the hospital on respiratory critically ill patients. Methods: We designed a retrospective study with a cohort of patients admitted to the RICU between February 2007 and October 2015. Two groups were defined depending if they were admitted directly from the emergency department (ED group) or transferred later from the conventional hospital ward (CHW group). At the time of entry in the hospital patients presented similar severity of their respiratory process. We compared the demographic features, clinical items, APACHE II, Charlson Index, delay in RICU admission, hospital stay, mortality and readmission of both groups. Results: 1522 patients were included, 1155 from the ED group and 367 from the CHW group. At the time of entry in the hospital no differences were observed between both groups for the assessed variables. However, patients from the CHW group accumulated more hours of delay and had a worse APACHE II score at the time of admission to the RICU than the ED group, differences that resulted to be statistically significant. Length of hospital stay was of 7.52 (6.61) days for ED group and 9.29 (8.12) days for the CHW group (p Conclusion: Delayed admission to the RICU might lead to a worse prognosis in respiratory critically ill patients.

Introduction: Pneumococcal conjugated vaccination (PCV) is recommended in children, adults≥65 years and ≤65 years with comorbidities. PCV13 was introduced for children in 2010 in Spain with a coverage of 61%. Objectives: Evaluation of distribution of serotypes in bacteriemic pneumococcal pneumonia (BPP) in adults, dependant on age and comorbidities after implementation of PCV in children. Methodology Prospective observational study performed in immunocompetent adult patientes admitted with BPP in 2 Spanish hospitals between 2001-2014. Evolution of serotypes, and distribution based on comorbidities and age were examined. Sample was divided in 3 periods: 2001-2005, 2006-2010, 2011-2014. Serotypes were classified in 3 groups: PCV7(7serotypes in PCV7), PCV13-PCV7(6 serotypes added in PCV13) and no-PCV13(not included in PCV13). Age was divided in 3 groups:18-49, 50-64, ≥65. Patients were classified in 3 groups:healthy adults, risk factor adults and adults with comorbidities. Results: 451 patients were included. Most prevalent serotypes were 3, 7F and 19A. A significant decrease of serotypes included in PCV7 was observed in 3 periods. An increase of PCV13-7 serotypes was noted. Serotype distribution based on comorbidities and age is shown in Tables1&2. Conclusions: After PCV7 vaccine was implemented, a decrease of BPP caused by these serotypes was noted. Despite the implementation of PCV13 in children in 2010, PCV13-7 serotypes increased in 3 periods of study, being statistically significant in adults ≥65 y.o and adults with comorbidities. Thus, PCV13 vaccination should include not only children but also adults with comorbidities.

Background Limited data are available regarding fit and healthy patients with pneumonia at different ages. We evaluated the association of age with clinical presentation, serotype and outcomes among healthy and well-functioning patients hospitalized for bacteremic pneumococcal community–acquired pneumonia. Methods We performed a prospective cohort study of consecutive healthy and well-functioning patients hospitalized for this type of pneumonia. Patients were stratified into younger (18 to 64 years) and older (≥65 years) groups. Results During the study period, 399 consecutive patients were hospitalized with bacteremic pneumococcal pneumonia. We included 203 (50.8%) patients who were healthy and well-functioning patients, of whom 71 (35%) were classified as older. No differences were found in antibiotic treatment, treatment failure rate, antibiotic resistance, or serotype, except for serotype 7F that was less common in older patients. In the adjusted multivariate analysis, the older patients had higher 30-day mortality (OR 6.83; 95% CI 1.22–38.22; P = 0.028), but were less likely to be admitted to the ICU (OR 0.14; 95% CI 0.05–0.39; P

Background Hospitalizations due to pneumonia increase steadily with age. The purpose of this study is to explore differences in host- and pathogen-related factors, process of care, and outcome as a function of age in elderly patients with bacteremic pneumococcal pneumonia and identify factors related to mortality. Methods This was a prospective observational study of a cohort of elderly (65-79 years) and very elderly patients (≥ 80 years old) diagnosed with bacteremic pneumococcal pneumonia. The serotypes of the strains isolated and their resistance were also analyzed. Results During the study period, 399 patients were identified, of whom 225 patients (140 elderly and 85 very elderly patients) were included. Despite the groups having similar characteristics on admission, very elderly patients had higher rates of both hospital (16.47% vs 7.14%, p = .028) and 30-day (20% vs 6.43%, p = .002) mortality. Factors found to be predictors of mortality were: altered mental status (odds ratio [OR]: 13.18; 95% confidence interval [CI]: 3.68-47.23), respiratory rate more than or equal to 30/min (OR: 5.82; 95% CI: 1.82-18.64), systolic blood pressure less than 90 mmHg (OR: 10.90; 95% CI: 1.45-81.93), blood urea nitrogen more than 30 mg/dL (OR: 5.41; 95% CI: 1.03-28.42), bilateral or multilobar lung involvement (OR: 5.24; 95% CI: 1.55-17.76), and age (OR: 1.19; 95% CI: 1.09-1.30). Conclusions Very elderly patients have poorer outcomes with no significant differences in host- and pathogen-related factors or process of care. Mortality rates in these patients are associated with age and the severity of their clinical condition.

Objective: Streptococcus pneumoniae is the leading cause of pneumonia worldwide. Respiratory failure (RF) is a severe complication that causes high morbidity and mortality. Our aim was to analyze the clinical presentation, process of care and outcomes in patients hospitalized with pneumococcal community-acquired pneumonia (PCAP) and RF. Methods: Prospective observational study, including all patients hospitalized for PCAP in the pneumology service of 2 hospitals for a 15-year period, which had arterial blood gas analysis or Sp O2 on admission. Two groups according to the presence (pO2 Results: We included 1121 patients, 503 (44.87%) with RF. Figure 1: main characteristics, diagnostic methods, treatment and outcome indicators. Figure 2: multivariate analysis of factors associated with RF. Conclusions : · 45% of the patients hospitalized for PCAP had RF · Age >65, high PSI score, tachypnea and multilobar radiological involvement on admission were independent risk factors of RF · Patients with RF had worse outcome, with higher ICU admission and IMV need, longer in-hospital stay and higher mortality.

Objective: The presence of bacteremia in pneumococcal community-acquired pneumonia (P-CAP) is associated with more morbidity and poorer outcome. Our aim was to identify factors associated with bacteremia in patients with P-CAP diagnosed by positive urinary antigen (+UA). Methods: Prospective observational study, including all immunocompetent patients hospitalized for P-CAP (diagnosed by +UA on admission) in the pneumology service of 2 hospitals for a 15-year period. Blood cultures (BC) were taken from all patients. Patients were divided in 2 groups according to the BC results. Univariate and multivariate analysis were performed. Results: We included 957 patients with P-CAP; 342 (35.7%) with positive BC. Figure1: main characteristics of both groups. Figure2: multivariate analysis of factors associated with bacteriemia. Conclusions : - Neoplastic disease, BUN ≥ 30, Na - Pneumococcal vaccine, previous antibiotic treatment and COPD were protective factors for bacteremia in our patients.

Importance The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) has not been well established. Objective To validate Infectious Diseases Society of America/American Thoracic Society guidelines for duration of antibiotic treatment in hospitalized patients with CAP. Design, Setting, and Participants This study was a multicenter, noninferiority randomized clinical trial performed at 4 teaching hospitals in Spain from January 1, 2012, through August 31, 2013. A total of 312 hospitalized patients diagnosed as having CAP were studied. Data analysis was performed from January 1, 2014, through February 28, 2015. Interventions Patients were randomized at day 5 to an intervention or control group. Those in the intervention group were treated with antibiotics for a minimum of 5 days, and the antibiotic treatment was stopped at this point if their body temperature was 37.8°C or less for 48 hours and they had no more than 1 CAP-associated sign of clinical instability. Duration of antibiotic treatment in the control group was determined by physicians. Main Outcomes and Measures Clinical success rate at days 10 and 30 since admission and CAP-related symptoms at days 5 and 10 measured with the 18-item CAP symptom questionnaire score range, 0-90; higher scores indicate more severe symptoms. Results Of the 312 patients included, 150 and 162 were randomized to the control and intervention groups, respectively. The mean (SD) age of the patients was 66.2 (17.9) years and 64.7 (18.7) years in the control and intervention groups, respectively. There were 95 men (63.3%) and 55 women (36.7%) in the control group and 101 men (62.3%) and 61 women (37.7%) in the intervention group. In the intent-to-treat analysis, clinical success was 48.6% (71 of 150) in the control group and 56.3% (90 of 162) in the intervention group at day 10 ( P = .18) and 88.6% (132 of 150) in the control group and 91.9% (147 of 162) in the intervention group at day 30 ( P = .33). The mean (SD) CAP symptom questionnaire scores were 24.7 (11.4) vs 27.2 (12.5) at day 5 ( P = .10) and 18.6 (9.0) vs 17.9 (7.6) at day 10 ( P = .69). In the per-protocol analysis, clinical success was 50.4% (67 of 137) in the control group and 59.7% (86 of 146) in the intervention group at day 10 ( P = .12) and 92.7% (126 of 137) in the control group and 94.4% (136 of 146) in the intervention group at day 30 ( P = .54). The mean (SD) CAP symptom questionnaire scores were 24.3 (11.4) vs 26.6 (12.1) at day 5 ( P = .16) and 18.1 (8.5) vs 17.6 (7.4) at day 10 ( P = .81). Conclusions and Relevance The Infectious Diseases Society of America/American Thoracic Society recommendations for duration of antibiotic treatment based on clinical stability criteria can be safely implemented in hospitalized patients with CAP. Trial Registration clinicaltrialsregister.eu Identifier:2011-001067-51

The aim of the present study is to evaluate the usefulness of two biomarkers—procalcitonin (PCT) and C-reactive protein (CRP)—in addition to the CURB-65 score for assessing the site of care and the etiology of non-severe community-acquired pneumonia (CAP). We conducted a prospective observational study from April 1, 2006, to June 30, 2007, in a single teaching hospital in northern Spain among patients with non-severe CAP. In addition to collecting data needed to determine the CURB-65 score, microbial cultures were taken and levels of PCT and CRP were measured. We compared the prognostic accuracy of these biomarkers with the CURB-65 score to predict hospitalization and microbial etiology using receiver operating characteristic (ROC) curves. A total of 344 patients with non-severe CAP were enrolled; 73 were admitted to the hospital and 271 were treated on an outpatient basis. An etiologic diagnostic was made for 44 %, with atypical pathogens predominating. Levels of PCT and CRP increased with increasing CURB-65 scores. Patients admitted to the hospital had higher PCT and CRP levels than outpatients (p < 0.001). For predicting hospitalization, PCT had a better area under the ROC curve (AUC) (0.81) than the CURB-65 score alone (0.77). For PCT plus the CURB-65 score, the AUC increased significantly from 0.77 to 0.83. In patients with bacterial CAP, the biomarker levels were significantly higher than among patients with atypical or viral etiology (p < 0.001). PCT with a cut-off point of 0.15 ng/mL was the best predictor for bacterial etiology and for select patients eligible for outpatient care. In conclusion, levels of PCT and CRP positively correlate with increasing severity of CAP and may have a role in predicting both patients who can safely receive outpatient care and the microbial etiology in patients with low CURB-65 scores.

Please cite this paper as: Castilla et al. (2013) Risk factors and effectiveness of preventive measures against influenza in the community. Influenza and Other Respiratory Viruses 7(2) 177–183. Background The role of different risk exposures and preventive measures against influenza has not been well established. Objective The aim of this study was to evaluate risk factors and measures to prevent influenza infection in the community. Methods We conducted a multicenter case–control study. Cases were 481 outpatients aged 18 years or older with laboratory-confirmed influenza A(H1N1)09 in the 2009–2010 season in Spain. A control was selected for each case from outpatients from the same area matched by age and date of consultation. Information on risk situations, preventive measures and other variables was obtained by interview and review of the medical record. Results In the multivariate conditional logistic regression analysis, the risk of a diagnosis of influenza increased with the number of cohabitants (compared with

Summary Multidimensional instruments for determining the severity and prognosis of chronic obstructive pulmonary disease (COPD) must be used in daily clinical practice. Objective: To develop and validate a new COPD severity score using variables readily obtained in clinical practice and to compare its predictive capacity with that of other multidimensional indexes. Data collected from a prospective cohort of 611 stable COPD patients were used to derive a clinical prediction rule that was later validated in a separate prospective cohort of 348 patients. In the multivariate analyses, six independent predictive factors were correlated with overall and respiratory mortality: h ealth status, physical a ctivity, d yspnea, airway o bstruction (FEV 1 ), a ge, and h ospitalizations for COPD exacerbations in the previous two years. These create the HADO-AH score. Based on the β parameter obtained in the multivariate model, a score was assigned to each predictive variable. The area under the curve for 5-year mortality was 0.79 (95% CI, 0.74–0.83) in the derivation cohort and 0.76 (95% CI, 0.71–0.81) in the validation cohort. The HADO-AH score was a significantly better predictor of mortality than the HADO-score and the Body-mass index, Obstruction, Dyspnea, Exercise-index were statistically significant ( p p = 0.021, respectively), but was similar to the Age, Dyspnea, and Obstruction-index ( p = 0.345). The HADO-AH score provides estimates of all-cause and respiratory mortality that are equal to, or better than, those of other multidimensional instruments. Because it uses only easily accessible measures, it could be useful at all levels of care.

Resumen Introduccion La neumonia adquirida en la comunidad (NAC) sigue siendo un problema sanitario importante. Para establecer su gravedad existen una serie de escalas de severidad, pero tienen sus limitaciones. Se han propuesto diferentes biomarcadores que podrian resultar de ayuda. Objetivo Evaluar el valor pronostico de proteina C reactiva (PCR), procalcitonina (PCT) y proadrenomedulina (PADM) para predecir mala evolucion intrahospitalaria en NAC. Material y metodos Se incluyeron todos los pacientes diagnosticados de NAC que quedaron ingresados durante un periodo de 13 meses. Se congelo a −80 °C suero y plasma EDTA obtenidos en el Servicio de Urgencias del Hospital para la determinacion de los biomarcadores. Se dividio a los pacientes en dos grupos: los que evolucionaron favorablemente y los que tuvieron mala evolucion. Los datos clinicos de los pacientes fueron recopilados por revision de la historia clinica. Resultados Las diferencias de las medianas de los tres biomarcadores para los dos grupos adquirieron significacion estadistica. Las areas bajo la curva de las curvas ROC correspondientes fueron: 0,67 para PCT, 0,62 para PCR y 0,74 para PADM. Los puntos de corte seleccionados con sus respectivos datos de sensibilidad y especificidad fueron: para PCT 0,5 ng/mL (S: 0,67/E: 0,61), para PCR 150 mg/L (S: 0,67/E: 0,47) y para PADM 1,2 nmol/L (S: 0,80/E: 0,53). Conclusiones Los resultados sugieren un posible valor pronostico de estos biomarcadores en relacion con la evolucion intrahospitalaria que presentaran los pacientes con NAC, destacando entre ellos la PADM.

Summary Purposes (1) To validate the Severe Community Acquired Pneumonia (SCAP) score in predicting 30-day mortality. (2) To validate its ability to identifying patients at low risk of death. (3) To compare it against the Pneumonia Severity Index (PSI), and the British Thoracic Society's CURB-65 rules. Methods The SCAP score was validated to predict 30-day mortality in an internal validation cohort of consecutive adult patients seen in one hospital. Consecutive inpatients from other three hospitals were used to externally validate the score and compare the SCAP with the PSI and CURB-65. The discriminatory power of these rules to predict 30-day mortality was tested by the Area under Curve (AUC), and their predictive accuracy with the sensitivity, specificity and predictive values. Results The 30-day mortality rate increased directly with increasing SCAP score (class 0: 0.5%, to class 4: 66.5% risk) in the internal validation cohort, and from 1.3% to 29.2% in external cohort ( P P =0.024). The SCAP score identified 62.4% (95% IC 58.8–66.0) low-risk patients, 52.5% (95% IC 48.8–56.2) the PSI and 46.2% (95% CI 42.5–49.9) the CURB-65 in the external cohort. Patients classified as low risk by the three rules had similar 30-day mortality (SCAP: 2.5%, PSI: 1.6% and CURB-65: 2.7%). Conclusion The SCAP is valid to predict 30-day mortality among low-risk patients and identifies a larger proportion of patients as low-risk than the other studied rules.

Exacerbations of chronic obstructive pulmonary disease (COPD) impair health-related quality of life (HRQoL). It is unknown whether exacerbations requiring hospitalisation have an impact on HRQoL. 611 ambulatory COPD patients were prospectively identified. The average age (SD) was 65.5 (8.6), FEV(1) (SD) was 52% (14%) of the predicted value. All patients completed the Saint George's Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study Short Form (SF-36) questionnaire at the beginning of the study. After five years of follow-up, the 391 survivors again completed these HRQoL instruments. No changes in HRQoL were observed among patients not hospitalised for COPD exacerbations. Those hospitalised during follow-up experienced significant declines in HRQoL. The largest changes were observed among patients with >or=3 hospitalisations, with a 13.6 unit increase in the total SGRQ and a 10.5 unit decrease in the physical component summary scale of the SF-36. Similar changes were observed among patients with FEV(1)>or=50% at baseline. In the multivariate analysis, after adjustment by FEV(1%), age, comorbidities, and HRQoL in the respective HRQoL domain at baseline, hospitalisations were an independent predictor of the change in HRQoL. Hospitalisations for exacerbations of COPD have an independent and negative impact on the evolution of HRQoL, regardless of COPD severity.