Posts filed under ‘Inmunizaciones’

CLINICAL PRACTICE – Measles

New England J of Medicine July 11, 2019

P.M. Strebel and W.A. Orenstein

A 38-year-old man presents to his primary care physician with a 3-day history of fever and cough. He is a father of two children, his wife is pregnant, and he has a history of recent travel outside the United States. The physical examination is notable for a body temperature of 39°C, conjunctivitis, and rhonchi on chest auscultation. The physician suspects bronchitis and prescribes antibiotic agents. Two days later, the patient returns with a red blotchy rash over his face and trunk. The physician becomes concerned about the possibility of measles. How should this case be further evaluated and managed? How might measles have been prevented, and what can be done to prevent the spread of the disease within the patient’s family and community? …..

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMcp1905181?query=TOC

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMcp1905181?articleTools=true

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July 11, 2019 at 3:54 pm

Efficacy and accuracy of qSOFA and SOFA scores as prognostic tools for community-acquired and healthcare-associated pneumonia

International Journal of Infectious Diseases July 2019 V.84 P.89-96

Nobuhiro Asai, Hiroki Watanabe, Arufumi Shiota, Hideo Kato, Daisuke Sakanashi, Mao Hagihara, Yusuke Koizumi, Yuka Yamagishi, Hiroyuki Suematsu, Hiroshige Mikamo

Highlights

  • The Japanese Respiratory Society recently updated the prognostic guidelines for pneumonia in 2017.
  • The new guidelines recommend that pneumonia severity be evaluated using the sequential organ failure assessment (SOFA) and the quick SOFA (qSOFA) scoring systems in a therapeutic strategy flowchart.
  • The combination of qSOFA and SOFA score could be an independent prognostic factor for 30-day mortality among patients with community-onset pneumonia.

Background

The Japanese Respiratory Society recently updated its prognostic guidelines for pneumonia, recommending that pneumonia severity be evaluated using the sequential organ failure assessment (SOFA) and quick SOFA (qSOFA) scoring systems in a therapeutic strategy flowchart. However, the efficacy and accuracy of these tools are still unknown.

Methods

All patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) who were admitted to the study institution between 2014 and 2017 were enrolled in this study. Pneumonia severity on admission was evaluated by A-DROP, CURB-65, PSI, I-ROAD, qSOFA, and SOFA scoring systems. Prognostic factors for 30-day mortality were also analyzed.

Results

This study included 406 patients, 257 male (63%) and 149 female (37%). The median age was 79 years (range 19–103 years). The 30-day and in-hospital mortality rates were both 5%. With respect to the diagnostic value of the predictive assessments for 30-day mortality, the area under the receiver operating characteristic curve (AUROC) value for the SOFA score was 0.769 for CAP patients and 0.774 for HCAP patients. Further, the AUROC values for the SOFA score in CAP and HCAP patients with a qSOFA score ≥2 were 0.829 and 0.784, respectively, for 30-day mortality.

Conclusions

qSOFA and SOFA scores were able to correctly evaluate the severity of CAP and HCAP.

FULL TEXT

https://www.ijidonline.com/article/S1201-9712(19)30190-0/fulltext

PDF

https://www.ijidonline.com/article/S1201-9712(19)30190-0/pdf

June 30, 2019 at 9:25 pm

Meningococcal Disease Among College-Aged Young Adults: 2014–2016

Pediatrics January 2019  V.143  N.1

BACKGROUND:

Freshman college students living in residence halls have previously been identified as being at an increased risk for meningococcal disease. In this evaluation, we assess the incidence and characteristics of meningococcal disease in college-aged young adults in the United States.

METHODS:

The incidence and relative risk (RR) of meningococcal disease among college students compared with noncollege students aged 18 to 24 years during 2014–2016 were calculated by using data from the National Notifiable Diseases Surveillance System and enhanced meningococcal disease surveillance. Differences in demographic characteristics and clinical features of meningococcal disease cases were assessed. Available meningococcal isolates were characterized by using slide agglutination, polymerase chain reaction, and whole genome sequencing.

RESULTS:

From 2014 to 2016, 166 cases of meningococcal disease occurred in persons aged 18 to 24 years, with an average annual incidence of 0.17 cases per 100 000 population. Six serogroup B outbreaks were identified on college campuses, accounting for 30% of serogroup B cases in college students during this period. The RR of serogroup B meningococcal (MenB) disease in college students versus noncollege students was 3.54 (95% confidence interval: 2.21–5.41), and the RR of serogroups C, W, and Y combined was 0.56 (95% confidence interval: 0.27–1.14). The most common serogroup B clonal complexes identified were CC32/ET-5 and CC41/44 lineage 3.

CONCLUSIONS:

Although the incidence is low, among 18- to 24-year-olds, college students are at an increased risk for sporadic and outbreak-associated MenB disease. Providers, college students, and parents should be aware of the availability of MenB vaccines.

FULL TEXT

https://pediatrics.aappublications.org/content/143/1/e20182130

PDF

https://pediatrics.aappublications.org/content/pediatrics/143/1/e20182130.full.pdf

June 17, 2019 at 6:59 pm

A Therapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy

Clinical Infectious Diseases April 1, 2019 V.68 N.7 P.1080-1088 

EDITOR’S CHOICE

We applied a single algorithm to all forms of pneumonia, which was followed in 82.5% of a cohort of 1089 patients. Only 4.3% received inappropriate therapy; in multivariate analysis, site of pneumonia acquisition was not predictive of 30-day mortality.

Background

Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition.

Methods 

We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of  1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP).

Results

Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0–1 MDR risk (25.8% vs 5.3%, P < .001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0–1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not.

Conclusions

Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality.

FULL TEXT

https://academic.oup.com/cid/article/68/7/1080/5063558

PDF (CLIC en PDF)

May 4, 2019 at 12:14 pm

Measles in 2019 — Going Backward

N Engl J of Medic April 18, 2019

C.I. Paules, H.D. Marston, and A.S. Fauci

In 2000, the United States achieved a historic public health goal: the elimination of measles, defined by the absence of sustained transmission of the virus for more than 12 months. This achievement resulted from a concerted effort by health care practitioners and families alike, working to protect the population through widespread immunization…..

FULL TEXT

https://www.nejm.org/doi/full/10.1056/NEJMp1905099?query=TOC

PDF

https://www.nejm.org/doi/pdf/10.1056/NEJMp1905099?articleTools

 

April 21, 2019 at 11:39 am

Imported toxin-producing cutaneous diphtheria— Minnesota, Washington, and New Mexico, 2015–2018.

MMWR Morb Mortal Wkly Rep March 29, 2019 V.68 N.12 P.281-284

Griffith J et al.

Summary

What is already known about this topic?

Cutaneous diphtheria has not been notifiable in the United States since 1980, and U.S. disease incidence data are limited.

What is added by this report?

Toxin-producing Corynebacterium diphtheriae was identified in cutaneous wounds from four U.S. residents after return from international travel. Public health response for toxin-producing diphtheria includes treating patients, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts.

What are the implications for public health practice?

Cutaneous toxin-producing diphtheria should be considered in travelers with wound infections who have returned from countries with endemic disease to permit prompt public health response and prevent disease transmission.

 

From September 2015 to March 2018, CDC confirmed four cases of cutaneous diphtheria caused by toxin-producing Corynebacterium diphtheriae in patients from Minnesota (two), Washington (one), and New Mexico (one). All patients had recently returned to the United States after travel to countries where diphtheria is endemic. C. diphtheriae infection was not clinically suspected in any of the patients; treating institutions detected the organism through matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry (MALDI-TOF) testing of wound-derived coryneform isolates. MALDI-TOF is a rapid screening platform that uses mass spectrometry to identify bacterial pathogens. State public health laboratories confirmed C. diphtheriae through culture and sent isolates to CDC’s Pertussis and Diphtheria Laboratory for biotyping, polymerase chain reaction (PCR) testing, and toxin production testing. All isolates were identified as toxin-producing C. diphtheriae. The recommended public health response for cutaneous diphtheria is similar to that for respiratory diphtheria and includes treating the index patient with antibiotics, identifying close contacts and observing them for development of diphtheria, providing chemoprophylaxis to close contacts, testing patients and close contacts for C. diphtheriae carriage in the nose and throat, and providing diphtheria toxoid–containing vaccine to incompletely immunized patients and close contacts. This report summarizes the patient clinical information and response efforts conducted by the Minnesota, Washington, and New Mexico state health departments and CDC and emphasizes that health care providers should consider cutaneous diphtheria as a diagnosis in travelers with wound infections who have returned from countries with endemic diphtheria.

FULL TEXT

https://www.cdc.gov/mmwr/volumes/68/wr/mm6812a2.htm?s_cid=mm6812a2_w

PDF

https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6812a2-H.pdf

April 18, 2019 at 9:57 am

Cost-effectiveness analysis of quadrivalent seasonal influenza vaccines in England.

BMC Med. September 8, 2017 V.15 N.1 P.166.

Thorrington D1, van Leeuwen E2,3, Ramsay M4, Pebody R2, Baguelin M2,5.

Author information

1 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK. dominic.thorrington@phe.gov.uk

2 Respiratory Diseases Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

3 Imperial College Faculty of Medicine, London, SW7 2AZ, UK.

4 Immunisation, Hepatitis & Blood Safety Department, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.

5 Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Abstract

BACKGROUND:

As part of the national seasonal influenza vaccination programme in England and Wales, children receive a quadrivalent vaccine offering protection against two influenza A strains and two influenza B strains. Healthy children receive a quadrivalent live attenuated influenza vaccine (QLAIV), whilst children with contraindications receive the quadrivalent inactivated influenza vaccine (QIIV). Individuals aged younger than 65 years in the clinical risk populations and elderly individuals aged 65+ years receive either a trivalent inactivated influenza vaccine (TIIV) offering protection from two A strains and one B strain or the QIIV at the choice of their general practitioner. The cost-effectiveness of quadrivalent vaccine programmes is an open question. The original analysis that supported the paediatric programme only considered a trivalent live attenuated vaccine (LAIV). The cost-effectiveness of the QIIV to other patients has not been established. We sought to estimate the cost-effectiveness of these programmes, establishing a maximum incremental total cost per dose of quadrivalent vaccines over trivalent vaccines.

METHODS:

We used the same mathematical model as the analysis that recommended the introduction of the paediatric influenza vaccination programme. The incremental cost of the quadrivalent vaccine is the additional cost over that of the existing trivalent vaccine currently in use.

RESULTS:

Introducing quadrivalent vaccines can be cost-effective for all targeted groups. However, the cost-effectiveness of the programme is dependent on the choice of target cohort and the cost of the vaccines: the paediatric programme is cost-effective with an increased cost of £6.36 per dose, though an extension to clinical risk individuals younger than 65 years old and further to all elderly individuals means the maximum incremental cost is £1.84 and £0.20 per dose respectively.

CONCLUSIONS:

Quadrivalent influenza vaccines will bring substantial health benefits, as they are cost-effective in particular target groups.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590113/pdf/12916_2017_Article_932.pdf

April 13, 2019 at 12:58 pm

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