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Sputum is not exact, and to the known difficulty involved in obtaining a good quality sample we need to add its lack of specificity, so it is difficult to assess. Blood culture allows a definitive diagnosis, but it is only positive in 15–20% of cases (poor sensitivity) and it takes a minimum 12–24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the search for a quick and simple diagnostic method of this bacterium, the <span class="elsevierStyleItalic">United States Food and Drug Administration</span> (FDA) approved in 1999 a urine antigen detection technique by immunochromatography (<span class="elsevierStyleItalic">Binax NOW urinary antigen assay</span>). The urine pneumococcal antigen (PA) is an easy-to-perform technique, which has significantly increased the number of diagnoses. It detects the capsular polysaccharide common to all serotypes of the bacteria. It provides the results in a short time (between 15<span class="elsevierStyleHsp" style=""></span>min and 2<span class="elsevierStyleHsp" style=""></span>h) and findings are considered qualitatively (positive or negative). Urine can be concentrated or not, concentrating it increases profitability, with percentages between 5 and 15%, and has a high specificity.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Furthermore, in the context of clinical and radiological signs and symptoms consistent with pneumonia its finding is considered a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Since its introduction, several CAP papers have been published on the profitability of this technique, all of them showing a significant increase in <span class="elsevierStyleItalic">S. pneumoniae</span> diagnosed cases with test sensitivities ranging between 50 and 80% of cases and with a very high specificity, above 90%.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,4</span></a> Most series included just a few cases, so perhaps the most relevant has been a recently published multicentre study conducted in our country, which included 3874 CAP who underwent PA determination in urine, 916 of them being positive tests (23.6%), of which 653 (71%) of pneumococcal CAP cases were diagnosed exclusively by this technique, having a test sensitivity of 60%, which rose to 68% when considering only bacteremic CAP cases, and a specificity of 99.7%.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">If anything has characterized this technique in the different series published on CAP in adults is its high specificity, always with figures above 90% of cases.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3–5</span></a> For that reason, the data presented by Salinas et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> in this issue of the magazine is striking, as urine PA determination has been performed in 385 patients with a mean age of 75.4 years, with suspected respiratory tract infection, 48 (12.4%) of them being positive and only 16, one third, showing radiographic infiltrate consistent with pneumonia. Of the positive cases, it was not specified whether they were those with or without pneumonia, 17 (35.4%) had received pneumococcal vaccination (none in the week prior to the start of the study) and 2 cases had recent pneumococcal infection.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first issue to discuss is who should have this test done in adults, as it should be performed only in cases where, apart from being clinically compatible with pneumonia, there is an infiltrate on chest radiograph; and even the different CAP regulations are quite strict and only recommend it in admitted patients.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,7</span></a> Therefore, their use would not be advisable in cases where a respiratory tract infection is suspected and a normal chest X-ray.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A second question would be to what could the positive cases be attributed if the chest X-ray was normal. This could be due to several causes. (1) Recent pneumococcal infection: it has been observed that PA may remain positive in some cases up to 6 months after the clinical signs and sympotoms<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a> and it is accepted that it is not possible to assess the results of this technique in any patient who has had an episode of pneumonia in the previous 3 months; and if the previous episode has been a pneumococcal pneumonia, the new determination, if positive, must always be taken with caution even if more than 3 months have gone by. (2) Asymptomatic Carrier of <span class="elsevierStyleItalic">S. pneumoniae</span> in nasopharynx. This is very common in children and so this technique is very questionable in this population<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>; whereas in adults it is less common, although it can occur in 9–10% of the adult population, with slightly higher numbers in patients with chronic obstructive pulmonary disease and in patients with some form of immunosuppression as those positive for the human immunodeficiency virus, 17–25% of whom are carriers.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9,11</span></a> In the Salinas et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> study, this information has not been sought, but it is possible that a number of positive PA cases may have been asymptomatic <span class="elsevierStyleItalic">S. pneumoniae</span> carriers. (3) Recent Pneumococcal vaccination: this is another factor to value, but according to studies, vaccine administration can cause false positives only between days 2 and 5 after administration of the same, so PA use is not recommended during the first week after vaccination.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12–14</span></a> In the Salinas et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> study there is a history of vaccination in 35.4% of positive PA cases, but the last case had the vaccine 20 days before the start of the study, so it seems unlikely that the cause of the positive PA is related to this fact. (4) Cross-reactions with other streptococci, such as <span class="elsevierStyleItalic">Streptococcus mitis</span> or <span class="elsevierStyleItalic">Streptococcus oralis</span>. These microorganisms are common in children and these cross-reactions have been observed with <span class="elsevierStyleItalic">S. pneumoniae</span>,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> but they are rare in adults so it is unlikely that this may have occurred in the mentioned study.</p><p id="par0035" class="elsevierStylePara elsevierViewall">With the implementation of this technique not only has its profitability been assessed, but also other characteristics of pneumococcal pneumonia. A comparative study of bacteremic and not bacteremic pneumococcal CAP (patients with positive PA and negative blood culture) found that patients with bacteremic CAP had worse outcomes with more complications and higher mortality.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Similarly, another study on 350 bacteremic pneumococcal CAP, with PA performed, showed that positive PA cases (74.6%) had worse outcomes than the negative PA, having a similar severity according to the PSI (<span class="elsevierStyleItalic">Pneumonia severity index</span>),<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> and this is probably due to an increased bacterial load, which, in less serious cases, may have contributed to the PA not being detected in urine.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We also studied the usefulness of this technique in administering the antibiotic treatment as the positive finding meant that a targeted and easier treatment could be established. However, the results on the attitude of doctors in simplifying the treatments are quite disappointing.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> In a recent study of 217 cases of pneumococcal CAP (all with positive PA), in 140 (65%) cases the diagnosis was only by PA, and the antibiotic treatment was only simplified in 75 (35%) cases.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Urine PA and other rapid diagnostic techniques should be performed as early as possible, so that the results could be obtained in a very short time, thus enabling knowing the results when just one dose of antibiotic has been administered, at the most. With this in mind, the antibiotic treatment may be rationalized in a larger number of patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally, also using urine as a sample, a study that simultaneously detects 13 pneumococcal serotypes that are relevant to the recent conjugate vaccine has been published. It is a “multiplex” test based on Luminex technology and detects the specific polysaccharides of these 13 serotypes secreted in the urine with the advantage that this implies, although it does not detect other serotypes.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> At the moment it is not marketed, but could be an excellent complement to the PA determination used today.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, on urine PA determination, the indication to use the technique should be well established. It should only be used in patients with clinical and radiological features consistent with pneumonia. Performing this technique in this type of patients is very interesting because it allows, in a simple and quick way, to significantly increase the number of diagnoses caused by pneumococcus, with good sensitivity and excellent specificity, always evaluating any history of previous pneumonia and possible asymptomatic carriers such as patients with chronic obstructive pulmonary disease and those immunosuppressed, as well as those who received the pneumococcal vaccine the previous week. It will also allow us to implement a targeted antibiotic treatment, since the results are obtained quickly, avoiding broad-spectrum empirical treatments.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zalacain R. 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Journal Information
Vol. 146. Issue 8.
Pages 348-349 (April 2016)
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Vol. 146. Issue 8.
Pages 348-349 (April 2016)
Editorial article
Practical use of pneumococcal antigen assessment in urine
Utilidad práctica del antígeno neumocócico en orina
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Rafael Zalacain
Servicio de Neumología, Hospital Universitario Cruces, Cruces-Baracaldo, Bizkaia, Spain
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