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Factores relacionados con la neumonía bacteriana en pacientes con COVID-19 en una unidad de cuidados intensivos de Barranquilla, Colombia
Factors related to bacterial pneumonia in patients with COVID-19 in an intensive care unit in Barranquilla, Colombia
Holmes Algarín-Laraa,
Autor para correspondencia
holmesalgarin@hotmail.com

Autor para correspondencia.
, Edwin Guevara-Romerob, Elber Osorio-Rodrígueza, Jhonny Patiño-Patiñoa, Víctor Flórez Garcíab,c, Rafael de Jesús Tuescab,c, Mauricio Aldana-Roaa, Yussef Said Arciniegas-Vergela, Rómulo Rodado-Villaa
a Grupo de Medicina Intensiva y Cuidados Integrales (GRIMICI), Departamento de Medicina Intensiva, Camino Universitario Distrital Adelita de Char, MiRed IPS, Barranquilla, Colombia
b Joseph J. Zilber School of Public Health, University of Wisconsin, Milwaukee, Wisconsin, Estados Unidos
c Departamento de Salud Pública, Universidad del Norte, Barranquilla, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">SARS-CoV-2 es el nuevo coronavirus que origina la enfermedad COVID-19&#44; la cual se ha convertido en la mayor pandemia en el nuevo milenio<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">1</span></a>&#46; Seg&#250;n datos del Center for Systems Science and Engineering de la Johns Hopkins University&#44; desde finales del 2019 hasta el 27 de junio del 2021 se infectaron 181&#46;038&#46;754 personas en el mundo&#44; de las cuales murieron 3&#46;921&#46;974<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">2</span></a>&#46; En Colombia&#44; hasta esa fecha se registraron 104&#46;678 defunciones&#44; de las cuales 8&#46;922 fueron reportadas en el departamento del Atl&#225;ntico<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Los pacientes con SARS-CoV-2 hospitalizados en la unidad de cuidados intensivos &#40;UCI&#41; tienen el riesgo de presentar neumon&#237;a bacteriana<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Esto se asocia a la corticoterapia mayor de 10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a>&#44; enfermedades cardiometab&#243;licas<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">7&#44;8</span></a>&#44; obesidad<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">9</span></a>&#44; uso de ventilaci&#243;n mec&#225;nica invasiva &#40;VMI&#41; durante m&#225;s de 48<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">10</span></a> y respuesta inmunoinflamatoria exacerbada<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">11</span></a>&#46; Estas condiciones incrementan considerablemente la tasa de mortalidad en los pacientes cr&#237;ticamente enfermos<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En nuestro estudio se evalu&#243; la frecuencia de neumon&#237;a bacteriana en pacientes con COVID-19 y los factores relacionados en la UCI de adultos de la red hospitalaria p&#250;blica de Barranquilla&#44; Colombia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Materiales y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Selecci&#243;n de pacientes y dise&#241;o del estudio</span><p id="par0020" class="elsevierStylePara elsevierViewall">Se realiz&#243; un estudio observacional tipo casos y controles anidado a una cohorte de pacientes ingresados en la UCI general de 29 camas en la ciudad de Barranquilla&#44; en la costa norte de Colombia&#44; entre los meses de marzo y agosto del 2020&#46; Se consideraron casos todos los pacientes que resultaron con neumon&#237;a bacteriana despu&#233;s de haber estado m&#225;s de 72<span class="elsevierStyleHsp" style=""></span>h en la UCI&#46; Se consideraron controles aquellos pacientes que despu&#233;s de estar m&#225;s de 72<span class="elsevierStyleHsp" style=""></span>h en la UCI no se infectaron&#46; Para la selecci&#243;n de los controles se tuvo en cuenta que fueran iguales en cuanto a sexo y con una diferencia de edad de &#177;<span class="elsevierStyleHsp" style=""></span>5 a&#241;os con la poblaci&#243;n que conformaban los casos&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Toda la poblaci&#243;n de estudio&#44; tanto los casos como los controles&#44; eran pacientes con prueba de RT-PCR COVID-19 &#40;positiva&#41; con hospitalizaci&#243;n en UCI mayor de 72<span class="elsevierStyleHsp" style=""></span>h debido a neumon&#237;a comunitaria grave&#44; definida a trav&#233;s de los criterios cl&#237;nicos de ingreso de la Infectious Diseases Society of America y la American Thoracic Society y requerimiento de monitorizaci&#243;n ventilatoria por alto riesgo de insuficiencia respiratoria aguda&#46; Se definieron los pacientes con neumon&#237;a bacteriana por muestra de aspirado de secreci&#243;n bronquial con aislamiento positivo del tracto respiratorio inferior para al menos un microorganismo bacteriano &#40;mayor o igual a 104<span class="elsevierStyleHsp" style=""></span>UFC&#47;mL&#41;&#44; durante la estancia y hospitalizaci&#243;n&#46; Se excluyeron los pacientes que ten&#237;an VMI mayor de 48<span class="elsevierStyleHsp" style=""></span>h sin toma de muestra de aspirado de secreci&#243;n bronquial y los pacientes con probabilidad de neumon&#237;a bacteriana asociada a VMI definida por criterios del Clinical Pulmonary Infection Score mayor de 6 puntos&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para la prevenci&#243;n de la neumon&#237;a asociada a la VMI en toda la poblaci&#243;n de estudio se realiz&#243; de forma rutinaria el protocolo institucional&#44; que consta de&#58; 1&#41; colocaci&#243;n de la cabecera del paciente a 30-45&#176;&#59; 2&#41; aspiraci&#243;n de secreciones por sistema cerrado diario&#59; 3&#41; cambio rutinario del circuito del ventilador cada 72<span class="elsevierStyleHsp" style=""></span>h&#59; 4&#41; mantenimiento de la presi&#243;n del neumotaponador a 30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; y 5&#41; lavado bucal con clorhexidina&#46; En nuestra unidad existe un cumplimiento de la adherencia superior al 95&#37; del paquete de prevenci&#243;n de neumon&#237;a asociada a la VMI&#46; Adem&#225;s&#44; en todos los pacientes se valoraba diariamente la necesidad de destete de VMI&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Las historias cl&#237;nicas de los pacientes se revisaron retrospectivamente teniendo en cuenta las normativas nacionales e institucionales&#44; y se recogieron en un instrumento de recolecci&#243;n de datos para su posterior ingreso en una base de datos de Microsoft Excel&#174;&#44; a la que solo ten&#237;an acceso los investigadores principales&#46; Las variables de nuestro estudio incluyen variables sociodemogr&#225;ficas&#44; comorbilidades cl&#237;nicas&#44; intervenci&#243;n terap&#233;utica &#40;antibioticoterapia emp&#237;rica&#44; corticoterapia&#41;&#44; reporte hematol&#243;gico y cultivos de secreci&#243;n bronquial &#40;perfil de susceptibilidad y resistencia&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">An&#225;lisis estad&#237;stico</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tanto para los casos como para los controles&#44; se agruparon variables teniendo en cuenta las comorbilidades como&#58; diabetes mellitus tipo 2&#44; hipertensi&#243;n arterial y sobrepeso&#46; Adem&#225;s&#44; se analizaron las variables relacionadas con el tiempo de hospitalizaci&#243;n antes y despu&#233;s del ingreso en la UCI&#46; Adicionalmente se evaluaron los tiempos de antibioticoterapia emp&#237;rica y corticoterapia&#46; Se calcularon medias y desviaci&#243;n est&#225;ndar en las variables cuantitativas y proporciones en las variables categ&#243;ricas&#46; Para evaluar las diferencias entre proporciones se us&#243; la prueba exacta de Fisher y para las diferencias de medias se us&#243; la prueba U de Mann-Whitney&#46; Las variables que presentaron diferencia estad&#237;sticamente significativa se corrieron en un modelo explicativo basado en una regresi&#243;n log&#237;stica binaria&#46; Todos los datos fueron analizados usando el software estad&#237;stico IBM&#174; SPSS&#174; Statistics versi&#243;n 25&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><p id="par0045" class="elsevierStylePara elsevierViewall">En la instituci&#243;n ingresaron 268 pacientes con COVID-19 en la UCI desde el 9 de mayo hasta el 7 de agosto del 2020&#44; de los cuales 168 &#40;62&#44;7&#37;&#41; eran hombres y 100 &#40;37&#44;3&#37;&#41; mujeres&#46; El promedio de edad de los hombres era de 59&#44;6 a&#241;os &#40;DE 11&#44;4&#41; y el de las mujeres de 54&#44;0 a&#241;os &#40;DE 15&#44;6&#41;&#46; El total de pacientes que luego de entrar a la UCI resultaron infectados con al menos un tipo de bacteria del tracto respiratorio inferior despu&#233;s de las 72<span class="elsevierStyleHsp" style=""></span>h de su ingreso fue de 27&#46; Por tanto&#44; el porcentaje de neumon&#237;a bacteriana fue del 10&#44;07&#37; &#40;27&#47;268&#41;&#46; Los controles se seleccionaron del resto de los pacientes&#46; En total se escogieron 27 pacientes que conformaron el grupo de controles&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Bacterias aisladas de secreci&#243;n bronquial en pacientes con COVID-19 despu&#233;s de 72<span class="elsevierStyleHsp" style=""></span>h de hospitalizaci&#243;n en UCI</span><p id="par0050" class="elsevierStylePara elsevierViewall">En el 48&#44;1&#37; de los pacientes con neumon&#237;a bacteriana se aisl&#243; <span class="elsevierStyleItalic">Klebsiella pneumoniae&#46;</span> Las otras 2 bacterias m&#225;s frecuentes fueron <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#40;14&#44;8&#37;&#41; y <span class="elsevierStyleItalic">Stenotrophomonas maltophilia</span> &#40;14&#44;8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; El porcentaje de bacterias resistentes fue bajo&#46; De las 16 <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> aisladas&#44; 4 &#40;25&#37;&#41; presentaban betalactamasas de espectro extendido&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Enfermedades de base</span><p id="par0055" class="elsevierStylePara elsevierViewall">El 14&#44;8&#37; &#40;4&#47;27&#41; de los pacientes con neumon&#237;a bacteriana ten&#237;an diabetes mellitus tipo 2&#44; el 40&#44;7&#37; &#40;11&#47;27&#41; presentaban hipertensi&#243;n arterial y el 18&#44;5&#37; &#40;5&#47;27&#41; sobrepeso&#46; Cuando se evalu&#243; la diferencia entre los pacientes que ten&#237;an infecci&#243;n del tracto respiratorio inferior y los que no con alguna de las enfermedades anteriormente mencionadas&#44; se encontr&#243; que no hubo diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;<span class="elsevierStyleItalic">&#46;</span></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Estancia hospitalaria y soporte ventilatorio</span><p id="par0060" class="elsevierStylePara elsevierViewall">El promedio del total de d&#237;as hospitalizado &#40;hospitalizaci&#243;n<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>UCI&#41; fue de 12&#44;78 d&#237;as &#40;DE 7&#44;06&#41;&#46; El promedio de estancia en UCI solamente fue de 9&#44;9 d&#237;as &#40;DE 6&#44;7&#41;&#46; Estos pacientes recibieron VMI en promedio 7&#44;85 d&#237;as &#40;DE 6&#44;07&#41;&#46; Cuando se evalu&#243; la diferencia entre los infectados con neumon&#237;a bacteriana y los no infectados no se encontraron diferencias estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Tiempo de consumo de antibi&#243;ticos emp&#237;ricos</span><p id="par0065" class="elsevierStylePara elsevierViewall">Con base en las recomendaciones de la Organizaci&#243;n Mundial de la Salud para el manejo de la infecci&#243;n asociada a SARS-CoV-2 y el compromiso pulmonar se inici&#243; terapia antimicrobiana de forma emp&#237;rica&#46; El promedio de consumo de cada uno de los antibi&#243;ticos suministrados a los pacientes se puede observar en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Al evaluar la diferencia en el consumo de antibi&#243;ticos entre los que se infectaron con neumon&#237;a bacteriana y los que no&#44; se encontr&#243; una diferencia estad&#237;sticamente significativa entre los que consumieron claritromicina&#46; En cuanto al tiempo de consumo de claritromicina&#44; el an&#225;lisis de regresi&#243;n log&#237;stica encontr&#243; que los pacientes que tomaron claritromicina durante m&#225;s de 7 d&#237;as aumentan el riesgo de desarrollar infecciones bacterianas del tracto respiratorio inferior 1&#44;567 veces comparados con aquellos que la consumieron durante menos tiempo &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Tiempo de consumo de corticoterapia</span><p id="par0070" class="elsevierStylePara elsevierViewall">Para controlar el proceso inflamatorio propio de la COVID-19 se suministr&#243; a los pacientes corticoterapia&#46; En promedio&#44; la dexametasona fue el corticosteroide con el promedio de d&#237;as m&#225;s largo&#58; 3&#44;31 &#40;DE 4&#44;085&#41;&#46; El resto de corticosteroides no ten&#237;an m&#225;s de un d&#237;a en promedio&#46; Al comparar entre casos y controles&#44; se encontr&#243; una diferencia estad&#237;sticamente significativa entre el promedio de d&#237;as que se les aplic&#243; a los casos &#40;infectados del tracto respiratorio inferior&#41; y los controles &#40;no infectados&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; Adicionalmente&#44; en nuestro estudio se encontr&#243; que los pacientes que tomaron dexametasona durante m&#225;s de 5 d&#237;as aumentan el riesgo de desarrollar neumon&#237;a bacteriana 1&#44;520 veces comparados con aquellos que la consumieron durante menos tiempo &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Perfil bioqu&#237;mico</span><p id="par0075" class="elsevierStylePara elsevierViewall">En el perfil bioqu&#237;mico se evalu&#243; el perfil hematol&#243;gico &#40;eritrocitos&#44; leucocitos&#44; neutr&#243;filos&#44; linfocitos&#44; hemoglobina y plaquetas&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; Adicionalmente&#44; se evaluaron los marcadores pron&#243;sticos como d&#237;mero D&#44; ferritina y lactato deshidrogenasa &#40;LDH&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; En cuanto al perfil hem&#225;tico identificado en toda la poblaci&#243;n en UCI&#44; el promedio de eritrocitos fue de 4&#44;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span> c&#233;l&#47;&#956;l &#40;DE 1&#44;4&#41;&#44; el promedio de leucocitos fue de 15&#44;0<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span> c&#233;l&#47;&#956;L &#40;DE 6&#44;59&#41;&#44; el promedio del porcentaje de neutr&#243;filo fue del 85&#37; &#40;DE 8&#44;5&#41;&#44; el promedio de linfocitos fue de 7&#44;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span> c&#233;l&#47;&#956;L &#40;DE 6&#44;2&#41;&#44; el promedio de bas&#243;filos fue de 0&#44;16<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span> c&#233;l&#47;&#956;L&#46; El promedio de plaquetas fue de 280&#46;800 plaquetas&#47;&#956;L &#40;DE 110&#44;720&#41;&#46; En los hombres&#44; el promedio de hemoglobina fue de 12&#44;2<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;DE 2&#44;3&#41;&#44; mientras que el de las mujeres fue de 11&#44;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;DE 1&#44;9&#41;&#46; Cuando se evalu&#243; si hab&#237;a diferencias entre los que presentaron neumon&#237;a bacteriana y los que no&#44; se encontraron solo diferencias significativas en el valor de las plaquetas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46; En los otros par&#225;metros los valores de p fueron<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Respecto a los valores de d&#237;mero D y LDH&#44; los valores promedio fueron 2&#46;188&#44;88<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;DE 3&#46;401&#44;4&#41; y 399&#44;8<span class="elsevierStyleHsp" style=""></span>UI&#47;L &#40;DE 312&#44;2&#41;&#44; respectivamente&#46; El promedio de ferritina se distribuy&#243; entre los hombres y las mujeres&#46; La ferritina en hombres fue de 1&#46;659&#44;73<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;DE 851&#44;920&#41; y en las mujeres fue de 909&#44;38<span class="elsevierStyleHsp" style=""></span>ng&#47;mL &#40;DE 942&#44;6&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">Las infecciones bacterianas del tracto respiratorio inferior son complicaciones frecuentes de las neumon&#237;as virales en pacientes cr&#237;ticamente enfermos&#44; siendo poco estudiadas en Latinoam&#233;rica<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">7&#44;12&#44;13</span></a>&#46; Estas infecciones asociadas a la COVID-19 han ejercido una presi&#243;n sin precedentes en los sistemas de salud de la regi&#243;n&#44; conduciendo a la necesidad de hospitalizaci&#243;n en UCI<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">14&#44;15</span></a>&#46; Esto se podr&#237;a asociar al uso excesivo de antibioticoterapia emp&#237;rica&#44; lo cual aumenta la probabilidad de muerte<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">11&#44;16&#44;17</span></a>&#46; En este estudio se encontr&#243; que el 10&#44;07&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41; de los cultivos de secreci&#243;n bronquial del tracto respiratorio inferior resultaron positivos para al menos una bacteria gramnegativa&#46; Este dato es inferior al evidenciado en un estudio de Goncalves Mendes Neto et al&#46;&#44; quienes encontraron que el 19&#37; de los aislamientos fueron positivos en pacientes cr&#237;ticos<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">7</span></a>&#44; mientras que en Espa&#241;a Garcia-Vidal et al&#46; plantearon que el 7&#44;4&#37; de los pacientes con COVID-19 presentaba neumon&#237;a bacteriana en el epitelio respiratorio&#44; incrementando el riesgo de desenlaces fatales<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">18</span></a>&#46; En un metaan&#225;lisis liderado por Lansbury et al&#46;&#44; concluyeron que aproximadamente el 7&#37; de los pacientes con COVID-19 ten&#237;an neumon&#237;a bacteriana&#44; lo que aument&#243; al 14&#37; solo en pacientes en una UCI<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En pacientes con COVID-19 las comorbilidades cardiometab&#243;licas se han relacionado con mayores tasas de infecci&#243;n bacteriana en el epitelio respiratorio y con una mayor gravedad cl&#237;nica<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">7&#44;8</span></a>&#59; en nuestro estudio no se evidenci&#243; dicha asociaci&#243;n&#46; En fases tempranas de la COVID-19&#44; en algunos estudios la proporci&#243;n de linfocitos T CD4&#43; y linfocitos T CD8&#43; se mantiene en niveles normales en pacientes con comorbilidades cardiometab&#243;licas&#44; disminuyendo la asociaci&#243;n con neumon&#237;a bacteriana<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">20</span></a>&#46; Sin embargo&#44; en nuestro estudio no se evaluaron estos niveles de linfocitos T CD4&#43; y linfocitos T CD8&#43;&#44; por lo que se propone la necesidad de hacer un estudio donde se eval&#250;e esta asociaci&#243;n&#46; De igual forma&#44; Crotty et al&#46; no encontraron ninguna diferencia estad&#237;sticamente significativa entre los pacientes que presentaban alguna comorbilidad cardiometab&#243;lica y la presencia de coinfecci&#243;n bacteriana &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En cuanto a los par&#225;metros hematol&#243;gicos como leucocitos&#44; neutr&#243;filos&#44; linfocitos y hemoglobina&#44; no se relacionaron con la presencia de neumon&#237;a bacteriana &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Buehler et al&#46; encontraron que los niveles de plaquetas son similares en los pacientes con neumon&#237;a bacteriana y en no infectados&#44; sin existir significaci&#243;n estad&#237;stica en ambos grupos<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">5</span></a>&#46; En nuestro estudio&#44; aunque en el an&#225;lisis bivariado se encontr&#243; una diferencia estad&#237;sticamente significativa en el conteo de plaquetas entre los pacientes que presentaban neumon&#237;a bacteriana y los que no la presentaban&#44; en el an&#225;lisis multivariado&#44; al ajustar las variables&#44; se evidenci&#243; que el n&#250;mero de plaquetas era estad&#237;sticamente similar tanto en los pacientes con neumon&#237;a bacteriana como en los que no presentaban infecci&#243;n&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La atenci&#243;n sanitaria ha tenido que responder y adaptarse r&#225;pidamente a los desaf&#237;os del uso de antimicrobianos en sospecha o curso de coinfecci&#243;n asociada a la COVID-19<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">16&#44;22</span></a>&#46; Seg&#250;n la Organizaci&#243;n Mundial de la Salud&#44; en situaciones de neumon&#237;a comunitaria grave se recomienda la aplicaci&#243;n de antimicrobianos intravenosos de amplio espectro dentro de la primera hora<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Estos incluyen el uso de macr&#243;lidos&#44; cefalosporinas de cuarta generaci&#243;n &#40;con factores de riesgo a <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#41;&#44; tetraciclinas y quinolonas&#44; teniendo en cuenta los factores del hu&#233;sped y el perfil epidemiol&#243;gico de resistencia local y hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">22&#44;25</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">En pacientes con neumon&#237;a comunitaria grave por COVID-19 se recomienda el uso de esquemas de antibioticoterapia emp&#237;rica como inhibidores betalact&#225;micos&#47;macr&#243;lidos y cefalosporinas&#47;macr&#243;lidos<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">23</span></a>&#46; Sin embargo&#44; hay diversas posiciones sobre el uso de antibioticoterapia emp&#237;rica&#46; Por ejemplo&#44; Du et al&#46; determinaron que el uso de antibioticoterapia emp&#237;rica de amplio espectro no modifica la evoluci&#243;n de la enfermedad en pacientes cr&#237;ticos dentro de su estudio<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">26</span></a>&#46; Esto es similar a lo publicado por Goncalves Mendes Neto et al&#46;&#44; donde la aplicaci&#243;n de antibioticoterapia emp&#237;rica en pacientes cr&#237;ticamente enfermos presentaba peores resultados<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">7</span></a>&#46; Por otra parte&#44; Bardi et al&#46; encontraron que la mayor&#237;a de los pacientes que recibieron un ciclo de cefalosporinas&#47;macr&#243;lidos presentaron neumon&#237;a bacteriana nosocomial asociada a la COVID-19 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a>&#46; En nuestro estudio encontramos bajas tasas de resistencia bacteriana en los cultivos de secreci&#243;n bronquial con al menos un aislamiento bacteriano&#44; pero s&#237; un alto consumo de antibioticoterapia emp&#237;rica generalizado&#44; parecido a lo encontrado por Nori et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a>&#46; Esto se explica por la incertidumbre cl&#237;nica&#44; la dificultad para diferenciar la progresi&#243;n y gravedad de la COVID-19<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">14</span></a>&#44; lo cual genera un problema en la prescripci&#243;n emp&#237;rica en los centros de salud a nivel mundial<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">7&#44;14</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Los corticosteroides son agentes antiinflamatorios utilizados en el s&#237;ndrome de dificultad respiratoria aguda&#44; shock s&#233;ptico refractario y en algunas comorbilidades respiratorias<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">27&#44;28</span></a>&#46; Actualmente&#44; el uso de glucocorticoides ha demostrado tener resultados positivos en la modulaci&#243;n de las respuestas inflamatorias<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">29</span></a>&#44; la reducci&#243;n de la mortalidad a corto plazo<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">30&#44;31</span></a> y un menor tiempo de VMI en pacientes con COVID-19<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">30&#44;32&#44;33</span></a>&#46; Sin embargo&#44; existen datos opuestos donde no se reduce el tiempo de eliminaci&#243;n del virus&#44; o la necesidad de VMI<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">34&#8211;37</span></a>&#46; Por esta raz&#243;n&#44; hay controversia en el uso de corticosteroides en el manejo de la infecci&#243;n respiratoria aguda por SARS-CoV-2<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">38</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Te&#243;ricamente&#44; la desregulaci&#243;n inmune secundaria a la infecci&#243;n por SARS-CoV-2<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">11&#44;39</span></a> y el efecto inmunosupresor del uso de corticoides<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a> son considerados factores relacionados de neumon&#237;a bacteriana&#44; pero no existe evidencia clara de esta relaci&#243;n&#46; En nuestros datos encontramos que en el consumo de corticoterapia generalizada &#40;metilprednisolona&#44; hidrocortisona&#44; betametasona&#41; no se encontr&#243; significaci&#243;n estad&#237;stica para la presencia de neumon&#237;a bacteriana&#46; Por el contrario&#44; los pacientes con neumon&#237;a bacteriana ten&#237;an tasas elevadas de consumo de dexametasona &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; similar a lo reportado por Goncalves Mendes Neto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">7</span></a>&#46; Sin embargo&#44; nuestro estudio es limitado en cuanto a responder a la asociaci&#243;n de causalidad-efecto entre la presencia de neumon&#237;a bacteriana y el uso de dexametasona&#46; Los glucocorticoides predisponen a una disminuci&#243;n de citocinas proinflamatorias&#44; factor nuclear kappa beta&#44; aumentando el riesgo de colonizaci&#243;n y neumon&#237;a bacteriana<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">40</span></a>&#46; Adem&#225;s&#44; aumenta la captaci&#243;n viral del SARS-CoV-2 por las c&#233;lulas alveolares tipo 2&#44; afectando la secreci&#243;n del surfactante e inhibiendo el aclaramiento del l&#237;quido alveolar vectorial&#44; lo que se relaciona con la presencia de neumon&#237;a bacteriana<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Con respecto a los marcadores pron&#243;stico &#40;d&#237;mero D&#44; ferritina&#44; LDH&#41;&#44; estos niveles son similares en los pacientes con neumon&#237;a bacteriana y los que no estaban infectados&#44; no existiendo significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; En contraste&#44; Crotty et al&#46; encontraron que los niveles elevados de LDH eran superiores cuando el paciente presenta coinfecci&#243;n bacteriana del tracto respiratorio inferior &#40;1&#46;210<span class="elsevierStyleHsp" style=""></span>UI&#47;l&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">21</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">La neumon&#237;a bacteriana en pacientes con COVID-19 coloca en alarma los sistemas de salud en las UCI&#46; Durante la COVID-19 el cambio de flora bacteriana presionado por las intervenciones deliberadas de antimicrobianos augura un nuevo reto desde el enfoque del paciente con infecci&#243;n&#46; En este estudio se encontraron tasas bajas de neumon&#237;a bacteriana&#59; predomina la <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> como la bacteria m&#225;s frecuente&#46; Se encontr&#243; un elevado consumo de terapia antibi&#243;tica emp&#237;rica&#44; por lo que se recomienda un mejor control&#44; estandarizaci&#243;n y creaci&#243;n de protocolos de uso seg&#250;n los patrones de resistencia de las instituciones cl&#237;nicas&#46; El uso excesivo de dexametasona en pacientes con COVID-19 en UCI podr&#237;a aumentar el riesgo de neumon&#237;a bacteriana&#46; Por este motivo&#44; debe evaluarse con mayor profundidad a trav&#233;s de la realizaci&#243;n de estudios cl&#237;nicos que puedan explicar causalidad y efecto&#46;</p></span></span>"
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              "titulo" => "Bacterias aisladas de secreci&#243;n bronquial en pacientes con COVID-19 despu&#233;s de 72 h de hospitalizaci&#243;n en UCI"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar los factores relacionados con la neumon&#237;a bacteriana en pacientes con COVID-19 en una unidad de cuidados intensivos de Barranquilla&#44; Colombia&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de casos y controles anidado&#44; unic&#233;ntrico&#44; realizado entre marzo y agosto del 2020&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Pacientes</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pacientes mayores de 18 a&#241;os&#44; con una estancia hospitalaria mayor de 72<span class="elsevierStyleHsp" style=""></span>h y soporte de ventilaci&#243;n mec&#225;nica invasiva&#44; admitidos en la unidad de cuidados intensivos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Intervenciones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Mediciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se agruparon variables cl&#237;nicas para casos y controles&#46; Se calcularon medias y desviaci&#243;n est&#225;ndar en variables cuantitativas y proporciones en variables categ&#243;ricas&#46; Para evaluar las diferencias entre proporciones se us&#243; la prueba exacta de Fisher y para las diferencias de medias se us&#243; la prueba U de Mann-Whitney&#46; Las variables con diferencia estad&#237;sticamente significativa se corrieron en un modelo explicativo basado en regresi&#243;n log&#237;stica binaria&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La frecuencia de neumon&#237;a bacteriana fue del 10&#44;07&#37;&#44; encontrando un elevado consumo de terapia antibi&#243;tica emp&#237;rica&#46; Se encontr&#243; asociaci&#243;n estad&#237;stica entre el tiempo de uso de dexametasona &#40;OR 1&#44;520&#59; IC 95&#37; 1&#44;131-2&#44;042&#41; y el desarrollo de neumon&#237;a bacteriana&#46; El resto de las variables no resultaron estad&#237;sticamente significativas tras ajustar el modelo con regresi&#243;n log&#237;stica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusi&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se encontraron tasas bajas de neumon&#237;a bacteriana&#44; predominando la <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> como la bacteria m&#225;s frecuente&#46; El uso excesivo de dexametasona en pacientes con COVID-19 en la unidad de cuidados intensivos podr&#237;a aumentar el riesgo de neumon&#237;a bacteriana&#46; Por este motivo&#44; debe evaluarse con mayor profundidad para explicar causalidad y efecto&#46;</p></span>"
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        "resumen" => "<span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To determine the factors related to bacterial pneumonia in patients with COVID-19 in an intensive care unit in Barranquilla&#44; Colombia&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Nested&#44; single-center case-control study&#44; conducted between March and August 2020&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patients</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patients over 18 years of age&#44; a hospital stay greater than 72<span class="elsevierStyleHsp" style=""></span>h&#44; with invasive mechanical ventilation support admitted to the intensive care unit&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Interventions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Measurements</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Clinical variables were grouped for both cases and controls&#46; Means and standard deviation were calculated in quantitative variables and proportions in categorical variables&#46; Fisher&#39;s exact test was used to evaluate the differences between proportions&#44; and the Mann-Whitney U test was used for differences in means&#46; Variables with statistically significant differences were run in an explanatory model based on binary logistic regression&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The frequency of bacterial pneumonia was 10&#46;07&#37;&#44; finding a high consumption of empirical antibiotic therapy&#46; A statistical association was found between the time of dexamethasone use &#40;OR 1&#46;520&#59; 95&#37; CI 1&#46;131-2&#46;042&#41; with the development of bacterial pneumonia&#46; The rest of the variables were not statistically significant after adjusting the model with logistic regression&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Low rates of bacterial pneumonia were found&#44; with <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> prevailing as the most frequent bacterium&#46; Overuse of dexamethasone in intensive care unit COVID-19 patients could increase the risk of bacterial pneumonia&#46; For this reason&#44; it must be evaluated in greater depth to explain causality and effect&#46;</p></span>"
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                  \t\t\t\t">Estancia hospitalaria &#40;d&#237;as previos UCI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tiempo con ventilaci&#243;n mec&#225;nica invasiva UCI &#40;d&#237;as&#41;&nbsp;\t\t\t\t\t\t\n
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Información del artículo
ISSN: 01227262
Idioma original: Español
DOI:10.1016/j.acci.2021.07.002
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