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When is useful the urinary antigen test?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "394" "paginaFinal" => "396" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Soraya Jodra Sánchez, Miguel Barrueco Ferrero" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Soraya" "apellidos" => "Jodra Sánchez" "email" => array:1 [ 0 => "sorayajodra_9@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Miguel" "apellidos" => "Barrueco Ferrero" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universidad de Salamanca, Salamanca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumonía por <span class="elsevierStyleItalic">Legionella</span>, ¿cuándo solicitar la antigenuria en orina?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since <span class="elsevierStyleItalic">Legionella pneumophila (L. pneumophila)</span> was identified in 1976 it has been recognized as a common cause of hospital-acquired and non-hospital-acquired pneumonia.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> The term “Legionellosis” includes 2 different syndromes: Legionnaire's disease, the most common cause of pneumonia caused by <span class="elsevierStyleItalic">Legionella</span> spp., and Pontiac fever, characterized by fever, headache and myalgia, but without pneumonia.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Legionella</span> family consists of 50 species, <span class="elsevierStyleItalic">L. pneumophila</span> being the most common,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> and within this, serotype 1 is the most frequently isolated. The incidence of community-acquired pneumonia (CAP) caused by <span class="elsevierStyleItalic">L. pneumophila</span> varies from one area to another, hovering around 1% in subjects treated as outpatients and 15–28% in hospitalized patients. Twenty five per cent of these require admission to an intensive care unit (ICU).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain <span class="elsevierStyleItalic">L. pneumophila</span> pneumonia is a notifiable disease since 1996. It is important that cases are quickly notified so that the source can be studied as soon as possible. Outbreaks are usually related to the contamination of cooling systems and water tanks, although more frequently <span class="elsevierStyleItalic">L. pneumophila</span> pneumonia appears as sporadic cases, predominantly affecting smokers, elderly and chronically ill patients or in routine treatment with glococorticoids.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Therefore, underdiagnosis of such cases is suspected.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Isolation of the bacteria by culturing respiratory specimens has been the traditional diagnostic method. It is the only available method to detect infections caused by any species and serotypes of <span class="elsevierStyleItalic">Legionella</span> (approximately 15–20% of infections are caused by different <span class="elsevierStyleItalic">L. pneumophila</span> species or serotypes). However, the drawback is the time it takes to grow the microorganism, as well as the serological diagnosis, providing a late diagnosis from a clinical point of view.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We must note the significant diagnostic advance the detection of <span class="elsevierStyleItalic">L. pneumophila</span> antigen in urine has meant, since it allows an etiologic diagnosis almost immediately.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5–7</span></a> Since included in clinical practice, it has been shown that <span class="elsevierStyleItalic">L. pneumophila</span> pneumonias are a lot more prevalent endemic disease than previously thought, and this has also allowed to detect outbreaks that otherwise would have gone unnoticed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The antigen is a soluble component of the <span class="elsevierStyleItalic">Legionella's</span> cell wall lipopolysaccharide. It is thermostable, and detectable from the onset of symptomatology and in some cases for many months later. The results do not appear clearly influenced by the previous administration of antibiotics.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The antigen diagnostic techniques have evolved significantly since their inception by agglutination with latex particles, passive hemagglutination or radioimmunoassay. The latter was the first useful, sensitive and specific technique. It has 60% sensitivity in direct urine and 80% in concentrated urine, with a 100% specificity in both cases. Currently these techniques have been replaced by enzyme immunoassay and membrane immunochromatography, with a sensitivity in concentrated urine ranging 80–90% and a 98–100% specificity. Both systems have a similar performance, although with 2 clear advantages for immunochromatography: a specific laboratory is not necessary and it is faster (15 vs 90<span class="elsevierStyleHsp" style=""></span>min). These techniques detect <span class="elsevierStyleItalic">L. pneumophila</span>, serogroup 1antigen, implying the possibility of false negative if a secondary infection with <span class="elsevierStyleItalic">L. pneumophila</span> serogroup. However, some enzyme immunoassay techniques are already able to detect all serogroups of <span class="elsevierStyleItalic">L. pneumophila</span> and other <span class="elsevierStyleItalic">Legionella</span> species, but this does not guarantee the same sensitivity for all serogroups and species. False positives have been detected in patients with serum sickness and in those who have had a previous infection by <span class="elsevierStyleItalic">Legionella</span>, since positivity may be evident from day one and in some cases it may last for more than a year. It should be noted that the heat treatment of the urine does not mean the disappearance of positivity but it eliminates false positives in negative samples.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5,8,9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the latest guidelines of the American Thoracic Society on the CAP, <span class="elsevierStyleItalic">L. pneumophila</span> is the fifth etiology, considering frequency, in patients requiring hospitalization and the third among those requiring ICU admission. This regulation recommends early identification of causative agents of pneumonia, since it requires changes in antibiotic coverage and also due to the epidemiological implications involving some etiologies, as in the case of <span class="elsevierStyleItalic">L. pneumophila</span>. Nevertheless, it does not establish the use of <span class="elsevierStyleItalic">L. pneumophila</span> antigen in urine as routine use, restricting it only to CAP hospitalized cases requiring ICU admission, treatment failure in patients with CAP treated on an outpatient basis, a history of alcohol abuse, recent trip and in case of pleural effusions. However, it would be optional in outpatients.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> In the paper by Engel et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> recently published, the authors analyze the cost-effectiveness ratio of their routine determination for the detection and early treatment of CAP caused by <span class="elsevierStyleItalic">Legionella</span> spp. They recommend restricting the use of urinary antigen to CAP patients with severe disease and/or risk factors. The paper by Molinos on antigen detection in urine also states that only in case of an outbreak of Legionnaires’ disease (regardless of treatment) or if CAP is serious, its presence should be investigated.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore, even though the various publications do not establish routine use, from our point of view there are 2 different aspects in terms of cost-effectiveness to be considered: (1) the importance of early detection and the influence it may have on treatment, and (2) the potential importance as “sentinel” for the early detection of outbreaks.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding the first point, in the opinion of several authors, early detection would help obtain a proper treatment early, leading to a better prognosis of the disease.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12–17</span></a> However, it should be noted that no randomized clinical trials are available to assess the effectiveness of a targeted therapy as an option, based on the positivity of urinary antigen test, compared to using standard empirical antibiotic treatment, in order to improve clinical outcomes. An example of this point is reflected in the clinical practice guidelines of the National Institute for Health and Care Excellence published in 2014, which raises the question whether in cases of moderate and severe CAP the routine use of urinary antigen would improve treatment outcomes. It states that routine use to confirm or rule out pneumonia due to <span class="elsevierStyleItalic">L. pneumophila</span> would improve the administration of antibiotics and compliance, and would reduce costs, but it stresses that there are no randomized studies to confirm this theory.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The second aspect concerning the “sentinel” character of antigenuria to detect outbreaks has not yet been reflected in the literature. It is clear that in an epidemic of Legionnaires’ disease (regardless of treatment) we would have to request the proper antigen,<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8,10</span></a> but since an important part of CAP patients visit the emergency departments, would it be advisable to request <span class="elsevierStyleItalic">L. pneumophila</span> antigenuria in urine in all pneumonias treated in those departments? Would this attitude allow to discover endemic outbreaks and, therefore, prevent them? The cost of antigenuria determination in urine in a hospital is around 5.80<span class="elsevierStyleHsp" style=""></span>€. Therefore, its implementation, protocolised at the emergency services, in both Primary Care and Specialized Care, would certainly be efficient from the “sentinel” perspective of early detection of cases. Neither in this case there is evidence to recommend for or against its use.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In short, <span class="elsevierStyleItalic">Legionella</span> pneumonia is an endemic and underdiagnosed disease that can occur as epidemics or by sporadic outbreaks. The prevalence of endemic cases is unknown and might be precisely related to the routine non-determination of antigenuria in urine, given the CAPs not requiring hospitalization and treated as outpatients after having been diagnosed mainly in Primary Care and Emergency services. Up to date this is just a theory, but it makes us consider the possibility of requesting routine antigenuria in urine to any CAP, regardless of diagnosis and severity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Therefore, the application of sensitive and specific tests, along with better outbreak investigation, will help us achieve a more accurate understanding of its epidemiology. As noted by Torres et Caylà,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> “it is clear that when the legionellosis occurs in outbreaks they hardly go unnoticed but, what might happen when a few cases occur or when it is isolated cases?” It is what the authors call Guadiana, a disease that comes and goes periodically, reaching significance only when it comes to outbreaks acquiring public significance.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest related to the content of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jodrá Sánchez S, Barrueco Ferrero M. Neumonía por <span class="elsevierStyleItalic">Legionella</span>, ¿cuándo solicitar la antigenuria en orina? Med Clin (Barc). 2016;146:394–396.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Legionnaire's disease: isolation of a bacterium and demonstration of its role in other respiratory disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.E. McDade" 1 => "C.C. Shepard" 2 => "D.W. Fraser" 3 => "T.R. Tsai" 4 => "M.A. Redus" 5 => "W.R. 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Journal Information
Vol. 146. Issue 9.
Pages 394-396 (May 2016)
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Vol. 146. Issue 9.
Pages 394-396 (May 2016)
Editorial article
Legionella's pneumonia. When is useful the urinary antigen test?
Neumonía por Legionella, ¿cuándo solicitar la antigenuria en orina?
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