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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fluxograma que mostra os crit&#233;rios de inclus&#227;o&#47;exclus&#227;o para crian&#231;as neste estudo&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">A pneumonia adquirida na comunidade &#40;PAC&#41; &#233; uma importante causa de morbidez e mortalidade em crian&#231;as&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Contudo&#44; o diagn&#243;stico etiol&#243;gico da PAC &#233; desafiador&#46; As radiografias de t&#243;rax t&#234;m sido usadas como uma ferramenta de diagn&#243;stico por meio da identifica&#231;&#227;o de padr&#245;es radiol&#243;gicos sugestivos de processo inflamat&#243;rio&#44; como infiltrados pulmonares&#46; Contudo&#44; o papel do raios X de t&#243;rax em PAC pedi&#225;trica continua controverso&#44; devido a problemas com o uso rotineiro desse exame&#44; como m&#225; concord&#226;ncia entre os observadores<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> e incapacidade de diferencia&#231;&#227;o entre agentes etiol&#243;gicos distintos&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4</span></a> Por outro lado&#44; uma propor&#231;&#227;o significativa de crian&#231;as com diagn&#243;stico cl&#237;nico de PAC apresenta raios X de t&#243;rax normal ap&#243;s interna&#231;&#227;o<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> e importantes diferen&#231;as na interna&#231;&#227;o e foi relatada evolu&#231;&#227;o entre crian&#231;as com PAC com ou sem confirma&#231;&#227;o radiol&#243;gica&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;9</span></a> De modo geral&#44; esses dados sugerem que a doen&#231;a em crian&#231;as com ou sem pneumonia radiologicamente confirmada pode ser causada por mecanismos distintos e&#47;ou diferentes agentes etiol&#243;gicos&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">No Brasil&#44; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> e <span class="elsevierStyleItalic">Moraxella catarrhalis</span> foram relatados como importantes agentes bacterianos de pneumonia pedi&#225;trica em crian&#231;as hospitalizadas&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> Neste estudo&#44; investigamos a presen&#231;a de infec&#231;&#227;o <span class="elsevierStyleItalic">S&#46; pneumoniae&#44; H&#46; influenzae</span> e <span class="elsevierStyleItalic">M&#46; catarrhalis</span> em crian&#231;as brasileiras n&#227;o hospitalizadas entre dois e 59 meses com diagn&#243;stico cl&#237;nico de pneumonia com ou sem confirma&#231;&#227;o radiol&#243;gica&#46; Ao faz&#234;&#8208;lo&#44; visamos a avaliar o papel do raios X de t&#243;rax na identifica&#231;&#227;o de prov&#225;veis causas de PAC causada por bact&#233;rias t&#237;picas&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Modelo do estudo e participantes</span><p id="par0015" class="elsevierStylePara elsevierViewall">Este estudo de coorte prospectivo fez parte de um ensaio cl&#237;nico que avaliou o uso de amoxicilina oral administrada tr&#234;s ou duas vezes ao dia em crian&#231;as entre 2&#8208;59 meses diagnosticadas com PAC &#40;ensaio de efic&#225;cia Pneumopac&#44; ClinicalTrials&#46;gov <a href="ctgov:NCT01200706">NCT01200706</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> Nesse ensaio&#44; participaram 820 crian&#231;as registradas na Unidade de Emerg&#234;ncia da Universidade Federal da Bahia&#44; em Salvador&#44; Nordeste do Brasil&#44; de novembro de 2006 a maio de 2011&#46; Todas as crian&#231;as fizeram o exame de raios X de t&#243;rax &#40;frontal e lateral&#41; na interna&#231;&#227;o e foram coletados amostras de sangue na interna&#231;&#227;o e na visita de acompanhamento 2&#8208;4 semanas depois&#46; Os crit&#233;rios de inclus&#227;o abrangeram o relato de queixas respirat&#243;rias e detec&#231;&#227;o de achados no trato respirat&#243;rio inferior&#44; juntamente com a presen&#231;a de infiltrado&#47;consolida&#231;&#227;o pulmonar no raios X de t&#243;rax&#44; de acordo com a interpreta&#231;&#227;o do pediatra respons&#225;vel&#46; Os respons&#225;veis legais pelos pacientes inclu&#237;dos forneceram um consentimento informado por escrito no momento da participa&#231;&#227;o&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Todos os raios X de t&#243;rax foram analisados independentemente por dois radiologistas pedi&#225;tricos &#40;CAA&#8208;N e SCA&#41; cegos com rela&#231;&#227;o aos dados cl&#237;nicos&#46; Foi demonstrada anteriormente uma concord&#226;ncia geral de 78&#44;7&#37; por esses dois radiologistas pedi&#225;tricos&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Caso n&#227;o tenha havido concord&#226;ncia com rela&#231;&#227;o aos achados finais de qualquer exame&#44; esse raios X de t&#243;rax foi ent&#227;o avaliado por um terceiro radiologista &#40;RVB&#41;&#46; Os achados radiol&#243;gicos foram registrados de acordo com a interpreta&#231;&#227;o padronizada de estudos epidemiol&#243;gicas publicada anteriormente pela Organiza&#231;&#227;o Mundial da Sa&#250;de&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> A pneumonia radiologicamente confirmada foi definida como a presen&#231;a de infiltrado ou consolida&#231;&#227;o pulmonar em duas avalia&#231;&#245;es independentes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">O uso de vacina pneumoc&#243;cica conjugada &#40;10&#8208;valente&#41; &#40;PCV10&#41; foi implantado universalmente em Salvador&#44; Brasil&#44; em julho de 2010&#44; para crian&#231;as &#60;<span class="elsevierStyleHsp" style=""></span>2 anos&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> Toda crian&#231;a inclu&#237;da no teste de efic&#225;cia Pneumopac que podia receber a PCV10 teve sua carteira de vacina&#231;&#227;o verificada pessoalmente por um dos pesquisadores &#40;ICB&#41; ap&#243;s o ensaio ser conclu&#237;do&#46; Os pacientes que receberam qualquer dose de PCV10 e aqueles cuja carteira de vacina&#231;&#227;o n&#227;o p&#244;de ser identificada foram exclu&#237;dos dessa an&#225;lise&#46; Os pacientes com desnutri&#231;&#227;o grave&#44; definida como escore Z de peso para a idade abaixo de &#8208;3&#44;00&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> tamb&#233;m foram exclu&#237;dos&#46; A avalia&#231;&#227;o nutricional foi feita com o <span class="elsevierStyleItalic">software</span> Anthro &#40;WHO&#44; World Health Organization&#41;&#46; As crian&#231;as com tiragem subcostal ou sinais de perigo &#40;incapacidade de ingerir l&#237;quidos&#44; convuls&#245;es&#44; cianose central&#44; gemidos em uma crian&#231;a calma&#41; foram exclu&#237;das do ensaio de efic&#225;cia Pneumopac&#44; bem como aquelas com doen&#231;as cr&#244;nicas subjacentes&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Este estudo foi aprovado pelo Comit&#234; de &#201;tica da Universidade Federal da Bahia e foi conduzido de acordo com os princ&#237;pios da Declara&#231;&#227;o de Helsinque&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedimentos laboratoriais</span><p id="par0035" class="elsevierStylePara elsevierViewall">Foi usado o imunoensaio &#224; base de <span class="elsevierStyleItalic">beads</span> multiplexadas fluorescentes &#40;FMIA&#41; para quantificar os n&#237;veis de anticorpos contra os ant&#237;genos proteicos de <span class="elsevierStyleItalic">S&#46; pneumoniae&#44; H&#46; influenzae e M&#46; catarrhalis</span> com a tecnologia Luminex xMAP&#174; &#40;Luminex Corporation&#44; TX&#44; EUA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Este ensaio incluiu oito prote&#237;nas recombinantes de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> &#40;pneumolisina &#91;Ply&#93;&#44; prote&#237;na de liga&#231;&#227;o da colina A &#91;CbpA&#93;&#44; prote&#237;na de superf&#237;cie pneumoc&#243;cica A fam&#237;lias 1 e 2 &#91;PspA 1 e 2&#93;&#44; prote&#237;na de liga&#231;&#227;o da colina pneumoc&#243;cica A &#91;PcpA&#93;&#44; prote&#237;na tr&#237;ade histidina pneumoc&#243;cica D &#91;PhtD&#93;&#44; prote&#237;na serina&#47;treonina quinase &#91;StkP&#8208;C&#44; SP1732&#8208;3&#93;&#44; prote&#237;na necess&#225;ria para separa&#231;&#227;o da parece celular do <span class="elsevierStyleItalic">Streptococcus</span> do Grupo B &#91;PcsB&#8208;N&#44; SP2216&#8208;1&#93;&#41;&#44; tr&#234;s prote&#237;nas recombinantes de <span class="elsevierStyleItalic">H&#46; influenzae</span> &#40;Prote&#237;na D NTHi&#44; NTHi0371&#8208;1 e NTHi0830&#41; e cinco prote&#237;nas recombinantes de <span class="elsevierStyleItalic">M&#46; catarrhalis</span> &#40;MC Omp CD&#44; MC&#95;RH4&#95;2506&#44; MC&#95;RH4&#95;1701&#44; MC&#95;RH4&#95;3729&#8208;1 e MC&#95;RH4&#95;4730&#41;<span class="elsevierStyleItalic">&#46;</span> Nove conjuntos de <span class="elsevierStyleItalic">beads</span> foram criados com as prote&#237;nas acima na seguinte combina&#231;&#227;o&#58; Ply&#44; CbpA&#44; PcpA&#44; PhtD&#44; StkP&#8208;C e PcsB&#8208;N e foram conjugadas em uma regi&#227;o de <span class="elsevierStyleItalic">beads</span>&#44; cada&#59; Ply&#44; CbpA&#44; PcpA&#44; PhtD&#44; StkP&#8208;C e PcsB&#8208;N foram conjugadas na mesma regi&#227;o de <span class="elsevierStyleItalic">beads</span>&#59; e todas as prote&#237;nas de <span class="elsevierStyleItalic">H&#46; influenzae</span> e <span class="elsevierStyleItalic">M&#46; catarrhalis</span> foram conjugadas em uma regi&#227;o de gr&#226;nulos por bact&#233;ria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Este ensaio forneceu os valores de intensidade m&#233;dia de fluoresc&#234;ncia &#40;MFI&#41; para cada ant&#237;geno e soro avaliado&#46; O valor de MGI representa uma medida indireta da concentra&#231;&#227;o de IgG em rela&#231;&#227;o aos ant&#237;genos estudados&#46; C&#243;pias verdadeiras foram usadas em todo o procedimento e suas leituras de fluoresc&#234;ncia foram calculadas pela m&#233;dia&#46; Para garantir a repetibilidade dos ensaios&#44; foram analisados controles altos e baixos em cada placa&#46; Adicionalmente&#44; amostras agudas e convalescentes foram analisadas na mesma placa&#46; Todas as amostras foram testadas com dilui&#231;&#245;es de 1&#58;400 e 1&#58;1&#46;600 e&#44; se necess&#225;rio&#44; foram feitas dilui&#231;&#245;es adicionais&#46; A ocorr&#234;ncia de uma resposta sorol&#243;gica contra <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foi definida como um aumento nos n&#237;veis de anticorpos &#8805; 2 vezes maior para IgG contra Ply&#44; CbpA&#44; PspA 1 e 2&#44; PhtD&#44; StkP&#8208;C e PcsB&#8208;N ou aumento de &#8805; 1&#44;5 vez maior para IgG contra PcpA&#44; com base na valida&#231;&#227;o de um teste sorol&#243;gico sens&#237;vel e espec&#237;fico para o diagn&#243;stico da doen&#231;a invasiva pneumoc&#243;cica&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> O diagn&#243;stico de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foi estabelecido pela detec&#231;&#227;o de resposta sorol&#243;gica contra quaisquer dos ant&#237;genos avaliados&#44; com base na especificidade do ensaio e na boa correla&#231;&#227;o com o Elisa&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> A sensibilidade e a especificidade de uma resposta sorol&#243;gica contra cada ant&#237;geno foram publicadas anteriormente&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> A ocorr&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; influenzae</span> ou <span class="elsevierStyleItalic">M&#46; catarrhalis</span> foi definida como um aumento nos n&#237;veis de anticorpos &#8805; 2 vezes entre as amostras aguda e convalescentes&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#44;17</span></a> Todos os testes sorol&#243;gicos foram feitos por DCA e ICB no Instituto Nacional de Sa&#250;de e Bem&#8208;Estar&#44; em Helsinque&#44; Finl&#226;ndia&#46; A frequ&#234;ncia dessas infec&#231;&#245;es analisadas por distribui&#231;&#227;o et&#225;ria&#44; intervalo de coleta de amostras e dura&#231;&#227;o da doen&#231;a foi publicada em outro lugar&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lise estat&#237;stica</span><p id="par0045" class="elsevierStylePara elsevierViewall">As vari&#225;veis categ&#243;ricas foram comparadas com o teste de qui&#8208;quadrado ou teste exato de Fisher&#44; conforme adequado&#44; e as vari&#225;veis cont&#237;nuas foram avaliadas com o teste U de Mann&#8208;Whitney&#44; pois elas apresentaram uma distribui&#231;&#227;o n&#227;o param&#233;trica&#46; Foi calculado o valor preditivo negativo do raios X de t&#243;rax normal para o diagn&#243;stico de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46; A regress&#227;o log&#237;stica multivariada foi feita com a presen&#231;a de pneumonia radiologicamente confirmada como a vari&#225;vel dependente e a infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> como a vari&#225;vel independente&#46; Esse modelo foi ajustado por idade e infec&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; Influenzae</span> ou <span class="elsevierStyleItalic">M&#46; catarrhalis&#46;</span> Todos os testes estat&#237;sticos foram bicaudais&#44; com um n&#237;vel de signific&#226;ncia de 0&#44;05&#46; O <span class="elsevierStyleItalic">software</span> Stata&#47;SE 12&#46;0 &#40;StataCorp&#46; 2011&#46;&#160;<span class="elsevierStyleItalic">Stata Statistical Software&#58; Release 12</span>&#46; College Station&#44; TX&#44; EUA&#41; foi usado para calcular o valor preditivo negativo do raios X de t&#243;rax normal e o <span class="elsevierStyleItalic">software</span> SPSS &#40;SPSS Inc&#46;&#44; vers&#227;o 9&#46;0&#46; Chicago&#44; EUA&#41; foi usado para o restante da an&#225;lise&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Dos 820 pacientes inclu&#237;dos no ensaio de efic&#225;cia Pneumopac&#44; 615 foram inclu&#237;dos neste estudo&#44; 249 &#40;40&#44;5&#37;&#41; dos quais apresentaram pneumonia radiologicamente confirmada e 366 &#40;59&#44;5&#37;&#41; apresentaram raios X de t&#243;rax normal&#46; A <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> mostra o fluxograma dos casos inclu&#237;dos e exclu&#237;dos nesta investiga&#231;&#227;o&#46; De modo geral&#44; 311 &#40;50&#44;6&#37;&#41; eram meninos e a idade m&#233;dia foi de 27&#44;2 meses &#40;percentil de 25 a 75&#58; 14&#44;9&#8208;41&#44;4 meses&#41;&#46; Consolida&#231;&#227;o foi detectada pelos radiologistas um&#44; dois e tr&#234;s em 84&#44;6&#37;&#44; 79&#44;8&#37; e 67&#44;3&#37; dos casos com pneumonia radiologicamente confirmada concordante&#44; respectivamente&#46; Os casos restantes de pneumonia radiologicamente confirmada foram diagnosticados com base na detec&#231;&#227;o de infiltrados pulmonares&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">A compara&#231;&#227;o dos n&#237;veis de anticorpos na interna&#231;&#227;o &#40;primeira amostra de soro&#41; contra os ant&#237;genos estudados com o uso de uma dilui&#231;&#227;o de 1&#58;1&#46;600 &#233; mostrada na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; As crian&#231;as com pneumonia radiologicamente confirmada apresentaram n&#237;veis significativamente maiores de anticorpos contra v&#225;rios ant&#237;genos proteicos de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> e <span class="elsevierStyleItalic">H&#46; influenzae</span> e menores n&#237;veis de anticorpos com rela&#231;&#227;o &#224;s prote&#237;nas de <span class="elsevierStyleItalic">M&#46; catarrhalis</span>&#46; Resultados semelhantes foram obtidos ao se usar um fator de dilui&#231;&#227;o de 1&#58;400 &#40;dados n&#227;o mostrados&#41;&#46; As crian&#231;as com pneumonia radiologicamente confirmada tamb&#233;m apresentaram uma maior frequ&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46; As respostas dos anticorpos contra as prote&#237;nas de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foram detectadas em 28&#44;5&#37; das crian&#231;as com pneumonia radiologicamente confirmada e em 13&#44;7&#37; das crian&#231;as com raios X de t&#243;rax normal &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; As respostas dos anticorpos contra a PcpA&#44; PhtD e PcsB foram detectadas com mais frequ&#234;ncia em crian&#231;as com pneumonia radiologicamente confirmada&#46; Esses resultados s&#227;o mostrados na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46; Quando os n&#237;veis de anticorpos contra os ant&#237;genos estudados na segunda amostra de soro foram comparados com um fator de dilui&#231;&#227;o de 1&#58;1&#46;600&#44; contatamos n&#237;veis maiores de IgG contra todas as prote&#237;nas de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> e <span class="elsevierStyleItalic">H&#46; influenzae</span> e menores n&#237;veis de anticorpos em rela&#231;&#227;o a <span class="elsevierStyleItalic">M&#46; catarrhalis</span>&#44; conforme mostrado na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46; Resultados semelhantes foram obtidos ao se usar um fator de dilui&#231;&#227;o de 1&#58;400 &#40;dados n&#227;o mostrados&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Foi feita uma regress&#227;o log&#237;stica multivariada para avaliar o efeito da infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> na presen&#231;a de pneumonia radiologicamente confirmada&#44; ajustou&#8208;se esse modelo por infe&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; Influenzae</span> ou <span class="elsevierStyleItalic">M&#46; catarrhalis</span> e idade&#46; A presen&#231;a de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> aumentou as chances de pneumonia radiologicamente confirmada em 2&#44;8 &#40;IC de 95&#37;&#59; 1&#44;8&#8208;4&#44;3&#41;&#46; A presen&#231;a de infec&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; Influenzae</span> ou <span class="elsevierStyleItalic">M&#46; catarrhalis</span> ou a idade da crian&#231;a n&#227;o afetaram as chances de detec&#231;&#227;o de pneumonia radiologicamente confirmada &#40;raz&#227;o de chance &#91;IC de 95&#37;&#58; 1&#44;42 &#91;0&#44;7&#8208;2&#44;9&#93;&#59; 0&#44;4 &#91;0&#44;1&#8208;1&#44;6&#93;&#59; e 0&#44;9 &#91;0&#44;9&#8208;1&#93;&#44; respectivamente&#41;&#46; Al&#233;m disso&#44; o valor preditivo negativo do raios X de t&#243;rax normal para o diagn&#243;stico de infec&#231;&#227;o pelo pneumococo foi de 86&#44;3&#37; &#40;IC de 95&#37;&#58; 82&#44;4&#37;&#8208;89&#44;7&#37;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discuss&#227;o</span><p id="par0065" class="elsevierStylePara elsevierViewall">Este estudo demonstra que as crian&#231;as com pneumonia radiologicamente confirmada apresentam uma maior frequ&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> do que as crian&#231;as com raios X de t&#243;rax normal&#46; A presen&#231;a de infec&#231;&#227;o por pneumococo foi associada de maneira independente a pneumonia radiologicamente confirmada entre crian&#231;as n&#227;o hospitalizadas com PAC cl&#237;nica&#46; Adicionalmente&#44; a presen&#231;a de raios X de t&#243;rax normal apresentou um alto valor preditivo negativo na detec&#231;&#227;o de respostas dos anticorpos contra a <span class="elsevierStyleItalic">S pneumoniae</span>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Constatamos uma maior frequ&#234;ncia de resposta dos anticorpos contra v&#225;rios ant&#237;genos de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> no grupo de crian&#231;as com pneumonia radiologicamente confirmada em compara&#231;&#227;o com crian&#231;as com raios X de t&#243;rax normal&#46; Esse achado corrobora os resultados de estudos anteriores que demonstraram que a presen&#231;a de infiltrados alveolares nos raios X de t&#243;rax foi associada a pneumonia bacteriana&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> Por exemplo&#44; Nascimento&#8208;Carvalho et al&#46; tamb&#233;m relataram que a infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foi detectada com mais frequ&#234;ncia entre crian&#231;as com PAC hospitalizadas que apresentaram pneumonia radiogr&#225;fica do que em crian&#231;as com raios X de t&#243;rax normal&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> Por outro lado&#44; as crian&#231;as com raios X de t&#243;rax normal apresentaram maior incid&#234;ncia de infec&#231;&#227;o viral&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> Este &#233; o primeiro relato sobre a associa&#231;&#227;o entre infec&#231;&#227;o pneumoc&#243;cica e pneumonia radiologicamente confirmada entre crian&#231;as n&#227;o hospitalizadas com PAC cl&#237;nica&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Dessa forma&#44; o valor preditivo negativo do raios X de t&#243;rax normal na detec&#231;&#227;o de infec&#231;&#227;o pneumoc&#243;cica foi alto &#40;86&#44;3&#37; &#40;IC de &#91;95&#37;&#58; 82&#44;4&#37;&#8208;89&#44;7&#37;&#41;&#46; Apesar de uma associa&#231;&#227;o entre a infec&#231;&#227;o bacteriana e os infiltrados alveolares&#47;consolida&#231;&#227;o ter sido descrita anteriormente&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> esses achados n&#227;o podem estabelecer de forma confi&#225;vel o diagn&#243;stico etiol&#243;gico da PAC&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a> Assim&#44; nosso achado que de o raios X de t&#243;rax normal tem um alto valor preditivo negativo na infec&#231;&#227;o pneumoc&#243;cica pode ajudar na interpreta&#231;&#227;o desse exame&#46; Vale notar que constatamos um alto valor preditivo negativo no raios X de t&#243;rax normal em uma popula&#231;&#227;o com alta preval&#234;ncia de infec&#231;&#227;o pneumoc&#243;cica&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> o que refor&#231;ou nossos resultados&#46; De modo geral&#44; nossos dados mostram que as crian&#231;as com PAC n&#227;o grave com pneumonia radiologicamente confirmada apresentam maior chance de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; ao passo que as crian&#231;as com raios X de t&#243;rax normal n&#227;o s&#227;o propensas a apresentar infec&#231;&#227;o por esse agente e podem n&#227;o ser beneficiadas pela terapia antibi&#243;tica emp&#237;rica&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Os dados dos ensaios de vacina refor&#231;am a rela&#231;&#227;o entre a infec&#231;&#227;o pneumoc&#243;cica e a pneumonia radiologicamente confirmada&#44; pois foi encontrado um efeito diferencial da vacina&#231;&#227;o pneumoc&#243;cica nas taxas de PAC pedi&#225;trica a depender dos crit&#233;rios diagn&#243;sticos aplicados&#46; Por exemplo&#44; a efic&#225;cia da vacina PCV &#40;10&#8208;valente&#41; foi significativamente maior em crian&#231;as com consolida&#231;&#227;o no raios X de t&#243;rax do que em crian&#231;as com infiltrados alveolares ou exclusivamente com diagn&#243;stico cl&#237;nico de PAC&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> O maior impacto da vacina&#231;&#227;o pneumoc&#243;cica em crian&#231;as com consolida&#231;&#227;o nos raios X de t&#243;rax sugere&#44; assim&#44; que os pacientes com esse diagn&#243;stico radiol&#243;gico apresentam maior incid&#234;ncia de infec&#231;&#227;o pneumoc&#243;cica&#46; Esses achados s&#227;o compat&#237;veis com aqueles relatados por Lucero et al&#46;&#44; que demonstraram uma boa efic&#225;cia da vacina PCV &#40;10&#8208;valente&#41; em crian&#231;as com pneumonia radiogr&#225;fica definida como consolida&#231;&#227;o e uma efic&#225;cia praticamente insignificante da vacina em crian&#231;a com diagn&#243;stico cl&#237;nico de pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Esse ensaios de vacina fornecem comprova&#231;&#227;o indireta da etiologia da pneumonia em crian&#231;as com padr&#245;es radiol&#243;gicos distintos&#44; indicam que as crian&#231;as com pneumonia radiologicamente confirmada de fato apresentam maior frequ&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae&#46;</span></p><p id="par0085" class="elsevierStylePara elsevierViewall">Contudo&#44; o papel do raios X de t&#243;rax no manejo de crian&#231;as com PAC tem sido amplamente discutido&#46; &#201; importante destacar que Bradley et al&#46; recomendaram que o raios X de t&#243;rax deve ser usado somente em crian&#231;as hospitalizadas ou com hipoxemia&#44; insufici&#234;ncia respirat&#243;ria significativa&#44; suspeita de complica&#231;&#245;es ou falha no tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Essa posi&#231;&#227;o &#233; corroborada por Harris et al&#46;&#44; que declararam que as crian&#231;as com sintomas e sinais sugestivos de pneumonia que n&#227;o estejam internadas n&#227;o devem ser submetidas a raios X de t&#243;rax rotineiramente&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Essas recomenda&#231;&#245;es devem&#8208;se&#44; em parte&#44; a estudos anteriores que mostraram que a pneumonia bacteriana n&#227;o pode ser diferenciada da pneumonia n&#227;o bacteriana com base exclusivamente nos achados de um raios X de t&#243;rax anormal&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4&#44;24</span></a> Adicionalmente&#44; a comprova&#231;&#227;o atual sugere que o uso de raios X de t&#243;rax n&#227;o melhora o resultado de pacientes pedi&#225;tricos com PAC&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Contudo&#44; &#233; importante enfatizar que&#44; quando o impacto do raios X de t&#243;rax sobre o manejo das crian&#231;as com CAP foi avaliado&#44; os pacientes receberam antibi&#243;ticos a crit&#233;rio do m&#233;dico respons&#225;vel&#44; independentemente dos achados radiol&#243;gicos&#44; o que limitou o poss&#237;vel benef&#237;cio de um estudo radiol&#243;gico nesses pacientes como uma ferramenta de diagn&#243;stico com implica&#231;&#245;es terap&#234;uticas&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Dessa forma&#44; Hariis et al&#46; recomendam o uso de antibi&#243;ticos em todas as crian&#231;as com diagn&#243;stico claro de PAC&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Contudo&#44; ambas as diretrizes concordam que crian&#231;as jovens n&#227;o necessitam de uso rotineiro de antibi&#243;ticos&#44; pois a maior delas apresenta infec&#231;&#227;o viral aguda do trato respirat&#243;rio inferior&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a> Nesse cen&#225;rio&#44; apesar de o raios X de t&#243;rax n&#227;o diferenciar inequivocamente os agentes etiol&#243;gicos da PAC&#44; ele pode ajudar a diferenciar os diferentes padr&#245;es de infec&#231;&#245;es do trato respirat&#243;rio inferior&#46; Uma comprova&#231;&#227;o recente demonstrou importantes diferen&#231;as entre as crian&#231;as com ou sem pneumonia radiologicamente confirmada no quadro cl&#237;nico e na evolu&#231;&#227;o&#46; As crian&#231;as com pneumonia radiologicamente confirmada apresentam maior frequ&#234;ncia e maior persist&#234;ncia de febre<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;8</span></a> e&#44; al&#233;m disso&#44; evoluem de forma mais grave&#44; com interna&#231;&#227;o mais prolongada&#44; maior necessidade de apoio respirat&#243;rio e maiores taxas de falha no tratamento&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> Essas diferen&#231;as indicam que as crian&#231;as com e sem pneumonia radiologicamente confirmada podem apresentar diferentes padr&#245;es de infec&#231;&#227;o no trato respirat&#243;rio inferior e o raios X de t&#243;rax&#44; quando feito&#44; pode ajudar no manejo de casos duvidosos de PAC n&#227;o grave&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Constatamos tamb&#233;m que as crian&#231;as com pneumonia radiologicamente confirmada apresentaram maiores n&#237;veis de anticorpos contra v&#225;rias prote&#237;nas pneumoc&#243;cicas na interna&#231;&#227;o e em convalescen&#231;a&#46; Foi relatado anteriormente que menores n&#237;veis de anticorpos antipneumoc&#243;citos na interna&#231;&#227;o est&#227;o associados &#224; maior frequ&#234;ncia de respostas dos anticorpos contra <span class="elsevierStyleItalic">S&#46; pneumoniae</span> devido &#224; particularidades dos m&#233;todos sorol&#243;gicos&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Portanto&#44; o n&#237;vel de anticorpos na interna&#231;&#227;o provavelmente n&#227;o foi respons&#225;vel pela maior taxa de respostas dos anticorpos contra o pneumococo em crian&#231;as com pneumonia radiol&#243;gica&#46; O maior n&#237;vel de anticorpos na interna&#231;&#227;o nesse grupo de crian&#231;as&#44; por sua vez&#44; pode ter sido causado por coloniza&#231;&#227;o anterior por <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46; A coloniza&#231;&#227;o nasofar&#237;ngea &#233; reconhecida como parte da hist&#243;ria natural da doen&#231;a pneumoc&#243;cica&#44; que progride se as barreiras imunol&#243;gicas forem cruzadas pelas bact&#233;rias colonizadoras&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> Al&#233;m disso&#44; as crian&#231;as com pneumonia cl&#237;nica e radiol&#243;gica tamb&#233;m s&#227;o colonizadas com mais frequ&#234;ncia por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> em compara&#231;&#227;o com controles saud&#225;veis&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> Portanto&#44; existe a possibilidade de que uma maior taxa de transporte de <span class="elsevierStyleItalic">S&#46; pneumoniae</span> em crian&#231;as com pneumonia radiologicamente confirmada tenha causado os maiores n&#237;veis de anticorpos antipneumoc&#243;cicos encontrados nesse subgrupo&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">N&#227;o encontramos diferen&#231;a nas taxas de resposta dos anticorpos contra <span class="elsevierStyleItalic">H&#46; influenzae e M&#46; catarrhalis</span>&#44; possivelmente devido aos baixos n&#250;meros de respondedores em nosso grupo de estudo&#46; Contudo&#44; n&#237;veis discretamente maiores de anticorpos contra <span class="elsevierStyleItalic">H&#46; influenzae</span> foram encontrados em crian&#231;as com pneumonia radiologicamente confirmada&#44; bem como menores n&#237;veis de anticorpos contra a <span class="elsevierStyleItalic">M&#46; catarrhalis</span>&#46; Sabe&#8208;se que v&#225;rios agentes bacterianos competem na coloniza&#231;&#227;o do trato nasofar&#237;ngeo de pacientes pedi&#225;tricos&#44; criam um processo din&#226;mico de rotatividade de agentes colonizadores&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> O aumento nas taxas de coloniza&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> tamb&#233;m pode ter contribu&#237;do para a redu&#231;&#227;o dos n&#237;veis de anticorpos contra <span class="elsevierStyleItalic">M&#46; catarrhalis</span> nas amostras coletadas de crian&#231;as com pneumonia radiologicamente confirmada na interna&#231;&#227;o&#46; Por outro lado&#44; j&#225; foi descrita uma correla&#231;&#227;o positiva entre coloniza&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae e H&#46; Influenzae</span>&#44; o que pode ter contribu&#237;do para os altos n&#237;veis de anticorpos na interna&#231;&#227;o encontrados contra <span class="elsevierStyleItalic">H&#46; influenzae&#46;</span><a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es de nosso estudo devem ser enfatizadas&#46; Primeiro&#44; os dados sobre a situa&#231;&#227;o de coloniza&#231;&#227;o das crian&#231;as avaliadas n&#227;o estavam dispon&#237;veis e n&#227;o foi avaliado o efeito putativo do transporte pneumoc&#243;cico sobre os n&#237;veis de anticorpos na interna&#231;&#227;o&#46; Segundo&#44; nosso estudo foi composto por crian&#231;as n&#227;o vacinadas&#44; o que n&#227;o representa a realidade na maior parte dos pa&#237;ses na era p&#243;s&#8208;PCV&#46; Contudo&#44; uma comprova&#231;&#227;o recente sugere que o uso da PCV n&#227;o interfere no resultado do ensaio sorol&#243;gico proteico em crian&#231;as com PAC&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> o que favorece a generaliza&#231;&#227;o de nossos resultados&#46; Al&#233;m disso&#44; n&#227;o tivemos dados sobre o uso de outras vacinas que podem ter influenciado os resultados aqui apresentados&#44; como vacina contra <span class="elsevierStyleItalic">H&#46; influenzae</span> tipo B&#46; Contudo&#44; a abrang&#234;ncia da vacina contra <span class="elsevierStyleItalic">H&#46; influenzae</span> tipo B entre a popula&#231;&#227;o pedi&#225;trica no Brasil &#233; alta &#40;&#62; 80&#37;&#41;&#44; ent&#227;o as taxas diferenciais da vacina&#231;&#227;o provavelmente n&#227;o afetam nossos resultados&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> Por fim&#44; como todos os ant&#237;genos de <span class="elsevierStyleItalic">H&#46; influenzae</span> e <span class="elsevierStyleItalic">M&#46; catarrhalis</span> foram conjugados em uma regi&#227;o de <span class="elsevierStyleItalic">beads</span> por bact&#233;ria&#44; leituras de fluoresc&#234;ncia individuais n&#227;o foram obtidas para esses ant&#237;genos&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Conclus&#227;o&#58; este estudo demonstra que&#44; entre as crian&#231;as n&#227;o hospitalizadas com PAC cl&#237;nica submetidas a raios X de t&#243;rax&#44; aquelas com pneumonia radiologicamente confirmada apresentaram maior frequ&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> em compara&#231;&#227;o com as crian&#231;as com raios X de t&#243;rax normal&#46; Adicionalmente&#44; a presen&#231;a de infec&#231;&#227;o pneumoc&#243;cica foi associada de maneira independente a pneumonia radiologicamente confirmada e o raios X de t&#243;rax normal apresentou um alto valor preditivo negativo de infec&#231;&#227;o pneumoc&#243;cica&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Financiamento</span><p id="par0110" class="elsevierStylePara elsevierViewall">Este trabalho foi patrocinado pela Funda&#231;&#227;o de Amparo &#224; Pesquisa do Estado da Bahia &#40;Fapesb&#41; e pelo Conselho Nacional de Desenvolvimento Cient&#237;fico e Tecnol&#243;gico &#40;CNPq&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflitos de interesse</span><p id="par0115" class="elsevierStylePara elsevierViewall">Andreas Meinke &#233; funcion&#225;ria da Valneva Austria GmbH&#46; Os outros autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Community&#8208;acquired pneumonia is an important cause of morbidity in childhood&#44; but the detection of its causative agent remains a diagnostic challenge&#46; The authors aimed to evaluate the role of the chest radiograph to identify cases of community&#8208;aquired pneumonia caused by typical bacteria&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The frequency of infection by <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; and <span class="elsevierStyleItalic">Moraxella catarrhalis</span> was compared in non&#8208;hospitalized children with clinical diagnosis of community acquired pneumonia aged 2&#8208;59 months with or without radiological confirmation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>249 and 366&#44; respectively&#41;&#46; Infection by <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was diagnosed by the detection of a serological response against at least one of eight pneumococcal proteins &#40;defined as an increase &#8805;2&#8208;fold in the IgG levels against Ply&#44; CbpA&#44; PspA1 and PspA2&#44; PhtD&#44; StkP&#8208;C&#44; and PcsB&#8208;N&#44; or an increase &#8805;1&#46;5&#8208;fold against PcpA&#41;&#46; Infection by <span class="elsevierStyleItalic">H&#46; influenzae</span> and <span class="elsevierStyleItalic">M&#46; catarrhalis</span> was defined as an increase &#8805;2&#8208;fold on the levels of microbe&#8208;specific IgG&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Children with radiologically confirmed pneumonia had higher rates of infection by <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#46; The presence of pneumococcal infection increased the odds of having radiologically confirmed pneumonia by 2&#46;8 times &#40;95&#37; CI&#58; 1&#46;8&#8208;4&#46;3&#41;&#46; The negative predictive value of the normal chest radiograph for infection by <span class="elsevierStyleItalic">S&#46; pneumoniae</span> was 86&#46;3&#37; &#40;95&#37; CI&#58; 82&#46;4&#8208;89&#46;7&#37;&#41;&#46; There was no difference on the rates of infection by <span class="elsevierStyleItalic">H&#46; influenzae</span> and <span class="elsevierStyleItalic">M&#46; catarrhalis</span> between children with community&#8208;acquired pneumonia with and without radiological confirmation&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Among children with clinical diagnosis of community&#8208;acquired pneumonia submitted to chest radiograph&#44; those with radiologically confirmed pneumonia present a higher rate of infection by <span class="elsevierStyleItalic">S&#46; pneumoniae</span> when compared with those with a normal chest radiograph&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar o papel do raios X de t&#243;rax na identifica&#231;&#227;o de casos de pneumonia adquirida na comunidade &#40;PAC&#41; causada por agentes bacterianos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A frequ&#234;ncia de infec&#231;&#227;o por <span class="elsevierStyleItalic">Streptococcus pneumoniae&#44; Haemophilus influenzae</span> e <span class="elsevierStyleItalic">Moraxella catarrhalis</span> em crian&#231;as com PAC n&#227;o hospitalizadas foi comparada com a presen&#231;a de confirma&#231;&#227;o radiol&#243;gica da pneumonia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>249 crian&#231;as com pneumonia radiologicamente confirmada e 366 crian&#231;as com raios X de t&#243;rax normal&#41;&#46; Infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foi diagnosticada com base na resposta sorol&#243;gica a pelo menos uma dentre oito prote&#237;nas pneumoc&#243;cicas investigadas &#40;aumento &#8805; 2 vezes nos n&#237;veis de IgG em rela&#231;&#227;o a Ply&#44; CbpA&#44; PspA1 e 2&#44; PhtD&#44; StkP&#8208;C e PcsB&#8208;N ou aumento&#8805; 1&#44;5 vez em rela&#231;&#227;o aPcpA&#41;&#46; Infec&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; influenzae</span> e <span class="elsevierStyleItalic">M&#46; catarrhalis</span> foi definida por aumento &#8805; 2 vezes nos n&#237;veis de IgG espec&#237;fica a ant&#237;genos de cada agente&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Crian&#231;as com pneumonia radiologicamente confirmada apresentaram maior taxa de infec&#231;&#227;o pelo pneumococo&#46; Al&#233;m disso&#44; a presen&#231;a de infec&#231;&#227;o pneumoc&#243;cica foi um fator preditor de pneumonia radiologicamente confirmada&#44; o que aumenta sua chance de detec&#231;&#227;o em 2&#44;8 vezes &#40;IC 95&#37;&#58; 1&#44;8&#8208;4&#44;3&#41;&#46; O valor preditivo negativo do raios X normal para a infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> foi 86&#44;3&#37; &#40;IC95&#37;&#58; 82&#44;4&#37;&#8208;89&#44;7&#37;&#41;&#46; N&#227;o houve diferen&#231;a nas frequ&#234;ncias de infec&#231;&#227;o por <span class="elsevierStyleItalic">H&#46; influenzae</span> e <span class="elsevierStyleItalic">M&#46; catarrhalis</span> entre crian&#231;as com PAC com ou sem confirma&#231;&#227;o radiol&#243;gica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Crian&#231;as com diagn&#243;stico cl&#237;nico de PAC submetidas a um raios X de t&#243;rax que apresentam confirma&#231;&#227;o radiol&#243;gica t&#234;m maior taxa de infec&#231;&#227;o por <span class="elsevierStyleItalic">S&#46; pneumoniae</span> comparadas com as crian&#231;as com raios X normal&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Como citar este artigo&#58; Andrade DC&#44; Borges IC&#44; Vilas&#8208;Boas AL&#44; Fontoura MS&#44; Ara&#250;jo&#8208;Neto CA&#44; Andrade SC&#44; et al&#46; Infection by <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> in children with or without radiologically confirmed pneumonia&#46; J Pediatr &#40;Rio J&#41;&#46; 2018&#59;94&#58;23&#8211;30&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2426
            "Ancho" => 2429
            "Tamanyo" => 321773
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        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fluxograma que mostra os crit&#233;rios de inclus&#227;o&#47;exclus&#227;o para crian&#231;as neste estudo&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabela 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabela "
            "rol" => "short"
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        "tabla" => array:2 [
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#176; de pneumonia radiologicamente confirmada<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>249&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#176; de raios X de t&#243;rax normais<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>366&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">299 &#40;98&#8208;865&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">274 &#40;82&#8208;663&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1682 &#40;349&#44;75&#8208;4064&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">H&#46; influenzae</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">152 &#40;90&#8208;273&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">128 &#40;87&#8208;219&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;047&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">M&#46; catarrhalis</span>&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Compara&#231;&#227;o dos valores de intensidade m&#233;dia de fluoresc&#234;ncia &#40;MFI&#41; da primeira amostra de soro de crian&#231;as com pneumonia radiologicamente confirmada ou aquelas com raios X de t&#243;rax normal&#44; com o uso de um fator de dilui&#231;&#227;o de 1&#58;1600</p>"
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