Pneumonia

 

Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:

 

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ABSTRACTS

3443. Abul H.  Abul A.  Khan I.  Mathew TC.  Ayed A.  Al-Athary E. Levels of IL-8 and myeloperoxidase in the lungs of pneumonia patients. Molecular & Cellular Biochemistry.  217(1-2):107-12, 2001 Jan.

Abstract

  Interleukin-8 (IL-8) is considered as the major polymorphonuclear neutrophils (PMNs) chemoattractant cytokine in lung diseases such as asthma and adult respiratory distress syndrome (ARDS). However, controversial results were obtained regarding the involvement of IL-8 in the pathogenesis of pneumonia. This study examines the role of IL-8 in the recruitment and activation of PMNs in the lung of pneumonia patients. The interesting aspect of this study is that it is a site- specific analysis of the infected and uninfected lungs of the same patient. The level of IL-8 mRNA, protein and myeloperoxidase present in the cells of the bronchioalveolar lavages (BALs) taken from the areas of known pneumonic consolidations on chest X-ray (infected lung) are compared with the BALs obtained from areas of no obvious infiltrate (non-infected lung). The results obtained from the infected and non-infected lungs of pneumonic patients were further compared with that of a control group of non-smoking patients. The level of IL-8 mRNA and protein were determined by RT-PCR and ELISA respectively. There was a significant increase in the level of IL-8 mRNA in the infected lung as compared to its level in the non-infected lung (p < 0.001). In correlation with the increase in mRNA, IL-8 protein concentrations in BAL fluids from the infected lung were 6 fold higher than those taken from the non-infected lung (p < 0.0001). This pattern was also consistent with MPO activity in the BALs (4.5 fold more MPO activity in the infected lung as compared to that of the non-infected lung), indicating that IL-8 is directly implicated in neutrophil accumulation that follows acute respiratory infection. The results of the present study, therefore, indicate the involvement of IL-8 in the pathogenesis of pneumonia.

 

3444. Akbas E.  Yu VL. Legionnaires' disease and pneumonia. Beware the temptation to underestimate this "exotic" cause of infection. [Review] [6 refs] Postgraduate Medicine.  109(5):135-8, 141-2, 147, 2001 May.

Abstract

  Legionnaires' disease is an often overlooked but common cause of community-acquired pneumonia. The clinical presentation is nonspecific, although fever higher than 39 degrees C (102.2 degrees F), gastrointestinal symptoms, and hyponatremia should raise the index of suspicion. In this article, Drs Akbas and Yu describe specialized laboratory tests needed for definitive diagnosis and discuss therapeutic options. [References: 6]

 

3445. Azadniv M.  Torres A.  Boscia J.  Speers DM.  Frasier LM.  Utell MJ.  Frampton MW. Neutrophils in lung inflammation: Which reactive oxygen species are being measured?.

  Abstract

       The oxidative burst in circulating polymorphonuclear leukocytes (PMN) plays a fundamental role in pulmonary defense and injury. Flow cytometric techniques have been developed for quantitation of oxidative burst activity at the single cell level using 2',7'-dichlorofluorescin (DCFH). However, the specific reactive oxidant species being measured using this method are not clearly defined. Isolated human PMN were loaded with DCFH diacetate, stimulated with phorbol myristate acetate (PMA) in the presence or absence of specific reagents, and analyzed using flow cytometry. Addition of PMA resulted in a 90-fold increase in the fluorescence intensity of DCFH-loaded neutrophils (p <.01). Inhibition of NADPH oxidase activity using a calmodulin antagonist (W-13) decreased PMA-induced DCFH oxidation by 70% (p <.05). Inhibition of nitric oxide synthase using N(G)-monomethyl-L-arginine (NMMA) did not significantly reduce DCFH oxidation, and did not alter the action of W-13. Addition of superoxide dismutase (SOD) had no effect, but catalase, with or without SOD, suppressed DCFH oxidation by 90% (p <.01). These data suggest that hydrogen peroxide, and not NO, is primarily responsible for the PMA-induced oxidation of DCFH in human PMN under these conditions.

 

3446. Bain KT.  Wittbrodt ET. Linezolid for the treatment of resistant gram-positive cocci. [Review] [64 refs] Annals of Pharmacotherapy.  35(5):566-75, 2001 May.

Abstract

OBJECTIVE: To provide a comprehensive review of linezolid, the first of a new class of antibiotics, the oxazolidinones. Therapeutic issues regarding the emergence of multidrug-resistant bacteria and a brief history of the oxazolidinones are also discussed. DATA SOURCES: A MEDLINE search (1966-March 2001) was conducted to identify pertinent literature, including preclinical trials, clinical trials, and reviews. Unpublished clinical data, adverse effects, and dosing information were abstracted from product labeling. STUDY SELECTION: Clinical efficacy data were extracted from clinical trials, case reports, and abstracts that mentioned linezolid. Additional information concerning antibiotic resistance, the oxazolidinones, in vitro susceptibility and the pharmacokinetic profile of linezolid also was reviewed. DATA SYNTHESIS: Linezolid exhibits activity against many gram-positive organisms, including vancomycin-resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus, and penicillin-resistant Streptococcus pneumoniae. Linezolid inhibits bacterial protein synthesis at an early step in translation and is rapidly and completely absorbed from the gastrointestinal tract following oral administration. Efficacy has been demonstrated in a number of unpublished clinical trials in adults with pneumonia, skin and skin structure infections, and vancomycin-resistant E. faecium infections. The adverse effect profile is similar to that of comparator agents (beta-lactams, clarithrornycin, vancomycin). CONCLUSIONS: Linezolid is the first oral antimicrobial agent approved for the treatment of vancomycin-resistant enterococci. Since the oxazoildinones have a unique mechanism of action and expanded spectrum of activity against virulent and highly resistant gram positive pathogens, linezolid is a valuable alternative to currently available treatment options. Clinical trials evaluating linezolid and other oxazolidinones for antibiotic-resistant gram-positive infections, as well as comparator studies comparing linezolid with other candidate drugs, such as quinupristin/dalfopristin and choramphenicol, will further define the role of linezolid. [References: 64]

 

3447. Baine WB.  Yu W.  Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia, 1991-1998.American Journal of Public Health.  91(7):1121-3, 2001 Jul.

Abstract

OBJECTIVES: This study determined hospitalization rates of elderly Americans for pneumonia from 1991 through 1998. METHODS: Epidemiologic data were described for 273,143 pneumonia hospitalizations. RESULTS: Annual hospitalizations for aspiration pneumonia increased by 93.5%. Pneumonia hospitalization rates increased steeply with age, especially among men. Black men were at highest risk for aspiration, unspecified, Klebsiella, "other gram-negative," and staphylococcal pneumonia; White men had the highest Haemophilus and pneumococcal pneumonia rates. Among women, Blacks predominated in aspiration and Klebsiella pneumonia; Whites had the highest Haemophilus and bronchopneumonia rates. CONCLUSIONS: An epidemic of hospitalization for aspiration pneumonia smoldered over 8 years. Significant disparities existed in hospitalization risks by race, sex, and principal diagnosis.

 

3448.  Bakhtawar I.  Schaefer RF.  Salian N. Utility of Wang needle aspiration in the diagnosis of actinomycosis. Chest.  119(6):1966-8, 2001 Jun.

Abstract

An 85-year-old man had a 4-year history of recurrent pneumonia with a persistent pleural effusion. He underwent repeated bronchoscopy that revealed a right bronchus intermedius mass, but bronchial washes and biopsies remained nondiagnostic. A repeat bronchoscopy was performed, and a Wang needle aspiration of the mass was obtained that showed sulfur granules, diagnosing actinomycosis. The patient was started on appropriate antibiotic therapy. Actinomycosis must be considered in a patient with recurrent pneumonia and an endobronchial mass. Wang needle aspiration via bronchoscopy may be an important diagnostic tool.

 

3449.  Barbato A.  Panizzolo C.  D'Amore ES.  La Rosa M.  Saetta M. Bronchiolitis obliterans organizing pneumonia (BOOP) in a child with mild-to-moderate asthma: evidence of mast cell and eosinophil recruitment in lung specimens. Pediatric Pulmonology.  31(5):394-7, 2001 May.

Abstract

  Bronchiolitis obliterans with organizing pneumonia (BOOP) is rarely described in children and little is known about its pathogenesis. This paper reports on an 11-year-old patient suffering from mild-to-moderate asthma. He presented with a retrocardiac density at chest computed tomography scan that was slow to resolve and failed to respond to antibiotic therapy. Open lung biopsy revealed a histological picture with buds of granulation tissue in respiratory bronchioles and alveolar ducts, with organized extensions into the alveoli. The use of monoclonal antibodies on biopsy specimens demonstrated the presence of an inflammatory process affecting not only the thickened alveolar walls, but also the remaining lung parenchyma, the pulmonary arteries, and the bronchioles. The inflammatory infiltrate consisted mainly of mast cells and eosinophils. The clinical condition improved with steroid therapy. To the best of the authors' knowledge, this is the first report of BOOP in an asthmatic child with recruitment of mast cells and eosinophils documented by using monoclonal antibodies. Copyright 2001 Wiley-Liss, Inc.

 

3450. Benito N.  Rano A.  Moreno A.  Gonzalez J.  Luna M.  Agusti C.  Danes C.  Pumarola T.  Miro JM.  Torres A.  Gatell JM. Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy era in Spain. Journal of Acquired Immune Deficiency Syndromes.  27(1):35-43, 2001 May 1.

Abstract

OBJECTIVE: To study the incidence, etiology, and outcome of pulmonary infiltrates (PIs) in HIV-infected patients and to evaluate the yield of diagnostic procedures. DESIGN: Prospective observational study of consecutive hospital admissions. SETTING: Tertiary hospital. PATIENTS: HIV-infected patients with new-onset radiologic PIs from April 1998 to March 1999. METHODS: The study protocol included chest radiography, blood and sputum cultures, serologic testing for "atypical" causes of pneumonia, testing for Legionella urinary antigen, testing for cytomegalovirus antigenemia, and bronchoscopy in case of diffuse or progressive PIs. RESULTS: One hundred two episodes in 92 patients were recorded. The incidence of PIs was 18 episodes per 100 hospital admission-years (95% confidence interval [CI]: 15-21). An etiologic diagnosis was achieved in 62 cases (61%). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), and mycobacteriosis were the main diagnoses. The incidences of BP and mycobacteriosis were not statistically different in highly active antiretroviral therapy (HAART) versus non-HAART patients. The incidence of PCP was lower in those receiving HAART (p =.011), however. Nine patients died (10%). Independent factors associated with higher mortality were mechanical ventilation (odds ratio [OR] = 83; CI: 4.2-1,682), age >50 years (OR = 23; CI: 2-283), and not having an etiologic diagnosis (OR = 22; CI: 1.6-293). CONCLUSIONS: Pulmonary infiltrates are still a frequent cause of hospital admission in the HAART era, and BP is the main etiology. There was no difference in the rate of BP and mycobacteriosis in HAART and non-HAART patients. Not having an etiologic diagnosis is an independent factor associated with mortality.

 

3451. Bitnun A.  Ford-Jones EL.  Petric M.  MacGregor D.  Heurter H.  Nelson S.  Johnson G.  Richardson S. Acute childhood encephalitis and Mycoplasma pneumoniae. Clinical Infectious Diseases.  32(12):1674-84, 2001 Jun 15.

Abstract

In a prospective 5-year study of children with acute encephalitis, evidence of Mycoplasma pneumoniae infection was demonstrated in 50 (31%) of 159 children. In 11 (6.9%) of these patients, M. pneumoniae was determined to be the probable cause of encephalitis on the basis of its detection in cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) or by positive results of serologic tests for M. pneumoniae and detection of the organism in the throat by PCR. CSF PCR positivity correlated with a shorter prodromal illness (P=.015) and lack of respiratory symptoms (P=.06). Long-term neurologic sequelae occurred in 64% of probable cases. Thirty children (18.9%) who were seropositive for M. pneumoniae but did not have the organism detected by culture or PCR had convincing evidence implicating other organisms as the cause of encephalitis, suggesting that current serologic assays for M. pneumoniae are not sufficiently specific to establish a diagnosis of M. pneumoniae encephalitis.

 

3452.               Dahlstrom JE.  Langdale-Smith GM.  James DT. Fine needle aspiration cytology of pulmonary lesions: a reliable diagnostic test. Pathology.  33(1):13-6, 2001 Feb.

Abstract

The objective of this study was to determine the accuracy of image-guided fine needle aspiration cytology (FNAC) in the diagnosis of pulmonary lesions. A retrospective study was undertaken of 286 patients with 288 lesions, who underwent a total of 302 procedures. The FNAC diagnoses were reported as malignant, suspicious, atypical, benign or non-diagnostic. Subsequently the FNAC diagnoses were correlated with either the histological or clinical diagnoses. Of the 288 lesions, 64.6% were reported on FNAC as malignant, 2.1% suspicious, 2.4% atypical, 20.8% benign and 10.1% nondiagnostic. On review of the suspicious, atypical, selected benign cases and non-diagnostic FNAC by an independent pathologist there was agreement with the original FNAC diagnosis in all cases. All of 186 malignant FNAC diagnoses were confirmed malignant either clinically or on subsequent histology. Four of the six suspicious FNAC diagnoses had a malignant outcome, one patient had organising pneumonia on excision biopsy and one was lost to follow up. Six of the seven atypical FNAC diagnoses were confirmed on histology as malignant, while one lesion resolved spontaneously. Fifty-two of 60 benign FNAC diagnoses were confirmed benign either clinically or on histology. Seven of the lesions diagnosed as benign on FNAC were proven to be malignant. One patient with a benign FNAC diagnosis was lost to follow-up. Ten of the 29 non-diagnostic FNAC group were later shown on clinical or histological follow up to be malignant. This study shows that image guided FNAC for the diagnosis of malignant pulmonary lesions has a sensitivity of at least 92% and a specificity of at least 96%. It is a reliable diagnostic test although its accuracy is limited by technical difficulties in obtaining an adequate sample.

 

 

3453. Egerer G.  Witzens M.  Spaeth A.  Breitbart A.  Moller P.  Goldschmidt H.  Ho AD. Successful treatment of bronchiolitis obliterans organizing pneumonia with low-dose methotrexate in a patient with Hodgkin's disease. Oncology.  61(1):23-7, 2001.

Abstract

Bronchiolitis obliterans organizing pneumonia (BOOP) is a rare disease, which is histopathologically defined by the presence of granulation tissue in the bronchioles, alveolar ducts and alveoli leading to plugging of the bronchiolar and alveolar lumen. BOOP is considered as a nonspecific response to many types of lung injury, including drugs, radiation, an underlying hematologic malignant neoplasm, autoimmune diseases, bacterial or virus infection, or an underlying lung disease, or occurs idiopathically. BOOP is mainly treated with corticosteroids, which induce a rapid clinical improvement. A frequent problem is relapse of disease when corticosteroid dosage is tapered off. We present the case of a 20-year-old patient with Hodgkin's disease developing BOOP after chemotherapy (COPP/ABVD) and irradiation. Initially, she responded well to corticosteroids, but relapsed when medication was discontinued. Complete remission of BOOP was achieved by long-term treatment with low-dose methotrexate (5-20 mg/week, i.v.). Copyright 2001 S. Karger AG, Basel

 

3454. Esposito S.  Blasi F.  Bellini F.  Allegra L.  Principi N.  Mowgli Study Group. Mycoplasma pneumoniae and Chlamydia pneumoniae infections in children with pneumonia. Mowgli Study Group. European Respiratory Journal.  17(2):241-5, 2001 Feb.

Abstract

The most common clinical signs, host responses and radiographic patterns were studied in 203 Italian children hospitalized for community-acquired pneumonia in order to clarify the role of clinical and radiological characteristics in the diagnosis of Mycoplasma pneumoniae and/or Chlamydia pneumoniae infections. Antibody measurements in paired sera and polymerase chain reaction on nasopharyngeal aspirates were used to establish the diagnoses of acute M. pneumoniae and C. pneumoniae infection, and the aetiologic data were correlated with the clinical, laboratory and radiographic data obtained on admission. No significant association was observed between evidence of M. pneumoniae and/or C. pneumoniae infection and periods of episode during the year, mean age of the study subjects, individual symptoms, physical findings or laboratory test results. Furthermore, no significant correlation was observed in relation to the radiological findings and M. pneumoniae and/or C. pneumoniae infection. This study shows that neither clinical findings nor laboratory parameters distinguished Mycoplasma pneumoniae and/or Chlamydia pneumoniae infection in children with pneumonia. Radiological findings also have a limited capacity to differentiate aetiologic agents. The priorities for future research include the development of rapid, easily accessible and cost-effective diagnostic tests useful for each episode of pneumonia in children.

 

3455. Esposito S.  Principi N. Asthma in children: are chlamydia or mycoplasma involved?. [Review] [77 refs]  Paediatric Drugs.  3(3):159-68, 2001.

Abstract

  Asthma aetiology is complex, involving interactions between genetic susceptibility, allergen exposure and external aggravating factors such as air pollution, smoking and respiratory tract infections. Available evidence supports a role for acute Chlaymdia pneumoniae or Mycoplasma pneumoniae respiratory tract infection as a trigger for 5 to 30% of wheezing episodes and asthma exacerbations. It also appears that acute infections with C. pneumoniae and M. pneumoniae can initiate asthma in some previously asymptomatic patients; however, the quantitative role for these atypical bacteria as asthma initiators is unknown at the present time. Whether chronic infections with these agents play an important role in persistent asthma symptoms and/or to asthma severity is unclear and additional information should be acquired before definite conclusions can be reached. Improvement in asthma symptoms after antimicrobial therapy active against C. pneumoniae and M. pneumoniae has been observed. In some studies C. pneumoniae seems to be more important for asthma pathogenesis and exacerbations than M. pneumoniae; in other reports the role of M. pneumoniae appears to be more significant. However, a number of questions remain unanswered. Carefully controlled randomised trials are clearly warranted to determine whether infection with atypical bacteria is really associated with asthma and to define the appropriate role of antimicrobial treatment. [References: 77]

 

3456. Graham SM.  Coulter JB.  Gilks CF. Pulmonary disease in HIV-infected African children. [Review] [93 refs]International Journal of Tuberculosis & Lung Disease.5(1):12-23, 2001 Jan.

Abstract

Childhood human immunodeficiency virus (HIV) infection is common in most regions of sub-Saharan Africa. Acute and chronic respiratory diseases are major causes of morbidity and mortality in HIV-infected children. They represent a significant added burden in a region where diagnostic capabilities are limited and management decisions are often made on the basis of clinical guidelines alone. Pneumocystis carinii pneumonia is now recognised as an important cause of acute severe pneumonia and death in HIV-infected infants. However, there are few data on incidence and aetiology for more treatable conditions such as bacterial pneumonia. The association of pulmonary tuberculosis and HIV infection is uncertain, and the diagnosis is further confused by the presence of lymphoid interstitial pneumonitis and other chronic HIV-related pulmonary disease. This article reviews the literature and highlights the urgent need for further research in order to improve clinical management and appropriate interventions. [References: 93]

 

3457.  Heller I.  Biner S.  Isakov A.  Kornitzky Y.  Shapira I.  Marmor S.  Topilsky M. TB or not TB: cavitary bronchiolitis obliterans organizing pneumonia mimicking pulmonary tuberculosis. Chest.  120(2):674-8, 2001 Aug.

Abstract

  Two patients with subacute symptoms and signs compatible with pulmonary tuberculosis (TB) had right upper lobe cavitary infiltrates shown on chest radiography. In both patients, purified protein derivative and microbiologic testing excluded TB, and tissue examination yielded typical histologic changes of bronchiolitis obliterans organizing pneumonia (BOOP). Glucocorticoid therapy led to clinical and radiologic resolution. Though probably rare in this situation, BOOP should be considered in the differential diagnosis of patients presenting with clinical and radiologic features of pulmonary TB.

 

3458. Kuschner WG.  Sarinas PS.  Chitkara R.Foreign body aspiration diagnosed by microscopy. [Review] [16 refs] American Journal of the Medical Sciences.  322(1):44-7, 2001 Jul.

Abstract

We report a rare case of foreign body aspiration diagnosed by microscopic analysis of a sample of the foreign body. A 50-year-old man presented with a 5-month history of 40 pound weight loss and a nonresolving right lower lobe pneumonia. Medical history, radiographic studies, direct visualization of the foreign body by flexible fiberoptic bronchoscopy, and gross examination of a sample of the foreign body retrieved by a forceps biopsy catheter failed to yield the diagnosis. Moderate bleeding associated with the bronchoscopic "biopsy" procedure contributed to a preliminary misdiagnosis of endobronchial tumor. Microscopic analysis of the "biopsy" specimen demonstrated vegetable matter. The patient underwent rigid bronchoscopy and a peanut was retrieved from the bronchus intermedius. He was maintained on antibiotics for an additional 8 weeks and had complete clinical and radiographic recovery. The epidemiology, presentation, and management strategies of foreign body aspiration in the adult are briefly reviewed. [References: 16]

 

3459. Lim TK. Management of parapneumonic pleural effusion. [Review] [30 refs] Current Opinion in Pulmonary Medicine.  7(4):193-7, 2001 Jul.

Abstract

Parapneumonic pleural effusion is a common and potentially serious complication of pneumonia. The management of parapneumonic pleural effusion involves early diagnosis, adequate empiric antibiotic cover, and appropriate risk categorization. High-risk patients require safe and expedient drainage of the infected pleural space. The management options include thoracentesis, tube thoracostomy, adjunctive intrapleural fibrinolytic therapy, and surgical drainage. The methods of surgical drainage include thoracoscopy, thoracotomy, and decortication. The relative clinical efficacy of these treatment options has been studied in a small number of controlled clinical trials, the results of which have been systematically reviewed by expert panels. Based on the limited clinical evidence, expert reviewers were unable to recommend a best method of pleural drainage. However, the consensus is that an aggressive approach with early surgical drainage results in shorter hospital stays and may be more cost-effective than conservative management. This review discusses the clinical evidence and describes an aggressive sequential management strategy that combines intrapleural fibrinolysis with early surgical drainage. [References: 30]

 

3460. Lindenburg CE.  Langendam MW.  Benthem BH.  Miedema F.  Coutinho RA. No evidence that vaccination with a polysaccharide pneumococcal vaccine protects drug users against all-cause pneumonia. AIDS.  15(10):1315-7, 2001 Jul 6.

Abstract

Individuals infected with HIV are at high risk of pneumonia and invasive disease caused by Streptococcus pneumoniae. To date, the effect of vaccination with a polysaccharide pneumococcal vaccine on this group is unclear. Breiman et al. suggested a protective effect of vaccination on the incidence of invasive disease, whereas a recent study in Uganda showed an increased risk of invasive disease and no protection against all-cause pneumonia among vaccinees.

 

3461. Maschmeyer G. Pneumonia in febrile neutropenic patients: radiologic diagnosis. [Review] [40 refs]Current Opinion in Oncology.  13(4):229-35, 2001 Jul.

Abstract

Pneumonia in febrile neutropenic cancer patients should be diagnosed as early as possible, because prompt institution of targeted therapeutic measures might be essential for their prognosis. Conventional chest radiographs frequently fail to detect lung infiltrates at an early stage, meaning that a normal chest radiograph finding must be interpreted with caution. Thoracic computed tomograph scans provide a much higher yield and are therefore recommended in patients at risk for a complicated pulmonary infection. Lung infiltrates documented by computed tomograph scans (eg, nodular infiltrates with or without a halo, ground-glass opacities, or cavitations with or without air crescent signs) open up a wide range of differential diagnoses, such as invasive pulmonary aspergillosis, other types of pneumonia, hemorrhage, infiltration by the underlying malignancy, drug toxicity, alveolar proteinosis, or acute respiratory distress syndrome. High-resolution techniques or magnetic resonance imaging may provide further details to help distinguish inflammatory processes from processes that may not require an antimicrobial intervention. Sequential nonculture-based monitoring for invasive fungal infections, using Aspergillus antigen sandwich enzyme-linked immunosorbent assay, and panfungal or Aspergillus-specific polymerase chain reaction, may add important tools in the early identification of patients who may benefit from systemic antifungal treatment. [References: 40]

 

3462. Navin TR.  Beard CB.  Huang L.  del Rio C.  Lee S.  Pieniazek NJ.  Carter JL.  Le T.  Hightower A.  Rimland D. Effect of mutations in Pneumocystis carinii dihydropteroate synthase gene on outcome of P carinii pneumonia in patients with HIV-1: a prospective study. Lancet. 358(9281):545-9, 2001 Aug 18.

Abstract

BACKGROUND: Investigators have reported that patients infected with Pneumocystis carinii containing mutations in the DHPS (dihydropteroate synthase) gene have a worse outcome than those infected with P carinii containing wild-type DHPS. We investigated patients with HIV-1 infection and P carinii pneumonia to determine if DHPS mutations were associated with poor outcomes in these patients. METHODS: We compared presence of mutations at the DHPS locus with survival and response of patients to co-trimoxazole or other drugs. FINDINGS: For patients initially given co-trimoxazole, nine (14%) of 66 with DHPS mutant died, compared with nine (25%) of 36 with wild type (risk ratio50.55 [95% CI=0.24-1.25]; p=0.15). Ten (15%) of 66 patients with a DHPS mutant did not respond to treatment, compared with 13 (36%) of 36 patients with the wild type (0.42 [0.20-0.86]; p=0.02). For patients aged 40 years or older, four (14%) of 29 with the mutant and nine (56%) of 16 with the wild type died (0.25 [0.09-0.67]; p=0.005). INTERPRETATION: These results, by contrast with those of previous studies, suggest that patients with wild-type P carinii do not have a better outcome than patients with the mutant when given co-trimoxazole. Our results suggest that presence of a DHPS mutation should be only one of several criteria guiding the choice of initial drug treatment of P carinii pneumonia in patients with HIV-1 infection.

 

3463. Niederman MS.  Mandell LA.  Anzueto A.  Bass JB.  Broughton WA.  Campbell GD.  Dean N.  File T.  Fine MJ.  Gross PA.  Martinez F.  Marrie TJ.  Plouffe JF.  Ramirez J.  Sarosi GA.  Torres A.  Wilson R.  Yu VL.  American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention.American Journal of Respiratory & Critical Care Medicine.  163(7):1730-54, 2001 Jun.

 

3464. Oh M.  Kim N.  Huh M.  Choi C.  Lee E.  Kim I.  Choe K. Scrub typhus pneumonitis acquired through the respiratory tract in a laboratory worker. Infection.  29(1):54-6, 2001 Jan-Feb.

Abstract

We report a case of scrub typhus pneumonitis in a laboratory worker who apparently acquired it through the respiratory tract. The patient was suffering from fever, cough and dyspnea. He had both cervical and axillary lymphadenopathy, and hepatomegaly. A chest X-ray showed interstitial infiltrates. A diagnosis of scrub typhus was established upon isolation of Orientia tsutsugamushi. 12 days before the patient showed symptoms, he had purified O. tsutsugamushi proteins from infected cells using an ultrasonication method which could generate aerosols containing O. tsutsugamushi.

 

3465. Orgus T.  Altinmakus S.  Bilgen F. Eccentric mitral regurgitation can imitate a diagnosis of pneumonia.International Journal of Cardiology.  77(2-3):307-9, 2001 Feb.

 

3466. Poulsen A.  Demeny AK.  Bang Plum C.  Gjerum Nielsen K.  Schmiegelow K.Pneumocystis carinii pneumonia during maintenance treatment of childhood acute lymphoblastic leukemia.Medical & Pediatric Oncology.  37(1):20-3, 2001 Jul.

Abstract

BACKGROUND: Pneumocystis carinii pneumonia (PCP) is a wellknown risk among patients with deficient T-cell function such as children treated for acute lymphoblastic leukemia (ALL). The purpose of this study was to estimate the risk for PCP during maintenance treatment (MT) to identify patients at risk who could benefit from prophylaxis. PROCEDURE: We registered all episodes of PCP during MT in 71 children diagnosed between January 1992 and June 1997 with non-B-cell ALL at The Copenhagen University Hospital. Sulphametoxazole and trimetroprim (SMX/TMP) prophylaxis against PCP was given during induction and consolidation therapy but stopped prior to MT with oral methotrexate/6-mercaptopurine. Patients with standard (SR), intermediate (IR), and high risk (HR) ALL started MT at 3, 8, and 15 months from diagnosis, respectively. RESULTS: The HR group had a cumulated risk of 70% for developing PCP, whereas the risk for PCP in children with IR and the SR was 11 and 8%, respectively (P < 0.0001). All but one of these 13 cases of PCP occurred within 8 months after cessation of SMX-TMP prophylaxis. CONCLUSIONS: The higher incidence of PCP among HR compared to non-HR patients following cessation of SMX/TMP prophylaxis probably reflects the significantly longer T-cell suppressive consolidation therapy in this group. The very low incidence of PCP during the later part of MT emphasizes that methotrexate/6-mercaptopurine MT have more impact on B-cell than on T-cell function. TMP/SMX prophylaxis should be recommended for all children treated for ALL. Copyright 2001 Wiley-Liss, Inc.

 

3467. Ryu JH.  Colby TV.  Hartman TE.  Vassallo R.Smoking-related interstitial lung diseases: a concise review. [Review] [98 refs] European Respiratory Journal.  17(1):122-32, 2001 Jan.

Abstract

Interstitial lung diseases (also known as diffuse infiltrative lung diseases) are a heterogeneous group of parenchymal lung disorders of known or unknown cause. These disorders are usually associated with dyspnoea, diffuse lung infiltrates, and impaired gas exchange. The majority of interstitial lung diseases are of unknown cause. Known causes of interstitial lung disease include inhalation of organic and inorganic dusts as well as gases or fumes, drugs, radiation, and infections. This review summarizes the clinical, radiological, and histopathological features of four interstitial lung disorders that have been linked to smoking. These disorders include desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, pulmonary Langerhans' cell histiocytosis, and idiopathic pulmonary fibrosis. Available evidence suggests most cases of desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, and pulmonary Langerhans' cell histiocytosis are caused by cigarette smoking in susceptible individuals. Smoking cessation should be a main component in the initial therapeutic approach to smokers with these interstitial lung diseases. In addition, smoking appears to be a risk factor for the development of idiopathic pulmonary fibrosis. [References: 98]

 

3468. Schultz TR.  Lin RJ.  Watzman HM.  Durning SM.  Hales R.  Woodson A.  Francis B.  Tyler L.  Napoli L.  Godinez RI. Weaning children from mechanical ventilation: a prospective randomized trial of protocol-directed versus physician-directed weaning. Respiratory Care.  46(8):772-82, 2001 Aug.

Abstract

OBJECTIVE: Compare outcomes between physician-directed and protocol-directed weaning from mechanical ventilation in pediatric patients. DESIGN: Prospective-randomized. SETTING: Pediatric and cardiac intensive care units in a 307-bed tertiary referral hospital for children. INTERVENTIONS: The control group (physician-directed) was weaned according to individual physician order for reduction in minute ventilation, positive end-expiratory pressure, and ordered oxygen saturation parameters for reduction in fraction of inspired oxygen (F(IO)(2)). The study group (protocol-directed) was weaned according to a predetermined algorithm developed for the purpose of this investigation. METHODS: The study enrolled 223 patients (116 physician-directed, 107 protocol-directed). All patients were monitored for hemodynamics, ventilator parameters, arterial blood gas values when available, oxygen saturation, weaning time, pre-weaning time, extubation time, and time on F(IO)(2) > or = 0.40. We also monitored the incidence of reintubation, subglottic stenosis, tracheitis, and pneumonia. The protocol-directed group had additional measurements of actual versus predicted minute volume, comparisons of respiratory rate (actual versus predicted for age), and presence of spontaneous breathing effort for 10 consecutive minutes. Data analysis was done according to intent to treat. RESULTS: There was no significant difference in 12-hour and 24-hour pediatric risk of mortality (PRISM III) scores between groups. The protocol-directed group overall had shorter total ventilation time, weaning time, pre-weaning time, time to extubation, and time on F(IO)(2) >0.40, although after stratification for respiratory diagnosis, only the difference in weaning time remained significant. There was no difference in the incidence of reintubation, new-onset tracheitis, subglottic stenosis, or pneumonia. CONCLUSIONS: Protocol-directed weaning resulted in a shorter weaning time than physician-directed weaning in these pediatric patients.

 

3469. Shann F. Uses of error: the wrong research costs lives. Lancet.  357(9269):1691, 2001 May 26.

 

3470. Skerrett SJ.  Park DR. Anti-inflammatory treatment of acute and chronic pneumonia. Seminars in Respiratory Infections.  16(1):76-84, 2001 Mar.

Abstract

The inflammatory response to infection is necessary for host defense but can contribute to the systemic toxicity and lung injury that may result from pneumonia. In some settings, adjunctive treatment of lower respiratory infections with anti-inflammatory agents can reduce morbidity. Corticosteroids have a well-documented role in the management of Pneumocystis carinii pneumonia complicating human immunodeficiency virus (HIV) infection. Corticosteroids also were found to reduce systemic symptoms of tuberculosis in a number of older studies, but their role as adjuncts to contemporary antimicrobial therapy are less clear. Corticosteroids also may be effective under some circumstances in the treatment of inflammatory sequelae of respiratory tract infection, such as tuberculous pleurisy, bronchiolitis obliterans organizing pneumonia, or prolonged acute respiratory distress syndrome. Nonsteroidal anti-inflammatory drugs may have limited applications in the modulation of chronic airway inflammation. Strategies targeting specific cytokines have not been effective to date, but remain active areas of investigation.

 

3471. Sleijfer S Bleomycin-induced pneumonitis. [Review] [96 refs] Chest.  120(2):617-24, 2001 Aug.

Abstract

  The cytotoxic agent bleomycin is feared for its induction of sometimes fatal pulmonary toxicity, also known as bleomycin-induced pneumonitis (BIP). The central event in the development of BIP is endothelial damage of the lung vasculature due to bleomycin-induced cytokines and free radicals. Ultimately, BIP can progress in lung fibrosis. The diagnosis is established by a combination of clinical symptoms, radiographic alterations, and pulmonary function test results, while other disorders resembling BIP have to be excluded. Pulmonary function assessments most suitable for detecting BIP are those reflecting lung volumes. The widely used transfer capacity of the lungs for carbon monoxide appeared recently not to be specific when bleomycin is used in a polychemotherapeutic regimen. There are no proven effective treatments for BIP in humans, although corticosteroids are widely applied. When patients survive BIP, they almost always recover completely with normalization of radiographic and pulmonary function abnormalities. This review focuses on BIP, especially on the pathogenesis, risk factors, and its detection. [References: 96]

 

3472. Smego RA Jr.  Nagar S.  Maloba B.  Popara M. A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia. Archives of Internal Medicine.  161(12):1529-33, 2001 Jun 25.

Abstract

OBJECTIVE: To determine the relative efficacies of alternative antipneumocystis agents in human immunodeficiency virus (HIV)-infected patients with Pneumocystis carinii pneumonia unresponsive to primary drug treatment with a combination product of trimethoprim and sulfamethoxazole or parenteral pentamidine. METHODS: Meta-analysis of 27 published clinical drug trials, case series, and case reports involving P carinii pneumonia. Data extracted included underlying disease, primary antipneumocystis treatment, days of failed primary treatment, salvage regimen, use of systemic corticosteroids and antiretroviral drugs, and clinical outcome. RESULTS: In 497 patients with microbiologically confirmed P carinii pneumonia (456 with HIV or acquired immunodeficiency syndrome), initial antipneumocystis treatment failed and they therefore required alternative drug therapy. Failed regimens included trimethoprim-sulfamethoxazole (160 patients), intravenous pentamidine (63 patients), trimethoprim-sulfamethoxazole and/or pentamidine (258 patients), aerosolized pentamidine (6 patients), atovaquone (3 patients), dapsone (3 patients), a combination product of trimethoprim and dapsone (2 patients), and trimethoprim-sulfamethoxazole followed by a combination of clindamycin and primaquine phosphate (2 patients). Efficacies of salvage regimens were as follows: clindamycin-primaquine (42 to 44 [88%-92%] of 48 patients; P<10(-8)), atovaquone (4 [80%] of 5), eflornithine hydrochloride (40 [57%] of 70; P<.01), trimethoprim-sulfamethoxazole (27 [53%] of 51; P<.08), pentamidine (64 [39%] of 164), and trimetrexate (47 [30%] of 159). CONCLUSION: The combination of clindamycin plus primaquine appears to be the most effective alternative treatment for patients with P carinii pneumonia who are unresponsive to conventional antipneumocystis agents.

 

3473.  Woske HJ.  Roding T.  Schulz I.  Lode H. Ventilator-associated pneumonia in a surgical intensive care unit: epidemiology, etiology and comparison of three bronchoscopic methods for microbiological specimen sampling. Critical Care (London).  5(3):167-73, 2001.

Abstract

BACKGROUND: Ventilator-associated bacterial pneumonia (VAP) is a important intensive care unit (ICU)-acquired infection in mechanically ventilated patients. Early and correct diagnosis of VAP is difficult but is an urgent challenge for an optimal antibiotic treatment. The aim of the study was to evaluate the incidence and microbiology of ventilator-associated pneumonia and to compare three quantitative bronchoscopic methods for diagnosis. METHODS: A prospective, open, epidemiological clinical study was performed in a surgical ICU. In a prospective study, 279 patients admitted to a 14-bed surgical ICU during a 1-year period were evaluated with regard to VAP. Three quantitative culture bronchoscopic techniques for identifying the etiological agent were compared [bronchoalveolar lavage (BAL), protected specimen brush (PSB) and bronchoscopic tracheobronchial secretion (TBS)]. RESULTS: Among 103 long-term ventilated patients, 49 (48%) developed one or more VAPs (a total of 60 VAPs). The incidence was 24 VAPs per 100 ventilated patients or 23 VAPs per 1000 ventilator days. BAL, PSB and TBS with quantitative measurements were equivalent in identifying the bacterial etiology. The VAP was caused predominantly by Staphylococcus aureus in 38% of cases, followed by Pseudomonas aeruginosa in 10%, Haemophilus influenzae in 10% and Klebsiella sp. in 9%. We did not find an increased mortality rate in patients undergoing long-term ventilation who acquired VAP in comparison with patients without VAP. CONCLUSION: For the identification of the microbiological etiology of VAP, one of three available bronchoscopic methods analysed by quantitative measurements is sufficient. In our study, quantitative bronchoscopic tracheal secretion analysis was very promising. Before accepting this method as a standard technique, other studies will have to confirm our results.

 

3474. Yamamoto T.  Tanida T.  Ueta E.  Kimura T.  Doi S.  Osaki T.Pulmonary infiltration with eosinophilia (PIE) syndrome induced by antibiotics, PIPC and TFLX during cancer treatment.Oral Oncology.  37(5):471-5, 2001 Jul.

Abstract

Drugs induce a variety of pulmonary diseases including pulmonary infiltration with eosinophilia (PIE) syndrome. We report a case of PIE syndrome which was observed after neck dissection. An 83-year-old male patient attended our clinic complaining of upper neck swelling and was diagnosed as advanced lymph node metastasis related to previously resected oral carcinoma and underwent neck dissection. Despite administration of antibiotics (piperacillin sodium, PIPC; and tosufloxacin tosilate, TFLX), fever and an elevation of the c-reactive protein (CRP) level with neutrophilia appeared, and an infiltration shadow was observed in the right lower pulmonary field. With the suspicion of pneumonia, the antibiotics were exchanged for panipenem/betamipron. However, the pulmonary infiltration spread widely, CRP increased to 12.9 mg/dl and severe eosinophilia (23%) was observed a few days after changing the antibiotics. PIE syndrome was suspected, and the patient underwent steroid mini-pulse therapy consisting of methylprednisolone sodium succinate (500 mg) and prednisolone (60 mg). After steroid therapy, the pulmonary condition largely improved. However, about 2 weeks after the start of steroid administration, a fever and a further elevation of CRP were observed with an increase of beta-D-glucan in serum. Roentgenography revealed diffuse infiltration shadows throughout the lungs, and the patient died about 3 weeks after the onset from respiratory distress. In vitro, blastogenesis of patient's peripheral blood lymphocytes was strongly enhanced by PIPC and TFLX, and they generated a large amount of interleukin-5 in the presence of PIPC or TFLX. The clinical course and laboratory examination results revealed that PIE syndrome may have been induced by PIPC and TFLX and that PIE syndrome should be suspected in treatment of carcinomas when dyspnea and pulmonary infiltration are complicated with eosinophilia.

 

3475. Zander DS.  Baz MA.  Visner GA.  Staples ED.  Donnelly WH.  Faro A.  Scornik JC. Analysis of early deaths after isolated lung transplantation. Chest.  120(1):225-32, 2001 Jul.

Abstract

STUDY OBJECTIVES: To determine the causes of death in patients dying within 30 days after lung transplantation at the University of Florida, to assess the importance of several diagnostic modalities for determining the causes of their decline, and to construct an algorithm for the evaluation of patients with severe respiratory compromise occurring early after lung transplantation. DESIGN: Retrospective review of medical records and pathology slides from all patients dying within 30 days after lung transplantation, and biopsy specimen diagnoses from all lung allograft recipients at the University of Florida. PATIENTS: Nine deaths occurred during the first 30 days after transplantation among 117 patients undergoing 123 isolated lung transplantation operations. RESULTS: Infections accounted for the greatest number of deaths (bacterial pneumonia, four patients; catheter-related bacteremia, one patient). Persistent pneumonia confirmed by biopsy specimen was usually accompanied by histologic manifestations of acute cellular rejection and was associated with poor patient outcome (ie, death or subsequent development of bronchiolitis obliterans syndrome). In two patients, antibody-mediated rejection either was the immediate cause of death (hyperacute rejection, one patient) or preceded a fatal case of pneumonia (accelerated antibody-mediated rejection, one patient). Other causes of death included hypoxic-ischemic encephalopathy secondary to an intraoperative cardiac arrest (one patient), pulmonary venous thrombosis with bacterial colonization of the thrombotic material (one patient), and ischemic reperfusion injury (one patient). In most patients, more than one type of diagnostic technique was needed to ascertain the cause of the catastrophic decline. CONCLUSIONS: The causes of early posttransplant death in our patient group included infections, antibody-mediated rejection, hypoxic-ischemic encephalopathy secondary to cardiac arrest, pulmonary venous thrombosis, and ischemic reperfusion injury. Because these processes often demonstrate overlapping clinical and morphologic features requiring multiple diagnostic techniques for resolution, a systematic multimodality approach to diagnosis is advantageous for determining the causes of decline in individual patients and for estimating the incidences of the different causes of early graft and patient loss in the lung transplant population.

 

3476. Zimmerman RK. Pneumococcal conjugate vaccine for young children. [see comments]. [Review] [17 refs] American Family Physician.  63(10):1991-8, 2001 May 15.

Abstract

Streptococcus pneumoniae causes approximately 3,300 cases of meningitis, 100,000 to 135,000 cases of pneumonia requiring hospitalization and 6 million cases of otitis media annually in the United States. Pneumococcal conjugate vaccine, approved in 2000 for use in the United States, was designed to cover the seven serotypes that account for about 80 percent of invasive infections in children younger than six years. This vaccine demonstrated 100 percent efficacy against invasive pneumococcal disease in the primary analysis of a large randomized, double-blind, controlled trial. In the follow-up analysis, performed eight months after the trial ended, efficacy against invasive disease was found to be 94 percent for the included serotypes. When initiated during infancy, the four-dose vaccination schedule is set at two, four, six and 12 to 15 months of age. The American Academy of Family Physicians recommends routine vaccination of infants, catch-up vaccination of children younger than 24 months and catch-up vaccination of children 24 to 59 months of age with high-risk medical conditions such as sickle cell disease and congenital heart disease. [References: 17]

 

3477. Zinkernagel AS.  Schaffner A.  Himmelman A. Photo quiz. Round pneumonia due to Streptococcus pneumoniae. Clinical Infectious Diseases.  32(8):1188, 1233-4, 2001 Apr 15.

 

 

Apr 02

4217.         AG, Colby TV, Wells AU. Nonspecific interstitial pneumonia and usual interstitial pneumonia: comparative appearances at and diagnostic accuracy of thin-section CT. Radiology 2001 Dec;221(3):600-5

 

PURPOSE: To compare the morphologic abnormalities on thin-section computed tomographic (CT) images in a group of patients with histopathologically confirmed nonspecific interstitial pneumonia (NSIP) or usual interstitial pneumonia (UIP) and a clinical presentation of idiopathic pulmonary fibrosis. MATERIALS AND METHODS: Thin-section CT imaging patterns and distribution of disease in 53 patients with histologic diagnoses of NSIP (n = 21) or UIP (n = 32) were quantified retrospectively and independently by four observers. The appearances of NSIP and UIP at CT were compared with univariate and multivariate techniques. RESULTS: The use of thin-section CT proved to have moderate sensitivity (70%), specificity (63%), and accuracy (66%) in the diagnosis of NSIP. An increased proportion of ground-glass attenuation was the cardinal feature of NSIP at CT (odds ratio: 1.04 for each 1% increase in the proportion of ground-glass attenuation). A histologic diagnosis of NSIP was most frequent (in 24 of 35 observations [69%]) when ground-glass attenuation predominated, and was more frequent with mixed (35 of 79 observations [44%]) than with predominantly reticular disease (25 of 98 [26%] observations, P < .005). Logistic regression analysis of the data indicated that misdiagnosis of UIP in patients with NSIP was associated with less ground-glass attenuation (P < .005) at CT and a subpleural disease distribution (P = .02), with the converse being true for UIP cases misdiagnosed as NSIP. CONCLUSION: In patients with a clinical presentation of idiopathic pulmonary fibrosis, the accuracy of thin-section CT in identifying NSIP is considerably higher than previously reported. At CT, NSIP is characterized by more ground-glass attenuation and a finer reticular pattern than is UIP. Nevertheless, considerable overlap in thin-section CT patterns exists between NSIP and UIP.

4218.         Ambrose HE, Ponce CA, Wakefield AE, Miller RF, Vargas SL. Distribution of Pneumocystis carinii f. sp. hominis types in the lung of a child dying of Pneumocystis pneumonia. Clin Infect Dis  2001 Nov 1;33(9):e100-2

 

Pneumocystis f. sp. hominis causes pneumonia in immunocompromised persons. In order to determine the types and distribution of P. carinii organisms within a single human lung, multiple samples were obtained from the lung of a child who died of P. carinii pneumonia. P. carinii DNA was detected in all of the samples and 2 different genotypes of P. carinii were identified, with uneven distribution in the lung, demonstrating that infection of the human lung is not necessarily clonal, and that different P. carinii genotypes may predominate in different areas of the lung.

4219.         Ambrose PG, Grasela DM, Grasela TH, Passarell J, Mayer HB, Pierce PF. Pharmacodynamics of fluoroquinolones against Streptococcus pneumoniae in patients with community-acquired respiratory tract infections. Antimicrob Agents Chemother  2001 Oct;45(10):2793-7

 

Fluoroquinolone antibiotic agents have demonstrated efficacy in the treatment of respiratory tract infections. This analysis was designed to examine the relationship between drug exposure, as measured by the free-drug area under the concentration-time curve at 24 h (AUC(24))/MIC ratio, and clinical and microbiological responses in patients with community-acquired respiratory tract infections involving Streptococcus pneumoniae. The study population included 58 adult patients (34 males, 24 females) who were enrolled in either of two phase III, randomized, multicenter, double-blind studies of levofloxacin versus gatifloxacin for the treatment of community-acquired pneumonia or acute exacerbation of chronic bronchitis. Clearance equations from previously published population pharmacokinetic models were used in conjunction with dose and adjusted for protein binding to estimate individual patient free-drug AUC(24)s. In vitro susceptibility was determined in a central laboratory by broth microdilution in accordance with NCCLS guidelines. Pharmacodynamic analyses were performed on data from all evaluable patients with documented S. pneumoniae infection using univariate and multivariable logistic regression; pharmacodynamic breakpoints were estimated using Classification and Regression Tree analysis. A statistically significant (P = 0.013) relationship between microbiological response and the free-drug AUC(24)/MIC ratio was detected. At a free-drug AUC(24)/MIC ratio of <33.7, the probability of a microbiological response was 64%, and at a free-drug AUC(24)/MIC ratio of >33.7, it was 100% (P < 0.01). These findings may provide a minimum target free-drug AUC(24)/MIC ratio for the treatment of infections involving S. pneumoniae with fluoroquinolone antibiotics and provide a paradigm for the selection of fluoroquinolones to be brought forward from drug discovery into clinical development and dose selection for clinical trials. Further, when target free-drug AUC(24)/MIC ratios are used in conjunction with stochastic modeling techniques, these findings may be used to support susceptibility breakpoints for fluoroquinolone antibiotics and S. pneumoniae.

4220.         Arozullah AM, Khuri SF, Henderson WG, Daley J; Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med  2001 Nov 20;135(10):847-57

 

BACKGROUND: Pneumonia is a common postoperative complication associated with substantial morbidity and mortality. OBJECTIVE: To develop and validate a preoperative risk index for predicting postoperative pneumonia. DESIGN: Prospective cohort study with outcome assessment based on chart review. SETTING: 100 Veterans Affairs Medical Centers performing major surgery. PATIENTS: The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery between 1 September 2023 and 31 August 2023 and was validated by using data on 155 266 patients undergoing surgery between 1 September 2023 and 31 August 1997. Patients with preoperative pneumonia, ventilator dependence, and pneumonia that developed after postoperative respiratory failure were excluded. MEASUREMENTS: Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia. RESULTS: A total of 2466 patients (1.5%) developed pneumonia, and the 30-day postoperative mortality rate was 21%. A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair, thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional status, weight loss, chronic obstructive pulmonary disease, general anesthesia, impaired sensorium, cerebral vascular accident, blood urea nitrogen level, transfusion, emergency surgery, long-term steroid use, smoking, and alcohol use. Patients were divided into five risk classes by using risk index scores. Pneumonia rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0% for those with 26 to 40 risk points, 9.4% for those with 41 to 55 risk points, and 15.3% for those with more than 55 risk points. The C-statistic was 0.805 for the development cohort and 0.817 for the validation cohort. CONCLUSIONS: The postoperative pneumonia risk index identifies patients at risk for postoperative pneumonia and may be useful in guiding perioperative respiratory care.

4221.         Astorga A, McCleskey FK, Huff WB, Niemeyer D, Lohman KL. Sensitive and specific method for rapid identification of Streptococcus pneumoniae using real-time fluorescence PCR. J Clin Microbiol  2001 Oct;39(10):3446-51

 

Molecular surveillance of pathogens has shown the need for rapid and dependable methods for the identification of organisms of clinical and epidemiological importance. As the leading cause of community-acquired pneumonia, Streptococcus pneumoniae was used as a model organism to develop and refine a real-time fluorescence PCR assay and enhanced DNA purification method. Seventy clinical isolates of S. pneumoniae, verified by latex agglutination, were screened against 26 negative control clinical isolates employing a TaqMan assay on a thermocycler (LightCycler). The probe, constructed from the lytA gene, correctly detected all S. pneumoniae genomes without cross-reaction to negative controls. The speed and ease of this approach will make it adaptable to identification of many bacterial pathogens and provide potential for adaptation to direct detection from patient specimens.

4222.         Bauer T, Ewig S, Marcos MA, Schultze-Werninghaus G, Torres A. Streptococcus pneumoniae in community-acquired pneumonia. How important is drug resistance?Med Clin North Am  2001 Nov;85(6):1367-79

 

Patients hospitalized with community-acquired pneumonia caused by S. pneumoniae strains with intermediate susceptibility to penicillin according to the conventional definition respond well to treatment with adequate doses of beta-lactam antibiotics. All studies currently available comparing mortality between patients with pneumonia caused by nonsusceptible and susceptible pneumococci agree that resistance of MIC 2 mg/L is not associated independently with an increased mortality. Most but not all studies could not prove an effect of microbial resistance on morbidity. There are data suggesting, however, that pneumococcal pneumonia caused by highly resistant strains (MIC > or = 4 mg/L) does affect the outcome. Pneumococcal resistance remains a matter of concern. Most reports show an increase not only of resistance rates, but also of the proportion of highly resistant strains. The selection of initial empirical antimicrobial treatment of patients with community-acquired pneumonia should be performed judiciously. Because the serum and pulmonary levels achieved with penicillin or related drugs are several times higher than the MICs of most strains, pneumonias caused by S. pneumoniae currently defined as not susceptible to penicillin should respond well to treatment with a beta-lactam antibiotic, used in optimal doses. Consequently, there is no reason fundamentally to change the current approach to initial empiric antimicrobial treatment of patients with community-acquired pneumonia. Nevertheless, increases in resistance to macrolides may prompt a limited use of these drugs in the outpatient setting. In any case, treatment failures may occur at higher levels of resistance, and a change in the definition of susceptibility categories toward higher cutoffs for S. pneumoniae seems to be reasonable.

4223.         Beck JM, Rosen MJ, Peavy HH. Pulmonary complications of HIV infection. Report of the Fourth NHLBI Workshop. Am J Respir Crit Care Med  2001 Dec 1;164(11):2120-6 No abstract.

4224.         Begemann M, Policar M. Pneumococcal vaccine failure in an HIV-infected patient with fatal pneumococcal sepsis and HCV-related cirrhosis. Mt Sinai J Med  2001 Nov;68(6):396-9

 

Pneumoccocal vaccination of HIV-positive individuals is recommended to prevent pneumococcal infection. We present a case of a 44-year-old HIV-infected male who came to the emergency room with bacterial pneumonia and sepsis. The patient also had a history of HBV and HCV infection. He expired in the emergency room and blood cultures were positive for Streptococcus pneumoniae. The autopsy confirmed the clinical diagnosis and, in addition, hepatitis C-related cirrhosis and splenic abnormalities. The patient had no history of opportunistic infections. His CD4 count 3 months prior to coming to the emergency room was 216 cells/microL with a viral load of 1,270 copies/mL. The patient had received Pneumovax two years before his death. The organism isolated from blood cultures was Streptococcus pneumoniae isotype 3, a strain included in Pneumovax. This is a case of pneumococcal vaccine failure with a fatal outcome in a person with an HIV infection and hepatitis C-related liver cirrhosis.

4225.         Bhansali A, Suresh V, Chaudhry D, Vaiphei K, Dash RJ, Kotwal N. Diabetes and rapidly advancing pneumonia. Postgrad Med J  2001 Nov;77(913):734-5, 740-1 No abstract.

4226.         Boe DM, Nelson S, Zhang P, Bagby GJ. Acute ethanol intoxication suppresses lung chemokine production following infection with Streptococcus pneumoniae. J Infect Dis 2001 Nov 1;184(9):1134-42

 

Alcohol intoxication impairs neutrophil function and increases host susceptibility to Streptococcus pneumoniae. In a rat model of pneumonia, the effects of acute intoxication were monitored for lung chemokine responses, neutrophil recruitment, and bactericidal activity. Alcohol delayed lung neutrophil recruitment, increased bacterial burden, and decreased survival. Before neutrophil recruitment, bronchoalveolar lavage (BAL) macrophage inflammatory protein-2 (MIP-2) and cytokine-induced neutrophil chemoattractant (CINC) were decreased by alcohol. This alcohol-induced effect was reversed at 6 h, when there were large numbers of neutrophils in control BAL fluid, compared with the alcohol-treated group. Cyclophosphamide-induced neutropenia decreased neutrophil recruitment, minimizing the effects of recruited neutrophils on chemokine levels, and extended the alcohol-induced chemokine suppression. MIP-2 and CINC mRNA contents also were suppressed by alcohol 4 and 6 h after infection. Thus, alcohol suppresses lung chemokine activity in response to S. pneumoniae, which is associated with delayed neutrophil delivery, elevated bacterial burden, and increased mortality.

4227.         Bond D, Vyas H. Viral pneumonia and hemoptysis. Crit Care Med  2001 Oct;29(10):2040-1 No abstract.

4228.         Campbell LA, Roberts S, Inoue S, Kong L, Kuo Cc CC. Evaluation of Chlamydia pneumoniae 43- and 53-kilodalton recombinant proteins for serodiagnosis by Western Blot. : Clin Diagn Lab Immunol  2001 Nov;8(6):1231-3

 

Chlamydia pneumoniae is a common cause of respiratory infection. It has also been shown to be associated with coronary heart disease. Two proteins that have been reported to be recognized frequently during human infection are proteins having molecular masses of 43 and 53 kDa. In order to develop a useful alternative serological test to the microimmunofluorescence (micro-IF) assay, recombinant 43-kDa and 53-kDa chlamydia-specific proteins were evaluated in dot blot and/or for comparison to the standard micro-IF test. Primers for amplification were derived from genome sequence information for two C. pneumoniae genes (CPn0809 and CPn0980) encoding 53-kDa proteins and four C. pneumoniae genes (CPn0562, CPn0927, CPn0928, and Cpn0929) encoding 43-kDa proteins of unknown function, which were Chlamydia specific and not found in Chlamydia trachomatis. The 53-kDa protein product of CPn0809 or the N-terminal 18-kDa portion had better specificity than any of the 43-kDa recombinants but was much less sensitive than micro-IF. In contrast, the 53-kDa protein encoded by CPn0980 was recognized by 11 of 12 (92%) acute-phase sera, 35 of 46 (76%) chronic sera, 0 of 12 micro-IF-negative sera (C. pneumoniae and C. trachomatis negative), and 1 of 12 (8%) C. pneumoniae negative, C. trachomatis positive sera. Thus, it appears that the 53-kDa protein encoded by CPn0980 has potential

use for serodiagnosis of C. pneumoniae infection.

 

4229.         Chen MZ, Hsueh PR, Lee LN, Yu CJ, Yang PC, Luh KT. Severe community-acquired pneumonia due to Acinetobacter  baumannii. Chest  2001 Oct;120(4):1072-7

 

STUDY OBJECTIVES: To investigate the clinical, epidemiologic, and microbiological characteristics of community-acquired pneumonia (CAP) due to Acinetobacter baumannii. METHODS: Retrospective chart and radiographic reviews of all patients who were admitted to National Taiwan University Hospital from January 1993 to August 1999, fulfilled the criteria for CAP, and had an isolate of A. baumannii from blood or pleural fluid at hospital admission. RESULTS: Thirteen patients (9 men and 4 women; age range, 37 to 85 years) met the criteria. Conditions associated with the infection included male gender, old age, alcoholism, malignancy, cerebrovascular disease, diabetes mellitus, renal disease, and liver cirrhosis. Eleven patients (85%) acquired the infection during the warmer months of April to October. Twelve patients (92%) had a fulminant course presenting with septic shock and respiratory failure, and 11 patients (85%) needed ventilator support and were treated in an ICU. Six patients (46%) had leukopenia. Lobar consolidations were found in 12 patients (92%), and pleural effusions were present in 4 patients (31%). All patients had positive blood culture results, two patients (15%) had positive pleural effusion culture findings, and nine patients (69%) positive sputum culture results. All the isolates were susceptible to imipenem, and most were susceptible to aminoglycosides, ceftazidime, ciprofloxacin, and extended-spectrum penicillins. Eight patients (62%) died. Four of the five survivors were initially treated with combination of a third-generation cephalosporin and an aminoglycoside. CONCLUSION: A. baumannii should be considered as a possible etiologic agent in community-acquired lobar pneumonia when (1) patients with a fulminant course present during the warmer and more humid months of the year, and (2) patients are younger alcoholics. A good sputum smear, defined as a Gram stain smear of an adequate sputum specimen that comes from the lower respiratory tract and contains > 25 leukocytes per high-power (100x) field on microscopic examination, can help early diagnosis and treatment. A combination of a third-generation cephalosporin and an aminoglycoside may be appropriate empirical therapy.

4230.         Clarkson AB Jr, Turkel-Parrella D, Williams JH, Chen LC, Gordon T, Merali S. Action of deferoxamine against  Pneumocystis carinii. Antimicrob Agents Chemother  2001 Dec;45(12):3560-5

 

We found earlier that deferoxamine (DFO), a drug used for treatment of iron overload, is active against a rat model of Pneumocystis carinii pneumonia (PCP). We had assumed a mode of action by deprivation of nutritional iron; however, data here show that DFO penetrates P. carinii, causing irreversible damage, thus indicating a different mode of action. Penetration was demonstrated by showing DFO uptake by high-pressure liquid chromatography analysis. By using calcein-AM as an indicator, exposure to DFO was shown to cause a reduction in P. carinii cytoplasmic free iron. Exposure to >or=100 microM DFO for >or=8 h in vitro caused growth to cease and cell numbers to decline over several days. This direct and irreversible damage to P. carinii led to the prediction that infrequent delivery of DFO to the lungs via an aerosol would be an effective treatment in the animal model of PCP. This prediction was confirmed by demonstrating that a once-a-week aerosol treatment of rats was 100% effective both as a prophylactic and as a curative treatment in a rat model of PCP.

4231.         Cross JT Jr, Campbell GD Jr. Therapy of nosocomial  pneumonia. Med Clin North Am  2001 Nov;85(6):1583-94

 

HAP remains a major cause of morbidity and mortality among hospitalized patients. Although early appropriate therapy results in improved outcomes, the cause of HAP frequently is not known at the time antimicrobial therapy is initiated. Most cases of HAP result from microaspiration of oropharyngeal secretions previously colonized with pathogenic bacteria, and the spectrum of potential pathogens is broad. Taking several factors into account can narrow this spectrum, including severity of illness, length of stay before the onset of pneumonia, and presence of risk factors for specific pathogens. When therapy has been initiated, follow-up of microbial studies and careful monitoring of the patient's course is important. The clinical improvement, even when therapy is appropriate, frequently takes days; therapy should not be changed for the first 2 to 3 days unless frank deterioration is noted. Patients who fail to respond or experience clinical deterioration should be re-examined carefully, and thought should be given to the possibility of other noninfectious processes.

4232.         Cunha BA. Oral or intravenous-to-oral antibiotic switch therapy for treating patients with community-acquired pneumonia. Am J Med. 2001 Oct 1;111(5):367-74. No abstract.

4233.         Cunha BA. Pneumonia in the  elderly. Clin Microbiol Infect  2001 Nov;7(11):581-8

 

Pneumonia is one of the commonest infections in elderly patients. The pathogens responsible for pneumonias in the elderly are the same as in younger adults. Because of associated cardiopulmonary disease and/or impaired host defenses, pneumonia in elderly patients is associated with increased mortality and morbidity compared to younger patients. The clinical importance of pneumonias in the elderly relates to age-dependent and pathologic changes in the immune system as well as the lungs. Pneumonias in the elderly may be classified, for clinical purposes, according to their location of acquisition, i.e. community-acquired pneumonias, nursing home-acquired pneumonias, or hospital-acquired pneumonias. The clinical presentation of pneumonias in the elderly may be difficult, due to pre-existing cardiopulmonary disease that mimics pneumonia. This review discusses the diagnostic and therapeutic approaches to elderly patients with pneumonia.

4234.         de la Fuente J, Nodar A, Sopena B, Martinez CA, Fernandez A. Rheumatic  pneumonia. Ann Rheum Dis  2001 Oct;60(10):990-1 No abstract.

4235.         Dominguez J, Gali N, Blanco S, Pedroso P, Prat C, Matas L, Ausina V. Urinary antigen test for pneumococcal pneumonia. Chest  2001 Nov;120(5):1748-50 No abstract.

4236.         Falade AG, Adegbola RA, Mulholland EK, Greenwood BM. Respiratory rate as a predictor of positive lung aspirates in young Gambian children with lobar pneumonia. Ann Trop Paediatr  2001 Dec;21(4):293-7

 

Clinical predictors of a positive bacterial culture from lung aspirate or blood culture were investigated in 90 children under 5 years of age with lobar pneumonia on whom both lung aspiration and blood culture were performed. Of the 66 children with a respiratory rate of > or = 50 breaths/min, 35 (53%) had positive bacterial lung aspirates compared with only five (21.7%) of 23 children with a respiratory rate of < 50 breaths/min (odds ratio [OR] 4.06, 95% confidence interval [CI] 1.24-15.46, p = 0.02). Of the 41 children with positive lung aspirates, 31 (76%) had negative blood cultures. In contrast with children with positive lung aspirates, there were no clinical predictors of a positive blood culture. A respiratory rate of > or = 50 breaths/min in children with radiological evidence of lobar pneumonia would support lung aspiration as a positive result is significantly more likely than in children with a lower respiratory rate.

4237.         Fireman E. Induced sputum: opening a new window to the lung. Sarcoidosis Vasc Diffuse Lung Dis  2001 Oct;18(3):263-71

The interest in sputum assessment as a non-invasive technique to retrieve cells and soluble material from the lung has increased and gained momentum during the last decade. As a marker of inflammation in airway diseases, induced sputum (IS) is a particularly promising procedure since it provides specific information on both the cellular and molecular constituents in inflammation. From 1950-1970, sputum cells had been examined on stained smears, with the procedure having been applied in both research and clinical settings. After having been recovered by spontaneous coughing, the cells were used to study lung cancer and respiratory infections and, later on, to diagnose Pneumocystis carinii pneumonia in patients infected with human immuno-deficiency virus (HIV). The method was widely improved upon by the induction of sputum with aerosol of hypertonic saline and then extended to become part of the assessment of airway inflammation in bronchial asthma and chronic obstructive pulmonary disease (COPD). It was recently shown that IS can be used to study interstitial lung diseases (ILD) and, more specifically, pneumoconiosis, sarcoidosis, non-granulomatous ILD and occupational lung diseases. In light of the fact that immunologic and functional bronchopulmonary abnormalities may be present in up to two-thirds of patients with Crohn's disease, we studied the use of IS in this condition as well. This review analyzes the value of IS and its present applications in pulmonary medicine.

4238.         Fischer S, Gill VJ, Kovacs J, Miele P, Keary J, Silcott V, Huang S, Borio L, Stock F, Fahle G, Brown D, Hahn B, Townley E, Lucey D, Masur H. The use of oral washes to diagnose Pneumocystis carinii pneumonia: a blinded prospective study using a polymerase chain reaction-based detection system. J Infect Dis  2001 Dec 1;184(11):1485-8

 

Pneumocystis carinii pneumonia (PCP) can be diagnosed by direct microscopic examination of induced sputum or by bronchoalveolar lavage (BAL). However, many institutions have little diagnostic success with induced sputum, and BAL is invasive and expensive. This prospective, blinded study assessed oral washes as a more convenient specimen than either sputum or BAL fluid and used a dissociation-enhanced lanthanide fluoroimmunoassay time-resolved fluorescent hybridization polymerase chain reaction (PCR) detection system that is feasible for clinical laboratories. The study assessed 175 oral washes, each paired with either an induced sputum that was positive for Pneumocystis or a BAL sample. The PCR test based on the Pneumocystis major surface glycoprotein primers had a sensitivity of 91% and a specificity of 94%, compared with a test based on mitochondrial large subunit rRNA primers, which had a sensitivity of 75% and a specificity of 96%. These results suggest that oral washes can provide a useful sample for diagnosis of PCP when a sensitive PCR detection system is used.

4239.         Fishman JA. Prevention of infection caused by Pneumocystis carinii in transplant recipients. Clin Infect Dis  2001 Oct 15;33(8):1397-405

 

Pneumocystis carinii remains an important pathogen in patients who undergo solid-organ and hematopoietic transplantation. Infection results from reactivation of latent infection and via de novo acquisition of infection from environmental sources. The risk of infection depends on the intensity and duration of immunosuppression and underlying immune deficits. The risk is greatest after lung transplants, in individuals with invasive cytomegalovirus disease, during intensive immunosuppression for allograft rejection, and during periods of neutropenia. Prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) prevents many opportunistic infections, including infection with P. carinii, Toxoplasma gondii, and community-acquired respiratory, gastrointestinal, and urinary tract pathogens. Intolerance of TMP-SMZ is common; desensitization is useful less often in transplant patients than in patients with AIDS. Alternative agents provide a narrower spectrum of protection than does TMP-SMZ and less adequate protection against Pneumocystis species. Clinically, the diagnosis of breakthrough Pneumocystis pneumonia often requires invasive procedures. Strategies for the prevention of Pneumocystis infection must be individualized on the basis of a stratification of risk for each patient.

4240.         Fleming CA, Balaguera HU, Craven DE. Risk factors for nosocomial pneumonia. Focus on prophylaxis. Med Clin North Am  2001 Nov;85(6):1545-63

 

Despite an increased understanding of the pathogenesis of NP and advances in diagnosis and treatment, the risk, cost, morbidity, and mortality of NP remain unacceptably high. This article has identified strategic areas for primary and secondary prophylaxis that are simple and cost-effective. Realizing that the pathogenesis of NP requires bacterial colonization and the subsequent entry of these bacteria into the lower respiratory tree helps highlight the role of cross-infection and the importance of standard infection control procedures. Similarly the role of sedation and devices as risk factors can be reduced by minimizing the duration and intensity of sedation and length of exposure to invasive devices. Additional low-cost interventions that have been shown to be effective in preventing NP are the positioning of patients in a semirecumbent position and the appropriate use of enteral feeding, antibiotics, and selected medical devices. Prophylaxis of NP and VAP is carried out best by a multidisciplinary management team comprised of physicians (critical care, pulmonary medicine, infectious diseases, and primary care), critical care and infection control nurses, and respiratory therapists, even though this approach may result in decreased professional autonomy and freedom. This group should review the current guidelines, pathways, and standards for short-term and long-term prophylaxis of NP and VAP, then integrate them into and monitor their use for routine patient care. The risk factors and prophylaxis strategies for NP discussed in this article apply primarily to patients in acute care facilities, but also are relevant to alternative health care settings as well as the care of ill patients in ambulatory settings. The routine use of effective team policies for prophylaxis needs to be monitored by the Joint Commission for the Accreditation of Health Care or other agencies. Research to delineate the most effective and feasible strategies for prophylaxis NP has been compromised by insufficient funding and lack of adequate, randomized multicenter studies to enable generalizability of results. Effective strategies for prophylaxis have not been disseminated widely or implemented in hospitals. Successful short-term and long-term strategies for prophylaxis must be evaluated and implemented by a team of physicians, nurses, and respiratory therapists. More than 100 years ago, Sir William Osler warned health care providers, "Remember how much you don't know." The authors would add that clinicians have acquired significant knowledge about risk factors and prophylaxis of NP in the 1980s and 1990s, but prophylaxis as a theory rather than an action. If the tree has not been planted, the time is now.

 

4241.         Formica N, Yates M, Beers M, Carnie J, Hogg G, Ryan N, Tallis G. The impact of diagnosis by legionella urinary antigen test on the epidemiology and outcomes of Legionnaires' disease. Epidemiol Infect  2001 Oct;127(2):275-80

 

Legionnaires' disease is an uncommon but important cause of life-threatening community-acquired or nosocomial pneumonia. The urinary antigen enzyme immunoassay test, used in Victoria since 1995, now accounts for the majority of initial laboratory notifications (81% in 1999). We review the impact of the test on the disease epidemiology and the public health investigative process. We focus on the major subgroup of cases due to Legionella pneumophila serogroup 1, comparing delays until notification and mortality for urinary antigen detected cases with culture detected cases. The urinary antigen test facilitates a 5-day reduction for the delay between onset of illness and notification. We observed that there was minimal clinical heterogeneity of urinary antigen detected cases whether they were subsequently culture confirmed or not. We encourage clinician use of the urinary antigen test in cases of community-acquired pneumonia where Legionnaires' disease is a possible diagnosis, in conjunction with culture of clinical specimens.

4242.         Franzin L, Scolfaro C, Cabodi D, Valera M, Tovo PA. Legionella pneumophila pneumonia in a newborn after water birth: a new mode of transmission. Clin Infect Dis  2001 Nov 1;33(9):e103-4

 

We report a case of Legionella pneumophila pneumonia in a 7-day old neonate. Because the hospital water, and particularly the pool water for water birthing, was contaminated by L. pneumophila serogroup 1, the newborn was infected following prolonged delivery in contaminated water, perhaps by aspiration. This is the first case of nosocomial Legionella pneumonia in neonate after water birth.

4243.         Glazer CS, Cohen LB, Schwarz MI. Acute eosinophilic  pneumonia in AIDS. Chest  2001 Nov;120(5):1732-5

 

A 39-year-old man with AIDS presented with acute respiratory distress and diffuse bilateral infiltrates seen on a chest radiograph. Acute eosinophilic pneumonia (AEP) was diagnosed by thoracoscopic lung biopsy. There was no evidence of an infectious etiology, and the patient rapidly improved with corticosteroid therapy. Several of the idiopathic interstitial pneumonias have been reported in adult patients with AIDS. To our knowledge, this case represents the first tissue-confirmed case of AEP associated with adult AIDS.

4244.         Glezen WP. Maternal   vaccines. Prim Care  2001 Dec;28(4):791-806, vi-vii

 

Acute lower respiratory illness (LRI) is the leading cause of disease worldwide as measured by disability-adjusted life years. New strategies are necessary to decrease the disease burden that is largely borne by infants. Respiratory syncytial virus is the most important cause of LRI in infants. Lower respiratory illness can be prevented by endowing infants with high levels of neutralizing antibodies from mothers whose antibodies are boosted during pregnancy with a potent subunit vaccine. Another important cause of infant mortality is group B streptococcus sepsis in the neonatal period; maternal immunization with a group B conjugate vaccine could prevent this devastating infection.

4245.         Golledge CL, Riley TV. The efficacy of an antibiotic protocol for community-acquired  pneumonia. Med J Aust  2001 Oct 15;175(8):445-6; discussion 446-7 No abstract.

4246.         Gotfried MH. Epidemiology of clinically diagnosed community-acquired pneumonia in the primary care setting: results from the 1999-2000 respiratory surveillance program. Am J Med  2001 Dec 17;111 Suppl 9A:25S-29S; discussion 36S-38S

 

To evaluate the prevalence of typical pathogens, level of resistance, and risk factors associated with community-acquired pneumonia (CAP) in the outpatient primary care setting and define current antibiotic treatment for office-based CAP, the Respiratory Surveillance Program (RESP) recruited 1,200 primary care clinics during the 1999-2000 respiratory infection season. Participating community-based physicians submitted sputum samples from patients presenting with a community-acquired respiratory infection including community-acquired pneumonia (CAP). All patients were aged > or =18 years. Patient demographics and risk factors were collected. Physicians express-mailed the specimens to a central laboratory for identification and susceptibility testing. All isolates were tested against a select panel of antimicrobial agents that are used to treat CAP. Patients with CAP were diagnosed by the treating physicians. Chest radiographs were not required as part of the study. A total of 610 specimens were submitted from patients with CAP. A smoking history or reported history of chronic obstructive pulmonary disease were present in >50% of those diagnosed with CAP. The most common pathogens were, in order of prevalence, Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. During the study period, a variety of antibiotics were prescribed for the treatment of outpatient CAP. The top 3 prescribed antibiotics include levofloxacin (23%), clarithromycin (19%), and azithromycin (10%). Gatifloxacin, which was approved in December 1999 and therefore available for only part of the study, accounted for 4% of the prescriptions. Of S pneumoniae isolates, 8% demonstrated high-level resistance to penicillin (> or =2 microg/mL) and 33% were found resistant to macrolides and trimethoprim/sulfamethoxazole. All S pneumoniae isolates were sensitive to gatifloxacin, vancomycin, and levofloxacin. Other less common organisms isolated were staphylococci, streptococci, Enterobacteriaceae, Pseudomonas spp, and Acinetobacter spp. The choice of antibiotic to treat outpatient CAP varies from practice to practice and does not appear to be influenced by the patient's age, the patient's history of smoking, or comorbidity.

4247.         Gray GC, Witucki PJ, Gould MT, Bell SJ, Hiliopoulos KM, McKeehan JA, Fuller JM,Barrozo CP, Hudspeth MK, Smith TC, Ledbetter EK, Wallace MR. Randomized, placebo-controlled clinical trial of oral azithromycin prophylaxis against respiratory infections in a high-risk, young adult population. Clin Infect Dis  2001 Oct 1;33(7):983-9

 

Military Special Forces trainees undergo intense psychological and physical stressors that often lead to respiratory infection. During 1998-2000, 477 Navy Special Forces trainees were enrolled in a double-blind trial of oral azithromycin (1 g given weekly) plus a placebo injection, compared with benzathine penicillin G (1.2 million U) plus azithromycin placebo tablets. Among the 464 subjects with complete data, 44 developed acute respiratory infection (20 with pneumonia) during the 2 weeks of most intense training; of these subjects, 12 (27.3%) had evidence of Chlamydia pneumoniae infection and 7 (15.9%) had evidence of Mycoplasma pneumoniae infection. Trainees who received azithromycin were less likely than were trainees who received benzathine penicillin G to develop acute respiratory infection (risk ratio, 0.50; 95% confidence interval [CI], 0.28-0.92) and less likely at the end of training to report episodes of breathing difficulty (odds ratio [OR], 0.59; 95% CI, 0.34-1.01) or sore throat (OR, 0.66; 95% CI, 0.41-1.05). Compared with benzathine penicillin G prophylaxis, weekly oral azithromycin was superior in preventing respiratory infection in this population at transient high risk.

4248.         Gross PA. Vaccines for pneumonia and new  antiviral therapies. Med Clin North Am  2001 Nov;85(6):1531-44

 

Influenza and pneumococcal diseases are preventable to a large extent. The Health Care Financing Agency of Medicare and the Joint Commission on Accreditation of Healthcare Organizations have made prevention of these two diseases a top priority. Immunization should remain the primary tool for prevention. When influenza epidemics appear, practitioners should be aware that effective drugs are available to treat influenza A or B if given promptly after the onset of illness.

4249.         Gupta SK, Imperiale TF, Sarosi GA. Evaluation of the Winthrop-University Hospital criteria to identify Legionella pneumonia. Chest  2001 Oct;120(4):1064-71

STUDY OBJECTIVE: To measure the ability of a set of clinical parameters, the Winthrop-University Hospital (WUH) criteria, to identify Legionella pneumonia while discriminating against bacteremic pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia (CAP). DESIGN: Retrospective case-control study. SETTING: An urban county hospital and a tertiary-care Veterans Affairs hospital. PATIENTS: Thirty-seven patients with Legionella pneumonia (diagnosed by a positive result of a urinary Legionella antigen test) and 31 patients with bacteremic pneumococcal pneumonia. A subgroup of patients with all required laboratory criteria were studied further. RESULTS: The WUH criteria correctly identified 29 of 37 patients with Legionella pneumonia (sensitivity, 78%; 95% confidence interval [CI], 61 to 90%), while successfully excluding legionellosis in 20 of 31 patients with bacteremic pneumococcal pneumonia (specificity, 65%; 95% CI, 45 to 80%). The positive and negative predictive values, adjusted for a relative prevalence of 1:3 between Legionella and Streptococcus pneumoniae bacteremia, were 42% (95% CI, 25 to 61%) and 90% (95% CI, 74 to 97%), respectively. In the subgroup analysis, the WUH criteria were successful in identifying 20 of 23 patients with Legionella pneumonia (sensitivity, 87%; 95% CI, 65 to 97%), while excluding legionellosis in 9 of 18 patients with bacteremic pneumococcal pneumonia (specificity, 50%; 95% CI, 27 to 73%). The adjusted positive and negative predictive values for a 1:3 relative prevalence were 37% (95% CI, 20 to 59%) and 92% (95% CI, 62 to 98%), respectively. The predictive values were changed in the directions expected for an increased relative prevalence of 1:1. The areas under the receiver operating characteristic curves were 0.72 +/- 0.06 for the entire study group and 0.68 +/- 0.09 for the subgroup. CONCLUSIONS: Although the WUH criteria discriminated fairly well between cases (mean +/- SE) and control subjects, the sensitivity is not high enough to exclude legionellosis confidently. These results suggest that empiric therapy for Legionella pneumonia should be included in the initial antibiotic regimen for hospitalized patients with CAP.

4250.         Gupta SK, Sarosi GA. The role of atypical pathogens in community-acquired  pneumonia. Med Clin North Am  2001 Nov;85(6):1349-65, vii

The atypical pathogens in community-acquired pneumonia traditionally have included Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella spp. Recent studies documenting their epidemiology and clinical characteristics have shown that these organisms are indistinguishable from the pneumococcus. Furthermore, therapy no longer depends on the specific bacterial cause of community-acquired pneumonia. Etiologic diagnosis is still difficult, although new methods are becoming available. This article focuses on these issues and on why the term atypical is no longer meaningful.

4251.         Guthrie R. Community-acquired lower respiratory tract infections: etiology and treatment. Chest  2001 Dec;120(6):2021-34

 

The current therapy for community-acquired lower respiratory tract infections is often empiric, usually involving administration of a beta-lactam or macrolide. However, the increasing prevalence of antibiotic resistance in frequently isolated respiratory tract pathogens has complicated the antimicrobial selection process. This review will discuss the incidence of various respiratory pathogens, as well as update the clinician on the various antimicrobial alternatives available, with particular emphasis on the role of the newer fluoroquinolones in the treatment of acute exacerbations of chronic bronchitis and community-acquired pneumonia.

4252.         Ito I, Ishida T, Osawa M, Arita M, Hashimoto T, Hongo T, Mishima M. Culturally verified Mycoplasma pneumoniae pneumonia in Japan: a long-term observation from 1979-99. Epidemiol Infect  2001 Oct;127(2):365-7

 

We describe the prevalence of community-acquired M. pneumoniae pneumonia diagnosed by culture methods in a single institute in Japan from January 1979 to December 1999. Cultures were performed in 2971 pneumonia cases and yielded M. Pneumoniae in 508 cases. The epidemic peaks recurred regularly at 4-year intervals (1980, 84, 88 and 91-2). Although a large epidemic has not occurred since 1992, traces of epidemic periodicity have still persisted from 1992 to 1999 at 3-year intervals.

4253.         Knaus WA, Scheld WM. Antibiotics for severe chronic obstructive  pulmonary disease. Lancet  2001 Dec 15;358(9298):2013  No abstract.

4254.         Kovacs JA, Gill VJ, Meshnick S, Masur H. New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia. JAMA  2001 Nov 21;286(19):2450-60

 

Pneumocystis carinii has been recognized as a human pathogen for nearly 50 years. We present a case of P carinii infection that typifies clinical presentation in the era of the acquired immunodeficiency syndrome epidemic. The high incidence of P carinii pneumonia in persons infected with human immunodeficiency virus (HIV) has served to focus laboratory and clinical research efforts on better understanding the biology of the organism and on improving diagnosis, treatment, and prevention of this disease. Although inability to culture P carinii has hampered research efforts, molecular and immunologic approaches have led to the recognition that the organism represents a family of fungi with a very restricted host range and have allowed characterization of clinically relevant antigens and enzymes. Molecular epidemiologic studies have identified more than 50 strains of human-derived P carinii and have suggested that recently acquired infection, as opposed to reactivation of latent infection, may account for many cases of clinical disease. Diagnosis has been improved by the development of organism-specific monoclonal antibodies and, more recently, by polymerase chain reaction using multicopy gene targets, together with induced sputum or oral wash samples. Chemotherapeutic prophylaxis is very effective in preventing P carinii pneumonia; the combination of trimethoprim-sulfamethoxazole remains the first-line agent for both therapy and prophylaxis. Prophylaxis needs to be administered only during periods of high risk; in HIV-infected patients responding to effective antiretroviral therapies, prophylaxis no longer needs to be lifelong. Molecular studies have identified mutations in the target of sulfa drugs that appear to represent emerging resistance in P carinii. Resistance to atovaquone, a second-line agent, may also be developing.

4255.         Kutty G, Ma L, Kovacs JA. Characterization of the expression site of the major surface glycoprotein of human-derived Pneumocystis carinii. Mol Microbiol  2001 Oct;42(1):183-93

The major surface glycoprotein (MSG) of Pneumocystis carinii, a pathogen responsible for pulmonary infection in AIDS and other immunocompromised patients, is an abundant surface protein that potentially allows the organism to evade host defences by antigenic variation. MSG is encoded by a multicopy gene family; in two specific forms of rat-derived P. carinii, regulation of MSG expression uses a single expression site, termed the upstream conserved sequence (UCS), through two related but distinct mechanisms. In the current study, the UCS of the MSG from human-derived P. carinii was obtained using an RNA ligase-mediated rapid amplification of cDNA ends technique. Southern blot analysis demonstrated that the UCS was present in a single copy per genome, whereas multiple copies of the downstream MSG gene were present. Sequencing and restriction fragment length polymorphism analysis of polymerase chain reaction products amplified from pulmonary samples of patients with P. carinii pneumonia demonstrated that multiple MSG genes were expressed in a given host, and that different patterns of MSG expression were seen among different patients. Tandem repeats present in the single intron occurred with varying frequency in different patient isolates, potentially providing a new method for typing human isolates. Thus, human-derived P. carinii regulates MSG expression in a manner similar to P. carinii f. sp. carinii and, in immunosuppressed patients, in whom immune pressures that probably drive antigenic variation are functioning inadequately, P. carinii can express a broad repertoire of MSG variants.

4256.         Lynch DA. Nonspecific interstitial pneumonia: evolving concepts. Radiology  2001 Dec;221(3):583-4 No abstract.

4257.         Memish ZA, Oni GA, Djazmati W, Cunningham G, Mah MW. A randomized clinical trial to compare the effects of a heat and moisture exchanger with a heated humidifying system on the occurrence rate of ventilator-associated pneumonia. Am J Infect Control  2001 Oct;29(5):301-5

BACKGROUND: The purpose of this study was to compare the performance of heat and moisture exchanger filters with heated humidifying systems in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and bacterial colonization. METHOD: Two hundred and forty-three consecutive patients who required mechanical ventilation for 48 hours or more in the adult intensive care unit were randomized to either a heat and moisture exchanger (HME) or a heated humidifying breathing circuit. RESULTS: The VAP rate among the group with HME was 11.4%; the rate among the group with heated humidifying system (HHS) was 15.8%. The difference was not statistically significant. Approximately 68% of the patients in the HME group had no pathogen isolated compared with 50% of the patients in the HHS group. This difference was statistically significant (P =.006). However, the distribution of the pathogens among those patients who had the isolated pathogens was mostly identical in the 2 groups. CONCLUSION: Even though the study did not find HME to be significantly advantageous over the HHS, in as much as VAP rate is concerned, other advantages such as reduced nurses workload, reduced financial cost, and better safety made HME a more favorable device for use in our adult intensive care unit.

4258.         Meyer KC. The role of immunity in susceptibility to respiratory infection in the aging lung. Respir Physiol  2001 Oct;128(1):23-31

 

Respiratory tract infections, particularly pneumonia, are a leading cause of death in persons 65 years or older in both developed and developing countries. Because many attributes of immunity wane with advancing age, the elderly may be more susceptible to respiratory infections, even if they appear to be in good health. A decline in the ability of lymphoid tissues to mount an antigen-specific response (adaptive immunity) to specific microorganisms such as influenza virus or Streptococcus pneumoniae is thought to be an important factor in increasing susceptibility to respiratory tract infection with advancing age. However, abnormalities in innate immunity may also contribute to increased susceptibility to respiratory infections and have been poorly characterized in the elderly. Although changes in immune parameters such as T cell subsets and immunoglobulin concentrations have been observed in respiratory secretions from older healthy individuals compared to younger subjects, the significance of these changes for protective immunity in the lung is unknown. The incidence of pneumonia may be lessened by measures such as optimizing treatment of comorbid conditions, optimizing nutrition, and addressing swallowing disorders. The use of vaccines directed against the influenza virus and S. pneumoniae appears to have made an impact on the degree of morbidity and mortality, and perhaps, the incidence, of community-acquired pneumonia. However, better stimulation of specific immune responses with improved vaccines and more widespread use of these vaccines for protection of elderly individuals are needed.

 

4259.         Muehlstedt SG, Richardson CJ, West MA, Lyte M, Rodriguez JL. Cytokines and the pathogenesis of nosocomial  pneumonia. Surgery  2001 Oct;130(4):602-9; discussion 609-11

 

BACKGROUND: Nosocomial pneumonia (NP) in injured patients is a significant clinical problem. We hypothesize that the pathogenesis of NP in injured patients involves an imbalanced cytokine response within the alveolar airspace that may inhibit effector cell function. METHODS: Proinflammatory (IL-8) and anti-inflammatory (IL-10) levels were measured in bronchoalveolar lavage (BAL) fluid from multitrauma patients on admission, 24, 48, and 72 hours post-injury and following lipopolysaccharide (LPS) induction of alveolar cells. Patients were compared based on IL-8 levels and the development of NP. RESULTS: A high level of IL-8 on admission was associated with the development of NP. In addition, levels of IL-8 were significantly greater in NP-positive patients at all time points. The IL-10 levels decreased from admission values in NP-negative patients but increased in NP-positive patients. Furthermore, a high level of IL-10 ( > 120 pg/mL) at 72 hours post-injury was associated with the development of NP. Alveolar cells from NP-positive patients produced significantly more IL-10 in response to LPS than cells from NP-negative patients. CONCLUSIONS: The pathogenesis of NP in injured patients involves an early and severe IL-8 process within the lung followed by an exaggerated IL-10 response that may inhibit effector cell function.

4260.         Nascimento-Carvalho C M C: Physical signs in children with pneumonia. Indian Pediat 2001, 38(3), 307-8.(013231). July 1,  2001 No abstract.

4261.         Niederman MS. Guidelines for the management of community-acquired pneumonia. Current recommendations and antibiotic selection issues. Med Clin North Am  2001 Nov;85(6):1493-509

 

Numerous guidelines for CAP have been developed, and although each is different, many principles are common to all recommendations. A guideline should focus on a wide range of issues surrounding the delivery of care, including advice about when to admit patients to the hospital or ICU; which antibiotic regimens to select for specific patient populations; which pathogens to target in empiric therapy; which diagnostic tests to order; how to assess the importance of specific causative pathogens, such as drug-resistant pneumococci, atypical pathogens, and gram-negative pathogens; how to evaluate the response to therapy and when to switch responding patients to oral therapy; and how to prevent CAP effectively through appropriate use of immunization against pneumococcus and influenza. Currently, many new antibiotic choices have emerged in the macrolide, quinolone, beta-lactam, ketolide, and oxazolidinone classes, and specific issues surrounding selection of these agents must be considered. All of the available data can be synthesized into a disease management guideline, and current therapy in the United States generally is consistent with existing recommendations. This consistency not only has led to more uniformity in patient care, but also has led to measurable benefits in patient outcomes, including reduced mortality for hospitalized patients with CAP. Guidelines not only are a useful tool for managing patients with CAP, but also they serve the purpose of defining current issues in patient care and stimulating the search for new tools and management approaches for this important clinical problem.

4262.         Oz HS, Hughes WT, Varilek G. Provocative effects of the immunosuppressants rapamycin, tacrolimus, and dexamethasone on pneumonitis in contrast to the anti- pneumonitis effects of mycophenolate mofetil. Transplantation  2001 Oct 27;72(8):1464-5 No abstract.

4263.         Padovan CS, Pfister HW, Bense S, Fingerle V, Abele-Horn M. Detection of Mycoplasma pneumoniae DNA in cerebrospinal fluid of a patient with M. pneumoniae infection-"associated" stroke. Clin Infect Dis  2001 Nov 15;33(10):E119-21

 

A 36-year-old woman presented with an acute ischemic stroke and a concomitant Mycoplasma pneumoniae infection that had been proven clinically, bacteriologically, and serologically. M. pneumoniae DNA was demonstrated in cerebrospinal fluid by positive nested polymerase chain reaction, and intrathecal antibody production was also detected. Contrary to previous reports about M. pneumoniae-associated stroke, most thrombostatic abnormalities in this patient occurred after stroke onset. Although the cause of stroke remains unclear in this patient, central nervous system invasion of M. pneumoniae DNA has to be considered a possible cause in rare cases of cerebral ischemia.

4264.         Pal S, Theodor I, Peterson EM, de la Maza LM. Immunization with the Chlamydia trachomatis mouse pneumonitis major outer membrane protein can elicit a protective immune response against a genital challenge. Infect Immun  2001 Oct;69(10):6240-7

 

Infertility, ectopic pregnancy, and chronic abdominal pain are frequent complications of genital infections with Chlamydia trachomatis. In an attempt to produce a vaccine to protect against this pathogen we purified and refolded the C. trachomatis mouse pneumonitis (MoPn) major outer membrane protein (MOMP). This preparation, mixed with Freund's adjuvant using vortexing or sonication, was used to immunize BALB/c mice that were subsequently challenged in the upper genital tract. Vaginal cultures were taken on a weekly basis, and mice were mated 6 weeks after the challenge. Gels of the vortexed MOMP showed a predominant band with a molecular size of 62 kDa and weaker bands at 42 and 132 kDa, while the sonicated MOMP had a single band with a molecular size of 42 kDa. Following immunization with these two preparations, strong humoral and cell-mediated immune responses were detected in the mice inoculated with the vortexed MOMP. On the other hand, mice immunized with the sonicated MOMP had a strong humoral immune response but a relatively weak cell-mediated immune response, as determined by a T-cell lymphoproliferative assay and level of cytokine production by splenocytes. Vaginal cultures showed that the mice immunized with the vortexed MOMP were significantly protected, as determined by a decrease in the number of animals with positive cultures, the length of time the mice shed viable organisms, and the number of inclusion-forming units recovered per mouse. Animals immunized with the sonicated MOMP, on the other hand, showed a weaker level of protection based on the same three parameters. After mating, the number of fertile animals and number of embryos per mouse were significantly higher for the mice immunized with vortexed MOMP, but not for the mice immunized with sonicated MOMP, compared to those of the control groups. In conclusion, immunization with a purified and refolded preparation of the C. trachomatis MoPn MOMP confers a significant level of protection in mice against a genital challenge.

4265.         Penington GR. Neurological effects of Mycoplasma pneumoniae  infection. Med J Aust  2001 Oct 1;175(7):389-90  No abstract.

4266.         Philpot CR. The efficacy of an antibiotic protocol for  community-acquired pneumonia. Med J Aust  2001 Oct 15;175(8):446-7 No abstract.

4267.         Pierce AB, Hoy JF. Is the recommendation for pneumococcal vaccination of HIV patients evidence based? J Clin Virol  2001 Oct;22(3):255-61

BACKGROUND: both the current NHMRC guidelines of Australia and the USPHS/IDSA guidelines recommend pneumococcal vaccine be given to all patients with HIV infection despite a paucity of data to support these recommendations. OBJECTIVES: the aim of this study was to assess the incidence of invasive pneumococcal disease and use of pneumococcal vaccine in HIV-infected patients at The Alfred Hospital, Melbourne, Australia, and to review the evidence for the current recommendations. STUDY DESIGN: a case record review of all HIV-infected patients followed at The Alfred Hospital diagnosed with pneumonia between 1 June 1996 and 1 June 2024 was performed. Main outcome measures were the incidence of invasive pneumococcal disease and the proportion of these individuals who received pneumococcal vaccination. RESULTS: Invasive pneumococcal disease was a relatively infrequent event with an incidence of 1.9 per 1000 person years. This rate is lower than the 8.2 per 1000 person years reported for confirmed disease by CDC. Of the 34 patients with either definite invasive, presumptive or possible pneumococcal disease, 16 (47%) had received pneumococcal vaccine, seven of these within 5 years prior to the episode of pneumonia. In 15 cases, the vaccine was administered when the CD4 cell count was <500 per microl. CONCLUSION: lack of efficacy data, rarity of invasive disease plus evidence of infrequent administration delivered predominantly to those who are least likely to benefit, has prompted us to question the value of routinely vaccinating all our HIV-infected patients with pneumococcal vaccine. Review of the published literature provides conflicting data in support of the current recommendations for administration of pneumococcal vaccine in HIV patients. It may be more cost-effective to concentrate efforts on strategies to improve adherence to ARV therapy, as this has unequivocally been shown to be associated with a reduction in the incidence of pneumococcal disease.

4268.         Reddy JC, Katz PP, Goldman L, Wachter RM. A pneumonia practice guideline and a hospitalistt-based reorganization lead t equivalent efficiency gains. Am J Manag Care  2001 Dec;7(12):1142-8

 

OBJECTIVE: To compare the impact of a practice guideline for a common inpatient disorder with that of a hospitalist-based reorganization of an academic medical service. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: In July 1995 we introduced a clinical practice guideline for the treatment of community-acquired pneumonia at University of California San Francisco Moffitt-Long Hospital. Simultaneously, we implemented a structural change for half of the inpatient medical service, requiring earlier and more intensive faculty intervention, primarily by hospitalists. For 1 year, we studied the effect of these interventions on hospital costs, length of stay, and resource use. RESULTS: As reported previously, the hospitalist-based intervention resulted in significant decreases in average adjusted cost ($7777 vs $7007, P = .05) and length of stay (4.9 days vs 4.3 days, P = .01) compared with both concurrent and historical controls. For patients with community-acquired pneumonia, a similar savings occurred when fiscal year 1996 was compared with fiscal year 1995 ($8164 vs $6282, P= .015; 5.0 vs 4.2 days, P= .04). However, the effect was identical for the hospitalist and nonhospitalist groups. The reduced length of stay was associated with a borderline significant reduction in readmission rates (from 4.8% to 0.7%, P = .055) and no change in mortality rates. CONCLUSIONS: In this study, a hospitalist-based reorganization improved efficiency, with its greatest impact on the care of patients with disorders not covered by a practice guideline. The introduction of a guideline for a common diagnosis improved efficiency on both hospitalist- and nonhospitalist-based services. For common diagnoses amenable to practice guidelines, successful implementation of and compliance with guidelines may be an alternative to major organizational change.

 

4269.         Rome L, Murali G, Lippmann M. Nonresolving pneumonia and mimics  of pneumonia. Med Clin North Am  2001 Nov;85(6):1511-30, xi

 

Physicians caring for patients with community-acquired pneumonia are often faced with the dilemma of how to approach a patient with slowly resolving or even nonresolving pneumonia. When the radiograph has failed to resolve by 50% in 2 weeks or completely in 4 weeks, the pneumonia should be considered to be nonresolving or slowly resolving. The causes of a nonresolving pneumonia and an approach to the work-up are presented.

4270.         Russell G. Community acquired pneumonia.Arch Dis Child  2001 Dec;85(6):445-6 No abstract.

4271.         Sarracco T, Cooper EC, Dratter V, Smith JJ, Frost KR; Trimethoprim-sulfamethoxazole (TMP-SMZ) dose escalation versus direct rechallenge for Pneumocystis Carinii pneumonia prophylaxis in human immunodeficiency virus-infected patients with previous adverse reaction to TMP-SMZ. J Infect Dis  2001 Oct 15;184(8):992-7

 

Trimethoprim-sulfamethoxazole (TMP-SMZ) is the most effective Pneumocystis carinii pneumonia (PCP) prophylactic agent, but adverse reactions are common among human immunodeficiency virus (HIV)-infected patients and limit its use. This randomized, double-blind controlled trial compared 2 methods of TMP-SMZ reintroduction, 6-day dose escalation and direct rechallenge, for PCP prophylaxis in HIV-infected patients who had experienced previous treatment-limiting reactions. The primary end point was the ability to take single-strength TMP-SMZ daily for 6 months. Seventy-five percent of the dose-escalation group and 57% of the direct-rechallenge group continued to receive daily single-strength TMP-SMZ for 6 months (P= .014). Among premature discontinuations, 58% of the dose-escalation group and 70% of the direct-rechallenge group were due to adverse reactions. None of these reactions was serious. This study provides evidence that it is possible to successfully reintroduce TMP-SMZ to a significant proportion of HIV-infected patients who have experienced mild-to-moderate treatment-limiting adverse reactions.

4272.         Skiest DJ, Kaplan P, Machala T, Boney L, Luby J. Clinical manifestations of influenza in HIV-infected  individuals. Int J STD AIDS  2001 Oct;12(10):646-50

 

Although influenza vaccination is recommended for individuals with HIV infection, there are no data indicating an increased incidence or severity of influenza in this population. We sought to describe the clinical manifestations and morbidity of influenza in HIV-infected patients. All cases of influenza occurring in HIV-infected individuals over 3 years at a large county hospital were reviewed. Forty-three cases of influenza were diagnosed. Most patients presented with typical signs and symptoms of influenza, including cough (90%), myalgias (64%), and fever (52%). Sore throat and headache occurred in less than half of patients. The mean CD4 cell count and HIV viral load in patients with influenza was 340 cells/mm(3) and 3.34 log copies/ml, respectively. No significant differences in CD4 counts or viral loads were noted in patients with pneumonia (n=7) compared with patients without pneumonia (n=36), P>0.5. Six patients were hospitalized. One patient each had encephalitis and renal failure, although the relationship to influenza was not clear. No new or unusual clinical manifestations were observed. The rate of pulmonary complications was similar to other studies in HIV-negative patients; however, the hospitalization rate was higher than commonly seen in HIV-negative individuals.

4273.         Stock F, Fahle G, Brown D, Hahn B, Townley E, Lucey D, Masur H. The use of oral washes to diagnose Pneumocystis carinii pneumonia: a blinded prospective study using a polymerase chain reaction-based detection system. J Infect Dis  2001 Dec 1;184(11):1485-8

 

Pneumocystis carinii pneumonia (PCP) can be diagnosed by direct microscopic examination of induced sputum or by bronchoalveolar lavage (BAL). However, many institutions have little diagnostic success with induced sputum, and BAL is invasive and expensive. This prospective, blinded study assessed oral washes as a more convenient specimen than either sputum or BAL fluid and used a dissociation-enhanced lanthanide fluoroimmunoassay time-resolved fluorescent hybridization polymerase chain reaction (PCR) detection system that is feasible for clinical laboratories. The study assessed 175 oral washes, each paired with either an induced sputum that was positive for Pneumocystis or a BAL sample. The PCR test based on the Pneumocystis major surface glycoprotein primers had a sensitivity of 91% and a specificity of 94%, compared with a test based on mitochondrial large subunit rRNA primers, which had a sensitivity of 75% and a specificity of 96%. These results suggest that oral washes can provide a useful sample for diagnosis of PCP when a sensitive PCR detection system is used.

4274.         Usha Rani N, Reddy V V R, Prem Kumar A, Vijay Kumar K V V, Ravindra Babu G, Babu Ram D: Clinical profile of Pneumocystis carinii pneumonia in HIV infected persons. Indian J Tuberc 2000, 47(2), 93-6.(013318) July 1, 2001.

 

Between Dec’97 and Nov’98, out of 120 patients infected with HIV, 23 cases of Pneumocystis carinii pneumonia (PCP) were found and their clinical profiles were studied at the department of TB and Chest Disease, Andhra Medical College, Visakhapatnam. The diagnosis of PCP was made using CDC criteria based on chest X-ray. It is concluded that PCP is not an uncommon complication in HIV infected individuals in this country. As many as 65% of PCP cases belonged to the economically productive age group of 21-30 years; 40% were truckers or manual laboureres; dry cough, dysponoea on exertion, low-grade fever were the most common presenting symptoms. In patients with initial SPO₂ less that 90% the degree of exercise induces oxygen  desaturation was more. The yield from induced sputum specimens stained by GMS was 50%. Almost 92% of the cases showed raised LDH level. Response rate to Cotrimozazole therapy was 74% and good drug tolerance was observe. Nearly 43% of the cases had coexistent tuberculosis, out of which 90% were having extra-pulmonary tuberculosis. 16 ref.

 

4275.         Wang GS, Yang KY, Perng RP. Life-threatening hypersensitivity pneumonitis induced by docetaxel (taxotere). Br J Cancer  2001 Nov 2;85(9):1247-50

 

4 patients with advanced non-small-cell lung cancer (NSCLC) treated with docetaxel developed life-threatening pneumonitis requiring mechanical ventilation. Docetaxel (30-60 mg x m(-2), according to a different protocol) was infused within one hour with standard premedications. One patient's pneumonitis occurred 5 days after the first dose of docetaxel, and that of the other 3 between the 2nd and 6th cycles. Based on the clinical course, radiological findings of an interstitial pneumonitis, and exclusion of other possible resultant causes, including metastatic cancer, radiation pulmonary injury, infection, or connective tissue disease, hypersensitivity pneumonitis was diagnosed. The patients were treated with hydrocortisone at 1200 mg per day or methylprednisolone at 240 mg per day. Although 3 of the 4 had a partial improvement in lung oxygenation, all patients' conditions of hypersensitivity pneumonitis persisted and were complicated by other events, such as hospital-acquired infection and tension pneumothorax. The presence of this unusual hypersensitivity pneumonitis, which was so severe as to be life-threatening and refractory to high-dose corticosteroid therapy, should be taken into account during docetaxel treatment. Copyright 2001 Cancer Research Campaign

4276.         Waterer GW, Wunderink RG. Controversies in the diagnosis of ventilator-acquired  pneumonia. Med Clin North Am  2001 Nov;85(6):1565-81

 

The appropriate investigation of patients with suspected VAP is controversial. Because it is unlikely that any new diagnostic technique will become available in the near future with better performance characteristics than those currently available, physicians need to tailor their diagnostic approach depending on individual patients and clinical scenarios. The most crucial factor in deciding which diagnostic approach to take is the influence that any test result would have on management. If preliminary screening tests, including Gram stain, are used to determine whether to start antibiotic therapy, invasive diagnostic techniques have an advantage over ETA. Quantitative cultures of respiratory specimens have a higher specificity than qualitative cultures and should be used if there is any possibility that a negative culture result would result in the discontinuation of antibiotic therapy. Physicians are caught between the need to treat VAP promptly with appropriate antibiotics and the undeniable problems of multidrug-resistant bacteria and their association with inappropriate antibiotic use. When clinically possible, a diagnostic strategy should be chosen that maximizes the possibility of limiting broad-spectrum antibiotic use. To give physicians greater comfort in the ability to withhold or discontinue antibiotics safely, further research is needed into the appropriate diagnostic strategies in different clinical settings that make this possible. The studies by Fagon et al and Singh et al are important steps in this direction.

 

4277.         Welsh DA, Mason CM. Host defense in respiratory infections. Med Clin North Am  2001 Nov;85(6):1329-47

 

Respiratory defenses against infection involve a diverse and complex system. Mechanical barriers limit exposure of the respiratory tract to potential pathogenic organisms, whereas the mucociliary apparatus and cough reflexes work to expel any microbes that may bypass the initial defenses. When microorganisms have gained entry to the lower respiratory tract, the alveolar macrophage and recruited phagocytes may eliminate the culprits before active infection can be established. Only after the failure of the innate immune defenses is a specific immune response mounted. Examination of clinical defects in host defense allows one to understand the importance of the multitude of components of the lung's immune defense system.

4278.         Wunderink RG, Waterer GW. Severe community-acquired pneumonia: the need to customize empiric therapy. Chest  2001 Oct;120(4):1053-5 No abstract.

4279.         Yang PS, Lee KS, Han J, Kim EA, Kim TS, Choo IW. Focal organizing pneumonia: CT and pathologic findings. J Korean Med Sci  2001 Oct;16(5):573-8

 

The purpose of this study was to describe the CT findings of focal organizing pneumonia and to compare the findings with pathology. CT findings of histologically proven focal organizing pneumonias in 26 consecutive patients were analyzed. In 17 patients who had undergone surgical resections, the findings were correlated with pathology. Focal organizing pneumonias appeared as a nodule (n= 13) or a mass (n=13), ranging from 9 mm to 66 mm in diameter. Ground-glass opacity was seen in 6/13 (46%) nodules and 6.5/13 (50%) masses (k=.48) with an extent ranging from 5% to 75% (mean, 16%). In 4/26 (15%) patients, the extent was more than 50% of the lesion. They showed smooth (n=4), lobulated (n=8), spiculated (n=1), or lobulated and spiculated margin (n=13). On correlative analysis, nodule or mass on CT consisted histologically of intraalveolar exudate or microabscess, chronic inflammatory cell infiltration, fibrotic nodules, and polypoid granulation tissue in the alveolar or bronchiolar spaces. Ground-glass opacity consisted of interstitial fibrosis and chronic inflammatory cell infiltration and intraalveolar polypoid granulation tissue. Focal organizing pneumonia may simulate a lung cancer with variable appearances on CT and the findings reflect underlying histopathology of the disease.

4280.         Zisman DA, McCune WJ, Tino G, Lynch JP 3rd. Drug-induced pneumonitis: the role of methotrexate. Sarcoidosis Vasc Diffuse Lung Dis  2001 Oct;18(3):243-52

 

Methotrexate (MTX) is a folate antagonist used in several chronic inflammatory and neoplastic conditions. Pulmonary toxicity occurs in 0.5% to 14% of patients receiving low-dose MTX. Manifestations of pulmonary toxicity are protean and include parenchymal inflammation, pneumonia, airway hyperreactivity, air trapping and possibly neoplasm. We performed an exhaustive review of the English literature and identified 189 cases of methotrexate-induced pneumonitis (MIP). Rheumatoid arthritis (RA) was the most frequent underlying disease. In most patients, symptoms present subacutely with progression over several weeks. Most patients present with dyspnea, dry cough, fever, and bibasilar crackles. Peripheral eosinophilia has been cited in one third of cases. The chest radiograph may be normal, but more commonly reveals bilateral interstitial or mixed, interstitial and alveolar infiltrates with a predilection for the bases. Chest computed tomography (CT) scans demonstrate ground-glass opacities, interstitial infiltrates, septal lines or widespread consolidation. Pulmonary function studies reveal a restrictive ventilatory defect and/or impaired gas exchange. Bronchoalveolar lavage (BAL) may be helpful in ruling out an infectious etiology and in supporting the diagnosis of MIP. Cellular interstitial infiltrates, granulomas, fibrosis, atypical epithelial cells, and diffuse alveolar damage (DAD) are the main histologic features. Once MIP is suspected, the MTX should be withdrawn. Corticosteroids may accelerate resolution and are recommended in severe or fulminant cases. The prognosis of MIP is usually favorable, but occasionally the outcome may be fatal.

 

 

July 02

 

4823.         Abraham WM.  Tryptase: potential role in airway inflammation and remodeling. Am J Physiol Lung Cell Mol Physiol. 2002 Feb;282(2):L193-6. Review. 

             No Abstract

4824.         Anuntaseree W, Patrapinyokul S, Suntornlohanakul S, Thongsuksai P.  Congenital bronchoesophageal fistula and tracheoesophageal fistula with esophageal atresia. Pediatr Pulmonol. 2002 Feb;33(2):162-4.

 

A case of initial esophageal atresia and tracheoesophageal fistula in a female newborn, later complicated by pneumonia and a second bronchoesophageal fistula, is reported. She was treated surgically by closure of the tracheoesophageal fistula and by end-to-end esophago-esophageal anastomosis. An esophagram at 1 month of age was normal. Three months later she developed severe, persistent right lower lobe pneumonia that required intensive antibiotic therapy and respiratory support. Esophagography was repeated and revealed a second fistula between the right main-stem bronchus and the lower esophagus. The bronchoesophageal fistula was repaired, and a right lower lobectomy was performed. Postoperative recovery was uncomplicated. Histologic examination indicated that the fistula was congenital in origin. To the best of our knowledge, this is the first reported case of a congenital bronchoesophageal fistula coexisting with a tracheoesophageal fistula and esophageal atresia. Copyright 2002 Wiley-Liss, Inc.

 

4825.         Arno PS, Gourevitch MN, Drucker E, Fang J, Goldberg C, Memmott M, Bonuck K, Deb N, Schoenbaum E.  Analysis of a population-based Pneumocystis carinii pneumonia index as an outcome measure of access and quality of care for the treatment of HIV disease. Am J Public Health. 2002 Mar;92(3):395-8.

 

OBJECTIVES: A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. METHODS: A zip code-level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). RESULTS: In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index =.05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village =.02532 vs Central Harlem =.08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island =.14035; northern Manhattan =.08756).  CONCLUSIONS: The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery.

 

4826.         Bader TR, Semelka RC, Pedro MS, Armao DM, Brown MA, Molina PL. Magnetic resonance imaging of pulmonary parenchymal disease using a modified breath-hold 3D gradient-echo technique: initial observations. J Magn Reson Imaging. 2002 Jan;15(1):31-8. No abstract.

 

4827.         Ball P, Baquero F, Cars O, File T, Garau J, Klugman K, Low DE, Rubinstein E, Wise R.  Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence. J Antimicrob Chemother. 2002 Jan;49(1):31-40. Review. No abstract.

 

4828.         Baughman RP, Henderson RF, Whitsett J, Gunther KL, Keeton DA, Waide JJ, Zaccardelli DS, Pattishall EN, Rashkin MC.  Surfactant replacement for ventilator-associated pneumonia: a preliminary report. Respiration. 2002;69(1):57-62.

 

BACKGROUND: Surfactant abnormalities have been described in bacterial pneumonia. OBJECTIVE: To determine the safety and effect of exogenous surfactant replacement in patients with ventilator-associated pneumonia (VAP). METHODS:

Patients with VAP were randomized in a double-blind study to receive either an artificial surfactant (Exosurf) consisting mostly of disaturated phospholipids (DSPL) or saline via a continuous nebulizer system for 5 days. Patients underwent bronchoscopy and bronchoalveolar lavage (BAL) prior to and after 4 days of therapy. RESULTS: Twenty-two patients were randomized, with 8 receiving Exosurf. There was no detected difference in outcome between the saline- and Exosurf-treated patients in terms of days on ventilator, 30-day or hospital mortality. At the follow-up lavage, the patients treated with Exosurf had a significant rise in the level of DSPL (p < 0.05), while the saline group did not, suggesting delivery of drug. Also at the follow-up lavage, the percentage of neutrophils in the BAL fell in the Exosurf patients (p < 0.01), but not in the saline group. CONCLUSION: Exogenous surfactant replacement given to patients with VAP increased the amount of DSPL retrieved by BAL. This treatment was associated with a fall in the neutrophil response to pneumonia. Copyright 2002 S. Karger AG, Basel

4829.         Booton R, Jacob BK.  Images in clinical medicine. Bronchoalveolar-cell  carcinoma. N Engl J Med. 2002 Jan 10;346(2):107. No abstract available.

4830.         Brock-Utne JG.  Is cricoid pressure necessary? Paediatr Anaesth. 2002 Jan;12(1):1-4.  No Abstract

4831.         Byington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO, Kaplan S, Carroll KC, Daly JA, Christenson JC, Samore MH.  An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002 Feb 15;34(4):434-40.

 

We investigated the increasing incidence of pediatric empyema during the 1990s at Primary Children's Medical Center in Salt Lake City. Of 540 children hospitalized with community-acquired bacterial pneumonia (CAP) who were discharged from 1 July 2023 through 1 July 1999, 153 (28.3%) had empyema. The annual population incidence of empyema increased during the study period from 1 to 5 cases per 100,000 population aged <19 years. Streptococcus pneumoniae was identified as the most common cause of CAP with or without empyema; serotype 1 accounted for 50% of the cases of pneumococcal empyema. Patients with empyema were more likely to be >3 years old, to have > or =7 days of fever, to have varicella, and to have received antibiotics and ibuprofen before admission to the hospital, compared with patients without empyema (P<.0001 for each factor). The increasing incidence of empyema was associated with infection due to S. pneumoniae serotype 1, outpatient treatment with certain antibiotics, ibuprofen use, and varicella.

 

4832.         Cortes G, Alvarez D, Saus C, Alberti S.  Role of lung epithelial cells in defense against Klebsiella pneumoniae pneumonia. Infect Immun. 2002 Mar;70(3):1075-80.

        The airway epithelium represents a primary site for the entry of pathogenic bacteria into the lungs. It has been suggested for many respiratory pathogens, including Klebsiella pneumoniae, that adhesion and invasion of the lung epithelial cells is an early stage of the pneumonia process. We observed that poorly encapsulated K. pneumoniae clinical isolates and an isogenic unencapsulated mutant invaded lung epithelial cells more efficiently than highly encapsulated strains independent of the K type. By contrast, the unencapsulated mutant was completely avirulent in a mouse model of pneumonia, unlike the wild-type strain, which produced pneumonia and systemic infection. Furthermore, the unencapsulated mutant bound more epithelially produced complement component C3 than the wild-type strain. Our results show that lung epithelial cells play a key role as a host defense mechanism against K. pneumoniae pneumonia, using two different strategies: (i) ingestion and control of the microorganisms and (ii) opsonization of the microorganisms. Capsular polysaccharide avoids both mechanisms and enhances the virulence of K. pneumoniae.

 

4833.         Della Volpe A, Ferreri AJ, Annaloro C, Mangili P, Rosso A, Calandrino R, Villa E, Lambertenghi Deliliers G, Fiorino C.  Lethal pulmonary complications significantly correlate with individually assessed mean lung dose in patients with hematologic malignancies treated with total body irradiation. Int J Radiat Oncol Biol Phys. 2002 Feb 1;52(2):483-8.

 

PURPOSE: To assess the impact of lung dose on lethal pulmonary complications (LPCs) in a single-center group of patients with hematologic malignancies treated with total body irradiation (TBI) in the conditioning regimen for bone marrow transplantation (BMT). METHODS: The mean lung dose of 101 TBI-conditioned patients was assessed by a thorough (1 SD around 2%) in vivo transit dosimetry technique. Fractionated TBI (10 Gy, 3.33 Gy/fraction, 1 fraction/d, 0.055 Gy/min) was delivered using a lateral-opposed beam technique with shielding of the lung by the arms. The median lung dose was 9.4 Gy (1 SD 0.8 Gy, range 7.8--11.4). The LPCs included idiopathic interstitial pneumonia (IIP) and non-idiopathic IP (non-IIP). RESULTS: Nine LPCs were observed. LPCs were observed in 2 (3.8%) of 52 patients in the group with a lung dose < or = 9.4 Gy and in 7 (14.3%) of 49 patients in the >9.4 Gy group. The 6-month LPC risk was 3.8% and 19.2% (p = 0.05), respectively. A multivariate analysis adjusted by the following variables: type of malignancy (acute leukemia, chronic leukemia, lymphoma, myeloma), type of BMT (allogeneic, autologous), cytomegalovirus infection, graft vs. host disease, and previously administered drugs (bleomycin, cytarabine, cyclophosphamide, nitrosoureas), revealed a significant and independent association between lung dose and LPC risk (p = 0.02; relative risk = 6.7). Of the variables analyzed, BMT type (p = 0.04; relative risk = 6.6) had a risk predictive role. CONCLUSION: The mean lung dose is an independent predictor of LPC risk in patients treated with the 3 x 3.33-Gy low-dose-rate TBI technique. Allogeneic BMT is associated with a higher risk of LPCs.

 

4834.         Duflo F, Debon R, Monneret G, Bienvenu J, Chassard D, Allaouchiche B.  Alveolar and serum procalcitonin: diagnostic and prognostic value in ventilator-associated pneumonia. Anesthesiology. 2002 Jan;96(1):74-9.

4835.         Fernando HC, Schauer PR, Rosenblatt M, Wald A, Buenaventura P, Ikramuddin S, Luketich JD.  Quality of life after antireflux surgery compared with nonoperative management for severe gastroesophageal reflux disease. J Am Coll Surg. 2002 Jan;194(1):23-7.

BACKGROUND: Gastroesophageal reflux disease significantly affects a patient's quality of life (QOL). Laparoscopic fundoplication offers an alternative to medical therapy, but few studies have compared outcomes. Our objective was to examine QOL scores in gastroesophageal reflux disease patients treated medically and surgically. STUDY DESIGN: We undertook a retrospective analysis of patients undergoing surgical or medical treatment for gastroesophageal reflux disease over a 1-year period (August 1997 to August 1998). Followup QOL was measured using the Short-Form 36, and heartburn severity was measured using the Health Related Quality of Life scale (a disease-specific instrument with a best score of 0 and a worst score of 45). RESULTS: Laparoscopic fundoplication was undertaken in 120 patients with a median age of 47 years (range 17 to 80 years). The medical cohort included 51 patients selected from the gastroenterology clinic with a median age of 48 years (range 17 to 82 years). Duration of heartburn was not significantly different, with 40 (78.4%) of the 51 medical and 98 (81.7%) of the 120 surgical patients having had symptoms for longer than 12 months. There were no operative deaths. There were 12 complications (esophageal perforation 1, pneumothorax 2, pneumonia 1, pulmonary embolus 3, other/miscellaneous 5). Mean length of stay was 1.6 days, time to oral intake 1.2 days, and return to normal activity 4.2 weeks. Routine followup was available in 118 surgical and 47 medical patients. The medical cohort had increased (p < 0.05) symptoms of heartburn (43% versus 19%), waterbrash (26% versus 8%), and regurgitation (30% versus 8%) and greater requirement for proton pump inhibitors (74% versus 19%) and propulsid (19% versus 3%) over the surgical group. Detailed outcomes were available in 101 surgical and 37 medical patients. Mean (+/-SE) Health Related Quality of Life scores were better (p < 0.05) in the surgical group (4+/-0.6 versus 21+/-1.4). More of the medical patients were dissatisfied (21.6% versus 5.9%). Short-Form 36 scores at followup were better (p < 0.05) in six of eight domains for surgical patients. CONCLUSION: Heartburn scores and global QOL scores were superior after laparoscopic fundoplication compared with medical management in this patient population. Laparoscopic fundoplication should be considered for patients who are dissatisfied with medical treatment.

 

4836.         Flanders S, Gonzales R.  Antibiotic prescribing: can we make it easier? J Gen Intern Med. 2002 Feb;17(2):160-1.

No Abstract

 

4837.         Gardner LI, Holmberg SD, Moore J, Arnsten JH, Mayer KH, Rompalo A, Schuman P, Smith DK.  Use of highly active antiretroviral therapy in HIV-infected women: impact of HIV specialist care. J Acquir Immune Defic Syndr. 2002 Jan 1;29(1):69-75. No abstract.

4838.         Gleason PP.  The emerging role of atypical pathogens in community-acquired pneumonia. Pharmacotherapy. 2002 Jan;22(1 Pt 2):2S-11S; discussion 30S-32S.

Community-acquired pneumonia (CAP) constitutes a major cause of morbidity and mortality. Although Streptococcus pneumoniae remains the bacterium most commonly implicated in CAP, the atypical respiratory patthogens Mycoplasma pneumoniae Legionella species, and Chlamydia pneumoniae are being isolated with increasing frequency Contrary to previous beliefs, these agents are capable of causing severe as well as mild-to-moderate illness. Moreover, they can affect all age groups. Indeed, atypical pathogens are implicated in up to 40% of CAP cases and commonly occur as copathogens in mixed-infection CAP, an etiology associated with particularly high mortality (up to 25%). Laboratory methods for detecting atypical pathogens are slow, and there is significant overlap between atypical and typical CAP manifestations. For these reasons, accurate prediction of etiology cannot be made purely on clinical or radiologic grounds. Consequently, empiric antimicrobial therapy for atypical pathogens (with agents such as macrolides, fluoroquinolones, in some cases tetracyclines, or the new ketolides) warrants careful consideration and now is recommended for the treatment of CAP.

4839.         Green SM, Krauss B.  Pulmonary aspiration risk during emergency department procedural sedation—an examination of the role of fasting and sedation depth. Acad Emerg Med. 2002 Jan;9(1):35-42. Review. No abstract.

4840.         Harger JH, Ernest JM, Thurnau GR, Moawad A, Momirova V, Landon MB, Paul R, Miodovnik M, Dombrowski M, Sibai B, Van Dorsten P.  Risk factors and outcome of varicella-zoster virus pneumonia in pregnant women. J Infect Dis. 2002 Feb 15;185(4):422-7.

To determine the factors associated with an increased risk of developing varicella-zoster virus (VZV) pneumonia during pregnancy, a case-control analysis was done in which 18 pregnant women with VZV pneumonia were compared with 72 matched control subjects. VZV infection was identified clinically, and VZV pneumonia was diagnosed by dyspnea and findings on chest radiographs. Of 347 pregnant women with VZV infection, 18 (5.2%) had pneumonia treated with acyclovir, and none died. Mean gestational age at rash onset was 25.8 plus minus 8.8 weeks for patients with pneumonia and 17.7 +/- 10.3 weeks for control subjects, which was not significant in the multivariable model. Women with VZV pneumonia were significantly more likely to be current smokers (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.6-16.7) and to have > or = 100 skin lesions (OR, 15.9; 95% CI, 1.9-130.2). Pregnant women with VZV infection may be more likely to develop varicella pneumonia if they are smokers or manifest > or = 100 skin lesions.

4841.         Ho TB, Rhodes A. Nitric oxide and prostacyclin in acute interstitial pneumonia. J R Soc Med. 2002 Jan;95(1):35-7. No abstract.

4842.         Janssen NA, Schwartz J, Zanobetti A, Suh HH.  Air conditioning and source-specific particles as modifiers of the effect of PM(10) on hospital admissions for heart and lung disease. Environ Health Perspect. 2002 Jan;110(1):43-9. No abstract.

4843.         Johnson JR.  Prevention of antibiotic resistance in hospitals. Ann Intern Med. 2002 Jan 15;136(2):173 discussion 173. No abstract.

4844.          Kanungo R; Dorothy D; Rajalakshmi B; Kumar A; Badrinath S. Emerging antibiotic resistant Pneumococci in invasive infection in South India: need for monitoring. Indian Journal of Pharmacology 2002 Feb; 34(1): 38-43

 

ABSTRACT: Objective: To detect antibiotic resistance in Streptococcus pneumoniae associated with invasive infection in a tertiary care referral center. Methods: Clinical isolates from patients with invasive pneumococcal infections were screened by the Kirby-Bauer disc diffusion method for their susceptibility to some of the commonly used antibiotics in the hospital. Minimum inhibitory concentrations of the antibiotics were determined by standard method. Results: Of the 124 isolates screened, MIC90 ranging between 0.1 to 1 miug/ml of penicillin was detected in 11.6 percent of the strains. Resistance to erythromycin and chloramphenicol were found in 1.8 percent of the organisms. However, a high level of resistance to cotrimoxazole was seen in 24 percent of the isolates. MIC of cefotaxime was well within the sensitive break point. Conclusion: A low level resistance in spite of high antibiotic consumption is a surprising finding in this study. Detection of resistance to some common antibiotics in use however, underlines the need to screen all clinically significant strains of S. pneumoniae.

4845.         Kaplan SL, Mason EO Jr, Wald E, Tan TQ, Schutze GE, Bradley JS, Givner LB, Kim KS, Yogev R, Barson WJ.  Six year multicenter surveillance of invasive pneumococcal infections in children. Pediatr Infect Dis J. 2002 Feb;21(2):141-7.

 

OBJECTIVE: Monitor clinical and microbiologic features including antimicrobial susceptibility of invasive pneumococcal infections among children. DESIGN: A 6-year (September, 1993, through August, 1999) prospective surveillance study of all invasive pneumococcal infections in children. PATIENTS: Infants and children cared for at eight children's hospitals in the United States with culture-proved invasive pneumococcal infection. RESULTS: During the 6-year period 2581 episodes of invasive pneumococcal infection occurred in 2498 children. Underlying conditions were present in 29% of the children. Of children without an underlying condition, 15% of the total infections occurred in those 25 to 60 months old. As the ages of the children advanced the proportion of cases classified as bacteremia declined, whereas the proportion classified as pneumonia increased. Also, as the ages of the children increased the proportion of isolates in serotypes/serogroups 1, 3 and 23 increased. whereas the proportion for serotype 14 diminished. During the 6 years of the study, there was a significant increase in the percentage of isolates intermediate or resistant to penicillin (P < 0.000001) or intermediate to ceftriaxone (P < 0.002). By the sixth year of the study, 37 and 11% of the isolates were nonsusceptible to penicillin or ceftriaxone, respectively. Antibiotic use in the 30 days before diagnosis of systemic pneumococcal infection occurred in 30 to 35% of the children for each of the 6 years. The overall case-fatality rate for children with systemic pneumococcal infection was 1.56%. Mortality was greatest in children >60 months old and in those with underlying conditions; mortality was not related to antibiotic susceptibility. CONCLUSIONS: The percentage of pneumococcal isolates recovered from children with systemic infection which were intermediate for penicillin or ceftriaxone or resistant to penicillin increased steadily during the 6-year period. There was also a trend toward increasing rates of resistance to ceftriaxone. The age and serogroup/serotype distributions of our patients support the recommendations to consider administration of the seven valent pneumococcal conjugate vaccine for all children 24 to 59 months old, with special consideration for selected groups.

4846.         Keeley D.  Guidelines for managing community acquired pneumonia in adults. BMJ. 2002 Feb 23;324(7335):436-7.

No Abstract

4847.         Kontoyiannis DP, Reddy BT, Torres HA, Luna M, Lewis RE, Tarrand J, Bodey GP, Raad II.  Pulmonary candidiasis in patients with cancer: an autopsy study. Clin Infect Dis. 2002 Feb 1;34(3):400-3. No abstract.

4848.         Loubieres Y, Grenet D, Simon-Bouy B, Medioni J, Landais P, Ferec C, Stern M.  Association between genetically determined pancreatic status and lung disease in adult cystic fibrosis patients. Chest. 2002 Jan;121(1):73-80.

 

STUDY OBJECTIVES: The association between genotype and phenotype in cystic fibrosis (CF) has been clearly established for pancreatic status, but not for lung disease. DESIGN: Retrospective study. SETTING: A respiratory unit of a teaching hospital. PATIENTS: We studied 51 adult CF patients for whom current data and genotype were available. Thirty-seven patients carried two severe mutations associated with pancreatic insufficiency phenotype (group S). Fourteen patients carried at least one mild (and dominant) mutation associated with pancreatic sufficiency phenotype (group M). MEASUREMENTS: We compared the course of the disease between the two groups, looking for a genotype/phenotype association for lung disease. RESULTS: The mean age of the population was 30 years. Patients with two severe mutations presented more severe disease with earlier onset (1.7 years vs 7.9 years, p = 0.0001). They presented with a more severe respiratory impairment, with a lower mean FEV(1) (29% of predictive value vs 58% of predictive value, p < 0.001); a higher Pseudomonas colonization rate (97% vs 57%, p < 0.01); a more frequent end-stage respiratory insufficiency, defined by a FEV(1) < 30% (73% vs 29%, p < 0.05); and a more marked yearly decline of FEV(1) (3% vs 1.4%, p < 0.001). By multivariate logistic regression analysis, carrying two severe mutations was the only independent predictor of a terminal respiratory insufficiency (relative risk, 6.75; 95% confidence interval, 1.79 to 26.50; p = 0.003). CONCLUSION: This study suggests that pulmonary disease appears to be associated with the severity of CF transmembrane regulator mutations.

 

4849.         Lynch III JP, Martinez FJ.  Clinical relevance of macrolide-resistant Streptococcus pneumoniae for community-acquired pneumonia. Clin Infect Dis. 2002 Mar 1;34 Suppl 1:S27-46. Review.

 

Macrolides are often the first choice for empirical treatment of community-acquired pneumonia. However, macrolide resistance among Streptococcus pneumoniae has escalated at alarming rates in North America and worldwide. Macrolide resistance among pneumococci is primarily due to genetic mutations affecting the ribosomal target site (ermAM) or active drug efflux (mefE). Prior antibiotic exposure is the major risk factor for amplification and perpetuation of resistance. Clonal spread facilitates dissemination of drug-resistant strains. Data assessing the impact of macrolide resistance on clinical outcomes are spare. Many experts believe that the clinical impact is limited. Ribosomal mutations confer high-grade resistance, whereas efflux mutations can likely be overridden in vivo. Favorable pharmacokinetics and pharmacodynamics, high concentrations at sites of infections, and additional properties of macrolides may enhance their efficacy. In this article, we discuss the prevalence of macrolide resistance among S. pneumoniae, risk factors and mechanisms responsible for resistance, therapeutic strategies, and implications for the future.

 

 

4850.         Makimoto A, Pearson MG, Jaffe N, Colasurdo GN.  Eosinophilic pneumonia in an infant. Med Pediatr Oncol. 2002 Jan;38(1):75-6.

No Abstract

4851.         McGuinness G, Naidich DP.  CT of airways disease and bronchiectasis. Radiol Clin North Am. 2002 Jan;40(1):1-19.

 

High-resolution CT is accepted as an accurate noninvasive means of diagnosing bronchiectasis. A wide spectrum of abnormalities may be identified at HRCT in patients with airway disease, including various distinctive patterns of bronchiectasis in specific clinical settings, such as ABPA, MAC infection, AIDS, and CF. Characteristic CT findings occasionally suggest a specific diagnosis that may not have been under clinical consideration. HRCT also provides significant clinical use in assessing the degree and extent of airway disease, and allows noninvasive monitoring of disease progression, regression, or response to therapy.

 

4852.         McIntosh K.  Community-acquired pneumonia in children. N Engl J Med. 2002 Feb 7;346(6):429-37. Review.

No Abstract

4853.         Mizukane R, Kadota Ji J, Yamaguchi T, Kiya T, Fukushima H, Nakatomi M, Kohno S.  An elderly patient with hemophagocytic syndrome due to severe mycoplasma pneumonia with marked hypercytokinemia. Respiration. 2002;69(1):87-91.

 

We present an extremely rare case of hemophagocytic syndrome (HPS) induced by fulminant Mycoplasma pneumoniae (Mp) pneumonia in an elderly adult. Erythrocytopenia and thrombocytopenia were observed in a patient with acute respiratory failure, liver dysfunction and renal failure. Mp-associated HPS was diagnosed in this case by clinical and laboratory findings, including a bone marrow aspiration specimen and serum Mp antibody titer. High serum levels of soluble interleukin-2 receptor, interleukin-6, human interleukin-10 and macrophage-colony stimulating factor were observed. Hypercytokinemia is a useful marker of disease activity and prognosis. Combined treatment with methylprednisolone and erythromycin was successful and led to a favorable outcome. Physicians should be aware of HPS as a complication in Mp infection. Copyright 2002 S. Karger AG, Basel

4854.         Moellering Jr RC.  The continuing challenge of lower respiratory tract infections.  Clin Infect Dis. 2002 Mar 1;34 Suppl 1:S1-3.

 

Lower respiratory tract infections have been a major cause of morbidity and mortality among humans since the dawn of history. The initial hope that the era of antibiotics would remove this scourge has been replaced by the more realistic view that although antimicrobial agents represent a major therapeutic advance, they have not yet solved all of the problems of lower respiratory tract infections. The pneumococcus, for example, causes mortality in a certain number of patients despite antimicrobial therapy. An even greater challenge is being imposed by the emergence of antimicrobial resistance among important bacterial pathogens, especially Streptococcus pneumoniae.

4855.         Montravers P, Veber B, Auboyer C, Dupont H, Gauzit R, Korinek AM, Malledant Y, Martin C, Moine P, Pourriat JL.  Diagnostic and therapeutic management of nosocomial pneumonia in surgical patients: results of the Eole study. Crit Care Med. 2002 Feb;30(2):368-75.

 

OBJECTIVE: To assess clinical, microbiological, and therapeutic features of nosocomial pneumonias in surgical patients. DESIGN: Prospective (October 1997 through May 1998), consecutive case series analysis of patients suspected of having pneumonia during the fortnight after a surgical procedure or trauma and receiving antibiotic therapy prescribed by the attending physician for this diagnosis. SETTING: A total of 230 study centers in teaching (n = 66) and nonteaching hospitals (n = 164) (surgical wards and intensive care units). PATIENTS: A total of 837 evaluable patients (mean age 61 +/- 18 yrs) including 629 intensive care unit patients. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The diagnostic and therapeutic procedures followed were based on guidelines. Antibiotics and any changes of therapy and duration of treatment were decided by the attending physician. The charts were reviewed by a panel of experts that classified the cases according to clinical, radiologic, and microbiological criteria (when available). The efficacy of treatment was evaluated over a 30-day period following the index episode. The patients were classified into three groups: definite pneumonia (n = 261), possible pneumonia (n = 392), or low-probability pneumonia (n = 184). Ventilator-acquired pneumonia was reported in 303 patients. Early onset pneumonia was reported in 512 cases. Microbiological sampling was performed in 718 patients, by bronchoscopy in 367 cases, recovering 450 organisms in 328 patients, including 94 polymicrobial specimens. High proportions of Gram-negative bacteria and staphylococci were cultured, even in early onset pneumonias. Antibiotic therapy was administered for 13 +/- 4 days, using monotherapy in 254 cases. Changes in the initial antibiotic therapy (135 monotherapies) were decided in 517 patients (including clinical failure or persistent infection, n = 171; organisms resistant to initial therapy, n = 177; pulmonary superinfection, n = 68). Death occurred in 180 patients, related to pneumonia in 53 cases. CONCLUSIONS: Nosocomial pneumonias in surgical patients are characterized by high frequency of early onset pneumonia, high proportion of nosocomial organisms even in these early onset pneumonias, and moderate mortality rate.

4856.         Nascimento-Carvalho CM, Rocha H, Benguigui Y. Association of crackles and/or wheezing with tachypnea or chest indrawing in children with pneumonia. Indian Pediatr. 2002 Feb;39(2):205-7.

No Abstract

4857.         Nayeri F, Millinger E, Nilsson I, Zetterstrom, Brudin L, Forsberg P.  Exhaled breath condensate and serum levels of hepatocyte growth factor in pneumonia. Respir Med. 2002 Feb;96(2):115-9.

 

Hepatocyte growth factor (HGF) is a protein produced by mesenchymal cells in many organs, which can stimulate epithelial growth. An enhanced production and concentration of HGF is observed after injuries. The lung is one of the major sources of HGF. By cooling exhaled air, a condensate is formed containing molecules from bronchi and alveoli. In order to investigate HGF-concentration and time course in pneumonia, paired serum and exhaled breath condensate was collected from 10 patients with pneumonia, 10 patients with non-respiratory infections and 11 healthy controls. The concentration of HGF was measured by an immunoassay kit. In the acute phase HGF-levels in breath condensate and serum were significantly higher in the patients with pneumonia compared to the control groups. Similar concentrations in breath condensate were seen in healthy

controls and in patients with non-respiratory infections. In the patients with pneumonia a decrease in serum HGF was seen already after 4-7 days while HGF values in breath condensate remained elevated even after 4-6 weeks. These results might imply local product on of HGF in the lungs and a long repair and healing process after pneumonia.

 

4858.         Nicholson AG, Wells AU, Hooper J, Hansell DM, Kelleher A, Morgan C.  Successful treatment of endogenous lipoid pneumonia due to Niemann-Pick Type B disease with whole-lung lavage. Am J Respir Crit Care Med. 2002 Jan 1;165(1):128-31. No abstract.

4859.         Perry CM, Ormrod D, Hurst M, Onrust SV.  Gatifloxacin: a review of its use in the management of bacterial infections. Drugs. 2002;62(1):169-207. Review. No abstract.

4860.         Pfausler B, Engelhardt K, Kampfl A, Spiss H, Taferner E, Schmutzhard E.  Post-infectious central and peripheral nervous system diseases complicating Mycoplasma pneumoniae infection. Report of three cases and review of the literature. Eur J Neurol. 2002 Jan;9(1):93-6.

 

Three patients with a central and peripheral nervous system disease complicating a Mycoplasma pneumoniae (M. pn.) infection are presented. Patient 1 suffered from bilateral optic neuritis as well as acute Guillain-Barre syndrome recovering after plasmapheresis. The two other patients suffered from severe haemorrhagic leukoencephalitis (Hurst) which only could be contained by aggressive decompressive craniectomy with duraplasty. All three illnesses were clearly shown to be associated with M. pn. infection.Our three patients represent the full scale of central nervous (CNS) (cerebral and myelitic) as well as peripheral nervous system (PNS) (GBS, optic neuritis) manifestation of a disease caused by the same pathogenetic - post-infectious - mechanism; pathogenic CNS and PNS epitopes might be shared in post-infectious neurological disease following M. pn. infection.

4861.         Piplani S; Handa A; Aggarwal R; Gupta BK; Mishra SC; Roy P; Gupta ID. Organophosphorous poisoning with intermediate syndrome Medical Journal Armed Forces India 2002 Jan; 58(1): 81-3

Kanungo R; Dorothy D; Rajalakshmi B; Kumar A; Badrinath S. Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-605006 Emerging antibiotic resistant Pneumococci in invasive infection in South India: need for monitoring Indian Journal of Pharmacology 2002 Feb; 34(1): 38-43 ABSTRACT: Objective: To detect antibiotic resistance in Streptococcus pneumoniae associated with invasive infection in a tertiary care referral center. Methods: Clinical isolates from patients with invasive pneumococcal infections were screened by the Kirby-Bauer disc diffusion method for their susceptibility to some of the commonly used antibiotics in the hospital. Minimum inhibitory concentrations of the antibiotics were determined by standard method. Results: Of the 124 isolates screened, MIC90 ranging between 0.1 to 1 miug/ml of penicillin was detected in 11.6 percent of the strains. Resistance to erythromycin and chloramphenicol were found in 1.8 percent of the organisms. However, a high level of resistance to cotrimoxazole was seen in 24 percent of the isolates. MIC of cefotaxime was well within the sensitive break point. Conclusion: A low level resistance in spite of high antibiotic consumption is a surprising finding in this study. Detection of resistance to some common antibiotics in use however, underlines the need to screen all clinically significant strains of S. pneumoniae.

4862.         Ruffini DD, Madhi SA.  The high burden of Pneumocystis carinii pneumonia in African HIV-1-infected children hospitalized for severe pneumonia. AIDS. 2002 Jan 4;16(1):105-12. No abstract.

4863.         Schlesinger C, Koss MN.  Bronchiolitis: update 2001. Curr Opin Pulm Med. 2002 Mar;8(2):112-6. Review.

In this review, reports from last year on the following topics are summarized: (1) reviews of bronchiolitis in infants; respiratory syncytial virus (RSV)-associated illness, including possible viral mechanisms of alteration of airway function and results of an epidemiologic study of bronchiolitis-associated mortality. Studies evaluating (2) the use of serum eosinophilic cationic protein as a marker for development of subsequent persistent wheezing infants; (3) parental bronchial responsiveness as an indicator of genetic susceptibility to acute bronchiolitis; (4) prophylactic use of monoclonal antibody (Palivizumab) to control an outbreak of RSV in a hospital nursery; (5) a controlled clinical trial of ribaviron in acutely ill children; (6) reports of new associations with bronchiolitis obliterans organizing pneumonia (BOOP); (7) case reports of use of methotrexate as an alternate to corticosteroids in treatment of BOOP; (8) a newly described entity, eosinophilic bronchiolitis.

4864.         Schwarzmeier JD.  A potentially fatal complication of Mycoplasma pneumoniae infection—the hemophagocytic syndrome. Respiration. 2002;69(1):14-5.

No Abstract

4865.         Sethi S.  Bacterial pneumonia. Managing a deadly complication of influenza in older adults with comorbid disease. Geriatrics. 2002 Mar;57(3):56-61. Review.

 

In patients with Influenza, the risk of death from pneumonia is closely associated with age and chronic conditions. Mortality from influenza and pneumonia in Americans age > or = 65 has been increasing since 1980. Pneumonia following influenza is usually caused by a secondary bacterial infection. Pathogens most commonly implicated are Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae. Prompt empiric therapy effective against the suspected pathogen is indicated, whether the patient is being treated as an outpatient or requires inpatient observation or hospitalization for i.v. administration. Influenza vaccination of older patients living in the community has been shown to decrease hospitalizations for influenza and pneumonia by 52% and mortality by 70% in those with chronic lung disease. Protective rates are similar for residents of long-term care facilities.

 

4866.         Shah RM, Wechsler R, Salazar AM, Spirn PW.  Spectrum of CT findings in nosocomial Pseudomonas aeruginosa pneumonia. J Thorac Imaging. 2002 Jan;17(1):53-7.

The purpose of this study was to evaluate CT findings in nosocomial Pseudomonas aeruginosa Pneumonia (PAP) and to compare features of PAP in patients with isolated P. aeruginosa cultures and those with coexistent infections. A retrospective database search revealed 28 patients with nosocomial PAP (12 men, 16 women; mean age, 57 years) in which thoracic CT had been performed within a mean of 1.7 days from the time of respiratory culture. Two chest radiologists blinded to culture data performed a consensus reading noting distribution and pattern of consolidation, ground-glass opacity, nodules, peribronchial infiltration, necrosis, effusions, and pleural enhancement. Coexistent respiratory cultures were recorded. Consolidation was present in all patients, involving multiple lobes in 23 (82%) and demonstrating upper zonal involvement in 23 (82%). Nodular features were present in 14 (50%), including tree-in-bud patterns with centrilobular distributions in 9 (64%) and larger, randomly distributed nodules in 5 (36%). Five of five patients with consolidations limited to the lower lung zones had associated upper lung nodules. Ground-glass opacity was seen in nine (31%) and peribronchial infiltration in 16 (57%). Necrosis was present in eight (29%). Thirteen (46%) bilateral and five (18%) unilateral pleural effusions were present with enhancement occurring in two (1%). Coexistent positive respiratory cultures were identified in 13 patients. The distribution of consolidation, frequency and distribution of nodules, and frequency of necrosis did not differ significantly between patients with and without other positive cultures. With CT, PAP most commonly presents with multifocal airspace consolidation. Nodular features were identified in half, with one-third demonstrating tree-in-bud opacities. Unsuspected necrosis occurred in one-third of cases. CT findings in patients with and without other respiratory isolates did not differ in the distribution and frequency of consolidations, nodularity, or necrosis.

 

4867.         Shee CD.  Wheeze and Mycoplasma pneumoniae. J R Soc Med. 2002 Mar;95(3):132-3.

No Abstarct

4868.         Shevlin JD, Summers-Bean C, Thomas D, Whitney CG, Todd D, Ray SM. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. Am J Prev Med  2002 Feb;22(2):92-7

BACKGROUND: While the Advisory Committee on Immunization Practices recommends a standing order as the most effective mechanism to increase pneumococcal and influenza vaccination rates, Georgia's Medical Practice Act does not authorize nurses to screen, order, and administer adult vaccines in inpatient settings. METHODS: The setting was a 1000-bed public teaching hospital in metropolitan Atlanta. A 1-month intervention (INT1) included four wards randomized to intervention or control. A 5-month hospital-wide intervention (INT2) followed INT1. The intervention used was provider reminder with in-service training. Chart review was the measure used. The main outcome was pneumococcal vaccination prior to discharge. RESULTS: During INT1, 534 patients (296 intervention and 238 control) were discharged. Of the 534 patients, 475 (89.0%) were African American, 188 (35.2%) were uninsured, and the median age was 48 (range 19 to 96). Of the 205 intervention patients with vaccine indications and no contraindications, 78 of 205 (38%) were vaccinated compared to 7 of 143 (4.9%) of the control patients (p<0.001). During INT2, 879 patient charts were reviewed. Patient demographics were similar to INT1. However, of 554 eligible patients, 16% were vaccinated, significantly higher than control floors during INT1 (p<0.001). Although nurses initiated the form almost 70% of the time, physicians assessed fewer than 35% of patients with indications. CONCLUSIONS: Significantly higher proportions of high-risk patients were vaccinated through the use of a preprinted nurse screening and physician order form. However, a significant percentage of patients did not receive the vaccine owing to the physician's failure to order it. In these cases, use of standing orders would have further increased vaccination rates while also promoting a more sustainable program.

4869.         Stralin K, Eliasson H, Back E.  An outbreak of primary pneumonic tularemia. N Engl J Med. 2002 Mar 28;346(13):1027-9; discussion 1027-9.

No Abstract

4870.         Surinder Kumar, Savita Kumari, Gur R, Arora B S, Vinay Kamal, Mathur M D. Pneumocystis carinii pneumonia : newer approaches to diagnosis. Indian J clin Pract 2001, 12(2), 44, 47-8.

Abstract : Pneumocystis carinii pneumonia can be confirmed only by laboratory tests and current dogma is that these need respiratory samples obtained by invasive procedures. Development of definitive laboratory tests requiring less invasive specimens is important because all non-invasive procedures are non-specific. 12 ref.

 

4871.         Swartz MN.  Attacking the pneumococcus -- a hundred years' war. N Engl J Med. 2002 Mar 7;346(10):722.

No Abstract

4872.         Szymanski M, Petric M, Saunders FE, Tellier R.  Mycoplasma pneumoniae pericarditis demonstrated by polymerase chain reaction and electron microscopy. Clin Infect Dis. 2002 Jan 1;34(1):E16-7.

4873.         van Elden LJ, van Kraaij MG, Nijhuis M, Hendriksen KA, Dekker AW, Rozenberg-Arska M, van Loon AM.  Polymerase chain reaction is more sensitive than viral culture and antigen testing for the detection of respiratory viruses in adults with hematological cancer and pneumonia. Clin Infect Dis. 2002 Jan 15;34(2):177-83.

4874.         Vogel F.  Intravenous/oral sequential therapy in patients hospitalised with community-acquired pneumonia: which patients, when and what agents? Drugs. 2002;62(2):309-17. Review.

Cost and pharmacoeconomic aspects are becoming more and more important in antibacterial therapy. Nevertheless, antibacterial therapy is curative and initial use of the right antibacterial with high activity and low resistance rates against the relevant pathogens can help to save costs. A new trend in antibacterial therapy is sequential therapy (intravenous/oral) in hospitalized patients with moderate to severe infections. Large studies comparing intravenous therapy with sequential therapy (intravenous/oral) have shown equivalence in clinical and bacteriological outcome. One main indication investigated is community-acquired pneumonia (CAP). CAP requires prompt and effective antibacterial treatment and conventional therapy for patients hospitalised with CAP has typically been parenteral antibacterial therapy for 7 to 10 days. However, clinical evidence shows that in most patients the objective and subjective indicators of infection are substantially improved within the first 2 to 3 days of treatment. Today a large number of clinical trials in patients with CAP have been undertaken and sequential therapy with appropriate antibacterials used in suitable patients has been proven as a treatment option. This demonstrates pharmacoeconomic benefits without compromising antibacterial efficacy. Recommended antibacterials for intravenous/oral sequential therapy in patients with CAP are second- and third- generation cephalosporins, aminopenicillins plus a beta-lactamase inhibitor, and new fluoroquinolones.

 

4875.         Wallington T, Weir E.  Varicella control and vaccine coverage: issues and challenges. CMAJ. 2002 Mar 5;166(5):631-2.

No Abstract

4876.       West SD, Brunskill NJ.  Complications associated with influenza infection. Postgrad Med J. 2002 Feb;78(916):100, 107-8.  No abstract.

4877.         Zacharisen MC.  Idiopathic interstitial pneumonia: are we missing hypersensitivity pneumonitis? Ann Allergy Asthma Immunol. 2002 Jan;88(1):4-6.

No Abstract

 

Oct 2002

5602. Arriaga AK, Orozco EH, Aguilar LD, Rook GA, Hernandez Pando R. Immunological and pathological comparative analysis between experimental latent tuberculous infection and progressive pulmonary tuberculosis. Clin Exp Immunol. 2002 May;128(2):229-37. Abstract.  Mycobacterium tuberculosis produces latent infection or progressive disease. Indeed, latent infection is more common since it occurs in one-third of the world's population. We showed previously, using human material with latent tuberculosis, that mycobacterial DNA can be detected by in situ PCR in a variety of cell types in histologically-normal lung. We therefore sought to establish an experimental model in which this phenomenon could be studied in detail. We report here the establishment of such a model in C57Bl/6 x DBA/2 F1 hybrid mice by the intratracheal injection of low numbers of virulent mycobacteria (4000). Latent infection was characterized by low and stable bacillary counts without death of animals. Histological and immunological study showed granulomas and small patches of alveolitis, with high expression of tumour necrosis factor alpha (TNFalpha), inducible nitiric oxide synthase (iNOS), interleukin 2 (IL-2) and interferon gamma (IFNgamma). In contrast, the intratracheal instillation of high numbers of bacteria (1 x 106) produced progressive disease. These animals started to die after 2 months of infection, with very high bacillary loads, massive pneumonia, falling expression of TNF-alpha and iNOS, and a mixed Th1/Th2 cytokine pattern. In situ PCR to detect mycobacterial DNA revealed that the most common positive cells in latently-infected mice were alveolar and interstitial macrophages located in tuberculous lesions, but, as in latently-infected human lung, positive signals were also seen in bronchial epithelium, endothelial cells and fibroblasts from histologically-normal areas. Our results suggest that latent tuberculosis is induced and maintained by a type 1 cytokine pattern plus  TNFalpha, and that mycobacteria persist intracellularly in lung tissue with and without histological evidence of a local immune response.

5603. Bondoc AY, White DA. Granulomatous Pneumocystis carinii pneumonia in patients with malignancy. Thorax. 2002 May;57(5):435-7. . Abstract. BACKGROUND: A review was undertaken of the clinical features and results of diagnostic tests in non-HIV infected patients who developed granulomatous Pneumocystis carinii pneumonia (PCP). METHODS: A retrospective review was performed of the charts and radiographs of patients with a granulomatous reaction to P carinii identified from computerised pathology records at Memorial Sloan Kettering Cancer Center, a university affiliated tertiary care hospital. RESULTS: Three cases were identified; the incidence of granulomatous PCP was 3%. All patients had risk factors for PCP and had received high dose corticosteroids which had been stopped. Two patients had received chemotherapy. Presentation was insidious with only mild symptoms; only one patient had fever. Chest radiographs showed a reticulonodular pattern. Bronchoscopy was negative for PCP in all cases and open lung biopsy was necessary. CONCLUSION: A granulomatous pathological reaction to PCP occurs rarely in patients with malignancy. In these cases the clinical presentation may be atypical and bronchoscopy can be non-diagnostic.

5604. Brumbaugh DE, Accurso FJ. Persistent silent aspiration in a child with Trisomy 21. Curr Opin Pediatr. 2002 Apr;14(2):231-3. No abstract.

5605. Busaba NY. Same-stage nasal and palatopharyngeal surgery for obstructive sleep apnea: is it safe? Otolaryngol Head Neck Surg. 2002 Apr;126(4):399-403. . Abstract.  OBJECTIVE: The study goal was to determine the safety of performing same-stage nasal and palatopharyngeal surgery for the treatment of obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND SETTING: We conducted a retrospective review of 91 consecutive patients who underwent surgery for OSAS at tertiary care facilities. METHODS: Patients were divided into 2 groups: group 1 had same-stage nasal and palatopharyngeal surgery (n = 63), whereas group 2 had palatopharyngeal surgery at a stage separate from the nasal surgery (n = 28). Patient demographics, severity of OSAS, type of surgery, perioperative care, and postoperative complications were reviewed. RESULTS: There were 55 men and 8 women in group 1, with an average age of 48 years. Group 2 consisted of 20 men and 8 women, with an average age of 45 years. The mean respiratory disturbance index was 36.5 and 33.5 for group 1 and 2, respectively. The mean lowest arterial Oxygen saturation for group 1 was 82%, whereas that of group 2 was 81%. Patients in both groups were observed in a hospital setting for a minimum of 1 day. They were admitted to a room close to the nurse's station, with continuous pulse oximeter monitoring. There were 3 complications reported for group 1: pneumonia (1 patient, postoperative day 4), tonsil bleed (1 patient, postoperative day 6), and septal hematoma (1 patient). One patient in group 2 had a tonsil bleed (postoperative day 8). There were no incidents of airway compromise or cardiopulmonary events in the immediate postoperative period. CONCLUSION: Same-stage nasal and palatopharyngeal surgery for OSAS is safe. Patients could be monitored with continuous pulse oximetry and managed outside of an intensive care unit setting in the immediate postoperative period.

5606. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002 Apr 1;165(7):867-903. Review. . Abstract. Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

5607. Choi KH, Lee HB, Jeong MY, Rhee YK, Chung MJ, Kwak YG, Lee YC. The role of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in cryptogenic organizing pneumonia. Chest. 2002 May;121(5):1478-85. . Abstract. BACKGROUND: The processes observed in interstitial lung disease are associated with the production, deposition, and proteolysis of the extracellular matrix (ECM), which may lead to irreversible pulmonary structural remodeling or to appropriate repair without fibrosis. Matrix metalloproteinases (MMPs) and a tissue inhibitor of metalloproteinases (TIMPs) are known to regulate remodeling of the ECM and thus to be important in the process of lung fibrosis. Pulmonary structures are extensively remodeled in usual interstitial pneumonia (UIP), whereas severe architectural remodeling is minimally present in cryptogenic organizing pneumonia (COP). However, not much is known about the roles of MMP-9 and/or TIMP-1 in COP. METHODS: Levels of MMP-9, TIMP-1 and the molar ratio of MMP-9/TIMP-1 in BAL fluids were investigated in 11 patients with UIP, in 8 patients with COP, and in 10 control subjects. We checked the levels of MMP-9 and TIMP-1 by means of enzyme immunoassay, and the hydrolytic activity of MMP-9 in BAL fluids was measured by gelatin zymography. Further, we evaluated the expression of MMP-9 and TIMP-1 in lung tissue by immunohistochemistry. RESULTS: The concentrations of MMP-9 and TIMP-1 were significantly increased in patients with UIP and were even higher in patients with COP compared with control subjects. The levels of MMP-9 and TIMP-1 were significantly higher in patients with COP than in patients with UIP. The molar ratio of MMP-9/TIMP-1 was significantly higher in patients with COP than in control subjects. In patients with COP, the concentration of MMP-9 significantly correlated with the number of neutrophils and lymphocytes. Zymographic analysis revealed that the activity of the 92-kd pro-MMP-9 was increased in patients with UIP and was even higher in patients with COP, compared with control subjects. CONCLUSIONS: These data suggest that overproduction of MMP-9 and TIMP-1, and an imbalance between MMP-9 and TIMP-1, may have a role as diagnostic references in COP.

5608. Cowles RA, Lelli JL Jr, Takayasu J, Coran AG. Lung resection in infants and children with pulmonary infections refractory to medical therapy. J Pediatr Surg. 2002 Apr;37(4):643-7. . Abstract. BACKGROUND/PURPOSE: Pulmonary infections in children are common and often resolve with antibiotics and supportive therapy. When these infections become refractory to medical therapy or develop into an abscess, operative intervention may become necessary. This study was undertaken to review the experience with these pulmonary infections at the authors' institution. METHODS: Charts of patients who underwent pulmonary resection for infectious causes were reviewed and their presentation, operative course, and long-term outcome analyzed. RESULTS: Between 1975 and 1999, 21 children underwent operative resection of lung parenchyma for infection. Sixty-six percent of children previously had required hospitalization for pneumonia, and 91% had been treated previously, either as an inpatient or as an outpatient, for pneumonia. Seventy-one percent of children had an identifiable underlying comorbidity. Eighteen lobectomies were performed on 17 children with the remaining children requiring either segmentectomy or wedge resection. The median length of stay was 6 days. There were 3 minor complications and 3 deaths. At follow-up (median, 8.25 months), all surviving children had improvement of the chest x-ray, and this was paralleled by clinical improvement. CONCLUSIONS: In children with pulmonary infection refractory to conservative medical therapy, operative resection can provide significant clinical improvement. When resection is performed, formal lobectomy often is required and yields a good outcome. Copyright 2002, Elsevier Science (USA). All rights reserved.

5609. Evans NR, Gardner SV, James MF. ProSeal laryngeal mask protects against aspiration of fluid in the pharynx. Br J Anaesth. 2002 Apr;88(4):584-7. . Abstract. BACKGROUND: The ProSeal laryngeal mask airway (PLMA) is a new device designed to isolate the airway from the digestive tract. METHODS: We studied the ability of the PLMA to isolate the airway in 103 anaesthetized adults who were breathing spontaneously or given neuromuscular blocking agents, by filling the hypopharynx with methylene blue-dyed saline introduced down the drainage tube once the mask was in place. At the beginning and end of the procedure, a fibre-optic bronchoscope was passed down the airway tube to observe any dyed saline in the bowl of the mask. RESULTS: The PLMA was positioned correctly in all successful attempts (102 out of 103 attempts) and was able to isolate the glottis from fluid in the hypopharynx in all patients initially. Leakage of saline into the bowl of the mask occurred in two patients in whom displacement of the mask was caused by upper airway events during the procedure. In the remaining 100 patients, the glottis was isolated successfully for the duration of the procedure. CONCLUSIONS: The PLMA can be positioned reliably. It can isolate the airway from fluid in the hypopharynx.

5610. Ewig S, Schlochtermeier M, Goke N, Niederman MS. Applying sputum as a diagnostic tool in pneumonia: limited yield, minimal impact on treatment decisions. Chest. 2002 May;121(5):1486-92. STUDY OBJECTIVES: We evaluated the role of sputum examination in the management of patients with community-acquired pneumonia (CAP) in a primary-care hospital without microbiologic laboratory facilities. Design and interventions: A diagnostic strategy using regular collection of sputum samples, Gram staining in a local laboratory, and mailing of samples to a commercial laboratory for culture analysis. SETTING: A 200-bed primary-care hospital without subspeciality physicians. PATIENTS: One hundred sixteen consecutive patients with a diagnosis of CAP were prospectively evaluated during a 12-month period. RESULTS: Of 116 patients, 42 patients (36%) were capable of producing a sputum sample. Age > or = 75 years (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.18 to 0.93) and prior ambulatory antimicrobial treatment (OR, 3.2; 95% CI, 1.2 to 8.4) were independent predictors of sputum production. A delay in collection and processing of sputum samples of > 24 h was present in 31% and 39%, respectively. A delay in collection yielded an increased number of Gram-negative enteric bacilli and nonfermenters (44% vs. 7%, p = 0.056). A delay in processing was associated with an increased number of Candida spp isolates (33% vs. 9%, p = 0.16). The overall diagnostic yield was low (10 of 116 patients, 9%) due to a limited number of valid samples (n = 23 of 42 patients, 55%) and a limited number of definitely or probably positive samples on Gram's stain and culture (n= 10 of 42 patients, 24%). Prior ambulatory antimicrobial treatment was associated with a reduction in diagnostic yield (14% vs. 56%, p = 0.09). The impact of diagnostic results on antimicrobial treatment decisions was minimal, with antimicrobial treatment directed to diagnostic results in only one patient. CONCLUSIONS: We conclude that in this setting representative of primary-care hospitals in Germany, sputum had a low diagnostic yield and did not contribute significantly to patient management.

5611. Gold JA, Rom WN, Harkin TJ. Significance of abnormal chest radiograph findings in patients with HIV-1 infection without respiratory symptoms. Chest. 2002 May;121(5):1472-7. . Abstract. STUDY OBJECTIVES: Patients with HIV-1 infection or AIDS may present with abnormal chest radiograph (CXR) findings in the absence of symptoms specific to the lung. The objective was to determine the spectrum of disease and the diagnostic modalities employed in these patients. METHODS: From 1996 to 1998, we identified patients with HIV-1 infection presenting to the Bellevue Hospital Chest Service with abnormal CXR findings, and absence of specific pulmonary symptoms. Charts were reviewed for presence of constitutional symptoms, CD4 lymphocyte count, use of Pneumocystis carinii pneumonia (PCP) prophylaxis, eventual diagnosis, and all diagnostic modalities employed. CXR findings were classified according to their predominant abnormalities: nodules, infiltrates, cavity, mass, adenopathy, or effusion. RESULTS: Forty-four patients were eligible for inclusion. Eight-six percent of patients had a CD4 lymphocyte count < 200 cells/microL, and 57% were receiving PCP prophylaxis. Nodular disease was the most common radiographic abnormality (57%), followed by adenopathy (17%). A definitive diagnosis was obtained in 86% of the patients. The most common diagnosis was tuberculosis (26%), followed by nontuberculous mycobacteria (NTM; 23%) and Kaposi sarcoma (12%). No patients had PCP or bacterial pneumonia. Sixty-two percent of patients required an invasive modality to establish a diagnosis. Only 18% of patients with tuberculosis (2 of 11 patients) received diagnoses by sputum analysis. CONCLUSIONS: Patients with HIV-1 infection, abnormal CXR findings, and lack of pulmonary symptoms have a high incidence of infectious disorders, especially pulmonary tuberculosis and infection due to NTM. The high prevalence of treatable and potentially communicable disorders warrants an aggressive diagnostic approach in these patients.

5612. Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics. 2002 May;109(5):959-61. . Abstract. The ingestion of toxic substances is a common pediatric emergency. Activated charcoal is part of the standard treatment for most toxic ingestions and is considered a benign therapy. We report a case of inadvertent administration of activated charcoal into the trachea that resulted in the development of chronic lung disease.

5613. Gurkin SA, Parikshak M, Kralovich KA, Horst HM, Agarwal V, Payne N. Indicators for tracheostomy in patients with traumatic brain injury. Am Surg. 2002 Apr;68(4):324-8; discussion 328-9. . Abstract. Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived >7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3+/-7.0 days). Logistic regression analysis identified presenting GCS < or =8, ISS > or =25, and ventilator days >7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days (P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS > or =9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS < or =8, an ISS > or =25, and ventilator days >7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.

5614. Hansell DM. Acute interstitial pneumonia: clues from the white stuff. Am J Respir Crit Care Med. 2002 Jun 1;165(11):1465-6. No abstract.

5615. Hay AD, Wilson AD. The natural history of acute cough in children aged 0 to 4 years in primary care: a systematic review. Br J Gen Pract. 2002 May;52(478):401-9. Review. . Abstract. Professional and parental uncertainty regarding the natural history of cough and respiratory tract infection (R77) in pre-school children may in part be responsible for the high consultation, reconsultation, and antibiotic prescribing rates in this age group. The aim of the study was to review the evidence about the natural history of acute cough in children aged between 0 and 4 years presenting to primary care in terms of illness duration and complications. The study was a systematic review, with qualitative and quantitative data synthesis, of control and placebo arms of systematic reviews, randomised controlled trials (RCTs), and cohort studies set in primary care. Searches were done of MEDLINE (between 1966 and June 1998), EMBASE (between 1988 and September 1998), and the Cochrane Library databases, using the MeSH terms 'respiratory tract infection, 'cough, and 'bronchitis, and the textwords 'cough' 'bronchitis, and 'chest infection, limited to children aged between 0 and 4years, and English language articles. Eight RCTs and two cohort studies met the review criteria. At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia. This review offers parents and clinicians more prognostic information about acute cough in pre-school children. Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult. This information may be useful to those designing patient information and self-help resources.

5616. Heggen J, West C, Olson E, Olson T, Teague G, Fortenberry J, Yeager AM. Diffuse alveolar hemorrhage in pediatric hematopoietic cell transplant patients. Pediatrics. 2002 May;109(5):965-71. . Abstract. OBJECTIVE: Diffuse alveolar hemorrhage (DAH) is defined as a syndrome of hypoxia, dyspnea, infiltrates on chest radiograph, and bloody fluid on successive bronchoalveolar lavages without apparent infection. Minimal experience has been reported with DAH after hematopoietic cell transplant (HCT) in children. We reviewed the incidence, management and outcome of DAH in a pediatric HCT population. METHODS: Retrospective review of 138 patients undergoing allogeneic (n = 89) or autologous (n = 49) HCT at a referral children's medical center between January 1996 and April 2000. RESULTS: Seven (5.1%) of 138 patients met criteria for DAH; all were allogeneic recipients. Mean age of DAH patients was 11 years (range: 1.4-15.2). Median onset of DAH following HCT was day 24 (range: 10-50), median day of engraftment day 20 and white blood cell count 0.54 x 10(9)/L (range: < 0.1-7.03), with no difference between survivors and nonsurvivors. All patients developed clinical respiratory failure and 6 required intubation, with PaO(2)/fraction of inspired oxygen <200. Patients were intubated a median of 12 days (range: 1-75). All patients experienced >1 episode of bleeding and 3 patients required reintubation after successful extubation resulting from recurrent DAH. Bronchoalveolar lavage fluid cultures were negative for viruses, bacteria and fungi. All DAH patients received steroids. Three patients died with progressive pulmonary failure and other organ system involvement. Four of 7 DAH patients (57%) survived to discharge, but 3 died from disease relapse at days 116, 138, and 273 post-HCT. CONCLUSION: DAH occurred more frequently in allogeneic HCT recipients compared with autologous recipients. Onset of DAH coincided closely with white blood cell engraftment. Although associated with significant respiratory failure and need for mechanical ventilation, HCT patients can survive DAH.

5617. Heyland D, Ewig S, Torres A. Pro/con clinical debate: the use of a protected specimen brush in the diagnosis of ventilator associated pneumonia. Crit Care. 2002 Apr;6(2):117-20. Review. . Abstract. Although mechanical ventilation is instituted as a life-saving technique, it may lead to complications that can negatively impact on patients' morbidity and/or mortality. Ventilator associated pneumonia (VAP) is one such complication that is a common challenge to intensivists. Although most experts would agree that early 'appropriate' antibiotic use is essential in patients who develop VAP, the best diagnostic test to guide decision-making is far from clear. One diagnostic test that is capable of providing microbiological samples from the lower respiratory tree is invasive bronchoscopy with a protected specimen brush. Such a procedure has long been available to intensivists and is frequently employed in many intensive care units. However, this procedure has associated costs and potential complications, and its utility in VAP has been challenged. In this issue of Critical Care Forum, the two sides of this debate are brought forward with compelling arguments. The authors' arguments should fuel future trials.

5618. Ichikado K, Suga M, Muller NL, Taniguchi H, Kondoh Y, Akira M, Johkoh T, Mihara N, Nakamura H, Takahashi M, Ando M. Acute interstitial pneumonia: comparison of high-resolution computed tomography findings between survivors and nonsurvivors. Am J Respir Crit Care Med. 2002 Jun 1;165(11):1551-6. . Abstract. This study compared high-resolution computed tomography (CT) findings between 10 survivors and 21 nonsurvivors of acute interstitial pneumonia and evaluated whether the CT findings were predictive of patients' response to treatment. The survivor and nonsurvivor groups with pathologically or clinically diagnosed acute interstitial pneumonia were similar in age, sex, disease duration, and lung injury score. Retrospective, subjective evaluations of the CT scans were conducted by two independent observers without knowledge of patient outcomes. CT findings were graded on a one to six scale corresponding to consecutive pathologic phases as follows: areas of (1) normal attenuation, (2) ground-glass attenuation, (3) consolidation, (4) ground-glass attenuation associated with traction bronchiolectasis or bronchiectasis, (5) consolidation associated with traction bronchiolectasis or bronchiectasis, and (6) honeycombing. An overall score was obtained by quantifying the extent of each abnormality in three lung zones in each lung. The extent of ground-glass attenuation or consolidation associated with traction bronchiolectasis or bronchiectasis was less in survivors than nonsurvivors (p = 0.004 and p = 0.009, respectively). Architectural distortion was less frequent, and ground-glass attenuation or consolidation without traction bronchiolectasis or bronchiectasis was more extensive in survivors than in nonsurvivors (p = 0.007, p = 0.002, and p =0.029, respectively). Overall CT scores of survivors were significantly lower than those of nonsurvivors (p = 0.0003). A CT score of less than 245 had an 80% positive and a 90% negative predictive value for survival. There was good interobserver agreement in the assessment of the CT findings (Kappa 0.75). The results indicate that CT assessment is potentially helpful in predicting patient prognosis in acute interstitial pneumonia regardless of the degree of physiologic abnormality.

5619. Karim A, Ahmed S, Rossoff LJ. Legionnaire's disease associated with acute encephalitis and arrhythmia. Crit Care Med. 2002 May;30(5):1028-9. . Abstract.  OBJECTIVE: To report an unusual, life-threatening combination of neurologic, cardiac, and gastrointestinal symptoms in the presence of a community-acquired pneumonia. DESIGN: Case report. SETTING: University hospital. PATIENT: Previously healthy young male. INTERVENTION: Diagnostic fiberoptic bronchoscopy, lumber puncture, magnetic resonance imaging of the brain, and institution of systemic antibiotics. MAIN RESULT: Gradual clinical improvement of a multiple-system illness. CONCLUSION: Legionellosis should be considered in the differential diagnosis of patients presenting with neurologic, cardiac, and gastrointestinal symptoms, particularly in the presence of radiographic pneumonia. Furthermore, Legionella meningoencephalitis may present with findings on magnetic resonance imaging previously thought to be characteristic of herpes encephalitis.

5620. Kharabsheh S, Abendroth CS, Kozak M. Fatal pulmonary toxicity occurring within two weeks of initiation of amiodarone. Am J Cardiol. 2002 Apr 1;89(7):896-8. No abstract.

5621. Kumar N, Singh N, Locham KK, Garg R, Sarwal D. Clinical evaluation of acute respiratory distress and chest wheezing in infants. Indian Pediatr. 2002 May;39(5):478-83.  No abstract.

5622. Macfarlane J. Severe pneumonia and a second antibiotic. Lancet. 2002 Apr 6;359(9313):1170-2. No abstract.

5623. Mehandru S, Smith RL, Sidhu GS, Cassai N, Aranda CP. Migratory pulmonary infiltrates in a patient with rheumatoid arthritis. Thorax. 2002 May;57(5):465-7. . Abstract. The case history is described of an elderly man with rheumatoid arthritis receiving treatment with sulfasalazine and the cyclooxygenase-2 inhibitor celecoxib who presented with severe shortness of breath, cough, and decreased exercise tolerance. The chest radiograph showed unilateral alveolo-interstitial infiltrates and a biopsy specimen of the lung parenchyma showed changes consistent with acute eosinophilic pneumonia. Antibiotic treatment was unsuccessful, but treatment with steroids and discontinuation of sulfasalazine and celecoxib resulted in a marked clinical improvement confirmed by arterial blood gas analysis. The condition may have developed as an adverse reaction either to sulfasalazine or to celecoxib, although hypersensitivity to the latter has not previously been reported.

5624. Metersky ML. Community-acquired pneumonia: process of care studies. Curr Opin Infect Dis. 2002 Apr;15(2):169-74. Review. . Abstract. New insight has been gained into the relationship between the processes of care undertaken for patients with community-acquired pneumonia and the resulting outcomes. Better insight into the risks for a complicated course can increase the percentage of patients treated as outpatients. Studies have also suggested that both the promptness and the choice of antibiotic therapy can affect patient outcomes. Promptly switching to oral antibiotic therapy can often lead to a shorter length of hospital stay; however, concern has arisen regarding the effect of shorter lengths of stay on patient outcomes.

5625. Miyazaki E, Nureki S, Fukami T, Shigenaga T, Ando M, Ito K, Ando H, Sugisaki K, Kumamoto T, Tsuda T.   Elevated levels of thymus- and activation-regulated chemokine in bronchoalveolar lavage fluid from patients with eosinophilic pneumonia. Am J Respir Crit Care Med. 2002 Apr 15;165(8):1125-31. . Abstract. Thymus- and activation-regulated chemokine (TARC/CCL17) is a lymphocyte-directed CC chemokine, which plays a role in the recruitment of CC chemokine receptor-4 positive T helper 2 (Th2) cells. In this study, we measured concentrations of TARC and Th2 cell-derived cytokines in bronchoalveolar lavage (BAL) fluid, as well as TARC concentrations in serum from patients with eosinophilic pneumonia and other interstitial lung diseases. TARC was significantly elevated in BAL fluids from patients with eosinophilic pneumonia (median, 240 pg/ml), whereas TARC was undetectable (< 7 pg/ml) in most cases of hypersensitivity pneumonitis, sarcoidosis, and idiopathic pulmonary fibrosis, as well as in healthy control subjects. Also, when present, quantities were less than 20 pg/ml. Elevated concentrations of interleukin (IL)-4, IL-5, and IL-13 were also detected in BAL fluid from patients with eosinophilic pneumonia. Interestingly, TARC concentrations in BAL fluids were closely correlated with the concentrations of IL-5 and IL-13. A serial examination showed that elevated TARC in BAL fluid rapidly fell to below detectable limits preceding decreases in IL-5 concentration and eosinophil percentage. Our results, in concordance with previous studies, demonstrate the potential activity of TARC for recruiting Th2 cells to the lungs and suggest a significant role for TARC in the pathogenesis of eosinophilic pneumonia.

5626. Mokhtari M, Bach PB, Tietjen PA, Stover DE. Bronchiolitis obliterans organizing pneumonia in cancer: a case series. Respir Med. 2002 Apr;96(4):280-6. Review. . Abstract. Bronchiolitis obliterans with organizing pneumonia (BOOP) is an infrequently encountered clinical condition that can mimic a number of other pathologic lung processes. The presentation of this treatable condition in cancer patients has not been described in any large series.We conducted a retrospective study of patients with BOOP at Memorial Sloan-Kettering Cancer Center, NewYork, NY, U.S.A. from January 1992 to December 1999. The type and treatment of primary cancer, clinical and radiographic features of initial BOOP presentation, and outcome following therapy were recorded. Forty-three patients with an underlying diagnosis of cancer were found on lung biopsy to have BOOP as an isolated entity. BOOP was encountered in patients with a variety of clinical presentations, and many types of malignancies. The symptom patterns were non-specific, as were the physiological abnormalities. The only clear relationship between the underlying malignancyand the diagnosis of BOOP at presentation was in the chest radiographic findings. Patients with solid organ tumors were more likely to have nodular or mass like radiographic abnormalities (81%) than to have diffuse infiltrates (19%).We observed the opposite pattern in patients with hematologic malignancies (22% vs.67%). The vast majority of patients recovered from this condition. In conclusion, For cancer patients, BOOP represents a treatable cause of lung disease with protean manifestations. BOOP can mimic pulmonary malignancy and pulmonary infection. In cancer patients, the evaluation of new pulmonary symptoms accompanied by radiographic changes should

5627. include a consideration of this diagnosis.

5628. Palmieri TL, Jackson W, Greenhalgh DG. Benefits of early tracheostomy in severely burned children. Crit Care Med. 2002 Apr;30(4):922-4. . Abstract. OBJECTIVE: The role of tracheostomy in burn patients is controversial. Previous studies, primarily in adults, suggested that severely burned patients with tracheostomies have a higher incidence of tracheostomy site infections, mortality, and pneumonia. The purpose of this study is to determine the safety and efficacy of early tracheostomy in severely burned children. DESIGN: Case series study analyzing mechanical ventilation and sedation requirements before and 24 hrs after tracheostomy. SETTING: Regional pediatric burn center. PATIENTS: All children admitted to a regional pediatric burn center requiring tracheostomy from March 1, 1998, to October 1, 2001. METHODS: Data were recorded on patients' demographics, extent of burn, presence of inhalation injury, and mortality. Mechanical ventilation variables measured pretracheostomy (pre) and posttracheostomy (post) and included mode of ventilation, ventilator settings, peak inspiratory pressures, and arterial blood gases (Pao2, Paco2, pH, and oxygen saturation). Calculated variables included compliance, Pao2:Fio2 ratio, and minute ventilation. Tracheostomy-related variables recorded included the interval to tracheostomy insertion, the duration of tracheostomy, and tracheostomy complications. MAIN RESULTS: A total of 38 patients (with a mean age of 4.7 +/- 0.6 yrs and a mean total body surface area involvement of 54% +/- 4%, 63% with inhalation injury) underwent tracheostomy a mean of 3.9 +/- 0.7 days after admission. Overall mortality was 21%. There were no tracheostomy site infections, tracheostomy-related deaths, or tracheal stenoses in survivors. Peak inspiratory pressures were lower after tracheostomy (30.4 +/- 1.4 [pre] vs. 27.6 +/- 1.5 cm H2O [post]; p <.05), ventilatory volumes were higher (190 +/- 22 mL [pre] vs. 225.5 +/- 25 [post]; p <.05), compliance improved (10.5 +/- 1.4 [pre] vs. 15.1 +/- 2.3 mL/cm H2O [post]; p <.05), and the Pao2:Fio2 ratio improved (300.6 +/- 20 [pre] vs. 348.6 +/- 16 [post]). There was no difference in oxygenation, ventilation, minute ventilation, or pH after tracheostomy. CONCLUSIONS: Early tracheostomy in severely burned children is safe and effective. It provides a secure airway and may result in improvement in ventilator management for these children.

5629. Pound MW, Drew RH, Perfect JR. Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia. Curr Opin Infect Dis. 2002 Apr;15(2):183-94. Review. . Abstract. Although pneumonia caused by fungi is not a common occurrence in the general population, disease in an enlarging immunocompromised population is encountered with increasing frequency. Fungal pneumonias are most frequently caused by Aspergillus spp., dimorphic fungi and Cryptococcus neoformans. Recent studies have identified risk factors of thrombocytopenia, environmental events (such as construction or renovation) and immunosuppressive drug therapies as being specific risk factors for invasive fungal disease in select patient opulations. Diagnostic strategies to detect circulating antigens and polymerase chain reaction based detection systems have been explored to improve identification prior to the progressive advanced disease. Advances in prophylactic strategies include increased use of aerosolized formulations of amphotericin B, usually in conjunction with new and old systemic antifungal agents. Despite recent published guidelines for treatment of fungal pneumonia based on etiology, mortality remains high in some infections with advanced disease. Caspofungin, a new echinocandin antifungal, has recently been approved by the US Food and Drug Administration for the treatment of invasive Aspergillus infections in patients unresponsive to or unable to receive amphotericin B. A triazole antifungal, voriconazole, has shown promise in phase III clinical trials in patients with refractory fungal infections and is expected to be available in early 2002. Other echinocandin and triazole antifungals are under development in attempts to provide improved effective therapy for fungal pneumonia.

5630. Principi N, Esposito S. Mycoplasma pneumoniae and Chlamydia pneumoniae cause lower respiratory tract disease in paediatric patients. Curr Opin Infect Dis. 2002 Jun;15(3):295-300. Review. . Abstract. New studies suggest that Mycoplasma pneumoniae and Chlamydia pneumoniae play a more significant role as causes of lower respiratory tract infections in childhood than was previously thought. In particular, the incidence of infections caused by these pathogens is high in children aged less than 5 years, the infections themselves seem to be a possible cause of wheezing, and may present a more complicated course when not treated with adequate antimicrobial agents. However, despite the increasing pathogenic significance of M. pneumoniae and C. pneumoniae, progress in fighting them is hampered by the lack of rapid and standardized diagnostic methods. This not only makes it practically impossible for practitioners to make a specific microbiological diagnosis, but has also had an adverse effect on treatment trials and has generated some questionable results. Carefully randomized and controlled trials are clearly needed to examine the effectiveness of different antibiotics against M. pneumoniae or C. pneumoniae and the optimal duration of therapy in various patient populations.

5631. Seago JA. A comparison of two patient classification instruments in an acute care hospital. J Nurs Adm. 2002 May;32(5):243-9.OBJECTIVE: Patient classification systems are alternately praised and vilified by staff nurses, nurse managers, and nurse executives. Most nurses agree that substantial resources are used to create or find, implement, manage, and maintain the systems, and that the predictive ability of the instruments is intermittent. The purpose of this study is to compare the predictive validity of two types of patient classification instruments commonly used in acute care hospitals in California. BACKGROUND: Acute care hospitals in California are required by both the Joint Commission on Accreditation of Healthcare Organizations and California Title 22 to have a reliable and valid patient classification system (PCS). The two general types of systems commonly used are the summative task type PCS and the critical incident or criterion type PCS. There is little to assist nurse executives in deciding which type of PCS to choose. There is modest research demonstrating the validity and reliability of different PCSs but no published data comparing the predictive validity of the different types of systems. The unit of analysis is one patient shift called the study shift. The study shift is defined as the first day shift after the patient has been in the hospital for a full 24 hours. Data were collected using medical record review only. Both types, criterion and summative, of PCS data collection instruments were completed for all patients at both collection points. Each patient had a before and after score for each type of instrument. Three hundred forty-nine medical records for inpatients meeting the inclusion criteria were examined. RESULTS: The average patient age was 76 years, the average length of stay was 6.6 days with an average of 6.7 secondary diagnoses recorded. Fifty-five percent of the sample was female and the most common primary diagnosis was CHF, followed by COPD, CVA, and pneumonia. There was a difference in mean summative predictor score and the mean summative actual score of 1.57 points with the predictor score higher (P =.001; CI =.62--2.5). For the criterion instrument, 68.4% of the predictor criterion scores were in category 2 compared to 65.5% of the actual criterion scores. The criterion predictor agreed with the criterion actual score 45% of the time for category 1 patients, 87.3% of the time for category 2 patients, 77.1% of the time for category 3 patients and 72.7% of the time for category 4 patients, with an overall agreement between predictor and actual criterion scores of 79.9% (Kappa P <.001, indicating agreement is not by chance). CONCLUSIONS: The most significant finding of this study is that there are virtually no differences in the predictive ability of summative versus criterion patient classification instruments. Using the same patients, both types of instruments predicted the actual score over 78% of the time.

5632. Sharma CP, Chaudhary D, Behera D. Pneumocystis carinii Pneumonia in a patient with active untreated systemic lupus erythematosus. India J Chest Dis all Sci. 2001; 43(3), 169-71.  Pnumonia due to Pneumocystis carinii (PCP) commonly occur in immunocompromised hosts. Although a treatable infection, it is associated with high mortality. A case of PCP presenting in an untreated case of systemic lupus erythematosus is reported, in view of the rarity of this association.

5633. Sheppard D. Killed by leukocytes that don't know when to leave. Nat Immunol. 2002 Apr;3(4):337-8.  No abstract.

5634. Shope AL, Islam S, Zaher A. Pathologic quiz case: a 30-year-old man with recurrent pneumonia. Intralobar bronchopulmonary sequestration. Arch Pathol Lab Med. 2002 May;126(5):623-4. No abstract.

5635. Sood BP, Sodhi KS, Khandelwal N, Suri S. Is the patient dead: CT scan diagnosis. J Emerg Med. 2002 Apr;22(3):293. No abstract.

5636. Stevens DL, Herr D, Lampiris H, Hunt JL, Batts DH, Hafkin B. Linezolid versus vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infections. Clin Infect Dis. 2002 Jun 1;34(11):1481-90. . Abstract. Linezolid, the first available member of a new antibiotic class, the oxazolidinones, is broadly active against gram-positive bacteria, including drug-resistant strains. In this randomized, open-label trial, hospitalized adults with known or suspected methicillin-resistant Staphylococcus aureus (MRSA) infections were treated with linezolid (600 mg twice daily; n=240) or vancomycin (1 g twice daily; n=220) for 7-28 days. S. aureus was isolated from 53% of patients; 93% of these isolates were MRSA. Skin and soft-tissue infection was the most common diagnosis, followed by pneumonia and urinary tract infection. At the test-of-cure visit (15-21 days after the end of therapy), among evaluable patients with MRSA, there was no statistical difference between the 2 treatment groups with respect to clinical cure rates (73.2% of patients in the linezolid group and 73.1% in the vancomycin group) or microbiological success rates (58.9% in the linezolid group and 63.2% in the vancomycin group). Both regimens were well tolerated, with similar rates of adverse events.

5637. Trouillet JL, Vuagnat A, Combes A, Kassis N, Chastre J, Gibert C. Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms. Clin Infect Dis. 2002 Apr 15;34(8):1047-54. . Abstract. We sought to determine the epidemiological characteristics of patients in an intensive care unit (ICU) who developed ventilator-associated pneumonia (VAP) caused by piperacillin-resistant Pseudomonas aeruginosa (PRPA; n=34) or piperacillin-susceptible P. aeruginosa (PSPA; n=101). According to univariate analysis, the factors associated with the development of PRPA VAP were presence of an underlying fatal medical condition, immunocompromised status, longer previous hospital stay, less-severe illness at the time of ICU admission, duration of mechanical ventilation before onset of VAP, number of classes of antibiotic received, and previous exposure to imipenem or fluoroquinolone. Multivariate logistic regression analysis identified the following significant independent factors: presence of an underlying fatal medical condition (odds ratio [OR], 5.6), previous fluoroquinolone use (OR, 4.6), and initial disease severity (OR, 0.8). We concluded that the clinical characteristics of patients who develop PRPA VAP differ from those of patients who develop PSPA VAP. Restricted fluoroquinolone use is the sole independent risk factor for PRPA VAP that is open to medical intervention.

5638. Virkki R, Juven T, Rikalainen H, Svedstrom E, Mertsola J, Ruuskanen O. Differentiation of bacterial and viral pneumonia in children. Thorax. 2002 May;57(5):438-41. . Abstract. BACKGROUND: A study was undertaken to investigate the differential diagnostic role of chest radiographic findings, total white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and serum C reactive protein (CRP) in children with community acquired pneumonia of varying aetiology. METHODS: The study population consisted of 254 consecutive children admitted to hospital with community acquired pneumonia diagnosed between 1993 and 1995. WBC, ESR, and CRP levels were determined on admission. Seventeen infective agents (10 viruses and seven bacteria) were searched for. Chest radiographs were retrospectively and separately reviewed by three paediatric radiologists. RESULTS: A potential causative agent was found in 215 (85%) of the 254 cases. Bacterial infection was found in 71% of 137 children with alveolar infiltrates on the chest radiograph, while 72% of the 134 cases with a bacterial pneumonia had alveolar infiltrates. Half of the 77 children with solely interstitial infiltrates on the chest radiograph had evidence of bacterial infection. The proportion of patients with increased WBC or ESR did not differ between bacterial and viral pneumonias, but differences in the CRP levels of >40 mg/l, >80 mg/l, and >120 mg/l were significant although the sensitivity for detecting bacterial pneumonia was too low for use in clinical practice. CONCLUSIONS: Most children with alveolar pneumonia, especially those with lobar infiltrates, have laboratory evidence of a bacterial infection. Interstitial infiltrates are seen in both viral and bacterial pneumonias.  

5639. Woodruff PG, Fahy JV. A role for neutrophils in asthma? Am J Med. 2002 Apr 15;112(6):498-500. No abstract.

5640. Ariffin H, Navaratnam P, Lin HP. Surveillance study of bacteraemic episodes in febrile neutropenic children. Int J Clin Pract. 2002 May;56(4):237-40. . Abstract. We prospectively studied the type, frequency and outcome of infections in 513 patients with 762 consecutive episodes of febrile neutropenia (FN) over a five-year period between 1995 and 1999 in a single paediatric oncology unit. The findings were then compared with a similar study carried out in our unit between 1990 and 1994. The types of bacterial isolates and sensitivity patterns were also studied to identify trends and to gauge the suitability of antibiotics chosen for empirical therapy. Bacteraemia was documented in 35.4% of FN episodes, although 70% of patients did not have an obvious site of sepsis. The majority of isolates (61.9%) were gram-negative bacteria, a consistent finding throughout the study period. Resistance to ceftazidime, amikacin and imipenem among gram-negative bacteria was 26.3%, 21.2% and 0.7%, respectively. Methicillin resistance among gram-positive bacteria was 26.3%, while no vancomycin-resistant bacteria were encountered. There were 36 sepsis-related deaths. Factors associated with a fatal outome were prolonged capillary refill time, hypotension, fever above 39 degrees C and pneumonia. Rapid neutrophil recovery was associated with a good prognosis. A change to our current choice of empirical antibiotics for FN, comprising ceftazidime/ceftriaxone and amikacin appears necessary because of the relatively high resistance rates found.

5641. Berti I, Faraguna D. Pneumonia in children. N Engl J Med. 2002 Jun 13;346(24):1916; discussion 1916. No abstract. Combes A, Figliolini C, Trouillet JL, Kassis N, Wolff M, Gibert C, Chastre J.  Incidence and outcome of polymicrobial ventilator-associated pneumonia. Chest. 2002 May;121(5):1618-23.  . Abstract. STUDY OBJECTIVE: To determine the epidemiology and outcome of polymicrobial  ventilator-associated pneumonia (VAP). SETTING: Two ICUs (18 and 17 beds) in a university hospital. DESIGN AND PATIENTS: We undertook a 16-month study of 124 patients in whom a first episode of VAP had been diagnosed. Patients in whom there was a suspicion of clinical or radiologic VAP underwent bronchoscopy, and VAP was confirmed by the presence of at least two of the following criteria: > or = 2% of cells with intracellular bacteria found on direct examination of BAL fluid (BALF); protected-specimen brush sample culture with > or = 10(3) cfu/mL; or BALF culture with > or = 10(4) cfu/mL. RESULTS: Monomicrobial infections were diagnosed in 65 patients (52%), and polymicrobial infections were diagnosed in 59 patients (48%). Two different bacteria were isolated in 42 patients (34%), three different bacteria were isolated in 10 patients (8%), and four different bacteria were isolated in 7 patients (6%). Patients' clinical characteristics at ICU admission and on the day of bronchoscopy were similar, particularly the prior duration of mechanical ventilation (MV), the type of ICU admission, disease severity scores, and antibiotic therapy received before VAP was diagnosed. The percentages of nonfermenting, Gram-negative bacilli and methicillin-resistant staphylococci involved in monomicrobial and polymicrobial episodes were similar. Furthermore, no significant difference was detected in outcome parameters, specifically in the mortality rate at 30 days, the ICU mortality rate, the duration of MV, and the rate of infection relapse. CONCLUSION: In our study population, the epidemiology and outcomes of patients with monomicrobial and polymicrobial VAP did not differ significantly.

5642. Cortes G, Borrell N, de Astorza B, Gomez C, Sauleda J, Alberti S. Molecular analysis of the contribution of the capsular polysaccharide and the lipopolysaccharide O side chain to the virulence of Klebsiella pneumoniae in a murine model of pneumonia. Infect Immun. 2002 May;70(5):2583-90. No abstract.

5643. Dean GL, Williams DI, Churchill DR, Fisher MJ. Transient clinical deterioration in HIV patients with Pneumocystis carinii pneumonia after starting highly active antiretroviral therapy: another case of immune restoration inflammatory syndrome. Am J Respir Crit Care Med. 2002 Jun 15;165(12):1670; discussion 1670. No abstract.

5644. Dooley KE, Golub J, Goes FS, Merz WG, Sterling TR. Empiric treatment of community-acquired pneumonia with fluoroquinolones, and delays in the treatment of tuberculosis. Clin Infect Dis. 2002 Jun 15;34(12):1607-12. . Abstract. Fluoroquinolones, which are widely used to treat community-acquired pneumonia, also have excellent in vitro activity against Mycobacterium tuberculosis. A retrospective cohort study was conducted among adults with culture-confirmed tuberculosis to assess the effect of empiric fluoroquinolone therapy on delays in the treatment of tuberculosis. Sixteen (48%) of 33 patients received fluoroquinolones for presumed bacterial pneumonia before tuberculosis was diagnosed and treated. There were no differences between the group who did and the group who did not receive fluoroquinolones, except that patients who received fluoroquinolones were more likely to present with shortness of breath. Among patients treated empirically with fluoroquinolones, the median time between presentation to the hospital and initiation of antituberculosis treatment was 21 days (interquartile range, 5-32 days); among those who were not, it was 5 days (interquartile range, 1-16 days; P=.04). Initial empiric therapy with a fluoroquinolone was associated with a delay in the initiation of appropriate antituberculosis treatment.

5645. D'Souza RM, D'Souza R. Vitamin A for preventing secondary infections in children with measles—a systematic review. J Trop Pediatr. 2002 Apr;48(2):72-7. Review. . Abstract. The objective of the present study was to determine whether vitamin A prevents pneumonia, diarrhoea and other infections in children with measles. A meta-analysis was carried out of randomized controlled trials identified through a systematic search of the medical literature for studies that used vitamin A to treat measles. A total of 492 children, aged from 6 months to 13 years, were supplemented with vitamin A, and 536 children were given placebo in six trials, five of which were conducted in hospitals and one in a community setting. The main outcome measures were: incidence of pneumonia, diarrhoea, croup, and otitis media; and duration of pneumonia, diarrhoea, fever and hospitalization. There was no significant reduction in the incidence of pneumonia or diarrhoea but there was a 47 per cent reduction in the incidence of croup (RR = 0.53; 95 per cent CI = 0.29-0.89) in children who were treated with 200 000 IU of vitamin A on 2 consecutive days. Only one study reported a 74 per cent reduction in the incidence of otitis media (RR = 0.26 95 per cent CI = 0.05-0.92). There was a statistically significant decrease in the duration of diarrhoea, pneumonia, hospital stay and fever in individual studies. It was concluded that vitamin A does have a beneficial effect on morbidity associated with measles and should be used as a treatment for hospitalized measles cases.

5646. Elward AM, Warren DK, Fraser VJ. Ventilator-associated pneumonia in pediatric intensive care unit patients: risk factors and outcomes. Pediatrics. 2002 May;109(5):758-64. . Abstract. OBJECTIVES: To determine the rates, risk factors, and outcomes of ventilator-associated pneumonia in pediatric intensive care unit (PICU) patients. METHODS: A prospective cohort study was conducted at the St Louis Children's Hospital PICU on all patients who were admitted to the PICU from September 1, 1999, to May 31, 2000, except those who died within 24 hours, were > or =18 years of age, or were neonatal intensive care unit patients on extracorporeal membrane oxygenation. The primary outcome measured was the development of ventilator-associated pneumonia. Secondary outcomes were death and hospital and PICU length of stay. Multiple logistic regression analysis was performed to determine independent predictors for ventilator-associated pneumonia. RESULTS: There were 34 episodes of ventilator-associated pneumonia in 30 patients of 911 admissions (3.3%) and 595 (5.1%) mechanically ventilated patients. The mean ventilator-associated pneumonia rate was 11.6/1000 ventilator days. By logistic regression analysis, genetic syndrome (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.01-5.46), reintubation (OR: 2.71; 95% CI: 1.18-6.21), and transport out of the PICU (OR: 8.90; 95% CI: 3.82-20.74) independently predicted ventilator-associated pneumonia. CONCLUSIONS: Ventilator-associated pneumonia occurs at significant rates among mechanically ventilated PICU patients and is associated with processes of care. Additional studies are necessary to develop interventions to prevent ventilator-associated pneumonia.

5647. Ikehara K, Suzuki M, Tsuburai T, Ishigatsubo Y. Lipoid pneumonia. Lancet. 2002 Apr 13;359(9314):1300.  No abstract.

5648. Khilnani GC. Fibrinolytic therapy for parapneumonic effusion and empyema. Indian J Chest Dis Allied Sci. 2002 Apr-Jun;44(2):81-4. No abstract.

5649. King TE Jr. Nonspecific interstitial pneumonia and systemic sclerosis. Am J Respir Crit Care Med. 2002 Jun 15;165(12):1578-9. No abstract.

5650. Li I. Feeding tubes in patients with severe dementia. Am Fam Physician. 2002 Apr 15;65(8):1605-10, 1515. Review. No abstract.

5651. Loens K, Ursi D, Ieven M, van Aarle P, Sillekens P, Oudshoorn P, Goossens H.  Detection of Mycoplasma pneumoniae in spiked clinical samples by nucleic acid sequence-based amplification. J Clin Microbiol. 2002 Apr;40(4):1339-45. No abstract.

5652. Matsui T, Yamaya M, Ohrui T, Arai H, Sasaki H. Sitting position to prevent aspiration in bed-bound patients. Gerontology. 2002 May-Jun;48(3):194-5.  No abstract.

5653. Matsushima T, Miyashita N, File TM Jr. Etiology and management of community-acquired pneumonia in Asia. Curr Opin Infect Dis. 2002 Apr;15(2):157-62. Review. No abstract.

5654. Mojon P. Oral health and respiratory infection. J Can Dent Assoc. 2002 Jun;68(6):340-5. Review. . Abstract.  he oral cavity has long been considered a potential reservoir for respiratory pathogens. The mechanisms of infection could be aspiration into the lung of oral pathogens capable of causing pneumonia, colonization of dental plaque by respiratory pathogens followed by aspiration, or facilitation by periodontal pathogens of colonization of the upper airway by pulmonary pathogens. Several anaerobic bacteria from the periodontal pocket have been isolated from infected lungs. In elderly patients living in chronic care facilities, the colonization of dental plaque by pulmonary pathogens is frequent. Notably, the overreaction of the inflammatory process that leads to destruction of connective tissue is present in both periodontal disease and emphysema. This overreaction may explain the association between periodontal disease and chronic obstructive pulmonary disease, the fourth leading cause of death in the United States. These findings underline the necessity for improving oral hygiene among patients who are at risk and those living in long-term care institutions.

5655. Mueller DK, Whitten PE, Tillis WP, Bond LM, Munns JR. Delayed closure of persistent postpneumonectomy bronchopleural fistula. Chest. 2002 May;121(5):1703-4. No abstract.

5656. Saraiva LR. Rheumatic pneumonia. Ann Rheum Dis. 2002 May;61(5):477; discussion 477.  No abstract.

5657. Zhang P, Bagby GJ, Happel KI, Summer WR, Nelson S. Pulmonary host defenses and alcohol. Front Biosci. 2002 May 1;7:d1314-30. Review. No abstract.

5658. Appelbaum PC. Resistance among Streptococcus pneumoniae: Implications for drug selection. Clin Infect Dis. 2002 Jun 15;34(12):1613-20. Review. . Abstract. Streptococcus pneumoniae is an important pathogen in many community-acquired respiratory infections in the United States and a leading cause of morbidity and mortality worldwide. Unfortunately, S. pneumoniae is becoming increasingly resistant to a variety of antibiotics. Results of recent surveillance studies in the United States show that the prevalence of penicillin-nonsusceptible S. pneumoniae ranges from 25% to >50%, and rates of macrolide resistance among pneumococci are reported to be as high as 31%. A high prevalence of resistance to other antimicrobial classes is found among penicillin-resistant strains. Newer quinolones (e.g., gatifloxacin, gemifloxacin, and moxifloxacin) that have better antipneumococcal activity in vitro are the most active agents and therefore are attractive options for treatment of adults with community-acquired respiratory infections. Efforts should be made to prevent pneumococcal nfections in high-risk patients through vaccination.

5659. Bavaro MF, Catbagan AC, Tasker SA, Gray DE, Waecker NJ, Wallace MR. Drug-resistant Streptococcus pneumoniae in a day care population. Clin Infect Dis. 2002 Apr 15;34(8):1164. No abstract.

5660. Greenberg SB. Respiratory viral infections in adults. Curr Opin Pulm Med. 2002 May;8(3):201-8. Review.  . Abstract. Respiratory viral infections in adults cause significant morbidity and mortality, especially in high-risk patients. The impact of influenza virus, rhinoviruses, and respiratory syncytial virus in immunocompromised cancer patients and in asthma and chronic bronchitis patients has been documented in recent publications. Cytomegalovirus pneumonia continues to be a major cause of morbidity and mortality in transplant recipients. Newer rapid diagnostic tests and the use of polymerase chain reaction technology have provided better understanding of the causes and epidemiology of acute respiratory illness in adults. The approved neuraminidase inhibitors for influenza viruses and the nonapproved capsid inhibitors of rhinoviruses may be useful in treating high-risk individuals. The inactivated influenza vaccine has been shown to benefit healthy adults and to be safe in asthmatic adults and children.

5661. Smits AJ, Hak E, Stalman WA, van Essen GA, Hoes AW, Verheij TJ. Clinical effectiveness of conventional influenza vaccination in asthmatic children. Epidemiol Infect. 2002 Apr;128(2):205-11. . Abstract. Influenza immunization rates among young asthmatics remain unsatisfactory due to persistent concern about the impact of influenza and the benefits of the vaccine. We assessed the effectiveness of the conventional inactivated trivalent sub-unit influenza vaccine in reducing acute respiratory disease in asthmatic children. We conducted a two-season retrospective cohort study covering the 1995-6 and 1996-7 influenza outbreaks in 22 computerized primary care practices in The Netherlands. In total, 349 patients aged between 0 and 12 years meeting clinical asthma-criteria were included; 14 children were lost to follow-up in the second season. The occurrence of physician-diagnosed acute respiratory disease episodes including influenza-like illness, pneumonia. bronchitis, bronchiolitis, asthma exacerbation and acute otitis media in vaccinated and unvaccinated children were compared after adjustments for age, prior health care and medication use. The occurrence of acute respiratory disease in unvaccinated children was 28% and 24% in the 1995-6 and 1996-7 season, respectively, and was highest in children under 6 years of age (43%). The overall pooled clinical vaccine effectiveness was 27% (95% confidence interval -7 to 51%, P = 0.11) after adjustments. A statistically higher vaccine protectiveness of 55% (95% CI 20-75%, P = 0.01) was observed among asthmatics under 6 years of age compared with -5% in older children (95% CI -81 to 39%). The occurrence of acute respiratory disease among asthmatic children during influenza epidemics is very high, notably in the youngest. Influenza vaccination may reduce morbidity in asthmatic infants and pre-school children. However, larger, preferably experimental, studies are needed to establish the benefits of vaccination, notably in older asthmatic children.

5662. Patel U, Agrawal M, Krishnan P, Niranjan S. Neuroleptic malignant syndrome presenting as pulmonary edema and severe bronchorrhea. J Natl Med Assoc. 2002 Apr;94(4):279-82. . Abstract. Neuroleptic malignant syndrome is a rare (incidence, 0.02%-3.2%) but dangerous complication following the use of neuroleptic drugs. When not promptly recognized, this disease carries a high mortality (10%-20%) and morbidity rate. We report an unusual case of neuroleptic malignant syndrome that presented predominantly with autonomic instability in the form of recurrent episodes of respiratory distress. The respiratory distress was initially caused by pulmonary edema and later was caused by severe bronchorrhea. We propose that aspiration pneumonia resulting in respiratory failure, the leading cause of death in neuroleptic malignant syndrome, may be a result of a combination of altered mental status and bronchorrhea. This has therapeutic implications because early institution of bromocriptine/dantrolene can prevent aspiration pneumonia and, hence, mortality from respiratory failure.

 

 

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