Archive for March 14, 2009

Health-Care–Associated Pneumonia Among Hospitalized Patients in a Japanese Community Hospital

Chest March 2009 V.135 N.3 p.633-640

Yuichiro Shindo, MD*, Shinji Sato, MD, PhD, Eiichi Maruyama, MD, Takamasa Ohashi, MD, PhD, Masahiro Ogawa, MD, Naozumi Hashimoto, MD, PhD, Kazuyoshi Imaizumi, MD, PhD, Tosiya Sato, PhD and Yoshinori Hasegawa, MD, PhD, FCCP

From the Department of Respiratory Medicine (Drs. Shindo, Hashimoto, Imaizumi, and Hasegawa), Nagoya University Graduate School of Medicine, Nagoya, Japan; the Department of Respiratory Medicine (Drs. S. Sato, Maruyama, Ohashi, and Ogawa), Handa City Hospital, Aichi, Japan; and the Department of Biostatistics (Dr. T. Sato), Kyoto University School of Public Health, Kyoto, Japan.

Background: Health-care–associated pneumonia (HCAP) is a relatively new concept. Epidemiologic studies are limited, and initial empirical antibiotic treatment is still under discussion. This study aimed to reveal the differences in mortality and pathogens between HCAP and community-acquired pneumonia (CAP) in each severity class, and to clarify the strategy for the treatment of HCAP.

Methods: We conducted a retrospective observational study of patients with HCAP and CAP who were hospitalized between November 2005 and January 2007, and compared baseline characteristics, severity, pathogen distribution, antibiotic regimens, and outcomes. In each severity class (mild, moderate, and severe) assessed using the A-DROP scoring system (ie, age, dehydration, respiratory failure, orientation disturbance, and low BP), we investigated the in-hospital mortality and occurrence of potentially drug-resistant (PDR) pathogens.

Results: A total of 371 patients (141 HCAP patients, 230 CAP patients) were evaluated. The proportion of patients in the severe class was higher in the HCAP patients than in CAP patients. In the moderate class, the in-hospital mortality proportion of HCAP patients was significantly higher than that of CAP patients (11.1% vs 1.9%, respectively; p = 0.008). In moderate-class patients in whom pathogens were identified, PDR pathogens were isolated more frequently from HCAP patients than from CAP patients (22.2% vs 1.9%, respectively; p = 0.002). The occurrence of PDR pathogens was associated with initial treatment failure and inappropriate initial antibiotic treatment.

Conclusions: The present study provides additional evidence that HCAP should be distinguished from CAP, and suggests that the therapeutic strategy for HCAP in the moderate class holds the key to improving mortality. Physicians may need to consider PDR pathogens in selecting the initial empirical antibiotic treatment of HCAP.


March 14, 2009 at 4:55 pm Leave a comment

Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century – The International Collaboration on Endocarditis–Prospective Cohort Study

Archives of Internal Medicine March 9, 2009 V.169 N.5 p.463-473

David R. Murdoch, MD, MSc; G. Ralph Corey, MD; Bruno Hoen, MD; José M. Miró, MD, PhD; Vance G. Fowler Jr, MD, MHS; Arnold S. Bayer, MD; Adolf W. Karchmer, MD; Lars Olaison, MD, PhD; Paul A. Pappas, MS; Philippe Moreillon, MD, PhD; Stephen T. Chambers, MD, MSc; Vivian H. Chu, MD, MHS; Vicenç Falcó, MD; David J. Holland, MB, ChB, PhD; Philip Jones, MD; John L. Klein, MD; Nigel J. Raymond, MB, ChB; Kerry M. Read, MB, ChB; Marie Francoise Tripodi, MD; Riccardo Utili, MD; Andrew Wang, MD; Christopher W. Woods, MD, MPH; Christopher H. Cabell, MD, MHS; for the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS) Investigators

Department of Pathology, University of Otago, Christchurch, New Zealand (Drs Murdoch and Chambers); Departments of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Corey, Fowler, Karchmer, Chu, Wang, Woods, and Cabell), Centre Hospitalier Universitaire, University of Lausanne, Lausanne, Switzerland (Dr Moreillon), Middlemore Hospital (Dr Holland) and North Shore Hospital (Dr Read), Auckland, New Zealand, and Wellington Hospital, Wellington, New Zealand (Dr Raymond); Duke Clinical Research Institute (Drs Corey, Fowler, and Cabell and Mr Pappas), Durham; Departments of Infectious Diseases, Hôpital Saint-Jacques, Besançon, France (Dr Hoen), Sahlgrenska University Hospital, Göteborg, Sweden (Dr Olaison), Hospital Universitari Vall D’Hebron, Barcelona, Spain (Dr Falcó), and University of New South Wales, Sydney, Australia (Dr Jones); Hospital Clinic–Institut d’Investigacions Biomèdiques August Pi I Sunyer, University of Barcelona, Barcelona (Dr Miró); Divisions of Infectious Diseases, University of California, Los Angeles, Harbor Medical Center, Torrance (Dr Bayer), and Beth Israel-Deaconess Medical Center, Boston, Massachusetts (Dr Karchmer); Department of Infection, St Thomas’ Hospital, London, England (Dr Klein); and Department of Cardiothoracic and Respiratory Services, Second University of Naples, Naples, Italy (Drs Tripodi and Utili).

Background We sought to provide a contemporary picture of the presentation, etiology, and outcome of infective endocarditis (IE) in a large patient cohort from multiple locations worldwide.

Methods Prospective cohort study of 2781 adults with definite IE who were admitted to 58 hospitals in 25 countries from June 1, 2000, through September 1, 2005.

Results The median age of the cohort was 57.9 (interquartile range, 43.2-71.8) years, and 72.1% had native valve IE. Most patients (77.0%) presented early in the disease (<30 days) with few of the classic clinical hallmarks of IE. Recent health care exposure was found in one-quarter of patients. Staphylococcus aureus was the most common pathogen (31.2%). The mitral (41.1%) and aortic (37.6%) valves were infected most commonly. The following complications were common: stroke (16.9%), embolization other than stroke (22.6%), heart failure (32.3%), and intracardiac abscess (14.4%). Surgical therapy was common (48.2%), and in-hospital mortality remained high (17.7%). Prosthetic valve involvement (odds ratio, 1.47; 95% confidence interval, 1.13-1.90), increasing age (1.30; 1.17-1.46 per 10-year interval), pulmonary edema (1.79; 1.39-2.30), S aureus infection (1.54; 1.14-2.08), coagulase-negative staphylococcal infection (1.50; 1.07-2.10), mitral valve vegetation (1.34; 1.06-1.68), and paravalvular complications (2.25; 1.64-3.09) were associated with an increased risk of in-hospital death, whereas viridans streptococcal infection (0.52; 0.33-0.81) and surgery (0.61; 0.44-0.83) were associated with a decreased risk.

Conclusions In the early 21st century, IE is more often an acute disease, characterized by a high rate of S aureus infection. Mortality remains relatively high.


March 14, 2009 at 4:54 pm Leave a comment


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