Archive for July, 2009

Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009

MMWR  Recommendations and Reports  July 31, 2009  V.58  N.RR-8  1-52

This report updates the 2008 recommendations by CDC’s Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of seasonal influenza. Information on vaccination issues related to the recently identified novel influenza A H1N1 virus will be published later in 2009. The 2009 seasonal influenza recommendations include new and updated information. Highlights of the 2009 recommendations include 1) a recommendation that annual vaccination be administered to all children aged 6 months–18 years for the 2009-10 influenza season; 2) a recommendation that vaccines containing the 2009–10 trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; and  3) a notice that recommendations for influenza diagnosis and antiviral use will be published before the start of the 2009-10 influenza season. Vaccination efforts should begin as soon as vaccine is available and continue through the influenza season.

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July 30, 2009 at 5:57 pm Leave a comment

Intensive-Care Patients With Severe Novel Influenza A (H1N1) Virus Infection — Michigan, June 2009

MMWR Weekly  July 17, 2009 V.58  N.27  p.749-752

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July 30, 2009 at 5:55 pm Leave a comment

Update: Novel Influenza A (H1N1) Virus Infections — Worldwide, May 6, 2009

MMWR Weekly May 8, 2009  V.58  N.17  p.453-458

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July 30, 2009 at 5:54 pm Leave a comment

Respiratory Syncytial Virus and Parainfluenza Virus

N Engl J of Medicine  June 21, 2001  V.344  N.25  p.1917-1928


Medical Progress

Caroline Breese Hall, M.D.



July 30, 2009 at 5:51 pm Leave a comment

A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia

N Engl J of Medicine  Dec.21, 2006  V.355  N.25  p.2619-2630

The Canadian Critical Care Trials Group

Background Critically ill patients who require mechanical ventilation are at risk for ventilator-associated pneumonia. Current data are conflicting as to the optimal diagnostic approach in patients who have suspected ventilator-associated pneumonia.

Methods In a multicenter trial, we randomly assigned immunocompetent adults who were receiving mechanical ventilation and who had suspected ventilator-associated pneumonia after 4 days in the intensive care unit (ICU) to undergo either bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid or endotracheal aspiration with nonquantitative culture of the aspirate. Patients known to be colonized or infected with pseudomonas species or methicillin-resistant Staphylococcus aureus were excluded. Empirical antibiotic therapy was initiated in all patients until culture results were available, at which point a protocol of targeted therapy was used for discontinuing or reducing the dose or number of antibiotics, or for resuming antibiotic therapy to treat a preenrollment condition if the culture was negative.

Results We enrolled 740 patients in 28 ICUs in Canada and the United States. There was no significant difference in the primary outcome (28-day mortality rate) between the bronchoalveolar-lavage group and the endotracheal-aspiration group (18.9% and 18.4%, respectively; P=0.94). The bronchoalveolar-lavage group and the endotracheal-aspiration group also had similar rates of targeted therapy (74.2% and 74.6%, respectively; P=0.90), days alive without antibiotics (10.4±7.5 and 10.6±7.9, P=0.86), and maximum organ-dysfunction scores (mean [±SD], 8.3±3.6 and 8.6±4.0; P=0.26). The two groups did not differ significantly in the length of stay in the ICU or hospital.

Conclusions Two diagnostic strategies for ventilator-associated pneumonia — bronchoalveolar lavage with quantitative culture of the bronchoalveolar-lavage fluid and endotracheal aspiration with nonquantitative culture of the aspirate — are associated with similar clinical outcomes and similar overall use of antibiotics.



July 26, 2009 at 9:56 pm Leave a comment

Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia

Am J of Respiratory and Critical Care Medicine  Feb 2005  V.171  N.4  p.388-416

American Thoracic Society Documents

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July 26, 2009 at 9:53 pm Leave a comment

Respiratory Syncytial Virus Infection in Elderly and High-Risk Adults

N Engl J of Medicine  Apr 28, 2005  V.352  N.17  p.1749-1759

Ann R. Falsey, M.D., Patricia A. Hennessey, R.N., Maria A. Formica, M.S., Christopher Cox, Ph.D., and Edward E. Walsh, M.D.

Background Respiratory syncytial virus (RSV) is an increasingly recognized cause of illness in adults. Data on the epidemiology and clinical effects in community-dwelling elderly persons and high-risk adults can help in assessing the need for vaccine development.

Methods During four consecutive winters, we evaluated all respiratory illnesses in prospective cohorts of healthy elderly patients (65 years of age) and high-risk adults (those with chronic heart or lung disease) and in patients hospitalized with acute cardiopulmonary conditions. RSV infection and influenza A were diagnosed on the basis of culture, reverse-transcriptase polymerase chain reaction, and serologic studies.

Results A total of 608 healthy elderly patients and 540 high-risk adults were enrolled in prospective surveillance, and 1388 hospitalized patients were enrolled. A total of 2514 illnesses were evaluated. RSV infection was identified in 102 patients in the prospective cohorts and 142 hospitalized patients, and influenza A was diagnosed in 44 patients in the prospective cohorts and 154 hospitalized patients. RSV infection developed annually in 3 to 7 percent of healthy elderly patients and in 4 to 10 percent of high-risk adults. Among healthy elderly patients, RSV infection generated fewer office visits than influenza; however, the use of health care services by high-risk adults was similar in the two groups. In the hospitalized cohort, RSV infection and influenza A resulted in similar lengths of stay, rates of use of intensive care (15 percent and 12 percent, respectively), and mortality (8 percent and 7 percent, respectively). On the basis of the diagnostic codes of the International Classification of Diseases, 9th Revision, Clinical Modification at discharge, RSV infection accounted for 10.6 percent of hospitalizations for pneumonia, 11.4 percent for chronic obstructive pulmonary disease, 5.4 percent for congestive heart failure, and 7.2 percent for asthma.

Conclusions RSV infection is an important illness in elderly and high-risk adults, with a disease burden similar to that of nonpandemic influenza A in a population in which the prevalence of vaccination for influenza is high. An effective RSV vaccine may offer benefits for these adults.



July 26, 2009 at 9:50 pm Leave a comment

Analysis of Two Double-Blind Studies of Patients With Methicillin-Resistant Staphylococcus aureus Nosocomial Pneumonia

Chest  November 2003  V.124  N.5  p.1789-1797

Linezolid vs Vancomycin*

Richard G. Wunderink, MD, FCCP, Jordi Rello, MD, PhD, Sue K. Cammarata, MD, FCCP, Rodney V. Croos-Dabrera, PhD, and Marin H. Kollef, MD, FCCP

From Methodist Healthcare Memphis and the University of Tennessee (Dr. Wunderink), Memphis, TN; Joan XXIII University Hospital (Dr. Rello), University Rovira i Virgili, Tarragona, Spain; Pharmacia (Drs. Cammarata and Croos-Dabrera), Kalamazoo, MI; and Department of Internal Medicine, Pulmonary and Critical Care Division (Dr. Kollef), Washington University School of Medicine, St. Louis, MO.

Objective: To assess the effect of baseline variables, including treatment, on outcome in patients with nosocomial pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA).

Design: Retrospective analysis of data from two prospective, randomized, double-blind studies.

Setting: Multinational study with 134 sites.

Patients: A total of 1,019 patients with suspected Gram-positive nosocomial pneumonia, including 339 patients with documented S aureus pneumonia (S aureus subset) and 160 patients with documented MRSA pneumonia (MRSA subset).

Interventions: Linezolid, 600 mg, or vancomycin, 1 g, q12h for 7 to 21 days, each with aztreonam.

Measurements and results: Outcome was measured by survival and clinical cure rates (assessed 12 to 28 days after the end of therapy). Logistic regression analysis was used to determine the effect of treatment and other baseline variables on outcome. Kaplan-Meier survival rates for linezolid vs vancomycin were 80.0% (60 of 75 patients) vs 63.5% (54 of 85 patients) for the MRSA subset (p = 0.03). Logistic regression analysis confirmed that the survival difference favoring linezolid remained significant after adjusting for baseline variables (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.0 to 4.8; p = 0.05). Other baseline variables associated with significantly higher survival rates in MRSA pneumonia were serum creatinine levels less than or equal to two times the upper limit of normal and absence of cardiac comorbidities. Clinical cure rates for linezolid vs vancomycin (excluding indeterminate or missing outcomes) were 59.0% (36 of 61 patients) vs 35.5% (22 of 62 patients) for the MRSA subset (p < 0.01). Logistic regression analysis confirmed that the difference favoring linezolid remained significant after adjusting for baseline variables (OR, 3.3; 95% CI, 1.3 to 8.3; p = 0.01). Other baseline variables associated with significantly higher clinical cure rates in MRSA pneumonia were single-lobe pneumonia, absence of ventilator-associated pneumonia, and absence of oncologic and renal comorbidities.

Conclusions: In this retrospective analysis, initial therapy with linezolid was associated with significantly better survival and clinical cure rates than was vancomycin in patients with nosocomial pneumonia due to MRSA.



July 26, 2009 at 6:59 pm Leave a comment

Evolution of antimicrobial resistance among Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae in Brooklyn, NY

Journal of Antimicrobial Chemotherapy  July 2007  V.60  N.1  p.78-82

David Landman1, Simona Bratu1, Sandeep Kochar1, Monica Panwar1, Manoj Trehan1, Mehmet Doymaz2 and John Quale1,*

1 State University of New York—Downstate, Brooklyn, NY, USA 2 Beth Israel Medical Center, New York, NY, USA

Objectives: To document resistance patterns of three important nosocomial pathogens, Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae, present in hospitals in Brooklyn, NY.

Methods: Susceptibility profiles of pathogens gathered during a surveillance study in 2006 were analysed and compared with similar surveys performed in 1999 and 2001. MICs were determined according to CLSI standards, and selected isolates were screened by PCR for the presence of VIM, IMP and KPC ß-lactamases.

Results: For P. aeruginosa, susceptibility to most antimicrobials fell in 2001 and then reached a plateau. However, there was a progressive decrease in the number of patients with P. aeruginosa during the three surveys. While the total number of isolates of A. baumannii remained steady, there was a progressive decrease in susceptibility to most classes of antimicrobial agents, and approximately one-third had combined resistance to carbapenems, fluoroquinolones and aminoglycosides. There was a noticeable rise in the number of isolates of K. pneumoniae over the surveillance periods, suggesting that this has become the predominant pathogen in many medical centres. Over one-third of K. pneumoniae collected in 2006 carried the carbapenemase KPC, and 22% were resistant to all three classes of antimicrobial agents.

Conclusions: Hospitals in our region have been beset with antimicrobial-resistant Gram-negative bacteria. K. pneumoniae has rapidly emerged as the most common multidrug-resistant pathogen. Improved therapeutic agents and methods of detection are needed to reduce transmission of these bacteria.



July 26, 2009 at 6:55 pm Leave a comment

Viral Infection in Adults Hospitalized With Community-Acquired Pneumonia

Chest  Dec 2008  V.134  N.6  p.1141-1148

Prevalence, Pathogens, and Presentation

Jennie Johnstone, MD, Sumit R. Majumdar, MD, MPH, Julie D. Fox, PhD, and Thomas J. Marrie, MD*

*From the Department of Medicine (Drs. Johnstone, Majumdar, and Marrie), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; and the Department of Microbiology (Dr. Fox), Provincial Laboratory for Public Health, Calgary, AB, Canada.

Background: The potential role of respiratory viruses in the natural history of community-acquired pneumonia (CAP) in adults has not been well described since the advent of nucleic amplification tests (NATs).

Methods: From 2004 to 2006, adults with CAP who were admitted to five hospitals were prospectively enrolled in the study, and clinical data, cultures, serology, and nasopharyngeal swabs were obtained. NATs from swabs were tested for influenza, human metapneumovirus (hMPV), respiratory syncytial virus (RSV), rhinovirus, parainfluenza virus 1–4, coronaviruses (OC43, 229E, and NL63), and adenovirus.

Results: A total of 193 patients were included; the median age was 71 years, 51% of patients were male, and 47% of patients had severe CAP. Overall, 75 patients (39%) had a pathogen identified. Of these pathogens, 29 were viruses (15%), 38 were bacteria (20%), 8 were mixed (4%), and the rest were “unknown.” Influenza (n = 7), hMPV (n = 7), and RSV (n = 5) accounted for most viral infections; other infections included rhinovirus (n = 4), parainfluenza (n = 3), coronavirus (n = 4), and adenovirus (n = 2). Streptococcus pneumoniae was the most common bacterial infection (37%). Compared with bacterial infection, patients with viral infection were older (76 vs 64 years, respectively; p = 0.01), were more likely to have cardiac disease (66% vs 32%, respectively; p = 0.006), and were more frail (eg, 48% with limited ambulation vs 21% of bacterial infections; p = 0.02). There were few clinically meaningful differences in presentation and no differences in outcomes according to the presence or absence of viral infection.

Conclusions: Viral infections are common in adults with pneumonia. Easily transmissible viruses such as influenza, hMPV, and RSV were the most common, raising concerns about infection control. Routine testing for respiratory viruses may be warranted for adults who have been hospitalized with pneumonia.


July 26, 2009 at 6:54 pm Leave a comment

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