Archive for December 12, 2009

Pneumonia Severity Index Class V Patients With Community-Acquired Pneumonia* – Characteristics, Outcomes, and Value of Severity Scores

Chest  Nov. 2009  V.136  N.5  Suppl  515-522

Mauricio Valencia, MD, Joan R. Badia, MD, Manuela Cavalcanti, MD, Miquel Ferrer, MD, Carles Agustí, MD, Joaquin Angrill, MD, Elisa García, MD, Josep Mensa, MD, Michael S. Niederman, MD, FCCP, and Antoni Torres, MD, FCCP

From the Servei de Pneumologia (Drs. Valencia, Badia, Cavalcanti, Ferrer, Agustí, Angrill, and Torres), Institut Clínic del Tórax, and the Servei de Malalties Infeccioses (Drs. García and Mensa), Institut Clínic de Medicina i Dermatologia, Hospital Clinic de Barcelona, Institut de Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; and the Department of Medicine (Dr. Niederman), Winthrop-University Hospital, Mineola, NY.

Background: Community-acquired pneumonia (CAP) with a pneumonia severity index (PSI) score in risk class V (PSI-V) is a potentially life-threatening condition, yet the majority of patients are not admitted to the ICU. The aim of this study was to characterize CAP patients in PSI-V to determine the risk factors for ICU admission and mortality, and to assess the performance of CAP severity scores in this population.

Methods: Prospective observational study including hospitalized adults with CAP in PSI-V from 1996 to 2003. Clinical and laboratory data, microbiological findings, and outcomes were recorded. The PSI score; modified American Thoracic Society (ATS) score; the confusion, urea, respiratory rate, low BP (CURB) score, and CURB plus age of ≥ 65 years score were calculated. A reduced score based on the acute illness variables contained in the PSI was also obtained.

Results: A total of 457 patients were included in the study (mean [± SD] age, 79 ± 11 years), of whom 92 (20%) were admitted to the ICU. Patients in the ward were older (mean age, 82 ± 10 vs 70 ± 10 years, respectively) and had more comorbidities. ICU patients experienced significantly more acute organ failures. The mortality rate was higher in ICU patients, but also was high for non-ICU patients (37% vs 20%, respectively; p = 0,003). A low level of consciousness (odds ratio [OR], 3.95; 95% confidence interval [CI], 2 to 5) and shock (OR, 24.7; 95% CI, 14 to 44) were associated with a higher risk of death. The modified ATS severity rule had the best accuracy in predicting ICU admission and mortality.

Conclusions: Most CAP patients PSI-V were treated on a hospital ward. Those admitted to the ICU were younger and had findings of more acute illness. The PSI performed well as a mortality prediction tool but was less appropriate for guiding site-of-care decisions.



December 12, 2009 at 12:59 pm Leave a comment

Kinetics of nasopharyngeal shedding of novel H1N1 (swine-like) influenza A virus in an immunocompetent adult under oseltamivir therapy

Clinical Microbiology and Infection  Nov. 2009  V.15  N.12  p.1189-1191


C. Charlier 1 , V. Enouf 2 , F. Lanternier 1 , M. Grandadam 3 , K. Amazzough 1 , S. Blanche 4 , M. Lecuit 1 , O. Lortholary 1,* and S. van der Werf 2,*

1) Université Paris Descartes, Service de Maladies Infectieuses et Tropicales, Centre d’Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris ,   2) National Influenza Centre (Northern France), Unité de Génétique Moléculaire des Virus à ARN, Institut Pasteur, URA3015 CNRS, Université Paris-Diderot ,   3) Unité des Interactions Moléculaires Flavivirus-Hôtes, Institut Pasteur and   4) Université Paris Descartes, Unité Hématologie Immunologie, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France


We describe a patient with confirmed novel H1N1 (swine-like) influenza A virus who had daily nasal swabs tested during oseltamivir therapy. Nasal shedding remained positive for 2 days and became negative on day 3. This report presents the first available data on the kinetics of shedding of this novel virus under antiviral therapy.


December 12, 2009 at 12:57 pm Leave a comment

Efficacy and tolerance of rifampicin–linezolid compared with rifampicin–cotrimoxazole combinations in prolonged oral therapy for bone and joint infections

Clinical Microbiology and Infection  Nov. 2009  V.15  N.12  p.1163-1169

S. Nguyen 1 , A. Pasquet 1 , L. Legout 1 , E. Beltrand 2 , L. Dubreuil 1 , H. Migaud 3 , Y. Yazdanpanah 1 and E. Senneville 1

1) Department of Infectious Diseases ,   2) Department of Orthopaedic Surgery, Dron Hospital of Tourcoing, Tourcoing and   3) Department of Orthopaedic Surgery, Lille University Hospital, Lille, France


Both linezolid and cotrimoxazole are antibiotics that are well suited for oral therapy of bone and joint infections (BJI) caused by otherwise resistant Gram-positive cocci (GPC) (resistance to fluoroquinolones, maccolides, betalactamines). However, in this context, no data are currently available regarding the safety and tolerance of these antibiotics in combination with rifampicin. The objective of this study was to compare the efficacy and safety of a combination of rifampicin and linezolid (RLC) with those of a combination of rifampicin and cotrimoxazole (RCC) in the treatment of BJI. Between February 2002 and December 2006, 56 adult patients (RLC, n = 28; RCC, n = 28), including 36 with infected orthopaedic devices (RLC, n = 18; RCC, n = 18) and 20 with chronic osteomyelitis (RLC, n = 10; RCC, n = 10), were found to be eligible for inclusion in this study. Patients who discontinued antibiotic therapy within 4 weeks of commencing treatment were considered to represent cases of treatment failure and were excluded. Rates of occurrence of adverse effects were similar in the two groups, at 42.9% in the RLC group and 46.4% in the RCC group (p = 1.00), and led to treatment discontinuation in four (14.3%) RLC and six (21.4%) RCC patients. Cure rates were found to be similar in the two groups (RLC, 89.3%, RCC, 78.6%; p = 0.47). Prolonged oral RLC and RCC therapy were found to be equally effective in treating patients with BJI caused by resistant GPC, including patients with infected orthopaedic devices. However, the lower cost of cotrimoxazole compared with linezolid renders RCC an attractive treatment alternative to RLC. Further larger clinical studies are warranted to confirm these preliminary results.


December 12, 2009 at 12:52 pm Leave a comment

Correlation between time to positivity of blood cultures with clinical presentation and outcomes in patients with Klebsiella pneumoniae bacteraemia: prospective cohort study

Clinical Microbiology and Infection  Nov. 2009  V.15  N.12  p.1119-1125

C.-H. Liao 1 , C.-C. Lai 2 , M.-S. Hsu 1 , Y.-T. Huang 3,4 , F.-Y. Chu 5 , H.-S. Hsu 1 and P.-R. Hsueh 3,4

1) Department of Internal Medicine, Far Eastern Memorial Hospital ,   2) Department of Internal Medicine, Yi-Min Hospital ,   3) Department of Internal Medicine ,   4) Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine and 5) Department of Clinical Pathology, Far Eastern Memorial Hospital, Taipei, Taiwan


Time to positivity (TTP) of blood cultures in patients with bacteraemia is considered to be a predictor of outcome for some bacterial species. Two hundred and thirty-one patients with Klebsiella pneumoniae monomicrobial bacteraemia at a hospital from 1 January to 31 December 2007 were prospectively enrolled. TTP  <7 h (46 patients, 19.9%) was associated with a higher Pittsburg bacteraemia score (6.2 ± 5.5 vs. 3.7 ± 4.3, p 0.002), fewer non-fatal diseases by the McCabe classification (39.1% vs. 64.9%, p 0.002), a higher percentage of patients with liver cirrhosis, active malignancy, and chemotherapy within 3 months (28.3% vs. 11.9%, p 0.007; 28.3% vs. 14.6%, p 0.031; 23.9% vs. 5.4%, p <0.001), more primary bacteraemia (45.7% vs. 22.2%, p 0.002), and a higher 30-day mortality rate (47.8% vs. 21.1%, p <0.001). Risk factors for 30-day mortality in the univariate analysis included higher Pittsburg bacteraemia score (5.8 ± 5.3 vs. 3.7 ± 4.3, p 0.002), primary bacteraemia (41.0% vs. 21.8%, p 0.004), TTP  <7 h (36.1% vs. 14.1%, p <0.001), and the presence of active malignancy (29.5% vs. 12.9%, p 0.004). In the multivariate analysis, higher Pittsburg bacteraemia score (OR 1.07; 95% CI  1.01–1.14), TTP  <7 h (OR 2.46; 95% CI  1.20–5.05) and active malignancy (OR 2.21; 95% CI  1.03–4.73) were the significant factors associated with 30-day mortality. In the Kaplan–Meier survival curve, short TTP was significantly associated with mortality at all time-points after admission. TTP of blood cultures, interpreted with a cut-off point of <7 h, in patients with K. pneumoniae bacteraemia can provide useful prognostic information.


December 12, 2009 at 12:50 pm Leave a comment

Clinical and molecular epidemiology of community-acquired, healthcare-associated and nosocomial methicillin-resistant Staphylococus aureus in Spain

Clinical Microbiology and Infection  Nov. 2009  V.15  N.12  p.1111-1118

J. Rodríguez-Baño 1 , M. Angeles Domínguez 2 , A. Blas Millán 1 , C. Borraz 2 , M. Pau González 2 , B. Almirante 3 , E. Cercenado 4 , B. Padilla 4 , M. Pujol 5 , on behalf of GEIH/GEMARA (SEIMC) and REIPI

1) Sección de Enfermedades Infecciosas, Hospital Universitario Virgen Macarena, Sevilla ,   2) Servicio de Microbiología, Hospital Universitario de Bellvitge, Barcelona ,   3) Servicio de Enfermedades Infecciosas, Hospital Vall d’Hebrón, Barcelona ,   4) Servicio de Microbiología, Hospital Gregorio Marañón, Madrid and   5) Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain


A prospective cohort study including all new cases of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in 64 Spanish hospitals during June 2003 was performed to investigate the epidemiology of MRSA in Spain. Only patients who yielded clinical MRSA-positive samples were included. Epidemiological and clinical data for a total of 370 cases were collected. Genotyping was performed using pulsed-field gel electrophoresis and multilocus sequence typing. Panton–Valentine leukocidin genes and the staphylococcal chromosomal cassette mec (SCCmec) were identified in representative isolates. MRSA was considered to be nosocomially acquired in 202 cases (55%), healthcare-associated (HCA) in 139 cases (38%), community-acquired (CA) in three cases, and of uncertain mode of acquisition in 26 (7%) cases. The pooled population-based rate was 2.31 cases/100 000 population/month, and the pooled nosocomial rate was 0.21 cases/1000 hospital stays (20.2% of S. aureus). Peripheral vascular disease, respiratory tract infections, catheter infections, bloodstream infections and crude mortality were more frequent among HCA cases, whereas neoplasia and urinary tract infections were more frequent among nosocomially acquired cases. Two clones related to the paediatric clone ST5-IV accounted for 71% of the isolates; EMRSA-16 has emerged in two different geographical areas. Only one isolate belonged to the formerly predominant Iberian clone. The three CA isolates were related to the USA300 clone. SCCmec type IV was the most frequent type in nosocomial and HCA isolates. The epidemiology of MRSA has changed in Spain; outpatients with previous healthcare contact represent a very important reservoir of MRSA, and community isolates are emerging.


December 12, 2009 at 12:49 pm Leave a comment

Single-dose extended-release oral azithromycin vs. 3-day azithromycin for the treatment of group A β-haemolytic streptococcal pharyngitis/tonsillitis in adults and adolescents: a double-blind, double-dummy study

Clinical Microbiology and Infection  Nov. 2009  V.15  N.12  p.1103-1110

D. M. Jorgensen

Pfizer Inc., New London, CT, USA


The azithromycin immediate-release formulation (AZ-IR) provides effective treatment for group A β-haemolytic streptococcal pharyngitis in adults. Single-dose therapy with a novel azithromycin extended-release (AZ-ER) formulation could reduce treatment failure and eliminate non-compliance contributing to antimicrobial resistance. A randomized, double-blind, double-dummy, multicentre trial was conducted comparing AZ-ER (single oral 2-g dose) with AZ-IR (3 days, 500 mg once daily) for the treatment of group A β-haemolytic streptococcal pharyngitis/tonsillitis in adults and adolescents (n = 598). The primary endpoint was bacteriological eradication at test -of-cure (TOC; day 24–28) in the bacteriological per-protocol population (n = 420). Bacteriological eradication was achieved in 85.4% (175/205) and 81.4% (175/215) of subjects in the AZ-ER and AZ-IR groups, respectively (95% CI  −3.1–11.1). Clinical cure at TOC occurred in 99.0% of subjects in the AZ-ER group and in 96.7% in the AZ-IR group. At long-term follow-up, bacteriological recurrence was observed in 5.5% (9/163) and 7.7% (12/156), respectively. Both treatments were well tolerated; and most adverse events (AEs) were mild to moderate in intensity. The most frequent treatment-related AE was diarrhoea, or loose stools, in 11% of both treatment groups. AZ-ER-treated and AZ-IR-treated subjects had AE burdens (AE  days/patient-year) of 7.6 days and 9.2 days, respectively. A similar trend in favour of AZ-ER was noted for treatment-related diarrhoea burden (1.9 days vs. 2.5 days). A single 2-g dose of AZ-ER is as effective and well tolerated as 3 days of AZ-IR (500 mg once daily) for treating group A β-haemolytic streptococcal pharyngitis/tonsillitis in adults and adolescents.


December 12, 2009 at 12:47 pm Leave a comment


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