Archive for February 2, 2013

Staphylococcus aureus infections in the intensive care unit: clinical and epidemiological characteristics.

An Pediatr (Barc). 2012 Dec;77(6):403-12.

[Article in Spanish]

Cabeza B, García Ruíz S, González-Abad MJ, Nieto-Moro M, Martínez de Azagra A, Iglesias-Bouzas MI, Casado-Flores J.


Servicio de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, España.



There has been an increase in invasive Staphylococcus Aureus infections over the last few years, which have required admission to the pediatric intensive care unit (PICU).


All patients with S. aureus infection who were admitted to PICU were enrolled in a retrospective study (January 2006-June 2010). The patients were classified into 2 groups: community-acquired infection (Group 1) and nosocomial infection (Group 2). We recorded epidemiological data, type of S. aureus (methicillin-susceptible S. aureus [MSSA], methicillin-resistant S. aureus [MRSA]), risk factors, site of infection, presence of hemodynamic instability, respiratory support, and mortality.


A total of 51 patients were enrolled, 21 belonging to Group 1 and 30 to Group 2. The median age was lower in Group 1 (1.6 years vs 3.2 years; P=.009). MSSA was isolated in 88% of cases. MRSA was detected in 6/51 (12%) of cases, which were isolated in the later study period (January 2009-June 2010). The risk factors for infection were: immunosuppression, venous catheter, institutionalization, mechanical ventilation, previous surgery, previous trauma and chronic osteomyelitis. A large majority (83%) of the patients with MRSA infection had risk factors. The type of infection was varied, with respiratory tract infection being the most common (75%). Hemodynamic instability was observed in 43% of patients. Most patients (86%) required respiratory support. One patient in Group 1 died of necrotizing pneumonia caused by MSSA.


Infections by S. aureus in children are severe and have a high morbidity. Respiratory infection was the most common in our series. Isolation of MSSA is common in these infections, although, an increase in the number of infections by MRSA was observed during the latter part of the study.


February 2, 2013 at 2:25 pm

Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality.

Chest. 2010 Mar;137(3):552-7.

Restrepo MI, Mortensen EM, Rello J, Brody J, Anzueto A.


Veterans Evidence Based Research Dissemination and Implementation Center, South Texas Veterans Health Care System, San Antonio, TX 78229, USA.



Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.


A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, >or= day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures.


Eighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02).


Patients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.


February 2, 2013 at 2:23 pm

Pneumonia recovery: discrepancies in perspectives of the radiologist, physician and patient.

J Gen Intern Med. 2010 Mar;25(3):203-6.

Bruns AH, Oosterheert JJ, El Moussaoui R, Opmeer BC, Hoepelman AI, Prins JM.


Division of Medicine, Department of Internal Medicine and Infectious Diseases, University Medical Center, PO Box 85500, 3508 GA Utrecht, The Netherlands.



Chest radiographs are often used to diagnose community-acquired pneumonia (CAP), to monitor response to treatment and to ensure complete resolution of pneumonia. However, radiological exams may not reflect the actual clinical condition of the patient.


To compare the radiographic resolution of mild to moderately severe CAP to resolution of clinical symptoms as assessed by the physician or rated by the patient.


Prospective cohort study.


One hundred nineteen patients admitted because of mild to moderately severe CAP with new pulmonary opacities.


Radiographic resolution and clinical cure of CAP were determined at day 10 and 28. Radiographic resolution was defined as the absence of infection-related abnormalities; clinical cure was rated by the physician and defined by improvement of signs and symptoms. In addition, the CAP score, a patient-based symptom score, was calculated.


Radiographic resolution, clinical cure and normalization of the CAP score were observed in 30.8%, 93% and 32% of patients at day 10, and in 68.4%, 88.9% and 41.7% at day 28, respectively. More severe CAP (PSI score >90) was independently associated with delayed radiographic resolution at day 28 (OR 4.7, 95% CI 1.3-16.9). All 12 patients with deterioration of radiographic findings during follow-up had clinical evidence of treatment failure.


In mild to moderately severe CAP, resolution of radiographic abnormalities and resolution of symptoms scored by the patient lag behind clinical cure assessed by physicians. Monitoring a favorable disease process by routine follow-up chest radiographs seems to have no additional value above following a patient’s clinical course.




February 2, 2013 at 2:22 pm

Legionellosis — United States, 2000-2009.

MMWR Morb Mortal Wkly Rep. 2011 Aug 19;60(32):1083-6.

Centers for Disease Control and Prevention (CDC).


Legionnaires disease (LD), a serious, sometimes lethal pneumonia, and Pontiac fever (PF), an influenza-like, self-limited illness, are the two most common forms of legionellosis, which is caused by Legionella bacteria. Legionellosis cases are reported to CDC through the National Notifiable Disease Surveillance System (NNDSS) and a Supplemental Legionnaires Disease Surveillance System (SLDSS) designed to manage surveillance data on travel-related cases and enhance outbreak detection. For this report, cases reported to NNDSS during 2000-2009 from the 50 states and the District of Columbia (DC) were assessed, and crude and age-adjusted incidence rates per 100,000 persons were calculated. U.S. legionellosis cases reported annually increased 217%, from 1,110 in 2000 to 3,522 in 2009, and the crude national incidence rate increased 192%, from 0.39 per 100,000 persons in 2000 to 1.15 in 2009. Because NNDSS is a passive surveillance system dependent on health-care providers and laboratories reporting cases, the actual incidence of legionellosis in the United States likely is higher. Although NNDSS does not record legionellosis cases by type, 99.5% of the legionellosis cases reported to SLDSS during 2005-2009 were classified as LD and 0.5% as PF. Legionellosis surveillance was added to the population-based Active Bacterial Core surveillance (ABCs) system in January 2011 to assess reasons for these increases in numbers of reported cases. The rise in reported cases reinforces the need for health-care providers in all parts of the United States to test and treat adults with severe community-acquired pneumonia for LD, to be vigilant for health-care–associated LD, and to report legionellosis cases to public health authorities.

PDF (see p.1083)

February 2, 2013 at 2:20 pm

Severe coinfection with seasonal influenza A (H3N2) virus and Staphylococcus aureus–Maryland, February-March 2012.

MMWR Morb Mortal Wkly Rep. 2012 Apr 27;61(16):289-91.

Centers for Disease Control and Prevention (CDC).


On March 5, 2012, the Maryland Department of Health and Mental Hygiene (DHMH) and the Calvert County Health Department were notified of three deaths following respiratory illness among members of a Maryland family. One family member (patient A) experienced upper-respiratory symptoms and died unexpectedly at home. Two others (patients B and C) sought medical care for fever, shortness of breath, and cough productive of bloody sputum and died during their hospitalizations. All three family members had confirmed infection with seasonal influenza A (H3N2) virus. Patients B and C had confirmed coinfection with methicillin-resistant Staphylococcus aureus (MRSA), which manifested in both patients as MRSA pneumonia and bacteremia. DHMH and the Calvert County Health Department, in collaboration with the District of Columbia Department of Health, local hospitals, and CDC, conducted an investigation to determine the cause of the illnesses and identify additional related cases. Three additional family members with influenza were identified, two of whom were confirmed to have influenza A (H3N2) and required hospitalization, but neither was coinfected with MRSA, and both recovered. Influenza vaccination remains the best method for preventing complications from influenza; when influenza infection is suspected, treatment with influenza antiviral agents is recommended in certain cases. In addition, when high clinical suspicion for serious S. aureus coinfection exists, empiric coverage with antibiotics, including those with activity against methicillin-resistant strains, should be instituted.

PDF (see p.289)

February 2, 2013 at 2:19 pm

High-dose, extended-interval colistin administration in critically ill patients: is this the right dosing strategy? A preliminary study.

Clin Infect Dis. 2012 Jun;54(12):1720-6.

Dalfino L, Puntillo F, Mosca A, Monno R, Spada ML, Coppolecchia S, Miragliotta G, Bruno F, Brienza N.


Anesthesia and Intensive Care Unit, Department of Emergeny and Organ Transplantion, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italy.



Gram-negative bacteria susceptible only to colistin (COS) are emerging causes of severe nosocomial infections, reviving interest in the use of colistin. However, consensus on the most effective way to administer colistin has not yet been reached.


All patients who had sepsis due to COS gram-negative bacteria or minimally susceptible gram-negative bacteria and received intravenous colistimethate sodium (CMS) were prospectively enrolled. The CMS dosing schedule was based on a loading dose of 9 MU and a 9-MU twice-daily fractioned maintenance dose, titrated on renal function. For each CMS course, clinical cure, bacteriological clearance, daily serum creatinine clearance, and estimated creatinine clearance were recorded.


Twenty-eight infectious episodes due to Acinetobacter baumannii (46.4%), Klebsiella pneumoniae (46.4%), and Pseudomonas aeruginosa (7.2%) were analyzed. The main types of infection were bloodstream infection (64.3%) and ventilator-associated pneumonia (35.7%). Clinical cure was observed in 23 cases (82.1%). Acute kidney injury developed during 5 treatment courses (17.8%), did not require renal replacement therapy, and subsided within 10 days from CMS discontinuation. No correlation was found between variation in serum creatinine level (from baseline to peak) and daily and cumulative doses of CMS, and between variation in serum creatinine level (from baseline to peak) and duration of CMS treatment.


Our study shows that in severe infections due to COS gram-negative bacteria, the high-dose, extended-interval CMS regimen has a high efficacy, without significant renal toxicity.


February 2, 2013 at 2:17 pm


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