[Community-acquired Staphylococcus aureus pneumonia following influenza and the choice of empirical antibiotic treatment]. / Thuis opgelopen pneumonie door Staphylococcus aureus na influenza en de keuze voor empirische antibiotische behandeling.

A 30-year-old man presented with community-acquired pneumonia (CAP), directly following influenza. Sputum Gram stain confirmed Staphylococcus aureus pneumonia. Initial empirical antimicrobial therapy did not cover S. aureus. The isolated S. aureus strain contained genes encoding exotoxins, such as Panton-Valentine leukocidin (PVL). This exotoxin is associated with high mortality and methicillin resistance, but in this patient the strain was susceptible to methicillin. The patient died. In the Netherlands the risk of methicillin resistance in PVL-positive S. aureus CAP is low but real. This should be taken into account when selecting empirical treatment, which can include the combination of flucloxacillin and rifampicin. This case report illustrates the difficulty in predicting the causative agent in CAP and highlights the usefulness of the sputum Gram stain. Moreover, clinical awareness and recognition of S. aureus CAP remains essential to the early initiation of directed therapy.

Early jugular bulb oxygenation monitoring in comatose patients after an out-of-hospital cardiac arrest.

OBJECTIVE: To determine the role of early jugular bulb oxygenation monitoring in comatose patients after cardiac arrest. DESIGN: Prospective sequential study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Thirteen patients comatose after out-of-hospital cardiac arrest. INTERVENTIONS: A standard hemodynamic protocol. MEASUREMENTS AND RESULTS: Jugular bulb oxygen saturation levels and oxygen extraction ratios could not discriminate between patients with good (6) and poor (7) cerebral outcome. This was also true for the jugular bulb-arterial lactate difference. Survivors had significantly higher overall oxygen transport values than non-survivors. CONCLUSIONS: Jugular bulb oxygenation monitoring during the first few hours after cardiac arrest cannot reliably discriminate between comatose patients with a good and poor cerebral outcome. Further studies with an extended monitoring period are thus required.

Evaluation of an emergency medical system. The prognosis in patients with an out-of-hospital cardiac arrest.

In a retrospective chart review, we evaluated the efficiency of the emergency medical system of the Leiden area in patients with an out-of-hospital cardiac arrest. A total of 309 adult patients were included. Two hundred patients (64.7%) died in the emergency department and 67 (21.7%) died during subsequent hospital stay. Finally, 42 patients (13.6%) survived after hospital discharge. Favourable prognostic factors were the presence of witnesses at the time of arrest, a short call-response interval, an initial cardiac rhythm of ventricular fibrillation or tachycardia, and adequate advanced cardiac life support provided by the emergency medical system. We detected several shortcomings in the system such as an unacceptably prolonged call-response interval for some patients at the periphery of the Leiden area and a delay in the first defibrillation attempt. Improvement of this "pre-hospital chain of survival" is likely to result in a better outcome for these patients.

Prolonged resuscitation efforts for cardiac arrest patients who cannot be resuscitated at the scene: who is likely to benefit?

STUDY OBJECTIVE: To determine who may benefit from prolonged resuscitation efforts after therapy by emergency medical services system (EMS) personnel has failed to restore vital signs. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Two hundred sixteen consecutive adult patients with out-of-hospital cardiac arrest who were admitted to the emergency department without vital signs. METHODS: Identification of prehospital resuscitation data, therapy in the ED, hospital course, and final outcome. RESULTS: Thirty-nine patients (18.1%) were resuscitated successfully. The odds ratio of successful resuscitation in the ED for the patients with ventricular fibrillation at the scene versus those with asystole or electromechanical dissociation was 3.4 (95% confidence interval, 1.5, 7.9). All patients with asystole or electromechanical dissociation, either at the scene or in the ED, died (95% confidence interval, 0, 4.3). CONCLUSION: Prolonged resuscitation efforts in the ED for patients with asystole or electromechanical dissociation usually are futile after previous efforts by the EMS personnel have failed to restore vital signs. Transportation to the hospital may not be indicated. However, for patients with persistent ventricular fibrillation, transport is indicated.

[Good results of 100% oxygen treatment for acute carbon monoxide poisoning; temporarily no indication for hyperbaric oxygenation]. / Goede resultaten van behandeling met 100% zuurstof wegens acute koolmonoxide-intoxicatie; voorlopig geen indicatie voor hyperbare zuurstoftoediening.

OBJECTIVE: To describe the complications in patients with acute carbon monoxide intoxication, if treated with 100% instead of hyperbaric oxygen. DESIGN: Retrospective chart review. PATIENTS: Thirty-three patients with acute-carbon monoxide intoxication admitted to the medical Intensive Care Unit of Leiden University Hospital. RESULTS: The mean carbon monoxide level of all patients was 29.4%. Ten patients had a carbon monoxide level above 40%. Seven patients (21%) were in coma on admission. Most complications occurred in the latter group. All patients were treated with normobaric 100% oxygen. Recovery was usually rapid. No patient showed neurological deficits at discharge. CONCLUSION: The short-term prognosis of patients with acute carbon monoxide intoxication is good, even if they are not treated with hyperbaric oxygen. There is still inconclusive evidence from the literature that hyperbaric oxygen improves the prognosis in these patients.

[Pneumococcal pneumonia with a fulminant course]. / Pneumokokken-pneumonie met fulminant beloop.

Four patients admitted with a pneumococcal pneumonia are described. Well-known risk factors such as immunodeficiency or preexisting cardiopulmonary problems were absent. They had been ill for three to five days and had not been treated with antibiotics. Three patients died; upon admission these had extensive pulmonary infiltrates (two or more lobes affected), respiratory insufficiency necessitating mechanical ventilation, and shock at or soon after admission. The prognosis of pneumococcal pneumonia with a fulminant course has not improved in the last few decades despite proper antibiotics and intensive care treatment. Mortality is over fifty percent. Early recognition and treatment can contribute to a better prognosis.