Inconsistent dosing of anti-tuberculosis drugs in Taipei, Taiwan.

SETTING: Taipei City, Taiwan. OBJECTIVES: To evaluate prescribing practices for anti-tuberculosis drugs in the treatment of tuberculosis (TB). METHOD: Medical audit of the medical charts of all patients notified and treated for TB in Taiwan in 2003 to determine the treatment regimens prescribed and to compare these with recommended dosages. RESULTS: A total of 24 different anti-tuberculosis regimens were prescribed. Of 1700 patients notified, 1096 (64.5%) had their body weight recorded. Of 506 patients prescribed a three-drug fixed-dose combination (FDC), the dosage was adequate in 374 (73.9%), too low in 100 (19.8%) and too high in 32 (6.3%). Of 75 patients prescribed a two-drug FDC, the dosage was adequate in 57 (76.0%), too low in 15 (20.0%) and too high in 3 (4.0%). Of 481 patients prescribed rifampicin, the dosage was adequate in 302 (62.8%), too low in 152 (31.6%) and too high in 27 (5.6%). Of 451 patients prescribed isoniazid, the dosage was adequate in 396 (87.8%), too low in 29 (6.4%) and too high in 26 (5.8%). CONCLUSION: The prescribing practices for anti-tuberculosis drugs were substandard and need improvement. These findings imply that the National TB Programme needs strengthening.

Tuberculosis-related deaths without treatment.

Of 536 culture-positive tuberculosis (TB) patients notified in 2003 in Taipei, 507 (94.6%) received anti-tuberculosis treatment in reporting health facilities and 29 (5.4%) did not. Of these 29 patients, 26 (89.7%) died, 2 (6.9%) were re-notified 1 year later and 1 (3.5%) was lost to follow-up. In multivariate analysis, patients aged > or =65 years, patients with negative smear or smear not done, patients with sepsis and/or respiratory failure and patients with liver diseases were significantly less likely to receive anti-tuberculosis treatment. Overall, of the 536 TB patients, 97 (18.1%) died, of whom 26 (26.8%) died without anti-tuberculosis treatment.

External quality assessment of sputum smear microscopy in Taiwan.

OBJECTIVE: To evaluate the quality of sputum smear microscopy in nine Taiwan Centers for Disease Control contract laboratories, an external quality assessment (EQA) programme has been implemented since 2005. DESIGN: A sampling strategy based on the lot quality assurance system was applied to select slides for rechecking. Supervisory visits and technical training were conducted to determine the causes of errors and to take corrective action. RESULTS: Of the 1017 slides sampled in 2005, 637 (63%) had proper smear size, 492 (48%) proper thickness and 884 (87%) proper staining; the corresponding figures were 972 (100%), 748 (77%) and 809 (99.6%) for the 972 slides rechecked in 2006. After training, the quality of size and staining of smear preparation had significantly improved (P < 0.001) in 2006. Rechecking of 981 readable slides in 2005 identified 3 (0.3%) high false-negatives, 3 (16.7%) low false-positives and 26 (2.8%) low false-negatives; the corresponding errors were 3 (0.3%), 8 (28.6%) and 12 (1.3%) for the 972 slides rechecked in 2006. Of the eight laboratories, two (25%) and four (50%) reached 80% sensitivity in 2005 and 2006, respectively. CONCLUSION: Technical training and EQA improved the quality of sputum smear microscopy services.

Tuberculosis outcomes in Taipei: factors associated with treatment interruption for 2 months and death.

SETTING: All individuals reported as being treated for pulmonary tuberculosis (PTB) among citizens of Taipei City, Taiwan, in 2003. OBJECTIVES: To investigate risk factors associated with treatment interruption for at least 2 consecutive months and death. DESIGN: The outcome of PTB cases was determined by consulting medical charts. RESULTS: Of 1127 PTB patients registered, 824 (73.1%) were successfully treated, 189 (16.8%) died, 65 (5.8%) interrupted treatment, 17 (1.5%) were still on treatment 15 months after commencing treatment and 32 (2.8%) failed. The only significant factor associated with treatment interruption was visits to other health facilities after commencing tuberculosis (TB) treatment. TB patients had a standardised mortality ratio of 8.7 (95%CI 7.5-10.0). Factors significantly associated with death were age (adjusted hazard ratio [adjHR] 1.06. 95%CI 1.05-1.08), sputum culture not performed/unknown (adjHR 2.07, 95%CI 1.47-2.92), and comorbidity with respiratory disease (adjHR 1.68, 95%CI 1.24-2.27), infectious disease (adjHR 2.80, 95%CI 2.07-3.78), renal disease (adjHR 2.58, 95%CI 1.82-3.66) or cancer (adjHR 3.31, 95%CI 2.35-4.65), compared with other patients. CONCLUSION: Visits to other health facilities were associated with interruption of treatment for at least 2 months. A high proportion of deaths was due to old age and comorbidity.

Factors associated with a clinician's decision to stop anti-tuberculosis treatment before completion.

OBJECTIVES: To investigate the diagnosis of pulmonary tuberculosis (PTB) and factors associated with a clinician's decision to stop anti-tuberculosis treatment before completion. DESIGN: The medical charts of all citizens of Taipei City, Taiwan, reported to have received treatment for PTB in 2003 were investigated. RESULTS: Of 1126 PTB patients, 512 (45.5%) started treatment immediately based solely on chest X-ray (CXR) findings; treatment for 214 (19.0%) was based on a positive sputum smear for acid-fast bacilli, for 261 (23.2%) it was based on other findings and for 139 (12.3%) it was based on a positive mycobacterial culture. Of the 1126 PTB patients, 156 (13.9%) had their diagnosis of TB changed by a clinician. Multivariate analysis shows that patients whose diagnosis was based on CXR or other findings, female patients, patients who interrupted treatment for 2 months, patients who continued care at other health facilities (transfer) and patients with lung cancer were significantly more likely to have their diagnosis changed than other groups. CONCLUSION: A substantial proportion of patients were prescribed anti-tuberculosis treatment based on CXR findings alone, and a considerable proportion were advised to stop treatment before completing a full course, findings that require the immediate attention of Taiwan's National Tuberculosis Programme.

Accuracy of classification of notified tuberculosis cases in Taiwan.

SETTING: Tuberculosis (TB) suspects and cases reported in 2003 in Taiwan. OBJECTIVES: To evaluate the accuracy of the classification of notified TB cases in Taiwan. DESIGN: A list of all TB cases reported in 2003 in Taiwan was obtained from the Taiwan Center for Disease Control, along with their classification. TB cases residing in Taipei City were investigated by consulting their medical charts. RESULTS: Of 1,973 patients, 782 (39.6%) were bacteriologically confirmed, 1,024 (52%) were not bacteriologically confirmed (indeterminate) and 167 (9%) were not TB cases (in whom non-tuberculosis mycobacteria [NTM] was isolated). Of the 1,973 cases, 1,716 (87%) had been treated with anti-tuberculosis drugs, while 257 (13%) had not been treated. Of the 782 bacteriologically confirmed cases, 68 (8.7%) were misclassified as non-notifiable (32 [4.1%] had their diagnosis changed by a clinician and 36 [4.6%] by administrative coding). Of the 167 cases in whom NTM were isolated, 72 (43.1%) were misclassified as TB cases. Of the 257 untreated suspects, 31 (12.1%) did not have any evidence of TB (20 indeterminate and 11 NTM cases) and were questionably classified as newly diagnosed cases. CONCLUSION: There was substantial misclassification of notified TB cases in Taiwan.

The effect of smoking on tuberculosis: different patterns and poorer outcomes.

SETTING: It has been well documented that smoking increases the risk of tuberculosis (TB). However, few studies have evaluated the impact of smoking on TB. We conducted this retrospective study to evaluate the influences of smoking on the manifestation and outcome of TB. DESIGN: All culture-confirmed TB patients from July 2002 to December 2003 were identified and their medical records reviewed. RESULTS: A total of 523 TB patients, including 207 (39.6%) who had ever smoked, were studied. The ever-smokers were significantly older, more likely to have underlying diseases and a duration of symptoms > 60 days, and less likely to have extra-pulmonary involvement and have completed treatment (64.7% vs. 78.5%). Radiographically, more ever-smokers with pulmonary tuberculosis (PTB) presented with miliary lesions, multiple nodules or masses, upper lung predominance and cavitation than never-smokers. Although smoking was associated with poor prognosis on univariate survival analysis, multivariate analysis revealed that independent poor prognostic factors included age, underlying disease, symptom duration < or = 60 days, extra-pulmonary involvement, serum albumin level < 3.5 g/dl and delayed treatment. CONCLUSIONS: Our results demonstrate that smoking is significantly associated with radiographic manifestations of PTB, but not with death among PTB patients.

Empirical treatment with a fluoroquinolone delays the treatment for tuberculosis and is associated with a poor prognosis in endemic areas.

BACKGROUND: A study was conducted to evaluate the effect of the empirical use of fluoroquinolones on the timing of antituberculous treatment and the outcome of patients with tuberculosis in an endemic area. METHODS: All patients with culture confirmed tuberculosis aged > or =14 years diagnosed between July 2002 and December 2003 were included and their medical records were reviewed. RESULTS: Seventy nine (14.4%) of the 548 tuberculosis patients identified received a fluoroquinolone (FQ group), 218 received a non-fluoroquinolone antibiotic (AB group), and 251 received no antibiotics before antituberculous treatment. Fifty two (65.8%) experienced clinical improvement after fluoroquinolone use. In the FQ group the median interval from the initial visit to starting antituberculous treatment was longer than in the AB group and in those who received no antibiotics (41 v 16 v 7 days), and the prognosis was worse (hazard ratio 6.88 (95% CI 1.84 to 25.72)). More patients in the FQ and AB groups were aged >65 years (53.2% and 61.0% v 31.5%), had underlying disease (53.2% and 46.8% v 34.3%), and were hypoalbuminaemic (67.2% and 64.9% v 35.1%). Of the nine mycobacterial isolates obtained after fluoroquinolone use from nine patients whose initial isolates were susceptible to ofloxacin, one (11.1%) was resistant to ofloxacin (after fluoroquinolone use for 7 days). Independent factors for a poor prognosis included empirical fluoroquinolone use, age >65, underlying disease, hypoalbuminaemia, and lack of early antituberculous treatment. CONCLUSIONS: 14.4% of our patients with tuberculosis received a fluoroquinolone before the diagnosis. With a 34 day delay in antituberculous treatment and more frequent coexistence of underlying disease and hypoalbuminaemia, empirical fluoroquinolone treatment was associated with a poor outcome. Mycobacterium tuberculosis isolates could obtain ofloxacin resistance within 1 week.

Re-emergence of meningococcal disease in Taiwan: circulation of domestic clones of Neisseria meningitidis in the 2001 outbreak.

The annual incidence of meningococcal disease (meningitis and septicaemia) in Taiwan was 0.94/10(5) population in 1953. It then declined to below 0.001 from 1980 to 1987, and re-emerged in 2000 with a rate of 0.07/10(5) population. In 2001 there was a further increase in incidence (43 cases, 0.19/10(5)). Of 43 isolates of Neisseria meningitidis available for this study, including 41 from patients treated in 2001, three (7.0%) were penicillin insensitive (MIC > or = 0.12 microg/ml), though all were beta-lactamase negative: 16 (37.2%) were resistant to trimethoprim-sulphamethoxazole (MIC > or = 4/76 microg/ml). Serogrouping and genotype analysis revealed nine domestic clones. None of the 43 patients had any relationship (travel or contact history) with the 2000 or 2001 Hajj pilgrimage. Epidemiological information and typing results suggested wide dissemination of a limited number of domestic clones of N. meningitidis, manifesting as serogroups W-135, B and Y. Two clones of serogroup W-135 involved in the outbreak were genetically distinct from the 2000 or 2001 Hajj-related W-135 clone.

Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation.

Mortality remains high among patients with pulmonary tuberculosis requiring mechanical ventilation (TBMV). This study was carried out to establish the mortality rates of TBMV and to identify factors that contribute to in-hospital mortality. From January 1996-April 2001, there were 825 patients with active pulmonary tuberculosis at the National Taiwan University Hospital, Taipei, Taiwan. Of these, 41 suffered acute respiratory failure and required mechanical ventilation in the intensive care unit (ICU). Of these 41 patients, 38 were followed up for 180 days. In-hospital deaths were documented in the medical records and all possible parameters contributing to mortality were collected. Of the 41 patients, 27 died in the hospital and 14 were discharged alive (in-hospital mortality rate 65.9%), with (mean +/- SD) 40.7 +/- 35.4 admission days before death. Of the 27 that died, 25 died during ICU admission and two died after being transferred to the ward. The mortality rate for the 180-day monitoring period was 79%. Factors contributing to in-hospital mortality included consolidations on chest radiographs and multiple organ failure. The mortality rate in the patients with pulmonary tuberculosis requiring mechanical ventilation is very high, with two factors affecting in-hospital mortality. These factors were multiple organ failure and consolidation on chest radiographs.

Tuberculous myositis: a rare but existing clinical entity.

OBJECTIVES: To investigate the clinical characteristics of patients with tuberculous myositis. METHODS: From January 1996 to March 2001, patients with positive cultures of Mycobacterium tuberculosis or histology-proven caseous granulomatous inflammation from muscular specimens were identified and their medical records were reviewed. RESULTS: Thirty-five patients were identified. Infection-related myositis was initially suspected in 20 patients (57.1%). The routes of infection were contiguous spread in 22 patients (62.8%), haematogenous spread in 10 (28.6%) and traumatic inoculation in three (8.6%). Five patients (14.3%), including the three who had received corticosteroids, died of uncontrolled sepsis. The computed tomography or the magnetic resonance imaging of the involved muscles showed findings suggestive of tuberculous myositis in 15 patients (42.9%). CONCLUSIONS: Tuberculosis should be considered as one of the possible aetiologies of myositis, especially among patients with suggestive radiographic findings or in endemic areas of tuberculosis. Patients who develop tuberculous myositis after using corticosteroids have poor prognoses.

Cryptococcaemia: clinical features and prognostic factors.

BACKGROUND: Limited data are available on the clinical significance of cryptococcaemia, which occurs in 10-30% of patients with cryptococcal diseases. AIM: To describe the clinical features of cryptococcaemia and identify its prognostic factors. STUDY DESIGN: Retrospective cohort study. METHODS: All adult patients with Cryptococcus neoformans isolated from blood culture at the National Taiwan University Hospital, Taipei, 1981-2001, were included. Demographic and clinical information was obtained from medical records. RESULTS: Fifty-two patients were diagnosed and treated for cryptococcaemia. Acquired immunodeficiency syndrome (24/52, 46%), immunosuppressive therapy (12/52, 23%) and decompensated liver cirrhosis (11/52, 21%) were the three major predisposing conditions. Forty-two patients (81%, n=52) had sepsis, including four patients with septic shock, when blood cultures were obtained. Of the 38 patients in whom lumbar puncture was done, cerebrospinal fluid culture showed meningeal involvement in 32 (84%). The 30-day fatality rate was 37%. Liver cirrhosis, septic shock at presentation, an initial APACHE II score >/=20, age >/=60 years and female gender were associated with mortality under univariate analysis. Starting antifungal therapy within 48 h after blood culture was associated with improved survival. Under multivariate analysis, liver cirrhosis remained a strong independent predictor of mortality at 30 days after blood culture (HR 16.3, 95%CI 2.6-101.7, p=0.003). DISCUSSION: Patients with cryptococcaemia have a high risk of mortality within 30 days. Sepsis and meningeal involvement are common. Those with liver cirrhosis have a particularly poor prognosis.

Variations in the NRAMP1 gene and susceptibility of tuberculosis in Taiwanese.

SETTING: National Taiwan University Hospital, Taipei, Taiwan. OBJECTIVE: To study the variations in the NRAMP1 gene using five genotypes (274C/T, 577-18G/A, A318V, D543N and 3' untranslated region [UTR]), and the susceptibility of tuberculosis and HIV infection in Taiwanese. DESIGN: The study sample included 49 patients with tuberculosis, 48 healthy control subjects and 60 HIV-infected patients. The polymerase chain reaction (PCR) products amplified from their genomic DNA were subjected to restriction enzyme digestion and were analysed using agarose gel electrophoresis. RESULTS: A318V was not polymorphic in the studied population. Only D543N and 3'UTR were more heterozygous. In 274 C/T and 577-18G/A, the allele frequencies showed the predominant type to be the homozygous patterns C/C (94%) and G/G (94%), respectively. There were no statistically significant differences between the tuberculosis patients and the healthy control subjects. Despite the high susceptibility to Mycobacterium tuberculosis in HIV-infected patients, genotypic frequencies in the HIV-positive patients were not significantly different between tuberculous (n = 29) and non-tuberculous patients (n = 31). In comparison with previous studies, there were significant differences between different ethnic groups in allele frequencies for 274C/T, D543N and 3'UTR. CONCLUSION: The allele and genotype of NRAMPI polymorphism among Taiwanese differed from those of Caucasians, Africans and Hispanics. No allelic associations were identified between the NRAMP1 alleles and tuberculosis susceptibility.

Gemcitabine and cisplatin in a multimodality treatment for locally advanced non-small cell lung cancer.

The role of new cytotoxic agents like gemcitabine has not yet been proven in the neoadjuvant settings. We designed a phase II study to test the feasibility of using gemcitabine and cisplatin before local treatment for stage III non-small cell lung cancer patients. Patients received three cycles of induction chemotherapy of gemcitabine (1000 mg m(-2), days 1, 8, 15) and cisplatin (90 mg m(-2), day 15) every 4 weeks before evaluation for operability. Operable patients underwent radical resection. Inoperable patients and patients who had incomplete resection received concurrent chemoradiotherapy with daily low dose cisplatin. All patients who did not progress after local treatment received three more cycles of adjuvant chemotherapy of gemcitabine and cisplatin. Fifty-two patients received induction treatment. Two patients had complete response and 31 patients had partial response (response rate 63.5%) after induction chemotherapy. Thirty-six patients (69%) were operable. Eighteen patients (35%) had their tumours completely resected. Two patients had pathological complete response. Median overall survival was 19.1 months, projected 1-year survival was 66% and 2-year survival was 34%. Three cycles of gemcitabine and cisplatin is effective and can be used as induction treatment before surgery for locally advanced non-small cell lung cancer patients.

Nosocomial Exophiala jeanselmei pseudoinfection after sonography-guided aspiration of thoracic lesions.

BACKGROUND AND PURPOSE: During the period from August 1994 to October 1998, a total of 19 isolates of Exophiala jeanselmei were recovered from 17 patients with various underlying thoracic diseases treated at National Taiwan University Hospital. The purpose of this study was to describe the clinical characteristics of these patients and to determine the microbiologic relatedness of the E. jeanselmei. METHODS: Of the 19 isolates, 11 from nine patients were preserved and were identified based on their biotypes as determined by the API ID32C System, their cellular fatty acid profiles by gas-liquid chromatography, their antibiotypes to five antifungal agents by the E-test, and their random amplified polymorphic DNA (RAPD) patterns by arbitrarily primed PCR. Extensive environmental surveillance cultures and cultures from the skin of eight patients and hands of one physician were also performed. RESULTS: One of the 17 patients had E. jeanselmei isolated from cutaneous phaeohyphomycosis (3 isolates), and the other 16 patients had isolations from pleural effusion specimens (15 isolates) or lung mass (1 isolate) following sonography-guided aspiration. The latter 16 patients had no clinical or pathologic evidence of fungal infection. Isolates (clone 1) from aspirated specimens had identical biotypes, antibiotypes, and RAPD patterns, which were different from those of the three isolates (clone 2) from the patient with a cutaneous lesion. All specimens from environmental sources, patients' skin, and the hands of the physician were negative for E. jeanselmei. CONCLUSION: This series of patients demonstrates the difficulty in identifying the sources of a nosocomial pseudoinfection due to this slow-growing microorganism when isolated from pleural effusion specimens.

High prevalence of inducible erythromycin resistance among Streptococcus bovis isolates in Taiwan.

Susceptibilities to 13 antimicrobial agents were determined by measurement of MICs for 60 isolates of Streptococcus bovis from blood cultures. Thirty-eight isolates (63.3%) had high-level resistance to erythromycin (MICs, >or=128 microg/ml). Among the 38 erythromycin-resistant strains, 21 isolates (55%) had inducible resistance to macrolides-lincosamides-streptogramin B (iMLS isolates) and 17 (45%) had constitutive resistance to macrolides-lincosamides-streptogramin B (cMLS isolates). Tetracycline resistance was also found among all of the erythromycin-resistant strains. None of the strains displayed resistance to penicillin, chloramphenicol, or vancomycin. Detection of erythromycin resistance genes by PCR and sequencing indicated that all 17 cMLS isolates were positive for the ermB gene and that 7 of 21 iMLS isolates carried the ermB gene and the remaining 14 iMLS isolates carried the ermT gene. Sequence analysis of amplified partial ermB fragments (594 bp) from S. bovis isolates revealed a 99.8% nucleotide identity and a 100% amino acid homology compared with the sequences from gene banks. The sequences of amplified fragments with primers targeted for ermC were shown to be very similar to that of ermGT (ermT) from Lactobacillus reuteri (98.5% nucleotide identity). This is the first report to describe the detection of the ermT class of erythromycin resistance determinants in S. bovis. The high rate of inducible erythromycin resistance among S. bovis isolates in Taiwan was not reported before. The iMLS S. bovis isolates were shown to be heterogeneous by randomly amplified polymorphic DNA analysis. These results indicate that the prevalence of inducible erythromycin resistance in S. bovis in Taiwan is very high and that most of the resistant strains carry the ermT or the ermB gene.

In vitro activity of moxifloxacin against common clinical bacterial isolates in Taiwan.

The in vitro antimicrobial activities of moxifloxacin were compared with 7 other antimicrobial agents. A total of 707 isolates of 11 common pathogenic bacteria were collected from the National Taiwan University Hospital; antimicrobial activities against these isolates were evaluated by minimum inhibitory concentration using an agar-dilution method. Most common pathogenic bacteria were susceptible to moxifloxacin, including methicillin-susceptible and -resistant Staphylococcus aureus, methicillin-susceptible and -resistant Staphylococcus epidermidis, Streptococcus pneumoniae, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, Burkholderia cepacia, Acinetobacter baumannii, and Stenotrophomonas maltophilia. For many of these bacterial species, moxifloxacin was the most active antimicrobial agent compared with the third- and fourth- generation cephalosporins, carbapenems, monobactam, and other quinolones. Some strains of methicillin-resistant S. aureus and methicillin-resistant S. epidermidis demonstrated very low levels of minimum inhibitory concentration for moxifloxacin, suggesting the potential application of the drug to treat some drug-resistant gram-positive bacterial infections. Moxifloxacin was less active against P. aeruginosa, but was more active against S. maltophilia when compared with other fluoroquinolones. In conclusion, moxifloxacin exhibits an increased potency against gram-positive bacteria as compared with other tested antimicrobial agents, while preserving excellent activity against gram-negative bacteria. The drug appears to be a promising agent expressing activity against a wide variety of bacteria in Taiwan.

High incidence of erythromycin resistance among clinical isolates of Streptococcus agalactiae in Taiwan.

The in vitro susceptibilities of 266 isolates of Streptococcus agalactiae determined by the agar dilution method showed that 6% of isolates were nonsusceptible to penicillin and 46% was resistant to erythromycin. Of the erythromycin-resistant isolates, 86.3% had the macrolide-lincosamide-streptogramin (MLS) resistance phenotype (constitutive MLS, 85.5%; inducible MLS, 0.8%) and 13.7% had the M phenotype.

Severe community-acquired pneumonia due to Acinetobacter baumannii.

STUDY OBJECTIVES: To investigate the clinical, epidemiologic, and microbiological characteristics of community-acquired pneumonia (CAP) due to Acinetobacter baumannii. METHODS: Retrospective chart and radiographic reviews of all patients who were admitted to National Taiwan University Hospital from January 1993 to August 1999, fulfilled the criteria for CAP, and had an isolate of A. baumannii from blood or pleural fluid at hospital admission. RESULTS: Thirteen patients (9 men and 4 women; age range, 37 to 85 years) met the criteria. Conditions associated with the infection included male gender, old age, alcoholism, malignancy, cerebrovascular disease, diabetes mellitus, renal disease, and liver cirrhosis. Eleven patients (85%) acquired the infection during the warmer months of April to October. Twelve patients (92%) had a fulminant course presenting with septic shock and respiratory failure, and 11 patients (85%) needed ventilator support and were treated in an ICU. Six patients (46%) had leukopenia. Lobar consolidations were found in 12 patients (92%), and pleural effusions were present in 4 patients (31%). All patients had positive blood culture results, two patients (15%) had positive pleural effusion culture findings, and nine patients (69%) positive sputum culture results. All the isolates were susceptible to imipenem, and most were susceptible to aminoglycosides, ceftazidime, ciprofloxacin, and extended-spectrum penicillins. Eight patients (62%) died. Four of the five survivors were initially treated with combination of a third-generation cephalosporin and an aminoglycoside. CONCLUSION: A. baumannii should be considered as a possible etiologic agent in community-acquired lobar pneumonia when (1) patients with a fulminant course present during the warmer and more humid months of the year, and (2) patients are younger alcoholics. A good sputum smear, defined as a Gram stain smear of an adequate sputum specimen that comes from the lower respiratory tract and contains > 25 leukocytes per high-power (100x) field on microscopic examination, can help early diagnosis and treatment. A combination of a third-generation cephalosporin and an aminoglycoside may be appropriate empirical therapy.