Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.

STUDY OBJECTIVE: To define the impact of BAL data on the selection of antibiotics and the outcomes of patients with ventilator-associated pneumonia (VAP). DESIGN: Prospective observation and bronchoscopy with BAL, performed within 24 h of establishing a clinical diagnosis of a new episode of hospital-acquired VAP or progression of a prior episode of nosocomial pneumonia (NP). SETTING: A 15-bed medical and surgical ICU. PATIENTS: One hundred thirty-two patients hospitalized for more than 72 h, who were mechanically ventilated and had a new or progressive lung infiltrate plus at least two of the following three clinical criteria for VAP: abnormal temperature (> 38 degrees C or < 35 degrees C), abnormal leukocyte count (> 10,000/mm3 or < 3,000/mm3), purulent bronchial secretions. INTERVENTIONS: Bronchoscopy with BAL within 24 h of establishing a clinical diagnosis of VAP or progression of an infiltrate due to prior VAP or NP. All patients received antibiotics, 107 prior to bronchoscopy and 25 immediately after bronchoscopy. RESULTS: Sixty-five of the 132 patients were BAL positive (BAL[+]), satisfying a microbiologic definition of VAP (> 10(4) cfu/mL), while 67 were BAL negative (BAL[-]). The BAL(+) patients had no differences in mortality, prior antibiotic use, and demographic features when compared with the BAL(-) patients. More of the BAL(+) patients (38/65) satisfied all three clinical criteria of VAP than did BAL(-) patients (24/67) (p < 0.05). A total of 50 BAL(+) patients received antibiotic therapy prior to bronchoscopy, and when this prior therapy was adequate (n = 16), as defined by the results of BAL, then mortality was 38%, while if prior therapy was inadequate (n = 34), mortality was 91% (p < 0.001), and if no therapy was given (n = 15), mortality was 60%. When therapy changes were made after bronchoscopy, more patients (n = 42) received adequate therapy, but mortality in this group was comparable to mortality among those who continued to receive inadequate therapy (n = 23). A total of 46 of the 65 BAL(+) patients died, with 23 of these deaths occurring during the 48 h after the bronchoscopy, before BAL results were known. When BAL data became available, 37 of the 42 surviving patients received adequate therapy, but their mortality was comparable to the patients who continued to receive inadequate therapy. CONCLUSIONS: Patients with a strong clinical suspicion of VAP have a high mortality rate, regardless of whether BAL cultures confirm the clinical diagnosis of VAP. When adequate antibiotic therapy is initiated very early (ie, before performing bronchoscopy), mortality rate is reduced if this empiric therapy is adequate, compared to when this therapy is inadequate or no therapy is given. If adequate therapy is delayed until bronchoscopy is performed or until BAL results are known, mortality is higher than if it had been given at the time of first establishing a clinical diagnosis of VAP. When patients were changed from inadequate antibiotic therapy to adequate therapy, based on the results of BAL, mortality was comparable to those who continued to receive inadequate therapy. Thus, even if bronchoscopy can accurately define the microbial etiology of VAP, this information becomes available too late to influence survival.

Multicenter study of street foods in 13 towns on four continents by the food and environmental hygiene study group of the international network of pasteur and associated institutes.

An international multicenter study of ready-to-eat foods, sandwiches, and ice creams or sorbets sold in the streets and their vendors was carried out to assess the microbiological quality of these foods and to identify characteristics of the vendors possibly associated with pathogens. Thirteen towns in Africa, America, Asia, and Oceania were involved in the study. A single protocol was used in all 13 centers: representative sampling was by random selection of vendors and a sample of foods bought from each of these vendors at a time and date selected at random. Microbiological analyses were carried out using standardized Association Française de Normalisation methods, and the use of a standardized questionnaire to collect data concerning the characteristics of the vendors. Fifteen surveys were carried out, with 3,003 food samples from 1,268 vendors. The proportion of unsatisfactory food samples was between 12.7 and 82.9% for ice creams and sorbets and between 11.3 and 92% for sandwiches. For ice creams and sorbets, the sale of a large number of units (>80 per day) increased the risk of unsatisfactory food by a factor of 2.8 (95% confidence interval [CI]: 1.5 to 5.1), lack of training in food hygiene by 6.6 (95% CI: 1.1 to 50). and by a factor of 2.8 (95% CI: 1.4 to 5.4) for mobile vendors. These risk factors were not identified for sandwiches, this difference may be due to the presence of a cooking step in their preparation. These results show that the poor microbiological quality of these street foods constitutes a potential hazard to public health, that the extent of this hazard varies between the cities studied, and that vendors' health education in food safety is a crucial factor in the prevention of foodborne infections.

[Life-sustaining therapy and dignified death. Myths and realities]. / Encarnizamiento terapéutico y muerte digna. Mitos y realidades.

The use of a variety of diagnostic and therapeutic procedures made available by modern technology for critical patients have given rise to forms of death which are incompatible with a person's dignity in cases in which the inevitable occurrence of death is inexplicably delayed. The search for the multiple factors influencing this phenomenon, related to the development and progress of medicine, leads to the investigation of four aspects deemed essential in their determination: imperative technology, sanctity of life, omnipotence of medicine and the lack of a unique medical decision. Apart from the availability of high technology, there is an increasing requirement of the patient's full autonomy with respect to the decisions involving the end of his life, which include the debated right to die. In the struggle towards death with dignity in a context where practical decisions are required, the following are taken into account: refusal of treatment, irreversibility of clinical diagnosis and palliative support, and withholding and withdrawal of life-sustaining therapy.

[Bacterial resistance and antimicrobial therapy in respiratory medicine and intensive care]. / Resistencia bacteriana y antibioticoterapia en medicina respiratoria y terapia intensiva.

Nosocomial pneumonia is the leading cause of mortality among the infections produced by multi-resistant microorganisms in intensive care units (ICU). The solution of this problem created by the colonization and infection of the respiratory tract is beyond respiratory medicine and requires a multi-disciplinary approach, involving other nosocomial infections in the ICU. Up to 80% ICU patients receive antibiotics for severe infections or prophylactically, frequently with no clear justification for these treatments. The extended use of antibiotics increases the problem by exerting a selective pressure favoring the development of resistant organisms. Some evidences suggest that the infections produced by multi-resistant pathogens increase the mortality of nosocomial pneumonia. The following mechanisms are responsible for the acquisition of resistance: alteration of bacterial wall permeability; production of inactivating enzymes, modification of the target site, or eflux. Resistance is genetically transmitted by chromosomes or by plasmids. At the present time staphylococci (Staphylococcus aureus and coagulase-negative staphylococci) and enterococci predominate among the gram-positives, and non-fermenters (Pseudomonas aeruginosa, Acinetobacter spp) and some Enterobacteriaceae among the gram-negatives. Antibiotics are the main determinants of the problem of resistance but also partially their vehicle. The solution of this problem includes infection control, diagnosis and adequate therapy (sufficient doses chosen according to the case and based on prefixed antibiotic politics). These antibiotic politics imply a rational use, reconsideration of the initial scheme according to microbiologic results, limited use of combination antimicrobial strategies, restricted list of drugs, rotation and correct use of prophylaxis.

[Sepsis due to Vibrio cholerae no 01]. / Sepsis por Vibrio cholerae no 01.

Two fatal sepsis cases in two male patients (58 and 14 years old) due to Vibrio cholerae non 01 are described. Their original diseases were hepatic cirrhosis and acute lymphoblastic leukemia in its third complete remission. In this last case, gastroenteritis due to V. cholerae non 01 was also diagnosed. These sepsis presented a rapid evolution and positive hemoculture after 24 and 48 hours of incubation. Both strains isolated presented similar biochemical characteristics and did not agglutinate in the presence of the specific serum against V. cholerae. Both strains were susceptible to most of the antibiotics available. Sepsis due to V. cholerae non 01 is usually associated to other original diseases and to immunodepression. Management of these sepsis is difficult and mortality rates are very high.