[Antimicrobial treatment of patients with severe acute exacerbation of COPD]. / Antimikrobielle Therapie bei intensivpflichtigen Patienten mit akuter Exazerbation einer COPD.

Chronic obstructive lung disease (COPD) is a leading cause of death worldwide. In patients with acute exacerbations admitted to an intensive care unit (ICU), potentially pathogenic microorganisms can be found in approximately 50%, with Haemophilus influenzae and Streptococcus pneumoniae as the leading strains, followed by enterobacteria and Pseudomonas aeruginosa. Viruses can also be detected in a large proportion of patients. The indication for antimicrobial treatment of acutely exacerbated COPD is still controversial but recommended by guidelines for all patients admitted to an ICU. Appropriate agents for an empiric initial treatment are penicillins + betalactamase inhibitor, 2(nd) and 3(rd) generation cephalosporins, carbapenems, and quinolones. Antimicrobial treatment should be adjusted according to the results of microbial investigation of sputum or endotracheal aspirate.

Invasive pneumococcal disease in Phramongkutklao Hospital 2004-2008: clinical data, serotype distribution and antimicrobial resistance patterns.

OBJECTIVE: To describe the clinical course, serotype distribution and antimicrobial resistance patterns of invasive pneumococcal disease (IPD) cases in a public hospital. MATERIAL AND METHOD: Retrospective review of IPD cases occurring from January 2004 through December 2008 was performed. Antibiotic susceptibility testing and serotyping were performed for available isolates. RESULTS: Fifty one IPD cases occurred during the study period, of which 47 had medical records available for review. The majority of cases occurred among children under 5 years of age (23.4%) and adults over 60 years of age (36.1%). Underlying diseases were identified in 72.3% of patients. Fifty-three percent of cases were associated with pneumonia, while 17% had meningitis, and 15% had isolated bacteremia. Serotype could be determined for 15 (31.9%) isolates, and 6B was most common. Based on current antibiotic susceptibility breakpoints for meningitis, 4 of the 7 available isolates from meningitis cases were penicillin resistant and one had reduced susceptibility to cefotaxime. Among non-meningitis isolates, 96.7% were penicillin susceptible and 3.3% had intermediate susceptibility to penicillin. Overall case fatality proportion was 19%. CONCLUSION: At this tertiary care hospital in Bangkok, IPD has disproportionately affected young children and the elderly. High rates of penicillin resistance among meningitis cases, the most severe form of IPD, underscore the need of appropriate treatment strategies and vaccine usage.

Invasive pneumococcal infection in urban Thai children: a 10-year review.

OBJECTIVE: To determine the disease frequency, demographic characteristics, clinical manifestations, laboratory findings and drug susceptibility patterns of childhood invasive pneumococcal infections in a hospital setting in Thailand. MATERIAL AND METHOD: A retrospective review was conducted of invasive pneumococcal infections among children aged < 18 years from January 1, 1998 - December 31, 2007 at the Queen Sirikit National Institute of Child Health (QSNICH). Medical records of case-patients were reviewed to collect information on demographics, clinical manifestations, laboratory findings, and drug susceptibility patterns of infecting isolates. RESULTS: Among the 745,983 children receiving care at QSNICH during the study period, culture-proven invasive pneumococcal infections were identified in 126 patients for an estimated incidence of 17 cases per 100,000 patients. Patient diagnoses included bacteremia (59.4%), meningitis (29.3%), and pneumonia (11.3%). Of the 31 pneumococcal meningitis cases, 54.8% were caused by penicillin-nonsusceptible S. pneumoniae (PNSSP), while 25.3% of 75 non-meningitis cases were PNSSP (records not available for the remaining 20 cases). Of 126 PNSSP, 8.2% were resistant to cefotaxime and 12.3% were resistant to ceftriaxone. All of the isolates were susceptible to vancomycin. The case fatality rate was 12.3%; 23.1% offatal cases were associated with HIV infection. Outcomes did not differ significantly between patients infected with penicillin-susceptible and non-susceptible pneumococcal strains. CONCLUSION: The results of this hospital-based study indicate that the incidence of invasive pneumococcal infection in QSNICH remains relatively low, but the case fatality rate is high, especially among those with HIV infection.

Factors associated with acute otitis media in children due to penicillin intermediately resistant Streptococcus pneumoniae.

OBJECTIVES: This study was conducted to analyze the association between recent antimicrobial use and acute otitis media (AOM) due to Streptococcus pneumoniae intermediately resistant to penicillin (PISP). The influence of drug resistance on the clinical course of AOM was also assessed. METHODS: A retrospective cohort study was conducted in infants at Japanese Red Cross Medical Center, Tokyo. Children included in the study were under 24 months of age and diagnosed with AOM due to infection with S. pneumoniae between April 2002 and March 2007. Crude risk ratios (cRR) of PISP infection in cases with recent antibiotic use and other factors were obtained. The Mantel-Haenszel estimate was applied for the adjustment of cRR. RESULTS: Of 35 children, 13 had AOM due to penicillin-susceptible S. pneumoniae (PSSP) and 22 had AOM due to PISP. The adjusted risk ratio (aRR) of penicillin antibiotic use within 1 month was 1.99 (95% confidence interval (CI): 1.36-2.92), and the aRR of penicillin antibiotic use within 1 week was 1.93 (95% CI: 1.33-2.67). Recent use of penicillin antibiotics was an associated factor for AOM due to PISP. The clinical course was not clearly different between cases infected with PSSP and those with PISP. CONCLUSION: Recent use of penicillin antibiotics might be a selective pressure for PISP.

Diagnosis and treatment of otitis media.

Diagnostic criteria for acute otitis media include rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms. Detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis. Observation is an acceptable option in healthy children with mild symptoms. Antibiotics are recommended in all children younger than six months, in those between six months and two years if the diagnosis is certain, and in children with severe infection. High-dosage amoxicillin (80 to 90 mg per kg per day) is recommended as first-line therapy. Macrolide antibiotics, clindamycin, and cephalosporins are alternatives in penicillin-sensitive children and in those with resistant infections. Patients who do not respond to treatment should be reassessed. Hearing and language testing is recommended in children with suspected hearing loss or persistent effusion for at least three months, and in those with developmental problems.

Antibiotic resistant infections due to Streptococcus pneumoniae: impact on therapeutic options and clinical outcome.

PURPOSE OF REVIEW: Streptococcus pneumoniae is a major cause of morbidity and mortality in the pediatric population. The development of increasing resistance to multiple classes of antibiotics is making treatment of infections due to this organism much more difficult. The ultimate impact of high-level antibiotic resistance on therapeutic options and clinical outcomes of various pneumococcal infections is unclear and remains to be determined. Use of the conjugate pneumococcal vaccine has markedly decreased invasive pneumococcal disease in children under 5 years of age; however, its impact on decreasing antibiotic resistance is currently unknown. RECENT FINDINGS: Studies suggest that response to therapy and clinical outcome of infections due to pneumococcal isolates with intermediate resistance to the beta-lactam antibiotics is no different from that of infections due to susceptible isolates. However, evidence is accumulating that infections caused by highly resistant pneumococcal isolates are associated with higher rates of treatment failure and mortality than infections due to susceptible strains. SUMMARY: Use of a conjugate pneumococcal vaccine in conjunction with educational intervention programs that promote appropriate and judicious antibiotic use is a safe and effective means of decreasing the prevalence of pneumococcal disease in the pediatric population, decreasing the use of broad-spectrum antibiotic agents and potentially decreasing the amount of antibiotic resistance currently being seen.

Effect of penicillin resistance of Streptococcus pneumoniae on the presentation, prognosis, and treatment of pneumococcal endocarditis in adults.

We performed a clinical study of pneumococcal endocarditis (PE) in adults at 15 major Spanish hospitals during a 21-year period (1978-1998). During this time, 63 patients had PE due to Streptococcus pneumoniae diagnosed. Of the 63 isolates recovered from these patients, 24 (38%) and 6 (10%) showed resistance to penicillin (minimum inhibitory concentration [MIC], 0.1-4 microg/mL) and cefotaxime (MIC, 1 microg/mL), respectively. Twenty-two (35%) of the patients died. Left-side heart failure, but not penicillin resistance, was independently associated with a higher risk of death (odds ratio, 1.33; 95% confidence interval, 1.04-1.71; P=.026). Patients without meningitis who had PE due to penicillin-resistant S. pneumoniae could be treated with high-dose penicillin or a third-generation cephalosporin if the MIC for penicillin was < or =1 microg/mL. For patients with concurrent meningitis, high doses of cefotaxime could be used if the MIC for cefotaxime was < or =1 microg/mL. Early recognition of heart failure and surgery may help to decrease mortality.

Resolution of infectious parameters after antimicrobial therapy in patients with ventilator-associated pneumonia.

Although recommended durations of antimicrobial therapy for ventilator-associated pneumonia (VAP) range from 7 to 21 d, these are not based on prospective studies and little is known about the resolution of symptoms after start of antibiotics. Resolution of these symptoms was investigated in 27 patients. VAP was diagnosed on clinical, radiographic, and microbiological criteria, including quantitative cultures of bronchoalveolar lavage. All patients received appropriate antibiotic therapy. Highest temperatures, leukocyte counts, Pa(O(2))/FI(O(2)) ratios, and semiquantitative cultures of endotracheal aspirates were recorded from start of therapy until Day 14. Resolution was defined as the first day that these parameters fulfilled the following definition: temperature < or = 38 degrees C, leukocytes < or = 10 x 10(9)/L, Pa(O(2))/FI(O(2)) ratio > or = 25 kPa, and no or +1 of bacterial growth of etiologic pathogens in cultures of endotracheal aspirate. VAP was caused by Enterobacteriaceae (n = 14), P. aeruginosa (n = 7), S. aureus (n = 6), H. influenzae (n = 3), and S. pneumoniae (n = 1). H. influenzae and S. pneumoniae were eradicated from tracheal aspirates, whereas Enterobacteriaceae, S. aureus, and P. aeruginosa persisted, despite in vitro susceptibility to antibiotics administered. Significant improvements were observed for all clinical parameters, most apparently within the first 6 d after start of antibiotics. Newly acquired colonization, especially with P. aeruginosa and Enterobacteriaceae, occurred in the second week of therapy. Six patients developed a recurrent episode of VAP, four of them with P. aeruginosa. Clinical responses to therapy for VAP occur within the first 6 d of therapy, endotracheal colonization with Gram-negative bacteria persists despite susceptibility to therapy, and acquired colonization usually occurs in the second week of therapy and frequently precedes a recurrent episode.

Celulitis orbitaria en la edad pediátrica. Revisión / Orbital cellulitis in childhood. Review

La celulitis orbitaria comprende dos patologías bien diferenciadas desde un punto de vista anatomoclínico: la forma preseptal y la postseptal. Constituye una enfermedad infecciosa relativamente frecuente en la edad pediátrica que, normalmente, es secundaria a sinusitis. Presentamos una revisión de esta patología haciendo especial hincapié en el cambio etiológico acontecido en la última década tras la vacunación sistemática contra Haemophilus influenzae tipo B. (AU)

Neumonía comunitaria severa: diagnóstico, pronóstico y pautas terapéuticas / Community acquired pneumonia: diagnosis, prognosis and therapeutic guidelines

Neumonía comunitaria es una enfermedad vista en todas las edades y que demanda importantes recursos de salud. La mortalidad promedio es de 13 por ciento que llega al 50 por ciento en los pacientes de las unidades críticas a pesar de la importante navegación, más del 50 por ciento de los casos queda sin resolver su real agente patógeno, y en las décadas pasadas se han tratado de uniformar su manejo, se han propuesto en cambio en la clasificación de la neumonía típica y atípica debido a la poca utilidad de algunas. Además que consideran los problemas de edad, riesgo y patología asociada. El Streptococo neumonía sigue siendo el germen más permanente. El presente artículo revisa los factores de mayor riesgo asociado a la evolución de la neumonía

[The metal content of the blood in patients with bacterial meningoencephalitis]. / Soderzhanie nekotorykh metallov v krovi bol'nykh bakterial'nymi meningoéntsefalitami.

A study is presented of the quantitative content of blood metals in 60 patients depending on the duration and severity of bacterial meningoencephalitis. It was established that examination of the concentration of macro- and microelements in their dynamics reflects the state of mineral blood homeostasis and can be used as supplementary criterion in the diagnosis of bacterial meningoencephalitis.