Utility of C-reactive protein in assessing the disease severity and complications of community-acquired pneumonia.

Previous studies on the usefulness of C-reactive protein (CRP) in patients with community-acquired pneumonia (CAP) have yielded somewhat inconsistent results. Our aim was to assess the value of CRP in estimating the severity and complications of CAP. CRP levels during the first 5 days of hospitalization were measured in 384 adult patients with CAP, and the data were evaluated using comprehensive statistical analyses. Significantly higher CRP levels on admission were detected in Pneumonia Severity Index (PSI) classes III-V than in classes I and II (p <0.001). An increment of 50 mg/L CRP on admission was associated with a 1.22-fold odds for a patient to be in PSI classes III-V as compared with classes I and II (OR 1.22, 95% CI 1.11-1.34; p <0.001). CRP levels were significantly higher in bacteraemic pneumonia than in non-bacteraemic pneumonia (p <0.001). An increment of 50 mg/L CRP was associated with a 1.67-fold odds for a patient to be bacteraemic (OR 1.67, 95% CI 1.46-1.92; p <0.001). CRP levels >100 mg/L on day 4 after the admission were significantly associated with complications (p <0.01). There was a trend for an association between the level of CRP on admission and the time to reach clinical stability (p <0.01). In conclusion, CRP may be valuable for revealing the development of complications in CAP. It may also be useful to assess the disease severity, thus being complementary to the assessment of the PSI. In our patients, high CRP levels were associated with a failure to reach clinical stability.

Infective endocarditis in a Finnish teaching hospital: a study on 326 episodes treated during 1980-2004.

OBJECTIVES: To evaluate potential changes of infective endocarditis (IE) in patients treated in a Finnish teaching hospital during the past 25 years. PATIENTS: 326 episodes of IE in 303 patients treated during 1980-2004 were evaluated for clinical characteristics and their changes over time. RESULTS: The mean age of the patients increased with time (from 47.2 to 54.5 years, p = 0.003). Twenty-five (7.7%) episodes were associated with intravenous drug use (IVDU), with a significant increase of these episodes after 1996 (from 0 to 19 (20%), p < 0.001). Viridans streptococci were the most common causative agents of IE during 1980-1994, but after that Staphylococcus aureus was the most common pathogen (p = 0.015). The proportion of IE of the aortic valve decreased during the study (from 30 (49%) to 26 (27%), whereas the proportions of mitral (11 (18%) to 33 (35%) and tricuspid valve IE (0 to 13 (14%) increased correspondingly (p = 0.001). This was mainly due to more patients with IVDU. Chronic dialysis for renal failure as an underlying condition increased over time (from 0 to 7 (7.4%), p = 0.015) but no other predisposing conditions changed. Complications such as neurological manifestations and heart failure did not change in frequency, but the incidence of lung emboli increased (from 0% to 10.5%, p < 0.001); 83% of these emboli occurred in patients with IVDU. The proportion of patients requiring surgical treatment and mortality due to IE did not change. CONCLUSIONS: During these 25 years, the causative agents, affected valves and complications of IE changed to some degree. These changes were mainly attributed to the increase of IVDU-associated IE. Except for the increase in age, the clinical presentation and outcome in non-addicts remained substantially unchanged.

Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.

BACKGROUND: Many previous studies have endeavored to find appropriate means to reduce the occurrence of neurologic manifestations in patients with infective endocarditis (IE). We evaluated patients with IE-associated neurologic complications and compared them with patients with IE who did not have neurologic symptoms. Particular attention was focused on assessing the impact of cardiac surgery and the presence of potential risk factors for complications on the outcome of the patients. METHODS: A total of 218 episodes designated as definite or possible IE according to Duke criteria and treated during the years 1980 through 1996 in a Finnish teaching hospital were retrospectively evaluated for neurologic manifestations. RESULTS: Neurologic complications were identified in 55 episodes (25%), with an embolic event as the most frequent manifestation (23/55; 42%). In the majority (76%) of episodes, the neurologic manifestation was evident before antimicrobial treatment was started, being the first sign of IE in 47% of episodes. Only 1 recurrent cerebral embolization was observed. Neurologic complications were significantly associated with Staphylococcus aureus infection (29% vs 10%; P =.001) and with IE affecting both the aortic and the mitral valves (56% vs 23%; P<.01), but not with echocardiographic detection of vegetations or anticoagulant therapy. Death during the acute phase of IE occurred in 13 episodes (24%) with neurologic complications and in 17 episodes (10%) without neurologic complications (P<.03). In episodes with neurologic complications, the IE-associated mortality rate was 25% (10/40) in the medical treatment group and 20% (3/15) in the surgical group. No neurologic deterioration was observed in these surgically treated patients postoperatively. CONCLUSIONS: Our results reinforce the belief that rapid diagnosis and initiation of antimicrobial therapy may still be the most effective means to prevent neurologic complications. These data underscore the importance of diagnostic alertness to the prognosis of patients with IE.

Eikenella corrodens prosthetic valve endocarditis in a patient with ulcerative colitis.

A 33-y-old male with ulcerative colitis developed prosthetic valve endocarditis (PVE) caused by Eikenella corrodens. The outcome of conservative treatment was successful. Only 2 cases of E. corrodens PVE were found in a survey of the English-language medical literature. In contrast to previous data indicating that eikenella infections usually derive from the oral cavity, our patient most likely acquired the infection by colonoscopy and mucosal biopsies, which were performed a few days before onset of the disease.

Diagnosis of infective endocarditis. Sensitivity of the Duke vs von Reyn criteria.

BACKGROUND: Because of the highly variable clinical manifestations of infective endocarditis (IE), different sets of diagnostic criteria have been used to standardize case definitions of IE. We evaluated the validity of the recently proposed Duke criteria, as compared with the older von Reyn criteria, in patients with no history of injecting drug abuse. METHODS: A total of 243 consecutive episodes of suspected IE in 222 patients treated during the years 1980 through 1995 in a Finnish teaching hospital were retrospectively evaluated for the likelihood of IE by means of these 2 classification schemes. RESULTS: Of all disease episodes, 114 were designated as definite IE by the Duke criteria, as compared with 64 episodes so classified by the von Reyn criteria (P < .001; Fisher exact test). Moreover, as many as 115 disease episodes were rejected by the von Reyn criteria, whereas only 37 episodes were rejected by the Duke criteria (P < .001). Of the cases rejected by the von Reyn criteria, the Duke clinical criteria designated 6 (5%) as definite IE and 72 (63%) as possible IE. Among histopathologically verified episodes, 46 were designated as definite IE by the Duke clinical criteria, as compared with a diagnosis of probable IE by the von Reyn criteria in 33 episodes (P = .02). Moreover, 26 pathologically proved cases would have been rejected by the von Reyn criteria had surgery not been performed, as compared with none being rejected by the Duke criteria (P < .001). CONCLUSIONS: Corroborating earlier findings, the higher sensitivity of the Duke criteria, as compared with the von Reyn criteria, was demonstrated in this study. These results confirm the validity of the Duke criteria in diagnosing IE in a non-drug-addict patient population.