Initial management of and outcome in patients with pneumococcal bacteremia: a retrospective study at a Swiss university hospital, 2003-2009.

PURPOSE: The aim of this quality control study was to assess the time to initial diagnostic procedures and the time to the first dose of antibiotics in patients with pneumococcal bacteremia, and to investigate whether the timeliness of these interventions influenced outcome. METHODS: We retrospectively studied patient characteristics, chronological sequence of diagnostic and therapeutic steps, and the course of disease of all patients with pneumococcal bacteremia at a Swiss university hospital between 2003 and 2009, and we analyzed associations between these factors and the length of hospital stay (LOS) and mortality. RESULTS: A total of 102 episodes of pneumococcal bacteremia in 98 patients were analyzed, of whom 15.7% died during hospitalization. The median time (interquartile range [IQR]) to the first antibiotic dose was 4.0 (2.0-5.9) h, and the median times (IQR]) to blood cultures, chest radiograph, lumbar puncture, and brain computed tomography (CT) scan or magnetic resonance imaging (MRI) were 1.4 (0.5-3.3), 2.5 (1.2-4.2), 4.2 (2.7-7.2), and 2.3 (0.6-6.2) h, respectively. The time to diagnostic procedures and therapy were not associated with LOS or death. Risk factors for death in the univariable analysis were: Charlson comorbidity index [odds ratio [OR] (95% confidence interval) per unit increase, 1.3 (1.1-1.6)], neutropenia [OR 10.1 (2.0-51.0)], human immunodeficiency virus (HIV) infection [OR 3.9 (1.1-13.8)], chronic respiratory disease [OR 4.4 (1.2-16.0)], chronic liver disease [OR 3.2 (1.0-9.7)], smoking [OR 3.8 (1.1-13.5)], injection drug use [OR 9.7 (1.5-63.7)], and antibiotic therapy within 6 months before admission [OR 4.0 (1.3-12.5)]. The multivariable analysis revealed age >60 years (P = 0.048) and alcoholism (P = 0.009) as risks for prolonged LOS. CONCLUSIONS: The outcome of pneumococcal bacteremia may be more influenced by patient characteristics than by minor differences in the timeliness of initial diagnostic and therapeutic measures within the first several hours after hospital admission.

Immunotherapy with a mass unit Parietaria judaica extract: a tolerance study with evidence of immunological changes to the major allergen Par j 1.

Specific immunotherapy with Parietaria judaica pollen extract has been proven to be effective in the treatment of patients with respiratory allergy induced by this pollen. Nevertheless, there is some controversy about its tolerability. We conducted an open uncontrolled study to evaluate the tolerability of an aluminium adsorbed P. judaica pollen extract whose major allergen (Par j 1) content was known. Changes in immunological parameters to a complete P. judaica extract and to a purified Par j 1 preparation were monitored. Twenty-one patients (12 women, 9 men; mean age 30.2 years) suffering from rhinoconjunctivitis and/or asthma due to Parietaria pollen were enrolled. The maximum dose was established at 10 BU/ml (0.6 microgram Par j 1). Skin and conjunctival reactivity as well as serum levels of specific IgE, IgG, IgG1 and IgG4 were evaluated before therapy (T0), when 1 BU was given (T1), 2 weeks after the maintenance dose was reached (T2) and after the pollen season (T3). Four-hundred and fifteen doses were administered during immunotherapy. Only one systemic reaction (0.24% of doses) and two local reactions were registered. Reactions occurred during the administration of the highest concentrated vial. Before immunotherapy, purified Par j 1 accounted for 94.2% of the cutaneous response elicited by the complete extract. A statistically significant decrease in cutaneous response was detected after 8 weeks of treatment. There were no significant changes in conjunctival reactivity throughout the study. Specific IgG, IgG1 and IgG4 showed a pronounced and significant increase during the study, while specific IgE levels initially decreased and increased after the pollen season. The kinetics of specific antibodies to P. judaica complete extract and purified Par j 1 showed a parallel trend. The present study demonstrates that immunotherapy with P. judaica extract is well tolerated in patients suffering from rhinoconjunctivitis and/or asthma due to Parietaria pollen. This therapy induces specific changes in the immunological response to P. judaica and to purified Par j 1. These changes can be detected at very early stages of therapy.