Effect of prior pneumococcal vaccination on clinical outcome of hospitalized adults with community-acquired pneumococcal pneumonia.

The aim of this study was to evaluate the effect of prior pneumococcal vaccination on the clinical outcome of 554 consecutive hospitalized adults with community-acquired pneumococcal pneumonia from 1995 to 2004, 61 of whom had been vaccinated in the 5 years before admission. Outcome variables that were compared in vaccinated and unvaccinated adults included the occurrence of bacteremia, the time to resolution of pneumonia symptoms, the length of hospital stay, and mortality. Prior pneumococcal vaccination was associated with a lower risk of bacteremia (odds ratio 0.46, 95% CI 0.22-0.98). Compared with unvaccinated patients, vaccine recipients had better clinical outcomes, which included a faster resolution of pneumonia symptoms. The median length of hospital stay was shorter in vaccinated patients (8.0 vs. 9.0 days; p=0.032). Overall case-fatality rates did not differ significantly between groups (1.6% vs. 6.2%; p=0.233). In conclusion, prior pneumococcal vaccination appears to be associated with a lower risk of bacteremia, a faster time to resolution of symptoms, and a shorter hospital stay in adults with pneumococcal pneumonia. The findings presented here provide additional support to the current vaccine recommendations and should encourage healthcare providers to increase pneumococcal vaccine coverage among targeted adult populations.

Clinical experience in the management of community-acquired pneumonia: lessons from the use of fluoroquinolones.

Community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality worldwide. The treatment of CAP has been complicated by several factors, including the expanding spectrum of causative organisms and the rising prevalence of antibiotic resistance among respiratory pathogens. Initial antimicrobial treatment for patients with CAP is usually selected empirically and should provide appropriate coverage against the most common causative organisms, including resistant strains. Respiratory fluoroquinolones, such as levofloxacin, are the only antimicrobials that are highly active against the pathogens most frequently implicated in CAP, including macrolide-resistant and penicillin-resistant pneumococci, Haemophilus influenzae, Legionella spp., and atypical agents. This paper reviews recent studies involving adult patients with CAP that suggest that levofloxacin, as compared with other conventional antibiotic treatments, may be associated with better clinical outcomes.

Valacyclovir prophylaxis for the prevention of Herpes simplex virus reactivation in recipients of progenitor cells transplantation.

HSV can cause oral lesions that exacerbate chemotherapy-related mucositis. Intravenous acyclovir is effective in preventing HSV reactivations, but expensive. Valacyclovir has good bioavailability and has not been studied for prophylaxis of HSV among PCT patients. We compared the efficacy and costs of valacyclovir in preventing HSV reactivation among HSV seropositive autologous progenitor cell transplantation (APCT) patients with historical controls in whom intravenous acyclovir or no HSV prophylaxis were used. Valacyclovir group: From October 1997 to April 1999 108 adult patients received valacyclovir 500 mg twice daily from day -3 of APCT until neutropenia recovery or day +30. Valacyclovir was switched to intravenous acyclovir in cases of oral intolerance (17 patients) or suspected HSV reactivation (five patients). Intravenous acyclovir group: From January 1996 to October 1997 43 patients received 5 mg/kg twice-daily intravenous acyclovir from day -3 until recovery from neutropenia. No prophylaxis group: 38 patients from January 1996 to October 1997 did not receive HSV prophylaxis. HSV reactivations were seen in 2.7%, 2% and 45% of patients in the valacyclovir, intravenous acyclovir, and no prophylaxis groups, respectively. Valacyclovir was well tolerated and was the least expensive strategy. Oral valacyclovir was as effective as intravenous acyclovir for the prophylaxis of HSV reactivation in APCT patients.

Clinical ergotism induced by ritonavir.

Ritonavir strongly inhibits cytochrome P450, thus altering the metabolism of other drugs. We report on an HIV-positive man who, on his 13th day of ritonavir therapy, developed severe ergotism after self-administration of low doses of ergotamine. Drug interactions, the degree of responsibility of the patient and the availability of over-the-counter medications must be considered when prescribing antiretroviral therapy.

Predisposing factors and outcome of Staphylococcus aureus bacteremia in neutropenic patients with cancer.

Staphylococcus aureus caused 30 of 438 (7%) cases of bacteremia in neutropenic patients with cancer during a 10-year study period. Acute leukemia as an underlying disease and severe oral mucositis were more frequent among patients with Staphylococcus aureus bacteremia (57% vs. 33%, P = 0.01, and 32% vs. 12%, P = 0.006, respectively) than among the 151 patients who had gram-negative bacteremia during the same study period. The most frequent source of Staphylococcus aureus bacteremia was the venous catheter (35% vs. 1%; P = 0.00001). Septic metastases were more frequent in patients with Staphylococcus aureus bacteremia (14% vs. 4%, P = 0.03). Attributable mortality was 10% and overall mortality 23%. Staphylococcus aureus bacteremia remains a significant cause of morbidity and mortality in neutropenic patients with cancer.