Mortality associated with Acinetobacter baumannii infections experienced by lung transplant recipients.

Lung transplantation (LTX) requires continual systemic immunosuppression, which can result in infections that may compromise recipient survival. A recent outbreak of Acinetobacter baumannii at our institution resulted in infections experienced in both LTX recipients and nontransplant patients. A retrospective review was conducted of patients who had A. baumannii recovered from blood, other normally sterile body fluids, and/or respiratory secretions and who had clinical follow-up extending to 1 year postinfection. A. baumannii was considered "multidrug-resistant" when its growth was not inhibited by minimum inhibitory concentrations of multiple antibiotics. Despite the resistance profile, patients were treated with a combination of antibiotics, which included tigecycline, colistimethate, and when susceptible, imipenem. Once infection was diagnosed, immunosuppression was reduced in all LTX recipients. Six LTX recipients became infected with A. baumannii and were contrasted to infections identified in 14 non-LTX, nonimmunosuppressed patients. A. baumannii was persistently recovered in 4 of 6 LTX recipients (66.7%) compared with only 1 of 14 (7.1%) non-LTX patients (χ(2) = 9.9, p = 0.005). LTX recipients received antibiotic therapy for an average of 76 ± 18.4 days compared with 16.0 ± 6.8 days for the non-LTX patients (p = 0.025, Mann-Whitney U test). All 4 of the 6 (66.7%) LTX recipients died as a consequence of their infection compared with 1 of 14 (7.1%) of the non-LTX patients (χ(2) = 9.9, p = 0.005). Despite receiving more antibiotic therapy, LTX recipients who were infected with multidrug-resistant A. baumannii were less likely to clear their infection and experienced greater mortality compared with non-LTX patients.

Use of aerosolized colistin sodium in cystic fibrosis patients awaiting lung transplantation.

BACKGROUND: In patients with cystic fibrosis (CF) who are awaiting lung transplant, prolonged exposure to systemic antibiotics has frequently led to airway colonization with resistant isolates of Pseudomonas. This resistance limits the arsenal of effective antimicrobials available for infections after the initiation of immunosuppression and has been considered a theoretical deterrent to lung transplantation. METHODS: Twenty CF transplant candidates with "pan-resistant" Pseudomonas received maintenance antibiotic therapy with aerosolized colistin sodium (75 mg b.i.d.), and intravenous antibiotics were eliminated. Ten other CF candidates did not use colistin sodium. Sputum cultures and antibiotic sensitivities were followed every 3-6 weeks. RESULTS: All 20 candidates (100%) who used aerosolized colistin sodium became colonized with sensitive isolates of Pseudomonas in an average of 45.1+/-20.2 days. In contrast, only 3 of 10 CF transplant candidates (30%) who did not use colistin sodium later became colonized with sensitive isolates. The mean time to spontaneous emergence of sensitive organisms was 144.6+/-48.0 days in candidates who did not use colistin sodium and was significantly longer than in the candidates who used colistin sodium (P=0.007). The occurrence of redeveloping sensitive isolates of Pseudomonas was significantly greater in the candidates who used colistin sodium (P<0.05). Of the candidates who used colistin sodium, six have been transplanted at our institution. In five of these six recipients (83.3%) bacterial cultures taken from the explanted lungs continued to demonstrate sensitive organisms. CONCLUSION: Aerosolized colistin sodium may be a useful therapy to promote emergence of sensitive microbes in CF candidates with pan-resistant isolates of Pseudomonas.

Teaching COPD patients upper extremity exercises at home.

While exercise training for patients with COPD is time consuming and strenuous, we have seen through our experience that patients who comply with this simple and easy exercise program reported subjective improvement in ability to perform their activities of daily living. The key to exercise success is consistency and availability of reinforcement of techniques through the use of both written and in-person instruction.

Home-based, upper-arm exercise training for patients with chronic obstructive pulmonary disease.

Prior studies demonstrate the ability of upper extremity training to increase arm strength and endurance when incorporated into a pulmonary rehabilitation program. However, patients with severe chronic obstructive pulmonary disease (COPD) may have transportation or mobility problems that make it difficult to travel to a rehabilitation site to obtain this training. This pilot study was designed to determine whether a home-based, upper-arm exercise program could increase arm strength and endurance, and decrease perceptions of breathlessness and fatigue during five activities of daily living. Twenty patients with severe COPD (FEV1 0.80 +/- 0.42) were randomized to an experimental (n = 10) or control group (n = 10). The experimental-group training included three upper arm exercises five times a week for 8 weeks, with training level incremented during weekly home visits. Control-group subjects were contacted weekly to equalize attention from health care providers. During the upper-extremity endurance test for number of rings moved, no significant differences between groups were seen for interaction or treatment. However, there was a significant interaction between treatment and time for perceived fatigue (p = 0.0012), with the experimental group perceiving less fatigue during upper arm work than did the control group. No change was seen in perceived breathlessness. Findings of this study suggest that a home-based, upper-arm exercise program can reduce perceptions of fatigue for patients with severe COPD during activities involving upper arm work. Testing in a larger sample is indicated to determine whether this training can also improve ability to perform unsupported arm work.