Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 µg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 µg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 µg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.

Safety of withholding anticoagulant therapy in patients who have clinically suspected pulmonary embolism and negative results on helical computed tomography.

BACKGROUND: Several studies have focused on the safety of withholding anticoagulant therapy in patients with negative results on helical computed tomography (CT). However, these studies were either retrospective or had a selection bias, since spiral CT was performed only in selected patients. Moreover, no special attention has been directed towards an alternative diagnosis which might explain patients' signs and symptoms. OBJECTIVES: To determine the safety of withholding anticoagulants in patients with clinically suspected pulmonary embolism (PE) and negative CT results when ultrasonography (US) was performed only in patients with clinical suspicion of deep vein thrombosis (DVT). Another goal was to evaluate the effect of CT findings on the final clinical diagnosis. METHODS: Among 192 consecutive patients who underwent CT for possible acute PE, 98 patients had negative images and 88 of them-- without clinical suspicion of DVT-- were prospectively followed up for 3 months for evidence of subsequent thromboembolic disease. They did not receive anticoagulation. Clinical probability of PE was assessed applying the Geneva score. These patients were also classified into several diagnostic categories according to the CT findings and clinical presentation. In addition, all patients who were alive (or a member of his or her family) were interviewed by phone once the last patient's follow-up was completed. RESULTS: One patient was lost to follow-up. Among the remaining 87 patients (35 with low, 47 with intermediate and 5 with high clinical probability), subsequent thromboembolic disease was found in 1 (1.1%; 95%CI: 0.03-6.2%). Two patients died during the follow-up period, but no deaths were attributed to PE. Alternative diagnoses were: nonspecific thoracic pain (43.3%), nonspecific pleuritis (19.5%), pneumonia (18.4%), other (18.8%). The telephone survey was performed in 74 patients (median follow-up: 11 months; range: 4-23). None of them had newly diagnosed episodes of PE and none of them had received anticoagulation for any reason. CONCLUSIONS: With the limitations of a small single-center series, our data suggest that withholding anticoagulation in patients with suspected acute PE and negative CT results appears to be safe when the clinical probability of PE is assessed as low or intermediate. This technique also provides useful information to pose an alternative diagnosis. US could be avoided in patients without clinical suspicion of DVT.

[Nodular pulmonary sarcoidosis, a radiological form of rare presentation or granulomatous vasculitis? A report of 3 cases]. / Sarcoidosis nodular pulmonar, una forma radiológica de presentación infrecuente o una vasculitis granulomatosa? Descripción de tres casos.

Three cases of nodular pulmonary sarcoidosis are presented. Chest roentgenograms demonstrated multiple bilateral nodules and the diagnosis was achieved by means of biopsy specimens after other diseases capable of producing a similar histologic or clinical picture were excluded we discuss the clinical, histologic and radiographic behaviors of nodular sarcoidosis.

Sarcoidosis nodular pulmonar, ¿una forma radiológica de presentación infrecuente o una vasculitis granulomatosa? Descripción de tres casos / Nodular pulmonary sarcoidosis, a radiological form of rare presentation or granulomatous vasculitis? A report of 3 cases

Presentamos los casos clínicos de 3 pacientes estudiados por la presencia de infiltrados nodulares en la radiografía de tórax. Todos ellos fueron histológicamente diagnosticados de sarcoidosis después de descartar enfermedades con manifestaciones clínico-radiológicas similares. Discutimos los aspectos conceptuales, diagnósticos, pronósticos y terapéuticos de esta inusual forma de presentación (AU)

Fallo respiratorio agudo como forma de presentación de una neumonitis por hipersensibilidad al esparto (estipatosis) / Acute respiratory failure presenting as pneumonitis due to esparto hipersensitivity (stipatosis)

Describimos el caso de un paciente con historia de exposición al esparto, que ingresó en la Unidad de Cuidados Intensivos por insuficiencia respiratoria aguda. El reconocimiento temprano de la enfermedad del paciente y la pronta iniciación del tratamiento con corticoides permitieron una buena evolución clínica. El diagnóstico de neumonitis por hipersensibilidad al esparto se sospechó por la anamnesis y el resultado de la biopsia pulmonar, y se confirmó con una prueba de provocación (AU)

[Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome]. / Ventilación pulmonar independiente sincronizada en el tratamiento del síndrome de distrés respiratorio del adulto.

INTRODUCTION: Synchronized independent lung ventilation (SILV) is an effective mode of mechanical ventilation for treating both unilateral and bilateral pulmonary lesions. Oxygenation improves with an increase in the ventilation/perfusion ratio and also diminishes the risk of barotrauma. We describe our broad experience with this technique. Our main objective was to confirm whether SILV is able to improve the alveolar-arterial oxygen difference [P(A-a)O2] of patients with severe adult respiratory distress syndrome (ARDS) in whom conventional mechanical ventilation has not brought about improvement after being used for over 48 hours. PATIENTS AND METHODS: We carried out a descriptive, open, controlled prospective study of 45 patients with severe ARDS, enrolled from among 68 who underwent treatment with SILV. The most frequent cause of ARDS in our study was multiple trauma. The patients diagnosed of ARDS who did not improve with conventional mechanical ventilation were treated with SILV. Clinical characteristics and mortality are described. APACHE II scores, PAOA-aO2, dynamic distensibility were analyzed before and after SILV. The results of SILV were considered good if PA-aO2 improved at least 30% within 48 hours, with no increase in distensibility. RESULTS: No complications due to the technique were observed. Twenty-two patients (48.8%) died, 18 as a result of multiple organ failure and only one (4.5%) because of hypoxia. The improvements in APACHE II and (PA-aO2 were statistically significant, while distensibility did not change. The result was defined as good in most cases (n = 34, 83.8%). CONCLUSIONS: SILV is useful for providing ventilatory support when ARDS fails to improve with conventional mechanical ventilation. Clear improvement in respiratory function was observed, with significant decrease in PA-aO2 and no change in distensibility. SILV is a safe technique with few complications and can be managed by the intensive care unit nursing staff.

[Hydropneumothorax secondary to enteral feeding tube]. / Hidroneumotórax secundario a sonda de nutrición enteral.

The placement of naso-gastric tubes is a routing procedure in Intensive Care Units. Their basic indications are the aspiration of gastric contents, as well as the enteral nutrition of the patients. Despite this being a simple technique, it is not exempt of complications, some of which are very serious, which should be kept in mind in order to prevent them and to diagnose them early. We describe a case of hydro-pneumothorax, secondary to the placement of a naso-gastric tube for enteral nutrition.