Treatment of community-acquired pneumonia. / Behandling av pneumoni oppstått utenfor sykehus.

BAKGRUNN: Helsedirektoratet gir ut nasjonale retningslinjer for antibiotikabruk i sykehus. For pneumoni oppstått utenfor sykehus anbefales penicillin ved mild til moderat pneumoni og penicillin i kombinasjon med gentamicin ved alvorlig pneumoni. Alvorlighetsgrad vurderes med CRB-65-kriteriene. Vi vet lite om etterlevelse av retningslinjene. METODE: Vi gjennomgikk journalene til pasienter innlagt med pneumoni med Streptococcus pneumoniae eller Haemophilus influenzae ved Infeksjonsmedisinsk avdeling ved Oslo universitetssykehus, Ullevål sykehus, i 2015 (N = 70) og undersøkte om behandlingen som ble gitt, var i samsvar med de nasjonale retningslinjene. RESULTATER: 24 (34 %) av pasientene fikk penicillin i monoterapi, 25 (36 %) fikk kombinasjonen penicillin og gentamicin, 14 (20 %) fikk kefalosporiner, mens 7 (10 %) fikk andre antibiotika. Totalt fikk 38 (54 %) pasienter empirisk antibiotika i henhold til retningslinjene. CRB-65-kriteriene ble ikke dokumentert hos noen av pasientene. 38 av 50 pasienter som fikk penicillin, fikk høyere doser enn anbefalt. 62 (89 %) pasienter fikk justert behandling etter at bakteriesvar forelå. Median lengde av antibiotikabehandling var 10 døgn (interkvartilintervall 8-11 døgn). FORTOLKNING: Bredspektrede antibiotika ble benyttet oftere enn retningslinjene skulle tilsi. Etter at bakteriesvar forelå, ble behandlingen justert i henhold til de nasjonale retningslinjene. Penicillindosene var ofte for høye og behandlingslengden for lang sammenholdt med de nasjonale retningslinjene.

Haemophilus influenzae and Haemophilus haemolyticus in tonsillar cultures of adults with acute pharyngotonsillitis.

OBJECTIVE: The aim of this study was to evaluate the clinical implication of Haemophilus haemolyticus, one of the closest relative of Haemophilus influenzae, on acute pharyngotonsillitis. METHODS: We applied polymerase chain reaction (PCR) for 16S ribosomal DNA (rDNA) and IgA protease gene (iga) to distinguish H. haemolyticus and H. influenzae. RESULTS: Among the 199 Haemophilus spp. isolated from 214 patients with acute pharyngotonsillitis, 52 (24.3%) H. influenzae strains and 23 (10.7%) H. haemolyticus strains were identified by polymerase chain reaction (PCR) for 16S rDNA and IgA protease gene (iga). All H. haemolyticus strains showed hemolysis on horse blood agar and there were no other Haemophilus spp., nonhemolytic H. haemolyticus and H. influenzae variant strains that had absent iga gene. H. hemolyticus showed close genetic relationship with H. influenzae evaluated by pulsed field gel electrophoresis (PFGE). The cases of acute pharyngotonsillitis showing WBC=7000/mm(3) or CRP=8 mg/dl were frequently found among cases with H. influenzae rather than cases with H. haemolyticus. CONCLUSION: H. haemolyticus is a pharyngeal commensal that is isolated frequently from adults with acute pharyngotonsillitis.

An outbreak of infections caused by non-typeable Haemophilus influenzae in an extended care facility.

Nosocomial outbreaks of infection due to non-typeable Haemophilus influenzae (NTHi) are rarely described. There are a few published reports that suggest that elderly patients with underlying pulmonary disease are at risk and that person-to-person spread is key to disease transmission. During the summer months of 2005, we documented an outbreak of NTHi infections in a Veterans Affairs nursing home. Thirteen patients developed conjunctivitis or lower respiratory infection involving a beta-lactamase-negative biotype III NTHi isolate, with an indistinguishable SmaI macrorestriction pattern. Patients were elderly males usually with underlying cardiac and pulmonary disease. A case-control study failed to demonstrate any specific significant risk factor for NTHi infection and there was no evidence of spatial clustering of cases within the nursing home. A random throat culture survey involving nursing home patients during the outbreak showed that only one of 19 persons was colonized with NTHi. The outbreak concluded following appropriate treatment and an emphasis on universal and respiratory droplet precautions. All patients recovered and a specific inciting event for the outbreak was never defined. Literature review revealed a spectrum of responses to nosocomial NTHi infections and a lack of consensus regarding the infection control approach towards NTHi outbreaks.

Comparison of oral findings in special needs children with and without gastrostomy.

PURPOSE: The objective of this study was to compare aspiration pneumonia (AP)-associated microflora, calculus, and oral hygiene/care seeking behaviors in special health care needs children (SC) with gastrostomy (GT) and without. METHODS: Twenty-seven GT SC, ages 3 to 12 years old and matched for age and gender with 27 non-GT SC, were examined by 2 trained investigators who recorded calculus and gingival inflammation and reconciled differences. Plaque was obtained using preweighed dry paper points and saliva sampled using sterile pipettes and cultured using standard bioassay procedures in a hospital laboratory. Parent/caretakers completed a medical and oral health questionnaire. RESULTS: No significant differences were noted for age, gender, weight, primary diagnosis, vomiting, constipation, or swallowing disorder, but GT children received 4 medications vs 1 for non-GT and were significantly more likely to have had AP, need special feeding, and drool (P < or = .05). Oral health measures were not significantly different for brushing frequency, dentifrice use, brushing problems, frequency of dental care, or gingival inflammation, but GT patients had significantly more plaque and calculus. GT patients had significantly more Haemophilus influenzae, with trends toward more gram negative enteric rods, pseudomonas, and Streptococcus pneumoniae and higher concentrations in several GT-patients and little or none in non-GT patients. GT SC had significantly less beta-streptococci than non-GT patients (P < or = .05). CONCLUSIONS: GT SC had significantly more of 1 AP-associated organism than non-GT SC and significantly more calculus and plaque, in spite of similar care seeking and hygiene behaviors.

Infected aortic aneurysms: imaging findings.

PURPOSE: To determine the imaging characteristics of infected aortic aneurysms. MATERIALS AND METHODS: Review of records of patients with surgical and/or microbiologic proof of infected aortic aneurysm obtained over a 25-year period revealed 31 aneurysms in 29 patients. This study included 21 men and eight women (mean age, 70 years). One radiologist reviewed 28 computed tomographic (CT) studies (22 patients underwent CT once and three patients underwent CT twice), 12 arteriograms (12 patients underwent arteriography once), eight nuclear medicine studies (six patients underwent nuclear medicine imaging once and one patient underwent nuclear medicine imaging twice), and three magnetic resonance (MR) studies (three patients underwent MR imaging once). Features evaluated included aneurysm size, shape, and location; branch involvement; aortic wall calcification; gas; radiotracer uptake on nuclear medicine studies; and periaortic and associated findings. The location of infected aortic aneurysms was compared with that of arteriosclerotic aneurysms. RESULTS: Aneurysms were located in the ascending aorta (n = 2, 6%), descending thoracic aorta (n = 7, 23%), thoracoabdominal aorta (n = 6, 19%), paravisceral aorta (n = 2, 6%), juxtarenal aorta (n = 3, 10%), infrarenal aorta (n = 10, 32%), and renal artery (n = 1, 3%). Two patients had two infected aortic aneurysms. CT revealed 25 saccular (93%) and two fusiform (7%) aneurysms with a mean diameter at initial discovery of 5.4 cm (range, 1-11 cm). Paraaortic soft-tissue mass, stranding, and/or fluid was present in 13 (48%) of 27 aneurysms, and early periaortic edema with rapid aneurysm progression and development was present in three (100%) patients with sequential studies. Other findings included adjacent vertebral body destruction with psoas muscle abscess (n = 1, 4%), kidney infarct (n = 1, 4%), absence of calcification in the aortic wall (n = 2, 7%), and periaortic gas (n = 2, 7%). Angiography showed 13 saccular aneurysms with lobulated contour in 10 (77%). Nuclear medicine imaging showed increased activity consistent with infection in six (86%) of seven aneurysms. MR imaging showed three saccular aneurysms. Adjacent abnormal vertebral body marrow signal intensity was seen in one (33%) of three patients. CONCLUSION: Saccular aneurysms (especially those with lobulated contour) with rapid expansion or development and adjacent mass, stranding, and/or fluid in an unusual location are highly suspicious for an infected aneurysm.

Analysis of invasive Haemophilus influenzae infections after extensive vaccination against H. influenzae type b.

Little clinical and microbiological information is available about invasive Haemophilus influenzae infection after widespread vaccination against H. influenzae type b (Hib). We conducted an active community surveillance study on invasive H. influenzae during a 2-year period in a community of more than 5 million people after vaccination against Hib in children was introduced. The median incidence was 16.3 cases/100000 persons per year in children less than 1-year-old and 4.41 cases/100000 persons in children less than <5 years old. The highest incidence in adults was observed in patients greater than 70 years old. Clinical diagnoses included bacteremia, pneumonia, and meningitis. Of the H. influenzae-infected patients, 74.3% had underlying predisposing conditions, including impaired immunity and respiratory diseases. A total of 73.6% of the isolates were nontypeable and 16.5, 6.6, and 3.3% were types b, f, and e, respectively. Infections due to capsulated strains b, e, and f were evenly distributed between children and adults. Ampicillin and cotrimoxazole resistance occurred at frequencies of 24.2 and 48.4%, respectively. Antibiotic resistance was more prevalent in capsulated than in noncapsulated H. influenzae. Invasive isolates were highly resistant to antibiotics that were used infrequently in the community. Nontypeable H. influenzae were genetically much more heterogeneous than capsulated strains. Capsule-deficient mutants (b(-)) were not detected. Plasmid carriage was linked to antibiotic resistance and capsulated strains. Over the study period, the incidence of invasive H. influenzae infections, either encapsulated or not, did not increase. In the post-Hib vaccination era, most invasive infections were due to noncapsulated strains and occurred in the extreme ages of life in patients with predisposing conditions.

Community-acquired pneumonia: etiology, epidemiology, and outcome at a teaching hospital in Argentina.

OBJECTIVE: To survey the etiology and epidemiology of community-acquired pneumonia (CAP) in relation to age, comorbidity, and severity and to investigate prognostic factors. DESIGN: Prospective epidemiologic study, single center. SETTING: University hospital at Buenos Aires, Argentina. PATIENTS: Outpatients and inpatients fulfilling clinical criteria of CAP. INTERVENTIONS: Systematic laboratory evaluation for determining the etiology, and clinical evaluation stratifying patients into mild, moderate, and severe CAP (groups 1 to 3), a clinical rule used for hospitalization. RESULTS: During a 12-month period, 343 patients (mean age, 64.4 years; range, 18 to 102 years) were evaluated. We found 167 microorganisms in 144 cases (yield, 42%). Streptococcus pneumoniae, the most common pathogen, was isolated in 35 cases (24%). Mycoplasma pneumoniae, present in 19 (13%), was second in frequency in group 1; Haemophilus influenzae, present in 17 cases (12%), was second in group 2; and Chlamydia pneumoniae, present in 12 cases (8%), was second in group 3. Etiology could not be determined on the basis of clinical presentation; identifying the etiology had no impact on mortality. Some findings were associated with specific causative organisms and outcome. A significantly lower number of nonsurvivors received adequate therapy (50% vs 77%). CONCLUSIONS: Age, comorbidities, alcohol abuse, and smoking were related with distinct etiologies. PaO(2) to fraction of inspired oxygen ratio < 250, aerobic Gram-negative pathogen, chronic renal failure, Glasgow score < 15, malignant neoplasm, and aspirative pneumonia were associated with mortality by multivariate analysis. Local microbiologic data could be of help in tailoring therapeutic guidelines to the microbiologic reality at different settings. The stratification schema and the clinical rule used for hospitalization were useful.

Differences in genetic diversity of nonecapsulated Haemophilus influenzae from various diseases.

Genetic relationships among 80 isolates of nonencapsulated Haemophilus influenzae recovered from different disease types were determined by multilocus enzyme electrophoresis (MEE) at 13 enzyme loci in an attempt to assess the association between multilocus genotype and disease. The isolates were obtained from 15 patients with meningitis, 10 with otitis media, 19 with chronic bronchitis, 20 with cystic fibrosis, and 16 were obtained from healthy carriers. The 80 isolates were assigned to 69 electrophoretic types (ETs) falling into 5 groups. Isolates from each disease entity were represented by a variety of genotypes; however, cluster analysis from a matrix of genetic distances between ETs revealed that the ETs of the otitis media and meningitis isolates were all clustered within a genetic distance of 0.55 (group I). In addition, no genotypes were shared between H. influenzae carrier isolates and isolates from cases of disease, H. influenzae isolates from healthy individuals were distributed significantly differently from those from chronic bronchitis meningitis and otitis media patients. The genetic diversity (H) of carrier strains was greatest, although not statistically different from that of isolates from patients with disease. It was concluded that the genetic distribution of acute disease isolates is not random over the five ET groups, although the genetic diversity within the groups is not different. The effect of bacterial persistence in the host on the genetic diversity of H. influenzae is discussed.

The burden of Haemophilus influenzae type b disease in Australia and an economic appraisal of the vaccine PRP-OMP.

OBJECTIVES: To estimate the incidence and sequelae of Haemophilus influenzae type b disease (Hib) in the Australian population, and to evaluate the costs and outcomes of a vaccination program using the vaccine PRP-OMP at two, four and 12 months. DESIGN: The evaluation was based on a decision analytic model developed by Merck Sharp and Dohme (Australia) Pty Ltd, to predict the number of children who would contract Hib, and suffer mild or severe sequelae or die as a result. The state of health of a cohort of children was modelled each month over a five-year period. A survey of medical records and interviews with parents of children who contracted meningitis in Western Australia from 1984-1990 was undertaken to provide data on the extent and costs of sequelae. RESULTS: The incidence of Hib among non-Aboriginal Australians under five years of age was estimated as 53 per 100,000, and 460 per 100,000 among Aborigines. In a single year at least 630 children may contract Hib, up to 19 may die, and a further 46 may have neurological damage, this being severe in up to 18 children. The number of deaths could be reduced by 17 per year and a further 25 cases of severe and 16 cases of mild disability could be averted. At a price of $20 per dose, and a 5% discount rate, the expected cost per year of life extended by a vaccination program is $3148. When adjusted for the increased number of years without neurological impairment, the incremental cost per quality adjusted life year (QALY) is $1965. Compared with a single vaccine at 18 months, the incremental cost per additional QALY gained is $5047. A separate analysis of the Aboriginal population showed that the proposed vaccination program would be of significant benefit, leading to a saving of resources.

Invasive Haemophilus influenzae type b disease.

In this overview, the characteristics of Haemophilus influenzae type b (Hib) as an organism and the important clinical and diagnostic features of the diseases it causes are discussed. Important developments in vaccination and in the treatment and prevention of Hib disease are outlined.

Infecciones severas por Haemophilus influenzae / Haemiphilus influenzae: severe systemic diseases

Haemophilus influenzae es el más importante microorganismo que causa serias infecciones bacterianas en niños. Un importante factor asociado con el riesgo de enfermedad invasiva es la edad, con un pico de incidencia entre los 6 y 23 meses. Esta revisión tiene como finalidad presentar al médico pediatra una actualización sobre el amplio espectro de infecciones invasivas por haemophilus influenzae.

Problem-orientated categorisation of "other conditions" seen in a genitourinary medicine clinic.

The case sheets of patients coded as D2 (other conditions requiring treatment) and D3 (other conditions not requiring treatment) in 1981 were reclassified on a problem-orientated basis. Ten discreet categories were delineated with ease. Women with non-specific vaginitis and men with Gardnerella vaginalis urogenital infection, usually coded D2 or C4, should be reclassified under the C group of conditions as, for example, "Gardnerella or other bacterial genital infections." It is suggested that codes D2 and D3 be replaced by the following nine categories: genital skin lesions or rashes; genitourinary symptoms; enteric conditions; other sexually transmitted infections; normal genital architecture, congenital conditions, or unconfirmed genital discharges; asymptomatic patients attending for routine examination; uninfected contacts of patients with sexually transmitted diseases; psychosexual problems; and others.

"Non-specific" vaginitis: a non-entity.

The author alleges that any knowledgeable physician owning a vaginal speculum and a microscope should rarely find the need for using the diagnosis, "non-specific" vaginitis, and that its too frequent use might well imply carelessness, indifference or a failure to employ available diagnostic methods. The suggestion is made that if the term "non-specific" vaginitis is to be retained in gynecologic nomenclature it should be assigned its rightful position and should include only those conditions without assignable etiology. The evidence shows that Gardnerella vaginalis (Haemophilus vaginalis, Corynebacterium vaginale) vaginitis is a precisely defined, specific vaginal infection, that the disease is sexually transmitted and that it accounts for most vaginitides previously classified as "nonspecific".