Ciprofloxacin increases serum levels of theophylline.

During a clinical trial of orally administered ciprofloxacin in respiratory tract infections, changes in serum theophylline levels were evaluated in 33 hospitalized patients who also required theophylline therapy. Patients received intravenous theophylline in standard titrated doses and 750 mg of oral ciprofloxacin twice daily. Serum theophylline levels in all patients were measured before and during ciprofloxacin therapy. The mean serum pretreatment theophylline level was 7.8 +/- 4.6 micrograms/ml; during ciprofloxacin therapy, the level increased to 14.6 +/- 7.4 micrograms/ml. Twenty of the 33 (61 percent) patients evaluated had increases in serum theophylline levels by a mean value of 10.5 micrograms/ml. In 30 percent of patients who experienced increases, theophylline concentrations were in the toxic range. This occurred more frequently in elderly patients with chronic obstructive pulmonary disease. In light of the frequency and potential severity of this interaction, careful monitoring of serum theophylline levels in patients receiving theophylline and ciprofloxacin is recommended.

Controlled, comparative study of ciprofloxacin versus ampicillin in treatment of bacterial respiratory tract infections.

The efficacy and safety of ciprofloxacin in bacterial bronchitis were compared with those of ampicillin in a double-blind, prospective clinical trial. Eighty-seven patients received either oral ciprofloxacin (750 mg twice daily) or oral ampicillin (500 mg four times daily). Ciprofloxacin was as effective as ampicillin and produced a 98 percent clinical cure rate. Significantly more pretreatment bacterial isolates were susceptible to ciprofloxacin (p less than 0.05), and ciprofloxacin had a significantly higher rate of sputum sterilization than did ampicillin (p less than 0.05). Ciprofloxacin showed broad in vitro antibacterial activity with particularly low minimal inhibitory concentrations for gram-negative organisms. Ciprofloxacin was well tolerated; there were few adverse effects, and patients had a significantly lower incidence of diarrhea with ciprofloxacin than with ampicillin (p less than 0.05). Ciprofloxacin was an effective and well-tolerated treatment for bacterial bronchitis that had the advantages of broad in vitro antibacterial activity and twice-daily dosing.

Aspergillomas complicating sarcoidosis. A prospective study in 100 patients.

During a ten-year study period, we evaluated 100 histologically-proven sarcoid patients for the development of aspergillomas. Serum precipitins against Aspergillus antigens were used to screen all patients regardless of sarcoid stage. Twelve patients had serum precipitins and were further investigated with tomography and serial serum precipitins testing. Ten of these 12 patients had aspergillomas and two patients died of massive hemoptysis. No aspergillomas occurred in stages I, II, or non-cystic stage III patients. All ten aspergillomas developed in the 19 stage III patients with cystic parenchymal damage. We believe that aspergillomas in sarcoidosis are not as rare as previously reported, but occur commonly in chronic cystic sarcoidosis. Additionally, we found serial testing for serum precipitins to be valuable both for the screening of cystic sarcoid patients for aspergillomas and for the management of this complication.

Incarceration of existing inguinal hernia as a complication of pulmonary function testing.

Pulmonary function testing (PFT) has not been listed as a risk for development of incarceration in an existing inguinal hernia. We report two patients who developed this complication after routine preoperative PFT. We also present data of our retrospective review of eight patients with inguinal hernia who were referred for preoperative PFT. Two out of eight patients suffered incarceration of an existing inguinal hernia. We found no significant difference in mean age, weight, smoking habits, number of forced expiratory maneuvers, time of sustained forced expiratory maneuver, or any PFT data between the groups with and without incarceration. Thus, incarceration of inguinal hernia could not have been predicted prior to PFT and was not related to other factors such as obesity or more severe airway obstruction.

Pulmonary manifestations of the acquired immunodeficiency syndrome (AIDS).

Fifteen patients with AIDS were hospitalized on the pulmonary service during the period from 1981 to 1983. We were impressed with the frequency and severity of lung involvement in these patients and evaluated them with respect to their pulmonary manifestations of AIDS. The 13 men and two women had a mean age of 32 years. Ten were active intravenous drug abusers with a mean drug use of 8.1 years. All presented with profound weight loss, ten with nonproductive cough, and eight with significant dyspnea. Fourteen of 15 patients had Pneumocystis carinii pneumonia (PCP) at the time of our evaluation. Chest radiographs in these 14 patients showed no uniform pattern which was predictive of PCP. However, all 13 patients tested had a widened alveolar arterial oxygen gradient (mean: 59 mm Hg) which correlated well with the presence of PCP. The most common pulmonary finding in our AIDS patients was infection: 14 had PCP which was readily diagnosed by transbronchial lung biopsy in eight patients, and five patients were found to have disseminated Mycobacterium avium-intracellulare which often developed after "recovery" from PCP. Therapy for PCP with trimethoprim/sulfamethoxazole (TMP/SMZ) was unsuccessful in eight of ten patients; four of these eight TMP/SMZ failures responded to pentamidine. Mortality was 100 percent in patients who had AIDS for more than one year, and 70 percent in those less than one year. Despite some symptomatic responses to therapy for pulmonary infections, the mortality in AIDS seems to be unaffected by appropriate therapy for the pulmonary manifestations of this disease.

COPD and other diseases in chronically ventilated patients in a prolonged respiratory care unit: a retrospective 20-year survival study.

OBJECTIVES: To evaluate the long-term prognosis of ventilator-dependent patients. DESIGN: Retrospective study. SETTING: A prolonged respiratory care unit (PRCU). The PRCU provides comprehensive medical, nursing, and respiratory care to tracheostomized, ventilator-dependent adult patients who had failed all attempts at weaning. Because of their medical complexity, these patients could not be discharged to a lower level of care. PATIENTS: Of the 293 patients admitted to the PRCU over a 20-year period beginning January 1, 1977, 145 had respiratory failure from COPD, 22 from spinal cord disease or trauma, 34 from primary CNS disease, 50 from primary neuromuscular disease, and 16 from chest wall disease. Twenty-six patients were not classifiable into the above categories. MEASUREMENTS: Demographics, diagnoses, and survival data were reviewed. The survival of patients with COPD was compared with the other diagnosis categories using the Cox proportional hazards model. RESULTS: The median survival for the entire group was 9 months; younger age and female gender were both predictive of longer survival (both, p < 0.001). The median survival of those with COPD (5 months) was significantly shorter than that of patients with spinal cord disease (47 months), neuromuscular disease (17 months), and chest wall disease (27 months) (all, p < 0.01). These differences in survival were present even with inclusion of gender and age in the model as covariates. The survival of patients with CNS disease was not significantly different from survival of patients with COPD. CONCLUSION: Chronically ventilated patients with respiratory failure from COPD have a significantly worse prognosis than patients with respiratory failure from other causes.

Acute pulmonary complications in systemic lupus erythematosus. Immunofluorescence and light microscopic study.

Lung tissue obtained from eight consecutive patients with systemic lupus erythematosus complicated by severe, acute pulmonary disease was studied by both light and immunofluorescence microscopy. Light microscopic examination disclosed interstitial pneumonia in four cases, cytomegalovirus pneumonitis in one case, bronchiolitis and peribronchiolitis in one case, pulmonary infarction in one case and focal atelectasis in the remaining case. Direct immunofluorescence examination revealed focally bound immunoglobulins or complement (C3) within pleural and/or pneumocyte nuclei in each specimen. Immunohistologic studies in these cases may thus suggest a diagnosis of systemic lupus erythematosus with acute pulmonary complications, despite the lack of specificity of the pathologic changes seen by light microscopy.

Utility of radiography and clinical features in the diagnosis of community-acquired pneumonia.

This article reviews the approach to the differential diagnosis of community-acquired pneumonia using clinical clues and radiography. Evidence is reviewed that indicates that the etiology of such pneumonias is changing. The basic clinical patterns, including bacterial, nonbacterial, and mixed presentations are discussed, as well as how aspiration, diabetes, and alcoholism affect the differential diagnosis.

Common complications in critically ill patients.

Patients in intensive care units (ICUs) are subject to many complications connected with the advanced therapy required for their serious illnesses. Complications of ventilatory support include problems associated with short-term and long-term intubation, barotrauma, gastrointestinal tract bleeding, and weaning errors. Cardiac tachyarrhythmias can arise from a patient's intrinsic cardiac disease, as well as from drug therapy itself. Hemodynamic monitoring is crucial to careful patient management, but it is associated with technical complications during insertion such as pneumothorax, as well as interpretive errors such as those caused by positive end-inspiratory pressure. Acute renal failure can develop as a result both of therapy with drugs such as aminoglycosides and hypotension of many etiologies, as well as the use of contrast media. Nosocomial infection, which is a dreaded complication in ICU patients, usually arises from sources in the urinary tract, bloodstream, or lung. Complications frequently can arise if the interactions of drugs commonly used in the ICU are not recognized. Further, the ICU patient is subject to nutritional complications, acid base problems, and psychological disturbances. This monograph deals with the frequency, etiology, and prevention of these common ICU complications.

Acquired immune deficiency syndrome. A deadly new disease.

The acquired immune deficiency syndrome (AIDS) represents a new epidemic of major proportions. Risk factors include homosexuality, intravenous drug abuse, Haitian descent, and multiple transfusion in the presence of hemophilia A. The etiology of AIDS remains unknown, but there is increasing evidence implicating a transmissible infectious agent and/or multiple antigenic exposures inducing a loss of immunoregulation. In a high-risk patient, the features of weight loss, generalized lymphadenopathy, and fever should arouse suspicion of AIDS. Diagnostic confirmation includes demonstration of reduced numbers of T lymphocytes with reversal of helper-suppressor T-lymphocyte ratio, presence of unusual opportunistic infections, and a progressive downhill course. The most common infection in AIDS is Pneumocystis carinii pneumonia. Treatment failures with trimethoprim-sulfamethoxazole (Bactrim, Septra) are common; pentamidine isethionate (Lomidine) may be more effective in eradicating the infection. In spite of initial improvement, recurrences of P carinii pneumonia and other opportunistic infections are common. In addition, other protozoan, viral, fungal, and atypical mycobacterial infections are frequent in patients with AIDS. Finally, rare neoplasms such as Kaposi's sarcoma and B-cell lymphoma, including primary lymphoma of the brain, are also being recognized as complications. At present there is no specific therapy for AIDS, and the disease is usually fatal. Continued research will hopefully result in immunomodulation techniques and specific vaccines to combat this serious epidemic.

The Medical Bookshelf.

Books received are listed as space permits, and those of particular interest to our readers are reviewed.

A regional weaning center for patients requiring mechanical ventilation: an 18-month experience.

This report reviews the outcomes of patients on mechanical ventilation admitted to a new regional weaning center. We reviewed the records of 47 patients admitted to the weaning center over an 18-month period. All patients had a tracheostomy, were ventilator dependent, and considered difficult to wean by their referring physician. The mean days of ventilator dependence prior to transfer to our facility was 86 days, with a range of 21 to 332 days. Patients were admitted to a 12-bed weaning unit at our chronic disease and rehabilitation hospital and assessed by a multi-disciplinary team of physicians, nurses, and therapists. Thirty patients were successfully weaned from prolonged mechanical ventilation and subsequently discharged from our unit. These data indicate that the majority of difficult to wean patients admitted to our regional weaning center were successfully liberated from prolonged mechanical ventilation.

Treatment of respiratory tract infections with ciprofloxacin.

The efficacy and safety of ciprofloxacin in an oral dose of 750 mg twice daily, in the treatment of respiratory infections was studied in 129 patients. Ciprofloxacin showed broad in-vitro antibacterial activity and was highly effective in both Gram-negative and Gram-positive infections with a clinical cure rate of 96%. The major side effect was an interaction with theophylline particularly in the elderly patients.

Spinal tuberculosis revisited.

Although the incidence of tuberculosis is decreasing, spinal tuberculosis is still an important disease. Delay in diagnosis and treatment results in long-term disability. We reviewed our cases of spinal tuberculosis diagnosed between 1975 and 1982, with special reference to those features that permit early diagnosis. Among the nine cases diagnosed, roentgenographic evidence of pulmonary tuberculosis (7/9) and positive PPD test (8/8) were found to be highly suggestive diagnostic clues. Computerized tomography (CT) of the spine was a useful way of determining the extent of the disease and following response to therapy. Various modes of therapy were used, and the outcome was related to the extent of the disease and duration of symptoms before initiation of therapy. In early stages, medical therapy alone is adequate; surgical intervention is necessary in cases with neurologic features.

Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the effectiveness of short-term, comprehensive inpatient pulmonary rehabilitation in severe chronic obstructive pulmonary disease (COPD). DESIGN: Retrospective analysis of several outcome measures. SETTING: Inpatient pulmonary rehabilitation unit. PARTICIPANTS: Thirty-eight consecutive adult patients with advanced COPD referred to our inpatient pulmonary rehabilitation program between January 1 and December 31, 1994. All but one were referred from acute care hospitals. The mean forced expiratory volume in 1 second (FEV1) was .69L; 79% required supplemental oxygen. MAIN OUTCOME MEASURES: (1) Discharge status; (2) timed walk, with measurements of distance and exertional dyspnea; and (3) functional status. RESULTS: All patients were able to be discharged home after a mean length of stay of 9.9 days. The 12-minute walk distance increased by 66%, from 416 +/- 282 feet to 690 +/- 337 feet (p < .001). Dyspnea during the walk testing also improved: the resting score decreased from 2.87 to .97, the 6-minute score from 7.84 to 3.05, and postwalk score from 8.53 to 3.51 (all p < .001). All patients showed improvement in the Pulmonary Function Status Scale (PFSS), with the functional activities subsection increasing by 39%, the dyspnea score by 65%, and psychosocial score by 35% (all p < .001). CONCLUSION: Short-term improvement in multiple areas can be accomplished with comprehensive pulmonary rehabilitation of short duration. This is particularly relevant to the current health care environment that dictates shorter in-hospital lengths of stay.