[Diagnostic and therapeutic aspects of pneumonias after cardiosurgical operations associated with artificial ventilation].

Artificial ventilation (AV)-associated pneumonias are the most common infectious complication in cardiosurgery. This prospective comparative study covered 50 patients with AV-associated pneumonias occurring after surgery under extracorporeal circulation (EC). All the patients received the routine perioperative antibiotic prevention regimen (cefuroxime or ceftriaxone). According to the initial therapy, the patients with evolving pneumonia, the patients were divided into 2 groups: 1) those were given cefuroxime (maxipim); 2) those receiving a combination of maxipim or clarithromycin (clacid). The analysis has indicated that if pneumonia develops after surgery under EC, then this most frequently occurs in the first 5 postoperative days, i.e. early AV-associated pneumonias are prevalent. In cases of concurrent pneumonia, the duration of EC, the length of stay in an intensive care unit, and the total period of hospi- talization considerably increase. For cardiosurgical patients, the laboratory guide for establishing the diagnosis of AV-associated pneumonia is the elevated blood cell levels of more than 15 x 10(9)/l, unlike those of more than 10 x 10(9)/l proposed for most patients. The etiology of AV-associated pneumonia is shown to vary with the timing of complication occurrence. There is evidence for the involvement of intracellular microorganisms (Chlamydia, Mycoplasma) in the development of early AV-associated pneumonias in at least every 10 patients. The advantages of a study of bronchoalveolar lavage samples over that of endotracheal aspirates for the etiological diagnosis of pneumonias were revealed. The advisability of prescribing a combination of a beta-lactam antibiotic (third- or fourth-generation cephalosporin) and a macrolide (clarythromycin) in early AV-associated pneumonias is warranted. The objective criterion for the adequacy of this combination is positive changes in the marker of severe bacterial infections (procalcitonin). An algorithm is offered for antibacterial therapy for AV-associated pneumonias developing after cardiosurgical operations, which considers the performed antibiotic prevention and the timing of pneumonia development.

[Diagnosis and treatment of pulmonary hypertension: current concepts].

Pulmonary hypertension is diagnosed when pulmonary artery pressure is above 25 mm Hg at rest and 30 mm Hg during exercise; it can be primary or secondary if complicates some basic disease. Untreated pulmonary hypertension leads to progressive right ventricular failure and is associated with high risk of sudden death. Necessary components of management of any variant of pulmonary hypertension are limitation or avoidance of isometric exercise, yearly influenza and pneumococcal vaccination, and active treatment of pulmonary infections. Drug therapy is aimed at three main pathophysiological mechanisms: thrombosis, vasoconstriction and proliferation. Anticoagulants and vasodilators (calcium antagonists, nitric oxide, and prostacyclin or its derivatives) constitute basis of treatment of pulmonary hypertension. However principally novel drugs such as endothelin receptor antagonists has been also suggested. Diuretics, digitalis and oxygen are added when necessary. Gene therapy has been considered as potential future intervention. Surgical approaches comprise mitral valvuloplasty or mitral valve replacement and embolectomy in case of major pulmonary artery branch thromboembolism. In cases of other treatment failure lung or heart-lung transplantation is appropriate but can not widely used.

[Clinical experience with the treatment of severe nosocomial infections by inhibitor-protected 3rd generation cephalosporin cefoperazone/sulbactam].

A retrospective analysis of the clinical and microbiological efficacy and safety of cefoperazone/sulbactam in the treatment of 39 cardiosurgical patients operated under the conditions of artificial circulation is presented. The age of the adult patients (n = 28) varied from 44 to 58 years and that of the pediatric patients varied from 4 months to 6 years. Antibacterial therapy of 26 patients was needed because of postoperative infectious complications, such as nosocomial pneumonia in 22 patients and sepsis in 4 patients. The antibacterial therapy with cefoperazone/sulbactam in 9 patients was performed during the operation because of active infectious endocarditis. In 4 patients there were observed clinical and laboratory signs of infection without the infection foci. The initial empirical therapy with cefoperazone/sulbactam was applied to 14 patients (group 1) and the target-aimed therapy based on the data of the pathogen susceptibility to cefoperazone/sulbactam was used in 6 patients (group 2). 19 patients (group 3) were treated with cefoperazone/sulbactam because of the fail of the previous antibacterial therapy, including the 4th generation cephalosporins and carbapenems as well. Cefoperazone/sulbactam was used in the monotherapy of 15 cases (38%). Cefoperazone/sulbactam showed high efficacy in the treatment of severe nosocomial infections and infectious endocarditis (in combination with vancomycin or linezolid). It amounted to 93, 100 and 79% in groups 1, 2 and 3 respectively, the total of 94%. The results of the microbiological assay were evident of the cefoperazone/sulbactam high activity against the problem gram nagative isolates of Klebsiella pneumoniae (n = 12), Acinetobacter baumanii (n = 4), Pseudomonas aeruginosa (n = 4) and Stenotrophomonas maltophilia (n = 5). Adverse reactions were stated in 2 patients (5%), 1 case of urticaria requiring discontinuation of the drug use. Many of the patients proved to be colonized by MRS before the therapy with cefoperazone/sulbactam. The high probability of staphylococcal superinfection required combination of cefoperazone/sulbactam with antistaphylococcal agents, such as rifampicin, fusidin, vancomycin, linezolid. The best results were provided by the target-aimed therapy based on the microbiological monitoring.