Nosocomial pneumonia: trying to make sense of the literature.

Nosocomial pneumonia is hard to diagnose with any certainty. Widely accepted concepts regarding the infection are based on data that are far from conclusive. Published recommendations for diagnosis and treatment often reflect a concentrated effort to consolidate these data. According to the authors of this article, initial empirical treatment may be defined by dividing patients into specific host groups. However, this approach should always be supplemented by earnest attempts at identifying the cause with microbial cultures.

Psychosocial impact of narcolepsy.

Despite remarkable progress in our understanding of narcolepsy, the disease continues to cause the sufferer severe negative life effects. Before and after diagnosis, narcoleptics often experience unrelenting severe psychosocial stress. Child and adolescent narcoleptics report embarrassment, academic decline and feelings of loss of self-worth related to the symptoms of their disease. Personality characteristics may be adapted in order to avoid social situations that would precipitate cataplexy or draw attention to the patient's degree of somnolence. Misdiagnosis of these illnesses may result in inappropriate treatment and underestimation of an individual's potential. Adult narcoleptics also face the concerns of the workplace. Worry about loss of job and income are a source of anxiety and are often based in reality. Accidents at home, while driving and in the workplace are increased, creating safety concerns for both the patient and the community. Marital difficulties are common and psychopathology is known to occur more frequently. Narcolepsy's marked impact on quality of life has been found to be similar across cultural lines and these effects appear to be an inherent part of the disease. The socioeconomic impact in general is even more severe than those of comparable forms of epilepsy. Successful diagnosis and treatment do not end the narcoleptic's difficulties. The need for stimulants often creates problems with pharmacists and family. Somnolence, which responds the most poorly of all narcoleptic symptoms, leads to continued problems in the workplace. Side effects related to stimulant use may be a further source of difficulty. Finally, families may be unwilling to accept the illness and thereby alienate the patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of four methods for assessing airway bacteriology in intubated, mechanically ventilated patients.

A prospective evaluation of lower airway bacteriology from intubated, mechanically ventilated patients was performed by comparing the qualitative and quantitative recovery of bacteria using four different techniques. Twelve intubated, mechanically ventilated patients who satisfied accepted clinical criteria for the suspicion of ventilator-associated pneumonia were studied. Airway secretions were obtained from each patient by: (1) blind endotracheal aspiration (ET); (2) Accu-cath pulmonary culture catheter (Accu); (3) bronchoscopic protected specimen brush (BPSB); and (4) bronchoalveolar lavage (BAL). ET specimens were cultured semi-quantitatively (1+ to 4+) aerobically, and all other specimens were cultured quantitatively both aerobically and anaerobically. The BPSB recovered 9 organisms in > or = 10(3) colony forming units/ml, a standard number often used to indicate significant growth. Of these 9 organisms, 7 were recovered at > or = 10(3) cfu/ml by Accu, and 6 were recovered at > or = 10(4) cfu/ml by BAL. All 8 aerobic isolates recovered in > or = 10(3) cfu/ml by BPSB also were recovered by ET aspirate. Five of these were recovered in > or = 3+ semi-quantitative growth by ET aspirate. Of 30 organisms recovered in < 3+ semi-quantitative growth by ET aspirate, 28 were recovered in < 10(3) cfu/ml by BPSB, indicating a negative predictive value of 93%. Thus, it appears that these four methods provide reasonably similar qualitative and quantitative recovery of bacteria from the lower airways of intubated, mechanically ventilated patients. In addition, routine Gram's stain and semi-quantitative aerobic culture of endotracheal aspirate may provide useful information in patients with suspected ventilator-associated pneumonia.

Bronchoscopic protected specimen brush and bronchoalveolar lavage in the diagnosis of bacterial pneumonia.

Despite marked improvements in antibiotic therapy, the accurate diagnosis and treatment of bacterial lower respiratory tract infection remain a challenge. The bronchoscopic protected specimen brush and bronchoscopic bronchoalveolar lavage combined with quantitative bacterial cultures can provide sensitive and relatively specific information about lower airway flora. Both of these methods require strict observance of the required protocol, careful processing of the obtained specimens, and the absence of prior antibiotic therapy to obtain best results. These procedures are also of some utility in sickle cell acute chest syndrome, bronchiectasis, and in the immunocompromised host.

Acute necrotizing pneumonia caused by Enterobacter cloacae.

We have described a 55-year-old man with fever, productive cough, and a right upper lobe infiltrate, which subsequently cavitated. Cultures of bronchial secretions obtained by bronchoscopic protected brush catheter technique revealed Enterobacter cloacae, a previously unreported cause of acute necrotizing pneumonia.