Eradication Therapy against Pseudomonas aeruginosa in Non-Cystic Fibrosis Bronchiectasis.

BACKGROUND: No prospective study has assessed eradication treatment of early Pseudomonas aeruginosa colonisation in bronchiectasis not due to cystic fibrosis (CF). OBJECTIVES: To evaluate the efficacy of 3 months of nebulised tobramycin after a short course of intravenous antibiotics in the eradication of P. aeruginosa and its clinical consequences in non- CF bronchiectasis following initial P. aeruginosa infection. METHODS: A 15-month, single-masked, randomised study including 35 patients was conducted in a tertiary university hospital. Following the isolation of P. aeruginosa and a 14-day intravenous treatment with ceftazidime and tobramycin, patients received 300 mg nebulised tobramycin twice daily or placebo during 3 months, and were followed up for 12 months thereafter. RESULTS: The median time to recurrence of P. aeruginosa infection was higher in the tobramycin than in the placebo group (p = 0.048, log-rank test). At the end of the study 54.5% of the patients were free of P. aeruginosa in the tobramycin group and 29.4% in the placebo group. The numbers of exacerbations (p = 0.044), hospital admissions (p = 0.037) and days of hospitalisation (p = 0.034) were lower in the tobramycin than in the placebo group. A global, non-significant trend to improvement in the tobramycin group was observed in most of the other studied parameters on comparing the two groups. Bronchospasm in the tobramycin group was remarkable. CONCLUSIONS: Our study shows that 3 months of nebulised tobramycin following a short course of intravenous antibiotics may prevent bronchial infection with P. aeruginosa and has a favourable clinical impact on non-CF bronchiectasis.

Budesonide efficacy and safety in patients with bronchiectasis not due to cystic fibrosis.

OBJECTIVE: The therapeutic benefit of inhaled corticoids in bronchiectasis not due to cystic fibrosis is still not well documented. The aim of the present study was to assess the efficacy and safety of inhaled corticoids in this disease. SETTING: This study was conducted at a tertiary university hospital in the city of Barcelona, Catalonia, (Spain). METHOD: A prospective, double-blind, parallel, placebo-masked study was conducted. Seventy-seven patients (40 women; mean age: 68 years) were randomly assigned to receive either 400 mcg budesonide twice daily or placebo and were regularly reviewed for six months. RESULTS: Differences in forced vital capacity and forced expiratory volume in the first second between the beginning and end of the study were not significantly lower in the budesonide group than in the placebo group, either in absolute values [-17.4 (386.9) versus -21.4 (375.5)] or in percentages [-1.9(9.5) versus -2.8 (11.6)]. Microbiological criteria applied to evaluate changes between the beginning and end of the study showed no worsening in the budesonide group compared with the control group, whereas a non-significant improvement was obtained in 8.1 % of cases in the budesonide group compared to 3 % in the placebo group. Although significance was only achieved for sputum eosinophils (p = 0.021), a consistent tendency towards improvement was also observed in secondary end-points (symptoms, number and duration of exacerbations, quality of life, sputum cytology and interleukin-8) in the budesonide group. CONCLUSION: Although further studies are required, inhaled corticoid treatment may be efficacious and safe in bronchiectasis not due to cystic fibrosis.

Current and potential usefulness of pneumococcal urinary antigen detection in hospitalized patients with community-acquired pneumonia to guide antimicrobial therapy.

BACKGROUND: The role of pneumococcal urinary antigen detection in the treatment of adults with community-acquired pneumonia (CAP) is not well defined. We assessed the usefulness of pneumococcal urinary antigen detection in the diagnosis and antimicrobial guidance in patients hospitalized with CAP. METHODS: A prospective study of all adults hospitalized with CAP was performed from February 2007 through January 2008. To evaluate the accuracy of the test, we calculated its sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. The gold standard used for diagnosis of pneumococcal pneumonia was isolation in blood or pleural fluid (definite diagnosis) and isolation in sputum (probable diagnosis). Antibiotic modifications, complications, and mortality were analyzed. RESULTS: A total of 474 episodes of CAP were included. Streptococcus pneumoniae was the causative pathogen in 171 cases (36.1%). It was detected exclusively by urinary antigen test in 75 cases (43.8%). Sixty-nine patients had CAP caused by a pathogen other than S pneumoniae. Specificity was 96%, positive predictive value ranged from 88.8% to 96.5%, and the positive likelihood ratio ranged from 14.6 to 19.9. The results of the test led the clinicians to reduce the spectrum of antibiotics in 41 patients. Pneumonia was cured in all of them. Potentially, this optimization would be possible in the 75 patients diagnosed exclusively by the test. CONCLUSION: When its findings are positive, the pneumococcal urinary antigen test is a useful tool in the treatment of hospitalized adult patients with CAP because it may allow the clinician to optimize antimicrobial therapy with good clinical outcomes.

Respiratory pasteurellosis: infection or colonization?

Respiratory infection by Pasteurella multocida is uncommon and usually occurs in patients with an underlying lung disease, advanced age and/or immunodepression. In this study, we describe the clinical and microbiological characteristics of a series of 14 patients in whom Pasteurella multocida was isolated from lower respiratory tract samples, over a period of 21 y (1986-2006). Differentiation between colonization and infection allows establishment of early antibiotic treatment.

[Treatment for Legionnaires' disease. Macrolides or quinolones?]. / Tratamiento de la neumonía por Legionella pneumophila. 'Macrolidos o quinolonas?

BACKGROUND: Macrolides and fluoroquinolones are the recommended treatment for Legionnaires' disease. The aim of our study was to analyze the clinical efficacy of clarithromycin, azithromycin and levofloxacin in patients with Legionnaires' disease. METHODS: Prospective, observational study involving all adult patients with Legionella pneumophila pneumonia attended at Hospital Universitario Vall d'Hebron (Barcelona, Spain) from January 2001 to December 2004. Duration of fever, length of hospital stay and mortality were compared among 52 patients treated with clarithromycin, 43 with azithromycin and 18 with levofloxacin. RESULTS: The proportion of patients with risk factors for Legionnaires' disease, the initial severity of the pneumonia and the number of patients who required intensive care unit admission were similar in patients treated with clarithromycin, azithromycin and levofloxacin. In-hospital mortality was 5.3%. There were no significant differences in fever duration, length of hospital stay or mortality among the 3 groups of patients. CONCLUSION: In our experience, clarithromycin, azithromycin and levofloxacin were all efficacious for the treatment of Legionnaires' disease.

Tratamiento de la neumonía por Legionella pneumophila. ¿Macrolidos o quinolonas? / Treatment for Legionnaires’ disease. Macrolides or quinolones?

Antecedentes. Los nuevos macrólidos y las fluorquinolonas constituyen actualmente el tratamiento de elección de la neumonía por Legionella pneumophila (NLP). El objetivo de nuestro estudio es analizar la eficacia de claritromicina, azitromicina y levofloxacino en el tratamiento de la NLP. Métodos. Estudio prospectivo observacional de todos los pacientes adultos diagnosticados de NLP en el Hospital Universitario Vall d'Hebron de Barcelona entre enero de 2001 y diciembre de 2004. Se han comparado variables clínicas evolutivas (duración de la fiebre, duración del ingreso hospitalario y mortalidad) entre 52 pacientes tratados con claritromicina, 43 con azitromicina y 18 con levofloxacino. Resultados. No se observaron diferencias significativas en cuanto a la presencia de factores de riesgo, porcentaje de pacientes inmunodeprimidos, gravedad inicial de la neumonía o necesidad de ingreso en la unidad de cuidados intensivos entre los pacientes tratados con claritromicina, azitromicina o levofloxacino. La mortalidad hospitalaria fue del 5,3%. No encontramos diferencias significativas con respecto al tiempo que se tardó en conseguir la apirexia, la media de estancia hospitalaria y la mortalidad entre ninguno de los 3 grupos. Conclusión. En nuestra experiencia, la eficacia clínica de claritromicina, azitromicina y levofloxacino es similar para el tratamiento de la NLP (AU)

Background. Macrolides and fluoroquinolones are the recommended treatment for Legionnaires' disease. The aim of our study was to analyze the clinical efficacy of clarithromycin, azithromycin and levofloxacin in patients with Legionnaires' disease. Methods. Prospective, observational study involving all adult patients with Legionella pneumophila pneumonia attended at Hospital Universitari Vall d'Hebron (Barcelona, Spain) from January 2001 to December 2004. Duration of fever, length of hospital stay and mortality were compared among 52 patients treated with clarithromycin, 43 with azithromycin and 18 with levofloxacin. Results. The proportion of patients with risk factors for Legionnaires' disease, the initial severity of the pneumonia and the number of patients who required intensive care unit admission were similar in patients treated with clarithromycin, azithromycin and levofloxacin. In-hospital mortality was 5.3%. There were no significant differences in fever duration, length of hospital stay or mortality among the 3 groups of patients. Conclusion. In our experience, clarithromycin, azithromycin and levofloxacin were all efficacious for the treatment of Legionnaires' disease (AU)

[Nocardiosis and bronchiectasis. An uncommon association?]. / Nocardiosis y bronquiectasias. 'Una asociación infrecuente?

OBJECTIVE: Nocardiosis is difficult to diagnose and infrequently associated with bronchiectasis or cystic fibrosis. This study analyzes the clinical and microbiological characteristics of 40 patients in whom microorganisms belonging to the Nocardia asteroides complex were isolated. METHODS: We studied 27 males and 13 females, with a mean age of 45 years (8-82). Nocardia spp. were isolated in 129 samples. Cultures were performed with conventional methods; additionally, when branching Gram-positive bacilli were visualized on microscopic examination, modified BCYE-alpha (m) medium was used. RESULTS: In 77.5% of the cases, investigation for Nocardia spp. was based on microscopy findings, in six patients it was a fortuitous finding in BCYE-alpha (m) medium, and in only three patients nocardiosis was clinically suspected. Twenty-five patients had nocardiosis (5 disseminated infection and 20 lung infection) and the remaining 15 were colonized. The most frequent risk factor in the infections, whether disseminated or not, was systemic glucocorticoid use (P 5 .001). The most frequent underlying pathology was bronchiectasis (80%), associated or not with cystic fibrosis. There were seven deaths and two patients had neurological sequelae. CONCLUSIONS: Bronchiectasis was an important risk factor for colonization by Nocardia spp. (P 5 0.01) in all the patients studied, and for infection (P 5 0.05) in patients without cystic fibrosis. The use of BCYE-alpha (m) medium in processing respiratory secretions highly facilitated the isolation of Nocardia spp.

Nocardiosis y bronquiectasias. ¿Una asociación infrecuente? / Nocardiosis and bronchiectasis. An uncommon association?

OBJETIVO. La nocardiosis es una enfermedad de difícil diagnóstico que, en contadas ocasiones, se ha asociado a bronquiectasias y/o fibrosis quística. Se analizan las características clínico-microbiológicas de 40 pacientes en los que se aislaron microorganismos pertenecientes al complejo Nocardia asteroides. MÉTODOS. Se estudiaron 27 varones y 13 mujeres, con una media de edad de 45 años (8-82). Se aisló Nocardia spp. en 129 muestras. El cultivo se realizó por métodos convencionales, utilizándose además BCYE-alfa modificado(m) al visualizarse bacilos grampositivos ramificados en el examen microscópico. RESULTADOS. En el 77,5% de los casos la investigación de Nocardia spp. estuvo motivada por el examen microscópico, en 6 pacientes fue un hallazgo fortuito en medio BCYE-alfa (m) y sólo en 3 pacientes existía la sospecha clínica de nocardiosis. Tenían nocardiosis 25 pacientes (5 infecciones diseminadas y 20 pulmonares)y los 15 restantes estaban colonizados. El factor de riesgo más frecuente en las infecciones, diseminadas o no, fue la utilización de glucocorticoides por vía sistémica(p = 0,001), la enfermedad de base que más se asoció a todos los cuadros clínicos fueron las bronquiectasias (80%), asociadas o no a fibrosis quística (FQ). Se produjeron 7 muertes y 2 pacientes presentaron secuelas neurológicas. CONCLUSIONES. Las bronquiectasias suponen un factor importante de riesgo para la colonización (p = 0,01)en todos los pacientes y para la infección (p = 0,05)por Nocardia spp. en los pacientes sin fibrosis quística. La utilización del medio de BCYE-alfa (m) en el procesamiento de las secreciones respiratorias facilitó extraordinariamente el aislamiento de Nocardia spp (AU)

OBJECTIVE. Nocardiosis is difficult to diagnose and infrequently associated with bronchiectasis or cysticfibrosis. This study analyzes the clinical and microbiological characteristics of 40 patients in whom microorganisms belonging to the Nocardia asteroides complex were isolated. METHODS. We studied 27 males and 13 females, with a mean age of 45 years (8-82). Nocardia spp. were isolated in129 samples. Cultures were performed with conventional methods; additionally, when branching Gram-positive bacilli were visualized on microscopic examination, modified BCYE-alpha (m) medium was used. RESULTS. In 77.5% of the cases, investigation for Nocardiaspp. was based on microscopy findings, in six patients it was a fortuitous finding in BCYE-alpha (m) medium, and in only three patients nocardiosis was clinically suspected. Twenty-five patients had nocardiosis (5 disseminated infection and 20 lung infection) and the remaining 15 were colonized. The most frequent risk factor in the infections, whether disseminated or not, was systemic glucocorticoiduse (P = .001). The most frequent underlying pathology was bronchiectasis (80%), associated or not with cysticfibrosis. There were seven deaths and two patients had neurological sequelae. CONCLUSIONS. Bronchiectas is was an important risk factor for colonization by Nocardia spp. (P = 0.01) in all the patients studied, and for infection (P = 0.05) in patients without cystic fibrosis. The use of BCYE-alpha (m) medium in processing respiratory secretions highly facilitated the isolation of Nocardia spp (AU)

Inhaled tobramycin in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection with Pseudomonas aeruginosa.

BACKGROUND: Non-cystic fibrosis (CF) patients with bronchiectasis usually develop chronic bronchial infection with Pseudomonas aeruginosa (PA) that is related to worsening lung function and increased morbidity and mortality. OBJECTIVE: To determine whether direct aerosol delivery of tobramycin to the lower airways may control infection and produce only low systemic toxicity. METHODS: A double-blind, placebo-controlled crossover trial involving 30 patients was conducted to determine the clinical effectiveness and safety of 6-month tobramycin inhalation therapy. Patients received 300 mg of aerosolized tobramycin or placebo twice daily in 2 cycles, each for 6 months, with a one-month washout period. The number of exacerbations, number of hospital admissions, number of hospital admission days, antibiotic use, pulmonary function, quality of life, tobramycin toxicity, density of PA in sputum, emergence of bacterial resistance, and emergence of other opportunistic bacteria were recorded. RESULTS: The number of admissions and days of admission (mean +/- SD) during the tobramycin period (0.15 +/- 0.37 and 2.05 +/- 5.03) were lower than those during the placebo period (0.75 +/-1.16 and 12.65 +/- 21.8) (p < 0.047). A decrease in PA density in sputum was associated with tobramycin administration in the analysis of the first 6-month cycle (p = 0.038). No significant differences were observed in the number of exacerbations, antibiotic use, pulmonary function, and quality of life. The emergence of bacterial resistance and other bacteria did not differ between the 2 periods of study. Inhaled tobramycin was associated with bronchospasm in 3 patients, but not with detectable ototoxicity or nephrotoxicity. CONCLUSIONS: Aerosol administration of high-dose tobramycin in non-CF bronchiectatic patients for endobronchial infection with PA appears to be safe and decreases the risk of hospitalization and PA density in sputum. Nevertheless, pulmonary function and quality of life are not improved, and the risk of bronchospasm is appreciable.

Microorganismos aislados en casos de síndrome pertusoide / Microorganisms isolated from patients with pertussis-like syndrome

Fundamento. El estudio etiológico del síndrome pertusoide, no sólo en cuanto concierne al género Bordetella, sino aplicándolo a otros microorganismos, durante un período de 11 años (1988-1998). Métodos. En todas las muestras de pacientes con tos pertusoide se investigó la presencia de Bordetella spp., otras bacterias, virus y micoplasmas. Los datos analizados incluyeron los resultados microbiológicos, así como aspectos epidemiológicos (edad, sexo, área de ingreso hospitalario, distribución anual y período estacional). Resultados. Se analizaron un total de 1.063 muestras la mayoría aspirados nasofaríngeos (910), correspondientes a 905 pacientes, y en el 56,9 por ciento de éstos se obtuvo un cultivo positivo. B. pertussis se aisló en el 10,5 por ciento de los pacientes y entre las otras bacterias destacaron Haemophilus influenzae con un 16,9 por ciento y Streptococcus pneumoniae con un 15,8 por ciento. El virus respiratorio sincitial se encontró en el 10,7 por ciento de los enfermos y los demás virus en el 9,4 por ciento de ellos. Entre los micoplasmas destacaba Ureaplasma urealyticum con un 2,9 por ciento de positividad. Cuatrocientos noventa y cinco pacientes eran varones y 410 mujeres, el 67,2 por ciento tenían entre 0 y 6 meses de edad y requirieron ingreso hospitalario 689 pacientes (76,1 por ciento). Los aislamientos de B. pertussis y adenovirus predominaron en primavera y verano, en contraste con H. influenzae, S. pneumoniae y virus respiratorio sincitial que fueron más frecuentes en los meses de invierno. Conclusiones. El mayor número de pacientes con síndrome pertusoide son niños menores de seis meses de edad. Los porcentajes de aislamiento de B. pertussis y virus respiratorio sincitial son idénticos, con lo que nos parece indiscutible la necesidad de su investigación en este cuadro clínico. La búsqueda de otros microorganismos está también justificada, ya que la sintomatología clínica es frecuntemente inespecífica en los lactantes (AU)

Estudio microbiológico de la biopsia pulmonar post mortem en pacientes pediátricos / Microbiologic study of post mortem pulmonary biopsy in pediatric patients

Objetivo: Correlacionar los hallazgos morfológicos y microbiológicos de las biopsias pulmonares post mortem en una serie de pacientes pediátricos. Material y métodos: Se realizó un estudio morfológico completo de todos los órganos en los pacientes incluidos en el estudio. En las muestras pulmonares remitidas por el patólogo se investigó la presencia de microorganismos aerobios y anaerobios, y la de hongos. Resultados: Se practicaron 93 biopsias pulmonares que correspondían a 77 pacientes fallecidos (47 niños y 30 fetos). Cuarenta y cinco pacientes tenían una histología pulmonar de proceso infeccioso. La concordancia entre la morfología y el cultivo microbiológico fue del 66,2 por ciento. Los microorganismos aislados con más frecuencia fueron cocos grampositivos (46,4 por ciento), seguidos de bacilos gramnegativos en un 30,4 por ciento de los casos. Conclusión: Aunque siempre hay que interpretar con cautela un cultivo de tejido pulmonar post mortem sin relacionarlo antes con los hallazgos morfológicos y las características clínicas del paciente, se ha observado una concordancia estadísticamente significativa entre el estudio anatomopatológico y los hallazgos microbiológicos. (AU)