[Vaccinations in respiratory medicine]. / Impfungen in der Pneumologie.

Vaccinations are the most successful and cost-effective measures for prevention of infections. Important pathogens of respiratory tract infections (e.g. influenza viruses and pneumococci) can be effectively treated by vaccinations. The seasonal trivalent and recently now quadrivalent influenza vaccines include antigens from influenza A and B type viruses, which have to be modified annually oriented to the circulating strains. The effective protection by influenza vaccination varies considerably (too short protection time, mismatch); therefore, administration late in the year is the best approach (November/December). Two pneumococcal vaccines are recommended for adults: the over 30-year-old 23-valent polysaccharide vaccine (PPV23) and the 4-year-old 13-valent conjugate vaccine (PCV13). The immunological and clinical efficacy of PPV23 is controversially discussed; however, a moderate reduction of invasive pneumococcal infections is widely accepted. The PCV13 stimulates a T-cell response and has currently demonstrated its clinical efficacy in an impressive study (CAPiTA). The problem of PCV13 is the relatively limited coverage of only 47% of the currently circulating invasive pneumococcal serotypes.

[Multiresistant pathogens--a challenge for clinicians]. / Multiresistente Erreger--eine infektiologische Herausforderung.

Gram-negative pathogens are currently isolated frequently in invasive nosocomial infections and give rise to major therapeutic problems due to their resistance pattern. Metaanalyses of randomised controlled studies have demonstrated that an antibiotic combination treatment is not indicated in many cases. However, in critically ill patients (septic shock) and also in immunocompromised patients with previous intensive care as well as broad spectrum antibiotic treatment, a combination of antibiotics is recommended. This therapy should be based on the source of the infection, on local resistance data, on antibiotic pretreatment, on basic diseases of the patient and on current liver and renal functions. The start of therapy should be as fast as possible after collection of optimal materials for microbiological analysis. Dosage of selected antibiotics should be based on rational pharmacokinetic and pharmacodynamic parameters. A de-escalation of antibiotics is strongly recommended in all international guidelines based on the microbiological results and the clinical response of the patient. New antibiotics or therapeutic strategies against multiresistant Gram-negative pathogens will not be available in the next 5 to 10 years; therefore, it is absolute mandatory to use the currently still effective antibiotics, like carbapenems and polymyxins, very rationally and restrictively.

Clinical impact of antibiotic-resistant Gram-positive pathogens.

The European Union's attention to the problem of antibacterial resistance will soon reach a 10-year mark, but the rates of resistance in Gram-positive and Gram-negative bacteria are still increasing. This review focuses on the clinical impact of resistant Gram-positive bacteria on patients. Multiple drug resistance in pneumococcal infections will lead to more treatment failures and higher mortality, which so far have been seen with penicillins and pathogens with high-level resistance. Several studies have demonstrated higher mortality, prolonged length of hospital stay and higher costs associated with methicillin-resistant Staphylococcus aureus infections, in comparison with methicillin-susceptible Staphylococcus aureus infections. Similarly, vancomycin-resistant enterococci bloodstream infections have a negative impact with respect to mortality, length of hospital stay and costs, in comparison with infections due to vancomycin-susceptible enterococci. Several distinctive prophylactic and therapeutic approaches have to be undertaken to successfully prevent the clinical consequences of antibiotic resistance in Gram-positive bacteria. This review addresses the impact of antibiotic-resistant Gram-positive pathogens on clinical outcomes.

Comparison of pneumococcal conjugate polysaccharide and free polysaccharide vaccines in elderly adults: conjugate vaccine elicits improved antibacterial immune responses and immunological memory.

BACKGROUND: High functional antibody responses, establishment of immunologic memory, and unambiguous efficacy in infants suggest that an initial dose of conjugated pneumococcal polysaccharide (PnC) vaccine may be of value in a comprehensive adult immunization strategy. METHODS: We compared the immunogenicity and safety of 7-valent PnC vaccine (7vPnC) with that of 23-valent pneumococcal polysaccharide vaccine (PPV) in adults >/=70 years of age who had not been previously vaccinated with a pneumococcal vaccine. One year later, 7vPnC recipients received a booster dose of either 7vPnC (the 7vPnC/7vPnC group) or PPV (the 7vPnC/PPV group), and PPV recipients received a booster dose of 7vPnC (the PPV/7vPnC group). Immune responses were compared for each of the 7 serotypes common to both vaccines. RESULTS: Antipolysaccharide enzyme-linked immunosorbent assay antibody concentrations and opsonophagocytic assay titers to the initial dose of 7vPnC were significantly greater than those to the initial dose of PPV for 6 and 5 of 7 serotypes, respectively (P < .01 and P < .05, respectively). 7vPnC/7vPnC induced antibody responses that were similar to those after the first 7vPnC inoculation, and 7vPnC/PPV induced antibody responses that were similar to or greater than antibody responses after administration of PPV alone; PPV/7vPnC induced significantly lower antibacterial responses, compared with those induced by 7vPnC alone, for all serotypes (P < .05). CONCLUSION: In adults, an initial dose of 7vPnC is likely to elicit higher and potentially more effective levels of antipneumococcal antibodies than is PPV. In contrast with PPV, for which the induction of hyporesponsiveness was observed when used as a priming dose, 7vPnC elicits an immunological state that permits subsequent administration of 7vPnC or PPV to maintain functional antipolysaccharide antibody levels.

Spinal sonography in infants with cutaneous birth markers in the lumbo-sacral region--an important sign of occult spinal dysrhaphism and tethered cord.

AIM: Cutaneous markers in the lumbo-sacral region are indicators of occult spinal dysrhaphism and tethered cord. By means of spinal sonography, anatomical abnormalities of the spinal cord can be shown in the neonatal period. PATIENTS: We report on 6 infants with lumbo-sacral cutaneous abnormalities who were investigated with a high resolution linear transducer (> 7.5 MHz) and a computer sonographic unit (Sequoia, Acuson). The investigations were performed between the first day of life and the ninth week (m: 26 days). The following cutaneous markers could be found: Asymmetrical gluteal crease (4); dermal sinus (2), hairy tuft (1); pigmented naevus (1); cutaneous appendage (1); haemangioma (1); unilateral peroneal paralysis with hypotrophic correspondic leg (1). RESULTS: Sonographic evaluation showed the following abnormalities: Tethered cord (6); diastematomyelia (2); tight filum terminale (2); spinal lipoma (3); lipomyelomeningocele (2), myelocystocele and hydromyelia (1). In all infants, sonographic diagnosis could be confirmed by MR imaging and intraoperatively. Surgical correction was performed at the age of 2 to 12 months (m: 7.7 months). CONCLUSION: All infants with cutaneous markers in the lumbo-sacral region should be investigated by spinal sonography as long as the vertebral arches are not completely ossified. Sonography of the spinal cord may detect occult spinal dysrhaphism and tethered cord and prevent neurological damage by early surgical correction at the end of the first year of life.

Spinal sonography in newborns and infants - part II: spinal dysraphism and tethered cord.

UNLABELLED: Patients with cutaneous markers in the lumbo-sacral region as well as infants with bladder and bowel dysfunction, orthopedic anomalies and progressive neurological dysfunction are at risk for spinal dysraphism and tethered cord. Three types of spinal dysraphism can be distinguished: Type I - open spinal dysraphisms with a non-skin covered back mass; type II - closed spinal dysraphisms with a skin covered back mass; type III - occult spinal dysraphisms without a back mass. All spinal dysraphisms can be associated with a tethered cord, characterized by a low position of the conus medullaris below L3. Type I dysraphisms are meningomyeloceles and myeloceles, which are associated with CHIARI-II malformations characterized by the low position of the cerebellar vermis within the foramen magnum. Type II dysraphisms are lipomyeloceles, lipomyelomeningoceles, posterior meningoceles and myelocystoceles. Lipomeningoceles and lipomyelomeningoceles are characterized by a subcutaneous echogenic mass which communicates with the spinal canal and may cause tethered cord. Posterior meningoceles are, dorsal cystic space occupying lesions without internal neural tissue. Myelocystoceles are characterized by a cystic dorsal mass which communicates with a dilated central canal characteristic of syringo-hydromyelia. Type III dysraphisms without a back mass are frequently associated with cutaneous markers in the lumbo-sacral region. Sonographically dermal sinus tracts, diastematomyelia, tight filum and lipoma of the filum terminale and the caudal regression syndrome have to be distinguished. Dermal sinuses are characterized by an echogenic tract from the skin to the spinal canal, often associated with a spinal dermoid. Diastematomyelia is characterized by a complete or partial duplication of the spinal cord which can only be shown on axial images. Tight filum terminale or lipoma of the filum terminale is characterized by a thick echogenic filum with a diameter of more than 2 mm, and a conus below L3. CONCLUSION: All different forms of spinal dysraphisms and tethered cord can be diagnosed sonographically in the neonatal period as long as the spinal arches are not completely ossified.

Spinal sonography in newborns and infants--Part I: method, normal anatomy and indications.

Spinal sonography can be performed in newborns and young infants as long as the vertebral arches are not completely ossified. With high resolution linear transducers (>10 MHz), excellent detailed images of the spine may be obtained from the base of the skull to the caudal end of the thecal sac. Sagittal and axial sections are performed routinely. Beside the spinal cord, the dorsal and ventral nerve roots and the cauda equina can be shown. The medullary conus normally ends above the level of L2/L3. Lower positions are suspective of tethered cord. M-mode sonographic examinations reveal oscillations of the cord due to respiration and the pulse cycle. Colour Doppler sonography displays the epidural venous plexus as well as the central branches of the anterior spinal artery. Normal variants are transient widening of the central canal, terminal ventricle and asymmetric nerve roots. Indications for spinal sonography are midline cutaneous markers in the lumbosacral region, subcutaneous masses, foot abnormalities, anorectal and genitourinary malformations and neurological abnormalities of the lower extremities. All these clinical symptoms are suspicious of spina bifida occulta and tethered cord which should be ruled out by spinal sonography.

[Management of community-acquired pneumonia in the physician's office]. / Fieber-Husten-Auswurf-Pleuraschmerz-Lungeninfiltrat. Nicht immer ist Verlass auf die Leitsymptome der Pneumonie.

The classical form of a community-acquired pneumonia is that caused by infection with pneumococcus, and differs clinically from atypical pneumonia in particular by fever-related differences. The diagnosis is based on the five cardinal symptoms: fever, cough, sputum production, pleuritic chest pain and a pulmonary infiltrate. Depending on whether there are further risk factors involved, a more or less comprehensive clinical and laboratory diagnostic work-up is needed. As a rule, oral antibiotic treatment with aminopenicillin, macrolides, fluorchinolones, ketolides or cephalosporins is applied, but decision-taking is also codetermined, for example, by whether an atypical pneumonia is suspected, or whether additional risk factors need to be taken into account.

[Trans-fontanellar Doppler sonography of the intracranial veins in infants. Part II--pathology]. / Transfontanelläre Doppler-Sonographie der Hirnvenen im Säuglingsalter Teil II--Pathologische Befunde.

Colour coded Doppler sonography can be very helpful for the diagnosis of haemorrhagic infarction of the brain parenchyma, cerebral venous thrombosis and arterio-venous malformations of the brain. Intracranial haemorrhages into the brain parenchyma are caused by the compression of the subependymal and terminal veins which impede the venous drainage from the white matter. Haemorrhage of the basal ganglia is highly suspicious of cerebral venous thrombosis especially of the deep venous drainage. Unilateral occlusion of only one internal cerebral vein causes unilateral haemorrhage, bilateral thrombosis of both internal cerebral veins as well as occlusion of the great vein of Galens or the straight sinus causes bilateral haemorrhage of the basal ganglia as well as ventricular haemorrhage and haemorrhagic infarction of the white matter. The most common arterio-venous malformation of the brain is AV-malformation of Galens's vein. Sonographically, a pulsating cystic structure behind the 3rd ventricle can be shown. Colour coded Doppler sonography demonstrates the vascular nature of the cyst. Doppler sonography can show the feeding arteries, most frequently the posterior choroidal arteries and the venous drainage by the straight sinus.

Vasculitis and infection: effects of immunosuppressive therapy.

The immunosuppressive therapy in systemic vasculitis leads to immunological dysfunctions. The consequences of granulocytopenia and cellular immune deficits are infections of different etiologies in up to 50% of vasculitis patients. The leading severe infections are sepsis and pneumonia induced by a broad spectrum of pathogens (extra- and intra-cellular growing bacteria, fungi, parasites and viruses). The contribution of infections to the mortality of vasculitis patients is important and should induce early and careful control of these events.

[Trans-fontanellar Doppler sonography of the intracranial veins in infants--part I--Normal values]. / Transfontanelläre Doppler-Sonographie der Hirnvenen im Säuglingsalter--Teil I--Normalbefunde.

Doppler sonographic flow measurements in the intracranial veins of infants are not often applied. For the understanding of intracranial pathology such as vascular malformations, intracranial hemorrhagic infarction and venous thrombosis, a thorough understanding of the anatomical position and of the normal flow profiles and flow velocities in intracranial veins is essential. We describe the normal anatomic course of the cerebral veins and their flow profiles and flow velocities in infants. In sagittal sections, the following veins can be shown by colour coded Doppler sonography and measured by pulsed Doppler sonography: The superior and inferior sagittal sinus, and the straight sinus as well as the internal cerebral vein, the vein of Galen and the thalamostriatic veins. In coronal sections, the medullary and subependymal veins, the terminal veins, the internal cerebral veins, the great vein of Galen, the superior sagittal, straight and transverse sinus can be demonstrated and measured.

Nosocomial pneumonia in the critical care unit.

Nosocomial pneumonia poses a major threat to the recovery of patients receiving mechanical ventilation. In addition, nosocomial pneumonia is often difficult to diagnose. This article examines the extent of the threat and some of the difficulties facing the critical care physician when diagnosing nosocomial pneumonia.

Clinical indications for beta-lactamase inhibitors in comparison to other antibiotics.

Combinations of beta-lactamase inhibitors and beta-lactam antibiotics have been used as a therapeutic strategy to overcome the growing problem of bacterial resistance. They have significant advantages over other existing antibiotic regimens and several such combinations have been developed for clinical use. Susceptibility studies have demonstrated the ability of sulbactam to extend the antibacterial activity of ampicillin to cover beta-lactamase-producing resistant strains. The clinical efficacy and safety of sulbactam/ampicillin has been emphasized by the results from a number of randomized trials, including studies in patients with community-acquired pneumonia, meningitis, endometritis and pelvic inflammatory disease, and diabetic foot infections. These studies have established the key role of sulbactam/ampicillin in the treatment of a wide variety of bacterial infections.