Community-acquired pneumonia and positive urinary antigen tests: Factors associated with targeted antibiotic therapy.

BACKGROUND: The use of rapid microbiological tests is supported by antimicrobial stewardship policies. Targeted antibiotic therapy (TAT) for community-acquired pneumonia (CAP) with positive urinary antigen test (UAT) has been associated with a favorable impact on outcome. We aimed to determine the factors associated with TAT prescription. PATIENTS AND METHODS: We conducted a retrospective multicenter study including all patients presenting with CAP and positive UAT for Streptococcus pneumoniae or Legionella pneumophila from January 2010 to December 2013. Patients presenting with aspiration pneumonia, coinfection, and neutropenia were excluded. CAP severity was assessed using the Pneumonia Severity Index (PSI). TAT was defined as the administration of amoxicillin for pneumococcal infection and either macrolides or fluoroquinolones (inactive against S. pneumoniae) for Legionella infection. RESULTS: A total of 861 patients were included, including 687 pneumococcal infections and 174 legionellosis from eight facilities and 37 medical departments. TAT was prescribed to 273 patients (32%). Four factors were found independently associated with a lower rate of TAT: a PSI score≥4 (OR 0.37), Hospital A (OR 0.41), hospitalization in the intensive care unit (OR 0.44), and cardiac comorbidities (OR 0.60). Four other factors were associated with a high rate of TAT: positive blood culture for S. pneumoniae (OR 2.32), Hospitals B (OR 2.34), E (OR 2.68), and H (OR 9.32). CONCLUSION: TAT in CAP with positive UAT was related to the hospitals as well as to patient characteristics.

Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease.

OBJECTIVE: The aim of this study was to determine the efficacy and safety of videothoracoscopic lung biopsy (VTLB) in the diagnosis of infiltrative lung disease (ILD) and compare the results of VTLB with the results previously obtained in patients with open lung biopsy at the same institution. METHODS: Forty-one patients undergoing VTLB between May 1991 and December 1994 were retrospectively studied and compared with 25 patients who have undergone OLB during the period from January 1987 to April 1991. The two groups were comparable with respect to age, sex, and severity of lung disease. RESULTS: Three of 41 patients (7%) who underwent VTLB with minithoracotomy. There was no significant difference between the group of VTLB (38 patients) and the group OLB (25 patients) with regard to, the number of biopsies (VTLB 1.8 +/- 0.4 versus OLB 2 +/- 0.6), or diagnostic yield (VTLB 37/38 versus OLB 25/25). In contrast, patients who underwent VTLB demonstrated a significant reduction of the operative time (VTLB 45.3 +/- 12.2 min), length of chest tube drainage (3.55 +/- 1.2 days), hospital stay (5.5 +/- 1.3 days), and analgesia (buprenorphine 0.85 +/- 0.44 mg; paracetamol 5.9 +/- 2.5 g) compared to patients who underwent OLB (55.6 +/- 11.2 min, 5.2 +/- 1.5 days; 7.1 +/- 2.3 days; buprenorphine 1.17 +/- 0.5 mg, paracetamol 8.9 +/- 2.3 g). Morbidity and mortality were similar in the two groups (morbidity VTLB 10.5%, OLB 12%; mortality VTLB 5.2%, OLB 8%). Regardless of the biopsy technique, the most serious complications and deaths occurred with the same frequency in those patients with a severe underlying disease. CONCLUSIONS: VTLB is a valid alternative to OLB in most cases. Along with a comparable efficacy, VTLB has several advantages that should make it the method of choice for patients with only minimally impaired respiratory function. In contrast, the role and advantages of VTLB compared to OLB in patients with severe lung disease, require further investigation.

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases.

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.

Surgical management of pleuropulmonary tuberculosis.

To define the current indications for surgical management of pleuropulmonary tuberculosis and analyze the results of operative procedures, the records of 59 patients operated on between January 1987 and December 1993 were reviewed. Three patient categories were defined. Group I patients (n = 25) underwent operation for diagnostic purposes: solitary mediastinal node or mediastinal adenopathy associated with pulmonary lesions (n = 10), pulmonary infiltrates (n = 4), pulmonary nodules or masses (n = 10), or chronic pleurisy (n = 1). Postoperative mortality and morbidity rates in this group were both 4%. Group II patients (n = 18) underwent operation for active lesions: intrapulmonary cavity (n = 6), destroyed lung parenchyma (n = 6), or chronic loculated pleural effusion (n = 6). Postoperative morbidity and mortality rates were 16.6% and 5.5%, respectively. Group III patients (n = 16) underwent operation for a complication of therapy or for sequelae of previously "cured" tuberculosis: calcified pyothorax (n = 8), empyema (n = 2), fistulized nodes (n = 2), bronchiectasis (n = 3), or aspergilloma (n = 1). Morbidity and mortality rates in this group were 31.25% and 12.5%, respectively. Surgery continues to have both diagnostic and therapeutic indications for management of pleuropulmonary tuberculosis, despite the morbidity and mortality rates associated with operative procedures.

[Current surgical methods for the etiological diagnosis of mediastinal adenopathies]. / Méthodes chirurgicales actuelles pour le diagnostic étiologique des adénopathies médiastinales.

The aim of this work was to determine the role of video-thoracoscopy and mediastinoscopy for the diagnosis of lymph node enlargement in the mediastinum of unknown aetiology. From January 1992 to December 1993, 26 patients were seen for surgical biopsy of mediastinal lymph nodes. Relative localization and the requirement for an associated gesture determined the choice between axial mediastinoscopy, parasternal scopy and videothoracoscopy. Mediastinoscopy was performed for peritracheal or right hilar (Baréty) nodes and parasternal scopy for anterior mediastinal masses. Videothroacoscopy was performed when the lymph nodes were localized at the preceding sites or when an associated manoeuver was required. Mediastinoscopy was performed in 16 patients. Lymphorrea which subsided after 4 days occurred in one patient and the mean hospital stay was 2.6 days. Diagnosis was achieved in 15 cases. The delay from procedure to treatment was 11 days on the average. Parasternal scopy was used 3 times and gave the diagnosis in all cases. Videothoracoscopy was used for 7 patients including 2 cases with pulmonary biopsies. Diagnosis was established 7 times and the delay to treatment was 12 days. No diagnostic thoracotomie were performed during this period. When access to the mass to be biopsied is difficult with mediastinoscopy (aorto-pulmonary, subcarenal, triangular ligament) videothoracotomy can be useful. Post-operative follow-up is simple and a specific treatment can be instaured rapidly. Videothoracotomy should be an important supplementary method for mediastinoscopy and helping avoid thoracotomy.

Chest wall invasion by bronchogenic carcinoma: evaluation with MR imaging.

The value of magnetic resonance (MR) imaging and the roles of various pulse sequences and contrast medium enhancement in detection of chest wall invasion were evaluated in 34 patients with primary bronchogenic carcinoma. Results were correlated with clinical data and computed tomographic studies. MR imaging criteria of parietal invasion included signal intensity identical to that of the tumor on T1-weighted images, intraparietal hyperintense signal of the tumor on T2-weighted images, and intraparietal enhancement with T1-weighted imaging and gadoterate meglumine administration. Twenty patients had parietal involvement, and MR imaging was positive in 18 of the 20 (sensitivity, 90%). Two false-positive errors occurred among the 14 patients without parietal involvement (specificity, 86%). T2-weighted sequences had a sensitivity of 65% (11 of 17 cases). Contrast-enhanced and non-contrast-enhanced T1-weighted sequences had the same sensitivity, but contrast medium uptake was revealed in two patients without parietal involvement. Good spatial resolution appears to be the main factor for detection of parietal invasion.

[Surgical treatment of pneumothorax by video-thoracoscopy]. / Traitement chirurgical du pneumothorax par vidéo-thoracoscopie.

Between May and December 1991, 12 patients with spontaneous pneumothorax were treated surgically, using video-thoracoscopy. With this technique bullous lesions could be excised in 10 cases and pleurodesis could be performed in all patients. Morbidity and mortality were nil. The cosmetic and functional advantages of video-thoracoscopy were obvious. Long-term results remain to be evaluated. This technique has shown that it is possible in all cases to create pleurodesis (pleural poudrage or pleurectomy) and to treat parenchymatous lesions (excision of bullous systems). This suggests that the long-term results will be the same as those obtained with conventional surgery.