Cephalosporin-resistant pneumococcal pneumonia: does it, affect outcome?

STUDY OBJECTIVES: Penicillin resistance has been reported in various studies to have no impact on the outcome of pneumococcal pneumonia. However, the importance of cephalosporin resistance has not been systematically studied. We conducted an analysis of patients with high-level cephalosporin-resistant Streptococcus pneumoniae pneumonia (H-CRSPP). DESIGN: Retrospective matched, case-control study. SETTING: Two inner-city academic hospitals. PATIENTS: Twenty-six patients with H-CRSPP admitted to the hospital between 1995 and 1999 were identified. Each patient was matched with two controls with cephalosporin-sensitive but oxacillin-resistant pneumococcal pneumonia admitted during the same time period. Matching was done based on pneumonia severity of illness index (PSI) and for other factors. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We evaluated a number of outcomes including mortality length of stay in the hospital, and time to respond to treatment. Patients with H-CRSPP took longer to respond to treatment (6.5 +/- 0.9 days vs 4.1 +/- 0.7 days, P=0.05) and had a longer length of stay in hospital (15.4 +/- 2.2 days vs 92 +/- 1.6 days, P=0.02). None of the other outcomes were different between the two groups. CONCLUSIONS: Overall, we have found that the presence of cephalosporin resistance does impact the course of pneumococcal pneumonia.

Dyspnea differentiation index: A new method for the rapid separation of cardiac vs pulmonary dyspnea.

STUDY OBJECTIVE: To assess the utility of a new parameter in the differentiation of dyspnea of cardiac origin from dyspnea of pulmonary origin. METHODS: The peak expiratory flow (PEF) rate and the partial pressure of oxygen in arterial blood (PaO(2)) were measured in 71 patients with the chief complaint of dyspnea. The patients were treated in the hospital, and the final diagnosis (cardiac or pulmonary) of the cause of dyspnea was made at discharge. We defined a new measure, the dyspnea differentiation index (DDI), as (PEF x PaO(2))/1,000. We performed a receiver operating characteristic (ROC) curve analysis of the data to define the measure that best distinguished cardiac from pulmonary dyspnea. The curves also allowed us to establish an optimal cut-off point to distinguish between cardiac and pulmonary dyspnea. RESULTS: Patients with pulmonary dyspnea had a significantly lower mean PEF than patients with cardiac dyspnea (144 +/- 66 vs 267 +/- 97 L/min, respectively; p < 0.001). They also had a lower DDI than patients with cardiac dyspnea (8.4 +/- 4.0 vs 18.4 +/- 7.9 L-mm/min, respectively; p < 0.001). These two measures, PEF and DDI, also best distinguished pulmonary from cardiac dyspnea. PEF was able to diagnose the correct cause of dyspnea in 72% of patients, and DDI was correct in 79% of patients. This compares favorably to the performance of the emergency department physicians, who were able to predict the correct diagnosis in only 69% of patients. CONCLUSION: These results demonstrate that the PEF by itself is useful in differentiating between cardiac and pulmonary causes of dyspnea, but that the calculation of DDI is superior in this regard.

Doxycycline is a cost-effective therapy for hospitalized patients with community-acquired pneumonia.

BACKGROUND: Doxycycline has a high degree of activity against many common respiratory pathogens and has been used in the outpatient management of lower respiratory tract infections, including pneumonia. OBJECTIVE: To evaluate the efficacy of intravenous doxycycline as empirical treatment in hospitalized patients with mild to moderately severe community-acquired pneumonia. PATIENTS AND METHODS: We conducted a randomized prospective trial to compare the efficacy of intravenous doxycycline with other routinely used antibiotic regimens in 87 patients admitted with the diagnosis of community-acquired pneumonia. Forty-three patients were randomized to receive 100 mg of doxycycline intravenously every 12 hours while 44 patients received other antibiotic(s) (control group). The 2 patient groups were comparable in their clinical and laboratory profiles. RESULTS: The mean+/-SD interval between starting an antibiotic and the clinical response was 2.21+/-2.61 days in the doxycycline group compared with 3.84+/-6.39 days in the control group (P = .001). The mean+/-SD length of hospitalization was 4.14+/-3.08 days in the doxycycline group compared with 6.14+/-6.65 days in the control group (P = .04). The median cost of hospitalization was $5126 in the doxycycline group compared with $6528 in the control group (P = .04). The median cost of antibiotic therapy in the doxycycline-treated patients ($33) was significantly lower than in the control group ($170.90) (P<.001). Doxycycline was as efficacious as the other regimens chosen for the treatment of community-acquired pneumonia. CONCLUSION: Doxycycline is an effective and inexpensive therapy for the empirical treatment of hospitalized patients with mild to moderately severe community-acquired pneumonia.

Pyogenic vertebral osteomyelitis presenting as exudative pleural effusion: a series of five cases.

Five patients are reported who have pleural effusion and pyogenic vertebral osteomyelitis. In four of the five patients, the presenting problem was a large pleural effusion, and three of these four patients had an exudative effusion. Initial evaluation and investigations in these patients were directed toward the pleuropulmonary disease, delaying the diagnosis of osteomyelitis, and in two patients, this delay resulted in neurologic complications. In the fifth patient, the pleural effusion was initially small; however, during the course of a workup for osteomyelitis, the effusion increased rapidly. Two out of the five patients had empyema, and the other three patients had a large pleural effusion associated with and apparently caused by vertebral osteomyelitis. Vertebral osteomyelitis should be considered in the differential diagnosis of pleural effusion of uncertain cause especially if there is associated back pain.

Extensive mesenteric inflammatory veno-occlusive disease of unknown etiology after primary cytomegalovirus infection: first case.

We report a young man who, shortly after a primary cytomegalovirus infection, presented with signs of intestinal ischemia requiring surgical intervention. The resected specimen of small bowel showed striking features of extensive phlebitis and venulitis affecting virtually all of the veins of the small intestine and mesentery. Although he had had a recent primary cytomegalovirus viremia, we could not identify any evidence of cytomegalovirus in the small bowel. He was not infected with HIV. The entity we describe is different from the recently reported mesenteric inflammatory veno-occlusive disease. The clinicopathologic entity represented by our patient's disease was heretofore unrecognized.

Study of ipratropium bromide inhalation in stable asthma.

An open two weeks short term trial of Ipratropium Bromide (IB) inhalation (0.02 mg per dose) was carried out in 20 stable asthamatics to study its efficacy and safety. Early significant rise in PEFR (P < 0.001) and FEV1 (P < 0.05) was observed after 15 min of IB inhalation and reached significant peak (P < 0.01) after 1 hour which was persistent beyond three hours after IB inhalation. No side effects were observed. It was concluded that Ipratropium Bromide Imhalation is safe and has efficient bronchodilatory effect on short term basis in stable asthmatics.

Comparative efficacy of oral sustained released bronchodilator in stable asthmatics.

Double blind randomized trial of oral conventional and sustained release bronchodilators was undertaken to observe comparative efficacy in 30 patients older than 15 years. All cases selected were stable asthmatics at least for last 2 years having FEV1 improvement > or = 20%. Basal Pulmonary functions like FEV1, FVC and PEFR were recorded before and after drug administration at 1/2, 1, 2, 3, 4, 6, 8, 10, 12 and 24 hours. Four drug regimens were given as a single dose in the morning on randomized crossover manner on 1st, 4th, 7th and 10th days, sustained release theophylline 300 mg+salbutamol 4 mg (Drug I), salbutamol 4 mg + theophylline 300 mg (Drug II), salbutamol sustained released (asthalin SA) 8 mg (Drug III), salbutamol sustained released (ventorlin CR) 8 mg (Drug IV). Mean FEV1 changes observed at 0, 6 and 12 hours for all the drugs were compared which showed no statistical significance (t = 2.3876). Therefore, we conclude that using single dose fixed combination of oral salbutamol and aminophylline either in a plain or slow released form have no additive bronchodilator effect as compared to salbutamol alone in stable asthmatics.