Pathogens in early-onset and late-onset intensive care unit-acquired pneumonia.

OBJECTIVES: To compare the type of pathogens isolated from patients with early-onset intensive care unit (ICU)-acquired pneumonia with those isolated from patients with late-onset ICU-acquired pneumonia and to study risk factors for the isolation of pathogens that are potentially resistant to multiple drugs. DESIGN: Prospective cohort study. SETTING: Patients admitted to the ICU of a 677-bed, university-affiliated teaching hospital in Belgium during 1997-2002. METHODS: ICU-acquired pneumonia was defined as a case of pneumonia that occurred 2 days or more after admission to the ICU in combination with a positive results of radiologic analysis, clinical signs and symptoms, and a positive culture result. All cases of pneumonia were categorized as either early onset (within 7 days after admission) and late onset (7 days or more after admission), with or without previous antibiotic treatment, and the corresponding pathogens were analyzed. Risk factors for the isolation of pathogens potentially resistant to multiple drugs (ie, Pseudomonas aeruginosa, Serratia marcescens, Enterobacter species, Morganella morganii, methicillin-resistant Staphylococcus aureus, Citrobacter species, Acinetobacter species, Burkholderia species, extended-spectrum beta -lactamase-producing pathogens, and Stenotrophomonas maltophilia) were analyzed using logistic regression analysis. RESULTS: A total of 4,200 patients stayed at the ICU for 2 or more days, 298 of whom developed ICU-acquired pneumonia, for an overall incidence of 13 cases (95% confidence interval [CI], 11-14 cases) per 1,000 ICU-days. Pathogens potentially resistant to multiple drugs were isolated from 52% of patients with early-onset pneumonia. Risk factors for the isolation of these pathogens were greater age and previous receipt of antibiotic prophylaxis (adjusted odds ratio [aOR], 4.6 [95% CI, 1.6-13.0]) or antibiotic therapy (aOR, 8.2 [95% CI, 2.8-23.8]). The length of ICU admission and hospital stay were weaker risk factors for the isolation of these pathogens. CONCLUSIONS: Pathogens potentially resistant to multiple drugs were isolated in 52% of cases of early-onset ICU-acquired pneumonia. Previous antibiotic use (both prophylactic and therapeutic) is the main risk factor for the isolation of these pathogens.

National guidelines for the judicious use of glycopeptides in Belgium.

OBJECTIVE: The 'HICPAC guidelines', published in the USA in 1995 stressed the crucial role of restrictive usage of glycopeptides in the strategy to limit the emergence and spread of resistant enterococci. Because controversy still remains in Belgium on the necessity and feasability of restricting glycopeptide usage, the infectious diseases advisory board (IDAB) developed a consensus statement on the judicious use of glycopeptides in Belgium. METHODS: The literature on the indications for glycopeptide treatment was reviewed, categorized and discussed by a working party of the IDAB.Consequently, the IDAB reached consensus on the warranted indications for glycopeptide use in Belgium. RESULTS: The opinion of the IDAB-members is reported in a consensus statement specifying the indications for treatment and for prophylaxis with glycopeptide antimicrobials, as well as the situations where glycopeptides should not be used, taking into account the specific epidemiology of bacterial resistance, the availability of antibiotics and the common prescribing practices in Belgium. CONCLUSIONS: The IDAB concludes that restrictive usage of glycopeptides must also be a priority in Belgium. Guidelines on the judicious use of these antibiotics adapted to the national situations must contribute to this objective.

Chylothorax and chylous ascites due to malignant lymphoma.

Chyle is a fluid rich in triglycerides and is characterized by the presence of chylomicrons. Chylous effusions are unusual complications of malignant neoplasms, usually lymphomas. The combination of chyloperitoneum and chylothorax is very rare. When abdominal lymphatics are obstructed, chylous ascites results and eventually leads to a chylothorax. We present the case of a 68-year-old woman with a chyloperitoneum and a right-sided chylothorax due to an underlying malignant B-cell lymphoma. After thoracocentesis and replacement therapy with medium chain triglycerides, she was treated with a combination of cyclophosphamide, vincristine and prednisone. This has resulted in a regression of the chylous effusions. A short review of the literature describes causes, diagnosis and therapy of chylous effusions.

Pulmonary actinomycosis. Case report.

Pulmonary actinomycosis. Case report. Pulmonary actinomycosis is a rare infectious disease. The major difficulty is mainly the diagnosis. A high dose of suspicion is required in each intrathoracic process showing malignant behaviour, despite benign histology. Especially if the process extends through normal tissue planes, actinomycosis should be suspected. The therapy of choice should consist in high dose of antibiotics for several months, occasionally followed by surgery. Often though, surgery is the first treatment because of the unability to differentiate the lesion from malignant tumor. Surgery should always be followed by long term antibiotic therapy.