[Genitourinary mycobacteriosis: retrospective study of 45 cases in a general hospital]. / Micobacteriosis genitourinaria: estudio retrospectivo de 45 casos en un hospital general.

INTRODUCTION: Genitourinary tuberculosis (GUT) is the third most frequent extrapulmonary tuberculous infection, following pleural and nodal involvement. Associated clinical symptoms are mild, and the diagnosis and treatment of this condition are often delayed. METHODS: This study determines the clinical and epidemiological characteristics, and outcome of patients diagnosed with GUT in our center over the last 10 years. Patients with positive Löwenstein-Jensen urine or biopsy culture, or pathologic study suggestive of tuberculosis were included. Cases of multifocal tuberculosis and positive Löwenstein-Jensen, but with no urinary symptoms or radiological alterations, were considered to have mycobacteriuria. RESULTS: Forty-five patients were analyzed (62% men; mean age, 49.4 years). Among the total, 33% had a coexisting disease (14 were infected by human immunodeficiency virus). Twenty-six patients (57%) had renal tuberculosis, 5 (11%) orchiepididymitis, and 14 (31%) were classified as having mycobacteriuria. The most frequent clinical manifestations were urination syndrome (61%), low back pain (44%), and macroscopic hematuria (12%). Ziehl stain was positive in 38% cases. Urine culture was positive for other microorganisms in 9 patients (20%). Intravenous urography oriented the diagnosis in 87.5% of cases. The average interval between onset of symptoms and diagnosis was 15 months. Cure without sequelae was obtained in 60%. Surgery was indicated in 10 patients. CONCLUSIONS: The index of suspicion for GUT should be high when patients present with repeated urinary syndromes. The current use of imaging studies other than urography and the finding of other microorganisms in urine culture can delay the diagnosis.

Micobacteriosis genitourinaria: estudio retrospectivo de 45 casos en un hospital general / Genitourinary mycobacteriosis: retrospective study of 45 cases in a general hospital

INTRODUCCIÓN. La tuberculosis genitourinaria (TGU) es la afección extrapulmonar más frecuente tras la pleural y ganglionar. Dada su escasa sintomatología clínica su diagnóstico y tratamiento son, a menudo, tardíos. MÉTODOS. Estudio de las características clínicas, epidemiológicas y evolutivas de los pacientes diagnosticados de TGU en nuestro centro los últimos10 años. Se han incluido los pacientes con cultivo de Löwenstein positivo, en orina o en muestras de biopsiaso con estudio anatomopatológico compatible con tuberculosis. Los casos de tuberculosis multifocal, Löwenstein positivo sin clínica urinaria ni alteraciones radiológicas se consideraron micobacteriuria. RESULTADOS. Se han analizado 45 pacientes (el 62%hombres con una edad media de 49,4 años). En el 33%coexistía enfermedad de base (14 infectados por el virus de la inmuno deficencia humana). Se diagnosticaron de tuberculosis renal 26 pacientes (57%), 5 (11%) de orquiepididimitis y 14 (31%) se catalogaron como micobacteriuria. La sintomatología más frecuente fue síndrome miccional (60%), dolor lumbar (44%) y hematuriama croscópica (12%). La tinción de Ziehl fue positiva en el38% de los casos. El urocultivo fue positivo para otros gérmenes en 9 pacientes (20%). La urografía intravenosa orientó el diagnóstico en 28/32 casos (87,5%). El intervalo medio de síntomas previos al diagnóstico fue de 15 meses. La curación sin secuelas se logró en el 60%. Se indicó cirugía en 10 casos. CONCLUSIONES. Se debe incrementar el grado de sospechade TGU ante síndromes urinarios de repetición. La menor utilización actual de la urografía frente a otras pruebas de imagen y el hallazgo de otros gérmenes en el urocultivo pueden retrasar el diagnóstico (AU)

INTRODUCTION. Genitourinary tuberculosis (GUT) is the third most frequent extrapulmonary tuberculous infection, following pleural and nodal involvement. Associated clinical symptoms are mild, and the diagnosis and treatment of this condition are often delayed. METHODS. This study determines the clinical and epidemiological characteristics, and outcome of patients diagnosed with GUT in our center over the last 10 years. Patients with positive Löwenstein-Jensen urine or biopsyculture, or pathologic study suggestive of tuberculosis were included. Cases of multifocal tuberculosis and positive Löwenstein-Jensen, but with no urinary symptoms or radiological alterations, were considered to have mycobacteriuria. RESULTS. Forty-five patients were analyzed (62% men; mean age, 49.4 years). Among the total, 33% had acoexisting disease (14 were infected by human immunodeficiency virus). Twenty-six patients (57%) had renal tuberculosis, 5 (11%) orchiepididymitis, and 14 (31%)were classified as having mycobacteriuria. The most frequent clinical manifestations were urination syndrome(61%), low back pain (44%), and macroscopic hematuria(12%). Ziehl stain was positive in 38% cases. Urine culture was positive for other microorganisms in 9 patients (20%).Intravenous urography oriented the diagnosis in 87.5% of cases. The average interval between onset of symptoms and diagnosis was 15 months. Cure without sequelae was obtained in 60%. Surgery was indicated in 10 patients. CONCLUSIONS. The index of suspicion for GUT should be high when patients present with repeated urinary syndromes. The current use of imaging studies other than urography and the finding of other microorganisms inurine culture can delay the diagnosis (AU)

Neumonía por Pseudomonas aeruginosa / Pneumonia due to Pseudomonas aeruginosa

Pseudomonas aeruginosa es uno de los principales bacilos gramnegativos que causa con mayor frecuencia neumonía nosocomial. Es además el patógeno más común causante de neumonía asociada a ventilación mecánica y el que se asocia a una mayor mortalidad entre las infecciones adquiridas en el hospital. P. aeruginosa produce un elevado número de toxinas y tiene en su superficie diversos componentes que lo hacen especialmente virulento comparado con otros microorganismos. Entre éstos se incluyen los pili, flagelos lipopolisacárido y otros productos excretados como exotoxina A, S y U, elastasa, proteasa alcalina, citotoxinas y fosfolipasas. La vía más común de infección en los pacientes ventilados mecánicamente es a través de la aspiración de secreciones procedentes del tracto respiratorio superior y previamente colonizadas debido a la manipulación de la vía respiratoria artificial o a través de las manos contaminadas del personal sanitario. El tratamiento antibiótico frente a P. aeruginosa debe de establecerse de forma precoz ante la sospecha o confirmación de la neumonía. Debe de iniciarse tratamiento empírico frente a P. aeruginosa, especialmente en los pacientes que han recibido previamente tratamiento antibiótico o que desarrollan una neumonía tardía

Pseudomonas aeruginosa is one of the leading causes of Gram-negative nosocomial pneumonia. It is the most common cause of ventilator-associated pneumonia and carries the highest mortality among hospital-acquired infections. P. aeruginosa produces a large number of toxins and surface components that make it especially virulent compared with other microorganisms. These include pili, flagella, membrane bound lipopolysaccharide, and secreted products such as exotoxins A, S and U, elastase, alkaline protease, cytotoxins and phospholipases. The most common mechanism of infection in mechanically ventilated patients is through aspiration of upper respiratory tract secretions previously colonized in the process of routine nursing care or via contaminated hands of hospital personnel. Intravenous therapy with an antipseudomonal regimen should be started immediately when P. aeruginosa pneumonia is suspected or confirmed. Empiric therapy with drugs active against P. aeruginosa should be started, especially in patients who have received previous antibiotics or present late-onset pneumonia

[Pneumonia due to Pseudomonas aeruginosa]. / Neumonía por Pseudomonas aeruginosa.

Pseudomonas aeruginosa is one of the leading causes of Gram-negative nosocomial pneumonia. It is the most common cause of ventilator-associated pneumonia and carries the highest mortality among hospital-acquired infections. P. aeruginosa produces a large number of toxins and surface components that make it especially virulent compared with other microorganisms. These include pili, flagella, membrane bound lipopolysaccharide, and secreted products such as exotoxins A, S and U, elastase, alkaline protease, cytotoxins and phospholipases. The most common mechanism of infection in mechanically ventilated patients is through aspiration of upper respiratory tract secretions previously colonized in the process of routine nursing care or via contaminated hands of hospital personnel. Intravenous therapy with an antipseudomonal regimen should be started immediately when P. aeruginosa pneumonia is suspected or confirmed. Empiric therapy with drugs active against P. aeruginosa should be started, especially in patients who have received previous antibiotics or present late-onset pneumonia.

Patterns of colonization by Pseudomonas aeruginosa in intubated patients: a 3-year prospective study of 1,607 isolates using pulsed-field gel electrophoresis with implications for prevention of ventilator-associated pneumonia.

OBJECTIVE: To identify routes and patterns of colonization with Pseudomonas aeruginosa in intubated patients to design strategies of prevention for respiratory infection. DESIGN AND SETTING: Prospective and observational study in the 16-bed intensive care unit of a teaching hospital. PATIENTS AND PARTICIPANTS: Ninety-eight intubated patients were investigated over a 3-year period. Those ventilated less than 72 h were excluded. MEASUREMENTS AND RESULTS: Samples from the tap water from each patient's room, stomach, oropharynx, subglottic secretions, trachea, and rectum were collected when the patient was intubated, and then three times per week. Pulsed-field gel electrophoresis was performed to type the strains. We identified 1,607 isolates pertaining to 35 different pulsotypes. Overall 54.2% of patients presented colonization, and tracheal colonization was present in 30.5%. Ten patients had colonization at intubation, and four of these developed ventilator-associated pneumonia (VAP) after a mean of 4+/-2 days. ICU-acquired colonization occurred in 31 patients, and 4 of these developed VAP after a median of 10+/-5 days. P. aeruginosa was isolated from the room's tap water in 62.4% of samples. More than 90% of tap water samples had pulsotypes 1 and 2, which were frequently isolated in the stomach (59%) but were only rarely associated with VAP. CONCLUSIONS: Although colonization/infection with P. aeruginosa in intubated patients tends to be endogenous, exogenous sources should not be ruled out. A combination of early identification (and eradication) of airways colonization by P. aeruginosa plus infection control measures targeted to reduce cross-contamination should be the basis to prevent pulmonary infection.

Prospective observational study of bacteremic pneumococcal pneumonia: Effect of discordant therapy on mortality.

STUDY OBJECTIVE: To evaluate the effect of discordant empirical therapy on outcome in bacteremic pneumococcal community-acquired pneumonia. DESIGN: Prospective observational study. SETTING: A 600-bed teaching hospital with a reference area of 400,000 inhabitants. PATIENTS: All patients aged > or =18 yrs with a diagnosis of community-acquired pneumonia whose blood cultures, obtained within the first 48 hrs of hospitalization, demonstrated growth of Streptococcus pneumoniae were included in the study. METHODS: Discordant therapy was defined as failure to administer an antibiotic with in vitro activity against the isolated strain within 24 hrs of hospital admission. The 2002 breakpoints recommended for respiratory infections by the National Committee for Clinical Laboratory Standards were used to classify therapy. RESULTS: A total of 100 patients with bacteremic pneumococcal pneumonia were identified. Penicillin- and macrolide-resistant strains were identified in 29 and 18 cases, respectively. Only two strains had minimum inhibitory concentrations of >2 microg/mL for cephalosporins. Discordant therapy was documented in ten patients, five of whom died. Mortality in patients receiving concordant therapy was 14% (13 of 90). Nursing home residence (odds ratio [OR] = 14.8) and immunocompromise (OR = 11.5) were independently (p <.05) associated with discordant therapy. Risk of discordant therapy was significantly higher (p <.05) when empirical therapy did not include cefotaxime or ceftriaxone (OR = 10.4). Discordant therapy (OR = 27.3), multilobar involvement (OR = 14.2), underlying chronic obstructive pulmonary disease (OR = 9.1), and hospitalization during the previous 12 wks (OR = 7.9) were independently associated (p <.05) with death. The excess mortality for initial discordant therapy was estimated to be 35.6% (95% confidence interval, 3.73-67.4). CONCLUSIONS: Survival in patients with bacteremic community-acquired pneumococcal pneumonia can be improved by avoiding suboptimal therapy. Using the 2002 breakpoints, it is very unlikely that discordant therapy would be given with ceftriaxone or cefotaxime. Clinical outcome is worse in those patients receiving antimicrobial therapy that in vitro testing suggests would be ineffective.

A 7-year study of severe hospital-acquired pneumonia requiring ICU admission.

OBJECTIVE: To examine the characteristics, prognostic factors, and outcome of patients with severe hospital-acquired pneumonia admitted to the ICU. DESIGN AND SETTING: Prospective observational clinical study in two medical-surgical ICUs with 16 and 20 beds PATIENTS AND PARTICIPANTS: During a 7-year period all hospitalized patients requiring admission to either ICU for hospital-acquired pneumonia were followed up. MEASUREMENTS AND RESULTS: We diagnosed 96 episodes of severe hospital-acquired pneumonia, and in 67 cases a causal diagnosis was made. Most episodes were late-onset pneumonia. Gram-negative micro-organisms were isolated in 51% of episodes diagnosed, and Pseudomonas aeruginosa was the most frequent pathogen isolated (24%). Clearly significant variations happened between hospitals, particularly affecting the incidence of Aspergillus spp. and Legionella pneumophila. Forty-nine patients developed septic shock (51%). Fifty-one patients died (53%). Aspergillosis and pneumonia due to P. aeruginosa were associated with the highest mortality. Septic shock (OR: 14.27) and chronic obstructive pulmonary disease (OR: 6.11) were independently associated with a poor prognosis. CONCLUSIONS: Patients with severe hospital-acquired pneumonia admitted to the ICU present high mortality. The presence of septic shock and chronic obstructive pulmonary disease in conjunction with specific microorganisms are associated with a poor prognosis. Local epidemiological data combined with a patient-based approach may allow a more accurate therapy decision making.

Microbiological testing and outcome of patients with severe community-acquired pneumonia.

STUDY OBJECTIVES: The study documents the impact of microbiological investigations on therapeutic decisions and outcome in patients with severe community-acquired pneumonia (SCAP). DESIGN: Retrospective analysis of prospectively collected data. SETTING: ICUs in two teaching Spanish hospitals. PATIENTS: Two hundred four consecutive patients admitted to intensive care with SCAP. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: One hundred six patients required intubation, while 98 other patients did not (81 of these patients were managed with noninvasive mechanical ventilation). The microbiologic diagnosis was established in 57.3% of patients. The most common pathogens were Streptococcus pneumoniae, Legionella pneumophila, and Haemophilus influenzae. Pseudomonas (6.6.% vs 1.0%, p < 0.05) and Legionella (15.1% vs 7.1%, p < 0.05) were more frequently documented in intubated patients. Overall mortality was 23.5% (44.3% in intubated patients), with S pneumoniae (n = 7), Pseudomonas aeruginosa (n = 7), and L pneumophila (n = 5) being the most common lethal pathogens. Bacteriological investigation led to changes in antibiotic prescription in 41.6% of patients, including 11 patients (5%) in whom initial treatment was ineffective against the microbial isolates. The most frequent reason for changes was simplification of therapy in 65 episodes (31.8%). CONCLUSIONS: We conclude that microbiological testing is fully justified in patients with SCAP, because identifying the causative agent and adjusting treatment both impact on patient outcome. Our findings suggest that intubated patients should be empirically treated for Pseudomonas and Legionella while awaiting bacteriology results.

Type III protein secretion is associated with poor clinical outcomes in patients with ventilator-associated pneumonia caused by Pseudomonas aeruginosa.

OBJECTIVE: Pseudomonas aeruginosa is a frequent cause of ventilator-associated pneumonia. Recent evidence suggests that production of type III secretion proteins is correlated with increased pathogenicity in both cellular and animal models of infection. The objective of this study was to determine whether this system contributes to disease severity in humans with ventilator-associated pneumonia. DESIGN: Retrospective pilot cohort study. SETTING: University hospital. PATIENTS: Thirty-five mechanically ventilated patients with bronchoscopically confirmed ventilator-associated pneumonia caused by P. aeruginosa. MEASUREMENTS AND MAIN RESULTS: Ventilator-associated pneumonia was categorized as severe (patients died or had a recurrence of their pneumonia despite appropriate antibiotic therapy) or mild (patients uneventfully recovered from their pneumonia). The type III secretion genotypes and phenotypes of isolates cultured from the patients with ventilator-associated pneumonia were determined. Whereas every examined isolate harbored type III secretion genes, only 27 (77%) were capable of secreting detectable amounts of type III proteins in vitro. Twenty-two (81%) of the patients infected with these 27 isolates had severe disease. Of the eight isolates that did not secrete type III proteins, only three (38%) were cultured from patients with severe disease. Thus, infection with a type-III-secreting isolate correlated with severe disease (p < .05). In vitro assays indicated that ExoU, the type III effector protein most closely linked to mortality in animal models, was secreted in detectable amounts in vitro by 10 (29%) of the 35 examined isolates. Nine (90%) of these 10 isolates were cultured from patients with severe disease (p < .05 when compared with the nonsecreting isolates). In contrast, ExoS was secreted by 16 (46%) of the 35 examined isolates. Twelve (75%) of these 16 isolates were cultured from patients with severe disease (p = .14 when compared with the nonsecreting isolates). CONCLUSIONS: In patients with ventilator-associated pneumonia, type-III-secreting isolates were associated with worse clinical outcomes, suggesting that this secretion system plays an important role in human disease. Our findings support the hypothesis that antibodies targeted against these proteins may be useful as adjunctive therapy in intubated patients with P. aeruginosa colonization or infection.

Effect of enriched thioglycolate on direct examination of respiratory specimens and guiding initial empirical therapy in intubated patients with pneumonia: a prospective, randomized study.

OBJECTIVE: To evaluate the use of enriched thioglycolate as a transport medium of protected specimen brush samples, in particular its value in direct examination of respiratory specimens and in guiding initial antibiotic prescription. DESIGN: Prospective, randomized, pilot study. SETTING: Medical-surgical teaching intensive care unit. SUBJECTS: Thirty adults with suspected ventilator-associated pneumonia. INTERVENTION: Bronchoscopy was performed by using standard techniques, and two consecutive protected specimen brush samples were taken. Transport medium consisted of 1 mL of sterile saline or thioglycolate. Gram stains were performed in all samples. Randomization was used to select which transport medium was used first. Each patient served as his or her own control. The laboratory was blind to the choice. MEASUREMENTS AND MAIN RESULTS: Causative agents were cultured in 16 episodes, and no significant differences were observed when the transport media were compared. Anaerobes were identified in only one episode. Direct staining in thioglycolate samples anticipated the presumptive diagnosis (in presence of false-negative cultures) in three additional patients in whom prior antibiotic therapy was prescribed; this was also the case in one patient with saline solution. The etiology was anticipated by direct Gram staining and permitted a more targeted initial empirical treatment in 75% of samples transported in thioglycolate, compared with only 37.5% of samples transported in saline solution (p <.05). CONCLUSION: When protected specimen brush samples are obtained, thioglycolate may contribute to early identification of the pathogen and may guide the initial empirical therapy.

El diagnóstico de neumonía en pacientes intubados: la infructuosa búsqueda de "el dorado" / The diagnosis of pneumonia in intubated patients: the unsuccessful search for "El Dorado"

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Evaluation of the BacT/Alert and VITAL blood culture systems for the diagnosis of bacteremia.

OBJECTIVE: To evaluate the detection of bacterial growth in the BacT/Alert (Organon Teknika) and VITAL (bioMérieux) automated blood culture systems. METHODS: In accordance with the protocol of study, 1021 blood sample pairs for culture were obtained from adult patients admitted to the Emergency Room and Intensive Care Unit. RESULTS: In total, 139 (13.6%) clinically significant blood cultures were detected, of which 79 (56.8%) were detected by both systems, 48 (34.5%) only by BacT/Alert and 12 (8.6%) only by VITAL (P cent0.0001). The BacT/Alert system detected positive blood cultures more rapidly for all groups of microorganisms. The VITAL system showed six false-negative blood cultures, while the BacT/Alert system showed none (P50.03). There was no significant difference between the number of false-positive blood cultures detected by the two systems. CONCLUSIONS: In our study, overall the BacT/Alert system achieved a better recovery of microorganisms than the VITAL system.