Patients' opinions on outcomes following critical illness.

BACKGROUND: Our aim was to explore which outcomes are most important to patients following ICU-discharge, and to explore whether intensive care unit (ICU)-nurses and anesthesiologists are aware of patients' priorities. METHODS: First, interviews with adult ICU-survivors were conducted until data saturation was achieved (10 interviews), and six areas with 36 items were identified. Second, interviews with another eight ICU-survivors were conducted, narrowing the list to 20. Finally, patients (inclusion criteria: consecutive adults, medical and surgical, ICU-admission > 5 days, 2-8 months post-ICU discharge) rated the items, as did ICU-nurses and anesthesiologists. RESULTS: A total of 32 patients participated (44% women, medians: age 70.5, time since discharge 179 days, length of stay in ICU 9 days, APACHEII 19.5). The three most important outcomes defined by patients were: lack of physical strength, fatigue, and decreased walking distance. The top three for ICU-nurses (54 participants) were: fatigue, difficulties concentrating, sadness/depression, and for anesthesiologists (17 participants): fatigue, difficulties in activities of daily living, and lack of physical strength. CONCLUSION: Patients chose lack of physical strength, fatigue, and decreased walking distance as the three most important outcomes following critical illness. Physicians had a higher focus on these physical impairments than ICU-nurses.

Allelic variation in a peptide-inducible two-component system of Streptococcus pneumoniae.

The peptide SpiP of Streptococcus pneumoniae regulates the induction of a complex signal transduction system spiR1spiR2spiH. Distinct alleles of spiP and the receptor histidine protein kinase gene spiH were recognized in different pneumococcal clones. The spi system in strain KNR7/87 is adjacent to a bacteriocin gene cluster encoding putative double glycine-type bacteriocins, immunity proteins, and translocator proteins. A direct repeat element upstream of the spiR1 promoter and another three potential transcription start sites within the bacteriocin cluster indicate that SpiP functions as an inducing peptide for bacteriocin synthesis in S. pneumoniae.

The fib locus in Streptococcus pneumoniae is required for peptidoglycan crosslinking and PBP-mediated beta-lactam resistance.

Penicillin resistance in pneumococci is mediated by modified penicillin-binding proteins (PBPs) that have decreased affinity to beta-lactams. In high-level penicillin-resistant transformants of the laboratory strain Streptococcus pneumoniae R6 containing various combinations of low-affinity PBPs, disruption of the fib locus results in a collapse of PBP-mediated resistance. In addition, crosslinked muropeptides are highly reduced. The fib operon consists of two genes, fibA and fibB, homologous to Staphylococcus aureus femA/B which are also required for expression of methicillin resistance in this organism. FibA and FibB belong to a family of proteins of Gram-positive bacteria involved in the formation of interpeptide bridges, thus representing interesting new targets for antimicrobial compounds for this group of pathogens.

A global gene pool for high-level cephalosporin resistance in commensal Streptococcus species and Streptococcus pneumoniae.

Highly penicillin- and cephalosporin-resistant Streptococcus mitis and Streptococcus oralis were isolated in Spain, Hungary, and Berlin. With chromosomal DNA of these strains, resistant transformants of Streptococcus pneumoniae were obtained that expressed low-affinity variants of penicillin-binding proteins (PBPs) 2x, 1a, 2a, and 2b in different combinations, depending on the selective conditions. The transformants had cefotaxime MICs of up to 6 microg/mL, and those with a low-affinity PBP 2b were highly deficient in penicillin-induced lysis. Sequence analysis of the pbp2x genes confirmed the presence of a global gene pool of penicillin resistance determinants shared by commensal and pathogenic streptococci.

Penicillin-binding proteins as resistance determinants in clinical isolates of Streptococcus pneumoniae.

Altered penicillin-binding proteins (PBPs) with reduced affinity for penicillin are encoded by mosaic genes in penicillin-resistant clinical isolates of Streptococcus pneumoniae. Generally, members of one bacterial clone contain the same mosaic gene. We report here on a serotype 19A clone of penicillin- and multiple-resistant S. pneumoniae prevalent in Hungary, members of which are exceptionally diverse in terms of PBP properties. The pbp2x gene of four 19A isolates was sequenced, and a distinct mosaic structure detected in each case. The pbp2x genes also differed from a homologous gene of a high-level penicillin-resistant S. mitis from Hungary. The contribution of PBPs to resistance development was studied on transformation experiments using the laboratory strain R6 as recipient, and PBP genes from the type 19A isolate Hu11. pbp2x and pbp2b function as primary resistance determinants for different beta-lactams. Secondary transformation with pbp1a increased the resistance level considerably for penicillins and cefotaxime. Chromosomal DNA of a high-level penicillin- and cefotaxime-resistant S. mitis from Hungary also transformed the R6 strain to increased resistance levels, and PBP2x and PBP2b functioned as primary resistance determinants as above. In contrast, high-level cefotaxime resistance appeared to be due to a low affinity PBP2a, indicating that this PBP can also function as a resistance determinant.

Penicillin-resistant Streptococcus pneumoniae in Germany: genetic relationship to clones from other European countries.

Penicillin-resistant Streptococcus pneumoniae strains isolated in different parts of Germany between 1982 and 1992 were compared with penicillin-resistant isolates, mainly of serogroups 6, 9, 14, 19 and 23, from other European countries. The main clones were recognised by their serotypes, antibiotic resistance patterns and penicillin-binding protein properties, and this typing was confirmed by multi-locus enzyme electrophoresis for a sample of 43 selected isolates. Eleven of the 14 resistant German isolates could be assigned to five genotypes isolated also in other countries. These included representatives of two distinct serotype 23F lineages predominant in Spain and France; a cluster of three serotype 6B isolates identical to clones in Spain, France, Finland and Hungary; and a serotype 9V clone of a type prevalent in Spain and now also in France. Serotype 19A clones of the type found in Hungary were not collected in Germany. The data suggest that two 23F lineages, represented by seven isolates from different locations, have become disseminated in Germany. Several resistant types found in the former West Germany resembled those found elsewhere in Western Europe whereas those from East Germany were distinct or, in one case, resembled a clone from Hungary. These data may reflect pre-unification travel patterns.

Cytochrome c550 from Pseudomonas aeruginosa.

In cells of Pseudomonas aeruginosa A.T.C.C. 17933 grown on ethanol the synthesis of a soluble c-type cytochrome, together with quinoprotein ethanol dehydrogenase, is induced. The cytochrome, with an alpha-absorption band at 550 nm, was purified to homogeneity. The molecular mass of the monomeric protein is 15 kDa, the pI is 4.8, and it contains one haem prosthetic group. The midpoint potential of the autoxidizable, but not autoreducible, cytochrome is 280 mV. Cytochrome c550 mediates electron transfer between quinoprotein ethanol dehydrogenase and ferricyanide. In a system composed of membrane particles with NN'NN'-tetramethyl-p-phenylenediamine oxidase activity and quinoprotein ethanol dehydrogenase, oxygen consumption is only observed in the presence of cytochrome c550. This indicates the participation of the cytochrome in the electron-transport chain linked to quinoprotein ethanol dehydrogenase in P. aeruginosa. The electron transport from ethanol dehydrogenase to oxygen is inhibited by myxothiazol and antimycin, indicating that a cytochrome bc1-like complex is involved.