Initial treatment of sepsis in non-neutropenic patients: ceftazidime alone versus 'best guess' combined antibiotic therapy.

We conducted a prospective, randomized, multicentric study in community hospitals. Patients with clinical sepsis, rectal temperature > or = 38 degrees C and pulse rate > or = 100 bpm were randomized to receive ceftazidime (group CAZ) or a combination of antibiotics freely chosen by the clinician following his 'best guess' (group COMB). On specified grounds, the clinician could also treat patients in an open group with a free combination of antibiotics (group OPEN). The severity of disease at study admission was assessed by a clinical estimation and an Apache II score. There were 128 patients included: 56 randomized in group CAZ, 50 in group COMB, and 22 in the OPEN group. Ninety-one patients were evaluable: 41 in group CAZ, 30 in group COMB, 20 in OPEN group. At the end of the period of empirical treatment (48-72 h), the clinical success rates (improvement of status) were 93, 93 and 75% (p for group OPEN vs. groups CAZ or COMB: 0.10). The bacteriological success rates (sterile blood cultures) were 91, 88 and 80% (p not significant). mean Apache II score was 16.7 and the score correlated significantly with outcome, as did clinical evaluation. In conclusion, ceftazidime alone was a safe antibiotic therapy in this study and we could not demonstrate a superiority of a combined antibiotic therapy chosen by the clinician following his 'best guess' over ceftazidime.

[Hemodynamic improvement during therapy using the intravascular oxygenator (IVOX)]. / Hämodynamische Verbesserung während Therapie mit intravaskulärem Oxygenator (IVOX).

The intravascular oxygenator (IVOX) is a new device which is implanted in the vena cava sup. and inf. where it oxygenates the blood and removes CO2. We report on its successful use in a young patient with severe pneumonia. This 21-year-old female was admitted to hospital with acute respiratory distress due to pneumococcal pneumonia and sepsis following chickenpox. Considering the rapidly progressive course with severe hypoxia and shock, PaO2/PaCO2 values of 6.5/6.4 kPa on mechanical ventilation with an FiO2 of 1.0 and a PEEP of 13 mbar, we decided to implant an intravascular oxygenator. Besides rapid improvement of oxygenation, we observed remarkable recovery of cardiovascular function such as an increase in mean arterial pressure and mixed-venous saturation, while the dose of vasopressors could be decreased. The intravascular oxygenator was removed without problems after 29 days of continuous use, when pulmonary function allowed an FiO2 of 0.45. The patient was discharged from the intensive care unit after 99 days in a good neurological and stable cardiovascular state.

[Opportunistic infections in HIV-infected patients]. / Opportunistische Infektionen bei HIV-infizierten Patienten.

HIV-infected patients are prone to frequent opportunistic infections (OI). Their fundamental differences to infections in the immunocompetent host are explained. The most frequent OI is pneumonia caused by pneumocystis carinii. A brief overview on diagnostic and therapeutic aspects of encephalitis due to toxoplasma gondii, candidiasis, meningitis due to cryptococcus neoformans, tuberculosis, infection by atypical mycobacteria, infection by viruses of the herpes group--in particular cytomegalovirus--and cryptosporidiosis is given.

[Circulating immune complexes before and after kidney allotransplantation]. / Zirkulierende Immunokomplexe vor und nach Nierenallotransplantation.

In a prospective study circulating immune complexes (CIC) were analyzed before and serially after renal transplantation in 141 consecutive patients. CIC were measured using the Raji cell assay as originally described by Theofilopoulos and Dixon. The amount of CIC was expressed as microgram heat aggregated human immunoglobulin G (IgG) equivalent/ml serum. The upper limit of normal sera was 25 micrograms/ml. The values are expressed as geometric means (- 1 SD/ + 1 SD). In 86 of 133 rejection episodes a renal biopsy was performed and the histopathologic changes were semiquantitatively assessed and classified in a cellular or vascular type of rejection. Before transplantation CIC were detected in 104 of 141 patients (73.8%) and the mean value was 65.6 (27.8-154.9) micrograms/ml. The level of CIC was positively correlated with the number of grafts (r: 0.43; P less than 0.01) and the occurrence of chronic active hepatitis (r: 0.31; P less than 0.01). No correlation was found between CIC and the underlying kidney disease, the number of blood transfusions prior to transplantation, and the pre-existing lymphocytotoxic antibodies. Graft survival and number of rejection episodes were not influenced by the level of CIC prior to transplantation. After transplantation CIC were elevated in 60 patients (41%), appeared transiently in 49 patients (35%) and were never detectable in 32 patients (23%). In patients with a graft survival less than or equal to 11 months the average and peak post-transplant CIC levels were significantly higher than patients with a graft survival of 12 months: 64.4 (21.8-191.0); 87.7 (26.0-295.8) versus 39.6 (18.4-85.3); 56.8 (21.0-150.1) micrograms/ml; P less than 0.01.(ABSTRACT TRUNCATED AT 250 WORDS)