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Biomedical subjects

R Auckenthaler

Publications and source records attributed to R Auckenthaler.

At least 55 records · Page 3Linked to original sources
PubMed1996

Bedside prediction of mortality from bacteremic sepsis. A dynamic analysis of ICU patients.

The prognosis in patients with sepsis depends on severity of acute illness, underlying chronic diseases, and complications associated with infection. Adjusting for these factors is essential for evaluation of new therapies. The purpose of the present study was to determine variables readily identifiable at the bedside that predict mortality in intensive care unit (ICU) patients with sepsis and positive blood cultures. For a 5-yr period, all patients of a surgical ICU presenting with positive blood cultures and sepsis were systematically analyzed for clinical variables and organ dysfunctions at the day of onset of sepsis and bacteremia and during the subsequent clinical course. The prognostic value of these variables was determined using logistic regression procedures. Of the 5,457 admissions to the ICU, 176 patients developed sepsis with positive blood cultures (3.2 per 100 admissions). The fatality rate was 35% at 28 days after the onset of sepsis; in-hospital mortality was 43%. Independent predictors of mortality at onset of sepsis were previous antibiotic therapy (odds ratio [OR], 2.40; 95% confidence interval [CI95], 1.59 to 3.62; p = 0.034), hypothermia (OR, 1.43; CI95, 1.04 to 2.44; p = 0.030), requirement for mechanical ventilation (OR, 2.97; CI95, 1.96 to 4.51; p = 0.009), and onset-of-sepsis APACHE II score (OR, 1.21; CI95, 1.13 to 1.29; p < 0.001). Vital organ dysfunctions developing after the onset of sepsis influenced outcome markedly. The best two independent prognostic factors were the APACHE II score at the onset of sepsis (OR, 1.13 per unit; CI95, 1.08 to 1.17; p = 0.0016) and the number of organ dysfunctions developing thereafter (OR, 2.39; CI95, 2.02 to 2.82; p < 0.001). In ICU patients with sepsis and positive blood cultures, outcome can be predicted by the severity of illness at onset of sepsis and the number of vital organ dysfunctions developing subsequently. These variables are easily assessed at the bedside and should be included in the evaluation of new therapeutic strategies.

APACHE↗
PubMed1996

Unusual cause of lethal pulmonary aspergillosis in patients with chronic obstructive pulmonary disease.

Two patients admitted to two different medical wards of our institution following respiratory decompensation of chronic obstructive pulmonary disease (COPD) were subsequently transferred to the same room of the medical intensive care unit (ICU) and intubated. Both patients developed invasive pulmonary aspergillosis and died soon after. Because COPD itself is rarely associated with lethal pulmonary aspergillosis, both cases were reviewed, and a retrospective investigation was conducted. Both patients had repeated sputum cultures while on the medical ward before their admission to the ICU; none of the sample grew Aspergillus spp. A. fumigatus was found in tracheal aspirates of both patients from the first day of their intubation while in the ICU. The pulmonary condition of both patients worsened, and invasive aspergillosis was diagnosed by bronchoalveolar lavage. Despite therapy with amphotericin B, the patients died 16 and 22 d after intubation, respectively. Both deaths were attributed to pulmonary aspergillosis; autopsy confirmed a massive pneumonia of the five lobes due to A. fumigatus in one patient. Investigation revealed that an air filter had been replaced 30 h before the first patient was admitted to the room. Experimental air filter replacement performed 12 d after the second patient died revealed the presence of A. fumigatus on the surface of the filters as well as a 10-fold increase in room air fungal counts during the procedure. This study shows that exposure to high concentrations of airborne Aspergillus spp. related to air filter change was associated with fatal invasive aspergillosis in two mechanically ventilated patients. Such infection can be prevented by the establishment and application of guidelines for air filter replacement.

Aged↗
PubMed1996

Aerosolized rhDNase in cystic fibrosis: effect on leucocyte proteases in sputum.

In cystic fibrosis (CF), large amounts of free leucocyte proteases are present in bronchial secretions, contributing to progressive lung damage. Recombinant, human deoxyribonuclease (rhDNase) is a new therapeutic agent that decreases sputum viscosity. However, deoxyribonuclease has been shown, in vitro, to release cationic enzymes from complexes with deoxyribonucleic acid (DNA). The present study was conducted to assess this effect in vivo. Free human leucocyte elastase (HLE), human leucocyte cathepsin G (HCG), total chemotactic activity, and interleukin-8 (IL-8) were determined in sputum from eight patients before, during and after rhDNase treatment. After 15 days of treatment, HLE activity increased by 81+/-44% (NS), and HCG by 189+/-70% (p<0.05). One week after stopping a 4-6 months treatment, HLE activity decreased by 35+/-18% (p<0.05), and HCG by 43+/-11% (p<0.05). Sputum bacterial density, chemotactic activity, and IL-8 concentration did not change. Thus, treatment with rhDNase can indeed increase the activity of HLE and HCG in the bronchial secretions of CF patients, and this effect is still detectable after several months of treatment. If this can be shown to be clinically relevant, combination therapy of recombinant human deoxyribonuclease with protease inhibitors should be considered as an approach to the problem.

Adult↗
PubMed1996

Automatic alerts for methicillin-resistant Staphylococcus aureus surveillance and control: role of a hospital information system.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an escalating problem in hospitals worldwide. The hospital reservoir for MRSA includes recognized and unrecognized colonized or infected patients, as well as previously colonized or infected patients readmitted to the hospital. Early and appropriate infection control measures (ICM) are key elements to reduce MRSA transmission and to control the hospital reservoir. OBJECTIVE: To describe the role of an expert system applied to the control of MRSA at a large medical center (1,600 beds) with high endemic rates. METHODS: The University Hospital of Geneva has an extended hospital information system (HIS), DIOGENE, structured with an open distributed architecture. It includes administrative, medical, nursing, and laboratory applications with their relational databases. Among available patient databases, clinical microbiology laboratory and admission-discharge-transfer (ADT) databases are used to generate computer alerts. A laboratory alert (lab alert) is printed daily in the Infection Control Program (ICP) offices, listing all patients with cultures positive for MRSA detected within the preceding 24 hours. Patients might be either newly detected patients colonized or infected with MRSA, or previously recognized MRSA patients having surveillance cultures. The ICP nurses subsequently go to the ward or call the ward personnel to implement ICM. A second alert, the "readmission alert," detects readmission to the hospital of any patient previously colonized or infected with MRSA by periodic queries (q 1 min) to the ADT database. The readmission alert is printed in the ICP offices, but also forwarded with added guidelines to the emergency room. RESULTS: During the first 12 months of application (July 1994 to June 1995), the lab alert detected an average of 4.6 isolates per day, corresponding to 314 hospital admissions (248 patients); the use of this alert saved time for the ICP nurses by improving work organization. There were 438 readmission alerts (1.2 alerts per day) over the study period; of 347 patients screened immediately upon readmission, 114 (33%) were positive for MRSA carriage. Delayed recognition of readmitted MRSA carriers decreased significantly after the implantation of this alert; the proportion of MRSA patients recognized at the time of admission to the hospital increased from 13% in 1993 to 40% in 1995 (P < .001). CONCLUSIONS: Hospital information system-based alerts can play an important role in the surveillance and early prevention of MRSA transmission, and it can help to recognize patterns of colonization and transmission.

Cross Infection↗
PubMed1995

Predicting bacteremia in older patients.

OBJECTIVE: To evaluate potential clinical predictors of bacteremia in hospitalized geriatric patients and to propose an individual risk score as an alternative to "subjective" clinical judgment for a more efficient approach in early recognition and treatment of bacteremia. DESIGN: A 16-month prospective study. SETTING: The University Geriatric Hospital of Geneva, Switzerland. PATIENTS: Four hundred thirty-eight patients aged 62 years or older in whom 558 episodes of bacteremia were suspected. MEASUREMENTS: The unit of evaluation was the blood culture episode, which was defined as a 48-hour period beginning with the drawing of the first blood for culture. An extensive precoded protocol, including clinical and biological data, was completed by the resident who requested the blood cultures. For each episode, the resident also provided a subjective assessment of the probability of bacteremia. Odds ratios and their variances were used to estimate the relative risks of potential predictors of bacteremia. The performance of a predictive clinical model based on risk score threshold was evaluated by means of a receiver-operating characteristic analysis. RESULTS: Of the 558 potentially bacteremic episodes investigated, 46 (8.2%) yielded positive blood cultures. The bacteremia rate was strongly associated with the type of episode: it reached 15.6% among the community-acquired (CA) episodes (those occurring within 48 hours of hospital admission) and 6.0% only among the hospital-acquired (HA) episodes (those occurring after the first two days of hospitalization). Predictors of bacteremia with highest relative risks included: bladder catheter removal, fever (> or = 38.5 degrees C), rigors, shock, total band count > or = 1500/mm3, and lymphocyte count < or = 1000/mm3. When assessed by episode type, it appeared that bladder catheter removal and rigors were good predictors of bacteremia in HA episodes only, whereas fever (> or = 38.5 degrees C) had a good predictive value in CA episodes only. The performance of the clinical model was two times better than the physician's subjective ability to predict bacteremia when the threshold of the risk score was fixed at two or more predictors per episode. CONCLUSIONS: These findings provide means to identify older hospitalized patients at high risk of bacteremia. Although the proposed predictive model will need further validation and more precise evaluation of the potential benefits, it may nevertheless be of some help in early recognition and treatment of bacteremia.

Age Factors↗
PubMed1995

Comparison of BacT/Alert with Signal blood culture system.

The BacT/Alert (Organon Teknika Corp., Durham, N.C.) is an automated blood culture system. It is based on the detection of CO2 by means of a colorimetric sensor internally attached to the bottom of culture bottles. The aerobic and anaerobic media of this system were compared with one bottle of the Signal system (Oxoid Ltd., Hampshire, United Kingdom). At bedside, 20 ml of blood was drawn from each adult patient. The two BacT/Alert bottles were inoculated with 5 ml of blood each; the Signal bottle was inoculated with 10 ml. A total of 5,284 sets (2,483 patients; 2.1 cultures per patient) consisting of three bottles each were evaluated, of which 781 sets (14.8%) revealed microorganisms (n = 892); 642 of these were considered to be pathogenic. Significantly more (P < 0.0001) pathogens were isolated from the two BacT/Alert bottles together (n = 584) than from the single Signal bottle (n = 515). Escherichia coli (P = 0.007), gram-negative bacteria other than members of the family Enterobacteriaceae or Pseudomonas spp. (P = 0.006), and yeasts (P = 0.02) were isolated more often from both or either BacT/Alert bottle. Comparing the systems in terms of 388 different organisms per septic episode, the difference between BacT/Alert and Signal was significant for the total number of septicemia cases (P = 0.003). More contaminants grew in the BacT/Alert system (173 versus 116; P = 0.0001). False-positive indications were more frequent in the BacT/Alert system, 198 (3.7%) aerobic bottles and 57 (1.1%) anaerobic bottles, than in the Signal bottles, 24 (0.5%) bottles. Pathogens could be detected significantly earlier (P < 0.0001) in the BacT/Alert system than in the Signal system. The BacT/Alert instrument with two bottles allowed earlier detection as well as the isolation of more microorganisms than the manual, one-bottle Signal system.

Bacteremia↗
PubMed1995

Intravascular device-related infections in critically ill patients.

Intravascular device-related infections (IVDRIs) are among the most common nosocomial infections in critically ill patients. Quantitative or semi-quantitative microbiology diagnosis is necessary for their management. Most causative organisms arise from the skin; staphylococci are responsible for two-thirds of the IVDRIs, with Staphylococcus aureus responsible for 5% to 15%. Complications may include septic shock, suppurative thrombophlebitis, and endocarditis. In critically ill patients, intravenous lines are responsible for at least 23% of nosocomial bloodstream infection, which has a mortality of 25% and is associated with a longer stay in intensive care and costs $28,960 per survivor. IVDRIs can be treated with intravenous antibiotics without removing the device, but removal of the catheter is recommended. Prevention is based on careful insertion practice and optimal catheter care. Systemic replacement of the intravenous lines every three to five days is common practice in the USA but not elsewhere in Europe. This issue should be studied, particularly in critically ill patients.

Bacterial Infections↗
PubMed1994

[Antibiotic sensitivity of gram-negative bacteria in intensive care units in Switzerland].

The sensitivity to the major antimicrobial agents of consecutively isolated gram-negative rods in intensive care units in Switzerland was investigated. A majority of strains originated from clinical specimens where infection or colonization could not be distinguished from each other. A total of 1024 isolates from 482 patients were tested by a standardized microtiter method. Of the beta-lactam antibiotics, imipenem (92% of bacteria sensitive), ceftazidime (90%), and aztreonam (85%) showed the greatest activity. 94% of the isolates were sensitive to ciprofloxacin, and 93% and 91% to amikacin and tobramycin respectively. There where considerable differences locally and in time, probably reflecting small outbreaks due to resistant bacteria and because selective pressure is locally dependent on the antimicrobial agents used. 122 patients were observed for an extended period. In 67 (55%) the same gram-negative rods persisted for up to 42 days without development of resistance. In 41 patients (34%) there was a change to other more resistant bacteria, especially to multi-resistant Pseudomonas aeruginosa, Flavobacterium meningo-septicum, Xanthomonas maltophilia or Enterobacter cloacae. In 12 patients (10%) bacteria of the same species with resistance to additional antimicrobial agents were observed.

Anti-Bacterial Agents↗
PubMed1994

[Multicenter evaluation of oral antibiotics: resistance behavior in 5 Swiss centers].

The susceptibility of 2196 fresh clinical isolates to twelve different oral compounds was assessed in five Swiss microbiology institutions during summer 1992. A standardized microdilution system including all other material necessary was employed to assess the antibacterial activity of penicillin G, ampicillin, ampicillin + sulbactam, amoxycillin + clavulanic acid, cefadroxil, cephalexin, cefaclor, cefuroxime, cefetamet, doxycycline, erythromycin and clindamycin. The aminopenicillins (including the beta-lactamase inhibitor combinations) were highly active against the streptococci, in combination with a beta-lactamase inhibitor they covered the majority of the bla+ E. coli and Proteus mirabilis and between 60 to 80% of the Klebsiella spp. and Proteus vulgaris isolates. All the cephalosporins exhibited good activity against the streptococci, they were active against Gram-negative fermentative rods to a varying degree. Cefetamet was also active against many cefaclor and cefuroxime-resistant isolates. A considerable part of the species studied exhibited resistance to doxycycline; the observed resistance of S. agalactia, P. mirabilis, and Morganella morganii agreed with previous findings. Most of the Streptococcus spp. were inhibited by erythromycin and clindamycin. There were only single penicillin resistant S. pneumoniae isolates in the five Swiss centers. Taking account of the above particulars the epidemiology of antimicrobial resistance in Switzerland can be considered satisfactory.

Anti-Bacterial Agents↗
PubMed1994

Evaluation of two commercial blood culture media for the detection of blood-borne pathogens.

To determine their ability to detect blood-borne pathogens, the blood culture media BCB Release (Becton Dickinson, USA) and Signal (Oxoid, UK) were evaluated on a total of 5,122 blood culture sets. Each of the two bottles was inoculated with an equal amount of blood from 2,262 patients at bedside (2.3 cultures per patient). In the laboratory, agar-coated paddles were attached to the BCB Release bottles and the Signal device was mounted onto the Signal bottles. Both systems were incubated at 35 degrees C for seven days. A total of 608 (11.9%) sets were positive, from which 549 pathogenic microorganisms could be isolated. These could be grown significantly (p < 0.0001) more often from the BCB Release broth (n = 483) than from the Signal system (n = 384). Mainly staphylococci, Escherichia coli and yeasts were isolated more often from the BCB Release, anaerobes were more often detected from the Oxoid Signal. The time to positivity was significantly shorter (p < 0.0001) with the BCB Release. The Signal system proved a valuable complement to the BCB Release broth.

Adolescent↗
PubMed1994

Candida colonization and subsequent infections in critically ill surgical patients.

OBJECTIVE: The authors determined the role of Candida colonization in the development of subsequent infection in critically ill patients. DESIGN: A 6-month prospective cohort study was given to patients admitted to the surgical and neonatal intensive care units in a 1600-bed university medical center. METHODS: Patients having predetermined criteria for significant Candida colonization revealed by routine microbiologic surveillance cultures at different body sites were eligible for the study. Risk factors for Candida infection were recorded. A Candida colonization index was determined daily as the ratio of the number of distinct body sites (dbs) colonized with identical strains over the total number of dbs tested; a mean of 5.3 dbs per patient was obtained. All isolates (n = 322) sequentially recovered were characterized by genotyping using contour-clamped homogeneous electrical field gel electrophoresis that allowed strain delineation among Candida species. RESULTS: Twenty-nine patients met the criteria for inclusion; all were at high risk for Candida infection; 11 patients (38%) developed severe infections (8 candidemia); the remaining 18 patients were heavily colonized, but never required intravenous antifungal therapy. Among the potential risk factors for candida infection, three discriminated the colonized from the infected patients--i.e., length of previous antibiotic therapy (p < 0.02), severity of illness assessed by APACHE II score (p < 0.01), and the intensity of Candida spp colonization (p < 0.01). By logistic regression analysis, the latter two who were the independent factors that predicted subsequent candidal infection. Candida colonization always preceded infection with genotypically identical Candida spp strain. The proposed colonization indexes reached threshold values a mean of 6 days before Candida infection and demonstrated high positive predictive values (66 to 100%). CONCLUSIONS: The intensity of Candida colonization assessed by systematic screening helps predicting subsequent infections with identical strains in critically ill patients. Accurately identifying high-risk patients with Candida colonization offers opportunity for intervention strategies.

Adult↗
PubMed1994

Chronic destructive lung disease associated with a novel mycobacterium.

A woman born in 1920 has suffered from a chronic destructive lung disease since 1972, with development of a severe combined restrictive and obstructive ventilatory defect. Large quantities of acid-fast microorganisms have been repeatedly observed in her sputum. Multiple courses of antimycobacterial treatment did not stop the progression of the disease. The mycobacterium involved was first identified as Mycobacterium gordonae, and later as Mycobacterium scrofulaceum. Analysis of part of the amplified gene of the 16S rRNA, however, revealed that its sequence differed from that of any established mycobacterial species, although it was observed once before in a German lymph node isolate, for which the name "Mycobacterium interjectum" has been proposed. Retrospective analysis confirmed the presence of this sequence in frozen samples which had been provided by the patient in 1983, 1985, 1989, 1990, and 1993. Our case confirms the value of amplification and sequencing of mycobacterial 16S rRNA for classifying mycobacteria, and suggests that "Mycobacterium interjectum" may be involved in cases of chronic destructive lung disease.

Aged↗
PubMed1993

[An epidemic of typhoid fever].

An outbreak of typhoid fever was observed in a group of students and accompanying teachers during a journey to Haiti in summer 1991. All (6) infected persons were symptomatic and rapidly cured by antibiotics. The Salmonella typhi strains isolated from blood cultures were all identical by ribotyping. All the participants had a medical checkup and stool cultures were obtained; asymptomatic carriers could be excluded. Secondarily infected persons were not observed. The infectious source has not been identified, but various hypotheses are considered. Oral vaccination does not appear to modify the risk of infection in exposed persons.

Adolescent↗
PubMed1993

Adult bacterial nasopharyngitis: a clinical entity?

OBJECTIVE: To investigate bacterial nasopharyngitis as a cause of adult upper respiratory infection. DESIGN: Prospective case series. SETTING: Walk-in medical clinic of a university hospital. PATIENTS: 507 patients with cold or flu symptoms, sore throat, or recent cough; 21 control subjects without symptoms of upper respiratory infection. MEASUREMENTS AND MAIN RESULTS: After thorough history and physical examination, the patients underwent nasopharyngeal aspiration and throat culture. Nasopharyngeal specimens were cultured for both bacteria and viruses; antigens for influenza, parainfluenza, and respiratory syncytial virus were sought by enzyme-linked immunosorbent assay (ELISA); serum antibodies to viral respiratory pathogens were determined. Group A beta-hemolytic streptococci grew from the throat specimens of 39 of the 507 patients (8%) or 38 of 334 patients (11%) who had clinical diagnoses of pharyngitis. Thirty-three cases of influenza A, 20 cases of influenza B, and seven cases of parainfluenza infections were diagnosed. Bacteria were cultured from the nasopharyngeal secretions of 284 patients (56%). In contrast to pharyngeal culture, commensal mixed flora were rarely found in nasopharyngeal culture. Nasopharyngeal culture of bacteria usually considered to be respiratory pathogens was significantly associated with the presence of leukocytes. Streptococcus pneumoniae (odds ratio 6.0, 95% confidence interval 2.6-14.2), Moraxella catarrhalis (odds ratio 12.9, 95% confidence interval 3.1-79.5), and Hemophilus influenzae (odds ratio 3.0, 95% confidence interval 1.2-7.4) were all associated with the presence of leukocytes. In contrast, nasopharyngeal culture of coagulase-negative staphylococci, mixed flora, and the documentation of a viral infection were not associated with the presence of leukocytes. For none of 21 control subjects were "pathogenic" bacteria found. CONCLUSIONS: These data suggest that potentially pathogenic bacteria may have a causal role in adult nasopharyngitis, although further data are needed to confirm this hypothesis.

Adolescent↗
PubMed1993

Chronic brucella empyema.

Brucellosis rates have decreased in developed countries in recent years, but the pathologic condition still occurs in developing countries and well-known endemic areas such as the Mediterranean and Middle Eastern countries. A Portuguese patient presented in Switzerland with long-term pleural empyema, which was later diagnosed as Brucella empyema through positive cultures of Brucella melitensis. Brucellosis should be considered in patients who have traveled to Middle Eastern countries or any other areas where brucellosis is more frequently encountered.

Adult↗
PubMed1993

Adult response to initial treatment with ampicillin in community acquired pneumonia in Yaoundé, Cameroon.

A prospective study was conducted to evaluate the efficacy of ampicillin as an initial therapy in 60 adult patients with community acquired pneumonia. Bacteriological etiology was obtained only in 24 (40pc) patients by microscopic examination, culture and antigen detection. Streptococcus pneumoniae was the leading causative agent identified in 15 cases. Other etiologies were Klebsiella pneumoniae (3), Streptococcus pyogenes (2) Staphylococcus aureus (2), Haemophilus influenzae (1) and Moraxella catarrhails (1). Patients were started on ampicillin one gram twice daily, empirically, and treated for 10 days. There were 52(86.7pc) patients cured, two(3.3pc) patients improved and six (10pc) were therapeutic failures. The causative agents in patients with failures were: Klebsiella pneumoniae (1), Staphylococcus aureus (1), Streptococcus pneumoniae (1) and unknown in three cases. Only six of 60 patients still febrile after three days were switched to amoxycillin/clavulanic acid or cefaclor according to culture results and susceptibilities or to roxythromycin because no organisms were isolated. Side effects were observed in only one (1.7pc) patient who developed a mild skin rash. Due to its low cost and its high efficacy, ampicillin still appears to be the drug of choice in adult community acquired pneumonia in our region.

Adolescent↗
PubMed1993

Determination of MICs for staphylococci using the API ATB quinolone and API ATB macrolide systems.

The determination of minimal inhibitory concentrations (MICs) is cumbersome, but remains necessary in certain cases. We tested the two ATB MIC experimental strips (Biomérieux SA), of which each contains 4 antimicrobials of the same class. These strips can be read automatically. The MIC quinolone strip contains nalidixic acid, pefloxacin, ofloxacin and ciprofloxacin, whereas the MIC macrolide (lincosamide-streptogramin) strip contains erythromycin, clindamycin, lincomycin, and pristinamycin. In order to evaluate these strips, 102 S. aureus and 63 coagulase negative staphylococci were used. Correlation coefficients for these MICs (micrograms/ml) and disk diffusion inhibition zone diameters (mm) were nalidixic acid -0.59, pefloxacin -0.95, ofloxacin -0.95, ciprofloxacin -0.91, erythromycin -0.98, clindamycin -0.96, lincomycin -0.96, and pristinamycin -0.64. Using the Biomic system (Giles Scientific USA), the same zone diameters were converted to MICs (micrograms/ml). Rates of agreement (+/- 1 dilution) between ATB MICs and Biomic MICs were nalidixic acid 96 p. cent, ciprofloxacin 98 p. cent, erythromycin 99 p. cent and clindamycin 98 p. cent. Rates of agreement between MICs for the same strains determined using agar dilution and ATB MICs were nalidixic acid 93 p. cent, pefloxacin 100 p. cent, ciprofloxacin 99 p. cent, ofloxacin 94 p. cent and erythromycin 96 p. cent. The ATB MIC strips are an easy-to-use tool for MIC determination and their composition is well-suited to the study of phenotypic resistance and detection of low-level resistance.

Ciprofloxacin↗