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Biomedical subjects

S Ewig

Publications and source records attributed to S Ewig.

At least 73 records · Page 4Linked to original sources
PubMed2000

Evaluation of antimicrobial treatment in mechanically ventilated patients with severe chronic obstructive pulmonary disease exacerbations.

OBJECTIVE: To study microbial and susceptibility patterns and antimicrobial treatment responses in patients with severe, acute exacerbations of chronic obstructive pulmonary disease requiring mechanical ventilation. DESIGN: Microbial investigation using tracheobronchial aspirates, bronchoscopy with a protected specimen brush, and bronchoalveolar lavage, as well as paired serologies. Evaluation of antimicrobial treatment by results of the initial investigation, susceptibility testing, and a repeated microbial investigation (tracheobronchial aspirates, bronchoscopy with a protected specimen brush, and bronchoalveolar lavage) after 72 hrs. SETTING: A respiratory intensive care unit of a 1,000-bed teaching hospital. PATIENTS: Fifty severely exacerbated and mechanically ventilated patients with chronic obstructive pulmonary disease. INTERVENTIONS: Initial empirical antimicrobial treatment according to clinical judgment. MEASUREMENTS AND MAIN RESULTS: Overall, 36 of 50 patients (72%) had evidence of a microbial origin. Community-acquired endogenous pathogens were present in 70% of patients, and Gram-negative enteric bacilli and Pseudomonas/Stenotrophomonas species were present in 30%. All five isolates of Streptococcus pneumoniae were resistant to penicillin (three intermediately and two highly), and three were resistant to multiple antibiotics. Pseudomonas species revealed multiresistance in four of nine isolates (44%), and Stenotrophomonas maltophilia revealed multiresistance in one of two isolates. Antimicrobial treatment was modified according to diagnostic results in 11 of 31 patients (36%) with potentially pathogenic microorganisms. In patients who underwent a repeat investigation after 72 hrs, 24% of the initially present and potentially pathogenic microorganisms persisted. Inappropriate initial antimicrobial therapy was associated significantly with bacterial persistence (p < .002). CONCLUSIONS: Considering the diversity of microbial pathogens and the resistance rates especially to S. pneumoniae in this patient population, antimicrobial treatment should be based on the constant study of local microbial and susceptibility patterns along with routine microbial investigation of the individual patient.

Aged↗
PubMed2000

Sampling methods for ventilator-associated pneumonia: validation using different histologic and microbiological references.

OBJECTIVE: To validate sampling techniques (tracheobronchial aspirates, protected specimen brush, and bronchoalveolar lavage, both conventional and protected) for the detection of ventilator-associated pneumonia (VAP) and causative microorganisms according to different histologic and microbiological references. DESIGN: Immediate, multiple bilateral lung biopsy, postmortem study. SETTING: Respiratory intensive care unit of a 1,000-bed teaching hospital. PATIENTS: Twenty-five mechanically ventilated patients (>72 hrs) who died in our intensive care unit. MEASUREMENTS: Lung tissue histologic examination and quantitative cultures (16 specimens/patient). The following four references for the diagnostic techniques were used: histology of guided lung biopsy, histology of blind lung biopsy, combined guided and blind lung biopsy histology and microbiology of lung tissue, and microbiology of lung tissue. RESULTS: Sensitivities when histologic reference tests were used ranged from 16% to almost 40%, whereas specificity rates were always <80%. When we combined both lung histology of guided or blind specimens and microbiology of lung tissue, all diagnostic techniques achieved considerably higher but still limited diagnostic yields (sensitivity range 43% to 83%; specificity range 67% to 91%). Causative organisms were missed in a significant number of cases by all techniques (17% to 83%). CONCLUSIONS: The diagnostic performances of different diagnostic techniques strongly depend on the reference used. All techniques for detecting VAP are of limited value. Finding a balance between clinical judgment and microbiological results is crucial to appropriately manage patients with VAP.

Biopsy↗
PubMed2000

Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications.

The aim of the study was to determine the causes and prognostic implications of antimicrobial treatment failures in patients with nonresponding and progressive life-threatening, community-acquired pneumonia. Forty-nine patients hospitalized with a presumptive diagnosis of community-acquired pneumonia during a 16-mo period, failure to respond to antimicrobial treatment, and documented repeated microbial investigation >/= 72 h after initiation of in-hospital antimicrobial treatment were recorded. A definite etiology of treatment failure could be established in 32 of 49 (65%) patients, and nine additional patients (18%) had a probable etiology. Treatment failures were mainly infectious in origin and included primary, persistent, and nosocomial infections (n = 10 [19%], 13 [24%], and 11 [20%] of causes, respectively). Definite but not probable persistent infections were mostly due to microbial resistance to the administered initial empiric antimicrobial treatment. Nosocomial infections were particularly frequent in patients with progressive pneumonia. Definite persistent infections and nosocomial infections had the highest associated mortality rates (75 and 88%, respectively). Nosocomial pneumonia was the only cause of treatment failure independently associated with death in multivariate analysis (RR, 16.7; 95% CI, 1.4 to 194.9; p = 0.03). We conclude that the detection of microbial resistance and the diagnosis of nosocomial pneumonia are the two major challenges in hospitalized patients with community-acquired pneumonia who do not respond to initial antimicrobial treatment. In order to establish these potentially life-threatening etiologies, a regular microbial reinvestigation seems mandatory for all patients presenting with antimicrobial treatment failures.

Community-Acquired Infections↗
PubMed2000

Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome.

Noninvasive and invasive diagnostic techniques have been shown to achieve comparable performances in the evaluation of suspected ventilator-associated pneumonia (VAP). We studied the impact of both approaches on outcome in a prospective, open, and randomized study in three intensive care units (ICUs) of a 1,000-bed tertiary care university hospital. Patients with suspected VAP were randomly assigned to noninvasive (Group 1) versus invasive (Group 2) investigation (tracheobronchial aspirates [TBAS] versus bronchoscopically retrieved protected specimen brush [PSB] and bronchoalveolar lavage [BAL]. Samples were cultured quantitatively, and BAL fluid (BALF) was examined for intracellular organisms (ICO) additionally. Initial empiric antimicrobial treatment was administered following the guidelines of the American Thoracic Society (ATS) and adjusted according to culture results (and ICO counts in Group 2). Outcome variables included length of ICU stay and mechanical ventilation as well as mortality. Overall, 76 patients (39 noninvasive, 37 invasive) were investigated. VAP was microbiologically confirmed in 23 of 39 (59%) and 23 of 37 (62%) (p = 0.78). There were no differences with regard to the frequencies of community-acquired and potentially drug-resistant microorganisms (PDRM). Antimicrobial treatment was changed in seven patients (18%) of Group 1 and 10 patients (27%) of Group 2 because of etiologic findings (including five of 17 with ICO = 2% (p = not significant [NS]). Length of ICU stay and mechanical ventilation were also not significantly different in both groups. Crude 30-d mortality was 31 of 76 (41%), and 18 of 39 (46%) in Group 1 and 14 of 37 (38%) in Group 2 (p = 0.46). Adjusted mortality was 16% versus 11% (p = 0.53), and mortality of microbiologically confirmed pneumonia 10 of 23 (44%) in both groups (p = 1.0). We conclude that the outcome of VAP was not influenced by the techniques used for microbial investigation.

Aged↗
PubMed2000

Etiology and microbial patterns of pulmonary infiltrates in patients with orthotopic liver transplantation.

STUDY OBJECTIVE: To evaluate the etiology and microbial patterns of pulmonary infiltrates in liver transplant patients using a bronchoscopic diagnostic approach and the impact of diagnostic results on antimicrobial treatment decisions. DESIGN: A prospective cohort study. SETTING: A 1,000-bed tertiary-care university hospital. PATIENTS AND METHODS: Fifty consecutive liver transplant patients with 60 episodes of pulmonary infiltrates (33 episodes during mechanical ventilation) were studied using flexible bronchoscopy with protected specimen brush (PSB) and BAL. RESULTS: A definite infectious etiology was confirmed in 29 episodes (48%). Eighteen episodes corresponded to probable pneumonia (30%), 10 episodes had noninfectious etiologies (17%), and 3 remained undetermined (5%). Opportunistic infections were the most frequent etiology (16/29, 55%, including 1 mixed etiology). Bacterial infections (mainly Gram-negative) accounted for 14 of 29 episodes (48%), including 1 of mixed etiology. The majority of bacterial pneumonia episodes (n = 10, 71%) occurred in period 1 (1 to 28 days posttransplant) during mechanical ventilation, whereas opportunistic episodes were predominant in periods 2 and 3 (29 to 180 days and > 180 days posttransplant, respectively; n = 14, 82%). Microbial treatment was changed according to diagnostic results in 21 episodes (35%). CONCLUSIONS: Microbial patterns in liver transplant patients with pulmonary infiltrates corresponded to nosocomial, mainly Gram-negative bacterial pneumonia in period 1, and to opportunistic infections in period 2 and, to a lesser extent, period 3. A comprehensive diagnostic evaluation including PSB and BAL fluid examination frequently guided specific antimicrobial therapy.

Adolescent↗
PubMed2000

Acute exacerbations in chronic obstructive pulmonary disease (COPD)--microbial patterns and risk factors.

Around 25% of patients with stable chronic obstructive pulmonary disease (COPD) show some evidence of tracheobronchial colonization. It is, however, probable that the vast majority of patients become colonized at some time during the course of the disease. A variety of factors including current smoking and viral infections predispose to bacterial colonization and subsequently acute exacerbations. In fact, infectious aetiologies account for around 50-75% of acute COPD exacerbations. Bacterial pathogens are present in around 50% of patients, Haemophilus influenzae and Streptococcus pneumoniae being the most frequently encountered pathogens. Pseudomonas aeruginosa and probably also Gram-negative enteric bacilli are more frequently found in patients with more severe airflow limitation. Viral infections are present in around 10-20%, with Influenzavirus representing the most frequent viral pathogen. Only recently, evidence for infection by Chlamydia pneumoniae has been found in 5-20% of patients. Predictors of distinct aetiologies have only infrequently been studied so far. Thus, it currently remains difficult to make adequate predictions on clinical grounds in the individual patient. Nevertheless, we would advocate to tentatively stratify the initial antimicrobial treatment according to the severity of the acute exacerbation episode and the presence of individual risk factors. The validation of such an approach may result in significant progress in our understanding of the role of infection and infectious agents in different subgroups of patients with acute exacerbations.

Humans↗
PubMed1999

[Successful treatment of chronic necrotizing pulmonary aspergillosis with oral itraconazole long-term therapy].

HISTORY AND ADMISSION FINDINGS: A 66-year-old man with bullous pulmonary emphysema, was being treated with oral prednisone, had over the previous two month experienced dyspnoea, productive cough and an 8 kg weight loss. Physical examination revealed inspiratory rales over the right middle lobe, with faint vesicular breathing in the other lobes. INVESTIGATIONS: Inflammation parameters were markedly elevated (WBC 24,800/microliter, C-reactive protein 28.6 mg/dl), while the chest radiograph showed liquid infiltrates in the right upper and middle lobes. Despite administration of antibiotics the infiltrates persisted. Aspergillus fumigatus was demonstrated in bronchial secretion. TREATMENT AND COURSE: Antifungal treatment with itraconazole (400 mg/d) was started and resulted in marked subjective improvement, normalization of the inflammation parameters and slow regression of the pulmonary infiltrates. Thoracic computed tomography one year later merely revealed residual post-inflammatory changes. CONCLUSION: An insidious course and treatment-resistant lung infiltrates in patients with steroid treatment should suggest chronic necrotizing pulmonary aspergillosis and this pathogen should be looked for in bronchial secretions. Antifungal treatment with itraconazole is essential and efficacious.

Administration, Oral↗
PubMed1999

Severe community-acquired pneumonia.

Severe CAP is a life-threatening condition defined by the presence of respiratory failure or symptoms of severe sepsis or septic shock. It accounts for approximately 10% of hospitalized patients with CAP. The majority of patients with severe pneumonia have underlying comorbid illnesses, with COPD, alcoholism, chronic heart disease, and diabetes mellitus being the most frequent. S. pneumoniae, Legionella spp, GNEB (especially K. pneumoniae), H. influenzae, S. aureus/spp, Mycoplasma pneumoniae, respiratory viruses (especially influenza viruses), and P. aeruginosa represent the most important causative organisms of severe CAP. Rapid initiation of appropriate antimicrobial treatment is crucial for a favorable outcome. Initial antimicrobial treatment should be based on an epidemiological (empiric) approach. Microbial investigation may be helpful in the individual case but is probably more useful to define local antimicrobial policies based on local epidemiologic and susceptibility patterns. Mortality rates range from 21% to 54%. The most important prognostic factors include general health state of the patient, appropriateness of initial antimicrobial treatment, and the existence of bacteremia, as well as factors reflecting severe respiratory failure, severe sepsis, septic hypotension or shock, and the extent of infiltrates in chest radiograph. Initial antimicrobial treatment should consist of a second (or third) generation cephalosporin and erythromycin. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for distinct pathogens. Promising new approaches of nonantimicrobial treatment, including noninvasive ventilation, treatment of hypoxemia, and immunomodulation, are under investigation.

Adult↗
PubMed1999

Role of glucocorticoids on inflammatory response in nonimmunosuppressed patients with pneumonia: a pilot study.

The aim of the study was to assess the potential role of glucocorticoids (GC) in modulating systemic and pulmonary inflammatory responses in mechanically ventilated patients with severe pneumonia. Twenty mechanically ventilated patients with pneumonia treated at a respiratory intensive care unit (RICU) of a 1,000-bed teaching hospital were prospectively studied. All patients had received prior antimicrobial treatment. Eleven patients received GC (mean+/-SD dose of i.v. methylprednisolone 677+/-508 mg for 9+/-7 days), mainly for bronchial dilatation. Serum and bronchoalveolar lavage fluid (BALF) tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6 and C-reactive protein levels were measured in all patients. The inflammatory response was attenuated in patients receiving GC, both systemically (IL-6 1,089+/-342 versus 630+/-385 pg x mL(-1), p=0.03; C-reactive protein 34+/-5 versus 19+/-5 mg x L(-1), p=0.04) and locally in BALF (TNF-alpha 118+/-50 versus 24+/-5 pg x mL(-1), p= 0.05; neutrophil count: 2.4+/-1.1 x 10(9) cells x L(-1) (93+/-3%) versus 1.9+/-1.8 x 10(9) cells x L(-1) (57+/-16%), p=0.03). Four of the 11 (36%) patients receiving GC died compared to six (67%) who were not receiving GC (p=0.37). The present pilot study suggests that glucocorticoids decrease systemic and lung inflammatory responses in mechanically ventilated patients with severe pneumonia receiving antimicrobial treatment.

Anti-Bacterial Agents↗
PubMed1999

Comparative validation of prognostic rules for community-acquired pneumonia in an elderly population.

The aim of the study was to validate the prediction rule of M.J. Fine and coworkers for clinical outcome variables and three prognostic rules for the individual outcome of community-acquired pneumonia in an elderly population (rule 1: respiratory frequency > or =30 breaths x min(-1), diastolic blood pressure < or =60 mmHg, blood urea nitrogen >7 mM; rule 2: respiratory frequency > or =30 breaths x min(-1), diastolic blood pressure < or =60 mmHg, mental confusion; and rule 3: systolic blood pressure < or =80 mmHg, cardiac frequency > or =90 beats x min(-1), lactate dehydrogenase activity > or =260 IU x L(-1); death was predicted in the presence of at least two of three parameters). Overall 168 consecutive episodes of community-acquired pneumonia in patients aged > or =65 yrs and hospitalized in a primary care hospital were studied prospectively. Fine's rule was tested for its ability to predict length of hospital stay, requirement for intensive care unit (ICU) admission and death. For the three prognostic rules of individual outcome, performance regarding predicting death was determined. Mortality was 17/168 (10%). Fine's rule accurately predicted length of stay, the requirement for ICU admission and the risk of death from pneumonia as compared to the original derivation and validation cohorts. All three rules achieved moderate-to-high specificity (73%, 88% and 80%, respectively) and high negative predictive values (95%, 94% and 93%, respectively) but had a low sensitivity (65%, 47% and 47%, respectively). Rule 2 most closely reflected the risk of death from pneumonia when Fine's classification was used as reference. Fine's rule proved to give valid estimations regarding clinical outcome variables of community-acquired pneumonia in the elderly. The prognostic rules may be useful in determining individual patients at lower risk of death caused by pneumonia.

Aged↗
PubMed1999

Atrial natriuretic peptide levels and pulmonary artery pressure awake, at exercise and asleep in obstructive sleep apnoea syndrome.

Elevated nocturnal plasma atrial natriuretic peptide (ANP) levels were found in patients with obstructive sleep apnoea (OSA). The purpose of our study was to examine the secretion of ANP during the night and to measure changes in oxygen saturation, pulmonary artery pressure and intrathoracic pressure swings in patients with OSA. Moreover, we analysed the secretion of ANP and the pulmonary artery pressure in different behavioural states, e.g. awake, at exercise and asleep. Consecutive apnoeas in non-rapid eye movement (NREM) sleep at the beginning, middle and end of the sleep study were analysed in six patients with obstructive sleep apnoea. In addition, we measured the plasma levels of ANP. The apnoea duration was significantly longer (P< 0.05) at the middle of the sleep study than at the beginning or end. Correspondingly, the end-apnoeic oxygen saturation and end-apnoeic oesophageal pressure were both significantly lower (P< 0.05) in the middle of the sleep study than at the beginning or end. No significant differences were found in the end-apnoeic systolic transmural pulmonary artery pressure (P(PATM)) and the levels of ANP. Evaluation of the ANP levels during different behavioural states revealed that the asleep levels were slightly, but not significantly, higher than the awake levels (0.235+/-0.088 vs. 0.207+/-0.057 nmol/L). However, the highest levels were found during exercise (0.334+/-0.170 nmol/L) with a significant difference compared with the awake and asleep levels. These data suggest that volume effects may be a potent factor in liberating ANP during exercise, but the role of OSA in ANP secretion when asleep is questionable.

Atrial Natriuretic Factor↗
PubMed1999

[Independent radiologic prognostic factors for fatal outcome of ambulatory-acquired pneumonia requiring inpatient treatment].

PURPOSE: To evaluate the independent prognostic impact of the chest radiograph for mortality from community-acquired pneumonia requiring hospitalization. METHODS: Chest radiographs of 67 patients with hospital-treated community-acquired pneumonia were analyzed with regard to the prognostic implications of radiographic patterns, extent and density of infiltrates, and its evolution during treatment. RESULTS: Non-survivors had a significantly higher extent of infiltrates (p = 0.008), density of infiltrates (p = 0.05), and radiographic spread during follow-up within 48-75 hours (p = 0.0001). In multivariate analysis, persistent or progressive infiltrates were associated with a 47-fold increase, and persistent or progressive density of infiltrates with an 18-fold increase in risk of mortality. The presence of both parameters could correctly predict 96% of survivors and 90% of non-survivors. CONCLUSIONS: The chest radiograph is an independent predictor of the severity of pneumonia. Both persistent or progressive infiltrates and persistent or progressive density of infiltrates are independently associated with mortality from community-acquired pneumonia.

Adolescent↗