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T J Marrie

Publications and source records attributed to T J Marrie.

At least 19 recordsLinked to original sources
PubMed2006

Addition of a macrolide to a ss-lactam in bacteremic pneumococcal pneumonia.

In the study presented here, data collected prospectively from 340 adult patients hospitalised in five countries with bacteremic pneumococcal CAP and treated with a ss-lactam +/- a macrolide were analysed retrospectively to evaluate the efficacy of this antimicrobial combination. Univariate and multivariate analyses revealed no significant effect on case fatality rate when a macrolide/ss-lactam regimen was used as initial therapy. Results were not affected by severity of illness, or by excluding patients who died within 2 days of admission. Identified predictors of death in a multivariate regression model were age >65 years (OR=2.6), two or more lung lobes affected (OR=2.2), and severity of disease as estimated using the acute physiology score (APS)>8.

Adult↗
PubMed2004

Therapeutic implications of macrolide resistance in pneumococcal community-acquired lower respiratory tract infections.

Macrolide anti-bacterials are widely used for the empirical treatment of lower respiratory tract infections (RTIs) due to their activity against Streptococcus pneumoniae and other common respiratory pathogens and good safety/tolerability profile. However, the prevalence of macrolide resistance, particularly pneumococcal macrolide resistance, is increasing all around the world. The mechanisms underlying macrolide resistance include efflux pump, methylase activity and, less commonly, ribosomal mutation, which produce differing levels of resistance. Growth in macrolide resistance has been linked to the increased use of these agents, and several risk factors for the development of resistance have been identified. There are emerging data to suggest that in vitro macrolide resistance may increase the likelihood of treatment failure in patients with lower RTIs. However, at present, treatment failure is rare and randomised; intervention-based trials investigating the impact of anti-bacterial resistance on clinical outcomes are lacking. Strategies to promote appropriate use of macrolides and other anti-bacterials are needed, both to maximise therapeutic impact and to minimise the development of resistance. Furthermore, there is a need for alternative anti-bacterial agents which have high efficacy against respiratory pathogens (including resistant strains) and a low potential to induce resistance.

Community-Acquired Infections↗
PubMed2004

Deaths in risk classes I-III: a measure of quality of care in patients hospitalised with CAP?

All deaths occurring in patients with community-acquired pneumonia in risk classes I-III were reviewed as a quality-of-care measure. The immediate and underlying causes of death were classified according to the World Health Organization protocol. Eleven (1.8%) of the 608 low-risk patients died. Three of the patients did not have pneumonia, one of whom was admitted with atypical pulmonary oedema due to stenosis of a prosthetic heart valve. Failure to include chronic lung disease in the severity-of-illness scoring system resulted in misclassification of seven patients. The most common underlying causes of death were pulmonary fibrosis at 27%, chronic obstructive lung disease at 18% and cancer at 27%. Respiratory failure was the immediate cause of death in 64% of patients, cardiac causes in 27%, and pneumonia in 9%. To conclude, the review of deaths in patients at low risk for mortality is useful for monitoring the quality of care received by patients who require admission for the treatment of community-acquired pneumonia, and that the pneumonia-specific severity-of-illness scoring system results in misclassification of patients with chronic obstructive lung disease and pulmonary fibrosis.

Adult↗
PubMed2003

Variation in management of community-acquired pneumonia requiring admission to Alberta, Canada hospitals.

Previous studies have shown small area variation in the rate of admission to hospital for patients with community-acquired pneumonia. We determined the rates of admission and length of stay for patients with community-acquired pneumonia in Alberta and the factors influencing admission rates and length of stay. Using hospital abstracts, hospital admissions for community-acquired pneumonia from 1 April 1994 to 31 March 1999 were compared. We classified Alberta hospitals according to geographical regions, by the number of beds, and by number of community-acquired pneumonia cases. There were 12,000 annual hospital discharges for community-acquired pneumonia costing over $40 million per year. The overall in-hospital mortality rate was 12% and the 1 year mortality rate was 26%. Compared with rural hospitals, regional and metropolitan hospitals admitted patients with greater severity of illness as demonstrated by greater in-hospital mortality, cost per case and comorbidity. Age-sex adjusted hospital discharge rates were significantly below the provincial average in both urban regions. Hospital discharge rates for residents in all rural regions and 4 of 5 regions with a regional hospital were significantly higher than the provincial average. After adjusting for comorbidity, the relative risk for a longer length of stay was 22% greater in regional hospitals and about 30% greater in urban hospitals compared to rural hospitals. Seasonal variation in the admission rate was evident, with higher rates in the winter of each year. We conclude that rural hospitals would be likely to benefit from a protocol to help with the admission decision and urban hospitals from a programme to reduce length of stay.

Adolescent↗
PubMed2003

Utility of blood cultures in the management of adults with community acquired pneumonia discharged from the emergency department.

STUDY OBJECTIVE: To assess the clinical value of blood cultures (BCs) in the management of adult patients discharged from the emergency department (ED) with a diagnosis of community acquired pneumonia (CAP). METHODS: The courses of antibiotic regimens and outcomes of patients with positive BC results were examined to assess their influence on BCs. RESULTS: BCs were obtained from 289 outpatients. Six clinically significant organisms were identified (a yield of 2.1%). Outpatients with CAP who had blood cultures performed had a 0.69% (2 of 289) chance of having a change of treatment directed by the results of the culture. CONCLUSION: BCs have little utility in the ambulatory management of CAP.

Adult↗
PubMed2003

Chlamydia species as a cause of community-acquired pneumonia in Canada.

Chlamydia pneumoniae has been implicated as a cause of community-acquired pneumonia (CAP) in several studies. However, there has been no comprehensive study of the role of Chlamydia species (C. pneumoniae, C. psittaci (avian and feline strains) and C. pecorum) as a cause of CAP. The aim of the present study was to determine the role of C. pneumoniae, C. psittaci and C. pecorum as causes of CAP. A prospective cohort observational study of CAP was conducted at 15 teaching centres in eight Canadian provinces between January 1996-October 1997. Acute (n=539) and convalescent (n=272) serum samples were obtained for determination of antibody titres to C. pneumoniae, C. psittaci, C. pecorum, C. trachomatis, Mycoplasma pneumoniae, Legionella pneumophila serogroups I-VI, Streptococcus pneumoniae and various respiratory viruses. Twelve of 539 (2.2%) patients had acute C. pneumoniae pneumonia and an additional 32 (5.9%) had possible acute infection. C. pneumoniae was the sole pathogen in 16 of 42 (38.1%) of these patients. The most common copathogens were S. pneumoniae, respiratory syncytial virus and influenza virus type A. C. pneumoniae pneumonia patients were older and more likely to show congestive heart failure compared to bacteraemic S. pneumoniae patients. The latter had a lower mean diastolic blood pressure, a higher white blood cell count and a lower arterial carbon dioxide tension. Two patients had antibody titres suggestive of recent infection with the feline strain of C. psittaci. Although numerically Chlamydia pneumoniae is an important cause of community-acquired pneumonia, no distinctive clinical features associated with this pathogen were detected in the present study. Feline Chlamydia psittaci may cause a few cases of community-acquired pneumonia. Avian Chlamydia psittaci should be considered only if there is a compatible epidemiological history.

Adolescent↗
PubMed2003

Coxiella burnetii pneumonia.

This report reviews the pulmonary and extrapulmonary manifestation of infections due to Coxiella burnetii. Q fever, a zoonosis, is due to infection with C. burnetii. This spore-forming microorganism is a small gram-negative coccobacillus that is an obligate intracellular parasite. The most common animal reservoirs are goats, cattle, sheep, cats, and occasionally dogs. The organism reaches high concentrations in the placenta of infected animals. Aerosolisation occurs at the time of parturition and infection follows inhalation of this aerosol. There are three distinct clinical syndromes of the acute form of the illness: nonspecific febrile illness, pneumonia, and hepatitis. The chronic form of Q fever is almost always endocarditis, but occasionally it is manifest as hepatitis, osteomyelitis or endovascular infection. The pneumonic form of the illness can range from very mild-to-severe pneumonia requiring assisted ventilation. Multiple round opacities are a common finding on chest radiography. Treatment with doxycycline or a fluoroquinolone is preferred. Susceptibility to macrolides is variable. In conclusion, Coxiella burnetii pneumonia should be considered when there is a suitable exposure history and when outbreaks of a pneumonic illness are being investigated.

Anti-Bacterial Agents↗
PubMed2003

Mortality during hospitalisation for pneumonia in Alberta, Canada, is associated with physician volume.

The association of mortality with patient factors (severity of illness, comorbidity), physician factors (specialty training, prehospitalisation visit, in-hospital consultation, volume of patients seen per physician) and healthcare organisation factors (patient-travel distances, regional beds per capita, admitting hospital-bed occupancy, admitting hospital-bed turnover, hospital location, volume of pneumonia cases per hospital) after hospital admission with community-acquired pneumonia was investigated using administrative data from Alberta, Canada from April 1, 1994-March 31, 1999. During the 5-yr study period there were 43,642 pneumonia hospitalisations, with an 11% in-hospital and 26% 1-yr mortality. Patient severity of illness and comorbidity were the strongest predictors of increased mortality. Physicians with the highest in-hospital pneumonia patient volume (>27 patients x yr(-1)) cared for patients with greater severity/comorbidity, but with decreased odds of in-hospital mortality, compared with the lowest volume physicians (less than seven patients per year). The effects of internal medicine specialist or subspecialist care were mixed, with a reduction in deaths for the first 72 h and an increase in in-hospital deaths. Prehospitalisation visit by a physician was associated with decreased mortality. Healthcare organisation factors were the least strong predictor of mortality, demonstrating an effect only for 1-yr mortality in those discharged alive from hospital. Admissions to larger volume or metropolitan hospitals were associated with a decrease in mortality. Severity of illness and comorbidity had the strongest association with mortality. The first association of high-volume physician and pre-hospital care with decreased in-hospital mortality for community-acquired pneumonia is reported.

Adolescent↗
PubMed2003

The effect of C. burnetii infection on the quality of life of patients following an outbreak of Q fever.

Sixty-six cases of Q fever were diagnosed in people affiliated with a goat-farming co-operative in rural Newfoundland in the spring of 1999. Follow-up studies which included administration of the Short Form 36 Health Survey (SF-36) were conducted 3 and 27 months after the initial outbreak to prospectively follow the effects of acute Q fever on the quality of life of the participants. Twenty-seven months after the outbreak 51% of those who had Q fever reported persistent symptoms including seven participants whose symptoms had initially resolved 3 months after the outbreak. Individuals with Q fever had significantly lower scores on five of the eight scales in the SF-36 and lower scores in the mental and physical summary scales compared to uninfected controls. Although this supports the hypothesis of a 'post Q fever fatigue syndrome' (QFFS), further study is warranted.

Case-Control Studies↗
PubMed2001

Atypical manifestations of chronic Q fever.

Chronic Q fever is uncommon, with the majority of cases manifesting as culture-negative endocarditis. In this report, we describe 3 patients who present with atypical manifestations of chronic Q fever. These were a 43-year-old man whose site of chronic Q fever was the central nervous system, a 53-year-old woman who underwent coronary angioplasty 6 days before the onset of symptoms of acute Q fever and within 4 months had serologic evidence consistent with chronic Q fever, and a 66-year-old man with fever of unknown origin, a pancreatic mass, and aorto-bifemoral grafts.

Adult↗
PubMed2001

Rickettsia africae, a tick-borne pathogen in travelers to sub-Saharan Africa.

BACKGROUND: African tick-bite fever occurs after contact with ticks that carry Rickettsia africae and that parasitize cattle and game. Sporadic reports suggest that this infection has specific clinical and epidemiologic features. METHODS: We studied patients who were tested for a rickettsial disease after returning from a visit to Africa or Guadeloupe. To assess the value of the microimmunofluorescence assay, Western blotting, and cross-adsorption assays, we compared the results of these tests in 39 patients in whom African tick-bite fever had been confirmed by the polymerase-chain reaction assay, cell culture, or both; 50 patients with documented R. conorii infection; and 50 blood donors. These diagnostic criteria were then applied to 376 additional patients who had returned from southern Africa and 2 who had returned from Guadeloupe and whose serum was being tested for rickettsial disease. RESULTS: In the 39 patients with direct evidence of R. africae infection, the combination of microimmunofluorescence assay, Western blotting, and cross-adsorption assays showing antibodies specific for R. africae had a sensitivity of 0.56; however, each test had a positive predictive value and a specificity of 1.0. An additional 80 patients were found to have an R. africae infection on the basis of these serologic criteria. Infections with R. africae were acquired by visitors to 11 African countries and Guadeloupe. The illness was generally mild and was characterized by a rash in 46 percent of the patients; the rash was usually maculopapular or vesicular and rarely purpuric. Ninety-five percent of patients had an inoculation eschar or eschars, and 54 percent of these patients had multiple eschars, a finding that is unusual in patients with rickettsial infection. CONCLUSIONS: In this series, R. africae was the cause of nearly all cases of tick-bite rickettsiosis in patients who became ill after a trip to sub-Saharan Africa.

Adolescent↗
PubMed2001

Effectiveness of levofloxacin for adult community-acquired pneumonia caused by macrolide-resistant Streptococcus pneumoniae: integrated results from four open-label, multicenter, phase III clinical trials.

BACKGROUND: The rate of macrolide resistance among Streptococcus pneumoniae clinical isolates is rising. Coresistance to several unrelated classes of antimicrobial agents is common and may limit the treatment options available for the management of infections caused by this pathogen. Although the fluoroquinolones appear to retain activity against macrolide-resistant pneumococci, limited clinical data exist to support their use in this setting. OBJECTIVE: This study integrated data from 4 clinical trials to determine whether the fluoroquinolone levofloxacin is an effective therapeutic agent for community-acquired pneumonia (CAP) caused by macrolide-resistant S. pneumoniae. METHODS: Across the 4 trials, 271 adult patients with CAP were diagnosed with infections caused by S. pneumoniae; these constituted the intent-to-treat population. Clinical isolates obtained from each patient at admission were tested using broth microdilution for in vitro sensitivity to the macrolide erythromycin (minimum inhibitory concentration breakpoints: susceptible, < or =0.25 microg/mL; intermediate, 0.5 microg/mL; resistant, > or =1.0 microg/mL). All patients received levofloxacin (500 mg once daily for 7-14 days) and were analyzed at a posttherapy visit (2-5 days after completion of therapy) for clinical and microbiologic outcomes; in 3 trials, patients were also examined at a poststudy visit (14-28 days after completion of treatment). Clinical and microbiologic outcomes were analyzed in patients infected with macrolide-resistant and macrolide-susceptible S. pneumoniae. RESULTS: A total of 235 evaluable patients infected with S. pneumoniae were identified from the 4 trials. Twenty-seven (11.5%) patients were infected with isolates resistant to erythromycin, of whom 26 (96.3%) were clinical successes. By comparison, the clinical success rate in patients infected with erythromycin-susceptible isolates was 97.7%. CONCLUSIONS: These results suggest that if future studies demonstrate the clinical relevance of macrolide resistance, levofloxacin may be a useful therapeutic option in patients with CAP caused by macrolide-resistant S. pneumoniae. However, caution may be warranted to prevent overprescription of levofloxacin and other fluoroquinolones, given the potential for the development of resistance in S. pneumoniae.

Anti-Bacterial Agents↗
PubMed2001

Arterial blood gas and pulse oximetry in initial management of patients with community-acquired pneumonia.

OBJECTIVE: To identify the factors associated with the use of arterial blood gas (ABG) and pulse oximetry (PO) in the initial management of patients with community-acquired pneumonia (CAP) and arterial hypoxemia at presentation. PARTICIPANTS: A total of 944 outpatients and 1,332 inpatients with clinical and radiographic evidence of CAP prospectively enrolled from 5 study sites in the United States and Canada. ANALYSES: Separate multivariate logistic regression analyses were used to 1) compare measurement of ABG and PO within 48 hours of presentation across sites while controlling for patient differences, and 2) identify factors associated with arterial hypoxemia (PaO2 <60 mm Hg or SaO2 <90% for non-African Americans and <92% for African Americans) while breathing room air. RESULTS: Range of ABG use by site was from 0% to 6.4% (P =.06) for outpatients and from 49.2% to 77.3% for inpatients (P <.001), while PO use ranged from 9.4% to 57.8% for outpatients (P <.001) and from 47.9% to 85.1% for inpatients (P <.001). Differences among sites remained after controlling for patient demographic characteristics, comorbidity, and illness severity. In patients with 1 or more measurements of oxygenation at presentation, hypoxemia was independently associated with 6 risk factors: age >30 years (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7 to 5.9), chronic obstructive pulmonary disease (OR, 1.9; 95% CI, 1.4 to 2.6), congestive heart failure (OR, 1.5; 95% CI, 1.0 to 2.1), respiratory rate >24 per minute (OR, 2.3; 95% CI, 1.8 to 3.0), altered mental status (OR, 1.6; 95% CI, 1.1 to 2.3), and chest radiographic infiltrate involving >1 lobe (OR, 2.2; 95% CI, 1.7 to 2.9). The prevalence of hypoxemia among those tested ranged from 13% for inpatients with no risk factors to 54.6% for inpatients with > or =3 risk factors. Of the 210 outpatients who had > or =2 of these risk factors, only 64 (30.5%) had either an ABG or PO performed. In the 48 outpatients tested without supplemental O2 with > or =2 risk factors 8.3% were hypoxemic. CONCLUSIONS: In the initial management of CAP, use of ABG and PO varied widely across sites. Increasing the assessment of arterial oxygenation among patients with CAP is likely to increase the detection of arterial hypoxemia, particularly among outpatients.

Adult↗
PubMed2000

Pseudomonas aeruginosa community-acquired pneumonia in previously healthy adults: case report and review of the literature.

We report a case of rapidly fatal Pseudomonas aeruginosa community-acquired pneumonia (CAP) in a previously healthy 67-year-old woman. Eleven published case reports of P. aeruginosa CAP in previously healthy adults are reviewed. According to our review, the mean age of affected patients is 45.3 years. Five patients described in the literature were smokers with a mean smoking history of 40 pack-years. The clinical presentation is nonspecific, and although the pneumonia can be rapidly fatal, only 33% of the patients who were reported died. However, mortality may be independent of treatment within the first 36 hours of presentation. Exposure to aerosols of contaminated water is a risk factor for P. aeruginosa CAP in this population. Pseudomonas CAP should be considered in the differential diagnosis for anyone with a smoking history who presents with rapidly progressive pneumonia. We discuss treatment recommendations that are based on evidence in the currently available literature on the subject.

Adult↗