RESUMEN
BACKGROUND: Ventilator-associated pneumonia (VAP) is diagnosed in about 30% to 50% of critically ill postsurgical and trauma patients. Early appropriate antibiotic therapy has been associated with improved survival rates. The diagnosis, however, continues to be a challenge. We routinely employ clinical pulmonary infection scores to warrant a bronchoalveolar lavage (BAL) quantitative culture to subsequently diagnose VAP. Presumptive antibiotic therapy for the first 48 to 72 hours is based on the sputum Gram stain, obtained at the time of BAL. This study was conducted to analyze the predictive value of sputum Gram stain for selecting appropriate early antibiotic therapy for VAP as confirmed by a BAL quantitative culture (>10 CFU/mL considered diagnostic). METHODS: The retrospective analysis included 124 consecutive intensive care unit patients with 186 identified episodes of presumed VAP from December 2002 to June 2006. VAP episodes were identified by a clinical pulmonary infection score > or =6, availability of a sputum Gram stain, and a corresponding quantitative culture result from a BAL sample. RESULTS: The overall correlation between Gram stain and subsequent organism identified on the BAL quantitative culture was only fair with a kappa score of 0.314. The best predictive value calculated was for the category of negative Gram stain. However, in 10 of 45 episodes where the sputum Gram stain did not identify a predominant organism, the BAL culture isolated pathogenic strains. Pseudomonas sp. was the most common bacteria isolated from the BAL samples. CONCLUSIONS: Irrespective of sputum Gram stain, presumptive triple antibiotic coverage should be instituted to provide dual antibiotic coverage for gram-negative bacilli, and vancomycin for gram-positive cocci. Additionally, identification of no organisms in the sputum Gram stain should still prompt broad-spectrum antibiotic coverage until the final results of the BAL quantitative culture are available.
Asunto(s)
Antibacterianos/uso terapéutico , Neumonía Asociada al Ventilador/tratamiento farmacológico , Neumonía Asociada al Ventilador/microbiología , Esputo/microbiología , Líquido del Lavado Bronquioalveolar/microbiología , Femenino , Violeta de Genciana , Humanos , Unidades de Cuidados Intensivos , Masculino , Fenazinas , Valor Predictivo de las Pruebas , Estudios RetrospectivosRESUMEN
OBJECTIVE: To test the hypothesis that alveolar plasminogen activator inhibitor-1 (PAI-1) can identify patients with witnessed aspiration at risk for progression to acute respiratory distress syndrome (ARDS). DESIGN: Prospective observational study. SETTING: Medical intensive care unit in a tertiary care center. PATIENTS: Fifty-one patients with witnessed aspiration who had a PaO2/FIO2<300 for a period no less than 4 h from admission. INTERVENTIONS: Alveolar fluid sampling was performed within 8 h of intubation via luminal suction of the distal airways using a 13-Fr catheter. Plasma levels were collected simultaneously by venipuncture. MEASUREMENTS AND RESULTS: Alveolar PAI-1 antigen levels were more than five times higher in those who progressed to ARDS than in those with uncomplicated aspiration pneumonitis (2687+/-1498 ng/ml vs. 587+/-535 ng/ml, respectively; p<0.001), while plasma levels of PAI-1 antigen were not significantly different between the two groups. The measured activity of PAI-1 antigen paralleled the levels observed in both media. A cut-off level of alveolar PAI-1 >1518 ng/ml was found to be 82.4% (56.6%-96.0%) sensitive and 97.1% (84.6%-99.5%) specific in predicting progression to ARDS. There was also a significant inverse relationship between elevation of PAI-1 antigen levels and the degree of lung injury as assessed by the days of unassisted ventilation (r2=0.37; p<0.001). CONCLUSIONS: Elevation of alveolar PAI-1 antigen levels postaspiration is the consequence of local rather than systemic activation of the fibrinolytic system. Measurement of alveolar PAI-1 antigen levels can be a useful clinical marker in predicting progression to ARDS after gastric aspiration.
Asunto(s)
Inhibidor 1 de Activador Plasminogénico/metabolismo , Neumonía por Aspiración/diagnóstico , Alveolos Pulmonares/metabolismo , Síndrome de Dificultad Respiratoria/prevención & control , Adulto , Biomarcadores/metabolismo , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Masculino , Inhibidor 1 de Activador Plasminogénico/inmunología , Neumonía por Aspiración/metabolismo , Estudios Prospectivos , Curva ROC , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: To assess the long-term prognosis of older patients with idiopathic exudative lymphocytic pleural effusion. DESIGN: Prospective observational study. SETTING: A university-affiliated tertiary care center. PARTICIPANTS: Forty-seven consecutive patients (aged 74.9+/-5.4) with idiopathic exudative lymphocytic pleural effusion were enrolled over a 42-month period. MEASUREMENTS: Baseline sociodemographic information, clinical data, and Charlson Comorbidity Index score were obtained. After an exhaustive examination, clinical evaluation and periodic chest radiographs were taken until one of the endpoints was met: complete resolution of the pleural effusion, death from all causes, or the end of the study period. RESULTS: The mean follow-up period was 16.3+/-17.0 months. During the course of the study, complete resolution of the pleural effusion occurred in 17% of the patients, whereas it remained stable in 45%, and progressed in 38%. In seven cases, the cause of the effusion was established after an average of 84 days, and in another two, the diagnosis was made postmortem. Malignancy was documented in eight of the nine cases. Although the burden of comorbidities and cardiac function at baseline were similar in the three categories, the 3-year survival rate was 63%, 5%, and 0%, respectively. None of the patients developed active tuberculosis, although 15% had positive tuberculin test. CONCLUSION: By categorizing the presence of idiopathic effusion into resolving, persistent, or progressive, this study may provide a more practical approach to the long-term prognosis of older patients with idiopathic exudative lymphocytic effusion who refuse or are considered too frail to undergo an invasive procedure.
Asunto(s)
Linfocitosis/mortalidad , Derrame Pleural Maligno/mortalidad , Derrame Pleural/mortalidad , Adenosina Desaminasa/metabolismo , Anciano , Anciano de 80 o más Años , Proteínas Sanguíneas/metabolismo , Causas de Muerte , Progresión de la Enfermedad , Femenino , Humanos , L-Lactato Deshidrogenasa/metabolismo , Estudios Longitudinales , Recuento de Linfocitos , Linfocitosis/diagnóstico por imagen , Linfocitosis/enzimología , Linfocitosis/etiología , Masculino , Grupo de Atención al Paciente , Derrame Pleural/diagnóstico por imagen , Derrame Pleural/enzimología , Derrame Pleural/etiología , Derrame Pleural Maligno/diagnóstico por imagen , Derrame Pleural Maligno/enzimología , Derrame Pleural Maligno/etiología , Estudios Prospectivos , Radiografía , Remisión Espontánea , Análisis de Supervivencia , Tasa de SupervivenciaRESUMEN
STUDY OBJECTIVES: Poor dental hygiene has been linked to respiratory pathogen colonization in residents of long-term care facilities. We sought to investigate the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping. METHODS: We assessed the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment. Plaque index scores and quantitative cultures of DPs were obtained on ICU admission. Protected BAL (PBAL) was performed on 14 patients who developed hospital-acquired pneumonia (HAP). Respiratory pathogens recovered from the PBAL fluid were compared genetically to those isolated from DPs by pulsed-field gel electrophoresis. MEASUREMENTS AND RESULTS: Twenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens. Staphylococcus aureus (45%) accounted for the majority of the isolates, followed by enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%). The etiology of HAP was documented in 10 patients. Of the 13 isolates recovered from PBAL fluid, nine respiratory pathogens matched genetically those recovered from the corresponding DPs of eight patients. CONCLUSIONS: These findings suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population.
Asunto(s)
Bacterias/aislamiento & purificación , Infección Hospitalaria/microbiología , Placa Dental/complicaciones , Placa Dental/microbiología , Neumonía Bacteriana/microbiología , Anciano , Anciano de 80 o más Años , Infección Hospitalaria/epidemiología , Placa Dental/epidemiología , Femenino , Humanos , Institucionalización , Masculino , Neumonía Bacteriana/epidemiología , Prevalencia , Estudios ProspectivosRESUMEN
BACKGROUND: Knowledge of the determinant factors responsible for the presence of antimicrobial-resistant pathogens in severe nursing home-acquired pneumonia (NHAP) is deemed essential for antibiotic selection. METHODS: Data for institutionalized patients with cases of severe pneumonia confirmed by culture of protected bronchoalveolar lavage fluid samples (> or =10(3) cfu/mL) during a 36-month period were analyzed. A classification tree with a sensitivity of 100% was developed using binary recursive partitioning to predict which patients are unlikely to have drug-resistant pathogen (DRP)-related pneumonia. RESULTS: Of the 88 patients who satisfied the inclusion criteria, 17 had at least 1 DRP recovered from the lower respiratory tract. The predictor variables were the Activity of Daily Living score and previous use of antibiotics. Prospective application of the model in 47 patients over a 24-month period yielded a sensitivity of 100% (95% confidence interval [CI], 71.3%-100%) and a specificity of 69.4% (95% CI, 51.9%-83.6%). CONCLUSIONS: The use of the tree may provide a more rational basis for selecting initial therapy for severe NHAP after it is validated in a large prospective study.
Asunto(s)
Farmacorresistencia Bacteriana , Hogares para Ancianos , Casas de Salud , Neumonía Bacteriana/epidemiología , Anciano , Anciano de 80 o más Años , Antibacterianos/metabolismo , Antibacterianos/uso terapéutico , Bacterias/crecimiento & desarrollo , Líquido del Lavado Bronquioalveolar/microbiología , Estudios de Cohortes , Comorbilidad , Bases de Datos Factuales , Femenino , Bacterias Gramnegativas/aislamiento & purificación , Hospitales Universitarios , Humanos , Klebsiella/aislamiento & purificación , Infecciones por Klebsiella/diagnóstico por imagen , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/enzimología , Masculino , Neumonía Bacteriana/diagnóstico por imagen , Estudios Prospectivos , RadiografíaRESUMEN
OBJECTIVE: To determine the homeostatic balance of patients with ventilator-associated pneumonia (VAP) with respect to the adequacy of antimicrobial therapy. DESIGN AND SETTING: Descriptive observational study in a 12-bed medical intensive care unit in a university-affiliated hospital. PATIENTS: Twenty-nine patients with VAP documented by quantitative culture of bronchoalveolar secretions and a control group of eight mechanically ventilated patients. METHODS: Serial bronchoalveolar lavage fluid (BALF) samples were assayed for prothrombin activation fragment (F1+2), thrombin-antithrombin (TAT) complex, fibrinolytic activity, urokinase-type plasminogen activator (u-PA), and plasminogen activator inhibitor type 1 (PAI-1) on days 1, 4, and 7 after VAP onset. RESULTS: Pathogens isolated from patients with inadequate empirical antimicrobial coverage included methicillin-resistant Staphylococcus aureus (n=2), Pseudomonas aeruginosa (n=4), and Acinetobacter baumannii (n=1). Compared to those who received adequate antibiotic therapy, TAT, F1+2, and PAI-1 levels increased while u-PA levels remained unchanged. Despite antibiotic adjustment on day 4, TAT levels remained elevated in those who lacked adequate antimicrobial coverage and were significantly correlated with PaO(2)/FIO(2). The procoagulant activity was accompanied by a local depression of fibrinolytic capacity that was attributed mainly to increased BALF PAI-1 levels. Nonsurvivors showed significantly higher levels of TAT and PAI-1 than survivors. No significant correlation between the bacterial burden and the homeostatic derangements was documented. CONCLUSIONS: The lung inflammatory response seems to promulgate a local procoagulant activity associated with hypoxemia in those with inadequate antibiotic therapy. The homeostatic derangement seems to be independent of the lung bacterial burden.
Asunto(s)
Antibacterianos/administración & dosificación , Infección Hospitalaria/tratamiento farmacológico , Utilización de Medicamentos/normas , Hemostasis/efectos de los fármacos , Neumonía/tratamiento farmacológico , Ventiladores Mecánicos/efectos adversos , Anciano , Antibacterianos/sangre , Antibacterianos/uso terapéutico , Coagulación Sanguínea/efectos de los fármacos , Infección Hospitalaria/sangre , Infección Hospitalaria/etiología , Infección Hospitalaria/microbiología , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Neumonía/sangre , Neumonía/etiología , Pronóstico , Estudios Prospectivos , Resultado del Tratamiento , Ventiladores Mecánicos/microbiologíaRESUMEN
To determine the causes, risk factors and complications of planned extubation failure of critically ill elderly patients, we conducted a prospective study of 175 consecutive patients (> or = 70 years old) admitted with respiratory failure. Thirty-six (21%) failed extubation within 72 h after planned extubation. Compared to a younger age group (< 70 years old) matched for severity of illness, inability to handle secretions (20%) was the most common reason of airway causes leading to extubation failure in the elderly while upper airway obstruction (22%) was the predominant cause in the control group. As for nonairway causes, COPD related hypercapnic respiratory failure accounted for the majority of cases in both groups. After adjusting for severity of illness, elderly patients who required reintubation had a higher risk of developing nosocomial pneumonia. The presence of underlying pulmonary disease (odds ratio (OR), 2.9; 95% confidence interval (CI) 1.2-6.9), length of intubation > 4 days (OR, 4.3; 95% CI 1.8-10.2), and albumin levels < 2.5 g/dl (OR, 2.7; 95% CI 1.2-6.7) were independently associated with extubation failure in the old. Objective measurements of cough strength and secretion volume are needed to reduce the morbidity of elderly patients at risk for extubation failure.