RESUMO
OBJECTIVE: To determine the cause of unexplained postoperative adult respiratory distress syndrome (ARDS). DESIGN: Case-control study of postoperative ARDS. SETTING: Intensive care unit (ICU) of a Veterans Affairs hospital. PATIENTS: Six postoperative patients recovering from uncomplicated vascular or cardiothoracic surgery developed unexplained ARDS. Controls were 17 patients having similar procedures without the development of ARDS. INTERVENTION: Infusion of fentanyl with a tamper-proof device. MEASUREMENTS AND MAIN RESULTS: Development of ARDS. ARDS began 1 to 4 days after surgery, was characterized by maximum alveolar-arterial oxygen gradient that ranged from 232 to 544 torr (30.9 to 72.5 kPa), and was associated with death of two patients. We observed no association with patient location before ARDS onset, nonanalgesic medication administered, staff assignment, or mode of respiratory therapy. All six patients who developed unexplained ARDS had received epidural fentanyl compared with none of 17 control patients without ARDS (p = .0002). We instituted a tamper-proof mode of parenteral fentanyl administration, and subsequently observed one case of ARDS in 26 consecutive surgical patients (p = .000014). CONCLUSIONS: Based on these findings, as well as a prior history of fentanyl theft at our institution, we conclude that tampering with fentanyl infusate was responsible for the ARDS epidemic that we observed.
Assuntos
Crime , Fentanila/administração & dosagem , Complicações Pós-Operatórias/etiologia , Síndrome do Desconforto Respiratório/etiologia , Idoso , Estudos de Casos e Controles , Cuidados Críticos , Contaminação de Medicamentos , Métodos Epidemiológicos , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Unidades de Terapia Intensiva , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Síndrome do Desconforto Respiratório/epidemiologia , Fatores de RiscoRESUMO
OBJECTIVES: To elucidate the epidemiology of widespread ciprofloxacin resistance in our Veterans Affairs medical center using whole cell DNA analysis. DESIGN: In vitro study of ciprofloxacin resistant and susceptible Enterobacteriaceae isolated during the course of a clinical epidemiologic study of quinolone resistance. SETTING: Veterans Affairs Medical Center with acute care and long-term care divisions. RESULTS: We examined 40 ciprofloxacin-resistant strains of Serratia marcescens, Proteus mirabilis, and Providencia stuartii using restriction endonuclease analysis of whole cell DNA and compared them with concomitantly isolated ciprofloxacin sensitive strains. We sought to determine whether resistant strains were identical to susceptible strains, indicating in vivo emergence of resistant strains from susceptible strains, and whether resistant strains were shared among patients. All 26 ciprofloxacin-resistant S marcescens isolates shared a single ecoRI restriction pattern. Multiple patterns were seen in the ciprofloxacin-susceptible S marcescens isolates; however, several isolates had a pattern matching that of the resistant isolates. Similar results were seen among the P mirabilis isolates. Three different ecoRI patterns were found among the ciprofloxacin-resistant P stuartii isolates; none matched those found among the susceptible isolates. The frequency of spontaneous emergence of ciprofloxacin resistance in susceptible S marcescens strains with restriction pattern matching that of the resistant strains was significantly higher than that of nonmatching strains. CONCLUSIONS: Ciprofloxacin-resistant strains of Enterobacteriaceae became widespread within a short period of time. Resistant strains of S marcescens and P mirabilis arose from endemic susceptible strains. The resistant strain of S marcescens appeared to arise from a susceptible strain with a relatively high frequency of spontaneous ciprofloxacin resistance.
Assuntos
Ciprofloxacina/farmacologia , DNA Bacteriano/genética , Enterobacteriaceae/efeitos dos fármacos , Estudos de Casos e Controles , Enzimas de Restrição do DNA/genética , Resistência Microbiana a Medicamentos , Enterobacteriaceae/genética , Hospitais de Veteranos , Humanos , Testes de Sensibilidade Microbiana , Serratia marcescens/efeitos dos fármacos , Serratia marcescens/genéticaRESUMO
Legionellae are ubiquitous aquatic organisms. They are unique among the agents commonly responsible for bacterial pneumonia in humans in that they are not part of the normal human flora but are acquired from environmental sources. Prospective studies have shown that legionellae consistently rank among the top three bacteria as etiologic agents of community-acquired pneumonia. The clinical presentation of Legionnaires' disease is not distinguishable from that of other bacterial pneumonias. Culture of respiratory secretions using selective media, combined with one or more rapid diagnostic methods (direct fluorescent antibody staining, radiolabelled DNA probe, or urinary antigen detection) provides a specific diagnosis in the vast majority of cases. Sporadic cases have been linked to legionella colonization of water systems in homes and the work setting. Antibiotics commonly used in the therapy of community-acquired pneumonias, such as beta-lactam agents, are ineffective. Specific therapy with erythromycin reduces mortality to less than 10%.