Risk Factors for Breakthrough Pneumocystis carinii Pneumonia on Aerosol Pentamidine Prophylaxis

OBJECTIVE: To identify baseline characteristics of human immunodeficiency virus (HIV)-infected individuals on aerosol pentamidine for Pneumocystis carinii prophylaxis that are predictive of subsequent breakthrough Pneumocystis carinii pneumonia (PCP).DESIGN: Nested case-control study assembled from a cohort of patients enrolled in the Toronto aerosol pentamidine program.METHODS: Subjects were selected from a cohort of HIV-infected individuals were enrolled in a community based aerosol pentamidine program between May 1989 and May 1992 in Toronto, Ontario. Cases - individuals who had breakthrough PCP - were matched with up to two controls enrolled in the same week. Risk factors examined for development of PCP for both primary and secondary prophylaxisincluded age, sex, smoking history, evidence of bronchospasm during aerosol pentamidine administration (fall of forced expiratory volume [FEV] 15% or more), administration of salbutamol before aerosol pentamidine, pulmonary function tests including lung volumes, flow rates and diffusing capacity for carbon monoxide. In the primary prophylaxis group, CD4 count at enrolment and in the secondary prophylaxis group, time from the most recent episode of PCP to enrolment for aerosol pentamidine and total time from the most recent episode of PCP to breakthrough PCP were examined as additional risk factors.RESULTS: A total or 1344 patients we re enrolled in the aerosol pentamidine program, 78% for primary prophylaxis and 22% for secondary prophylaxis. At the time of census at the end or 1992 there had been 96 episodes or breakthrough PCP, 5% on primary prophylaxis and 14.5% on secondary prophylaxis. In the primary prophylaxis group, enrolment CD4 count was significantly lower in the cases developing breakthrough PCP: 116±74 compared with 175±85 cells/mm3 in the control group (P=0.001). There was no difference in any other variable. In the secondaryprophylaxis group, time from the most recent episode of PCP to initiation of aerosol pentamidine therapy was longer in the cases developing breakthrough PCP: mean delay 6.1±6.6 months compared with 3.1±2.1 in controls (P=0.02). There was no difference in the other variables examined.CONCLUSIONS: The results of this study support immune augmentation for patients receiving aerosol pentamidine for primary prophylaxis, and aerosol pentamidine should be recommenced as soon as possible following an episode of PCP, for secondary prophylaxis.Peer Reviewe

Interim Report on Drug Utilization Review of Community Acquired, Nursing Home Acquired and Nosocomial Pneumonia: Clinical, Bacteriological and Radiological Spectrum

OBJECTIVES: To review the epidemiology of community acquired, nursing home acquired and nosocomial pneumonia in terms of clinical. bacteriological and radiological features and to examine the spectrum of and response to antimicrobial agents used in its management.DESIGN: A retrospective review of all hospital records with pneumonia coded in the discharge diagnoses over a five-year period from April 1987 to March 1993.SETTING: University-affiliated, community-based hospital with a mixed primary to tertiary referral base.PATIENT SELECTION: Patients included in the study were all patients with a diagnosis of pneumonia as identified by computer records of diagnostic codes of all discharges: patients with a specific diagnosis of Pneumocystis carinii pneumonia were excluded. One thousand seven hundred and eighty-two patients out of 74.435 discharges over the five-year period met the inclusion criteria.RESULTS: The initial 1300 of the 1782 cases of pneumonia are included in this interim report. Mean age was 65 years (range 16 to 103) wilh 60% men and 40% women. Sixty-two percent of all cases were community acquired, 29% were hospital acquired and 9% were nursing home acquired. One thousand two hundred and sixty (97%) patients had al least one concomitant medical condition. mainly cardiac disease. alcoholism and chronic obstructive lung disease. Chest roentgenogram was abnormal in 98%. Cultures of sputum, bronchoalveolar lavage fluid, blood and/or serology revealed positive results in 785. The most common pathogens were Streptococcuspneumoniae (154). Haemophilus influenzae (147). Staphylococcus aureus (111) and Pseudomonas aeruginosa (100). In the group with community acquired pneumonia, S pneumoniae and H influenzae predominated. In the hospital acquired pneumonia group S aureus and P aeruginosa were more common. although S pneumoniae remains a significant pathogen. In the nursing home acquired pneumonia group. Gram-negative agents were the most common. The pattern of antimicrobial agents used, usually begun empirically when culture results are pending. showed that the majority of patients was treated with combination antibiotics for both Gram-positive and Gram-negative coverage. Ceftriaxone was usually prescribed with either erythromycin or clindamycin. In about half the patients. the ceftriaxone dose was 1 g per clay. Ninety-six (7%) patients developed complications of pneumonia and 207 (16%) patients required intensive care unit admission. Nine hundred and fifty-nine (73%) patients were cured or improved at time of discharge, 21 ( 1.5%) patients discharged themselves against medical advice and 320 (25%) patients died during admission to hospital, of whom 165 cases had pneumonia listed as a cause on the death certificate.CONCLUSIONS: Pneumonia remains a significant illness with high morbidity and mortality. Those affected and requiring hospitalization are elderly and ill. The most common pathogens overall continue to be S pneumoniae and H influenzae, although Gram-negative organisms and S aureus were also significant agents in nosocomial and nursing home acquired pneumonia. The high percentage of Gram-negative infections in the community acquired group has not been previously described and may represent a change in the pattern of pathogens affecting this group. Three of the 53 community acquired cases in whom P aeruginosa was implicated were detected on blood cultures and were definitely pathogens. Ten of the 53 patients had underlying bronchiectasis or cystic fibrosis and one patient had a history of hematogenous malignancy. Whether the finding of P aeruginosa represents true pathogenicity or colonization in the 53 cases is difficult to differentiate in a retrospective fashion. However. all but two received antibiotic therapy. and 10 of the 40 survivors in this subgroup received adequate coverage for pseudomonas. Although yield from routine investigations is only 60% (785 of 1300 patients in this study), cultures of blood and sputum should be sent in all patients as it may help to narrow choice of antimicrobial agents and aid in oral step-down selection . Only in select patients should serum serology and more costly and invasive procedures such as bronchoscopy and thoracocentesis be done. It appears that the current pattern of antimicrobial use is appropriate for management of pneumonia given the pattern of offending organisms seen. In the present study, pragmatic use of ceftriaxone at 1 g/24h in these sick patients appeared to result in a therapeutic outcome similar to other antibiotic combination therapy.Peer Reviewe

Community acquired, nursing home acquired and hospital acquired pneumonia: A five-year review of the clinical, bacteriological and radiological characteristics

Purpose: To assess the contemporary clinical, bacteriological and radiographic features of hospitalized patients with community acquired (ca), nursing home acquired (na) and hospital acquired pneumonia (ha) and to examine patient outcome

Community Acquired, Nursing Home Acquired and Hospital Acquired Pneumonia: A Five-Year Review of the Clinical, Bacteriological and Radiological Characteristics

Purpose: To assess the contemporary clinical, bacteriological and radiographic features of hospitalized patients with community acquired (ca), nursing home acquired (na) and hospital acquired pneumonia (ha) and to examine patient outcome.Patients and Methods: All hospital records of patients with pneumonia over a five-year period from April 1987 to March 1992 were reviewed retrospectively. Patients included in the study were all those with a diagnosis of pneumonia as identified by computer records of diagnostic codes at discharge; patients with a specific diagnosis of Pneumocystis carinii pneumonia were excluded. Of 74,435 discharges over the five-year period, 1782 patients met the inclusion criteria.Results: Charts of 1622 of the total 1782 cases were reviewed. Mean age was 64.4 years with 59.4% men and 40.6% women. Sixty-three per cent were ca, 28.5% were ha and 8.5% were na. A total of 1542 patients (95%) had at least one concomitant medical condition. Chest roentgenogram was abnormal in 97%. Common organisms isolated overall were Haemophilus influenzae (from 204 patients), Staphylococcus aureas (from 152 patients), Streptococcus pneumoniae (from 143 patients ), Escherichia coli (from 113 patients) and Pseudomonas aeruginosa (from 111 patients). H influenzae and S pneumoniae were most common in ca pneumonia, whereas S aureus and Gram-negative organisms were more common in the ha group and Gram-negative agents in the na group. One hundred and four patients developed complications. Fifteen per cent required intensive care unit admission. The average length of hospitalization in the ca and na groups was 17 days and in the ha group, 43 days. At time of discharge 1261 patients (78%) were cured or improved, and 361 patients (22%) died during the admission.Conclusions: These results suggest that hospitalization for pneumonia in the 1990s is primarily for elderly patients with significant co-morbidity. Although microbiology appears unchanged compared with earlier reports, the contemporary population is significantly sicker than previous cohorts. This may account for the persistently high morbidity and mortality despite better or newer antibiotics.Peer Reviewe

Interim Report on Drug Utilization Review of Community Acquired, Nursing Home Acquired and Nosocomial Pneumonia: Clinical, Bacteriological and Radiological Spectrum

OBJECTIVES: To review the epidemiology of community acquired, nursing home acquired and nosocomial pneumonia in terms of clinical. bacteriological and radiological features and to examine the spectrum of and response to antimicrobial agents used in its management

Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries

Purpose: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. Methods: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 – 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). Results: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. Conclusion: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice

Current worldwide nuclear cardiology practices andradiationexposure: results from the 65 country IAEA nuclear cardiology protocols cross-sectional study (INCAPS)

Aims To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiationoptimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. Methods and results We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposurewere identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs Conclusion Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally