Acute Brochitis

A 40-year-old man with no underlying lung disease has a 7-day history of mild shortness of breath with exertion, as well as cough that is now productive of purulent sputum. He reports no paroxysms of cough and no contact with ill persons in his community. He does not appear to be in distress. His temperature is 37°C, his pulse 84 beats per minute, and his respiratory rate 17 breaths per minute. On auscultation of the lungs, no rales are heard; scattered wheezes are heard in the lung bases. How should he be evaluated and treated? Summary and Recommendations The patient described in the vignette most likely has a viral infection causing uncomplicated acute bronchitis. On the basis of data from clinical trials, antibacterial agents are not recommended. Chest radiography is not indicated, given the absence of signs of pneumonia on physical examination. In the absence of an influenza outbreak in the community, no rapid testing for viral causes should be ordered, and no antiviral therapy should be prescribed; influenza is especially unlikely in a patient who is afebrile. In the absence of a history of contact with a person with suspected pertussis (or a person with a history of persistent cough), this diagnosis is unlikely. If paroxysms of cough developed later or if whooping or post-tussive vomiting occurred, testing for pertussis would be reasonable. The patient should be advised that the cough may persist for an additional 10 to 21 days and that infrequently, it persists longer. For his wheezing and shortness of breath with activity, clinical experience suggests that a β2-agonist such as albuterol may provide relief, although data from clinical trials are inconsistent. On the basis of clinical experience, the patient might be offered short-term use of codeine or hydrocodone-containing preparations or inhaled corticosteroids if the cough is persistent, although data from trials to support their use are lacking

Antibiotic Prevention of Acute Exacerbations of COPD

An estimated 24 million persons in the United States have COPD on the basis of lung-function testing.1 Globally, COPD is the fourth leading cause of death,2 and in the United States it is the third most common cause of death and chronic complications.3 The average person with COPD has one to two acute exacerbations each year, with wide variation from patient to patient.4 In 2000 in the United States, 726,000 patients were hospitalized with acute exacerbations of COPD.1 During an acute exacerbation, antibiotics are generally administered for 5 to 10 days,5 creating a national burden of 120 million to 480 million antibiotic-days annually. The median hospital stay per exacerbation has been estimated at 9 days.6 In a 2007 Canadian study, the median cost of a hospital stay after an acute exacerbation of COPD was $9,557 (Canadian dollars).7 Acute exacerbations of COPD requiring hospitalization are associated with a 30-day rate of death from any cause of 4 to 30%.6 A study in Sweden showed an all-cause mortality of 26% at 30 days and of 69% at 3 years.8 Acute exacerbations also accelerate the progressive decline in lung function associated with COPD. Overall, the FEV1 falls by approximately 33 ml per year in patients with COPD.4 Each acute exacerbation increases the rate of decline by an additional 2 ml per year4 and by up to 7 ml per year in smokers.

Microbiological Factors Influencing the Outcome of Nosocomial Bloodstream Infections: A 6-Year Validated, Population-Based Model

All patients (n = 1,745) with nosocomial bloodstream infection identified between 1986 and 1991 at a single 900-bed tertiary care hospital were studied to identify microbiological factors independently associated with mortality due to the infection. Patients were identified by prospective, case-based surveillance and positive blood cultures. Mortality rates were examined for secular trends. Prognostic factors were determined with use of univariate and multivariate analyses, and both derivation and validation sets were used. A total of 1,745 patients developed nosocomial bloodstream infection. The 28-day crude mortality was 22%, and crude in-hospital mortality was 35%. Factors independently (all P < .05) associated with increased 28-day mortality rates were older age, longer length of hospital stay before bloodstream infection, and a diagnosis of cancer or disease of the digestive system. After adjustment for major confounders, Candida species were the only organisms independently influencing the outcome of nosocomial bloodstream infection (odds ratio [OR] for mortality = 1.84; 95% confidence interval [CI], 1.22-2.76; P = .0035). The two additional microbiological factors independently associated with increased mortality were pneumonia as a source of secondary infection (OR = 2.74; 95% CI, 1.87-4.00; P < .0001) and polymicrobial infection (OR = 1.68; 95% CI, 1.22-2.32; P = .0014). Our data suggest that microbiological factors independently affect the outcome of nosocomial bloodstream infectio

Time to blood culture positivity as a predictor of clinical outcome of Staphylococcus aureus bloodstream infection

Few studies have assessed the time to blood culture positivity as a predictor of clinical outcome in bloodstream infections (BSIs). the purpose of this study was to evaluate the time to positivity (TTP) of blood cultures in patients with Staphylococcus aureus BSIs and to assess its impact on clinical outcome. We performed a historical cohort study with 91 adult patients with S. aureus BSIs. TTP was defined as the time between the start of incubation and the time that the automated alert signal indicating growth. in the culture bottle sounded. Patients with BSIs and TTPs of culture of 12 h (n = 47) were compared. Septic shock occurred in 13.6% of patients with TTPs of 12 h (P = 0.51). A central venous catheter source was more common with a BSI TTP of :512 h (P = 0.010). Univariate analysis revealed that a Charlson score of >= 3, the failure of at least one organ (respiratory, cardiovascular, renal, hematologic, or hepatic), infection with methicillin-resistant S. aureus, and TTPs of = 20 at BSI onset, inadequate empirical antibiotic therapy, hospital-acquired bacteremia, and endocarditis were not associated with mortality. Multivariate analysis revealed that independent predictors of hospital mortality were a Charlson score of >= 3 (odds ratio [OR], 14.4; 95% confidence interval [CI], 2.24 to 92.55), infection with methicillin-resistant S. aureus (OR, 9.3; 95% CI, 1.45 to 59.23), and TTPs of <= 12 h (OR, 6.9; 95% Cl, 1.07 to 44.66). in this historical cohort study of BSIs due to S. aureus, a TTP of :512 h was a predictor of the clinical outcome.Universidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilVirginia Commonwealth Univ, Med Coll Virginia, Sch Med, Dept Internal Med, Richmond, VA 23298 USAVirginia Commonwealth Univ, Med Coll Virginia, Sch Med, Dept Pathol, Richmond, VA 23298 USAUniversidade Federal de São Paulo, Dept Infect Dis, São Paulo, BrazilWeb of Scienc

Emerging resistance among bacterial pathogens in the intensive care unit – a European and North American Surveillance study (2000–2002)

Background Globally ICUs are encountering emergence and spread of antibiotic-resistant pathogens and for some pathogens there are few therapeutic options available. Methods Antibiotic in vitro susceptibility data of predominant ICU pathogens during 2000–2 were analyzed using data from The Surveillance Network (TSN) Databases in Europe (France, Germany and Italy), Canada, and the United States (US). Results Oxacillin resistance rates among Staphylococcus aureus isolates ranged from 19.7% to 59.4%. Penicillin resistance rates among Streptococcus pneumoniae varied from 2.0% in Germany to as high as 20.2% in the US; however, ceftriaxone resistance rates were comparably lower, ranging from 0% in Germany to 3.4% in Italy. Vancomycin resistance rates among Enterococcus faecalis were ≤ 4.5%; however, among Enterococcus faecium vancomycin resistance rates were more frequent ranging from 0.8% in France to 76.3% in the United States. Putative rates of extended-spectrum β-lactamase (ESBL) production among Enterobacteriaceae were low, \u3c6% among Escherichia coli in the five countries studied. Ceftriaxone resistance rates were generally lower than or similar to piperacillin-tazobactam for most of the Enterobacteriaceae species examined. Fluoroquinolone resistance rates were generally higher for E. coli (6.5% – 13.9%), Proteus mirabilis (0–34.7%), and Morganella morganii (1.6–20.7%) than other Enterobacteriaceae spp (1.5–21.3%). P. aeruginosa demonstrated marked variation in β-lactam resistance rates among countries. Imipenem was the most active compound tested against Acinetobacter spp., based on resistance rates. Conclusion There was a wide distribution in resistance patterns among the five countries. Compared with other countries, Italy showed the highest resistance rates to all the organisms with the exception of Enterococcus spp., which were highest in the US. This data highlights the differences in resistance encountered in intensive care units in Europe and North America and the need to determine current local resistance patterns by which to guide empiric antimicrobial therapy for intensive care infections

Targeted inhibition of Gq signaling induces airway relaxation in mouse models of asthma

Obstructive lung diseases are common causes of disability and death worldwide. A hallmark feature is aberrant activation of Gq protein–dependent signaling cascades. Currently, drugs targeting single G protein (heterotrimeric guanine nucleotide–binding protein)–coupled receptors (GPCRs) are used to reduce airway tone. However, therapeutic efficacy is often limited, because various GPCRs contribute to bronchoconstriction, and chronic exposure to receptor-activating medications results in desensitization. We therefore hypothesized that pharmacological Gq inhibition could serve as a central mechanism to achieve efficient therapeutic bronchorelaxation. We found that the compound FR900359 (FR), a membrane-permeable inhibitor of Gq, was effective in silencing Gq signaling in murine and human airway smooth muscle cells. Moreover, FR both prevented bronchoconstrictor responses and triggered sustained airway relaxation in mouse, pig, and human airway tissue ex vivo. Inhalation of FR in healthy wild-type mice resulted in high local concentrations of the compound in the lungs and prevented airway constriction without acute effects on blood pressure and heart rate. FR administration also protected against airway hyperreactivity in murine models of allergen sensitization using ovalbumin and house dust mite as allergens. Our findings establish FR as a selective Gq inhibitor when applied locally to the airways of mice in vivo and suggest that pharmacological blockade of Gq proteins may be a useful therapeutic strategy to achieve bronchorelaxation in asthmatic lung disease

Length of carotid stenosis predicts peri-procedural stroke or death and restenosis in patients randomized to endovascular treatment or endarterectomy.

BACKGROUND: The anatomy of carotid stenosis may influence the outcome of endovascular treatment or carotid endarterectomy. Whether anatomy favors one treatment over the other in terms of safety or efficacy has not been investigated in randomized trials. METHODS: In 414 patients with mostly symptomatic carotid stenosis randomized to endovascular treatment (angioplasty or stenting; n = 213) or carotid endarterectomy (n = 211) in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), the degree and length of stenosis and plaque surface irregularity were assessed on baseline intraarterial angiography. Outcome measures were stroke or death occurring between randomization and 30 days after treatment, and ipsilateral stroke and restenosis ≥50% during follow-up. RESULTS: Carotid stenosis longer than 0.65 times the common carotid artery diameter was associated with increased risk of peri-procedural stroke or death after both endovascular treatment [odds ratio 2.79 (1.17-6.65), P = 0.02] and carotid endarterectomy [2.43 (1.03-5.73), P = 0.04], and with increased long-term risk of restenosis in endovascular treatment [hazard ratio 1.68 (1.12-2.53), P = 0.01]. The excess in restenosis after endovascular treatment compared with carotid endarterectomy was significantly greater in patients with long stenosis than with short stenosis at baseline (interaction P = 0.003). Results remained significant after multivariate adjustment. No associations were found for degree of stenosis and plaque surface. CONCLUSIONS: Increasing stenosis length is an independent risk factor for peri-procedural stroke or death in endovascular treatment and carotid endarterectomy, without favoring one treatment over the other. However, the excess restenosis rate after endovascular treatment compared with carotid endarterectomy increases with longer stenosis at baseline. Stenosis length merits further investigation in carotid revascularisation trials

Comparison of severity of illness scoring systems for patients with nosocomial bloodstream infection due to Pseudomonas aeruginosa

BACKGROUND: Several acute illness severity scores have been proposed for evaluating patients on admission to intensive care units but these have not been compared for patients with nosocomial bloodstream infection (nBSI). We compared three severity of illness scoring systems for predicting mortality in patients with nBSI due to Pseudomonas aeruginosa. METHODS: We performed a historical cohort study on 63 adults in intensive care units with P. aeruginosa monomicrobial nBSI. RESULTS: The Acute Physiology, Age, Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiologic Score (SAPS II), were calculated daily from 2 days prior through 2 days after the first positive blood culture. Calculation of the area under the receiver operating characteristic (ROC) curve confirmed that APACHE II and SAPS II at day -1 and SOFA at day +1 were better predictors of outcome than days -2, 0 and day 2 of BSI. By stepwise logistic regression analysis of these three scoring systems, SAPS II (OR: 13.03, CI95% 2.51–70.49) and APACHE II (OR: 12.51, CI95% 3.12–50.09) on day -1 were the best predictors for mortality. CONCLUSION: SAPS II and APACHE II are more accurate than the SOFA score for predicting mortality in this group of patients at day -1 of BSI

A comparison of particle mass spectrometers during the 1999 Atlanta Supersite Project

During the Atlanta Supersite Project, four particle mass spectrometers were operated together for the first time: NOAA's Particle Analysis by Laser Mass Spectrometer (PALMS), University of California at Riverside's Aerosol Time-of-Flight Mass Spectrometer (ATOFMS), University of Delaware's Rapid Single-Particle Mass Spectrometer II (RSMS-II), and Aerodyne's Aerosol Mass Spectrometer (AMS). Although these mass spectrometers are generally classified as similar instruments, they clearly have different characteristics due to their unique designs. One primary difference is related to the volatilization/ionization method: PALMS, ATOFMS, and RSMS-II utilize laser desorption/ionization, whereas particles in the AMS instrument are volatilized by impaction onto a heated surface with the resulting components ionized by electron impact. Thus mass spectral data from the AMS are representative of the ensemble of particles sampled, and those from the laser-based instruments are representative of individual particles. In addition, the AMS instrument cannot analyze refractory material such as soot, sodium chloride, and crustal elements, and some sulfate or water-rich particles may not always be analyzed with every laser-based instrument. A main difference among the laser-based mass spectrometers is that the RSMS-II instrument can obtain size-resolved single particle composition information for particles with aerodynamic diameters as small as 15 nm. The minimum sizes analyzed by ATOFMS and PALMS are 0.2 and about 0.35 μm, respectively, in aerodynamic diameter. Furthermore, PALMS, ATOFMS, and RSMS-II use different laser ionization conditions. Despite these differences the laser-based instruments found similar individual particle classifications, and their relative fractions among comparable sized particles from Atlanta were broadly consistent. Finally, the AMS measurements of the nitrate/sulfate mole ratio were highly correlated with composite measurements (r^2 = 0.93). In contrast, the PALMS nitrate/sulfate ion ratios were only moderately correlated (r^2 ∼ 0.7)

Automated Detection of Infectious Disease Outbreaks in Hospitals: A Retrospective Cohort Study

Susan Huang and colleagues describe an automated statistical software, WHONET-SaTScan, its application in a hospital, and the potential it has to identify hospital infection clusters that had escaped routine detection