Severe<Emphasis Type="Italic"> Chlamydia pneumoniae</Emphasis> infection in a patient with mild neutropenia during treatment of Hodgkin’s disease

Chlamydia pneumoniae is known to cause acute respiratory tract infections in the non-immunocompromised population. So far, no data about the incidence of chlamydial infections in neutropenic patients are available. Macrolide antibiotics are not considered to be first-line treatment options in neutropenic patients. We report the case of a patient with Hodgkins disease who developed C. pneumoniae pneumonia during mild neutropenia. C. pneumoniae should be considered as a causative agent of pneumonia in neutropenic patients.     

High Rate of Seropositivity of Chlamydia pneumoniae IgA in Male Patients with Nonalcoholic Steatohepatitis

The aim of this study was to investigate if there was any relationship between nonalcoholic steatohepatitis and the rate of Chlamydia pneumoniae seropositivity in a male population. Fifteen men with nonalcoholic steatohepatitis and 20 healthy men were enrolled in the study. The seropositivity rate of Chlamydia pneumoniae immunoglobulin A in the nonalcoholic steatohepatitis and control groups was 53.3 and 5%, respectively. The rate of Chlamydia pneumoniae immunoglobulin A positivity was significantly higher in the nonalcoholic steatohepatitis group than the controls (P = 0.002), while such a difference did not occur for Chlamydia pneumoniae immunoglobulin G positivity (P > 0.05). There is an association between nonalcoholic steatohepatitis and persistent Chlamydia pneumoniae infection as a probable causative or triggering agent. These findings suggest that further studies are necessary to clarify this association.     

Azithromycin therapy in patients with chronic Chlamydia pneumoniae infection and coronary heart disease: immediate and long-term effects on inflammation, coagulation, and lipid status in a double-blind, placebo-controlled study

Background: An association between Chlamydia pneumoniae (Cp) infection and coronary heart disease (CHD) has already been reported. We investigated the relationship between Cp infection and other risk factors in CHD patients, as well as the effects of azithromycin treatment. Methods: We studied 38 patients with Cp infection (Cp-pos) and 15 without (Cp-neg). Cp-pos patients had, both at inclusion and 2 years prior to inclusion, elevated Cp-specific IgA-antibodies, with or without the presence of pharyngeal Cp by polymerase chain reaction (PCR) detection. Blood was analyzed for Cp-antibodies, interleukin-6, interleukin-1 receptor antagonist (IL-1ra), CRP, orosomucoid, fibrinogen, leukocytes, PAI-1, tPA, von Willebrand factor (vWf), platelet count and aggregation, and lipids. Cp-pos patients were randomized to placebo or oral azithromycin, 500 mg on day 1 and then 250 mg/day for 4 days, with repeated therapy after 3 weeks. Blood was taken immediately, as well as 3 months and 2 years after therapy. Results: CRP and IL-1ra levels were higher in Cp-pos than in Cp-neg patients: median, interquartile range 8.5 (3.0–20) vs. 2.0 (1.0–3.8) mg/l, and 316 (165–404) vs. 178 (118–195) ng/l, p=0.0006 and p=0.002, and platelet aggregation was lower: 4.8 (2.9–6.4) vs. 8.1 (4.7–11.4) Ω, p<0.05. tPA levels increased in azithromycin-treated patients between entry and 3-month follow-up: mean±S.D. 3.7±4.2 vs. 1.0±2.1 μg/l, p<0.05. Other variables did not differ. Conclusions: Cp infection was associated with increased inflammatory activity and lower platelet aggregability, suggesting that inflammation may be of greater pathophysiological importance than platelet activity in these patients. Although an effect on Cp infection was not shown, azithromycin may have a positive effect on fibrinolysis, as increased levels of tPA were observed in the treatment group.     

Antibiotic Therapy in Coronary Heart Disease—Where Do We Currently Stand?

A casual association between Chlamydia pneumoniae infection and atherosclerosis remains unresolved but plausible. Evidence comes from sero-epidemiological data, pathological specimen examinations, animal models and in vitro experiments. A number of prospective antibiotic intervention trials targeted against C pneumoniae infection in patients with coronary heart disease are now underway. We remain wary that C pneumoniae infection can persist in cell lines (associated with atherosclerosis) despite antibiotic therapy and also that reactivation of infection can occur. Issues such as delineating the patient group that could be targeted for treatment, choice of optimal antibiotic regimens, duration of therapy and effective methods of monitoring treatment response remain controversial and, as yet, unresolved. The relevance of persistence of C pneumoniae infection and potential antimicrobial resistance will require equal consideration.     

Evidence for persistent Chlamydia pneumoniae infection of human coronary atheromas

To date, structures representing developmental stages of Chlamydia pneumoniae, especially persistent forms of this intracellular bacteria, have not been described in human atherosclerotic tissues using specific antibody labeling and transmission electron microscopy.Staining of atherosclerotic tissue from five patients seeking heart transplantation with gold-labeled antibodies specific for up-regulated chlamydial heat shock proteins, GroEL and GroES, and visualisation via transmission electron microscopy revealed intracellular, atypical, round to oval structures of variable diameter. These structures resembled reticulate bodies of Chlamydia, were surrounded by membranes and were located within smooth muscle cells, macrophages or fibroblasts. By using double immunogold electron microscopy technique (GroEL and GroES in combination with chlamydial LPS/MOMP antibodies), we demonstrated these structures were of chlamydial origin.In the current study, we demonstrated the presence of aberrant bodies of C. pneumoniae in vivo in archival coronary atheromatous heart tissues by the immunogold electron microscopy technique.     

Atypical Bacterial Pneumonia and Asthma Risk

The role of respiratory infections in asthma is poorly understood. Atypical bacteria Mycoplasma pneumoniae and Chlamydia pneumoniae are present in the lower airways of approximately 50% of asthmatics. This study tested the hypothesis that early life community‐acquired pneumonia caused by Mycoplasma pneumoniae or Chlamydia pneumoniae is associated with increased asthma prevalence. Thirty‐five subjects with a history of community‐acquired pneumonia (22 due to atypical bacteria, 13 due to nonatypical pathogens) were evaluated by questionnaire 7–9 years after the episode of pneumonia. Subjects with a history of either typical or atypical pneumonia demonstrated increased asthma prevalence. Current or past asthma prevalence was 55% in subjects with atypical bacterial pneumonia and 61.5% in subjects with nonatypical bacterial pneumonia. Significant between‐group differences were not demonstrated with regard to asthma prevalence (risk ratio = 0.89; 95% confidence interval = 0.49–1.61), current bronchodilator use [1.18 (0.44–3.17)], and family history of atopy [1.18 (0.73–1.91)], or asthma [1.63 (0.68–3.88)]. These data suggest that atypical bacterial pneumonia confers a risk of asthma similar to that seen with nonatypical bacterial pneumonia. Prospective studies are warranted to more fully evaluate the importance of atypical bacterial pneumonia as an asthma risk factor.     

Chronic infection in the etiology of atherosclerosis-the case for chlamydia pneumoniae

Established cardiovascular risk factors do not fully explain the variations in the prevalence and severity of coronary heart disease. Recent evidence suggests that common chronic infections may contribute, either by direct or indirect mechanisms, to the etiology and/or progression of coronary atherosclerosis. Of the candidate infectious agents implicated, Chlamydia pneumoniae has emerged as the most likely pathogen to have a causal role. Evidence for this is based on seroepidemiologic, pathologic, and laboratory-based evidence, in addition to recent small-scale antibiotic intervention studies. Concerted efforts are now focused on the design of large prospective trials with antibiotics active against C. pneumoniae in the secondary prevention of coronary heart disease.     

The role of Chlamydia in upper respiratory tract infections

Although Chlamydia pneumoniae and Chlamydia psittaci are well-established causes of community-acquired pneumonia, little is known about the role of Chlamydia species in upper respiratory tract infections. C. pneumoniae may play a role in the pathogenesis of acute otitis media. Although C. pneumoniae has been isolated from the middle-ear fluid of children with otitis, children in whom the organism was isolated from middle-ear fluid improved despite being treated with antibiotics that are not active against C. pneumoniae. Although many patients with community-acquired pneumonia caused by C. pneumoniae have symptoms suggestive of sinusitis, there is only one report of isolation of the organism from the maxillary sinus of a patient with sinusitis. Studies of the association with pharyngitis are all based on serology, which often has a poor correlation with isolation of the organism by culture.     

Juvenile spondyloarthropathies associated with Mycoplasma pneumoniae infection

Background Reactive arthritis (ReA) has been sporadically reported as triggered by Mycoplasma pneumoniae. This study examined the potential relationship between the acute M. pneumoniae infection and juvenile spondyloarthropathy (jSpA) in children.Patients and methods Twelve patients with ReA secondary to acute M. pneumoniae were examined. M. pneumoniae-specific IgM, IgG and IgA antibodies were serologically confirmed by enzyme-linked immunosorbent assay (ELISA) tests (Savyon Diagnost., Israel). Due to the early appearance and relatively short life time of M. pneumoniae-specific IgM antibodies, their detection allowed the diagnosis of acute infection using single serum sample, confirmed by parallel serum in 7 of 12 patients. Specific IgM and IgG titers higher than 10 U/l were considered positive and those higher than 50 U/l as highly positive. Specific IgA antibodies were detected in only one patient.Results Four patients were female and eight were male. The mean age at onset was 9 years, and the mean duration of follow-up was 24.1 months (range 18–32). The mean number of involved joints was 2.8, and the knee joints were involved in 7 of 12 patients. The mean recovery time was 4.5 weeks (range 1–28) in eight reactive arthritis (ReA) cases; three patients developed enthesitis-related arthritis, and in one patient, genuine juvenile ankylosing spondylitis (jAS) was diagnosed. Two patients were HLA-B27-positive, and one patient was HLA-B7/B27-positive. Six patients had preceding respiratory symptoms, and five were treated with antibiotics.Conclusions Our findings provide clear evidence of ReA diagnosis following an acute M. pneumoniae infection that in four patients progressed to chronic jSpA. Our results suggest that detecting M. pneumoniae-specific antibodies in serological screening of jSpA patients might be useful. It is presently unclear whether antibiotic treatment would change the disease course in those patients.     

Angiogenèse tumorale: physiopathologie, valeur pronostique et perspectives thérapeutiques

Introduction. -- Angiogenesis activation plays a crucial role in tumoral growth and metastases dissemination. This review summarizes and analyzes current knowledge on molecular mechanisms related to angiogenesis and the prognostic value of its effectors. It also focuses on the therapeutical relevance of various drugs that might inhibit angiogenesic processes.Current knowledge and key points. -- Tumor angiogenesis involves complex interactions between tumoral, stromal, endothelial cells, fibroblasts and the extracellular matrix. Normal and malignant angiogenesis depends on the balance of proangiogenic and antiangiogenic factors. Endothelial cells are activated by growth factors, such as Vascular Endothelial Growth Factor (VEGF), and proliferate; they release proteases able to induce degradation of the basement membrane and extracellular matrix, and undergo migration and tubulogenesis. Angiostatin and endostatin are two powerful inhibitors of angiogenesis in experimental models. Assessment of intratumoral microvessel density and quantification of angiogenic factors, including VEGF, are of prognostic value in most cancers, particularly in breast cancer. However, the use of these prognosis markers in clinical practice is still controversial due to the lack of prospective studies and to technical limits inherent to the scoring and standardization of immunohistochemical methods.Future prospects and projects. -- Better understanding of the molecular basis of angiogenesis allows the development of new therapeutical strategies. Biochemical targets of antiangiogenic therapy are: the interaction between angiogenic factors and their receptors; the interaction of endothelial cells with the extracellular matrix; and intracellular signaling pathways. Angiogenesis inhibitors may not cause tumor regression, but inhibit cellular growth and produce «disease dormancy». Extensive phase I to III clinical trials involving antiangiogenesis therapy are in progress.

Résumé

Propos. -- Dans les cancers, l'activation de l'angiogenèse joue un rôle important dans le développement tumoral et dans la dissémination métastatique. L'objectif de cette revue est de faire le point sur la physiopathologie et la valeur pronostique de l'angiogenèse tumorale, et sur les perspectives thérapeutiques visant à l'inhiber.Actualités et points forts. -- L'angiogenèse tumorale se met en place grâce à des interactions cellulaires et moléculaires complexes entre cellules cancéreuses, cellules endothéliales, cellules du stroma tumoral et les constituants de la matrice extracellulaire. La croissance et la dissémination des tumeurs solides malignes dépendent d'un équilibre existant entre régulateurs positifs et négatifs de l'angiogenèse tumorale. Les cellules endothéliales peuvent, grâce à l'action de facteurs de croissance sécrétés par les cellules cancéreuses eg vascular endothelial growth factor (VEGF), entrer dans le cycle cellulaire, migrer après rupture de la membrane basale et s'organiser spatialement, pour former les vaisseaux irriguant la tumeur. L'angiostatine et l'endostatine, sont deux puissants inhibiteurs de l'angiogenèse dans des modèles de carcinogenèse expérimentale. De nombreuses études rétrospectives, portant le plus souvent sur la densité en microvaisseaux et plus rarement sur le VEGF, ont montré dans de nombreux cancers et en particulier le cancer du sein, une association entre angiogenèse et pronostic. Cependant, l'intérêt en clinique de ces facteurs pronostiques est controversé en raison du manque d'études prospectives et des limitations inhérentes à la quantification et à la standardisation des études immunohistochimiques.Perspectives et projets. -- Une meilleure compréhension des processus moléculaires et physiopathologiques activant l'angiogenèse tumorale permet d'élaborer de nouvelles approches thérapeutiques. Actuellement, les inhibiteurs de l'angiogenèse visent trois cibles moléculaires : la liaison des facteurs angiogéniques aux récepteurs, l'interaction entre les cellules endothéliales et la matrice extracellulaire et la transmission intracellulaire du signal. Les thérapeutiques anti-angiogéniques sont en cours d'évaluation dans des études de phase I à III.     

Mycoplasma pneumoniae et infections respiratoires aiguës

Mycoplasma pneumoniae infection can be entirely asymptomatic but it can also lead to bronchitis or pneumonis. M. pneumoniae is the first cause of community-acquired pneumonia in children older than five years of age. Clinical symptoms are often mild but treatment is required because of the risk of sequelae, mainly a decrease of gas diffusion. In children at risk for asthma, M. pneumoniae infection can cause acute attacks. In a study performed on children with an attack of severe asthma with hypoxemia hospitalized at the St-Vincent-de-Paul hospital, 26% of those having an exacerbation of their pre-existing asthma had a mycoplasma infection. Furthermore, when hospitalized for their first asthma attack, 50% of those children who were at risk for asthma had a mycoplasma infection.     

Chlamydia pneumoniae IgG and the severity of coronary atherosclerosis

BACKGROUND: The aim of this study was to compare Chlamydia pneumoniae IgG and the extent of coronary atherosclerosis. METHODS: We investigated 92 patients with stable angina pectoris who underwent coronary angiography to assess chest pain. Before angiography, C. pneumoniae IgG was analyzed. The number of major coronary arteries (1-3) having at least one diameter narrowing (>/=50%) stenosis was determined. The patients were divided into two groups of equal size, according to C. pneumoniae IgG levels. One group included individuals with C. pneumoniae IgG levels exceeding 46 enzyme-immuno-units (EIU)/L and the other consisted of subjects with IgG concentrations below 46 EIU/L. RESULTS: Subjects with higher antibody concentrations had a more severe disease. The number of diseased arteries was 2.1+/-0.8 (S.D.) and 1.4+/-0.6 (S.D.) for the two groups, respectively. The difference is highly significant (p<0.0001). CONCLUSIONS: This study suggests a causative relationship between C. pneumoniae IgG and the degree of coronary atherosclerosis. It does not, however, prove causality.     

Physiopathologie et diagnostic des infections à Mycoplasma pneumoniae

Mycoplasma pneumoniae is the only mycoplasma clearly involved in respiratory tract infections in man. Implicated most often in tracheobronchitis, it is the second most frequent agent responsible for community-wide bacterial pneumonia, and in addition it probably causes asthma exacerbations. M. pneumoniae infection occurs endemically, with epidemic peaks every 4–7 years, mostly in children above five years of age. The laboratory diagnosis of these infections, mainly by serology, is made only in severe cases because of the fastidious growth of this microorganism. M. pneumoniae can, however, be detected easily by molecular amplification techniques. Macrolides and related antibiotics are considered the treatment of choice for M. pneumoniae infection in both adults and children. Antibiotic sensitivity testing of M. pneumoniae is not done routinely because resistant isolates have only rarely been described, the results are delayed, and they have no immediate therapeutic consequence.     

Vieillissement et régression de l’hypertrophie cardiaque chez l’hypertendu

Objective. -- This study was aimed at determining factors acting on the regression of left ventricular hypertrophy due to essential hypertension.Methods. -- It was a non-randomized, echocardiographic study of 60 previously untreated hypertensive subjects (20 to 75 years of age).Results. -- Following a 5-year therapy, the decrease in the left ventricular mass was 14%. Normalization of blood pressure and reversal of left ventricular hypertrophy were obtained in 50% and 58% of patients, respectively. Patients of the non-responder group (non-response being defined as a less than 10% decrease in the left ventricular mass) were older and had a longer history of high blood pressure. A positive correlation was observed between age and decrease in the left ventricular mass, the latter being less marked in older patients. Antihypertensive drugs classes had no influence on reversal of left ventricular hypertrophy.Conclusion. -- Ageing may be a factor of resistance to the decrease in left ventricular mass with therapy. These results suggest that early screening and management of hypertension are essential.

Résumé

Propos. -- Indépendent de l'élévation de la pression artérielle, le vieillissement est associé à un remodelage concentrique du ventricule gauche qui pourrait moduler avec le temps l'effet des traitements antihypertenseurs sur le cœur. L'objectif de la présente étude était de mettre en évidence les facteurs pouvant influencer la régression de l'hypertrophie ventriculaire gauche chez les hypertendus.Méthodes. -- Il s'agissait d'une étude de suivi, non randomisée, portant sur 60 patients hypertendus, âgés de 20 à 75 ans, jamais traités à l'inclusion et présentant une hypertrophie ventriculaire gauche.Résultats. -- Après 5 ans d'évolution sous traitement antihypertenseur, la diminution de la masse ventriculaire gauche de 14 % est largement significative. La pression artérielle s'était normalisée et l'hypertrophie avait régressé chez, respectivement, 50 et 58 % des patients. Le groupe de patients qui ne répondaient pas au traitement (44 % de la population), dont la diminution de la masse cardiaque, inférieure à 10 %, n'était pas significative, étaient plus âgés, la durée d'évolution de l'hypertension artérielle étant plus longue. Dans l'ensemble de la population, il a été montré l'existence d'une relation positive entre la diminution de la masse cardiaque et l'âge: c'est chez les patients les plus âgés que la diminution de la masse ventriculaire gauche est la moins importante. En revanche, il n'a pas été trouvé de relation avec la classe thérapeutique utilisée.Conclusions. -- La diminution de la masse cardiaque sous traitement antihypertenseur n'est pas seulement le résultat d'une diminution de la pression artérielle, mais fait intervenir d'autres facteurs. Parmi ceux-ci, le vieillissement pourrait être un facteur de résistance à l'action du traitement sur la diminution de la masse ventriculaire gauche. Ces résultats justifient un dépistage et une prise en charge précoce de la maladie hypertensive.     

Transplantation hépatique de l’adulte: qui et quand greffer?

Introduction. -- The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.Current knowledge and key points. -- Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criterias for indication in the most common liver diseases can be summerized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 μmol/L is generally required; c) apart from «small» hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.Future prospects and projects. -- In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

Résumé

Introduction. -- L'augmentation du nombre de transplantations hépatiques est limitée par l'insuffisance des ressources en donneurs. La nécessité impose donc un choix parmi les patients susceptibles de bénéficier de ce traitement -- les cas plus graves? ou ceux qui ont les meilleures chances de guérir? -- et une évaluation optimale du moment de la transplantation dans l'histoire de la maladie: ni trop tôt, ni trop tard.Actualités et points forts. -- La transplantation doit être réservée aux patients souffrant d'une affection hépatique irréversible et symptomatique. Elle doit, en règle générale et par ordre d'importance, d'une part modifier l'histoire naturelle de la maladie et, d'autre part, pour un risque minimal. Les critères majeurs d'indication peuvent être ainsi schématisés pour les hépatopathies les plus fréquentes: 1) pour les cirrhoses non choléstatiques, un score de Pugh-Child de 9-10, ou un score inférieur si des accidents évolutifs se sont déjà produits, est un critère nécessaire et souvent suffisant ; 2) pour les cirrhoses choléstatiques, un taux de bilirubine sérique supérieur à 100-150 μmol/L est un critère admis ; 3) si l'on excepte les «petits» carcinomes hépatocellulaires sur cirrhose (moins de trois nodules de moins de 5 cm), presque tous les cancers sont une contre-indication à la transplantation ; 4) l'insuffisance hépatique aiguë nécessite un transfert précoce en milieu spécialisé pour une éventuelle indication de transplantation en urgence.Perspectives et projets. -- Dans un contexte de pénurie qui risque de perdurer, l'amélioration des conditions d'accès à la transplantation nécessite qu'un avis consultatif puisse être pris précocement dans l'histoire naturelle de la maladie auprès des équipes en charge de la transplantation.     

Chlamydia trachomatis in reactive arthritis

Summary Evidence of deposition of chlamydial antigen in the joint was sought in 10 patients (9 of them male) with classic sexually acquired reactive arthritis, 15 women with unclassified seronegative oligoarthritis involving the knee and 15 individuals with established rheumatic disorders not associated with genital-tract or other infections. Using a fluorosceinated monoclonal antibody to the major outer membrane protein of Chlamydia trachomatis (Micro Trak, Syva) in a direct immunofluorescence test, particulate antigen with physical characteristics of chlamydial elementary bodies was seen in synovial fluid cell smears or synovial biopsies, or both, from 6, 5, and 0 patients, respectively. No typical chlamydial intracellular inclusions were seen. Corroborative evidence of recent chlamydial infection was provided by the finding of high titres of serum chlamydial antibody in all antigen-positive patients with sexually acquired reactive arthritis, including 3 from whom a genital-tract isolate was obtained, and 3 of the 5 women with unclassified arthritis. It is postulated that Chlamydia trachomatis organisms reach the joint during acute genital-tract infection, and the processing and presentation by class I major histocompatibility determinants of chlamydial antigens is a critical step in the initiation of reactive arthritis in some patients.     

The pattern of micro-organisms and the efficacy of new macrolide in acute lower respiratory tract infections

Abstract Lower respiratory tract infection (LRTI) is one of the major health problems in developing countries such as Indonesia. According to the National Household Health Survey conducted by the Ministry of Health in 1992, LRTIs still rank fourth as the main cause of death in Indonesia. The problem of LRTIs could be simply managed as long as the causative organism can be identified and the proper antibiotic known. In some occasions, it is not quite so easy to identify the causative micro-organism, especially in lower tract infections. There are several methods of obtaining specimens from LRTIs for cultures. The easiest, most simple way is to collect expectorated sputum. Unfortunately, because of the high rate of contamination by upper respiratory tract flora, this method is not reliable. Recognizing the difficulties with routine expectorated sputum cultures, two alternative approaches have been suggested. One approach is to bypass potential expectorated sputum ‘contaminants’ in the oropharynx by transtracheal aspiration or transthoracic aspiration. The second approach is to modify the usual technique of processing expectorated sputum by either washing techniques or by quantitative cultures. Azithromycin and clarithromycin are chemically related to macrolide erithromycin. Both antibiotics retain the traditional macrolide spectrum of activity against Gram-positive and atypical pneumonia pathogens, while demonstrating improved activity against Gram-negative bacteria. The American Thoracic Society (ATS) recommended the use of macrolide for outpatients with community-acquired pneumonia, without comorbidity and 60 years of age or younger. A total of 34 outpatients with acute LRTIs were open-comparative, randomly allocated to treatment with the new macrolide in Persahabatan Hospital, Jakarta, 1996. The purposes of this study were: (i) to identify the causative micro-organisms; and (ii) to evaluate the clinical efficacy of the new macrolide in these infections. Azithromycin 500 mg was given orally once a day for 3 days and was administered 1 h before or 2 h after every meal. Clarithromycin 500 mg was given orally every 12 h for 10 days. The diagnosis of the patients were: 16 with pneumonia, 10 with acute bronchitis and 8 with acute exacerbation of chronic bronchitis. In this study of 34 patients, the sputum specimens were washed with N acetylcysteine before culture and we could only detect micro-organisms in one patient. Before treatment, we found 47 strains in 33 (97.05%) patients and after treatment we found five strains. From serological examination, only four (11.76%) atypical bacterial were detected. The most frequently found micro-organisms were 23 strains of Klebsiella pneumoniae (40.42%), 10 of Streptococcus alpha haemolyticus (21.26%), five of Streptococcus pneumoniae (10.63%) and five of Staphylococcus aureus (10.63%). The atypical bacterial were: two Legionella pneumophila, one Mycoplasma pneumoniae and one Chlamydia pneumoniae. The clinical efficacy of new macrolides were 100% and the bacteriological responses with eradication of 94.12% vs 70.59% of isolates in the azithromycin and clarithromycin groups are shown in Table 1. There were no adverse reactions detected in the two treatment groups until the end of the study.