Pharmacological treatment of bacterial infections of the respiratory tract

Bacterial infection of the respiratory tract is amongst the most common presentations to primary and secondary care. In addition to supportive care, the mainstay of pharmacotherapy is antibiotics. Antibiotic treatment of bacterial infections of the respiratory tract needs to consider patient factors such as age, comorbidities, location, previous antibiotic use, microbiological results and allergy. The emergence of multi-drug-resistant bacteria, partly a consequence of inappropriate antibiotic use, has both focussed the need for careful management of bacterial infection and presented a new therapeutic challenge. The choice of antibiotic for respiratory infections needs to be within national guidelines modified by local susceptibility profiles. Bacterial infections of the respiratory tract affect all levels of the airway tree and can be simply classified by their anatomical location, for example, epiglottitis, exacerbations of chronic obstructive pulmonary disease and bronchiectasis and pneumonia. As with all pharmacotherapy, alongside the benefit the potential side effects of the treatment needs to be considered. This is particularly important for the 6-month treatment of tuberculosis, which should only be managed by a specialist. The majority of bacterial infections of the respiratory tract respond well to therapy, but it is important to recognize that this remains a major cause of mortality.     

Pharmacological treatment of bacterial infections of the respiratory tract

Bacterial infection of the respiratory tract is amongst the most common presentations to primary and secondary care. In addition to supportive care, the mainstay of pharmacotherapy is antibiotics. Antibiotic treatment of bacterial infections of the respiratory tract needs to consider patient factors such as age, co-morbidities, location, previous antibiotic use, microbiological results and allergy. The emergence of multi-drug-resistant bacteria, partly a consequence of inappropriate antibiotic use, has both focussed the need for careful management of bacterial infection and presented a new therapeutic challenge. The choice of antibiotic for respiratory infections needs to be within national guidelines modified by local susceptibility profiles. Bacterial infections of the respiratory tract affect all levels of the airway tree and can be simply classified by their anatomical location for example: epiglottitis, exacerbations of chronic obstructive pulmonary disease and bronchiectasis and pneumonia. As with all pharmacotherapy, alongside the benefit the potential side effects of the treatment needs to be considered. This is particularly important for the 6-month treatment of tuberculosis, which should only be managed by a specialist. The majority of bacterial infections of the respiratory tract respond well to therapy, but it is important to recognize that this remains a major cause of mortality.     

Infektionen der Hand

The hand as a tactile organ is continuously exposed to pathogens with the risk of developing severe hand infection. Bacterial infections are encountered most frequently. Next to severe soft tissue trauma, small lesions with or without foreign body entrapment often prove to be the causative agents for hand infections. Bite wounds caused by humans or animals are in particular prone to spread of infection as they lead to a deep bacterial inoculation in the different anatomical spaces of the hand. In order to prevent severe infection initial diagnosis and adequate treatment is of major importance. Surgical treatment is primarily indicated with radical debridement of all affected structures. Delayed diagnosis by temporizing treatment strategies can lead to fulminant infection with functional deficits or in the end to septic shock with multiple organ failure.     

Postoperative infections of the spine

The incidence of postoperative infections after spinal surgery ranges from less than 1% to 15%. This rate can vary based on several surgical- and patient-related risk factors, such as the type and duration of the procedure, nutritional status, immunosuppression, and comorbidities of the patient. Most surgeons routinely administer intravenous antibiotics prophylactically, and may employ other measures in an effort to prevent postoperative infection. Multiple diagnostic modalities, in conjunction with examination findings, should be utilized in the assessment of possible postoperative spinal infections. In particular, wound discharge or erythema, and an elevation in the erythrocyte sedimentation rate and C-reactive protein beyond expected postoperative values should raise a clinician's level of suspicion for an infection. The diagnosis of a postoperative spine infection can be difficult to confirm with diagnostic imaging, given findings are not all that different from normal postoperative changes. When suspected, the preferred treatment for a postoperative spinal infection is open irrigation and aggressive debridement of all necrotic tissue and bone, followed by antibiotic treatment based on culture sensitivity.     

Occupational blood-borne diseases in surgery

BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) infections are transmitted by blood exposure. Surgeons have been concerned about the risks of blood exposure in the operating room as a potential source of occupational infections from these viruses. The actual risk and frequency of operating room transmission remains poorly understood by many surgeons. METHODS: The pertinent recent literature on the pathophysiology, diagnosis, prevention, and treatment of HIV, HBV and HCV were reviewed to address the current understanding of these viruses as occupational risks to surgeons. RESULTS: HIV transmission to surgeons has not been documented in the United States by the Centers for Disease Control. HIV transmission from a surgeon to a patient in the environment of the operating room, as well as transmission from an HIV-infected surgeon to a patient, has not been documented. HBV infection of surgeons has declined with the general acceptance of the HBV vaccine. HCV infection remains a real risk for transmission in the operating room, given that no vaccine is currently available and that the overall number of chronically infected patients remains quite high. CONCLUSION: The risk of occupational infection from known viral pathogens for surgeons is low, but it is not zero. Effective barriers, modified patterns of behavior, and prompt responses to blood exposure events are the best methods for prevention.     

骨折相关感染细菌培养规范取材的研究进展

骨折相关感染是困扰诸多骨科医生的一大难题,因其诊断存疑、治疗费时、迁延不愈、花费昂贵等,严重损害患者的身心健康。鉴于骨折相关感染患者在损伤机制、损伤程度、细菌来源、发病时间等方面存在一定的差异,为了提高细菌培养的阳性率和致病菌的检出率,规范临床标本取材操作显得尤为重要。因此,本文围绕标本取材的前期准备、时机、部位、类型、数量、后期处理等方面进行综述,以提高对标本取材规范操作的认识,更好地服务于临床诊疗。     

血清降钙素原和血清前白蛋白检测在呼吸道感染性疾病中的应用

目的：探讨血清降钙素原（PCT）和血清前清蛋白（PA）检测在呼吸道感染性疾病诊断中的临床价值。方法选取90例经呼吸内科确诊的细菌感染患者为观察组,另选48例健康体检者为对照组。PCT和PA检测分别采用免疫发光法和比色法,测定两组血清水平,并进行统计学分析。结果观察组患者PCT水平显著高于对照组（χ2=7.512,P=0.0046）,而PA水平则低于对照组（χ2=7.126,P=0.0058）;观察组患者以上两项指标阳性率显著高于对照组（χ2=7.628,P=0.0047）。治疗1周后,观察组PCT水平显著降低,而PA水平显著升高,治疗前后差异具有统计学意义（χ2=3.629,P=0.034）。结论血清PCT和PA测定可作为呼吸道感染性疾病诊断和鉴别诊断的常规指标,对指导抗菌药物的合理使用,病情评估和疗效判断均具有重要的指导意义。     

Gas gangrene and necrotizing fasciitis in the upper extremity

Necrotizing soft tissue infections encompass a wide variety of clinical syndromes resulting from introduction of various pathogens into injured or devitalized tissue. The extent of microbial involvement in such tissue may range from simple contamination to overt and progressive local tissue necrosis, which, if untreated, may lead to septicemia and death. Early differentiation among these infections is not always possible, as there are overlapping classification criteria. These infections exist along a continuum of clinical severity with different etiological agents and associated medical conditions. The often subtle clues heralding the presence of a necrotizing soft tissue infection must be sought so that expeditious surgical debridement and broad-spectrum antibiotic management are initiated. Although experience enables the clinician to make a specific diagnosis based on early findings, aggressive and proper treatment of suspected infections remains the priority. The purpose of the article is to provide an overview of necrotizing soft tissue infections in the upper extremity, focusing on gas gangrene, or clostridial myonecrosis, and necrotizing fasciitis, to facilitate early diagnosis and optimal management of these lethal diseases.     

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目的 了解外科重症监护病房（SICU）中医院获得性感染（nosocomial infection,NI)的流行病学规律。指导临床防治。方法 对SICU1996年1月至2000年12月间181例NI情况进行回顾性分析。结果 平均感染率9.81%,常见感染部位是呼吸道（36.96%)、胸腹腔（25.47%)和血行感染（9.32%),各部位主要病原菌种类具有统计学差异,呼吸道、胸腹腔和胆道以细菌为主,泌尿道和消化道以真菌为主,混合感染52.25%。常见病原菌是肠球菌、耐甲氧西林的葡萄球菌、铜绿假单胞菌、大肠埃希杆菌、白色念珠菌和热带念珠菌。结论 SICU内NI主要病原菌因感染部位而不同,菌种复杂,耐药菌株多,应建立相应的监控制度,掌握病原菌变化规律,现有效地预防和治疗ICU内获得性感染。     

降钙素原和C-反应蛋白水平及白细胞计数联合检测对呼吸道感染的诊断价值

目的探讨血浆降钙素原（PCT）、C-反应蛋白（CRP）水平及白细胞（WBC）计数联合检测在呼吸道感染诊断中的临床意义。 方法选取2013年7月至2014年4月于本院就诊的呼吸道感染者共104例,按照是否伴有细菌感染分组,选取同期健康体检者40例作为对照组,比较两组研究对象血浆PCT、CRP水平和WBC计数的差异,计算各指标联合检测对呼吸道细菌感染的诊断效率。 结果细菌感染组患者血浆PCT、CRP水平和WBC计数较非细菌感染组患者均显著升高,差异具有统计学意义（t = 9.316、8.389、8.495,P均= 0.000）;三者联合检测的敏感度与PCT、CRP、WBC检测差异均具有统计学意义（χ² = 30.687、21.682、22.753,P均= 0.000）,联合检测的特异度与CRP、WBC检测差异均具有统计学意义（χ² = 11.665、11.665,P均= 0.000）。 结论PCT、CRP水平和WBC计数联合检测能够有效地提高临床对于呼吸道感染的诊断率,同时有利于对细菌性感染的准确判定,亦为临床合理用药提供了一定的依据。     

Infection in the critically ill surgical patient

After surgery, critically ill patients in the intensive care unit (ICU) may acquire infections which differ from those acquired elsewhere with regard to the anatomical site involved and the causative micro-organisms. Specific risk factors for infection in the ICU have been shown to be associated with exposure to invasive devices and the use of broad-spectrum antibiotic treatment. Control of infection depends on the timely suspicion of its presence and the identification of the potential anatomical source of infection. Furthermore, the collection of adequate fluid samples for cultures before any anti-microbial treatment is introduced is paramount in order to identify responsible microbes correctly and to re-adjust therapy subsequently. It should be stressed that, when empirical anti-microbial therapy is started before micro-organism identification, the initial treatment will be appropriate only in half of the cases. Gram-negative bacteria of the Pseudomonas aeruginosa and Enterobacter cloaca strains remain the leading cause of nosocomial infection in the ICU. Other pathogens which have caused concern in ICU patients over the past decade are Staphylococcus aureus and fungal infection mainly of theCandida spp.This chapter reviews the more common infections encountered in the high-risk surgical patients in the ICU according to the anatomical localization of the infection, i.e. respiratory, abdominal, urinary, wound and bloodstream infections.     

骨科假体相关性感染的末端限制性片段长度多态性分析

背景：随着骨科假体植入的增加,假体相关性感染日益增多。只有深入研究感染中病原菌的分布特点,才能对假体相关性感染的机理和治疗方式有更全面的认识。目的：应用末端限制性片段长度多态性（T-RFLP）技术分析骨科假体相关性感染的细菌学特征。方法：选取骨科假体相关性感染患者的感染灶样本15例和非假体相关性感染患者的感染灶样本10例,提取样本总DNA,对其16S rDNA进行PCR扩增,应用T-RFLP技术分析样本中微生物群落分布情况。结果：假体相关性感染组检测阳性率为46.7%,非假体相关性感染组检测阳性率为20%;聚类分析结果显示相同解剖部位的感染中细菌群落分布均具有很高的相似性。结论：假体相关性感染检测阳性率高于非假体相关性感染;无论有无假体存在,相同解剖部位的感染中细菌群落的分布具有很高的相似性。     

Necrotizing soft-tissue infections

Necrotizing fasciitis is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen, or perineum. Necrotizing fasciitis typically begins with trauma; however, the inciting event may be as seemingly innocuous as a simple contusion, minor burn, or insect bite. Differentiating necrotizing infections from common soft-tissue infections, such as cellulitis and impetigo, is both challenging and critically important. A high degree of suspicion may be the most important aid in early diagnosis. Prompt diagnosis is imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death. Although group A Streptococcus is the most common bacterial isolate, a polymicrobial infection with a variety of Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is more common. Orthopaedic surgeons are often the first physicians to evaluate patients with such infections and therefore need to be familiar with this potentially devastating disease and its management. Prompt diagnosis, immediate administration of broad-spectrum antibiotic coverage, and emergent aggressive surgical debridement of all compromised tissues are critical to reduce the morbidity and mortality of these rapidly progressing infections.     

Early respiratory viral infections in infants with cystic fibrosis

BackgroundViral infections contribute to morbidity in cystic fibrosis (CF), but the impact of respiratory viruses on the development of airway disease is poorly understood.MethodsInfants with CF identified by newborn screening were enrolled prior to 4 months of age to participate in a prospective observational study at 4 centers. Clinical data were collected at clinic visits and weekly phone calls. Multiplex PCR assays were performed on nasopharyngeal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent bronchoscopy with bronchoalveolar lavage (BAL) and a subset underwent pulmonary function testing. We present findings through 8.5 months of life.ResultsSeventy infants were enrolled, mean age 3.1 ± 0.8 months. Rhinovirus was the most prevalent virus (66%), followed by parainfluenza (19%), and coronavirus (16%). Participants had a median of 1.5 viral positive swabs (range 0–10). Past viral infection was associated with elevated neutrophil concentrations and bacterial isolates in BAL fluid, including recovery of classic CF bacterial pathogens. When antibiotics were prescribed for respiratory-related indications, viruses were identified in 52% of those instances.ConclusionsEarly viral infections were associated with greater neutrophilic inflammation and bacterial pathogens. Early viral infections appear to contribute to initiation of lower airway inflammation in infants with CF. Antibiotics were commonly prescribed in the setting of a viral infection. Future investigations examining longitudinal relationships between viral infections, airway microbiome, and antibiotic use will allow us to elucidate the interplay between these factors in young children with CF.     

Therapeutic considerations: lower respiratory tract infections in smokers.

Tobacco smoke can alter both the structural and the immunologic defenses of the lungs against infection. The gases from smoke can also inhibit repair of the damages they create. Smokers have been found to have increased bacterial adherence to the respiratory tract, decreased IgA and IgG, and a decrease in vital capacity two to three times greater than that of nonsmokers. These and other respiratory tract alterations put smokers at an added disadvantage when acute lower respiratory tract infections strike. A history of smoking influences the diagnosis of respiratory tract infections because smokers are more prone than nonsmokers to infection by certain organisms. The major causes and characteristics of lower respiratory tract infections, methods of outpatient diagnosis, and the pros and cons of various modes of therapy are discussed.     

Chlamydia pneumoniae respiratory infection after allogeneic stem cell transplantation

Chlamydia pneumoniae is a common cause of upper and lower respiratory tract infections in immunocompetent patients; however, its role as a respiratory pathogen in immunocompromised hosts has been infrequently recognized. We describe C. pneumoniae lower respiratory tract infection in a 19-year-old male after allogeneic stem cell transplantation. The patient developed fever on day +14, and a subsequent computed tomography scan of the chest revealed a right lateral pleural-based opacity, which was then resected during thoracoscopy. Diagnosis was made by culture and staining of the resected tissue with C. pneumoniae-specific monoclonal antibodies, and azithromycin was administered. To the best of our knowledge, this is the first report of C. pneumoniae respiratory infection after stem cell or marrow transplantation. C. pneumoniae often coexists with other etiologic agents of pneumonia in immunocompromised patients. Considering the infrequency of infections from this organism in this clinical setting, one must still rule out other more likely respiratory pathogens.     

膝关节创伤的微创处理

关节镜技术最早应用于膝关节内创伤微创性诊断与治疗．提高了急性膝关节损伤时关节内软骨损伤的诊断率；可以正确评估半月板损伤的部位、类型和范围，合理选择损伤半月板缝合、部分切除等术式，最大限度保留了半月板；可以进行前、后交叉韧带损伤的修复与重建。关节镜技术结合做创内固定技术可以治疗胫骨平台、髌骨、股骨髁骨折，辅助完成逆行交锁钉治疗股骨远端骨折。经皮微创解剖钢板内固定(如LISS)治疗膝关节邻近股、胫骨干骺端骨折，均提供了临床疗效。     

Infectious complications in renal transplant recipients

Renal transplantation has become a well-established therapeutic option for end-stage renal disease, but infectious diseases remain a significant cause of morbidity and mortality. Although a wide variety of pathogens may cause infection, viral ones must be regarded as the single most important class of infections. Progress has been made both in the prevention and the early recognition treatment of infections that are closely linked to rejection. Immunosuppressive therapy is central to the pathogenesis of both. Because of the particular characteristics of transplant recipients, it is desirable to establish a close collaboration between nephrologists, surgeons, and infectious disease specialists for the management of these patients. In this article, we describe the different kinds of infectious disease that may affect patients with kidney transplant and the fundamental principles of clinical management, particularly our experience in Polyoma virus (BK) infection.     

Zuckerkandl结节的研究进展

Zuckerkandl结节是甲状腺腺体自身突起而形成的结节,近年来逐渐引起解剖学者与外科医师的重视.临床上行甲状腺手术时为了避免伤及喉返神经及其分支与上甲状旁腺,外科医师常需要借助于特定解剖学标志,如甲状软骨下角、甲状腺下动脉、甲状腺下极、气管食管沟和甲状腺悬韧带等,这些特定解剖学标志有以下共同的特点:(1)标志本身位...