Impact of urinary tract infection on nursing and healthcare-associated pneumonia

Nursing and healthcare-associated pneumonia (NHCAP), a concept of pneumonia proposed by the Japanese Respiratory Society, mostly occurs among elderly people in long-term care facilities. Similarly, the risk of urinary tract infection (UTI) also increases with age, with UTIs common among those in long-term care. Therefore, NHCAP is sometimes complicated by the presence of a UTI. However, pneumonia complicated by a UTI has not been clinically well characterized. We retrospectively analyzed 376 patients with NHCAP admitted to our hospital over a three-year period. Sixty-seven patients (17.8%) showed complications by a UTI. Patients with a UTI had lower renal function (higher blood urea nitrogen [P = 0.001], higher creatinine [P = 0.001]), lower systolic blood pressure (P = 0.04), higher A-DROP scores (P = 0.005) and higher positive blood culture rates (P = 0.03) than those without a UTI. Furthermore, based on urine, sputum and blood culture results, nearly half of the microorganisms (4/7) in blood cultures were identical with those of urine, suggesting that a concurrent UTI increases positive blood culture rates. Multivariate analysis showed that UTI was not an independent factor associated with 30-day mortality (P = 0.17), although patients with a UTI showed higher 30-day mortality (P = 0.04) than those without a UTI in univariate analysis. In summary, patients with NHCAP and a UTI were more prone to complications than those without a UTI, although UTI itself did not affect the prognosis of patients with NHCAP. A concurrent UTI had a negative impact on the severity of NHCAP.     

Prospective validation of a standardized questionnaire for estimating childhood mortality and morbidity due to pneumonia and diarrhoea

This paper reports the validation of a 'best-judgement' standardised questionnaire using guidelines and algorithms developed by an expert working group conducted in Nicaragua between 1995 and 1997. Prospective hospital data, including standardised medical recording of selected signs and symptoms, laboratory and radiographic test results and physician diagnoses were collected for children < 5 years admitted with any serious life-threatening condition in 3 study hospitals. The mothers or caregivers of the children were later traced and interviewed using the 'best-judgement' questionnaire. Interviews were completed 1-22 months after admission to hospital for 1115 children (400 who died during the stay in hospital and 715 who were discharged alive). The cause of death or admission to hospital was determined by an expert algorithm applied to hospital data. A similar procedure was used to derive the cause using the answers to questions from interviews. Hospital causes were compared with interview causes and sensitivity and specificity calculated, together with the estimated cause-specific fraction for diarrhoea and pneumonia. Multiple diagnoses were allowed; 378 children in the sample (104 deaths, 274 survivors) had a reference diagnosis of diarrhoeal illness, and 506 (168 deaths, 338 survivors) a reference diagnosis of pneumonia. When results for deaths and survivors in all age groups were combined, the expert algorithms had sensitivity between 86% and 88% and specificity between 81% and 83% for any diarrhoeal illness; and sensitivity between 74% and 87% and specificity between 37% and 72% for pneumonia. Algorithms tested in previous validation studies were also applied to data obtained in this study, and the results are compared. Despite less than perfect sensitivity and specificity, reasonably accurate estimates of the cause-specific mortality and morbidity fractions for diarrhoea were obtained, although the accuracy of estimates in other settings using the same instrument will depend on the true cause-specific fraction in those settings. The algorithms tested for pneumonia did not produce accurate estimates of the cause-specific fraction, and are not recommended for use in community settings.     

125Ⅰ粒子覆膜支架对正常兔食管组织的放射性损伤实验研究

目的 观察125I粒子覆膜食管支架对于正常兔食管组织的放射性损伤.方法 将实验用兔分两组,每组各6只,实验组置入125I粒子支架(单颗粒子剂量22.2MBq ×3颗粒子),对照组植入无放射粒子的支架.于支架植入后2、4、8周分别取实验组和对照组兔2只,行食管造影,观察支架、粒子移位情况,处死后取标本行肉眼、显微镜观察.结果 支架释放过程及术后随访未发现125I粒子脱落.所有动物未发现穿孔等严重并发症.实验组术后2周,食管中部仅为轻微的病理学损伤,鳞状上皮明显增生.黏膜卜炎性细胞浸润.术后4周,出现肉芽组织增生,少量纤维组织增生.术后8周,肉芽组织、纤维结缔组织进一步增生.粒子相对处的食管组织损伤程度明显轻于粒子接触处食管组织.对照组支架中间部分食管与正常食管组织相似,可见食管鳞状卜皮轻增生.支架两端实验组和对照组局部增生食管组织覆盖支架,可见肉芽组织、纤维结缔组织明显增牛.结论 125I粒子支架置人正常兔食管壁组织造成病理性改变,主要表现为肉芽组织、纤维结缔组织增生,无出血、穿孔.     

Transbronchial biopsy is clinically useful in classifying patients with interstitial pneumonia associated with polymyositis and dermatomyositis

Background and objective: The histological type of intraluminal fibrosis is an important prognostic factor for interstitial pneumonia. We therefore examined whether transbronchial lung biopsy (TBLB) specimens are useful for predicting the clinical course and prognosis of patients with interstitial pneumonia associated with polymyositis and dermatomyositis (PM/DM), with particular attention to the different types of intraluminal fibrosis. Methods: Twenty‐five cases of interstitial pneumonia associated with PM/DM were classified according to the pattern of intraluminal fibrosis as assessed by TBLB, and the clinical course and response to treatment were compared. Interstitial fibrosis was evaluated by sequential thin‐section CT scans. Results: In 19 of 25 (76%) cases, there was sufficient intraluminal fibrosis to perform an evaluation. Intraluminal fibrosis was classified as bud (polyp) type or mural incorporation type (either alone or mixed with bud type). The bud type was seen in five cases and these improved following treatment with corticosteroids only. The mural incorporation type was seen in 14 cases. In 11 of these 14 cases, progressive long‐term fibrosis developed and four cases were fatal, in spite of corticosteroid and immunosuppressive therapy. The response to drugs (P < 0.01) and survival (P < 0.05) were significantly greater in patients with bud‐type than mural incorporation‐type intraluminal fibrosis. Conclusions: Classification of the pattern of intraluminal fibrosis as assessed by TBLB is useful for predicting the response to treatment, clinical course and prognosis of interstitial pneumonia associated with PM/DM.     

Familial idiopathic pulmonary fibrosis: clinical features and outcome

STUDY OBJECTIVES: Familial idiopathic pulmonary fibrosis (FIPF) has been defined as idiopathic pulmonary fibrosis (IPF) occurring in two or more members of a family. The clinical course of FIPF has not been fully defined. Accordingly, the current study was undertaken to establish clinical, radiologic, and histologic features, and survival in a consecutive series of patients with FIPF. DESIGN: Retrospective analysis of clinical, radiologic, and pathologic data from a consecutive series of patients with FIPF who were seen at Mayo Medical Center. Survival in patients with FIPF was contrasted to that of previously characterized patients with nonfamilial IPF who were evaluated at our institution. SETTING: Tertiary referral medical center. PATIENTS: We screened 47 patients and family members with FIPF from 15 families who were identified between the years 1992 and 2002. We further analyzed the subgroup of FIPF patients that was composed of 27 patients from 15 families in whom the complete clinical course was monitored at our institution. MEASUREMENTS: All patients exhibited clinical features that were compatible with IPF and either compatible high-resolution CT (HRCT) scan findings or histologic evidence of usual interstitial pneumonia. Clinical data, including symptoms, physical findings, HRCT scan findings, lung function test results, biopsy results, and survival were abstracted from the clinical records. RESULTS: Compared to patients with nonfamilial IPF, patients with FIPF did not demonstrate any notable differences in clinical, radiologic, or pathologic features. We observed that the total number of affected members in a family with FIPF was a significant risk factor for earlier mortality (p = 0.0157; hazard ratio, 1.434). Overall, however, patients with FIPF had a statistically similar outcome to those patients with nonfamilial IPF. CONCLUSIONS: Although uncommon, FIPF represents a distinct syndrome, which has clinical features and patient survival rates that are similar to those of nonfamilial IPF.     

低分子肝素对老年重症肺炎患者预后的影响

目的探讨低分子肝素抗凝治疗对老年重症肺炎预后的影响。方法选取2018年1月至2019年1月入住北京世纪坛医院呼吸与危重症医学科重症监护病房(RICU)的年龄≥65岁的重症肺炎患者100例,利用随机数字表分为两组,对照组给予常规治疗,试验组在常规治疗基础上加用低分子肝素4000 U皮下注射,每日1次,治疗14 d。分别于治疗前及治疗第3、7、14天比较两组患者急性生理和慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分、血气分析、凝血指标、D二聚体、血常规、C反应蛋白、降钙素原,以及28天死亡率、出血率、深静脉血栓形成率。结果治疗前,两组患者的基本资料和APACHEⅡ评分差异无统计学差异(P>0.05)。治疗第3天,两组患者的APACHEⅡ评分、D二聚体、白细胞、中性粒细胞百分比和C反应蛋白水平无显著差异。治疗第7天、14天,试验组的上述指标显著低于对照组(P<0.05)。血气分析显示,仅在治疗第14天,试验组乳酸水平显著低于对照组(P<0.05)。治疗期间,两组患者凝血指标和降钙素原差异均无统计学意义(P>0.05)。试验组的28天平均死亡率为8%,显著低于对照组(24%,P<0.05)。两组患者出血发生率无显著差异(P>0.05)。试验组深静脉血栓形成率显著低于对照组(P<0.05)。结论临床上对老年重症肺炎患者应用低分子肝素辅助治疗,可减少APACHEⅡ评分,降低28天死亡率,减少医院内深静脉血栓的发生。     

Prognostic factors in severe community-acquired pneumonia in patients without co-morbid illness

OBJECTIVES: We wished to determine the prognostic factors and the impact of initial empirical antibiotic therapy on the outcome of severe community-acquired pneumonia in patients without underlying co-morbid illness. METHODOLOGY: This is a retrospective record review of consecutive patients with severe community-acquired pneumonia who were divided into those with and without underlying co-morbid illness. RESULTS: There were 182 patients including 112 primary (no co-morbid illness) and 70 secondary (underlying co-morbid illness) pneumonias. The overall mortality was 41.8% and there were no differences in APACHE II score or mortality when comparing cases with primary (37.5%) and secondary infections (48.6%). The mortality was significantly higher in patients with negative microbiology. Univariate analysis identified a number of parameters and various antibiotic regimens, which appeared to be associated with a significantly poorer outcome. On multivariate analysis multilobar pulmonary consolidation, need for mechanical ventilation, inotropes and dialysis were documented to be independent predictors of mortality. Only in their absence could different antibiotic regimens be shown to have an apparent impact on outcome and further analysis suggested that the reason for these differences related predominantly to differences in the severity of the infection. CONCLUSIONS: Markers of disease severity appear to be the most important predictors of outcome in patients with severe community-acquired pneumonia.     

What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?

OBJECTIVE: One of the major factors influencing length of stay for patients with community-acquired pneumonia is the timing of conversion from intravenous to oral antibiotics. We measured physician attitudes and beliefs about the antibiotic switch decision and assessed physician characteristics associated with practice beliefs. DESIGN: Written survey assessing attitudes about the antibiotic conversion decision. SETTING: Seven teaching and non-teaching hospitals in Pittsburgh, Pa. PARTICIPANTS: Three hundred forty-five generalist and specialist attending physicians who manage pneumonia in 7 hospitals. MEASUREMENTS AND RESULTS: Factors rated as "very important" to the antibiotic conversion decision were: absence of suppurative infection (93%), ability to maintain oral intake (79%), respiratory rate at baseline (64%), no positive blood cultures (63%), normal temperature (62%), oxygenation at baseline (55%), and mental status at baseline (50%). The median thresholds at which physicians believed a typical patient could be converted to oral therapy were: temperature < or =100 degrees F (37.8 degrees C), respiratory rate < or =20 breaths/minute, heart rate < or =100 beats/minute, systolic blood pressure > or =100 mm Hg, and room air oxygen saturation > or =90%. Fifty-eight percent of physicians felt that "patients should be afebrile for 24 hours before conversion to oral antibiotics," and 19% said, "patients should receive a standard duration of intravenous antibiotics." In univariate analyses, pulmonary and infectious diseases physicians were the most predisposed towards early conversion to oral antibiotics, and other medical specialists were the least predisposed, with generalists being intermediate (P <.019). In multivariate analyses, practice beliefs were associated with age, inpatient care activities, attitudes about guidelines, and agreeableness on a personality inventory scale. CONCLUSIONS: Physicians believed that patients could be switched to oral antibiotics once vital signs and mental status had stabilized and oral intake was possible. However, there was considerable variation in several antibiotic practice beliefs. Guidelines and pathways to streamline antibiotic therapy should include educational strategies to address some of these differences in attitudes.     

呼吸机相关性肺炎病原菌与耐药性分析

目的 监测重症监护病房(ICU)中呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)患者下呼吸道病原菌的分布及其耐药性,为临床治疗VAP提供经验性选药依据.方法 经人工气道采集患者下呼吸道分泌物标本,对连续2次培养为同一优势致病菌的菌株纳入本研究中,采用纸片法测定该菌的体外药物敏感性.结果 51例检出89株致病菌,其中革兰阴性细菌占78.7%(70/89),革兰阳性细菌占6.7%(6/89),真菌占14.6%(13/89),药敏结果显示这类菌株耐药现象严重.结论 ICU中VAP患者的感染致病菌以革兰阴性菌为主,呈多重耐药,提倡严密动态监测VAP病原菌,应重视并强调对抗生素药物的合理应用.