Treatment of severe respiratory infection. Legionella pneumonia

This paper discusses the evaluation of new macrolides and new quinolones for the treatment of Legionnaires' disease in in vitro susceptibility test, penetration to polynuclear leukocytes and treatment in an animal model. Some kinds of biological response modifier (BRMs) such as granulocyte colony stimulating factor (GCSF), monocyte CSF (M-CSF), GM-CSF, recombinant interleukin-1 (IL-1) and IL-2 were also evaluated. The antimicrobial activity (MIC) of new macrolides to Legionella pneumophila (45 strains) showed the highest activity in TE-031 (Taisho Pharmaceutical Co., Tokyo, Japan) and then rokitamycin (RKM), RU-28965 (Roussel, France), erythromycin (EM), josamycin (JM) in decreasing order of activity. According to the results of the data of cell-penetration and survival rate after treatment of guinea pigs with experimental Legionella pneumonia, the new macrolides such as TE-031, RKM and RU-28965 are expected to be more effective in the treatment of Legionnaires' disease than EM. New quinolones such as ciprofloxatin (CPFX), NY-198 (Hokuriku Pharmaceutical Co., Japan) or T-3262 (Toyama Kagaku Pharmaceutical Co., Toyama Japan) were compared to ofloxacin (OFLX), enoxacin (ENX) or rifampin (RFP) for evaluation. These drugs showed excellent activity against L. pneumophila and good penetration to polynuclear leukocytes. Regarding the treatment of guinea pig with legionella pneumonia, OFLX was the most effective, and NY-198 or T-3262 were more effective than EM treatment. The highest survival rate was obtained with IL-2 in infected guinea pigs. We also observed the efficacy of combined use of IL-2 and HR-8 10 (Horchst FRG) which is a newly developed cephem antibiotic.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influenza. How to prevent and control nursing home outbreaks.

Influenza is an important cause of acute respiratory illness among older adults in general and within the nursing home in particular. Epidemics typically are reported in the late fall and throughout the winter. In the nursing home, vaccination may not prevent clinical illness but can reduce the risk of pneumonia, hospitalization, and death. Atypical presentations, including delirium and nonspecific functional changes, are common in older patients. Rapid diagnosis is imperative, as early antiviral treatment and prophylaxis can control a nursing home outbreak.     

Upper respiratory tract infection and serum antibody responses in nursing home patients

Residents of a Veterans Administration nursing home care unit (NHCU) were observed for the development of upper respiratory tract infection (URI) during 12 consecutive months to determine the frequency of sporadic cases or outbreaks of URI and to characterize them clinically and by laboratory means. Fifty-nine episodes of URI occurred in 56 residents during the study period. Serologic testing or virus isolation proved or suggested an etiologic agent on 22 occasions. URI was more common in late Fall and Winter and was caused by various agents, including influenza, Mycoplasma pneumoniae, respiratory syncytial virus, and parainfluenza viruses. A minor outbreak of influenza B in February 1986 contrasted with previous cases of URI in that the patients had a higher mean temperature and abnormal breath sounds, and they were clinically sicker. This suggests that clinical and epidemiologic surveillance during the influenza season may allow the early recognition of influenza in elderly nursing home residents. Over a 4-year period 147 serum antibody responses after influenza infection or influenza vaccination were compiled. Antibody responses to individual influenza vaccine components were measured 75 to 90 days after vaccination. The geometric mean titer (GMT) and the percentage of samples with antibody levels greater than 1:40 were determined for each of the three antigenic subtypes on 3 consecutive years. The GMT to individual vaccine components was consistently greater than 1:40, except to influenza B/Singapore in 1984 and A/Chile and B/U.S.S.R. in 1985, when these subtypes were first included in the vaccine, suggesting the NHCU residents responded less vigorously to unfamiliar vaccine subtypes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Legionella infection.

As specialized laboratory tests became more widely available, Legionella species were found to be common causes of nosocomial and community-acquired pneumonia. Patients with chronic lung disease and organ transplants are at greatest risk. Clinical manifestations are non-specific, although fever greater than 39 degrees C and diarrhea are common. Erythromycin remains the antibiotic of choice, although many alternative agents are available. Once cases are discovered, a search for the organism in water distribution systems and respiratory equipment can be fruitful. Disinfection of water distribution systems by superheating and flushing or by hyperchlorination is feasible.     

Legionella longbeachae pneumonia infection from home garden soil]

A 72-year-old critically ill and intubated man was transferred to our hospital, because of worsening pneumonia unresponsive to Cefazolin and Meropenem, from the hospital where he had been admitted 8 days before to start maintenance hemodialysis for chronic renal failure but had fever from admission. In a few days his critical condition rapidly subsided with the initiation of Ciprofloxacin and his sputum culture on GVPC medium indicated Legionellosis, which was afterwards identified as L. longbeachae by PCR and DNA-DNA hybridization. After recovery he said that he had been fond of gardening and had been gardening immediately before the initial admission. Moreover, several reports from Australia suggested inhalation of aerosolized potting soil as the route of L. longbeacachae infection; therefore, we examined the soil of his home garden and identified it. Thus, we present this case as the first of L. longbeachae pneumonia in Japan, proved to be infected via inhalation of aerosolized home garden soil.     

Two outbreaks of Yersinia pseudotuberculosis 5a infection in Japan

In the summer of 1984 there occurred 2 outbreaks of infection with Yersinia pseudotuberculosis 5a. 58 persons ate meat products, vegetables and rice at a Japanese barbecue restaurant. 39/58 (67%) developed symptoms. In 19/39 persons an infection with Y. pseudotuberculosis could be diagnosed by stool cultures and/or serological techniques. Fever occurred in all patients, exanthema in 68% and abdominal pain in 68%. Thus, human yersiniosis due to Y. pseudotuberculosis 5a could be a febrile disease with exanthema and gastrointestinal disturbances. A transient acute renal failure developed around the 10th day of illness in 4 children. The source and mode of spread of this infection could not be clarified.     

Two studies of pacing in the nursing home

Two studies concerning pacing by nursing home residents are presented. The first was a cross-sectional survey of 402 residents, which found that 39% of the subjects were pacers. In comparison to residents who did not pace, the pacers had fewer medical diagnoses, better appetites, and had resided in the facility for fewer years. Additionally, pacing was positively related to cognitive impairment and to past life-threatening experiences. Results of the second study, an observational study of six cognitively impaired residents who paced frequently, showed that these residents paced more when the environmental conditions were conducive to pacing (e.g., adequate lighting, enough room within which to pace). We believe that pacing is a reflection of good health within the nursing home population and suggest that caregivers may want to encourage rather than inhibit this behavior in some nursing home residents.     

Two cases of respiratory infection complicating treatment with infliximab]

Infliximab, an anti-TNF-alpha agent, is highly effective against rheumatoid arthritis and Crohn's disease. However, respiratory infection can occur as a complication. We report two cases complicated by respiratory infection following administration of infliximab. The first case, a 67-year-old woman with rheumatoid arthritis, developed pneumocystis pneumonia after three courses of infliximab therapy. The second case, a 31-year-old man with Crohn's disease, developed pulmonary tuberculosis after four courses of infliximab therapy. Respiratory complications associated with anti-TNF therapy include infectious diseases such as pneumocystis pneumonia, tuberculosis, and bacterial pneumonia. They often lead a fulminant course, and early diagnosis is essential. The final report of a survey of the initial 5000 cases with rheumatoid arthritis treated with infliximab in Japan was released in April 2006; pulmonary infectious complications included 22 cases of pneumocystis pneumonia, 14 cases of tuberculosis, and 108 cases of bacterial pneumonia. The growing use of anti-TNF therapy might lead to increasing pulmonary complications. Accumulation of similar cases is expected to elucidate the mechanism of the complications and methods for effective prophylaxis.     

Legionella species infection in adult febrile respiratory tract infections in the community

Legionella spp. (Lsp) are well recognized as etiologic factors in pneumonia but less so in respiratory tract infections (RTI) in the community. The objective of the present study was to characterize febrile RTI patients with a documented Legionella etiology, in terms of specific serogroups, clinical manifestations of the disease, disease course and the effect of antibiotic therapy. Ambulatory adults with febrile RTI (n = 250) were included in a prospective study in which the etiological causes of the infection were identified using sophisticated serological techniques. Paired sera were obtained for each of the patients and were tested for 41 different serotypes of Lsp using micro-immuno-fluorescence (MIF) serology. Only a significant change in IgG and/or IgM antibody titers was considered diagnostic. In 28 patients (11.2%) there was serological evidence of acute infection with 1 of the types of Lsp. The infections were manifested clinically as upper RTI in 9 patients and as lower RTI in the other 19 patients (community-acquired pneumonia in 2 of these). L. pneumophila serogroup 1 was identified in 3 patients, L. pneumophila serogroups higher than 1 were identified in 13 patients and L. non-pneumophila serogroups in 18 patients. The clinical and laboratory findings in patients with acute Lsp infection were not significantly different from those in patients without evidence of this infectious agent. The length and course of the disease were similar in the 12 patients treated with specific antibiotics for Lsp and in those who were not. We conclude that Lsp can be identified in a significant percentage of patients with acute febrile RTI. No specific clinical or laboratory features were observed for these patients and specific antibiotic therapy does not affect the course of the disease.     

Outcomes of infection in nursing home residents with and without early hospital transfer

Objectives: To compare outcomes of infection in nursing home residents with and without early hospital transfer.
Design: Observational cohort study.
Setting: Fifty-nine nursing homes in Maryland.
Participants: Two thousand one hundred fifty-three individuals admitted to nursing homes between 1992 and 1995.
Measurements: Incident infection was recorded when a new infectious diagnosis was documented in the medical record or nonprophylactic antibiotic therapy was prescribed. Early hospital transfer was defined as transfer to the emergency department or admission to the hospital within 3 days of infection onset. Infection, resident, and facility characteristics were entered into a multivariate model to create a propensity score for early hospital transfer. Association between early hospital transfer and outcomes of infection, namely pressure ulcers and death between Days 4 and 34 after infection onset, were examined, controlling for propensity score.
Results: Four thousand nine hundred ninety infections occurred in 1,301 residents. Genitourinary (28%), skin (19%), upper respiratory (13%), and lower respiratory (12%) were the most common types. Three hundred seventy-five episodes in which residents survived 3 days (7.6%) resulted in early hospital transfer. In multivariate regression, individuals with early hospital transfer had higher mortality (odds ratio (OR) 1.44, 95% confidence interval (CI)=1.04–1.99) and, in 1-month survivors, a greater occurrence of pressure ulcers (OR 1.61, 95% CI=1.17–2.20) than those without, after adjusting for propensity score.
Conclusion: Using observational data and propensity score methods, outcomes were worse in nursing home residents transferred to the hospital within 3 days of infection onset than in those who remained in the nursing home.     

UTI: managing the most common nursing home infection

Urinary tract infections (UTIs) are the most common type of infection in nursing homes. Asymptomatic bacteriuria, the most common form, requires no treatment. Symptomatic UTI requires treatment, but symptoms (acute deterioration in functional ability or mental status) may be nonspecific. Complicated UTI is more common in nursing home residents than in other populations. Immobility and the use of bedpans instead of commodes contribute to decreased bladder emptying and an increased potential for UTI. Poor perineal hygiene in many females in nursing homes also increases the potential for UTI. For this reason, obtaining urine for culture by catheterization rather than voided specimen should be the norm for female nursing home patients.     

Treatment of nursing home residents with dementia and lower respiratory tract infection in the United States and The Netherlands: an ocean apart

OBJECTIVES: To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands. DESIGN: Two separate but simultaneous prospective cohort studies. SETTING: Nursing homes in Missouri (n=36) and the Netherlands (n=61). PARTICIPANTS: Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia. MEASUREMENTS: Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow-up. Treatment and mortality, stratified for dementia severity, are reported. RESULTS: Treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall. CONCLUSION: Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals.     

Aortic valve endocarditis associated with Legionella infection after Mycoplasma pneumonia.

A 38 year old woman with diabetes mellitus and bronchial asthma was admitted to hospital with pneumonia caused by Mycoplasma pneumoniae; she recovered promptly on erythromycin treatment. Six weeks later she presented with aortic valve endocarditis without concurrent lung disease. A concurrent increase in titres of antibody to Legionella bozemanii, L longbeachae, and L jordanis indicated a Legionella infection. Legionella infection should be considered, even in the absence of pneumonia, in cases of endocarditis where no other cause can be detected.     

Oral hygiene reduces respiratory infections in elderly bed-bound nursing home patients

In the elderly, aspiration is a common and serious problem. A procedure to minimize respiratory infections caused by silent aspiration was conducted on elderly bed-bound nursing home patients who suffered mainly from cerebral infarction and dementia. Oral care was provided by a dentist and a dental hygienist once a day and the mouth cleansed with povidone iodine by nurses after each meal to restrict respiratory bacterial infection caused by silent aspiration. In period I, neither group of patients received particular care. In period II, the A group was orally cared for and the B group was not cared for. In period III, the A group was not cared for and B group was cared for. During oral treatment for 6 months, febrile days did not improve but degradation of febrile days were prevented by oral care in a limited number of patients. We suggest that oral care may be useful to some extent in elderly patients to prevent respiratory infections.     

Legionella pneumonia associated with adult respiratory distress syndrome caused by Legionella pneumophila serogroup 3

A 68-year-old man developed pneumonia 2 days after nearly drowning in a bathtub of a hot spring spa. Chest radiography revealed bilateral consolidation shadows associated with adult respiratory distress syndrome. Initial treatment with antibiotics and pulse therapy with methylprednisolone was not effective. The patient died on the 4th hospital day. A urinary antigen test for Legionella was positive. Legionella pneumophila serogroup 3 was recovered from an intratracheal specimen. The same serotype of Legionella was isolated from the hot spring water. Restriction enzyme analysis by pulse-field gel electrophoresis revealed identical restriction fragments. We conclude that the water at the hot spring spa could have been the source of infection.