Reducing the duration of antibiotic therapy in acute community-acquired pneumonia

In theory, the expected benefits of a reduction of the duration of antibiotic therapy during the immunocompetent adult's community-acquired pneumonia (CAP) are of four types: improved observance; reduction of the iatrogenic risk; decrease in the emergence of resistance in the commensal flora; reduction in direct and indirect costs. In practice, the expected benefits must be weighed against the risks of lesser efficiency, i.e., continuing evolution or recurrence. The experimental models of humanized pneumonia treatments show that the period of bacterial eradication is not uniform. If it lasts 48 hours for pneumonia with sensitive pneumococci, it is longer for pneumococci resistant to amoxicillin or atypical bacteria. Thus, if the clinical trials conducted in adults with non-severe CAP, have shown that the duration of treatment could be reduced, depending on the existence or not of a comorbidity, to a 3 days amoxicillin treatment, to a 5 days telithromycin treatment, to a 5 days of levofloxacin 750 mg/day treatment or to a 5 days of ceftriaxone 1g / day treatment, it is logical to assume that such reductions cannot be extrapolated to severe unqualified PACs with severe or to those caused by resistant bacteria or atypical bacteria.     

Infective complications of aplastic anaemia

Patients with aplastic anaemia have a relatively specific immune defect--leucopenia with neutropenia. We have carried out a retrospective analysis of infective episodes in 11 patients with aplastic anaemia. 5723 follow-up days accrued and 29 infective episodes were documented. Overall the number of infective episodes was significantly associated with the mean white cell and monocyte counts (r = 0.59, 0.02 less than P less than 0.05) but not with length of follow-up, presentation values of white cell, neutrophil and monocyte counts, or mean neutrophil count. The patients appeared to divide clinically into two groups, those at low risk (seven patients) and those high risk (four patients) of infection. Patients in the high risk group had significantly more infections (P = 0.01) and significantly lower monocyte counts (0.02 less than P less than 0.05) than patients in the low risk group. These results are in contrast to similar studies in patients with chemotherapy-induced neutropenia; in our patients the overall rate and severity of infection was low, Gram negative infections were uncommon and monocytopenia appeared to be of greater importance than neutropenia in determining susceptibility to infection.     

Infective endocarditis related to acute cholecystitis

A 30-year-old woman with a homologous dura-mater valve prosthesis developed infective endocarditis related to acute purulent cholecystitis occurring in chronic cholelithiasis. During anti-bacterial treatment refractory heart failure ensued which compelled replacement of the infected prosthesis. She died in the post-operative period. Autopsy revealed endocarditis on the implanted bioprosthesis, purulent cholecystitis and a gallbladder stone. It is warningly concluded that the surgical treatment of endocarditis was unsuccessful because of persistence of purulent cholecystitis that led to reinfection of the inserted prosthesis.     

Thermoregulatory failure secondary to acute illness: complications and treatment.

We report on six patients in whom hypothermia secondary to acute illnesses, including pneumonia, congestive heart failure, renal failure, drug overdose, and hypoglycemia, developed. Complications that occurred were metabolic acidosis in six patients, altered sensorium in five, bradyarrhythmia in three, and hyperamylasemia in two. All patients failed to demonstrate a shivering response and represent cases of acute thermoregulatory failure. Five of the six patients survived. In the course of treatment, the choice of active or passive rewarming should be based on whether or not normal thermoregulatory mechanisms are intact.     

Ascariasis mimicking an acute abdomen.

Infection with the roundworm Ascaris lumbricoides is common in children and may mimic an acute abdomen. The cases of two pediatric patients who presented to the emergency department with signs and symptoms of a surgical abdomen are presented to highlight the presentation of this infection. Both cases were diagnosed by physical examination and radiographs and were treated successfully without surgical intervention. These cases illustrate the need for heightened awareness by the emergency physician of ascariasis in the differential diagnosis of acute abdomen.     

Prevention and treatment of pulmonary complications in patients after surgery of the upper abdomen

Pulmonary complications are the leading cause of morbidity and death during the postoperative period in patients who have undergone upper abdominal surgery. Significant pulmonary mechanical alterations, such as reductions in VC, TV, and FRC and an increase in CV, are noted postoperatively in this patient population. Preexisting patient conditions, postoperative treatments, and certain respiratory maneuvers may increase the patient's risk in the development of postoperative pulmonary complications. Current research unanimously advocates sustained maximal inspiration, the normal physiologic sigh maneuver, as the best method of prevention and treatment of this problem. Commonly utilized maneuvers, such as blowing into a rubber glove or bag, blow bottles, and the like, should be avoided in all situations. A guide for preoperative and postoperative pulmonary assessment and care based on current research is included. After consideration of the data in addition to personal clinical experience, I conclude that to prevent pulmonary complications in patients after upper abdominal surgery, as well as in all hospitalized patients, sustained maximal inspiration, preferably with an incentive spirometer, and conscientious nurse supervision and coaching is the method of choice.     

Sporadic intra-abdominal desmoid with acute abdomen.

We report a 72-year-old man with sporadic intra-abdominal desmoid tumor manifesting as acute abdomen. CT scan revealed an air-containing tumor 7 cm in diameter; three weeks later, the tumor had shrunk to 4 cm on antibiotics. At surgery, a tumor arising from the transverse colon mesentery and infiltrating the jejunum was resected. No recurrence occurred over a 1-year follow-up.     

Approach to the complications of treatment for acute leukemia in the elderly

Acute leukemia is common in the elderly and, due to the aging population and poorer prognosis, represents a major challenge. Elderly acute leukemia patients have been arbitrarily defined as >or=55 to 65 years of age and are underrepresented in clinical trials. There are physiologic differences between elderly and non-elderly patients. A comprehensive understanding of these differences allows the development of a systematic approach to assessing the risks for treatment-related complications. Use of a comprehensive geriatric assessment (CGA), initially developed and validated in the general geriatric population, may allow more accurate assessment of the likelihood of chemotherapy-induced complications and allow for proactive risk minimization. Once complications to therapy develop, aggressive treatment is essential. Treatment related to common complications that arise from therapy will be reviewed. Further research directed at this population is required.     

Ultrasound of acute abdomen

Ultrasound is an important tool in the diagnosis of acute abdominal pain, which is mainly caused by gastrointestinal diseases. This article gives an overview on the important differential diagnosis related to pain localization. Sonomorphological signs and their sensitivity and specificity are discussed. In contrast to other imaging methods ultrasound is hand guided. The present article differentiates the diagnostic capability of ultrasonic diagnosis depending on technical equipment and sonographer's educational level. These facts are important to stabilize the position of ultrasound in the ensemble of other imaging methods. The use of mobile ultrasound machines and an improved training (e.g. by computer assisted sonosimulator systems) will lead to an increasing importance of ultrasound.     

Laparoscopy in the acute abdomen

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.