Systemic inflammatory response syndrome in nosocomial bloodstream infections with Pseudomonas aeruginosa and Enterococcus Species: comparison of elderly and nonelderly patients

OBJECTIVES: To determine whether the systemic inflammatory response syndrome (SIRS), clinical course, and outcome of monomicrobial nosocomial bloodstream infection (BSI) due to Pseudomonas aeruginosa or Enterococcus spp. is different in elderly patients than in younger patients. DESIGN: Historical cohort study. SETTING: An 820-bed tertiary care facility. PARTICIPANTS: One hundred twenty-seven adults with P. aeruginosa or enterococcal BSI. MEASUREMENTS: SIRS scores were determined 2 days before the first positive blood culture through 14 days afterwards. Elderly patients (> or =65, n=37) were compared with nonelderly patients (<65, n=90). Variables significant for predicting mortality in univariate analysis were entered into a logistic regression model. RESULTS: No difference in SIRS was detected between the two groups. No significant difference was noted in the incidence of organ failure, 7-day mortality, or overall mortality between the two groups. Univariate analysis revealed that Acute Physiology And Chronic Health Evaluation (APACHE) II score of 15 or greater at BSI onset; adjusted APACHE II score (points for age excluded) of 15 or greater at BSI onset; and respiratory, cardiovascular, renal, hematological, and hepatic failure were predictors of mortality. Age, sex, use of empirical antimicrobial therapy, and infection with imipenem-resistant P. aeruginosa or vancomycin-resistant enterococci did not predict mortality. Multivariate analysis revealed that hematological failure (odds ratio (OR)=8.1, 95% confidence interval (CI)=2.78-23.47), cardiovascular failure (OR=4.7, 95% CI=1.69-13.10), and adjusted APACHE II > or = 15 at BSI onset (OR=3.1, 95% CI=1.12-8.81) independently predicted death. CONCLUSION: Elderly patients did not differ from nonelderly patients with respect to severity of illness before or at the time of BSI. Elderly patients with pseudomonal or enterococcal BSIs did not have a greater mortality than nonelderly patients.     

Comparative Effectiveness of White Blood Cell Growth Factors on Neutropenia,Infection, and Survival in Older People with Non‐Hodgkin's Lymphoma Treated with Chemotherapy

OBJECTIVES: To determine the effect of colony‐stimulating factor (CSF) on incidence of febrile neutropenia, infection, and survival in older people with non‐Hodgkin's lymphoma (NHL) treated with chemotherapy. DESIGN: Retrospective cohort study. SETTING: The Surveillance, Epidemiology, and End Results–Medicare database. PARTICIPANTS: Thirteen thousand two hundred twenty‐three people diagnosed with NHL at age 65 and older (mean age 74.9, range 65–102) in 1992 to 2002 who received chemotherapy within 12 months of diagnosis. MEASUREMENTS: Primary prophylaxis was defined as CSF administered at the start of chemotherapy before febrile neutropenia or infection; secondary prophylaxis was defined as CSF use after febrile neutropenia or infection. RESULTS: Participants with five to nine administrations of primary prophylactic CSF had a 42% lower risk of febrile neutropenia (odds ratio (OR)=0.58, 95% confidence interval (CI)=0.41–0.83), and participants with 10 or more administrations had a 48% lower risk (OR=0.52, 95% CI=0.36–0.76) after adjusting for age, stage, histology, and comorbidity. Results did not differ significantly after adjusting for propensity score of receiving CSF. There was no significant association between primary prophylactic CSF and overall survival, but secondary prophylactic CSF was significantly associated with better survival. Four to 10 administrations of secondary prophylactic CSF was associated with 9% lower mortality risk (hazard ratio (HR)=0.91, 95% CI=0.84–0.99), 11 to 23 administrations was associated with 23% lower mortality risk (HR=0.77, 95% CI=0.71–0.84) and 24 or more administrations was associated with 13% lower mortality risk (HR=0.87, 95% CI+0.79–0.95) than in participants not receiving CSF after neutropenia or infection. CONCLUSION: Primary prophylactic CSF was observed to be effective in reducing the incidence of neutropenia and infection. These findings substantiate the clinical guidelines for recommending prophylactic CSF in older people with NHL receiving chemotherapy.     

Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients

STUDY OBJECTIVE: To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS: Two thousand consecutive patients requiring admission to the medical or surgical ICU. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission. CONCLUSIONS: Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.     

Methicillin-resistant Staphylococcus aureus meningitis in adults: a multicenter study of 86 cases

Methicillin-resistant Staphylococcus aureus (MRSA) meningitis is an uncommon disease, and little is known about its epidemiology, clinical features, therapy, and outcome. We performed a multicenter retrospective study of MRSA meningitis in adults. Eighty-six adult patients were included and the following data were obtained: underlying diseases, clinical presentation, analytical and microbiologic data, response to therapy, and outcome.There were 56 men (65%) and the mean age was 51.5 years; 54 of them (63%) had severe comorbidities. There were 78 cases of postoperative meningitis and 8 of spontaneous meningitis. The infection was nosocomial in 93% (80/86) of the cases. Among the 78 patients with postoperative meningitis, the most common predisposing conditions were cerebrospinal fluid (CSF) devices (74%), neurosurgery (45%), CSF leakage (17%), and head trauma (12%). Most patients had fever (89%), altered mental status (68%), headache (40%), and meningeal signs (29%). The most common CSF findings were pleocytosis (90%), elevated protein level (77%), and hypoglycorrhachia (30%). CSF Gram stain and blood cultures were positive in 49% (32/65) and 36% (16/45) of cases, respectively. An associated MRSA infection and polymicrobial meningitis appeared in 33% (28/86) and 23% (20/86) of cases, respectively. Antimicrobial therapy was given to 84 patients. Most of them received vancomycin (92%) either as monotherapy (64%) or in combination with other antibiotics (28%), for a median of 18 days. Overall 30-day mortality was 31% (27/86). Multivariate study identified 2 independent factors associated with mortality: spontaneous meningitis (odds ratio [OR], 21.4; 95% confidence interval [CI], 2.3-195.4; p = 0.007), and coma (OR, 9.7; 95% CI, 2.2-42.3; p = 0.002).In conclusion, MRSA is a relatively uncommon but serious disease. Although most cases are nosocomial infections appearing in neurosurgical patients, spontaneous meningitis may present as a community-onset infection in patients with severe comorbidities requiring frequent contact with the health care system. Most patients have a favorable response to vancomycin, but the beneficial effect of combined and intraventricular therapy, or alternative drugs, remains unclear. MRSA meningitis is associated with a high mortality, and the presence of spontaneous infection and coma are the most important prognostic factors.     

APACHE II Predicts long-term survival in COPD patients admitted to a general medical ward

OBJECTIVE: The Acute Physiology and Chronic Health Evaluation II (APACHE II) was developed to predict intensive-care unit (ICU) resource utilization. This study tested APACHE II's ability to predict long-term survival of patients with chronic obstructive pulmonary disease (COPD) admitted to general medical floors. DESIGN: We performed a retrospective cohort study of patients admitted for COPD exacerbation outside the ICU. APACHE II scores were calculated by chart review. Mortality was determined by the Social Security Death Index. We tested the association between APACHE II scores and long-term mortality with Cox regression and logistic regression. PATIENTS: The analysis included 92 patients admitted for COPD exacerbation in two Burlington, Vermont hospitals between January 1995 and June 1996. MEASUREMENTS AND MAIN RESULTS: In Cox regression, APACHE II score (hazard ratio [HR] 1.76 for each increase in a 3-level categorization, 95% confidence interval [CI] 1.16 to 2.65) and comorbidity (HR 2.58; 95% CI, 1.36 to 4.88) were associated with long-term mortality (P <.05) in the univariate analysis. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with long-term mortality (HR 2.19; 95% CI, 1.27 to 3.80). In univariate logistic regression, APACHE II score (odds ratio [OR] 2.31; 95% confidence internal [CI] 1.24 to 4.30) and admission pCO2 (OR 4.18; 95% CI, 1.15 to 15.21) were associated with death at 3 years. After controlling for smoking history, comorbidity, and admission pCO2, APACHE II score was independently associated with death at 3 years (OR 2.62; 95% CI, 1.12 to 6.16). CONCLUSION: APACHE II score may be useful in predicting long-term mortality for COPD patients admitted outside the ICU.     

Cerebrospinal Fluid Leakage During Transsphenoidal Surgery: Postoperative External Lumbar Drainage Reduces the Risk for Meningitis

Postoperative meningitis is a well known complication of transsphenoidal surgery (TSS). The objective of this study was to evaluate whether postoperative external cerobrospinal fluid (CSF) drainage in case of intraoperative CSF-leakage, reduces the risk of postoperative meningitis. We retrospectively reviewed a series of 278 consecutive transsphenoidal operations. In all operations with intraoperative CSF leakage, an external lumbar drain (ELD) was inserted directly postoperatively, and removed after at least 5 days. The incidence of postoperative meningitis was compared with that in a previously studied series of 228 consecutive transsphenoidal operations, without insertion of an ELD in cases with intraoperative CSF leakage. In the present series, postoperative meningitis occurred in 2/278 (0.7%) operations, compared to 7/228 (3.1%) operations in the previous study period (P < 0.05). Intraoperative CSF leakage was noted in 70/278 (25.2%) operations. All these patients received an ELD immediately after surgery for at least 5 days. There were no reported complications of ELD insertion. In the present series, 1 of 70 (1.4%) patients with intraoperative CSF leakage developed meningitis, compared to 3 of 22 (13.6%) patients in the previous study (P < 0.05). The present report on 278 consecutive transsphenoidal operations shows that the routine insertion of an ELD in patients in whom intraoperative CSF leakage is observed significantly reduces the incidence of postoperative meningitis. Possibly, diversion of CSF prevents the formation of a CSF fistula and thereby the risk of infection. The role of prophylactic antibiotic treatment in patients with CSF rhinorrhea after TSS remains to be established.     

Soluble urokinase receptor is elevated in cerebrospinal fluid from patients with purulent meningitis and is associated with fatal outcome

The urokinase-type plasminogen activator system has been suggested to play a pathophysiological role in brain damage. The aim of this study was to evaluate CSF levels of suPAR in 183 patients clinically suspected of having meningitis on admission. Of these, 54 patients were found to have purulent meningitis, 63 had lymphocytic meningitis, 12 had encephalitis, and 54 patients were suspected of, but had no evidence of, meningitis. There was a significant difference in suPAR levels among patient groups (Kruskal Wallis test, p < 0.0001) with significantly higher CSF suPAR levels in patients with CNS infection (purulent meningitis: median suPAR 2.41 microg/l (range 0.12-35), lymphocytic meningitis: 1.10 microg/l (0.15-5.31), and encephalitis (1.77 microg/l (0.17-11.7)) than in patients without meningitis (0.64 microg/l (0-5.34) (Dunn's multiple comparison test, p < 0.05). Also, patients with purulent meningitis had significantly higher CSF suPAR levels than patients with lymphocytic meningitis (p < 0.001). Patients with purulent meningitis who died (n = 8, 4.9 microg/l (1.3-35) had significantly higher CSF levels of suPAR than patients who survived (n = 46, 2.1 microg/l (0.1-24), Mann Whitney, p = 0.046). Employing a cut-off point of 3.1 and above, the OR (95%CI) for fatal outcome was 11.9 (1.4-106), univariate logistic regression analysis, p = 0.026. In conclusion, CSF suPAR levels may be an important predictor for fatal outcome in purulent meningitis.     

Predictive factors of hyperlipidemia in HIV-infected subjects receiving lopinavir/ritonavir

We studied 382 multiexperienced HIV-infected patients followed up for > or =3 months after starting lopinavir/ritonavir (LPV/r) to identify the factors predicting hypertriglyceridemia and high non-HDL cholesterol levels (triglycerides > or =200 mg/dl and/or non-HDL cholesterol > or =190 mg/dl) after 6 and 12 months of LPV/r exposure. The predictors of hypertriglyceridemia were higher baseline triglyceride levels [OR: 2.28 (95% CI: 1.67-3.12) for each additional 100 mg/dl; p = 0.001], the total duration of antiretroviral treatment [OR: 1.26 (95% CI: 1.12-1.41) for each additional year; p = 0.01], CDC stage C (OR: 2.06; 95% CI: 1.24-3.88; p = 0.02), and male gender (OR: 2.52; 95% CI: 1.42-4.74; p = 0.02); intravenous drug abusers seem less likely to develop the event (OR: 0.52; 95% CI: 0.37-0.92; p = 0.03). The predictors of high non-HDL cholesterol levels were higher baseline levels [OR: 3.92 (95% CI: 1.92-6.24) for each additional 100 mg/dl; p = 0.001) and the combination of NRTIs and NNRTIs with LPV/r (OR: 1.83; 95% CI: 1.10-3.69; p = 0.03). The 75 patients stopping LPV/r showed a significant reduction in median triglyceride and non-HDL cholesterol levels after 3 months of 39 mg/dl and 20 mg/dl (p = 0.01 for both), respectively. Patients with high triglyceride and non- HDL cholesterol levels at the start of LPV/r treatment are at higher risk of developing hyperlipidemia.     

AIDS-related alveolar hemorrhage: a prospective study of 273 BAL procedures

STUDY OBJECTIVES: To evaluate the frequency and diagnostic significance of alveolar hemorrhage (AH) in HIV-infected patients. DESIGN: A 3-year prospective cohort study. SETTING: A university hospital in Paris, France. PATIENTS: Two hundred forty-three HIV-infected patients undergoing 273 BAL procedures during the study period. METHODS: AH was assessed by using the Golde score. Data on the patients treated and observed in our institution were collected, as well as on their survival rate 12 months after undergoing BAL. Risk factors for AH were sought by comparing patients with AH (cases) and those without AH (control subjects). RESULTS: AH frequently occurred but usually was subclinical and cytologically mild. AH did not alter the 12-month survival rate. AH always was associated with at least one specific AIDS-related pulmonary disorder, and the following four independent risk factors were identified in a stepwise forward logistic regression model: pulmonary Kaposi's sarcoma (KS; odds ratio [OR], 5.3; 95% confidence interval [CI], 1.8 to 16.7; p = 0.003), cytomegalovirus (CMV) pneumonia (OR, 9.8; 95% CI, 1 to 100; p = 0.05), hydrostatic pulmonary edema (OR, 16.4; 95% CI, 1.8 to 142; p = 0.01), and platelet count < 60,000 cells/microL (OR, 5.6; 95% CI, 1.5 to 20; p = 0.009). CONCLUSIONS: AH is frequently diagnosed during BAL in HIV-infected patients. Its presence may point to an underlying cause, such as pulmonary KS, CMV pneumonia, or hydrostatic pulmonary edema, or to triggering factors such as thrombocytopenia.     

Risk factors and clinical outcomes of multidrug-resistant Acinetobacter baumannii bacteremia at a university hospital in Thailand

Multidrug-resistant (MDR) Acinetobacter baumannii has become a major cause of hospital-acquired infection worldwide. There are few papers regarding this particular subject. Our aim was to assess the incidence of bacteremia due to MDR Acinetobacter baumannii, factors associated with the infection, and clinical outcomes. We studied 49 cases of A. baumannii bacteremia in adult patients admitted to a university hospital in Northeast Thailand between 2005 and 2007. The incidence of MDR A. baumannii bacteremia was 3.6 episodes per 10,000 hospital admissions. Significantly independent factors associated with MDR A. baumannii bacteremia were previous: 1) ICU admission [odds ratio (OR) 10.01; 95% confidence interval (CI) 1.39-72.20]; 2) use of beta-lactam/beta-lactamase inhibitor antibiotics (OR 8.06; 95%CI 1.39-46.64); and 3) use of a carbapenem antibiotics (OR 11.40; 95%CI 1.44-89.98). The overall mortality rate was significantly higher in the MDR group than in the susceptible group (91.7% vs 48%, respectively) (p=0.001). The significantly independent factors related to mortality were: 1) APACHE II score (OR 1.25; 95%CI 1.03-1.52) and 2) secondary bacteremia (OR 14.86; 95%CI 1.37-161.90). This study revealed the significantly independent factors associated with MDR A. baumannii bacteremia were prior ICU admission and prior use of broad spectrum antibiotics. This infection has a high mortality rate. Emphasis needs to be on prevention, strict application of infection control and appropriate use of antibiotics.     

Risk factors for cryptococcal meningitis in HIV-infected patients.

To identify the risk factors for cryptococcal meningitis in patients with HIV disease we conducted a nested case-control study of 37 incident cases of cryptococcal meningitis and 74 controls, identified from a cohort of more than 2000 HIV-infected patients. Conditional logistic regression was used to study demographic and AIDS-related variables in addition to fluconazole and steroid use. No difference in demographic variables, HIV risk factors, or stage of AIDS was detected between cases and controls. Exposure to fluconazole for more than 90 days reduced the risk of cryptococcal meningitis by 82% (OR=0.18; 95% CI=0.04-0.85; p=0.03). We did not find a difference in steroid use between cases and controls for either the length or amount of steroid exposure (p=0.41). No difference in survival during follow-up in the clinic was observed by the log-rank test (p=0.74). Among the cases, a cryptococcal antigen was positive in more than 97% of the CSF or blood samples. CSF and blood cultures were positive in 81 and 44% of the samples, respectively. We conclude that demographic factors did not affect the risk of cryptococcal meningitis in an inner city United States population. While fluconazole use has a protective effect, steroid use was not associated with an increased risk of cryptococcal meningitis in HIV-infected patients.     

Clinical course, prognostic factors, and outcome prediction for HIV patients in the ICU. The PIP (Pulmonary complications, ICU support, and prognostic factors in hospitalized patients with HIV) study

STUDY OBJECTIVE: To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU. DESIGN: Prospective, observational. SETTING: A university-affiliated medical center. METHODS:: We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4(+) lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS. RESULTS: The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4(+) lymphocyte count (median, 27.5 cells/microL vs 59 cells/microL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001). CONCLUSIONS: The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.     

Streptococcus pneumoniae infections in 47 hematopoietic stem cell transplantation recipients: clinical characteristics of infections and vaccine-breakthrough infections, 1989-2005

Streptococcus pneumoniae infections can cause serious systemic disease in patients following hematopoietic stem cell transplantation (HSCT), and the response to pneumococcal vaccine is inadequate in most HSCT recipients. We evaluated the clinical spectrum of pneumococcal disease and vaccine-breakthrough infections in HSCT recipients at our cancer center in a retrospective analysis of all consecutive episodes of S. pneumoniae infection from 1989 through 2005. During the study period, 7888 patients underwent HSCT at our center; we identified 47 HSCT recipients with 54 S. pneumoniae infections. The overall incidence of S. pneumoniae infection was 7 per 1000 HSCTs. The incidence was higher in recipients of allogeneic grafts than in recipients of autologous grafts (9 vs. 5 per 1000 HSCTs, respectively; p 相似文献   

Factors predicting relapse and poor outcome in type I autoimmune hepatitis: role of cirrhosis development, patterns of transaminases during remission and plasma cell activity in the liver biopsy

AIM: To determine factors predicting relapse and poor outcome in patients with type I autoimmune hepatitis (AIH). METHODS: Patients with AIH were retrospectively recruited. Definitions-remission: AST/ALT < 2 ULN; relapse: AST/ALT > or = 2 ULN; poor outcome: cirrhosis complications, transplantation (OLTx), and death; abnormal transaminases: AST/ALT > ULN but within the remission range; abnormal transaminases index (ATI): number of occasions AST/ALT abnormal/years of remission. Liver biopsies were assessed by Ishak system, and additional score given for portal and parenchymal plasma cells. Data are presented as median (range). RESULTS: Seventy-one patients were identified. Twenty (28%) had cirrhosis at presentation, 14 (20%) developed it during follow-up of 52 months (18-336). Of the 14, four had histological confirmation, and the remainder had clinical/radiological evidence of cirrhosis. Factors independently associated with cirrhosis development were inability to have consistently normal transaminases during remission, OR 19.3 (95% CI 2.2-40), p = 0.002. Treatment was discontinued in 40/69 patients of whom 30 (75%) relapsed within 2 months (1-23), culminating in one death. Factors independently associated with relapse were: time to initial remission, OR 5.5, 95% CI 1.3-22, p = 0.01; failure to have consistently normal transaminases during remission OR 11.8, 95% CI 1.3-100, p = 0.02; and portal plasma cell score (PPCS) OR 10.6 (95% CI 1.0-107), p = 0.04. Time to remission > or = 5 months, PPCS > or = 3 and ATI > or = 2 was associated with > 90% probability of relapse (PPV 100%). Fifteen percent had a poor outcome. Independent predictors of poor outcome were: globulins at onset OR 3.4 (95% CI 1.1-10.1), p = 0.02 and cirrhosis development, OR 23 (95% CI 1.7-307), p = 0. CONCLUSIONS: Seventy percent of patients with AIH relapse upon drug cessation. Time to remission > or = 5 months, ATI > or = 2 and PPCS > or = 3 were associated with > 90% probability of relapse. Factors predicting poor outcome were globulins at onset and cirrhosis development.     

Correlation of TIMI risk score with angiographic severity and extent of coronary artery disease in patients with non-ST-elevation acute coronary syndromes

The Thrombolysis In Myocardial Infarction (TIMI) risk score predicts adverse clinical outcomes in patients with non-ST-elevation acute coronary syndromes (NSTEACS). Whether this score correlates with the coronary anatomy is unknown. We sought to determine whether the TIMI risk score correlates with the angiographic extent and severity of coronary artery disease (CAD) in patients with NSTEACS undergoing cardiac catheterization. We conducted a retrospective review of 688 consecutive medical records of patients who underwent coronary angiography secondary to NSTEACS. Patients were classified into 3 categories according to TIMI risk score: TIMI scores 0 to 2 (n = 284), 3 to 4 (n = 301), and 5 to 7 (n = 103). One-vessel disease was found in patients with TIMI score 3 to 4 as often as in patients with TIMI score 0 to 2 (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.74 to 1.56; p = 0.66). However, 1-vessel disease was found more often in patients with TIMI score 3 to 4 than in patients with TIMI score 5 to 7 (OR 2.16, 95% CI 1.18 to 3.95; p = 0.01), and in patients with TIMI score 0 to 2 than in those with TIMI score 5 to 7 (OR 1.99, 95% CI 1.08 to 3.66; p = 0.02). Two-vessel disease was more likely found in patients with TIMI score 3 to 4 than in those with TIMI scores 0 to 2 (OR 3.96, 95% CI 2.41 to 6.53; p <0.001) and 5 to 7 (OR 2.05, 95% CI 1.12 to 3.75; p = 0.004). Three-vessel or left main disease was more likely found in patients with TIMI score 3 to 4 than in patients with TIMI score 0 to 2 (OR 3.19, 95% CI 2.00 to 5.10; p <0.001), and in patients with TIMI score 5 to 7 than in patients with TIMI score 3 to 4 (OR 6.34, 95% CI 3.88 to 10.36; p <0.001). In patients with NSTEACS undergoing cardiac catheterization, the TIMI risk score correlated with the extent and severity of CAD.     

Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

Abstract Background: Patients admitted to intensive care units (ICUs) are at a high risk of acquiring blood stream infections. We examined whether SOFA score on ICU admission and on the day of bacteremia can predict the occurrence of bacteremia and the outcome of bacteremic ICU patients. Patients and Methods: All patients admitted to a multidisciplinary ICU for more than 48 h from January 1, 2002 to December 31, 2004, were prospectively studied. Demographic, clinical and laboratory data were recorded on admission for all patients and additionally, on the day of the first bacteremic episode for those patients who developed bacteremia. Accordingly, APACHE II and SOFA scores were calculated on the same day. Results: A total of 185 patients developed one or more episodes of bacteremia, giving an incidence of 9.6 per 1,000 ICU days. The ICU mortality rate was 43.9% for bacteremic and 25.8% for the remaining patients (p < 0.001). Admission SOFA score was independently associated with the occurrence of bacteremia (OR = 1.20, 95% CI: 1.11–1.26, p < 0.001). Among bacteremic patients, SOFA score on the day of bacteremia was the only independent prognostic factor for outcome (OR = 1.44, 95% CI: 1.21–1.71, p < 0.001). When all patients were included in the multivariate analysis, admission SOFA (OR = 1.3, CI: 1.16–1.38, p < 0.001), APACHE II (OR = 1.1, CI: 1.02–1.11, p = 0.003) score and the presence of bacteremia (OR = 1.8, CI: 1.1–2.9, p = 0.023) were independently associated with the outcome. Conclusion: Admission SOFA score is independently associated with the occurrence of ICU-acquired bacteremia, whereas it is not sufficient to predict the outcome of patients who subsequently will develop this complication. However, SOFA score on the first day of bacteremia is an independent prognostic factor for outcome in these patients.     

Association of CagA+ Helicobacter pylori infection with aortic atheroma

BACKGROUND: To investigate possible association between infection with CagA(+) strains of Helicobacter pylori and aortic atheroma diagnosed by transesophageal echocardiography. METHODS AND RESULTS: One hundred and eighty-eight consecutive subjects prospectively examined for presence of aortic atheroma (localized intimal thickening of >/=3mm) by transesophageal echocardiography were tested for serum IgG antibodies against H. pylori (enzyme-linked immunosorbent assay) and CagA protein (Western blot assay). The association between infection with H. pylori, CagA status of the infecting H. pylori strains, and aortic atherosclerosis was evaluated after adjusting for coronary artery disease risk factors. There was a linear trend for presence of atheroma in subjects with CagA-positive H. pylori infection (51/81, 63%) compared to subjects with CagA-negative H. pylori infection (21/45, 46.7%) and uninfected subjects (18/62, 29%) (p=0.003). H. pylori seropositivity was not associated with aortic atheroma (OR 2.9; 95% CI, 0.8-10.3; p=0.11) when CagA status is not taken into account. On multivariate analysis, parameters associated with risk of aortic atheroma were CagA-positive H. pylori seropositivity (OR 4.4; 95% CI, 1.4-14.7; p=0.01), older age (OR 1.2; 95% CI, 0.9-14.7; p=0.01), having ever smoked cigarettes (OR 3.6; 95% CI, 1.3-10.0; p<0.001), and elevated serum triglyceride level (OR 3.4; 95% CI, 1.3-9.4; p=0.02). CONCLUSIONS: After controlling for H. pylori infection and coronary artery disease risk factors, infection with a CagA-positive strain of H. pylori was independently associated with aortic atherosclerosis. This study suggests a gradient of atherosclerosis between uninfected individuals and patients with CagA-positive H. pylori infection and should prompt research into the role of CagA-positive H. pylori infection in the inflammatory atherosclerotic process.     

Determinants of the length of mechanical ventilation in patients with COPD in the intensive care unit

BACKGROUND: About 10% of the patients with chronic obstructive pulmonary disease (COPD) are at high risk for prolonged mechanical ventilation (MV >21 days), and mortality ranges from 55 to 78% in these patients. OBJECTIVE: To determine the potential risk factors for MV over periods of 1, 2 and 3 weeks in patients with COPD. PATIENTS AND METHOD: The characteristics of patients during the stable period of their disease, on admission to the intensive care unit (ICU) and during the ICU stay were recorded prospectively and analyzed retrospectively for this study. t test, chi(2) test and logistic regression analysis were used for statistical analysis. RESULTS: 86 patients with COPD requiring MV were included in the study. 73, 33, and 13% of the patients required MV longer than 1, 2 and 3 weeks, respectively. There were no significant relationships between the duration of MV and bronchiectasis or the presence of community-acquired pneumonia on admission, baseline pulmonary function test results or blood gas parameters on admission. Development of ventilator-associated pneumonia (VAP; odds ratio, OR: 6; 95% confidence interval, CI: 2-23, p = 0.011) and sepsis (OR: 10; 95% CI: 2-54, p = 0.007) were independent predictors for MV >7 days. VAP was still a risk factor for MV >15 days with an OR of 14 (95% CI: 3-66, p = 0.001). On the other hand MV >21 days was primarily determined by increasing age (OR: 1.2; 95% CI: 1-1.3, p = 0.042), severity of the disease on admission measured by APACHE II score (OR: 1.4; 95% CI: 1-1.7, p = 0.002) and albumin levels (OR: 0.10, 95% CI: 0.01-0.54, p = 0.007). CONCLUSION: Advanced age, severity of disease on admission and development of VAP during ICU stay are the main determinants of MV duration in patients with COPD.     

Bacteremia is a prognostic factor for poor outcome in spontaneous bacterial peritonitis

We performed a retrospective study to determine the influence of bacteremia on the mortality of patients with spontaneous bacterial peritonitis (SBP), a major complication of liver cirrhosis. Patients with SBP with identified pathogens from ascites and/or blood were analyzed by retrospective review of clinical and laboratory records in a university hospital in Korea for 3 y and classified into the bacteremic and non-bacteremic groups. The underlying liver function was determined by model for end-stage liver disease (MELD) score. Microbiological response rate, ascites polymorphonuclear leukocyte (PML) count reduction rate, and SBP-related mortality were compared between the 2 groups. To identify the independent risk factors of mortality, a multiple logistic regression model was used to control for the confounders. A total of 189 patients was enrolled in the study. Among 189 patients, 110 (58.2%) were bacteremic, and 79 (41.8%) non-bacteremic. Escherichia coli was the most common etiologic organism, followed by Klebsiella pneumoniae. MELD scores, microbiological response rate (82.6% vs 88.6%, p=0.295), and ascites PML count reduction rate (33.2% vs 44.8%, p=0.479) were not different between the bacteremic and non-bacteremic group. However, the SBP-related mortality rate of the bacteremic group was significantly higher than that of the non-bacteremic group (37.3% vs 12.7%, p<0.001). Bacteremia (OR=2.86: 95% CI 1.06-7.74, p=0.038), APACHE II score (OR=1.20: 95% CI 1.10-1.31, p<0.001), MELD score (OR=1.07: 95% CI 1.01-1.31, p=0.016) and microbiological no response (OR=5.51: 95% CI 1.82-16.72, p=0.003) were independent risk factors of SBP-related mortality.     

High concentrations of intrathecal interleukin-6 in human bacterial and nonbacterial meningitis.

Interleukin-6 (IL-6) is multipotent cytokine that acts in a network of factors directing the inflammatory reaction of purulent bacterial meningitis (PBM). However, little is known about the role of IL-6 in aseptic or "viral" meningitis (AM). IL-6 was assayed by RIA in cerebrospinal fluid (CSF) and serum samples obtained from patients with AM (n = 65), PBM (n = 8), and lymphocytic bacterial meningitis (LBM, n = 11). Of patients with AM, 89% had detectable IL-6 in CSF, with high IL-6 titers (median, 2160 pg/mL; 95% confidence interval [CI], 1320-2540 pg/mL) compared with 100% in patients with PBM (median, 6575 pg/mL; 95% CI, 450-32,000 pg/mL) and 90.9% in patients with LBM (median, 875 pg/mL; 95% CI, 150-2180 pg/mL). There was a highly symmetrical correlation between IL-6 and the percentage of polymorphonuclear cells in CSF of patients with PBM (r = .97, P = .01) and AM (r = .49, P = .002). In conclusion, this study shows evidence that IL-6 is released into the meningeal space in aseptic meningitis and is correlated with the local acute inflammatory response.