Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes?

PURPOSE OF REVIEW: Associations between processes of care for hospitalized community-acquired pneumonia patients and clinical outcomes are important because of the high incidence of such admissions and substantial related mortality. Several studies have examined these associations. RECENT FINDINGS: Large retrospective studies of older patients have demonstrated associations between time to first dose as short as 4 h and length of stay and mortality during and after hospitalization. Results of smaller studies have been less consistent. The association appears to be strongest among older patients who have not received antibiotics prior to arrival at the hospital. SUMMARY: A significant and causal relationship appears to exist between antibiotic timing and improved outcomes, especially among older patients. Even modest improvements in timeliness of antibiotic administration could impact a substantial number of lives because of the high incidence of community-acquired pneumonia hospitalization.     

How gluten-free is gluten-free,and what does this mean to coeliac patients?

A gluten-free diet is the cornerstone treatment of coeliac disease. Until now, it is not known conclusively whether trace amounts of gluten might be allowed in the diet, as suggested by Codex Alimentarius. Gluten-free foods intended for dietary use can now be analysed reliably for residual gluten by the new R5 enzyme-linked immunosorbent assay (ELISA) system. Some major problems of gluten analysis (sensitivity, specificity, reproducibility) can be solved by the new method. Therefore, the information given by the new test system is relevant and superior to earlier methods. Further clinical studies using small dose challenges and dietary records including gluten analysis are necessary until a more meaningful discussion on standards for gluten-free foods can be started.     

Empiric therapy of community-acquired pneumonia: guidelines for the perplexed?

This article discusses the key clinical aspects of empiric therapy of community-acquired pneumonia (CAP). Antibiotic selection, severity of CAP, single vs multiple pathogens, pharmacokinetic considerations, antibiotic resistance, i.v. vs oral antibiotic therapy for CAP, oral therapy for non-ICU hospitalized patients with CAP, beta-lactams, macrolides, ketolides, doxycycline, respiratory quinolones, and pharmacoeconomic implications are discussed.     

ST elevation after myocardial infarction: what does it mean?

See article on page 1376     

Changes in the incidence of inflammatory bowel disease: what does it mean?

A sharp rise in the incidence of inflammatory bowel disease (IBD) has been observed in the western world since the early 1950s. The increase in the incidence of ulcerative colitis preceded the increase in the incidence of Crohn's disease by about 10-15 years. In high-incidence areas, a female preponderance at a young age (20-40 years) is observed in Crohn's disease, whereas in ulcerative colitis male incidence is still high at older ages. IBD is more common in the developed world than in the developing world and, in both the United States and Europe, a north-south incidence gradient has been reported, with IBD more common in the north than in the south. There are also indications that, in typically low-incidence areas, more cases are being seen lately. At present, IBD is rather common in western Europe, affecting 0.5-1.0% of the population during their lifetime. It will be interesting to follow these temporal trends in the coming years, as they may teach us more about the role of environmental factors in the pathogenesis of IBD.     

Occult hepatitis C virus infection: what does it mean?

Occult hepatitis C virus infection (OCI) is a recently identified entity of which the existence became evident when nucleic acid amplification assays of enhanced sensitivity were introduced for the detection of hepatitis C virus (HCV) genome and its replication. This form of HCV infection has been found to persist in the presence of antibodies against HCV and normal levels of liver enzymes for years after spontaneous or antiviral therapy‐induced resolution of hepatitis C and, therefore, can be termed as secondary OCI. HCV RNA in OCI circulate at fluctuating levels normally not exceeding 200 genome copies per millilitre of serum or plasma, while low levels of virus genome and its replicative intermediate RNA‐negative strand are detectable in the liver and, importantly, immune cells, which provide an opportunity to detect active virus replication without the need for acquiring a liver biopsy. In addition to secondary OCI, a form of OCI accompanied by persistently moderately elevated serum liver enzymes in the absence of antibodies to HCV, which can be termed as cryptogenic OCI, has also been described. The current understanding of the nature and characteristics of OCI, methods and pitfalls of its detection, as well as the documented and expected pathological consequences of OCI will be summarized in this review.     

Transfusion immunomodulation or TRIM: what does it mean clinically?

Evidence from a variety of sources indicate that allogeneic blood transfusions can induce clinically significant immunosuppression, as well as other effects, in recipients. This clinical syndrome is generally referred to in the Transfusion Medicine literature as transfusion-associated immunomodulation, or TRIM. TRIM has been linked to an improved clinical outcome in the setting of renal allograft transplantation. Possible deleterious TRIM-associated effects include an increased rate of cancer recurrence and of post-operative bacterial infection. The recognition that TRIM can increase morbidity and mortality in allogeneically transfused individuals has become a major concern for those involved in Transfusion Medicine. However, based on available randomized controlled trials, whether TRIM predisposes recipients to increased risk for cancer recurrence and/or bacterial infection is still unproven. In contrast, data from experimental animal studies suggest that TRIM is an immunologically mediated biological effect, associated with the transfusion of allogeneic leukocytes; an effect, which can be completely ameliorated by the pre-storage leukoreduction of blood products. Relevantly, several (n = 5) recent large observational trials have provided important evidence for the existence of deleterious TRIM and related effects (mortality and organ dysfunction) of leukocyte-containing allogeneic cellular blood products. These latter data suggest that allogeneic blood product transfusions, containing leukocytes, are associated with an increased risk both for mortality, and organ dysfunction in recipients.     

Severe community-acquired pneumonia: what's in a name?

PURPOSE OF REVIEW: Formerly, patients with community-acquired pneumonia admitted to an intensive care unit were considered as having the severe form of the disease. Recently, guidelines have distinguished severe and non-severe community-acquired pneumonia based on clinical definitions. In this review, we describe the different definitions of severe community-acquired pneumonia, and whether a differentiation based on these definitions reflects variation in etiology, risk factors, diagnostic approaches and treatment. RECENT FINDINGS: New definitions do not seem to accurately identify patients with high risks of mortality; patients not admitted to an intensive care unit could also be diagnosed as having severe community-acquired pneumonia. Host-factors, such as genetic factors and underlying diseases, can influence severity of presentation of community-acquired pneumonia. Distribution of pathogens in severe and non-severe disease forms is comparable. Initial antibiotic therapy in patients with severe disease should provide coverage of Streptococcus pneumoniae and Legionella pneumophila, as delay is associated with worse outcomes. However, recent studies also suggested an additional benefit of atypical coverage in non-severe disease. As a result, initial therapy with a beta-lactam plus a macrolide or an anti-pneumococcal fluoroquinolone is recommended for all patients with community-acquired pneumonia. Furthermore, the value of vaccination against pneumococci to prevent episodes of severe disease is yet unknown. SUMMARY: As current guidelines do not adequately identify patients with high risk of mortality and intensive care unit admittance, clinical judgment remains important. Based on distribution of pathogens, investigational procedures and therapy recommended in recent guidelines, differentiation between severe and non-severe community-acquired pneumonia does not seem useful. Whether atypical coverage indeed has additional value in non-severe or pneumococcal CAP, however, remains to be determined. In addition, the preventive benefit of influenza and pneumococcal vaccination for development of SCAP awaits further evidence.