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 15,372 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Pulmonary infections are a very common complication in acquired immune deficiency syndrome (AIDS) patients. These infections may be severe enough to initiate the admission of these patients to intensive care units (ICU). Pneumocystis carinii pneumonia (PCP) is the most frequent cause of ICU admission because of acute respiratory failure. Mortality of ICU-admitted patients with this infection has changed with time. Initial reports confirmed a high mortality (80% to 90%). After 1985, the mortality rate decreased (50%). Factors such as the use of corticosteroids, better patient care, and a better knowledge of the disease probably explain this change. In recent years (1990 to 1995), mortality has worsened again, perhaps, because ICU facilities were offered more liberally to patients failing aggressive conventional treatment, including adjuvant therapy with corticosteroids. However, for those patients able to be discharged, the prognosis is not worse than expected according to the stage of their human immunodeficiency virus-1 (HIV-1) infection and immunologic status. Consequently, at least a limited period of ICU care and some respiratory support (either continuous positive airway pressure or mechanical ventilation) should be considered and offered to all HIV-1-infected patients with PCP and respiratory failure. Cytomegalovirus may be another cause of severe pulmonary infection in AIDS patients. This infection is difficult to diagnose; hence, it should be suspected when patients with PCP do not progress appropriately, or when no responsible pulmonary pathogen is found. When associated with PCP, mortality is very high. Disseminated tuberculosis is another potential cause of severe respiratory failure and respiratory secretions should be routinely examined for acid-fast bacilli in AIDS patients with pulmonary infiltrates. Finally, bacterial pneumonia (Streptococcus pneumoniae, Neisseria catarrhalis, Haemophilus influenzae, Staphylococcus aureus, and Pseudomonas aeruginosa) may also be the etiological agents of severe acute respiratory failure. Empiric antibacterial treatment to cover these microorganisms should be given when a bacterial agent is suspected.
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PMID:Severe pulmonary infections in AIDS patients. 877 81

Severe community-acquired pneumonia (CAP) is a life-threatening condition that requires intensive care unit (ICU) admission. Clinical presentation is characterized by the presence of respiratory failure, severe sepsis, or septic shock. Severe CAP accounts for approximately 5-35% of hospital-treated cases of pneumonia with the majority of patients having underlying comorbidities. The most common pathogens associated with this disease are Streptococcus pneumoniae, Legionella spp., Haemophilus influenzae, and Gram-negative enteric rods. Microbial investigation is probably helpful in the individual case but is likely to be more useful for defining local antimicrobial policies. The early and rapid initiation of empiric antimicrobial treatment is critical for a favorable outcome. It should include intravenous beta-lactam along with either a macrolide or a fluoroquinolone. Modifications of this basic regimen should be considered in the presence of distinct comorbid conditions and risk factors for specific pathogens. Other promising nonantimicrobial new therapies are currently being investigated. The assessment of severity of CAP helps physicians to identify patients who could be managed safely in an ambulatory setting. It may also play a crucial role in decisions about length of hospital stay and time of switching to oral antimicrobial therapy in different groups at risk. The most important adverse prognostic factors include advancing age, male sex, poor health of patient, acute respiratory failure, severe sepsis, septic shock, progressive radiographic course, bacteremia, signs of disease progression within the first 48-72 hours, and the presence of several different pathogens such as S. pneumoniae, Staphylococcus aureus, Gram-negative enteric bacilli, or Pseudomonas aeruginosa. However, some important topics of severity assessment remain controversial, including the definition of severe CAP. Prediction rules for complications or death from CAP, although far from perfect, should identify the majority of patients with severe CAP and be used to support decision-making by the physician. They may also contribute to the evaluation of processes and outcomes of care for patients with CAP.
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PMID:Optimizing treatment outcomes in severe community-acquired pneumonia. 1472 21

Ventilator-associated pneumonia (VAP) is a common complication of ventilatory support for patients with acute respiratory failure and is associated with increased morbidity, mortality, and costs. Awareness of the microbiology of VAP is essential for selecting optimal antibiotic therapy and improving these outcomes. The specific microbial causes of VAP are many and varied. Most cases of VAP are caused by bacterial pathogens that normally colonize the oropharynx and gut, or that are acquired via transmission by health-care workers from environmental surfaces or from other patients. Common pathogens include Pseudomonas species and other highly resistant Gram-negative bacilli, staphylococci, the Enterobacteriaceae, streptococci, and Haemophilus species. Antibiotic-resistant pathogens such as Pseudomonas and Acinetobacter species and methicillin-resistant strains of Staphylococcus aureus are much more common after prior antibiotic treatment or prolonged hospitalization or mechanical ventilation, and when other risk factors are present. The bacterial pathogens responsible for VAP also vary depending on patient characteristics and in certain clinical circumstances, such as in acute respiratory distress syndrome or following tracheostomy, traumatic injuries, or burns. But these differences appear to be due primarily to the duration of mechanical ventilation and/or degree of prior antibiotic exposure of these patients. The causes of VAP can vary considerably by geographic location (even between units in the same hospital), emphasizing the importance of local epidemiological and microbiological data. Atypical bacteria, viruses, and fungi also have been implicated as causes of VAP, but these pathogens have not been studied systematically and their role is presently unclear. In conclusion, information about the microbiology of VAP serves to guide optimal antibiotic therapy. The risk of antibiotic-resistant pathogens can be estimated using simple clinical features and awareness of local microbiology patterns. The roles of atypical bacterial and nonbacterial pathogens in VAP are incompletely understood and should be investigated further.
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PMID:The microbiology of ventilator-associated pneumonia. 1591 66

Pulmonary infections span a wide spectrum, ranging from self-limited processes (e.g., tracheobronchitis) to life-threatening infections including both community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Together, pneumonia and influenza rank as the sixth leading cause of death in the United States and lead all other infectious diseases in this respect. Pneumonia is the second-most-common hospital-acquired infection in the United States, accounting for 17.8% of all hospital-acquired infections and 40,000 to 70,000 deaths per year. HAP is the most common nosocomial infection occurring in patients requiring mechanical ventilation, developing in 6.5% of patients after 10 days and in 28% of patients after 30 days of ventilatory support. Patients acquiring HAP have a greater risk of mortality than comparably ill ventilated patients who do not develop pneumonia. Ventilator-associated pneumonia (VAP) specifically refers to a bacterial pneumonia developing in patients with acute respiratory failure who have been receiving mechanical ventilation for at least 48 hours. The etiologic bacteriologic agents associated with VAP typically differ based on the timing of the occurrence of the infection relative to the start of mechanical ventilation. VAP occurring within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-sensitive bacteria that colonize the patient prior to hospital admission (e.g., Streptococcus pneumoniae, Haemophilus influenza, oxacillin-sensitive Staphylococcus aureus). VAP developing after 96 hours of ventilatory support is more often associated with antibiotic-resistant bacteria including oxacillin-resistant Staphylococcus aureus, Acinetobacter species and Pseudomonas aeruginosa. However, more recent data suggest that hospitalization and exposure to antibiotics prior to the start of mechanical ventilation are important risk factors for the occurrence of VAP attributed to antibiotic-resistant bacteria. Therefore, these risk factors should be considered when deciding on an appropriate empiric antibiotic regimen regardless of the onset of VAP. VAP and catheter-associated bloodstream infections are the leading causes of infection acquired in the intensive care unit (ICU) setting. Patients in the ICU have rates of HAP that are as much as five to ten times higher than the rates in general hospital wards. Additionally, like nosocomial bloodstream infections, VAP is associated with an attributable mortality beyond that accounted for by patients' severity of illness. The attributable mortality associated with VAP appears to be greatest for "high-risk'' antibiotic-resistant bacteria including Pseudomonas aeruginosa and oxacillin-resistant Staphylococcus aureus. The greater hospital mortality associated with these "high-risk'' pathogens has been attributed to the virulence of these bacteria and the increased occurrence of inadequate initial antibiotic treatment of VAP due to the presence of antibiotic resistance. This review provides an overview of the clinical importance of VAP. We then describe how this nosocomial infection influences the management and outcomes of patients with the acute respiratory distress syndrome (ARDS).
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PMID:Ventilator-associated pneumonia complicating the acute respiratory distress syndrome. 1608 83

Lower respiratory tract infection is easily suggested on clinical signs (cough and sputum) associated with fever. To discriminate between pneumonia and acute bronchitis is crucial because of the mortality associated with pneumonia and of its specific management. Chest X-ray is a key exam for the diagnosis and should be performed on the basis of validated clinical signs that are however of weak diagnostic value. Clinical as well as radiological signs cannot be reliably used to identify the causative germ. Sputum examination, the search for pneumococcal and legionella urinary antigens are of good diagnostic value. An associated COPD may lead to an acute respiratory failure. Acute exacerbation of chronic bronchitis results from various causes but infection is involved in about 50% of the cases, mostly viral and most often due to a rhinovirus. Viral infection can be associated to bacterial infection and the most frequently isolated germs are Streptococcus pneumoniae, Haemophilus influenzae, and B. catarrhalis. Severity assessment relies on the value of basal FEV1 that is often non available. Therefore Afssaps suggests using a dyspnea index to assess exacerbation severity.
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PMID:[Definition of low respiratory tract infections]. 1683 58