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Background: A substantial proportion of patients admitted to the hospital for pneumonia have been treated in a hospital during the preceding 4 to 5 years, and patients previously treated in a hospital for pneumonia seem to be at an especially high risk for another episode of pneumonia. Many cases of pneumococcal infection might therefore be prevented by immunizing admitted patients with pneumococcal vaccine at discharge or at follow-up. The aim of this study was to investigate the type-specific antibody response to pneumococcal vaccine in middle-aged and elderly patients at follow-up 8 weeks after hospital treatment for pneumonia. Methods: A total of 92 individuals, 50 to 85 years old, participated in the study. One group consisted of 65 individuals treated in the hospital for pneumonia 8 weeks before vaccination (mean age, 67 years), and another group consisted of 27 individuals who had not recently been treated for pneumonia (mean age, 67 years). All 92 individuals received a single dose of a 23-valent pneumococcal vaccine. The type-specific antibody responses to six pneumococcal capsular polysaccharide antigens included in the vaccine as well as antibodies against the 23-valent pneumococcal vaccine were measured before and 3 to 4 weeks after vaccination by use of an enzyme-linked immunosorbent assay. Results: The antibody concentrations before and after vaccination were comparable in the two groups, as were antibody fold increases from prevaccination to postvaccination serum. No serious adverse events were recorded. Conclusions: Pneumococcal vaccination at follow-up 8 weeks after treatment in the hospital for pneumonia seems to elicit an adequate antibody response without notable adverse reactions. (Arch Intern Med. 1994;154:1961-1965)

The case fatality rate in bacteremic pneumonococcal pneumonia (Pnb) has been reported to be lower in Sweden than in the United States. We retrospectively compared 231 adult Pnb patients in [...]

A model for performing fiberoptic bronchoscopy as a supplement to noninvasive diagnostic methods, in patients with community-acquired pneumonia, was prospectively studied. Twenty-four patients underwent bronchoscopy, seven pilot patients and 17 [...]

Abstract: Alemtuzumab (Campath-1H) is a humanized CD52 monoclonal antibody that targets normal as well as malignant B- and T-lymphocytes. Alemtuzumab has significant antitumor activity in chronic lymphocytic leukemia (B-CLL) but also induces immunosuppression. We describe a case of fatal adenovirus infection in a heavily pretreated patient with fludarabine-refractory B-CLL receiving alemtuzumab therapy, drawing attention to the fact that also viruses other than cytomegalovirus (CMV) and herpes simplex (HSV) need to be considered in B-CLL patients with fever of unknown origin while on alemtuzumab treatment.

The efficacy of oral acyclovir, a purine nucleoside analogue with activity against human herpes viruses, is limited as a result of its low bioavailability. Valacyclovir, the L-valyl ester of acyclovir, has been developed as a pro-drug to improve the bioavailability. The aim of the present study was to compare the pharmacokinetics of acyclovir after intravenous administration and after oral administration of vala cyclovir. The pharmacokinetics of acyclovir were studied in 18 children aged 1.4–18.1 years (median: 6.9 years; 9 females) after intravenous infusion (1 hr; median dose: 10.5 mg/kg). In 10 of the children the pharmacokinetics of acyclovir were also studied after oral administration of valacyclovir (median dose: 34.1 mg/kg). Quantification of acyclovir in serum was performed by reversed-phase liquid chromatography with fluorometric detection. The pharmacokinetic analysis was performed by pharmacokinetic modelling. The serum concentration versus time curves of acyclovir were described by the two compartment model after intravenous administration and by the one compartment model with a zero- or first-order absorption phase after oral administration of valacyclovir. The bioavailability of acyclovir after oral administration of valacyclovir was 45% (median value; 95% CI: 37–55%). It is possible to substitute intravenous acyclovir therapy by oral valacyclovir therapy in children with leukopenia and mucositis after chemotherapy. This finding can at present not be fully implemented in clinical practice, since a commercial pharmaceutical formulation of valacyclovir aimed for children not able to swallow intact tablets is lacking. Crushed valacyclovir tablets have a very unpleasant taste, but can be administered to children through nasogastric tubes. Med. Pediatr. Oncol. 2002;38:240–246. © 2002 Wiley-Liss, Inc.

The objectives of this study were to estimate the feasibility of a self-administration outpatient parenteral antibiotic therapy (OPAT) model, to record the complication rate and to estimate patient acceptance during the OPAT period in patients with acute leukaemia (AL) or aggressive non-Hodgkin lymphoma (NHL). Patients were trained to administer the antibiotic infusions themselves, via their central venous access device, according to a checklist and step-by-step instructions. Study-specific questionnaires were used to evaluate patient acceptance. Eleven patients [AL (n=8) and NHL (n=3), median age 51 years, range 29–66] participated in the education programme and subsequent OPAT during ten episodes of documented infection and six episodes of fever of unknown aetiology. All patients had assessment of the infectious episode and initial parenteral antibiotic therapy in the hospital before they continued self-administration at home. The median education time was 3 h (range 0.75–4.5). The patients could stay at home for 4 days (median, range; 1–12) with ongoing intravenous antibiotic therapy instead of being hospitalised. None of the patients developed recurrent fever. All patients reported that OPAT was of great value and they would favour OPAT again during subsequent antibiotic therapy. In conclusion, the results of this pilot series suggest that OPAT, in this setting, is a safe alternative during the last days of an episode of fever / infection. All patients were satisfied overall, and none was readmitted.

Toxic deaths due to intensified treatment are of increasing concern in view of the generally improved prognosis for children with malignancies. Pneumocystis carinii pneumonia (PCP) during immunosuppressive treatment in children with malignancies is a severe complication with a poor prognosis if mechanical ventilation is required. Extracorporeal membrane oxygenation (ECMO) is a recognized technique that provides temporary respiratory support for patients with intractable respiratory failure. We here report successful ECMO support in four children with PCP, secondary to chemotherapy-induced immunosuppression, in whom the respiratory situation deteriorated despite pharmacological treatment and mechanical ventilation. The duration of ECMO was 7–43 days. Three children with acute lymphoblastic leukemia recovered from their PCP to continue chemotherapy and are now in complete continuous remission. Their pulmonary function normalized completely during 6–12 months after ECMO therapy. One child with a primitive neuroectodermal tumor survived the PCP and was off ECMO for 11 days before succumbing to unrelated complications. We conclude that ECMO offers an important means of respiratory support in children with severe PCP that can also be adopted during treatment for malignant disease. Med. Pediatr. Oncol. 32:25–31, 1999. © 1999 Wiley-Liss, Inc.

The enzyme linked immunosorbent assay (ELISA) was used for estimation of the IgG and IgM antibody responses against 13 type specific pneumococcal capsular polysaccharides, individually and in a pool, in 52 patients with pneumococcal pneumonia and in 20 control patients with non-pneumococcal pneumonia or enterobacterial septicemia. By use of the isolated type 3 polysaccharide as antigen a ≥50% increase in absorbance from acute to convalescence phase serum, equivalent to a doubling in antibody titer, was seen significantly more often in 22 patients with type 3 pneumococcal pneumonia than in the 20 control patients (for IgG 14 vs. 3, p< 0.01; for IgM 14 vs. 4, p< 0.01). However, for an acceptable degree of specificity to be obtained (≤10% control patients positive) a doubling of the IgG or IgM absorbance values had to be demanded. With this criterium only half of the patients infected with pneumococcal types included in the antigen set up used, showed a type specific antibody response and only one third of all patients with pneumococcal pneumonia could be diagnosed by use of the 13 polysaccharides as a pool antigen.

Recurrent epidemic spread of β-hemolytic streptococci of Lancefield group A was seen in our maternity wards during a period when 70% ethanol was used for umbilical care. This prompted us to compare this regimen with one using 4% chlorhexidine in detergent for a period of 9 consecutive months. 2016 infants were studied. Umbilical colonization with group A, C and G streptococci was almost eliminated by use of 4 % chlorhexidine in detergent and epidemic spread was not seen. Colonization rate of Staphylococcus aureus at the umbilical cord was reduced from 92% to 27%. The incidence of superficial infections during the first 4 postnatal weeks was reduced. Following the 9 months of comparative study 4% chlorhexidine in detergent has been routinely used in umbilical cord care at our hospital for more than 1 year without any epidemic spread of streptococci and with the same antibacterial efficiency.

Of 191 consecutive clinical isolates of Streptococcus pneumoniae tested for antibiotic susceptibility with the agar dilution technique 87 % were fully sensitive to all of 11 antimicrobial agents examined. 90 % of the strains were inhibited by 0.016 μg/ml of benzylpenicillin, by 0.032 μg/ml of ampicillin, cefuroxime, erythromycin, clindamycin or rifampicin, by 0.13 μg/ml of cephalothin, oxacillin or doxycycline, by 4.0 μg/ml of chloramphenicol and by 8.0 μg/ml of cotrimoxazole. 18 strains exhibited a reduced susceptibility to one (11 strains) or more (7 strains) of erythromycin, doxycycline, chloramphenicol and cotrimoxazole. One of these strains also showed a reduced susceptibility to all 5 examined beta-lactamantibiotics, as did another 4 strains. Two of these 5 strains were isolated from small children recently adopted from 2 Asian countries. Cotrimoxazole-resistant strains were significantly more often isolated from children 1 yr of age or less than from older patients. All strains were fully sensitive to clindamycin and rifampicin. The existence of pneumococcal strains with resistance or reduced susceptibility to antibiotics commonly used for treatment of pneumococcal infections is important to bear in mind and nessecitates antibotic susceptibility testing of strains isolated from patients with severe infections.

In a prospective randomized comparison, 217 episodes of fever (oral temperature > 38.5°C on 1, or 38.0°C on 2 occasions with a minimum interval of 4 h between recordings) during neutropenia (neutrophil count <0.5× 109/l), patients were empirically treated with trimethoprim-sulfamethoxazole plus amikacin (TMP/SMZ plus AMI) or ceftazidime. Successful antibiotic treatment was defined as eradication of all signs, symptoms and microbiological evidence of infection on the primary therapy alone. The overall success rate did not differ between the 2 treatment groups: 31/102 (30%; 21-39%, 95% confidence interval, CI) for TMP/SMZ plus AMI and 41/115 (36%; 27-44%) for ceftazidime (difference 0.06 ±0,13, 95%, CI). The corresponding numbers for documented infections were 12/50 (24%; 12-36%) and 14/60 (23%; 12-35%), respectively (difference 0.01 ±0.16). One patient in the TMP/SMZ plus AMI group and 2 patients in the ceftazidime group died from Gram-negative bacteraemias within 72 h. No other early deaths were observed. Antibiotics were changed due to adverse events in 2 episodes of each treatment group. In conclusion, this study demonstrates that TMP/SMZ plus AMI combination is comparable (i.e. a difference of <20%) to ceftazidime monotherapy with regard to efficacy and safety in haematological patients with severe neutropenia. Both regimens require frequent modifications, particularly in bacteraemic fever episodes. However, in centres with a low frequency of isolation of Pseudomonas and especially of multi-resistent Pseudomonas strains, TMP/SMZ plus AMI offers an inexpensive alternative for the empirical treatment of febrile neutropenia.

279 patients with 285 episodes of bacteremic pneumococcal pneumonia (Pnb), treated at the 2 departments for infectious diseases in Stockholm Sweden, were reviewed retrospectively. Almost half of all episodes were caused by serotypes 3, 9 and 4 (in that order). The overall mortality rate was 7% and as low as 5% if patients with extrapulmonary complications were excluded. As in other studies male sex, alcoholism and absence of leukocytosis on admission to hospital were all associated with a higher mortality rate. However, the prognosis for old patients was much better than in most other studies. This was true also when the infecting strain was of serotype 3. For 89 consecutive patients out of the 279 ones with Pnb the clinical, laboratory and chest X-ray data were compared with those of 44 patients with non-bacteremic pneumococcal pneumonia (Pn) and 27 patients with Mycoplasma pneumoniae pneumonia (MP). Within the pneumococcal group almost all non-bacteremic patients had respiratory tract symptoms compared to less than half of the patients with bacteremic disease. High age, alcoholism, chills, pleuritic chest pain, a leukocyte count of >15×109/l and an elevated CRP were factors significantly more common among those with pneumococcal pneumonia than among the MP patients. On chest X-ray an alveolar pattern was seen in all but 2 of the totally 133 patients with a pneumococcal pneumonia, but also in half the patients with MP.

AbstractDuring 1976–1978 1 347 pneumococcal strains from 3 bacteriological laboratories in the Stockholm region were typed using antisera from the State Serum Institute, Copenhagen, Denmark. Typing was done with immunoelectroosmophoresis (IEOP), which has been found to be a simple and reliable method for this purpose. In the whole material types 6, 23, 19 and 3 were the most common, accounting for 21, 18, 17 and 12, respectively. Types 6, 19 and 23 dominated greatly in children <7 years, accounting for 67 of the isolates; a more even distribution with type 3 as the most frequent (16) pneumococcal type was seen in people ≥15 years. In relation to their overall frequency, type 4, and to a lesser degree types 3, 8 and 9, were more often isolated from blood and spinal fluid. Types 3 and 9 were also more frequently isolated from patients with pneumonia than from pneumococcal carriers, while types 6 and 19 were more frequent in carriers. Types represented in the recently introduced 14-valent pneumococcal vaccine constituted 70–86.

Sputum samples from 151 patients admitted to Roslagstull Hospital for Infectious Diseases, Stockholm, from Sept. 1978 through May 1979 with acute community-acquired lower respiratory tract disease and roentgenological evidence of acute pneumonia were examined by direct microscopy of gram-stained smears and semiquantitative culture. It was carefully noted if the specimen was collected before or after initiation of antibiotic therapy. For an estimate of the suitability of the samples for bacteriological examination 2 criteria were applied: (i) presence of alveolar macrophages, and (ii) purulence, i.e. a ratio leukocytessquamous epithelial cells of >5. The latter was found to be a good indicator of sample suitability, while the presence of macrophages was not. Of the 266 samples examined 76 were deemed purulent. Potentially pathogenic bacteria in numbers of ≥105colony forming unitsml were found in 67 of the purulent sputum samples obtained before antibiotic therapy but in only 36 if such treatment had already been started. Pneumococci were isolated from 52 of pre-treatment samples but from only 8 after treatment. H. influenzae was found as often in post-treatment samples (17) as in pre-treatment ones (16) and enteric gram-negative rods twice as often in post-treatment samples (11 vs. 6). The use of gram-stained smears was a valuable aid in the interpretation of the culture results and the results could be made available to the clinician within minutes after receipt of the specimen. The results were in agreement with those of the cultures for about 75 of the purulent samples.

Rapid diagnostic methods are important in managing respiratory tract infections and in identifying epidemics at an early stage. In viral infections, diagnosis may be obtained in 1 to 5 hours by the detection of viral antigens or nucleic acids directly in the clinical specimen. During the past year, excellent reports have been published on the use of such methods for diagnosis of the influenza, parainfluenza, respiratory syncytial, rhino-, and adenoviruses. Polymerase chain reaction and sensitive immunoassays can also be used to detect other agents not normally present in theairways, ie, Mycoplasma, Chlamydia, Legionella, and Pneumocystisorganisms and Mycobacterium tuberculosis. Inthe management of bacterial pneumonia, however, gram stain of sputum with an assessment of sputum quality and bacterial numbers is still very useful because the mere presence of the commonly causative bacteria does not imply a causative diagnosis. Detection of soluble pneumococcal polysaccharide antigen may give supplementary information, especially in patients treated with antibiotics and in those unable to produce a representative sputum specimen. Broncho-scopically obtained material is preferred when possible, both for bacterial culture and for a rapid diagnostic test.

Attempts to demonstrate Streptococcus pneumoniae, or its soluble type-specific polysaccharide antigen were made on specimens from 205 patients with acute community-acquired pneumonia by (i) blood, nasopharynx and sputum culture, (ii) counterimmunoelectrophoresis (CIE) of serum, urine and sputum specimens utilizing omni-, pool- and type-specific rabbit antisera, and (iii) microscopy of gram-stained sputum smears. Pneumococci could be cultured andor pneumococcal antigen detected in specimens from 93 (45) of the patients with the following frequencies in samples obtained before (and after) start of antimicrobial treatment: culture from blood 25 (6), nasopharynx 59 (18) and sputum 80 (13), CIE on serum 3 (9), urine 8 (18), urine 20× concentrated 18 (24), and sputum 56 (56). Microscopy of sputum smears revealed pneumococci in 65 (17) of the 93 patients. The value of cultures from blood and sputum was most evident when the samples were obtained early in the course of the disease. With nasopharynx culture and CIE on sputum the number of positive results was doubled if the sampling was repeated. For rapid diagnosis direct Gram stain and CIE on sputum were about equally effective and also strikingly complementary, alone diagnosing 42 and 48 of the patients, respectively, but together detecting 65 of them. Gram stain was most rewarding on early pretreatment samples and CIE on post-treatment samples.

In order to investigate the predisposing conditions and aetiologic agents in patients with recurrent pneumonia, we prospectively studied 653 immunocompetent patients, 50-85 years of age, who had been treated in hospital for community-acquired pneumonia. After an average patient follow-up period of 32 months, 11 variables were examined for association with the following end points: death, recurrence of pneumonia and recurrence of pneumococcal pneumonia. During the follow-up period there were 171 episodes of pneumonia in 115 of the 653 patients, and 52 deaths (all causes). Multivariate analysis showed that age, male sex, congestive heart failure and presence of other chronic diseases were significantly associated with higher mortality. Age and chronic pulmonary disease were associated with recurrence of pneumonia. The major aetiologic agents were Streptococcus pneumoniae (26%), Haemophilus influenzae (11%) and Moraxella catarrhalis (6%). We conclude that pneumonia recurrences are common in middle-aged and elderly patients after treatment in hospital for community-acquired pneumonia. The recurrence risk is higher in elderly patients, and in those with chronic pulmonary diseases. Given the prominence of H. influenzae and M. catarrhalis found in the present study, these organisms should always be considered when choosing the initial antibiotic in patients with recurrent pneumonia.

AbstractThree cases of non-neonatal group B streptococcal meningitis are described. All cases occurred in 1974 suggesting an increased incidence of the disease, which has been reported rarely in the past. The etiologic significance of the isolated group B streptococci was confirmed by demonstration of precipitating antibodies by crossed immunoelectrophoresis.

The diagnostic and prognostic value of admission serum levels of interleukin-6 (IL-6) and C-reactive protein (CRP) was investigated in 203 hospital-treated patients with community-acquired pneumonia (CAP). In serum samples obtained during the first 24 h after admission, IL-6 was detectable in 198 patients (98%), with a median value of 50 ng/l. Ten % of the patients had IL-6 values of 1000 ng/l. A clear positive correlation between IL-6 and CRP was found (r = 0.29, p < 0.0001). Patients with high IL-6 or CRP levels had longer duration of fever, longer hospital stay, and had less often recovered clinically or radiographically on follow-up weeks after discharge. A high IL-6, but not a high CRP, also seemed to be associated with a higher mortality. Bacteremic pneumococcal pneumonia had the highest levels of IL-6 (mean 2852 and median 420 ng/l) and CRP (mean 292 and median 285 mg/l). High IL-6 values were also seen in patients with non-bacteremic pneumococcal pneumonia, while all patients with pneumonia due to other bacterial, or viral, aetiology had IL-6 levels of ≤ 300 ng/l. In conclusion, IL-6 and CRP are promising diagnostic and prognostic tools in the management of CAP. Further studies are needed to establish the usefulness of repeated measurements early in the hospital course of the disease.

Cancer patients, especially those with acute leukaemia, represent a group that has the greatest risk for deep fungal infection. Almost no cases were seen before the advent of modern chemotherapy, and prior to the availability of antibacterial agents, less than 5% of’ patients with acute leukaemia died of fungal infection. These infections are now responsible for 40% or more of the deaths at some institutions. Candida species continues to be the most common fungal pathogen. Rapid and specific diagnosis of invasive candiosis enabling early effective therapy is therefore an important measure for reducing mortality in patients. Here the current status of clinical and laboratory diagnosis of invasive Candida infection in neutropenic patients is discussed and recommendations made as to future development programmes.

Patients with pneumonia not responding to treatment with betalactam drugs and patients where an "atypical" etiology is suspected from the beginning, are often given erythromycin to cover mycoplasma and legionella. Erythromycin has also been effective for Chlamydia pneumoniae. If, however, ornithosis is suspected the recommended drug has been tetracycline. Since we noted that several patients had a favourable course on erythromycin despite a final serological diagnosis of ornithosis, we retrospectively studied patients admitted with acute lower respiratory tract infection and a 4-fold titer rise to C. psittaci. We found 35 patients treated with a betalactara drug (n = 12), tetracycline (n = 2), or erythromycin (n = 5) alone, or with a betalactam, which because of nonresponsiveness was followed by either tetracycline (n = 4) or erythromycin (n = 12). The data were analysed with survival analysis by a Cox' regression model. There was a significant (p < 0.001) effect of treatment on the time to defervescence, mainly due to a difference between the erythromycin treated group and the betalactam treated group. We found erythromycin to be at least as effective as tetracycline for treating C. psittaci pneumonia. Since erythromycin has to be used to cover legionella in patients with severe pneumonia when an atypical etiology cannot be excluded, it is an important conclusion that this drug seems to cover C. psittaci as well.

ABSTRACTThe median bioavailabilities of aciclovir after administration of aciclovir and its prodrug valaciclovir were 21.5 and 70.1%, respectively, in 12 patients with malignant hematological diseases with leukopenia after chemotherapy. The interindividual variations of the bioavailability were 48.5 and 21.0% after administration of aciclovir and valaciclovir, respectively. Neither the bioavailability nor the interindividual variation of area under the concentration-time curve of oral aciclovir or valaciclovir differed from that reported in healthy volunteers.

AbstractA 24-year-old woman acquired a Staphylococcus aureus pneumonia during an influenza A infection. The disease progressed despite treatment with cloxacillin. The staphylococcal strain isolated was found to be tolerant to the bactericidal activity of cloxacillin. Clinical improvement was seen with gentamicin in combination with cefuroxime.

AbstractA 22-year-old woman had a remarkably late and poor inflammatory response to pneumococci invading the cerebrospinal fluid. Splenectomy 5 years previously following trauma and oral doxycycline therapy for 4 days prior to admission may explain the unusual course. The importance of correct handling and of giving proper information to the splenectomized patient is stressed.

The case fatality rate among adults with community-acquired bacteremic pneumococcal pneumonia (Pnb) in Stockholm in 1984 was 11% (7/62), corresponding to an incidence of fatal Pnb of 0.5/100000. This figure is low compared to data from the US and the UK, but corresponds well to our finding of a 7% mortality among patients with Pnb in a recent study covering part of the Stockholm population (2 hospitals).

Bacteremia is a major cause of morbidity and mortality in patients with hematological disorders during chemotherapy-induced neutropenia. Initial antimicrobial treatment is chosen empirically. Increasing antimicrobial resistance is a global obstacle for improving outcome for hematological patients. The aim of this study was to compare temporal trends in species distribution and antimicrobial susceptibility in bacteremic patients hospitalized in a hematology ward at Karolinska University Hospital, Stockholm, Sweden, over a 21-year period.A total of 794 clinically significant isolates, 667 clinical episodes of bacteremia in 463 patients were identified during the last 7 years and the results were compared with those published from the same ward during the preceding 14 years. Isolates and episodes were identified from the laboratory information system, which has been in use during the entire 21-year period. For coagulase-negative staphylococci (CoNS), Corynebacterium spp., Propionibacterium spp. and Bacillus spp. bacteremia was considered significant only if the isolates were detected in two or more blood specimens. No major changes in patient selection were introduced during these 21 years and quinolone prophylaxis was used only to a very limited extent.Any shift between Gram-negative and Gram-positive bacteria has not been noted at any time and the proportion of Gram-positive isolates has remained at a level of 53–55%. In the last 7-year period the male patient predominance increased from 58% to 62%, and the median age increased from 58 to 62 years. The 7- and 30-day crude mortality rates were 5.3% and 14.8%, respectively, compared with 6.3% and 16% in the preceding 7-year period (p>0.05). Polymicrobial bacteremia, defined as growth of more than one organism during the same bacteremic episode within 24 hours or 72 hours, was seen in 13.7% and 14.8% of patients respectively, compared to 11% (24 hours) in the preceding 7-year period (p>0.05). Polymicrobial bacteremia was seen in 25% and 28% respectively of patients who died within 7 days. Crude mortality at day 7 in patients with polymicrobial bacteremia was significantly higher than for patients with monomicrobial bacteremia (p=<0.0001).As in the previous periods the dominating pathogens were Escherichia coli (18%), CoNS (15%), viridans streptococci (14%) and Klebsiella spp. (10%). A significant increase of Enterobacter spp. (from 3.1 to 5.4%) and decrease of Staphylococcus aureus (from 10 to 6.9%) was seen compared with the middle 7-year period. Enterococcus faecium increased during the middle 7-year period and has remained frequent and stable at 8%.In E. coli resistance to piperacillin-tazobactam (TZP) was 9.2%, ciprofloxacin (CIP) 8.5% and ceftazidime (CAZ) 2.1%, whereas no resistance was observed to imipenem-cilastatin (IPM). In Klebsiella spp. resistance to TZP was 9.0%, CIP 1.3% and CAZ 1.3%, whereas no resistance was observed to IPM. Among Enterobacter spp. resistance to TZP was 26%, CAZ 26%, IPM 2.3% and CIP 4.7%. In P. aeruginosa resistance to IPM was 12%, TZP 4.8% and CIP 7.1%, whereas no CAZ-resistant strains were found. Among CoNS resistance to isoxazolyl-penicillin was 71% in the last period, compared to 58% in the middle period. Only one isolate of E. faecium (cultured in the last 7-year period) was resistant to vancomycin. Two methicillin-resistant S. aureus were detected in the last 7-year period. Resistance to benzyl-penicillin among viridans streptococci was 20% in the last 7-year period and 12% in the middle 7-year period. Only the increase in CIP resistance in E. coli during the last 7-year period was statistically significant (p= 0.02).We observed a stable distribution of species and a low rate of antimicrobial resistance during a period of 21 years. In the last 7-year period a significant increase in CIP-resistance was observed in E. coli. This finding can possibly be related to a very limited use of antibacterial prophylaxis in our centre, but also reflects the general low level of antimicrobial resistance in Sweden. Crude mortality was unchanged during the study period. Mortality was higher in patients with poly- th.No relevant conflicts of interest to declare.

Background: Appropriately aggressive treatment of haematological malignancies can be complicated by a variety of life threatening events. Despite high hospital mortality rates for such patients admitted to intensive care units (ICU) it is now generally considered to be appropriate to offer intensive care to selected cases, provided there is a reasonable prospect of cure or at least worthwhile palliation. Aims and Methods: We conducted a retrospective observational study to assess outcome and prognostic indicators in consecutive patients with hematological diseases admitted to the ICU during a 6-year-period. Results: From 1996 through 2001, a total of 95 patients with hematological diseases and a median age of 57 years (range 16–86) were admitted to the ICU. The median duration of ICU stay was 1 day (mean 4.2 days: range 1–67 days). The Mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 20 (± 9). The large majority of patients underwent active treatment of a hematological malignancy (90%) with acute leukaemia (27%), non-Hodgkin lymphoma (24%) and multiple myeloma (10%) dominating. Respiratory failure (46%), sepsis (24%), cardiovascular complications (9%) and bleeding disorders (7%) were the major reasons for ICU admission. A total of 49 patients (51%) had a microbiologically verified infection and 21 (22%) had bacteremia. Crude ICU, 4-week and 6-month mortality rates were 28%, 45%, and 57%, respectively. An APACHE II score > 30 predicted a high short-term mortality rate (p= 0.0001). However, age > 65 years, respiratory failure, bacteremia, and a diagnosis of acute leukemia were not significantly associated with a poor short-term survival (p> 0.05). A total of 30 patients (31%) were alive after a minimum follow up of 3.5 years. Conclusion: The lower mortality rate as compared with most other series is probably explained by a more liberal attitude towards ICU admission. Not withstanding this, for a substantial proportion of critically ill hematological patients a short time care at an ICU is life saving. Patients with life threatening complications of haematological disease should be offered intensive care unless or until it is clear that there is no prospect of recovery from the acute illness or that the underlying malignancy cannot be controlled.

Patients with hematological diseases undergoing diagnostic or therapeutic splenectomy are at increased risk of acquiring fulminant pneumococcal infections. Vaccination is a straightforward option in reducing these infections. Certain patient subgroups showing inadequate immunological response to pneumococcal vaccination may be candidates for alternative prophylactic measures. We prospectively studied the antibody response to vaccination with 23-valent pneumococcal capsular polysaccharide vaccine (Pneumovax N) in splenectomized patients with hematological disorders in relation to clinical characteristics and pneumococcal disease. A total of 76 splenectomized patients (Hodgkin s lymphoma 26, indolent lymphoma 10, aggressive lymphoma 8, immune hemolytic anemia 6, immune thrombocytopenic purpura 22, and others 4) with a median age of 52 years (range 18–82) were included. Antibody titers were determined using an enzyme-linked immunosorbent assay before and 12 months after vaccination. A weak immunological response was observed in 27 (35%) patients (poor responders) and an adequate response in 49 (65%) (good responders). During the follow-up period of 5–9 years after vaccination and despite repeated revaccination in many cases, a total of 5 episodes of microbiologically verified pneumococcal infections were reported in poor responders, while only one episode was noted among good responders (p=.01). Underlying malignant hematological diseases were more frequent among poor responders than among good responders (p=.002). The distribution of patients according to age, gender, immunoglobulin levels, time between splenectomy and vaccination (<1 year>), time between preceding chemotherapy/radiotherapy and vaccination (<6 months>) and/or previous radiotherapy did not differ between poor and good responders. In conclusion, a significant number of splenectomized patients with hematological diseases respond poorly to pneumococcal vaccination and have a significantly increased risk of post-splenectomy pneumococcal infections despite vaccination. In the absence of clinical parameters that can reliably predict a poor antibody response, measurement of antibody titers 12 months after vaccination seems to be the most adequate method for identification of patients in this subgroup. Poor responders may be offered other prophylactic measures such as antibiotic prophylaxis and/or immunization with pneumococcal conjugate vaccines. Studies to further elucidate the last alternative are ongoing.

The number of reported cases of invasive pneumococcal infections in Sweden increased more than threefold from 1988 through 1992. We studied the capsular types and the antibiotic susceptibility of 619 pneumococcal strains isolated from blood or CSF at 18 Swedish microbiological laboratories in 1987 and in 1992. These strains belonged to 35 of the 84 recognized capsular types. We noted a remarkable increase in the prevalence of invasive infections with type 14 from 1987 (8.2%) to 1992 (18%) (P = .001), which corresponded to a sevenfold increase in absolute numbers. The most prominent increase in infections was seen among elderly people; in 1992, type 14 accounted for 22.5% of the isolates from infected persons who were >64 years of age. The majority of the strains were susceptible to all antibiotics tested. However, there was a significant increase in trimethoprim-sulfamethoxazole resistance from 1.4% in 1987 to 7.1% in 1992. Nine multiresistant isolates (1.5%) were found.

Total concentrations of amino acids, as measured by fluorometry of primary amino nitrogen with the use of fluorescamine, were determined in the cerebrospinal fluid (CSF) of 50 patients with purulent meningitis, 40 patients with aseptic meningitis, and 36 control subjects. On admission total concentrations of amino acids in the CSF were significantlyhigher in patients with purulent meningitis (mean ± SEM, 2.27 ± 0.27 mM) than in patients with aseptic meningitis (1.07 ± 0.03 mx, P < 0.001) or in control subjects (1.16 ± 0.04 mM, P < 0.001). This value was higher when the patients with purulent meningitis were reexamined one to two days later and reached a maximum after three to four days of illness. The fluorometry method proved to be simple, rapid, and precise and may be used as an additional test in diagnosing bacterial meningitis, especially in patients who are treated with antibiotics before admission. For patients with bacterial meningitis, a high concentration of amino acids in the CSF on admission may indicate a poor outcome.