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Abstract: The primary antibody deficiency syndromes are characterised by recurrent respiratory tract infections and the inability to produce effective immunoglobulin (Ig) responses. The best-known primary antibody deficiencies are common variable immunodeficiency (CVID), X-linked agammaglobulinaemia (XLA), immunoglobulin G (IgG) subclass deficiency, and selective antibody deficiency with normal immunoglobulins (SADNI). Therapy in these patients consists of prophylactic antibiotics and/or Ig replacement therapy. Diagnostic delay remains common owing to limited awareness of the presenting features and may result in increased morbidity and mortality. Replacement therapy with immunoglobulins increases life expectancy and reduces the frequency and severity of infections, but the effect on end-organ damage is still unknown. Both intravenous immunoglobulin (IVIg) and subcutaneous immunoglobulin (SCIg) treatment appear to be safe, with comparable efficacy. A starting dose of 300–400mg/kg/month in IVIg and 100mg/week for SCIg is recommended. IgG trough levels should be >5g/L for patients with agammaglobulinaemia and 3g/L greater than the initial IgG level for patients with CVID; however, the clinical response should be foremost in choosing the dose and trough level. Infusion-related adverse reactions are generally mild owing to improved manufacturing processes. In this paper, aspects of Ig replacement therapy in primary antibody-deficient patients will be addressed. [Copyright &y& Elsevier]

Abstract: We conducted a prevalence study to gain greater insight into the aetiology, bacterial resistance and risk factors for community-acquired pneumonia (CAP) in the region of León, Nicaragua. During the period from July 2002 to January 2005, all consecutive patients with signs and symptoms suggestive of CAP were included in the study. Sputum samples, paired serum samples and urinary samples were collected for the detection of respiratory pathogens. The most frequently identified pathogens were Streptococcus pneumoniae (17%), followed by Staphylococcus aureus (5%), Chlamydia pneumoniae (5%) and Mycoplasma pneumoniae (4%). Pseudomonas aeruginosa was cultured from 5% of patients. No pathogens were identified in 55%. All tested S. pneumoniae were sensitive to erythromycin and penicillin. In contrast, resistance of S. aureus to penicillin and erythromycin was high. [Copyright &y& Elsevier]

Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of Leo´n, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria ≥10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as ≥105 cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby–Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in Leo´n and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (>90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC90 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC90 32 mg/l), cephalothin (58%, MIC90, 32 mg/l), ciprofloxacin (30%; MIC90, 32 mg/l), amoxicillin/clavulanate (21%, MIC90 8 mg/l) and gentamicin (12%, MIC90 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern. [Copyright &y& Elsevier]

Obtaining diagnostic microbiological cultures before initiating empirical antimicrobial therapy is part of the diagnostic work-up of intensive care patients with a clinical suspicion of infection. However, it is unknown to what extent these cultures provide a microbiological cause of infection and to what extent antimicrobial therapy is influenced. During a 6-month period, all episodes of suspected clinical infection were analysed and categorised as non-microbiologically proven infection (non-MPI) or MPI. Effects of culture results on antibiotic therapy were analysed for episodes of respiratory tract infection. Invasive diagnostic techniques were not routinely used for diagnosis of respiratory tract infections. Among 212 patients admitted, 147 episodes of clinical suspicion of infection were recorded (104 for respiratory tract infection) and 1147 microbiological cultures were obtained (0.64 culture per patient day). Antibiotics were administered on 1111 (62%) of 1803 patients days. Of the respiratory tract infections, 571 cultures resulted in 49 (47%) MPI. Cover with empirical antibiotics was inappropriate in 7 of 104 cases (8%) of respiratory infections. In 12 cases (11.5%) empirical therapy could have been changed based on culture results. Negative cultures were never followed by cessation of therapy, but the duration of treatment was significantly shorter for non-MPI. Forty-seven percent of respiratory tract infections were microbiologically confirmed and, based on culture results, empirical antimicrobial therapy could have been influenced in 11.5% of cases of respiratory tract infections. These findings provide aspects to evaluate and improve the diagnostic work-up of infections in the ICU. [Copyright &y& Elsevier]