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The Purple Urine Bag Syndrome (PUBS) is a rare condition in which the urine turns purple. It may occur in Urinary Tract Infections (UTIs) when bacteria metabolize dietary tryptophan to indole resulting in indigo (blue) and indirubin (red). This condition is mostly seen in elderly female patients with permanent urinary bladder catheterization. Patients, relatives and health professionals may be concerned about this discolouration, which is usually harmless. Medical management of PUBS involves frequent urinary bag change, antibiotic therapy and most importantly reassurance. We report an 89-years-old long-term catheterized female nursing home resident who was admitted to the emergency room because of a Community Acquired Pneumonia (CAP). After a few days of inpatient treatment her urine bag turned purple. Antibiotic therapy continued and the indwelling urinary catheter was changed resulting in clear urine. Keywords: Purple urine bag syndrome (PUBS); purple discolouration; urinary tract infection (UTI); long-term catheterization.

Referring to a literature review published recently in this Journal, we report a single-center case series of 45 children and adolescents (age 2-17 years) with suspected tuberculosis (TB) and negative microscopy on repeated sputum or gastric aspirate samples. All subjects underwent flexible airway endoscopy including bronchoalveolar lavage (BAL) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) without adverse events. Among 41 subjects with a final TB diagnosis, Mycobacterium tuberculosis was detected by PCR and/or culture in 20 (49% bacteriological confirmation) with 11 cases relying exclusively on results from TBNA samples. Only 7 of 17 positive culture results related to sputum (17% confirmation rate), and 9 of 17 on the combination of sputum and BAL (22%) respectively. The sampling site of a person’s first positive culture was TBNA in 13 of 17 cases (76%). Bacteriological confirmation was essential for diagnostic accuracy and tailored treatment based on individual drug susceptibility testing. We therefore recommend the inclusion of bronchoscopy and EBUS-TBNA in a comprehensive diagnostic protocol for smear-negative pediatric TB suspects.

Summary Objectives The coronavirus disease 2019 (COVID-19) pandemic situation in Germany is unique among large European countries in that incidence and case fatality rate are distinctly lower. We describe the clinical course and examine factors associated with outcomes among patients hospitalized with COVID-19 in Germany. Methods In this retrospective cohort study we included patients with COVID-19 admitted to a national network of German hospitals between February 12, and June 12, 2020. We examined demographic characteristics, comorbidities and clinical outcomes. Results We included 1904 patients with a median age of 73 years, and 48.5% (924/1904) were female. The mortality rate was 17% (317/1835; 95% confidence interval [CI] 16-19), the rate of admission to the intensive care unit (ICU) 21% (399/1860; 95% CI 20–23), and the rate of invasive mechanical ventilation 14% (250/1850: 95% CI 12–15). The most prominent risk factors for death were male sex (hazard ratio [HR] 1.45; 95% CI 1.2-1.8), preexisting lung disease (HR 1.61; 95% CI 1.20-2.16), and increased patient age (HR 4.1 [95% CI 2.6–6.6] for age >79 years versus

Objective The qSOFA (quick sepsis-related organ failure assessment) score shows similarities to the CRB-65 pneumonia score, but its prognostic accuracy in patients with community-acquired pneumonia (CAP) has not been extensively evaluated. Our aim was to validate the qSOFA (-65) score in a large cohort of CAP patients. Methods We conducted a retrospective population-based cohort study including all CAP cases hospitalized between 1st January 2014 and 31st December 2018 from the German nationwide mandatory quality assurance programme. We excluded cases transferred from another hospital, with mechanical ventilation present on admission, and without documented respiratory rate. Predefined outcomes were hospital mortality and need for mechanical ventilation. Results Among the 1,262,250 included cases, hospital mortality was 12.4% and the mechanical ventilation rate was 7.1%. All CRB and qSOFA criteria were associated with both outcomes, but the qSOFA had inferior sensitivity compared to the CRB-65 for mortality prediction. Including the age criterion ≥65 years, qSOFA-65 and CRB-65 performed similarly (AUC 0.69, 95%CI 0.69–0.69 versus 0.68, 95%CI 0.68–0.68). A qSOFA-65 of 0 was associated with fewer missed deaths (3328, 2.0%) compared to a CRB-65 of 0 (5480, 2.4%). The sensitivity of the suggested qSOFA cut-off of ≥2 for sepsis was low (mortality 25.8%, 95%CI 25.6–26.0%; mechanical ventilation 24.1%, 95%CI 23.8–24.4%). Results were similar when frail and palliative patients were excluded. Conclusions The qSOFA parameters show prognostic accuracy similar to the CRB parameters in CAP, but the sepsis cut-off of ≥2 lacked sensitivity. For sensitive mortality prediction, the age criterion ≥65 years should be added to the qSOFA.

We present a 74-year-old male with nonspecific interstitial pneumonia (NSIP) during treatment with ibrutinib for mantle cell lymphoma. Previously, the patient had received six cycles of bendamustine and rituximab and six cycles of R-CHOP, followed by rituximab maintenance therapy. Respiratory tract complications of ibrutinib other than infectious pneumonia have not been mentioned in larger trials, but individual case reports hinted to a possible association with the development of pneumonitis. In our patient, the onset of alveolitis that progressed towards NSIP together with the onset of ibrutinib treatment suggests causality. One week after ibrutinib was discontinued, nasal symptoms resolved first. A follow-up CT showed a reduction in the reticular hyperdensities and ground-glass opacities, suggestive of restitution of the lung disease. To our knowledge, this is the first case showing a strong link between ibrutinib and interstitial lung disease, strengthening a previous report on subacute pneumonitis. Our findings have clinical implications because pulmonary side effects were reversible at this early stage. We, therefore, suggest close monitoring for respiratory side effects in patients receiving ibrutinib.

Background In patients with non-small cell lung cancer (NSCLC) the pathologic lymph node status N1 is a heterogeneous entity, and different forms of lymph node involvement may represent different prognoses. For methodological reasons, the 8th edition of the TNM staging system for NSCLC makes no official changes to the N descriptor. However, there is evidence that different subforms of N1 disease are associated with different prognoses, and it is now recommended that clinicians record the number of affected lymph nodes and nodal stations for further analyses. In this investigation we sought to determine whether patients with different levels and types of N1 lymph node involvement had significantly different 5-year survival rates. Methods We retrospectively identified 90 patients with NSCLC (61 men, 29 women), who were treated between 2008 and 2012 and found to have pathologic N1 lymph node involvement and tumor sizes corresponding to T1 or T2. All patients were treated in curative intent with surgical lung resection and systematic mediastinal and hilar lymph node dissection. Results The overall 5-year survival rate was 56.3%. In the univariate analysis, lower tumor stage and tumor histology other than large-cell carcinoma were significantly associated with better long-term survival. Patients with solitary lymph node metastases also had longer disease-free survival than those with multiple nodal metastases. In the multivariate analysis, large-cell carcinoma and Union for International Cancer Control (UICC) stage IIB were independently associated with worse survival, while pneumonectomy, compared to lobar or sublobar resection, was independently associated with better survival. Conclusions Although we did not observe significant prognostic differences between N1 subcategories within our patient population, other analyses may yield different results. Therefore, these data highlight the need for large, well-designed multicenter studies to confirm the clinical significance of N1 subcategories.

Based on the results of studies from the 1960s-1980s the current four drug combination therapy was established as standard or short course tuberculosis therapy worldwide. The regional epidemiology and the often unique conditions within a national health system create the need for specific adjustments. Over the last years these were realized by the German central committee against tuberculosis (DZK) in the recommendations for tuberculosis therapy. Because of the recent development of migration into Germany from countries with higher tuberculosis incidences an increase in tuberculosis cases is to be expected. The expected increase in tuberculosis cases will lead to more contact with tuberculosis patients even in the outpatient setting. New S2k guidelines guided by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) for the treatment of tuberculosis for children and adults are under development. Before the release of the comprehensive guidelines, practical evidence for the diagnosis and treatment of uncomplicated tuberculosis is summarized in this document to meet the challenges of the recent developments.

These data support the safety and tolerability of delamanid in the treatment of patients with MDR- and XDR-TB, even with drug exposure for longer than 6 monthshttps://bit.ly/3cPQQPS

Background: Pulmonary nocardiosis (PN) is an uncommon but potentially life-threatening infection. Most of our knowledge on PN is derived from case reports and small case series. Increasing incidence rates of PN have been reported recently. The aim of this study was to describe the clinical course of and risk factors for PN in four Western European countries and to estimate population-based annual hospitalization rates. Methods: This was a retrospective evaluation (1995–2011) of the clinical course of and risk factors for PN in patients at 11 hospitals in four European countries (Germany, Austria, Switzerland, and the Netherlands). Population-based estimates of hospitalization rates for PN in Germany (2005 to 2011) were calculated using official German nationwide diagnosis-related groups (DRG) hospital statistics. Results: Forty-three patients fulfilled stringent criteria for proven (n = 8) and probable (n = 35) PN; seven had extrapulmonary dissemination. For these 43 patients, the major risk factors for PN were immunocompromising (83.7%) and/or pulmonary (58.1%; as only comorbidity in 27.9%) comorbidities. The median duration of PN targeted therapy was 12 weeks. Distinctive patterns of resistance were observed (imipenem susceptibility: Nocardia farcinica 33.3%; Nocardia asteroides 66.7%). The overall mortality rate was 18.9% (50% in disseminated PN). Over time, annual PN hospitalization rates remained unchanged at around 0.04/100 000, with the highest rate among men aged 75–84 years (0.24/100 000). Conclusions: PN is a rare, but potentially life-threatening disease, and mainly affects immunocompromised elderly males. Overall, annual hospitalization rates remained stable between 2005 and 2011. Keywords: Nocardiosis, Nocardia, Pulmonary nocardiosis

Item does not contain fulltext BACKGROUND: Estimating attributable mortality of ventilator-associated pneumonia has been hampered by confounding factors, small sample sizes, and the difficulty of doing relevant subgroup analyses. We estimated the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. METHODS: We identified relevant studies through systematic review. We analysed individual patient data in a one-stage meta-analytical approach (in which we defined attributable mortality as the ratio between the relative risk reductions [RRR] of mortality and ventilator-associated pneumonia) and in competing risk analyses. Predefined subgroups included surgical, trauma, and medical patients, and patients with different categories of severity of illness scores. FINDINGS: Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20-29 and simplified acute physiology score [SAPS 2] 35-58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1.13 (95% CI 0.98-1.31). The overall daily risk of discharge after ventilator-associated pneumonia was 0.74 (0.68-0.80), leading to an overall cumulative risk for dying in the ICU of 2.20 (1.91-2.54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients (2.97, 95% CI 2.24-3.94) and patients with mid-range severity scores at admission (ie, cumulative risks of 2.49 [1.81-3.44] for patients with APACHE scores of 20-29 and 2.72 [1.95-3.78] for those with SAPS 2 scores of 35-58). INTERPRETATION: The overall attributable mortality of ventilator-associated pneumonia is 13%, with higher rates for surgical patients and patients with a mid-range severity score at admission. Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay. FUNDING: None.

Nach Schatzungen der Weltgesundheitsorganisation (WHO) kam es im Jahr 2011 global zu 8,7 Mio. Tuberkulose(TB)-Neuerkrankungen und 1,4 Mio. Todesfallen. In Deutschland dagegen ist die TB heute eine seltene Erkrankung. Im Jahr 2011 lag die Inzidenz bei 5,3/100.000 Einwohner. Daher nimmt die arztliche Erfahrung mit diesem Krankheitsbild ab. In dieser Ubersicht werden die Standardtherapie der TB und die dabei verwendeten Medikamente beschrieben. Vor Therapiebeginn muss eine grundliche anamnestische Evaluation in Bezug auf Risikofaktoren einer resistenten TB erfolgen. Auch die bakteriologische Sicherung durch den mikroskopischen und kulturellen Erregernachweis sowie eine phanotypische Resistenztestung sind anzustreben. Die Behandlung der TB ist stets als antibiotische Kombinationstherapie angelegt. Die Wahl der Wirkstoffe hangt masgeblich vom Resistenzstatus der Erregerstamme ab. Fur weitere Informationen zur Therapie der TB sei auf die 2012 erschienenen Therapieempfehlungen des Deutschen Zentralkomitees zur Bekampfung der Tuberkulose e. V. (DZK) und der Deutschen Gesellschaft fur Pneumologie und Beatmungsmedizin (DGP) verwiesen.

The aim of this study was to investigate treatment failure (TF) in hospitalised community-acquired pneumonia (CAP) patients with regard to initial antibiotic treatment and economic impact. CAP patients were included in two open, prospective multicentre studies assessing the direct costs for in-patient treatment. Patients received treatment either with moxifloxacin (MFX) or a nonstandardised antibiotic therapy. Any change in antibiotic therapy after >72 h of treatment to a broadened antibiotic spectrum was considered as TF. Overall, 1,236 patients (mean ± SD age 69.6 ± 16.8 yrs, 691 (55.9%) male) were included. TF occurred in 197 (15.9%) subjects and led to longer hospital stay (15.4 ± 7.3 days versus 9.8 ± 4.2 days; p < 0.001) and increased median treatment costs (€2,206 versus €1,284; p

Introduction: Colonization of the lower respiratory tract is an independent risk factor for ventilator-associated pneumonia. Little is known about the frequency of viral colonization on intubation and during mechanical ventilation. Methods: Overall, 65 eligible intubated patients with no initial signs of pulmonary infection were studied over a period of up to 7 days. Tracheobronchial aspirates were taken: (i) within 48 h after intubation; and (ii) when clinical signs of nosocomial tracheobronchitis were present, before extubation, or after 7 days. Presence of respiratory viruses was investigated using quantitative polymerase chain reaction. Results: Patients were 67 ± 11 years old and had been in hospital for 5.1 ± 8.4 days when intubated (major cause for intubation: cardio-pulmonary resuscitation 25/65, 38%). The average Acute Physiology and Chronic Evaluation II score was 27.3 ± 4.9. Microbiology detected Candida spp. (17/65; 26%) and Staphylococcus aureus (methicillin sensitive: 11/65; 17%; methicillin resistant: 3/65; 5%) and only few respiratory viruses (4/65, 6%). Thirty-eight percent of the samples (25/65) were sterile. At the given endpoints, 27/65 (42%) patients were available for follow-up and only one aspirate became positive for respiratory syncytial virus (RSV). Conclusions: After endotracheal intubation, fungi, but not viruses were most frequently isolated. Only one patient acquired RSV, therefore colonization with respiratory viruses does not seem to play a major role early after intubation. Please cite this paper as: Hauptmeier BM, Borg I, Rohde G, Anders A, Kronsbein J, Gatermann S, Bufe A, Blum T, Schultze-Werninghaus G and Bauer TT. Viral colonization in intubated patients: initial pathogen pattern and follow-up. The Clinical Respiratory Journal 2010; 4: 139–146.

Non-tuberculous mycobacterioses differ substantially from infections with M. tuberculosis complex in regard to both clinical presentation and treatment. In persons infected with HIV the pathogenic organism is almost always M. avium complex, which leads to various pulmonary diseases with specific characteristics and disseminated courses. In patients not infected with HIV, a number of factors that reduce local resistance and certain systemic conditions increase the risk of the infection's reaching a degree of severity requiring treatment. Since these factors are associated with a wide variety of clinical presentations and treatment is species-specific, assessment needs to be individualised for almost all patients. In contrast to the treatment of tuberculosis, in non-tuberculous mycobacterioses the extent to which the treatment can be based on in vitro resistance tests is limited. Clinicians therefore have to draw on their previous clinical experience and the few existing controlled studies, at least initially. In view of the high rate of recurrence compared to tuberculosis, surgical removal of local risk factors (bronchiectasis, bullae, post-specific changes) and thus the mycobacterial infection itself should be considered in all cases.

Background: Palliative chemotherapy is standard of treatment of stage IV NSCLC. Although there is evidence for the effectiveness of the first 3 lines of therapy, little is known about the response to further therapy beyond the 3 rd line. Our aim is to analyze response rates after 4 th , 5 th or 6 th line chemotherapy in stage IV NSCLC. Methods: A retrospective analysis of stage IV NSCLC patients who received firstline therapy in our institution from 2008 to 2013 was performed. Patients who had at least one cycle of 4 th line treatment were selected for further evaluation. We analyzed therapy regime and best response (according to RECIST 1.1). Results: Overall, we identified 1174 Pat with first-line therapy during the period. Of these, 40% (469 Patients) received a 2 nd line therapy and 17% (199) 3 rd line therapy.Thereafter, 4 th line therapy was performed in 6.2% (n=73), 5 th line in 1.8%. (21) and 0.4% (5) had a 6 th line of therapy, respectively. Objective response rates (PR, CR) were: in 4 th line 1.4% (1/73), in 5 th line 14.3% (3/21) and in 6 th line 0% (0/5), respectively. The proportion of patients with stable disease (SD) was: 4 th line 37% (27/73), 5 th line 33% (7/21) and 6 th line 60% (3/5). The median time between diagnosis of lung cancer and initiation of fourth line treatment was 495 days (165-1887 days). In 42 patients with 4 four or more lines of therapy, who were eligible for molecular testing, we detected 4 cases of EGFR mutation and one EML-ALK fusion. Conclusion: The effective response to systemic therapy beyond 3 rd line seems to be limited but short term stabilization was seen in a proportion of patients. Because of unclear benefits, further lines of therapy should be limited to selected groups of patients.

Ingo H Flessenkaemper,1 Robert Loddenkemper,2 Stephanie Roll,3 Kathrin Enke-Melzer,1 Henrik Wurps,2 Torsten T Bauer21Department for Vascular Medicine, 2Department of Pneumology, Helios Klinikum Emil von Behring, Berlin, Germany; 3Institute for Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Berlin, GermanyPurpose: Screening for abdominal aortic aneurysm (AAA) in “men aged over 65years who have ever smoked” is a recommended policy. To reduce the number of screenings, it may be of value to define subgroups with a higher prevalence of AAA. Since chronic obstructive pulmonary disease (COPD) and AAA are associated with several common risk factors, this study investigates the prevalence of AAA in COPD patients.Patients and methods: Patients with COPD were identified via the hospital information system. Inclusion criteria were: COPD stage I–IV, ability to give full consent, and age >18years; exclusion criteria were: patient too obese for an ultrasound check, previously diagnosed AAA, prior surgery for AAA, or ethical grounds such as concomitant advanced malignant or end-stage disease. The primary endpoint of the study was an aortic diameter measured by ultrasound of ≥30mm. Defined secondary endpoints were evaluated on the basis of medical records and interviews.Results: Of the 1,180 identified COPD patients, 589 were included in this prospective study. In 22 patients (3.70%), the aortic diameter was ≥30mm, representing an AAA prevalence of 6.72% among males aged >65years. The risk of AAA increased with the following comorbidities/risk factors: male sex (odds ratio [OR] 2.98), coronary heart disease (OR 2.81), peripheral arterial occlusive disease (OR 2.47), hyperlipoproteinemia (OR 2.77), AAA in the family history (OR 3.95), and COPD stage I/II versus IV (OR 1.81).Conclusion: The overall AAA prevalence of 3.7% in our group of COPD patients is similar to that of the general population aged >65years. However, the frequency of AAA in male COPD patients aged >65years is considerably higher (6.72%) and increased further still in those individuals with additional comorbidities/risk factors. Defining subgroups with a higher risk of AAA may increase the efficiency of screening.Keywords: chronic obstructive pulmonary disease, AAA, screening, risk factors, epidemiology, inflammatory disease, tobacco abuse

Background Airway colonization and infection are frequent complications during the course of ARDS. The impact on outcomes of microbiological patterns recovered within the first 24 h after diagnosis has not been evaluated. Objectives To describe the incidence and patterns of bronchial colonization and lung infection within the first 24 h of ARDS diagnosis and to evaluate the influence on ICU outcomes. Methods Prospective study of ARDS patients evaluated within 24 h of diagnosis. Patients were studied with tracheobronchial aspirate and right and left bronchoscopic protected specimen brush. All samples were cultured quantitatively. Results Fifty-five consecutive patients were included. Twelve patients (22%) were clinically suspected of having nosocomial pneumonia (NP), which was confirmed microbiologically in 7 patients, a frequency of 13%. In those patients without suspected pneumonia, we also found potentially pathogenic microorganisms (PPMs) and potentially drug-resistant microorganisms (PDRMs) in 36% and 31%, respectively. Mortality was not significantly higher in those patients with recovery of a PPM (87% vs 73%, p = 0.31), PDRM (89% vs 74%, p = 0.18), or with NP (79% vs 85%, p = 1.0). Conclusion There is a strikingly high rate of PPM recovery in early ARDS. However, neither isolation of pathogenic microorganisms nor the confirmation of NP could be associated with an increased mortality.

Background nCPAP-therapy is standard for patients with obstructive sleep apnea syndrome (OSAS). This study investigated, if nCPAP changed the patients lung function. Patients and methods Lung function of 228 OSAS patients without co-prevalent lung disease, who received nCPAP for the first time, was examined (whole body plethysmography, spirometry, and blood gas analysis). After 1, 2, and 3 years the results of the re-examined patients were compared with their individual starting results. Results The results of the patients in the basic and in the follow-up examinations was within standard range. During reexamination, an improvement of inspiratory vital capacity was registered repetitively, especially in smokers. On the other hand, MEF 50 decreased within the first two years and FEV (1) %VC, but not FEV (1), decreased after 2 and 3 years of reexamination. Conclusions Neither obstructive nor restrictive lung diseases were diagnosed under nCPAP-therapy within three years. This study with a retrospective design showed significant improvements of vital capacity (VC) in patients with OSAS, especially in smokers, under nCPAP-therapy. This increase can be explained by an effect of practice in the examination and by recruitment of formerly hypoventilated lung areas. As MEF 50 and FEV (1) %VC depend on VC, the decrease of both parameters may be caused by the increase of VC. In summary, nCPAP did not cause negative effects of lung function in the investigated patients over a period of 3 years.

Background: A study was undertaken to validate the modified American Thoracic Society (ATS) rule and two British Thoracic Society (BTS) rules for the prediction of ICU admission and mortality of community acquired pneumonia and to provide a validation of these predictions on the basis of the pneumonia severity index (PSI). Method: Six hundred and ninety six consecutive patients (457 men (66%), mean (SD) age 67.8 (17.1) years, range 18–101) admitted to a tertiary care hospital were studied prospectively. Of these, 116 (16.7%) were admitted to the ICU. Results: The modified ATS rule achieved a sensitivity of 69% (95% CI 50.7 to 77.2), specificity of 97% (95% CI 96.4 to 98.9), positive predictive value of 87% (95% CI 78.3 to 93.1), and negative predictive value of 94% (95% CI 91.8 to 95.8) in predicting admission to the ICU. The corresponding predictive indices for mortality were 94% (95% CI 82.5 to 98.7), 93% (95% CI 90.6 to 94.7), 49% (95% CI 38.2 to 59.7), and 99.5% (95% CI 98.5 to 99.9), respectively. These figures compared favourably with both the BTS rules. The BTS-CURB criteria achieved predictions of pneumonia severity and mortality comparable to the PSI. Conclusions: This study confirms the power of the modified ATS rule to predict severe pneumonia in individual patients. It may be incorporated into current guidelines for the assessment of pneumonia severity. The CURB criteria may be used as an alternative tool to PSI for the detection of low risk patients.

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are a common cause of hospital admission. Many exacerbations are believed to be due to upper and/or lower respiratory tract viral infections, but the incidence of these infections in patients with COPD is still undetermined.Respiratory syncytial virus (RSV), influenza A and B, parainfluenza 3, and picornaviruses were detected by nested reverse transcription polymerase chain reaction (RT-PCR) in upper (nasal lavage) and lower respiratory tract specimens (induced sputum). In a 2:1 case-control set up, 85 hospitalised patients with AE-COPD and 42 patients with stable COPD admitted for other medical reasons were studied.Respiratory viruses were found more often in sputum and nasal lavage of patients with AE-COPD (48/85, 56%) than in patients with stable COPD (8/42, 19%, p0.01). The most common viruses were picornaviruses (21/59, 36%), influenza A (15/59, 25%), and RSV (13/59, 22%). When specimens were analysed separately, this difference was seen in induced sputum (exacerbation 40/85 (47%) v stable 4/42 (10%), p0.01) but was not significant in nasal lavage (exacerbation 26/85 (31%) v stable 7/42 (17%), p=0.14). In patients with AE-COPD, fever was more frequent in those in whom viruses were detected (12/48, 25%) than in those in whom viruses were not detected (2/37, 5%, p=0.03).Viral respiratory pathogens are found more often in respiratory specimens of hospitalised patients with AE-COPD than in control patients. Induced sputum detects respiratory viruses more frequently than nasal lavage in these patients. These data indicate that nasal lavage probably has no additional diagnostic value to induced sputum in cross-sectional studies on hospitalised patients with AE-COPD and that the role of viral infection in these patients is still underestimated.

Measuring the respiratory rate is an important and simple tool for assessing the severity of acute cardiorespiratory and metabolic diseases. The first British Thoracic Society survey (1982–1983) on prognostic factors for community-acquired pneumonia revealed a close association between respiratory rate and mortality (1). The mortality in this study rose from 0 for a respiratory rate below 20/min to 1.7%, 9% and 16% for respiratory rate values in the ranges 20 to 29, 30 to 39, and 40 to 49, respectively (1). The prognostic significance of the respiratory rate was confirmed in numerous studies about acute respiratory infections in different age groups (2– 5). Accordingly, the respiratory rate is included in standard prognostic tools, such as the CRB 65 Index (confusion, respiratory rate, blood pressure, age ≥ 65 years) or the Pneumonia Severity Index (PSI or FINE Score) (6, 7). Although the German and international guidelines recommend the use of these scores (8– 10), the respiratory rate is often not recorded in acute care situations, or the need for monitoring the respiratory rate is questioned (11– 15). The main reason for that is the lack of awareness of the prognostic significance of this vital sign (13– 15). Since the introduction of mandatory external quality assurance in 2005, the respiratory rate of patients with community-acquired pneumonia is recorded on admission and on discharge. The objective of this analysis is to study the prognostic significance of the respiratory rate based on the external quality assurance data collected from an unselected patient population with community-acquired pneumonia.

BACKGROUND: The non-invasive diagnosis of cardiac sarcoidosis (CS) is difficult. Cardiovascular magnetic resonance (CMR) has become a very valuable diagnostic tool in patients with suspected CS, but usually a combination of different tests is used. Oxygen uptake efficiency slope (OUES) is a parameter of cardiopulmonary exercise testing (CPET), which is used as an indicator for cardiovascular impairment. We investigated the predictive value of OUES for the diagnosis of myocardial involvement in sarcoid patients. METHODS: Retrospectively 37 consecutive patients (44.9+/-13.8 years) with histologically confirmed sarcoidosis and clinical suspicion of heart involvement underwent noninvasive diagnostic testing including CMR. CS was diagnosed according to the guidelines from the Japanese Society of Sarcoidosis and other Granulomatous Disorders with additional consideration of CMR findings. Furthermore, CPET with calculation of predicted OUES according to equations by Hollenberg et al. was carried out. RESULTS: Patients with CS (11/37; 30%) had a worse cardiovascular response to exercise. OUES was significantly lower in CS-group compared to non-CS-group (59.3+/-19.1 vs 88.0+/-15.4%pred., p

BACKGROUND Sleep related hypoxemia (SRH) in chronic obstructive pulmonary disease (COPD) can be easily detected by pulse-oximetry and may contribute to the development of pulmonary hypertension (PH). Since several parameters for the quantification of SRH are in use, we investigated which of these parameters has the strongest relation to the awake pulmonary arterial pressure (PAP) and is able to distinguish between patients without and with PH. PATIENTS AND METHODS 44 COPD-patients (awake PaO2 > or = 60 mm Hg) were investigated. PAP at rest (PAP; pathological threshold > 20 mm Hg) and under physical exercise (PAPB; p.t. > 28 mm Hg) were determined during daytime by Swan-Ganz-catheter. To quantify the degree of SRH the following parameters of nocturnal pulse-oximetry were used: mean nocturnal oxygen saturation (SaO2 m; p.t. 30%). Linear correlations and regressions as Chi 2-respectively Fisher-test were used for statistical analysis (p 30%, however, had a much worse selectivity (p = 0.487 resp. 0.057). CONCLUSIONS In COPD-patients with SRH the closest relation can be found between nadir SaO2 and PAP resp. PAPB. Furthermore nadir SaO2 (< 85%) could more precisely separate patients into those without and with pulmonary hypertension than t90. The overall weak relation between nocturnal oxygenation and pulmonary hypertension shows, however, that other factors such as daytime PaO2, hypercapnia or emphysema are involved in the development of pulmonary hypertension in COPD.

Bronchoscopic bronchoalveolar lavage (BAL) may be followed by a systemic inflammatory response. Previous reports have suggested pneumonia as a predisposing condition and systemic cytokines as possible mediators.To test this hypothesis, systemic levels of interleukin (IL)-1β, IL-6 and tumour necrosis factor-alpha (TNF-α) were studied before and at 12 h and 24 h after bronchoscopically guided BAL in 30 mechanically ventilated patients (median age 67 (range 54–76) yrs, simplified acute physiology score II (SAPS II) 33 (12–56)), 20 of whom had pneumonia and 10 of whom were control patients without pneumonia. Arterial oxygen partial pressure to inspired oxygen fraction ratio (Pa,O2/FI,O2), body temperature, mean arterial pressure, and cardiac frequency were recorded. The majority of patients (28/30, 93%) received antibiotic treatment prior to the procedure.Pa,O2/FI,O2ratio was lower at 12 h compared to baseline in patients with pneumonia (baseline median 192 (range 65–256); 12 h 160 (66–190) mmHg, p−1) did not increase at 12 h (pneumonia: 35 (0–64); p=0.735; controls: 16 (0–21) pg·mL−1, p=0.123 comparison to baseline) or 24 h (pneumonia: 31 (0–36), p=0.464; controls: 19 (0–43) pg·mL−1, p=0.358). No changes of IL-1β (baseline: pneumonia 0 (0–13); controls 1 (0–32) pg·mL−1) or IL-6 (baseline: pneumonia, 226 (9–4300); controls, 53 (0–346) pg·mL−1) were detected.No deterioration of clinical variables and no increase in systemic cytokine release has been observed after bronchoalveolar lavage, in critically ill patients. The potential cytokine increase is probably too small, in relation to the pre-existing inflammatory response, to yield clinical significance in this population otherwise antibiotic therapy may have been protective.

To examine the antibacterial efficacy and tolerability of the new 8-methoxy-fluoroquinolone moxifloxacin in patients hospitalised with community-acquired pneumonia (CAP). Postmarketing surveillance study involving 389 physicians conducted at 410 hospitals throughout Germany. A total of 2188 patients were treated with oral moxifloxacin 400mg once daily for up to 10 days. Patients were followed for the entire duration of therapy and until discharge from hospital. Physicians’ global assessments of efficacy rated 93.4% of patients cured or improved after moxifloxacin treatment. The majority of patients (60.4%) demonstrated distinct improvement in clinical symptoms after only 3 days of treatment. 73.7% of patients were symptom-free by day 7 and 87.0% by day 10. Overall, 2.7% of patients experienced an adverse drug reaction. The profile of adverse events (AEs) was similar to that previously reported for moxifloxacin, mostly involving gastrointestinal disturbances and skin rash. Only one patient experienced a cardiac event (transient hypotension) judged to be probably treatment-related, seven patients experienced abnormal but reversible liver function tests, and one patient had prolonged abnormal liver function test results. In the remaining cases, AEs resolved or were improved. The results of this study confirm the evidence from clinical studies indicating that moxifloxacin 400mg once daily is an effective and well tolerated therapy for CAP, providing rapid and comprehensive resolution of symptoms in a broad range of patients.

Background—The inflammatory response has been widely investigated in patients with acute respiratory distress syndrome (ARDS) and pneumonia. Studies investigating the diagnostic values of serum cytokine levels have yielded conflicting results and only little information is available for the diVerential diagnosis between ARDS and pneumonia. Methods—Clinical and physiological data, serum concentrations of tumour necrosis factor (TNF)-AE, interleukin (IL)-1‚ and IL-6, and quantitative cultures of lower respiratory tract specimens were obtained from 46 patients with ARDS and 20 with severe pneumonia within 24 hours of the onset of the disease and from 10 control subjects with no inflammatory lung disease. Cytokine concentrations were compared between groups and determinants in addition to the diagnosis were tested. Results—Serum TNF-AE levels were significantly higher in ARDS patients (67 (57) pg/ml) than in patients with severe pneumonia (35 (20) pg/ml; p = 0.031) or controls (17 (8) pg/ml; p = 0.007). For IL-1‚ and IL-6 the observed diVerences were not statistically significant between patients with ARDS (IL-1‚: 34 (65) pg/ml; IL-6: 712 (1058) pg/ml), those with severe pneumonia (IL-1‚: 3 (4) pg/ml, p = 0.071; IL-6: 834 (1165) pg/ml, p = 1.0), and controls (IL-1‚: 6 (11) pg/ml, p = 0.359; IL-6: 94 (110) pg/ml, p = 0.262). TNF-AE (standardised coeYcient ‚ = 0.410, p

Der 56-jahrige Mann klagte seit ca. vier Wochen uber Husten mit rostbraunem Auswurf, Kraftlosigkeit und uber einen Gewichtsverlust von ca. 15 kg. An Vorerkrankungen waren ein Herzinfarkt, 2 Lungenembolien und ein Ulcus cruris des rechten Unterschenkels bekannt. Die korperliche Untersuchung zeigte einen reduzierten Allgemeinzustand, ein abgeschwachtes, aber vesikulares Atemgerausch uber allen Lungenabschnitten; auserdem fiel ein entzundlich gerotetes Ulcus am rechten Knochel auf. Im Labor fanden sich Entzundungszeichen (Leukozytose, CRP, BSG-Erhohung). Die Thoraxaufnahme (p.a.) lies im Bereich des linken Lungenoberfeldes eine ca. 7,5 cm grose Kaverne erkennen. In der Phlebographie wurde eine frische Thrombose aller dreier Unterschenkelfaszikel sowie ein Zustand nach Thrombose der V. poplitea, femoralis und iliaca mit ausgepragtem Kollateralkreislauf uber oberflachliche Venen nachgewiesen. Bei Verdacht auf Lungentuberkulose wurde zunachst eine 4-fach Therapie eingeleitet. Zusatzlich wurde die tiefe Beinvenenthrombose mit intravenoser Heparingabe (zunachst 25.000 i.E. uber 24 h) therapiert. In der Bronchoskopie ergaben sich weder mikroskopisch noch kulturell Hinweise fur eine Lungentuberkulose. Innerhalb von zwei Wochen konnte eine fast vollstandige Ruckbildung der Kaverne erreicht werden. Die ursprungliche Arbeitshypothese einer tuberkulosen Kaverne war aufgrund der raschen Ruckbildung und des fehlenden Nachweises von Mykobakterien unwahrscheinlich geworden. Wegen eines weiteren klinisch typischen thrombembolischen Ereignisses wurde ein CT des kleinen Beckens angefertigt, in dem eine ausgedehnte Thrombosierung der V. cava bis zum Abgang der Nierenvenen zur Darstellung kam. Es handelte sich in diesem Fall um die Kaverne einer einschmelzenden Infarktpneumonie.

Die akute Exazerbation einer COPD (AECOPD) ist eine bedrohliche klinische Situation. Dieser Beitrag erlautert die Definition einer AECOPD, die Schweregradeinteilung, typische klinische Phanomene mit Hinweis auf haufige Fallstricke in der Diagnostik, Therapie und Prognose. Obligate Aspekte der speziellen Anamnese und korperlichen Untersuchung fur die klinische Einschatzung vor allem bei schwergradigen Exazerbationen werden erlautert. Die notwendigen apparativen Begleituntersuchungen wie Thoraxrontgenuntersuchung, Blutgasanalyse, EKG und Echokardiographie und deren differenzialdiagnostische sowie therapeutische Signifikanz werden beschrieben. Bezuglich der wichtigsten Laboruntersuchungen wird auch zu strittigen Parametern, z. B. Procalcitonin, Stellung genommen und auf den differenzierten Bedarf der mikrobiologischen Sputumaufbereitung hingewiesen. Besonderes Gewicht wird auf die wesentlichen Saulen des therapeutischen Managements der schweren AECOPD gelegt. Praktische Aspekte der unkontrollierten Sauerstofftherapie, Substanzauswahl und Applikationsform der inhalativen Akuttherapie, Dosis und Dauer von Glukokortikoiden, der Indikation zu Antibiose, maschineller Beatmung, aber auch Opiaten werden zusammengefasst.

OBJECTIVE: To determine differences in aetiologies, initial antimicrobial treatment choices and outcomes in patients with nursing-home-acquired pneumonia (NHAP) compared with patients with community-acquired pneumonia (CAP), which is a controversial issue. METHODS: Data from the prospective multicentre Competence Network for Community-acquired pneumonia (CAPNETZ) database were analysed for hospitalised patients aged >/=65 years with CAP or NHAP. Potential differences in baseline characteristics, comorbidities, physical examination findings, severity at presentation, initial laboratory investigations, blood gases, microbial investigations, aetiologies, antimicrobial treatment and outcomes were determined between the two groups. RESULTS: Patients with NHAP presented with more severe pneumonia as assessed by CRB-65 (confusion, respiratory rate, blood pressure, 65 years and older) score than patients with CAP but received the same frequency of mechanical ventilation and less antimicrobial combination treatment. There were no clinically relevant differences in aetiology, with Streptococcus pneumoniae the most important pathogen in both groups, and potential multidrug-resistant pathogens were very rare (/=65 years (26.6% vs 7.2% and 43.8% vs 14.6%, respectively). However, there was no association between excess mortality and potential multidrug-resistant pathogens. CONCLUSIONS: Excess mortality in patients with NHAP cannot be attributed to a different microbial pattern but appears to result from increased comorbidities, and consequently, pneumonia is frequently considered and managed as a terminal event.

Lithium can be toxic to rodents at plasma concentrations (0.6–1.2 mmol/L) that also phase delay circadian rhythms. In hamsters, raising the concentration of calcium in the diet from 0.1%–3% reduced weight loss and polydipsia caused by 0.4% lithium carbonate. Calcium ingestion did not affect plasma lithium concentration or the phase of the circadian wheel-running rhythm in lithium-treated animals. Calcium ingestion did not alter weight gain, salt or water intake, or circadian rhythms in hamsters not receiving lithium. Dietary calcium supplementation may prevent some toxic effects of lithium without interfering with other central nervous system actions.

Background The aim of this study was to investigate the efficacy and safety of oxaliplatin ± gemcitabine in patients with diffuse malignant pleural mesothelioma (MPM) pretreated with pemetrexed. Methods The study enrolled consecutive patients with relapsed MPM, all of them pretreated with a platin-pemetrexed-based chemotherapy. Oxaliplatin 80 mg/m2 was administered as monotherapy or in combination with gemcitabine 1000 mg/m2 given on day 1 and 8. Cycles were repeated every 21 days. The primary endpoints were response rate and disease control rate. Secondary endpoints included overall survival (OS), time to tumour progression (TTP), progression-free survival (PFS), time to treatment failure (TTF), and toxicity. Results Between February 2005 and September 2007 29 patients (median age: 65.0 years, World Health Organisation (WHO) performance status: 0–3) were enrolled. The follow-up period encompassed 5.4 to 97.4 weeks (median: 24.3 weeks). Out of these 29 patients, 15 were treated in second, 10 in third, 3 in fourth and 1 in fifth line, respectively. The majority of the patients received the combination oxaliplatin and gemcitabine (n = 25 vs. 4; 86.2 vs. 13.8%). The median overall survival (OS) was 71.7 weeks (30.6–243.3 weeks), whereas survival from the start of oxaliplatin/gemcitabine-treatment was 24.3 weeks (5.4–97.3 weeks). Median time to tumour progression (TTP) was 9.3 weeks (3.0–67.6 weeks). Partial response (PR) was observed in 2 patients (6.9%), stable disease (SD) for at least three courses of treatment in 11 patients (37.9%). Thus, disease control rate was 44.8%, whereas 16 of 29 patients exhibited progressive disease (55.2%). The toxicity profile was favourable, with no WHO grade 4-toxicities, only few dose-reductions were performed due to non-symptomatic haematotoxicities (neutropenia, thrombopenia). Mild WHO grade 2 neurotoxicity was seen in 6 patients. Conclusion Pemetrexed-pretreated patients with progressive MPM may benefit from a consecutive chemotherapy with oxaliplatin and gemcitabine without significant toxicity.

Objective. The study was performed to validate the CURB, CRB and CRB-65 scores for the prediction of death from community-acquired pneumonia (CAP) in both the hospital and out-patient setting. Design. Data were derived from a large multi-centre prospective study initiated by the German competence network for community-acquired pneumonia (CAPNETZ) which started in March 2003 and were censored for this analysis in October 2004. Setting. Out- and in-hospital patients in 670 private practices and 10 clinical centres. Subjects. Analysis was done for n = 1343 patients (n = 208 out-patients and n = 1135 hospitalized) with all data sets completed for the calculation of CURB and repeated for n = 1967 patients (n = 482 out-patients and n = 1485 hospitalized) with complete data sets for CRB and CRB-65. Intervention. None. 30-day mortality from CAP was determined by personal contacts or a structured interview. Results. Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients, P

Background and methods Human metapneumovirus (hMPV) is a recently discovered respiratory virus associated with bronchiolitis, pneumonia, croup and exacerbations of asthma. Since respiratory viruses are frequently detected in patients with acute exacerbations of COPD (AE-COPD) it was our aim to investigate the frequency of hMPV detection in a prospective cohort of hospitalized patients with AE-COPD compared to patients with stable COPD and to smokers without by means of quantitative real-time RT-PCR. Results We analysed nasal lavage and induced sputum of 130 patients with AE-COPD, 65 patients with stable COPD and 34 smokers without COPD. HMPV was detected in 3/130 (2.3%) AE-COPD patients with a mean of 6.5 × 105 viral copies/ml in nasal lavage and 1.88 × 105 viral copies/ml in induced sputum. It was not found in patients with stable COPD or smokers without COPD. Conclusion HMPV is only found in a very small number of patients with AE-COPD. However it should be considered as a further possible viral trigger of AE-COPD because asymptomatic carriage is unlikely.

Community-acquired pneumonia (CAP) is a widespread disease with important implications for health-care systems worldwide. This study investigated direct costs, treatment patterns, and outcomes associated with two patient cohorts hospitalized with CAP.The study design was naturalistic, prospective, and open.The study enrolled 580 patients. Two hundred sixty-one patients were treated initially with IV moxifloxacin (45%, cohort M); the remaining 319 patients received nonstandardized treatment (cohort S).Twenty-two hospitals in Germany.Clinical success rates were similar between treatment groups (cohort M, 242 of 256 patients, 95%; cohort S, 286 of 312 patients, 92%; p = 0.208). Mean +/- SD length of hospital stay was 10.8 +/- 5.2 days, with cohort M having a significantly shorter hospital stay (10.0 +/- 4 days) compared to cohort S (11.5 +/- 6 days; p0.001). Median of all direct costs was dollar 1,333 (minimum, dollar 127; maximum, dollar 9,488), with direct costs of dollar 1,250 in cohort M (minimum, dollar 372; maximum, dollar 9,488) and dollar 1,409 in cohort S (minimum, dollar 127; maximum, dollar 9,366) per treated episode of CAP (p = 0.066).Major determinants of costs were length of hospital stay and ICU admission, whereas costs for staff and hotel were major contributors to direct costs. Initial antibiotic therapy with moxifloxacin resulted in similar clinical efficacy and direct costs compared to nonstandardized therapy; however, patients treated with moxifloxacin benefited with an earlier hospital discharge.

The aim of the study was to determine the causes and prognostic implications of antimicrobial treatment failures in patients with nonresponding and progressive life-threatening, community-acquired pneumonia. Forty-nine patients hospitalized with a presumptive diagnosis of community-acquired pneumonia during a 16-mo period, failure to respond to antimicrobial treatment, and documented repeated microbial investigation >/= 72 h after initiation of in-hospital antimicrobial treatment were recorded. A definite etiology of treatment failure could be established in 32 of 49 (65%) patients, and nine additional patients (18%) had a probable etiology. Treatment failures were mainly infectious in origin and included primary, persistent, and nosocomial infections (n = 10 [19%], 13 [24%], and 11 [20%] of causes, respectively). Definite but not probable persistent infections were mostly due to microbial resistance to the administered initial empiric antimicrobial treatment. Nosocomial infections were particularly frequent in patients with progressive pneumonia. Definite persistent infections and nosocomial infections had the highest associated mortality rates (75 and 88%, respectively). Nosocomial pneumonia was the only cause of treatment failure independently associated with death in multivariate analysis (RR, 16.7; 95% CI, 1.4 to 194.9; p = 0.03). We conclude that the detection of microbial resistance and the diagnosis of nosocomial pneumonia are the two major challenges in hospitalized patients with community-acquired pneumonia who do not respond to initial antimicrobial treatment. In order to establish these potentially life-threatening etiologies, a regular microbial reinvestigation seems mandatory for all patients presenting with antimicrobial treatment failures.

Little evidence exists to support the theory that small-bore nasogastric tubes prevent gastroesophageal reflux and microaspiration in intubated patients.To determine whether gastroesophageal reflux and microaspiration in intubated patients can be reduced by the use of a small-bore nasogastric tube.Randomized, two-period crossover trial.Respiratory intensive care unit of a university hospital.17 patients intubated for more than 72 hours.Radioactive technetium colloid was instilled in each patient's stomach. Patients were studied with two nasogastric tubes (one tube with a 6.0-mm external bore and one tube with a 2.85-mm external bore) in randomized order; measurements of radioactive counts with the alternate size of nasogastric tube were repeated 72 hours after original measurements were taken. Sequential samples of serum, gastric juice, and pharyngeal and tracheal secretions were obtained.Comparison of the time course of radioactive counting in all samples (obtained during the use of each nasogastric tube size in each patient).The mean radioactive count of pharyngeal aspirates (P = 0.004) was greater than the baseline count at all time points, as was the cumulative radioactive count of pharyngeal aspirates 17 hours after the first dose of technetium colloid was administered (P = 0.001); however, the count of tracheal aspirates was never greater than the count at baseline. No differences were found between tube types when the time course and cumulative counts of pharyngeal and tracheal samples were compared.Small-bore nasogastric tubes in intubated patients do not reduce gastroesophageal reflux or microaspiration.

Objectives Owing to novel therapy strategies in epidermal growth factor receptor (EGFR)-mutated patients, molecular analysis of the EGFR and KRAS genome has become crucial for routine diagnostics. Till date these data have been derived mostly from clinical trials, and thus collected in pre-selected populations. We therefore screened ‘allcomers’ with a newly diagnosed non-small cell lung carcinoma (NSCLC) for the frequencies of these mutations. Design A cohort study. Setting Lung cancer centre in a tertiary care hospital. Participants Within 15 months, a total of 552 cases with NSCLC were eligible for analysis. Primary and secondary outcome measures Frequency of scrutinising exons 18, 19 and 21 for the presence of activating EGFR mutation and secondary codon 12 and 13 for activating KRAS mutations. Results Of the 552 patients, 27 (4.9%) showed a mutation of EGFR. 19 of these patients (70%) had deletion E746-A750 in codon 19 or deletion L858R in codon 21. Adenocarcinoma (ACA) was the most frequent histology among patients with EGFR mutations (ACA, 22/254 (8.7%) vs non-ACA, 5/298 (1.7%); p

The study was conducted at a tertiary care and teaching hospital with about 200 beds for internal medicine. The objective was to determine the diagnostic yield and value in directing antibiotic therapy of a routine microbial approach in patients with community-acquired pneumonia referred to a tertiary care center. We studied 93 episodes in a retrospective study. 69/93 (74%) cases were treated with at least one empirical antibiotic therapy prior to admission. Microbial investigation was performed in 83/93 cases (89%). An etiological agent was established in 19/83 (23%) cases including 7/50 (14%) by blood culture and 12/52 (23%) by serology. Bronchoscopy with 18 protected specimen brush and 20 bronchoalveolar lavage examinations was definitely diagnostic in only 1/25 (4%) cases, and this case was also identified by blood culture. 5/25 (20%) were probably diagnostic. Three pathogens, Streptococcus pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila, accounted for 15/19 (79%) of the identified agents. The diagnostic results directed a change in antibiotic therapy in 6/19 (32%) of cases with definitely proven pathogens. 4/19 (21%) of cases would have been treated with an inappropriate regimen without diagnostic results. The diagnostic yield of routine microbial investigation in pretreated patients is low. The routine approach reveals its limited value especially in patients with severe courses. The role of bronchoscopy remains to be defined for patients with severe (and pretreated) community-acquired pneumonia.

Pneumocystis carinii pneumonia (PCP) in HIV-infected patients remains a life-threatening complication in the course of HIV infection. Despite effective treatment, mortality may still be as high as 10%. The identification of risk factors associated with a lethal outcome might be helpful as a guide to therapy for patients at risk and in the evaluation of new drugs with anti-pneumocystic activity. In a retrospective study 58 first episodes of HIV-associated PCP without prophylaxis were analyzed. Variables associated univariately with higher mortality were identified. A prognostic rule was established in a multivariate approach using canonical discriminant analysis. Cut-off values for parameters included were determined in order to allow a clinically applicable estimate of the individual risk. Variables associated with early mortality were hemoglobin, hematocrit, platelet count, albumin, total protein, gamma-globulins, and AaDO2. LDH values, percentage of neutrophils in the BAL, as well as the cellular immunologic state as indicated by CD4-cell count were not significantly associated with the outcome. The discriminant function yielded the best classification results with the inclusion of hemoglobin, albumin, and gamma-globulins (overall accuracy 86%). Two or more of the following parameters were associated with a 14-fold increased risk of in-hospital mortality: hemoglobin less than 10 g/dl, albumin less than 3 g/dl, and gamma-globulins less than 1.2 g/dl. This prognostic rule was 80% sensitive and 94% specific with a negative predictive value of 94%, yielding an overall accuracy of 91%. Patients with HIV-associated PCP with a positive prognostic rule have a 14-fold increased risk for in-hospital lethal outcome. This discriminant rule may be helpful in identifying patients at risk.

In community-acquired pneumonia (CAP) mortality may be reduced by early identification of patients requiring intensive care treatment. The purpose of this study was to determine prognostic factors of outcome in patients with CAP in order to establish a clinically applicable discriminant rule. Ninety three episodes of CAP in 92 patients were retrospectively reviewed with regard to epidemiological, clinical, laboratory and microbiological data. The prognostic analysis included a univariate as well as a multivariate approach, in order to identify parameters associated with death using the Cox regression hazard function in a backward stepwise selection model. The three parameters found to contribute most to the significance of the model were used in a discriminant rule for classification of outcome. The parameters found to be significantly different between survivors and non-survivors were heart rate, systolic and diastolic as well as mean blood pressures, leucocyte count, percentage of lymphocytes, and lactate dehydrogenase (LDH) values. The multivariate analysis revealed that heart rate, systolic arterial pressure, and LDH serum levels were most closely associated with fatal outcome. A prognostic rule composed of the variables heart rate > or = 90 beats.min-1, systolic arterial blood pressure < or = 80 mmHg, and LDH > or = 260 U.l-1 achieved a sensitivity of 77%, a specificity of 75%, and positive and negative predictive values of 42 and 93%, respectively. It was associated with a six fold increased risk of fatal outcome. In conclusion, heart rate, systolic blood pressure, and LDH values were most closely associated with death in a multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)