Search

Byline: Guy J. Oudhuis (1), Judith Beuving (1), Dennis Bergmans (2), Ellen E. Stobberingh (1), Guul Velde (3), Catharina F. Linssen (1), Annelies Verbon (1,4) Keywords: Artificial respiration; Biological marker; Early diagnosis; Enzyme-linked immunosorbent assay; Intensive care; Respiratory tract infections Abstract: Purpose Soluble Triggering Receptor Expressed on Myeloid cells-1 (sTREM-1) has proven to be a good biomarker for sepsis. For the diagnosis ventilator-associated pneumonia (VAP), however, there have only been a few, relatively small, studies on the role of this receptor. The aim of the study was to evaluate the usefulness of sTREM-1 in bronchoalveolar lavage fluid (BALF) from Intensive Care Unit patients as rapid diagnostic test for VAP. Methods The concentration of sTREM-1 in 240 BALF samples was measured using a quantitative sandwich enzyme immunoassay. Two researchers who were blind to the assay results determined whether a VAP was present or not. Clinical suspicion of a VAP was confirmed by the presence of aY=2% cells containing intracellular organisms and/or a quantitative culture result of aY=10.sup.4 colony forming units per millilitre BALF. Results The mean concentration of sTREM-1 was significantly higher in the BALF of patients with confirmed VAP than in that of patients without confirmed VAP. However, the area under the receiver-operating characteristic curve was 0.58 (95% confidence interval 0.50--0.65, P = 0.04). Conclusions The results imply that the sTREM-1 assay in BALF may not be discriminative for VAP. Author Affiliation: (1) Department of Medical Microbiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands (2) Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands (3) Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands (4) Department of Internal Medicine, Division of General Internal Medicine, Section Infectious Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands Article History: Registration Date: 20/03/2009 Received Date: 03/10/2008 Accepted Date: 07/12/2008 Online Date: 03/04/2009

Byline: Olivier Baldesi (1), Fabrice Michel (2), Christophe Guervilly (2), Nathalie Embriaco (2), Aliocha Granfond (3), Bernard Scola (4), Henri Portugal (5), Laurent Papazian (2) Keywords: Epithelial lining fluid; Pneumonia; Diagnosis; BAL; Urea; Dilution; Accuracy Abstract: Objective This study was designed to determine if bronchoalveolar lavage (BAL) quantitative culture results can be used confidently for the diagnosis of bacterial ventilator-associated pneumonia (VAP) without taking dilution into account. Design Prospective observational cohort study. Setting A 12-bed medical ICU in a teaching hospital. Patients A total of 241 BAL (three 50-mL aliquots) were performed in 127 patients presenting a suspicion of VAP. Interventions All consecutive adults who were ventilated more than 48 h were included if VAP was clinically suspected. A dilution factor, k, was developed according to the formula: dilution factor k = concentration of urea in plasma/concentration of urea in lavage fluid recovered. Using this dilution factor, the quantitative bacterial counts were interpreted accordingly with a corrected positive threshold at 10.sup.5 colony forming unit (CFU) mL.sup.-1. Measurements and results Eighty-nine BAL with at least one micro-organism aY=10.sup.4 CFU mL.sup.-1 were identified (37%). In 176 BAL (73%), k ranged from 10 to 100. Median k was 24.4 (9.7--40.2) in VAP group and 24.6 (13.1--57.8) in patients without pneumonia (NS). Among the 25 BAL with micro-organism counts of 10.sup.4 CFU mL.sup.-1, 3 had a dilution factor lower than 10, resulting in corrected counts below the threshold of 10.sup.5 CFU mL.sup.-1. Two out of 15 patients with micro-organism counts of 10.sup.3 CFU mL.sup.-1 had corrected micro-organism counts of 10.sup.5 CFU mL.sup.-1. Finally, only five BAL (2.1%) were misclassified when the dilution correction factor was applied. Conclusions Using urea as dilution factor, we showed that BAL dilution variations did not alter the interpretation of BAL quantitative bacterial culture when administrating three aliquots of 50 mL of saline. Author Affiliation: (1) Service de Reanimation medico-chirurgicale, Centre Hospitalier du Pays d'Aix, Aix-en-Provence, France (2) Reanimation Medicale, Assistance Publique, Hopitaux de Marseille, URMITE CNRS-UMR 6236, Universite de la Mediterranee, Marseille, France (3) Reanimation polyvalente, Hopital Font-Pre, Toulon, France (4) Laboratoire de Bacteriologie, Assistance Publique, Hopitaux de Marseille, URMITE CNRS-UMR 6236, Universite de la Mediterranee, Marseille, France (5) Laboratoire de Biologie, Hopital Sainte-Marguerite, Universite de la Mediterranee, 13009, Marseille, France Article History: Registration Date: 16/01/2009 Received Date: 11/08/2008 Accepted Date: 30/12/2008 Online Date: 03/02/2009 Article note: This study was conducted in the Medical Intensive Care Unit of the Hopital Sainte-Marguerite, 13009 Marseille, France.

Byline: Boris Jung (1), Mustapha Sebbane (1), Gerald Chanques (1), Patricia Courouble (1), Daniel Verzilli (1), Pierre-Francois Perrigault (1), Helene Jean-Pierre (2), Jean-Jacques Eledjam (1), Samir Jaber (1) Keywords: Endotracheal aspiration; Broncho-alveolar lavage; Ventilator-associated pneumonia; Nosocomial pneumonia; Antibiotic therapy; Mechanical ventilation Abstract: Objectives Any delay in adequate antibiotic treatment compromises the outcome of ventilator-associated pneumonia (VAP). However, the diagnosis and optimal treatment of VAP remain a challenge for intensivists. We assessed the potential impact of using results of routine weekly endotracheal aspirate (EA) cultures to guide initial antibiotic treatment for VAP. Design and setting Retrospective analysis of prospectively collected data in a medical--surgical intensive care unit (ICU) of a university hospital. Patients and methods We studied 113 VAP episodes and evaluated the concordance between the latest EA and the broncho-alveolar lavage (BAL). We stratified patients into three groups: concordant EA--BAL (concordant group), discordant EA--BAL (discordant group) and EA not performed group. We then compared the adequacy of the antibiotic prescribed initially and outcomes between the three groups. Measurements and main results Ninety assessable EA--BAL samples were evaluated. When guided by EA, the initial antibiotic regimen was adequate in 85% of situations, a proportion significantly superior (P < 0.05) to that resulting from application of the ATS guidelines (73%). When clinicians did not have a pre-VAP EA to guide their treatment (EA not performed group), only 61% of treatments were adequate. No significant difference was observed between the three groups for length of mechanical ventilation, length of ICU stay, nonpulmonary nosocomial infections and mortality. Conclusion Once-a-week routine quantitative EA cultures may help to improve the adequacy of empiric antibiotic therapy for VAP. Author Affiliation: (1) Intensive Care Unit, Department of Critical Care and Anesthesiology, DAR B CHU de Montpellier, Hopital Saint Eloi, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France (2) Bacteriology Department, CHU de Montpellier, Hopital Arnaud de Villeneuve, 191 Av Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France Article History: Registration Date: 18/07/2008 Received Date: 14/07/2007 Accepted Date: 13/07/2008 Online Date: 19/08/2008 Article note: This article is discussed in the editorial available at: doi: 10.1007/s00134-008-1249-7. Presented in part at the 2006 Annual Meeting of European Society of Intensive Care Medicine (Barcelona, Spain, 24--27 September 2006). All authors declare the absence of any involvement in any organization with a direct financial interest in the subject of the manuscript.

Byline: Renato Seligman (1,2), Jana Papassotiriou (3), Nils G. Morgenthaler (3), Michael Meisner (4), Paulo J. Z. Teixeira (2) Keywords: Midregional pro-atrial natriuretic peptide; Ventilator-associated pneumonia; Sepsis; Septic shock Abstract: Objective This study aimed to investigate the correlation of midregional pro-atrial natriuretic peptide (MR-proANP) with severity of septic status in patients with ventilator-associated pneumonia (VAP) and the usefulness of MR-proANP for mortality prediction in VAP. Design Prospective observational cohort study. Setting University Hospital. Patients Seventy-one patients consecutively admitted to ICU who developed VAP. Patients were followed for 28 days after diagnosis, when they were considered survivors. There were no interventions. Results MR-proANP levels increased from sepsis to severe sepsis and septic shock on D0 and D4 of VAP (0.002 and 0.02 respectively). Median MR-proANP levels on day 0 and day 4 (pmol/L [interquartile range]) were 149.0 (79.8--480.0) and 249.0 (93.6--571.0) in septic patients, 438.5 (229.3--762.0) and 407.5 (197.8--738.0) in severe sepsis, 519.5 (369.5--1282.3) and 632.0 (476.0--1047.5) in septic shock. On day 0 and day 4, MR-proANP levels were significantly higher in non-survivors (525.0 [324.0--957.8] and 679.5 [435.0--879.5], respectively) than in survivors (235.0 [102.0--535.0] and 254.0 [110.0--571.0], respectively P = 0.004). Univariate logistic regression model for mortality included age, gender, APACHE II score, creatinine, logarithmic transformed MR-proANP (LnMR-proANP). Mortality was directly related to LnMR-proANP on D0 and D4, with odds ratios (OR) of 2.06 (95% CI 1.21--3.51) and 2.63 (1.33--5.23), respectively. In multivariate logistic regression, only LnMR-proANP D0 with OR = 2.35 (1.05--5.26) and LnMR-proANP D4 with OR = 3.76 (1.39--10.18) remained significant. Conclusions Our data demonstrated that MR-proANP levels increase progressively with the severity of sepsis and are independent predictors of mortality in VAP. Author Affiliation: (1) Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, 90035-003, Brazil (2) Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400, Porto Alegre, 90035-003, Brazil (3) Research Department, B.R.A.H.M.S AG, Neuendorfstrasse 25, 16761, Hennigsdorf/Berlin, Germany (4) Hospital of Dresden-Neustadt, Industriestrasse 40, 01129, Dresden, Germany Article History: Registration Date: 23/05/2008 Received Date: 02/11/2007 Accepted Date: 17/05/2008 Online Date: 04/06/2008

Byline: Charles-Edouard Luyt (1), Alain Combes (1), Catherine Reynaud (1), Guillaume Hekimian (1), Ania Nieszkowska (1), Marc Tonnellier (1), Alexandra Aubry (2), Jean-Louis Trouillet (1), Maguy Bernard (3), Jean Chastre (1) Keywords: Ventilator-associated pneumonia; Procalcitonin; Diagnosis; Clinical pulmonary infection score Abstract: Objective To assess the predictive capacity for the diagnosis of ventilator-associated pneumonia (VAP) of serum procalcitonin levels before and on the day it is suspected. Design and setting Single-center observational study in the intensive care unit of a teaching hospital. Patients and participants Consecutive patients whose serum procalcitonin levels were available on the day that VAP was clinically suspected (day 1) and at some time within the preceding 5 days ('before'). Measurements and results Serum procalcitonin levels were determined on day 1 and 'before'. Among the 73 suspected episodes VAP was confirmed by quantitative bronchoalveolar lavage cultures in 32 and refuted in 41. Respective median 'before' procalcitonin levels were 1.89 ng/ml (interquartile range 0.18--6.01) and 2.14 (0.76--5.75) in patients with and without VAP, but their respective median day-1 procalcitonin levels did not differ: 1.07a-ng/ml (0.39--6.57) vs. 1.40 (0.67--3.39). On day 1 a 0.5a-ng/ml procalcitonin threshold had 72% sensitivity but only 24% specificity for diagnosing VAP. Between 'before' and day 1, procalcitonin increased in 41% and 15% of patients with and without VAP, respectively. Thus a procalcitonin rise on day 1, compared to its 'before' level, had 41% sensitivity and 85% specificity for diagnosing VAP, with respective positive and negative predictive values of 68% and 65%. Conclusions Crude values and procalcitonin rise had poor diagnostic value for VAP in this particular setting and thus should not be used to initiate antibiotics when VAP is clinically suspected. Author Affiliation: (1) Service de Reanimation Medicale, Groupe Hospitalier Pitie Salpetriere, AP-HP, Universite Paris 6, Pierre-et-Marie-Curie, 47 boulevard de l'Hopital, 75651, Paris Cedex 13, France (2) Service de Bacteriologie, Groupe Hospitalier Pitie Salpetriere, AP-HP, Universite Paris 6, Pierre-et-Marie-Curie, 47 boulevard de l'Hopital, 75651, Paris Cedex 13, France (3) Service de Biochimie, Groupe Hospitalier Pitie Salpetriere, AP-HP, Universite Paris 6, Pierre-et-Marie-Curie, 47 boulevard de l'Hopital, 75651, Paris Cedex 13, France Article History: Registration Date: 25/03/2008 Received Date: 20/12/2007 Accepted Date: 13/03/2008 Online Date: 18/04/2008 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1112-x) contains supplementary material, which is available to authorized users.

Coccidioidomycosis is a common cause of community-acquired pneumonia (CAP) in disease-endemic areas. Because testing rates influence interpretation of reportable-disease data and quality of CAP patient care, we determined the proportion [...]

Byline: Lorenzo Berra (1), Francesco Curto (2), Gianluigi Li Bassi (2), Patrice Laquerriere (3), Betsey Pitts (4), Andrea Baccarelli (5), Theodor Kolobow (2) Keywords: Endotracheal tube; Mechanical ventilation; Bacterial biofilm; Ventilator-associated pneumonia; Silver sulfadiazine Abstract: Objective Antibiotic-resistant bacterial biofilm may quickly form on endotracheal tubes (ETTs) and can enter the lungs, potentially causing pneumonia. In an attempt to prevent bacterial colonization, we developed and tested in an in-vitro study and animal study several antibacterial-coated ETTs (silver sulfadiazine with and without carbon in polyurethane, silver sulfadiazine and chlorhexidine with and without carbon in polyurethane, silver--platinum with and without carbon in polyurethane, chlorhexidine in polyurethane, and rose bengal for UV light). Design, setting, animals, interventions After preliminary studies, silver sulfadiazine in polyurethane (SSD-ETT) was selected among the coatings to be challenged every 24a-h with 10.sup.4--10.sup.6 Pseudomonas aeruginosa/ml and evaluated at 6a-h, 24a-h, and 72a-h with standard microbiological studies, scanning electron microscopy, and confocal scanning microscopy. Subsequently, eight sheep were randomized to receive either a SSD-ETT or a standard ETT (St-ETT). After 24a-h of mechanical ventilation, standard microbiological studies were performed together with scanning electron microscopy and confocal microscopy. Measurements and results In the in-vitro study SSD-ETT remained bacteria-free for up to 72a-h, whereas St-ETT showed heavy P. aeruginosa growth and biofilm formation (pa- Conclusion This study describes several effective and durable antibacterial coatings for ETTs. Particularly, SSD-ETT showed prevention against P. aeruginosa biofilm formation in a 72-h in-vitro study and lower respiratory tract colonization in sheep mechanically ventilated for 24a-h. Author Affiliation: (1) Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WHT-4-436, Boston, MA, USA (2) Pulmonary and Critical Care Medicine Branch, NHLBI, National Institutes of Health, 9000 Rockville Pike, 20892, Bethesda, MD, USA (3) Laboratoire de Microscopie Electronique, UFR Sciences, University of Reims Champagne Ardenne, INSERM-ERM 0203, 21 rue Clement Ader, BP 138, 51685, Reims, Cedex 2, France (4) Center for Biofilm Engineering and Department of Chemical Engineering, Montana State University Bozeman, 59717-3980, Bozeman, MT, USA (5) Department of Environmental Health, Harvard School of Public Health, 02215, Boston, MA, USA Article History: Registration Date: 11/03/2008 Received Date: 07/04/2006 Accepted Date: 10/12/2007 Online Date: 17/04/2008 Article note: This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-008-1101-0.

Pneumonia is an important cause of illness and death in England. To describe trends in pneumonia hospitalizations, we extracted information on all episodes of pneumonia that occurred from April 1997 [...]

It is very vital for a physician to critically appraise the original diagnosis in the case of a lack of improvement despite appropriate therapy. This can be seen from the case of a man suffering from repeated bouts of dyspnea and cough who was diagnosed with pneumonia.

Byline: Nilton Brandao da Silva (1,2), Lucas Martins (2), Frederico Martins (2), Jose Anflor (2), Tiago Tonietto (2), Cristiano Koefender (2), Paulo G. Cardoso (2), Jose Moreira (3) Keywords: Nosocomial pneumonia; Streptococcus pneumoniae; Pseudomonas aeruginosa; Bronchoalveolar lavage; Intracellular organisms Abstract: Objective To assess the accuracy of direct examination and quantitative cultures of BAL to diagnose pneumonia with or without antibiotic treatment. Design Experimental rat models. Interventions Pneumonia was induced by intratracheal inoculation of S. pneumoniae ([10.sup.9]a-cfu/ml) or P. aeruginosa ([10.sup.8]a-cfu/ml). Controls (na-=a-10) received sterile inoculum. Study animals received penicillin (na-=a-19) or saline (na-=a-18) (pneumococcal model) amikacin (na-=a-13), ceftazidime (na-=a-11), or saline (na-=a-13) (Pseudomonas model). BAL was assessed 48a-h after infection. The animals were killed for histopathological analysis. Results All study animals developed pneumonia, which was more extensive in the pneumococcal than in the Pseudomonas model. In pneumococcal pneumonia the sensitivity of BAL cultures ([10.sup.3]a-cfu/ml or higher) was 77.8% with saline and 21.0% with penicillin. In the Pseudomonas ceftazidime group all specimens were negative, precluding diagnosis. The sensitivity of cultures with amikacin was 23.1% vs. 30.8% with saline. In the pneumococcal model intracellular organism (ICO) count of 2% or higher had a sensitivity of 100% for detecting pneumonia with saline and 57.9% with penicillin. In the Pseudomonas model the sensitivity of ICO was 69.2% with both amikacin and saline and 36.3% with ceftazidime. The sensitivity of neutrophil count above 50% in pneumococcal pneumonia was 77.8% and 64.7% with saline and penicillin, respectively, and 69.2%, 61.5%, and 81.8% with saline, amikacin, and ceftazidime, respectively, in Pseudomonas pneumonia. Conclusions BAL-positive intracellular organisms were more accurate than cultures for the diagnosis of recent pneumonia, and were less affected by antibiotic treatment. Author Affiliation: (1) Centro de Terapia Intensiva, Hospital Moinhos de Vento, 90035-001, Porto Alegre RS, Brazil (2) Laboratorio Experimental, Fundacao Faculdade Federal de Ciencias Medicas, Porto Alegre, Brazil (3) Post-Graduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil Article History: Registration Date: 11/07/2007 Received Date: 15/11/2006 Accepted Date: 10/07/2007 Online Date: 03/08/2007 Article note: This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-007-0812-y.

Byline: Kemal Agbaht (1), Thiago Lisboa (1), Angel Pobo (1), Alejandro Rodriguez (1), Alberto Sandiumenge (1), Emili Diaz (1), Jordi Rello (1) Keywords: Ventilator-associated pneumonia; Trauma; Antibiotics; Methicillin resistance; Staphylococcus aureus Abstract: Objective Antibiotic exposure and timing of pneumonia onset influence ventilator-associated pneumonia (VAP) isolates. The first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms. Design A retrospective, single-center, observational cohort study. Setting Multidisciplinary teaching ICU. Patients Adult patients requiring mechanical ventilation identified as having VAP. Interventions Retrospective evaluation of a prospective manual database. Measurements and main results VAP isolates in a multidisciplinary ICU documented by quantitative respiratory cultures and recorded in a 42-month database were compared, based on the presence or absence of trauma. Causative microorganisms were classified in four groups, based on mechanical ventilation duration (>a-5 days), and previous antibiotic exposure. One hundred eighty-three patients developed 196 episodes of VAP (98 trauma). Methicillin-sensitive Staphylococcus aureus (MSSA) was more frequent (34.5% vs. 11.5%, pa- Conclusions Trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. Our data demonstrate that patients with trauma had a higher prevalence of MSSA, but the overall prevalence was sufficiently high to warrant S. aureus coverage for both groups. On the other hand, since no MRSA was isolated during the first 10 days of mechanical ventilation on trauma patients, MRSA coverage in these patients becomes necessary only 10 days after admission. Author Affiliation: (1) Critical Care Department, Joan XXIII University Hospital, Institut Pere Virgili, CIBERa---a-Enfermedades Respiratorias, University of Rovira & Virgili, Carrer Dr. Mallafre Guasch 4, 43007, Tarragona, Spain Article History: Registration Date: 09/05/2007 Received Date: 18/12/2006 Accepted Date: 08/05/2007 Online Date: 12/06/2007 Article note: Supported by Fondo de Investigaciones Sanitarias (CIBERes 06/06/0036 and PI05/2410) and AGAUR (2005/SGR/920).

Byline: Carolina A. M. Schurink (1), Stefan Visscher (1), Peter J. F. Lucas (2), Henk J. Leeuwen (1,3), Erik Buskens (4), Reinier G. Hoff (5), Andy I. M. Hoepelman (1,3), Marc J. M. Bonten (1,3,4) Keywords: Ventilator-associated pneumonia; Decision-support system; Bayesian network Abstract: Objective To determine the diagnostic performance of a Bayesian Decision-Support System (BDSS) for ventilator-associated pneumonia (VAP). Design A previously developed BDSS, automatically obtaining patient data from patient information systems, provides likelihood predictions of VAP. In a prospectively studied cohort of 872 ICU patients, VAP was diagnosed by two infectious-disease specialists using a decision tree (reference diagnosis). After internal validation daily BDSS predictions were compared with the reference diagnosis. For data analysis two approaches were pursued: using BDSS predictions (a) for all 9422 patient days, and (b) only for the 238a-days with presumed respiratory tract infections (RTI) according to the responsible physicians. Measurements and results 157 (66%) of 238a-days with presumed RTI fulfilled criteria for VAP. In approach (a), median daily BDSS likelihood predictions for days with and without VAP were 77% [Interquartile range (IQR)a-=a-56--91%] and 14% [IQR 5--42%, pa- Conclusions As compared with the reference diagnosis, the BDSS had good test characteristics for diagnosing VAP, and might become a useful tool for assisting ICU physicians, both for routinely daily assessment and in patients clinically suspected of having VAP. Empirical validation of its performance is now warranted. Author Affiliation: (1) Division of Internal Medicine, Geriatrics and Infectious Diseases, University Medical Center Utrecht, Heidelberglaan 100, HP F.02.126, 3584 CX, Utrecht, The Netherlands (2) Institute for Computing and Information Sciences, Radboud University, Nijmegen, The Netherlands (3) Eijkman-Winkler Laboratory for Microbiology, University Medical Center Utrecht, Heidelberglaan 100, HP F.02.126, 3584 CX, Utrecht, The Netherlands (4) Julius Center for Health Sciences and Primary Health Care, University Medical Center Utrecht, Heidelberglaan 100, HP F.02.126, 3584 CX, Utrecht, The Netherlands (5) Division of Perioperative and Emergency Care, University Medical Center Utrecht, Heidelberglaan 100, HP F.02.126, 3584 CX, Utrecht, The Netherlands Article History: Registration Date: 09/05/2007 Received Date: 10/11/2006 Accepted Date: 08/05/2007 Online Date: 16/06/2007 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-007-0728-6) contains supplementary material, which is available to authorized users.

Objective Trials of environmental risk factors and acute lower respiratory infections (ALRI) face a double challenge: implementing sufficiently sensitive and specific outcome assessments, and blinding. We evaluate methods used in the first randomized exposure study of pollution indoors and respiratory effects (RESPIRE): a controlled trial testing the impact of reduced indoor air pollution on ALRI, conducted among children [less than or equal to] 18 months in rural Guatemala. Methods Case-finding used weekly home visits by fieldworkers trained in integrated management of childhood illness methods to detect ALRI signs such as fast breathing. Blindness was maintained by referring cases to study physicians working from community centres. Investigations included oxygen saturation (Sa[0.sub.2]), respiratory syncytial virus (RSV) antigen test and chest X-ray (CXR). Findings Fieldworkers referred > 90% of children meeting ALRI criteria, of whom about 70% attended a physician. Referrals for cough without respiratory signs and self-referrals contributed 19.0% and 17.9% of physician-diagnosed ALRI cases respectively. Intervention group attendance following ALRI referral was 7% higher than controls, a trend also seen in compliance with RSV tests and CXR. There was no evidence of bias by intervention status in fieldworker classification or physician diagnosis. Incidence of fieldworker ALRI (1. 12 episodes/child/year) is consistent with high sensitivity and low specificity; incidence of physician-diagnosed ALRI (0.44 episodes/child/year) is consistent with comparable studies. Conclusion The combination of case-finding methods achieved good sensitivity and specificity, but intervention cases had greater likelihood of reaching the physician and being investigated. There was no evidence of bias in fieldworkers&apos; classifications despite lack of concealment at home visits. Pulse oximetry offers practical, objective severity assessment for field studies of ALRI. Objectif Les etudes de l&apos;influence de facteurs environnementaux sur les infections aigues des voies respiratoires basses (ALRI) se heurtent a une double difficulte, a savoir la mise en ceuvre de methodes d&apos;evaluation des resultats suffisamment sensibles et specifiques et le masquage des identites. Nous avons donc evalue les methodes utilisees dans la premiere etude d&apos;exposition randomisee des effets sur les voies respiratoires de la pollution interieure RESPIRE (etude cas-temoins randomisee de l&apos;impact d&apos;une reduction de la pollution de l&apos;air interieur sur les infections aigues des voies respiratoires basses, menee sur des enfants de 18 mois au plus, en milieu rural au Guatemala). Methodes Pour depister ces maladies, on a eu recours a des visites domicile par des agents de terrain formes aux methodes de prise en charge integree des maladies de l&apos;enfance permettant d&apos;en detecter les signes, comme l&apos;acceleration du rythme respiratoire par exemple. La confidentialite a ete maintenue en orientant les cas vers des medecins de l&apos;etude travaillant dans des centres communautaires. Parmi les examens pratiques flguraient notamment la determination de la saturation arterielle en oxygene (Sa[O.sub.2]), un test de detection antigenique du virus respiratoire syncytial (VRS) et une radiographie thoracique. Resultats Les agents de terrain ont oriente vers un specialiste plus de 90% des enfants remplissant les criteres de presence d&apos;une ALRI, parmi lesquels 70% ont consulte un medecin. Les orientations vers un specialiste pour toux sans signe respiratoire et les consultations de specialiste a l&apos;initiative des sujets euxmemes ont represente respectivement 19,0% et 17,9% des cas d&apos;ALRI medicalement diagnostiques. Les membres du groupe d&apos;intervention etaient plus nombreux que les temoins (+ 7%) a sume la recommandation de consulter un specialiste pour suspicion d&apos;ALRI, tendance egalement observee dans la soumission au test de depistage du VRS et a la radiographie thoracique. On n&apos;a releve aucun element indiquant la presence d&apos;un biais lie a la participation du sujet a l&apos;intervention dans la classification par les agents de terrain ou le diagnostic par les medecins. L&apos;incidence des ALRI detectees par des agents de terrain (1,12 episode/enfant/an) etait coherente avec la forre sensibilite et la faible specificite de cette methode de depistage. Celle des cas d&apos;ALRI diagnostiques par des medecins (0,44 episode/enfant/an) etait egalement coherente avec celle obtenue dans des etudes comparables. Conclusion L&apos;association des deux methodes de depistage a permis d&apos;obtenir une sensibilite et une specificite satisfaisantes, mais la probabilite d&apos;etre vu par un medecin et d&apos;etre examine etait plus forte pour les cas ayant beneficie de l&apos;intervention. Aucun element n&apos;indiquait la presence d&apos;un biais dans la classification etablie par les agents de terrain, en depit du manque de confidentialite des visites a domicile. La sphygmo-oxymetrie offre un moyen pratique et objectif pour evaluer la gravite de la pathologie dans le cadre des etudes sur le terrain des ALRI. Objetivo Los ensayos sobre los factores de riesgo ambientales y las infecciones agudas de las vias respiratorias inferiores (IAVRI) encaran un doble reto: la necesidad de implementar evaluaciones de resultados suficientemente sensibles y especificas, y la aplicacion de metodos de enmascaramiento. Evaluamos los metodos utilizados en el primer estudio aleatorizado de la exposicion a la contaminacion del aire en interiores y sus efectos respiratorios (RESPIRE), un ensayo controlado realizado entre ninos [less than or equal to] 18 meses en zonas rurales de Guatemala para determinar el impacto de la reduccion de ese tipo de contaminacion en las IAVRI. Metodos La localizacion de casos se hizo mediante visitas domiciliarias semanales realizadas por agentes sobre el terreno adiestrados en los metodos de la atencion integrada a las enfermedades prevalentes de la infancia para detectar los signos de IAVRI, como por ejemplo una respiracion rapida. El enmascaramiento se logro derivando los casos a medicos que trabajaban en centros comunitarios. Como parte del estudio se determinaron la saturacion de oxigeno (Sa[O.sub.2]) y la presencia del virus sincitial respiratorio (VSR) y se hizo una radiografia de torax (RXT). Resultados Los trabajadores sobre el terreno derivaron a mas del 90% de los ninos que cumplian los criterios de IAVRI, alrededor del 70% de los cuales fueron llevados al medico. Las derivaciones por tos sin signos respiratorios y las autoderivaciones representaron el 19,0% y el 17,9% de los casos de IAVRI diagnosticados por los medicos, respectivamente. Las visitas al medico en el grupo de intervencion fueron un 7% mas frecuentes que en el grupo de control, tendencia observada tambien en la realizacion de las pruebas del VSR y la RXT. No hubo ningun dato que indicara un posible sesgo por estado de intervencion en la clasificacion de los trabajadores sobre el terreno o el diagnostico de los medicos. La incidencia de IAVRI basada en las evaluaciones de los trabajadores sobre el terreno (1,12 episodios/nino/ano) refleja una alta sensibilidad y una baja especificidad; la incidencia de IAVRI diagnosticadas por los medicos (0,44 episodios/nino/ano) es similar a la de otros estudios comparables. Conclusion La combinacion de metodos de busqueda de casos permitio conseguir una buena sensibilidad y especificidad, pero los casos del grupo de intervencion tenian mas probabilidades de llegar al medico y ser estudiados. No se observo ningun indicio de sesgo en las clasificaciones de los trabajadores sobre el terreno pese a la falta de ocultacion en las visitas domiciliarias. La oximetria de pulso permite evaluar de forma practica y objetiva la gravedad del estado en los estudios de campo de las IAVRI., Introduction Acute lower respiratory infections (ALRI) are the single most important cause of death of children under 5 years, responsible annually for approximately 20% of the 10 million under-5 deaths [...]

The precision and accuracy of clinical, radiographic, and laboratory data to diagnose bacterial Ventilator-associated pneumonia (VAP) relative to a histological gold standard is reviewed. It is suggested that clinicians caring for ventilated patients with a clinical syndrome consistent with VAP should be ready to consider additional diagnoses and further investigations, particularly when an empirical trial of antibiotics does not lead to improvement within 48 to 72 hours.

Methicillin-resistant Staphylococcus aureus of clonal lineage ST398 that exhibits related spa types and contains SCCmec elements of types IVa or V has been isolated from colonized and infected humans and [...]