Controversies in the diagnosis of ventilator-acquired pneumonia.

The appropriate investigation of patients with suspected VAP is controversial. Because it is unlikely that any new diagnostic technique will become available in the near future with better performance characteristics than those currently available, physicians need to tailor their diagnostic approach depending on individual patients and clinical scenarios. The most crucial factor in deciding which diagnostic approach to take is the influence that any test result would have on management.

Airflow limitation is underrecognized in well-functioning older people.

Objectives: Dyspnea is a common symptom in older people. A reduced forced expiratory volume in 1 second (FEV1) is associated with a higher mortality rate from cardiovascular and respiratory disease, and increased admissions to hospitals. Underrecognized or undertreated airflow limitation may exacerbate the problem.

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.

Background: Although monotherapy for pneumococcal pneumonia is standard, a survival benefit of combination beta-lactam and macrolide therapy has been suggested.

Hypothesis: Initial empirical therapy with a combination of effective antibiotic agents would have a better outcome than a single effective antibiotic agent in patients with bacteremic pneumococcal pneumonia.

Methods: A review of adult bacteremic pneumococcal pneumonia within the Methodist Healthcare System, Memphis, Tenn, between January 1, 1996, and July 31, 2000.

Septic shock and respiratory failure in community-acquired pneumonia have different TNF polymorphism associations.

Genetic factors are likely to contribute to the variable presentation of community-acquired pneumonia (CAP). The purpose of this prospective cohort study was to determine whether the LTalpha+250 (TNFbeta+250) and TNFalpha-308 gene polymorphisms are associated with different presentations of CAP. Septic shock (SS) was defined using American College of Chest Physicians/Society of Critical Care Medicine (ACCP-SCCM) criteria.

Increasing threat of Gram-negative bacteria.

The widespread use of broad-spectrum antibiotics has led to emergence of antibiotic-resistant strains of many Gram-negative organisms. This problem is particularly serious in critically ill patients, especially those with ventilator-associated pneumonia. Extensive antibiotic resistance has developed in Gram-negative bacteria, due both to innate resistance in some species and the fact that they are highly adept at acquiring antibiotic-resistant determinants from each other.

The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures.

The value of blood cultures in community-acquired pneumonia (CAP) has been questioned. At issue is the potential for blood cultures to change management. We prospectively studied the yield and impact of blood cultures in patients admitted with CAP.

Legionella and community-acquired pneumonia: a review of current diagnostic tests from a clinician's viewpoint.

Many physicians are unaware of the limitations of the available tests for diagnosing infections with Legionella organisms. Geographic differences in the importance of nonpneumophila Legionella species as pathogens are underrecognized, in part because available diagnostic tests are biased toward the detection of pneumophila serogroup 1. Routine laboratory practices reduce the likelihood of culturing Legionella species from clinical isolates.

Bronchostenosis due to childhood tuberculosis and manifested as an asymptomatic mass.

We report a case of bronchostenosis manifested as an asymptomatic mass on preoperative chest roentgenogram. Bronchoscopic biopsy inadvertently led to drainage of the obstructed bronchus. The various pathogenic origins of bronchostenosis are discussed, with the most likely cause in this case being previous tuberculosis.

Reducing electrostatic charge on spacer devices and bronchodilator response.

Aims: Plastic spacers are widely used with pressurized metered dose inhalers (pMDI). Reducing electrostatic charge by washing spacers with detergent has been shown to greatly improve in vitro and in vivo drug delivery. We assessed whether this finding is associated with an improved bronchodilator response in adult asthmatics.

Pulmonary capillaritis associated with the antiphospholipid antibody syndrome and rapid response to plasmapheresis.

Objective: Pulmonary capillaritis is an uncommon complication of antiphospholipid antibody syndrome but has important therapeutic implications.

Case Report: A patient with antiphospholipid antibody syndrome presented with haemoptysis and respiratory failure. Investigation including open lung biopsy, demonstrated vasculitis as the underlying pathology, rather than thrombosis.

The impact of blood cultures on antibiotic therapy in pneumococcal pneumonia.

Introduction: The cost-effectiveness of blood cultures in community-acquired pneumonia (CAP) has been questioned. Although penicillin-resistant Streptococcus pneumoniae is an increasing problem, penicillin therapy, where appropriate, reduces cost and may reduce antibiotic resistance. Blood cultures, however, can only reduce cost if physicians are prepared to alter therapy based on the results.