Severe Bacterial Pneumonia Research Articles

重症肺炎による敗血症に対し，左右独立肺換気を用いた気道洗浄にて救命し得た１例

We report a 26-year-old woman suffering from sepsis due to severe pneumonia successfully managed with sufficient irrigation of airpassages under differential lung ventilation (DLV). The patient had attempted suicide by jumping from a building, sustaining a unilateral pulmonary contusion, multiple rib fractures with hemothorax, liver injury, pelvic fracture, and open fractures of the lower leg. Although we successfully treated the multiple injuries, she went into septic shock due to severe bacterial pneumonia in the lung opposite the contused one. Both sputum and blood culture revealed Pseudomonas aeruginosa. Her condition did not improve despite antibiotic therapy specific to the organism. Frequent bronchoscopy with sufficient irrigation of the left bronchial tree appeared necessary to drain transbronchial pus. DLV was used to avoid hypoxemia and prevent the spread of infection to the opposite lung during irrigation. This airway management from day 21 after injury ameliorated bacterial infection and enabled her to recover from sepsis. DLV was maintained for 26 days and replaced by conventional ventilation through a single lumen tube. DLV thus was beneficial in sepsis due to severe unilateral pneumonia.

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries

Simplified guidelines for the emergency care of children have been developed to improve the triage and rapid initiation of appropriate emergency treatments for children presenting to hospitals in developing countries....

G-CSF May Help Treat Severe Bacterial Pneumonia.

Since neutrophils fight bacterial infections, shouldn't a cytokine that stimulates neutrophil release be helpful against bacterial pneumonia? This

Results of Extracorporeal Membrane Oxygenation in Children With Sepsis

Background. Despite good results in neonates, extracorporeal membrane oxygenation (ECMO) is less well accepted in pediatric patients. Older children frequently undergo ECMO for severe bacterial, viral, or aspiration pneumonia and many have coexisting systemic sepsis. We reviewed data from a national registry to study the influence of sepsis on survival from ECMO. Methods. Six hundred fifty-five patients (aged 2 weeks to 17 years) with respiratory failure treated with ECMO were divided into two groups by the presence (n = 76) or absence (n = 579) of sepsis. Groups were compared by univariate analysis and by multivariate logistic regression that considered 10 additional pre-ECMO variables (age, sex, weight, arterial blood gas results, ventilator parameters, and renal failure). Results. By univariate analysis, survival was lower in septic children (36.8% versus 51.6%; p < 0.02). However, by multivariate analysis, sepsis was not an independent survival predictor (odds ratio, 0.578; 95% confidence interval, 0.288–1.162; p = 0.12). The ECMO complications predicted by the presence of sepsis included (1) seizures, (2) other neurologic complications, and (3) infection at other sites (all p < 0.05). Conclusions. Systemic sepsis does not independently influence survival in pediatric ECMO. This therapy should not be withheld solely because of sepsis, although neurologic complications may occur more frequently.

Intolerable Pruritis in an HIV-Infected Man

Angel C. is a 40-year old HIV-infected man for whom you have been caring since his initial episode of PCP almost four years ago. He has extensive Kaposi's sarcoma, disseminated MAC, and is quite debilitated. Since his last hospitalization for a severe bacterial pneumonia, he has been living at home with a rotation of health aides. He has expressed the wish for comfort-directed medical care only from now on. Mr. C. comes to see you for a routine appointment complaining of a terrible itch all over his body. The aide accompanying him confirms that Mr. C. has been scratching nonstop for almost two weeks, despite a variety of over-the-counter skin creams they have tried. Mr. C. went to see a dermatologist in his neighborhood last week, who provided several sample-sized tubes of a steroid cream. This medication helped the itch somewhat, but Mr. C. has used up his supply and begs you to write him a prescription for more. Reviewing Mr. C.'s chart, you confirm that the only medications he is taking are those he's been …

Influence of Three Factors on the Diagnostic Effectiveness of Transthoracic Needle Aspiration in Pneumonia

Prior antibiotic therapy, size of the infiltrate, and the person who performed the technique were the three factors that we studied to assess their influence on the effectiveness of transthoracic needle aspiration (TNA). Ninety-one patients with a diagnosis of severe bacterial pneumonia, who underwent TNA, have been included in the study. The technique was carried out with an ultrathin needle gauge 25 and without fluoroscopic control. A univariate (UA) and a multivariate statistical analysis were made. The sensitivity of TNA was 34.1%. Fifty-seven of 91 (62.6%) had received antibiotic therapy prior to TNA; sensitivity was higher in nontreated patients than in treated patients (p = 0.0033; UA). There were 34 patients with an infiltrate that was smaller than a lobe (MINLOB); 39 cases affected a complete lobe (LOB) and 18 more than one lobe (MAJLOB). The TNA sensitivity was higher in LOB cases than in MINLOB cases (p = 0.0004; UA) while when comparing LOB cases and MAJLOB cases, sensitivity was higher in the former (p = NS; UA). In 28 of 91 cases (30.8%), the TNA was performed by A (a trained physician who regularly carries out the technique) and in 63 of 91 cases (69.2%) by B (other physicians, 10 in our study, who sporadically perform the technique). The TNA sensitivity was higher when the technique was performed by A, although this difference was not significant; if we add negative TNA with leukocytes present in Gram stains (which would indicate that aspiration was done in the correct area) to positive TNA, the difference between A and B was higher (p = 0.0248). The multivariate statistical analysis confirmed that there are two variables that are independently connected to a positive TNA (prior antibiotic therapy and size of the infiltrate). As regards the variable "person who carries out the technique," a significant association with a positive TNA was not established, although the estimations we obtained show a possible clinical relevance.

Once-Daily Intramuscular Ceftriaxone in the Outpatient Treatment of Severe Community-Acquired Pneumonia in Children

Ceftriaxone, a broad spectrum third-generation cephalosporin with a half-life of six to eight hours, was evaluated prospectively in 147 children with severe community-acquired bacterial pneumonia during the period 11/15/88-5/15/89. Thirty-nine of the children had been unsuccessfully treated with vanous oral antibiotics prior to admission [corrected]. All the patients were initially hospitalized and started on once a day intramuscular ceftriaxone. Mean duration of ceftriaxone therapy was five days. Pathogens were recovered from blood cultures of 17 (11.6%) patients and included S. pneumoniae (13 patients), H. influenzae (three, all resistant to ampicillin) and S. viridans (1) [corrected]. All isolates were sensitive to ceftriaxone. An additional patient had L. pneumophila diagnosed by serology. Cure was achieved in 142 (96.6%) patients; improvement was usually observed within 24-48 hours. After 48 hours, 121 (82.2%) children could be discharged and continued the therapy on ambulatory basis. Based on previous experience we estimated that 383 hospitalization days were saved. No serious side effects were observed. Five patients were considered therapeutic failures; two of them developed empyema and one of them required repeated drainage procedures. A third patient experienced a relapse of pneumonia shortly after completion of therapy. The other two remained febrile for more than seven days; their subsequent improvement was unrelated to the antibiotic therapy, suggesting a viral or mycoplasmal syndrome. Our data suggest that once daily intramuscular ceftriaxone can be successfully used for the outpatient treatment of most community-acquired severe bacterial pneumonias in children. In our opinion it represents the treatment of choice for patients who failed treatment with other antimicrobials and are clinically stable enough not to require hospitalization.

Artificial ventilation in severe pertussis.

A retrospective review was conducted of all children admitted to our intensive care unit over eight years with a diagnosis of pertussis that had been proved on culture. Altogether 789 children were seen as outpatients and inpatients. Twenty four of these children were admitted to the intensive care unit, 13 of whom required ventilatory support; two of the ventilated patients died. Intubation and ventilation were usually started for appreciable apnoea. Most patients requiring support were less than 3 months of age and required intervention within the first 16 days of cough. For these patients ventilation was neither difficult nor prolonged. Coughing spasms were not a problem and intubation and ventilation appeared to attenuate the progress of the disease. The presence of severe bacterial pneumonia associated with difficult ventilation requiring neuromuscular paralysis indicated a poor prognosis. It is suggested that intubation and ventilation can be safely used in very severe pertussis infection and, because of their greater risk of hypoxic damage and death, it should not be reserved as a last resort in critically ill infants.

Cefotaxime in the treatment of severe bacterial pneumonia in paediatric patients.

Cefotaxime in the treatment of severe bacterial pneumonia in paediatric patients.

EFFECT OF INDOMETHACIN ON ARTERIAL OXYGENATION IN CRITICALLY ILL PATIENTS WITH SEVERE BACTERIAL PNEUMONIA

The effect of indomethacin (1 mg/kg) on gas exchange was studied in ten patients with hypoxaemic respiratory failure precipitated by bacterial pneumonia. Mean arterial oxygen tension (PaO2) improved significantly (79 ± 16 mm Hg to 98 ± 20 mm Hg) but the response varied between patients: five showed substantial responses (27-42 mm Hg), three lesser responses (7-9 mm Hg), and two no response. Similar changes were found in the alveolar-arterial oxygen gradient and the ratio of PaO2 to fractional inspired oxygen concentration. In two responders studied further, PaO2 had fallen to baseline values 4-6 h later and a repeat indomethacin challenge again increased PaO2 by > 25 mm Hg with concomitant changes in pulmonary shunt. There were no significant changes in the other gas-exchange or haemodynamic variables measured and there was no clear reason for the variability in response to indomethacin. These results suggest a role for products of the cyclo-oxygenase pathway of arachidonic acid metabolism in the pathogenesis of hypoxaemia in patients with severe bacterial pneumonia.

Mechanical ventilation with 100% oxygen does not increase intrapulmonary shunt in patients with severe bacterial pneumonia.

Pure oxygen ventilation has been shown to increase the right to left shunt QS/QT in both normal and diseased lungs. Nitrogen absorption atelectasis, an explanation of the phenomenon, is likely to occur in lung units with low ventilation/perfusion ratio. In 11 patients with severe unilateral or bilateral bacterial pneumonia, we assessed the effects of increasing FlO2 from maintenance level (m = 0.44 +/- 0.11) to 1.0. Venous admixture (QVA/QT) was calculated using the O2 method, and the distribution of the VA/Q ratios were assessed with the 6 inert gas (IG) technique providing the distribution between the true shunt (QS/QT IG) and the low VA/Q units. Although a large part of perfusion was distributed preferentially to low VA/Q units, ranging from 2 to 43% of cardiac output, thus placing large zones of lung parenchyma at risk of absorption atelectasis, QVA/QT decreased from 31 +/- 13% to 25 +/- 10% and IG shunt did not increase after 30 min of O2 ventilation. In addition, QS/QT IG remained unaltered despite PVO2 increased from 32 to 43 mmHg, suggesting a poor level of hypoxic vasoconstriction in human bacterial pneumonia.

Hyperkinetic shock in viral and pneumococcal pneumonias

Ten patients, suffering from severe viral or bacterial pneumonia had circulatory shock, characterised haemodynamically by normal or high cardiac output (CI = 4.1 +/- 1.2 1/min/m2) and low systemic resistance (SVR = 14 +/- 3.7 mm Hg/1/min/m2). Existence of such a hyperkinetic state greatly complicates the management of patients. Plasma volume expansion, performed in five cases of initial hypovolaemia, and Dopamine infusion (five patients) increased markedly the intra-pulmonary shunting. High level PEEP ventilation was not tolerated, despite the improvement of blood gases it produced. Extra-corporeal membrane lung oxygenation (three cases), whilst giving an initial decrease of shunting and restoring SVR, produced no long term surviors. All ten patients died from intractable shock and severe hypoxaemia. Spontaneous ventilation with positive expiratory pressure (CPAP) is believed to be an attractive alternative, due to its absence of deleterious haemodynamic effects.

Viral Disease and Islet Cell Dysfunction

To the Editor.— Recent focus has been given to the concept that certain viral diseases may be causally related to islet cell dysfunction of the pancreas. 1-2 The experimental work of Craighead 3 and Muntefering 4 has demonstrated the existence of preferential viral receptor sites for variants of encephalomyocarditis virus on B cells, as opposed to acinar or ductal cells of the pancreas. Isolated observations in man have suggested that such a postulate might be functional in certain instances of congenital rubella infections. 5-6 Nevertheless, there has been no evidence in man that pancreatic involvement could be so extensive as to possibly impair future function. At the University of Florida, a 4-month-old girl with documented combined immune deficiency died of severe necrotizing bacterial pneumonia and Pneumocystis carinii interstitial pneumonia. In addition to severe thymic dysplasia (0.7 g), abnormal lymph nodes, and hypoplastic bone marrow, at necropsy she had massive generalized

Serum immunoglobulin levels in the course of acute pneumonia.

AbstractSerum levels of 5 immunoglobulins (IgG, IgA, IgM, IgD and IgE) have been determined at frequent intervals in the course of acute pneumonia. 12 patients were examined, 8 with bacterial pneumonia, 4 with pneumonia caused by Mycoplasma pneumoniae.IgG increased to high levels in the third or fourth week of illness in 2 patients with long-standing and severe bacterial pneumonia. Simultaneously, there was a rise in IgA in both patients, and in IgD in one. No appreciable changes in IgM concentration occurred. Only minor immunoglobulin changes were revealed in the remaining 6 patients with bacterial pneumonia, responding readily to antibiotic therapy. In the cases of bacterial pneumonia, a significant decrease in IgE concentration was noticed, the lowest levels of IgE appearing in the fourth week.In the Mycoplasma pneumonia patients an increase in IgM was found, reaching a maximum in the fourth or fifth week. The IgM increase was greatest in a patient with complicating meningitis. No other remarkable chan...