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Pneumonia Due to Pseudomonas aeruginosa: Part I: Epidemiology, Clinical Diagnosis, and Source.

Pseudomonas aeruginosa is an uncommon cause of community-acquired pneumonia (CAP), but a common cause of hospital-acquired pneumonia. Controversies exist for diagnostic methods and antibiotic therapy.

We review the epidemiology of CAP, including that in patients with HIV and also in hospital-acquired pneumonia, including ventilator-associated pneumonia (VAP) and bronchoscope-associated pneumonia. We performed a literature review of clinical studies involving P aeruginosa pneumonia with an emphasis on treatment and prevention.

Pneumonia due to P aeruginosa occurs in several distinct syndromes:

  1. CAP, usually in patients with chronic lung disease;
  2. hospital-acquired pneumonia, usually occurring in the ICU; and
  3. bacteremic P aeruginosa pneumonia, usually in the neutropenic host.

Radiologic manifestations are nonspecific. Colonization with P aeruginosa in COPD and in hospitalized patients is a well established phenomenon such that treatment based on respiratory tract cultures may lead to overtreatment.

We present circumstantial evidence that the incidence of P aeruginosa has been overestimated for hospital-acquired pneumonia and reflex administration of empirical antipseudomonal antibiotic therapy may be unnecessary. A diagnostic approach with BAL and protected specimen brush using quantitative cultures for patients with VAP led to a decrease in broad-spectrum antibiotic use and improved outcome. Endotracheal aspirate cultures with quantitative counts are commonly used, but validation is lacking. An empirical approach using the Clinical Pulmonary Infection Score is a pragmatic approach that minimizes antibiotic resistance and leads to decreased mortality in patients in the ICU.

The source of the P aeruginosa may be endogenous (from respiratory or GI tract colonization) or exogenous from tap water in hospital-acquired pneumonia. The latter source is amenable to preventive measures.

Inferior vena cava filters in cancer patients: to filter or not to filter.

Cancer and its treatment are recognized risk factors for venous thromboembolism (VTE); active cancer accounts for almost 20% of all newly diagnosed VTE. Inferior vena cava (IVC) filters are utilized to provide mechanical thromboprophylaxis to prevent pulmonary embolism (PE) or to avoid bleeding from systemic anticoagulation in high-risk situations.

In this report, and utilizing a case study, we will address the appropriate utilization of such filters in cancer patients.

Multidetector-CT angiography in pulmonary embolism-can image parameters predict clinical outcome?

To assess if pulmonary CT angiography (CTA) can predict outcome in patients with pulmonary embolism (PE).

METHODS: Retrospective analysis of CTA studies of patients with PE and documentation of pulmonary artery (PA)/aorta ratio, right ventricular (RV)/left ventricular (LV) ratio, superior vena cava (SVC) diameter, pulmonary obstruction index (POI), ventricular septal bowing (VSB), venous contrast reflux (VCR), pulmonary infarction and pleural effusion. Furthermore, duration of total hospital stay, necessity for/duration of ICU therapy, necessity for mechanical ventilation and mortality were recorded. Comparison was performed by logistic/linear regression analysis with significance at 5%.

RESULTS: 152 patients were investigated. Mean duration of hospital stay was 21 ± 24 days. 66 patients were admitted to the ICU; 20 received mechanical ventilation. Mean duration of ICU therapy was 3 ± 8 days. Mortality rate was 8%. Significant positive associations of POI, VCR and pulmonary infarction with necessity for ICU therapy were shown. VCR was significantly associated with necessity for mechanical ventilation and duration of ICU treatment. Pleural effusions were significantly associated with duration of total hospital stay whereas the RV/LV ratio correlated with mortality.

CONCLUSION: Selected CTA findings showed significant associations with the clinical course of PE and may thus be used as predictive parameters.

The modified wells score accurately excludes pulmonary embolus in hospitalized patients receiving heparin prophylaxis.

The usefulness of the Wells score has not been assessed in hospitalized patients receiving prophylactic heparin.

Pneumothorax in cystic fibrosis.

Cystic fibrosis (CF) is a complex genetic disease affecting many organs, although 85% of the mortality is a result of lung disease. The natural history of the lung disease consists of early and persistent infection, an exaggerated inflammatory response, structural airway changes (i.e. bronchiectasis), and progressive airways obstruction, ultimately resulting in respiratory failure. As airways disease worsens, there is an increased likelihood of respiratory complications, such as pneumothorax, that may be serious. This review describes our current understanding of the pathogenesis of pneumothorax in CF and its treatment.

RECENT FINDINGS: The CF Foundation Pulmonary Therapies Committee recently published their recommendations for the treatment of hemoptysis and pneumothorax. As insufficient data exist from which a systematic review of the literature could be used to develop guidelines, the recommendations were derived from a formalized expert panel consensus process.

SUMMARY: We now have recommendations on specific care of the patient with CF who has a pneumothorax.

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