New methods for identifying respiratory pathogens have led to several reports of a high yield of mixed infections in patients with community-acquired pneumonia (CAP). The clinical impact of these findings has, however, not been fully evaluated. We aimed to compare patients with a pure bacterial etiology with those with findings of both bacteria and virus regarding severity of illness and length of hospital stay.

Methods: Adults with CAP admitted to Karolinska University Hospital were studied prospectively (N = 184). Microbiological methods included cultures from blood, sputum and nasopharyngeal secretions; sputum samples analyzed with quantitative real-time polymerase chain reaction for Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; nasopharyngeal specimens analyzed with polymerase chain reaction and serology for Mycoplasma pneumoniae, Chlamydophila pneumoniae and viruses common in the respiratory tract; and urine antigen assays for detecting pneumococcal and Legionella pneumophila antigens. The pneumonia severity index (PSI) was used to assess the severity of illness.

Results: The likelihood of getting a score corresponding to PSI classes IV or V was higher in patients with findings of both bacteria and virus than in those with a bacterial pathogen alone (odds ratio 4.98, 95% confidence interval 2.09-11.89; p < 0.001). The median length of hospital stay was 7 days among patients with mixed infections and 4 days among those with a bacterial etiology alone (p = 0.018).

Conclusions: Patients infected with a virus and a bacterial pathogen more often develop severe CAP and have a longer hospitalization than those with a bacterial etiology alone.

Lire la suite...

Lower respiratory tract infection with Pseudomonas aeruginosa (PA) is associated with increased morbidity in CF patients. Current treatment guidelines for inhaled antibiotics are not universally followed due to the perception of decreased efficacy, increasing resistance, drug intolerance, and high treatment burden with current aerosol antibiotics. New treatment options for CF pulmonary infections are needed.

OBJECTIVE: This study assessed the efficacy and safety of a novel aerosol formulation of levofloxacin (MP-376, AeroquinTM) in a heavily-treated CF population with PA infection.

METHODS: This study randomized 151 CF patients with chronic PA infection to one of 3 doses of MP-376 (120 mg QD, 240 mg QD, 240 mg BID) or placebo for 28 days. The primary efficacy endpoint was the change in sputum PA density. Secondary endpoints included changes in pulmonary function, the need for other anti-PA antimicrobials, changes in patient-reported symptom scores, and safety monitoring.

RESULTS: All doses of MP-376 resulted in reduced sputum PA density at Day 28, with MP-376 240 mg BID showing a 0.96 log difference compared to placebo (P = 0.001). There was a dose-dependent increase in FEV1 (L) for MP-376, with a difference of 8.7% in FEV1 (L) between the 240 mg BID group and placebo (P = 0.003). Significant reductions (61% to 79%) in the need for other anti-PA antimicrobials were observed with all MP-376 treatment groups compared to placebo. MP-376 was generally well tolerated relative to placebo.

CONCLUSION: Nebulized MP-376 was well tolerated and demonstrated significant clinical efficacy in heavily-treated CF patients with PA lung infection.

Lire la suite...

Chronic bronchitis in COPD is associated with an accelerated lung function decline and an increased risk of respiratory infections. Despite its clinical significance, the chronic bronchitic phenotype in COPD remains poorly defined.

METHODS: We analyzed data from subjects enrolled in the COPDGene® study. 1061 subjects with GOLD 2-4 disease were divided into two groups: chronic bronchitis (CB+) if subjects noted chronic cough and phlegm production for ≥3 months/year for 2 consecutive years, and no chronic bronchitis (CB-) if they did not.

RESULTS: There were 290 and 771 subjects in the CB+ and CB- groups, respectively. Despite similar lung function, the CB+ group was younger (62.8±8.4 vs. 64.6±8.4 years, p=0.002), smoked more (57±30 vs. 52±25 pack-years, p=0.006), and had more current smokers (48% vs. 27%, p<0.0001). A greater percentage of the CB+ group reported nasal and ocular symptoms, wheezing, and nocturnal awakenings secondary to cough and dyspnea. History of exacerbations was higher in the CB+ group (1.21±1.62 vs. 0.63±1.12/patient, p<0.027), and more patients in the CB+ group reported a history of severe exacerbations (26.6% vs. 20.0%, p=0.024). There was no difference in %emphysema or %gas trapping, but the CB+ group had a higher mean segmental airway wall area percent (63.2±2.9% vs. 62.6±3.1%, p=0.013).

CONCLUSIONS: Chronic bronchitis in COPD is associated with worse respiratory symptoms and higher risk of exacerbations. This group may need more directed therapy targeting chronic mucus production and smoking cessation not only to improve symptoms but also to reduce risk, improve quality of life, and improve outcomes.

Lire la suite...

Parapneumonic effusions or empyemas are frequently seen in patients with lower respiratory tract infections. The condition is associated with significant morbidity and mortality. Since Gram stains and bacterial cultures are usually negative, treatment focuses on empiric antibiotic treatment and chest tube drainage. The role of intrapleural fibrinolytics is still a matter of debate.

Medical thoracoscopy is a simple and effective therapeutic alternative associated with better outcome and fewer complications than conservative treatment. Furthermore, it can be performed in analgo-sedation in a bronchoscopy suite.

Video-assisted thoracic surgery carries the advantage of providing optimal visibility of the pleural cavity, thus allowing better debridement. Thoracotomy is the treatment of choice when thoracoscopic cleaning is not satisfactory.

Lire la suite...