Alan Street

A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia

Background: Several severity scores have been proposed to predict patient outcome and to guide initial management of patients with community acquired pneumonia (CAP). Most have been derived as predictors of mortality. A study was undertaken to compare the predictive value of these tools using different clinically meaningful outcomes as constructs for “severe pneumonia”. Methods: A prospective cohort study was performed of all patients presenting to the emergency department with an admission diagnosis of CAP from March 2003 to March 2004. Clinical and laboratory features at presentation were used to calculate severity scores using the pneumonia severity index (PSI), the revised American Thoracic Society score (rATS), and the British Thoracic Society (BTS) severity scores CURB, modified BTS severity score, and CURB-65. The sensitivity, specificity, positive and negative predictive values were compared for four different outcomes (death, need for ICU admission, and combined outcomes of death and/or need for ventilatory or inotropic support). Results: 392 patients were included in the analysis; 37 (9.4%) died and 26 (6.6%) required ventilatory and/or inotropic support. The modified BTS severity score performed best for all four outcomes. The PSI (classes IV+V) and CURB had a very similar performance as predictive tools for each outcome. The rATS identified the need for ICU admission well but not mortality. The CURB-65 score predicted mortality well but performed less well when requirement for ICU was included in the outcome of interest. When the combined outcome was evaluated (excluding patients aged >90 years and those from nursing homes), the best predictors were the modified BTS severity score (sensitivity 94.3%) and the PSI and CURB score (sensitivity 83.3% for both). Conclusions: Different severity scores have different strengths and weaknesses as prediction tools. Validation should be done in the most relevant clinical setting, using more appropriate constructs of “severe pneumonia” to ensure that these potentially useful tools truly deliver what clinicians expect of them.

Electronic antibiotic stewardship—reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting

OBJECTIVES Antibiotic stewardship is important, but the ideal strategy for providing stewardship in a hospital setting is unknown. A practical, sustainable and transferable strategy is needed. This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital. Effects on drug consumption, antibiotic resistance patterns of local bacteria and patient outcomes were monitored. METHODS The study was conducted at a tertiary referral teaching hospital in Melbourne, Australia. The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials. Data were collected over 7 years: 5 years before and 2 years after deployment. Uptake of the system was evaluated using an in-built audit trail. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Antibiograms of local bacteria were prospectively evaluated. In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported. RESULTS Between 250 and 300 approvals were registered per month during 2006. The gradients in the use of third- and fourth-generation cephalosporins (+0.52, -0.05, -0.39; P < 0.01), glycopeptides (+0.27, -0.53; P = 0.09), carbapenems (+0.12, -0.24; P = 0.21), aminoglycosides (+0.15, -0.27; P < 0.01) and quinolones (+0.76, +0.11; P = 0.08) all fell after deployment, while extended-spectrum penicillin use increased. Trends in increased susceptibility of Staphylococcus aureus to methicillin and improved susceptibility of Pseudomonas spp. to many antibiotics were observed. No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed. CONCLUSIONS The system was successfully adopted and significant changes in antimicrobial usage were demonstrated.

Depression in People Living with HIV/AIDS Attending Primary Care and Outpatient Clinics

Objective: Our aim was to gain an estimate of the rate of depressive disorder in patients with HIV/AIDS attending general practice and to investigate factors associated with depression. A further objective was to determine the ability of non-mental health medical practitioners to detect depressive symptoms in their patients with HIV/AIDS. Method: Participants comprised 322 persons living with HIV/AIDS ((PLWHA); 13 females, 309 males; mean age 41.4, SD = 8.9) who were recruited from four general practice clinics specializing in HIV medicine and from an infectious diseases clinic. Medical, psychiatric and sociodemographic data were obtained. In addition, participants completed the Inventory to Diagnose Depression (IDD), a self-report measure to detect depression. Results: Twenty-two per cent of the sample met criteria for a current Major Depressive Episode (DSM-IV defined) on the IDD. Overall, there was moderate agreement between treating doctors’ diagnosis of depression and patients’ self-report of depressive symptoms. A multivariate model indicated that being in a current relationship was associated with lowered odds of depression (OR = 0.43; CI = 0.23–0.81). The factors strongly associated with increased odds of depression were a past history of illicit drug use (OR = 2.98; CI = 1.60–5.54) and a diagnosis of ‘stress’ by treating doctors (OR = 5.65; CI = 2.50–12.77). HIV-related medical variables such as immune function, use of antiretroviral medication and duration of HIV infection were not associated with depression. Conclusions: There was a high rate of self-reported depression in this group of PLWHA which was also recognized by treating clinicians. Being in a relationship appeared to afford protection against depression while having a history of illicit drug use and current ‘stress’ were highly associated with depression. Interestingly, HIV-related medical variables including laboratory markers of HIV disease, duration of illness and antiretroviral medication regimen were not related to depression.

Vitamin D deficiency is common and unrecognized among recently arrived adult immigrants from The Horn of Africa.

Abstract

Suicidal Behaviour in People with HIV/AIDS: A Review

Objective: To review the existing literature on suicidal behaviour in people with HIV/AIDS infection. Method: A search on the Index Medicus/MEDLINE database was performed, for articles that investigated and/or reviewed suicidal behaviour in people with HIV at any stage of the illness. Only articles written in English were used in this review. Results: Most studies have been done on homosexual/bisexual groups, with little data available for heterosexual populations or women. Studies show an increased rate of suicidal ideation, suicide attempts and completed suicide in individuals with HIV/AIDS. Of note, there is a high prevalence of psychiatric illness and substance abuse in those with suicidal behaviour. Conclusions: The increased rate of suicidal behaviour in HIV-infected persons is consistent with findings in other medically ill groups with chronic, life-threatening disorders. However, assessment of any possible direct effect of HIV/AIDS on suicidal behaviour is confounded by methodological limitations of many of the studies. More longitudinal studies encompassing other affected groups including heterosexual populations and women are needed to elucidate the relationship between suicidal behaviour and HIV/AIDS.

Identifying severe community‐acquired pneumonia in the emergency department: A simple clinical prediction tool

Objective:  To identify independent predictors of severe pneumonia in a local population, and create a simple severity score that would be useful in the ED.

Febrile adults presenting to the emergency department: outcomes and markers of serious illness.

Objectives: To determine outcomes and markers of serious illness for febrile patients presenting to an adult emergency department. Methods: A prospective cohort study of patients presenting to the emergency department with a temperature ⩾38°C. Medical staff obtained demographic data and risk factor profiles while assessing each febrile patient. All were followed up to determine death, admission to intensive care, length of stay in hospital, or subsequent admission to hospital within 30 days. Univariate and multivariate analysis determined which factors were markers of serious illness. Results: For febrile adults admitted to hospital 3.0% died, 6.1% were admitted to intensive care, median length of stay in hospital was 7.2 days. Independent risk factors were—death: age (OR = 1.04), respiratory rate (OR = 1.06), white cell count (OR = 1.02), cardiac disease (OR = 3.3), and jaundice (OR = 21.4). Admission to intensive care: respiratory rate (OR = 1.1), pulse rate (OR = 1.03), and jaundice (OR = 5.1). Increased length of hospital stay: age (p<0.01), jaundice (p<0.01), respiratory rate (p = 0.01), focal neurological signs (p = 0.01), and changed mental state (p = 0.04). For febrile adults sent home 7.9% required admission to hospital within 30 days. Risk factors were respiratory rate (OR = 1.2), being female (OR = 5.36), malignancy (OR = 15.3), and cardiac disease (OR = 19.7). Initially having no focus of infection was protective (OR = 0.13). No febrile patient sent home from the emergency department died or required admission to intensive care. Conclusions: Few febrile adults presenting to the emergency department suffer an adverse outcome suggesting effective risk stratification is occurring. The identification of factors associated with adverse events may further improve this process.

A cautionary tale: fatal lactic acidosis complicating nucleoside analogue and metformin therapy.

mining subcellular localization of HCVgenomic RNA in lymphocytes. The aim of our study was merely to determine whether the cervical smear cells obtained from HCV-seropositive women were infected with HCV genomic RNA. We will include the subcellular staining of HCVinfected cells in our continuing study. FISH was performed in accordance with the protocol by Pinkel et al. [3]. The sequence of the 5′-fluorescein labeled oligonucleotide probe used in our study is an HCV-specific primer that has been published [4]. HCV contains a positivestranded RNA genome of ∼9401 nucleotides, consisting of a single, uninterrupted, long open-reading frame that encodes a polyprotein of 3010–3011 amino acids. The gene sequence of the nucleocapsid protein is the region of highest stability (97%–100%) in the HCV genome; this suggests that the oligonucleotide probe is the genomic sequence of the nucleocapsid protein. If so, then the FISH signal is due to the presence of viral genomic RNA. As for the presentation, in table 2 of our article [2], of hemoglobin amounts for the cervical smear samples, the cervical specimens were washed before RT-PCR. Thus, the last wash samples analyzed by PCR were negative for HCV.

Fatal Clostridium difficile infection of the small bowel after complex colorectal surgery

Pseudomembranous colitis is a well recognized complication of antibiotic use1 and is due to disturbances of the normal colonic bacterial flora, resulting in overgrowth of Clostridium difficile. For recurrent or severe cases, oral vancomycin or metronidazole is the treatment of choice. Progression to acute fulminant colitis with systemic toxic effects occasionally occurs, especially in the elderly and in the immunosuppressed. Some of these patients may need surgical intervention for complications such as perforation.2 Clostridium difficile is commonly regarded as a colonic pathogen and there are few reports of C. difficile enteritis with involvement of the small bowel (Table 1). Pseudomembrane formation caused by C. difficile is generally restricted to the colon, with abrupt termination at the ileocaecal valve.1,3,5,8,9 We report a case of fulminant and fatal C. difficile infection with pseudomembranes throughout the entire small bowel and colon in a patient following complex colorectal surgery. The relevant literature is reviewed.

Reduced valve replacement surgery and complication rate in Staphylococcus aureus endocarditis patients receiving acetyl-salicylic acid

OBJECTIVES To assess the influence of acetyl-salicylic acid (ASA) on clinical outcomes in Staphylococcus aureus infective endocarditis (SA-IE). METHODS The International Collaboration on Endocarditis - Prospective Cohort Study database was used in this observational study. Multivariable analysis of the SA-IE cohort compared outcomes in patients with and without ASA use, adjusting for other predictive variables, including: age, diabetes, hemodialysis, cancer, pacemaker, intracardiac defibrillator and methicillin resistance. RESULTS Data were analysed from 670 patients, 132 of whom were taking ASA at the time of SA-IE diagnosis. On multivariable analysis, ASA usage was associated with a significantly decreased overall rate of acute valve replacement surgery (OR 0.58 [95% CI 0.35-0.97]; p<0.04), particularly where valvular regurgitation, congestive heart failure or periannular abscess was the indication for such surgery (OR 0.46 [0.25-0.86]; p<0.02). There was no reduction in the overall rates of clinically apparent embolism with prior ASA usage, and no increase in hemorrhagic strokes in ASA-treated patients. CONCLUSIONS In this multinational prospective observational cohort, recent ASA usage was associated with a reduced occurrence of acute valve replacement surgery in SA-IE patients. Future investigations should focus on ASAs prophylactic and therapeutic use in high-risk and newly diagnosed patients with SA bacteremia and SA-IE, respectively.