213. Treatment and prevention of lower respiratory tract infections M , S

Thematic Poster Session
Hall A-25 - 12:50-14:40
M ONDAY, S EPTEMBER 14 TH 2009
213. Treatment and prevention of lower
respiratory tract infections
P2420
Antioxidant defence at the beginning of community-acquired pneumonia
with lung infiltrative affection of different duration
Tatyana Zhavoronok 1 , Elena Stepovaya 1 , Natalya Ryazanceva 2 , Fedor Tetenev 3 ,
Tatyana Ageeva 4 , Sergey Mishustin 4 . 1 Department of Biochemistry and
Molecular Biology, Siberian State Medical University, Tomsk, Russian
Federation; 2 Department of Fundamental Basics of Clinical Medicine, Siberian
State Medical University, Tomsk, Russian Federation; 3 Department of Internal
Medicine Propedeutics, Siberian State Medical University, Tomsk, Russian
Federation; 4 Department for Postgraduate Medicine, Tomsk Military Medical
Institute, Tomsk, Russian Federation
Aim: to evaluate oxidative metabolism and glutathione-dependent enzyme (GDE)
collaboration in anti-oxidant cell defence during community-acquired pneumonia (CAP) depending on lung infiltrative affection duration – segmental (CAPs),
polisegmental (CAPp).
Materials and methods: During CAP beginning 35 patients were examined: 20
CAPs and 15 CAPp. Control group – 13 healthy volunteers. In blood plasma diene
conjugates (DC) and malonic dialdehyde (MD), protein-antioxidant ceruloplasmin
(CP), catalase (CT) and superoxide dismutase (SOD) content was estimated; in
erythrocytes – reduced glutathione (RG) content, DGE activity – peroxidase (GP),
reductase (GR), transferase (GT).
Results: Clinical signs in CAP acute period were more apparent during CAPp.
In patients with CAP not depending on lung infiltrate extension oxidative stress
signs were registrated: DC and MD concentration increase, CT and SOD activity
inhibition against the background of protein content compensatory growth of CP
acute phase in blood plasma (p<0.05). Erythrocyte redox-potential decreased at
the expense of RG amount decrease (p<0.001) and GP (p<0.05), GR and GT
(p<0.01) activity inhibition. Glutathione system indices in erythrocytes of patients
with CAPs and CAPp were comparable (p>0.05).
Conclusions: Lipid peroxidation product accumulation, SOD, CT, RG and GDE
potential inhibition indicated oxidative disbalance formation at CAP beginning at
the molecular-cellular level, which was equally expressed both during CAPs and
CAPp regardless of disease clinical finding.
426s
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Thematic Poster Session
Hall A-25 - 12:50-14:40
M ONDAY, S EPTEMBER 14 TH 2009
P2421
Effect on duration of hospitalization by introducing a clinical pathway for
pneumonia in a super-aging society
Atsushi Nakagawa, Tatsuyoshi Ikeue, Kenjiro Furuta, Kyohei Morita,
Tomoko Tajiri, Ko Maniwa, Shigeki Watanabe, Takakazu Sugita,
Sadao Horikawa, Hideki Nishiyama. Respiratory Medicine, Japanese Red Cross
Society Wakayama Medical Center, Wakayama, Japan
Background: Pneumonia is a major cause of morbidity and mortality, and hospitalization rates and length tend to increase in the elderly.
Objectives: Our hospital is located in Wakayama prefecture in Japan, where more
than 21 percent of residents are aged 65 years or older. This study assessed whether
using a clinical pathway for pneumonia could reduce duration of hospitalization
in such an aging society.
Methods: Prospective study that included patients with pneumonia hospitalized
between February 2008 and July 2008, excepting lung abscess, pulmonary tuberculosis, opportunistic pneumonia, obstructive pneumonia, complications of
malignancies, and chronic respiratory tract disease. Our clinical pathway included
severity staging, use of antimicrobials, and response evaluation. Primary endpoint
was duration of hospitalization.
Results: 47 patients were hospitalized, 31 males and 16 females. The mean age
was 79.5 years old (SD 9.1). 27 patients (57.4%) were treated with the clinical
pathway, and 24 of them were diagnosed with aspiration pneumonia. There were no
significant differences between the clinical pathway group and the usual treatment
group in age or severity. The mean duration of hospitalization was 18.4 days in
the clinical pathway group vs 16.5 days in the usual treatment group.
Conclusions: Our clinical pathway could not reduce duration of hospitalization.
In the elderly, swallowing disturbance is an important cause of pneumonia. Our
clinical pathway may need to include dysphagia rehabilitation and physical therapy
in order to reduce hospitalization rates and length.
P2422
Steroids are not associated with an improvement in clinical outcomes in
hospitalized patients with community-acquired pneumonia (CAP)
Paola Castellotti 1 , Valeria Betti 1 , Valeria Giunta 1 , Stefano Aliberti 1 ,
Maria Pappalettera 1 , Paolo Tarsia 1 , Paula Peyrani 2 , Julio A. Ramirez 2 ,
Francesco Blasi 1 . 1 Dipartimento Toraco-polmonare e Cardiovascolare, IRCCS
Fondazione Po.Ma.Re, University of Milan, Milan, Italy; 2 Division of Infectious
Diseases, Department of Medicine, University of Louisville, Louisville, KY,
United States of America
There is a controversy regarding the use of steroids in hospitalized patients with
CAP. Some literature suggests that steroids could improve outcomes in severe
CAP (sCAP) patients and no data are currently available in non sCAP patients.
In order to evaluate the impact of steroids on mortality in hospitalized patients
with CAP, we retrospectively analyzed consecutive CAP patients admitted to our
institution between 04/08 and 01/09. Patients were divided into 2 groups according
to the use (S+) or not (S-) of steroids either on admission or during hospitalization.
sCAP was defined according to the ATS 2007 guidelines. In-hospital mortality
was the primary outcome analyzed.
Among the 231 patients enrolled in the study (54% males; age:75±13), steroids
were used in 33 patients. Mortality is depicted in Table, based on the severity of
CAP on admission.
In-hospital mortality in the study population
Study population (231 pts)
sCAP (76 pts)
Non sCAP (155 pts)
Group S+
Group S-
p value
6/33 (18%)
5/14 (36%)
1/19 (5.3%)
33/198 (17%)
24/62 (39%)
9/136 (6.6%)
0.498
0.544
0.647
The use of steroids seems to be not associated with better clinical outcomes both
in severe and non severe CAP patients. At the present time, steroids could not
been recommended for the management of CAP patients.
P2423
Does the management and outcome of community-acquired pneumonia differ
depending on the route of admission to hospital?
Thomas Bewick, Wei Shen Lim. Respiratory Medicine, Nottingham University
Hospitals NHS Trust, Nottingham, Nottinghamshire, United Kingdom
In the UK, patients with suspected community-acquired pneumonia (CAP) are
admitted to hospital via the emergency department (ED) or direct from primary
care to a medical assessment unit. The aim of this study was to see whether the
assessment and outcome of CAP differed according to route of admission.
All immunocompetant adults admitted with CAP to a UK teaching hospital from
September 2008 to January 2009 were prospectively enrolled. Inclusion criteria
were symptoms of respiratory infection and new infiltrates on a chest x-ray. Exclusion criteria were recent hospital admission and pneumonia in association with
obstructing lung cancer. Outcome measures were times from admission to chest
x-ray and first antibiotics, length of stay (LOS) and 30-day mortality.
277 patients were included. 151 patients were admitted via ED (group A) and 126
from primary care (group B). The median time to first chest x-ray was 0.89 hours
(interquartile range (IQR) 0.42–1.75) in group A and 4.30 hours (IQR 2.31–9.03)
in group B (p<0.0001). Median time to first antibiotic was 2.06 hours (IQR 1.35–
3.59) in group A and 5.58 hours (IQR 3.50–8.83) in group B (p<0.0001). Disease
severity was similar in both groups (mean CURB-65 2.10 vs. 1.78; p=0.063). LOS
was shorter in group A than group B (median LOS 7.45 days (IQR 3.37–11.69) vs.
8.61 days (IQR 4.74–15.51); p<0.05). 30-day mortality was 20% in both groups.
Patients admitted to hospital with CAP via ED are diagnosed and treated faster
than those admitted direct from primary care. This is associated with a shorter
LOS with no increase in 30-day mortality.
P2424
Hospital-acquired pneumonia in patients receiving immunosuppressive
therapy
Ebru Cakir Edis 1 , Osman N. Hatipoglu 1 , Ilker Yilmam 1 , Alper Eker 2 ,
Ozlem Tansel 2 , Necdet Sut 3 , Emre Tekgunduz 4 , Muzaffer Demir 4 . 1 Department
of Pulmonary Medicine, Trakya University Medical Faculty, Edirne, Turkey;
2
Department of Infectious Diseases and Clinical Bacteriology, Trakya University
Medical Faculty, Edirne, Turkey; 3 Department of Biostatistics, Trakya University
Medical Faculty, Edirne, Turkey; 4 Department of Hematology, Trakya University
Medical Faculty, Edirne, Turkey
Background: The aims of this study were to determine the pathogens, clinical
success rates, effect of pathogen isolation and neutropenia on the treatment’s success rate, risk factors related to mortality, and survival in patients who developed
hospital-acquired pneumonia (HAP) while receiving immunosuppressive therapy.
Methods: Forty-five adult patients receiving immunosuppressive therapy who had
developed HAP were included in this prospective study. The Kaplan Meier method
was used for the survival analysis and Cox regression was used for the determination of mortality-related independent risk factors. The relationship among
pathogen isolation, neutropenia, and clinical success rate was studied using the
Chi Square test.
Results: The most frequently isolated pathogens were Acinetobacter spp. and
Escherichia coli. The success rate at the end of the treatment was 66.7%. The
survival rates for the 3rd, 14th, 42nd, and 365th days were 97%, 82%, 58%, and
20%, respectively. The elevated levels of urea [OR=1.007 (%95 CI: 1.001–1.014)]
and blood glucose [OR=1.011 (%95 CI: 1.001–1.021)], and the decreased level of
potassium [OR = 0.549 (%95 CI: 0.314–0.960)] were considered to be independent risk factors affecting survival. The success rate was higher in patients without
neutropenia (n=25) than in those with neutropenia (n=20) (p=0.034). The success
rate for cases in which we could not isolate the pathogen (n=27) was significantly
higher compared to that of the cases in which the pathogen was isolated (n=18)
(p=0.053).
Conclusion: Mortality rates of HAP in patients receiving immunosuppressive
therapy are high. The most important factors for the success of treatment seem to
be patient-related factors.
P2425
Adherence to the American College of Chest Physicians’ guidelines on the
indication of pleural drainage in parapneumonic effusion
Carmen Lucena 1,4 , Jacobo Sellarés 1,4 , Catia Cilloniz 1,4 , Eva Polverino 1,4 , Juan
Antonio Riesco 1 , Mar Ortega 2 , Mª Angeles Marcos 3 , Josep Mensa 2 ,
Antoni Torres 1,4 . 1 Servei de Pneumologia, Hospital Clinic, Barcelona, Spain;
2
Servei de Malalties Infeccioses, Hospital Clínic, Barcelona, Spain; 3 Servei de
Microbiologia, Hospital Clínic, Barcelona, Spain; 4 CiberRES, CiberRES,
Barcelona, Spain
Introduction: Management of parapneumonic effusion (PPE) is controversial and
varies depending on the different respiratory societies. An interesting approach was
proposed by the American College of Chest Physicians (ACP), who divided PPE
into 4 categories and recommended pleural drainage in categories 3-4 (Colice G.L.
et al. Chest 2000,18: 1158-1171). We assessed whether these guidelines match the
clinical practice of our institution.
Methods: Patients with PPE examined in the emergency department of one-single
hospital were consecutively included. Patients were divided into: (1) categories
3-4, in which ACP recommended pleural drainage and (2) categories 1-2, not
susceptible to pleural drainage.
Results: We studied 353 patients with the diagnosis of PPE. 96 (27%) patients
received pleural drainage, whereas 83 (23%) were classified as category 3-4. The
ACP recommendation and the use of pleural drainage agreed in 297 (84%) patients
(kappa coefficient: 0.64, p < 0.001), with a sensitivity of 86%, specificity of
83%, positive predictive value of 66% and negative predictive value of 94%. In
43 patients of category 3-4, the pleural effusion was not drained. Pleural glucose,
cell counts and lactic acid dehydrogenase (LDH) presented a good capacity to
discriminate category 3-4 from category 1-2 (ROC curves, area under the curve =
0.76, 0.61 and 0.73, respectively).
Conclusions: The use of ACP guidelines to identify patients with PPE who require
pleural drainage is reliably concordant with clinical practice. Future studies must
assess the potential additional role of other inflammatory pleural biomarkers in
this classification.
427s
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Thematic Poster Session
Hall A-25 - 12:50-14:40
M ONDAY, S EPTEMBER 14 TH 2009
P2426
Resolution characteristics of multidrug-resistant Acinetobacter baumannii
ventilator-associated pneumonia
Pavlos Myrianthefs, Konstantinos Ioannides, George Baltopoulos. ICU, KAT
Hospital, Athens, Greece
Introduction: There are no data regarding the pattern of resolution of infectious
parameters in ventilator-associated pneumonia (VAP) due to multidrug-resistant
(MDR) Acinetobacter baumannii and for the appropriate duration of antibiotic
therapy.
Methods: We prospectively collected data regarding temperature, white blood
count, PaO2 /FiO2 and clinical pulmonary infection score (CPIS) on a daily basis
for 15 consecutive days in patients suffering from MDR A. baumannii VAP who
survived.
Results: During the study we identified 52 episodes of VAP (mortality 19.2%).
Among these episodes, 41 (78.8%) were due to A. baumannii all of them MDR
(mortality 19.5%; 8/41). The remaining 33 survivors had MDR A. baumannii VAP
and were timely and appropriately treated according to cultures and sensitivity
results. All infectious parameters improved over time. PaO2 /FiO2 was rapidly
increased from day 1 and was the most useful parameter for resolution during the
first five days. After that day CPIS was the best predictor of VAP resolution. The
median time for resolution of PaO2 /FiO2 , CPIS, fever, and WBCs were 4, 5, 7,
and 10 days respectively.
Mean duration of antibiotic treatment was 14.4±5.8 days (median, 13).
Conclusions: The most useful parameter for resolution was the PaO2 /FiO2 ratio
followed by the CPIS. A shorter duration than 2 weeks of antimicrobial therapy is
recommended for the management of MDR A. baumannii VAP.
P2427
Study on mechanism of resistance in Acinetobacter baumannii to quinolones
Mao Huang, Yanli Wang, Wenjin Wang. Respiroluog, The First Affiliated
Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
Objective: To study the mechanism of resistance against quinolones occuring in
Acinetobacter baumannii.
Methods: MIC to Ciprofloxacin with CCCP in different doses were done by
microbroth dilution for 80 strains isolated from sputum cultures from May 2006
to Februlary 2007. The gyrA and praC genes were amplified by polymerase chain
reaction (PCR) and analyzed by restrict fragment length polymorphism (RFLP).
The PCR products were sequenced. The gene expression of adeB mRNA were
analyzed by real-time RT-PCR.
Results: The susceptibility rate of Acinetobacter baumannii to Ciprofloxacin was
15%. Greater susceptibility was found after addition of CCCP and it approached to
Imipenem. According to the PCR-RFLP results, among 58 resistant strains, gyrA
genes amplified from 39 strains and praC genes amplified from 23 strians could
be cut off by Hinf I. They had gene mutations. The expression of adeB mRNA
was significantly higher in resistant strains than sensitive strains.
Conclusion: The decreased susceptibility to Ciprofloxacin in Acinetobacter baumannii is not only associated with gyrA praC gene mutations, but also associated
with over-expression of efflux pump gene adeABC.
P2428
Change of antibiotics resistance pattern of microorganism cultured in
tracheal aspirates in mechanical ventilator patients after antibiotics
restriction policy
Young Hwang 1 , Ho Kim 2 , Chong Lee 3 . 1 Internal Medicine, Gyeongsang
National University Hospital, Jinju, Republic of Korea; 2 Internal Medicine,
Gyeongsang National University Hospital, Jinju, Republic of Korea; 3 Internal
Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
Background: To reduce production of resistant bacteria by over use antibiotics,
it is known that an antibiotics restriction policy may be effective. However, there
are different views on it’s effects. This study aims to examine antibiotic resistant
of pathogenic organisms cultured in tracheal aspirates of the patients who need
to maintain mechanical ventilation in medical intensive care before and after the
antibiotics restriction policy
Methods: Antibiotics restriction policy was carried out in Gyeongsang university
hospital before and after 2 years from 2003. It was retrospectively investigated the
antibiotic resistance pattern of bacteria cultured in tracheal aspirates of the patient
who is maintained by mechanical ventilation for more than 48 hours in the medi-
cal intensive unit. Restricted antibiotics are ceftrazidime, piperacillin/tazobactam,
imipenem, meropenem, vancomycin,and teicoplamin.
Results: There were 306 and 565 patients registered before and after the antibiotics restriction policy. Total use of antibiotics was reduced except piperacillin/
tazobactam and that of cefotaxim and ceftraxone was increased. There was no
significant change in antibiotic resistance among acinetobacter, pseudomonas, and
Enterobacter species
Conclusions: The result of this study shows that the antibiotics restriction policy
does not reduce production of antibiotic resistant bacteria in tracheal aspirate in a
medical intensive care unit. But long term observation may be necessary.
P2429
Importance of setting the correct antibiotherapy in intensive care units
Aslihan Yalcin, Elif Sen, Serhat Erol, Aydin Ciledag, Zeynep Pinar Onen,
Banu Gülbay, Akin Kaya. Dept of Pulmonary Diseases, Ankara University
School of Medicine, Cebeci, Ankara, Turkey
To determine responsible antibiotherapies for resistant microorganisms in intensive care unit (ICU), indications of hospitalisation, existing infections, cultures and
antibiotics susceptibility tests, ongoing antibiotherapies of patients between 2005
to 2007 were evaluated.
Results: 257; 146 COPD, 38 lung cancer, 24 bronchiectasis, 13 obesity hypoventilation, 10 IPF, 9 acute PTE, 7 kyphoscoliosis patients with 107(43.3%) type I
respiratory failure, 94(38.4%) type II respiratory failure, 30(12%) respiratory arrest,
6(2.4%) cardiac arrest, 4(1.5%)acute coronary syndrome, 3(1.2%)acute cerebrovascular disease, 2(0.8%)malign arrhythmia, 1(0.4%)gastrointestinal bleeding were
included in the study. Patients diagnosed with community acquired 102(41.3%) and
nasocomial pneumonia 30(12.1%) had already been on an antibiotherapy. Cultures
of sputum of 44 (20.9% P. aeruginosa, 14% S.pneumonia, 14% E.coli, 11.6% C.
Pneumonia 9.3% MRSA, 7% H. influenza, 4.7% A. baumani, 4.7% M. catarrhalis,
4.6% Enterobacter, 2.7% Corynebacterium) and tracheal aspirate of 36 (24.3%
MRSA, 18.9% P. aeruginosa, 16.2% A. baumani, 8.1% C. Pneumonia, 2.7% S.
maltophilia) showed expressive bacterial growth. Antibiotics susceptibility tests
showed resistance to cefuroxim (5.7%), amicasin (4.5%), ciprofloxacin (3.2%),
meropenem (2%), piperacillin tazobactam (1.6%), vancomicyn (1.2%), cephoperazon (0.8%), imipenem (0.4%). Resistance to claritromisin, teicoplanin and
colistin was not determined. Antibiotics substitution was resulted with extended
hospitalisation in the ICU (p=0.013).
Conclusion: Antibiotics resistant infections in the ICU are related with not only
increased mortality and morbidity but also extended hospitalisation and high costs.
P2430
Does overprescribing antibiotics (abx) put patients (pts) at risk? A two part
retrospective study
Andrea Collins, Elizabeth Brohan, Victoria Price, Ana De Ramon. Respiratory
Medicine, North Cheshire NHS Foundation Trust, Warrington, United Kingdom
Introduction: Recently public awareness of hospital acquired infections has significantly increased. Respiratory tract infections (RTIs) constititute a large proportion
of hospital admissions & respiratory pts are at particular risk of Clostridium difficile
toxin diarrhoea (CDTD), often receiving multiple or prolonged abx courses.
Method: 2-part case notes review of respiratory ward admissions (March 2008).
Firstly (1), we analysed pts who developed CDTD during admission (n=13) &
secondly (2), whether abx were prescribed according to British Thoracic Society
(BTS) & local abx guidelines (n=44).
Results: (1) The mortality rate was 30%, 2 pts died directly due to CDTD. Mean
age (yrs) = 71. 100% received broad-spectrum abx. Mean number of abx used =
3.8. 30% of these pts were overtreated with abx.
(2) 44% were diagnosed with community acquired pneumonia (CAP), 33% infective exacerbation COPD (IECOPD), 18% other RTIs. CURB 65 was calculated
retrospectively, as no CURB 65 scores were documented on admission. Initially,
IV abx were prescribed to 72% with CAP, but only 59% had CURB 65 > 1. 20%
of pts with IECOPD & 37% with other RTIs initially received IV abx.
Conclusions: Overall, 30% of pts in CDTD cohort, 30% with CAP & 26% with
other RTIs were initially overtreated. This appears in part, due to a lack of initial
diagnostic accuracy & knowledge of abx guidelines +/- defensive practice. In our
study cefuroxime was the biggest culprit of CDTD.
Our CDTD incidence has more recently significantly declined, this is attributed to
improvements in abx prescribing & guidelines & in the dissemination of information, education & tightening of infection control measures, including setting up a
cohort ward.
P2431
Hospital doctors’ knowledge of current antibiotic (abx) guidelines
Andrea Collins, Elizabeth Brohan, Victoria Price, Ana De Ramon. Respiratory
Department, North Cheshire Foundation Trust, Warrington, United Kingdom
Introduction: Abx guidelines play a vital role in reducing the risk of Clostridium
difficile toxin diarrhoea to patients (pts) whilst providing adequate abx treatment.
Method: We performed a clinical questionnaire based study of 57 doctors (from
A&E & medicine), at various levels of training (March 2008). We aimed to assess
abx prescribing knowledge in a variety of common respiratory infection scenarios
428s
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M ONDAY, S EPTEMBER 14 TH 2009
& knowledge of British Thoracic Society (BTS) community acquired pneumonia
(CAP) & hospital abx policy guidelines.
Results: Significant findings included: Only 47% of doctors (drs) prescribed abx
according to BTS/hospital guidelines to pts with infective exacerbation COPD
(IECOPD) & severe CAP.
17.5% would not prescribe abx to pts with COPD exacerbation, despite pyrexia,
purulent sputum & tachypnoea.
21% prescribed IV abx to pts with CURB-65 = 0.
Only 11% drs could accurately give details of CURB-65 score, & only 61% knew
to whom it applied.
Overall, ∼ 50% of drs overtreated CAP & 40% would either not treat or overtreat
IECOPD.
Opinions varied on when to change from IV to oral abx.
Conclusions: Drs to not appear to differentiate between IECOPD & CAP in terms
of abx selection. This may be due to a lack of knowledge +/- misinterpretation/lack
of awareness of guidelines +/- defensive practice.
With our new education programme, we aim to reduce the use of inappropriate
broad-spectrum abx by increasing education on diagnosis & treatment of respiratory infections. We need to instill caution of both under & over-prescribing of
abx. Where possible, we need unification of national & local guidelines. Clear &
simple abx guidelines are vital. A co-ordinated approach is key for the dissipation
of this information to all abx prescribers.
P2432
Resections lung of pulmonary hydatid cysts
Costel Mitrofan 1 , Dragos Barzu 1 , Cristina-Elena Mitrofan 2 , Lucian Farmatu 1 .
1
Clinic of Thoracic Surgery, University of Medicine and Pharmacy “Gr.T.Popa”,
Iasi, Romania; 2 Clinic of Pneumology, University of Medicine and Pharmacy
“Gr.T.Popa”, Iasi, Romania
Introduction: The current treatment for pulmonary hydatid cyst (PHC) is complete
excision with maximum preservation of lung tissue.
Aim: The autors present the experience of thoracic surgery department concerning
lung resections in PHC.
Material and methods: A clinical retrospective study was carried out on a series
of 257 cases with PHC, admitted in the Clinic of Thoracic Surgery between 1999
and 2008. Pulmonary resections was needed in 46 cases (17,9%) and conservative
procedure in 211 cases (82,1%). Patients with pulmonary resections were 27 men
(58,7%) and 19 women (41,3%), aged between 15 and 67 years. Of these, 39
patients (84,8%) had complicated cysts and 7 patients (15,2%) had uncomplicated
forms. The most common presenting symptoms were cough, expectoration and
chest pain. The cysts were located in the right lung in 24 cases (52%) and in the
left lung in 22 cases (48%).
Results: Pulmonary resection was used in 46 cases (18,6%), including 16 wedge
resections, 27 lobectomies and 3 pneumonectomies. The patients were treated with
Albendazol (15 mg/kg/day), for a period of 3 months postoperatively. One patient
(67 years old) with associated pathology died on the 3th post-operative day from
pulmonary embolism. In our series, the overall incidence of postoperative complications was 4,6%, consisting of: in 2 cases hemothorax, in 4 cases - prolonged air
leak, in 3 cases - atelectasis and one bronchial stump.
Conclusion: The authors conclude that surgery is capital and the operative techniques must be adapted to each different case. The decision of resection must be
taken carefully and is a second option in surgical treatment pulmonary hydatid
cysts recommended only in a few anatomopatological and topographical forms of
disease.
P2433
Empyema thoracis: therapeutic management and outcome
Anissa Zouaoui, Sonia Sanai, Jouda Cherif, Nesrine Rojbi, Nadia Mehiri,
Zouhair Souissi, Hanene Smadhi, Slim Mahmoud, Mohamed Osman, Ines Saada,
Bechir Louzir, Jalloul Daghfous, Majed Beji. Department of Pulmonology, Rabta
Hospital, Tunis, Tunisia
Introduction: Empyema thoracis is responsible for significant morbidity and
mortality and its clinical management is difficult.
Objective: Our aim is to study the management and outcome of patients with
thoracic empyema in pulmonology department at La Rabta hospital.
Patients and measurements: It is a retrospective chart review of patients hospitalized for thoracic empyema from 1998 to 2007. Patients with tuberculosis pleurisy
were excluded.
Results: One hundred patients (78 men and 22 women) were included. The mean
age was 48±17.3 years (range 16 to 82). Smoking was noted in 57 patients and
alcoholism in 14. Five patients were COPD and 14 were diabetics. Socioeconomic
level was low in 40 cases. Delay of management was on average 10.8±13.6 days.
The germ was identified in 42 patients.The most common germ was streptococcus
melliri group. All patients had antibiotic therapy for an average of 41.7±13.1 days.
Chest drainage was performed in 37 patients and lasted 15.6±10.5 days, the intra
pleural lavage was performed in 41 patients and 79 patients had pleural needle
evacuations. Pleural physiotherapy was practiced in all our patients and only three
had surgical decortication. Duration of hospitalization was on average 31.2±14.6
days. Favourable outcome was noted in 67 patients. Four patients died during
hospitalization. Extensive radiological sequelae were noted in 18 cases, reccurence
of pleurisy was found in 7 cases and 4 patients were lost.
Conclusion: Successfull management of pleural purulent effusions requires prompt
treatment involving antibiotics, adequate drainage, pleural lavage, physiotherapy
and surgical decortication when necessary. Empyema thoracis continue to cause
therapeutic problems.
P2434
Pleuropulmonary manifestations disclosing hepatic amebiasis
Frédéric Rivière, Hervé Le Floch, Augustin Bonnichon, Patrick Saint Blancard,
Pierre L’Her, Alexia Mairovitz, Claude Marotel, Fabien Vaylet, Jacques Margery.
Pneumologie, Hôpital d’Instruction des Armées Percy, Clamart, France
Cases. During a mission in ex-Yougoslavia between 2001 and 2004, three French
militaries have been sent to home respectively because of right pneumopathy,
right pleurisy after appendicectomy, hemoptysis and liver hematoma. They were
ever been in Africa and/or in South America. First diagnosis had been quickly
modified: pleuropulmonary manifestations of amebic hepatic abscess in two cases,
and pleuropulmonary amebiasis in the last case. Outcome was favorable with
standard anti-amebic treatment.
Discussion: Our reports illustrate the possibility of hepatic amebiasis with local pleuropulmonary manifestations and an exceptional case of pleuropulmonary
amebiasis with hepato-bronchial fistula. We want report this experience because it
demonstrates that amebiasis in european countries remains an often forgotten diagnosis. Even though stay in developing countries is ancient, amebiasis in military
or in traveler should be systematically considered.
P2435
Dispersion of exhaled air during oxygen delivery via a venturi mask
David Hui 1 , Benny Chow 2 , Stephen Hall 3 , Leo Chu 4 , Susanna Ng 1 , Tony Gin 4 ,
Matthew Chan 4 . 1 Medicine & Therapeutics, The Chinese University of Hong
Kong, Shatin, Hong Kong; 2 Center for Housing Innovations, The Chinese
University of Hong Kong, Shatin, Hong Kong; 3 Mechanical Engineering, The
Univ. of NSW, Sydney, Australia; 4 Anaesthesia and Intensive Care, The Chinese
University of Hong Kong, Shatin, Hong Kong
Background: We studied exhaled air dispersion during administration of oxygen
via a Venturi mask to a high fidelity Human-Patient Simulator (HPS) on a medical
ward with double exhaust fan for room ventilation and HEPA filter.
Methods: Airflow was marked with intrapulmonary smoke. 24% and 40% of
oxygen was administered at 4 L/min and 8L/min respectively to the HPS, sitting
at 45 degree in normal respiratory mechanics (oxygen consumption 200 ml/min
and lung compliance 70 ml/cmH2 O) and severe lung injury (oxygen consumption
500 ml/min and lung compliance 10 ml/cmH2 O). The leakage jet plume was
revealed by a laser light-sheet and images captured by high definition video.
Smoke concentration in the plume was estimated from the light scattered by smoke
particles.
Findings: As 24% oxygen was delivered to the HPS with normal lung mechanics
and then severe lung injury, the exhaled air dispersion distances of a low normalized concentration of smoke through the exhalation port were 400 and 318 mm
whereas those of a high normalized concentration of smoke were 170 and 138
mm respectively. When 40% oxygen was delivered to the HPS in the two lung
conditions, the exhaled air dispersion distances of a low normalized concentration
of smoke were 330 and 290 mm respectively whereas those containing high
normalized concentration of smoke were the same at 140 mm.
Interpretation: Substantial exposure to exhaled air occurs within 0.4 m from
patients receiving oxygen via a Venturi mask. Healthcare workers should take
extra infection control precaution when managing patients with pneumonia and
respiratory failure within this distance.
(Project funded by the RFCID Grant #06060202, Food & Health Bureau, HK).
P2436
Exhaled air dispersion distances during oxygen delivery via a
non-rebreathing mask
David Hui 1 , Benny Chow 2 , Stephen Hall 3 , Leo Chu 4 , Susanna Ng 1 , Tony Gin 4 ,
Matthew Chan 4 . 1 Division of Respiratory Medicine, The Chinese University of
Hong Kong, China; 2 Institute of Space & Earth Information Science, The
Chinese University of Hong Kong, China; 3 Dept of Mechanical Engineering,
UNSW, Australia; 4 Dept of Anaesthesia & ICU, The Chinese University of Hong
Kong, China
Background: We studied exhaled air dispersion during administration of oxygen
via a non-rebreathing mask to a high fidelity Human-Patient Simulator (HPS) in
an negative pressure (-5Pa) isolation room.
Methods: Airflow was marked with intrapulmonary smoke. Oxygen was administered at 6 L/min and gradually increased to 12 L/min, with the HPS sitting
at 45 degree in normal respiratory mechanics (oxygen consumption 200 ml/min
and lung compliance 70 ml/cmH2 O) and severe lung injury (oxygen consumption
500 ml/min and lung compliance 10 ml/cmH2 O). The leakage jet plume was
revealed by a laser light-sheet and images captured by high definition video.
Smoke concentration in the plume was estimated from the light scattered by smoke
particles.
Findings: As oxygen was delivered at 6, 8, 10, and 12 L/min to the HPS with
normal lung mechanics, the exhaled air dispersion distances of a low normalized
429s
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concentration of smoke through the one-way exhalation valve ranged from 64 to
100 mm whereas those of a high normalized concentration of smoke ranged from
20 to 40 mm. In severe lung injury mode, the exhaled air dispersion distances of a
low normalized concentration of smoke ranged from 74 to 94 mm whereas those
containing high normalized concentration of smoke ranged from 16 to 38 mm.
The exhaled air distance was not proportional to the oxygen flow rate in either
lung condition.
Interpretation: Substantial exposure to exhaled air occurs within 0.1m from
patients receiving oxygen via a non-rebreathing mask. Healthcare workers should
take extra precaution when managing patients with pneumonia and respiratory
failure at close distance.
(Project funded by the RFCID Grant #06060202, Food & Health Bureau, HK).
P2437
Tuberculosis pneumonia: a study of 59 cases
Jamila B. Fochesatto 1 , Marisa Pereira 2 , Ana-Luiza Moreira 2 , Jose Moreira 1 .
1
Post Graduation Program in Chest Diseases, Universidade Federal do Rio
Grande do Sul, Porto Alegre, RS, Brazil; 2 Chest Diseases, Pav. Pereira Filho (S.
Casa), Porto Alegre, RS, Brazil
Objectives: To study the clinical, radiographic and endoscopic features found in
individuals with tuberculosis pneumonia, and to verify the frequency of use of
different methods yielding the microbiological confirmation of the disease.
Methods: Among 2828 consecutive tuberculosis patients who were treated between December 2005 and February 2007 in a Public Heath Unity (Porto AlegreBrazil) there were 59 (2.1%) with a clinical-radiological pneumonic appearance,
presumably occurring through a lymph node to bronchus fistula formation.
Results: Of the 59 patients, 42 (71.2%) had age between 20 and 50 years old;
53.0% were male, and 47.0% of them were black. The more frequent symptoms were cough (100.0%), fever (88.0%), expectoration (81.0%) and weight loss
(40.0%). Some co-morbidity was registered in 35 patients (60.0%), mainly AIDS
(20.0%), and diabetes (15.0%). On the chest x-ray the consolidation predominated
in upper lobes (68.0%). In 41 patients (69.5%) acid-fast bacilli were found in the
sputum. Bronchoscopy was performed in 18 patients (30.5%), 10 of them yielding
acid fast bacilli in BAL and 8 in biopsy material from the bronchial lesion, which
was clearly seen in three cases.
Conclusions: The tuberculosis pneumonia presented as an acute pulmonary infection disease, with alveolar consolidation, cough, fever and expectoration. It
was frequently associated to some co morbidity, specially AIDS and diabetes.
In most of cases the microbiologic confirmation was made by the direct sputum
examination.
Reference: Schwartz Ph. Tuberculose Pulmonaire. Role des Ganglions Lymphatiques. Masson, Paris, 1959.
P2439
The emerging problem of treating pulmonary M. avium complex (MAC)
disease – microbial substitution of MAC to M. abscessus, Scedosporium and
Nocardia after multi-drug chemotherapy in pulmonary MAC disease
Masashi Matsuyama, Ataru Moriya, Kei Shimizu, Nariaki Kokuho, Yukiko Miura,
Shigeo Otsuka, Takumi Kiwamoto, Kenji Hayashihara, Takefumi Saito.
Department of Respiratory Medicine, National Hospital Organization
Ibarakihigashi National Hospital, Nakagun Tokai-mura, Ibaraki, Japan
Mycobacterium avium-intracellulare (MAC) is the most common cause of nontuberculous pulmonary diseases. Although medical treatment of MAC pulmonary
disease in HIV negative patients has yielded inconsistent results, multidrug
macrolide-containing treatment trials in MAC pulmonary diseases showed that
initial sputum conversion rates were high. Although the multi-drug regimen is
effective in pulmonary MAC disease, other pulmonary infections sometimes occur after disappearance of MAC. Those microbes include M. abscessus (MA),
Scedosporium (Sce), Nocardia (NC) and Aspergillus (Asp).
We diagnosed 574 cases as pulmonary MAC disease from January of 2000 to
November of 2008 in our hospital. Among those cases with MAC pulmonary
disease, MA in 3 cases, Sce in 2 ones, NC in 3 ones and Asp in 30 ones were
newly detected after multi-drug chemotherapy was started. A retrospective chart
review of those 38 patients with MAC pulmonary disease revealed 3 cases with
consequent pulmonary MA disease (3/3), 2 ones with pulmonary Sce disease
(2/2), 2 ones with pulmonary NC disease (2/3) and 5 ones with pulmonary Asp
disease (5/30). In sputum culture, MAC disappeared by the clarithromycin (CAM)
- containing regimen in all cases except ones with pulmonary Asp disease.
We concluded that the MA, NC, and Sce pulmonary infections in those pulmonary MAC cases might be the result of microbial substitution due to efficacy of
CAM-containing combination regimens. If this is the case, the guidelines for the
treatment of MAC might need to be modified to eliminate microbial substitution.
P2438
Pulmonary infection with nontuberculous mycobacteria: management and
follow up of 5 infected patients
Abdullah Simsek, Z. Mujgan Guler, Ruhsar Ofluoglu, Ebru Unsal,
Nermin Capan. Chest Diseases, Ataturk Chest Diseases and Chest Surgery
Education and Researchc Hospital, Ankara, Turkey
Background: Nontuberculous mycobacteria (NTM) is increasing in the world.
Treatment decisions and managements are difficult.
Methods: In this study we evaluated diagnosis, management and treatment of 5
patients with NTM pulmonary infection.
Results: 2 patients infected with M abscessus, 1 with M chelonae, 1 with M
gordonae, 1 with M szulgai. Mean age of the patients was 57 years (range 20-73).
4 patients were male and 1 was female. 1 patient with romatoid artritis, 1 patient
with chronic obstructive pulmonary disease (COPD) 1 patient with coronary artery
disease, 1 patient with emphysema, 1 patient with diabetus mellitus. NTM was
identified at sputum or bronchial lavage TB culture sent at the begining of anti TB
treatment for two patients, sputum TB culture sent at second mounth of antiTB
treatment for one patient, sputum TB culture sent at the third mounth of antiTB
treatment for one patient, sputum TB culture sent at the fourth mounth of antiTB
treatment for one patient. Treatment for NTM infection was initiated for tree patients. M chelonae and M gordonae that were not given treatment were accepted as
saprophytic infection. One of patients treated for M abscessus died after 7 months
of NTM treatment. Treatment for other patient with M abscessus and for patient
with M szulgai are continued yet. There is no any change at clinicoradiological
profile of patients with Mchelonae for 7 months without treatment and patient
withM gordonae for 12 months without treatment.
Conclusion: For correct diagnosis and the successful treatment of NTM pulmonary disease, a knowledge of clinical, radiological and microbiological findings
is important.
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