MONDAY, SEPTEMBER 9TH 2013 263. Respiratory infections: a combination of problems

Thematic Poster Session
HALL 1-32 - 12:50 - 14:40
263. Respiratory infections: a combination of problems
needing early treatment
Smoking status and respiratory infections during mechanical ventilation
Lucas Boeck1, Hans Pargger2, Peter Schellongowski3, Charles-Edouard Luyt4,
Marco Maggiorini5, Maurizio Bernasconi6, Kathleen Jahn1, Jean Chastre4, Rene
Lötscher7, Evelyne Bucher2, Nadine Cueni2, Michael Koller8, Annekathrin
Mehlig7, Thomas Staudinger3, Heiner Bucher8, Michael Tamm1, Daiana Stolz1.
Clinic of Pulmonary Medicine and Pulmonary Cell Research, University
Hospital Basel, Basel, Switzerland; 2Department of Anaesthesia and Surgical
Intensive Care Medicine, University Hospital Basel, Basel, Switzerland;
Department of Internal Medicine I, University Hospital Vienna, Basel,
Switzerland; 4Service De Réanimation Médicale, Groupe Hospitalier PitiéSalpêtrière, Paris, France; 5Department of Internal Medicine, Intensive
Care Unit, University Hospital Zürich, Zürich, Switzerland; 6Intensive Care
Medicine, Hospital Civico, Lugano, Switzerland; 7Surgical and Medical
Intensive Care Medicine, Kantonsspital Baselland, Liestal, Switzerland; 8Basel
Institute for Clinical Epidemiology and Biostatistics, University Hospital, Basel,
Background: Smoking is associated with an increased risk of pulmonary
infections. However, little is known about smoking history and respiratory
infections during mechanical ventilation.
Objectives: To assess smoking status in ventilator-associated respiratory
Methods: Preliminary data from the multicentric prospective BioVent study,
investigating mechanically ventilated critical ill patients, were analysed.
Responsible intensivists evaluated the presence of a respiratory infection.
Respiratory infections during mechanical ventilation, from 48 hours after start
up to 14 days, were assessed.
Results: Out of 173 mechanically ventilated patients (mean age 62 ± 16 years;
mean duration of mechanical ventilation 8 ± 10 days) 45 patients (26%) never
smoked, 61 patients (39%) stopped smoking more than one month before
mechanical ventilation and 67 patients (35%) smoked until the month before
mechanical ventilation.
The time to first respiratory infection was shorter in current smokers as compared
to never smokers (p = 0.042) and shorter in former smokers as in never smokers
(p = 0.002; figure). There was no difference between current and former smokers
(p = 0.30). In cox regression the smoking status was associated with respiratory
infection, independent of age, gender, COPD and duration of mechanical
Conclusions: A smoking history probably increases the risk of respiratory
infections during mechanical ventilation.
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Empyema necessitatis: A rare entity
Kalliopi Athanassiadi1, Stavroula Boulia2, Iosif Galinos4, Ilias Samiotis1, Irini
Mavromati3, Theodoros Kakkavas4, Vassilis Papastamopoulos4, Maria Mis3.
Thoracic Surgery, “Evangelismos” General Hospital, Athens, Greece;
Pulmonology, “Evangelismos” General Hospital, Athens, Greece;
Anaesthesiology, “Evangelismos” General Hospital, Athens, Greece; 4Unit of
Intectious Diseases, “Evangelismos” General Hospital, Athens, Greece
Empyema necessitatis is a rare complication of empyema in which the pleural
infection spreads outside of the pleural space to involve the soft tissues of the
chest wall. The most common cause of empyema necessitatis is mycobacterial
infection, streptococus and staphylococcus infection. We present our experience
in treating empyema necessitatis.
MATERIAL  METHOD: Out of 350 patients treated for postpneumonic
empyema, 7 presented with empyema necessitatis. There were male ranging in
age from 45 to 67 years and all but one were immunocompromized patients,
either HIV-positive or drug addicted. The diagnosis was put during clinical
examination and was confirmed by CT scan and paracentesis. All patients were
primary drained and then were led to the operating room and submitted to minithoracotomy, drainage and decortication by using a videothoracoscope.
RESULTS: There was no mortality, while one of patients due to uncontrolled
sepsis at the time of presentation needed a prolonged stay at the ICU. The
hospitalization ranged from 10 to 31 days and there was no recurrence in a follow
up of 6 months.
CONCLUSION: Empyema necessitatis should be suspected in any patient with
pulmonary symptoms presenting with a chest wall mass as well as in patients
with known skin and soft tissue infections of the chest wall. Imaging studies and
sampling of the lesions by aspiration or biopsy are the mainstays of diagnosis.
Appropriate antimicrobial therapy and surgical drainage of the empyema are the
mainstays to a successful outcome in cases of empyema necessitatis.
group). Methods included clinical, laboratory, instrumental, microbiological,
Results. According to etiological factor study group was divided into 2
subgroups: 1 - 19 pts with bacterial sCAP, 2 - 5 HIV-positive pts with sCAP, 4
of them had Pneumocystis sCAP, 1 - pneumococcal. In subgroup 1 of pts with
bacterial etiology level of PCT and CRP were respectively 12,85±2,91 ng/ml
(normal - up to 0,1 ng / ml) and 204,49±20,47 mg / l (normal - up to 10 mg/l).
In HIV-infected patients with Pneumocystis jirovecii PCT level was slightly
above normal and was 0,35±0,12 ng/ml, and CRP level was normal (8,9 mg/l). 3
patients were excluded from the study with severe heart failure, acute myocardial
infarction and pulmonary neoplasm. There level of PCT was within normal limits
(0,079±0,033 mg/ml), and CRP level was 34,38 mg/l.
Conclusions: PCT and CRP can be used as markers of etiologic of severe CAP:
1) at increasing of PCT up to 10-15 ng/ml and CRP up to 180-220 mg / it should
be regarded as bacterial sCAP and continue antibiotic therapy;
2) at slight increasing of PCT (up to 0,2-0,4 ng / ml) and normal CRP it is value
to exclude immunodeficiency state and optionally assign a specific therapy
including antipneumocystic;
3) at normal levels of PCT regardless of CRP diagnostic search should be
continue to exclude other pathology, which could mimic the sCAP.
The “Tree in bud” pattern on chest CT: Radiologic and microbiologic
Shimon Goldberg, Nissim Arish, Yonit Wiener-Well, Naama Bogot, Ariel
Rokach, Gabriel Izbicki.
Pulmonary Institute, Infectious Diseases Unit, and Radiology Department,
Shaare-Zedek Medical Center, Jerusalem, Israel
Patterns of disease in patients with middle lobe predominant non-cystic
fibrosis bronchiectasis
Mohammed Ahmed1, Melissa McDonnell1, Carol Donagh2, Deidre Wall3,
Micahael O’Mahony1, David Breen1, John Joseph Gilmartin1, John Bruzzi2,
Anthony O’Regan1, Robert Rutherford1.
Department of Respiratory Medicine, Galway University Hospital, Galway,
Ireland; 2Department of Radiology, Galway University Hospital, Galway,
Ireland; 3School of Mathematics Statistics and Applied Maths, National
University of Ireland Galway, Galway, Ireland
Background: The tree-in-bud pattern is a well described radiologic image seen
on high resolution chest CT reflecting bronchiolar mucoid impaction. However
its microbiologic significance is yet to be formally elucidated.
Methods: We performed a two arm study of all patients with the tree-in-bud
pattern detected on chest CT in our institution over a period of five years. A
computer search was performed on all chest CT reports during the study period
to identify studies with the tree in bud pattern as evaluated by a senior radiologist.
Microbiology samples were ascertained where available in order to assess the
frequency of the various organisms isolated in the tree in bud population. The
number of lobes with the tree in bud pattern was documented in each case as was
the presence of relevant clinical co-morbidities such as underlying lung disease
and immune-compromise.
Results: During the above period, the tree-in-bud pattern was described in 326
patients undergoing chest CT. Of these, 220 (67.5%) patients had an infectious
etiology, 34 (10.4%) had aspiration pneumonia, 13 (4%) had lung malignancy,
31 (9.5%) had other malignancies, 20 cases (6%) were inconclusive or incidental
findings and 8 (2.5%) had other non-infectious inflammatory disorders.
The relative incidence of the various organisms isolated on sputum culture
reflected the overall incidence of these bacteria in the populations independent
of the tree-in-bud pattern. Conclusion:The tree-in-bud pattern reflects endobronchial inflammation due mainly but not exclusively to an infectious cause.
The microbiologic etiology in patients with this finding is similar to that of
community acquired pneumonia.
Background: Right middle lobe and lingular bronchiectasis is classically
described in an asthenic female phenotype where prevalence of chest wall
and thoracic spine abnormalities is high and there is an association with nontuberculous mycobacterial infection.
Objective: The purpose of this study is to analyse the frequency and clinical
characteristics of patients with middle lobe / lingular predominant bronchiectasis
in a cohort of Irish patients in order to compare with the classical phenotype.
Methods: A retrospective cohort study of 81 consecutive bronchiectasis patients
over an 18 month period was performed. Data was collected on baseline
demographics, microbiology, and lung function. All scans were reviewed by an
independent thoracic radiologist and scored according to the modified Bhalla
Results: Of the 81 patients, 24 (29.6%) (18FM) were confirmed to have
isolated middle lobe/ lingular disease on HRCT (12 RML, 5 lingula, 7 both).
Of those, 3/24 (12.5%) were associated with NTM, all females, with none in the
non-middle lobe / lingular group (p=0.023). In the middle lobe disease group
cultures were positive for S aureus in 1/24 and pseudomonas in 0/24 compared
to 11/57 (p=0.09) and 4/57 (p=0.31) respectively in the other group. FEV1% was
significantly better in the middle lobe/ lingular disease group (p=0.049) and these
patients were also younger (56.1 versus 65.2 years, p=0.009).
Conclusions: Our cohort shows middle lobe / lingular predominant disease in
younger patients than classically described. Only 12.5% had NTM infection.
Lung function in this patient group is relatively normal, perhaps suggesting a
milder phenotype in patients with this form of the disease.
Procalcitonin (PCT) and C-reactive protein (CRP) as markers of the
differential diagnosis of severe community acquired pneumonia (sCAP)
Oleksii Bielosludtsev1, Kseniia Bielosludtseva2, Olexander Nazarenko3.
Sergical #1, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine;
Faculty Therapy and Endocrinology, Dnipropetrovsk State Medical Academy,
Dnipropetrovsk, Ukraine; 3Intensive Care, City Hospital #16, Dnipropetrovsk,
“Masks” of severe pneumonia (retrospective analysis of letal severe
community-acquired pneumonia (sCAP))
Oleksii Bielosludtsev1, Kseniia Bielosludtseva2, Olexander Nazarenko3.
Sergical #1, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine;
Faculty Therapy and Endocrinology, Dnipropetrovsk State Medical Academy,
Dnipropetrovsk, Ukraine; 3Intensive Care, City Hospital #16, Dnipropetrovsk,
Aim: to optimizate the tactics to sCAP depending on the etiological factors
including levels of PCT and CRP.
Methods. From 27 patients (pts) who were admitted to the intensive care
with sCAP (age - 57,85±2,58) diagnosis was confirmed at 24 pts (the main
For describing such states which often mimic sCAP we have allocated a separate
term “mask” of sCAP.
Aim: to identify the main causes of hupodiagnostic of sCAP and to separate
“masks” of sCAP (main groups of diseases that often mimic sCAP) through
retrospective analysis of letal sCAP.
Materials and methods: a retrospective analysis of medical documents of 103 letal
sCAP during 2011-2012 (age - 49.4±1.4 years, men - 67.9%, women - 32.3%)
Results: most powerful risk factors for fatal outcome were terminal state (50.5%),
severe comorbidities and asocial lifestyle (72.8%), incorrect or untimely sCAP
diagnosis (39.8%), errors of antibiotic therapy (48.5%). Frequency of differences
of clinical and pathologic diagnoses was 40%. The most often aggravating factor
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for diagnostic errors was impaired consciousness (92.3%). In 26 cases sCAP was
never verified in vivo but the description and microbiological seeding of lung
autopsy material showed its presence. This erroneous clinical diagnoses can be
divided into groups.
Group of neurological diseases:
- acute violation of cerebral circulatory;
Group of cardiac diseases:
-acute myocardial infarction;
-coronary artery disease.
Group of surgical diseases:
-acute pancreatitis 2
Group of pulmonary diseases:
-pulmonary embolism;
-exacerbation of COPD,
-pulmonary tuberculosis,
-pulmonary neoplasm.
number of cases
Conclusion: there are the “masks” of sCAP: “acute neurological pathology”,
“cardiac” mask, “acute abdomen”, the mask of another lung disease,
“tuberculosis”, “pulmonary embolism”.
Community acquired pneumonia, hepcidin and anemia
Maria Carrabba1,3, Marina Zarantonello1, Lorena Duca3, Natascia Campostrini2,
Alessandra Colombo1, Cinzia Hu3, Giovanna Fabio1,3.
Department of Clinical Science and Community Health, Universita’ Degli
Studi, Milano, Italy; 2Department of Clinical and Experimental Medicine,
University of Verona, Policlinico G.B. Rossi, Verona, Italy; 3Department
of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milano, Italy
Pneumonia is an acute inflammation often complicated by the development of
anemia. Hepcidin is an IL-6-induced key modulator of inflammation-associated
anemia. The association between inflammation, hepcidin and anemia has not
been investigated in pneumonia.
60 patients were enrolled if admitted out of an infection and serum C-RP 3mg/
dl. On day 1 (T1) and 6 (T6) serum hepcidin (HEPC), cytokines, inflammation
and iron markers were tested. Systemic Inflammatory Response Syndrome and
Pneumonia Severity Index (PSI) were assessed at admission.
Patients with pneumonia were 27 and 33 patients had other acute infectious
diseases. On T1 main findings are showed in figure 1. IL-6 and C-RP concentrations
correlated with HEPC levels and the rate of decrease of hemoglobin (Hb) in all
patients (r= -0.330, p= 0.009). On T6, both groups lost a Hb mean of 0.5g/dL, but
patients with pneumonia were more frequently anemic (77.8%) than the others
(48.5%; p=0.032), with an odd ratio of 3.7 for being anemic.
According to PSI, 37.0% patients were stratified in the low-risk, 48.2% in the
intermediate and 14.8% in the highest-risk-class. Hb loss had a weak negative
correlation with PSI score.
70.4% of patients with pneumonia and 42.4% of the other group had sepsis.
Despite high T1 HEPC mean levels in both groups, only patients with sepsis and
pneumonia had a significant Hb decrease between T1 (11.9g/dL) and T6 (11.3g/
dL; p=0.013). Patients with pneumonia had an associated 30-day mortality rate
of 7.4%, compared to 3% of patients without pneumonia.
Hb g/dL
C-RP mg/dL
IL-6 pg/mL
with pneumonia
without pneumonia
severely burned patient remains unreliable. Objective: The aim of this research
is to study the incidence, early diagnosis and management of nosocomial
pneumonia and to discuss the relationship between pneumonia and death in burn
patients. Methods This study was carried out on 80 burn patients (35 males and
45 females) admitted to Menoufiya University Hospital Burn Center and Chest
Department (Egypt) from September 2011 to Mars 2012. Results Our study
found an overall burn patient mortality rate of 26.25 %( 21/80). The incidence
of pneumonia was 15% (12/80). The mortality rate among patients of pneumonia
was 50% (6/12) compared with 22 %( 15/68) for those without pneumonia. The
pneumonia was two times higher in the subset of patients with inhalation injury
compared with group of patients without inhalation injury (P< 0.001).It was
found that the presence of pneumonia, inhalation injury, increased burn size, and
advanced age were all associated with increased mortality (P< 0.001). There were
attributed mortality associations with late onset pneumonia. Severity of disease,
severity of illness (APACHE score), presence of organ failure, underlying
comorbidity, VAP PIRO score have significant correlation with mortality rate.
Conclusions Pneumonia was an important factor for predicting burn patient
mortality. Early detection and management of pneumonia are absolutely essential.
Why low risk class CURB patients with CAP are hospitalized?
Adamantia Liapikou1, Myrsini Melachrinidou1, Elpida Theodorakopoulou1,
Andromaxi Spiliotopoulou1, Andreas Anastasopoulos2, Antonia Koutsoukou3,
Nikolaos Koulouris3, Panos Demertzis1.
3rd Respiratory, Sotiria Chest Diseases Hospital, Athens, Greece; 26rd
Respiratory, Sotiria Chest Diseases Hospital, Athens, Greece; 31st Department
of Pulmonary Medicine-Athens Medical School, Sotiria Chest Diseases
Hospital, Athens, Greece
Background: CURB65score has been used to predict mortality in patients with
community-acquired pneumonia (CAP) and is also a useful tool for predicting
need for hospital admission. The aim of our study is to define why patients with
CURB65 0, I score were admitted to the hospital.
Method: An observational, retrospective study of CAP patients was performed
at a tertiary Hospital for 16 months. CAP patients with CURB-65 score of 0 or 1
were identified, compared with those with CURB65> 2, to determine the reasons
for hospitalization.
Results: Of a total of 272 patients, 94 were classified as CURB-65 class of 0 or
1. These patients were younger (52,5 +/-18.5 vs. 70.2+/-15 74.9+/-respectively,
p<0.001) and had fewer comorbidities (54% vs. 87%, p<0,001), than the other
CAP patients. Main reasons for their hospitalization were hypoxemia (40%),
with PAFI< 250 in 14 patients, failure of outpatient antibiotic therapy (44%) and
COPD exacerbation (18%).
Classes 0,I
Class>2 N=178
Smoking Habit
51 (54%)
74 (43%)
Neurological disease
15 (16%)
34 (20%)
Heart Failure
15 (16%)
95 (54%)
2 (2%)
18 (10%)
Pre-antibiotic treatment
41 (44%)
62 (39%)
37 (40%)
Multilobar involvement
30 (32%)
64 (37%)
Pleural effusion
16 (17%)
39 (23%)
CURB65 0,1 classes had shorter hospitalizations than high-risk groups (8+/-5 vs.
12+/-10 days, respectively, p<0.001) and 3 of them were admitted to the ICU.
Conclusion: In CAP patients with CURB-65 scores of 0 or 1, hypoxemia and
comorbitidies may influence the need for hospitalization according to clinical
Community acquired pneumonia in asthma patients
Adamantia Liapikou1, Dimitra Bakali1, Ioannis Pantazopoulos2, Katerina
Dimakou1, Antonia Koutsoukou3, Mina Gaga4, Michalis Toumbis3, Panos
3rd Respiratory, Sotiria Chest Diseases, Athens, Greece; 21st Pulmology,
Sotiria Hospital-Athens Medical School, Athens, Greece; 36th Respiratory,
Sotiria Chest Diseases, Athens, Greece; 47th Respiratory, Sotiria Chest Diseases
Hospital, Athens, Greece
Early detection of pneumonia as a risk factor for mortality in burned
patients in Menoufiya University Hospital
Rana El-Helbawy1, Mohamed Megahed2, Ayman Omar3, Hala Elmeselhy4,
Rabab Abd El-Halim4.
Chest, Faculty of Medicine - Menoufia University, Shebin El-Kom, Menoufiya,
Egypt; 2Plastic Surgery, Faculty of Medicine - Menoufia University, Shebin
El-Kom, Menoufiya, Egypt; 3General  Vascular Surgery, Faculty of Medicine
- Menoufia University, Shebin El-Kom, Menoufiya, Egypt; 4Family Medicine
Departments, Faculty of Medicine - Menoufia University, Shebin El-Kom,
Menoufiya, Egypt
Background Pneumonia is common among critically ill burned patients. It is a
major cause of morbidity and mortality in burn victims. Prediction of mortality in
Background: Although asthma was the most common co-morbidity among
patients hospitalized with pandemic influenza A (H1N1) infection, in community
acquired pneumonia (CAP) there not data about the influence of asthma in its
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prognosis. The aim of this study was to compare the differences between asthma
and non-asthma hospitalized patients with CAP.
Methods: A prospective study was performed to investigate the characteristics,
severity and outcomes of asthma patients hospitalized with CAP, in 2 respiratory
clinics and an ICU during 2 years period.
Results: During the study period 272 patients were recruited [median age 69.3
+/-9.5 years] and categorized in two groups: group A, asthma [n=19,age 55 +/20)] and group B non-asthma patients (n=251, age 65 +/-18years). Patients with
asthma had more frequently comorbitidies (90% vs. 75%, p=0,15). They had
received more often antibiotics before admission (56% vs. 40%, p=0,19) and
presented earlier to the hospital (3,6 vs. 5,15 days, p=0,382), with lower CURB65
class (1,6 vs. 2,3, p=0, 15) and lower CRP levels (10,78 vs.16, 83, p=0,23). Two
patients died, but were elderly (mean age 88 years) persons with other underline
The decreasing intensity of VOCs from breeding grounds when overgrown with
bacteria could be used to detect growth, because this was detected before growth
of bacteria could be identified with conventional methods. Furthermore, if the
pattern of decreasing VOCs is specific, these VOCs could even be potential
biomarkers for certain bacterial cultures. It shows that ambient peaks should
always taken in account when searching for biomarkers.
Table 1: Characteristics of asthma pts
Asthma pts,n=19
Heart Failure
Neurological disease
pre-antibiotic treatment
PAFI <250
Multilobar involvement 4(21%)
Background. It is generally recognized that effective management of hospitalacquired pneumonia (HAP) should be based on detailed knowledge of specific
epidemiological pattern in a given medical facility.
Aim. To evaluate local epidemiological profile of HAP in one of leading
neurosurgical centers in the southern Ukraine, including HAP incidence,
outcomes, range of causative agents and their susceptibility to antibiotics.
Methods. A retrospective (2006-2011) analysis of 4528 medical records
including 115 cases complicated with HAP was performed.
Results. HAP was diagnosed in 2.5% of neurosurgical patients on record. In 89
cases (77.4%) HAP was ventilator-associated. Fatal outcome and recovery were
registered for 41.7% and 37.4% of HAP patients, respectively. Bacteriological
analysis of sputum was performed in 62.6% of HAP cases only. From the
overall number of bacteriological assays (n = 484) 6.6% showed no microbal
growth. The most common isolated pathogens were Pseudomonas aeruginosa
(26.5%), Candida spp. (13.4%), Klebsiella pneumoniae (10.1%) and Proteus
mirabilis (9.1%). P. aeruginosa largely exhibited resistance to antipseudomonal
drugs, such as ciprofloxacin (97.7%), ceftazidime (97.3%), gentamicin (96.2%),
cefepime (94.6%) and amikacin (91.6%).
Conclusions. Increased mortality and high incidence of HAP, low bacteriologic
coverage of HAP cases and excessive antimicrobial resistance of Pseudomonas
were revealed. The results should be utilized to remove shortcomings in local
practice of HAP treatment and microbiologic testing in the neurosurgical center.
Also they may be helpful for improvement of relevant protocols of medical care
in surgical facilities of Ukraine in whole.
Non-asthma pts
Epidemiological features of hospital-acquired pneumonia in a
neurosurgical center in Ukraine
Alexei Birkun.
Anaesthesiology and Emergency Medicine, Crimean State Medical University,
Simferopol, Ukraine
Conclusions: CAP patients with asthma presented earlier to the hospital and
with less severe disease. More data are needed for further evaluation of this
comorbidity in pneumonia’s course.
Decreasing intensities of certain VOCs as potential biomarkers for bacteria
Roman Purkhart1, Gunther Becher2, Rolf Graupner3, Werner Schüler4.
RD, IFU GmbH, Oberlichtenau, Germany; 2RD, BecherConsult GmbH,
Bernau, Germany; 3RD, Graupner GmbH  CoKG, Geyer, Germany;
Entwicklung, Step Sensortechnik GmbH, Pockau, Germany
Volatile organic compounds (VOCs) are potential biomarkers for various
applications, such as detection of diseases or detection of bacterial growth. On
bacterial cultures is examined whether change of intensities of ambient VOCs
also could be potential biomarkers.
Headspace of bacteria cultures, e.g. mycobacterium avium, staph. aureus or e.
coli were measured with a GC-ion-mobility-spectrometry (STEP) and a GCdifferential-ion-mobility-spectrometry (SIONEX). Breeding grounds with no
growth were used as comparison. Air was collected with a disposable PTFE tube
and spectra were analyzed by a statistical program based on cluster analysis.
Different VOCs only appeared at growth of a specific bacterial culture. The
intensities of some VOCs actually correlated with the amount of growth.
Interestingly, the intensity of many VOCs, which appeared in headspace of
breeding grounds per se, was significantly decreased when overgrown with
bacteria (example shown in Fig. 1).
Secondary infestation of the pleura as a complication of intrapulmonary
Walid Feki, Wajdi Ketata, Najla Bahloul, Sameh Msaed, Samy Kammoun.
Pulmonary, Hedi Chaker Hospital, Sfax, Tunisia
Hydatid cystic disease is caused by larvae of the Tapeworm Echinococcus. The
organs most commonly affected are the liver and the lungs. Pleural involvement
is rare, and usually follows the rupture of a pulmonary or hepatic cyst inside the
pleural space.
The purpose of this study was to exhibit some characteristics of secondary
infestation of the pleura as a complication of intrapulmonary echinococcosis.
Materials and methods
We retrospectively reviewed the medical and radiological records of patients who
had hospitalized for pulmonary hydatid disease complicated by pleural effusion
at the center for Chest Diseases of Hedi Chaker hospital, Sfax, Tunisia, between
1 January 1993 and 31 December 2012.
Five patients were included. There were two females and three males with a
mean age of 48. The most common symptoms were cough-sputum (4 cases) and
chest pain (3 cases). Chest examination revealed diminished movements over
hemithorax with decreased breath sounds in all patients. The most common
radiologic finding was the pleural fluid (n=4). The other findings included
hydropneumothorax (n=1), air-fluid level mimicking abscess (n=2) and a round
cystic opacity (n=3). All patients underwent surgical resection of the pulmonary
cysts. In addition, three patients required a pleurectomy. No patient died as a
result of echinococcal disease or complications from surgery.
Hydatid cyst rupture in the pleura should be considered in the differential diagnosis
of cases with pleural effusion, empyema, pneumothorax and hydropneumothorax
occurring in endemic regions. Performing the surgery without delay favorably
affects postoperative morbidity and mortality.
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Are we using the urinary legionella antigen test appropriately?
Daniel Sommer, Sudhakar Koduri.
Respiratory Medicine, Pennine Acute Hospitals NHS Trust, Manchester, United
Legionella pneumophila can cause severe respiratory infections with a mortality
rate approaching 25% [1]. Diagnosing Legionella pneumonia has significant
clinical and public health implications. The urinary antigen screening test used
at the Pennine Acute Hospitals NHS Trust costs ≤21.17 and the British Thoracic
Society produce strict criteria for when the test should be considered [2]. An audit
was undertaken to determine the proportion of tests that are ordered appropriately
within the trust.
The case notes of 32 patients who were tested towards the beginning of 2012
were analysed to determine if testing was appropriate, the results of the test and
which wards were ordering these tests. 72% of tests were ordered inappropriately
according to guidelines, of which 100% were negative. If the guidelines were
followed, a large number of unnecessary tests could be saved.
In times of economic hardship and when the NHS is required to make ≤20bn
in efficiency savings by 2015, it makes sense that doctors should adhere to
evidence-based policy when ordering expensive tests.
We aim to educate doctors about when it is appropriate to order this test, and to
change trust guidelines to reflect best practice as outlined by the BTS.
[1] Bartlett, J., Johns Hopkins Medicine ABX Guide – Legionnaire’s disease,
Guide/540307/all/Legionnaires%26apos%3B+Disease, accessed 09-02-2013
(Updated January 2013).
[2] Macfarlane J, et al. (BTS Pneumonia Guidelines Committee). BTS Guidelines
for the management of community acquired pneumonia in adults. Thorax.
2001;56. (Update published in 2004).
Severity scores and management of community acquired pneumonia
Jihen Ben Halima, Wided Ben Ahmed, Leila El Gharbi, Besma Dhari, Saloua
Azzabi, Mohamed Ali Baccar, Hichem Aouina, Hend Bouacha.
Pulmonary Departement, Charles Nicolle Hospital, Tunis, Tunisia
Background: International guidelines recommend a severity-based approach to
management in community-acquired pneumonia(CAP). CURB65, CRB65 and
the Pneumonia Severity Index (PSI) are the most widely recommended severity
The aim of this study was to compare the performance characteristics of these
scores for predicting mortality in CAP.
Methods: This retrospective study was carried on at Charles Nicolle hospital.
115 patients with an admission diagnosis of CAP were enrolled. Patients
were stratified into 2 groups according to evolution: favorable (recovery after
antibiotic therapy) or unfavorable (transfer to intensive care unit or deaths).
Clinical and laboratory features at presentation were used to calculate severity
scores using the PSI and BTS severity score (CRB65). We compared sensitivity,
specificity, predictive values, likelihood ratios and the discriminatory power (area
under the receiver operating characteristic curve) of these scores according to
the evolution.
Results: The age of patients ranged from 17 to 87 years with an average of 60
years (72% male). Sixty patients (52 %) had more than 65 years. 11 patients
(9.5%) died or required intensive care transfer. PSI and CRB65 were the only
factors independently correlated to unfavorable evolution. PSI IV and CRB652
had a high sensitivity but lower specificity for predicting a bad evolution. CRB65
was more sensitive (90.9%) than the PSI (72.7%). The area under the receiver
operating characteristic curve was 0.79 for both the PSI and the CRB65 (p=0.002,
for each pairwise comparison).
Conclusions: Although, severity assessment tools are useful guides in the
management of patients with CAP, clinical judgment must remain decisive.
Nosocomial pneumonia-epidemiological and microbiological
characterization of a pulmonology department
Daniela Madama, Ana Silva, Ana Franco.
Pulmonology, University Hospitals of Coimbra, Coimbra, Portugal
Introduction:Nosocomial Pneumonia(NP) can be classified in Health
VentilatorAssociated(VAP).Objectives:Characterize the population of patients admitted
in a Pulmonology department with the diagnosis of NP and identify the most
frequent microorganisms,using a prospective study carried out for 12months.
Results:100patients were included with an average age of 75,08(±12,04),74%
were male.The HCAP was the most prevalent(67%),followed by HAP(29%)
and VAP(4%)with an average of days of hospitalization of 20,79(±15,15).The
length of hospitalization was higher in VAP(27,14).The patients had many
co-morbidities associated,with 67% having up to 2.The cardiovascular(49%)
and neurological diseases(23%)were the most prevalent.Blood cultures were
performed(BC)in 59 patients,with 10% being positive,leading to the identification
of Gram+bacteria in 5 cases.The bacteriological examination of sputum(BES)
was obtained in 77 patients,but was negative in 44%.Gram + were identified in
18 patients,with the prevalence of MRSA(32%) and in 31 cases,Gram- bacteria
were present,A baumannii being the most common(32%).Microbiological
analysis of bronchial aspirate was performed in 23 cases,identifying the etiologic
agent in 19 cases(positivity rate82,6%).The prevalence of MRSA(52%) and A
baumannii(17,4%)was maintained.Conclusions:The patients with the diagnosis
of NP are old and mainly male,with a high rate of co-morbidities,leading to a
high length of hospitalization(over 20 days).Infection by multiresistant bacteria
and Gram- is more prevalent,and the most effective microbiological method for
identifying bacteria was BES and culture of bronchial aspirate.
Prevalence of viral infection in a cohort with acute respiratory failure
Mireia Serra Fortuny, Silvia Capilla Rubio, Daniel-Ross Monserrate Mitchell,
Miguel Gallego Diaz, Jordi Valles Daunis, Eduard Monsó Molas.
Respiratory, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain;
Microbiology, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain;
Respiratory, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain;
Respiratory, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain;
Intensive Care Unit, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona,
Spain; Respiratory, Coorporació Sanitària Parc Taulí, Sabadell, Barcelona,
To determine the prevalence of respiratory viral infection in a cohort with acute
respiratory failure (ARF) requiring hospitalization.
We conducted a prospective observational study including patients with ARF
who required admission from December 2010 to January 2011. Nasopharyngeal
swabs were obtained and RT-PCR was performed to detect H1N1 virus and
seasonal Influenza. We also froze these samples at -80ºC to analyse them
afterwards with multiplex RT-PCR nested method described by Coiras et al1.
This method allows to simultaneously detect the following virus: parainfluenza
virus (1,2,3,4), coronavirus, rhinovirus, respiratory syncytial virus, adenovirus
and influenza A, B and C.
We excluded patients under 18, nosocomial infection and mild episodes that did
not meet the criteria for admission. Demographic data, comorbidities and final
diagnosis were analysed.
50 patients (46% female) were evaluated. Average age was 54,7 ± 18 years. In 49
patients Chest X-ray showed pulmonary infiltrates compatible with pneumonia.
Using PSI score, 73% of pneumonias were class IV/V. 21 patients (42%) required
ICU admission. Mortality was 12% (6 subjects).
Main comorbidities were Diabetes Mellitus (26%), imunosuppression (24%)
and other respiratory diseases (22%). In patients diagnosed with viral infection
(40%), H1N1 was the most frequent 70% (14/20).Other viruses isolated were
rhinovirus (4 cases) and parainfluenza 4 (2 cases). In 35% of H1N1 subjects,
bacterial coinfection was found, whereas in subjects with other viral infection
bacterial coinfection was 50%.
Prevalence of viral infection was 40%, with H1N1 as the most frequent (70%)
1. J Med Virol 72 : 484-95.
Outbreak of pneumocystis jiroveci pneumonia among renal transplant
Sayaka Tachibana, Koji Inoue, Masaaki Siojiri, Norihiko Nakanishi, Tomonori
Department of Respiratory Disease, Ehime Prefectural Central Hospital,
Kasuga-cho 83, Ehime, Japan
Pneumocystis jiroveci pneumonia(PJP) is an important cause of morbidity
and mortality in renal transplant recipients (RTRs). The epidermiology and
pathogenesis of this infection are poorly understood, and the exact mode of
transmission remains unclear. In general, reactivation of latent infection was
considered the mechanism of infection. However, recent studies reported clusters
or outbreaks of PJP among immunocompromised patients as RTRs, interhuman
transmission has been suggested.
We experienced 9 consecutive development cases with PJP from May to December
2012 despite no occurrence of PJP in the past 10 years. These 9 cases consisted
of 7 males and 2 females. The age range of patients was 30–74 years (mean
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age: 54.7 years). The interval from the renal transplantation was 1.3–11.5 years
(mean: 5.8 years). In all cases, patients visited our hospital due to symptoms such
as fever, cough, and shortness of breath. CT images shows diffuse ground-glass
opacity in both lung. In blood examination, -d glucan was 37-1319 (mean: 376)
pg/ml. In 8 patients, on admission we had bronchial endoscopy and investigated
with segmental alveolar lavage. Pneumocystis carinii-PCR was positive in all
cases. Among these, 4 cases were established a diagnosis using cytology by
Grocott methanamine silver staining. Trimethoprim-Sulfamethoxazole was
administered to all patients, 8 patients were discharged, but 1 patient died. The
route of Pneumocystis jiroveci infection remains uncertain. The clustering of PJP
suggests that possibility of nosocomial transmission.
Analysis of endobronchial hydatid cyst positive and negative cases
Ilim Irmak, Sibel Arinc, Pinar Atagun Guney, Umut Kasapoglu.
Chest Disease, Süreyyapasa Chest Disease and Thoracic Surgery Research and
Training Hospital, Istanbul, Turkey
Background: Throughout the world as well as Turkey hydatic cyst is still
an important public health problem. The aim of this study was to assess
the relationship between endobronchial hydatic cyst positive(group I) and
endobronchial hydatic cyst negative( group II).
Methods: The medical records of 77 pulmonary hydatic cyst patients done
bronchoscopy were reviewed. Patients were divited into two groups. Group
I(14 cases) with endobronchial hydatid cyst positive, group II(63 cases) with
endobronchial hydatid cyst negative. Data related to age, gender, symptoms,
radiological localization, liver involvement, microbiological finding, complicated
hydatid cyst rate, pleural effusion were analyzed and compared.
Results: In both groups the most common symptom was cough followed by
hemoptysis respectively. There were no difference between the two groups with
respect to localization, symptoms and relaps. Although all of them(group I) were
symptomatic and complicated hydatid cyst rate were higher in group I(p=0.07 not
statistically meaningful) than group II but liver involvement was higher group II
and 14.2% cases were asymptomatic in group II.
Conclusion: Bronchoscopy can be used as diagnostic method especially
in complicated hydatid cyst. Endobronchial hydatid cyst cases tend to be
Utility and cost of routine bronchoalveolar lavage in diagnosing pulmonary
fungal infections
Fasih Ur Rahman1, Muhammad Irfan1, Ahmed Suleman Haque1, Kauser
Medicine, Aga Khan University, Karachi, Pakistan; 2Pathology 
Microbiology, Aga Khan University, Karachi, Pakistan
Bronchial washings(BW) for microbiological examination is a useful
investigation for detecting microorganism causing respiratory tract infections.
Considering low prevalence of fungal pneumonia in the community, routine
practice of sending BW for fungal smear and C/S increases the cost considerably.
The cost of fungal C/S is approximately Rs 1600 (17 US$) in Pakistan.
To evaluate the yield and cost of routine fungal smear and culture/sensitivity
on BW.
Clinical records of all cases undergoing bronchoscopy with BW were reviewed
for fungal smear and culture during the period of 2011-2012.
273 cases underwent bronchoscopy during the study period .Of these 205 samples
were sent for fungal C/S. The 3 most common indications of bronchoscopy were
hemoptysis, non-resolving pneumonia or suspicion of malignancy.
Out of 205 samples 31 patients were positive on smear and/or culture (15.1%).
16 cases (7.8%) were both smear and C/S positive. Only 5 (2.4%) were clinically
significant and required treatment.
Aspergillus fumigatus was most common fungus on culture (2 out of 5), followed
by Aspergilus niger, A.terreus and A. flavus. Most of the C/S were positive in
patients who had received chemotherapy.
Only 5 (2.4%) cases was clinically significant (at a cost of Rs 8000 as against a
total cost of Rs. 3,20,000)
We report that huge amount of money is unnecessarily spent on requesting
routine fungal smear and C/S on BW. These test should only be sent in high
risk patients so that burden on the patient/health care systems can be minimized.
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