Characteristics of carbapenem-resistant Pseudomonas aeruginosa strains in patients with ventilator-associated pneumonia in intensive care units

The aim of this study was to determine the characteristics of carbapenem-resistant Pseudomonas aeruginosa (P. aeruginosa) strains and 5-year changes in resistance in a tertiary university hospital.

MATERIAL AND METHODS

The study included 90 and 101 randomly selected P. aeruginosa strains serotyped in 2003 and 2008, respectively. The standardized disk diffusion test and E-test were used to determine resistance to antibiotics. P. aeruginosa strains were considered to have high-level resistance if a minimum inhibitory concentration (MIC) for imipenem or meropenem was >32 µg/mL. To identify serogroups, sera containing specific antibodies against O group antigens of P. aeruginosa were used. P. aeruginosa isolates resistant to imipenem or/and meropenem were screened for metallo-β-lactamase (MBL) production by using the MBL E-test.

RESULTS

Comparison of the changes in resistance of P. aeruginosa strains to carbapenems within the 5-year period revealed that the level of resistance to imipenem increased. In 2003, 53.3% of P. aeruginosa strains were found to be highly resistant to imipenem, while in 2008, this percentage increased to 87.8% (P=0.01). The prevalence of MBL-producing strains increased from 15.8% in 2003 to 61.9% in 2008 (P<0.001). In 2003 and 2008, carbapenem-resistant P. aeruginosa strains were more often resistant to ciprofloxacin and gentamicin than carbapenem-sensitive strains. In 2008, carbapenem-resistant strains additionally were more often resistant to ceftazidime, cefepime, aztreonam, piperacillin, and amikacin than carbapenem-sensitive strains. MBL-producing P. aeruginosa strains belonged more often to the O:11 serogroup than MBL-non-producing strains (51.7% vs. 34.3%, P<0.05). A greater percentage of non-MBL-producing strains had low MICs against ciprofloxacin and amikacin as compared with MBL-producing strains.

CONCLUSIONS

The results of our study emphasize the need to restrict the spread of O:11 serogroup P. aeruginosa strains and usage of carbapenems to treat infections with P. aeruginosa in the intensive care units of our hospital.

Hospitalized adult patients with 2009 pandemic influenza A (H1N1) in Kaunas, Lithuania

The objective of this study was to identify case characteristics and clinical course of the disease in patients hospitalized with 2009 pandemic influenza A (H1N1) infection during the first wave of the pandemic and to identify risk factors associated with the complicated course of illness.

MATERIAL AND METHODS

A retrospective study of adult cases of the laboratory-confirmed 2009 pandemic influenza A (H1N1) virus admitted to three hospitals in Kaunas between November 1, 2009, and March 15, 2010, was carried out. The main outcome measures were clinical characteristics, risk factors for complicated disease, treatment, and clinical course of the disease.

RESULTS

The study enrolled 121 of the 125 patients hospitalized due to 2009 pandemic influenza A (H1N1) virus infection. The median age was 31 years (range, 18-83); 5% of the patients were aged more than 65 years. Pregnant and postpartum women comprised 26% of all hospitalized cases. Nearly half (49.5%) of those who underwent chest radiography had findings consistent with pneumonia, which was bilateral in one-third of cases. The risk to have pandemic influenza complicated by pneumonia increased significantly with one-day delay from symptom onset to antiviral treatment (OR, 2.241; 95% CI, 1.354-3.710). More than half (57%) of the patients received antiviral treatment. In 45% of the treated patients, antiviral drugs were administered within 48 hours from symptom onset. Intensive care was required in 7.4% of the cases. The overall mortality was 5% (6/121). The median age of the patients who died was 43.5 years (range, 23-62); 4 patients had been previously healthy, 1 patient suffered from chronic lympholeukemia, and 1 patient was a pregnant woman.

CONCLUSION

The 2009 pandemic influenza A (H1N1) caused considerable morbidity in a significant proportion of hospitalized adults. The main risk factor associated with the complicated course of illness was delayed antiviral treatment.

Changes in the dependence of Pseudomonas aeruginosa O serogroup strains and their resistance to antibiotics in a university hospital during a 5-year period

The aim of our study was to determine the changes in antibiotic resistance and O serogroup dependence of P. aeruginosa strains isolated from lower respiratory tract specimens of patients in 2003 and 2008; the patients were treated in intensive care units of the biggest treatment facility in Lithuania (Hospital of Lithuanian University of Health Sciences, HLUHS, former Hospital of Kaunas University of Medicine)

MATERIAL AND METHODS

The study included 90 P. aeruginosa strains serotyped in 2003 and 101 P. aeruginosa strains serotyped in 2008, which were randomly selected. The resistance of P. aeruginosa strains was determined by the disc diffusion method based on the standard guidelines. The sizes of inhibition zones were interpreted according to the National Committee for Clinical Laboratory Standards (M(2)-A(6)). Isolates were serotyped using sera with specific antibodies against the O antigens of P. aeruginosa (Bio-Rad, France).

RESULTS

Comparison of changes in the distribution of P. aeruginosa serogroups in 2003 and 2008 showed that P. aeruginosa strains of serogroups O:1, O:2, and O:3 were more prevalent in 2003 as compared with 2008 (23.3%, n=21; 27.8%, n=25; 12.2%, n=11 vs. 9.9%, n=10; 10.9%, n=11; 4.0%, n=4, P<0.05). P. aeruginosa strains of serogroups O:6 and O:11 were isolated more frequently in 2008 than 2003 (26.7%, n=27; 34.7%, n=35 vs. 4.4%, n=4; 10.0%, n=9, P<0.001). The results showed that 18 of the 90 P. aeruginosa strains in 2003 and 25 of the 101 P. aeruginosa strains in 2008 were resistant to three or more antibiotics tested, i.e., they were multidrug-resistant. Analysis of the distribution of serogroups among these P. aeruginosa strains isolated in 2003 and 2008 revealed a significantly higher frequency of O:11 serogroup than other serogroups. Meanwhile, in the group of nonmultidrug-resistant P. aeruginosa strains, P. aeruginosa O:11 serogroup strains were identified less frequently and accounted only for 2.8% (n=2, P<0.001) of the isolates in 2003 and 27.6% (n=21, P<0.01) in 2008.

CONCLUSIONS

During the 5-year period, the isolation rate of P. aeruginosa strains belonging to serogroup O:11 increased. P. aeruginosa strains isolated in 2003 and 2008 belonging to serogroup O:11 were more frequently multidrug resistant. The increasing resistance of P. aeruginosa to reserve antibiotics of carbapenem group was observed.

[Recommendations for the prevention and management of tuberculosis in patients treated with tumor necrosis factor alpha inhibitors: a consensus of lithuanian pulmonologists and rheumatologists]

Patients receiving tumor necrosis factor alpha inhibitors for the treatment of rheumatic diseases (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis) are at high risk of developing tuberculosis during treatment. This article gives the recommendations for the prevention and management of tuberculosis in patients with rheumatic diseases before initiating therapy with tumor necrosis factor alpha inhibitors. They are adapted considering the high prevalence of tuberculosis, high drug resistance of Mycobacterium tuberculosis, and extensive bacille Calmette-Guérin vaccination against tuberculosis in Lithuania. In order to reduce the risk of tuberculosis, the screening should be done before starting antitumor necrosis factor alpha therapy. This includes complete medical history and posterior-anterior, lateral chest radiography. Tuberculin skin test using the Mantoux method with 5 tuberculin units and interferon-gamma release assay should be performed in patients without posttuberculous radiological lesions. If Ghon's complex or untreated posttuberculous lesions are present, or if the results the Mantoux test or interferon-gamma release assay are positive, the patient should be treated for latent tuberculosis. For the treatment of latent tuberculosis, isoniazid and rifampicin are given for 3 months, and the introduction of antitumor necrosis factor alpha therapy is delayed at least for one month. In cases of suspected active Mycobacterium tuberculosis infection, tuberculosis should be confirmed microbiologically or morphologically, and adequate antituberculosis treatment should be initiated.

Sarcoidosis--moving to the new standard of diagnosis?

In this article, the most recent literature data regarding the diagnosis of sarcoidosis have been reviewed. The diagnosis of sarcoidosis can be reliably established when there is a compatible clinical/radiological picture together with pathologic evidence of noncaseating epithelioid cell granulomas. Pathologic specimens can be obtained by conventional bronchoscopy with endobronchial, transbronchial lung biopsy, bronchoalveolar lavage, and recently introduced endoscopic ultrasound techniques (endoscopic ultrasound-guided fine-needle aspiration, EUS-FNA, and endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA) or surgical procedures such as thoracotomy, thoracoscopy, and mediastinoscopy. The place and value of EBUS-TBNA or EUS-FNA in diagnosis of sarcoidosis are discussed.

The effect of induced sputum and bronchoalveolar lavage fluid from patients with chronic obstructive pulmonary disease on neutrophil migration in vitro

OBJECTIVE

The aim of study was to investigate a chemotactic effect of induced sputum and bronchoalveolar lavage fluid on blood neutrophils in patients with chronic obstructive pulmonary disease (COPD) and healthy individuals.

MATERIAL AND METHODS

Forty-three smokers with COPD, 19 ex-smokers with COPD, 13 healthy smokers, and 17 healthy nonsmokers were recruited to the study. Neutrophils were isolated from peripheral blood of study individuals. For the same experimental conditions, pooled induced sputum and bronchoalveolar lavage fluid of 20 COPD patients were used. Neutrophil chemotaxis in vitro was performed in cell-transmigration chamber. Substances tested for chemoattraction (interleukin-8, induced sputum, bronchoalveolar lavage fluid directly or in addition to interleukin-8) were added to lower wells. Upper wells were filled with 2.5 x 10(6)/mL of neutrophil culture and incubated for 2 hours. Migration was analyzed by flow cytometry.

RESULTS

Interleukin-8 (10-100 ng/mL) induced a dose-dependant neutrophil migration in all the groups. Only 100 ng/L of interleukin-8 induced more intensive chemotaxis of neutrophils from COPD smokers as compared to ex-smokers (P<0.05). Such difference between healthy individuals was obtained using 30 ng/mL of interleukin-8 (P<0.05). Induced sputum/interleukin-8 (10-100 ng/mL), as well as induced sputum directly, induced neutrophil migration (P<0.05). Chemotaxis of neutrophils isolated from COPD patients and healthy nonsmokers did not depend on additional interleukin-8 concentration. Bronchoalveolar lavage fluid/interleukin-8 (30-100 ng/mL) induced more intensive migration of neutrophils from COPD patients than bronchoalveolar lavage fluid (P<0.05) alone.

CONCLUSIONS

Migration of neutrophils isolated from patients with COPD was more intensive compared to healthy individuals. Induced sputum and bronchoalveolar lavage fluid directly and with addition of interleukin-8 stimulated chemotaxis, and it was higher in neutrophils from COPD patients. Migration of neutrophils did not depend on smoking status.

Late-onset nocturnal intractable seizure during sleep: what is the origin?

A 54-year-old man was admitted to the Sleep Laboratory, Hospital of Kaunas University of Medicine, for assessment of nocturnal seizures of unknown origin during sleep. This patient complained of increasing daytime sleepiness, morning headaches. Before the admission to the Sleep Laboratory, the treatment with depakine and clonazepam had been prescribed. Despite the treatment, the frequency of nocturnal seizures and daytime sleepiness increased. Full night polysomnography was performed. Ten central apneas were registered during all night. Two central sleep apneas with deep desaturation followed by generalized tonic-clonic seizures were documented. First sleep apnea lasted for 180 seconds and was terminated by epileptic tonic-clonic seizures. The second central sleep apnea with oxygen desaturation of 65% was detected 20 minutes later. It lasted for 200 seconds and was also terminated by epileptic tonic-clonic seizures. The conclusion was drawn that the patient had epileptic seizures caused by central sleep apneas with deep oxygen desaturation. The treatment with nasal continuous positive airway pressure device was started. The seizures disappeared completely. Clonazepam was stopped. Depakine was gradually withdrawn during the two weeks. One-year follow-up showed very good compliance, no seizures, and diminished daytime sleepiness.

Pseudomonas aeruginosa bacteremia: resistance to antibiotics, risk factors, and patient mortality

The aim of our study was to determine the prevalence of Pseudomonas aeruginosa bacteremia, risk factors, and outcome of patients treated at the Hospital of Kaunas University of Medicine.

MATERIAL AND METHODS

All hospitalized patients with blood culture positive for Pseudomonas aeruginosa during the 5-year period were included. A retrospective data analysis was performed to evaluate patients' risk factors and mortality caused by P. aeruginosa bacteremia.

RESULTS

A total of 47 (58.8%) bacteremia episodes occurred in an intensive care unit (ICU). A primary source of bacteremia was identified in 50 (62.5%) episodes. Overall mortality rate was 58.8%. Univariate risk factors analysis showed the factors, which significantly increased the risk of death: mechanical ventilation (13.67 times, P<0.001), patient hospitalization in the ICU (8.51 times, P<0.001), acute respiratory failure (8.44 times, P<0.001), infection site in the respiratory tract (4.93 times, P=0.003), and central vein catheter (4.44 times, P=0.002). Timely and appropriate treatment and surgery were significant protective factors for 30-day mortality (11.1 and 5.26 times, respectively; P=0.001). Meropenem-resistant Pseudomonas aeruginosa strains caused bacteremia more frequently in patients older than 65 years than meropenem-sensitive strains (57.9%, n=11). All 19 patients with meropenem-resistant Pseudomonas aeruginosa bacteremia received inappropriate empirical antibiotic therapy.

CONCLUSIONS

Treatment at the intensive care unit, mechanical ventilation, acute respiratory failure, source of infection in respiratory tract, and central vein catheter are the major risk factors associated with an increased mortality rate in patients with Pseudomonas aeruginosa bacteremia. The patients older than 65 years are at increased risk for bacteremia caused by carbapenem-resistant Pseudomonas aeruginosa strains. Carbapenems are not antibiotics of the choice of treatment for Pseudomonas aeruginosa bacteremia at the Hospital of Kaunas University of Medicine.

Smoking affects eotaxin levels in asthma patients

BACKGROUND

Chronic airway inflammation is most important pathological finding in asthma. Cigarette smoking may modify type of inflammation as well as may influence disease severity and response to the treatment.

OBJECTIVE

Thus the aim of this study was to investigate whether cigarette smoking may have an influence on the levels of eotaxin-1, eotaxin-2, eotaxin-3 and IL-5 in patients with stable mild/moderate asthma.

METHODS

45 steroid naive asthmatics (mean age: 55.2 +/- 2.2 yrs) and 23 "healthy" smokers and non-smokers control subjects (mean age: 54.4 +/- 9.7 yrs) were investigated. Asthmatics were divided into two subgroups according to their smoking histories: asthmatic smokers (n = 19) who currently smoke and have a history of > 10 pack-years and asthmatic never-smokers (n = 26). BAL and induced sputum were performed. Cytospins of induced sputum and BAL were stained with May-Grunwald-Giemsa for differential cell counts. Eotaxin-1, eotaxin-2, eotaxin-3 and IL-5 concentrations in serum, sputum and BAL supernatant was measured using a commercial ELISA kit.

RESULTS

In sputum supernatant from asthma smokers was significantly higher concentration of eotaxin-1 than in non-smokers asthmatics (203.4 +/- 10.0 vs. 140.2 +/- 9.5 respectively, p < 0.05). In non-smokers asthma patients levels of BAL eotaxin-1 strongly related to percent and absolute numbers of BAL eosinophils and neutrophils (Rs = 0.737 and Rs = 0.514 respectively, p < 0.05). The number and percent of sputum neutrophils and eosinophils, obtained from smokers asthmatics, significantly correlated with eotaxin-2 concentration in sputum supernatant (Rs = 0.58 and Rs = 0.75 respectively, p < 0.05). IL-5 levels in the serum and sputum from asthmatic never-smokers were significantly higher than they were from asthmatic smokers and "healthy" smokers. Asthmatic never-smokers showed a significantly higher amount of IL-5 in serum and sputum than the asthmatic smokers showed.

CONCLUSIONS

This study showed the elevated levels of sputum eotaxin-1 as well as serum, sputum and BAL eotaxin-2 in asthmatic smokers without a significant increase of eosinophils compared to asthmatic never-smokers. The eotaxin concentrations were related not only with number of eosinophils but also with the number of neutrophils in all the studied tissue compartments. The data herein permits a suggestion that smoking may influence change in asthmatic airway inflammation by stimulating the production of eotaxins.

Biomarker analyses from the phase III placebo-controlled SATURN study of maintenance erlotinib following first-line chemotherapy for advanced NSCLC

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Background: The SATURN (BO18192) study investigated whether erlotinib maintenance therapy improved PFS in patients (pts) with advanced NSCLC who had obtained clinical benefit from 1st-line chemotherapy. This study included a prospective analysis of the prognostic/predictive value of several molecular markers. Methods: 889 pts with advanced NSCLC whose disease had not progressed following 4 cycles of 1st-line platinum-doublet chemotherapy were randomized to erlotinib 150 mg/day or placebo. Mandatory tumor specimens were collected at baseline and tested for EGFR protein expression using immunohistochemistry (IHC), EGFR gene copy number using fluorescent in-situ hybridization (FISH), and EGFR and KRAS somatic mutations using DNA sequencing. Pts were stratified according to EGFR IHC status (any membranous staining in ≥10% tumor cells used as cut-off); the co-primary endpoint was PFS in EGFR IHC+ pts. Baseline whole blood samples were obtained for genotyping of EGFR (intron 1 CA-repeat polymorphisms). Results: In the overall population, erlotinib significantly prolonged PFS vs placebo (HR 0.71, p<.0001; primary endpoint). The co-primary endpoint was also met, with erlotinib significantly improving PFS in the EGFR IHC+ group (HR 0.69, p<.0001). Many tumor samples were assessable for molecular marker status (see table). Biomarker data suggest that patients derived a PFS benefit with erlotinib irrespective of EGFR FISH or EGFR intron 1 CA-repeat status. The magnitude of benefit with erlotinib was similar in both KRAS-mutant and KRAS wild-type pts. Conclusions: This is the largest biomarker analysis performed for erlotinib in a randomized, placebo-controlled setting, and answers key scientific questions regarding the prognostic and predictive value of potential biomarkers of efficacy. Full data will be presented.

[Table: see text]

[Table: see text]

[Assessment of disease control in patients with asthma]

International guidelines indicate that the main criterion of asthma management is asthma control level. The aim of this study was to assess asthma control and its relation with age, gender, and lung function.

MATERIAL AND METHODS

A total of 106 family physicians and 13 pulmonologists and allergists took part in this study. Each doctor had selected 10-15 asthma patients and had sent invitations to them by post. On the visit day, the patients themselves filled in the Asthma Control Test. The doctors interviewed the patients and filled in a special questionnaire. Pulmonologists and allergists also assessed lung function by performing spirometry. According to the results of the Asthma Control Test, the disease control level was indicated as "totally controlled" (25 points), "well controlled" (24-20 points), and "uncontrolled" (19 points or less).

RESULTS

A total of 876 asthma patients were examined. Uncontrolled asthma was diagnosed to 56.2% of the patients, 36.5% of patients had well controlled and 7.3% totally controlled asthma. There was no significant difference in asthma control level comparing men and women. A correlation between asthma control level and age was found revealing poorer asthma control in older patients. Ninety-five percent of patients were treated with inhaled steroids; most of them had used inhaled steroids in combination with long-acting beta(2) agonists. It was found that lung function correlated with clinical symptoms of asthma, the demand of short-acting beta(2) agonists, and asthma control level.

CONCLUSION

The study showed that uncontrolled asthma was diagnosed to more than half of the patients, despite most of them used inhaled steroids. Asthma control was worsening with the age of patients with asthma and it correlated with lung function. We suggest that periodical assessment of asthma control should help to optimize asthma management.

High frequency of the c.3207C>A (p.H1069Q) mutation in ATP7B gene of Lithuanian patients with hepatic presentation of Wilson's disease

AIM

To investigate the prevalence of the ATP7B gene mutation in patients with hepatic presentation of Wilson's disease (WD) in Lithuania.

METHODS

Eleven unrelated Lithuanian families, including 13 WD patients were tested. Clinically WD diagnosis was established in accordance to the Leipzig scoring system. Genomic DNA was extracted from whole venous blood using a salt precipitation method. Firstly, the semi-nested polymerase chain reaction (PCR) technique was used to detect the c.3207C>A (p.H1069Q) mutation. Patients not homozygous for the c.3207C>A (p.H1069Q) mutation were further analyzed. The 21 exons of the WD gene were amplified in a thermal cycler (Biometra T3 Thermocycler, Gottingen, Germany). Direct sequencing of the amplified PCR products was performed by cycle sequencing using fluorescent dye terminators in an automatic sequencer (Applied Biosystems, Darmstadt, Germany).

RESULTS

Total of 13 WD patients (mean age 26.4 years; range 17-40; male/female 3/10) presented with hepatic disorders and 16 their first degree relatives (including 12 siblings) were studied. Some of WD patients, in addition to hepatic symptoms, have had extrahepatic disorders (hemolytic anemia 3; Fanconi syndrome 1; neurophsychiatric and behavioural disorder 2). Liver biopsy specimens were available in all of 13 WD patients (8 had cirrhosis; 1-chronic hepatitis; 3-acute liver failure, 1-liver steatosis). Twelve of 13 (92.3%) WD patients had the c.3207C>A (p.H1069Q) mutation, 6 of them in both chromosomes, 6 were presented as compound heterozygotes with additional c.3472-82delGGTTTAACCAT, c.3402delC, c.3121C>T (p.R1041W) or unknown mutations. For one patient with liver cirrhosis and psychiatric disorder (Leipzig score 6), no mutations were found. Out of 16 first degree WD relatives, 11 (68.7%) were heterozygous for the c.3207C>A (p.H1069Q) mutation. Two patients with fulminant WD died from acute liver failure and 11 are in full remission under penicillamine or zinc acetate treatment. Three women with WD successfully delivered healthy babies.

CONCLUSION

The c.3207C>A (p.H1069Q) missense mutation is the most characteristic mutation for Lithuanian patients with WD. Even 92.3% of WD patients with hepatic presentation of the disease are homozygous or compound heterozygotes for the p.H1069Q mutation.

Psychometric properties of the Lithuanian version of Sleep Apnea Quality of Life Index (a pilot study)

OBJECTIVE

To arrange and test for its psychometric properties Lithuanian version of Sleep Apnea Quality of Life Index and assess quality of life among snoring and obstructive sleep apnea patients before and after the treatment.

MATERIAL AND METHODS

Cross-cultural adaptation of Lithuanian version of Calgary Sleep Apnea Quality of Life Index was accomplished according to generally accepted methodology. In total, 36 (29 males and 7 females) patients (mean age, 41.1+/-9.7 years) suffering from socially disturbing snoring and obstructive sleep apnea were included into the study. All patients underwent complete full-night polysomnography (mean apnea/hypopnea index, 12.7+/-11.2) and were treated with two sessions of radiofrequency tissue ablation at the palatal and tong base (if it was necessary) levels. Lithuanian version of the Calgary Sleep Apnea Quality of Life Index was presented before the treatment with radiofrequency tissue ablation and in the period of 2 to 3 months after the treatment. Thirty-five patients repeated the same questionnaire after three weeks to assess the reliability of scores.

RESULTS

The Cronbach's a coefficients of internal reliability were above the standard (0.7 for groups) in all subdomains and domains. Test-retest correlation coefficients for each domain (ranged from 0.92 to 0.94) were statistically significant (P<0.0001). Lithuanian version of the questionnaire was found to be responsive to clinical change. A statistically significant difference in the mean Sleep Apnea Quality of Life Index scores in the study group patients before and after the surgery was found in all daily functioning subdomains and social interactions domains.

CONCLUSIONS

Overall, the results of the present pilot study demonstrate that the Lithuanian version of Sleep Apnea Quality of Life Index is applicable for clinical purposes.

[C-reactive protein levels in patients with chronic obstructive pulmonary disease and asthma]

Chronic obstructive pulmonary disease (COPD) and asthma are defined as chronic inflammatory airway diseases. There is increasing evidence that systemic inflammation may be involved in their pathogenesis too. We aimed to investigate the C-reactive protein levels in plasma of patients with COPD, asthma and control subjects and to evaluate associations of C-reactive protein levels with pulmonary function and smoking history.

MATERIAL AND METHODS

We investigated 87 persons: 41 with COPD, 30 with asthma, and 16 controls. Clinical evaluation, pulmonary function tests, C-reactive protein concentration measurement, body mass index and smoking history evaluation were performed.

RESULTS

We determined significantly higher C-reactive protein concentrations in COPD patients compared with asthma patients and controls (8.37+/-1.14 vs 3.14+/-0.67 and 2.39+/-0.59 mg/L, respectively; P<0.001). C-reactive protein concentrations in smokers and ex-smokers with COPD were significantly higher than in COPD non-smokers (8.38+/-1.52 and 10.4+/-2.22 vs 4.10+/-0.86 mg/L, respectively; P<0.05). In COPD patients, C-reactive protein level correlated with FEV(1) (R=-0.463, P=0.002), FEV(1)/FVC (R=-0.449, P=0.003), and pack-years (R=0.572, P=0.001). There was no correlation between C-reactive protein level and analyzed parameters in asthmatics and control group.

CONCLUSIONS

Our data support the hypothesis that systemic inflammation plays a role in the pathogenesis of COPD, and cigarette smoking might influence this inflammation.

Patterns of airway inflammation and MMP-12 expression in smokers and ex-smokers with COPD

BACKGROUND

Smoking activates and recruits inflammatory cells and proteases to the airways. Matrix metalloproteinase (MMP)-12 may be a key mediator in smoke induced emphysema. However, the influence of smoking and its cessation on airway inflammation and MMP-12 expression during COPD is still unknown. We aimed to analyse airway inflammatory cell patterns in induced sputum (IS) and bronchoalveolar lavage (BAL) from COPD patients who are active smokers and who have ceased smoking >2 years ago.

METHODS

39 COPD outpatients - smokers (n = 22) and ex-smokers (n = 17) were studied. 8 'healthy' smokers and 11 healthy never-smokers were tested as the control groups. IS and BAL samples were obtained for differential and MMP-12+-macrophages count analysis.

RESULTS

The number of IS neutrophils was higher in both COPD groups compared to both controls. The amount of BAL neutrophils was higher in COPD smokers compared to healthy never-smokers. The number of BAL MMP-12+-macrophages was higher in COPD smokers (1.6 +/- 0.3 x 106/ml) compared to COPD ex-smokers, 'healthy' smokers and healthy never-smokers (0.9 +/- 0.4, 0.4 +/- 0.2, 0.2 +/- 0.1 x 106/ml respectively, p < 0.05).

CONCLUSION

The lower amount of BAL neutrophils in COPD ex-smokers, compared to COPD smokers, suggests positive alterations in alveolar compartment after smoking cessation. Smoking and disease itself may stimulate MMP-12 expression in airway compartments (IS and BAL) from COPD patients.

Serum and bronchial lavage fluid concentrations of IL-8, SLPI, sCD14 and sICAM-1 in patients with COPD and asthma

BACKGROUND

Airway inflammation is associated with an increased expression and release of inflammatory reactants that regulate processes of cell migration, activation and degranulation. The purpose of this study was to quantify bronchial lavage (BAL) fluid and serum levels of chemokine (IL-8), secretory leukocyte protease inhibitor (SLPI), soluble intracellular adhesion molecules-1 (sICAM-1) and sCD14, as surrogate markers of inflammatory and immune response in asthma and chronic obstructive pulmonary disease (COPD) patients with similar disease duration time.

METHODS

Biomarkers in serum and BAL fluid from asthma (n=13) and COPD (n=25) patients were measured using commercially available ELISA kits.

RESULTS

We found that in asthma and COPD groups the concentrations of IL-8 and SLPI are significantly higher in BAL fluid than in serum, while levels of sICAM-1 and sCD14 in BAL fluid are significantly lower than in serum. Of these 4 measured biomarkers, only the BAL IL-8 was higher in COPD patients when compared to asthma (P<0.05). In both groups, BAL IL-8 correlated with SLPI (r=0.577, P<0.01 and r=0.589, P<0.05, respectively). In patients with COPD the BAL sICAM-1 correlated with sCD14 (r=0.576, P<0.01), while in asthma patients BAL sICAM-1 correlated with FEV(1)/FVC (r=0.418, P<0.01). Moreover, in asthma patients the serum SLPI correlated with sCD14 (r=0.688, P<0.01) and serum sICAM-1 negatively correlated with FEV(1)/FVC (r=-0.582, P<0.05).

CONCLUSION

Our findings point to the importance of selecting a correct biological fluid when analyzing specific biomarkers, and also show that of 4 measured biomarkers, only the BAL IL-8 was higher in COPD patients when compared to asthma.

Changes in cough reflex sensitivity after cessation and resumption of cigarette smoking

Previous studies have shown that healthy cigarette smokers have diminished cough reflex sensitivity compared to healthy nonsmokers. We have recently demonstrated that cough reflex sensitivity is enhanced soon after smoking cessation, suggesting that diminished cough sensitivity in smokers results from chronic cigarette smoke-induced desensitization of airway cough receptors. In this study, we evaluated cough reflex sensitivity to capsaicin (C(5)) in 11 chronic smokers who had discontinued smoking for at least 2 weeks, and then resumed smoking. Two weeks after smoking cessation there was a significant enhancement of cough reflex sensitivity; mean (+/-SEM) log C(5) decreased from 1.77+/-0.18 to 1.47+/-0.14 (p=0.01). All subjects resumed smoking after 2-12 weeks of abstinence. Repeat capsaicin cough challenge was performed 14-23 days after resumption of smoking. Mean log C(5) increased compared to the last value obtained during the smoking cessation period: 1.42+/-0.15 vs. 1.77+/-0.16 (p=0.0004). Mean log C(5) after resumption of smoking returned to almost exactly the baseline value. Our findings suggest that the sensitivity of airway cough receptors is a dynamic phenomenon, promptly affected and modulated by changes in environmental conditions, such as the presence or absence of cigarette smoke.

[Relationship between isolation of extended spectrum beta-lactamase-producing Klebsiella pneumoniae and course of hospital-acquired pneumonia]

AIM OF THE STUDY

To evaluate relationship between isolation of extended spectrum beta-lactamase-producing Klebsiella pneumoniae strains and course of hospital-acquired pneumonia.

MATERIALS AND METHODS

K. pneumoniae strains isolated from bronchial secretions or bronchoalveolar lavage fluid samples of patients hospitalized at an intensive care unit of Kaunas University of Medicine Hospital were analyzed. By means of synergistic two-antibiotics disc method, K. pneumoniae strains producing extended spectrum beta-lactamases were selected for further analysis using E-test (AB Biodisk, Solna, Sweden). Hospital-acquired pneumonia was diagnosed based on standard criteria for the diagnosis of pneumonia if signs of pneumonia occurred after 48 hours following admission. Late-onset hospital-acquired pneumonia was considered if these signs of pneumonia occurred on fifth day of hospitalization or later.

RESULTS

Total of 45 strains of K. pneumoniae were isolated during the study period; 18 isolated strains produced ESBL. Thirty-two patients investigated have developed hospital-acquired pneumonia, 20 of which were cases of late-onset hospital-acquired pneumonia. Thirteen cases of K. pneumoniae isolation were classified as airway colonization. Extended spectrum beta-lactamase-producing K. pneumoniae strains were more frequently isolated from patients with hospital-acquired pneumonia (88.9%, n=16 and 11.1%, n=2, P<0.05) in comparison with non-producing strains. Extended spectrum beta-lactamase-producing strains were more prevalent in late-onset pneumonia group (93.8%, n=15) than in early-onset group (6.2%, n=1, P<0.001).

CONCLUSIONS

Extended spectrum beta-lactamase-producing K. pneumoniae strains were more frequently isolated from patients with hospital-acquired pneumonia as compared to colonized patients. Extended spectrum beta-lactamase-producing K. pneumoniae strains were more frequently isolated from patients with late-onset hospital-acquired pneumonia.

Effect of smoking cessation on cough reflex sensitivity

Recent studies have shown that cigarette smokers have diminished cough reflex sensitivity compared with nonsmokers. The current authors proposed a mechanism of chronic cigarette smoke-induced desensitisation of airway cough receptors. To investigate this hypothesis, cough sensitivity to inhaled capsaicin (C5) in chronic smokers was measured both while they were actively smoking and 2, 6, 12 and 24 weeks after smoking cessation. In total, 29 subjects underwent baseline capsaicin challenge while smoking and 2 weeks after smoking cessation. Mean+/-sem log C5 fell from 1.86+/-0.12 to 1.60+/-0.12, demonstrating significant enhancement of cough reflex sensitivity. Of the total, 20, 18 and 14 subjects successfully abstained from smoking for 6, 12 and 24 weeks, respectively. Mean log C5 values after 12 and 24 weeks of smoking cessation were significantly diminished from baseline. In a control group of smokers, mean log C5 did not decrease from baseline after 6, 12 and 24 weeks. Overall, the log C5 profile of the smoking cessation group showed a clear, linearly decreasing trend over time compared with the control group. Even after many years of smoking, cough sensitivity is enhanced as early as 2 weeks after smoking cessation. Given the importance of an intact cough reflex, these changes may provide clinical benefit.