Dilemmas and realities of rapid diagnostic tests for tuberculosis

The Bacteriology of Pleural Infection by Genetic and Standard Methods and Its Mortality Significance

BACKGROUND

Antibiotic choices for pleural infection are uncertain as its bacteriology is poorly described.

METHODS

Pleural fluid from 434 pleural infections underwent standard culture and a screen for bacteria by amplification and sequencing of bacterial 16S ribosomal RNA gene.

RESULTS

Approximately 50% of community-acquired infections were streptococcal, and 20% included anaerobic bacteria. Approximately 60% of hospital-acquired infections included bacteria frequently resistant to antibiotics (methicillin-resistant Staphylococcus aureus, 25%; Enterobacteriaceae, 18%; Pseudomonas spp., 5%, enterococci, 12%). Mortality was increased in hospital-acquired infection (hospital, 17/36 [47%]; community, 53/304 [17%]; relative risk, 4.24; 95% confidence interval, 2.07-8.69; p < 0.00001; chi(2), 1 df = 17.47) and in gram-negative (10/22 [45%]), S. aureus (15/34 [44%]), or mixed aerobic infections (13/28 [46%]), compared with streptococcal infection (23/137 [17%]) and infection including anaerobic bacteria (10/49 [20%]; p < 0.00001, chi(2), 4 df = 23.35).

CONCLUSION

Pleural infection differs bacteriologically from pneumonia and requires different treatment. Antibiotics for community-acquired infection should treat aerobic and anaerobic bacteria. Hospital-acquired, gram-negative S. aureus and mixed aerobic infections have a high mortality rate.

The promises and pitfalls of evidence-based medicine

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to "cookbook medicine." Studies show, however, that few guidelines lead to consistent changes in provider behavior. The hopes, fears, and mixed record of EBM are rooted in the traditional professional perspective of the clinician as sole decisionmaker. Multifaceted implementation strategies that take the collaborative nature of medical work into consideration promise more effective changes in clinical practice.