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Farida H, Gasem MH, Suryanto A, Keuter M, Zulkarnain N, Satoto B, van der Eijk AA, Djokomoeljanto R, Wahyono H, Verbrugh HA, Severin JA, van den Broek PJ. Viruses and Gram-negative bacilli dominate the etiology of community-acquired pneumonia in Indonesia, a cohort study. Int J Infect Dis 2015; 38:101-7. [PMID: 26255889 PMCID: PMC7110756 DOI: 10.1016/j.ijid.2015.07.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/20/2015] [Accepted: 07/25/2015] [Indexed: 01/10/2023] Open
Abstract
Objective Knowledge about the etiology of community-acquired pneumonia (CAP) is essential for adequate management. Presently, few studies about CAP are available from Southeast Asia. This study aimed to investigate the etiology, severity, and outcome of CAP in the most populous Southeast Asia country, Indonesia. Methods From October 2007 to April 2009, adult patients admitted with CAP to two hospitals in Semarang, Indonesia, were included to detect the etiology of CAP using a full range of diagnostic methods. The severity of disease was classified according to the Pneumonia Severity Index (PSI). The outcome was assessed as 30-day mortality. Results In total, 148 consecutive patients with CAP were included. Influenza virus (18%), Klebsiella pneumoniae (14%), and Streptococcus pneumoniae (13%) were the most common agents identified. Other Gram-negative bacilli, Mycobacterium tuberculosis, Chlamydia pneumoniae each accounted for 5%. The bacteria presented wild type antibiotic susceptibility profiles. Forty-four percent of subjects were high-risk patients (PSI class IV-V). The mortality rate (30%) was significantly associated with disease severity score (P<0.001), and with failure to establish an etiological diagnosis (P=0.027). No associations were found between etiology and underlying diseases, PSI class, nor mortality. Conclusions Viruses and Gram-negative bacilli are dominant causes of CAP in this region, more so than S. pneumoniae. Most of the bacteria have wild type susceptibility to antimicrobial agents. Patients with severe disease and those with unknown etiology have a higher mortality risk.
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Affiliation(s)
- Helmia Farida
- Department of Medical Microbiology, Faculty of Medicine Diponegoro University - Dr. Kariadi Hospital, Semarang, Indonesia.
| | - M Hussein Gasem
- Department of Internal Medicine, Dr. Kariadi Hospital - Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Agus Suryanto
- Department of Internal Medicine, Dr. Kariadi Hospital - Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Monique Keuter
- Department of General Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nasirun Zulkarnain
- Department of Radiology, Dr. Kariadi Hospital - Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Bambang Satoto
- Department of Radiology, Dr. Kariadi Hospital - Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | | | - R Djokomoeljanto
- Department of Internal Medicine, Dr. Kariadi Hospital - Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Hendro Wahyono
- Department of Medical Microbiology, Faculty of Medicine Diponegoro University - Dr. Kariadi Hospital, Semarang, Indonesia
| | - Henri A Verbrugh
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Farida H, Rondags A, Gasem MH, Leong K, Adityana A, van den Broek PJ, Keuter M, Natsch S. Development of quality indicators to evaluate antibiotic treatment of patients with community-acquired pneumonia in Indonesia. Trop Med Int Health 2015; 20:501-9. [DOI: 10.1111/tmi.12452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Helmia Farida
- Department of Microbiology; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Angelique Rondags
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - M. Hussein Gasem
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | - Katharina Leong
- Department of Anesthesiology; Radboud University Medical Centre; Nijmegen The Netherlands
| | - A. Adityana
- Department of Internal Medicine; Faculty of Medicine, Diponegoro University and Dr. Kariadi Hospital; Semarang Indonesia
| | | | - Monique Keuter
- Department of General Internal Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Stephanie Natsch
- Department of Pharmacy; Radboud University Medical Centre; Nijmegen The Netherlands
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Manniën J, van den Hof S, Muilwijk J, van den Broek PJ, van Benthem B, Wille JC. Trends in the Incidence of Surgical Site Infection in The Netherlands. Infect Control Hosp Epidemiol 2015; 29:1132-8. [DOI: 10.1086/592094] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To evaluate the time trend in the surgical site infection (SSI) rate in relation to the duration of surveillance in The Netherlands.Setting.Forty-two hospitals that participated in the the Dutch national nosocomial surveillance network, which is known as PREZIES (Preventie van Ziekenhuisinfecties door Surveillance), and that registered at least 1 of the following 5 frequently performed surgical procedures for at least 3 years during the period from 1996 through 2006: mastectomy, colectomy, replacement of the head of the femur, total hip arthroplasty, or knee arthroplasty.Methods.Analyses were performed for each surgical procedure. The surveillance time to operation was stratified in consecutive 1-year periods, with the first year as reference. Multivariate logistic regression analysis was performed using a random coefficient model to adjust for random variation among hospitals. All models were adjusted for method of postdischarge surveillance.Results.The number of procedures varied from 3,031 for colectomy to 31,407 for total hip arthroplasty, and the SSI rate varied from 1.6% for knee arthroplasty to 12.2% for colectomy. For total hip arthroplasty, the SSI rate decreased significantly by 6% per year of surveillance (odds ratio [OR], 0.94 [95% confidence interval {CI}, 0.90–0.98]), indicating a 60% decrease after 10 years. Nonsignificant but substantial decreasing trends in the rate of SSI were found for replacement of the head of the femur (OR, 0.94 [95% CI, 0.88–1.00]) and for colectomy (OR, 0.92 [95% CI, 0.83–1.02]).Conclusions.Even though most decreasing trends in the SSI rate were not statistically significant, they were encouraging. To use limited resources as efficiently as possible, we would suggest switching the surveillance to another surgical procedure when the SSI rate for that particular procedure has decreased below the target rate.
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Jansen IAV, Hopmans TEM, Wille JC, van den Broek PJ, van der Kooi TII, van Benthem BHB. Appropriate use of indwelling urethra catheters in hospitalized patients: results of a multicentre prevalence study. BMC Urol 2012; 12:25. [PMID: 22954383 PMCID: PMC3502298 DOI: 10.1186/1471-2490-12-25] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 09/03/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although indwelling urethra catheterization is a medical intervention with well-defined risks, studies show that approximately 14-38% of the indwelling urethra catheters (IUCs) are placed without a specific medical indication. In this paper we describe the prevalence of IUCs, including their inappropriate use in the Netherlands. We also determine factors associated with inappropriate use of IUCs in hospitalized patients. METHODS In 28 Dutch hospitals, prevalence surveys were performed biannually in 2009 and 2010 within the PREZIES-network. All patients admitted to a participating hospital and who had an IUC in place at the day of the survey were included. Pre-determined criteria were used to categorize the indication for catheterization as appropriate or inappropriate. RESULTS A total of 14,252 patients was included and 3020 (21.2%) of them had an IUC (range hospitals 13.4-27.3). Initial catheter placement was inappropriate in 5.2% of patients and 7.5% patients had an inappropriate indication at the day of the survey. In multivariate analyses inappropriate catheter use at the time of placement was associated with female sex, older age, admission on a non-intensive care ward, and not having had surgery. Inappropriate catheter use at the time of survey showed comparable associated factors. CONCLUSIONS Although lower than in many other countries, inappropriate use of IUC is present in Dutch hospitals. To reduce the inappropriate use of IUCs, recommended components of care (bundle for UTI), including daily revision and registration of the indication for catheterization, should be introduced for all patients with an IUC. Additionally, an education and awareness campaign about appropriate indications for IUC should be available.
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Affiliation(s)
- Irálice AV Jansen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO box 1 (postbak 75), 3720 BA, Bilthoven, The Netherlands
| | - Titia EM Hopmans
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO box 1 (postbak 75), 3720 BA, Bilthoven, The Netherlands
| | - Jan C Wille
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO box 1 (postbak 75), 3720 BA, Bilthoven, The Netherlands
| | | | - Tjallie II van der Kooi
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO box 1 (postbak 75), 3720 BA, Bilthoven, The Netherlands
| | - Birgit HB van Benthem
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO box 1 (postbak 75), 3720 BA, Bilthoven, The Netherlands
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Abstract
BACKGROUND People requiring long-term bladder draining commonly experience catheter-associated urinary tract infection and other problems. OBJECTIVES To determine if certain catheter policies are better than others in terms of effectiveness, complications, quality of life and cost-effectiveness in long-term catheterised adults and children. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 September 2011). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA All randomised and quasi-randomised trials comparing catheter policies (route of insertion and use of antibiotics) for long-term (more than 14 days) catheterisation in adults and children. DATA COLLECTION AND ANALYSIS Data were extracted by two reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If the data in trials had not been fully reported, clarification was sought from the authors. When necessary, the incidence-density rates (IDR) and/or the incidence-density differences (IDD) within a certain time period were calculated. MAIN RESULTS Eight trials met the inclusion criteria involving 504 patients in four cross-over and four parallel-group randomised controlled trials. Only two of the pre-stated six comparisons were addressed in these trials. Four trials compared antibiotic prophylaxis with antibiotics when clinically indicated. For patients using intermittent catheterisation, there were inconsistent findings about the effect of antibiotic prophylaxis on symptomatic urinary tract infection (UTI). Only one study found a significant difference in the frequency of UTI favouring prophylaxis. For patients using indwelling urethral catheterisation, one small trial reported fewer episodes of symptomatic UTI in the prophylaxis group.Four trials compared antibiotic prophylaxis with giving antibiotics when microbiologically indicated. For patients using intermittent catheterisation, there was limited evidence that receiving antibiotics reduced the rate of bacteriuria (asymptomatic and symptomatic). There was weak evidence that prophylactic antibiotics were better in terms of fewer symptomatic bacteriuria. AUTHORS' CONCLUSIONS No eligible trials were identified that compared alternative routes of catheter insertion. The data from eight trials comparing different antibiotic policies were sparse, particularly when intermittent catheterisation was considered separately from indwelling catheterisation. Possible benefits of antibiotic prophylaxis must be balanced against possible adverse effects, such as development of antibiotic resistant bacteria. These cannot be reliably estimated from currently available trials.
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de Breij A, Eveillard M, Dijkshoorn L, van den Broek PJ, Nibbering PH, Joly-Guillou ML. Differences in Acinetobacter baumannii strains and host innate immune response determine morbidity and mortality in experimental pneumonia. PLoS One 2012; 7:e30673. [PMID: 22347396 PMCID: PMC3275605 DOI: 10.1371/journal.pone.0030673] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/20/2011] [Indexed: 11/18/2022] Open
Abstract
Despite many reports documenting its epidemicity, little is known on the interaction of Acinetobacter baumannii with its host. To deepen our insight into this relationship, we studied persistence of and host response to different A. baumannii strains including representatives of the European (EU) clones I–III in a mouse pneumonia model. Neutropenic mice were inoculated intratracheally with five A. baumannii strains and an A. junii strain and at several days morbidity, mortality, bacterial counts, airway inflammation, and chemo- and cytokine production in lungs and blood were determined. A. baumannii RUH875 and RUH134 (EU clone I and II, respectively) and sporadic strain LUH8326 resulted in high morbidity/mortality, whereas A. baumannii LUH5875 (EU clone III, which is less widespread than clone I and II) caused less symptoms. A. baumannii type strain RUH3023T and A. junii LUH5851 did not cause disease. All strains, except A. baumannii RUH3023T and A. junii LUH5851, survived and multiplied in the lungs for several days. Morbidity and mortality were associated with the severity of lung pathology and a specific immune response characterized by low levels of anti-inflammatory (IL-10) and specific pro-inflammatory (IL-12p40 and IL-23) cytokines at the first day of infection. Altogether, a striking difference in behaviour among the A. baumannii strains was observed with the clone I and II strains being most virulent, whereas the A. baumannii type strain, which is frequently used in virulence studies appeared harmless.
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Affiliation(s)
- Anna de Breij
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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Wildenbeest JG, van den Broek PJ, Benschop KSM, Koen G, Wierenga PC, Vossen ACTM, Kuijpers TW, Wolthers KC. Pleconaril revisited: clinical course of chronic enteroviral meningoencephalitis after treatment correlates with in vitro susceptibility. Antivir Ther 2011; 17:459-66. [PMID: 22293148 DOI: 10.3851/imp1936] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND Human enteroviruses (HEVs) can cause severe infections, especially in patients with a deficient humoral immune response, such as X-linked agammaglobulinemia. In this patient group, chronic enteroviral meningitis (CEMA) is feared because of extensive morbidity and high fatality rate. Treatment options consist of intravenous immunoglobulin (IVIG), with various outcomes. Pleconaril is an antiviral agent with in vitro activity against HEVs that has been used in the treatment of HEV infections. METHODS The efficacy of pleconaril and IVIG against HEV isolated from the patients was assessed in vitro in two patients with CEMA. RESULTS Echovirus 11 was found in the cerebrospinal fluid (CSF) of case 1. Treatment with high-dose IVIG and pleconaril did not provide any clinical improvement and HEV PCR in CSF remained positive. Case 2 (echovirus 13 positive in CSF) was also treated with IVIG and pleconaril. The patient recovered completely and HEV PCR in CSF became negative. Recent IVIG batches contained low titres of neutralizing antibodies against the patient strains. Echovirus 11 (case 1) was resistant to pleconaril in vitro, whereas echovirus 13 (case 2) was susceptible, in accordance with virological response after treatment and subsequent clinical results. CONCLUSIONS This is the first report that evaluates efficacy of antiviral treatment in CEMA patients in relation to in vitro susceptibility of clinical virus isolates. Since pleconaril is no longer available for compassionate use we strongly propagate that new drugs should be developed against these potential life threatening HEV infections.
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Affiliation(s)
- Joanne G Wildenbeest
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
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Ammerlaan HSM, Kluytmans JAJW, Berkhout H, Buiting A, de Brauwer EIGB, van den Broek PJ, van Gelderen P, Leenders S(ACAP, Ott A, Richter C, Spanjaard L, Spijkerman IJB, van Tiel FH, Voorn GP, Wulf MWH, van Zeijl J, Troelstra A, Bonten MJM, van de Berg CMF, Bosman J, Bremer A, Bril W, Commeren D, van Essen G, Gigengack-Baars A, van Kasteren MME, Lommerse EJM, Mascini E, Renders NHM, van Rijen M, Schellekens J, Smeets E, Sprangers T, Vandenbroucke-Grauls CMJE, Verbon A, Verduin K, Wagenvoort JHT, van Wijngaarden P. Eradication of carriage with methicillin-resistant Staphylococcus aureus: effectiveness of a national guideline. J Antimicrob Chemother 2011; 66:2409-17. [DOI: 10.1093/jac/dkr243] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Heidi S. M. Ammerlaan
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jan A. J. W. Kluytmans
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Laboratory for Microbiology and Infection Control, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Hanneke Berkhout
- Department of Medical Microbiology, Immunology and Hygiene and Infection Prevention, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands
| | - Anton Buiting
- Department of Medical Microbiology, St Elisabeth Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - Els I. G. B. de Brauwer
- Department of Medical Microbiology, Atrium Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | - Peterhans J. van den Broek
- Department of Infectious Diseases, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Paula van Gelderen
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | - Alewijn Ott
- Laboratory for Infectious Diseases, Van Ketwich Verschuurlaan 92, 9721 SW Groningen, The Netherlands
| | - Clemens Richter
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Lodewijk Spanjaard
- Department of Medical Microbiology and Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ingrid J. B. Spijkerman
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Frank H. van Tiel
- Department of Medical Microbiology, Academic Hospital Maastricht, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - G. Paul Voorn
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Mireille W. H. Wulf
- PAMM Laboratory for Medical Microbiology, De Run 6250, 5504 DL Veldhoven, The Netherlands
| | - Jan van Zeijl
- Izore, Centre Infectious Diseases Friesland, Jelsumerstraat 6, 8917 EN Leeuwarden, The Netherlands
| | - Annet Troelstra
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marc J. M. Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Julius Centre for Healthcare Science and First line Medicine, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Ammerlaan HSM, Kluytmans JAJW, Berkhout H, Buiting A, de Brauwer EIGB, van den Broek PJ, van Gelderen P, Leenders S(ACAP, Ott A, Richter C, Spanjaard L, Spijkerman IJB, van Tiel FH, Voorn GP, Wulf MWH, van Zeijl J, Troelstra A, Bonten MJM, van de Berg CMF, Bosman J, Bremer A, Bril W, Commeren D, van Essen G, Gigengack-Baars A, van Kasteren MME, Lommerse EJM, Mascini E, Renders NHM, van Rijen M, Schellekens J, Smeets E, Sprangers T, Vandenbroucke-Grauls CMJE, Verbon A, Verduin K, Wagenvoort JHT, van Wijngaarden P. Eradication of carriage with methicillin-resistant Staphylococcus aureus: determinants of treatment failure. J Antimicrob Chemother 2011; 66:2418-24. [DOI: 10.1093/jac/dkr250] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Heidi S. M. Ammerlaan
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jan A. J. W. Kluytmans
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Laboratory for Microbiology and Infection Control, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Hanneke Berkhout
- Department of Medical Microbiology, Immunology and Hygiene and Infection Prevention, VieCuri Medical Centre, Tegelseweg 210, 5912 BL Venlo, The Netherlands
| | - Anton Buiting
- Department of Medical Microbiology, St Elisabeth Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - Els I. G. B. de Brauwer
- Department of Medical Microbiology, Atrium Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | - Peterhans J. van den Broek
- Department of Infectious Diseases, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Paula van Gelderen
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | - Alewijn Ott
- Laboratory for Infectious Diseases, Van Ketwich Verschuurlaan 92, 9721 SW Groningen, The Netherlands
| | - Clemens Richter
- Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Lodewijk Spanjaard
- Department of Medical Microbiology and Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ingrid J. B. Spijkerman
- Department of Medical Microbiology and Infection Control, VUmc Medical University, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Frank H. van Tiel
- Department of Medical Microbiology, Academic Hospital Maastricht, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - G. Paul Voorn
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Mireille W. H. Wulf
- PAMM Laboratory for Medical Microbiology, De Run 6250, 5504 DL Veldhoven, The Netherlands
| | - Jan van Zeijl
- Izore, Centre Infectious Diseases Friesland, Jelsumerstraat 6, 8917 EN Leeuwarden, The Netherlands
| | - Annet Troelstra
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marc J. M. Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Julius Centre for Healthcare science and First line Medicine, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Niël-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC, van den Broek PJ. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care 2011; 15:R111. [PMID: 21481251 PMCID: PMC3219392 DOI: 10.1186/cc10135] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Revised: 03/12/2011] [Accepted: 04/11/2011] [Indexed: 01/30/2023]
Abstract
Introduction A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one. Methods A systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure. Results Three trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes. Conclusions Although the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.
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Affiliation(s)
- Barbara S Niël-Weise
- Leiden University Medical Center, Dutch Working Party Infection Prevention, C7-130, Postbus 9600, 2300 RC Leiden, Germany.
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van den Broek PJ. [Sterile gloves are necessary in minor surgery]. Ned Tijdschr Geneeskd 2011; 155:A3341. [PMID: 21466736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The use of sterile gloves as part of asepsis during surgery goes back to the end of the nineteenth century, but now the preventive value of this measure during minor surgery is questioned. One randomized study showed no difference in wound infection rates whether sterile or nonsterile gloves were used for repair of uncomplicated lacerations of the skin. An observational and a retrospective study in minor dermatological surgery confirm that the use of sterile or nonsterile gloves makes no difference for excisions of tumours as long as no reconstructions of the skin are performed. However, in more complicated minor dermatological surgery, 80% less wound infections were observed when sterile gloves were used. In conclusion, the available evidence is too limited to change the recommendation to use sterile gloves for minor surgery.
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van den Broek PJ, Cools HJM, Wulf M, Das PHAC. How much time should long-term care and geriatric rehabilitation facilities (nursing homes) spend on infection control? Am J Infect Control 2010; 38:723-5. [PMID: 20605266 DOI: 10.1016/j.ajic.2010.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 03/05/2010] [Accepted: 03/08/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND For hospitals, standards for the required number of infection control personnel are outdated and disputed. Such standards are not even available for long-term care and geriatric rehabilitation facilities (ie, nursing homes). This study addressed the question of how much time nursing homes should spend on infection control. METHODS Through group discussions and individual sessions, experienced infection control practitioners, medical microbiologists, and nursing home doctors evaluated the time needed to perform infection control activities in a model nursing home. RESULTS The number of hours needed was estimated as 513 per 100 beds, or 154 per 10,000 care-days per year. CONCLUSION Given that significant differences can be expected among the various facilities identified as nursing homes, long-term care facilities, or geriatric rehabilitation centers, as well as among countries, the standard that we propose for The Netherlands will not be generally applicable. However, the method we have used to determine this standard can be easily applied in other countries and settings.
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Gooskens J, Jonges M, Claas ECJ, Meijer A, van den Broek PJ, Kroes AM. Morbidity and mortality associated with nosocomial transmission of oseltamivir-resistant influenza A(H1N1) virus. JAMA 2009; 301:1042-6. [PMID: 19255111 DOI: 10.1001/jama.2009.297] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The sudden emergence and rapid spread of oseltamivir-resistant influenza A(H1N1) viruses with neuraminidase (NA) gene H274Y amino acid substitution is the hallmark of global seasonal influenza since January 2008. Viruses carrying this mutation are widely presumed to exhibit attenuated pathogenicity, compromised transmission, and reduced lethality. OBJECTIVE To investigate nosocomial viral transmission in a cluster of patients with influenza A(H1N1) virus infection. DESIGN, SETTING, AND PATIENTS Descriptive outbreak investigation of 2 hematopoietic stem cell transplant recipients and an elderly patient who developed hospital-acquired influenza A virus infection following exposure to an index patient with community-acquired H274Y-mutated influenza A(H1N1) virus infection in a medical ward at a Dutch university hospital in February 2008. The investigation included a review of the medical records, influenza virus polymerase chain reaction and culture, phenotypic oseltamivir and zanamivir susceptibility determination, and hemagglutinin chain 1 (HA(1)) gene and NA gene sequence analysis. MAIN OUTCOME MEASURE Phylogenetic relationship of patient cluster influenza A(H1N1) viruses and other 2007-2008 seasonal influenza A(H1N1) viruses. RESULTS Viral HA(1) and NA gene sequence analysis from the 4 patients revealed indistinguishable nucleotide sequences and phylogenetic clustering of H274Y-mutated, oseltamivir-resistant influenza A(H1N1) virus, confirming nosocomial transmission. Influenza virus pneumonia (3 patients) and attributable mortality (2 patients) during active infection was observed in patients with lymphocytopenia at onset. CONCLUSION Seasonal oseltamivir-resistant influenza A(H1N1) viruses with NA gene H274Y mutation are transmitted and retain significant pathogenicity and lethality in high-risk patients.
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MESH Headings
- Aged
- Aged, 80 and over
- Amino Acid Sequence
- Amino Acid Substitution
- Antiviral Agents/pharmacology
- Cross Infection/epidemiology
- Disease Transmission, Infectious
- Drug Resistance, Viral
- Enzyme Inhibitors/pharmacology
- Female
- Hemagglutinin Glycoproteins, Influenza Virus/genetics
- Humans
- Influenza A Virus, H1N1 Subtype/drug effects
- Influenza A Virus, H1N1 Subtype/genetics
- Influenza A Virus, H1N1 Subtype/pathogenicity
- Influenza, Human/epidemiology
- Influenza, Human/mortality
- Influenza, Human/transmission
- Influenza, Human/virology
- Male
- Middle Aged
- Molecular Sequence Data
- Morbidity
- Neuraminidase/antagonists & inhibitors
- Neuraminidase/genetics
- Oseltamivir/pharmacology
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Affiliation(s)
- Jairo Gooskens
- Department of Medical Microbiology, E4-65, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
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Nemec A, Maixnerová M, van der Reijden TJK, van den Broek PJ, Dijkshoorn L. Relationship between the AdeABC efflux system gene content, netilmicin susceptibility and multidrug resistance in a genotypically diverse collection of Acinetobacter baumannii strains. J Antimicrob Chemother 2007; 60:483-9. [PMID: 17595288 DOI: 10.1093/jac/dkm231] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the occurrence of the genes of the AdeABC efflux system and their association with antimicrobial resistance in Acinetobacter baumannii. METHODS A set of 116 strains selected for their diversity both in genotypic properties and geographic origin was investigated for the presence of the structural (adeA, adeB and adeC) and regulatory (adeR and adeS) genes of the AdeABC system by PCR, for resistance to 11 antimicrobials by disc diffusion, for MIC of netilmicin and for the presence of aacC2 and aacA4, encoding netilmicin-modifying enzymes. RESULTS Ninety-five strains were positive for adeA, adeB, adeR and adeS, 10 were positive for 1 to 3 of these genes and 11 were negative for all genes. The adeC gene was found in 49 strains with one or more of the other genes. Forty-one strains were resistant to a maximum of one agent and 75 strains to two or more agents. Netilmicin MICs showed an almost bimodal distribution with respective peaks of 0.5-1 and 8 mg/L; aacC2 or aacA4 was found in six strains with netilmicin MIC of >or=64 mg/L. All 61 strains with netilmicin MICs >or= 4 mg/L were both adeABRS-positive and resistant to two or more agents, whereas netilmicin MICs <or= 2 mg/L (n = 51) were found for all strains resistant to a maximum of one agent and those negative for one or more of the adeABRS genes. CONCLUSIONS The AdeABC genes are common in A. baumannii, but may be absent in some, mostly fully susceptible strains. Decreased susceptibility to netilmicin (MIC 4-32 mg/L) is associated with both the presence of these genes and multidrug resistance and may be indicative of AdeABC overexpression.
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Affiliation(s)
- Alexandr Nemec
- Centre of Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
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Duerink DO, Lestari ES, Hadi U, Nagelkerke NJD, Severin JA, Verbrugh HA, Keuter M, Gyssens IC, van den Broek PJ. Determinants of carriage of resistant Escherichia coli in the Indonesian population inside and outside hospitals. J Antimicrob Chemother 2007; 60:377-84. [PMID: 17595290 DOI: 10.1093/jac/dkm197] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Antibiotic resistance is a worldwide healthcare problem exacerbated by antibiotic use and transmission of resistant bacteria. Not much is known about resistance in commensal flora and about determinants for resistance in Indonesia. This study analysed recent antibiotic use as well as demographic, socioeconomic, disease-related and healthcare-related determinants of rectal carriage of resistant Escherichia coli in the community and in hospitals in Indonesia. METHODS Carriers of susceptible E. coli were compared with carriers of E. coli with resistance to any of the tested antibiotics. Logistic regression analysis was performed to determine which variables were associated with carriage of resistant E. coli. Individuals in the community with varying levels of contact with healthcare institutions and hospitalized patients were analysed as separate populations. RESULTS AND CONCLUSIONS Of 3275 individuals (community 2494, hospital 781), 54% carried resistant E. coli. Recent antibiotic use was the most important determinant of resistance in both populations [community: odds ratio (OR) 1.8, 95% confidence interval (95% CI) 1.5-2.3; hospital: OR 2.5, 95% CI 1.6-3.9]. In the community, hospitalization (OR 2.4, 95% CI 2.0-3.0), diarrhoeal symptoms (OR 1.9, 95% CI 1.3-2.7) and age under 16 years (adults: OR 0.4, 95% CI 0.3-0.5) were associated with carriage of resistant E. coli. For hospitalized patients, having no health insurance was associated with less resistance (OR 0.6, 95% CI 0.4-0.9) and differences were observed between hospitals (Semarang: OR 2.2, 95% CI 1.5-3.3) and departments (Paediatrics: OR 4.3, 95% CI 1.7-10.7). Further research is needed to investigate whether transmission is responsible for these differences.
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Affiliation(s)
- D Offra Duerink
- Department of Infectious Diseases, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands, and Department of Clinical Microbiology, Dr Kariadi Hospital, Semarang, Indonesia.
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Abstract
OBJECTIVES To evaluate the diagnostic accuracy of C reactive protein in detecting radiologically proved pneumonia and to evaluate how well it can discriminate between bacterial and viral infections of the lower respiratory tract. DATA SOURCES Medline and Embase (January 1966 to April 2004), with reference checking. STUDY SELECTION We included articles comparing C reactive protein with a chest radiograph or with microbiological work-up as a reference test. Two authors independently assessed methodological items. RESULTS None of the studies met all validity criteria. Six studies used an infiltrate on chest radiograph as reference test. Sensitivities ranged from 10% to 98%, specificities from 44% to 99%. For adults, the relation of C reactive protein with an infiltrate (in a subgroup analysis of five studies) showed an area under the curve of 0.80 (95% confidence interval 0.75 to 0.85). In 12 studies, the relation of C reactive protein with a bacterial aetiology of infection of the lower respiratory tract was studied. Sensitivities ranged from 8% to 99%, specificities from 27% to 95%. These data were epidemiologically and statistically heterogeneous, so overall outcomes could not be calculated. CONCLUSION Testing for C reactive protein is neither sufficiently sensitive to rule out nor sufficiently specific to rule in an infiltrate on chest radiograph and bacterial aetiology of lower respiratory tract infection. The methodological quality of the diagnostic studies is generally poor. The evidence not consistently and sufficiently supports a wide introduction of C reactive protein as a rapid test to guide antibiotics prescription.
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Affiliation(s)
- Victor van der Meer
- Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, Netherlands.
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Templeton KE, Scheltinga SA, van den Eeden WCJFM, Graffelman WA, van den Broek PJ, Claas ECJ. Improved diagnosis of the etiology of community-acquired pneumonia with real-time polymerase chain reaction. Clin Infect Dis 2005; 41:345-51. [PMID: 16007532 PMCID: PMC7107904 DOI: 10.1086/431588] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Accepted: 03/17/2005] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality. Polymerase chain reaction (PCR) has been shown to be more sensitive than current standard microbiological methods and, therefore, may improve the accuracy of microbiological diagnosis for patients with CAP. METHODS Conventional detection techniques and multiplex real-time PCR for atypical bacteria and respiratory viruses were performed on samples collected from 105 adults enrolled in a prospective study. An infiltrate was visible on each patient's chest radiograph, and a pneumonia severity index score was determined for each patient. RESULTS Microbiological diagnoses were determined for 52 (49.5%) of 105 patients by conventional techniques and for 80 (76%) of 105 patients by real-time PCR. The time to obtain the result of real-time PCR could be reduced to 6 h. PCR methodology was significantly more sensitive for the detection of atypical pathogens and viruses (P< or =.001). Respiratory viral infections and mixed infections were detected in 15 (14.2%) and 3 (2.8%) of 105 patients, respectively, by conventional methods, but were detected in 59 (56.2%) and 28 (26.5%) of 105, respectively, by real-time PCR. Presence of a mixed infection was significantly associated with severe pneumonia (P=.002). Human rhinoviruses and coronaviruses, OC43 and 229E, were frequently identified pathogens. CONCLUSIONS The combined real-time PCR assay is more sensitive for diagnosis of the main viruses and atypical bacteria that cause CAP compared with conventional methods, and obtains results in a clinically relevant time period.
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Affiliation(s)
| | | | | | - Willy A. Graffelman
- Departments of Center of Infectious Diseases and Department of General Practice and Nursing Home Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Eric C. J. Claas
- Departments of Medical Microbiology and Leiden University Medical Center, Leiden, The Netherlands
- Reprints or correspondence: Dr. E. C. J. Claas, Dept. of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands ()
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Dijkshoorn L, Brouwer CPJM, Bogaards SJP, Nemec A, van den Broek PJ, Nibbering PH. The synthetic N-terminal peptide of human lactoferrin, hLF(1-11), is highly effective against experimental infection caused by multidrug-resistant Acinetobacter baumannii. Antimicrob Agents Chemother 2005; 48:4919-21. [PMID: 15561882 PMCID: PMC529198 DOI: 10.1128/aac.48.12.4919-4921.2004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The lactoferrin-derived peptide hLF(1-11), but not its control peptide, was highly effective against five multidrug-resistant Acinetobacter baumannii strains in vitro (3 to 4 log reduction) and against four of these strains in an experimental infection in mice (2 to 3 log reduction). Therefore, this peptide is a promising candidate as a novel agent against infections with multidrug-resistant A. baumannii.
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Affiliation(s)
- Lenie Dijkshoorn
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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Graffelman AW, Knuistingh Neven A, le Cessie S, Kroes ACM, Springer MP, van den Broek PJ. Pathogens involved in lower respiratory tract infections in general practice. Br J Gen Pract 2004; 54:15-9. [PMID: 14965401 PMCID: PMC1314772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND There are few investigations into the aetiology of lower respiratory tract infections (LRTIs) in general practice. AIM To describe the aetiology of LRTI among adult patients in general practice in The Netherlands. DESIGN OF STUDY Prospective observational study. SETTING General practices in the Leiden region, The Netherlands. METHOD Adult patients with a defined LRTI were included. Standard medical history and physical examination were performed. Sputum, blood and throat swabs were collected for diagnostic tests. Aetiological diagnosis, categorised as definite or possible, was based on the results of bacterial and viral cultures, serological techniques, and on polymerase chain reaction. Proportions of pathogens causing LRTI were assessed in relation to chest X-ray findings. RESULTS A bacterial cause was established in 43 (30%), and a viral cause in 57 (39%) of the 145 patients with a LRTI. Influenza virus A was the most frequently diagnosed microorganism, followed by Haemophilus influenzae, and Mycoplasma pneumoniae. Streptococcus pneumoniae was found in 6% of the patients. CONCLUSIONS Pathogens were found in two-thirds of the patients. In half of these patients there was a viral cause. Influenza virus A was the most frequently found pathogen. The treatment with antibiotics of at least one-third of the patients with LRTI was superfluous. This observation should result in changes in the prescription of antibiotics in LRTI.
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Affiliation(s)
- A Willy Graffelman
- Department of General Practice and Nursing Home Medicine, Leiden University Medical Center, Leiden, The Netherlands.
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Graffelman AW, Knuistingh Neven A, le Cessie S, Kroes ACM, Springer MP, van den Broek PJ. A diagnostic rule for the aetiology of lower respiratory tract infections as guidance for antimicrobial treatment. Br J Gen Pract 2004; 54:20-4. [PMID: 14965402 PMCID: PMC1314773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND The majority of patients with lower respiratory tract infections (LRTIs) are treated with antibiotics; some of them are unnecessary because of a viral cause. Information on prediction of the aetiology, especially in a general practice setting, is missing. AIM To differentiate between viral and bacterial LRTI on simple clinical criteria, easily obtained at the bedside. DESIGN OF STUDY Prospective observational study. SETTING General practices in the Leiden region of The Netherlands. METHOD Adult patients with LRTI were included. Standard medical history and physical examination were performed. Sputum, blood and throat swabs were collected for diagnostic tests. According to microbiological findings, patients were classified as bacterial, viral, dual infection and unknown cause. In a logistic regression model independent predictors were determined. Scoring systems were developed. The accuracies of the diagnostic rules were tested by using receiver operating characteristic (ROC) curves. RESULTS One-hundred and forty-five patients were classified as having bacterial (n = 35), viral (n = 49), or dual infection (n = 8), or infection of unknown cause (n = 53), respectively. Independent predictors for bacterial infection were fever (odds ratio [OR] = 8.0; 95% confidence interval [CI] = 0.9 to 71.0), headache (OR = 4.3; 95% CI = 1.0 to 19.1) cervical painful lymph nodes (OR = 8.7; 95% CI = 1.1 to 68.0), diarrhoea (OR = 0.3; 95% CI = 0.1 to 1.0) and rhinitis (OR = 0.3; 95% CI = 0.1 to 0.9). As an additional independent predictor, an infiltrate on chest X-ray (OR = 5.0; 95% CI = 1.2 to 20.5) was found. The diagnostic rules developed from these variables classified the aetiology of LRTI with a ROC curve area of 0.79 (clinical score), 0.77 (simplified score) and 0.83 (extended score). CONCLUSIONS A diagnostic rule was developed, based on information that is easy to obtain at the bedside, to predict a bacterial infection. This diagnostic rule may be a tool for general practitioners in their management of patients with LRTI.
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Affiliation(s)
- A Willy Graffelman
- Department of General Practice and Nursing Home Medicine, Leiden University Medical Center, Leiden, The Netherlands.
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