Seminars in respiratory infections
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Community-acquired pneumonia (CAP) is the most common serious infection encountered in medical practice, with 1% to 10% of patients requiring admission to a hospital. The mortality rate of patients admitted is considerable, ranging from 5% to 25%. Motivated by the results of the British Thoracic Society (BTS) study, different investigators have identified several risk factors associated with a high mortality rate. ⋯ Pneumonia- and non-pneumonia-related complications are often observed. Adverse prognostic factors that have been reported in several studies are: advanced age, the presence of comorbidities, development of septic shock, need for mechanical ventilation (including use of positive end-expiratory pressure and FiO2 >60%), development of adult respiratory distress syndrome, progression of radiographic abnormalities, bacteremia (especially when due to P aeruginosa), non-pneumonia-related complications, and inadequate antibiotic treatment. To reduce mortality, prospective studies focusing on adverse prognostic factors at the start of and during antibiotic treatment are urgently needed at all three stages.
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The nature of the causative organisms involved in community-acquired pneumonia has always attracted the interest of investigators. Despite multiple studies using different methodological approaches, it remains a matter of controversy because a reliable cause cannot be obtained in a significant percentage of cases, even when using more sophisticated diagnostic procedures. ⋯ Recently, common respiratory pathogens such as the pneumococcus or Haemophilus influenzae, among others, showed a progressive tendency to develop resistance to penicillins and other antibiotics. Although this phenomenon has a variable impact among different countries, its growing importance is changing the classical therapeutic approach to community-acquired pneumonia.
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Semin Respir Infect · Mar 1999
ReviewUtility of fibrinolytic agents for draining intrapleural infections.
Multiple studies have shown that the intrapleural instillation of fibrinolytic agents provides an effective and safe mode of treatment for complicated parapneumonic effusions and empyemas that decrease the need for surgical interventions. Although most investigators use streptokinase and urokinase, the technique of instillation is not standardized. The usual dose of streptokinase is 250,000 IU, but doses range from 50,000 to 220,000 IU for urokinase. ⋯ Although complications of fibrinolytic therapy rarely occur, they result most often from allergic reactions to streptokinase. Urokinase is safer but more expensive. More randomized, comparative, controlled studies are needed to further define the most effective mode of fibrinolytic therapy for subgroups of patients with pleural infection.
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Epidemiological knowledge of sarcoidosis is based mainly on studies performed more than 30 years ago. These early case-control studies produced some interesting risk factor-disease associations, but a clear causative mechanism in sarcoidosis remains unknown. Studies in military and veteran populations showed a clear preponderance of sarcoidosis in African Americans compared with Caucasians. ⋯ We have found that familial sarcoidosis is almost three times more common in African-American (17%) than Caucasian cases (6%). Future genetic studies can benefit from the extensive catalog of candidate genes that is emerging from the human genome project. The epidemiological evidence to date strongly suggests that studies seeking causes for sarcoidosis need to consider both environmental and genetic risk factors to be successful because the two likely interact with each other to produce disease.
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Treatment of sarcoidosis is controversial. The clinical expression and natural history of sarcoidosis is variable, and spontaneous remissions occur in up to 60% of patients. ⋯ Toxicities associated with therapy may be substantial, particularly when high dosages are used. We review the pharmacologic agents used to treat sarcoidosis, toxicities associated with treatment, and appropriate use and monitoring of these therapeutic modalities.