A holistic approach to MRSA eradication in critically ill patients with MRSA pneumonia

BACKGROUND

The number of Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia cases is increasing in many European countries. In this observational study in one medical and three surgical ICUs multiple interventions for the treatment and eradication of nosocomial MRSA-pneumonia were used.

PATIENTS AND METHODS

Twenty-one critically ill patients (age: 59 +/- 14 years, 15 males/6 females, 18 ventilator-associated, 3 nosocomial, clinical pulmonary infection score > 6 in all patients, APACHE II 18 +/- 5) were enrolled. The patients were treated with a 7-day course of iv linezolid (600 mg bid) plus rifampicin (600 mg bid), endotracheal vancomycin 100 mg qid, thrice daily mouth and throat washing with chlorhexidine 1% fluid and nasal mupirocin ointment, twice daily skin and hair washings with chlorhexidine gluconate 4% and tracheostomy (n = 8) wound care with povidone-iodine spray. Control samples (endotracheal secretions, nose, wound, and pharyngeal swabs) were taken 2, 3, 4, 7 days and 2 months thereafter. Multilobular pneumonia was seen in 16, pleural effusion in 12, and MRSA bacteremia in 4 patients.

RESULTS

One patient died during the follow-up period due to cerebral bleeding. In the remaining 20 patients, pneumonia was clinically cured in all patients and all patients were free of MRSA after eradication. Six patients died due to myocardial infarction (n = 3), gram-negative septic shock (n = 2), herpes encephalitis (n = 1) > 7 days after eradication. No MRSA reinfection occurred during the control period.

CONCLUSION

We conclude that in patients with MRSA pneumonia an approach using a 7-day course of intravenous linezolid plus rifampicin, intratracheal vancomycin, nasal mupirocin, cutaneous and oropharyngeal chlorhexidin plus povidone-iodine cures pneumonia and is effective for MRSA eradication.

Successful antibiotic treatment of Borreliosis associated pseudolymphomatous systemic infiltrates

The clinical management of late stage Borreliosis can be difficult due to various associated symptoms and signs and cumbersome microbiological tests. We report a case of successful antibiotic treatment of Borreliosis-associated pseudolymphomatous infiltrates in bone marrow and lymph nodes, which were diagnosed by bone marrow trephine biopsy and positron emission tomography.

[Hemorrheology and quality of life in fibrinogen- and lipid-lowering therapy]

Previous studies have demonstrated that heparin-induced extracorporeal LDL precipitation is able to reduce total cholesterol, LDL, triglycerides and plasma fibrinogen at the same time and thus improve the hemorheologic pattern. A combination of H.E.L.P. and bezafibrate, which also has a lipid- and fibrinogen-lowering potency, was applied in patients suffering from cerebral multi-infarct dementia and disturbances of the hemorheologic situation. In view of observations regarding improved quality of life after H.E.L.P., a prospective, randomized trial was conducted to determine possible interactions between improved hemorheology and better quality of life. To obtain a low baseline of laboratory parameters, all the patients underwent a single H.E.L.P. session and were then (double-blind) stratified into 2 groups: group 1 (16 males, 5 females, age 67.9 +/- 6.8 years) received sustained-release bezafibrate 400 mg (Bezalip) per day, while group 2 served as controls, and comprised 14 males and 5 females (age 69.2 +/- 6.8 years) who received placebo for a period of 56 days. After H.E.L.P. a statistically significant reduction of the following parameters relevant to hemorheology was obtained: fibrinogen (p < 0.0001), whole blood viscosity (low shear rate p < 0.007 and high shear rate p < 0.005), plasma viscosity (p < 0.002) and red cell transit time (p < 0.0001). Also, the metabolic parameters were influenced positively (p < 0.0001 for total cholesterol, LDL and triglycerides).(ABSTRACT TRUNCATED AT 250 WORDS)

White matter signal abnormalities in normal individuals: correlation with carotid ultrasonography, cerebral blood flow measurements, and cerebrovascular risk factors

We studied 52 asymptomatic subjects using magnetic resonance imaging, and we compared age-matched groups (51-70 years old) with and without white matter lesions with respect to carotid ultrasonography, cerebral blood flow (xenon-133 injection), and cerebrovascular risk factors. In the group with white matter signal abnormalities, we noted a higher frequency of extracranial carotid artery disease, a lower mean gray matter blood flow (F1), and a significant reduction (p less than 0.05) in blood flow of the slow-flowing (F2) compartment. Hypertension, diabetes mellitus, and cardiac diseases (p less than 0.002) were found more often in this group. Our results indicate that a higher incidence of changes known to be associated with an increased risk for stroke exists in the presence of white matter lesions in normal elderly individuals.

Nuclear magnetic resonance image white matter lesions and risk factors for stroke in normal individuals

The incidence, average number, and localization of lesions of the white matter detected by the T2-weighted nuclear magnetic resonance images among volunteers without cerebrovascular symptoms have been correlated with the number of risk factors for stroke. Accepted risk factors were arterial hypertension, diabetes mellitus, smoking, hypercholesterolemia, and cardiac disease. The 42 subjects examined were divided into Group A (0-1 risk factor, mean age 59.36 +/- 5.73 years), Group B (2 risk factors, mean age 61.54 +/- 8.33 years), and Group C (greater than or equal to 3 risk factors, mean age 62.57 +/- 9.83 years). Multiple risk factors among the age-matched groups was accompanied by a highly significant increase (p less than 0.001, Group A versus Group B; p less than 0.01, Group A versus Group C) of the incidence of white matter lesions. The average number of white matter lesions was increased (p less than 0.001) when Group A was compared with Groups B and C. Ninety-two percent of the white matter lesions were localized in watershed zones. Only 11 of the 155 abnormalities of the white matter detected by nuclear magnetic resonance imaging could be detected by computed tomography. White matter lesions in T2-weighted images appear to be an early stage of cerebrovascular disease.

[Parkinsonism with a high vascular risk--Lechner-Ott syndrome]

A syndrome described as Parkinsonism with high hemodynamic risk was represented. The clinical symptomatology was characterized by late onset, high incidence of diabetes mellitus, increased blood viscosity, enhanced platelet aggregation spontaneously as well as induced by adenosine diphosphate (ADP). The EEG shows reduction of alpha frequency and appearance of slow waves in the theta range located in the temporal region. A reduced in cerebral blood flow and a poor respond to L-Dopa treatment was observed. Focal changes was demonstrable in Computertomography and magnetic resonance imaging as well.

[Fatal eosinophilic meningoencephalitis following lacquer poisoning. Case report and differential diagnostic considerations]

The authors report about a 43-year-old male patient, who suffered from an acute toxic brain injury. Twelve days prior to death, after sealing his floor, he experienced progressively increasing headache without fever; the CSF examination disclosed marked eosinophilia. The clinical and pathomorphological features of his illness are discussed and together with the various possible etiologies of eosinophilia in the CSF.

[Chronic tuberculous meningoencephalitis as a cause of cerebrovascular insufficiency--a differential diagnostic problem]

The often complicated diagnosis in the reason of uncertain primary clinical symptoms, in a chronical prolonged tuberculous meningoencephalitis, in correlation with the demonstration of an exemplary case, in the present study is reported. In addition, in this case the morphological and clinical signs are very uncommon also in cause of uncharacteristically and misleadingly clinical symptoms. The findings in computed tomography and finally also the rarely autopsy findings, like tuberculous ventriculitis and vasculitis are presented. The possibilities of different diagnosis will be discussed, in regard to the literature. The present study should be understood as a contribution to a quick and certain diagnose in tuberculous meningoencephalitis.

Sleep-inducing effect of L-tryptophane

Night sleep recordings were performed in 10 patients with sleep disturbance in falling asleep as well as in maintaining sleep using a mobile 4-channel EEG registration system. Three consecutive nights, which were spent under different conditions, were evaluated automatically. The first night without treatment was used as a baseline night to objectify the disturbed sleep, the second night was measured following an infusion of a physiological saline solution and prior to the third recording 5 g l-tryptophane were applied to the patients. Besides a significant decrease of delayed latency times until the appearance of the light sleep stages, an influence was seen on the quantitative sleep parameters such as sleep period time and total sleep time. In parallel, an improvement of the subjective feeling measured by a self-rating scale resulted after l-tryptophane. On the other hand, no definite influence on the other sleep parameters such as an increase of slow wave sleep was observed, so that the use of this treatment might be recommended in disturbances in falling asleep particularly.

[EEG in multi-infarcts with and without intellectual deterioration]

The character and extent of changes in EEG in 124 patients with multiple infarctions, verified by CT, were reported. Further, the EEG diagnoses of patients with (55) or without (50) accompanying dementia were compared. In 19 patients the evidence of dementia could not be defined clearly. The EEG-diagnoses in these patients were compared with a group consisting of 41 patients with primary degenerative dementia (Alzheimer). The EEG showed pathological results in 89 patients with multiple infarctions and focal abnormalities were dominant. In 55 patients with symptoms of dementia and multiple infarctions significantly more pathological EEG-reports were present than in the other patients with multiple-infarcts and a significantly slower basic rhythm could be found. In patients with neurological deficits as compared to the group without neurological symptoms and multiple infarctions the pathological changes dominated significantly. The comparison between patients with multi-infarct-dementia and 41 patients with a senile dementia of the Alzheimer type only revealed a more frequent occurrence of focal abnormalities in patients with multi-infarct-dementia. However there was no significant difference between the number of normal and pathological EEGs.

Therapeutical aspects of cerebrovascular disease

Treatment of hemorheologic alterations in patients with CVD must be directed to reduce enhanced platelet and red cell aggregation, to improve reduced red cell deformability, and to control plasmatic hypercoagulability.

Rheological aspects of cerebrovascular disease

Disturbances of the flow properties of the blood may occur in more than 40% of patients with CVD. Abnormal rheologic conditions can be measured as increased blood viscosity and may be caused by corpuscular as well as by plasmatic factors.

CNS cysticercosis--a problem of differential diagnosis

Although a well-known disease worldwide, cerebral cysticercosis in European countries is a rare event. Due to increased travel to East-Asian and Latin American countries it is possible that the occurrence of brain cysticercosis will become more frequent. These facts should remind us of the possibility of cysticercosis of the nervous system. A case of cerebral and spinal cord cysticercosis is presented, causing symptoms of progressive dementia with ventricular occlusion and hydrocephalus. Differential diagnosis causes a major problem. It is shown that myelography may demonstrate characteristic features of the disease.

[Post-traumatic epilepsy. Clinical, neurophysiological and computer-tomographical aspects]

In 55 patients with posttraumatic epilepsy there was evidence of pathologic computertomographic findings in 76.4% and of pathologic EEG findings in 83.6% of the patients. On the contrary focal neurological signs have been detected in only 13 patients (23.6%). In 8 of these patients neurological symptomatology correlated well with pathologic findings.