- Email: [email protected]
Tuberculosis 1:00 pm-2:30 pm
Tuesday, October 28, 1997 Critical Care Outcomes, continued 3. Increased mortality in the PAC group was att ributed to severity of illness, although additional risk from PAC is not excluded. Clinical Implications: PAC may be of use in high risk patients, but safety, accuracy and relevance of data, and improvement in outcome remain to be established.
APACHE II score was 20.6 (SD9.9). ICU mortality was 30.2%. Hospital mortality was 44.6%.
Overall accuracy* Sensitivity* Specificity"
PR EOPERATI VE PREDICT ORS OF RESPIRAT ORY FAILURE FOLLOWING MAJOR NONCARDIAC SURGERY Ahsan M Arozullah, MD; J Daley, MD; W Henderson, PhD ; SF Khuri, MD-BrocktonlWest Roxbury VAMC, West Roxbury, MA, Hines VAMC, Hines, IL and the National VA Surgical Risk Study Purpose: To determine preoperative predictors of postoperative respiratory failure. Metho ds: We studied 87,070 subjects enrolled in the National VA Surgical Risk Study. Subject information was collected prospectively by surgical risk study nurses at 44 VA medical centers (10/1/91-12131/93). Respiratory failure (RF) was defined as failure to wean 48 hours after surgery or intubation and mechanical ventilation subsequent to extubation. Specific preoperative variables were selected as potential predictors based on literature review. Logistic regression was used to create a base model including all potential predictors. Those variables that were not significant predictors (based on the Wald chi-square statistic) were sequentially deleted from the base model until any further deletions resulted in a statistically significant (p< 0.05)-2 log likelihood chi-square statistic. Resul ts: RF occurred in 4.5% (n= 3793) of subjects with a 30-day mortality rate of 33%. Preoper ative predictors of RF (p< O.OO1) in the final model included ASA (classzeS), worse functional status, emergency operation, smoking within two weeks of surgery, history of chronic obstructive pulmonary disease (COPD), current pneumonia, general anesthesia, worse dyspnea, coma for > 24 hours (COMA), age (> 50 years), > 10% loss of body weight in last 6 months (W f LOSS), > 4 units of blood transfused preoperatively (TRANSFUS), and increased blood urea nitrogen (BUN, >30 mg/dl). The final model had a c-statistic of 0.861. Conclusions: Preoperative predictors of RF relate to general wellbeing (ASA class, functional status, emergency operation), respiratory (smoking, COPD, current pneumonia, general anesthesia, dyspnea), neurological (COMA), immune (age>50 years, WfLOSS), and hemodynamic (TRANSFUS, increased BUN) status. Clinical Implication s: Using our model, it may be possible to preoperatively predict the risk of postoperative RF. Studies to evaluate interventions designed to prevent RF in high risk subjects should be pur sued .
PREDICT ING T HE OUTCOME OF MEDICAL I NTE NSIVE CARE UNIT (MICU) PATI E NTS USING TWO SYSTEMSAPACHE II AND ODIN Tan Keng Leong, P Eng, AAL Hsu, IT Ong-Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore Pu rpose: To validate the APACHE II (Knaus, 1985) and the ODIN (Fagon, 1993) systems in risk prediction for mortality. Methods: All consecutive admissions to the eight-bedded MICU of the Singapore General Hospital from 1 January 1996 to 28 February 1997 were studied prospectively. Data regarding the relevant predictive variables dUring the initial 24 hours of admission to the MICU, APACHE II, ODIN scores, ICU and hospital outcomes were entered into a computer database. The predicted probabilities of hospital mortality and ICU mortality based on the respective APACHE II and ODIN predictive equations were calculated and compared to the observed hospital and ICU outcomes. Results: Data was complete for calculation of APACHE II and ODIN scores for 517 (92.0%) out of 562 admissions. Outcome analysis was performed on 516 (91.8%) admissions as one was still hospitalized during analysis. Mean age of all admissions was 55.7 (SD18.6) years. The mean
285
Positive predictive value* Negative predictive value* Mortality ratio
APACHE II
ODIN
73.1 (69.2-76.9) 52.8 (47.0-58.6) 89.2 (85.6-92.8) 79.6 (73.1-86.1) 70.3 (65.6-75.0) 1.5
75.6 (71.9-79.3) 34.6 (29.7-39.6) 92.9 (90.2-95.5) 67.1 (56.6-77.6) 77.1 (73.2-81.1) 1.9
*Percentage (95% confidence interval) Concl usions: The observed mortality was not comparable to that predicted by the APACHE II and ODI N. Clinical Implicati on s: Before adopting the APACHE II and ODIN systems in our institution, the uniformity of fit needs to be improved by new equations derived from multiple logistic regression analysis of our own database. Supported by a research grant from the National Medical Research Council, Singapore.
Tuberculosis 1:00 pm-2:30 pm E PIDEMIOLOGY OF DR UG-R ESISTANT TUBERCU LOSIS I N AN I NNER CITY HOSPITAL-A THREE YEAR REVIEW (19941996 ) S Kaul MD and J Fleischman MD-Mt Sinai Services at Queens Hospital Center, Jamaica, New York Purpose : To evaluate the overall incidence of tuberculosis (TB) & the epidemiology of drug-resistant TB (DR-TB) in an inner city hospital. Methods: Retrospective chart review of patients with culture positive TB from 1994-1996. Results: There were a total of 112 patients with culture positive mycobacterial TB. 99 charts were available for review. 51/99 (51%) were foreign born. 24/112 patients (21%) had evidence of DR-TB. 13/24 (54%) showed Single drug resistance while 11/24 (46%) were resistant to :2:2 anti TB drugs. There was a 47% decrease ( t ) in new TB cases during this time period & an even greater t in the new cases of DR-TB. The majority of the patients with DR-TB were U.S. bom-17/24 (71%). 8/24 (one third ) had previous history of inadequately treated TB. 12124 (50%) were HIV positive. Conclusio ns: o The incidence of TB & DR-TB declined significantly from 1994 to 1996. o Foreign nationality did not appear to be a major contributing factor to DR-TB. This is of particular significance since the borough of Queens is the most ethnically diverse borough of New York City. o Other factors such as prior inadequate treatment & underlying immune function may be more important risk factors for DR-TB in this ethnically diverse patient population.
ADVERSE REACT IONS (AR) TO DR UGS USED IN THE TREA TMENT OF MULTIDRUG-RE SISTANT PULM ONARY TUBER CULOSIS (MDR PTB) Maria Korzeniewska-Kosela, MD; D Michalowska-Mitczuk, MD; S Wedzicha, MD; J Kus, MD-Institute of Tuberculosis and Lung Diseases, Warsaw, Poland Pu rp ose: To determine the frequency and to describe AR to the second-line anti-TB drugs. Metho ds: AR that occurred in the patients with MDR PTB treated in our hospital from 01.01.1993- to 05.15.1997 were prospectively analysed. Abstracts of Original Investigations, CHEST 1997-Slide Presentations
Tuesday, October 28, 1997 Tuberculosis, continued Only the AR that resulted in the perm anent withd rawal of the relevant drug are presented be low. Results: Capreomycin (CAP)-AR were observed in 12 of 23 (52.2%) subjects treated with CAP. 10 patient s had been treated earlier with SM or with CAP. AR-skin changes (2), dizziness (8), increased serum creatinine concen tration (ISCC) (2). Amikacin-AR occurred in 23 of 62 (37.1%) subjec ts treated with this dru g. AR- ototoxicity (8), dizziness (10), ISCC or prot einuria (5). 16 patients had been treated previously with SM or with CAP. Cycloserine (CS)-AR were observed in 15 of 73 (20.5% ) subjects treated with CS. AR- convulsions (2)- includin g a man after a head injury), night mares, anxiety, suicidal obsessions, mental depression (12), swelling (l pati ent with previous renal dysfunction ). C!o!azimine-AR occurred in 2 of 70 (2.9%) patients treated with this drug. AR-skin changes (1), abdom inal pain (1). Ojloxacin-AR occurred in 5 of 85 (5.9%) patient s. AR-increase in Q-T interval in EC G (1), hepatic enzyme elevation (HEE) (2), ISCC (1), anxiety and sleeplessness (1). Rifabutine-AR occurred in 7 of 33 (21.2%) subjects treated with this drug . AR-leukop enia (3), diarrh ea (1), HEE (2), anemia (1). Ethionamide-AR were obse rved in 29 of 73 (39.7%) persons. Severe gastroint estinal upset (18), HEE (4), intolerable met allic taste and anorexia (1), severe arthralgia (4), skin changes (1), leukop enia (1). Conclusions: Severe AR are Significant causes of the treatment alterations in patients with MD R PTB. Clinical Implications: MDR PTB patient s should be checked regularly to early det ect AR.
OUTCOME OF TREATMENT OF 245 PATIENTS WITH MULTIDRUG-RESISTANT PULMONARY TUBERCULOSIS Paul A Willcox, MD ;' S Rachm an, MD ;2 PG Morri s, MD ;2 P Groenewald, MD ;3 VAF de Azevedo, MD ;4 AT Musewe, MD ;5 G Maartens, MD;' KP Shean, SRN 2- De part ment of Medicine, Groot e Schuur Hospital and University of Cape Town,' Brooklyn Chest Hospital! MRC Natio nal Tub erculous Research Program," Cape Town Mun icipality" Cape Metropolitan Cotmcil," Cap e Town, South Africa Purpose: With the world-wide upsurge in tub erculosis, there is concern about the developm ent of mult idru g-resistant tub erculosis (MD R-TB). There is however, very little information from Africa on the out come of treatment of patients with this disease. In January 1990 we established a dedicated MDR- TB clinic. We report on the first three years of that clinic. Methods: Patients with MDR- T B, ie resistance to at least isoniazid and rifampi cin, were treated where possible with at least thr ee dru gs to which M tub ercul osis was suscep tible for 18 months . Progress was monitored by sputum cultures performed month ly initially until conversion to negative, which was defined as at least two consecutive negative monthly cultures. Results: Between 1st January 1990 and 31st Decemb er 1992, 245 consecutive patient s were comm enced on treatment. Four tested positive for the hum an immunodeficiency virus. Of 208 patient s who completed at least 6 months of therap y, 170 (82%) und erwent sputu m cultu re conversion. Mean time to conversion was 2.3 month s. Following a course of treatment , 129 (53%) patients had no evide nce of disease. Seven ty two (29%) were followed up for at least two years after completing therap y. Fifty one (21%) patient s int errupted treatment and 29 (17%) who und erwen t sputum conversion subsequently relapsed. Sixty four patients (26%) died . Conclusions: Sputum cultu re conversion rates were high, but overall success in eradicating disease was moderate as the cure rat e was only 53%. Clinical Implications: Provided patient s with MDR-TB comply with an individualised regimen of treatment , the outlook is good. Grea ter efforts are needed to prevent inte rruption of treatm ent. Supported by the Medical Research Council.
SPECTRUM AND TREATMENT OF PULMONARY INFECTION WITH NONTUBERCULOUS MYCOBACTERIA IN IMMUNOCOMPETENT PATIENTS MM Tor MD ; K Hewan-Lowe MD ; GW Staton MD-SSK Sureyyapasa Ce nte r for Ches t Diseases and Thoracic Surgery, Istanbul, Turk ey; Emory Univ, School of Medicine , Pathology and Pulmonary and Critical Care Medicin e, Atlanta, GA, USA
Purpose: Pulmonary infection caused by non-tub erculous mycobacteria (NT M) has bee n reported in immunocomp etent patients . Methods: 13 patient s, 9 women/4 men (mean age 68 years) with a diagnosis of NTM pulmonary infection (M.avium-intracellulare in 12, M.chelonae in one ) were reviewed . Results: Symptom s were cough (70%), chest pain (54%), and fever (46%). Du ration of symptoms was 3 months to 12 years. Roentgenographic appea rances were focal infiltrates in 11/13, diffuse in 2113. Bronchiectasis was seen in 9/ 13. Cavitation was seen in only 1 pati ent. One smoker had infected bullous disease and one had mild scoliosis and pectus excavatum. Diagnosis of NT M infect ion was made by spu tum in 5 patients, sputum and BAL in 5 pat ients, and BAL in 3 patient s. Six patient s had lung biopsies and 4/6 had sarcoid-like non-caseous gran ulomatous inflammati on (NCG!). One patien t received no therap y and died of massive hemoptysis. Of the remaining 12 patien ts, 2 were treated with chest physiotherapy (CPT) and bron chodilato rs and have done well. Ten patient s have been treated with a combination of antimycobacte rial therapy (AMT) based on in vitro sen sitivities, bro nchodilators, and C PT. Six patient s are in remission, and 3 patient s are improved , and one patient died of respiratory failure. Conclusions and Clinical Implications: NT M infections should be considere d in immunocomp etent hosts, especially in elde rly female patient s with productive cough and focal infiltrat es due to bronchiectasis. NCGI can be seen on lung biopsy and must not be misdiagnosed as sarcoidosis. Some patient s can be treated with tracheobronchial toilet alone, but most also require AMT with good results. Supported by the Carlyle Fra ser Heart Ce nter.
ATYPICAL MYCOBACTERIAL CONTAMINATION OF FLEXIBLE FIBEROPTIC BRONCHOSCOPIES DUE TO AN AUTOMATED DISINFECTION MACHINE Ryland P Byrd, Jr, MD ; Jesus Ramirez, MD ; Thom as M Chandler , MD ; Thomas M Roy, MD-James H Quillen College of Medicine, Johnson City, TN , USA Purpose: Over a 14-month period, 193 patient s und erwent fiberoptic bron choscopy. In 13 cases, acid fast bacilli (AF B) were not ed on bronchial-washings in patients who were not suspected to have a mycobacterial infection. An int ensive microbacterial investigation was und ertaken to identi fy the source of the AFB organisms. Methods: AFB smears and cultures were perfo rmed on the suction and biopsy port s of bron choscopes as well as ste rile saline flushes through the channels of the bronchoscopes. Specimens were also taken from the xylocaine nebuli zer, brush es used in cleaning the bron choscopes, the water inlet hose into the automated disinfectant machine , and the disinfectant machine itself. In addition , a retrospective chart review was perfo rmed to see if any of these patient had a disease process consistent with a mycobact erial infection, whether treatment was directed toward the AFB isolate , and wheth er there was a cross contamination from patient to patient or tran smission of infection to the patien t from a contaminated bronchoscope . Results: One saline flush throu gh the suction port of one of thr ee bron choscopies was AFB smear positive but culture negative. Wat er from the inlet hose to and the rinse water holding tank in the automated disinfection machine were AFB smear positive and grew Mycobacteriu m gordonae on cultures. All other smears and cultu res were neg ative . None of the patient s met the crite ria for disease caused by mycobacterium other than tuberculosis. No patient received treatment directed at the AFB ide ntified on smear alone. No cross contamination from patient to patien t or transmission of infection from the contaminated bro nchoscope occurred. Conclusions: Colonization of the water inlet hose and the rinse water holding tank of an automa ted disinfectan t machin e by Mycobacterium gordonae resulted in 13 cases of AFB smear positive and culture negative bronchial washings. Despite constant recycling of disinfectant the automated disiufectant equipment and outlets may pose a source of repeat contaminat ion. CHEST / 112/ 3 / SEPTEMBER, 1997 SUPPLEMENT
295
APACHE II score was 20.6 (SD9.9). ICU mortality was 30.2%. Hospital mortality was 44.6%.
Overall accuracy* Sensitivity* Specificity"
PR EOPERATI VE PREDICT ORS OF RESPIRAT ORY FAILURE FOLLOWING MAJOR NONCARDIAC SURGERY Ahsan M Arozullah, MD; J Daley, MD; W Henderson, PhD ; SF Khuri, MD-BrocktonlWest Roxbury VAMC, West Roxbury, MA, Hines VAMC, Hines, IL and the National VA Surgical Risk Study Purpose: To determine preoperative predictors of postoperative respiratory failure. Metho ds: We studied 87,070 subjects enrolled in the National VA Surgical Risk Study. Subject information was collected prospectively by surgical risk study nurses at 44 VA medical centers (10/1/91-12131/93). Respiratory failure (RF) was defined as failure to wean 48 hours after surgery or intubation and mechanical ventilation subsequent to extubation. Specific preoperative variables were selected as potential predictors based on literature review. Logistic regression was used to create a base model including all potential predictors. Those variables that were not significant predictors (based on the Wald chi-square statistic) were sequentially deleted from the base model until any further deletions resulted in a statistically significant (p< 0.05)-2 log likelihood chi-square statistic. Resul ts: RF occurred in 4.5% (n= 3793) of subjects with a 30-day mortality rate of 33%. Preoper ative predictors of RF (p< O.OO1) in the final model included ASA (classzeS), worse functional status, emergency operation, smoking within two weeks of surgery, history of chronic obstructive pulmonary disease (COPD), current pneumonia, general anesthesia, worse dyspnea, coma for > 24 hours (COMA), age (> 50 years), > 10% loss of body weight in last 6 months (W f LOSS), > 4 units of blood transfused preoperatively (TRANSFUS), and increased blood urea nitrogen (BUN, >30 mg/dl). The final model had a c-statistic of 0.861. Conclusions: Preoperative predictors of RF relate to general wellbeing (ASA class, functional status, emergency operation), respiratory (smoking, COPD, current pneumonia, general anesthesia, dyspnea), neurological (COMA), immune (age>50 years, WfLOSS), and hemodynamic (TRANSFUS, increased BUN) status. Clinical Implication s: Using our model, it may be possible to preoperatively predict the risk of postoperative RF. Studies to evaluate interventions designed to prevent RF in high risk subjects should be pur sued .
PREDICT ING T HE OUTCOME OF MEDICAL I NTE NSIVE CARE UNIT (MICU) PATI E NTS USING TWO SYSTEMSAPACHE II AND ODIN Tan Keng Leong, P Eng, AAL Hsu, IT Ong-Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore Pu rpose: To validate the APACHE II (Knaus, 1985) and the ODIN (Fagon, 1993) systems in risk prediction for mortality. Methods: All consecutive admissions to the eight-bedded MICU of the Singapore General Hospital from 1 January 1996 to 28 February 1997 were studied prospectively. Data regarding the relevant predictive variables dUring the initial 24 hours of admission to the MICU, APACHE II, ODIN scores, ICU and hospital outcomes were entered into a computer database. The predicted probabilities of hospital mortality and ICU mortality based on the respective APACHE II and ODIN predictive equations were calculated and compared to the observed hospital and ICU outcomes. Results: Data was complete for calculation of APACHE II and ODIN scores for 517 (92.0%) out of 562 admissions. Outcome analysis was performed on 516 (91.8%) admissions as one was still hospitalized during analysis. Mean age of all admissions was 55.7 (SD18.6) years. The mean
285
Positive predictive value* Negative predictive value* Mortality ratio
APACHE II
ODIN
73.1 (69.2-76.9) 52.8 (47.0-58.6) 89.2 (85.6-92.8) 79.6 (73.1-86.1) 70.3 (65.6-75.0) 1.5
75.6 (71.9-79.3) 34.6 (29.7-39.6) 92.9 (90.2-95.5) 67.1 (56.6-77.6) 77.1 (73.2-81.1) 1.9
*Percentage (95% confidence interval) Concl usions: The observed mortality was not comparable to that predicted by the APACHE II and ODI N. Clinical Implicati on s: Before adopting the APACHE II and ODIN systems in our institution, the uniformity of fit needs to be improved by new equations derived from multiple logistic regression analysis of our own database. Supported by a research grant from the National Medical Research Council, Singapore.
Tuberculosis 1:00 pm-2:30 pm E PIDEMIOLOGY OF DR UG-R ESISTANT TUBERCU LOSIS I N AN I NNER CITY HOSPITAL-A THREE YEAR REVIEW (19941996 ) S Kaul MD and J Fleischman MD-Mt Sinai Services at Queens Hospital Center, Jamaica, New York Purpose : To evaluate the overall incidence of tuberculosis (TB) & the epidemiology of drug-resistant TB (DR-TB) in an inner city hospital. Methods: Retrospective chart review of patients with culture positive TB from 1994-1996. Results: There were a total of 112 patients with culture positive mycobacterial TB. 99 charts were available for review. 51/99 (51%) were foreign born. 24/112 patients (21%) had evidence of DR-TB. 13/24 (54%) showed Single drug resistance while 11/24 (46%) were resistant to :2:2 anti TB drugs. There was a 47% decrease ( t ) in new TB cases during this time period & an even greater t in the new cases of DR-TB. The majority of the patients with DR-TB were U.S. bom-17/24 (71%). 8/24 (one third ) had previous history of inadequately treated TB. 12124 (50%) were HIV positive. Conclusio ns: o The incidence of TB & DR-TB declined significantly from 1994 to 1996. o Foreign nationality did not appear to be a major contributing factor to DR-TB. This is of particular significance since the borough of Queens is the most ethnically diverse borough of New York City. o Other factors such as prior inadequate treatment & underlying immune function may be more important risk factors for DR-TB in this ethnically diverse patient population.
ADVERSE REACT IONS (AR) TO DR UGS USED IN THE TREA TMENT OF MULTIDRUG-RE SISTANT PULM ONARY TUBER CULOSIS (MDR PTB) Maria Korzeniewska-Kosela, MD; D Michalowska-Mitczuk, MD; S Wedzicha, MD; J Kus, MD-Institute of Tuberculosis and Lung Diseases, Warsaw, Poland Pu rp ose: To determine the frequency and to describe AR to the second-line anti-TB drugs. Metho ds: AR that occurred in the patients with MDR PTB treated in our hospital from 01.01.1993- to 05.15.1997 were prospectively analysed. Abstracts of Original Investigations, CHEST 1997-Slide Presentations
Tuesday, October 28, 1997 Tuberculosis, continued Only the AR that resulted in the perm anent withd rawal of the relevant drug are presented be low. Results: Capreomycin (CAP)-AR were observed in 12 of 23 (52.2%) subjects treated with CAP. 10 patient s had been treated earlier with SM or with CAP. AR-skin changes (2), dizziness (8), increased serum creatinine concen tration (ISCC) (2). Amikacin-AR occurred in 23 of 62 (37.1%) subjec ts treated with this dru g. AR- ototoxicity (8), dizziness (10), ISCC or prot einuria (5). 16 patients had been treated previously with SM or with CAP. Cycloserine (CS)-AR were observed in 15 of 73 (20.5% ) subjects treated with CS. AR- convulsions (2)- includin g a man after a head injury), night mares, anxiety, suicidal obsessions, mental depression (12), swelling (l pati ent with previous renal dysfunction ). C!o!azimine-AR occurred in 2 of 70 (2.9%) patients treated with this drug. AR-skin changes (1), abdom inal pain (1). Ojloxacin-AR occurred in 5 of 85 (5.9%) patient s. AR-increase in Q-T interval in EC G (1), hepatic enzyme elevation (HEE) (2), ISCC (1), anxiety and sleeplessness (1). Rifabutine-AR occurred in 7 of 33 (21.2%) subjects treated with this drug . AR-leukop enia (3), diarrh ea (1), HEE (2), anemia (1). Ethionamide-AR were obse rved in 29 of 73 (39.7%) persons. Severe gastroint estinal upset (18), HEE (4), intolerable met allic taste and anorexia (1), severe arthralgia (4), skin changes (1), leukop enia (1). Conclusions: Severe AR are Significant causes of the treatment alterations in patients with MD R PTB. Clinical Implications: MDR PTB patient s should be checked regularly to early det ect AR.
OUTCOME OF TREATMENT OF 245 PATIENTS WITH MULTIDRUG-RESISTANT PULMONARY TUBERCULOSIS Paul A Willcox, MD ;' S Rachm an, MD ;2 PG Morri s, MD ;2 P Groenewald, MD ;3 VAF de Azevedo, MD ;4 AT Musewe, MD ;5 G Maartens, MD;' KP Shean, SRN 2- De part ment of Medicine, Groot e Schuur Hospital and University of Cape Town,' Brooklyn Chest Hospital! MRC Natio nal Tub erculous Research Program," Cape Town Mun icipality" Cape Metropolitan Cotmcil," Cap e Town, South Africa Purpose: With the world-wide upsurge in tub erculosis, there is concern about the developm ent of mult idru g-resistant tub erculosis (MD R-TB). There is however, very little information from Africa on the out come of treatment of patients with this disease. In January 1990 we established a dedicated MDR- TB clinic. We report on the first three years of that clinic. Methods: Patients with MDR- T B, ie resistance to at least isoniazid and rifampi cin, were treated where possible with at least thr ee dru gs to which M tub ercul osis was suscep tible for 18 months . Progress was monitored by sputum cultures performed month ly initially until conversion to negative, which was defined as at least two consecutive negative monthly cultures. Results: Between 1st January 1990 and 31st Decemb er 1992, 245 consecutive patient s were comm enced on treatment. Four tested positive for the hum an immunodeficiency virus. Of 208 patient s who completed at least 6 months of therap y, 170 (82%) und erwent sputu m cultu re conversion. Mean time to conversion was 2.3 month s. Following a course of treatment , 129 (53%) patients had no evide nce of disease. Seven ty two (29%) were followed up for at least two years after completing therap y. Fifty one (21%) patient s int errupted treatment and 29 (17%) who und erwen t sputum conversion subsequently relapsed. Sixty four patients (26%) died . Conclusions: Sputum cultu re conversion rates were high, but overall success in eradicating disease was moderate as the cure rat e was only 53%. Clinical Implications: Provided patient s with MDR-TB comply with an individualised regimen of treatment , the outlook is good. Grea ter efforts are needed to prevent inte rruption of treatm ent. Supported by the Medical Research Council.
SPECTRUM AND TREATMENT OF PULMONARY INFECTION WITH NONTUBERCULOUS MYCOBACTERIA IN IMMUNOCOMPETENT PATIENTS MM Tor MD ; K Hewan-Lowe MD ; GW Staton MD-SSK Sureyyapasa Ce nte r for Ches t Diseases and Thoracic Surgery, Istanbul, Turk ey; Emory Univ, School of Medicine , Pathology and Pulmonary and Critical Care Medicin e, Atlanta, GA, USA
Purpose: Pulmonary infection caused by non-tub erculous mycobacteria (NT M) has bee n reported in immunocomp etent patients . Methods: 13 patient s, 9 women/4 men (mean age 68 years) with a diagnosis of NTM pulmonary infection (M.avium-intracellulare in 12, M.chelonae in one ) were reviewed . Results: Symptom s were cough (70%), chest pain (54%), and fever (46%). Du ration of symptoms was 3 months to 12 years. Roentgenographic appea rances were focal infiltrates in 11/13, diffuse in 2113. Bronchiectasis was seen in 9/ 13. Cavitation was seen in only 1 pati ent. One smoker had infected bullous disease and one had mild scoliosis and pectus excavatum. Diagnosis of NT M infect ion was made by spu tum in 5 patients, sputum and BAL in 5 pat ients, and BAL in 3 patient s. Six patient s had lung biopsies and 4/6 had sarcoid-like non-caseous gran ulomatous inflammati on (NCG!). One patien t received no therap y and died of massive hemoptysis. Of the remaining 12 patien ts, 2 were treated with chest physiotherapy (CPT) and bron chodilato rs and have done well. Ten patient s have been treated with a combination of antimycobacte rial therapy (AMT) based on in vitro sen sitivities, bro nchodilators, and C PT. Six patient s are in remission, and 3 patient s are improved , and one patient died of respiratory failure. Conclusions and Clinical Implications: NT M infections should be considere d in immunocomp etent hosts, especially in elde rly female patient s with productive cough and focal infiltrat es due to bronchiectasis. NCGI can be seen on lung biopsy and must not be misdiagnosed as sarcoidosis. Some patient s can be treated with tracheobronchial toilet alone, but most also require AMT with good results. Supported by the Carlyle Fra ser Heart Ce nter.
ATYPICAL MYCOBACTERIAL CONTAMINATION OF FLEXIBLE FIBEROPTIC BRONCHOSCOPIES DUE TO AN AUTOMATED DISINFECTION MACHINE Ryland P Byrd, Jr, MD ; Jesus Ramirez, MD ; Thom as M Chandler , MD ; Thomas M Roy, MD-James H Quillen College of Medicine, Johnson City, TN , USA Purpose: Over a 14-month period, 193 patient s und erwent fiberoptic bron choscopy. In 13 cases, acid fast bacilli (AF B) were not ed on bronchial-washings in patients who were not suspected to have a mycobacterial infection. An int ensive microbacterial investigation was und ertaken to identi fy the source of the AFB organisms. Methods: AFB smears and cultures were perfo rmed on the suction and biopsy port s of bron choscopes as well as ste rile saline flushes through the channels of the bronchoscopes. Specimens were also taken from the xylocaine nebuli zer, brush es used in cleaning the bron choscopes, the water inlet hose into the automated disinfectant machine , and the disinfectant machine itself. In addition , a retrospective chart review was perfo rmed to see if any of these patient had a disease process consistent with a mycobact erial infection, whether treatment was directed toward the AFB isolate , and wheth er there was a cross contamination from patient to patient or tran smission of infection to the patien t from a contaminated bronchoscope . Results: One saline flush throu gh the suction port of one of thr ee bron choscopies was AFB smear positive but culture negative. Wat er from the inlet hose to and the rinse water holding tank in the automated disinfection machine were AFB smear positive and grew Mycobacteriu m gordonae on cultures. All other smears and cultu res were neg ative . None of the patient s met the crite ria for disease caused by mycobacterium other than tuberculosis. No patient received treatment directed at the AFB ide ntified on smear alone. No cross contamination from patient to patien t or transmission of infection from the contaminated bro nchoscope occurred. Conclusions: Colonization of the water inlet hose and the rinse water holding tank of an automa ted disinfectan t machin e by Mycobacterium gordonae resulted in 13 cases of AFB smear positive and culture negative bronchial washings. Despite constant recycling of disinfectant the automated disiufectant equipment and outlets may pose a source of repeat contaminat ion. CHEST / 112/ 3 / SEPTEMBER, 1997 SUPPLEMENT
295