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Background: Ventilator-associated pneumonia (VAP) is an important intensive care unit (ICU) infection in mechanically ventilated patients. VAP occurs approximately in 9-27% of all intubated patients. Due to the increasing incidence of multidrug-resistant organisms in ICUs, early and correct diagnosis of VAP is an urgent challenge for an optimal antibiotic treatment. Aim of the Study: The aim of the study was to assess the incidence of VAP caused by multidrug-resistant organisms in the multidisciplinary intensive care unit (MICU) of our tertiary care 1,400-bedded hospital. Materials and Methods: This prospective study was done in the period from December 2005 to August 2006, enrolling patients undergoing mechanical ventilation (MV) for >48 h. Endotracheal aspirates (ETA) were collected from patients with suspected VAP, and quantitative cultures were performed on all samples. VAP was diagnosed by the growth of pathogenic organism _10 ⁵ cfu/ml. Results: Incidence of VAP was found to be 45.4% among the mechanically ventilated patients, out of which 47.7% had early-onset (<5 days MV) VAP and 52.3% had late-onset (>5 days MV) VAP. Multiresistant bacteria, mainly Acinetobacter spp. (47.9%) and Pseudomonas aeruginosa (27%), were the most commonly isolated pathogens in both types of VAP. Most of the isolates of Escherichia coli (80%) and Klebsiella pneumoniae (100%) produced extended-spectrum beta lactamases (ESBLs). As many as 30.43% isolates of Acinetobacter spp. showed production of AmpC beta lactamases among all types of isolates. Metallo-beta lactamases (MBLs) were produced by 50% of Pseudomonas aeruginosa and 21.74% of Acinetobacter spp. Conclusion : High incidence (45.4%) of VAP and the potential multidrug-resistant organisms are the real threat in our MICU. This study highlighted high incidence of VAP in our setup, emphasizing injudicious use of antimicrobial therapy. Combined approaches of rotational antibiotic therapy and education programs might be beneficial to fight against these MDR pathogens and will also help to decrease the incidence of VAP.

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Central venous catheter (CVC) placement in the intensive care unit (ICU) is a common practice and is being increasingly used also in general wards. Its use is associated with both mechanical and infectious complications. Objective : To determine the infectious and mechanical complication rate of central venous catheterization in an ICU. Design : A retrospective study about complications of 1319 central venous catheter placements. Setting : An 11-bed adult medical, surgical, neuro-trauma ICU at salmaniya medical complex, Bahrain . Materials and Methods : This was a retrospective review of all central venous catheter inserted over 4 year's period from October 2002 to December 2006. Results : There were 12 mechanical complications and 128 infectious complications total of 1319 CVCs placed. Conclusions : The CVC can be performed safely in an ICU if done by a competent physician with all aseptic precautions

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Gastropleural fistula is a rare condition. We report a case where fistula developed iatrogenically during repeated intercostal drainage tube insertions for empyema.

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A 21-year-old primigravida, at 32 weeks of gestation, presented with acute onset of respiratory failure and circulatory shock. Chest imaging showed findings suggestive of ruptured hydatid cyst, which was confirmed by histology post-thoracotomy. Tissue cultures from the removed cyst grew Mycobacterium tuberculosis also. She was successfully managed in the intensive care unit and was then discharged home on antituberculosis medications in addition to albendazole after prolonged hospitalization and a need for chest tube for bronchopleural fistula. Acute respiratory failure and anaphylactic shock secondary to ruptured pulmonary hydatid cyst and superimposed pulmonary tuberculosis in a pregnant lady should be considered in patients living in endemic areas.

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Background: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, is the largest HIV-care center in South East Asia. As many as 29,300 HIV patients visited this center at least once in the year 2005 for care and support. Objectives: Clinical manifestations and the modes of presentation of tuberculosis were assessed among 12,750 adult and adolescent patients with human immunodeficiency virus (HIV) attending the hospital for the first time. Materials and Methods: Database of Hospital Information System, specially evolved for managing patients afflicted with tuberculosis and HIV, was utilized. The particulars confined to patients with tuberculosis and HIV co-infection who visited the hospital for the first time from January to December 2005 were considered for the analysis. Proportion test and Chi-square test with Yates correction were done. Results: As many as 12,750 adult and adolescent HIV-confirmed patients were screened for the possible presence of tuberculosis. Out of them, 4,383 (34.4%) patients had tuberculosis. Among them, 2,448 (55.9%) had pulmonary tuberculosis, and the remaining 1,935 (44.1%) had either disseminated or extra-pulmonary tuberculosis (P<0.001). Positive sputum-smear microscopy for acid fast bacilli was evident in 1,363 (31.1%) patients; however, it was significantly lower compared to positive smear rate of 44% in HIV patients (P< 0.001). Conclusion: Tuberculosis was found to be the predominant co-infection among the symptomatic patients infected with HIV attending the largest care center for the first time in India. Advanced tuberculosis, disseminated tuberculosis and sputum smear negative pulmonary tuberculosis were the presenting clinical manifestations in 44% of the patients, as they had moderate to advanced immunosuppression. Early detection of tuberculosis co-infection is absolutely necessary.

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Background : Problems in the diagnosis of tuberculosis using smear and culture techniques have necessitated the exploration of the utility of serodiagnosis to support clinical suspicion of tuberculosis. Anti-A60 antigen IgG enzyme-linked immunosorbent assay (ELISA) was evaluated as a tool for the diagnosis of active pulmonary tuberculosis. Materials and Methods : ELISA was used for the detection of immunoglobulin G (IgG) against A60 antigen in parallel with other familiar diagnostic methods in 70 patients with pulmonary tuberculosis (Group_I) along with 70 controls showing evidence of latent tuberculosis infection (Group II). Results: ELISA results were positive in 63 (90%) patients in Group_I compared to three (4%) controls in Group_II. Group_I patients had significantly higher titers of IgG (mean = 750.79 ± 115.87 U/ml against the A60 antigen as compared to Group II controls (mean = 206.67 ± 20.81 U/ml ( P < 0.0001). The overall sensitivity and specificity obtained using ELISA were 90 and 95.7% respectively in active pulmonary tuberculosis. Ziehl-Nielsen (Z-N) stains for acid-fast bacilli were positive in 60 (85.7%) patients. In 48 (68.6%) patients, M. tuberculosis grew on both Lowenstein-Jensen (L-J) medium and BACTEC MGIT 960 liquid medium with mean detection times of 45 and 8 days respectively. Tuberculin skin test was positive in 38 (54.3%) patients. Chest X-ray results were consistent with the diagnosis of pulmonary tuberculosis in 53 (75.7%) patients. Conclusion : Anti-A60 IgG ELISA results were significantly positive and associated with elevated antibody titers in pulmonary tuberculosis as compared to latent mycobacterium infection. The high diagnostic performance of the test makes it a useful, simple and rapid supporting tool to validate clinical suspicion of active pulmonary disease.

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¹⁸ F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a useful technique to characterize the solitary pulmonary nodule, diagnose primary lung cancer, carry out mediastinal and extrathoracic staging, plan radiotherapy, therapeutic response assessment and detect recurrence. PET may help to determine the ideal site for tissue diagnosis as well as predict prognosis. Combined PET and computed tomography (PET / CT) has the best of both worlds of metabolic and anatomic imaging and may provide optimal disease assessment.

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