Current opinion in pulmonary medicine
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Pleural infection is a common, increasing clinical problem with a high morbidity and mortality. Medical management of pleural infection often fails, requiring invasive thoracic surgery to drain infected pleural collections, and for many years intrapleural agents have been assessed to reduce the need for surgical drainage and improve clinical outcomes. Randomized trials assessing intrapleural fibrinolytic agents have given conflicting results, and recent evidence provides important information on the role of intrapleural agents in the treatment of pleural infection, and the possible biology associated with infection progression in these patients. ⋯ Fibrinolytic therapy alone has not been proven to be of use in the treatment of pleural infection. The MIST2 study provides clear-cut evidence demonstrating improved chest radiographs, and highly suggestive secondary outcomes suggesting improved clinically important outcomes, using a combination of intrapleural tPA and DNase. This novel treatment combination may represent an important step in our understanding and treatment of pleural infection; however, larger clinical studies specifically addressing important clinical outcomes and further laboratory research describing the potential mechanisms of action are now required.
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The postpericardiotomy syndrome (PPS) is a relatively common complication following cardiac surgery, whose epidemiology is not well known because there are no standardized definitions. The aim of the present study is to review more recent updates on the diagnosis, therapy, prognosis, and especially prevention of the PPS. ⋯ Contemporary series of the PPS are scarce. About 20% of patients are affected by the syndrome after cardiac surgery with a significant increase in hospital stay, readmissions, and management costs. The overall short-term and middle-term prognosis is relatively good but constriction may develop in a long-term follow-up in a minority of patients. Therapeutic and preventive strategies, especially based on the use of colchicine, are worthy of further investigations to develop a more evidence-based approach to treatment and prevention.
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Necrotizing pneumonia is a rare complication of bacterial lung infection. Its cause is owing to either a virulence factor of the microorganism or a predisposing factor of the host. This disease may cause devastating complications such as diffuse pulmonary inflammation, septic shock, and respiratory failure, making treatment more difficult. In the recent decade, the cause of necrotizing pneumonia and the role of surgical treatment have raised considerable attention, leading to therapeutically specific suggestions. ⋯ The current knowledge of cause, clinical features, diagnosis, treatment, and prognosis of necrotizing pneumonia are summarized. Antibiotics remain the mainstay of treatment. Lung resection can be considered an alternative treatment option in patients who are unresponsive to antibiotic therapy and develop parenchymal complications. Outcome is affected by the degree of disease progression and comorbidities.
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Despite important geographical variations, Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species (ESKAPE) pathogens constitute more than 80% of ventilator-associated pneumonia (VAP) episodes. Their clinical importance relies on their virulence and ability in developing mechanisms to decrease susceptibility to antimicrobials, increasing inappropriate therapy and affecting negatively on ICU patients' outcome. This review updates information on VAP due to ESKAPE pathogens. ⋯ VAP due to ESKAPE pathogens represents a global challenge that can be prevented using stewardship programmes promoting diversity.
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Severe pneumonia is a common disease that intensive care physicians have to face. The review highlights recent findings about microbiology, diagnosis and treatment, including the management of critically ill patients with severe respiratory failure. ⋯ Despite advancements in antibiotic and life-supportive treatments, severe pneumonia remains a leading cause of intensive care unit (ICU) admission and death. Prompt and appropriate antimicrobial therapy is essential. The use of new nonconventional strategies for ARF management might be effective in more severe patients.