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H influenzae and other Haemophilus species may cause sinusitis, otitis, bronchitis, epiglottitis, pneumonitis, cellulitis, arthritis, meningitis, and endocarditis Nontypeable strains are responsible for most disease in adults Alcoholism, smoking, chronic lung disease, advanced age, and HIV infection are risk factors Haemophilus species colonize the upper respiratory tract in patients with chronic obstructive pulmonary disease and frequently cause purulent bronchitis -Lactamase-producing strains are less common in adults than in children For adults with sinusitis, otitis, or respiratory tract infection, oral amoxicillin, 750 mg twice daily for 10 14 days, is adequate For -lactamase-producing strains, use of the oral fixed drug combination of amoxicillin, 875 mg, with clavulanate, 125 mg, is indicated For the penicillin-allergic patient, oral cefuroxime axetil, 250 mg twice daily, or trimethoprim-sulfamethoxazole, 800/160 mg orally twice daily, for 10 days is effective Azithromycin and clarithromycin are less effective In the more seriously ill patient (eg, the toxic patient with multilobar pneumonia) ceftriaxone, 1 g/d intravenously is recommended pending determination of whether the infecting strain is a -lactamase producer Trimethoprim-sulfamethoxazole administered intravenously based on a dose of 10 mg/kg/d of trimethoprim, can be used for the penicillin-allergic patient A 10- to 14-day course of therapy is adequate for most cases Epiglottitis is characterized by an abrupt onset of high fever, drooling, and inability to handle secretions An important clue to the diagnosis is complaint of a severe sore throat despite an unimpressive examination of the pharynx Stridor
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LEGIONNAIRE S DISEASE
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Patients are often immunocompromised, smokers, or have chronic lung disease Scant sputum production, pleuritic chest pain, toxic appearance Chest radiograph shows focal patchy infiltrates or consolidation Gram stain of sputum shows polymorphonuclear leukocytes and no organisms
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Legionella infection ranks among the three or four most common causes of community-acquired pneumonia and is
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considered whenever the etiology of a pneumonia is in question Legionnaire s disease is more common in immunocompromised persons, in smokers, and in those with chronic lung disease Outbreaks have been associated with contaminated water sources, such as shower heads and faucets in patient rooms and air conditioning cooling towers
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eases likely to be fatal in 5 years, such as solid tumors, cirrhosis, and aplastic anemia, die in 15 20% of cases; and individuals with no underlying diseases have a mortality rate of 5% or less
Clinical Findings
A Symptoms and Signs
Most patients have fevers and chills, often with abrupt onset However, 15% of patients are hypothermic (temperature 364 C) at presentation, and 5% never develop a temperature above 375 C Hyperventilation with respiratory alkalosis and changes in mental status are important early manifestations Hypotension and shock, which occur in 20 50% of patients, are unfavorable prognostic signs
Clinical Findings
A Symptoms and Signs
Legionnaire s disease is one of the atypical pneumonias, so called because a Gram-stained smear of sputum does not show organisms However, many features of Legionnaire s disease are more like typical pneumonia, with high fevers, a toxic patient, pleurisy, and grossly purulent sputum Classically, this pneumonia is caused by Legionella pneumophila, though other species can cause identical disease
B Laboratory Findings
Neutropenia or neutrophilia, often with increased numbers of immature forms of polymorphonuclear leukocytes, is the most common laboratory abnormality in septic patients Thrombocytopenia occurs in 50% of patients, laboratory evidence of coagulation abnormalities in 10%, and overt disseminated intravascular coagulation in 2 3% Both clinical manifestations and the laboratory abnormalities are nonspecific and insensitive, which accounts for the relatively low rate of blood culture positivity (approximately 20 40%) If possible, three blood cultures from separate sites should be obtained in rapid succession before starting antimicrobial therapy The chance of recovering the organism in at least one of the three blood cultures is greater than 95% The falsenegative rate for a single culture of 5 10 mL of blood is 30% This may be reduced to 5 10% (albeit with a slight falsepositive rate due to isolation of contaminants) if a single volume of 30 mL is inoculated into several blood culture bottles Because blood cultures may be falsely negative, when a patient with presumed septic shock, negative blood cultures, and inadequate explanation for the clinical course responds to antimicrobials, therapy should be continued for 10 14 days
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