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The goal of this study was to compare outcomes and costs of two management strategies for non-ventilator-associated nosocomial pneumonia (NP) in a medical ward. In this single-centre study, NP patients (n = 68) were randomized to receive non-invasive management (NIM) with immediate empirical antibiotic treatment (n = 34), or invasive management (IM) based on protected brush sampling of specimens (n = 34). The economic analysis adopted the hospital's perspective and took into account only direct costs. Baseline characteristics did not differ significantly between the two patient groups. The most frequently isolated organisms were Staphylococcus (25.4%), Streptococcus (23.7%) and Pseudomonas (18.6%) species. The 28-day clinical cure rate did not differ notably between the two groups (NIM, 79.4%; IM, 73.5%). Mortality at 28 days tended to be lower in the NIM group (10.0% vs. 21.8%). Mean antibiotic costs were lower in the IM group (euro194 +/- 355 vs. euro300 +/- 335, p <0.001) but overall management costs were similar (respectively, euro367 +/- 355 and euro346 +/- 363 in the IM and NIM groups, p = 0.08). With respect to both outcome and cost, this study does not support routine management of NP in medical wards using invasive procedures.

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We measured the serum concentrations of IgG subclasses in healthy subjects (n = 26) and in patients with community-acquired pneumonia (CAP) on admission (n = 38), at recovery (n = 21), and 9 months after admission (n = 19). Then, in 8 of the control subjects and 15 of the patients, we measured IgG subclasses and mean serum antibody concentrations of pneumococcal capsular polysaccharides before and 3 wk after immunization with a pneumococcal vaccine. Compared to the control subjects, the serum concentration of the IgG2 subclass was lower at admission in patients with CAP of bacterial or unknown cause (p less than 0.005). Concentrations of IgG subclasses in patients did not differ between admission and recovery, or between admission and 9 months later. After vaccination, in both control subjects and patients, there was an increase in the concentrations of IgG2 subclasses (p = 0.01) and antipneumococcal antibodies (p less than 10(-4)). We show that serum IgG2 concentration in patients with CAP of bacterial or unknown cause is lower than in healthy subjects and remains lower for several months. After immunization with a pneumococcal vaccine, the increase in serum concentrations of IgG subclasses and antipneumococcal antibodies in patients does not differ from those in control subjects.

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(fig 1). Pulmonary scintigraphy showed a substantial decrease in perfusion of the right lung. Echocardiography showed nothing abnormal.A conventional angiogram via the right femoral vein disclosed an infrahepatic interruption of the inferior vena cava with an azygos vein continuation. The supradiaphragmatic examination was non-contributory owing to incom-

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