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The benefits of antibiotic treatment and a nasopharyngeal culture in children with longstanding cough were analysed in a prospective randomized open study. Clinically suspected pertussis was excluded. Of 40 children given erythromycin for 7 days, 35 (88%) recovered in one week, compared with 17/47 (36%) untreated (p < 0.0001). Erythromycin eliminated Moraxella catarrhalis from the nasopharynx in 21/31 children (68%), compared with spontaneous disappearance in 7/35 (20%) untreated controls (p < 0.001). Purulent bronchitis or otitis media occurred in 2 children (5%) in the treatment group and in 21 (45%) in the control group (p < 0.01). To evaluate the clinical role of isolated pathogens, the 47 untreated subjects were studied. Seven of 35 children harbouring M. catarrhalis recovered, compared with 8/12 in whom this bacterium was absent (p < 0.01). No correlation was found between the isolation of Haemophilus influenzae or Streptococcus pneumoniae and the clinical outcome. Children with persistent cough > 10 days may benefit from erythromycin treatment. M. catarrhalis in the nasopharynx indicates prolonged symptoms and increased risk of bacterial complications.

Introduction: According to national organisations, obstetric services should be able to initiate a caesarean delivery within 30 minutes of the decision to operate. This is uniquely challenging in a small, rural hospital. In 2001, the authors' hospital was unable to meet this guideline reliably. This project demonstrates how we improved our emergency caesarean delivery response time. Methods: The caesarean delivery process was examined, project co-chairs were selected and key personnel were identified. Four working groups (doctors, nurses, anaesthesia, operating room personnel) were formed to analyse and improve component parts of the process. Over time, multiple small changes were made, initially by each working group and then by the entire caesarean delivery team. Decision-to-incision time was the main outcome measure. The authors also measured standard birth statistics and tracked the percentage of caesarean deliveries that were classified as an emergency. Results: Forty emergency caesarean deliveries occurred during the study. The mean decision-to-incision time dropped from 31 to 20 minutes and the treatment to goal ratio increased from 0.5 to 1.0. The percentage of caesarean deliveries that were classified as emergencies dropped significantly. There has been no change in the overall caesarean delivery rate or other markers of obstetric quality. Conclusions: A small, rural community hospital with limited resources can consistently meet the 30 minute decision-to-incision guideline for emergency caesarean delivery.

High serum levels of hepatocyte growth factor (HGF) may reflect the regenerative effect and enhanced local and systemic production of this cytokine after organ injuries. The possibility of using serial serum HGF values in order to predict the results of therapy for pneumonia was investigated in this study. In a prospective multicenter study we investigated the serum levels of HGF and CRP before and within 48 h after treatment in 70 patients with pneumonia. Serum levels of HGF before treatment were significantly higher than the HGF levels of a normal population (p < 0.0001). Within 48 h serum HGF levels had decreased significantly in those patients who ultimately responded to the initial antibiotic therapy (p < 0.0001). Serum HGF levels at 48 h were unchanged or increased in cases in whom the initial therapy was ineffective and had to be changed. CRP and HGF levels were significantly correlated. Using multivariate logistic regression analysis it was found that individual changes in acute serum HGF levels and serum HGF levels obtained within 48 h could predict the results of therapy at least as significantly (p < 0.003) as CRP (p = 0.05), although CRP levels were known and used by the physician to decide whether or not to change the initial therapy. We conclude that serial control of serum HGF levels can be used as an early indicator to predict the results of therapy during treatment of pneumonia.

We report a nosocomial outbreak of Legionella pneumophila serogroup (sg) 1 infection at the general hospital, Värnamo, Sweden. From December 1990 to February 1991, 28 patients and 3 staff fell ill with pneumonia and 3 died. L. pneumophila sg 1 together with several other Legionellae were isolated from the hot water supply to 17 of 20 hospital wards, probably being spread by aerosolization via shower nozzles. Raising the hospital's hot water temperature from 45 degrees C to 65 degrees C, together with heat disinfection of the shower equipment, arrested the outbreak within a week. Keeping the hot water temperature > or = 60 degrees C without chlorination eliminated L. pneumophila from > 75% of the wards. During a period of 2 years after the outbreak we have diagnosed only 1 case of nosocomial legionellosis at the hospital despite an active surveillance program.

Among the species that compose the expanding genusBartonella, thus far only B. henselae andB. quintana have reportedly been isolated from humans in Europe. To evaluate the prevalence of Bartonella infection in Sweden, we conducted a retrospective serological examination of 126 human serum samples. These samples were analyzed for antibodies toB. henselae, B. quintana, and B. elizabethae. Serum samples from 100 blood donors, who spanned the ages of 20 to 60 and had no apparent clinical signs of illness, were also studied as a control group. An immunoglobulin G indirect fluorescence antibody assay revealed 4 and 8.3% Bartonellapositivity rates for the blood donor and patient group, respectively, when a cutoff titer of ≥64 was chosen. Among the blood donors, four were seropositive to B. elizabethae; one of these also had concordant positive titer to B. henselae. In the patient group, 14 serum samples were positive against Bartonellaspp. These serum specimens represented nine patients. In three of these seropositive patients, paired serum samples displayed a fourfold increase in antibody titer to at least one of the three antigens. These three patients are discussed. In this report we also present a case study of a 60-year-old Swedish male with fatal myocarditis. Postmortem serological analysis revealed a high titer against B. elizabethae. PCR and nucleotide sequencing of the myocardial tissue from this patient, and of liver tissue from one of the other three patients, showed sequences similar to B. quintana. The age, geographical origin, animal contacts, and serological response pattern to the different Bartonella antigens differed among the four patients. This study substantiates the presence ofBartonella spp. in Sweden, documents the seroreactivity to three Bartonella antigens in Swedish patients, and reports the first two cases of B. quintana-like infections in Sweden.

The genotypic distribution of Legionella pneumophila serogroup 1 was investigated in the water distribution system of a 450-bed Swedish hospital and the surrounding community. A single genotype identified by amplified fragment length polymorphism (AFLP) analysis, was found in all 34 hospital isolates and in 18 out of 20 community isolates over a 12-y surveillance period. All isolates were either monoclonal antibody subtypes Benidorm or Bellingham. In a geographical comparison, the hospital genotype was also identified in 2 out of 6 Swedish hospitals, both located within 100 km of the studied community. In all, 70 isolates originating from 7 Swedish communities clustered in 4 groups, each also containing 1 AFLP type as defined by the European Working Group on Legionella Infections (EWGLI). It was concluded that a single Legionella pneumophila serogroup 1 genotype may colonize a large water distribution system over a long period of time, and that certain clones seem to be widely spread in the environment. Results from molecular typing of isolates originating from a limited geographical area must, therefore, be interpreted cautiously in epidemiological investigations of Legionnaires' disease.

To evaluate current serological criteria for Legionella pneumophila serogroup 1 (Lp1), the antibody response was prospectively studied in all patients hospitalized for Legionnaires' disease in a Swedish county during 11 y (n = 62). A 4-fold or greater rise in antibody titre to > or = 128 (the minimum convalescent antibody level for diagnosis, as recommended by the Centers for Disease Control and Prevention), using the indirect immunofluorescence antibody test, was found in 21/52 (40%) of tested patients. By referring to the titre levels in healthy residents from the local population (World Health Organization criteria), 45/52 (87%) cases were confirmed serologically. In 21 patients followed longitudinally for 10 y, the median antibody titre fell from 256 (range 32-1024) to 16 (range 2-128) in 3 y. No booster reactions were observed in any patient. After 10 y, the geometric mean titre of this clinical cohort had reached the same level as observed in the background population 5 y earlier. Titre levels in subjects exposed to Legionella from a municipal water system indicate that only 1 out of 10 of all infections are identified clinically. Indirect immunofluorescent antibody testing with local reference sera is a sensitive method for laboratory confirmation of Lp1 in an unselected pneumonia population.