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Query: UMLS:C0032285 (pneumonia)
 54,520 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Ventilator-associated pneumonia occurs in the evolution of 8 to 70% of patients in the Intensive Care Unit. It is the main site of nosocomial infection for mechanically ventilated patients. Nosocomial pneumonia represents an important cause of morbidity and mortality, despite progresses in antibiotic prescription, use of intensive care and prevention. This review is based on the ATS guidelines, and reviews epidemiology, diagnosis and treatment of ventilator-acquired pneumonia, in non-immunocompromised adults.
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PMID:[Management of ventilator acquired pneumonia]. 1669 38

We sought to evaluate the safety and feasibility of inhaled aminoglycosides or colistin in cancer patients with ventilator-associated pneumonia (VAP) due to Gram-negative bacteria (GNB). A retrospective case-matched study was obtained after obtaining IRB approval in patients at the intensive care unit at our NCI-designated comprehensive cancer center between 1999 and 2005. Sixteen patients with GNB-VAP who received inhaled aminoglycosides or colistin were compared with 16 patients who had received these antibiotics intravenously alone. Eligible patients were required to have received at least six doses of inhaled therapy, or 3 or more days of intravenous therapy. Clinical Pulmonary Infection Scores were used to assess pneumonia severity. Standard ATS criteria were used to define VAP. Patients treated with inhaled antibiotics were less likely to have received corticosteroids (13% vs 50%; P < 0.02) and had a higher median baseline creatinine level (0.85 vs 0.6 mg/dL; P < 0.02) than patients treated intravenously. Pseudomonas aeruginosa (69%) was the most common cause of VAP. There were no serious adverse events associated with inhaled antibiotics. Patients who received these antibiotics intravenously developed renal dysfunction (31%); none of the patients treated with inhaled antibiotics developed nephrotoxicity (P < or = 0.04). Patients treated with inhaled antibiotics were more likely to have complete resolution of clinical (81% vs 31% in the intravenous antibiotic group; P < 0.01) and microbiologic infection (77% vs 8% in the intravenous antibiotic group: P < 0.0006). In a multivariate analysis adjusted for corticosteroid use, inhaled antibiotic therapy was predictive of complete clinical resolution (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.1, 37.6; P < 0.04) and eradication of causative organisms (OR 36.7; 95% CI, 3.3, 412.2; P < 0.003). In critically ill cancer patients with Gram-negative VAP, inhaled aminoglycosides were tolerated without serious toxicity and may lead to improved outcome.
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PMID:Inhaled aminoglycosides in cancer patients with ventilator-associated Gram-negative bacterial pneumonia: safety and feasibility in the era of escalating drug resistance. 1875 7

We retrospectively analyzed the severity of community-acquired pneumonia in 293 patients. Based on the Japanese Respiratory Society (JRS) risk stratification guidelines (A-DROP), patients were classified as follows: mild, 74 (25%); moderate, 140 (48%); severe, 53 (18%); and extremely severe, 26 (9%). The mortality of each category was classified as follows: mild, 0 (0%); moderate, 4 (3%); severe, 8 (15%); and extremely severe, 8 (31%). Based on the Pneumonia Severity Index (PSI) score used in the Infectious Disease Society of America/American Thoracic Society (IDSA/ATS) consensus guidelines, patients were classified as follows: I, 36 (12%); II, 44 (15%); III, 61 (21%); IV, 92 (31%); and V, 60 (20%). The mortality of each category was classified as follows: I-III, 0 (0%); IV, 5 (25%); or V, 15 (75%). Comparisons made between patients who died within 14 days and those who survived, showed that leukocytes and CRP values were higher among the fatality group. Moreover, Alb/BUN correlated with the PSI score (r = - 0.62). We propose Alb/BUN as a new index for prognostic factor of community-acquired pneumonia.
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PMID:[Evaluation of the severity of community-acquired pneumonia based on the JRS and IDSA/ATS guidelines]. 1919 97

Healthcare-associated pneumonia (HCAP) is a category of nosocomial pneumonia defined by the 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to include any patient who has been hospitalized in an acute care hospital for 2 or more days within the past 90 days; residents of a nursing home or long-term care facility; recipients of recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days; or patients who have attended a hospital or hemodialysis clinic. In creating this relatively new category the ATS/IDSA acknowledged that these patients are at increased risk for infection with antibiotic-resistant organisms and that initial inadequate antibiotic coverage leads to increased mortality. Risk factors for the development of pneumonia and the development of pneumonia caused by drug-resistant pathogens, primarily methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, are not the same among the subgroups of HCAP (i.e., dialysis patients have different risks than nursing home patients). Furthermore there is significant heterogeneity of risk factors for HCAP within the subgroups due to variations in contextual factors such as local microbiology and methods of health care delivery and variations of individual risk factors such as functional status or prior antibiotic exposure. This review examines the evidence for the creation of the category of HCAP, including the risk factors for drug-resistant pneumonia in each of the subgroups that constitute HCAP. This review demonstrates that the guidelines have effectively targeted a population at greater risk for pneumonia caused by drug-resistant pathogens. However, within the broad range of HCAP infections, there is significant heterogeneity in terms of the magnitude of the risk as well as the type of risk (i.e., risk for MRSA, multidrug-resistant gram-negative bacilli (MDR-GNB), or both).
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PMID:What are the important risk factors for healthcare-associated pneumonia? 1919 84

The first point of a good diagnostic strategy for healthcare-associated pneumonia (HCAP) is correct classification of patients with specific criteria, as suggested by the last American Thoracic Society/ Infectious Diseases Society of America (ATS/IDSA) guidelines. However, clinical practice and recent literature have suggested new risk factors for multidrug-resistant infection (MRI): the presence of permanent indwelling devices, prior antibiotic use in the last 3 months, chronic and advanced pulmonary diseases (chronic obstructive pulmonary disease, bronchiectasis, etc.), history of alcoholism, and immunosuppression. The clinical presentation in HCAP patients is often unusual (mild respiratory symptoms and frequent extrapulmonary manifestations) due to different factors: advanced age, neurological disorders, and multiple chronic comorbidities. Moreover, HCAP commonly presents a worse clinical course than community-acquired pneumonia, a prolonged length of stay, and a mortality rate close to hospital-acquired pneumonia. Chest radiography and routine laboratory markers (including C-reactive protein) are always needed for clinical evaluation and severity assessment. The clinical use of new biomarkers of infection and sepsis (procalcitonin, etc.) is currently being investigated. Extensive microbiological testing to overcome the high prevalence of MRI in HCAP, including urinary antigens for Legionella and Streptococcus pneumoniae; blood cultures; Gram staining and low respiratory tract secretions (sputum, tracheobronchial aspirate, fibrobronchial aspirate, protected specimen brush, bronchoalveolar lavage); and cultures for aerobic, anaerobic, mycobacterial, and fungal pathogens are recommended, whereas the indication for serology tests for respiratory viruses and atypical pathogens is low. By contrast, the new polymerase chain reaction-based techniques for the rapid identification (2 to 4 hours) of microbial pathogens in respiratory samples (nasopharyngeal swab, bronchoalveolar lavage) seem to be the most innovative future perspective in the diagnostics of HCAP.
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PMID:Diagnostic strategies for healthcare-associated pneumonia. 1919 85

The number of individuals receiving health care outside the hospital setting, including home wound care or infusion therapy, dialysis, nursing homes, and similar settings is constantly increasing. One of the most frequent causes of hospitalization and mortality in these patients is pneumonia. Hence a new class of pneumonia has been identified: healthcare-associated pneumonia (HCAP). The last American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) guidelines define specific criteria to identify HCAP; however, the clinical practice suggests that the presence of indwelling devices (permanent catheters, etc.) may also be considered an additional criterion. Different studies have shown that, in comparison with community-acquired pneumonia (CAP) patients, HCAP patients are significantly older, have a higher number of comorbidities (cerebrovascular diseases, congestive heart failure, dementia, and diabetes mellitus) and show worse functional status before admission. It has also been observed that HCAP differs from CAP in terms of clinical presentation, risk factors, etiology, prognostics, and, likely, therapeutic approach. The clinical presentation of HCAP is often unusual because it is frequently conditioned by advanced age, multiple chronic comorbidities, and neurological disorders. Classic respiratory symptoms of pneumonia are often mild in HCAP, whereas extrapulmonary manifestations, including mental confusion and gastrointestinal disorders, are frequent. HCAP patients, commonly present a worse clinical presentation (hypoxemia, altered consciousness, Fine score, multilobar infiltrates, etc.) than CAP, and a mortality rate close to that of hospital-acquired pneumonia. Many studies have attributed these findings to a nosocomial etiology [methicillin-resistant Staphylococcus aureus (MRSA) , Pseudomonas aeruginosa, etc.] with a high frequency of multidrug-resistant infections (MRIs), even though this remains controversial. Further investigation on microbial composition and MRI risk factors of HCAP is fundamental because no definitive therapeutic indications are currently available.
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PMID:Current perspective of the HCAP problem: is it CAP or is it HAP? 1929 21

The site of care decision is one of the most important in the management of patients with community-acquired pneumonia (CAP). Several scoring systems have been developed to predict mortality risk in CAP, and these have been applied to guide physicians about whether patients should be admitted to the hospital or to the intensive care unit (ICU). However, these tools were initially developed to predict mortality risk, and studies have demonstrated that the risk for death does not always equate with need for hospitalization or ICU care. The most widely studied scoring systems are the Pneumonia Severity Index (PSI) and the CURB-65 (a modification of the British Thoracic Society rule). Each has advantages and limitations, with the more-complex PSI developed to identify low-mortality risk patients, and the CURB-65, which is simpler, being developed to easily identify more severely ill individuals. No scoring system can replace clinical judgement about the admission decision, and prospective studies have shown that physicians still admit at least 30-60% of low mortality risk patients when using the PSI to guide this decision. Limitations of these prognostic tools include their variable utility in the elderly, and their failure to include certain comorbidities (COPD, immune suppression) and social factors, in their calculations. The need for ICU care is also not well-defined by measuring the PSI or CURB-65, and other tools such as those developed by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guideline committee and the SMART-COP rule may have greater utility for this purpose. In the future, measurements of serum biomarkers, such as procalcitonin, may augment the information provided by prognostic scoring tools for patients with CAP.
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PMID:Making sense of scoring systems in community acquired pneumonia. 1935 70

In these guidelines, antimicrobials are selected according to the severity ranking and in conformance with the health insurance system in Japan and the prevailing situation with regard to hospital-acquired pneumonia. Reference was made to the 2005 ATS/IDSA guidelines as precedents for guidelines regarding hospital-acquired pneumonia. After examining these guidelines, the need to consider the medical system and particularities of infectious disease treatment in each country was identified. Preparation of these guidelines was thus necessary to take into consideration special conditions in Japan, including the long period of hospitalization, large number of patients with mild pneumonia, and large differences in test methods and antimicrobial doses. In the selection of specific antimicrobials, the mild group (A) corresponds to the early-onset group or the group with no risk factors for drug-resistant strains of bacteria in the ATS/IDSA guidelines, and the severe group (C) corresponds to the late group or group with risk of drug-resistant bacteria. Antimicrobial selection for the moderate group (B) between these two groups is carried out with consideration of drug-resistant bacteria, including Pseudomonas aeruginosa. In cases when MRSA is suspected, administration of anti-MRSA agents is recommended in addition to the antimicrobial for the respective group. Moreover, according to pharmacokinetic/pharmacodynamic theory, a sufficient antimicrobial dose needs to be administered in the early stage. As the efficacy of aminoglycoside drugs may be low using the doses and administration methods applied in Japan, administration using therapeutic drug monitoring is emphasized.
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PMID:Basic approach for the selection of antibacterial agents. 1985 18

The classification scheme of interstitial lung diseases has undergone numerous revisions. The criteria for distinguishing seven distinct subtypes of idiopathic interstitial pneumonias are now well defined by consensus in the recently published ATS/ERS classification of these lung diseases. In our present review the histological patterns of the different types are described and the differential diagnosis of idiopathic interstitial pneumonias is discussed. Surgical lung biopsy remains the gold standard for the diagnosis of interstitial pneumonias, and sampling from at least 2 sites is recommended. Video-assisted thoracoscopic surgical biopsy is the preferred method for obtaining lung tissue as this procedure offers a similar yield as an open thoracotomy The most common histological subtype of chronic interstitial lung disease is the usual interstitial pneumonia [UIP] which makes up 47-71% of cases. The key histologic features include patchy subpleural and paraseptal distribution of remodeling lung architecture with dense fibrosis, frequent honeycombing, and large fibroblastic foci. Temporal and spatial heterogeneity are the hallmarks. Nonspecific interstitial pneumonia [NSIP] occurs primarily in middle-aged women who have never smoked, with more than 5-years survival rate in 80% of patients. The major feature of NSIP is a uniform interstitial thickening of alveolar septa by a fibrosing or cellular process. The cardinal histological feature in respiratory bronchiolitis and desquamative pneumonia is an excess of intraalveolar histiocytes. In both patterns, there is variable interstitial fibrosis and chronic inflammation, and a strong association with a history of smoking. Organizing pneumonia (idiopathic bronchiolitis obliterans-organizing pneumonia [BOOP]) is not strictly an interstitial process, because the alveoli and bronchioles are filled by intraluminal polyps of fibroblastic tissue and the expansion of the interstitium is mild. Lymphocytic interstitial pneumonia [LIP] is currently viewed as a pattern of diffuse reactive pulmonary hyperplasia associated in most cases with EB virus, immunosuppression, or a connective tissue disorder. Malignant transformation may rarely occur. A dense mixed interstitial lymphoid infiltrate is a typical histological finding. Diffuse alveolar damage [DAD] from unknown causes is termed acute interstitial pneumonia [AIP], and is synonymous with cases of Hamman-Rich disease. Hyaline membranes in the exsudative phase and marked expansion of the interstitium later are present.
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PMID:[Histopathological classification of idiopathic interstitial pneumonias]. 2128 Feb 74

Given the inherent difficulty of determining the cause of community-acquired pneumonia (CAP) (an etiological diagnosis is only established in 40-60 % of cases), assessment of severity plays a key role in stratifying CAP patients arriving at the emergency department in three groups according to the need for hospitalization: outpatient, hospitalization, and the need for intensive care unit (ICU) admission. The two most common severity scales used to assess the need for hospital admission in CAP are the Pneumonia Severity Index (PSI) and CURB-65 score while ATS-IDSA 2007 criteria are specific to evaluate the need for ICU admission. Because of the possible etiological differences between the three groups, distinct etiological tests and empiric antibiotic treatments will be required in each subgroup, although a possible pneumococcal etiology should always be considered, since Streptococcus pneumoniae is the most common etiology of CAP in all three groups. Clinical status must be reassessed 48 hours after empirical antibiotic treatment is started.
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PMID:[Community-acquired pneumonia]. 2131 47


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