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Query: UMLS:C0729233 (Thoracic)
 6,478 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Empiri c therapy of ventilator-associated pneumonia (VAP) in surgical patients should be based on intensive care unit (ICU)-specific surveillance data, because microbial flora patterns vary widely between geographic regions as well as within hospitals. Surgical ICUs have higher VAP rates than other units. Data from the National Nosocomial Infection Surveillance (NNIS) System report Pseudomonas aeruginosa and Staphylococcus aureus to be the most frequent isolates (each 17.4%). Data from the NNIS documents high resistance patterns in ICUs compared with hospitals at large, as well as unit-specific patterns. VAP risk factors for surgical patients include thoracoabdominal surgery, altered level of consciousness, advanced age, diabetes mellitus, malnutrition, chronic obstructive pulmonary disease, and prior antibiotic administration. Promising prevention strategies include restricting ventilator circuit changes, in-line heat moisture exchange filters, semi-recumbant positioning, and continuous subglottic aspiration. Pharmacodynamics should be considered when choosing antibiotic regimens. Postantibiotic effect and time-dependent versus concentration-dependent killing should be studied in clinical trials. Current guidelines for choosing regimens have been well developed by the American Thoracic Society.
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PMID:Empiric therapy for pneumonia in the surgical intensive care unit. 1080 57

Empiri c therapy of ventilator-associated pneumonia (VAP) in surgical patients should be based on intensive care unit (ICU)-specific surveillance data, because microbial flora patterns vary widely between geographic regions as well as within hospitals. Surgical ICUs have higher VAP rates than other units. Data from the National Nosocomial Infection Surveillance (NNIS) System report Pseudomonas aeruginosa and Staphylococcus aureus to be the most frequent isolates (each 17.4%). Data from the NNIS documents high resistance patterns in ICUs compared with hospitals at large, as well as unit-specific patterns. VAP risk factors for surgical patients include thoracoabdominal surgery, altered level of consciousness, advanced age, diabetes mellitus, malnutrition, chronic obstructive pulmonary disease, and prior antibiotic administration. Promising prevention strategies include restricting ventilator circuit changes, in-line heat moisture exchange filters, semi-recumbant positioning, and continuous subglottic aspiration. Pharmacodynamics should be considered when choosing antibiotic regimens. Postantibiotic effect and time-dependent versus concentration-dependent killing should be studied in clinical trials. Current guidelines for choosing regimens have been well developed by the American Thoracic Society.
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PMID:Empiric therapy for pneumonia in the surgical intensive care unit. 1087 6

Nosocomial pneumonia or hospital-acquired pneumonia (HAP) causes considerable morbidity and mortality. It is the second most common nosocomial infection and the leading cause of death from hospital-acquired infections. In 1996 the American Thoracic Society (ATS) published guidelines for empirical therapy of HAP. This review focuses on the literature that has appeared since the ATS statement. Early diagnosis of HAP and its etiology is crucial in guiding empirical therapy. Since 1996, it has become clear that differentiating mere colonization from etiologic pathogens infecting the lower respiratory tract is best achieved by employing bronchoalveolar lavage (BAL) or protected specimen brush (PSB) in combination with quantitative culture and detection of intracellular microorganisms. Endotracheal aspirate and non-bronchoscopic BAL/PSB in combination with quantitative culture provide a good alternative in patients suspected of ventilator-associated pneumonia. Since culture results take 2-3 days, initial therapy of HAP is by definition empirical. Epidemiologic studies have identified the most frequently involved pathogens: Enterobacteriaceae, Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus ('core pathogens'). Empirical therapy covering only the 'core pathogens' will suffice in patients without risk factors for resistant microorganisms. Studies that have appeared since the ATS statement issued in 1996, demonstrate several new risk factors for HAP with multiresistant pathogens. In patients with risk factors, empirical therapy should consist of antibacterials with a broader spectrum. The most important risk factors for resistant microorganisms are late onset of HAP (>/=5 days after admission), recent use of antibacterial therapy, and mechanical ventilation. Multiresistant bacteria of specific interest are methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter calcoaceticus-baumannii, Stenotrophomonas maltophilia and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Each of these organisms has its specific susceptibility pattern, demanding appropriate antibacterial treatment. To further improve outcomes, specific therapeutic options for multiresistant pathogens and pharmacological factors are discussed. Antibacterials developed since 1996 or antibacterials with renewed interest (linezolid, quinupristin/dalfopristin, teicoplanin, meropenem, new fluoroquinolones, and fourth-generation cephalosporins) are discussed in the light of developing resistance.Since the ATS statement, many reports have shown increasing incidences of resistant microorganisms. Therefore, one of the most important conclusions from this review is that empirical therapy for HAP should not be based on general guidelines alone, but that local epidemiology should be taken into account and used in the formulation of local guidelines.
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PMID:Nosocomial pneumonia : rationalizing the approach to empirical therapy. 1640 13

Hospital-acquired pneumonia is the second most frequent nosocomial infection and the first in terms of morbidity, mortality, and cost. In recent years, international societies and, most recently, the American Thoracic Society jointly with the Infectious Disease Society of America, have developed guidelines for the management of hospital-acquired pneumonia, health care-associated pneumonia, and ventilator-associated pneumonia. These guidelines include recommendations for risk stratification, initial and definitive antibiotic treatment, and prevention. The validation of these guidelines is important because it confirms that they can be used in clinical practice, as quality indicators, and as a standard of care. Several processes can be validated and are included in the guidelines, such as the accuracy of the prediction of microorganisms according to stratification criteria and the impact of guidelines on outcomes, including length of hospital and intensive care unit stay, duration of mechanical ventilation, complications, and in-hospital and 30-day mortality. Clinical studies have shown that the accuracy of predicting microorganisms according to risk stratification is reliable ( approximately 80% and approximately 90%). Three studies suggest that the implementation of guidelines, with a special emphasis on antibiotic treatment, improves several parameters of outcome. Only one study, using a before-and-after design, showed a decrease in 14-day mortality after guidelines implementation. A key issue for these studies is to modify recommendations according to local patterns of microbiology and drug resistance. In summary, implementation of guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia decreases the rate of initial inappropriate antibiotic treatment and decreased 14-day mortality in a study. More clinical studies to validate the influence of guidelines on outcome are warranted.
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PMID:Treatment guidelines and outcomes of hospital-acquired and ventilator-associated pneumonia. 2059 72

Hospital-acquired pneumonia (HAP) is a common cause of nosocomial infection associated with significant morbidity and mortality. New clinical practice guidelines for the management of adults with hospital-acquired pneumonia have been published in 2016 by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS). This review focuses on the recent recommendations and their limitations. We also focus on new therapeutic options that might improve the treatment and outcomes of these patients.
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PMID:Empirical treatment of adults with hospital-acquired pneumonia: lights and shadows of the 2016 Clinical Practice ATS/IDSA Guidelines. 2888 12

BACKGROUND Ventilator-associated pneumonia (VAP) is a nosocomial infection commonly seen in patients in intensive care units (ICU). This study aimed to analyze factors affecting prognosis of patients diagnosed with VAP. MATERIAL AND METHODS Critically ill patients with VAP were retrospectively evaluated between June 2002 and June 2011 in the ICU. VAP diagnosis was made according to 2005 ATS/IDSA (Infectious Diseases Society of America/American Thoracic Society) criteria. First pneumonia attacks of patients were analyzed. RESULTS When early- and late-onset pneumonia causes were compared according to ICU and hospital admittance, resistant bacteria were found to be more common in pneumonias classified as early-onset according to ICU admittance. APACHE II score of >21 (p=0.016), SOFA score of >6 (p<0.001) on admission to ICU and SOFA score of >6 (p<0.001) on day of diagnosis are risk factors affecting mortality. Additionally, low PaO2/FIO2 ratio at onset of VAP had a negative effect on prognosis (p<0.001). SOFA score of >6 on the day of VAP diagnosis was an independent risk factor for mortality [(p<0.001; OR (95%CI): 1.4 (1.2-1.6)]. CONCLUSIONS Resistant bacteria might be present in early-onset VAP. Especially, taking LOS into consideration may better estimate the presence of resistant bacteria. Acinetobacter baumannii, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent causative microorganisms for VAP. SOFA score might be more valuable than APACHE II score. Frequently surveilling SOFA scores may improve predictive performance over time.
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PMID:Prognostic Risk Factors in Ventilator-Associated Pneumonia. 2950 36