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Primary ciliary dyskinesia (PCD) is a rare genetic disorder caused by the malfunction of motile cilia and a specific etiology of adult bronchiectasis of unknown prevalence. A better understanding of the clinical phenotype of adults with PCD is needed to identify individuals for referral to diagnostic testing.

Die nosokomiale Pneumonie ist definiert als eine Pneumonie, die ≥ 48 h nach Krankenhausaufnahme bei einem Patienten ohne schwere Immunsuppression auftritt. Sie kann spontan atmende bzw. nichtinvasiv sowie beatmete Patienten betreffen. Bei Verdacht auf eine VAP (ventilatorassoziierte Pneumonie) sollen (semi)quantitative Kulturen eines Tracheobronchialsekrets oder einer bronchoalveolären Lavageflüssigkeit gewonnen werden. Die initiale kalkulierte antimikrobielle Therapie richtet sich nach dem Risiko für multiresistente Erreger (MRE). Der Vorteil der Kombinationstherapie steigt mit der MRE-Prävalenz. Die initiale kalkulierte antimikrobielle Therapie sollte nach Vorliegen der mikrobiologischen Ergebnisse angepasst werden. Nach 72 h ist eine Reevaluation erforderlich, die sowohl das Therapieansprechen als auch die Überprüfung der Verdachtsdiagnose Pneumonie in strukturierter Form einschließt. Ein Therapieversagen kann primär oder sekundär auftreten und erfordert bei primärer Progression eine erneute umfassende Diagnostik vor jeglicher Antibiotikatherapie.

Die stationär behandelte ambulant erworbene Pneumonie des Immunkompetenten ist mit einer Inzidenz von 3/1000 Personen häufig und steigt deutlich ab dem 60. Lebensjahr. Sie geht mit einer hohen 30-Tages- als auch Langzeit-Letalität einher, zudem kann ein (nicht immer reversibler) Funktionsverlust bei Überlebenden verbleiben. Initial soll die Bestimmung des Therapieziels sowie des Schweregrades erfolgen. Patienten mit leichtgradigen Pneumonien können ambulant behandelt werden. Mittel- und schwergradige Pneumonien weisen ein erhöhtes Letalitätsrisiko auf, daher ist eine stationäre intensivierte Therapie bzw. Intensivtherapie angezeigt. Die initiale kalkulierte antimikrobielle Therapie besteht aus einem β‑Laktam sowie (je nach Schweregrad) Makrolid. Schwergradige Verläufe mit Hyperinflammation sollen zusätzlich Hydrocortison erhalten. Die Evaluation des Therapieansprechens erfolgt nach klinischen Kriterien und durch Inflammationsparameter. Die reguläre antimikrobielle Therapiedauer beträgt 5 Tage, bei schweren Pneumonien 7 Tage. Im Falle eines Therapieversagens ist das weitere Vorgehen abhängig davon, welche Art des (primären oder sekundären) Therapieversagens vorliegt.

Prolonged life expectancy has currently increased the proportion of the very elderly among patients with community-acquired pneumonia (CAP). The aim of this study was to determine the influence of age and comorbidity on microbial patterns in patients over 65 years of age with CAP.

Healthcare-associated pneumonia (HCAP) was introduced in 2005 by American Thoracic SocietyInfectious Diseases Society of America guidelines as a new entity of pneumonia, resembling nosocomial pneumonia rather than community-acquired pneumonia (CAP) in terms of frequency of multidrug-resistant (MDR) pathogens and outcomes, thus requiring broad spectrum initial antimicrobial coverage in order to prevent inadequate treatment and, as a consequence, excess mortality. This concept continues to be a subject of controversy. Main concerns relate to the definition of HCAP, the true frequency of MDR pathogens, and the impact of MDR pathogens on outcomes.

Recent reports have identified alcoholism to have an important public health impact and cause a substantial loss of lives worldwide. For a long time alcoholism has been identified to favor pulmonary infections. But only in the last 2 decades the alterations induced by ethanol to the complex mechanisms of lung defense have been recognized. Alcohol alters lung defenses on all levels. It is known to favor oropharyngeal colonization by potentially pathogenic bacteria, aspiration by altering the cough reflex, and to decrease ciliary motility and surfactant production. Innate and adaptive immune responses on the systemic and alveolar level are compromised by alteration of cytokines, decreased chemotaxis, and phagocytic activity of alveolar macrophages and neutrophils. Recent data suggest that Streptococcus pneumoniaeis the leading pathogen responsible for community-acquired pneumonia in alcoholic patients. However, series have reported Klebsiella pneumoniae, Legionella pneumophilia, and other Gram-negative enterobacteriaceae to be frequent, especially in severe cases. Anaerobes may play a role if aspiration after acute intoxication is the cause. The clinical course of community-acquired pneumonia in alcoholic patients is more severe leading to more intensive care unit care, longer hospital stay, and a delay of clinical improvement after initiation of therapy. Convincing data are available showing a predisposition of alcoholic patients for the development of acute respiratory distress syndrome. Some issues still remain controversial as to the rate of multiresistant bacteria or an increased mortality. Regarding the treatment of alcoholic patients, particularities and potential modifiers of antimicrobial treatment have to be accounted for. These include other frequent comorbid conditions such as chronic obstructive pulmonary disease and liver disease, complex socioeconomic and psychiatric conditions, and poor adherence to therapy.

This review describes the most recent advances in the management and prevention of nosocomial pneumonia. The new ATS guidelines in particular are most likely to affect clinical practice outside the USA.

Alcohol consumption is known to affect both systemic and pulmonary immunity, predisposing the patient to pulmonary infections. The aim of this study was to compare the etiology of disease, the antibiotic resistance of Streptococcus pneumoniae, the severity of disease, and the outcome of patients with alcohol abuse to those of nonalcoholic (NA) patients who have been hospitalized for community-acquired pneumonia (CAP).

Airway colonization and infection are frequent complications during the course of ARDS. The impact on outcomes of microbiological patterns recovered within the first 24 h after diagnosis has not been evaluated.

Abstract

Although several pneumonia severity criteria have been firmly established, the exact definition of severe community-acquired pneumonia (CAP) remains elusive. Mortality from CAP remains high, reaching 50 in some series. The particular role of Pseudomonas aeruginosaand Acinetobacterspp. in severe CAP has been defined more clearly. Microbial diagnosis in the individual patient remains a difficult task. Despite promising new diagnostic tools, concerns about possible mixed origins preclude a change from the currently advocated broad-spectrum approach of antimicrobial treatment. Although there is some evidence that guidelines may optimize outcomes, their role in limiting the spread of resistance has only recently received attention. Finally, although there are promising data on the use of noninvasive positive pressure ventilation to treat pneumonia in patients without chronic obstructive pulmonary disease, its place in the management of acute respiratory failure remains to be defined in randomized studies.

To determine whether traditional risk factors for cardiovascular disease (CVD) and regional fat distribution, especially the central obesity type and increased parapharyngeal fat pads, are associated with the degree of obstructive sleep apnea (OSA). To determine whether there are interrelationships between body fat, serum leptin levels, and the degree of OSA.

Although mechanical ventilation is instituted as a life-saving technique, it may lead to complications that can negatively impact on patients' morbidity and/or mortality. Ventilator associated pneumonia (VAP) is one such complication that is a common challenge to intensivists. Although most experts would agree that early 'appropriate' antibiotic use is essential in patients who develop VAP, the best diagnostic test to guide decision-making is far from clear. One diagnostic test that is capable of providing microbiological samples from the lower respiratory tree is invasive bronchoscopy with a protected specimen brush. Such a procedure has long been available to intensivists and is frequently employed in many intensive care units. However, this procedure has associated costs and potential complications, and its utility in VAP has been challenged. In this issue of Critical Care Forum, the two sides of this debate are brought forward with compelling arguments. The authors' arguments should fuel future trials.

Worldwide, the increasing rates of microbial resistance represent a serious public health problem. Therefore, measures to prevent ventilator-associated pneumonia gain increasing importance. Because antimicrobial treatment in the ICU is a major source of microbial resistance, prevention should be understood not only as the sum of preventive measures but also as part of any management strategy. In this year of review, several important contributions have been made to a better understanding of the relative role of preventive measures. This is particularly true of noninvasive ventilation, continuous aspiration of subglottic secretions, and closed endotracheal suctioning. Management strategies for ventilator-assisted pneumonia remain highly controversial. Despite two decades of vigorous research, there is still no evidence that invasive bronchoscopic techniques should form part of a routine approach to suspected ventilator-assisted pneumonia. Moreover, an impact in terms of important outcome variables could not be consistently demonstrated. In the authors' view, the controversy regarding the relative validity of diagnostic tools should end, and the focus should shift to strategies that define low-risk patients with suspected ventilator-assisted pneumonia who can safely be treated by short-term monotherapy. Finally, several contributions have refined the established treatment regimen. Several new drugs for the treatment of ventilator-assisted pneumonia caused by Gram-positive multiresistant pathogens have been evaluated with promising results.

The worldwide spread of drug-resistant Streptococcus pneumoniaerepresents a serious challenge to current management of patients with adult community-acquired pneumonia. Algorithms including rapid diagnostic tests hold the promise to reduce the dependence on empiric antimicrobial treatment. The concomitant application of sputum Gram stain, antigen detection, and polymerase chain reaction for Streptococcus pneumoniaeand Legionellaspp. may represent an attractive alternative approach; however, issues of limited availability, absence of data evaluating impact on morbidity, mortality, and cost-effectiveness currently preclude implementation of these tools in routine practice. Current levels of resistance (mean inhibitory concentration, 1–2 mg/L) mostly seem to be appropriately treated with high doses of penicillin or other -lactams. In patients with documented drug-resistant pneumococcal pneumonia, new drugs with increased activities against penicillin-resistant Streptococcus pneumoniae,such as streptogramins, oxazolidinones, and ketolides, should be restricted to patients who do not tolerate or fail to respond to conventional treatment regimes and to those with high levels of resistance (mean inhibitory concentration ≥ 4 mg/L). Likewise, empiric antimicrobial treatment approaches for patients with mild and moderate pneumonia may still rely mainly on -lactams and macrolides and retain carbapenems and vancomycin for patients with documented treatment failure or high levels of resistance. The use of new quinolones as a first-line antimicrobial treatment is only advocated in regions with high rates of resistance to penicillin and macrolides and (in combination with -lactams) in patients with severe pneumonia.

Die nosokomiale Pneumonie ist eine häufige Komplikation, insbesonders unter maschineller Beatmung. Bei der früh entstehenden Pneumonie (bis zum vierten Tag nach Krankenhausaufnahme) überwiegen Staphylococcus aureus, Streptococcus pneumoniae und Haemophilus influenzae, während bei der spät entstehenden Pneumonie (ab dem fünften Tag) zusätzlich Gram-negative Enterobakterien und potenziell multiresistente Erreger vorherrschen. Dieses Grundmuster wird nach Maßgabe bestimmter individueller Risikofaktoren modifiziert. Die Diagnostik der nosokomialen Pneumonie hat drei Ziele: die Definition des Schweregrades der Pneumonie, die Sicherung des Vorliegens einer nosokomialen Pneumonie sowie die Identifikation des zugrunde liegenden Erregers. Ergebnisse der mikrobiologischen Diagnostik dürfen jedoch nur im Zusammenhang mit der klinischen Situation interpretiert werden. Die antimikrobielle Therapie erfolgt primär in Unkenntnis des Erregers als kalkulierte Therapie auf dem Boden oben genannter Grundmuster des zu erwartenden Erregerspektrums. Hierbei muss zwischen spontan atmenden und beatmeten Patienten unterschieden werden. Im Falle eines Therapieversagens ist eine umfassende Reevaluation des Patienten angezeigt.

To evaluate the etiology and microbial patterns of pulmonary infiltrates in liver transplant patients using a bronchoscopic diagnostic approach and the impact of diagnostic results on antimicrobial treatment decisions.

Approaches for the diagnosis of ventilator-associated pneumonia have two goals, namely to determine the presence of pneumonia as well as its causative pathogens. Traditional diagnostic measures such as clinical and radiographic criteria and qualitative cultures of tracheobronchial aspirates (TBAS) are associated with considerable limitations as regards sensitivity and particularly specificity. Therefore, patients are at risk to be “overtreated” with antibiotics. On the other hand, prolonged antibiotic treatment represents an important risk factor for pneumonia. The specificity of isolates in culture can be significantly improved by applying the quantitative culture technique. Bronchoscopic techniques to retrieve respiratory secretions (PSB, BAL with quantitative culture) have only marginally increased specificity as compared to quantitative cultures of TBAS. Morbidity and Mortality are not influenced by the techniques used for microbial investigation. Therefore, TBAS is useful as primary diagnostic measure. Bronchoscopic techniques may be applied individually and, therefore, should be established and available as well. Die Diagnostik der beatmungsassoziierten Pneumonie hat zwei Ziele, die Identifikation einer Pneumonie sowie deren ursächlicher Erreger. Die herkömmliche Diagnostik, die auf klinischen und radiologischen Kriterien sowie einer qualitativen Kultur des Tracheobronchialsekrets beruht, weist erhebliche Limitationen in Sensitivität, besonders aber Spezifität auf. Es besteht daher die Gefahr einer antibiotischen „Übertherapie“. Eine lang andauernde Antibiotika-Therapie ist ihrerseits ein wichtiger Risikofaktor für die Pneumonieentstehung. Die Technik der quantitativen Kultur verbessert die Spezifität der kulturellen Isolate. Bronchoskopische Techniken der Gewinnung respiratorischer Sekrete (PSB, BAL mit quantitativer Kultur) sind gegenüber dem quantitativen Tracheobronchialsekret allenfalls geringfügig spezifischer. Ein Vorteil der bronchoskopischen Methodik gegenüber dem quantitativen Tracheobronchialsekret konnte hinsichtlich Morbidität und Letalität nicht gezeigt werden. Das quantitative Tracheobronchialsekret eignet sich daher als primäre diagnostische Maßnahme. Bronchoskopische Techniken bleiben individuellen Indikationen vorbehalten und sollten daher etabliert und verfügbar sein.

Patients with chronic obstructive pulmonary disease (COPD) are especially prone to bronchial colonization and acute infection, including acute infectious exacerbations and community-acquired as well as nosocomial pneumonia. Bacterial colonization may promote bronchial inflammation, predispose to acute exacerbations, and thereby contribute to respiratory decline. Haemophilus influenzaeand Streptococcus pneumoniaeare the most frequently encountered pathogens in both stable disease as well as acute exacerbations. The role of bacterial infection in acute exacerbations remains subject to controversy; however, evidence is in favor of regular antimicrobial treatment in patients with severe exacerbations. COPD represents an important risk factor for community-acquired pneumonia (CAP). Microbial patterns for CAP differ from exacerbations in that S. pneumoniaeand “atypical” bacterial pathogens predominate. Similarly, COPD has been recognized as an important risk factor for nosocomial pneumonia. Initial empiric antimicrobial treatment of both severe acute exacerbations and pneumonia should take into account regional drug resistance rates to penicillin of S. pneumoniaeand should cover Gram-negative enteric bacilli. The additional treatment of atypical bacterial pathogens and Pseudomonas aeruginosashould be considered individually.

To determine predictors of mortality from pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy, and the significance of those factors related to the underlying malignancy and its therapy as well as of those related to the severity of the illness associated with pulmonary infiltrates.

Zusammenfassung: Quantitative Kulturen respiratorischer Sekrete stellen einen Fortschritt in der Diagnostik von Beatmungspneumonien dar. Durch bakterielle Keimzahltrennwerte können Kontamination bzw. Kolonisation und Infektion mit einer befriedigenden Spezifität unterschieden werden. Ihr Einsatz ermöglicht lokale epidemiologische Daten als Grundlage der kalkulierten antimikrobiellen Therapie sowie im individuellen Fall häufigauch eine gezielte antimikrobielle Therapie. HIV-assoziierte Pneumonien stellen eine weitere mögliche Indikation dar. Einer Etablierung in der Routine steht der hohe Kenntnis- und Erfahrungsstand entgegen, der zu ihrer erfolgreichen Anwendung erforderlich ist. Zumindest größere Behandlungszentren sollten insbesondere im Hinblick auf eine Kontrolle bakterieller Resistenzen diese leistungsfähigste Methode der Infektionsdiagnostik jedoch auch in der Routineversorgung nutzen.

We describe an atypical diagnostic feature of a breakthrough Pneumocystis carinii pneumonia (PCP) during primary prophylaxis with aerosolized pentamidine. Our case disclosed infiltrates restricted to the left upper lobe. After 2 weeks a solitary cavity developed. Diagnosis was easily established by bronchoalveolar lavage when performed in the affected segment bronchus. Cavitation clearly demonstrated localized infection, with tissue destruction as one main pathogenetic pattern of a breakthrough PCP during aerosolized pentamidine prophylaxis.

Efectuou-se um estudo prospectivo que englobou 25 doentes submetidos a ventilação mecânica e que