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Background: Patients commonly present to primary care services with upper and lower respiratory tract infections, and guidelines to help physicians investigate and treat acute cough due to suspected pneumonia and influenza are needed., Methods: A systematic search was carried out with eight patient, intervention, comparison, outcome questions related to acute cough due to suspected pneumonia or influenza., Results: There was a lack of randomized controlled trials in the setting of outpatients presenting with acute cough due to suspected pneumonia or influenza who were not hospitalized. Both clinical suggestions and research recommendations were made on the evidence available and CHEST Expert Cough Panel advice., Conclusions: For outpatient adults with acute cough due to suspected pneumonia, we suggest the following clinical symptoms and signs are suggestive of pneumonia: cough; dyspnea; pleural pain; sweating, fevers, or shivers; aches and pains; temperature ≥ 38°C; tachypnea; and new and localizing chest examination signs. Those suspected of having pneumonia should undergo chest radiography to improve diagnostic accuracy. Although the measurement of C-reactive protein levels strengthens both the diagnosis and exclusion of pneumonia, there was no added benefit of measuring procalcitonin levels in this setting. We suggest that there is no need for routine microbiological testing. We suggest the use of empiric antibiotics according to local and national guidelines when pneumonia is suspected in settings in which imaging cannot be performed. Where there is no clinical or radiographic evidence of pneumonia, we do not suggest the routine use of antibiotics. There is insufficient evidence to make recommendations for or against specific nonantibiotic, symptomatic therapies. Finally, for outpatient adults with acute cough and suspected influenza, we suggest that initiating antiviral treatment (according to Centers for Disease Control and Prevention advice) within 48 hours of symptoms could be associated with decreased antibiotic use and hospitalization and improved outcomes., (Copyright © 2018 American College of Chest Physicians. All rights reserved.)

Background: The objective of this study was to perform a systematic review and meta-analysis of the impact of the 2005 American Thoracic Society/Infectious Diseases Society of America guideline-concordant antimicrobial therapy (GCAT) on mortality following healthcare-associated pneumonia (HCAP)., Methods: We searched MEDLINE, EMBASE, BIOSIS, Cochrane CENTRAL Register of Controlled Trials, and Scopus for clinical trials and observational studies comparing GCAT to other treatment regimens in adults with HCAP. The primary outcome chosen was 30-day mortality from any cause. Secondary outcomes assessed length of hospital stay and time to clinical stability. Random effects models were used to generate pooled odds ratios (ORs) and weighed mean differences (WMDs). Heterogeneity was evaluated by the I(2)., Results: A total of six studies were included in the analysis and involved 15,850 participants. Meta-analysis showed that GCAT was associated with increased 30-day mortality compared to non-GCAT (OR 1.80, 95 % confidence interval [CI] 1.26-2.7). There was no advantage in GCAT over non-GCAT in terms of hospital length of stay (WMD 1.18 days, 95 % CI -0.48 to 2.84) or time to clinical stability (WMD 0.17 days, 95 % CI -0.32 to 0.67)., Conclusion: In hospitalized patients with HCAP, GCAT did not show survival benefit compared to non-GCAT. However, our results are limited by the cohort design of the selected studies and the degree of heterogeneity among them. Future trials are needed to identify risk factors for multidrug-resistant pathogens in HCAP patients who may benefit from broad-spectrum antimicrobial regimens.

Vaccination remains the primary preventive strategy in the elderly against Streptococcus pneumoniae and influenza infections. The effectiveness of this strategy in preventing pneumonia has been in doubt despite the increase in vaccination coverage among older adults. Randomized controlled trials (RCTs) and observational studies aimed at determining clinical outcomes and immune response following pneumococcal vaccination have yielded conflicting results. The protective efficacy of pneumococcal vaccination against pneumonia in older adults has not been firmly established due to a lack of RCTs specifically examining patients ≥ 65 years of age. Similarly, the reported benefits of influenza vaccination have been derived from observational data. The assessment of clinical benefit from influenza vaccination in the elderly population is complicated by varying cohorts, virulence of the influenza strain, and matching of vaccine and circulating viral strains. The presence of selection bias and use of nonspecific end points in these studies make the current evidence inconclusive in terms of overall benefit. The development of more immunogenic vaccines through new formulations or addition of adjuvants holds the promise of revolutionizing delivery and improving efficacy. Dismantling existing barriers through education, providing technology assistance predominantly to developing countries, and establishing clear regulatory guidance on pathways for approval are necessary to ensure timely production and equitable distribution.

Background: Several severity scores have been advanced to predict a patient's outcome from community-acquired pneumonia (CAP). The purpose of this study is to compare the accuracy of confusion, urea, respiratory rate, BP (CURB); CURB plus age ≥ 65 years (CURB-65); CURB-65 minus urea (CRB-65); and systolic BP, oxygenation, age, and respiratory rate (SOAR) scoring systems in predicting 30-day mortality and ICU admission in patients with nursing home-acquired pneumonia (NHAP)., Methods: A retrospective analysis of a prospectively collected database of 457 nursing home residents hospitalized with pneumonia at two university-affiliated tertiary care facilities. Clinical and laboratory features were used to compute severity scores using the British Thoracic Society severity rules and the SOAR criteria. The sensitivity, specificity, and positive and negative predictive values were compared for need for ICU admission and 30-day mortality., Results: The overall 30-day mortality and ICU admission rates were 23% and 25%, respectively. CURB, CURB-65, and CRB-65 performed similarly in predicting mortality with areas under the receiver operating characteristic curves (AUCs) of 0.605 (95% CI, 0.559-0.650), 0.593 (95% CI, 0.546-0.638), and 0.592 (95% CI, 0.546-0.638), respectively, whereas SOAR showed superior accuracy with an AUC of 0.765 (95% CI, 0.724-0.803) (P < .001). The need for ICU care was also better identified with the SOAR model compared with the other scoring rules., Conclusions: All three British Thoracic Society rules had lower performance accuracy in predicting 30-day mortality of hospitalized NHAP than SOAR. SOAR is also a superior alternative for better identification of severe NHAP. An improved rule for severity assessment of hospitalized NHAP is needed.

Pneumonia is a major cause of morbidity and mortality among nursing home residents. The approach to managing these patients has lacked uniformity because of the paucity of clinical trials, complexity of underlying comorbid diseases, and heterogeneity of administrative structures. The decision to hospitalize nursing home patients with pneumonia varies among institutions depending on staffing level, availability of diagnostic testing, and laboratory support. In the absence of comparative studies, choice of empirical antibiotic therapy continues to be based on expert opinion. Validated prognostic scoring models are needed for risk stratification. Pneumococcal and influenza vaccination are the primary prevention measures. As of January 2010, Medicare no longer pays for consultation codes; thus, practitioners must instead use existing evaluation and management service codes when providing these services.

Objective: To review the risk factors, etiologic profile, treatment approaches, and guidelines for the management of nursing home-acquired pneumonia (NHAP)., Research Design and Methods: A search of the current literature was conducted using the MEDLINE and Embase databases. This search, limited to studies performed in humans and published in English between January 1, 1990 and October 31, 2009, included the terms 'acquired pneumonia', 'associated pneumonia', 'nursing home', 'long-term care', 'institution', and 'healthcare'., Results: Older age, male gender, swallowing difficulty, and inability to take oral medications are all significant risk factors for pneumonia. Medications such as antipsychotics and anticholinergics, histamine receptor blockers and proton pump inhibitors have also been linked to higher risk of pneumonia. The etiology of NHAP overlaps with that of community-acquired pneumonia (CAP), with Streptococcus pneumoniae and Haemophilus influenzae as predominant pathogens in long-term care facilities. In patients who require hospitalization, Chlamydophila pneumoniae, Staphylococcus aureus, and influenza virus have also been identified. In contrast, the etiology of severe NHAP overlaps with that of hospital-acquired pneumonia (HAP), with S. aureus, including methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and enteric Gram-negative bacilli as important causative pathogens. Therapy is dependent on disease severity and, on the treatment setting. Respiratory fluoroquinolones or β-lactams plus a macrolide are recommended in patients with NHAP. Patients hospitalized with severe NHAP may require triple combination therapy that covers both MRSA and P. aeruginosa. However, there is little evidence of the clinical superiority of one regimen over another, making it challenging to establish guidelines for the treatment of NHAP in the nursing home setting., Conclusion: There is a pressing need for clinical trials of antibiotic therapy in nursing home patients that would help establish uniform guidelines to standardize therapy in the nursing home setting.

Background: Considerable research has increased our understanding of antibiotic prescribing practices in hospital settings when it comes to nosocomial pneumonia. Much less is known about the antibiotic prescribing patterns for hospitalized non-critically ill patients with nursing home-acquired pneumonia (NHAP)., Objective: As part of a multisite quality improvement project, we sought to examine patterns of antibiotic prescription among healthcare providers as a function of underlying comorbid, functional, and clinical factors., Setting: Three tertiary care centers., Intervention: Chart reviews of 397 individual admissions were performed on patients admitted from nursing homes with the diagnosis of pneumonia between January 2005 and September 2007., Results: Compliance with national guidelines for the treatment of NHAP was poor. Overall, the 3 most commonly used compounds for inpatient treatment were fluoroquinolones (51.4%), ceftriaxone (45.0%), and azithromycin (42.1%). Monotherapy was prescribed in 57.1%. Fluoroquinolones represented 79.5% of these cases. Patients with higher acuity of illness were more likely to receive a combination of vancomycin plus piperacillin/tazobactam (P < 0.001). Median duration of treatment was 8.0 (range, 3-21) days. Stratified analyses showed that combination therapy was used more often on University-affiliated services than on private service (54% vs. 35%; P < 0.001)., Conclusions: There was poor adherence with antibiotic guidelines for the treatment of NHAP. In the absence of outcome data on guidelines compliance, antibiotic use was influenced by patients' age, severity of illness, and providers' academic affiliation. Future research should focus on outcome measures and physicians factors that influence nonadherence.

Objectives: To compare the 2003 community-acquired pneumonia (CAP) guideline and the 2005 healthcare-associated pneumonia (HCAP) guideline on time to clinical stability, length of hospital stay, and mortality in nursing home patients hospitalized for pneumonia., Design: Retrospective study., Setting: Three tertiary-care hospitals., Participants: Three hundred thirty-four nursing home patients., Measurements: Patients were classified according to the antibiotic regimens they received based on the 2003 CAP guideline or the 2005 HCAP guideline. Time to clinical stability, time to switch therapy, and mortality were evaluated in an intention-to-treat analysis. A multivariate survival model using propensity analysis was used to adjust for heterogeneity between the two groups., Results: Of the 334 patients, 258 (77%) were treated according to the 2003 HCAP guideline. Time to clinical stability did not differ between those treated according to the 2003 CAP or the 2005 HCAP guidelines. Only the Pneumonia Severity Index (P=.006) and multilobar involvement (P=.005) were significantly associated with delay in achieving clinical stability. Adjusted in-hospital and 30-day mortality were comparable in both cohorts (odds ratio (OR)=0.87, 95% confidence interval (CI)=0.49-1.34, and OR=0.79, 95% CI=0.42-1.31, respectively), although time to switch therapy and length of stay were longer for those treated according to the 2005 HCAP guideline., Conclusion: In hospitalized nursing home patients with pneumonia, treatment with an antibiotic regimen according to the 2003 CAP guideline achieved comparable time to clinical stability and in-hospital and 30-day mortality with a regimen based on the 2005 HCAP guideline.

Nursing home-acquired pneumonia (NHAP) was first described in 1978. Since then there has been much written regarding NHAP and its management despite the lack of well-designed studies in this patient population. The most characteristic features of patients with NHAP are the atypical presentation, which may lead to delay in diagnosis and therapy. The microbial etiology of pneumonia encompasses a wide spectrum that spans microbes recovered from patients with community-acquired pneumonia to organisms considered specific only to nosocomial settings. Decision to transfer a nursing home patient to an acute care facility depends on a host of factors, which include the level of staffing available at the nursing home, patients' advance directives, and complexity of treatment. The presence of risk factors for multidrug-resistant pathogens dictates approach to therapy. Prevention remains the cornerstone of reducing the incidence of disease. Despite the advance in medical services, mortality from NHAP remains high.

Objective: To investigate the potential role of serum and alveolar soluble triggering receptor expressed on myeloid cells (sTREM-1) as a biological marker of pulmonary aspiration syndromes., Design: Prospective cohort study., Setting: University-affiliated intensive care unit., Patients: Seventy-five patients with pulmonary aspiration and 13 controls receiving mechanical ventilation., Interventions: Blood and bronchoalveolar lavage (BAL) fluid samples were collected on enrollment. Soluble TREM-1 levels were measured by an enzyme-linked immunosorbent assay., Measurements and Results: Thirty-eight of 75 participants had documented BAL culture-positive pulmonary aspiration. While circulating levels of sTREM-1 were comparable between those with aspiration syndromes (19.81 +/- 12.09 pg/ml) and controls (15.96 +/- 11.16 pg/ml) (p=0.27), the alveolar levels of sTREM-1 were higher in patients with culture-positive pulmonary aspiration (344.41 +/- 152.82 pg/ml) compared with those culture-negative pulmonary aspiration (142.76 +/- 89.88 pg/ml; p < 0.001). A cut-off value of 250 pg/ml for alveolar sTREM-1 achieved a sensitivity of 65.8% (95% CI 48.6-80.4) and a specificity of 91.9% (95% CI 78.1-98.2) with an area under the curve of 0.87 (95% CI 0.78-0.94)., Conclusions: Alveolar sTREM-1 levels can be a potential biomarker for distinguishing BAL culture-positive from BAL culture-negative pulmonary aspiration.

Understanding mechanisms that underlie lung disorders is crucial to achieving optimum care and improved outcomes in pulmonary medicine. Extensive investigations have revealed that inflammation displays an active role in the pathogenesis of these diseases. The byproduct of these inflammatory reactions has been shown to propagate pulmonary disease in consonance with alteration in haemostatic balance. It is now apparent that the two phenomena constitute an interwoven relationship with protective but damaging effects, when dysregulated. However, the precise role of coagulation abnormalities in pulmonary pathology is still evolving. A large body of evidence suggests that an imbalance in intra-alveolar procoagulant and fibrinolytic activities occurs in a variety of lung conditions. This imbalance may even herald a number of pulmonary diseases. Its sequelae have been observed in lung parenchyma of humans and in animal models of lung inflammation. As the pathogenesis of coagulation-related lung diseases continues to be unraveled, therapeutic measures to mitigate pulmonary disease-specific coagulopathy are emerging. Current efforts are directed at depicting multifaceted molecules capable of selective but simultaneous interference with relevant aspects of the dual coagulation-fibrinolytic pathway.

Objective: To identify modifiable risk factors of nosocomial pneumonia (NP) in elderly patients post-cardiac surgery., Design: A case-control study., Setting: Post-operative intensive care unit of a tertiary-level university affiliated hospital., Subjects: Seventy three case-control pairs. Case patients referred to elderly patients who developed pneumonia post-cardiac surgery. Controls subjects were matched for age, gender, type of surgery, forced expiratory volume in 1s (FEV(1)), and ejection fraction., Measurements: Baseline sociodemograpahic information, Charlson Comorbidity Index score, intra- and post-operative data were collected. When suspected, the presence of NP was confirmed by quantitative culture of protected bronchoalveolar lavage fluid 10(3) colony forming unit/ml or positive blood/pleural fluid culture identical to that recovered from respiratory samples., Results: The incidence of NP in elderly post-heart surgery was 8.3%. The mean duration after heart surgery to the occurrence of pneumonia was 7.2+/-4.9 days. Four variables were found to be significantly related to the development of NP by multivariate analysis: Charlson Index >2 (adjusted odds ratio [AOR] 4.7; 95% confidence interval [CI], 1.9-11.4; P<0.001), reintubation (AOR 6.2; 95% CI, 1.1-36.1; P=0.04), transfusion 4 units of PRBC (AOR 2.8; 95% CI, 1.2-6.3; P=0.01), and the mean equivalent daily dose of morphine (AOR 4.6; 95% CI, 1.4-14.6; P=0.01)., Conclusions: Although there are limited effective measures to lessen the burden of comorbidities, avoiding reintubation, finding a substitute to allogenic blood transfusion, and improved assessment of pain management could reduce the rate of NP in the post-operative period of cardiac surgery in the elderly population.

Objectives: To identify modifiable risk factors of late unplanned readmissions for elderly with community-acquired pneumonia., Design: A case-control study., Setting: Three university-affiliated tertiary-care hospitals., Participants: Two hundred four case-control pairs. Case patients referred to all patients readmitted with pneumonia 30 days to 1 year after discharge. Control subjects were matched for age, admission date, and residence before admission., Measurements: Baseline sociodemographic information, clinical data, activity of daily living (ADLs) information, and Charlson Comorbidity Index score were obtained. The Pneumonia Severity Index was calculated with swallowing dysfunction and pattern and extent of radiographic abnormalities, antimicrobial coverage, and total duration recorded., Results: Median time to readmission was 123 days (interquartile range=65-238 days). Readmission was not associated with increased severity or length of hospital stay. In a Cox proportional hazards regression model, swallowing dysfunction (hazard ratio (HR)=2.15, 95% confidence interval (CI)=1.46-2.97), current smoking (HR=2.04, 95% CI=1.48-2.82), use of tranquilizers (HR=1.5, 95% CI=1.02-2.22), and lower ADL scores (HR=1.06, 95% CI=1.02-1.10) were independently associated with readmission for pneumonia. The receipt of angiotensin-converting enzyme inhibitors (HR=0.46, 95% CI=0.27-0.78) and prior pneumococcal vaccination (HR=0.59, 95% CI=0.42-0.82) had a protective effect., Conclusion: Although there are limited effective measures to improve functional status, preventive strategies that include smoking cessation and pneumococcal vaccination should be actively pursued. Routine evaluation of swallowing dysfunction and use of pharmacological agents to improve the cough reflex deserve further evaluation in multicenter controlled trials.

Objective: To determine the homeostatic balance of patients with ventilator-associated pneumonia (VAP) with respect to the adequacy of antimicrobial therapy., Design and Setting: Descriptive observational study in a 12-bed medical intensive care unit in a university-affiliated hospital., Patients: Twenty-nine patients with VAP documented by quantitative culture of bronchoalveolar secretions and a control group of eight mechanically ventilated patients., Methods: Serial bronchoalveolar lavage fluid (BALF) samples were assayed for prothrombin activation fragment (F1+2), thrombin-antithrombin (TAT) complex, fibrinolytic activity, urokinase-type plasminogen activator (u-PA), and plasminogen activator inhibitor type 1 (PAI-1) on days 1, 4, and 7 after VAP onset., Results: Pathogens isolated from patients with inadequate empirical antimicrobial coverage included methicillin-resistant Staphylococcus aureus (n=2), Pseudomonas aeruginosa (n=4), and Acinetobacter baumannii (n=1). Compared to those who received adequate antibiotic therapy, TAT, F1+2, and PAI-1 levels increased while u-PA levels remained unchanged. Despite antibiotic adjustment on day 4, TAT levels remained elevated in those who lacked adequate antimicrobial coverage and were significantly correlated with PaO(2)/FIO(2). The procoagulant activity was accompanied by a local depression of fibrinolytic capacity that was attributed mainly to increased BALF PAI-1 levels. Nonsurvivors showed significantly higher levels of TAT and PAI-1 than survivors. No significant correlation between the bacterial burden and the homeostatic derangements was documented., Conclusions: The lung inflammatory response seems to promulgate a local procoagulant activity associated with hypoxemia in those with inadequate antibiotic therapy. The homeostatic derangement seems to be independent of the lung bacterial burden.

PurposeSevere community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes.MethodsThis double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72-96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up.ResultsBetween January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57-1.40). There were no significant differences in secondary outcomes or complications.ConclusionsIn patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications.

Background: The primary objective of this study is to assess whether baseline renal function impacts treatment outcomes of linezolid and vancomycin (with a dose-optimized regimen) for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.Methods: We conducted a retrospective cohort analysis of data generated from a prospective, randomized, controlled clinical trial (NCT 00084266). The analysis included 405 patients with culture-proven MRSA pneumonia. Baseline renal function was stratified based on creatinine clearance. Clinical and microbiological success rates and presence of nephrotoxicity were assessed at the end of treatment (EOT) and end of study (EOS). Multivariate logistic regression analyses of baseline patient characteristics, including treatment, were performed to identify independent predictors of efficacy. Vancomycin concentrations were analyzed using a nonlinear mixed-effects modeling approach. The relationships between vancomycin exposures, pharmacokinetic-pharmacodynamic index (trough concentration, area under the curve over a 24-h interval [AUC0-24], and AUC0-24/MIC) and efficacy/nephrotoxicity were assessed in MRSA pneumonia patients using univariate logistic regression or Cox proportional hazards regression analysis approach.Results: After controlling for use of vasoactive agents, choice of antibiotic therapy and bacteremia, baseline renal function was not correlated with clinical and microbiological successes in MRSA pneumonia at either end of treatment or at end of study for both treatment groups. No positive association was identified between vancomycin exposures and efficacy in these patients. Higher vancomycin exposures were correlated with an increased risk of nephrotoxicity (e.g., hazards ratio [95% confidence interval] for a 5 μg/ml increase in trough concentration: 1.42 [1.10, 1.82]).Conclusions: In non-dialysis patients, baseline renal function did not impact the differences in efficacy or nephrotoxicity with treatment of linezolid versus vancomycin in MRSA pneumonia. [ABSTRACT FROM AUTHOR]

Background: The primary objective of this meta-analysis is aimed at determining whether β-lactams prolonged infusion in patients with nosocomial pneumonia (NP) results in higher cure rate and improved mortality compared to intermittent infusion. Materials and Methods: Relevant studies were identified from searches of MEDLINE, EMBASE, and CENTRAL from inception to September 1st, 2015. All published articles which evaluated the outcome of extended/continuous infusion of antimicrobial therapy versus intermittent infusion therapy in the treatment of NP were reviewed. Results: A total of ten studies were included in the analysis involving 1,051 cases of NP. Prolonged infusion of β-lactams was associated with higher clinical cure rate (OR 2.45, 95% Cl, 1.12, 5.37) compared to intermittent infusion. However, there was no significant difference in mortality (OR 0.85, 95% Cl 0.63-1.15) between the two groups. Subgroup analysis for β-lactam subclasses and for severity of illness showed comparable outcomes. Conclusion: The limited data available suggest that reduced clinical failure rates when using prolonged infusions of β-lactam antibiotics in critically ill patients with NP. More detailed studies are needed to determine the impact of such strategy on mortality in this patient population. [ABSTRACT FROM AUTHOR]

Objectives: In patients with ventilator-associated pneumonia (VAP), Pseudomonas aeruginosa type III (TTSS) secreting isolates have been linked to poor clinical outcomes. Differential expression of matrix metalloproteinases (MMPs) induced by type III effector proteins may herald an irreversible lung injury.Methods: Serial bronchoalveolar lavage fluids collected from 41 patients with P. aeruginosa at onset of VAP, day 4, and day 8 after antibiotic therapy were assayed for MMP-8, MMP-9, tissue inhibitor of metalloproteinase-1 (TIMP-1), and alpha-2 macroglobulin levels.Results: At the onset of VAP, isolates secreting ExoU had the highest MMP-9 levels. The response to antimicrobial therapy showed a differential drop in MMPs with significant decrease in MMP-8 and MMP-9 levels on days 4 and 8 in patients with TTSS(-) compared to TTSS(+) phenotype. The ratio of MMP-9/TIMP-1 was significantly associated with alpha-2 macroglobulin at end of therapy (r=0.4, p=0.02). Patients who survived had a lower MMP-9/TIMP-1 ratio than those who died (p=0.003).Conclusions: VAP linked to P. aeruginosa Type III phenotype portrays a divergent antibiotic treatment response in regards to the concentrations of metalloproteinases in the alveolar space. The imbalance between MMP-9 and TIMP-1 may determine the intensity of alveolocapillary damage and ultimate outcome of P. aeruginosa VAP. [ABSTRACT FROM AUTHOR]

Study objectives: Poor dental hygiene has been linked to respiratory pathogen colonization in residents of long-term care facilities. We sought to investigate the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping. Methods: We assessed the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment. Plaque index scores and quantitative cultures of DPs were obtained on ICU admission. Protected BAL (PBAL) was performed on 14 patients who developed hospital-acquired pneumonia (HAP). Respiratory pathogens recovered from the PBAL fluid were compared genetically to those isolated from DPs by pulsed-field gel electrophoresis. Measurements and results: Twenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens. Staphylococcus aureus (45%) accounted for the majority of the isolates, followed by enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%). The etiology of HAP was documented in 10 patients. Of the 13 isolates recovered from PBAL fluid, nine respiratory pathogens matched genetically those recovered from the corresponding DPs of eight patients. Conclusions: These findings suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population. [ABSTRACT FROM AUTHOR]

To investigate the radiographic clearance of proven community-acquired nontuberculous bacterial pneumonia in nonimmunocompromised older patients to provide working estimates of the rate of radiographic resolution as a function of the patient cumulative comorbidities, extent of initial radiographic involvement, functional status, and causative pathogens. A prospective study. Seventy-four patients aged 70 and older, consecutively admitted to a hospital for community-acquired bacterial pneumonia. A university-affiliated teaching hospital. Chest radiographs were performed every 3 weeks from the date of admission for a total period of 12 weeks or until all radiographic abnormalities had resolved or returned to baseline. Sixty-four patients (86%) completed the study. The rate of radiographic clearance was estimated at 35.1% within 3 weeks, 60.2% within 6 weeks, and 84.2% within 12 weeks. Radiographic resolution was significantly slower for those with high comorbidity index, bacteremia, multilobar involvement, and enteric gram-negative bacilli pneumonias. Multivariate regression analysis demonstrated that the comorbidity index (relative risk for clearance=0.67 per class index, P<.001) and multilobar disease (relative risk for clearance=0.24 for more than one lobe, P<.001) had independent predictive value (Cox proportional hazards regression model) on the rate of resolution. The radiographic resolution of nontuberculous bacterial pneumonia in the elderly should take into account the extent of lobar disease and the burden of underlying illnesses. A waiting period of 12 to 14 weeks is recommended for slowly resolving pneumonia to be considered nonresolving. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop a prognostic model to predict outcome of older patients with severe pneumonia requiring mechanical ventilation. DESIGN: A nonconcurrent prospective study. SETTING: A 24-bed intensive care unit (ICU) within two university-affiliated tertiary care hospitals. PARTICIPANTS: All patients age 75 and older with severe pneumonia between June 1996 and September 1999 were included. Demographic data including activities of daily living (ADL) index score before admission, and clinical and laboratory data were collected in the first 24 hours of admission to the ICU. One hundred four patients (mean age ± standard deviation (SD) 82.3 ± 5.5 years) met the inclusion criteria. MEASUREMENTS: A classification tree was developed using binary recursive partitioning to predict hospital discharge. The model was compared with a logistic regression model using variables selected by the tree analysis and with the Acute Physiologic and Chronic Health Evaluation (APACHE) II. RESULTS: Outcome predictors for the classification tree were use of vasopressors, presence of multilobar pneumonia on chest radiograph, ratio of blood urea nitrogen to creatinine, Glasgow Coma Scale, urine output, and ADL score before admission. The tree achieved a sensitivity of 83.8% (95% confidence interval (CI) 69.2–92.4) and a specificity of 93.3% (95% CI 83–98.1). The predictive accuracy as assessed by the area under the curve (c-index ± standard error) was significantly higher with the classification tree (0.932 ± 0.03) than with logistic regression and APACHE II, (0.801 ± 0.028 and 0.711 ± 0.049, respectively (P < .05). CONCLUSIONS: The classification tree model demonstrated a superior predictive accuracy to that of logistic regression and APACHE II. If validated prospectively, the classification tree can be used as a tool to assess the outcome of older patients with severe pneumonia requiring mechanical ventilation on admission to the ICU. In... [ABSTRACT FROM AUTHOR]

Objective: To evaluate the predictive ability of three severity of illness scoring systems in elderly patients with severe pneumonia requiring mechanical ventilation compared to a younger age group.Design: Prospective cohort study.Setting: Two university-affiliated tertiary care hospitals.Patients and Participants: One hundred four patients 75 years of age and older and 253 patients younger than 75 years of age enrolled from medical intensive care units.Measurements and Results: Probabilities of hospital death for patients were estimated by the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Mortality Probability Model (MPM) II and the Simplified Acute Physiology Score (SAPS) II. Predicted risks of hospital death were compared with observed outcomes using three methods of assessing the overall goodness of fit. The actual mortality of the elderly group was 54.87 % (95 % confidence interval [CI]: 45.2-64.4 %) compared to 28.9 % (95 % CI, 23.3-34.4 %) in the younger age group. There was a significant difference in the predictive accuracy of the scoring systems as assessed by the c-index, which is equivalent to the area under the receiver operator characteristics (ROC) curve, between the two groups, but not within individual groups. Calibration was insufficient for APACHE II and SAPS II in the elderly cohort as in-hospital mortality was lower than the predicted mortality for both models.Conclusions: Although the three severity of illness scoring systems (APACHE II, MPM II and SAPS II) demonstrated average discrimination when applied to estimate hospital mortality in the elderly patients with severe pneumonia, MPM II had the closest fit to our database. Alternative modeling approaches might be needed to customize the model coefficients to the elderly population for more accurate probabilities or to develop specialized models targeted to the designed population. [ABSTRACT FROM AUTHOR]

The article presents a research that studied the effect of linezolid on methicillin-resistant Staphylococcus aureus pneumonia. The research was carried out on BALB/c mice that were inoculated with methicillin-resistant S. aureus American Type Culture Collection and then subjected to treatment with vancomycin and linezolid. After examination, it was found that linezolid did not have an advantage over vancomycin in the immune response of mice with the pneumonia.