Seminars in respiratory and critical care medicine
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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 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.
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Semin Respir Crit Care Med · Feb 2009
ReviewTackling empirical antibiotic therapy for ventilator-associated pneumonia in your ICU: guidance for implementing the guidelines.
Guidelines published jointly by the American Thoracic Society and Infectious Diseases Society of America endorse the practice of appropriate empirical antibiotic therapy for ventilator-associated pneumonia (VAP) and even provide recommendations for specific antibiotics based on whether a patient has risk factors for multidrug-resistant infections. Unfortunately, the current guidelines provide little insight into how a specific institution can best develop a strategy for providing empirical antibiotic therapy. ⋯ A proper deescalation strategy will also be vital to managing antibiotic choices and dosages, as well as providing useful recommendations for discontinuation of therapy. Finally, continued feedback of program results is critical to maintaining compliance as well as for reevaluating empirical antibiotic choices.
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Semin Respir Crit Care Med · Feb 2009
ReviewImpact of superinfection on hospital length of stay and costs in patients with ventilator-associated pneumonia.
Ventilator-associated pneumonia (VAP) increases length of stay (LOS) in VAP versus non-VAP patients, but LOS differences among VAP patients remain unexplained. We explored the economic impact of developing a respiratory superinfection while being treated for VAP. This was a retrospective, observational cohort study conducted in 74 patients discharged between January 2004 and July 2005 identified as having VAP. ⋯ Younger age (P < 0.001), admission to the surgical ICU (P = 0.004), superinfection (P = 0.002), and previous antibiotic exposure (P = 0.009) predicted increased costs (adjusted R(2) = 0.394). Mean (95% CI) LOS and total costs after contracting VAP were greater for superinfection patients [47.8 days (39.0 to 56.5) versus 27.9 (22.4 to 33.1), P < 0.001; $140,850 ($98,426 to $183,275) versus $73,801 ($58,946-$88,656), P < 0.001], with 15.6 days and $48,527 attributable to superinfection. While not affecting mortality in those patients with VAP, superinfections independently predict increased LOS after VAP ID, contributing to substantial additional cost.
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Semin Respir Crit Care Med · Feb 2009
ReviewThe alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP.
The classification of pneumonia is increasingly complex as the patient population becomes more diverse. More and more patients are identified with pneumonia attributed to multidrug-resistant (MDR) bacteria, occurring both in the hospital setting and outside of the hospital. This is likely related to the expanding pool of patients at risk for colonization with MDR bacteria. ⋯ However, the new designation for pneumonia acquired in these environments is healthcare-associated pneumonia (HCAP). Additionally, some authors have categorized patients in nursing homes as developing nursing home-acquired pneumonia (NHAP) because there may be distinct epidemiological associations with this infection. Although HCAP is currently treated with the same protocols as CAP in many hospitals, recent evidence indicates that HCAP differs from CAP with respect to pathogens and prognosis, and in fact, more closely resembles hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) requiring broader empirical antimicrobial therapy than CAP.
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Semin Respir Crit Care Med · Feb 2009
ReviewDiagnostic strategies for healthcare-associated pneumonia.
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. ⋯ 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.