Current opinion in pulmonary medicine
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Review Comparative Study
Comparing current US and European guidelines for nosocomial pneumonia.
In the last 2 years, two major guidelines for the management of nosocomial pneumonia have been published: The International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Asociación Latinoamericana de Toráx guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) and the American guidelines for management of adults with HAP and VAP; both the guidelines made important clinical recommendations for the management of patients. ⋯ American and European guidelines promote prompt and appropriate empiric treatment which is immediately guided by local microbiological data, followed by an adequate de-escalation protocol based on culture results with a 1-week course of treatment. Both also questioned the use of biomarkers in HAP/VAP, whether as part of the diagnosis or daily assessment of patients. On the contrary, they have conflicting views in regards to the optimum method of diagnosis, the risk factors used to stratify patients, the use of clinical scoring systems and the various antibiotic classes used. All were presented with varying levels of evidence to support these differences in opinion, indicating that further research into these areas is required before a consensus can be agreed upon.
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Although most patients with community-acquired pneumonia (CAP) are treated as outpatients, the majority of data regarding CAP management is provided by hospitals, either from emergency department or inpatients. This was already noted in the first CAP guidelines, published in 1993, and the challenges regarding the outpatient management of CAP persist nowadays. These include the uncertainty of the initial diagnosis and risk stratification, the empirical choice of antibiotics, the overgrowing of antibiotic resistance bacteria and the relative scarcity of novel antibiotics. ⋯ Most of CAP cases are managed in the outpatient setting. However, most research is focused on hospitalized severe patients. New and awaited advances might contribute to aid diagnosis, cause and assessment of patients with CAP in the community. This knowledge might prove decisive in improving outcomes, as well as to the execution of stewardship programs that maintain current antibiotics, safeguard future ones and reinforce prevention.
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Transmission of acute respiratory tract viral infections in healthcare environments is a major problem worldwide. We review recent literature of viruses imported to hospitals from the local community and from abroad, their modes of transmission and measures required to reduce and contain them. ⋯ Although viruses circulating in the local community are common causes of hospital outbreaks, major outbreaks have been caused by the coronaviruses imported from abroad by travelers. A high degree of clinical awareness and rapid enforcement of infection control measures are required to prevent transmission and spread.
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Bronchiectasis is a chronic respiratory disease with heterogeneous clinical manifestations and outcomes. Identifying clinical phenotypes could help in managing bronchiectasis patients and hopefully improve disease prognosis by adopting personalized treatment. We review the current literature on clinical phenotypes of bronchiectasis and try to highlight priorities for future research. ⋯ Although numerous attempts to identify clinical phenotypes in bronchiectasis have been performed, currently there is need to further investigate the host-related factors (endotypes) that surely play a determinant role in disease severity.
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Despite advances in our understanding of the obese asthma phenotype, heterogeneity and large gaps in knowledge have hindered significant advances in directed interventions. ⋯ Obesity confounds traditional asthma biomarkers and lung function measurements, thus defining obese asthma endotypes remains challenging. Novel pathways are being identified and hold promise for future targeted therapies. However, we are in dire need of updated guidelines regarding asthma diagnosis in obese patients and the development of biomarkers that more accurately identify specific endotypes.