Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2-10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized. In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.

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Guidelines for Preventing Health-Care-- Associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

Substantial efforts have been devoted to improving the means for early and accurate diagnosis of ventilator-associated (VA) pneumonia in intensive care unit (ICU) patients because of its high incidence and mortality. A good diagnostic yield has been reported from quantitative cultures of bronchoalveolar lavage (BAL) fluid or a protected specimen brush, both obtained by fiberoptic bronchoscopy. As bronchoscopy requires specific skills and is costly, we evaluated a simpler method to obtain BAL fluid, that is, by a catheter introduced blindly into the bronchial tree. Quantitative cultures from bronchoscopically sampled BAL (B-BAL) and blindly nonbronchoscopically collected BAL (NB-BAL) were assessed for sensitivity, specificity, and predictive value for the diagnosis of VA pneumonia. A total of 40 pairs of samples were examined in 28 patients requiring prolonged mechanical ventilation and presenting a high risk of developing pneumonia. For comparison with bacteriologic data we defined a clinical score for pn...

/pdf/diagnosis-of-ventilator-associated-pneumonia-by-1fyxfh7dt5.pdf

Diagnosis of Ventilator-associated Pneumonia by Bacteriologic Analysis of Bronchoscopic and Nonbronchoscopic “Blind” Bronchoalveolar Lavage Fluid

Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia

This Task Force was supported and endorsed by the following Societies: European Respiratory Society, European Society of Intensive Care Medicine, European Society of Clinical Microbiology and Infectious Diseases and European Society of Anaesthesiology.

⇓In the last decade, considerable investigational efforts have been made in the field of the management of ventilator-associated pneumonia (VAP). Several studies have provided important insights into the relationship of histology and bacteriology of VAP, which remain fundamental for all future research. Moreover, epidemiological research has allowed establishment of concepts for empiric initial antimicrobial treatment that are expected to improve clinical outcomes. Important contributions have also been made regarding prevention of VAP.



Fig. 1.— 

However, despite these advances, the majority of issues related to the management of VAP remain unresolved and are subject to controversy. This is particularly true for the diagnostic evaluation of the patient with suspected VAP. The lack of consensus regarding the best way to diagnose VAP explains in part why incidence rates vary widely from one study to another, from 5 to >50% of mechanically ventilated intensive care unit (ICU) patients.

In this review, a panel of experts in the field of VAP from four European societies has tried to provide an overview of the most important aspects under debate. In order to stimulate further research and discussion, presentation of the main topics was focussed on the breaking current knowledge. The issue of attributable mortality, which is also a matter of controversy, will not be addressed in this review. Each section of the review has been written in an attempt to answer three main questions: 1) what is not controversial, 2) what is still controversial and 3) what should be investigated? The following topics were reviewed: clinical diagnosis, bacteriological and histological aspects, aetiology, diagnostic techniques, antimicrobial treatment and prevention.

#### What is not controversial?

Clinical criteria for the diagnosis …

https://erj.ersjournals.com/content/erj/17/5/1034.full.pdf

Ventilator-associated pneumonia

We compared the diagnostic value of quantitative cultures of bronchoalveolar lavage (BAL) and telescoping plugged catheter (TPC) samples in 34 nonimmunocompromised, mechanically ventilated (MV) patients with suspected bacterial pneumonia. A control group of seven “noninfected” MV patients was also studied. In 92% of patients with bacterial pneumonia (32 of 34), simple endotracheal aspiration samples recovered one or more microorganisms. Both BAL and TPC samples cultured colony-forming units (cfu) ⩾ 103/ml of one or more microorganisms in 56% (19 of 34) of patients. TPC and BAL culture results agreed on 88.5% (54 of 61) of the recovered microorganisms. Sterile TPC and BAL cultures agreed on 80% (4 of 5) of the cases. Microorganisms cultured from blood samples were also cultured from BAL and TPC specimens. Culture results from the two techniques completely disagreed in only one case (3%). In the control group, one TPC and two BAL cultures yielded microorganisms in cfu ⩾ 103/ml. Specificities of BAL and TPC ...

Diagnostic Value of Quantitative Cultures of Bronchoalveolar Lavage and Telescoping Plugged Catheters in Mechanically Ventilated Patients with Bacterial Pneumonia

Albert Agustí Vidal

Papers

Diagnostic Value of Quantitative Cultures of Bronchoalveolar Lavage and Telescoping Plugged Catheters in Mechanically Ventilated Patients with Bacterial Pneumonia