Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto, John G. Bartlett, G. Douglas Campbell, Nathan C. Dean, Scott F. Dowell, Thomas M. File, Jr. Daniel M. Musher, Michael S. Niederman, Antonio Torres, and Cynthia G. Whitney McMaster University Medical School, Hamilton, Ontario, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, and Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas; Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; Division of Pulmonary and Critical Care Medicine, LDS Hospital, and University of Utah, Salt Lake City, Utah; Centers for Disease Control and Prevention, Atlanta, Georgia; Northeastern Ohio Universities College of Medicine, Rootstown, and Summa Health System, Akron, Ohio; State University of New York at Stony Brook, Stony Brook, and Department of Medicine, Winthrop University Hospital, Mineola, New York; and Cap de Servei de Pneumologia i Allergia Respiratoria, Institut Clinic del Torax, Hospital Clinic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain.

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Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

Infectious Diseases Society of America.

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)

John G. Bartlett,1 Scott F Dowell,2 Lionel A. Mandell,6 Thomas M. File, Jr.,3 Daniel M. Musher,4 and Michael J. Fine5 'Johns Hopkins University School of Medicine, Baltimore, Maryland, 2Centers for Disease Control and Prevention, Atlanta, Georgia, 3Northeastern Ohio Universities College of Medicine, Cleveland, Ohio, 4Baylor College of Medicine and Veterans Affairs Medical Center, Houston, Texas, and 5University of Pittsburgh, Pennsylvania, USA; and 6McMaster University, Toronto, Canada

https://www.jstor.org/stable/pdfplus/4482307.pdf

Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults

Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention.

We compared high-resolution computed tomography (HRCT) with chest radiography (CR) to determine if there is any advantage to using HRCT in the diagnosis of community-acquired pneumonia (CAP). Simultaneously obtained chest radiographs were compared with HRCT scans for 47 patients with clinical symptoms and signs suspicious for CAP, HRCT identified all 18 CAP cases (38.3%) apparent on radiographs as well as eight additional cases (i.e., 55.3%); P = .004. The corresponding figures for bilateral involvement were six by CR (33.3%) and 16 by HRCT (61.5%), P = .001. CR did not show changes particularly affecting the upper and lower lung lobes and the lingula. Bronchopneumonia was visualized by CR in 11 cases (61.1%) and by HRCT in 22 cases (84.6%). The corresponding figures for airspace pneumonia were four (22.2%) and one (3.8%), respectively. The use of HRCT seems to increase the number of CAP cases confirmed by imaging and to improve the accuracy of diagnosing and typing of CAP.

High-Resolution Computed Tomography for the Diagnosis of Community- Acquired Pneumonia

The basic feature in the pathogenesis of abdominal aortic aneurysm (AAA) is the degradation of extracellular matrix components. This process is induced partly by cytokines secreted from inflammatory and mesenchymal cells. Circulating levels of inflammatory cytokines were studied in AAA patients and compared with subjects suffering from atherosclerotic disease only. Furthermore, the predictive value of cytokine concentrations was evaluated for aneurysm expansion rate. Circulating levels of interleukin 1 beta (IL-1 beta), interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) were measured in 50 AAA patients (40 men, 10 women), 42 patients with coronary heart disease (CHD) (23 men, 19 women), and 38 controls whose angiogram was normal (17 men, 21 women). No differences in cytokine concentrations were found between the CHD patients and the controls. AAA disease was found to be associated with significantly higher IL-1 beta and IL-6 concentrations in both male patients (median concentrations of 19.40 pmol/L and 6.45 pmol/L, respectively) and female patients (19.26 pmol/L and 7.99 pmol/L) than in either the CHD patients or the controls (P < .005). TNF-alpha levels were slightly higher in the AAA patients (1.64 pmol/L in the males and 1.59 pmol/L in the females) than in the other groups (P < .05). IFN-gamma levels were elevated significantly in the female AAA patients (3.75 pmol/L) compared with levels found in the other female (P < .05) or male (P < .01) patient groups. The measured cytokine concentrations were not related to the size of the aneurysm or the maximal thickness of the thrombus within the aneurysm. IFN-gamma concentration showed a significant positive correlation to the aneurysm expansion (R = .37, P < .02) and negative correlation to the concentration of aminoterminal propeptide of type III procollagen during 6-month follow up (R = -.42, P < .005). The results show that circulating levels of inflammatory cytokines are elevated in patients with AAA disease, suggesting that the production of these cytokines is increased in these patients compared with CHD patients and controls. Elevated INF-gamma concentrations seem to predict an increased rate of expansion in AAA.

Elevated Circulating Levels of Inflammatory Cytokines in Patients With Abdominal Aortic Aneurysm

The etiology of community-acquired pneumonia during a Chlamydia pneumoniae epidemic was studied among 125 hospitalized patients. Etiologic investigations included blood and sputum cultures, pneumococcal antigen detection, and serologic investigations for common respiratory viruses and for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumococcal antigen detection, and serologic investigations for common and for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and Chlamydia species. A specific microbial agent was identified in 110 patients (88%). Some 48% of the patients had mixed infections. S. pneumoniae was the most common pathogen (55%), followed by C. pneumoniae (43%). C. pneumoniae was found both as a single etiologic agent and as a mixed infection, most often with S. pneumoniae. In conclusion, S. pneumoniae is the most common cause of community-acquired pneumonia, even during a C. pneumoniae epidemic. The organism, alone or with other pathogens (especially S. pneumoniae), may cause community-acquired pneumonia that requires hospital treatment.

The etiology of community-acquired pneumonia among hospitalized patients during a Chlamydia pneumoniae epidemic in Finland

Background. The role of viral infections in the etiology of severe community-acquired pneumonia (SCAP) was prospectively evaluated from 2008 to 2012 at a university-level intensive care unit.

Methods. Clinical data and microbiological tests were assessed: blood cultures, urine pneumococcal and legionella antigens, Mycoplasma pneumoniae and Chlamydia pneumoniae antibodies from paired serums, and respiratory virus detection by multiplex, real-time polymerase chain reaction (PCR) from nasopharyngeal swabs and lower tracheal specimens via intubation tube.

Results. Of 49 mechanically ventilated SCAP patients (21 men and 28 women; median age, 54 years), the etiology was identified in 45 cases (92%). There were 21 pure bacterial infections (43%), 5 probably pure viral infections (10%), and 19 mixed bacterial–viral infections (39%), resulting in viral etiology in 24 patients (49%). Of 26 viruses, 21 (81%) were detected from bronchial specimens and 5 (19%) from nasopharyngeal swabs. Rhinovirus (15 cases, 58%) and adenovirus (4 cases, 15%) were the most common viral findings. The bacterial–viral etiology group had the highest peak C-reactive protein levels (median, 356 [25th–75th percentiles, 294–416], P = .05), whereas patients with probably viral etiology had the lowest peak procalcitonin levels (1.7 [25th–75th percentiles, 1.6–1.7]). The clinical characteristics of pure bacterial and mixed bacterial–viral etiologies were comparable. Hospital stay was longest among the bacterial group (17 vs 14 days; P = .02).

Conclusions. Viral findings were demonstrated in almost half of the SCAP patients. Clinical characteristics were similar between the pure bacterial and mixed bacterial–viral infections groups. The frequency of viral detection depends on the availability of PCR techniques and lower respiratory specimens.

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Lower Respiratory Tract Virus Findings in Mechanically Ventilated Patients With Severe Community-Acquired Pneumonia

A complement fixation (CF) test, a micro-immunofluorescence (micro-IF) test and an enzyme immunoassay (EIA) using Re-lipopolysaccharide as antigen were compared in the diagnosis of chlamydial infection in 136 mainly elderly patients hospitalized with community-acquired pneumonia during aChlamydia pneumoniae epidemic in Finland in 1986–1987. Chlamydial pneumonia was diagnosed in 58 (42.6 %) of the 136 pneumonia patients; 44 (75.9 %) of them could be shown by micro-IF to be caused byChlamydia pneumoniae, three byChlamydia psittaci and four byChlamydia spp. Only 5 (11.4 %) of 44 patients withChlamydia pneumoniae pneumonia were IgM-positive, indicating that the majority of cases were reinfections. In this population of mainly elderly patients the CF test was insensitive, being positive in only 6 (10.3 %) of 58 cases of chlamydial pneumonia. The EIA detected 72.4 % of cases and micro-IF 87.9 % of cases (including infections withChlamydia pneumoniae, Chlamydia psittaci andChlamydia spp.). In the EIA 77 % of positive cases were positive in serum samples taken a week apart, whereas the corresponding figure for micro-IF was 50 %. In micro-IF the measurement of IgA antibody levels is recommended and IgM-positive sera should be retested after removal of IgG antibody to avoid false-positive findings due to presence of rheumatoid factor. The collection of a third serum sample, for instance one month after onset, is also recommended, since half of the patients showed a diagnostic response in the micro-IF only in the sera taken one month apart.

Hannu Syrjälä

Papers

High-Resolution Computed Tomography for the Diagnosis of Community- Acquired Pneumonia

Elevated Circulating Levels of Inflammatory Cytokines in Patients With Abdominal Aortic Aneurysm

The etiology of community-acquired pneumonia among hospitalized patients during a Chlamydia pneumoniae epidemic in Finland

Lower Respiratory Tract Virus Findings in Mechanically Ventilated Patients With Severe Community-Acquired Pneumonia

Evaluation of serological methods in the diagnosis of Chlamydia pneumoniae pneumonia during an epidemic in Finland.