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)

Timothy H. Dellit, Robert C. Owens, John E. McGowan, Jr., Dale N. Gerding, Robert A. Weinstein, John P. Burke, W. Charles Huskins, David L. Paterson, Neil O. Fishman, Christopher F. Carpenter, P. J. Brennan, Marianne Billeter, and Thomas M. Hooton Harborview Medical Center and the University of Washington, Seattle; Maine Medical Center, Portland; Emory University, Atlanta, Georgia; Hines Veterans Affairs Hospital and Loyola University Stritch School of Medicine, Hines, and Stroger (Cook County) Hospital and Rush University Medical Center, Chicago, Illinois; University of Utah, Salt Lake City; Mayo Clinic College of Medicine, Rochester, Minnesota; University of Pittsburgh Medical Center, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; William Beaumont Hospital, Royal Oak, Michigan; Ochsner Health System, New Orleans, Louisiana; and University of Miami, Miami, Florida

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Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship

Summary of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship

Antibiotic use plays a major role in the emerging public health crisis of antibiotic resistance. Although the majority of antibiotic use occurs in agricultural settings, relatively little attention has been paid to how antibiotic use in farm animals contributes to the overall problem of antibiotic resistance. The aim of this review is to summarize literature on the role of antibiotics in the development of resistance and its risk to human health. We searched multiple databases to identify major lines of argument supporting the role of agricultural antibiotic use in the development of resistance and to summarize existing regulatory and policy documents. Several lines of reasoning support the conclusion that agricultural antibiotics are associated with resistance, yet most public policy is based on expert opinion and consensus. Finally, we propose strategies to address current gaps in knowledge.

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A review of antibiotic use in food animals: perspective, policy, and potential.

Background
Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

Objectives
To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.

To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

Search methods
For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

Selection criteria
We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

Data collection and analysis
Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

Main results
The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

Authors' conclusions
The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

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Printed educational materials: effects on professional practice and healthcare outcomes

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.

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Impact of statewide program to promote appropriate antimicrobial drug use.

Adolescents working in agricultural settings may be exposed to noise levels that result in hearing loss. The article describes the design, implementation, and results of a four-year, hearing conservation program (HCP) conducted at school. Thirty-four schools (753 students) were randomly assigned to either an intervention or control group. The intervention included multicomponent educational strategies and employed features of an industrial HCP. Final compliance surveys indicated 87.5% of intervention students reported using hearing protection devices (HPD) at least some of the time, compared to 45% of control students. The HCP components with the greatest reported influence were distribution of HPDs for use on the farm and yearly hearing tests. Eighty percent of intervention students reported intention to use HPDs in the future. It is feasible to conduct a hearing conservation program with junior high school and senior high school students, and it appears possible to persuade teen-agers to protect themselves from exposure to loud noise while working on a farm.

A Hearing Conservation Program for Wisconsin Youth Working in Agriculture

Background: Parent education is an integral component to promoting judicious antibiotic use. Opportunities to educate parents directly are limited. Child care providers are in a position to relay information to parents. Methods: A group-randomized trial assessed the impact of a child care center staff intervention on parental knowledge and attitudes regarding appropriate antibiotic use. A 9-point knowledge score and 3 attitude items were measured. Results: Surveys were returned by 151 (51%) of 298 intervention center parents and 150 (42%) of 361 control center parents. Intervention center respondents were significantly more likely than control center respondents to be college graduates, non-Hispanic white, and insured. Among college graduates, the median knowledge score was 7.0 at intervention centers and 6.5 at control centers (P<0.01). No significant differences were found in knowledge scores among noncollege educated parents (P=0.11). After adjusting for clustering within child care centers, multivariate analysis demonstrated high knowledge score was associated with white race (P=0.02), being a college graduate (P=0.02), and being in the intervention group (P=0.06). Conclusion: An appropriate antibiotic use program for child care providers promotes better knowledge among parents of children aged <5 years, particularly among highly educated parents.

Impact of a child care educational intervention on parent knowledge about appropriate antibiotic use.

Hearing conservation program for agricultural students: Short-term outcomes from a cluster-randomized trial with planned long-term follow-up

OBJECTIVES: We had the rare opportunity to conduct a cluster-randomized controlled trial to observe the long-term (16-year) effects of a well-designed hearing conservation intervention for rural high school students. This trial assessed whether the intervention resulted in (1) reduced prevalence of noise-induced hearing loss (NIHL) assessed clinically and/or (2) sustained use of hearing protection devices. METHODS: In 1992–1996, 34 rural Wisconsin schools were recruited and 17 were assigned randomly to receive a comprehensive, 3-year, hearing conservation intervention. In 2009–2010, extensive efforts were made to find and contact all students who completed the original trial. Participants in the 16-year follow-up study completed an exposure history questionnaire and a clinical audiometric examination. Rates of NIHL and use of hearing protection were compared. RESULTS: We recruited 392 participants from the original trial, 200 (53%) from the intervention group and 192 (51%) from the control group. Among participants with exposure to agricultural noise, the intervention group reported significantly greater use of hearing protection compared with the control group (25.9% vs 19.6%; P = .015). The intervention group also reported significantly greater use of hearing protection for shooting guns (56.2% vs 41.6%; P = .029), but the groups reported similar uses of protection in other contexts. There was no significant difference between groups with respect to objective measures of NIHL. CONCLUSION: This novel trial provides objective evidence that a comprehensive educational intervention by itself may be of limited effectiveness in preventing NIHL in a young rural population.

Mary Jo Knobloch

Papers

Impact of statewide program to promote appropriate antimicrobial drug use.

A Hearing Conservation Program for Wisconsin Youth Working in Agriculture

Impact of a child care educational intervention on parent knowledge about appropriate antibiotic use.

Hearing conservation program for agricultural students: Short-term outcomes from a cluster-randomized trial with planned long-term follow-up

Randomized Trial of a Hearing Conservation Intervention for Rural Students: Long-term Outcomes