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)

A summary of the initial management of patients admitted to hospital with suspected community acquired pneumonia (CAP) is presented in fig 8. Tables 4 and 5, respectively, summarise (1) the relevant microbiological investigations and (2) empirical antibiotic choices recommended in patients with CAP.



Figure 8 
Hospital management of community acquired pneumonia (CAP) in the first 4 h. CXR, chest x ray; DBP, diastolic blood pressure; SBP, systolic blood pressure.



View this table:

Table 4 
Recommendations for the microbiological investigation of community acquired pneumonia (CAP)



View this table:

Table 5 
Initial empirical treatment regimens for community acquired pneumonia (CAP) in adults



### Investigations ( Section 5 )

#### When should a chest radiograph be performed in the community?

1. It is not necessary to perform a chest radiograph in patients with suspected CAP unless:

2. 

#### When should a chest radiograph be performed in hospital?

1. All patients admitted to hospital with suspected CAP should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis. [D] The objective of any service should be for the chest radiograph to be performed in time for antibiotics to be administered within 4 h of presentation to hospital should the diagnosis of CAP be confirmed.

#### When should the chest radiograph be repeated during recovery?

1. The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. [D]

2. A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy (especially smokers and those aged >50 years) whether or not they have been admitted to hospital. [D]

3. Further investigations which may include bronchoscopy should be considered in patients with persisting signs, symptoms …

https://thorax.bmj.com/content/thoraxjnl/64/Suppl_3/iii1.full.pdf

BTS guidelines for the management of community acquired pneumonia in adults: update 2009.

Proteinase-activated receptors

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61404-X/pdf

Guidelines for the management of adult lower respiratory tract infections ‐ Full version

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61403-8/pdf

Guidelines for the management of adult lower respiratory tract infections - Summary

Health-Care–Associated Pneumonia Among Hospitalized Patients in a Japanese Community Hospital

Background and objective:  The initial assessment of the severity of community-acquired pneumonia (CAP) is important for patient management. The Japanese Respiratory Society (JRS) has proposed a 6-point scale (0–5) to assess the clinical severity of CAP. The A-DROP scoring system assesses the following parameters: (i) Age (male ≥ 70 years, female ≥ 75 years); (ii) Dehydration (blood urea nitrogen (BUN) ≥ 210 mg/L); (iii) Respiratory failure (SaO2 ≤ 90% or PaO2 ≤ 60 mm Hg); (iv) Orientation disturbance (confusion); and (v) low blood Pressure (systolic blood pressure ≤ 90 mm Hg). A-DROP is a modified version of CURB-65 (confusion, BUN > 7 mmol/L (200 mg/L), respiratory rate ≥ 30/min, low blood pressure (diastolic ≤ 60 mm Hg or systolic < 90 mm Hg, and age ≥ 65 years) proposed by the British Thoracic Society. However, validation of A-DROP has not been attempted nor has it been compared with CURB-65. The aim of this study was to confirm that A-DROP is equivalent to CURB-65 for predicting severity of CAP.

Methods:  A retrospective observational study was conducted of patients with CAP hospitalized at a single centre between November 2005 and January 2007. The 30-day mortality after admission was compared following assessment of severity using the A-DROP and CURB-65 scoring systems.

Results:  Three-hundred and twenty-nine patients were evaluated. The areas under the receiver operating characteristic curves were 0.846 (95% confidence interval (CI): 0.790–0.903) and 0.835 (95% CI: 0.763–0.908) for A-DROP and CURB-65, respectively.

Conclusion:  The JRS A-DROP can be used to assess severity of CAP, and gives similar results to CURB-65.

Comparison of severity scoring systems A-DROP and CURB-65 for community-acquired pneumonia.

The present study investigated mechanisms underlying apical and basolateral P2Y1-mediated Cl− secretion in human airway epithelial cells. Apical and basolateral ATP induced short-circuit currents (Isc) with different properties via P2Y1 receptors. The former comprised an immediate rise followed by a slow attenuation, whereas the latter was a transient rise with a higher peak and shorter duration (< 2 min). The actions of ATP were simulated by those of ADP, ADPβS, and ATPγS. Antagonists of phosphatidylinositol-phospholipase C (U73122, ET-18-OCH3) were without any effect on the bilateral ATP-induced Isc, which were, in contrast, attenuated by a phosphatidylcholine-phospholipase C inhibitor (D609) and an adenylate cyclase inhibitor (SQ22536). The responses to ATP from either aspect were also sensitive to an intracellular Ca2+ chelator, 1,2-bis (o-amino-phenoxy)-ethane-N,N,N′,N′-tetraacetic acid tetra-(acetoxymethyl)-ester, or a Ca2+-activated K+ channel inhibitor, charybdotoxin, although differential Ca2+ si...

https://www.atsjournals.org/doi/pdf/10.1165/rcmb.2003-0183OC

Apical and basolateral ATP-induced anion secretion in polarized human airway epithelia.

Airway mucociliary clearance is subject to the autocrine/paracrine regulation of extracellular nucleotides released from the airway epithelial cells. The present study was performed in pursuit of effective modulators of ATP release under physiologic conditions in polarized human airway epithelial cells (Calu-3). Neither isoproterenol, forskolin, nor ionomycin augmented extracellular ATP release detected by luciferase assay. However, direct activation of the human intermediate conductance, Ca2+-activated K+ channel (hIK-1) by 1-ethyl-2-benzimdazolinone (1-EBIO, 1 mM) and chlorzoxazone (CZ, 1 mM) increased ATP release predominantly in the apical compartment. Measurement of fluo-3 signals revealed that 1-EBIO– and CZ-stimulated cytosolic Ca2+ mobilization was suppressed by the presence of MRS-2179, a specific P2Y1 receptor antagonist. The hIK-1–mediated ATP release was inhibited by a hIK-1 blocker (charybdotoxin), and an Na+-K+-2Cl− cotransport blocker (bumetanide) without interruption by GdCl3, an inhibitor...

Shinji Sato

Papers

Health-Care–Associated Pneumonia Among Hospitalized Patients in a Japanese Community Hospital

Comparison of severity scoring systems A-DROP and CURB-65 for community-acquired pneumonia.

Apical and basolateral ATP-induced anion secretion in polarized human airway epithelia.

ATP release triggered by activation of the Ca2+-activated K+ channel in human airway Calu-3 cells.

Reduction of airway anion secretion via CFTR in sphingomyelin pathway.