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)

The purpose of the study was to examine risk factors for nosocomial pneumonia in the surgical and medical/respiratory intensive care unit (ICU) populations. In a public teaching hospital, all cases of nosocomial pneumonia in the surgical and medical/respiratory ICUs (n = 20, respectively) were identified by prospective surveillance during a 5-yr period from 1987-1991. Each group of ICU cases was compared with 40 ICU control patients who did not acquire pneumonia, and analyzed for 25 potential risk factors. Surgical ICU patients were found to have consistently higher rates of nosocomial pneumonia than medical ICU patients (RR = 2.2). The strongest predictor for nosocomial pneumonia in both the surgical and medical/respiratory ICU groups was found to be prolonged mechanical ventilation (> 1 d) resulting in a 12-fold increase in risk over nonventilated patients. APACHE III score was found to be predictive of nosocomial pneumonia in the surgical ICU population, but not in the medical/respiratory ICU population. We conclude that certain groups deserve special attention for infection control intervention. Surgical ICU patients with high APACHE scores and receiving prolonged mechanical ventilation may be at the greatest risk of acquiring nosocomial pneumonia of all hospitalized patients.

Risk factors for nosocomial pneumonia comparing adult critical-care populations

Actinomyces are nonmotile, filamentous, Gram-positive bacteria that cause actinomycosis in immunodeficiency patients. Although the prognosis of actinomycosis is good, the diagnosis of actinomycosis is quite difficult. Recent studies on actinomycosis have shown that Actinomyces play an important role in various biological and clinical processes, such as the formation of dental plaque and the degradation of organics in the gastrointestinal tract. Here, the distribution of Actinomyces in the digestive tract, and different biological effects of actinomycosis, and its clinical association with inflammatory diseases are discussed. Furthermore, an overview of the most commonly used treatment methods and drugs used to treat Actinomyces infected alimentary canal diseases is presented.

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Actinomyces and Alimentary Tract Diseases: A Review of Its Biological Functions and Pathology.

A 38-year-old gentleman with no significant past medical history but had recent COVID-19 exposure presented to the hospital with the chief complaints of fever, shortness of breath, and generalized myalgia. He was unfortunately found to be severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive. Laboratory findings showed creatine kinase (CK) >42,670 U/L along with elevated inflammatory markers and unremarkable creatinine, cardiac troponin level. The cause of his rhabdomyolysis was discovered to be due to COVID-19 as he had no evidence of other viral infections, strenuous exercise, seizure, or other nontraumatic exertional etiologies. He received aggressive fluid resuscitation while we trended his CK levels along with other inflammatory markers throughout his hospitalization course. His diffuse myalgia improved with treatments, and he was found to maintain stable hemodynamics and was subsequently discharged home.

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A Rare Presentation of Coronavirus Disease 2019 (COVID-19) Induced Viral Myositis With Subsequent Rhabdomyolysis

The understanding and management of Wilson disease (WD) have dramatically improved since the first description of the disease by K. Wilson more than a century ago. However, the persistent long delay between the first symptoms and diagnosis emphasizes challenges in diagnosing earlier this copper overload disorder. As a treatable disease, WD should be detected early in the course of the disease by any health professionals at any care level, but the rare prevalence of the disease explains the lack of awareness of referring physicians. The most important challenge is to train physicians to recognize atypical or rare symptoms of WD that will lead to discuss the diagnosis more systematically. Atypia can come from the age of onset, the liver [non-alcoholic steatohepatitis (NASH) presentation], the central or peripheral nervous system (neuropathy, epilepsy, sleep disorders…) or may be due to lesions of other organs (renal manifestations, osteo-articular disorders or endocrine disturbances). Isolated biological anomalies, rare radiological findings or inadequate interpretation of copper test may also lead to misdiagnosis. The second challenge is to confirm the diagnosis faster and more effectively so as not to delay the initiation of treatment, and expand family screening as the genetic prevalence is higher than previously expected. Generalization of the exchangeable copper assay and the next generation sequencing (NGS) are two promising ways to overcome this ultimate challenge. By drawing attention to the earliest and rare symptoms and to new biomarkers and diagnostic tools, we hope that this article will increase diagnostic awareness and reduce delays so that patients can start their treatment earlier in the course of the illness and thus have a better disease prognosis.

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Challenges in the diagnosis of Wilson disease.

Background
Acute Fibrinous and Organizing Pneumonia is a rare entity characterized by the histological pattern suggestive of diffuse alveolar damage, eosinophilic pneumonia and organizing pneumonia; the presence of intra alveolar “fibrin balls” distinguishes it from these conditions Herein, we describe the association of acute fibrinous and organizing pneumonia with a respiratory tract infection We believe that such an association has been extremely rarely described

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Acute fibrinous and organizing pneumonia masquerading as a lower respiratory tract infection: a case report and review of the literature.

Novel coronavirus (2019-nCoV) pandemic is currently one of the most influential topics as it not only impacts the field of medicine but most importantly, it affects the lives of many individuals throughout the world We report an interesting 2019-nCoV case in a tertiary community hospital with the initial concern of acute pyelonephritis without respiratory symptoms that ultimately led to the quarantine of a number of healthcare providers This case emphasizes the importance of radiological evidence in diagnosing 2019-nCoV in the setting of an initial atypical presentation It also serves as an example of how healthcare providers may need to increase their suspicion for COVID-19 to ensure self-protection and prompt diagnosis in the era of an ongoing pandemic

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1016&context=abingtonfp

Novel Coronavirus (2019-nCoV) in Disguise

Immunoglobulin M nephropathy (IgMN) is characterized by the deposition of immunoglobulin M in a dominant distribution in the renal glomeruli. Primary immunoglobulin M nephropathy is diagnosed after consistent light microscopy (LM), immunofluorescence (IF), electron microscopy (EM) results, and exclusion of known systemic disorders causing immunoglobulin M deposition in the glomeruli. The secondary disease has been reported with a few conditions though it has never been reported with any primary disease of the liver. We report the case of an adolescent male patient who presented with nausea, vomiting, diarrhea, and worsening anasarca. He was found to have nephrotic-range proteinuria that did not respond to conventional corticosteroid treatment. He was subjected to a renal biopsy which revealed a diagnosis of immunoglobulin M nephropathy. His liver function tests were deranged and an ultrasound scan of the abdomen revealed a coarse irregular liver. Workup revealed elevated urine copper excretion and a low ceruloplasmin level. He was diagnosed as a case of Wilson's disease and started on penicillamine and pyridoxine. He was also started on intravenous cyclophosphamide for the corticosteroid-resistant nephrotic syndrome to which he responded remarkably well. His edema settled, proteinuria resolved, and liver functions normalized. Currently, he is in remission and enjoying good health. To the best of our knowledge, we report the first known association between IgM nephropathy and Wilson's disease. It is presently not clear if causation can necessarily be established. This may be the result of defective IgM clearance by the liver or an altered metabolism of the antibody or immune complexes, as with hepatic-associated immunoglobulin M (IgM) nephropathy. Further studies are needed to elucidate the exact mechanism of this disease.

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Immunoglobulin M Nephropathy in a Patient with Wilson's Disease.

Eosinophilic granulomatosis with polyangiitis also known as Churgg-Strauss syndrome is a systemic multi system vasculitis. Neurological involvement is mostly in the form of peripheral nervous system disease. Central nervous system involvement is relatively uncommon with most cases being secondary to ischaemic infarctions. Intra cerebral haemorrhage is rare and is usually in the form of solitary haemorrhagic lesions. Multiple intra cerebral haemorrhages are exceptionally rare with only one case documented in medical literature. Here, we present the case of a middle aged male who presented to us with multiple intra cerebral haemorrhages, mono neuritis multiplex, renal and respiratory tract involvement and peripheral blood eosinophilia. Upon fulfilling the American College of Rheumatology criteria, he was diagnosed as an exceptionally rare case of EGPA with multiple intra cerebral haemorrhages. He was treated with intra venous corticosteroids and immune suppressants, and made a good recovery.

Eosinophilic granulomatosis with polyangiitis presenting with multiple intracerebral haemorrhages - A case report.

Objective: To evaluate the spectrum of ventilator-associated pneumonia (VAP) and relation of length of intensive care unit (ICU) stay, patient’s age and gender on the likelihood of being discharged from the ICU.Study Design: A cross sectional study.Place and Duration of Study: Shifa International Hospital, Islamabad, Pakistan over a period of 12 months extending, from Apr 2015 to Apr 2016.Material and Methods: We included 470 patients out of whom only 106 patients were diagnosed with VAP while on mechanical ventilation in ICU for >48 hours. A positive culture of tracheo-bronchial secretions, with any one of these; >48-h infiltrate on chest radiograph, fever of >38.3°C, leukocytosis of >12 × 109/ml and increase in tracheo-bronchial secretions established the diagnosis of VAP.Results: The mean age of the male and female patients was 49.8 ± 18 years and 50.6 ± 21.4 years respectively with 16.6 ± 13 days as the mean duration of ICU stay. About 30.2% VAP patients had Acinetoba cterbaumanni with 96.8% sensitivity to colistin, 27.4% patients had Klebsiella pneumonia with 72% and 62% sensitivity to colistin and carbapenems respectively and 15.1% patients had methicillin-resistant Staphylococcus aureus with 100% sensitivity to vancomycin. There was an increased incidence 60.4% of late-onset VAP compared to 39.6% early onset VAP. The overall mortality in VAP patients was 28.6%.Conclusion: We recommend the empirical combination therapy of colistin, carbapenem, and vancomycin in VAP. No statistical significant association was found between length of ICU stay and patient’s mortality. The odds of getting discharged were found to be 3.2 times greater for male participants as opposed to female patients. Decreasing age was associated with an increased likelihood of being discharged., , .

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Zain Ul Abideen

Papers

Acute fibrinous and organizing pneumonia masquerading as a lower respiratory tract infection: a case report and review of the literature.

Novel Coronavirus (2019-nCoV) in Disguise

Immunoglobulin M Nephropathy in a Patient with Wilson's Disease.

Eosinophilic granulomatosis with polyangiitis presenting with multiple intracerebral haemorrhages - A case report.

Spectrum of ventilator associated pneumonia with effect on intensive care unit’s patient outcome