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)

Hospital-acquired infections are most commonly associated with mechanical ventilation, invasive medical devices, or surgical procedures. Gram-negative bacteria are responsible for more than 30% of hospital-acquired infections and predominate in hospital-acquired pneumonia. They are highly efficient at up-regulating or acquiring mechanisms of antibiotic drug resistance, especially in the presence of antibiotic selection pressure. This review updates what clinicians should know about these often life-threatening infections.

/pdf/hospital-acquired-infections-due-to-gram-negative-bacteria-3ctqtxi861.pdf

Hospital-Acquired Infections Due to Gram-Negative Bacteria

SUMMARY Sepsis is among the most common causes of death in hospitals. It arises from the host response to infection. Currently, diagnosis relies on nonspecific physiological criteria and culture-based pathogen detection. This results in diagnostic uncertainty, therapeutic delays, the mis- and overuse of antibiotics, and the failure to identify patients who might benefit from immunomodulatory therapies. There is a need for new sepsis biomarkers that can aid in therapeutic decision making and add information about screening, diagnosis, risk stratification, and monitoring of the response to therapy. The host response involves hundreds of mediators and single molecules, many of which have been proposed as biomarkers. It is, however, unlikely that one single biomarker is able to satisfy all the needs and expectations for sepsis research and management. Among biomarkers that are measurable by assays approved for clinical use, procalcitonin (PCT) has shown some usefulness as an infection marker and for antibiotic stewardship. Other possible new approaches consist of molecular strategies to improve pathogen detection and molecular diagnostics and prognostics based on transcriptomic, proteomic, or metabolic profiling. Novel approaches to sepsis promise to transform sepsis from a physiologic syndrome into a group of distinct biochemical disorders and help in the development of better diagnostic tools and effective adjunctive sepsis therapies.

New Approaches to Sepsis: Molecular Diagnostics and Biomarkers

There are a number of limitations to using conventional diagnostic markers for patients with clinical suspicion of infection. As a consequence, unnecessary and prolonged exposure to antimicrobial agents adversely affect patient outcomes, while inappropriate antibiotic therapy increases antibiotic resistance. A growing body of evidence supports the use of procalcitonin (PCT) to improve diagnosis of bacterial infections and to guide antibiotic therapy. For patients with upper and lower respiratory tract infection, post-operative infections and for severe sepsis patients in the intensive care unit, randomized-controlled trials have shown a benefit of using PCT algorithms to guide decisions about initiation and/or discontinuation of antibiotic therapy. For some other types of infections, observational studies have shown promising first results, but further intervention studies are needed before use of PCT in clinical routine can be recommended. The aim of this review is to summarize the current evidence for PCT in different infections and clinical settings, and discuss the reliability of this marker when used with validated diagnostic algorithms.

/pdf/procalcitonin-for-diagnosis-of-infection-and-guide-to-1mz5bxe7l9.pdf

Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future.

Purpose
Colloids are administered to more patients than crystalloids, although recent evidence suggests that colloids may possibly be harmful in some patients. The European Society of Intensive Care Medicine therefore assembled a task force to compile consensus recommendations based on the current best evidence for the safety and efficacy of the currently most frequently used colloids—hydroxyethyl starches (HES), gelatins and human albumin.

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

Background: Procalcitonin (PCT) has been increasingly used as an inflammatory marker to identify patients with systemic infection. Moreover, PCT guidance allowed significant reduction of antibiotic therapy in patients with respiratory disease. The aim of this qualitative review was, therefore, to evaluate the role of PCT measurements in febrile neutropenic patients in differentiating between various causes of fever and to investigate the value of PCT levels in terms of diagnosing infection or predicting outcome in these patients. 

Patients and methods: A MEDLINE search was performed using the keyword 'procalcitonin' crossed with 'febrile neutropenia', 'neutropenia', 'fever', 'bone marrow transplantation', and 'stem cell transplantation', and limited to human studies published between January 1990 and October 2006. Bibliographies of identified articles were also searched. Predefined variables were collected from the articles, including year of publication, study design, number of patients included, age group, disease group, markers other than PCT, and study results. 

Results: From the 30 articles included, PCT seems to be able to discriminate fever due to systemic forms of infection from non-infectious etiologies. Patients with fungal infection may have a delayed increase in PCT levels. PCT has a minimal role, if any, in discriminating Gram-negative from Gram-positive infections. PCT may be useful in outcome prediction in patients with febrile neutropenia but is not superior to interleukin-6 or C-reactive protein concentrations for this purpose. 

Conclusions: Despite lack of standard definitions, heterogeneity of study populations, and small numbers of patients included in some studies, our review provides important insight into the value of PCT as a diagnostic and prognostic tool in patients with febrile neutropenia.

/pdf/the-role-of-procalcitonin-in-febrile-neutropenic-patients-2u6intijmx.pdf

The Role of Procalcitonin in Febrile Neutropenic Patients: Review of the Literature

/pdf/effects-of-hydroxyethyl-starch-and-gelatin-solutions-on-58rq9t4csl.pdf

Effects of hydroxyethyl starch and gelatin solutions on renal function in surgical intensive care unit patients

Purpose
To compare the effects of predominantly hydroxyethyl starch (HES 6% 130/0.4)-based with predominantly gelatin 4%-based fluid therapy on renal function in surgical intensive care unit (ICU) patients.

Effects of a predominantly hydroxyethyl starch (HES)-based and a predominantly non HES-based fluid therapy on renal function in surgical ICU patients

Early, accurate diagnosis is fundamental in the management of patients with ventilator-associated pneumonia (VAP). The aim of this qualitative review was to compare various criteria of diagnosing VAP in the intensive care unit (ICU) with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response. A MEDLINE search was performed using the keyword 'ventilator associated pneumonia' AND 'diagnosis'. Our search was limited to human studies published between January 1966 and June 2007. Only studies of at least 25 adult patients were included. Predefined variables were collected, including year of publication, study design (prospective/retrospective), number of patients included, and disease group. Of 572 articles fulfilling the initial search criteria, 159 articles were chosen for detailed review of the full text. A total of 64 articles fulfilled the inclusion criteria and were included in our review. Clinical criteria, used in combination, may be helpful in diagnosing VAP, however, the considerable inter-observer variability and the moderate performance should be taken in account. Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP. Blood cultures are relatively insensitive to diagnose pneumonia. The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP. C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP. An integrated approach should be followed in diagnosing and treating patients with VAP, including early antibiotic therapy and subsequent rectification according to clinical response and results of bacteriologic cultures.

/pdf/diagnosis-of-ventilator-associated-pneumonia-a-systematic-40t4weo594.pdf

Diagnosis of ventilator-associated pneumonia: a systematic review of the literature

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Papers

The Role of Procalcitonin in Febrile Neutropenic Patients: Review of the Literature

Effects of hydroxyethyl starch and gelatin solutions on renal function in surgical intensive care unit patients

Effects of a predominantly hydroxyethyl starch (HES)-based and a predominantly non HES-based fluid therapy on renal function in surgical ICU patients

Diagnosis of ventilator-associated pneumonia: a systematic review of the literature