Japanese Respiratory Society Guidelines Research Articles

Management of the Diagnosis and Treatment of Pneumonia in an Aging Society.

The diagnosis of pneumonia is based on respiratory and systemic symptoms, blood test findings, chest radiographic findings, and the condition of the patient. Physicians in aging or aged societies such as Japan carefully evaluate the comprehensive situation of each pneumonia patient with adequate evaluation and treatment according to "the Japanese Respiratory Society guidelines for the management of pneumonia in adults in 2024". These guidelines categorize pneumonia into three types: community-acquired, nursing- and healthcare-associated, and hospital-acquired. The selection of treatment settings and empirical antimicrobials for pneumonia depends on pneumonia classification, severity, and risk factors for potential drug-resistant bacteria, as outlined in the JRS guidelines. This review concisely describes the historical evolution of the diagnosis and treatment of pneumonia in elderly societies, including aspiration pneumonia, from multiple perspectives. In addition, it explores the differential diagnoses when antimicrobial treatment for pneumonia is ineffective, highlighting key aspects through chest radiography and computed tomography.

Interstitial lung disease with and without progressive fibrosing phenotype in patients with idiopathic inflammatory myopathies: data from a large multicentric cohort

ObjectivesPatients with connective tissue diseases can develop interstitial lung disease (ILD), leading to a progressive fibrosing ILD (PF-ILD) phenotype in some cases. We aimed to investigate the occurrence of PF-ILD...

Questionnaire for diagnosing asthma-COPD overlap in COPD: Development of ACO screening questionnaire (ACO-Q)

BackgroundThe considerable prevalence and worse outcomes of asthma-COPD overlap (ACO) in COPD have been reported, and optimal introduction of ICS is essential for ACO. However, diagnostic criteria for ACO consist of multiple laboratory tests, which is challenging during this COVID-19 era. The purpose of this study was to create a simple questionnaire to diagnose ACO in patients with COPD. MethodsAmong 100 COPD patients, 53 were diagnosed with ACO based on the Japanese Respiratory Society Guidelines for ACO. Firstly, 10 candidate questionnaire items were generated and further selected by a logistic regression model. An integer-based scoring system was generated based on the scaled estimates of items. ResultsFive items, namely a history of asthma, wheezing, dyspnea at rest, nocturnal awakening, and weather- or season-dependent symptoms, contributed significantly to the diagnosis of ACO in COPD. History of asthma was related to FeNO >35 ppb. Two points were assigned to history of asthma and 1 point to other items in the ACO screening questionnaire (ACO-Q), and the area under the receiver operating characteristic curve was 0.883 (95% CI: 0.806–0.933). The best cutoff point was 1 point, and the positive predictive value was 100% at a cutoff of 3 points or higher. The result was reproducible in the validation cohort of 53 patients with COPD. ConclusionsA simple questionnaire, ACO-Q, was developed. Patients with scores ≥3 could be reasonably recommended to be treated as ACO, and additional laboratory testing would be recommended for patients with 1 and 2 points.

Development and implementation of an aspiration pneumonia cause investigation algorithm.

The diagnostic criteria of aspiration pneumonia have not been established, and it remains an underdiagnosed entity. Diagnosis and cause investigation is essential in improving the management of aspiration pneumonia. The Japanese Respiratory Society Guidelines for the Management of Pneumonia in Adults (JRS Guidelines) show a list of risk factors for aspiration pneumonia. We developed an algorithm to aid physicians in evaluating these possible underlying factors and guide their management with a focus on aspiration pneumonia. The algorithm was developed based on the JRS Guidelines. The algorithm suggested dysphagia screening, pneumococcal and influenza vaccination, and other preventative measures for pneumonia. The algorithm was implemented in the acute setting of a general hospital among olderpatients admitted with pneumonia. Their outcomes were compared with a historical control group constituting similar patients from the previous year. Forty patients with pneumonia were assessed with the algorithm group, and 44 patients were included in the control group. In the algorithm group, significantly more cases (95.0% vs. 15.9%, p < 0.01) underwent early screening for a swallowing disorder. Two patients in the algorithm group were diagnosed with a new condition causing aspiration pneumonia, as opposed to none in the control group. Drugs with a potential risk for aspiration were identified and discontinued in 27.5% of the patients in the algorithm group and 4.5% in the control group. In conclusion, an aspiration pneumonia cause investigation algorithm translating the JRS guideline approach into practice enhanced the rate of swallow screening and preventative measures for aspiration.

Corrigendum to “The Japanese Respiratory Society guidelines may reduce unnecessary chest computed tomography in patients with pneumonia requiring hospitalization: A retrospective study” [Respir. Investig. 60 (2022) 264–270

Corrigendum to “The Japanese Respiratory Society guidelines may reduce unnecessary chest computed tomography in patients with pneumonia requiring hospitalization: A retrospective study” [Respir. Investig. 60 (2022) 264–270

A phase 3, randomized, double-blind, clinical study to evaluate the long-term safety and efficacy of gefapixant in Japanese adult participants with refractory or unexplained chronic cough

BackgroundIn two phase 3, global clinical trials (COUGH-1 and COUGH-2), the P2X3-receptor antagonist gefapixant significantly reduced objective 24-h cough frequency in participants with refractory or unexplained chronic cough (RCC or UCC) at a dosage of 45 mg twice daily (BID), with an acceptable safety profile. The primary objective of this phase 3, randomized, double-blind, parallel-group study was to assess the safety and tolerability of gefapixant in Japanese participants with RCC or UCC (ClinicalTrials.gov, NCT03696108; JAPIC-CTI, 184154). MethodsParticipants aged ≥20 years with chronic cough lasting ≥4 months and a diagnosis of RCC or UCC despite treatment in accordance with Japanese Respiratory Society guidelines were randomized 1:1 to receive gefapixant 15 or 45 mg BID for 52 weeks. The primary objective was to evaluate the safety and tolerability of gefapixant, including adverse events (AEs) and discontinuations due to AEs. Cough-specific quality of life was assessed using the Leicester Cough Questionnaire as a secondary objective. ResultsOf 169 randomized and treated participants, 63% were female and mean age was 58 years. Adverse events were reported by 79 (94%) and 82 (96%) participants in the 15- and 45-mg BID groups, respectively. Most treatment-related AEs were taste related. Discontinuations due to AEs occurred in 6 (7%) and 17 (20%) participants receiving gefapixant 15 or 45 mg BID, respectively. There were no serious treatment-related AEs or deaths. Leicester Cough Questionnaire total scores improved from baseline through Week 52. ConclusionsGefapixant had an acceptable safety profile, with no serious treatment-related AEs in Japanese participants.

The Japanese Respiratory Society guidelines may reduce unnecessary chest computed tomography in patients with pneumonia requiring hospitalization: A retrospective study.

With the abundance of CT scanners in Japan, doctors can easily order CT scans to diagnose pneumonia. The Japanese Respiratory Society (JRS) guidelines uniquely recommend conditions for which additional CT scans should be considered at the time of diagnosis of pneumonia, a feature not found in other guidelines. In this study, we aimed to evaluate the usefulness of the recommendations in a bid to reduce the number of unnecessary CT examinations. We retrospectively reviewed the electronic medical records of consecutive patients with pneumonia hospitalized between April 2016 and March 2017 to extract patients' backgrounds and clinical courses. Conformity with the JRS guideline recommendations was also examined. In the patients who did not meet the recommendations, we investigated the proportion of them for whom an additional CT scan influenced the clinical decisions. Finally, we evaluated whether there was a difference in hospital stay depending on the additional chest CT at the time of admission. We included 363 hospitalized patients with pneumonia. Chest CT scan was performed in 306 patients (84.3%), of whom 186 (60.8%) did not meet the JRS guideline recommendations. Chest CT revealed findings requiring a change in treatment strategy in only 14 (7.5%) of the 186 patients. Among the 240 patients (66.1%) who did not meet the recommendations, no statistically significant difference was observed in the hospital stay or mortality between patients with and without CT scans. Adherence to the JRS guideline recommendations may reduce the excessive use of CT scans in the diagnosis of pneumonia.

Clinical Differences between Community-Acquired Mycoplasma pneumoniae Pneumonia and COVID-19 Pneumonia.

Mycoplasmapneumoniae is one of the major causative pathogens of community-acquired pneumonia (CAP). M. pneumoniae CAP is clinically and radiologically distinct from bacterial CAPs. One feature of the Japanese Respiratory Society (JRS) guidelines is a trial to be carried out to differentiate between M. pneumoniae pneumonia and bacterial pneumonia for the selection of antibiotics. The purpose of the present study was to clarify the clinical and radiological differences of the M. pneumoniae CAP and coronavirus disease 2019 (COVID-19) CAP. This study was conducted at 5 institutions and assessed a total of 210 patients with M. pneumoniae CAP and 956 patients with COVID-19 CAP. The median age was significantly younger in patients with M. pneumoniae CAP than COVID-19 CAP. Among the clinical symptoms, cough and sputum were observed more frequently in patients with M. pneumoniae CAP than those with COVID-19 CAP. However, the diagnostic specificity of these findings was low. In contrast, loss of taste and anosmia were observed in patients with COVID-19 CAP but not observed in those with M. pneumoniae CAP. Bronchial wall thickening and nodules (tree-in-bud and centrilobular), which are chest computed tomography (CT) features of M. pneumoniae CAP, were rarely observed in patients with COVID-19 CAP. Our results demonstrated that there were two specific differences between M. pneumoniae CAP and COVID-19 CAP: (1) the presence of loss of taste and/or anosmia and (2) chest CT findings.

Antibiotics prescriptions for pneumonia analyzed by claim information in Japan

OBJECTIVE Japan is an aging society, and pneumonia is the leading cause of death, but the suitability of antibiotics for treating community-acquired pneumonia (CAP) in Japan is not clear. The purpose of this study was to investigate antibacterial drugs for treating CAP according to age. MATERIALS AND METHODS Using the Japanese national database from 2011 to 2014, we analyzed the usage of antibiotics for CAP according to age. RESULTS The numbers of claim information were 9,386, and 70% of the patients were aged ≥ 75 years. Sulbactam/ampicillin (SBT/ABPC) or ceftriaxone (CTRX) was used in 60%, but broad-spectrum antibiotics, combination therapy, and anti-mycoplasma antibiotics were used in 15 - 28% of all age groups. The 30-day survival rate did not differ between SBT/ABPC or CTRX vs. others. There was no difference in 30-day mortality and risk in any group between the ages of 15 and 64 years. On the other hand, the use of anti-mycoplasma antibiotics reduced the 30-day mortality by 0.50 times (p < 0.01), and the use of two or more antibiotics increased the 30-day mortality by 1.45 times (p = 0.02) at age ≥ 65 years. CONCLUSION Approximately half of the antibiotics used for CAP requiring hospitalization consisted of CTRX or SBT/ABPC as recommended by the Japanese Respiratory Society (JRS) guidelines. On the other hand, the usage of broad-spectrum antibiotics and combination therapy were relatively frequent at all ages, although their use does not always contribute to survival. Our data provide basic information for analyzing the outcome of pneumonia treatment in terms of an antimicrobial resistance action plan in Japan.

The Japanese respiratory society guidelines for the management of cough and sputum (digest edition)

Cough and sputum are common complaints at outpatient visits. In this digest version, we provide a general overview of these two symptoms and discuss the management of acute (up to three weeks) and prolonged/chronic cough (longer than three weeks). Flowcharts are provided, along with a step-by-step explanation of their diagnosis and management. Most cases of acute cough are due to an infection. In chronic respiratory illness, a cough could be a symptom of a respiratory infection such as pulmonary tuberculosis, malignancy such as a pulmonary tumor, asthma, chronic obstructive pulmonary disease, chronic bronchitis, bronchiectasis, drug-induced lung injury, heart failure, nasal sinus disease, sinobronchial syndrome, eosinophilic sinusitis, cough variant asthma (CVA), atopic cough, chronic laryngeal allergy, gastroesophageal reflux (GER), and post-infectious cough. Antibiotics should not be prescribed for over-peak cough but can be considered for atypical infections. The exploration of a single/major cause is recommended for persistent/chronic cough. When sputum is present, a sputum smear/culture (general bacteria, mycobacteria), cytology, cell differentiation, chest computed tomography (CT), and sinus X-ray or CT should be performed. There are two types of rhinosinusitis. Conventional sinusitis and eosinophilic rhinosinusitis present primarily with neutrophilic inflammation and eosinophilic inflammation, respectively. The most common causes of dry cough include CVA, atopic cough/laryngeal allergy (chronic), GER, and post-infectious cough. In the last chapter, future challenges and perspectives are discussed. We hope that the clarification of the pathology of cough hypersensitivity syndrome will lead to further development of "pathology-specific non-specific therapeutic drugs" and provide benefits to patients with chronic refractory cough.

Laryngeal allergy.

Many patients with allergic rhinitis have accompanying laryngeal symptoms such as persistent cough and/or globus. Chronic laryngeal allergy is suspected to be an important cause of these laryngeal symptoms. We have been working toward establishing the concept of a new pathological condition termed “laryngeal allergy” since 1988. In Japan, the first diagnostic criteria for laryngeal allergy were established in 1995. However, these early criteria were inadequate because there was inadequate distinction between laryngeal allergy and other causes of persistent cough and globus. Therefore, more advanced criteria were reconstructed from a completely different viewpoint in 2005 to correctly distinguish laryngeal allergy from other similar diseases. The criteria established in 2005 were modified slightly in 2011 to improve the diagnostic accuracy based on the results of fundamental and clinical investigations. The Japanese Respiratory Society (JRS) included chronic laryngeal allergy in the diagnostic flowchart of the JRS guidelines for the management of cough and sputum in 2019, and chronic laryngeal allergy has recently gained wider recognition in Japan. The accurate diagnosis of conditions resembling laryngeal allergy is important in controlling cough and/or globus and preventing the unnecessary use of medical resources. Therefore, further investigations are warranted to better understand laryngeal allergy and similar diseases.

Antibiotic de-escalation therapy in patients with community-acquired nonbacteremic pneumococcal pneumonia.

Background De-escalation therapy is recommended as an effective antibiotic treatment strategy for several infectious diseases. While there is limited evidence supporting its clinical and cost-effective outcomes in patients with community-acquired bacteremic pneumonia, there is no evidence in patients with nonbacteremic pneumonia. Objective This study aimed to evaluate the antibiotic costs in patients who did and did not receive de-escalation therapy, based on the 2017 Japanese guidelines for the management of community-acquired nonbacteremic pneumococcal pneumonia of the Japanese Respiratory Society (JRS). Setting Kobeuniversity hospital, Japan. Methods A retrospective case series review including antibiotic use and length of hospital stay was conducted using the medical records from April 2008 to May 2019 at a university hospital in Japan. Main outcome measure Impact of antibiotic de-escalation therapy on the antibiotic costs. Results Among 55 patients who were eligible, the treating physicians de-escalated antibiotics in 28 (51%). The differences in the median length of hospital stay and the incidence of adverse drug reactions between the two groups were not statistically significant (p = 0.67 and 1.0, respectively). However, the median total antibiotic cost per infected patient in the de-escalated group was significantly lower than that in the non-de-escalated group [$269.8 ($195-$389) vs. $420.5 ($221-$799), p = 0.048]. Conclusion Antibiotic de-escalation based on the 2017 JRS guidelines leads to a reduction in total antibiotic costs for the management of community-acquired nonbacteremic pneumococcal pneumonia.

The prevalence and clinical features of asthma-COPD overlap (ACO) definitively diagnosed according to the Japanese Respiratory Society Guidelines for the Management of ACO 2018.

Background Asthma-COPD overlap (ACO) is a disease that shares clinical features of both asthma and COPD. The purpose of this study is to investigate the prevalence and clinical features of ACO. Methods We retrospectively reviewed data for 170 patients with persistent airflow limitation and diagnosed them according to "The Japanese Respiratory Society Guidelines for the Management of ACO 2018". Results Of the 170 patients, 111 were diagnosed as follows : COPD (74 patients, 66.6%), ACO (34 patients, 30.6%), and asthma (3 patients, 2.8%). There was no significant difference in clinical features between ACO and COPD patients. The following pulmonary function tests were significantly lower in ACO than in COPD patients : forced expiratory volume in 1 second/forced vital capacity, peak expiratory flow, maximal mid-expiratory flow, and the maximum expiratory flow at 50%and75%. The following respiratory impedance parameters were significantly higher in ACO than in COPD patients : respiratory resistance (Rrs) at 5 Hz (R5), Rrsat 20 Hz (R20), R5-R20, and low-frequency reactance area. Conclusions About 30% of patients with persistent airflow limitation were diagnosed with ACO. ACO patients had lower lung function and higher respiratory impedance compared with COPD patients. J. Med. Invest. 66 : 157-164, February, 2019.

Etiological analysis and epidemiological comparison among adult CAP and NHCAP patients in Okinawa, Japan.

Etiological epidemiology and diagnosis are important issues for CAP and NHCAP. Despite the availability of effective therapies, significant morbidity and mortality ensues. We retrospectively analyzed the etiology of 200 pneumonia patients at the University of the Ryukyus Hospital. Patients were categorized into CAP (n=97) or NHCAP (n=103), according to the Japanese Respiratory Society guidelines. Diagnoses were made using clinical tests including, Gram stain, bacterial culture, serum and urinary tests. Pathogens were detected in 71% of patients, and identified as the source of infection in 52% (104/200). The majority of patients suffered from Streptococcus pneumoniae (32/200), Haemophilus influenzae (22/200), and Moraxella catarrhalis (16/200). Gram stain guided pathogen-oriented therapy decisions for 38 of 96 patients with unknown pathogens. Atypical pathogens were only diagnosed in CAP patients (n=5). Severity of pneumonia was related to male sex (p=0.006), and preexisting conditions, such as chronic heart failure (p<0.001) and COPD (p<0.001). Risk factors associated with increased length of stay included chronic heart failure, chronic renal failure, other pulmonary diseases and diabetes. Mortality for NHCAP patients was associated with lung cancer and bronchiectasis. CAP patients were more frequently admitted during winter months, while NHCAP patients were admitted during all other seasons. Seasonal patterns for individual pathogens could not be determined. Gram staining remains useful to guiding diagnostics. Pathogens affecting CAP and NHCAP patients were not significantly different; as such, attention should be focused on the management of underlying conditions. Clinical outcomes were not affected by guideline discordant therapy.

Role of combined indacaterol and glycopyrronium bromide (QVA149) for the treatment of COPD in Japan.

Once-daily dual-bronchodilator therapy with combined indacaterol and glycopyrronium bromide in one device (Ultibro, Breezhaler), often called QVA149, was first approved in 2013 in Japan and Europe. As of November 2014, more than 40 countries had approved this medication except for the USA. This is the first dual bronchodilator in one device. Now, the Breezhaler is the only device that can provide long-acting muscarinic antagonist (glycopyrronium bromide), long-acting beta agonist (indacaterol), and a combination of the two medications (QVA149). The choice among the three medications allows a patient to use the same inhalation device even when the regimen is changed from single-bronchodilator therapy to dual-bronchodilator therapy. In addition, the quick bronchodilation effect and once-daily administration can improve patient adherence to medical treatment for chronic obstructive pulmonary disease (COPD). To our knowledge, as of November 2014, the safety and the efficacy of QVA149 have been evaluated in 14 randomized controlled trials. The 14 trials generally showed good safety profiles, and there were better or not-inferior bronchodilator effects of QVA149 when compared with placebo, or other inhaled medication. According to the Japanese Respiratory Society guidelines, QVA149 is a combination of the two first-line bronchodilators. Our meta-analysis indicated that QVA149 is superior to the salmeterol–fluticasone combination to treat COPD in respect of the frequency of adverse effects, exacerbation, pneumonia, and improvement of trough forced expiratory volume in 1 second (FEV1). Thus, we believe that QVA149 can be a key medication for COPD treatments.

Efficacy and safety of garenoxacin tablets on clinically diagnosed atypical pneumonia: postmarketing surveillance in Japan.

We performed a postmarketing surveillance study to determine the efficacy and safety of the oral quinolone antibacterial agent garenoxacin (Geninax(®) Tablets 200 mg) against atypical pneumonia. Between October 2009 and July 2011, patients with community-acquired pneumonia visited 26 facilities in Japan; we collected survey forms from 105 of these patients who were suspected of having atypical pneumonia based on the Japanese Respiratory Society Guidelines for the Management of Community-Acquired Pneumonia in Adults. We examined the safety in 105 patients and the efficacy in 71 patients. 1. The efficacy rates among patients suspected of having atypical pneumonia and those with a confirmed diagnosis of atypical pneumonia were 94.8% (55/58 patients) and 92.3% (12/13 patients), respectively. The efficacy rate was 4/4 for patients in whom Chlamydophila pneumoniae was detected (including 1 patient with a polymicrobial infection with another bacterial strain) and 90% (9/10 patients) for patients in whom Mycoplasma pneumoniae was detected (garenoxacin was ineffective in 1 of 2 patients with a polymicrobial infection with another bacterial strain). 2. The incidence of adverse drug reactions (including abnormal laboratory tests) was 4.8% (5/105 patients). Among the adverse drug reactions, gastrointestinal disorders, infection and infestation, nervous system disorder, and skin and subcutaneous tissue disorder were observed in 2.9% of patients (3/105), 1.0% (1/105), 1.0% (1/105), and 1.0% (1/105), respectively. In conclusion, garenoxacin showed an efficacy rate of greater than 90% for suspected atypical pneumonia and confirmed atypical pneumonia. Garenoxacin is considered to be useful in daily practice.

Year in review 2012: Lung cancer, respiratory infections, tuberculosis, pleural diseases, bronchoscopic intervention and imaging

This Year in Review series addresses the most relevant articles published in Respirology and other respiratory medicine journals during 2012 concerning five specific areas that we consider to be of importance to practicing pulmonologists, namely lung cancer, respiratory infections, tuberculosis (TB), pleural diseases, and interventional pulmonology and imaging. Some important findings that will be commented on more in depth are that: 1) screening for lung cancer using low-dose computed tomography (CT) in high risk populations is promising, although not firmly established, 2) an enhanced CURB (which stands for confusion, urea, respiratory rate, blood pressure) score as well as the Japanese A-DROP (age, dehydration, respiratory failure, orientation disturbance, and pressure) prognostic scale are as accurate as the pneumonia severity index (PSI) scoring system to predict mortality in patients with community-acquired pneumonia (CAP), 3) randomized trials are urgently needed to optimize multidrug-resistant (MDR)-TB treatment, 4) the use of video-assisted thoracoscopic surgery (VATS) to quantify pleural tumor burden and, if feasible, perform an intrathoracic cytoreduction in patients with malignant effusions secondary to ovarian cancer (OC) may have a significant impact on further patient management plans, and 5) respiratory endoscopy and its different diagnostic and therapeutic modalities, is a safe procedure with overall complication rates less than 1%.

Transmission of macrolide-resistant Mycoplasma pneumoniae within a family

Outbreaks of Mycoplasma pneumoniae have occurred in closed surroundings, including among families, university students, in military camps, and in schools, but available data on outbreaks of macrolide-resistant (MR) M. pneumoniae are limited. We encountered a family outbreak of MR M. pneumoniae pneumonia in four sisters (16, 14, 10, and 8years of age). M. pneumoniae was isolated from all four patients, and an A-to-G transition at position 2063 in domain V of the 23S rRNA gene was identified. Although three of four patients received azithromycin, which is the first-choice antimycoplasmal agent, this agent was not effective. All isolates had an identical antibiotic susceptibility pattern. The MIC values for 14- and 15-membered macrolides, such as erythromycin, clarithromycin, and azithromycin, were >128, >128, and 64μg/ml, respectively. On admission, all four patients were diagnosed with suspected M.pneumoniae pneumonia using the Japanese Respiratory Society (JRS) guidelines scoring system. We carried out culture and polymerase chain reaction tests for the detection of M.pneumoniae in their parents (mother, 49years old, and father, 56years old) four times, but no M.pneumoniae organism was detected using either test. In conclusion, MR M. pneumoniae strains can occur in outbreaks in closed surroundings, such as within families, as well as macrolide-sensitive strains. To prevent outbreaks of M.pneumoniae infection, especially MR M. pneumoniae, in closed populations, physicians should pay careful attention to the potential occurrence of infections involving MR M.pneumoniae.

Effects of adherence to ventilator-associated pneumonia treatment guidelines on clinical outcomes

Two guidelines are currently available to guide Japanese clinicians caring for patients with ventilator-associated pneumonia (VAP): the 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines or the 2008 Japanese Respiratory Society (JRS) guidelines. We aimed to measure compliance with guideline recommendations for VAP in Japanese intensive care units (ICUs) and to assess the effects of guideline-compliant treatment on outcomes. We retrospectively reviewed the records of all patients with microbiologically confirmed VAP in five Japanese ICUs between January 1, 2006, and December 31, 2009. We evaluated whether empiric antibiotic prescriptions were guideline compliant and correlated compliance with clinical outcomes. Among the 95 patients with VAP who were included, 85 patients received empiric antibiotics. Of these, therapy of 62 patients (73%) was appropriate based on in vitro sensitivity testing. Using ATS/IDSA criteria, 16 patients (19%) received guideline-compliant therapy and 69 patients (81%) received noncompliant treatment. Using JRS criteria, 24 patients (28%) received guideline-compliant therapy and 61 patients (72%) received noncompliant treatment. All-cause 28-day mortality was 24%. When compared to patients who received noncompliant therapy, there were no differences in 28-day mortality rates for patients who received ATS/IDSA guideline-compliant regimens (25 vs. 25%, p=1.00) or JRS guideline-compliant regimens (21 vs. 26%, p=0.78). Our study demonstrates poor compliance with guideline-recommended antibiotic therapy for VAP in Japanese ICUs. Compliance with current VAP guidelines was not associated with increased rates of appropriate antibiotic treatment or improved 28-day mortality.

Evaluation of serological tests for diagnosis of Chlamydophila pneumoniae pneumonia in patients with nursing and healthcare-associated pneumonia

Nursing and healthcare-associated pneumonia (NHCAP) is a new category that is distinct from community-acquired pneumonia that has been documented in the 2011 Japanese Respiratory Society (JRS) guidelines. We aimed to evaluate an ELNAS Plate test for detecting anti-Chlamydophila pneumoniae-specific immunoglobulin M (IgM) antibodies in patients with NHCAP, by comparing the results of the ELNAS test with those of the Hitazyme enzyme-linked immunosorbent assay (Hitazyme-ELISA) and those of immunoblotting and microimmunofluorescence (MIF) tests. During the study period, we enrolled 739 patients with pneumonia in a university hospital and 812 patients with pneumonia in a community hospital; of these, 250 (34%) and 349 (43%), respectively, were classified as having NHCAP. C. pneumoniae pneumonia was detected in five cases by the MIF test and ELNAS test. All five cases demonstrated significant IgG antibody seroconversion, while one case was IgM-positive. Sixty-seven of the total of 599 patients (11%) were C. pneumoniae IgM-positive on the Hitazyme-ELISA. One of the IgM-positive cases was confirmed by other methods and was shown to be a true positive. In the remaining cases, however, three other tests-the ELNAS test, the MIF test, and immunoblotting analysis-did not reveal any positive cases. The ELNAS, Hitazyme-ELISA, and MIF tests did not detect any significant increases in IgG or IgA antibody titers between paired sera. The results of the newly available ELNAS test for detecting anti-C. pneumoniae-specific IgM antibody correlated well with the results of the other established serological tests. To increase the diagnostic rate in patients with NHCAP, physicians should measure IgG antibody rather than IgM antibody using paired sera.