Nursing And Healthcare-associated Pneumonia Research Articles

Is the JRS atypical pneumonia prediction score useful in detecting COVID-19 pneumonia under nursing or healthcare settings?

BackgroundSARS-CoV-2 causes frequent outbreaks in elderly care facilities that meet the criteria for nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the Japanese Respiratory Society (JRS) atypical pneumonia prediction score could be adapted to the diagnosis of nursing and healthcare acquired COVID-19 (NHA-COVID-19) with pneumonia. MethodsWe analyzed 516 pneumonia patients with NHA-COVID-19 and compared them with 1505 pneumonia patients with community-associated COVID-19 (CA-COVID-19). NHA-COVID-19 patients were divided into six groups; 80 cases had the ancestral strain, 76 cases had the Alfa variant, 30 cases had the Delta variant, 120 cases had the Omicron subvariant BA.1, 53 cases had the Omicron subvariant BA.2, and 157 cases had the Omicron subvariant BA.5. ResultsThe sensitivities of the diagnosis of atypical pneumonia in patients with NHA-COVID-19 based on four or more predictors were 22.8 % in the ancestral strain group, 32.0 % in the Alfa variant group, 34.5 % in the Delta variant group, 23.1 % in the BA.1 subvariant group, 32.7 % in the BA.2 subvariant group, and 30.4 % in the BA.5 subvariant group. The diagnostic sensitivity for the presumptive diagnosis of atypical pneumonia was significantly lower for NHA-COVID-19 than for CA-COVID-19 (28.2 % vs 64.1 %, p < 0.0001). ConclusionsOur present study demonstrated that the JRS atypical pneumonia prediction score is not a useful tool in elderly patients even if there is a lot of atypical pneumonia in the NHCAP group. The caution is necessary that JRS atypical pneumonia prediction score was not fully applied to prediction for NHA-COVID-19 pneumonia.

Positive Rate and Utility of Blood Culture among Nursing and Healthcare-associated Pneumonia Inpatients: A Cross-sectional Study.

Objective Although blood cultures to identify the presence of bacteremia are recommended for nursing- and healthcare-associated pneumonia (NHCAP), the incidence of true bacteremia and the relationship between true bacteremia and the outcome remain unclear. Physicians can therefore sometimes be confused regarding whether or not blood cultures should be obtained for NHCAP patients. This study assessed the incidence of true bacteremia and the relationship between true bacteremia and the outcome of NHCAP in a Japanese hospital setting. Methods We retrospectively analyzed NHCAP patients hospitalized between April 2016 and March 2021. The primary outcome was the incidence of true bacteremia in blood cultures. The incidence of true bacteremia was also examined according to quick Sequential Organ Failure Assessment (qSOFA) and A-DROP scores. In addition, we compared the incidence of true bacteremia between survivors and non-survivors. Results In total, 205 patients were included in this study. Blood cultures were obtained from 150 of the 205 patients (73.2%). Positive blood cultures were detected in 26 patients (17.3%), of which only 8 cases (5.3%; 95% confidence interval, 2.3-10.2%) were considered true bacteremia. Trend analyses for the incidence of true bacteremia according to qSOFA and A-DROP scores did not show any statistically significant results (p=0.49 for qSOFA; p=0.14 for A-DROP). The proportion of true bacteremia cases did not differ significantly between survivors and non-survivors. Conclusions The incidence of true bacteremia among NHCAP patients was very low. A strategy for determining indications for obtaining blood cultures from NHCAP patients needs to be established.

Prognostic value of B-type natriuretic peptide for nursing- and healthcare-associated pneumonia and aspiration pneumonia in comparison with procalcitonin and A-DROP score: a prospective cohort study.

Pneumonia in elderly patients who require nursing care is becoming more and more common among the aging populations of developed countries, and treatment is an important topic worldwide. A simpler prognostic indicator would be expected to improve the treatment of pneumonia. This single-center, prospective cohort study aimed to compare the usefulness of B-type natriuretic peptide (BNP), procalcitonin (PCT), and the A-DROP score, which have been reported to correlate with pneumonia prognoses, such as aspiration pneumonia (AP). We included patients who were admitted to the Kanazawa Medical University Himi Municipal Hospital with a diagnosis of either nursing- and healthcare-associated pneumonia (NHCAP) or AP between January 1, 2012 and July 31, 2019. We collected demographic, clinical, and laboratory characteristics and outcome data from electronic medical records, and calculated A-DROP scores. The primary outcome was 30-day mortality. We evaluated correlations with the primary outcome using the chi-square test, Fisher exact test, t-test, Cox-regression analysis, and receiver operating characteristic curve analysis. Of the 1,215 patients with pneumonia, 297 were eligible for the study, of whom 37 (12%) died whin 30 days. After univariate analysis, we performed Cox proportional-hazards analysis for BNP, PCT, A-DROP score, albumin, C-reactive protein, and disseminated intravascular coagulation, which were significantly correlated with the primary outcome in univariate analysis. As a result, only BNP showed a significant correlation (P=0.008, 95% CI: 1.30-6.06). No significant correlation was obtained in PCT (P=0.529) and A-DROP score (P=0.107). Furthermore, we generated receiver operating characteristic curve to estimate the prognostic cut-off values of BNP for the primary outcome of NHCAP and AP. The optimal cut-off value of BNP for predicting death was 179.3 pg/mL (sensitivity 62.2%, specificity 76.2%, negative likelihood ratio 0.50%, positive likelihood ratio 2.61%). And, BNP yielded the highest area under the curve (0.72) in comparison with PCT (0.67) and A-DROP score (0.69). BNP may be a more clinically useful prognostic factor for NHCAP and AP than PCT or A-DROP score, and should be considered as a routine test at the beginning of these treatments.

Evaluation of efficacy and safety of lascufloxacin for nursing and healthcare associated pneumonia: single-arm, open-label clinical trial: A study protocol.

Lascufloxacin hydrochloride (LSFX) is a quinolone antibiotic that inhibits DNA gyrase and topoisomerase IV of bacteria, it is anticipated to minimize antibiotic resistance in bacteria. It exhibits antibacterial activity against a relatively wide range of bacterial species, including anaerobic bacteria, and its efficacy and safety against community-acquired pneumonia have been shown; however, its efficacy and safety against nursing and healthcare associated pneumonia (NHCAP) have not been verified. Here, a single-arm, open-label, uncontrolled study was conducted in which LSFX was administered to patients with NHCAP at 24 facilities. The research subjects (77 cases) were orally administered 75 mg of LSFX once a day for 7 days. The primary endpoint was the clinical efficacy at the time of test of cure (TOC) (TOC; 5-10 days after the end of LSFX administration), while the secondary endpoints were the efficacy at the time of end of treatment, early clinical efficacy, microbiological efficacy at the time of TOC and end of treatment, and safety evaluation of LSFX. NHCAP is a common pneumonia in clinical settings and a notable pneumonia whose mortality is high compared to community-acquired pneumonia. The present study showed the efficacy and safety of LSFX against NHCAP, which could lead to a larger number of therapeutic options for NHCAP.

Assessment of the pneumonia severity score in community-acquired and nursing and healthcare-associated pneumonia due to COVID-19

IntroductionThe Japanese Respiratory Society (JRS) pneumonia guidelines recommend simple predictive rules, the A-DROP scoring system, for assessment of the severity of community-acquired pneumonia (CAP) and nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the A-DROP system can be adapted for assessment of the severity of coronavirus disease 2019 (COVID-19) pneumonia. MethodsData from 1141 patients with COVID-19 pneumonia were analyzed, comprising 502 patients observed in the 1st to 3rd wave period, 338 patients in the 4th wave and 301 patients in the 5th wave in Japan. ResultsThe mortality rate and mechanical ventilation rate were 0% and 1.4% in patients classified with mild disease (A-DROP score, 0 point), 3.2% and 46.7% in those with moderate disease (1 or 2 points), 20.8% and 78.3% with severe disease (3 points), and 55.0% and 100% with extremely severe disease (4 or 5 points), indicating an increase in the mortality and mechanical ventilation rates in accordance with severity (Cochran–Armitage trend test; p = <0.001). This significant relationship between the severity in the A-DROP scoring system and either the mortality rate or mechanical ventilation rate was observed in patients with COVID-19 CAP and NHCAP. In each of the five COVID-19 waves, the same significant relationship was observed. ConclusionsThe mortality rate and mechanical ventilation rate in patients with COVID-19 pneumonia increased depending on severity classified according to the A-DROP scoring system. Our results suggest that the A-DROP scoring system can be adapted for the assessment of severity of COVID-19 CAP and NHCAP.

Impact of initial empirical antimicrobial choice and cause of in-hospital death in patients with nursing and healthcare-associated pneumonia (NHCAP): A retrospective study.

To examine the differences in antimicrobial selection outcomes in nursing and healthcare-associated pneumonia (NHCAP) patients with and without risk factors for drug-resistant pathogen (RDRP) infection, and to identify the cause of in-hospital death after improvement of NHCAP. We conducted a retrospective analysis of the medical records of hospitalized adult patients with NHCAP. NHCAP patients were divided into the RDRP and non-RDRP groups. The RDRP group was further classified into the narrow and broad subgroups according to the type of empirical antimicrobial agent selected. The difference in mortality between these subgroups was then examined. The cause of all in-hospital deaths was also evaluated. e evaluated 220 patients with NHCAP. There was no difference in mortality between the narrow and broad subgroups (11.8% vs. 15.4%, p=0.655). Among the group with improved NHCAP, 11.3% (n=23/203) died in hospital before discharge. Although the causes of death in patients who improved after NHCAP were diverse, the most common was recurrence of pneumonia. Empirical antimicrobial therapy for NHCAP may not always require selection of broad-spectrum antimicrobial agents, as has been previously reported. Patients with NHCAP may die from other causes, even after NHCAP has improved.

Prognosis of activities of daily living function in hospitalized patients with nursing and healthcare-associated pneumonia due to COVID-19.

Nursing and healthcare‐associated pneumonia (NHCAP) is associated with decreased physical function. We investigated the functional outcomes at 1 year after hospital discharge in patients with COVID‐19 pneumonia. Functional decline rates for calculating the Barthel Index at the time of hospital discharge and at 1 year after hospital discharge were significantly higher in the NHCAP group than the community‐acquired pneumonia group (at hospital discharge, 54.0% vs. 31.2%, respectively, p < 0.0001; 1 year follow‐up, 37.9% vs. 8.6%, respectively, p < 0.0001). It is necessary to consider early rehabilitation, and treatment depending on the presence or absence of applicable criteria for NHCAP.

Clinical features of nursing and healthcare-associated pneumonia due to COVID-19

IntroductionThe objective of this study was to clarify the clinical differences between nursing and healthcare-associated pneumonia (NHCAP) and community-acquired pneumonia (CAP) due to COVID-19. We also investigated the clinical characteristics to determine whether there is a difference between the variant and non-variant strain in patients with NHCAP due to COVID-19. In addition, we analyzed the clinical outcomes in NHCAP patients with mental disorders who were hospitalized in a medical institution for treatment of mental illness. MethodsThis study was conducted at five institutions and assessed a total of 836 patients with COVID-19 pneumonia (154 cases were classified as NHCAP and 335 had lineage B.1.1.7.). ResultsNo differences in patient background, clinical findings, disease severity, or outcomes were observed in patients with NHCAP between the non-B.1.1.7 group and B.1.1.7 group. The median age, frequency of comorbid illness, rates of intensive care unit stay, and mortality rate were significantly higher in patients with NHCAP than in those with CAP. Among the patients with NHCAP, the mortality rate was highest at 37.5% in patients with recent cancer treatment, followed by elderly or disabled patients receiving nursing care (24.3%), residents of care facilities (23.0%), patients receiving dialysis (13.6%), and patients in mental hospitals (9.4%). ConclusionsOur results demonstrated that there were many differences in the clinical characteristics between NHCAP patients and CAP patients due to COVID-19. It is necessary to consider the prevention and treatment content depending on the presence or absence of applicable criteria for NHCAP.

Inflammatory biomarkers are not useful for predicting prognosis in nursing and healthcare-associated pneumonia: A prospective, cohort study

IntroductionWhether inflammatory biomarkers including procalcitonin (PCT) and C-reactive protein (CRP) are useful for predicting prognosis in nursing and healthcare-associated pneumonia (NHCAP) is unknown. The aim of the present study was to investigate the utility of serial PCT and CRP measurements for predicting prognosis and treatment efficacy for hospitalized NHCAP patients. MethodsThis prospective, observational, cohort study enrolled consecutive NHCAP patients hospitalized at Kurashiki Central Hospital from October 2010 to September 2017. PCT and CRP were measured twice, once on admission and again within 48–72 h after admission. The primary outcome was 30-day all-cause mortality, and the secondary outcome was initial treatment failure. ResultsA total of 299 patients were included. The 30-day mortality rate was 8.4% (25/299), and the initial treatment failure rate was 15.4% (46/299). On multivariate analysis, performance status [odds ratio (OR) (95% confidence interval (CI)): 2.25 (1.34–3.77), P = 0.002], temperature [OR (95%CI): 0.53 (0.32–0.88), P = 0.02], heart rate [OR (95%CI): 1.03 (1.01–1.06), P = 0.007], albumin [OR (95%CI): 0.42 (0.18–0.95), P = 0.04], and blood urea nitrogen [OR (95%CI): 1.02 (1.00–1.05), P = 0.04] were significant prognostic factors, and CRP D3 [OR (95%CI): 1.07 (1.02–1.11), P = 0.003] and PSI [OR (95%CI): 1.01 (1.00–1.02), P = 0.01] were the predictors of initial treatment failure. Consecutive measurements of PCT and CRP were not significant predictors of 30-day mortality. ConclusionsInflammatory biomarkers including PCT and CRP were not useful for predicting prognosis and treatment efficacy in NHCAP patients. We should carefully evaluate the patients’ vital signs and comorbidities when managing NHCAP patients.

The current definition, epidemiology, animal models and a novel therapeutic strategy for aspiration pneumonia.

In the 21st century, aspiration pneumonia (ASP) is very common in older patients, and has a high mortality rate. ASP is diagnosed following confirmation of inflammatory findings in the lungs and overt aspiration or the existence of dysphagia. It is dominant in hospitalized community-acquired pneumonia (CAP), nursing and healthcare-associated pneumonia (NHCAP), and hospital-acquired pneumonia (HAP). The incidence of ASP is increasing every year. The human and experimental animal data revealed that micro-aspiration due to dysphagia during the night is the central mechanism of ASP. Therefore, the precise assessment of swallowing function is the key to diagnose ASP. From a therapeutic point of view, an appropriate administration of antibiotics, as well as a comprehensive approach for dysphagia plays a pivotal role in the prognosis and recovery from ASP. The non-pharmacologic approach, including swallowing rehabilitation and oral care, and a pharmacologic approach including ACE inhibitors and bronchodilators, are essential modalities for treatment and prevention of ASP. The clinical data of NHCAP provides us with a promising treatment strategy for ASP.

Efficacy and validity of guideline-concordant treatment according to the JRS guidelines for the managements of pneumonia in adults updated in 2017 for nursing and healthcare-associated pneumonia. A propensity-matching score analysis

IntroductionPatients with nursing and healthcare-associated pneumonia (NHCAP) commonly receive empiric antibiotic therapy according to the guideline's recommendation corresponding to the patient's deteriorated conditions. However, it is unclear whether guideline-concordant treatment (GCT) could be effective or not. Patients and methodsTo evaluate the efficacy and validity of GCT according to the current guideline for pneumonia, we conducted this retrospective study. NHCAP patients who were admitted to our institute between 2014 and 2017 were enrolled. Based on the initial antibiotic treatment, these patients were divided into two groups, the GCT group (n = 83) and the non-GCT group (n = 146). Propensity score matching (PSM) was used to balance the baseline characteristics and potential confounders between the two groups. After PSM, patients’ characteristics, microbial profiles, and clinical outcomes were evaluated. ResultsBoth groups were well-balanced after PSM, and 78 patients were selected from each group. There were no differences in patients’ characteristics or microbial profiles between the two groups. As for outcomes, there were no differences in 30-day, in-hospital mortality rate, duration of antibiotic treatment, or admission. The severity of pneumonia was more severe in patients with the GCT group than those with the non-GCT group. Anti-pseudomonal agents as initial treatment were more frequently seen in patients with the GCT group than those in the non-GCT group. ConclusionUnlike previous studies, GCT's recommendation for management of pneumonia by the JRS in 2017 would appear to be valid and does not increase the mortality rate.

Study of factors related to recurrence within 30 days after pneumonia treatment for community-onset pneumonia

IntroductionIt is not uncommon for patients hospitalized with pneumonia to experience an early relapse. Here, we investigated the factors related to pneumonia recurrence in Japan. PurposeWe aimed to elucidate the factors related to early recurrence after completion of pneumonia treatment. MethodsWe examined 696 patients with community-acquired pneumonia (CAP) and nursing and healthcare-associated pneumonia (NHCAP) who were admitted to our hospital between October 2010 and February 2018, excluding those who died during hospitalization. Logistic regression analysis was used to assess the endpoint of recurrence within 30 days after the end of antibiotic treatment. ResultsNHCAP, chronic lung disease and duration of antibiotic treatment were significant risk factors for recurrence of pneumonia within 30 days after antibiotic discontinuation. Aspiration pneumonia was not be a significant factor in the early recurrence of pneumonia. ConclusionsLong-term use of antimicrobials may be a risk factor in early recurrence of pneumonia.

Evaluation of pneumonia severity scoring systems in nursing and healthcare-associated pneumonia for predicting prognosis: A prospective, cohort study

The usefulness of existing pneumonia severity indices for predicting mortality in nursing and healthcare-associated pneumonia (NHCAP) is unclear. This study compared the usefulness of existing pneumonia severity indices for predicting mortality in NHCAP and community-acquired pneumonia (CAP). Consecutive hospitalized pneumonia patients including NHCAP and CAP patients were prospectively enrolled between October 2010 and November 2017. Admission pneumonia severity was assessed using CURB-65, Pneumonia Severity Index (PSI), A-DROP, Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) severe pneumonia criteria, and I-ROAD. The primary outcome was 30-day mortality. The discriminatory ability of each severity index was evaluated by receiver operating characteristic curve analysis. Overall, 828 patients had NHCAP, and 1330 patients had CAP. Thirty-day mortality was 12.8% and 5.6% in NHCAP and CAP patients, respectively. The area under the curve of PSI (0.717, 95% confidence interval 0.673–0.761) was the highest among all pneumonia severity indices, with significant differences compared with CURB-65 (0.651, 95% confidence interval 0.598–0.705, P = 0.02) and IDSA/ATS severe pneumonia criteria (0.659, 95% confidence interval 0.612–0.707, P = 0.03). The predictive abilities for 30-day mortality of the pneumonia severity indices, excluding PSI and I-ROAD, were significantly inferior for NHCAP than for CAP. PSI may be the most useful pneumonia severity score for predicting mortality in NHCAP. However, the predictive ability for mortality of each pneumonia severity score was worse for NHCAP than for CAP; therefore, the prognostic factors in NHCAP need to be identified for better management of NHCAP patients.

Impact of urinary tract infection on nursing and healthcare-associated pneumonia

Nursing and healthcare-associated pneumonia (NHCAP), a concept of pneumonia proposed by the Japanese Respiratory Society, mostly occurs among elderly people in long-term care facilities. Similarly, the risk of urinary tract infection (UTI) also increases with age, with UTIs common among those in long-term care. Therefore, NHCAP is sometimes complicated by the presence of a UTI. However, pneumonia complicated by a UTI has not been clinically well characterized. We retrospectively analyzed 376 patients with NHCAP admitted to our hospital over a three-year period. Sixty-seven patients (17.8%) showed complications by a UTI. Patients with a UTI had lower renal function (higher blood urea nitrogen [P = 0.001], higher creatinine [P = 0.001]), lower systolic blood pressure (P = 0.04), higher A-DROP scores (P = 0.005) and higher positive blood culture rates (P = 0.03) than those without a UTI. Furthermore, based on urine, sputum and blood culture results, nearly half of the microorganisms (4/7) in blood cultures were identical with those of urine, suggesting that a concurrent UTI increases positive blood culture rates. Multivariate analysis showed that UTI was not an independent factor associated with 30-day mortality (P = 0.17), although patients with a UTI showed higher 30-day mortality (P = 0.04) than those without a UTI in univariate analysis. In summary, patients with NHCAP and a UTI were more prone to complications than those without a UTI, although UTI itself did not affect the prognosis of patients with NHCAP. A concurrent UTI had a negative impact on the severity of NHCAP.

The efficacy and safety of sitafloxacin and garenoxacin for the treatment of pneumonia in elderly patients: A randomized, multicenter, open-label trial

Oral treatment for elderly outpatients with pneumonia is becoming increasingly important in this super-aged society from the perspective of cost-effectiveness and limited hospital capacities. We evaluated the efficacy and safety of two oral respiratory quinolones, sitafloxacin and garenoxacin, in elderly patients with pneumonia. This randomized, multicenter, open-label trial was conducted among patients aged ≥65 years with clinically and radiographically confirmed pneumonia in Japan. Patients were randomly assigned (1:1) to receive either sitafloxacin (100 mg/day) or garenoxacin (400 mg/day) for 3–10 days. The primary efficacy endpoint was the clinical cure rate at 5–10 days after the end of treatment. From December 2013 to November 2017, we enrolled 120 patients at 11 hospitals and randomly assigned 59 patients to the sitafloxacin group (1 patient withdrew) and 61 patients to the garenoxacin group. These included 30 patients with nursing and healthcare-associated pneumonia (NHCAP) (18 receiving sitafloxacin, 12 receiving garenoxacin) and 37 patients with aspiration pneumonia (16 receiving sitafloxacin, 21 receiving garenoxacin). The clinical cure rates in the sitafloxacin and garenoxacin groups were 88.5% (95% confidence interval: 76.6–95.6) and 88.9% (95% confidence interval: 77.4–95.8), respectively. No significant differences were observed in the incidence rates of drug-related adverse events between the sitafloxacin (20.7%; 12/58 patients) and garenoxacin (27.9%; 17/61 patients) groups. The most common adverse event was hepatic dysfunction, which occurred in seven patients in each group. We conclude that sitafloxacin and garenoxacin are comparably effective and safe for the treatment of pneumonia, including NHCAP and aspiration pneumonia, in elderly patients.

A comparison of pneumonia care quality between general physicians and pulmonologists.

BackgroundWe compared the quality of care for nursing‐ and healthcare‐associated pneumonia (NHCAP) and aspiration pneumonia provided by general physicians and pulmonologists.MethodsQuestionnaires were mailed to 2490 medical facilities across Japan. The questionnaire assessed participants’ implementation of microbiological investigations for NHCAP or aspiration pneumonia, as well as steps taken to prevent pneumonia recurrence (eg, use or discontinuation of drugs associated with swallowing and administration of pneumococcal polysaccharides). Survey results were statistically compared between the two groups using chi‐square tests.ResultsWe received responses from 350 hospitals; of those, medical care for aspiration pneumonia was provided by pulmonologists at 190 hospitals and by general physicians at 79 hospitals. No significant differences were observed between the two groups of physicians for any of the items regarding proactive microbiological investigations or measures for preventing pneumonia recurrence. However, general physicians tended to be more proactive in conducting Gram's stains for sputum, sputum culture inspections, and blood culture tests. They also were more likely to implement measures for preventing pneumonia recurrence such as striving to increase patients’ consciousness levels, reducing medication doses, and discontinuing drugs that cause difficulty with swallowing (response rates of “is done in nearly all cases” were 73.4%, 88.6%, 36.7%, 35.4%, and 40.5%, respectively).ConclusionsThe quality of care provided by general physicians may be on par with pulmonologists in terms of proactive microbiological investigations and preventing pneumonia recurrence.

Risk Factors for Death from Psychiatric Hospital-acquired Pneumonia.

Objectives Pneumonia is a major cause of death among inpatients at psychiatric hospitals. Psychiatric hospital-acquired pneumonia (PHAP) is defined as pneumonia developed in inpatients at psychiatric hospitals. PHAP is a type of nursing and healthcare-associated pneumonia (NHCAP). The purpose of this study was to clarify the risk factors for mortality among PHAP patients. Methods We retrospectively reviewed the clinical files of patients transferred to Tokyo Metropolitan Matsuzawa Hospital from psychiatric hospitals for PHAP treatment during the 10-year period from September 2007 to August 2017. We analyzed the clinical differences between the survivors and non-survivors and assessed the usefulness of severity classifications (A-DROP, I-ROAD, and PSI) in predicting the prognosis of PHAP. Results This study included a total of 409 PHAP patients, 87 (21.3%) of whom expired and 322 (78.7%) of whom survived. The mortality rates, according to the A-DROP classifications, were 4.9% in the mild cases, 21.6% in the moderate cases, 40.7% in the severe cases, and 47.6% in the very severe cases. The mortality rates, according to the I-ROAD classifications, were 9.5% in group A, 34.7% in group B, and 36.2% in group C. The mortality rates, according to the PSI classifications, were 0% in class II and III, 23.1% in class IV, and 44.9% in class V. The mortality rate increased as the severity increased. We identified 3 factors (age ≥65 years, body mass index ≤18.5 kg/m2, and bilateral pneumonic infiltration) as significant predictors of mortality. We therefore added two factors (body mass index ≤18.5 kg/m2 and bilateral pneumonic infiltration) to the A-DROP classification and established a modified A-DROP classification with a range of 0 to 7. The area under the receiver operation characteristic curves for predicting mortality were 0.699 for the A-DROP classification and 0.807 for the modified A-DROP classification. Conclusion The mortality rate in PHAP patients tended to increase with increasing classifications of severity. The modified A-DROP classification may be useful for predicting the prognosis of PHAP patients.

Bacteriological testing and recurrence prevention efforts in the diagnosis and treatment of nursing- and healthcare-associated pneumonia and aspiration pneumonia: A questionnaire survey of hospitals across Japan.

Clinical practice guidelines for nursing- and healthcare-associated pneumonia (NHCAP) were developed for pneumonia caused by drug-resistant bacteria and pneumonia in elderly patients, particularly aspiration pneumonia. The identification of pathogenic bacteria and implementation of efforts to prevent the recurrence of aspiration pneumonia are very important in clinical practice. This study examined the extent to which clinicians have established bacteriological testing and recurrence prevention efforts for NHCAP and aspiration pneumonia. Questionnaire surveys were mailed to the heads of internal medicine and respiratory medicine departments at 2490 Japanese hospitals. The questionnaire evaluated bacteriological testing for NHCAP or aspiration pneumonia and prevention of the recurrence of aspiration pneumonia. A total of 350 hospitals responded. These hospitals were grouped on the basis of whether a pulmonologist provided medical care for aspiration pneumonia and whether the hospital employed an infectious disease specialist. For hospitals in which pulmonologists treated aspiration pneumonia, the response rates for "is done in nearly all cases" were 70.0%, 84.7%, 31.6%, and 48.9% for sputum gram staining, sputum culture tests, blood culture tests, and pneumococcal vaccination, respectively. In hospitals that employed an infectious disease specialist, the response rates for "is done in nearly all cases" were 72.8% and 41.3% for sputum gram staining and blood culture tests, respectively. Recurrence prevention for aspiration pneumonia (other than pneumococcal vaccination) was not actively implemented. Sputum gram staining, sputum culture tests, and other bacteriological tests were implemented quite actively. However, physicians who treat aspiration pneumonia should implement efforts to prevent pneumonia recurrence more actively.

A-DROP system for prognostication of NHCAP inpatients.

Nursing and healthcare-associated pneumonia (NHCAP) is a category of healthcare-associated pneumonia that was modified for the healthcare system of Japan. The NHCAP guidelines stated the difficulty in assessing the severity classifications, for instance, A-DROP. We compared the usefulness of different severity classifications (A-DROP, CURB-65, PSI, and I-ROAD) in predicting the prognosis of nursing and healthcare-associated pneumonia. We conducted a retrospective analysis on 303 adult patients hospitalized for nursing healthcare-associated pneumonia and community-acquired pneumonia, which were diagnosed at the Department of Respiratory Medicine of Niigata General City Hospital between January 2012 and December 2014. We evaluated 159 patients with community-acquired pneumonia and 144 with nursing and healthcare-associated pneumonia. In the nursing and healthcare-associated pneumonia group, 30-days mortality and in-hospital mortality rates were 6.5% and 8.7%, respectively, in severe cases and 16.1% and 25.0%, respectively, in the most severe cases, based on A-DROP. With I-ROAD, these rates were 11.1% and 11.1%, respectively, in group B and 14.9% and 20.7%, respectively, in group C. With PSI, the rates were 2.3% and 6.8%, respectively, in class IV and 14.3% and 19.8%, respectively, in class V. Despite some variability due to the small sample size, both the 30-days and in-hospital mortality rates increased as the severity increased. In this study, both the 30-days mortality and in-hospital mortality rates in the nursing and healthcare-associated pneumonia group tended to increase in severity with the A-DROP. We found that A-DROP was useful in predicting the prognosis of nursing and healthcare-associated pneumonia.

Case-control study of pneumonia patients with Streptococcus anginosus group bacteria in their sputum

In recent years, Streptococcus anginosus group (SAG) bacteria are becoming increasingly recognized as important pneumonia-causing pathogens. Although several small studies have been reported, the features of SAG pneumonia remain unclear, because the identification of SAG from sputum cultures is not routinely performed in most microbiology laboratories. The aim of this study was to elucidate the clinical characteristics of SAG pneumonia. This was a retrospective case-control study utilizing data obtained in our hospital between September 2009 and June 2016. We investigated 31 patients with SAG pneumonia (PWP), and also assessed the difference between the 31 PWP and 37 patients without pneumonia (PWOP) in whose sputum SAG was detected. Seventy-one percent of the patients were men and the median age was 78 years in the PWP. Univariate analysis indicated that the PWP were significantly more often a bed-ridden (p<0.01) with comorbid aspiration than were the PWOP (p<0.05). Among the PWP, nursing and healthcare-associated pneumonia (NHCAP) was the more common type of pneumonia (54.8%). S.anginosus was detected significantly more frequently in sputum cultures of PWP than PWOP (p<0.01), and multiple pathogens were detected more frequently in PWP (p<0.01). Streptococcus constellatus was the most frequently detected pathogen in patients with a single bacterial infection. Empyema was observed only in patients with multiple bacteria. SAG should be recognized as important causative pathogens of pneumonia, particularly among elderly patients with underlying disease associated with aspiration. NHCAP was the more common type of SAG pneumonia in this study.