Risk Factors For Multidrug-resistant Pathogens Research Articles

Modern Directions of Optimization of Empirical Antimicrobial Therapy of Community-Acquired Pneumonia (Review)

Modern Directions of Optimization of Empirical Antimicrobial Therapy of Community-Acquired Pneumonia (Review)

Antibiotic treatment of acute bacterial skin and skin structure infections.

Acute bacterial skin and skin structure infections (ABSSSI) are a leading cause of morbidity, with a considerable variety of clinical presentation and a wide range of etiological pathogens. Of importance, the spread of multidrug-resistant (MDR) strains (i.e. methicillin-resistant Staphylococcus aureus or Gram-negative bacteria) is increasingly reported in some regions. in this review, we summarize the current clinical approach to patients with ABSSSI. Accurate diagnosis and identification of risk factors for MDR pathogens are key determinants for administering appropriate therapy in patients with ABSSSI. In daily clinical practice, this can be critical as there are many features defining the 'high risk patient' including both disease and host-associated risk factors. Antibiotic therapy should be based according to the different clinical spectrum of disease belonging to the ABSSSI, on the pathogens most likely to be involved and local resistance. Careful evaluation of antibiotic therapy after 48-72 h of initial therapy could help clinicians to early identify patients with treatment failure and to consider an alternative approach. Close monitoring of patients with multiple comorbidities, drug-drug interaction or adverse host factors are also necessary.

Analysis of risk factors for multidrug-resistant pathogens and appropriate treatment indications for pneumonia in children with neurologic impairment

IntroductionThe features of pneumonia in children with neurologic impairment (NI) resemble those of healthcare-associated pneumonia is defined as pneumonia occurring in the community associated with healthcare risk factors. There are currently no guidelines for the treatment of pneumonia in children with NI. Here, we assessed whether the guidelines applicable for treating pneumonia in adults could be applied to children with NI. MethodsBetween 2008 and 2019, we enrolled children with NI who developed pneumonia and were treated in the pediatric ward of Kawasaki Medical School Hospital. We evaluated patient characteristics, the frequency of isolation of multidrug-resistant (MDR) pathogens, and clinical outcomes. ResultsMDR pathogens were more frequently isolated from patients receiving tube feeding (TF) and/or with tracheostomy than from patients without these risk factors. Other risk factors, including a history of antibiotic therapy and methicillin-resistant Staphylococcus aureus isolation, recent hospitalization, residence in a nursing home or extended care facility, and low-dose, long-term macrolide therapy, did not significantly affect the frequency of MDR pathogen isolation. In patients receiving TF and/or with tracheostomy, treatment success was achieved in all cases treated with broad-spectrum antibiotics and 72.2% of cases treated with non-broad-spectrum antibiotics (P = 0.007). Conversely, among patients without these risk factors, no such difference was observed. ConclusionsOur findings indicate that the guideline to select antibiotics for treating pneumonia in children with NI should be simpler and more useful than the current guidelines for adult pneumonia, based on risk factor assessment for MDR pathogens.

Ventilator-associated pneumonia: new principles guiding empiric antibiotic therapy.

Ventilator-associated pneumonia (VAP) is a serious event in critically ill patients. We aim to review the most recent evidences about VAP, including its cause, the main differences between the American and European guidelines in the definition of risk factors for multidrug-resistant pathogens, the main principles guiding empirical antibiotic treatment, and the potential role of molecular diagnostic tests. The 2016 ATS/IDSA and the 2017 ERS/ESICM/ESCMID/ALAT guidelines provide different approaches for the management of VAP. Both guidelines highlight the need to use local epidemiological data for antibiotic choice; however, they identify different risk factors that can assist with decision making when local data are not available. Nevertheless, validation studies of the American guidelines suggest that empiric antibiotic therapy based on risk factors may lead to an overuse of broad-spectrum antibiotics. Rapid diagnostic tests may allow a faster identification of VAP cause, resulting in more adequate antimicrobial therapy and reduced exposition to broad-spectrum antibiotics. Clinical studies should be conducted to evaluate the benefits of implementing guidelines and new approaches such as combinations of clinical data with rapid diagnostic tests; meantime adaptations of guidelines to local settings should be carried out by a local multidisciplinary expert team.

Community-acquired pneumonia in critically ill very old patients: a growing problem.

Very old (aged ≥80 years) adults constitute an increasing proportion of the global population. Currently, this subgroup of patients represents an important percentage of patients admitted to the intensive care unit. Community-acquired pneumonia (CAP) frequently affects very old adults. However, there are no specific recommendations for the management of critically ill very old CAP patients. Multiple morbidities, polypharmacy, immunosenescence and frailty contribute to an increased risk of pneumonia in this population. CAP in critically ill very old patients is associated with higher short- and long-term mortality; however, because of its uncommon presentation, diagnosis can be very difficult. Management of critically ill very old CAP patients should be guided by their baseline characteristics, clinical presentation and risk factors for multidrug-resistant pathogens. Hospitalisation in intermediate care may be a good option for critical ill very old CAP patients who do not require invasive procedures and for whom intensive care is questionable in terms of benefit.

An overview of guidelines for the management of hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria.

Multidrug-resistant (MDR) Gram-negative pathogens in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are associated with poor clinical outcomes. These pathogens represent a global threat with few therapeutic options. In this review, we discuss current guidelines for the empiric management of HAP/VAP caused by MDR Gram-negative pathogens. The incidence of MDR Gram-negative bacteria is rising among cases of nosocomial pneumonia, such that it is now becoming a significant challenge for clinicians. Adherence to international guidelines may ensure early and adequate antimicrobial therapy, guided by local microbiological data and awareness of the risk factors for MDR bacteria. Due to the increasing prevalence of HAP/VAP caused by MDR Gram-negative pathogens, management should be guided by the local ecology and the patient's risk factors for MDR pathogens. The main risk factors are prior hospitalization for at least 5 days, prior use of broad-spectrum antibiotics, prior colonization with resistant pathogens, admission to hospital settings with high rates of MDR pathogens, and septic shock at the time of diagnosis with nosocomial pneumonia.

Hospital-acquired pneumonia - new guidelines

The role of multidrug-resistant (MDR) pathogens in nosocomial infections is increasing. However national data in Germany do not show significant changes in the spectrum of pathogens in hospital-acquired pneumonia (HAP). The assessment of individual risk factors for MDR pathogens remains central for the selection of empiric antimicrobial therapy. Thoracic ultrasound may be added as part of the diagnostic work-up and for the detection of complications. Procalcitonin and lactate testing are recommended for the diagnosis of sepsis/septic shock in addition to sepsis scores. Detection of influenza virus by PCR from respiratory samples is recommended during influenza season. Empiric combination therapy is only recommended for patients with severe HAP (invasive ventilation, septic shock) and high risk of infection with MDR pathogens, since combination therapy has only been shown to be superior in this situation. Deescalation according to clinical and microbiological criteria is highly recommended. In patients with septic organ dysfunction/septic shock antibiotic dosing of adequately choosen betalactams according to Pk/Pd criteria is endorsed. adjunctive aerosolised therapy should only be performed in experienced centres. This remains an option for patients with detection of MDR pathogens, who are not deemed successfully treatable with systemic therapy alone.

Unsolved Issues in the Treatment of Spontaneous Peritonitis in Patients with Cirrhosis: Nosocomial Versus Community-acquired Infections and the Role of Fungi.

Historically, spontaneous bacterial peritonitis (SBP) has represented one of the most frequent and relevant infectious complications of advanced liver disease, and this is still valid today. Nevertheless, in recent years the role of fungi as causative pathogens of primary peritonitis in patients with cirrhosis has become not negligible. Another issue is linked with the traditional distinction, instrumental in therapeutic choice, between community-acquired and nosocomial forms, according to the onset. Between these two categories, another one has been introduced: the so-called "healthcare-associated infections". To discuss the most controversial aspects in the management of SBP nowadays in the light of best available evidence. A review of recent literature through MEDLINE was performed. The difference between community-acquired and nosocomial infections is crucial to guide empiric antibiotic therapy, since the site of acquisition impact on the likelihood of multidrug-resistant bacteria as causative agents. Therefore, third-generation cephalosporins cannot be considered the mainstay of treatment in each episode. Furthermore, the distinction between healthcare-associated and nosocomial form seems very subtle, especially in areas wherein antimicrobial resistance is widespread, warranting broad-spectrum antibiotic regimens for both. Finally, spontaneous fungal peritonitis is a not common but actually underestimated entity, linked to high mortality. Especially in patients with septic shock and/or failure of an aggressive antibiotic regimen, the empiric addition of an antifungal agent might be considered. Spontaneous bacterial peritonitis is one of the most important complications in patients with cirrhosis. A proper empiric therapy is crucial to have a positive outcome. In this respect, a careful assessment of risk factors for multidrug-resistant pathogens is crucial. Likewise important, mostly in nosocomial cases, is not to overlook the probability of a fungal ascitic infection, namely a spontaneous fungal peritonitis.

New guidelines for nosocomial pneumonia

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain important causes of morbidity and mortality in hospitalized patients. New evidence-based guidelines for the diagnosis and treatment of these entities were released by the Infectious Diseases Society of America and the American Thoracic Society in 2016. This review summarizes the recommendations contained within these guidelines and their supporting rationale. With respect to diagnosis of HAP and VAP, the guidelines suggest using semiquantitative cultures of noninvasively obtained respiratory samples instead of quantitative cultures of invasively obtained samples. With respect to antibiotic treatment, the guidelines separate the treatment approach for VAP and HAP (non-VAP), and stress the importance of devising an appropriate empiric regimen based on an appropriate hospital or unit-specific antibiogram. For VAP, coverage of methicillin-resistant Staphylococcus aureus is recommended only when patients have specific risk factors for multidrug-resistant (MDR) pathogens or in units where greater than 10-20% of Staphylococcus aureus isolates are methicillin resistant. Single coverage for MDR gram-negative pathogens can be used in many HAP and VAP patients without risk factors for MDR pathogens when the antibiogram demonstrates that at least 90% of gram negatives are sensitive to the agent being considered for monotherapy. A 7-day course of antibiotics was recommended for most patients, including those with glucose nonfermenting gram-negative organisms. New guidelines for the diagnosis and treatment of HAP and VAP contain several novel recommendations regarding the diagnosis and treatment of these entities.

Türkiye'de sağlık bakımı ile ilişkili pnömoni olgularının klinik özellikleri ve sonuçları

Pneumonia in cases with preceding hospitalization, hemodialysis, intravenous therapy, wound care, or chemotherapy within the prior 30 days and residence in nursing homes are defined as healthcare associated pneumonia (HCAP). The aim of this study was to compare the demographic and laboratory data, isolated causative agents and prognosis of patients with community-acquired pneumonia (CAP) and HCAP in a large population in Turkey. The data of 785 cases (average age 65.3 ± 16.4, 530 male) registered to Turkish Thoracic Society Respiratory Infections Study Group CAP database (TURCAP) were examined. The demographic data, clinical history, pneumonia severity scores (PSI), laboratory and radiologic findings of the CAP and HCAP patients were compared. Out of 785 cases, 207 (26.4%) were diagnosed with HCAP and 578 (73.6%) with CAP. Among HCAP cases, 140/207 (67.6%) had preceding hospitalization in the last 90 days, 28/207 (13.5%) were on a hemodialysis program during the previous 30 days and 22/207 (10.6%) were staying in nursing homes. Patients with HCAP more frequently had comorbidities (93.2% vs. 81.6%; p= 0.001) and higher PSI scores (103.9 ± 37.2 vs. 94.6 ± 35.4; p= 0.002) compared to patients with CAP. A causative microorganism was isolated in only 12.1% (70/578) of CAP and 14.5% (30/207) of HCAP patients. The length of stay in hospital was higher in HCAP than CAP (8.6 ± 5.5 vs. 7.5 ± 6.1 days, p= 0.03); however the rates of treatment failure, intensive care unit admission and mortality were similar. In comparison to CAP, HCAP patients tend to have more severe disease, despite have no difference in mortality. The current criteria for HCAP do not predict worse clinical outcomes. Further work is required to define local risk factors for multidrug-resistant pathogens.

Multidrug-resistant pathogens in patients with pneumonia coming from the community.

Identification of patients with multidrug-resistant (MDR) pathogens at initial diagnosis is essential for the appropriate selection of empiric treatment of patients with pneumonia coming from the community. The term Healthcare-Associated Pneumonia (HCAP) is controversial for this purpose. Our goal is to summarize and interpret the data addressing the association of MDR pathogens and community-onset pneumonia. Most recent clinical studies conclude that HCAP risk factor does not accurately identify resistant pathogens. Several risk factors related to MDR pathogens, including new ones that were not included in the original HCAP definition, have been described and different risk scores have been proposed. The present review focuses on the most recent literature assessing the importance of different risk factors for MDR pathogens in patients with pneumonia coming from the community. These included generally MDR risk factors, specific risk factors related to methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa and clinical scoring systems develop to assess the MDR risk factors and its application in clinical practice. Different MDR risk factors and prediction scores have been recently developed. However, further research is needed in order to help clinicians in distinguishing between different MDR pathogens causing pneumonia.

Update on ventilator-associated pneumonia

To highlight the importance of escalating pathogen resistance in ventilator-associated pneumonia (VAP) along with diagnostic and treatment implications. In a period of rising bacterial resistance, VAP remains an important infection occurring in critically ill patients. Risk factors for multidrug-resistant pathogens depend on both local epidemiology and host factors. New diagnostic techniques and antimicrobials can help with rapid bacterial identification and timely and appropriate treatment while avoiding emergence of bacterial resistance. Clinicians should be aware of risk factors for multidrug-resistant pathogens causing VAP and also of particularities of diagnosis and treatment of this important clinical entity.

A New Strategy for Healthcare-Associated Pneumonia: A 2-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-Resistant Pathogens to Select Initial Empiric Therapy

Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) is uncertain. We prospectively applied a therapeutic algorithm, based on the presence of risk factors for multidrug-resistant (MDR) pathogens in a multicenter cohort study of 445 pneumonia patients, including both community-acquired pneumonia (CAP; n = 124) and HCAP (n = 321). MDR pathogens were more common (15.3% vs 0.8%, P < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0-1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, yet 92.9% received appropriate therapy for the identified pathogen. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0-1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .012). In multivariate analysis, initial treatment failure, but not inappropriate empiric antibiotic therapy, was a mortality risk factor (odds ratio, 72.0). Basing empiric HCAP therapy on its severity and the presence of risk factors for MDR pathogens is a potentially useful approach that achieves good outcomes without excessive use of broad-spectrum antibiotic therapy. Japan Medical Association Center for Clinical Trials, JMA-IIA00054.

Guideline-Concordant Antimicrobial Therapy for Healthcare-Associated Pneumonia: A Systematic Review and Meta-analysis

The objective of this study was to perform a systematic review and meta-analysis of the impact of the 2005 American Thoracic Society/Infectious Diseases Society of America guideline-concordant antimicrobial therapy (GCAT) on mortality following healthcare-associated pneumonia (HCAP). We searched MEDLINE, EMBASE, BIOSIS, Cochrane CENTRAL Register of Controlled Trials, and Scopus for clinical trials and observational studies comparing GCAT to other treatment regimens in adults with HCAP. The primary outcome chosen was 30-day mortality from any cause. Secondary outcomes assessed length of hospital stay and time to clinical stability. Random effects models were used to generate pooled odds ratios (ORs) and weighed mean differences (WMDs). Heterogeneity was evaluated by the I(2). A total of six studies were included in the analysis and involved 15,850 participants. Meta-analysis showed that GCAT was associated with increased 30-day mortality compared to non-GCAT (OR 1.80, 95% confidence interval [CI] 1.26-2.7). There was no advantage in GCAT over non-GCAT in terms of hospital length of stay (WMD 1.18 days, 95%CI -0.48 to 2.84) or time to clinical stability (WMD 0.17days, 95%CI -0.32 to 0.67). In hospitalized patients with HCAP, GCAT did not show survival benefit compared to non-GCAT. However, our results are limited by the cohort design of the selected studies and the degree of heterogeneity among them. Future trials are needed to identify risk factors for multidrug-resistant pathogens in HCAP patients who may benefit from broad-spectrum antimicrobial regimens.

Emergence of methicillin-resistant Staphylococcus aureus USA300 genotype as a major cause of late-onset nosocomial pneumonia in intensive care patients in the USA

To compare demographic and clinical characteristics, and methicillin-resistant Staphylococcus aureus (MRSA) strain characteristics, in patients with early-onset (EO) and late-onset (LO) MRSA nosocomial pneumonia. This was a retrospective analysis of data from a multicenter observational study of nosocomial pneumonia patients admitted between November 2008 and July 2010. Laboratory analyses performed on MRSA isolates included confirmation of antimicrobial susceptibility and heteroresistance to vancomycin, USA typing, staphylococcal cassette chromosome (SCC) mec typing, and detection of Panton-Valentine leukocidin (PVL) genes. We identified 134 patients; 42 (31%) had EO MRSA pneumonia and 92 (69%) had LO MRSA pneumonia. The patients in the LO group were more likely to have risk factors for multidrug-resistant pathogens (98% vs. 76%, p<0.001). The MRSA USA300 strain was found with equal frequency in the EO and LO groups. Likewise, both groups had similar frequencies of isolates exhibiting PVL and SCCmec type IV. Our findings provide further evidence of the continued migration of community-associated MRSA into the healthcare setting in the USA. MRSA USA300 genotype has emerged as a significant cause of LO nosocomial pneumonia in intensive care units. Appropriate anti-MRSA antimicrobial therapy should be considered for both EO and LO hospital-acquired pneumonia and ventilator-associated pneumonia.

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Introduction: Based upon ATS/IDSA guideline recommendations for the management of adults with healthcare-associated pneumonia, patients with early-onset infection (within 4 days of admission) without risk factors for multidrug-resistant (MDR) pathogens should receive empiric monotherapy. However, more recent data suggests that this early- and late-onset classification should be abandoned as similar pathogens and mortality have been identified in the two subgroups of patients. Hypothesis: We hypothesize that there is no difference in the incidence of MDR pathogens between episodes of early-onset and late-onset pneumonia within our institution. Methods: We conducted a retrospective chart review of respiratory cultures (endotracheal aspirates and bronchoalveolar lavages) obtained at our institution between June 2008 and December 2011. Results: Five hundred eighty four cultures were reviewed to include 150 patients. Thirty-nine of 65 (60%) patients with early-onset pneumonia had infection with MDR organisms versus 63 of 85 (74%) patients with late-onset pneumonia (p=0.07). In patients with early-onset pneumonia with and without risk factors, MDR organisms accounted for 24 of 33 (73%) and 15 of 32 (47%) infections, respectively (p=0.04). Compared to the 47% incidence of MDR pathogens in patients without risk factors, MDR organisms were identified in 74% (87 of 118) of all patients with expected risk of MDR pathogens (late onset/other risk factors) (p=0.005). No difference was observed in mechanical ventilator-free days, intensive care unit length of stay, or mortality between the latter two groups described. Conclusions: We observed a similar incidence of infection with MDR pathogens in patients with early- and late-onset pneumonia; however, more MDR pathogens were observed in patients with risk factors for MDR pathogens regardless of timing of onset. While this study confirms the high incidence of pneumonia associated with MDR organisms in patients with risk factors, half of patients with early-onset pneumonia without identified risk factors experienced infection with MDR organisms. Consideration should be given to broad-spectrum empiric antibiotic regimens in patients with early-onset pneumonia in our hospital.

Is healthcare-associated pneumonia a distinct entity needing specific therapy?

Healthcare-associated pneumonia (HCAP) was introduced in 2005 by American Thoracic Society/Infectious Diseases Society of America guidelines as a new entity of pneumonia, resembling nosocomial pneumonia rather than community-acquired pneumonia (CAP) in terms of frequency of multidrug-resistant (MDR) pathogens and outcomes, thus requiring broad spectrum initial antimicrobial coverage in order to prevent inadequate treatment and, as a consequence, excess mortality. This concept continues to be a subject of controversy. Main concerns relate to the definition of HCAP, the true frequency of MDR pathogens, and the impact of MDR pathogens on outcomes. Definitions of HCAP and the relative frequencies of HCAP defining subgroups were highly variable. All studies demonstrated an increased severity of pneumonia at presentation and an excess mortality from HCAP as compared to CAP. The incidence of MDR pathogens in different observational studies was slightly increased but generally low in most studies originating from Europe, South Korea, Canada, and Japan. However, the data do not support a causal relationship of MDR incidence and excess mortality. Instead, after adjustment for confounders, mortality might be related to hidden or documented treatment restrictions in elderly and severely disabled patients. Accordingly, HCAP guideline concordant antimicrobial treatment did not improve outcomes. The HCAP concept is based on varying definitions poorly predictive of MDR pathogens. The incidence of MDR pathogens is far lower than supposed in the original guideline document, and MDR pathogens do not seem to be the main cause of excess mortality. Broad antimicrobial coverage does not alter outcomes. As the HCAP concept results in a tremendous overtreatment without any evidence for improved outcomes, it should not be implemented in clinical practice prior to clear evidence that it is superior to a careful assessment of individual risk factors for MDR pathogens.

Stratifying Risk Factors for Multidrug-Resistant Pathogens in Hospitalized Patients Coming From the Community With Pneumonia

Not all risk factors for acquiring multidrug-resistant (MDR) organisms are equivalent in predicting pneumonia caused by resistant pathogens in the community. We evaluated risk factors for acquiring MDR bacteria in patients coming from the community who were hospitalized with pneumonia. Our evaluation was based on actual infection with a resistant pathogen and clinical outcome during hospitalization. An observational, prospective study was conducted on consecutive patients coming from the community who were hospitalized with pneumonia. Data on admission and during hospitalization were collected. Logistic regression models were used to evaluate risk factors for acquiring MDR bacteria independently associated with the actual presence of a resistant pathogen and in-hospital mortality. Among the 935 patients enrolled in the study, 473 (51%) had at least 1 risk factor for acquiring MDR bacteria on admission. Of all risk factors, hospitalization in the preceding 90 days (odds ratio [OR], 4.87 95% confidence interval {CI}, 1.90-12.4]; P = .001) and residency in a nursing home (OR, 3.55 [95% CI, 1.12-11.24]; P = .031) were independent predictors for an actual infection with a resistant pathogen. A score able to predict pneumonia caused by a resistant pathogen was computed, including comorbidities and risk factors for MDR. Hospitalization in the preceding 90 days and residency in a nursing home were also independent predictors for in-hospital mortality. Risk factors for acquiring MDR bacteria should be weighted differently, and a probabilistic approach to identifying resistant pathogens among patients coming from the community with pneumonia should be embraced.

Ventilator‐Associated Tracheobronchitis and Pneumonia: Thinking Outside the Box

Lower respiratory tract infections in intubated patients include ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). These infections are increasingly caused by multidrug-resistant bacteria, which colonize the patient's oropharynx and enter the lower respiratory tract around the endotracheal tube cuff or through the lumen. Progression of colonization to VAT and, in some patients, to VAP is related to the quantity, types, and virulence of invading bacteria versus containment by host defenses. Diagnostic criteria for VAT and VAP overlap in terms of clinical signs and symptoms, and they share similar microbiologic criteria when endotracheal sputum aspirate samples are used. In addition, the diagnosis of VAP requires a new and persistent infiltrate on a chest radiograph, which may be difficult to assess in critically ill patients, and a significant bacterial culture of a endtotracheal aspirate or bronchoalveolar lavage specimen. Current guidelines for the management of VAP strongly recommend the use of early, appropriate empirical antibiotic therapy based on patient risk factors for multidrug-resistant pathogens. An alternative model focused on VAT, using serial surveillance of endotracheal aspirate specimens to identify multidrug-resistant pathogens and their antibiotic susceptibilities, would allow earlier, targeted antibiotic treatment that could improve outcomes in patients, prevent VAP, and provide an attractive model for clinical research trials.

Nursing Home–Acquired Pneumonia

Nursing home-acquired pneumonia (NHAP) was first described in 1978. Since then there has been much written regarding NHAP and its management despite the lack of well-designed studies in this patient population. The most characteristic features of patients with NHAP are the atypical presentation, which may lead to delay in diagnosis and therapy. The microbial etiology of pneumonia encompasses a wide spectrum that spans microbes recovered from patients with community-acquired pneumonia to organisms considered specific only to nosocomial settings. Decision to transfer a nursing home patient to an acute care facility depends on a host of factors, which include the level of staffing available at the nursing home, patients' advance directives, and complexity of treatment. The presence of risk factors for multidrug-resistant pathogens dictates approach to therapy. Prevention remains the cornerstone of reducing the incidence of disease. Despite the advance in medical services, mortality from NHAP remains high.