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Background: Data regarding the comparative profiling of HCAP and HAP from developing countries like India are scant. We set out to address the microbial aetiology, antibiotic resistance and treatment outcomes in patients with HCAP and HAP., Methods: 318 consenting patients with HCAP (n = 165, aged 16-90 years; median 60 years; 97 males) or HAP (n = 153; aged 16-85 years; median 45 years; 92 males) presenting to a tertiary care hospital in North India from 2013 to 2015 were prospectively recruited for the study. Data on patient characteristics, microbial aetiology, APACHE II scores, treatment outcomes and mortality were studied. Clinical outcomes were compared with various possible predictors employing logistic regression analysis., Results: Patients in HCAP had more comorbidity. Escherichia coli (30, 18%) and Acinetobacter baumannii (62, 41%) were the most commonly isolated bacteria in HCAP and HAP, respectively. Multidrug-resistant bacteria were isolated more frequently in HCAP, only because the incidence of extensively drug-resistant bacteria was markedly high in HAP (p = 0.00). The mean APACHE II score was lower in HCAP (17.55 ± 6.406, range 30) compared to HAP (19.74 ± 8.843, range 37; p = 0.013). The length of stay ≥ 5 days (p = 0.036) and in-hospital mortality was higher in HAP group (p = 0.002). The most reliable predictors of in-hospital mortality in HCAP and HAP were APACHE II score ≥ 17 (OR = 14, p = 0.00; HAP: OR = 10.8, p = 0.00), and septic shock (OR = 4.5, p = 0.00; HAP: OR = 6.9, p = 0.00)., Conclusion: The patient characteristics in HCAP, treatment outcomes, bacterial aetiology, and a higher incidence of antibiotic-resistant bacteria, suggest that HCAP although not as severe as HAP, can be grouped as a separate third entity.

Background: Health care-associated pneumonia (HCAP) affects a heterogeneous group of patients in frequent contact with health care systems. However, HCAP criteria poorly predict infection with drug-resistant (DR) pathogens., Objective: To validate our previously reported risk-scoring model (predictive of DR pathogen infection) in patients admitted to hospital with pneumonia., Design: We evaluated 580 patients admitted with culture-positive bacterial pneumonia. We identified risk factors, evaluated the risk-scoring model's capacity to predict infection by DR pathogens and compared the model's diagnostic accuracy with that of current HCAP criteria., Results: DR pathogens were observed in 227/580 patients (39.1%). Of 269 HCAP patients, 153 (56.9%) were infected with DR pathogens. Overtreatment was more common in HCAP than in community-acquired pneumonia (58.7% vs. 41.2%, P < 0.001). Recent hospitalisation, admission from a long-term care facility, recent antibiotic treatment and tube feeding were independently associated with DR pathogens. For pathogen prediction, the risk-scoring model showed better diagnostic accuracy than HCAP criteria (area under receiver operating-characteristic curve = 0.723 vs. 0.673, P < 0.001)., Conclusion: According to current HCAP criteria, half of the HCAP patients were treated unnecessarily with broad-spectrum antibiotics. Risk scoring by stratifying risk factors could improve the identification of patients likely to be infected with DR pathogens.

Contagious bovine pleuropneumonia (CBPP), caused by Mycoplasma mycoides subsp. mycoides SC (MmmSC), is one of the most important diseases of cattle in Sub-Saharan Africa. The live T1/44 vaccine is normally used for its control but produces only transient protection and gives rise to adverse reactions. The present study evaluated the efficacy of danofloxacin (2.5% Advocintrade mark, Pfizer Ltd.) for the treatment of naturally infected cattle and in the prevention of CBPP transmission to in-contact cattle. Adult cattle, taken from a natural outbreak, were placed into two groups of 10 animals and kept on a research farm in paddocks 50m apart. One group was treated with 2.5mg/kg danofloxacin on days 0, 1 and 2; the other group were saline treated. On day 2, 10 CBPP-free, seronegative cattle were placed in contact with each of the two groups. All cattle were monitored for 3.5 months. No differences were seen in clinical improvement of the CBPP-affected cattle treated with danofloxacin compared with the untreated CBPP-affected cattle with approximately half of each group being withdrawn because of CBPP or showing CBPP lesions at post mortem examination. Clinical scores of the two groups were also similar. However cattle kept in contact with the danofloxacin-treated CBPP-affected animals showed significantly fewer lesions, less mortality and fewer animals were seropositive (P<0.02) and had reduced clinical scores (P<0.001) compared to cattle kept in contact with untreated CBPP-affected cattle. MmmSC was also isolated from fewer contact controls kept with the treated group. These findings could have important implications for the control of CBPP in Africa.

Purpose: To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary., Methods: We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a "not observed" cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an "observed for 1 day" cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts., Results: A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 "not observed" and 2712 "observed for 1 day" patients). Mean length of stay was 3.8 days for the "not observed" cohort and 4.5 days for the "observed for 1 day" cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the "not observed" cohort vs 7.2% "observed for 1 day" cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% "not observed" cohort vs 4.4% in the "observed for 1 day" cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the "not observed" and "observed for 1 day" cohorts., Conclusions: Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.

Study Objective: Evaluation of efficacy and safety of pristinamycin (PRI), compared with amoxicillin (AMX), both at 3 g daily for 7 to 10 days in adults with community-acquired pneumonia (CAP)., Patients and Methods: Multinational, randomized, double blind, double dummy clinical trial of non-inferiority was conducted in 399 patients with a CAP., Results: At inclusion, the mean age was 47.8+/-18.3 years, 24.3% patients were 65 or older. The Fine score was < or =III in 85.4% patients. The bacterial etiology was documented in 34.8% of patients: Streptococcus pneumoniae (48.1%), Mycoplasma pneumoniae (18.6%), Haemophilus influenzae (14.7%), Chlamydia pneumoniae (13.2%), Legionella pneumophila (9.3%). In the clinical per-protocol population, the clinical success rate was 87.6% in each group: 149/170 patients (PRI) and 148/169 (AMX); The 95% confidence interval was [-6.61%; 7.23%]. In modified intend to treat population, the clinical success rate was 79.9% (151/189) in the PRI group and 83.0% (151/182) in the AMX group [CI 95% (-10.87%; 4.69%)]. A satisfactory bacteriological response was observed in 82.3% (51/62) of PRI patients and 88.1% (59/67) of AMX patients. Treatment related adverse events occurred similarly in both groups according to the expected tolerance profile of the two drugs. No serious adverse events in both groups were related to the study drugs., Conclusions: In this study, PRI 3 g daily was clinically as effective and well tolerated as AMX 3 g daily, for 7 to 10 days, in PPc, in the treatment of bacterial community-acquired pneumonia.

Objective: To prospectively evaluate the predictive factors for the nonresponse to empirical antibiotic treatment and mortality in patients with intensive care unit-acquired pneumonia., Design: A 1-yr prospective cohort of patients with suspicion of intensive care unit-acquired pneumonia., Setting: Five medical and surgical intensive care units of Hospital Clinic in Barcelona., Patients: A total of 71 patients with intensive care unit-acquired pneumonia were studied. The definition of nonresponse included at least one of the following: failure to improve the Pao2/Fio2 ratio or need of intubation because of pneumonia, persistence of fever or hypothermia and purulent respiratory secretions, worsening of pulmonary infiltrates, or occurrence of septic shock or multiple organ dysfunction not present at onset of pneumonia., Interventions: Clinical assessment, including severity scores, blood and quantitative cultures of respiratory secretions, and cytokine measurements in serum and bronchoalveolar lavage at onset of pneumonia and 72 hrs after antimicrobial treatment., Measurements and Results: A total of 44 patients (62%) fulfilled criteria of nonresponse, and at least one cause of nonresponse could be determined in 28 cases (64%): inappropriate treatment in ten (23%), superinfection in six (14%), concomitant foci of infection in 12 (27%), and noninfectious causes in seven cases (16%). The remaining 16 patients with no definite cause of nonresponse presented with septic shock, multiple organ dysfunction, or acute respiratory distress syndrome. Increased levels of interleukin-6 at onset of pneumonia (odds ratio, 9.7; p =.014) was an independent predictor of nonresponse to treatment. Likewise, increased level of interleukin-6 at follow-up (odds ratio, 27; p =.001) was the only independent predictor for hospital mortality., Conclusion: Increased systemic inflammatory response was the main predictor of nonresponse to treatment and mortality.

The management of patients with community-acquired pneumonia confronts the practicing physician with the requirement to make two principal decisions. The first decision is on the site of treatment of this infection. The options are to either treat the patient as an outpatient or to hospitalize the patient. The second decision concerns the selection of an appropriate antimicrobial agent. Over the course of the last five years, a prediction rule was developed and validated in the U.S., which allows to accurately identify those patients that carry a low risk for the development of complications of their infections. Hence, these patients can safely be managed as outpatients. On the other hand, patients with high scores (risk classes III-V) should be hospitalized and at least initially managed as inpatients. The calculation of this score requires the collection of a substantial number of parameters. However, good clinical practice requires the evaluation of most of this parameters. Therefore, the additional work resulting from the calculation of this score is moderate and certainly justifiable. Details of the prediction rule according to Fine et al. are presented in this article. Several guidelines exist for the empiric antibiotic treatment of patients with community-acquired pneumonia. Some key recommendations are influenced by the aggravating problem of antibiotic resistance in the U.S. The situation in Switzerland differs from the American situation and therefore recommendations in this article reflect this difference. In daily clinical practice it is somewhat rare to know the microbiological etiology of the individual episode of community-acquired pneumonia with certainty. Therefore, antibiotic treatment is started empirically and also continued empirically in most cases.

The etiology of acute lower respiratory tract infections (mostly pneumonia) in children is well characterized, but these are only some of the community-acquired infections warranting parenteral antimicrobial therapy. We prospectively evaluated all such infections among children aged 3 months to 15 years by use of blood cultures, examination of nasopharyngeal aspirates, and serologies for 15 viral, 7 bacterial, and 1 protozoal agent. Immunocompromised patients and those with urinary tract infection, meningitis, or osteoarticular infection were excluded. In all, 170 children were included. The pathogenic agent was identified in 62% of the cases. Bacteria were detected in 54%, and a pneumococcus was found in 59% of the cases identified. Viruses were found in 15% overall. Sole bacterial or viral infections were detected in 47.1% and 8.1%, respectively. Since thorough screening established the etiology in less than two-thirds of patients ill enough to be hospitalized and treated parenterally, better diagnostics are needed, especially to identify those who would truly benefit from antimicrobial therapy.

According to the statistics prepared by health insurance carriers community-acquired pneumonia has an incidence of some 300,000 to 400,000 cases per year. In old age (more than 80 years), the mortality rate increases from 20 to 2000 per 100,000 head of the population, that is, by a factor of 100. The former classification into "typical" and "untypical" pneumonia has now been abandoned, the modern approach being that of "calculated antibiotic therapy" that involves the placing of patients in "risk groups". To each risk group a probable pathogen spectrum is assigned and a recommendation for the selection of an appropriate antibiotic then made. Thus, for example, for the pathogen spectrum in group 1 (ambulatory patients under 60 years of age and no major secondary diseases), the macrolides are the antibiotics of first choice. The procedure to be followed in the other risk groups and in the event of treatment failures is discussed. Criteria that identify the need for hospitalization are presented.