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Background and study objectives: The range and relative impact of microbial pathogens, particularly viral pathogens, as a cause of community-acquired pneumonia (CAP) in hospitalized adults has not received much attention. The aim of this study was to determine the microbial etiology of CAP in adults and to identify the risk factors for various specific pathogens. Methods: We prospectively studied 176 patients (mean [± SD] age, 65.8 ± 18.5 years) who had hospitalized for CAP to identify the microbial etiology. For each patient, sputum and blood cultures were obtained as well as serology testing for Mycoplasma pneumoniae and Chlamydophila pneumoniae , urinary antigen testing for Legionella pneumophila and Streptococcus pneumoniae , and a nasopharyngeal swab for seven respiratory viruses. Results: Microbial etiology was determined in 98 patients (55%). S pneumoniae (49 of 98 patients; 50%) and respiratory viruses (32%) were the most frequently isolated pathogen groups. Pneumococcal pneumonia was associated with tobacco smoking of > 10 pack-years (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2 to 5.4; p = 0.01). Respiratory viruses were isolated more often in fall or winter (28%; p = 0.011), and as an exclusive etiology tended to be isolated in patients ≥ 65 years of age (20%; p = 0.07). Viral CAP was associated with antimicrobial therapy prior to hospital admission (OR, 4.5; 95% CI, 1.4 to 14.6). Conclusions: S pneumoniae remains the most frequent pathogen in adults with CAP and should be covered with empirical antimicrobial treatment. Viruses were the second most common etiologic agent and should be tested for, especially in fall or winter, both in young and elderly patients who are hospitalized with CAP.

Background/Aim: Community-acquired pneumonia (CAP) is a frequent cause for hospitalization and may result in a number of different renal and electrolyte complications. The purpose of this study was to describe the incidence of hyponatremia in CAP and to analyze risk factors for its occurrence. Methods: Records were reviewed for all 342 subjects who participated in the Community-Acquired Pneumonia Standardized Order Set study, a 2-year trial of supplemental treatment tools in hospital pneumonia treatment. Results: Hyponatremia (serum sodium concentration Conclusion: Hyponatremia is a common complication present at the time of admission for CAP. It is associated with more severe illness, increased mortality risk and extended hospital stays. Hyponatremia develops less frequently during the hospitalization and is unrelated to severity of illness on admission, but is an iatrogenic complication and thus initial treatment with isotonic saline may reduce the risk of this complication.

Importance In patients with severe community-acquired pneumonia, treatment failure is associated with excessive inflammatory response and worse outcomes. Corticosteroids may modulate cytokine release in these patients, but the benefit of this adjunctive therapy remains controversial. Objective To assess the effect of corticosteroids in patients with severe community-acquired pneumonia and high associated inflammatory response. Design, Setting, and Participants Multicenter, randomized, double-blind, placebo-controlled trial conducted in 3 Spanish teaching hospitals involving patients with both severe community-acquired pneumonia and a high inflammatory response, which was defined as a level of C-reactive protein greater than 150 mg/L at admission. Patients were recruited and followed up from June 2004 through February 2012. Interventions Patients were randomized to receive either an intravenous bolus of 0.5 mg/kg per 12 hours of methylprednisolone (n = 61) or placebo (n = 59) for 5 days started within 36 hours of hospital admission. Main Outcomes and Measures The primary outcome was treatment failure (composite outcome of early treatment failure defined as [1] clinical deterioration indicated by development of shock, [2] need for invasive mechanical ventilation not present at baseline, or [3] death within 72 hours of treatment; or composite outcome of late treatment failure defined as [1] radiographic progression, [2] persistence of severe respiratory failure, [3] development of shock, [4] need for invasive mechanical ventilation not present at baseline, or [5] death between 72 hours and 120 hours after treatment initiation; or both early and late treatment failure). In-hospital mortality was a secondary outcome and adverse events were assessed. Results There was less treatment failure among patients from the methylprednisolone group (8 patients [13%]) compared with the placebo group (18 patients [31%]) ( P = .02), with a difference between groups of 18% (95% CI, 3% to 32%). Corticosteroid treatment reduced the risk of treatment failure (odds ratio, 0.34 [95% CI, 0.14 to 0.87]; P = .02). In-hospital mortality did not differ between the 2 groups (6 patients [10%] in the methylprednisolone group vs 9 patients [15%] in the placebo group; P = .37); the difference between groups was 5% (95% CI, −6% to 17%). Hyperglycemia occurred in 11 patients (18%) in the methylprednisolone group and in 7 patients (12%) in the placebo group ( P = .34). Conclusions and Relevance Among patients with severe community-acquired pneumonia and high initial inflammatory response, the acute use of methylprednisolone compared with placebo decreased treatment failure. If replicated, these findings would support the use of corticosteroids as adjunctive treatment in this clinical population. Trial Registration clinicaltrials.gov Identifier:NCT00908713

Community-acquired pneumonia (CAP) is a frequent cause of morbidity and mortality worldwide. Approximately 20% of CAP patients require hospital admission [1, 2], leaving a large percentage of patients treated in the community as outpatients. In addition, bacteraemia is associated with worse outcomes, such as a higher prevalence of intensive care unit (ICU) admission and longer length of stay. Current international guidelines [1, 3, 4] do not recommend blood cultures as part of routine microbiological tests in patients managed in the community. However, there is little information regarding the prevalence and clinical impact of bacteraemia in CAP patients treated outside the hospital. Previous studies reported incidences of 2.1–7%, respectively [5–8]. However, few data exist regard predictive factors and the clinical outcomes associated with positive blood cultures in this population [8]. The current study aimed to determine the predictive factors and the clinical outcomes of bacteraemic outpatients with CAP, and describe their clinical, epidemiological and microbiological characteristics. CAP patients who are discharged but have a high risk of bacteraemia can be identified using risk factors

Background Very few data exist on the management of community-acquired pneumonia (CAP) in patients admitted to hospitals in the Gulf region. The objectives of this study were to describe treatment patterns for CAP in 38 hospitals in five Gulf countries (United Arab Emirates, Kuwait, Bahrain, Oman, and Qatar) and to compare the findings to the most recent Infectious Diseases Society of America (IDSA) / American Thoracic Society (ATS) guidelines. Methods This was a prospective, observational study conducted between January 2009 and February 2011. Adult patients hospitalised (excluding intensive care units) for CAP and subsequently discharged were included. Data were collected retrospectively at hospital discharge, and prospectively during two follow-up visits. Data on medical history, mortality-risk scores, diagnostic criteria, antibiotic treatment, isolated pathogens and clinical and radiographic outcomes were collected. Care practices were compared to the IDSA/ATS guidelines. Results A total of 684 patients were included. The majority (82.9 %) of patients were classified as low risk for mortality (pneumonia severity index II and III). The majority of patients fulfilled criteria for treatment success at discharge, although only 77.6 % presented a normalised leukocyte count. Overall, the management of CAP in Gulf countries is in line with the IDSA/ATS guidelines. This applied to the diagnosis of CAP, to the identification of high-risk CAP patients, to the identification of etiologic agent responsible for CAP and to the type of treatment despite the fact that combinations of antimicrobial agents were not consistent with the guidelines in 10 % of patients. In all patients, information about Gram’s staining was not captured as recommended by the IDSA/ATS and in the majority of patients (>85 %) chest radiography was not systematically performed at the post-discharge follow-up visits. Discussion The management of CAP in the Gulf region is globally in line with current IDSA/ATS guidelines, although rates of pathogen characterisation and post-discharge follow-up need to be improved. Conclusion Compliance with established guidelines should be encouraged in order to improve the management of the disease in this region.

Among various risk factors for death among critically ill patients with serious infection, inappropriate antimicrobial therapy is an important factor that clinicians can modify directly. The presence of multidrug-resistant bacteria is the primary reason that patients with ventilator-associated pneumonia receive inappropriate antimicrobial therapy. Empirical antimicrobial therapy for ventilator-associated pneumonia should be initiated promptly and should have a broad spectrum that covers all potential antimicrobial-resistant pathogens. Delaying the start of therapy or modifying an inappropriate antimicrobial regimen does not improve outcome, probably because the change comes too late to redirect the course of illness. Timely empirical therapy with highly effective agents that are rapidly bactericidal could minimize the emergence of resistance. Broad-spectrum therapy should be streamlined (i.e., de-escalated), as appropriate, on the basis of microbiological data and clinical response. Switching to narrower-spectrum therapy that is directed by culture results may minimize the emergence of resistance. For some patients, clinical response will allow a shortening of the duration of antimicrobial therapy.

Many antibiotics, including macrolides and quinolones, are used incorrectly in the treatment of presumed respiratory tract infections. The use of broad-spectrum antibiotics increased considerably in the 1990s, but often this use is inappropriate. Guidelines, such as those for community-acquired pneumonia, encourage rational therapy and more prudent prescribing. There are strong links between appropriate use, compliance and resistance as well as between regimen complexity and compliance. These issues provide a platform for thinking about a short-duration, high-compliance drug therapy with good clinical efficacy. Such therapy will need to be combined with programs to promote rational antibiotic use, particularly targeting inappropriate prescribing for viral infections and use of agents with a broader antimicrobial spectrum than is necessary.

Community-acquired pneumonia (CAP) is a common disorder that is potentially life-threatening, especially in older adults and patients with comorbid disease. Despite substantial progress in therapeutic options, CAP remains a primary cause of death from infectious disease in the United States. The mainstay of treatment for most patients is appropriate antimicrobial therapy This article reviews the principles for initial antimicrobial therapy, highlights some of the differences in approaches to antimicrobial drug selection in selected guidelines, and includes new recommendations for empiric and pathogen-directed therapy of CAP.

Community-acquired pneumonia (CAP) is a costly disease that is associated with significant morbidity and mortality. The growing prevalence of this disease has resulted in various advances in diagnosis and treatment. The most common pathogens of CAP include Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens; however, the underlying pathogen often is unknown. Treatment of CAP has evolved because of changing etiologic patterns and increasing antimicrobial resistance among common respiratory pathogens. Among the groups that have established treatment guidelines for CAP are the American Thoracic Society (ATS), the Infectious Diseases Society of America (IDSA), and the Centers for Disease Control and Prevention (CDC). These guidelines establish risk factors associated with drug resistance or infection with specific pathogens. In addition, each guideline provides unique recommendations that are similar in some ways, yet different in others. By understanding the various risk factors for drug resistance and the treatment options endorsed by these guidelines, physicians can treat patients with the most appropriate antimicrobial available.

Background: A study was undertaken to validate the modified American Thoracic Society (ATS) rule and two British Thoracic Society (BTS) rules for the prediction of ICU admission and mortality of community acquired pneumonia and to provide a validation of these predictions on the basis of the pneumonia severity index (PSI). Method: Six hundred and ninety six consecutive patients (457 men (66%), mean (SD) age 67.8 (17.1) years, range 18–101) admitted to a tertiary care hospital were studied prospectively. Of these, 116 (16.7%) were admitted to the ICU. Results: The modified ATS rule achieved a sensitivity of 69% (95% CI 50.7 to 77.2), specificity of 97% (95% CI 96.4 to 98.9), positive predictive value of 87% (95% CI 78.3 to 93.1), and negative predictive value of 94% (95% CI 91.8 to 95.8) in predicting admission to the ICU. The corresponding predictive indices for mortality were 94% (95% CI 82.5 to 98.7), 93% (95% CI 90.6 to 94.7), 49% (95% CI 38.2 to 59.7), and 99.5% (95% CI 98.5 to 99.9), respectively. These figures compared favourably with both the BTS rules. The BTS-CURB criteria achieved predictions of pneumonia severity and mortality comparable to the PSI. Conclusions: This study confirms the power of the modified ATS rule to predict severe pneumonia in individual patients. It may be incorporated into current guidelines for the assessment of pneumonia severity. The CURB criteria may be used as an alternative tool to PSI for the detection of low risk patients.

To compare hospitalization rates among patients with community-acquired pneumonia (CAP) treated with oral telithromycin and clarithromycin, based on pooled data from two randomized, double-blind, multinational clinical trials.Adult patients with CAP eligible for oral therapy (Study 1, n = 448; Study 2, n = 575) received telithromycin 800 mg once daily for 10 (Study 1, 2-arms), 5 or 7 (Study 2, 3-arms) days, or clarithromycin 500 mg twice daily for 10 days. Frequency of CAP-related hospitalizations, physician visits/tests/procedures, and additional respiratory tract infection-related antibacterial use, as well as CAP-related length of hospital stay and hospitalization costs, were compared by treatment group (intent to treat populations) up until the late post-therapy visit (Days 31-36). Study investigators blinded to treatment regimen assessed whether hospital admissions were CAP related.Despite equivalent clinical efficacy for telithromycin vs clarithromycin in the clinically evaluable per-protocol populations (n = 784) (88.8% [428/482] vs 90.1% [272/302]--difference: -1.3%; 95% CI: -6.0, 3.4), telithromycin treatment for 5, 7, or 10 days was associated with significantly fewer CAP-related hospitalizations (p = 0.023) and CAP-related hospital days (p = 0.025) vs clarithromycin (reduction of 2.3 hospitalizations and 23.4 hospital days per 100 patients). Accordingly, estimated CAP-related hospitalization costs were significantly lower (p = 0.025) for telithromycin recipients (30,231 US dollars less per 100 patients). CAP-related hospitalizations, duration of hospital stay, and hospitalization costs for 7- to 10-day telithromycin--the approved dosing regimen for CAP--were significantly lower (p = 0.023, 0.025, and 0.025, respectively) than for clarithromycin.Data from this study indicate that telithromycin 800 mg once daily for 5, 7, or 10 days provides an effective therapy for patients with CAP, and may be associated with fewer CAP-related hospitalizations and hospital days than clarithromycin 500 mg twice daily for 10 days. Treatment with telithromycin could, therefore, potentially translate into cost savings in the management of CAP.

SUMMARYAims: To compare the impact on hospitalization rates and the clinical efficacy of oral telithromycin and clarithromycin treatment in patients with community-acquired pneumonia (CAP).Patients and methods: Outpatients aged >18 years (n = 448) with CAP were enrolled in a randomized, double-blind, multinational study and received telithromycin 800 mg once daily (n = 224) or clarithromycin 500 mg twice daily (n = 224) for 10 days. The primary outcome measure was clinical efficacy at post-therapy/test of cure (Days 17–24) in the per-protocol population. Frequency of CAP-related hospitalizations, physician visits/tests/procedures, and additional respiratory tract infection-related antibacterial use were compared by treatment group (intent to treat population) up to the late post-therapy visit (Days 31-36). Study investigators who were blinded to the treatment arm assessed whether hospital admissions were CAP related or not. Hospitalization costs (US$) associated with telithromycin and clarithromycin treat...

Nosocomial pneumonia (NP), and its most serious form, ventilator-associated pneumonia (VAP), is a major cause of morbidity and mortality in the ICU. Numerous controversies exist, from diagnostic criteria to prevention and treatment, including the issues of attributable mortality of VAP, differences in the approach to early and late VAP, and the best diagnostic methods. Initial, accurate therapy is one of the most important factors determining outcome in VAP. Antibiotic monotherapy versus combination therapy is not clearly defined, as clinicians struggle with the dual risk of inadequate therapy negatively affecting outcome and overtreatment promoting antibiotic resistance. The role of airway and gastrointestinal colonization and innovative preventive strategies such as noninvasive ventilation, antibiotic rotation, and aerosolized antibiotics are discussed. No uniform standards exist for the approach to VAP. The authors highlight the major controversies and dilemmas in the clinical approach to VAP, with recommendations for the bedside management of these patients.

Acute upper viral respiratory infection (VRI) is the number one cause of illness for which patients seek medical care in the United States. Rhinoviruses, members of the family Picornaviridae, are the causative pathogens in more than half of VRIs, and they are associated with acute exacerbations of respiratory disease, including asthma, sinusitis, otitis media, and COPD. Owing to the lack of commercial availability of rapid and cost-effective laboratory tests to confirm the presence of VRI, the diagnosis is most commonly made empirically, based on patient history and physical examination. Currently, no antiviral agents that are active against picornaviruses are available for clinical use. Antimicrobial agents, frequently prescribed for VRIs, are not active against viruses, and their inappropriate and widespread use has contributed to an increase in antimicrobial resistance among bacteria commonly involved in respiratory tract infections. Several newer antiviral agents are being evaluated for treatment of VRIs. Although a variety of mechanisms and agents have been tested, few have shown significant clinical benefit in human trials. The most advanced antiviral agent in clinical trials is pleconaril, a novel viral capsid–binding inhibitor with potent and highly specific in vitro activity against the majority of serotypes of rhinoviruses and enteroviruses. Clinical trials of pleconaril for the treatment of VRIs have been conducted, and the role of pleconaril in patients with chronic lung disease is being evaluated.

The use of inadequate empirical antimicrobial therapy is common in intensive care unit patients and contributes to a number of poor outcomes. Selecting appropriate antimicrobial therapy is complicated by many factors, including the large number of agents available, the presence of resistant organisms, and the general desire among practitioners to use the most focused therapy available. An important aspect of appropriate antimicrobial use is prompt initiation of adequate empirical therapy, which has been shown to improve mortality rates in hospitalized patients with pneumonia and other serious infections. Other key strategies include streamlining antimicrobial therapy when a pathogen is identified and switching from intravenous to oral therapy when clinically indicated. In addition, antibiotic rotation (or cycling) has been evaluated in several trials as a means to minimize resistance. Promoting appropriate antimicrobial therapy ultimately will require a multidisciplinary, system-oriented, institution-specific approach because each intensive care unit has its own unique flora and antimicrobial resistance patterns.

CAP in elderly patients carries a significant economic and clinical burden and will be more commonly encountered in the future as the US population ages. Diagnosis may be obscured by a nonclassic presentation in an elderly patient, and the clinician needs to be especially suspicious of pneumonia whenever the clinical status of an elderly patient deteriorates. The single most important clinical decision is the site of care; this determination is not always based on clinical factors but also on social factors. Severity assessment is key to stratifying appropriate therapy and to predicting outcome. Timely and appropriate empiric therapy enhances the likelihood of a good clinical outcome, although clinical resolution may be more delayed than in younger patients. Newly emerging patterns of antibiotic resistance have altered recent guidelines for CAP treatment; DRSP is now a consideration in elderly patients because an age older than 65 years is a well-described risk factor for infection with this organism. Prevention should always be implemented, with a focus on pneumococcal and influenza vaccination.

Nosocomial pneumonia is the second most frequent nosocomial infection and represents the leading cause of death from infections that are acquired in the hospital. In the last decade, a large body of data has accumulated that points to the substantial impact of inadequate antibiotic treatment as a major risk factor for infection-attributed mortality in ventilator-associated pneumonia (VAP) patients. In most instances, high-risk pathogens (eg, highly resistant Gram-negative bacilli, such as Pseudomonas aeruginosa and Acinetobacter spp, as well as methicillin-resistant staphylococci) are the predominant microorganisms causing excess mortality. Among various risk factors for mortality from VAP, which include the severity of the underlying disease and the degree of functional physiologic impairment caused by the pulmonary infectious process, only inappropriate antibiotic therapy is directly amenable to modification by clinicians. Secondary modifications of an initially failing antibiotic regimen do not substantially improve the outcome for these critically ill patients. Therefore, the best approach for reducing infection-related mortality seems to be the initial institution of an adequate and broad-spectrum antibiotic regimen in severely ill patients, which should be modified in a de-escalating strategy when the results from microbiologic testing become available. To circumvent the inherent danger of the emergence of resistance in ICU patients, additional measures have to be implemented and tested in clinical trials to reduce antibiotic consumption, shorten the duration of antibiotic treatment, and reduce the selection pressure on the ICU flora. This latter goal could be met by new antibiotic strategies including scheduled changes of recommended empiric antibiotic regimens at fixed intervals on a rotating basis.

Study objective: To conduct a cost-effectiveness analysis of IV-to-oral regimens of azithromycin vs cefuroxime with or without erythromycin in the treatment of patients hospitalized with community-acquired pneumonia (CAP). Patients: Of the 268 evaluable patients enrolled into a randomized, multicenter clinical trial of adults, 266 patients had sufficient data to be included in this cost-effectiveness analysis. One hundred thirty-six patients received azithromycin, and 130 patients received cefuroxime with or without erythromycin. Methods: A pharmacoeconomic analysis from the hospital provider perspective was conducted. Health-care resource utilization was extracted from the clinical database and converted to national reference costs. Decision analysis was used to structure and characterize outcomes. Sensitivity analyses were performed, and statistics were applied to the cost-effectiveness ratios. Results: The clinical success and adverse event rates and antibiotic-related length of stay were 78%, 11.8%, and 5.8 days for the azithromycin group and 75%, 20.7%, and 6.4 days for the group receiving cefuroxime with or without erythromycin, respectively. Geometric mean treatment costs were $4,104 (95% confidence interval [CI], $3,874 to $4,334) for the azithromycin group, and $4,578 (95% CI, $4,319 to $4,837) for the group receiving cefuroxime with or without erythromycin (p 0.06). The cost-effectiveness ratios were $5,265 per expected cure for the azithromycin group, and $6,145 per expected cure for group receiving cefuroxime with or without erythromycin (p 0.05). Conclusions: Despite a higher per-dose purchase price, overall costs with azithromycin tended to be lower due to decreased duration of therapy, lower preparation and administration costs, and reduced hospital length of stay. As empiric therapy, azithromycin monotherapy was cost-effective compared to cefuroxime with or without erythromycin for patients hospitalized with CAP who have no underlying cardiopulmonary disease, and no risk factors for either drug-resistant pneumococci or enteric Gram-negative pathogens. (CHEST 2002; 122:1271–1279)

Despite abundant literature on the management of nosocomial pneumonia, a number of aspects, from diagnosis to the therapy of nosocomial pneumonia, are still controversial. This review focuses on recent advances that can aid in the day-to-day care of these critically ill patients.The risk factors for nosocomial pneumonia in specific subsets of trauma, postoperative and burn injury patients have been identified, with emphasis on the type of pneumonia developing in these populations - early or late onset nosocomial pneumonia. Resolution of nosocomial pneumonia, in terms of improvement of clinical parameters such as oxygenation, fever, leukocytosis and bacterial eradication, has been reported, and these data can lead to a better understanding of the natural course of the disease. The importance of initial, accurate empiric therapy in improving mortality in nosocomial pneumonia has been reinforced by multiple studies. Newer techniques to study colonization and the routes of spread of pathogenic organisms in the intensive care unit are adding to our understanding of how pneumonia develops, the role of infection control measures and the types of strategies that are needed for prevention. Oral decontamination is showing promise as a technique to prevent ventilator-associated pneumonia, and noninvasive ventilation has been shown to be useful in various etiologies of respiratory failure, with the beneficial effect of reducing the incidence of ventilator-associated pneumonia and its associated mortality. The implementation of protocolized treatment guidelines and antibiotic rotation policies are emerging as useful tools for reducing the frequency of antibiotic resistance and the impact of nosocomial pneumonia.There is a better understanding of nosocomial pneumonia risk factors, mechanisms of bacterial colonization, and resolution of illness, with exciting developments in prevention and treatment emerging, and these data can help us achieve more effective management of this complex illness.

Study objectives We evaluated the role of sputum examination in the management of patients with community-acquired pneumonia (CAP) in a primary-care hospital without microbiologic laboratory facilities. Design and interventions A diagnostic strategy using regular collection of sputum samples, Gram staining in a local laboratory, and mailing of samples to a commercial laboratory for culture analysis. Setting A 200-bed primary-care hospital without subspeciality physicians. Patients One hundred sixteen consecutive patients with a diagnosis of CAP were prospectively evaluated during a 12-month period. Results Of 116 patients, 42 patients (36%) were capable of producing a sputum sample. Age ≥ 75 years (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.18 to 0.93) and prior ambulatory antimicrobial treatment (OR, 3.2; 95% CI, 1.2 to 8.4) were independent predictors of sputum production. A delay in collection and processing of sputum samples of > 24 h was present in 31% and 39%, respectively. A delay in collection yielded an increased number of Gram-negative enteric bacilli and nonfermenters (44% vs 7%, p = 0.056). A delay in processing was associated with an increased number of Candida spp isolates (33% vs 9%, p = 0.16). The overall diagnostic yield was low (10 of 116 patients, 9%) due to a limited number of valid samples (n = 23 of 42 patients, 55%) and a limited number of definitely or probably positive samples on Gram's stain and culture (n = 10 of 42 patients, 24%). Prior ambulatory antimicrobial treatment was associated with a reduction in diagnostic yield (14% vs 56%, p = 0.09). The impact of diagnostic results on antimicrobial treatment decisions was minimal, with antimicrobial treatment directed to diagnostic results in only one patient. Conclusions We conclude that in this setting representative of primary-care hospitals in Germany, sputum had a low diagnostic yield and did not contribute significantly to patient management.

Little is known about the natural history of resolution of nosocomial pneumonia, and thus it is likely that we are not always using the optimal duration of therapy in all patients. For some patients, with few risk factors for a poor outcome, and infection with easily treated pathogens, we can probably treat with a more abbreviated course of therapy than is commonly used. For other patients with risk factors for a poor outcome, and infection with ;;high risk'' pathogens such as Pseudomonas aeruginosa, we may need longer durations of therapy. We review the clinical and microbiological definitions of resolution, including improvement, delayed resolution, relapse, or recurrent infection. There are also microbiological end points for resoution including eradication, persistence, and superinfection. The clinical parameters that affect resolution are patient related, microbiological, and treatment related, and these factors are summarized here. Currently, the time course of resolution is being defined using clinical end points such as the clinical pulmonary infection score (CPIS) and microbiological end points such as quantitative cultures of respiratory secretions. The hope for the future is to be able to identify whether the clinical response is adequate, at the earliest posible time point. This may allow for interventions to help the nonresponding patient, or shorten the duration of therapy in the responding patient.

The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago. Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms. In addition, important differences between approaches in Europe and the USA have become apparent. The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP. Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives. The Latin American Thoracic Association was also invited. A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink). Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population–intervention–comparison–outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention.

Over the last decade, and particularly since the public reporting of the Center for Medicare and Medicaid Service’s (CMS) quality based performance evaluation of potentially preventable conditions in hospitalized patients, the incidence of ventilator associated pneumonia (VAP) has taken a sharp drop with several institutions in United States reporting a “zero incidence” (1). Lately this discrepancy between VAP rates among quality monitoring reports and the actual care given to patients has widened, and the accuracy of reporting zero VAP has been questioned. While the application of several infection prevention measures, implemented as a “bundled approach” ,with effective implementation, has been viewed to be an effective measure for decreasing the incidence of VAP, the credibility of these reports has been questioned (2-5). Recognizing the formidable challenge of accurately diagnosing VAP and the existing gaps between surveillance and clinical definitions, the Centers for Disease Control and Prevention (CDC) in 2013 shifted its focus to complications related to ventilation, rather than to identifying infection, through the new surveillance definition—ventilator associated events (VAE) (6). VAE includes ventilator-associated complications (VAC), infection-related ventilator-associated complications (IVAC), as well as possible and probable VAP (PVAP).

In Japan, the routine use of early antiviral therapy for patients with influenza is standard.This multicenter prospective cohort evaluation of hospitalized patients with laboratory-confirmed influenza identified prognostic factors among the patients receiving antiviral therapy.Of 1,345 patients with influenza (766 pediatric, 579 adult), excluding those aged1 year (who are not approved for antiviral therapy), 97.7% (1,224 of 1,253) received antiviral therapy. Among the adult patients, 24 (4.1%) died within 30 days, whereas none of the pediatric patients died. Five hundred twenty-eight (91.2%) adult patients had influenza A, 509 (87.9%) had a chronic underlying illness, and 211 (36.4%) had radiographically confirmed pneumonia. Twenty of the 24 patients who died had pneumonia of the following etiologies: Streptococcus pneumoniae (12.3%); Staphylococcus aureus (10.9%), including methicillin-resistant S aureus (MRSA) 3.3%; Enterobacteriaceae (8.1%); and Pseudomonas aeruginosa (3.3%). Of the adult patients, 151 were classified as having community-acquired pneumonia (CAP) and 60 as having health-care-associated pneumonia (HCAP). Inappropriate therapy was more common in HCAP than in CAP (15.2% vs 2%, P = .001). Potential multidrug-resistant (MDR) pathogens were more common (21.7% vs 2.6%, P.001) in patients with HCAP, particularly MRSA (10% vs 0.7%, P = .002) and P aeruginosa (8.3% vs 1.3%, P = .021). Using Cox proportional hazards modeling with prescribed independent variables, male sex, severity score, serum albumin levels (malnutrition), and pneumonia were associated with survival 30 days from the onset of influenza.Among the prognostic factors, malnutrition and pneumonia are amenable to medical intervention. An opportunity exists to improve empirical therapy for patients with HCAP and influenza.Japan Medical Association Center for Clinical Trials; No.: JMA-IIA00123; URL: http://www.jmacct.med.or.jp/en/.

Infectious complications, particularly in the respiratory tract of critically ill patients, are related to increased mortality. Severe infection is part of a multiple system illness and female patients with severe sepsis have a worse prognosis compared to males. Kallistatin is a protective hormokine released during monocyte activation and low levels in the setting of septic shock can predict adverse outcomes. Presepsin is another biomarker that was recently evaluated and is elevated in patients with severe sepsis patients at risk of dying. The Centers for Disease Control and Prevention has introduced new definitions for identifying patients at risk of ventilator-associated complications (VACs), but several other conditions, such as pulmonary edema and acute respiratory distress syndrome, may cause VACs, and not all patients with VACs may have ventilator-associated pneumonia. New studies have suggested strategies to identify patients at risk for resistant pathogen infection and therapies that optimize efficacy, without the overuse of broad-spectrum therapy in patients with healthcare-associated pneumonia. Innovative strategies using optimized dosing of antimicrobials, maximizing the pharmacokinetic and pharmacodynamic properties of drugs in critically ill patients, and newer routes of drug delivery are being explored to combat drug-resistant pathogens. We summarize the major clinical studies on respiratory infections in critically ill patients published in 2013.

The sensitivity of blood cultures in the diagnosis of bacteraemia for community-acquired pneumonia is low. Recommendations, by guidelines, to perform blood cultures are discordant. We aimed to determine the incidence, microbial aetiology, risk factors and outcomes of bacteraemic patients with community-acquired pneumonia, including cases with antibiotic-resistant pathogens (ARP).A prospective, observational study was undertaken on consecutive adult patients admitted to the Hospital Clinic of Barcelona (Barcelona, Spain) with community-acquired pneumonia and blood cultures were obtained.Of the 2892 patients included, bacteraemia was present in 297 (10%) patients; 30 (10%) of whom had ARP (multidrug-resistantStreptococcus pneumoniae, methicillin-resistantStaphylococcus aureus,Pseudomonas aeruginosa, and an extended spectrum of beta-lactamase producingEnterobacteriaceae). In multivariate analyses, pleuritic pain, C-reactive protein ≥21.6 mg·dL−1and intensive care unit admissions were independently associated with bacteraemia, while prior antibiotic treatment and pneumococcal vaccine were protective factors. The risk factors for ARP bacteraemia were previous antibiotics and C-reactive protein −1, while pleuritic pain was the only protective factor in the multivariate analysis. Bacteraemia (excluding ARP), appropriate empiric treatment, neurological disease, arterial oxygen tension/inspiratory oxygen fraction versus3%, respectively, pAntibiotic therapy protected against bacteraemia, but increased specifically the risk of bacteraemia from ARP due to the inappropriate coverage of these pathogens. Identifying patients at risk of ARP bacteraemia would help in deciding appropriate empiric antimicrobial therapy. The results from this study provide evidence concerning community-acquired pneumonia patients in whom blood cultures should not be performed.

Book details Chalmers JD, Pletz MW, Aliberti S (Eds): Community-Acquired Pneumonia. European Respiratory Monographs. Sheffield: European Respiratory Society; 2014, ISBN 978-1-849-84049-1.

Introduction Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention. Results Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a ‘ventilator bundle’ can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies. Conclusion The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.

Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in nosocomial pneumonia and is associated with significant morbidity and mortality. Clinical outcomes for nosocomial pneumonia are dependent on patient age, co-morbidities, severity of illness and appropriate antibiotic therapy. The objective of this secondary analysis was to identify baseline clinical variables that are associated with clinical success at the end of the study observation period. Data from a randomized blinded trial (NCT00084266) comparing linezolid (600-mg twice daily) to vancomycin (15-mg/kg twice daily, dose-adjusted) for the treatment of culture-proven MRSA pneumonia were analyzed to evaluate baseline clinical and demographic factors that may predict clinical success at end of study (EOS) (7-30 days after end of treatment). A multivariate logistic regression was conducted to identify baseline factors that are associated with clinical success. Patients treated with linezolid (OR 1.55 95% CI: 1.013, 2.355), no vasopressor receipt (OR 2.30, 95% CI: 1.303, 4.069), unilateral involvement (OR 1.70, 95% CI: 1.078, 2.681) and normal renal function (eGFR 30-80 vs >80 OR 0.48, 95% CI: 0.303, 0.750) were more likely to have clinical success. From a clinical standpoint, identifying reliable predictors of outcome and who might benefit more from one therapy versus another can help inform treatment decisions.

Numerous guidelines for CAP have been developed, and although each is different, many principles are common to all recommendations. A guideline should focus on a wide range of issues surrounding the delivery of care, including advice about when to admit patients to the hospital or ICU; which antibiotic regimens to select for specific patient populations; which pathogens to target in empiric therapy; which diagnostic tests to order; how to assess the importance of specific causative pathogens, such as drug-resistant pneumococci, atypical pathogens, and gram-negative pathogens; how to evaluate the response to therapy and when to switch responding patients to oral therapy; and how to prevent CAP effectively through appropriate use of immunization against pneumococcus and influenza. Currently, many new antibiotic choices have emerged in the macrolide, quinolone, beta-lactam, ketolide, and oxazolidinone classes, and specific issues surrounding selection of these agents must be considered. All of the available data can be synthesized into a disease management guideline, and current therapy in the United States generally is consistent with existing recommendations. This consistency not only has led to more uniformity in patient care, but also has led to measurable benefits in patient outcomes, including reduced mortality for hospitalized patients with CAP. Guidelines not only are a useful tool for managing patients with CAP, but also they serve the purpose of defining current issues in patient care and stimulating the search for new tools and management approaches for this important clinical problem.

Study objective: To determine the cost-effectiveness of sequential IV to oral gatifloxacin therapy vs IV ceftriaxone with or without IV erythromycin to oral clarithromycin therapy to treat community-acquired pneumonia (CAP) patients requiring hospitalization. Patients: Two hundred eighty-three patients enrolled in a randomized, double-blind, clinical trial were eligible for inclusion in the cost-effectiveness analysis. Methods: Data collected included patient demographics, clinical and microbiological outcomes, length of stay (LOS), and antibiotic-related LOS (LOSAR). Costs evaluated include drug acquisition (level 1); plus costs of preparation, dispensing, and administration, treating adverse events, and clinical failures (level 2); plus hospital per diem costs (level 3). Robustness of economic findings was tested using sensitivity analyses. Results: Two hundred three patients were clinically and economically evaluable (98 receiving gatifloxacin and 105 receiving ceftriaxone). IV erythromycin was administered to 35 patients in the ceftriaxone-treated group. Oral conversion was achieved in 98% of patients in each group. Clinical cure and microbiological eradication rates did not differ statistically (98% and 97% with gatifloxacin vs 92% and 92% with ceftriaxone, respectively). Overall, neither geometric mean LOS nor LOSAR differed significantly (4.2 days and 4.1 days with gatifloxacin vs 4.9 days and 4.9 days with ceftriaxone, respectively). Treatment failures in the ceftriaxone group contributed to a mean incremental increase in LOSAR of 1.09 days and increased mean cost per patient. The geometric mean costs per patient (level 3) were $5,109 for gatifloxacin and $6,164 for ceftriaxone (p = 0.011). The cost-effectiveness ratios (mean cost per expected success) were $5,236:1 and $7,047:1 for gatifloxacin and ceftriaxone, respectively. Conclusions: Gatifloxacin monotherapy for CAP patients requiring hospitalization is clinically effective and provides an economic advantage compared to the regimen of ceftriaxone with or without erythromycin IV with a switch to oral clarithromycin.

Hospital-acquired pneumonia (HAP) is a serious cause of morbidity and mortality. It is the second leading cause of nosocomial infection in the United States and the one with the highest rate of mortality. 6,26 Hospital-acquired pneumonia is defined as any pneumonia occurring after the third day of hospitalization 6 ; that is, more than 48 to 72 hours after admission, exclusive of any pneumonia that may be incubating at the time of admission. The diagnostic criteria for nosocomial pneumonia require that the patient have an examination showing rales, dullness to percussion, or an infiltrate on chest radiograph, accompanied by at least one of the following: purulent sputum, isolation of a pathogen (from respiratory samples or blood culture), or histopathologic evidence of pneumonia. Ventilator-associated pneumonia (VAP) is a variant of HAP and is defined as bacterial pneumonia arising in any patient who has been mechanically ventilated for at least 48 hours. Criteria for definite and probable VAP have been developed (table 1), and the definition is designed to eliminate pneumonia that is incubating at the time of intubation. In the intensive care unit (ICU), most (>85%) pneumonias are associated with mechanical ventilation 6,18,70 and are generally VAPs. In the ICU, many patients on mechanical ventilation require tracheostomy, and many of these patients develop pneumonia, but the pathogenesis, epidemiology, and clinical significance of respiratory infection in this population may be different from those seen in the endotracheally intubated patient. In this review, the authors focus on the problems associated with VAP, with a particular emphasis on the patient on long-term ventilation with tracheostomy who is recovering from acute (often on top of chronic) illness.

Use of nucleic acid amplification techniques has increased the identification of respiratory viruses (RVs) in adult patients with community-acquired pneumonia (CAP). The objectives of the present study were to identify RV in patients with CAP using three different sampling methods and to compare CAP virus proportions and types with two comparison groups.The study population included 183 adult patients with CAP, 450 control subjects, and 201 patients with nonpneumonic lower respiratory tract infection (NPLRTI). Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washing, and the samples were tested for detection of 12 RVs by multiplex TaqMan Hydrolysis probe-based real-time polymerase chain reaction (Integrated DNA Technology; Coralville, IA).At least one RV was identified in 58 patients with CAP (31.7%) compared with 32 (7.1%) in control subjects and 104 (51.7%) in patients with NPLRTI (P.01 and P.01, respectively). Coronaviruses were identified in 24 (13.1%) patients with CAP, compared with 17 (3.8%) in control subjects, and 21 (10.4%) patients with NPLRTI. Respiratory syncytial virus was identified in 13 (7.1%), four (0.9%), and seven (3.5%); rhinovirus in nine (4.9%), nine (2.0%), and 15 (7.5%); and influenza virus in eight (4.4%), two (0.4%), and 63 (31.3%) patients with CAP, control subjects, and patients with NPLRTI, respectively.The proportion of RV involvement in CAP is higher than previously reported. The proportion of RV identified in healthy subjects is significantly lower than in CAP, but it is not zero and should be weighed when interpreting corresponding proportions among patients.

The purpose of this study was to evaluate intravenous (i.v.) azithromycin followed by oral azithromycin as a monotherapeutic regimen for community-acquired pneumonia (CAP). Two trials of i.v. azithromycin used as initial monotherapy in hospitalized CAP patients are summarized. Clinical efficacy is reported from an open-label randomized trial of azithromycin compared to cefuroxime with or without erythromycin. Bacteriologic and clinical efficacy results are also presented from a noncomparative trial of i.v. azithromycin that was designed to give additional clinical experience with a larger number of pathogens. Azithromycin was administered to 414 patients: 202 and 212 in the comparative and noncomparative trials, respectively. The comparator regimen was used as treatment for 201 patients; 105 were treated with cefuroxime alone and 96 were given cefuroxime plus erythromycin. In the comparative trial, clinical outcome data were available for 268 evaluable patients with confirmed CAP at the 10- to 14-day visit, with 106 (77%) of the azithromycin patients cured or improved and 97 (74%) of the comparator patients cured or improved. Mean i.v. treatment duration and mean total treatment duration (i.v. and oral) for the clinically evaluable patients were significantly ( P < 0.05) shorter for the azithromycin group (3.6 days for the i.v. group and 8.6 days for the i.v. and oral group) than for the evaluable patients given cefuroxime plus erythromycin (4.0 days for the i.v. group and 10.3 days for the i.v. and oral group). The present comparative study demonstrates that initial therapy with i.v. azithromycin for hospitalized patients with CAP is associated with fewer side effects and is equal in efficacy to a 1993 American Thoracic Society-suggested regimen of cefuroxime plus erythromycin when the erythromycin is deemed necessary by clinicians.

The role of infection in exacerbations of COPD remains controversial and incompletely understood. Although some investigators believe that bacteria are not important for patients with exacerbation, we disagree and believe that patients with at least two of the three cardinal symptoms of exacerbation should receive antibiotic therapy. With an open-minded view of the area, we review the data, showing that bacteriologic studies, pathologic investigations, and clinical trials all support roles for bacteria and antibiotic therapy in this disease. Still, many questions remain, and future studies will be needed to better define the mechanisms of bacterial invasion in the bronchitic patient and to develop effective vaccines to prevent exacerbations. In the meantime, we must rely on antibiotic therapy, and we will need prospective studies to corroborate preliminary findings showing that different patients may require different therapies; thus, patient subsetting may be vital in the selection of antibiotic therapy for exacerbations of COPD.

F ew investigators have studied the role of bronchoscopy in evaluating and managing patients with nosocomial pneumonia who are not responding to initial antibiotic therapy. This discussion examines whether the information provided by bronchoscopy has value in this setting, as well as whether the concept of using bronchoscopy for the nonresponding patient is a logical one. Importantly, serial bronchoscopy is generally performed while the patient is receiving antibiotic therapy. Such therapy can reduce the yield and accuracy of quantitative cultures of respiratory secretions. The presumption for using serial cultures in the nonresponding patient is that bacteria are present that have not been eliminated by currently administered antibiotics. Moreover, these organisms can be identified early enough so that changes in therapy will improve the outcome in these patients.

Objectives To determine the effect of age, severity of lung disease, severity and frequency of exacerbation, steroid use, choice of an antibiotic, and the presence of comorbidity on the outcome of treatment for an acute exacerbation of COPD. Design A retrospective chart analysis over 24 months. Setting A university Veterans Affairs medical center. Patients Outpatients with COPD who were treated with an antibiotic over a period of 24 months for an acute exacerbation of COPD. Methods Severity of an acute exacerbation of COPD was defined using the criteria of Anthonisen et al: increased dyspnea, increased sputum volume, and increased sputum purulence. Severity of lung disease was stratified based on FEV 1 percent predicted using American Thoracic Society guidelines (stage I, FEV 1 ≥ 50%; stage II, FEV 1 35 to 49%; stage III, FEV 1 Results One-hundred seven patients with COPD (mean age ± SD, 66.9 ± 9.5 years) experienced 232 exacerbations over 24 months. First-line antibiotics (trimethoprim-sulfamethoxazole, ampicillin/amoxicillin, and erythromycin) were used to treat 78% of all exacerbations. Treatment failure was noted in 12.1% of first exacerbations and 14.7% of all exacerbations, with more than half the failures requiring hospitalization. Host factors that were independently associated with treatment failure included the following: FEV 1 Conclusion The results of our study suggest that patient host factors and not antibiotic choice may determine treatment outcome. Prospective studies in appropriately stratified patients are needed to validate these findings.

The role of antibiotics in acute exacerbations of chronic bronchitis (AECB) remains controversial because patients commonly harbor the same bacteria in their sputum at times of stability and at times of acute illness. However, prospective randomized controlled trials do show a benefit for the use of antibiotics, compared with placebo, in AECB, particularly if patients have at least 2 of the following 3 symptoms: increased dyspnea, increased sputum volume, increased sputum purulence. In this setting, antibiotics have value, leading to a more rapid resolution of symptoms and a more rapid return of peak flow rate, compared with placebo. In addition, antibiotics may prevent some patients from developing secondary pneumonia and may prolong the time between exacerbations. When antibiotics are used, a variety of factors must be considered in choosing an agent. These include the likelihood of antibiotic-resistant bacteria, a factor that relates to defining subsets of patients. Patients can fall into 1 of 3 categories, each with a different suggested therapy. These categories include simple AECB, complicated AECB, and AECB at risk for infection with P. aeruginosa. In addition, an antibiotic should be chosen with pharmacokinetics and pharmacodynamic behavior in mind. In the future, research will need to confirm that careful selection of specific agents for specific patients can lead to improved patient outcomes, but already some preliminary data are supporting this concept.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients agedor =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged65 years. We calculated a total treatment cost of $1.2 billion for patients agedor =65 years and $419 million for patients aged65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients agedor =65 years, and $408 million for the 73,299 patients aged65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients agedor =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those agedor =65 years and 237,000 visits for those aged65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those agedor =65 years and 4.2 million visits for those aged65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.

Community-acquired pneumonia (CAP) is a common illness, with increased mortality in certain populations, particularly the elderly and those with severe illness 1–3. The association between advanced age and mortality is well known; Sir William Osler's infamous view was that pneumonia was the “friend of the aged” that often allowed patients with advanced illness to die peacefully. In spite of this viewpoint, it remains uncertain whether ageing itself adds to this mortality risk or whether the adverse outcomes of CAP in the elderly are the consequence of other factors, some of which might be modified, such as the presence of comorbid illnesses and the therapies required to manage them, or the delays in the diagnosis of pneumonia that result from indistinct clinical presentations in the elderly. Fry et al. 1 studied the data of the National Hospital Discharge Survey and found that in older hospitalised patients with pneumonia, at least one underlying medical condition was reported in most medical records. Marston et al. 2 studied hospitalised patients with CAP for 1 yr in two counties in Ohio, USA. Amongst the 2,776 patients studied, the incidence and mortality of pneumonia in the elderly was much higher than in younger populations. Kaplan et al. 3 reported the 1-yr mortality of elderly patients admitted for CAP and observed that beyond the immediate 12% in-patient mortality rate, there was a 1-yr death rate of >40%, raising the question as to whether pneumonia is a surrogate marker of other types of serious illness in the elderly. Numerous factors could contribute to the high mortality rate of CAP in the elderly. It is more difficult to diagnose pneumonia in the elderly than in young patients because the usual clinical clues for its diagnosis might be absent at the time of onset of illness. Riquelme et …