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If you manage this site and have a question about why the site is not available, please contact us directly. What is the best initial treatment of an adult patient with healthcare-associated pneumonia? SearchWhat is the best initial treatment of an adult patient with healthcare-associated pneumonia?
A 68-year-old man with hypertension, diabetes, and recent hip fracture with poor functional status presents from a nursing home with a productive cough, shortness of breath, and chills of two-day duration.
What is the proper duration of antibiotic treatment in adults hospitalized with community-acquired pneumonia?
Modern medicine exists over a continuum of care that is delivered in a manifold of different settings.
Patients who meet current HCAP criteria might benefit from empiric treatment with broad-spectrum antibiotics, but further assessment of multi-drug-resistant infection risks and knowledge of local resistance patterns should be obtained. HCAP represents a diagnostic category of pneumonia created to differentiate patients with infections caused by a different microbiological subset of bacteria, including possible multi-drug-resistant (MDR) organisms, from patients with CAP.
Kollef and colleagues performed a multicenter, retrospective cohort study of 4,543 patients with bacterial respiratory culture-positive pneumonia between 2002 and 2003. How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis?
The Hospitalist, is the winner of two 2015 APEX Awards for Publication Excellence for Health and Medical Writing. SHM’s online collaborative forum for its members is a place to network, share resources, and discuss pressing issues with colleagues from across the country. View the latest feature-length films on hospitalist practice from the editors of The Hospitalist. Meningitis is of two types namely viral meningitis (caused by virus which does not become very serious) and bacterial meningitis (caused by bacterial infection and can be life threatening). In infants meningitis symptoms do not cause headache or stiff neck, but the child may develop high fever with constant crying.
Very often, meningitis is caused by viral infection but in some cases bacterium can cause meningitis and in rare cases even fungus can cause this infection. Some of the bacteria that cause meningitis include streptococcus pneumoniae, Neisseria meningitis, Hemophilus influenza, and Listeria monocytogenes. You are putting your childa€™s life at risk for developing meningitis if you are not properly vaccinating him.
Since meningitis is contagious, the infected person can easily spread the disease on camps, college dormitories and boarding schools. Meningitis, if left untreated can cause serious complications like loss of hearing, poor concentration, disability in learning, seizures, brain damage, kidney failure, gait and sometimes death. Your doctor would look for the above symptoms and order for certain diagnostic tests like blood culture and imaging tests like CT or MRI scan.
Your doctor should identify the type of meningitis infection before starting the course of treatment.
The infected person has to drink plenty of fluids to keep hydrated and can use pain relievers for reducing body pain and fever. Division of Paediatric Critical Care and Children's Heart Disease, School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Rondebosch IIFCPaed (SA). Patients routinely receive complex medical care at home, including wound care and infusion of intravenous antibiotics. Hospitalists will continue to be responsible for choosing the initial antibiotic regimen for these patients, and they need to be able to recognize this disease process in order to treat it appropriately.
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.
The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine. The meninges are soft membranes that cover the brain which becomes swollen during this infection.
He may not be active as before and for some infants a tiny spot is seen on the babya€™s forehead. Meningitis often occurs on infants and young children and hence children below 6 years have increased risk for developing this infection.
Bacterial meningitis are treated with antibiotics (intravenously) or by oral corticosteroid medications.
If the result indicates it is fungal meningitis then your doctor may prescribe antifungal drugs. Every child should take regular shots for preventing measles, pneumonia, chickenpox and influenza.
Paediatric Intensive Care Unit, Red Cross War Memorial Children's Hospital, Rondebosch IIIFCPaed (SA), Cert Pulm (Paed). Additionally, many patients are interfacing with the healthcare system on a regular basis via hemodialysis centers or sub-acute rehabilitation centers.
It may also cause nausea, vomiting, confusion of thoughts, difficulty in concentrating and sleepiness.
Viral meningitis is often caused by enteroviruses and most of them are not serious and does not require immediate treatment. Bacterial infections can occur on individuals below 20 years and this is more particular for those who live in community settings.
Individuals with weakened immune system (having AIDS, diabetes etc.) are more susceptible to develop meningitis than others. He may do a lumbar puncture for collecting cerebrospinal fluid and testing it in the laboratory. Division of Paediatric Pulmonology and Intensive Care, Department of Paediatrics and Child Health, University of KwaZulu-Natal and Inkosi Albert Luthuli Hospital, Durban IVFCPaed (SA), PhD. Coarse breath sounds are noted in the right lung field and his chest X-ray reveals a right-middle-lobe infiltrate. If detected in early stages, this disease can be managed by suitable medications but if ignored it can cause serious complications or even death.


The result would also clearly indicate the type of bacterium that has caused the infection.
Viral meningitis can be managed by over the counter medications and by taking complete bed rest.
If meningitis has developed due to weakened immunity your doctor would prescribe suitable cortisone drugs.
Follow good hygiene by washing your hands thoroughly with medicated soap solution before eating and after using the toilet.
Infants of 2 months age can be vaccinated for Hib (Haemophilus influenza) and Pneumococcal vaccine can be given for children (2-5 years). In rare cases meningitis may become chronic causing symptoms of high fever, confusion, nausea and vomiting for weeks together. Avoid spending more of your time in crowded places which puts you under risk of developing the infection. Now single dose of Meningococcal conjugate vaccine can be given for children (11-13 years) with additional shot at 16 years.
This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and - importantly - limit inappropriate use of antimicrobial agents. Only a doctor can distinguish the type of meningitis and sometimes bacterial meningitis is very deadly. Meningitis can also be caused by allergic reactions of medications, certain chemicals and some cancer types like sarcoidosis. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out. Until recently, however, the recognition of histological pneumonia varied between pathologists2 and there was a discrepancy between the bacterial density of cultures taken via the airway and histological features of pneumonia.3 This could be expected, as the histological changes would depend on the infection and also the response mounted by the patient. Although it is unlikely that a universally applicable and acceptable definition of VAP in children will be established in the near future, there would be substantial advantages if centres in South Africa could collect data related to an agreed definition. Primarily, this would establish a database that could allow assessment of the extent of the problem and response to chosen intervention programmes. In addition, poor socio-economic circumstances and poor access to health care9 may delay presentation to tertiary institutions, so that patients are more severely ill on admission.
However, it is important to develop appropriate guidelines for use in our resource-constrained environment to ensure optimal utilisation of scarce resources, including the small number of PICU beds servicing a large paediatric population. Therefore, if this is a requirement, studies should report that no servo controllers were used, no paracetamol was given and no tepid sponging was done by nursing staff. Bacterial pneumonia cannot be differentiated from viral pneumonia on the basis of clinical characteristics, routine laboratory tests, or chest radiographs, and it is unclear whether white blood cell concentration or serum C-reactive protein (CRP) concentration consistently differentiates between them.24 Leucopenia or leucocytosis have been suggested as clinical criteria for the diagnosis of VAP. It may also be helpful to indicate whether septic markers are increasing or decreasing, considering the high infectious load of South African PICU patients (level of evidence: D). Together they may indicate a change in clinical status, but there is no evidence to support this (level of evidence: D). Over-treatment may occur on the basis of results of respiratory specimens with poor specificity, such as endotracheal aspirates.28 It is therefore recommended that, wherever possible, lower respiratory tract specimens (BAL) should be performed on admission and thereafter if there is a clinical indication to change therapy.
This strategy could prevent the indiscriminate use of antibiotic coverage in all patients who develop signs and symptoms suggestive of pneumonia, thereby minimising the emergence of resistant organisms.29 Although non-bronchoscopic BAL has complications in the South African paediatric population,31 its risks must be weighed against the benefits for the individual and the community of identifying true pathogenic organisms.
Clinical signs, which have good sensitivity but poor specificity, should be used in conjunction with a highly specific test such as BAL. Where possible, invasive respiratory specimens should be taken rather than wasting precious resources to obtain frequent, poor-quality specimens from the upper respiratory tract (level of evidence: B). Aetiology Aspiration may be an important cause of VAP in children,7,8,33 and prolonged mechanical ventilation,4 genetic syndromes, transport into and out of the PICU, re-intubation,8 prior antibiotic use, continuous enteral feeding, bronchoscopy8 and immunodeficiency33 have all been identified as independent predictors of VAP. Prior use of carbapenems and third-generation cephalosporins are independent risk factors for acquisition of multidrug-resistant (MDR) Acinetobacter baumannii.34 A.
These results are similar to a Brazilian study - a developing country with some challenges common to those of South Africa.35 In an Indian paediatric VAP study, Escherichia coli and K.
However, it is not known what angle of inclination is optimal or achievable in this age group. In infants, a reverse Trendelenburg position may be used with bassinettes and open incubators.49 In addition to head-of-bed elevation, post-pyloric feeding is recommended for infants at high risk of GOR and aspiration,49,54 although there is no objective evidence to support this.
Clinicians should routinely assess the paediatric patient's readiness for extubation instead of implementing weaning protocols (level of evidence: A (RCT of 182 infants and children61)). Conversely, increasing gastric pH (as would occur when using histamine-2-receptor (H2)-antagonists and antacids as stress ulcer prophylaxis) may increase colonisation, thereby predisposing to VAP.62 Sucralfate is an alternative agent that does not change gastric pH, and it was therefore postulated that it would also decrease the incidence of VAP.
Meticulous oral hygiene reduces the incidence of VAP in adults,75 as does oral decontamination with chlorhexidine.76 The age-related pattern of bacterial colonisation is connected with the development of dentition,77 but no studies have related this to the development of VAP in children. It is particularly important to emphasise this measure in resource-constrained PICUs with poor staffing levels.
Although the 'bundle' approach reduces the incidence of VAP in adults,49 most components have not been validated in the paediatric age group, and many may not be suitable or practical for the PICU. In well-resourced countries with sufficient staffing, it may be appropriate to implement a number of low-risk interventions which may have some benefit.
However, in South Africa, where resources are limited, unnecessary interventions should be avoided as these will increase the workload of overloaded nursing staff, and predispose to adverse events.87 Therefore, to avoid inappropriate use of scarce resources in an attempt to improve patient outcome, research is needed to evaluate all the 'bundle' interventions in the paediatric age group - including efficacy, potential harm, and optimal application. Treatment of VAP Prior antibiotic therapy may select for resistant organisms already present in the respiratory tract, thereby predisposing to VAP.8 Prior use of carbapenems and third-generation cephalosporins are independent risk factors for acquisition of MDR A. If the cultures are negative and the PCT is low, one may consider stopping the empirical antibiotics unless there are other issues such as immunosuppression or low WCC. 1 provides an algorithm for the management of VAP, based on adult recommendations.88 We have modified the suggested broad-spectrum antibiotic treatment for suspected MDR organisms, mainly because most patients admitted to PICU in South Africa have significant risks for MDR pathogens.
It is therefore suggested that unit-based policies should be developed according to the prevalent organisms in each PICU.
The most common cause of developing antimicrobial resistance is an inappropriately chosen antimicrobial at a sub-therapeutic dose for a long duration. Table III comprises a list of antimicrobials used commonly in PICUs, along with dosages, complications and other considerations.
Drug-drug interactions occur with various agents and require adjustments in terms of dosages or changes in the choice of antibiotics.97 The minimum inhibitory concentration (MIC) is the lowest concentration of an antibiotic that can inhibit the growth of the pathogen.


The MIC90 is the minimum inhibitory concentration of the drug that is required to decrease growth of 90% of the pathogen.
The clinically relevant breakpoint is the level of the antimicrobial that should inhibit growth effectively. These antibiotics must be dosed more frequently or a sustained- or extended-release formulation be used. In addition, the highest possible dose to ensure a drug level at least tenfold greater than the MIC is essential to ensure effective eradication of the pathogens and to prevent development of resistance. Penicillin, cephalosporin, linelozid, piperacillin-tazobactam and carbepenem are antibiotics that use time-dependent pharmacokinetic principles as a mode of action. Vancomycin uses a time-dependent killing and displays moderate to prolonged persistent effects and therefore requires the maximum amount of drug to be above the MIC for 24 hours.
Adverse effects of aminoglycosides are related to high trough levels, and dosing schedules should aim at a single daily dose that would achieve high peaks and low trough. Additional interventions, such as renal replacement therapy including dialysis or continuous haemofiltration, may affect drug levels. Therefore, measurement of drug levels with appropriate dosage adjustment is crucial to ensure adequate therapeutic drug levels. There is a clinical concern that it may be unwise to change a 'winning' antimicrobial regimen, but continuation of the broad-spectrum antimicrobial regimen has been associated with harm. Clinically relevant pathogens not covered by a narrow-spectrum antimicrobial are likely to be identified promptly if repeat microbiological screens are performed to ensure eradication of the primary pathogen or to pick up any missed secondary pathogen.
Many VAP patients acquire new non-microbial co-morbidities attributed to secondary nosocomial infections, which influences inappropriate prolonged use of antimicrobials. In general, antimicrobials should be used for a maximum of 7 days, or 3 days after there has been sufficient resolution as determined by clinical and laboratory markers.106 If there is lack of adequate response after 48 - 72 hours, patients should be re-screened for nosocomial pathogens.
Drug-related factors such as plasma or tissue levels, protein binding, volume of distribution, drug-drug interactions, or host factors such as development of sanctuary sites of infection (e.g.
If there is no response by day 7, the antimicrobial should be stopped and the patient re-evaluated, with a revision in the diagnosis. Ertapenem, a first-generation carbepenem with poor efficacy against Pseudomonas, currently has low levels of resistance to ESBL-producing organisms, but there are concerns that with excessive use it is likely to induce cross-resistance to the entire carbepenem class of antimicrobials. Dr Morrow was supported by grants from the Medical Research Council of Southern Africa and the University of Cape Town. Reproducibility of the histologic diagnosis of pneumonia among a panel of four pathologists: Analysis of a gold standard. The diagnosis of ventilator-associated pneumonia: A comparison of histologic, microbiologic, and clinical criteria. Ventilator-associated pneumonia in a paediatric intensive care unit in a developing country with high HIV-prevalence.
Emergence of multi-drug-resistant acinetobacter anitratus species in neonatal and paediatric intensive care units in a developing country: Concern about antimicrobial policies. Ventilator-associated pneumonia in pediatric intensive care unit patients: Risk factors and outcomes. Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: A 30-month prospective surveillance. Burden of illness for children and where we stand in measuring the quality of this health care.
Clinical pulmonary infection score for ventilator-associated pneumonia: Accuracy and inter-observer variability. Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit. Reliability of the chest radiograph in the diagnosis of lower respiratory infections in young children. Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Ventilator-associated pneumonia in intubated children: Comparison of different diagnostic methods. Risks and complications of nonbronchoscopic bronchoalveolar lavage in a pediatric intensive care unit. A simple method of reducing complications of pediatric nonbronchoscopic bronchoalveolar lavage.
Nosocomial pneumonia and tracheitis in a pediatric intensive care unit: A prospective study. Risk factors for the isolation of multi-drug-resistant acinetobacter baumannii and pseudomonas aeruginosa: A systematic review of the literature. Pneumocystis carinii pneumonia (PCP) in HIV negative patients (PTS): Nosocomial transmission? The role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia. Tailoring the Institute for Health Care Improvement 100,000 lives campaign to pediatric settings: The example of ventilator-associated pneumonia.
Guidelines for preventing health-care--associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee.
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomised trial. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: The effect of body position.



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