Biomarkers are useful in community-acquired pneumonia (CAP). Recently, midregional (MR) proadrenomedullin (proADM) has been shown to be of potential prognostic use. We sought to determine whether this prognostic role depends on the cause of CAP. We conducted a prospective cohort study of immunocompetent patients with CAP. Pneumonia Severity Index (PSI) and CURB-65 score (confusion (abbreviated mental test score of ≤8), urea ≥7 mol/L, respiratory rate ≥30 breaths/min, blood pressure <90 mmHg systolic or <60 mmHg diastolic, and age ≥65 yrs), blood C-reactive protein, procalcitonin, MR-proADM, and microbiological studies were systematically performed. Patients were grouped as bacterial, viral/atypical and mixed CAP, and were followed up at 30, 90 and 180 days, and 1 yr. We recruited 228 CAP patients. Identification of at least one pathogen was achieved in 155 (68%) patients. MR-proADM levels closely correlated with increasing severity scores, and showed an important predictive power for complications and short- and long-term mortality (1 yr). Its addition to PSI and CURB-65 significantly improved their prognostic accuracy. A MR-proADM cutoff of 0.646 nmol/L identified 92% of patients scored as PSI classes IV and V as high risk. MRproADM outcome prediction power was not affected by different aetiologies. MR-proADMhas high short- and long-term prognostic accuracy, and increases the accuracy of clinical scores. The prognostic value of MR-proADM is not modified by different possible CAP aetiologies.

Clinical severity scores, the Pneumonia Severity Index (PSI)4, and CURB-65 score5, are the most frequently used tools for evaluating CAP-associated risk of mortality. Traditionally biomarkers of infection for diagnostic and prognostic purposes have widely been used such as white blood cell count and C-reactive protein (CRP) but their prediction of risk in CAP is limited. Recently hormokine such as procalcitonin has increasing evidence for better diagnosis and guiding antibiotic therapy, and assessing severity6. Also, MR-proADM has been shown to be potential biomarker to predict severe complication, mortality and risk stratification of clinical scores7. In this study by Bello et al.3, MR-proADM levels showed considerable prognostic value with/without clinical severity scores such as PSI and CURB-65 independently of etiology of CAP. Although this study didn't show that MR-proADM discriminated the etiology of CAP, ProADM could be used for the identification of patients with a high risk of mortality that be needed a more rapid initiation of appropriate therapy.

Current recommendations by US Advisory Committee on Immunization Practices (ACIP) are for immunization of persons 2 years and older with conditions at increased risk of serious pneumococcal infections and all persons 65 years and older with 23-valent pneumococcal polysaccharide vaccine (PPSV23)9. Although most studies show that PPSV23 has at least moderate effectiveness in preventing invasive pneumococcal disease (IPD), its effectiveness in preventing nonbacteremic pneumococcal pneumonia (NPP), which is at least 10 times more common than IPD, appears to be limited. In 2000, 7-valent pneumococcal conjugate vaccine (PCV7) was introduced for routine childhood immunization. In 2010, PCV13 replaced PCV7 for routine childhood immunization. Also PCV13 has recently been approved by the Food and Drug Administration for use among adults aged 50 years and older10. However, the effectiveness of PCV13 in preventing NPP in adults is unclear and clinical trials are ongoing. Routine childhood vaccination with PCV13 might have potential further indirect effects in adults. This study by Smith et al.8 suggests that PCV13 instead of PPSV23 for routine immunization of adults, favor in prevention against pneumococcal disease in an economically reasonable fashion. But they need two assumptions. First, PCV13 would be effective in preventing NPP in adults and secondly herd immunity effect from childhood PCV13 would not been greater. In the future, improvements in vaccines against pneumococci and increased rates of immunization in community will bring reductions in the incidence of pneumococcal disease.

Early diagnosis and rapid initiation of appropriate antibiotics is most important in treatment for CAP12. There are many studies to use corticosteroid in severe pneumonia and sepsis because dexamethasone is lowering of the cytokine response. But recent guideline for sepsis recommend not to use corticosteroids to treat sepsis in the absence of shock unless the patient's endocrine function isn't intact or patients has corticosteroid history13. The effect of corticosteroids in addition to antibiotics in patients with CAP who are admitted to general ward is unclear. In this article, the authors suggested the early use of dexamethasone in immunocompetent patients could reduce the length of hospital stay and costs despite increase of hyperglycemia.

To determine differences in aetiologies, initial antimicrobial treatment choices and outcomes in patients with nursing-home-acquired pneumonia (NHAP) compared with patients with community-acquired pneumonia (CAP), which is a controversial issue.

Data from the prospective multicenter Competence Network for Community-acquired pneumonia (CAPNETZ) database were analysed for hospitalized patients aged ≥65 years with CAP or NHAP. Potential differences in baseline characteristics, comorbidities, physical examination findings, severity at presentation, initial laboratory investigations, blood gases, microbial investigations, aetiologies, antimicrobial treatment and outcomes were determined between the two groups.

Patients with NHAP presented with more severe pneumonia as assessed by CRB-65 (confusion, respiratory rate, blood pressure, 65 years and older) score than patients with CAP but received the same frequency of mechanical ventilation and less antimicrobial combination treatment. There were no clinically relevant differences in aetiology, with Streptococcus pneumoniae the most important pathogen in both groups, and potential multidrug-resistant pathogens were very rare (<5%). Only Staphylococcus aureus was more frequent in the NHAP group (n=12, 2.3% of the total population, 3.1% of those with microbial sampling compared with 0.7% and 0.8% in the CAP group, respectively). Short-term and long-term mortality in the NHAP group was higher than in the CAP group for patients aged ≥65 years (26.6% vs 7.2% and 43.8% vs 14.6%, respectively). However, there was no association between excess mortality and potential multidrug-resistant pathogens.

Excess mortality in patients with NHAP cannot be attributed to a different microbial pattern but appears to result from increased comorbidities, and consequently, pneumonia is frequently considered and managed as a terminal event.

Hospital-acquired pneumonia (HAP) and ventilator associated pneumonia (VAP) remain important causes of morbidity and mortality. Increasing antimicrobial resistance has aroused the concern of the failure of antibiotic treatment.

To determine the distribution of the bacterial isolates of HAP and VAP, their antimicrobial resistance patterns, and impact of discordant antibiotic therapy on clinical outcome in Asian countries.

A prospective surveillance study was conducted in 73 hospitals in 10 Asian countries from 2008-2009. A total of 2,554 cases with HAP or VAP in adults were enrolled and 2,445 bacterial isolates were collected from 1,897 cases. Clinical characteristics and antimicrobial resistance profiles were analyzed.

Major bacterial isolates from HAP and VAP cases in Asian countries were Acinetobacter spp., Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae. Imipenem resistance rates of Acinetobacter and P. aeruginosa were 67.3% and 27.2%, respectively. Multidrug-resistant rates were 82% and 42.8%, and extensively drug-resistant rates were 51.1% and 4.9%. Multidrug-resistant rate of K. pneumoniae was 44.7%. Oxacillin resistance rate of S. aureus was 82.1%. All-cause mortality rate was 38.9%. Discordant initial empirical antimicrobial therapy increased the likelihood of pneumonia-related mortality (odds ratio, 1.542; 95% confidence interval, 1.127-2.110).

Acinetobacter spp., P. aeruginosa, S. aureus, and K. pneumonia are the most frequent isolates from adults with HAP or VAP in Asian countries. These isolates are highly resistant to major antimicrobial agents, which could limit the therapeutic options in the clinical practice. Discordant initial empirical antimicrobial therapy significantly increases the likelihood of pneumonia-related mortality.

Ventilator-associated tracheobronchitis (VAT) is considered an intermediate condition between bacterial airway colonization and ventilator-associated pneumonia (VAP). The purpose of this prospective cohort study was to further characterize VAT in terms of incidence, etiology, and impact on patient outcomes.

Patients intubated for > 48 h in the surgical and medical ICUs of Barnes-Jewish Hospital were screened daily for the development of VAT and VAP over 1 year. Patients were followed until hospital discharge or death, and patient demographics, causative pathogens, and clinical outcomes were recorded.

A total of 28 patients with VAT and 83 with VAP were identified corresponding to frequencies of 1.4% and 4.0%, respectively. VAP was more common in surgical than medical ICU patients (5.3% vs 2.3%; P< .001), but the occurrence of VAT was similar between surgical and medical patients (1.3% vs 1.5%; P=.845). VAT progressed to VAP in nine patients (32.1%) despite antibiotic therapy. There was no significant difference in hospital mortality between patients with VAP and VAT (19.3% vs 21.4%; P=.789). VAT was caused by a multidrug-resistant (MDR) pathogen in nine cases (32.1%).

VAT occurs less commonly than VAP but at a similar incidence in medical and surgical ICU patients. VAT frequently progressed to VAP, and patients diagnosed with VAT had similar outcomes to those diagnosed with VAP, suggesting that antimicrobial therapy is appropriate for VAT. VAT is also frequently caused by MDR organisms, and this should be taken into account when choosing antimicrobial therapy.