Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults.

RATIONALE: Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES: The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN: A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS: The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS: The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS: The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.

Surgical Science and the Evolution of Critical Care Medicine.

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial.

Importance: Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective: To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions: Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures: The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results: Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance: In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02582957.

A serial cross-sectional study of trends and predictors of prescription controlled substance-related traumatic injury.

Pre-injury drug use is a key contributor to traumatic injury. However, limited research has examined trends and predictors of controlled substance-related trauma. The present study aims to provide better clarity on the specific role of prescription-controlled substances (PCS) in traumatic injury events. The data source was the American College of Surgeons National Trauma Data Bank. Trends by injury mechanism and intent for patients with PCS and no-confirmed substances were compared from 2007 to 2014. Logistic regression models were also performed to examine the association between substance use and injury mechanism and intent for data across the study period. Of 405,334 trauma patients, 328,623 (81.1%) had no-confirmed substances and 76,711 (18.9%) had PCS detected. The majority of events in the PCS and no-confirmed substance groups were classified as unintentional. Motor vehicle traffic (MVT), falls, other transport, and cut/pierce injuries accounted for approximately 80% of all injuries. From 2007 to 2014, the proportion of injuries with PCS increased for all injury mechanisms and injury intents. The injury mechanisms of fire/burn, firearm, machinery, poisoning, and other transport were significantly more likely to have PCS relative to MVT injuries. For injury intent, self-harm was more likely to have a toxicology test positive for PCS, while assault was less likely to have a toxicology test positive for PCS compared to unintentional injuries. PCS-related traumatic injuries increased significantly over time and across injury mechanisms and intents. These findings can be used to inform prescribing and understand risk factors to reduce the likelihood of PCS-related traumatic injury.

Intra-abdominal Infections.

Intra-abdominal infections (IAIs) are a common cause of sepsis, and frequently occur in intensive care unit (ICU) patients. IAIs include many diagnoses, including peritonitis, cholangitis, diverticulitis, pancreatitis, abdominal abscess, intestinal perforation, abdominal trauma, and pelvic inflammatory disease. IAIs are the second most common cause of infectious morbidity and mortality in the ICU after pneumonia. IAIs are also the second most common cause of sepsis in critically ill patients, and affect approximately 5% of ICU patients. Mortality with IAI in ICU patients ranges from 5 to 50%, with the wide variability related to the specific IAI present, associated patient comorbidities, severity of illness, and organ dysfunction and failures. It is important to have a comprehensive understanding of IAIs as potential causes of life-threatening infections in ICU patients to provide the best diagnostic and therapeutic care for optimal patient outcomes in the ICU.

Need for Emergent Intervention within 6 Hours: A Novel Prediction Model for Hospital Trauma Triage.

Objective: A tiered trauma team activation system allocates resources proportional to patients' needs based upon injury burden. Previous trauma hospital-triage models are limited to predicting Injury Severity Score which is based on > 10% all-cause in-hospital mortality, rather than need for emergent intervention within 6 hours (NEI-6). Our aim was to develop a novel prediction model for hospital-triage that utilizes criteria available to the EMS provider to predict NEI-6 and the need for a trauma team activation.Methods: A regional trauma quality collaborative was used to identify all trauma patients ≥ 16 years from the American College of Surgeons-Committee on Trauma verified Level 1 and 2 trauma centers. Logistic regression and random forest were used to construct two predictive models for NEI-6 based on clinically relevant variables. Restricted cubic splines were used to model nonlinear predictors. The accuracy of the prediction model was assessed in terms of discrimination.Results: Using data from 12,624 patients for the training dataset (62.6% male; median age 61 years; median ISS 9) and 9,445 patients for the validation dataset (62.6% male; median age 59 years; median ISS 9), the following significant predictors were selected for the prediction models: age, gender, field GCS, vital signs, intentionality, and mechanism of injury. The final boosted tree model showed an AUC of 0.85 in the validation cohort for predicting NEI-6.Conclusions: The NEI-6 trauma triage prediction model used prehospital metrics to predict need for highest level of trauma activation. Prehospital prediction of major trauma may reduce undertriage mortality and improve resource utilization.

When blood is not an option: Optimal bloodless management of severe anemia in pregnancy.

Standard treatment for severe anemia in pregnancy is allogeneic blood transfusion, but this is not acceptable to all patients. Options for alternative anemia treatment are available. In this case report, a 32-year-old G2P1 woman who was a Jehovah's Witness presented at 27 weeks gestation with dyspnea, palpitations, and severe anemia (hemoglobin 2.8 g/dL) related to chronic rectal bleeding. She declined blood transfusion. An anemia management protocol (high-dose erythropoietin-stimulating agent, iron, vitamin D, vitamin C, folate, vitamin B12) rapidly increased endogenous erythropoiesis. After 12 days, hemoglobin increased to 8 g/dL. A bovine hemoglobin-based oxygen carrier was available for acute bleeding but was not used. This case highlights that early initiation of multimodal therapy can adequately increase endogenous erythropoiesis to treat life-threatening anemia in antepartum patients who do not accept blood transfusion.

Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance.

BACKGROUND: Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS: This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS: Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13). CONCLUSIONS: The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.

Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation.

OBJECTIVES: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. DESIGN: Retrospective review of the literature and expert consensus. SETTING: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. SUBJECTS: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. INTERVENTIONS: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. MEASUREMENTS AND MAIN RESULTS: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. CONCLUSIONS: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Redefining the Trauma Triage Matrix: The Role of Emergent Interventions.

BACKGROUND: A tiered trauma team activation (TTA) system aims to allocate resources proportional to the patient's need based upon injury burden. The current metrics used to evaluate appropriateness of TTA are the trauma triage matrix (TTM), need for trauma intervention (NFTI), and secondary triage assessment tool (STAT). MATERIALS AND METHODS: In this retrospective study, we compared the effectiveness of the need for an emergent intervention within 6 h (NEI-6) with existing definitions. Data from the Michigan Trauma Quality Improvement Program was utilized. The dataset contains information from 31 level 1 and 2 trauma centers from 2011 to 2017. Inclusion criteria were: adult patients (≥16 y) and ISS ≥5. RESULTS: 73,818 patients were included in the study. Thirty percentage of trauma patients met criteria for STAT, 21% for NFTI, 20% for TTM, and 13% for NEI-6. NEI-6 was associated with the lowest rate of undertriage at 6.5% (STAT 22.3%, NFTI 14.0%, TTM 14.3%). NEI-6 best predicted undertriage mortality, early mortality, in-hospital mortality, and late (>60 h) mortality. Most patients who met criteria for TTM (58%), NFTI (51%), and STAT (62%) did not require emergent intervention. All four methods had similar rates of early mortality for patients who did not meet criteria (0.3%-0.5%). CONCLUSIONS: NEI-6 performs better than TTM, NFTI, and STAT in terms of undertriage, mortality and need for resource utilization. Other methods resulted in significantly more full TTAs than NEI-6 without identifying patients at risk for early mortality. NEI-6 represents a novel tool to determine trauma activation appropriateness.

Rapid breath analysis for acute respiratory distress syndrome diagnostics using a portable two-dimensional gas chromatography device.

Acute respiratory distress syndrome (ARDS) is the most severe form of acute lung injury, responsible for high mortality and long-term morbidity. As a dynamic syndrome with multiple etiologies, its timely diagnosis is difficult as is tracking the course of the syndrome. Therefore, there is a significant need for early, rapid detection and diagnosis as well as clinical trajectory monitoring of ARDS. Here, we report our work on using human breath to differentiate ARDS and non-ARDS causes of respiratory failure. A fully automated portable 2-dimensional gas chromatography device with high peak capacity (> 200 at the resolution of 1), high sensitivity (sub-ppb), and rapid analysis capability (~ 30 min) was designed and made in-house for on-site analysis of patients' breath. A total of 85 breath samples from 48 ARDS patients and controls were collected. Ninety-seven elution peaks were separated and detected in 13 min. An algorithm based on machine learning, principal component analysis (PCA), and linear discriminant analysis (LDA) was developed. As compared to the adjudications done by physicians based on the Berlin criteria, our device and algorithm achieved an overall accuracy of 87.1% with 94.1% positive predictive value and 82.4% negative predictive value. The high overall accuracy and high positive predicative value suggest that the breath analysis method can accurately diagnose ARDS. The ability to continuously and non-invasively monitor exhaled breath for early diagnosis, disease trajectory tracking, and outcome prediction monitoring of ARDS may have a significant impact on changing practice and improving patient outcomes. Graphical abstract.

Are Predictive Energy Expenditure Equations in Ventilated Surgery Patients Accurate?

BACKGROUND:: While indirect calorimetry (IC) is the gold standard used to calculate specific calorie needs in the critically ill, predictive equations are frequently utilized at many institutions for various reasons. Prior studies suggest these equations frequently misjudge actual resting energy expenditure (REE) in medical and mixed intensive care unit (ICU) patients; however, their utility for surgical ICU (SICU) patients has not been fully evaluated. Therefore, the objective of this study was to compare the REE measured by IC with REE calculated using specific calorie goals or predictive equations for nutritional support in ventilated adult SICU patients. MATERIALS AND METHODS:: A retrospective review of prospectively collected data was performed on all adults (n = 419, 18-91 years) mechanically ventilated for >24 hours, with an Fio2 ≤ 60%, who met IC screening criteria. Caloric needs were estimated using Harris-Benedict equations (HBEs), and 20, 25, and 30 kcal/kg/d with actual (ABW), adjusted (ADJ), and ideal body (IBW) weights. The REE was measured using IC. RESULTS:: The estimated REE was considered accurate when within ±10% of the measured REE by IC. The HBE, 20, 25, and 30 kcal/kg/d estimates of REE were found to be inaccurate regardless of age, gender, or weight. The HBE and 20 kcal/kg/d underestimated REE, while 25 and 30 kcal/kg/d overestimated REE. Of the methods studied, those found to most often accurately estimate REE were the HBE using ABW, which was accurate 35% of the time, and 25 kcal/kg/d ADJ, which was accurate 34% of the time. This difference was not statistically significant. CONCLUSION:: Using HBE, 20, 25, or 30 kcal/kg/d to estimate daily caloric requirements in critically ill surgical patients is inaccurate compared to REE measured by IC. In SICU patients with nutrition requirements essential to recovery, IC measurement should be performed to guide clinicians in determining goal caloric requirements.

Trial of short-course antimicrobial therapy for intraabdominal infection.

BACKGROUND: The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear. METHODS: We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections. RESULTS: Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes. CONCLUSIONS: In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Hepcidin and Anemia in Surgical Critical Care: A Prospective Cohort Study.

OBJECTIVE: Because anemia of inflammation is common in ICU patients and hepcidin is the key regulator of iron homeostasis, we examined time-dependent changes in hepcidin, erythropoietin, iron, and inflammatory markers in surgical ICU patients with anemia. DESIGN: Prospective single-center clinical noninterventional study. SETTING: Surgical ICUs; U.S. university hospital. PATIENTS: One hundred surgical adult ICU patients. MEASUREMENTS AND MAIN RESULTS: Time-dependent changes in serum hepcidin, hematologic, and erythropoietic studies were performed on ICU admission and at serial time-points through day 28, and correlated with hematologic and iron parameters and inflammatory response. Median serum hepcidin levels were significantly increased at ICU admission and decreased over time (144-36 ng/mL; p < 0.0001). Despite increased reticulocyte counts (1.3-2.9%), mean serum erythropoietin levels remained low (29-44 mU/mL) and hemoglobin did not significantly change. Hepcidin was positively correlated with RBC transfusion, C-reactive protein, interleukin-6, ferritin, and negatively correlated with iron, total iron binding capacity, transferrin, and reticulocyte response. Hepcidin did not correlate with tumor necrosis factor-α serum concentrations. Regression analyses confirmed that ferritin, C-reactive protein, and reticulocyte number were predictive of same-day hepcidin; hepcidin and C-reactive protein were predictive of same-day reticulocyte count. CONCLUSIONS: Hepcidin serum concentrations are markedly increased on ICU admission, and decrease significantly over the course of the ICU stay (28 d). Decreased hepcidin concentrations are associated with increased reticulocyte response and decreased inflammatory response reflected by decreased interleukin-6 and C-reactive protein concentrations, but not with anemia resolution.

Whole-Exome Sequencing Reveals Mutations in Genes Linked to Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome in Fatal Cases of H1N1 Influenza.

BACKGROUND: Severe H1N1 influenza can be lethal in otherwise healthy individuals and can have features of reactive hemophagocytic lymphohistiocytosis (HLH). HLH is associated with mutations in lymphocyte cytolytic pathway genes, which have not been previously explored in H1N1 influenza. METHODS: Sixteen cases of fatal influenza A(H1N1) infection, 81% with histopathologic hemophagocytosis, were identified and analyzed for clinical and laboratory features of HLH, using modified HLH-2004 and macrophage activation syndrome (MAS) criteria. Fourteen specimens were subject to whole-exome sequencing. Sequence alignment and variant filtering detected HLH gene mutations and potential disease-causing variants. Cytolytic function of the PRF1 p.A91V mutation was tested in lentiviral-transduced NK-92 natural killer (NK) cells. RESULTS: Despite several lacking variables, cases of influenza A(H1N1) infection met 44% and 81% of modified HLH-2004 and MAS criteria, respectively. Five subjects (36%) carried one of 3 heterozygous LYST mutations, 2 of whom also possessed the p.A91V PRF1 mutation, which was shown to decrease NK cell cytolytic function. Several patients also carried rare variants in other genes previously observed in MAS. CONCLUSIONS: This cohort of fatal influenza A(H1N1) infections confirms the presence of hemophagocytosis and HLH pathology. Moreover, the high percentage of HLH gene mutations suggests they are risk factors for mortality among individuals with influenza A(H1N1) infection.

Executive Summary: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.