Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study.

BACKGROUND: The usefulness of sputum Gram stain in patients with community-acquired pneumonia (CAP) is controversial. There has been no study to evaluate the diagnostic value of this method in patients with healthcare-associated pneumonia (HCAP). The purpose of this study was to evaluate the usefulness of sputum Gram stain in etiological diagnosis and pathogen-targeted antibiotic treatment of CAP and HCAP. METHODS: We conducted a prospective observational study on hospitalized patients with pneumonia admitted to our hospital from August 2010 to July 2012. Before administering antibiotics on admission, Gram stain was performed and examined by trained physicians immediately after sputum samples were obtained. We analyzed the quality of sputum samples and the diagnostic performance of Gram stain. We also compared pathogen-targeted antibiotic treatment guided by sputum Gram stain with empirical treatment. RESULTS: Of 670 patients with pneumonia, 328 were CAP and 342 were HCAP. Sputum samples were obtained from 591 patients, of these 478 samples were good quality. The sensitivity and specificity of sputum Gram stain were 62.5% and 91.5% for Streptococcus pneumoniae, 60.9% and 95.1% for Haemophilus influenzae, 68.2% and 96.1% for Moraxella catarrhalis, 39.5% and 98.2% for Klebsiella pneumoniae, 22.2% and 99.8% for Pseudomonas aeruginosa, 9.1% and 100% for Staphylococcus aureus. The diagnostic yield decreased in patients who had received antibiotics or patients with suspected aspiration pneumonia. Pathogen-targeted treatment provided similar efficacy with a decrease in adverse events compared to empirical treatment. CONCLUSIONS: Sputum Gram stain is highly specific for the etiologic diagnosis and useful in guiding pathogen-targeted antibiotic treatment of CAP and HCAP.

Systemic lupus erythematosus presenting with lymphoid interstitial pneumonia as an initial manifestation.

A 25-year-old woman with an extensive travel history developed chronic cough and multiple lung nodules. The lung biopsy revealed lymphoid interstitial pneumonia. The patient later developed cervical lymphadenopathy, arthritis and livedo reticularis, then systemic lupus erythematosus was diagnosed with positive double-stranded DNA and low complement. The patient's symptoms responded to prednisolone and azathioprine.

When critical illness becomes chronic: informational needs of patients and families.

PURPOSE: A large and growing group of intensive care unit survivors are "chronically critically ill," with ongoing respiratory failure and poor outcomes for postdischarge survival and functional recovery. In this qualitative study, we investigated what information is relevant and important for clinician-patient/family communication when critical illness becomes chronic, as indicated by tracheotomy for prolonged mechanical ventilation. METHODS: We conducted focus groups and structured interviews of patients who survived chronic critical illness, of surrogates of such patients and of nonsurvivors, and of clinicians with relevant experience. Discussions were audiotaped, transcribed, and analyzed using grounded theory. RESULTS: Twenty-five subjects participated (4 survivors, 7 survivors' surrogates, 4 nonsurvivors' surrogates, 10 clinicians). We found broad agreement on 6 major domains of information that are relevant and important: (1) nature of illness/treatments, (2) prognosis, (3) impact of treatment, (4) potential complications, (5) expected care needs after hospitalization, and (6) alternatives to continuation of treatment. Participants endorsed the multidisciplinary family meeting as an effective communication strategy. CONCLUSIONS: Given poor outcomes for most patients and high costs and burdens of treatment, effective communication is essential when critical illness enters a chronic phase. Our findings provide a framework for such communication and a basis for further research.