These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.

Background-There are few data on paediatric community acquired pneumonia (PCAP) in the UK. Aims-To investigate the aetiology and most useful diagnostic tests for PCAP in the north east of England. Methods-A prospective study of hospital admissions with a diagnosis of PCAP. Results-A pathogen was isolated from 60% (81/136) of cases, and considered a definite or probable cause of their pneumonia in 51% (70/136). Fifty (37%) had a virus implicated (65% respiratory syncytial virus) and 19 (14%) a bacterium (7% group A streptococcus, 4% Streptococcus pneumoniae), with one mixed infection. Of a subgroup (51 patients) in whom serum antipneumolysin antibody testing was performed, 6% had evidence of pneumococcal infection, and all were under 2 years old. The best diagnostic yield was from paired serology (34%, 31/87), followed by viral immunofluorescence (33%, 32/98). Conclusion-Viral infection accounted for 71% of the cases diagnosed. Group A streptococcus was the most common bacterial infective agent, with a low incidence of both Mycoplasma pneumoniae and S pneumoniae. Pneumococcal pneumonia was the most common bacterial cause of pneumonia in children under 2 years but not in older children. Inflammatory markers and chest x ray features did not diVerentiate viral from bacterial pneumonia; serology and viral immunofluorescence were the most useful diagnostic tests. (Arch Dis Child 2000;83:408-412)

The aim of this study was to determine if gastroenteric viruses were present on surfaces and equipment in a pediatric primary immunodeficiency unit (PPIU) by environmental sampling using swabs and subsequent nucleic acid extraction and reverse transcriptase PCR assays. A PPIU was chosen, and 11 swabs were taken at the same sites every 2 weeks for 6 months. Nested/heminested PCR assays were used to screen for astroviruses (AsV), noroviruses (NoV), and rotaviruses (RV). AsV, NoV, and RV were detected at multiple swab sites during the study period. NoV was the most frequently detected virus on environmental surfaces; however, RV was detected on 79% and NoV on 50% of swabbing dates during the study period. Toilet taps were the most contaminated sites. Fecal samples from selected patients in the unit were also screened during the study period, and patients excreted AsV, NoV, and RV at times during the study. New cleaning schedules and changes in some of the PPIU sanitary furniture have been suggested as a means of reducing environmental contamination.

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An outbreak of astrovirus gastroenteritis occurred in the Primary Immunodeficiency Unit at Newcastle General Hospital in March 2004. Environmental swabbing of the unit was undertaken after the outbreak, with multiple sites swabbed pre- and postcleaning. Astroviruses were detected in four environmental swabs and from two patient fecal samples using heminested reverse transcriptase PCR. An astrovirus genotype 3 strain was identified in both environmental swabs and fecal specimens and was the strain identified as being responsible for the outbreak. Environmental transmission of the virus was thought to have occurred by contamination of a syringe pump outside the laminar-flow curtain of a patient who was admitted with astrovirus gastroenteritis. This was subsequently transmitted to a cubicle next door and to a television/games console in a parents' room in the ward. Environmental monitoring of surfaces/equipment, using PCR assays for gastroenteric viruses in hospital situations where infection can give rise to serious clinical complications, may have a role in controlling and monitoring cleaning and the subsequent prevention of nosocomial transmission of gastroenteritis.

The aims of this study were to examine the extent of gastroenteric virus contamination in a pediatric primary immunodeficiency (PPI) ward and a general pediatric ward over a winter season and to determine whether changes to hospital infection control interventions would have an impact on environmental contamination levels within pediatric units. Environmental swabs were collected weekly from 11 sites in both wards from 15 December 2005 to 3 March 2006 and examined for the presence of norovirus (NoV), astrovirus, and rotavirus (RV) by reverse transcriptase PCR. Viruses were detected in 17% and 19% of swabs from both wards. Virus contamination for NoV and RV decreased from 20% to 6% and 15% to 10% of swabs, respectively, in the PPI ward from the 2004 study by Gallimore et al.

Western blot detection of the species-specific pneumococcal product, pneumolysin (SPN), was shown to be almost as sensitive as PCR for the non-cultural detection of pneumococci in 27 Streptococcus pneumoniae culture-positive sputa from patients stated to have chest infections. Both techniques were considerably more sensitive than countercurrent immuno-electrophoresis for pneumococcal capsular polysaccharide antigens (CPS-CIE) on the same specimens. Sensitivities for PCR, SPN-immunoblotting and CPS-CIE were loo%, 85% and 67%, respectively. In 11 S. pneumoniae culture-negative sputa taken from patients receiving antibiotics, but with proven recent pneumococcal infection, PCR and SPN-blot were positive in six (in two of which CPS-CIE was also positive), PCR alone was positive in one and SPN-blot alone was positive in one. In 11 S. pneumoniae culture-negative samples from patients not receiving antibiotics, all three tests were negative in eight, PCR was positive in three (in one of which CPS-CIE was also positive), but SPN-blot was negative in all 11. In 16 S. pneumoniae culture-negative samples from patients receiving antibiotics and with no known recent pneumococcal infections, one or more non-cultural test was positive in 11. Although further evaluation is required to assess the significance of pneumolysin detection in relation to carriage and infection and to devise a more suitable test format, these preliminary studies suggest that pneumolysin detection is a promising new approach to the non-cultural diagnosis of pneumococcal chest infection.

Objective: To describe the use of intra-reservoir gentamicin for the treatment of a Pseudomonas aeruginosa infected baclofen pump. Setting: Regional Spinal Injuries Centre, Hexham, Northumberland, England. Subject: Male patient aged 32 years with progressive multiple sclerosis and severe bilateral spasticity. Results: Intra-reservoir gentamicin proved successful in treating infection with Pseudomonas aeruginosa. Conclusion: Intra-reservoir gentamicin may be successful in treating pump infection with Pseudomonas aeruginosa without the need for pump removal.