We sought to investigate prospectively the microbial etiology and prognostic indicators of 95 institutionalized elders with severe aspiration pneumonia, and to investigate its relation to oral hygiene in using quantitative bronchial sampling. Data collection included demographic information, Activity of Daily Living, Plaque Index, antimicrobial therapy, and outcome. Out of the 67 pathogens identified, Gram-negative enteric bacilli were the predominant organisms isolated (49%), followed by anaerobic bacteria (16%), and Staphylococcus aureus (12%). The most commonly encountered anaerobes were Prevotella and Fusobacterium species. Aerobic Gram-negative bacilli were recovered in conjunction with 55% of anaerobic isolates. The Plaque Index did not differ significantly between the aerobic (2.2 +/- 0.4) and the anaerobic group (2.3 +/- 0.3). Functional status was the only determinant of the presence of anaerobic bacteria. Although seven cases with anaerobic isolates received initially inadequate antimicrobial therapy, six had effective clinical response. The crude mortality was 33% for the aerobic and 36% for the anaerobic group (p = 0.9). Stepwise multivariate analysis identified hypoalbuminemia (p < 0.001) and the burden of comorbid diseases (p < 0.001) as independent risk factors of poor outcome. In view of the rising resistance to antimicrobial agents, the importance of adding anaerobic coverage for aspiration pneumonia in institutionalized elders needs to be reexamined.

Current recommendations for management of obese patients post-extubation are based on clinical experience and expert opinions. It was hypothesised that the application of noninvasive ventilation (NIV) during the first 48 h after extubation in severely obese patients would reduce post-extubation failure and avert the need for reintubation.Following protocol-driven weaning trials, 62 consecutive severely obese patients (body mass index o35 kg?m -2 ) were assigned to NIV via nasal mask immediately post-extubation and compared with 62 historically matched controls who were treated with conventional therapy. The primary end-point was the incidence of respiratory failure in the first 48 h post-extubation.Compared with conventional therapy, the institution of NIV resulted in 16% (95% confidence interval 2.9-29.3%) absolute risk reduction in the rate of respiratory failure. There was a significant difference in the intensive care unit and lengths of hospital stay between the two groups. Subgroup analysis of hypercapnic patients showed reduced hospital mortality in the NIV group compared with the control group.In conclusion, noninvasive ventilation may be effective in averting respiratory failure in severely obese patients when applied during the first 48 h post-extubation. In selected patients with chronic hypercarbia, early application of noninvasive ventilation may confer a survival benefit.

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The aim of the study was to investigate the etiology and the impact of invasive quantitative sampling on the management of severe pneumonia in institutionalized older people with antimicrobial treatment failure. Fifty-two institutionalized patients aged 70 years and older hospitalized with a presumptive diagnosis of severe pneumonia and failure to respond to treatment after 72 hours of initiation of outpatient antimicrobial therapy were enrolled. Microbial investigation included blood culture, serology, pleural fluid, and bronchoalveolar samples. A definite etiology could be established in 24 of 52 (46%) patients. Methicillin-resistant Staphylococcus aureus (33%), enteric Gram-negative bacilli (24%), and Pseudomonas aeruginosa (14%) accounted for most isolates. Atypical infections (2%) were uncommon. Invasive bronchial sampling directed a change of microbial therapy in 8 (40%) and discontinuation of antibiotics in 2 of 20 cases (10%) of definite pneumonia. Overall hospital mortality was 42%. There was no difference in mortality among definite or unverified cases or those who had invasive bronchial sampling-guided change in therapy. We conclude that antimicrobial therapy should be targeted toward "nosocomial" pathogens in those institutionalized patients who received prior antibiotic treatment. When combined with microbial investigation, direct visualization of the tracheobronchial tree might be useful in determining the presence of bacterial pneumonia.

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