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priate starting point for consultation by specialists. Substantial overlap exists among the patients whom these guidelines address and those discussed in the recently published guidelines for health care-associated pneumonia (HCAP). Pneumonia in nonambulatory residents of nursing homes and other long-term care facilities epidemiologically mirrors hospital-acquired pneumonia and should be treated according to the HCAP guidelines. However, certain other patients whose conditions are included in the designation of HCAP are better served by management in accordance with CAP guidelines with concern for specific pathogens.

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.

IMPORTANCE: The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. OBJECTIVE: To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. DESIGN, SETTING, AND PARTICIPANTS: Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. EXPOSURES: Ambulatory care visits. MAIN OUTCOMES AND MEASURES: Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. RESULTS: Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. CONCLUSIONS AND RELEVANCE: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II) (table 1). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). Infectious Diseases Society of America—United States Public Health Service Grading System for ranking recommendations in clinical guidelines. 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 1–2 weeks usually suffices, but some require an additional 1–2 weeks; for moderate and severe infections, usually 2–4 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 4–6 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to ⩾1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from and may but bone is for the of osteomyelitis, for the and for the antibiotic of (B-II). field has is The especially that adequately studies be to and for infection, diagnosing osteomyelitis, optimal antibiotic regimens in various and the role of in treating osteomyelitis of the Foot infections in with diabetes are a and addition to severe for the of and are the most cause of amputations Diabetic foot infections require careful attention and coordinated management, preferably by a multidisciplinary foot-care team (A-II) The team managing these infections should preferably include, or have ready access to, an infectious diseases specialist or a medical microbiologist of diabetic foot infections can the of the for and duration of and the of major limb amputation these infections are This may from a of of and insufficient to the or a of effective multidisciplinary The of is to help the medical and with diabetic foot infections. The of is on managing the diabetic patient with or foot infection, other the of the diabetic foot and diabetic foot The that the of care and the of in some clinical the of some of the and that in all care is usually more difficult to or care and This should a for treating all diabetic patients who have a foot health care be to it better and of of may the and with including those related to antibiotic wound care, surgical and adjunctive it to the of lower in with the may may be by an for foot care, (especially and vascular This is of Infectious Diseases Society of with experience and interest in diabetic foot infections, many of also have experience in guidelines. are from and other their and clinical infectious diseases clinical and of the are also of the on the Diabetic which on and Diabetic Foot Infections in an extensive the the the diabetic foot and and of of and all evidence in a of and and a of that and these as a basis for the which that based on both and of the of or other evidence in most of recommendations are based on and (table to a and to an extensive for those who to the data diabetic foot infection is most defined as any infection in a with diabetes These necrotizing and The most and is the infected diabetic foot This wound results from a of risk factors which are in 2. the with disturbances of and to to or on a foot that the of is tissues are to This wound may to and, by the infection can This of can be or especially in an especially those that may some diabetic and these likely the risk and severity of foot infections factors for foot and Aerobic gram-positive cocci are the predominant that and in the S. aureus and the and but especially are the most pathogens wounds a more including various obligate and, other gram-negative surgical and, especially, or antibiotic therapy may patients to infection with or have previously been from cases are and are with in patients with diabetic foot infections S. aureus has been in the cases of S. aureus a diabetic patient with a foot infection The necrotic or bone may as and to a role infections in patients who have not recently received antimicrobials are often with an aerobic gram-positive chronic infections are often of specimens obtained from patients with infections generally including gram-positive and gram-negative and The role of in a infection is often clinical infection and the pathogens most likely in with with various clinical Diabetic patients may many of foot wounds, any of which can should be diagnosed clinically on the basis of the presence of purulent or at least of the of or and or not all ulcers are infected an infection often to, but is not defined healing of an of diabetic foot infections and the severity of infection as the basis for the appropriate to treatment (B-II). The of osteomyelitis is particularly and and is with to treating a diabetic patient with a foot wound of the infection should at as in and the patient as a the limb or and the infected The is to determine the clinical (table and the (table of the infection, the or of the any of foot to the cause of the wound thus, to any of vascular (especially and the presence of any systemic of the or experience to any of these should appropriate Evaluating the diabetic patient who has an infected of soft-tissue specimens from an infected diabetic foot for The results of the in can be used to determine the severity of the infection and to a (B-II). the of on wound and infection of The has been used for but for the is severe and all infections a is that the issues in a diabetic foot wound are (in which tissues are and the wound is by ischemia or infection (B-II). The on the Diabetic Foot recently a on a diabetic foot ulcer for The are by the infection, and The infection includes of and or and of a systemic response is to be to all it includes a of for uninfected 2–4 are to those in 6. to treating a diabetic patient with a foot if any of the are systemic toxicity and metabolic severe or or infection, substantial necrosis or gangrene, or presence of of or and to care for or of a diabetic foot infected wounds the most important is to patients who require parenteral and empirical antibiotic therapy, and consideration of and surgical have defined these infections as Infections defined as must be from clinically uninfected lesions but are to infections as the a of wounds, some of which can be and limb have used the and with mild and but to with the various that can a The moderate and severe infections has to with the of the foot with the patient to it is This is by the that of patients with a infection not systemic signs or the in as a basis for in and (B-II). antibiotics for uninfected that many uninfected diabetic foot ulcers are a of defined as of that results in and wound healing Available evidence does not support the use of antibiotics for the of clinically uninfected to wound healing or as infection antibiotic use and may cause adverse therapy of uninfected some it is difficult to a chronic wound is as when the foot is has or a has tissue, is with or or when an ulcer fails to healing these cases, a of antibiotic therapy may be appropriate (C-III). the for is the most of treating a diabetic foot infection, and on consideration of both medical and Patients with infections that are severe or by limb ischemia should generally be patients with mild infections and more patients with moderate infections may also may be for or factors are likely to their wound care or to antibiotic the of these most patients with mild or moderate infections can be as (A-II) the to the metabolic of the patient is This may of the and of and and treatment of other patients who require should usually be to the should usually not be for after to the The of may in both the infection and healing the wound the infection may be to an antibiotic of the antibiotic regimen initially the of therapy, the of to be and the specific to and the regimen and the duration of therapy is usually empirical and should be based on the severity of the infection and on any data, as recent culture results or severe infections and for chronic moderate infections, it is to therapy with agents. These should have gram-positive cocci (including in is as as gram-negative and obligate anaerobic (B-III). ensure adequate and therapy should be at least initially (C-III). some suggest empirical therapy for most infections the of many can be with agents with a as those only aerobic gram-positive cocci (A-II) anaerobic are from many severe infections are in mild-to-moderate infections and there is evidence to support the for therapy in most infections (B-III). mild-to-moderate infections in patients without and for an oral with the appropriate is oral therapy is often especially with bioavailable agents (A-II). infected wounds with limited data support the use of therapy in effective in infected diabetic foot lesions is with the of the specific and, especially, the arterial supply to the with diabetes There are few clinical of antibiotic therapy for diabetic foot antibiotic patients with various and soft-tissue infections have some patients with diabetic foot infections. a of clinical that on therapy of diabetic foot infections, or as an of a The of among these the of of regimens The of infection severity and clinical that used in these the to a for the basis of the or of agents to be to Antibiotic agents used in clinical studies of diabetic foot infections. some empirical antibiotic regimens to the clinical severity of the infection, the data not to recommend any specific antibiotic regimen for diabetic foot infections (B-II). These agents are from clinical and experience and are not to be of all agents be depending on various and antibiotic therapy when culture and susceptibility results are (C-III). choices for patients who are not to antibiotic therapy should agents that a or of The regimens in are in of the does not by the of antibiotic agents should be selected to of the and the and the experience of the and should be on the basis of any (especially and other clinical factors. empirical antibiotic based on clinical for diabetic foot infections. to a diabetic patient with a foot infection who is not to of the for infections require surgical that from and of infected and necrotic tissues to of the lower and of soft-tissue or surgical treatment of diabetic foot infections is based on evidence that for antibiotic therapy Seek surgical consultation for or infections, as those with necrotizing gangrene, extensive soft-tissue or evidence of or those in with ischemia (A-II) surgical specialist should also patients who have foot or evidence of a infection, deep or infection in the of appropriate medical care and surgical debridement, including limited or may the for amputation especially in an can cause and patients with infections, it may be appropriate to to the of medical therapy or to determine the necrotic and The must determine the adequacy of the supply to the consider infection among foot to the deep or the and a for soft-tissue secondary or The surgical should the for healing and should to the of the of the foot addition to the must have sufficient and experience to when and to The is important or of the of the the of and infection, and experience with and for the field most the should to the patient until the infection is and the wound is healing (B-III). some cases, amputation is the or only amputation is usually required only when there is extensive necrosis or infection amputation may be for the patient who has has of foot or require or care of the of amputation must into consideration and issues the should to as of the limb as possible. a amputation that results in a more if a is may be a better a foot that is to or to all or of a foot has gangrene, it may be preferable (especially for a patient for is a to the necrotic may also be to in especially on the until to be more removed, there does not to be an of infection If the infected limb to be the patient should be to a with vascular most cases, ischemia is to to the and the to be may be amenable to or vascular Patients with ischemia those with an to of can usually be without a vascular vascular disease of the many have use of in diabetic patients a patient with a infected it is usually preferable to any needed early after the infection 1–2 to in of (and antibiotic therapy the other careful debridement of necrotic infected should not be surgical may require a The wound may require additional attention after the debridement the (table The is to and tissue, wound healing and a of pathogens may limited This can usually be as a or and without especially for a debridement with or is generally preferable to or which are and and may require and There are many products that are as to healing in various but a of these is The infected wound should be in a that and a (B-III). evidence any type of and are important of from a foot wound is crucial to the healing of can the infected but it is important to that and have many of including wound factors and therapy treatment likely has some appropriate for infected wounds, evidence is insufficient to recommend use of any of these for treatment or adjunctive granulocyte colony-stimulating factors have been in diabetic foot infections of these that does not of infection but may the for and suggest that hyperbaric oxygen therapy may be of for treatment of diabetic foot wounds, and a few recent studies have results recent that hyperbaric oxygen therapy the risk of major amputation related to a diabetic foot ulcer (B-I). additional clinical can for and with these and limited be used in the treatment of diabetic foot infections. should be used as a for proper surgical debridement and observation of the response to therapy is and should be for and perhaps initially for (B-III). The of are of local and systemic symptoms and clinical signs of inflammation. including and as the and the are of limited use for is it to and cause for when to antibiotic therapy for a diabetic patient with a foot methicillin-resistant Staphylococcus a patient is ready for or an for the should and 1. Select the antibiotic the culture and susceptibility results and any adverse related to the antibiotic a antibiotic regimen (including the treatment on the basis of the results of or other and the clinical response (C-III). is not necessary to all from S. aureus and or should be but in a infection, and may be important (B-II). If the infection has not responded to the empirical agents with all a clinically stable patient who has ⩾1 of therapy, consider discontinuing antimicrobials for a few and optimal specimens for culture (C-III). 2. the the to ensure that the infection is and that the wound is If is the for surgical evidence antibiotics for the entire that the wound remains should be used for a defined by the of the infection and by the clinical as in (A-II). If clinical evidence of infection the on the with antibiotics and for adverse factors These may the of antibiotic a an deep or of osteomyelitis, or ischemia that is more severe initially and of antibiotic therapy, by clinical 3. the off-loading and wound care the and the the consultation when 4. that and other of the metabolic are adequately with osteomyelitis is perhaps the most difficult and in the of diabetic foot infections among is that the of a of the disease the of studies and there are many but often the presence of osteomyelitis the of surgical including and the required duration of antibiotic therapy osteomyelitis healing of the wound and as a for to consider the osteomyelitis as a of any deep or extensive especially that is chronic or a osteomyelitis when an ulcer does not after at least weeks of appropriate care and ulcer in which bone is or can be with a is likely to be by osteomyelitis patients with a infection, results of a may be as sufficient for but the of have not been foot in a patient with a of foot ulceration, a a or an or should also of osteomyelitis (B-II). bone an ulcer should be to osteomyelitis a diabetic patient who has osteomyelitis of the and or be or preferably after antibiotic therapy has been for 1–2 weeks to the is usually not on radiography the early of disease and can infection, diagnosing osteomyelitis at the the patient to the can be difficult on may help in cases are more sensitive for osteomyelitis the early of but are and can be The of various of but the of bone is generally MRI is the most useful of the MRI is the most for bone infection, and it also the most of deep soft-tissue infections. The of all these are with the of osteomyelitis, and are most useful for cases The for diagnosing osteomyelitis is of from a obtained of bone to with findings of and (B-II). few of the studies that have or have treatment have used MRI is usually not needed as a in cases of diabetic foot osteomyelitis is a obtaining often If these evidence of pathological findings in the patient should be for weeks for the soft-tissue If of osteomyelitis radiography 2–4 weeks If the of osteomyelitis and and and if there is of a for osteomyelitis, preferably after obtaining appropriate specimens for culture (B-III). If findings of radiography are only but not osteomyelitis, of the choices should be 1. MRI is the with preferably use or a If results of the are osteomyelitis is if results suggest osteomyelitis, consider bone is needed 2. antibiotic therapy for 2–4 weeks and to determine have suggest 3. an appropriate as defined of a of a or is if the remains in after or if osteomyelitis is likely but the etiologic or antibiotic are not also specimens of most or these are more difficult to and more often lead to a the an can the should preferably be or if possible. patients with may be of as by and and by have been specimens if at least for culture and for it may only be to a few of of foot bone and consider it to be a (B-II). of bone specimens more data those of soft-tissue specimens for patients with osteomyelitis medical and surgical have that a bone with chronic osteomyelitis for some have the for surgical Definitive surgical to osteomyelitis, as and may risk of the in and additional of and systemic of infection may make osteomyelitis for the who may for at medical management. these diabetic may also bone with or in infection, additional bone or soft-tissue and a These have some health care professionals to diabetic foot osteomyelitis with or surgical intervention on treatment with a of antibiotics have clinical in of cases these often to a of osteomyelitis, patients patients or and debridement of bone The of which patients are for as as duration of antibiotic therapy is needed, are important for there are cases in which of osteomyelitis be (B-II). 1. There is surgical of the infection cause of 2. The patient has ischemia by vascular disease but to 3. is to the and there is soft-tissue 4. The patient and health care that surgical risk or is not appropriate or therapy for osteomyelitis consider the is there necrotic or infected bone or surgical that should be or the selected antibiotic regimen likely the and adequate in and it for a sufficient the to bone infection the cause of the wound an usually in consultation with a patients may from antibiotics in or hyperbaric oxygen therapy, or may or antibiotic in some cases, an antibiotic The most appropriate duration of therapy for any type of diabetic foot infection has not been defined is important to consider the presence and of any or infected bone and the of the a infected tissue, antibiotic therapy is needed (B-II). if infected bone or despite treatment is osteomyelitis, some parenteral therapy may be especially if an with is used (C-III). therapy may be in the recommendations for duration of therapy are based on the clinical and are in 9. The of treating a diabetic foot infection are the of clinical evidence of infection and the of soft-tissue and a clinical response of clinical evidence of to appropriate therapy in of mild-to-moderate infections and in of severe infections or cases of osteomyelitis with a signs of systemic infection limb perfusion, osteomyelitis the presence of necrosis or gangrene an and of the infection in of especially in those with may be difficult to from a recent of of the Infections that the for treating diabetic foot osteomyelitis systematic of and patient treatment may be useful for and for multidisciplinary foot-care (B-II). patient who has foot infection is more likely to have a to with the patient of is the to prevent foot infections. the patient the of appropriate at all foot of the and any to health care professionals (A-II). can be in a few should these by patients foot care and their and Patients with severe substantial foot or ischemia should be to appropriate to with these (A-II). of the recommendations in are based on and adequately There are in which be particularly 1. a for infected foot lesions to studies of their and support to the for 2. there is a role for antibiotic therapy in managing clinically uninfected 3. optimal antibiotic regimens and for various of soft-tissue and bone infections. 4. a of osteomyelitis in the diabetic 5. and a for the and treatment of infections, especially 6. the of surgical and of of support or for and for for and and support from support or for and and for and support from and and for and of support from and for and and

The Infectious Diseases Society of America (IDSA) produced guidelines for community-acquired pneumonia (CAP) in immunocompetent adults in 1998 and again in 2000 [1, 2]. Because of evolving resistance to antimicrobials and other advances, it was felt that an update should be provided every few years so that important developments could be highlighted and pressing questions answered. We addressed those issues that the committee believed were important to the practicing physician, including suggestions for initial empiric therapy for CAP. In some cases, only a few paragraphs were needed, whereas, in others, a somewhat more in-depth discussion was provided. Because many physicians focus on the tables rather than on the text of guidelines, it was decided that all of the information dealing with the initial empiric treatment regimens should be in tabular format with footnotes (tables 1–3). The topics selected for updating have been organized according to the headings used in the August 2000 CAP guidelines published in Clinical Infectious Diseases [2]. The major headings were “Epidemiology,” “Diagnostic Evaluation,” “Special Considerations,” “Management,” “Prevention,” and “Performance Indicators,” and each section had a number of subentries. Our current topics are either updates of specific subheadings or are new contributions, and the committee's recommendations are given at the beginning of each section. A summary of prior IDSA recommendations presented in 2000 and the updated and new recommendations can be found in table 4. Ratings of the strength of the supporting evidence and the quality of the data are given in parentheses after each recommendation, and the grading system used to categorize them is in table 5. The next guidelines for the treatment of CAP will be a joint effort by the IDSA and the American Thoracic Society (ATS). A working group representing both societies has been formed and is already at work on the next CAP treatment guidelines. Recommendation 1. The initial site of treatment should be based on a 3-step process: (1) assessment of preexisting conditions that compromise safety of home care; (2) calculation of the pneumonia PORT (Pneumonia Outcomes Research Team) Severity Index (PSI) with recommendation for home care for risk classes I, II, and III; and (3) clinical judgment (A-II). Recommendation 2. For discharge criteria, during the 24 h prior to discharge to the home, the patient should have no more than 1 of the following characteristics (unless this represents the baseline status): temperature, >37.8°C; pulse, >100 beats/min; respiratory rate, >24 breaths/min; systolic blood pressure, <90 mm Hg; blood oxygen saturation, <90%; and inability to maintain oral intake (B-I). Comment. Selection of the initial site of treatment, whether home or hospital, continues to be one of the most important clinical decisions made in the treatment of patients with CAP, often determining the selection and route of administration of antibiotic agents, intensity of medical observation, and use of medical resources. This decision is often made in the emergency department, the portal of entry for 75% of the 1 million annual pneumonia admissions in the United States. Two recent articles suggest that the initial site of treatment decision be selected using a systematic 3-step process [3, 4]. Step 1 involves assessment of any preexisting conditions that compromise the safety of home care, including severe hemodynamic instability, active coexisting conditions that require hospitalization, acute hypoxemia or chronic oxygen dependency, and inability to take oral medications. The second step involves calculation of the pneumonia PSI, with a recommendation for home care for patients in risk classes I, II, or III. A description of how the PSI is derived is shown in Appendix A. The third step involves clinical judgment regarding the overall health of the patient and the suitability for home care. Mitigating factors for step 3 include frail physical condition, severe social or psychiatric problems compromising home care (including a history of substance abuse), and an unstable living situation or homelessness. Clinical judgment should supercede decisions made on the basis of PSI alone. At the present time, 3 North American medical practice guidelines advocate use of the PSI as an objective measure of risk stratification to help determine the initial site of treatment for CAP [2, 5, 6]. Preliminary results from the Emergency Department Triage of Community-Acquired Pneumonia Study indicate that implementation of the PSI significantly increases the proportion of low-risk patients with pneumonia managed in the emergency department who are treated as outpatients without compromising outcomes, as measured by short-term mortality or subsequent hospitalization [7]. In this randomized, controlled study that involved 32 hospital emergency and patients with CAP, implementation of the PSI with and implementation in a significantly proportion of low-risk patients treated in the The committee continues to use of the PSI as a of risk stratification and that this process be with assessment of the patient and use of clinical discharge are of the initial site of treatment are data that use of can mortality The discharge are during the 24 h discharge to the home, the patient should have no more than 1 of the following characteristics (unless this represents the baseline status): temperature, >37.8°C; pulse, >100 beats/min; respiratory rate, >24 breaths/min; systolic blood pressure, <90 mm Hg; blood oxygen saturation, <90%; and inability to maintain oral for are the of a in or a of using a in or a of respiratory using that for Comment. is an important respiratory it has been with chronic as a for the of with this is this for the in the and for a of the of this it is that is with to The IDSA CAP recommendations of the for and in the United and the for in are that include and or For the short-term treatment of patients with CAP, either the of by or the of the by or of respiratory is most to be increases in by and an are to be more in or For only is acute using a in the or an of be of a is Because the by to from to and should be in the on the are important to the of the and to for of a either of the by of subsequent or with the use of are for of in clinical has and only the for a is no that has been by the and is in A of have been used to in including in and The of is that of the to specific and the The is an to the of blood and and with the of results to those for Comment. that has been by the for using a is as a for the of pneumonia in The is an used to is to all are using and results of the are with the results using for pneumonia in the from to and the is on the of The in in adults has been to be In one of the published to on from adults with CAP. was in of patients with of the patients who had pneumonia with no was in that a of that are by can be with of from patients with pneumonia to other were problems with have the of of that the was no more to be with pneumonia than and it was significantly more to be those who were of this is to be for with pneumonia from those who are and the to be for the has been include the of a for patients with to or a to that of and the for of a For the should the of for CAP, and a of this administration of therapy This be for patients therapy at the of it should be a for will be to specific are to the clinical of and to determine in clinical should be that results from of in a patient with pneumonia by the basis of the present the this a to blood and other for pneumonia in The committee at of results in the Recommendation 1. of to and in should be as an of should be as an of and should be as an of Recommendation 2. or are the for treatment of pneumonia without for with to with of or of Recommendation is the antibiotic for oral treatment of pneumonia Comment. of the the for and The new to treatment of by and that with of are to be those with of are and those with of are This is the that the has provided for from and and should more of pneumonia to be treated with for were derived from for Because the of antibiotic in is only a of that in to be an have a The new that by to be and some that were as can be treated with the of or are the for pneumonia the of with an of The could be for use of for The IDSA committee and to the new as for the clinical should be in the to for and other Recommendation 1. care be in of important include the for to including health care and Recommendation 2. include clinical and and include for the for are (1) for (2) of during the acute of or any after or (3) of by second by using a second of the or a of it to the use of Recommendation The major is care Recommendation 4. include in patients with or include of and and of and Comment. is the used to of pneumonia that were in in in and that during of of have been from The of were in and with and severe and A of health care and with patients who had and were by the to most has been from patients to with a of with respiratory and respiratory have been to be the most important of and have been as the of the to in a to to of a and to a number of other without with a has the of whether by or by care a of should take safety and should from an in should include and of and and the patient in a and use of or for all who the are for include many on patients of the evidence for to health care in the use of This include of or and an of that can be to should be for at the of and some be for a of the of information should be from active as those of the and the a number of were in patients with including and it is that a is the an of this in patients with by of respiratory and and of with the with produced a severe respiratory to in The of of of the in and a number of other are and a number of are to the The of the has been the in the and either as a of 1 of the 3 or in a group For using clinical and criteria, has been as or cases, and the working by have been for to the for a a patient have and clinical of respiratory of and as as of to an with of or of with a or of A is one that the for in has either evidence of respiratory or with pneumonia or respiratory without an of have as new information has in the updated of with of should be from the or of the criteria, most in the United and have been using clinical and of the is evidence of the of have had both with results and with of in both the of and in the Because to have been found in the to be a the current and the after the second of to the or are to be is to is or with the Because of the of results of and only the of in a after is by the to be a for are for use in clinical should to other in patients of and and should be for a specific has been and should be from patients the and to and health for at the Clinical is a clinical with the in from other of pneumonia a an of the most initial is with or without or and respiratory often the during the of and are present in some The and the that and are help to patients with from with respiratory initial are few physical with a or without and no The or only during the few to a is most are including and of in the of the include with in the are to to and are in of In most cases, after the In of to the respiratory and the patients require care and of have of respiratory is with mortality of for patients than with chronic or to be at risk for severe adults have The most in on have been with and of in some cases, have shown or the of without A of have been are no data from controlled and the evidence is that any of the treatment have patients have been treated the with and other have been be to have any on the in of and other the has produced evidence of in and a number of including the and have been used in the use of for should be the of a controlled clinical of the of and the of evidence of for any treatment to from a in to an with of this the has in most of the in with health including and on a during the or A second of in and of new the of as the acute of the The of the on and medical care is only beginning to be and the of is that will be an important of pneumonia in the and the of outpatients at risk for of the pneumonia Infectious physicians will to that maintain and that for the and to from Recommendation 1. empiric therapy prior to of data for a patient to require to a hospital can be with a or a respiratory to care and is a a of a either a or a respiratory should be used Recommendation 2. data are and it is that the patient has pneumonia with without evidence to with a treatment will in the is a or be used the is or a respiratory or other by in be used Comment. The mortality for pneumonia is it was that in was The guidelines from the the and the Infectious Diseases Society and Thoracic Society a and or a for empiric treatment of patients to a hospital and a or a for patients to the for has been In the therapy was based on the results of that that a was with a of and mortality For this recommendation was based on a of data as for severe CAP, as as with a have that therapy that a given mortality with pneumonia the that were that had is important to that the of initial empiric therapy the results of blood were of therapy after the results of blood were and the that the results of the of Two for the results with a are the of or and the of A is to determine the without or the A of data patients years with severe pneumonia by the that with a was as as any other a or The were mortality and mortality therapy for patients with CAP to a hospital can be with either a or a respiratory alone. For those to require to the and in is an initial empiric treatment any data are should be with a either a or a blood a as and is no evidence of with a the decision to with therapy or to to a is on an basis to include the and any as as the and to a is to be the committee that pneumonia should be treated with or the is and it should be treated with a respiratory or other by in the is Recommendation 1. are the and of respiratory on (A-II). Recommendation 2. for is for any patient with pneumonia This is in patients with pneumonia severe to require care in the in the of an or is to to a Recommendation for is is evidence of this results Recommendation 4. The treatment for for patients is or a and is only as an oral For patients who require hospitalization, include or a (A-II). should be as as is (A-II). Comment. is in of CAP in most is to and as in risk factors include recent with an of the home, to recent in or and are immunocompetent was 1 of major respiratory in patients with CAP who to the according to of recent that the following of clinical this of or severe have in of from other of CAP on the basis of initial clinical or A clinical system that a of clinical and is specific to a help specific of include and require for and selection of is is and are no The are the and of respiratory The for 1 is and and to of community-acquired of it is for of of other than 1 on all is and for is for any patient with is for patients with pneumonia severe to require hospitalization in an pneumonia in a in the of an and to to treatment with a should be that no for all patients with the In the clinical and therapy for should be given or the results of are The therapy for the of the health of the and patient patients with pneumonia hospitalization be treated with a of agents, including and or a or are for severe is only in an oral A in therapy is with an mortality rate, and treatment should be as as The of treatment should be it should be for of Recommendation 1. are are for in adults and are for adults Recommendation 2. A for is for of this for treatment that A and are Recommendation treatment h after of is in the treatment of A using or and is in the treatment using and (B-I). of is for with a of of h be used to in patients or for pneumonia Recommendation 4. treatment of of should and with as or a respiratory Recommendation 5. Pneumonia by or should be treated with (A-II). Recommendation is no with for the treatment of adults with the or Comment. are of often of in patients with chronic and patients with study of adults found respiratory in on of those for an acute respiratory of or chronic and that or for 75% of A of and for the that was for an of and in the United States. were with and the as years of was in an of with most and with chronic or of respiratory are and is in a section in this is a to be a important respiratory pneumonia in both and adults The clinical of and the of are on patient and of immunocompetent adults with CAP have evidence of this from in A recent from the United evidence of a in of patients with CAP, with and in and of the and other can are in and the has from to in The most of is has been found in to of patients in In the of a no clinical or are to with from with for respiratory for can a the next and are to be in patient at can a in with the specific of and patient is in adults so that results the have to be to based on the of and in the of an some can A and have for are with use of respiratory from for respiratory is in the of a of a specific controlled of treatment of adults have been therapy is for with and other in selected The and are active only for A the are for both A and to be as as the other for A and is it is with of are for and treatment of have been in 1 found that has been by the for was more than oral in of home during A in of of resistance to the treatment of in adults with or oral the of respiratory The use of the of respiratory as by use of in patients with In adults with a of had no was found in one study of treatment Because patients often have after after hospitalization, treatment Because of risk of resistance and of is an for For with therapy with an and this has been shown to clinical in a is for treatment of or treatment of is for other in immunocompetent has been used in has been this for is for use for of in Recommendation 1. should the to and the to health in of Recommendation 2. and guidelines are those of the for and of the as for the specific of for A of for blood and for blood and and of and for of blood and or in 3 Comment. A number of can be by as that can of The most to severe are and and or be with The with was the that or to in in the United Clinical to the of from CAP have been of this a of initial and without and some and on on and were for of h The mortality in this and prior in the antibiotic were The most important are of antibiotic treatment and of selection should be based on the have an resistance to and should be have shown in of in the of of oral or for with should be that the of in the United in so any of or should of health in the United of of in in as a was by by the in the The most of with after is or Clinical include an of and and a often with is the be from blood or only with using or other as or This represents a to and should be only in a are including and are only in or health treatment is is is more can be given and is an and are treatment and are more with is for has been used in and The of treatment is with or more and has a mortality The with during that mortality was is risk of and the recommendation for for is or for is a of it has a in the of antibiotic treatment, and can be from to Clinical of include and that is to and The or that is of is to be present with A of of in the United for that only were of the The is with of or blood often to this is the should be in for at for one and at for the other of the care are at risk of so respiratory should be patients have therapy for The treatment for pneumonia is administration of or in for be given for treatment or resistance has been to be as as in with and be given for treatment or of or for is the has or is selection for patients with CAP is the as for all adults with CAP for and in the are as of the recommendations given in the following on of CAP. Comment. In the United CAP is the of in and an of care a of are at risk of pneumonia the of the of pneumonia in adults is In a study CAP was the in of patients was in in in and respiratory in The of pneumonia in living in the is it is in those with For home data are more The proportion of of pneumonia in care that are to is The of to and were and and were In risk factors for pneumonia risk and of In a study to risk factors for pneumonia in of care and the inability to take oral were found to be Clinical The clinical of CAP has been as more in have been few systematic to A study of patients found that years and years had and than those years The of was most for those to and and and care to hospital with pneumonia were with with CAP, it was that home were to and for the of CAP in the have been in randomized, controlled selection recommendations for patients with CAP are the as for all adults with CAP A discussion of of and is in the following on of CAP. Recommendation 1. at risk for and of should as by the on The is the for most at risk of with for of and for health care The is an for some years without chronic including and chronic medical conditions should be to at hospital discharge or during treatment during the and care in and and care should annual Recommendation 2. by in the United is for according to current guidelines, including use for years and for those with selected be either at hospital discharge or during treatment Comment. and is the of pneumonia for A systematic that 1 and for frail had an of for for hospitalization, and for A recent study of adults years found that was with a in the risk of hospitalization for and pneumonia or as as a in the risk of to all In care of health care with is an important health from have shown to either the of of health care or to no of of health care was with a in patient mortality rate, from to a care in of health care with no of health care significantly mortality who had a of in health care were with were with the are more to the has been in randomized, controlled of one clinical that the provided some pneumonia other pneumonia or without the use of have the to an Two have pneumonia of care including a recent and adults with chronic medical conditions have of for of and for of pneumonia without The overall immunocompetent years is 75% with adults be from of of In a was for use in in the United States. to data from the of pneumonia with and in with baseline by years of and adults years the is only for the safety and have been in patients with CAP should and as by the The for is and in and is for those who were and can be given at the in The should be provided either at hospital discharge or at the of can be used to the process of that patients are recommendations that should be given to all of who are at risk for from for include of any who in a home or other care who have a chronic of the or including or who have a chronic that or hospitalization in the prior as chronic (including or (including by or by and who will be in the second or third of during the health care or work involves any patient including with home should to to In of all and is was in by the guidelines on use were published in The is for use and is as an for of of the new include the to both and and the of administration using the rather than Because it is made from care should be to it to rather than the should be given to years or with with or other chronic of the or with other medical including as and or who have or who are or or other of the of with and Because data are on of from to use of is for health care and who have with can be used as an to for and of and have for treatment and of A and is for and treatment of both A and is for the treatment of both A and is for an to the in be during this for with to who or work in with an and other at risk for in the of a be for with to or be given in to to in the be The use of for treatment or should to the

BACKGROUND: Radiation therapy is effective in palliating pain from bone metastases. We investigated whether 8 Gy delivered in a single treatment fraction provides pain and narcotic relief that is equivalent to that of the standard treatment course of 30 Gy delivered in 10 treatment fractions over 2 weeks. METHODS: A prospective, phase III randomized study of palliative radiation therapy was conducted for patients with breast or prostate cancer who had one to three sites of painful bone metastases and moderate to severe pain. Patients were randomly assigned to 8 Gy in one treatment fraction (8-Gy arm) or to 30 Gy in 10 treatment fractions (30-Gy arm). Pain relief at 3 months after randomization was evaluated with the Brief Pain Inventory. The Wilcoxon-Mann-Whitney test was used to compare response to treatment in terms of pain and narcotic relief between the two arms and for each stratification variable. All statistical comparisons were two-sided. RESULTS: There were 455 patients in the 8-Gy arm and 443 in the 30-Gy arm; pretreatment characteristics were equally balanced between arms. Grade 2-4 acute toxicity was more frequent in the 30-Gy arm (17%) than in the 8-Gy arm (10%) (difference = 7%, 95% CI = 3% to 12%; P = .002). Late toxicity was rare (4%) in both arms. The overall response rate was 66%. Complete and partial response rates were 15% and 50%, respectively, in the 8-Gy arm compared with 18% and 48% in the 30-Gy arm (P = .6). At 3 months, 33% of all patients no longer required narcotic medications. The incidence of subsequent pathologic fracture was 5% for the 8-Gy arm and 4% for the 30-Gy arm. The retreatment rate was statistically significantly higher in the 8-Gy arm (18%) than in the 30-Gy arm (9%) (P < .001). CONCLUSIONS: Both regimens were equivalent in terms of pain and narcotic relief at 3 months and were well tolerated with few adverse effects. The 8-Gy arm had a higher rate of re-treatment but had less acute toxicity than the 30-Gy arm.

Abstract Guidelines for the treatment of persons with influenza virus infection were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic issues, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal (interpandemic) influenza. They are intended for use by physicians in all medical specialties with direct patient care, because influenza virus infection is common in communities during influenza season and may be encountered by practitioners caring for a wide variety of patients.

Abstract Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

CONTEXT: Late preterm births (340/7-366/7 weeks) account for an increasing proportion of prematurity-associated short-term morbidities, particularly respiratory, that require specialized care and prolonged neonatal hospital stays. OBJECTIVE: To assess short-term respiratory morbidity in late preterm births compared with term births in a contemporary cohort of deliveries in the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective collection of electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all neonates with respiratory compromise admitted to a neonatal intensive care unit (NICU), and late preterm births were compared with term births in regard to resuscitation, respiratory support, and respiratory diagnoses. A multivariate logistic regression analysis compared infants at each gestational week, controlling for factors that influence respiratory outcomes. MAIN OUTCOME MEASURES: Respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, respiratory failure, and standard and oscillatory ventilator support. RESULTS: Of 19,334 late preterm births, 7055 (36.5%) were admitted to a NICU and 2032 had respiratory compromise. Of 165,993 term infants, 11,980 (7.2%) were admitted to a NICU, 1874 with respiratory morbidity. The incidence of respiratory distress syndrome was 10.5% (390/3700) for infants born at 34 weeks' gestation vs 0.3% (140/41,764) at 38 weeks. Similarly, incidence of transient tachypnea of the newborn was 6.4% (n = 236) for those born at 34 weeks vs 0.4% (n = 155) at 38 weeks, pneumonia was 1.5% (n = 55) vs 0.1% (n = 62), and respiratory failure was 1.6% (n = 61) vs 0.2% (n = 63). Standard and oscillatory ventilator support had similar patterns. Odds of respiratory distress syndrome decreased with each advancing week of gestation until 38 weeks compared with 39 to 40 weeks (adjusted odds ratio [OR] at 34 weeks, 40.1; 95% confidence interval [CI], 32.0-50.3 and at 38 weeks, 1.1; 95% CI, 0.9-1.4). At 37 weeks, odds of respiratory distress syndrome were greater than at 39 to 40 weeks (adjusted OR, 3.1; 95% CI, 2.5-3.7), but the odds at 38 weeks did not differ from 39 to 40 weeks. Similar patterns were noted for transient tachypnea of the newborn (adjusted OR at 34 weeks, 14.7; 95% CI, 11.7-18.4 and at 38 weeks, 1.0; 95% CI, 0.8-1.2), pneumonia (adjusted OR at 34 weeks, 7.6; 95% CI, 5.2-11.2 and at 38 weeks, 0.9; 95% CI, 0.6-1.2), and respiratory failure (adjusted OR at 34 weeks, 10.5; 95% CI, 6.9-16.1 and at 38 weeks, 1.4; 95% CI, 1.0-1.9). CONCLUSION: In a contemporary cohort, late preterm birth, compared with term delivery, was associated with increased risk of respiratory distress syndrome and other respiratory morbidity.

RATIONALE: We recently reported two novel biomarkers for acute kidney injury (AKI), tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), both related to G1 cell cycle arrest. OBJECTIVES: We now validate a clinical test for urinary [TIMP-2]·[IGFBP7] at a high-sensitivity cutoff greater than 0.3 for AKI risk stratification in a diverse population of critically ill patients. METHODS: We conducted a prospective multicenter study of 420 critically ill patients. The primary analysis was the ability of urinary [TIMP-2]·[IGFBP7] to predict moderate to severe AKI within 12 hours. AKI was adjudicated by a committee of three independent expert nephrologists who were masked to the results of the test. MEASUREMENTS AND MAIN RESULTS: Urinary TIMP-2 and IGFBP7 were measured using a clinical immunoassay platform. The primary endpoint was reached in 17% of patients. For a single urinary [TIMP-2]·[IGFBP7] test, sensitivity at the prespecified high-sensitivity cutoff of 0.3 (ng/ml)(2)/1,000 was 92% (95% confidence interval [CI], 85-98%) with a negative likelihood ratio of 0.18 (95% CI, 0.06-0.33). Critically ill patients with urinary [TIMP-2]·[IGFBP7] greater than 0.3 had seven times the risk for AKI (95% CI, 4-22) compared with critically ill patients with a test result below 0.3. In a multivariate model including clinical information, urinary [TIMP-2]·[IGFBP7] remained statistically significant and a strong predictor of AKI (area under the curve, 0.70, 95% CI, 0.63-0.76 for clinical variables alone, vs. area under the curve, 0.86, 95% CI, 0.80-0.90 for clinical variables plus [TIMP-2]·[IGFBP7]). CONCLUSIONS: Urinary [TIMP-2]·[IGFBP7] greater than 0.3 (ng/ml)(2)/1,000 identifies patients at risk for imminent AKI. Clinical trial registered with www.clinicaltrials.gov (NCT 01573962).

Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties. Recommendations for diagnosis, laboratory investigation, and empiric antimicrobial and adjunctive therapy were developed.

Recent studies related to global terrorism have suggested the potential of posttraumatic growth (PTG) following experiences of terror exposure. However, investigations of whether psychological distress is reduced or increased by PTG in other trauma contexts have been inconsistent. Results from our studies conducted in New York following the attacks of 11 September 2001 and in Israel during recent tumultuous periods of violence and terrorism, the Al Aqsa Intifada, have found posttraumatic growth to be related to greater psychological distress, more right‐wing political attitudes, and support for retaliatory violence. Only when individuals were deeply involved in translating growth cognitions to growth actions in our research on the forced disengagement of settlers from Gaza did we find positive benefit in posttraumatic growth. Findings are considered within the framework of a new formulation of action‐focused growth. De récentes recherches en rapport avec le terrorisme international ont souligné le potentiel du développement post‐traumatique (PTG) découlant de la confrontation à la terreur. Toutefois, les travaux cherchant à savoir si la détresse psychologique était atténuée ou accentuée par le PTG dans d’autres contextes traumatiques se sont révélés contradictoires. Nos investigations à New York après l’attentat du 11 septembre 2001 et en Israël durant des périodes récentes de violence et de terrorisme, la seconde Intifada, ont montré que le développement post‐traumatique était plutôt liéà une grande détresse psychologique, à des opinions politiques de droite et à une attente de représailles. On a observé lors du déménagement obligatoire des colons de Gaza que ce n’est que lorsque les individus étaient profondément impliqués dans la transformation des cognitions de développement en actions de développement que le développement post‐traumatique avait des retombées positives. Ces résultats sont appréhendés dans le cadre d’une nouvelle approche du développement centré sur l’action.

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.

Abstract 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.

BACKGROUND: The β-lactamase inhibitor relebactam can restore imipenem activity against imipenem-nonsusceptible gram-negative pathogens. We evaluated imipenem/relebactam for treating imipenem-nonsusceptible infections. METHODS: Randomized, controlled, double-blind, phase 3 trial. Hospitalized patients with hospital-acquired/ventilator-associated pneumonia, complicated intraabdominal infection, or complicated urinary tract infection caused by imipenem-nonsusceptible (but colistin- and imipenem/relebactam-susceptible) pathogens were randomized 2:1 to 5-21 days imipenem/relebactam or colistin+imipenem. Primary endpoint: favorable overall response (defined by relevant endpoints for each infection type) in the modified microbiologic intent-to-treat (mMITT) population (qualifying baseline pathogen and ≥1 dose study treatment). Secondary endpoints: clinical response, all-cause mortality, and treatment-emergent nephrotoxicity. Safety analyses included patients with ≥1 dose study treatment. RESULTS: Thirty-one patients received imipenem/relebactam and 16 colistin+imipenem. Among mITT patients (n = 21 imipenem/relebactam, n = 10 colistin+imipenem), 29% had Acute Physiology and Chronic Health Evaluation II scores >15, 23% had creatinine clearance <60 mL/min, and 35% were aged ≥65 years. Qualifying baseline pathogens: Pseudomonas aeruginosa (77%), Klebsiella spp. (16%), other Enterobacteriaceae (6%). Favorable overall response was observed in 71% imipenem/relebactam and 70% colistin+imipenem patients (90% confidence interval [CI] for difference, -27.5, 21.4), day 28 favorable clinical response in 71% and 40% (90% CI, 1.3, 51.5), and 28-day mortality in 10% and 30% (90% CI, -46.4, 6.7), respectively. Serious adverse events (AEs) occurred in 10% of imipenem/relebactam and 31% of colistin+imipenem patients, drug-related AEs in 16% and 31% (no drug-related deaths), and treatment-emergent nephrotoxicity in 10% and 56% (P = .002), respectively. CONCLUSIONS: Imipenem/relebactam is an efficacious and well-tolerated treatment option for carbapenem-nonsusceptible infections. CLINICAL TRIALS REGISTRATION: NCT02452047.

BACKGROUND: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. PARTICIPANTS AND METHODS: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. RESULTS: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. CONCLUSIONS: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Although information about individuals' exposure to highly stressful events such as traumatic stressors is often very useful for clinicians and researchers, available measures are too long and complex for use in many settings. The Trauma History Screen (THS) was developed to provide a very brief and easy-to-complete self-report measure of exposure to high magnitude stressor (HMS) events and of events associated with significant and persisting posttraumatic distress (PPD). The measure assesses the frequency of HMS and PPD events, and it provides detailed information about PPD events. Test-retest reliability was studied in four samples, and temporal stability was good to excellent for items and trauma types and excellent for overall HMS and PPD scores. Comprehensibility of items was supported by expert ratings of how well items appeared to be understood by participants with relatively low reading levels. In five samples, construct validity was supported by findings of strong convergent validity with a longer measure of trauma exposure and by correlations of HMS and PPD scores with posttraumatic stress disorder (PTSD) symptoms. The psychometric properties of the THS appear to be comparable or better than longer and more complex measures of trauma exposure.

BACKGROUND: Obesity indices (i.e. BMI, waist-to-hip ratio) show differential relationships to other health outcomes, though their association to neurocognitive outcome is unclear. METHODS: We examined whether central obesity would be more closely associated with cognitive function in 1,703 participants from the Baltimore Longitudinal Study of Aging. RESULTS: Longitudinal mixed-effects regression models showed multiple obesity indices were associated with poorer performance in a variety of cognitive domains, including global screening measures, memory, and verbal fluency tasks. Obesity was associated with better performance on tests of attention and visuospatial ability. An obesity index by age interaction emerged in multiple domains, including memory and attention/executive function. CONCLUSION: Obesity indices showed similar associations to cognitive function, and further work is needed to clarify the physiological mechanisms that link obesity to poor neurocognitive outcome.

Purpose NRG Oncology/RTOG 1203 was designed to compare patient-reported acute toxicity and health-related quality of life during treatment with standard pelvic radiation or intensity-modulated radiation therapy (IMRT) in women with cervical and endometrial cancer. Methods Patients were randomly assigned to standard four-field radiation therapy (RT) or IMRT radiation treatment. The primary end point was change in patient-reported acute GI toxicity from baseline to the end of RT, measured with the bowel domain of the Expanded Prostate Cancer Index Composite (EPIC). Secondary end points included change in patient-reported urinary toxicity, change in GI toxicity measured with the Patient-Reported Outcome Common Terminology Criteria for Adverse Events, and quality of life measured with the Trial Outcome Index. Results From 2012 to 2015, 289 patients were enrolled, of whom 278 were eligible. Between baseline and end of RT, the mean EPIC bowel score declined 23.6 points in the standard RT group and 18.6 points in the IMRT group ( P = .048), the mean EPIC urinary score declined 10.4 points in the standard RT group and 5.6 points in the IMRT group ( P = .03), and the mean Trial Outcome Index score declined 12.8 points in the standard RT group and 8.8 points in the IMRT group ( P = .06). At the end of RT, 51.9% of women who received standard RT and 33.7% who received IMRT reported frequent or almost constant diarrhea ( P = .01), and more patients who received standard RT were taking antidiarrheal medications four or more times daily (20.4% v 7.8%; P = .04). Conclusion Pelvic IMRT was associated with significantly less GI and urinary toxicity than standard RT from the patient's perspective.

BACKGROUND: Evidence-based practice and decision-making have been consistently linked to improved quality of care, patient safety, and many positive clinical outcomes in isolated reports throughout the literature. However, a comprehensive summary and review of the extent and type of evidence-based practices (EBPs) and their associated outcomes across clinical settings are lacking. AIMS: The purpose of this scoping review was to provide a thorough summary of published literature on the implementation of EBPs on patient outcomes in healthcare settings. METHODS: A comprehensive librarian-assisted search was done with three databases, and two reviewers independently performed title/abstract and full-text reviews within a systematic review software system. Extraction was performed by the eight review team members. RESULTS: Of 8537 articles included in the review, 636 (7.5%) met the inclusion criteria. Most articles (63.3%) were published in the United States, and 90% took place in the acute care setting. There was substantial heterogeneity in project definitions, designs, and outcomes. Various EBPs were implemented, with just over a third including some aspect of infection prevention, and most (91.2%) linked to reimbursement. Only 19% measured return on investment (ROI); 94% showed a positive ROI, and none showed a negative ROI. The two most reported outcomes were length of stay (15%), followed by mortality (12%). LINKING EVIDENCE TO ACTION: Findings indicate that EBPs improve patient outcomes and ROI for healthcare systems. Coordinated and consistent use of established nomenclature and methods to evaluate EBP and patient outcomes are needed to effectively increase the growth and impact of EBP across care settings. Leaders, clinicians, publishers, and educators all have a professional responsibility related to improving the current state of EBP. Several key actions are needed to mitigate confusion around EBP and to help clinicians understand the differences between quality improvement, implementation science, EBP, and research.