Nosocomial pneumonia, especially ventilator-associated pneumonia, is a common infection in ICUs. The main etiologic factors involve colonizing and opportunistic bacteria from the oral cavity. Oral hygiene measures, including the use of oral antiseptic agents, such as chlorhexidine, have proven useful in reducing its incidence. The objective of this article was to review the literature on the importance of the oral environment in the development of nosocomial pneumonia.

Keywords: Intensive care; Oral hygiene; Cross infection; Pneumonia.

Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs), and oral antiseptic is used as a preventive measure. We reviewed meta-analyses and randomized clinical trials indexed in the Medical Literature Analysis and Retrieval System and Cumulative Index to Nursing and Allied Health Literature databases regarding the topical use of chlorhexidine in the prevention of VAP. Eight publications were analyzed. In seven (87.5%) chlorhexidine diminished the colonization of the oropharynx, and in four (50%) there was a reduction of VAP. Chlorhexidine seems to reduce colonization, thus reducing the incidence of VAP.

Keywords: Pneumonia, ventilator-associated; Oral hygiene; Chlorhexidine.

Objective: In ICU patients on mechanical ventilation (MV), ventilator-associated pneumonia (VAP) is a common infection. However, such infection can be prevented through oral care protocols. The objective of this study was to compare the efficiency of the use of chlorhexidine and oral hygiene protocols (brushing and clinical procedures) with that of the use of chlorhexidine alone (intervention group and control group, respectively) in decreasing the prevalence of VAP in patients ≥ 18 years of age admitted to the ICU and requiring MV. Methods: In this systematic review and meta-analysis, studies were identified through searches of various national and international databases, as well as of the gray literature, and were selected in accordance with eligibility criteria. Results: We evaluated six studies, involving a collective total of 1,276 patients. We classified the risk of bias as low in three studies, high in two, and uncertain in one; among the six risk domains evaluated, a low risk of bias was predominant in five. The results for random risks were similar in terms of direction and statistical magnitude-chi-square = 6.34; risk difference: −0.06 (95% CI: −0.11 to −0.02); I2 = 21%; p = 0.007. There was a decrease in the prevalence of VAP in the intervention group (n = 1,276) included in the meta-analysis. Conclusions: Protocols that include the mechanical removal of oral biofilm in combination with the use of chlorhexidine can reduce the incidence of VAP among ICU patients requiring MV.

Keywords: Intensive care units; Pneumonia, ventilator-associated; Oral hygiene; Respiration, artificial.

Objective: To evaluate the impact that the implementation of therapeutic guidelines has on the empirical treatment of nosocomial pneumonia. Methods: A clinical trial, using historical controls and involving current ICU patients who had acquired nosocomial pneumonia, was carried out from June of 2002 to June of 2003. All were treated according to therapeutic guidelines developed by the Commission for Nosocomial Infection Control of the institution (group with intervention). As controls, the medical charts of the patients who acquired nosocomial pneumonia between June of 2000 and June of 2001 (group without intervention) were analyzed. Mortality and mean treatment period, as well as the length of hospital and ICU stays, were determined for the patients who acquired nosocomial pneumonia. Results: Mortality associated with pneumonia was lower in the group treated according to the therapeutic guidelines (26 vs. 53.6%; p = 0.00). As for overall mortality, there was no statistically significant difference between the two periods (51 vs. 57.9%; p = 0.37). There was also no difference in the type of microorganisms isolated, treatment period, length of hospital stay or length of ICU stay. Conclusion: The implementation of therapeutic guidelines for the treatment of nosocomial pneumonia acquired in the ICU can be efficacious in decreasing mortality rates.

Keywords: Pneumonia/treatment; Cross infection; Intensive care units; Mortality.

Objective: To determine the prevalence of nosocomial pneumonia in autopsies at a public university hospital; to identify the risk factors for nosocomial pneumonia and the potential prognostic factors associated with fatal nosocomial pneumonia and with fatal aspiration pneumonia; and to determine whether anatomopathological findings correlate with nosocomial pneumonia or aspiration pneumonia. Methods: A retrospective study involving 199 autopsied patients, older than 1 year of age, who had been admitted to the São Paulo State University Botucatu School of Medicine Hospital das Clínicas and died of nosocomial pneumonia (underlying or contributing cause), between 1999 and 2006. Demographic, clinical and anatomopathological variables were tested regarding their association with the outcomes (fatal nosocomial pneumonia and fatal aspiration pneumonia). The significant variables were analyzed using multivariate analysis. Results: The mean age was 59 ± 19 years. The prevalence of nosocomial pneumonia in autopsies was 29%, and the disease was the cause of death in 22.6% of the autopsied patients. Fatal nosocomial pneumonia correlated with the following anatomopathological findings: tobacco‑associated structural lesions (OR = 3.23; 95% CI: 1.26-2.95; p = 0.02) and bilateral pneumonia (OR = 3.23; 95% CI: 1.26-8.30; p = 0.01). None of the variables were found to be significantly associated with fatal aspiration pneumonia. Conclusions: In our sample, there was a high prevalence of nosocomial pneumonia, which was responsible for almost 25% of all of the deaths. Smoking-related structural lesions and bilateral pneumonia all favored mortality. These findings corroborate the results of various clinical studies on nosocomial pneumonia.

Keywords: Autopsy; Risk factors; Prognosis; Pneumonia, aspiration; Pneumonia/mortality.

Objective: To evaluate oral health-related quality of life (OHRQoL) among individuals with severe asthma, comparing it with that observed among individuals with mild-to-moderate asthma and individuals without asthma. Methods: We conducted a cross-sectional study of 125 individuals: 40 with severe asthma; 35 with mild-to-moderate asthma; and 50 without asthma. We calculated the decayed, missing, and filled teeth (DMFT) index, as well as the Periodontal Screening and Recording index, and determined the stimulated salivary flow rate. We applied three structured questionnaires: the 14-item Oral Health Impact Profile (OHIP-14); the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2); and the Work Ability Index (WAI). Results: Periodontitis and reduced salivary flow were both more common in the severe asthma group than in the mild-to-moderate asthma and no-asthma groups. In addition, the WAI scores were lower in the severe asthma group than in the mild-to-moderate asthma and no-asthma groups, as were the scores for all SF-36v2 domains. The individuals with severe asthma also scored lower for the OHIP-14 domains than did those without asthma. Although the mean DMFT index did not differ significantly among the groups, the mean number of missing teeth was highest in the severe asthma group. Strong correlations between the SF-36v2 Component Summaries and poorer OHRQoL were only observed in the severe asthma group. Conclusions: Severe asthma appears to be associated with poorer oral health, poorer OHRQoL, a lower WAI, and lower scores for SF-36v2 domains.

Keywords: Oral health; Periodontal diseases; Asthma.

Objective: To determine the prevalence, outcomes, and predictors of multidrug-resistant nosocomial lower respiratory tract infections (LRTI) in patients in an ICU. Methods: This was an observational cohort study involving patients with nosocomial LRTI (health care-associated pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia). Data were prospectively collected between 2015 and 2019. The multidrug-resistant pathogens (MDRPs) identified in the isolates studied included resistant to extended-spectrum cephalosporin-resistant and carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus at microbiological diagnosis. Results: During the study period, 267 patients in the ICU were diagnosed with LRTI, microbiological confirmation of LRTI having been obtained in 237. Of these, 146 (62%) had at least one MDRP isolate. Patients infected with MDRP were found to have poorer outcomes than patients infected with susceptible strains, such as prolonged mechanical ventilation (18.0 days vs. 12.0 days; p < 0.001), prolonged ICU length of stay (23.0 days vs.16.0 days; p < 0.001), and higher mortality (73% vs. 53%; p < 0.001) when compared with patients infected with susceptible strains. Hospital length of stay = 5 days (OR = 3.20; 95% CI: 1.39-7.39; p = 0.005) and prolonged use vasoactive drugs (OR = 3.15; 95% CI: 1.42-7.01; p = 0.004) were independent predictors of LRTI caused by MDRPs (LRTI-MDRP). The presence of LRTI-MDRP was found to be an independent predictor of death (OR = 2.311; 95% CI: 1.091-4.894; p = 0.028). Conclusions: Prolonged use of vasoactive drugs and prolonged hospital length of stay were independent predictors of LRTI-MDRP in this population of critically ill patients with very poor outcomes.

Keywords: Drug resistance, multiple; Healthcare-associated pneumonia; Pneumonia, ventilator-associated; Cross infection; Intensive care units.

Leptospirosis is an infectious disease characterized by multisystemic involvement. The lung involvement is common, usually mild and frequently neglected. When respiratory manifestations are prominent in a patient with leptospirosis, there is the potential for diagnostic confusion. The authors report a severe case of leptospiral pneumonia, with the objective of highlighting this etiological possibility of community pneumonia, especially when there is suspicion of epidemic features.

Background: Patients with chronic obstructive pulmonary disease usually present intolerance to physical exertion due to ventilatory limitation. L-carnitine has been used to enhance aerobic capacity in patients with chronic diseases, but no study seems to be available for this patient population. Objective: To evaluate the influence of L-carnitine supplementation (2 g/day) in chronic obstructive pulmonary disease patients undergoing physical training three times a week for six weeks. Method: Patients (mean age 69 ± 7 years, n = 30) with stable chronic obstructive pulmonary disease and < 65% of predicted forced expiratory volume in 1 second (FEV1) were separated into three groups of 10 patients each. Group 1 (G1, n = 10) received physical training and L-carnitine (2 g/day), group 2 (G2, n = 10) received physical training and placebo, and group 3 (G3, n = 10) received only L-carnitine (2 g/day). Spirometry and a 6-minute walking distance test were performed before and after intervention. Plasma levels of free carnitine were measured at the beginning and end of the study. Results: A significant increase in walking distance was found only in G1 and G2 (421 ± 100 to 508 ± 80.7 and 496 ± 78.7 to 526 ± 64.3 respectively). In addition, heart rates during physical training sessions were found to be significantly lower in G1 when compared to G2. There were no significant changes in spirometric variables, oxygen saturation or dyspnea in any group. Plasma levels of free L-carnitine were found to increase only in G3 (59.2 ± 13.8 to 102.3 ± 15.3 mmol/L). Conclusion: Oral L-carnitine supplementation combined with physical training may improve tolerance to physical exertion in chronic obstructive pulmonary disease patients.

Keywords: Chronic obstructive pulmonary disease. Carnitine/therapeutic use. Spirometry/methods. Exercise. Walking.

Chronic eosinophilic pneumonia is a rare disease of unknown cause characterized by eosinophilic alveolar and interstitial infiltration. The authors describe the case of a 49-year-old caucasian woman, presenting dyspnea on minimum effort, with insidious beginning and progressive course in the last six months. The main findings were serum eosinophilia and in the sputum, chest radiographs showing multifocal infiltrations of irregular distribution in both lungs and a restrictive functional impairment. The patient was submitted to an open lung biopsy, which demonstrated a chronic eosinophilic pneumonia. There was a dramatic clinical, radiological, and functional response after corticosteroid therapy.

Objective: Staphylococcal pneumonia typically presents high rates of morbidity and mortality. It typically occurs in cases of influenza (airborne transmission) or during episodes of bacteremia (blood-borne transmission). Methods: A retrospective and descriptive study was conducted in patients admitted to our hospital between January of 1992 and December of 2003. All of he patients included had been diagnosed with community-acquired pneumonia caused by Staphylococcus aureus. All were older than 14 years of age, and none were intravenous drug users. Results: Community-acquired pneumonia was identified in 332 cases, of which 24 (7.3%) were identified as cases of staphylococcal pneumonia. Age ranged from 14 to 89 years. Fifteen patients were male, and nine were female. Twelve patients met the criteria for severe pneumonia. Chest X-rays showed unilateral consolidation in 14 cases, bilateral consolidation in 10, pleural effusion in 15, rapid radiological progression of pulmonary lesions in 14, cavitation in 6 and pneumothorax in 1. Most of the patients presented comorbidities, of which diabetes mellitus was the most common. Twelve patients presented complications such as empyema and septic shock. Four patients died, translating to a mortality rate of 16.6% in our sample. Conclusions: The clinical presentation of pneumonia caused by S. aureus is similar to that of pneumonia caused by other etiological agents. Radiological findings, epidemiological data and risk factors provide important clues to the diagnosis. These factors are important for clinical suspicion, since S. aureus is not typically addressed in empirical treatment.

Keywords: Staphylococcal pneumonia; Staphylococcal infections; Community-acquired infections.

Objective: To describe the characteristics of patients with influenza A (H1N1)-associated pneumonia treated at two hospitals in the region of Liguria, Italy, as well as to describe their treatment and outcomes. Methods: This was a prospective observational study including all patients older than 16 years of age with a confirmed diagnosis of influenza A (H1N1) who were admitted to Villa Scassi Hospital, in the city of Genoa, Italy, or to the Sestri Levante General Hospital, in the city of Sestri Levante, Italy, between September of 2009 and January of 2010. The primary outcome measure was mortality within 60 days after diagnosis. Secondary outcome measures were the need for mechanical ventilation and the length of hospital stay. Results: Of the 40 patients with a confirmed diagnosis of influenza A (H1N1), 27 presented pneumonia during the study period. The mean age of the 27 patients was 42.8 ± 14.8 years, and the mean length of hospital stay was 11.6 ± 8.2 days. Of the 27 patients, 20 had respiratory failure, 4 underwent invasive mechanical ventilation, and 5 underwent noninvasive ventilation. One patient had comorbidities, developed multiple organ failure, and died. Conclusions: During the influenza A (H1N1) pandemic, the associated mortality rate was lower in Italy than in other countries, and cases reported in the country typically had a milder course than did those reported elsewhere. Nevertheless, 9 of our cases (33%) rapidly evolved to respiratory failure, requiring mechanical ventilation.

Keywords: Pneumonia; Influenza A virus, H1N1 subtype; Respiratory insufficiency.

48 years-old woman, asymptomatic, presented with radiographic findings of patchy airspace consolidation with nodular opacities in the upper right lobe, middle lobe and lingula. The differential diagnoses of neoplasms, sarcoidosis, granulomatous diseases and tuberculosis were considered. Diagnosis of Bronchiolitis obliterans organizing pneumonia was made by means of videothoracoscopy whereupon treatment with corticosteroids was begun. The patient had a positive evolution with resolution of the radiographic finding.

Keywords: bronchiolitis obliterans organizing pneumonia, bronchiolitis obliterans

Pneumocystosis is an opportunistic infection that occurs frequently in immunodeficient patients, mainly in those with the acquired immunological deficiency (AIDS). The authors report the case of a patient with insidious symptoms of fever, cough, and weight loss. Thorax radiography revealed a tumoral image in the right costophrenic angle. Treatment for tuberculosis (therapeutic test) presented no response. An open lung biopsy was performed and the histological examination revealed Pneumocystis carinii pneumonia. The patient presented significant clinical and radiological improvement with specific treatment.

Keywords: pneumocystis carinii pneumonia; AIDS-related opportunistic infections

Objective: To determine the frequency of HRCT findings and their distribution in the lung parenchyma of patients with organizing pneumonia. Methods: This was a retrospective review of the HRCT scans of 36 adult patients (26 females and 10 males) with biopsy-proven organizing pneumonia. The patients were between 19 and 82 years of age (mean age, 56.2 years). The HRCT images were evaluated by two independent observers, discordant interpretations being resolved by consensus. Results: The most common HRCT finding was that of ground-glass opacities, which were seen in 88.9% of the cases. The second most common finding was consolidation (in 83.3% of cases), followed by peribronchovascular opacities (in 52.8%), reticulation (in 38.9%), bronchiectasis (in 33.3%), interstitial nodules (in 27.8%), interlobular septal thickening (in 27.8%), perilobular pattern (in 22.2%), the reversed halo sign (in 16.7%), airspace nodules (in 11.1%), and the halo sign (in 8.3%). The lesions were predominantly bilateral, the middle and lower lung fields being the areas most commonly affected. Conclusions: Ground-glass opacities and consolidation were the most common findings, with a predominantly random distribution, although they were more common in the middle and lower thirds of the lungs.

Keywords: Cryptogenic organizing pneumonia; Respiratory tract diseases; Tomography, X-ray computed.

Most interstitial lung diseases (ILD) are indolent in nature, producing subacute or chronic symptoms that progress at various rates and are usually present for months to years before a diagnosis is established. This report describes a case of a fulminating and life-threatening variant of idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP). Early suspicion, histologic diagnosis, and prompt initiation of corticosteroid therapy is important to prevent mortality.

Keywords: Bronchiolitis obliterans with organizing pneumonia (BOOP). Interstitial lung disease.

The authors report the case of an adolescent with bilateral interstitial bronchopneumonia caused by measles. They discuss this rare presentation and the usefulness of thorax CT scan for the diagnosis of this disease.

Keywords: Measles. Pneumonia. CT scan.