Management of Non-Ventilated hospital acquired pneumonia

Non-ventilated hospital acquired pneumonia (NV-HAP) is defined as pneumonia that develops at least 48 h after hospital admission in the non-invasively ventilated patient. Guidance in the management of NV-HAP has historically used extrapolated research from the wider field of HAP, which includes patients with the separate clinical entity of ventilator associated pneumonia (VAP), or the field of community acquired pneumonia (CAP). However, NV-HAP is being increasingly recognised as a subtype of HAP owing to its high incidence, mortality, morbidity and health-economic burden. With a wide range of underlying causative organisms, the management approach focuses on initial broad-spectrum coverage of common bacterial pathogens. If microbiological results are available, targeted treatment can be started. Throughout all phases of treatment, supportive measures must also be considered. This includes the use of physiotherapy, oxygen and ventilatory support, fluid therapy and nutritional support. Research is ongoing into novel treatments, including new antimicrobials, nebulised therapies and monoclonal antibodies. Future research would benefit from a focussed approach that aims to standardise clinical and research definitions and treats NV-HAP as a separate entity to VAP. Collection of specific data would allow for the development of risk-stratification or severity tools which have been fundamental in improving the management of other pneumonia patients, for example, the use of CURB-65 in CAP. Review of commonplace supportive measures in the NV-HAP population would also be beneficial in view of the mostly frail co-morbid population affected

Are they high on steroids? Tailored interventions help improve screening for steroid-induced hyperglycaemia in hospitalised patients.

Steroid-induced hyperglycaemia (SIH) is a common adverse effect in patients both with and without diabetes. This project aimed to improve the screening and diagnosis of SIH by improving the knowledge of healthcare professionals who contribute to the management of SIH in hospitalised patients. Monitoring and diagnosis of SIH were measured in areas of high steroid use in our hospital from May 2016 to January 2017. Several interventions were implemented to improve knowledge and screening for SIH including a staff education programme for nurses, healthcare assistants and doctors. The Trust guidelines for SIH management were updated based on feedback from staff. The changes to the guideline included shortening the document from 14 to 4 pages, incorporating a flowchart summarising the management of SIH and publishing the guideline on the Trust intranet. A questionnaire based on the recommendations of the Joint British Diabetes Societies for SIH was used to assess the change in knowledge pre-intervention and post-intervention. Results showed an increase in junior doctors' knowledge of this topic. Although there was an initial improvement in screening for SIH, this returned to near baseline by the end of the study. This study highlights that screening for SIH can be improved by increasing the knowledge of healthcare staff. However, there is a need for ongoing interventions to sustain this change

Utility of severity assessment tools in COVID-19 pneumonia: a multicentre observational study.

BACKGROUND Severity scores in pneumonia and sepsis are being applied to SARS-CoV-2 infection. We aimed to assess whether these severity scores are accurate predictors of early adverse outcomes in COVID-19. METHODS We conducted a multicentre observational study of hospitalised SARS-CoV-2 infection. We assessed risk scores (CURB65, qSOFA, Lac-CURB65, MuLBSTA and NEWS2) in relation to admission to intensive care or death within 7 days of admission, defined as early severe adverse events (ESAE). The 4C Mortality Score was also assessed in a sub-cohort of patients. FINDINGS In 2,387 participants, the overall mortality was 18%. In all scores examined, increasing score was associated with increased risk of ESAE. Area under the curve (AUC) to predict ESAE for CURB65, qSOFA, Lac-CURB65, MuLBSTA and NEWS2 were 0.61, 0.62, 0.59, 0.59 and 0.68, respectively. AUC to predict ESAE was 0.60 with ISARIC 4C Mortality Score. CONCLUSION None of the scores examined accurately predicted ESAE in SARS-CoV-2 infection. Non-validated scores should not be used to inform clinical decision making in COVID-19