The presence of many morphologic microorganisms which a predominant morphotype was not identified was considered as polymicrobial flora. In good quality samples, >10 microorganisms of same morphotype at OIF were considered as meaningful. Other samples were excluded from the evaluation. Sputum samples were considered of good quality if they had 10 polymorphonuclear leukocytes (PMNs) per oil immersion field (OIF). The Gram stain was performed and interpreted by trained resident physicians (Post-graduate year 1 or 2) as soon as possible after the sputum samples were obtained. Nasotracheal suctioned sputum samples were collected by the attending nurse from the patients who could not expectorate due to altered mental status. Sputum samples were collected as part of standard patient care and as this was an observational study, written informed consent was deemed unnecessary.Įxpectorated sputum samples were collected before administering antibiotics. This study was approved by ethics committee of Okinawa Chubu Hospital. We also compared pathogen-targeted antibiotic treatment guided by sputum Gram stain with empirical treatment. We analyzed the diagnostic performance of the sputum Gram stain. Sputum Gram stain was performed and interpreted by trained physicians in the emergency room on admission. We excluded patients if they were considered at follow up to have other diseases that distinguished them from pneumonia. Pneumonia was defined as a new infiltrate on chest X-ray together with signs and symptoms of a lower respiratory tract infection: fever, cough, sputum, dyspnea, chest pain. We conducted a prospective observational study of consecutive patients with pneumonia who were hospitalized at Okinawa Chubu Hospital (a 550-bed acute care hospital in Okinawa, Japan) from August 2010 to July 2012. The secondary objective was to assess the effectiveness of the initial antibiotic treatment guided by sputum Gram stain. Primary objective of our study was the diagnostic performance of sputum Gram stain. We therefore conducted a prospective study to assess the usefulness of sputum Gram stain on hospitalized patients with CAP and HCAP. Thus far no study has evaluated the usefulness of sputum Gram stain in patients with HCAP. HCAP is distinct from CAP because which has risk factors for multidrug-resistant (MDR) pathogens that often carry a poor prognosis. Healthcare-associated pneumonia (HCAP) is a relatively new category of pneumonia proposed by the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines. However, this treatment strategy has not been validated. The Japanese Respiratory Society (JRS) guidelines recommends pathogen-specific treatment using rapid diagnostic methods such as sputum Gram stain if possible. Guidelines do not recommend routine sputum Gram stain on patients with CAP. Some studies have had doubt on the usefulness of sputum Gram stain in terms of difficulty to obtain good quality samples, sensitivity, reliability, and overall impact on treatment decisions. However, the usefulness of sputum Gram stain in the initial approach to patients with community-acquired pneumonia (CAP) is still controversial. The sputum Grain stain is a simple and inexpensive method for the rapid diagnosis of microbial etiologies of pneumonia.
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