Background: This American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociaci on Latinoamericana de T orax guideline updates prior idiopathic pulmonary fibrosis (IPF) guidelines and addresses the progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than IPF.Methods: A committee was composed of multidisciplinary experts in ILD, methodologists, and patient representatives. 1) Update of IPF: Radiological and histopathological criteria for IPF were updated by consensus. Questions about transbronchial lung cryobiopsy, genomic classifier testing, antacid medication, and antireflux surgery were informed by systematic reviews and answered with evidence-based recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.2) Progressive pulmonary fibrosis (PPF): PPF was defined, and then radiological and physiological criteria for PPF were determined by consensus. Questions about pirfenidone and nintedanib were informed by systematic reviews and answered with evidence-based recommendations using the GRADE approach.Results: 1) Update of IPF: A conditional recommendation was made to regard transbronchial lung cryobiopsy as an acceptable alternative to surgical lung biopsy in centers with appropriate expertise. No recommendation was made for or against genomic classifier testing. Conditional recommendations were made against antacid medication and antireflux surgery for the treatment of IPF. 2) PPF: PPF was defined as at least two of three criteria (worsening symptoms, radiological progression, and physiological progression) occurring within the past year with no alternative explanation in a patient with an ILD other than IPF. A conditional recommendation was made for nintedanib, and additional research into pirfenidone was recommended.Conclusions: The conditional recommendations in this guideline are intended to provide the basis for rational, informed decisions by clinicians.

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1 ) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2 ) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3 ) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4 ) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5 ) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement). Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

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OBJECTIVE Antibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often in contrast to published guidelines. We evaluated risk factors for treatment of ASB. DESIGN Retrospective observational study SETTING A tertiary academic hospital, county hospital, and community hospital PATIENTS Hospitalized adults with bacteriuria METHODS Patients without documented symptoms of urinary tract infection per Infectious Disease Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors, broad-spectrum antibiotic usage, and quantified diagnostic concordance between IDSA and National Healthcare Safety Network (NHSN) criteria. RESULTS Among 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By NHSN criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa = 0.52). After excluding those given antibiotics for non-urinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 versus 24 white blood cells per high-powered field, p<0.01), hospital identity (Hospital C vs. A, OR 0.34, 95% CI 0.14–0.80, p=0.01), presence of leukocyte esterase (OR 5.48, 95% CI 2.35–12.79, p<0.01), presence of nitrites (OR 2.45, 95% CI 1.11–5.41, p=0.03), and E. coli on culture (OR 2.4, 95% CI 1.2–4.7, p=0.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%. CONCLUSIONS ASB treatment was prevalent across diverse inpatient settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment, regardless of symptoms, may drive unnecessary antibiotic use and provides an opportunity for antibiotic stewardship interventions.