**7. Conclusions**

*loccocus epidermidis* which were the leading three isolates. Among these patients, 47 were diagnosed with pneumonia and 57 pathogens were isolated. From the sputa specimen of pneumonia patients, MRSA and *C. albicans* were most frequently isolated. *Stenotrophomonas maltophilia* (*S. maltophilis*) was also isolated and found to be resistant to older generation cephalosporins, carbapenems, and quinolones. However, new fluoroquinolones, such as levofloxacin, were found to be affective. Among the 138 patients suspected of respiratory tract infections, 15 out of 23 patients infected with *S. maltophilia* died, resulting in the highest mortality among all patients with nosocomial pneumonia examined. With this survey, we concluded that MHD patients suffered from nosocomial pneumonia with multi-drug resistant pathogens. Consequently, *S. maltophilia-*related infections are associated with a high mortality

Of the different types of pneumonia, AP is of particular interest due to its recent increase in occurrence in the aged MHD population. Aged patients are susceptible to dysphagia caused by neurological dysfunctions due to cerebral infarctions, cognitive deficits, and muscle weakness. Since HD patients are susceptible to sarcopenia and malnutrition, these changes increases the risk of development of AP. We recently reported on the clinical characteristics of AP in MHD patients [9]. We surveyed consecutive MHD patients with nosocomial AP who were admitted to our university hospital between April 2007 and December 2008. We deter‐ mined hospitalized MHD patients as a high-risk population for AP, and we revealed that the mortality rate of HD patients with AP was high. We analyzed the risk factors for AP and found that the rate of decline of serum creatinine and albumin levels indicative of the decrease in muscle mass and malnutrition were of predictive value for the contraction of AP. We also

found that he AP patients fed via nasal tube feeding or oral intake tended to survive.

Based on the clinical backgrounds, MHD patients suffered from nosocomial pneumonia with multi-drug resistant pathogens. Significantly, we reported that *S. maltophilia-*related infections should be taken seriously due to the associated high mortality rate. In addition, we stressed the clinical importance of AP for MHD patients suffering from PEW. Various treatment options to prevent AP were advocated, including oral hygiene, altered food viscosity, and positioning [9]. Medications for this purpose include angiotensin-converting enzyme inhibitors and amantadine. In our study, early initiation of tube feeding appears to provide more favorable outcomes in light of intestinal conditions or fluid restrictions in HD patients. Parenteral nutrition directly affects the total body fluid volume and is prone to volume overload as compared to tube feeding. In addition, malnutrition and sarcopenia lead to silent aspiration where the symptoms are not always clinically evident. Since hospitalized patients with hemodialysis often progress to a state of malnutrition, the patients should be considered to

**6. Management of nosocomial pneumonia**

have silent aspiration and treated with tube feeding.

rate and should be taken very seriously.

**5. AP in MHD patients**

140 Updates in Hemodialysis

Various backgrounds including multiple comorbidities, PEW or frailty, impaired immune response, infectious diseases and pneumonia were prevalent in MHD patients. Our surveil‐ lance revealed that MHD patients suffered from nosocomial pneumonia with multi-drug resistant pathogens. *S. maltophilia-*related infections should be very seriously in light of the associated high mortality rate. Based on the PEW condition, both the contraction and mortality rates of nosocomial AP were high among HD patients.
