text:
Roy Hodgson warned yesterday the next World Cup in Brazil in two years' time could present the Football Association with "major logistical problems" having been out to inspect England's potential options for a base camp.
Click HERE to view 'Brazil 2014: A world of differences' graphic
Hodgson was part of an FA delegation that visited prospective bases, providing the team qualifies, in Sao Paulo, Rio de Janeiro and Belo Horizonte this month and said that the size of the country and the differences in climate between the north-western tropical areas and the much cooler south will be a major consideration.
Ideally, the FA would like to be based in Rio de Janeiro but Hodgson warned, at an event for team sponsors Vauxhall, that the city was likely to be the preference of most of the 32 competing nations. He also said that the FA has found it hard to identify a hotel it can "commandeer", as it has done in the recent past, which could make privacy for the team an issue.
Hodgson said: "They've got a major logistical problem. It's a vast country. I don't think we realise quite how vast. There's going to be enormous difficulties for the teams that qualify, according to where they're drawn.
"You've got to remember, it's the Brazilian winter, so it's not going to be particularly much of a sunbathing time unless you find yourself in Rio. If you're down in Porto Alegre, you'll need fur coats because it snows and temperatures reach single figures, and maybe even sometimes lower.
"And if you find yourself in Manaus then you won't be sunbathing but you will find 45-50 degrees of heat and plenty of mosquitoes as well being near the Amazon jungle."
One team in the group stages – drawn in Group F – will have to play two of their three first-round games in the southernmost venue, Porto Alegre, and Manaus, in the Amazon basin.
Hodgson was simply voicing concerns many nations have about Fifa's policy of playing group games all over the country. He did say that a Brazil World Cup "adds some spice to this tournament because it is such a major footballing power". The FA's Club England managing director Adrian Bevington said: "We have had no concerns over what will be delivered. It will be a fantastic World Cup."
Hodgson confirmed that he would select John Terry when he names his squad on Thursday for next month's two World Cup qualifiers against Moldova and Ukraine, although that was before news of the defender's neck injury emerged. Terry is suspended for next week's European Super Cup game against Atletico Madrid.
The FA is planning two high-profile friendlies at Wembley in February and May next year to mark 150 years since the governing body was founded, with Germany potential opponents. Bevington said the opposition would be "reflective of the history of the England national team and will be extremely attractive to everybody."
The May friendly will be played three days after Wembley hosts the Champions League final on 26 May. Following that friendly, the England squad will fly to Brazil to play two games, one against their hosts and a second opponent, possibly Uruguay or the United States, while basing themselves at the hotel and training ground they hope to use in 2014.
Hodgson said he had been impressed by Team GB players Jack Butland, Tom Cleverley, Daniel Sturridge and Ryan Bertrand, all selected in this month's Italy friendly squad. He said he could select players in Thursday's squad who are not first choice for their club sides. "The most important thing is are they fit ... whether they play is up to their club coaches and up to them to a certain extent as well.
"The transfer window has not closed yet, who knows if those players will still be with the club [when it closes]. The bottom line is I shall choose from the players who can do the job."
- More about:
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Available ebook formats: epub mobi pdf lrf pdb html
Doranna's quirkiness of spirit has led to an eclectic publishing journey since that her first award-winning novel, spanning genres over nearly 50 novels to include mystery, SF/F, action-romance, paranormal, franchise, and a slew of essays and short stories.
Beyond that, mostly she still prefers to hang around outside her New Mexico mountain home with the animals, riding dressage on her Lipizzan and training for performance sports with the dogs. She doesn't believe so much in mastering the beast within, but in channeling its power. For good or bad has yet to be decided...
Along with the occasional original, these Smashwords editions are author presentations of favorites once found on bookstore shelves.
Review by:
on Feb. 16, 2014 :
The descriptions I've seen on Goodreads and Smashwords all led me to believe that this story would focus more on the bonding process between Shadia and Feef, one of the pets Shadia regularly took care of. That didn't turn out to be the case. While the descriptions of the various pets and their individual characteristics and needs were really interesting, not much attention was paid to any one pet, at least until the disaster. Shadia didn't seem any closer to Feef than she was to Gite or any of the other pets.
For me, this story was so-so. It was too brief to do much more than scratch the surface of anything. Shadia, a loner, is rarely shown interacting with anyone. A short paragraph described some of the gifts her clients gave her, and I found myself wishing that the story had continued, even just a bit, past the ending. I wanted to see her begin to make connections with others more. I felt like I barely got to know her, any of the pets, the space station, and the other residents of the station.
(Originally posted on http://familiardiversions.blogspot.com/2013/04/feefs-house-e-short-story-by-doranna.html)
(reviewed long after purchase)

subset: commoncrawl


text:
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© Copyright 2017 Mistress of Word Play. All rights reserved.
Status: Finished
Genre: Romance
Ah! This was sweet my love. You did great! Love you! Gary
I liked this one. It made me smile thinking about you reading and when you got to the end.
Shame on you sneaking a peek at his journal. Was he made? I guess not I see you hugging up there. Lily
Aw! thank you Susan for posting this one it is just an amazing write. so many treasure you found in there huh? Beautiful simply beautiful. Always Chiqui i wish i could give this 100 "I LIKES!"
I love this one. I can just see you doing this. Great job! Tanya
A lovely dedication to that special person who means everything to you.Bravo !! there are so many words which might never have been said had you not looked in the journal.We can often understand the secrets and confessions which are kept away from our partners for our hearts are sometimes over burdened with life's worries and committments,you did well on this poem a fabulous tribute to the special one.
Hi Eileen and thank you. You know when you love someone it is a natural thing to want to really know them. Of course being a woman curiousity gets the best of me sometimes. I appreciate it my friend. Just glad he wasn't upset about it. Susan :)
Nice job on this poem. You did fine.
A vision from your mind. Loved this one! Angie :)
Suprised he wasn't angry. Nice job!
As always just beautiful. Happy Easter my friend.
This was so wonderful. Well versed and the story it told. Nice! M
Love this one! Just breath taking.
I love this poem it is beautiful and wonderful a great write!=)
Beautiful dear lady. Like this one very much!
Book / Fantasy
Book / Fantasy
Book / Horror
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mr bean park - download fast -=cDsv=-
mr bean park.zip - download 2015
Name: mr bean park.zip
Release: 2015
Type: WinZip
Total Downloads: 14196
License model: Shareware
Language: English
Last updated on: 01/21/2015 11:06:20
Supported OS: Windows 8, Windows 7, Windows Vista, Windows XP
Keys:01/21/2015 11:06:20
8/25/2009 · OFFICIAL MR BEAN. Mr Bean tries to avoid paying for his parking ticket by tricking the barriers. From 'The Curse of Mr Bean'. FOR MORE BEAN CLICK HERE ...Mr. Bean is a British television programme series of fourteen 25-minute episodes written by and starring Rowan Atkinson as the title character. Different episodes ...Caricature représentant Mr. Bean. Données clés Titre original Mr. Bean Genre Série comique , familiale Création Rowan Atkinson Richard Curtis Production Tiger ...9/12/2013 · Mr Bean will NOT be stuck in the car park !! FOR MORE BEAN CLICK HERE: http://bit.ly/1rhPvax Stay tuned, click here: http://bit.ly/SubscribeToMrBean …This is an episode guide for the television series Mr. Bean, starring Rowan Atkinson, which ran between 1 January 1990 and 15 December 1995. Contents 1 Episodes 2 ...Be wowed by the wide range of merchandise from Mr Bean at these unique merchandise stores today. From a plated Mr Bean trophy to a cute Mr Bean Plush or a magic …Mr. Bean (1990–1995) is a British comedy show that ran on ITV and starred Rowan Atkinson as its main character Mr. Bean. There is also an animated version of the ...
mr bean park
01/21/2015 11:06:20
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text:
Serving size: 1/2 cup
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I am an avid lover of Kraft Creamy Cucumber dressing! Since it is high fat & sodium, could I toss this recipe into the blender & use it for my dressing on other salads? Dietitian comment: You may need to make it thinner by adding some water, but I think it might work as a dressing. Plan to use it over 2-3 days.
Love it! Refreshing side dish for a hot summer day. I added 1 tablespoonful of chopped red onion, and to avoid a trip to the store I used apple cider vinegar and dill weed from my spice rack and it still came out great. Next time I make it,(soon!) I will probably cut the sugar back to 1 teaspoonful.
I made this but didn't add the sour cream, I don't like sour cream & I used sweetner & added extra vinegar & it still is too sweet so, what can I do? I'm going to add extra cucumbers & more vinegar today, does anyone have any suggestions? Thanks. Dietitian comment: Try omitting the sweetener and see how it tastes. Be sure the vinegar you use is not seasoned. Some seasoned vinegar,s like seasoned rice vinegar, contain sugar.
great salad
can I use salad dressing or mayo in place of sour cream?? Dietitian comment: You can but be aware the fat and sodium content is higher with this change.
This was fantastic. I loved it. My wife added a little more dill and used lemon. I put it on top of my lettuce.
I make this for my father-in-law using the lemon juice, light sour cream, and sugar substitute. It's quick, easy, and he loves it!
I have a different creamy cucumber salad option. It must have come from Mrs. Dash. 1 lg cucumber thinly sliced 2 tsp Mrs. Dash Garlic/Herb 1 tsp Mrs. Dash lemon/pepper 1 1/2 Tbs vinegar 1 1/2 tsp sugar 1/2 cup sour cream 1/2 cup chopped onion Mix together and chill 1-2 hours before serving. I make this and use 3 tbs. on top of lettuce replacing salad dressing.
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The Royal Playa del Carmen-All Inclusive - Adults Only
Constituyentes No 2, 77780 Playa del Carmen, Mexico – Great location - show map
Excellent location – rated 9.5/10! (score from 498 reviews)
Rated by guests after their stay at The Royal Playa del Carmen-All Inclusive - Adults Only.
|Room Type
|Royal Master One Bedroom Suite
|Royal Junior Suite with Garden View
|Royal Master One Bedroom Suite with Ocean Views - Beach Front
|Royal Junior Suite with Pool Access - Ocean Front
|Royal Presidential Suite with Private Pool and Ocean Views - Penthouse
|Royal Junior Suite with Pool Access and Ocean Views
|Royal Junior Suite with Central Garden View
|Royal Junior Suite
|Royal Junior Suite with Ocean View
|Royal Junior Suite Oceanfront
|Royal Junior Suite Beachfront Walk Out
6 Reasons to Choose The Royal Playa del Carmen-All Inclusive - Adults Only
Low rates
Manage your bookings online
The staff speaks English
Booking is safe
One of our top picks in Playa del Carmen
Redesigned and redefined, AAA Four-Diamond THE ROYAL Playa del Carmen is one of the most successful adults-only resorts (18 years & older) on the Riviera Maya. The Resort boasts a perfect beachfront location, mere steps from Playa del Carmen's famed Fifth Avenue, with its hip night spots, trendy cafes, colorful shops and local color while experiencing THE ROYAL's flawless hospitality. The resort's interior is as impressive as its palatial exterior, where the use of textures, fabrics and natural materials reflects sophisticated seaside grace. The richness of the extra spacious suites (many of which are ocean view or oceanfront), the exquisite furniture, handcrafted by local artisans, the spacious marble bathrooms and furnished terraces, plus an array of unique and exceptional guest amenities assure an experience that goes beyond luxury for discerning guests. Designed for romance, the resort features new concierge-style check-in services, beautiful lobby overlooking the Caribbean, a new lobby lounge with panoramic views as well as butler (available in higher categories), beach butler & romance concierge services, new romantic beach walk-out & Swim Up Suites.
The Royal Playa del Carmen-All Inclusive - Adults Only takes special requests – add in the next step!
- Asiana
- Rincon Mexicano
- El Mediterraneo
- Marie Marie
- Chef's Plate
- Spice
- Pelicanos
AsianaOpen for: Lunch / Dinner
- Asian
Restaurant features
- À la carte
Rincon MexicanoOpen for: Lunch / Dinner
- Mexican
Restaurant features
- À la carte
El MediterraneoOpen for: Breakfast / Lunch / Dinner
- Mediterranean
Restaurant features
- À la carte
Marie MarieOpen for: Dinner
- French
- Mexican
Restaurant features
- À la carte
Chef's PlateOpen for: Dinner
- International
Restaurant features
- À la carte
- Reservations welcome
SpiceOpen for: Breakfast / Lunch / Dinner
- International
Restaurant features
- Buffet
PelicanosOpen for: Breakfast / Lunch / Dinner
- Seafood
Restaurant features
- À la carte
Resort Facilities at The Royal Playa del Carmen-All Inclusive - Adults Only
- Terrace
- Grounds
Pool and Spa
- Outdoor Pool (all year)
- Turkish/Steam Bath
- Hot Tub/Jacuzzi
- Massage
- Spa
- Fitness Center
- Sauna
Pets are not allowed.
- Entertainment Staff
- Bikes Available (free)
- Cycling
- Library
- Bicycle Rental (surcharge)
- Windsurfing
- Ping-Pong
- Pool Table
- Game Room
- Tennis Court
Food & Drink
- Snack Bar
- Breakfast in the Room
- Bar
- Restaurant
Free! WiFi is available in public areas and is free of charge.
Free! Free private parking is available on site (reservation is not needed).
Front Desk Services
- Concierge Service
- ATM On Site
- Baggage Storage
- Tour Desk
- Currency Exchange
- Express Check-in/Check-out
- 24-Hour Front Desk
Cleaning Services
- Shoeshine
- Ironing Service
- Dry Cleaning
- Laundry
Business Facilities
- Fax/Photocopying
- Business Center
- Meeting/Banquet Facilities
- Designated Smoking Area
- Air Conditioning
- Shops (on site)
- Car Rental
- Packed Lunches
- Souvenir/Gift Shop
- Safe
- Elevator
- VIP Room Facilities
- Hair/Beauty Salon
- Facilities for Disabled Guests
- Non-smoking Rooms
- Newspapers
- Room Service
Languages Spoken
- Spanish
- English
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Area Info – Great location - show map
Closest Landmarks
- Kool Beach Club 0.2 miles
- Plaza Quinta Alegria 0.3 miles
- ADO International Bus Station 0.6 miles
- Disabled-friendly beach 0.7 miles
- Playa del Carmen Maritime Terminal 0.7 miles
Most Popular Landmarks
- Church of Guadalupe 1.2 miles
- Rio Secreto 5.6 miles
- Isla Pasion Weddings 11.2 miles
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From 3:00 PM
Until 12:00 PM
Cancellation and prepayment policies vary according to room type. Please enter the dates of your stay and check what conditions apply to your preferred room.
Children and Extra Beds
Children older than 18 years are welcome.
One adult is charged 80 % of the room stay per night and person when using existing beds.
The maximum number of extra beds in a room is 1.
Additional fees are not calculated automatically in the total cost and will have to be paid for separately during your stay.
Pets are not allowed.
When booking more than 4 rooms, different policies and additional supplements may apply.
Cards accepted at this property
Hover over the cards for more info.
Please note that children under 18 years old cannot be accommodated at this property.
100% Verified Reviews
Real guests. Real stays. Real opinions.
Review Score
Based on 498 reviews
Wonderful: 9+
Good: 7 – 9
Okay: 5 – 7
Poor: 3 – 5
Very Poor: 1 – 3
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Store Details
The Allison Park, PA Home Depot isn't just a hardware store. Did you know we employ a number of veterans and are actively involved in community events?
When you're working on a DIY project, our team is here to show you how to do it right. If you have questions about insulation or interior paint, we're here to help. We also enjoy being involved with Hampton High School, local veterans associations, Hosanna Industries and other local organizations. We're at the intersection of PA Turnpike and Rte. 8, right by North Park and Wildwood so come in and meet us next time you're in the area. We look forward to seeing you soon!
Welcome to the Allison Park Home Depot. Let us help you build your dreams!
Your Allison Park Store Team


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Step up into the chic Chaussure Cleo, ready for any night out! The perforated upper and peep-toe screams trendy and the velcro back makes these beauties easy. Pair up with your "going out" dresses or if you're feeling a little daring you can dress them down and wear with your cropped pants during the day.
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our Standard Delivery service. 30 Day Returns. See our delivery FAQs for more info.


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Sleepover: At the Playground
- Posted July 8, 2010 by Kevin in Ohio - Brunswick. Viewed 2393 times
- This is a migrated legacy post. Image resolution is low. Info
Today we hosted my nieces and Stephanie's goddaughter for a sleepover. Day 1 consisted of dinner at Winking Lizard, a trip to a neighborhood park (pictured), Guitar Hero (actually Band Hero), make-your-own-sundaes, Ghosts In the Graveyard, liberal use of a glitter roll-on stick, and other fun stuff.
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An initiative by members of the Labor party - including senior members - would examine the possibility of entering the government despite the expressed opposition of party leader Shelly Yechimovich, according to a Monday-morning report by Israel Defense Forces Radio.
The party will meet, Monday, for the first time since Tuesday's Knesset elections, which saw the party fall from the second largest.
Tags:coalition, Labor, Shelly Yechimovich


text:
Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance
- Christophe Adrie1, 2Email author,
- Carole Schwebel3,
- Maïté Garrouste-Orgeas4, 5,
- Lucile Vignoud5,
- Benjamin Planquette6,
- Elie Azoulay7,
- Hatem Kallel8,
- Michael Darmon9,
- Bertrand Souweine10,
- Anh-Tuan Dinh-Xuan11,
- Samir Jamali12,
- Jean-Ralph Zahar13,
- Jean-François Timsit3, 5 and
- This article was written on behalf of the Outcomerea Study Group
DOI: 10.1186/cc13095
© Adrie et al.; licensee BioMed Central Ltd. 2013
Received: 3 May 2013
Accepted: 16 September 2013
Published: 7 November 2013
Several guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission. We compared the impact on 60-day mortality of using one or two antibiotics. We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.
This is an observational cohort study of 956 immunocompetent patients with CAP admitted to ICUs in France and entered into a prospective database between 1997 and 2010.
Patients with chronic obstructive pulmonary disease were excluded. Multivariate analysis adjusted for disease severity, gender, and co-morbidities was used to compare the impact on 60-day mortality of receiving adequate initial antibiotics and of receiving one versus two initial antibiotics.
Initial adequate antibiotic therapy was significantly associated with better survival (subdistribution hazard ratio (sHR), 0.63; 95% confidence interval (95% CI), 0.42 to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 1.00; p = 0.05). Dual therapy was associated with a higher frequency of initial adequate antibiotic therapy. However, no difference in 60-day mortality was found between monotherapy (β-lactam) and either of the two dual-therapy groups (β-lactam plus macrolide or fluoroquinolone). The rates of nosocomial pneumonia and multidrug-resistant bacteria were not significantly different across these three groups.
Initial adequate antibiotic therapy markedly decreased 60-day mortality. Dual therapy improved the likelihood of initial adequate therapy but did not predict decreased 60-day mortality. Dual therapy did not increase the risk of nosocomial pneumonia or multidrug-resistant bacteria.
Community-acquired pneumonia (CAP) is among the most common severe infections in critically ill patients [1] and is associated with a high death toll. Failure to use adequate antibiotics (that is, antibiotics active in vitro on the causative organism) considerably increases the risk of death, particularly in patients with severe sepsis [2, 3]. Consequently, the recommended antibiotic regimen for patients with CAP requiring hospital admission is either a fluoroquinolone alone or a combination of two antibiotics, including a macrolide [4–6]. Many trials suggest greater efficacy of dual therapy (usually with a β-lactam and a macrolide or fluoroquinolone) compared to monotherapy (usually with a β-lactam) [3, 7–15]. Macrolides may be particularly useful, as they blunt the inflammatory response via immunomodulating effects and may exert effects on bacteria not included in their spectrum [16]. However, current recommendations are based chiefly on theoretical grounds, as opposed to high-quality studies [17–19]. Furthermore, a systematic review of randomized controlled trials found no evidence that empirical antibiotic therapy covering atypical pathogens improved survival or clinical efficacy in patients admitted for CAP [18].
Our primary objective in this observational cohort study of a prospective database was to determine whether using two initial antibiotics instead of one improved 60-day mortality in patients admitted to the ICU for CAP. We also assessed the effect on 60-day mortality of receiving adequate antibiotic therapy initially versus secondarily. Subgroup analyses were done in patients with specific organisms and in those with the most severe acute-illness syndromes. The risks of nosocomial pneumonia and multidrug-resistant (MDR) bacteria were compared in patients given one versus two antibiotics.
Material and methods
Inclusion and exclusion criteria
Because diagnostic coding using the International Classification of Diseases has been found unreliable in the ICU [20], we used parameters collected prospectively by data-capture software to identify the 956 patients admitted to 12 ICUs for CAP between 1996 and 2010 and included in the OutcomeRea® database (http://www.outcomerea.org). Patients were classified into three groups based on antibiotics received for at least 48 hours within the first three days after ICU admission: β-lactam alone, β-lactam plus macrolide and β-lactam plus fluoroquinolone.
We excluded patients given non-β-lactam monotherapy; patients with chronic obstructive pulmonary disease (COPD), pneumonia more than two days after ICU admission (possible ICU-acquired pneumonia), previous hospitalization, or immunodeficiency (or example, HIV infection, long-term glucocorticoid therapy, long-term hemodialysis, or cancer chemotherapy); [21] and patients who died within three days after ICU admission.
CAP was defined as symptoms and signs consistent with lower respiratory tract infection, new lung infiltrates by radiography or computed tomography, and infection acquired outside the hospital [4]. Patients with CAP were identified based on the ICU-admission diagnosis and microbiological findings in blood and respiratory tract specimens (sputum, bronchoalveolar lavage fluid, endotracheal aspirates or protected plugged catheter) [22], according to recently updated definitions developed by the Centers for Disease Control and the International Sepsis Consensus Conference [23]. We also took into account the results of urinary antigen tests for Legionella pneumophila (serotype 1) and Streptococcus pneumoniae.
Initial adequate antibiotic therapy was defined as one or more antibiotics active in vitro on the identified microorganisms or, in non-documented CAP, as treatment according to current guidelines [5], started at ICU admission and not requiring a change (secondary adjustment of antibiotic therapy) upon re-evaluation 48 hours later. Classical definitions were used for sepsis, severe sepsis and septic shock [24]. MDR bacteria were divided into four classes (methicillin-resistant Staphylococcus aureus (MRSA); extended-spectrum β-lactamase (ESBL)-producing Enterobacteriacae; non-fermenting bacteria (Pseudomonas species, Acinetobacter spp., and Stenotrophomonas maltophilia); and Clostridium difficile). Treatment duration was at least five days [5] but was otherwise at the discretion of the attending physician.
Data collection
Data were collected daily by senior physicians in the participating ICUs. For each patient, the data were entered into an electronic case-report form using VIGIREA® and RHEA® data-capture software, and all case-report forms were then entered into the OutcomeRea® data warehouse (Outcomeréa, Paris, France). All codes and definitions were established prior to study initiation. For each patient, age, sex and McCabe score were recorded. Severity of illness was evaluated on the first ICU day using the Simplified Acute Physiology Score (SAPS II), Sequential Organ Failure Assessment (SOFA) score and Glasgow Coma Scale (GCS) score. Knaus scale definitions [25] were used to record pre-existing chronic organ failures, including respiratory, cardiac, hepatic, renal and immune system failures. Finally, the CURB-65 (Confusion, Urea, Respiratory rate, Blood pressure in ≥65-year-old patients) severity score was determined [26].
Relationships with mortality and other endpoints were evaluated for the following variables: severity scores; age; sex; ICU and hospital stay lengths; co-morbidities; presence at admission of sepsis, severe sepsis or septic shock; use of invasive or noninvasive ventilation, inotropic agents, glucocorticoids or hemodialysis-hemofiltration; and recovered pathogens.
Quality of the database
The data-capture software automatically conducted multiple checks for internal consistency of most of the variables at entry into the database. Queries generated by these checks were resolved with the source ICU before incorporation of the new data into the database. At each participating ICU, data quality was controlled by having a senior physician from another participating ICU check a 2% random sample of the study data. A one-day coding course was held annually for the study investigators and contract research organization monitors.
Ethical issues
This study was approved by our institutional review board (CECIC Clermont-Ferrand - IRB n°5891; Ref: 2007-16), which waived the need for signed informed consent of the participants, in accordance with French legislation on non-interventional studies. However, the patients and their next of kin were asked whether they were willing to participate in the database, and none declined participation.
Statistical analyses
The data are described as the number (%) for categorical variables and median (interquartile range) for continuous variables, unless stated otherwise. Comparisons relied on the Fisher exact test or χ 2 test for categorical data and on the Kruskal-Wallis test for continuous data. The primary outcome was 60-day mortality and the secondary outcomes were first episodes of nosocomial pneumonia with and without MDR bacteria. Patient outcomes were censored 60 days after ICU admission. Because patients discharged alive from the hospital within the first 60 days represented an informative censor for assessing mortality, nosocomial infection and presence of MDR bacteria, a Fine-and-Gray adaptation of the Cox model was used. Results were expressed as sub-distribution hazard ratios (sHR) with their 95% confidence intervals (95% CIs).
Variables yielding P- values <0.20 by univariate analysis were entered into a multivariate model using backward selection, with P <0.05 considered significant. Glucocorticoid therapy and time to initial therapy were forced into the model. The following variables collected at ICU admission were considered for the multivariate model: gender, SAPSII, co-morbidities, severe sepsis, septic shock, invasive mechanical ventilation, glucocorticoid therapy, time to initial antibiotic therapy, hemodialysis-hemofiltration, bacteremia and pathogens with P <0.20 by univariate analysis. Among severity markers, the SAPSII was selected, because it had a better Akaike Information Criterion compared to CURB-65, or SOFA score and age. Continuous variables were proposed to the model in their native form if they verified the log-linearity assumption; otherwise, they were converted and entered as dummy variables. Clinically sound two-way interactions were tested. Sub-analyses were performed considering only patients with identified pathogens or with septic shock. Adjusted sHR values with their 95% CIs were calculated for each parameter estimate. P- values <0.05 were considered significant. Analyses were performed using the SAS 9.2 software package (SAS Institute, Cary, NC, USA).
Patient characteristics and pathogens
Total (n = 956)
Died within 60 days (n = 259, 27%)*
Alive on day 60 (n = 697, 73%)
P- value
Variables at admission
Male, n (%)
633 (66.2)
190 (73.4)
443 (63.6)
Age, years (median [IQR])
62 [46; 76]
72 [58; 80]
58 [42; 73]
Scores, median [IQR]
43.5 [31; 59]
60 [43; 74]
39 [27; 53]
SOFA score
6 [4; 9]
9 [6; 12]
5 [3; 8]
LOD score
5 [2; 7]
7 [4; 10]
4 [2; 6]
Coma Glasgow Scale
13 [5; 15]
7 [3; 15]
14 [7; 15]
McCabe, n (%)
684 (71.7)
140 (54.1)
544 (78.3)
235 (24.6)
98 (37.8)
137 (19.7)
35 (3.7)
21 (8.1)
14 (2.0)
CURB-65, n (%)
13 (1.4)
0 (0)
13 (1.9)
62 (6.5)
58 (8.3)
176 (18.4)
22 (8.5)
154 (22.1)
292 (30.6)
65 (25.2)
227 (32.6)
252 (26.4)
90 (34.9)
162 (23.2)
160 (16.8)
77 (29.8)
83 (11.9)
Co-morbidities (Knaus definitions), n (%)
Chronic hepatic failure
43 (4.5)
22 (8.5)
21 (3.0)
Chronic heart failure
107 (11.2)
38 (14.7)
69 (9.9)
Chronic respiratory failure
167 (17.5)
55 (21.2)
112 (16.1)
Chronic renal failure
19 (2.0)
7 (2.7)
12 (1.7)
123 (12.9)
40 (15.4)
83 (11.9)
≥ One co-morbidity
352 (36.8)
124 (47.9)
228 (32.7)
Smokers ( >20 pack-year), n (%)
243 (30.6)
57 (26.6)
186 (32.1)
Alcohol ( >80 g/day), n (%)
189 (23.8)
44 (20.6)
145 (25.0)
Sepsis, n (%)
928 (97.1)
676 (97.0)
Severe sepsis, n (%)
828 (86.6)
235 (90.7)
593 (85.1)
Septic shock, n (%)
325 (34.0)
132 (51.0)
193 (27.7)
Treatments, n (%) unless otherwise stated
Invasive ventilation
604 (63.3)
207 (79.9)
397 (57.0)
Noninvasive ventilation
107 (11.2)
25 (9.7)
82 (11.8)
Inotropes or vasoactive agents
422 (44.1)
167 (64.5)
255 (36.6)
182 (19.0)
66 (25.5)
116 (16.6)
63 (6.6)
33 (12.7)
30 (4.3)
Antibiotic therapy duration in days (median [IQR])
7 [4; 13]
8 [3; 15]
7 [4; 13]
Organisms, n (%)
Streptococcus pneumoniae
202 (21.1)
52 (20.1)
150 (21.5)
Staphylococcus aureus
104 (10.9)
73 (10.5)
Streptococcus spp.
36 (3.8)
12 (4.6)
24 (3.4)
Enterocococcus spp.
3 (0.3)
3 (0.4)
Hemophilus influenzae
97 (10.1)
25 (9.7)
72 (10.3)
Escherichia coli
34 (3.6)
16 (6.2)
18 (2.6)
Enterobacter spp.
13 (1.4)
6 (2.3)
7 (1.0)
Klebsiella pneumoniae
28 (2.9)
13 (5.0)
15 (2.2)
Serratia marescens
4 (0.4)
0 (0)
4 (0.6)
Proteus mirabilis
9 (0.9)
5 (1.9)
4 (0.6)
Pseudomonas aeruginosa
29 (3.0)
16 (6.2)
13 (1.9)
Legionella pneumophila
25 (2.6)
4 (1.5)
21 (3.0)
Mycoplasma pneumoniae
1 (0.1)
0 (0)
1 (0.1)
Chlamydia pneumoniae
2 (0.2)
1 (0.4)
1 (0.1)
Aspergillus fugimatus
3 (0.3)
2 (0.8)
1 (0.1)
Mycobacterium tuberculosis
14 (1.5)
3 (1.2)
11 (1.6)
24 (2.5)
3 (1.2)
21 (3.0)
14 (1.5)
4 (1.5)
10 (1.4)
Multiple organisms
92 (9.6)
29 (11.2)
63 (9.0)
None identified
418 (43.7)
99 (38.2)
319 (45.8)
121 (12.7)
45 (17.4)
76 (10.9)
Acquisition of MDR pathogen or nosocomial pneumonia, n (%)
MDR bacteria
105 (11.0)
34 (13.1)
25 (2.6)
9 (3.5)
16 (2.3)
Enterobacteriaceae ESBL
38 (4.0)
15 (5.8)
23 (3.3)
Nonfermentative GNB
56 (5.9)
16 (6.2)
40 (5.7)
Clostridium difficile
9 (0.9)
2 (0.8)
7 (1.0)
Nosocomial pneumonia
127 (13.3)
48 (18.5)
79 (11.3)
ICU stay in days, median [IQR]
7 [3; 15]
8 [3; 17]
6 [3; 14]
Hospital stay in days, median [IQR]
16 [8; 31]
10 [4; 22]
18 [10; 38]
As expected, survivors and non-survivors differed significantly regarding multiple organ failure prevalence, co-morbidities, gender and CURB-65 score. Compared to survivors, non-survivors had higher rates of P. aeruginosa, Escherichia coli, K. pneumonia, P. mirabilis and bacteremia (Table 1). However, none of these characteristics was independently associated with mortality in the multivariate analysis adjusted for confounders (SAPSII, at least one co-morbidity and gender). Nosocomial pneumonia after the CAP episode was associated with higher mortality in the unadjusted analysis but not in the adjusted analysis.
Impact of initial adequate antibiotic therapy on 60-day mortality
Factors independently associated with 60-day mortality between initially and secondarily adequate antibiotic therapy groups
Multivariate analysis (n = 898)
sHR (95% CI)
P- value
Inadequate antibiotic therapy (reference)
0.63 (0.42 to 0.94)
Initial adequate antibiotic therapy
Secondary adequate antibiotic therapy
0.69 (0.37 to 1.27)
SAPSII per 10 points
1.65 (1.53 to 1.77)
Female gender
0.70 (0.52 to 0.94)
At least one co-morbidity
1.49 (1.13 to 1.97)
Adequate antibiotic therapy on day 2 versus day 1
1.33 (0.92 to 1.93)
Adequate antibiotic therapy on day 3 versus day 1
1.29 (0.76 to 2.20)
0.98 (0.72 to 1.32)
Impact of one vs. two initial antibiotics on 60-day mortality
Comparison of the groups given monotherapy and dual therapy
Monotherapy (β-lactam)
Dual therapy
Total population (n = 471)
Total population (n = 394)
β-lactam + Macrolide (n = 164)
β-lactam + Fluoroquino-lone (n = 230)
Variables at admission
Male, n (%)
301 (63.9)
274 (69.5)
110 (67.1)
164 (71.3)
Age in years, median [IQR]
60 [45; 75]
64 [48; 77]
64 [49; 79]
64 [47; 76]
Scores, n (%)
47 [34; 60]
39.5 [28; 57]
37 [28.5; 51]
43[28; 63]
SOFA score£
6 [4; 9]
6 [3; 9]
5 [3; 8]
7 [4; 10]
LOD score*£
5 [3; 7]
4 [2; 7]
3 [2; 5.5]
4 [2; 8]
Coma Glasgow Scale*£
8 [4; 15]
15 [8.5; 15]
15 [11;15]
14 [7; 15]
McCabe, n (%)
326 (69.2)
284 (72.4)
119 (73.5)
165 (71.7)
124 (26.3)
98 (25.0)
40 (24.7)
58 (25.2)
21 (4.5)
10 (2.6)
3 (1.9)
7 (3.0)
CURB-65,* n (%)
3 (0.6)
7 (1.8)
1 (0.6)
6 (2.6)
20 (4.2)
38 (9.6)
15 (9.1)
23 (10.0)
88 (18.7)
71 (18.0)
34 (20.7)
37 (16.1)
157 (33.3)
107 (27.2)
42 (25.6)
65 (28.3)
122 (25.9)
107 (27.2)
46 (28.0)
61 (26.5)
81 (17.2)
64 (16.2)
26 (15.9)
38 (16.5)
Co-morbidities (Knaus definitions), n (%)
Chronic hepatic failure£
23 (4.9)
17 (4.3)
3 (1.8)
14 (6.1)
Chronic heart failure
47 (10.0)
48 (12.2)
25 (15.2)
23 (10.0)
Chronic respiratory failure*£
65 (13.8)
86 (21.8)
52 (31.7)
34 (14.8)
Chronic renal failure
9 (1.9)
7 (1.8)
3 (1.8)
4 (1.7)
58 (12.3)
48 (12.2)
16 (9.8)
32 (13.9)
≥One co-morbidity*
153 (32.5)
161 (40.9)
75 (45.7)
86 (37.4)
Smokers (>20 pack-years), n (%)
114 (31.1)
97 (28.1)
41 (29.3)
56 (27.3)
Alcohol (>80 g/d)* n (%)
101 (27.6)
73 (21.2)
31 (22.1)
42 (20.5)
Sepsis, n (%)
458 (97.2)
383 (97.2)
158 (96.3)
225 (97.8)
Severe sepsis, n (%) *
395 (83.9)
360 (91.4)
146 (89)
214 (93.0)
Septic shock, n (%)*
146 (31.0)
55 (33.5)
Treatments, n (%) unless otherwise stated
Invasive ventilation*£
340 (72.2)
207 (52.5)
73 (44.5
134 (58.3)
Noninvasive ventilation*
40 (8.5)
58 (14.7)
27 (16.5)
31 (13.5)
Inotropes or vasoactive agents*£
189 (40.1)
191 (48.5)
67 (40.9)
124 (53.9)
69 (14.6)
96 (24.4)
40 (24.4)
56 (24.3)
23 (4.9)
31 (7.9)
11 (637)
20 (8.7)
Antibiotic therapy duration in days, median [IQR]*
7 [4; 13]
8 [4; 14]
7 [4; 13]
8 [4; 15]
Organisms, n (%)
Streptococcus pneumoniae* £
125 (26.5)
69 (17.5)
42 (25.6)
27 (11.7)
Staphylococcus aureus* £
65 (13.8)
25 (6.3)
5 (3.0)
20 (8.7)
Streptococcus spp.
22 (4.7)
9 (2.3)
2 (1.2)
7 (3.0)
Enterocococcus spp.
3 (0.6)
0 (0)
0 (0)
0 (0)
Hemophilus influenzae*
57 (12.1)
29 (7.4)
15 (9.1)
14 (6.1)
Klebsiella pneumoniae
16 (3.4)
8 (2.0)
3 (1.8)
5 (2.2)
Escherichia coli
23 (4.9)
10 (2.5)
2 (1.2)
8 (3.5)
Enterobacteriaceae spp.*
11 (2.3)
2 (0.5)
1 (0.6)
1 (0.4)
Serratia marescens
3 (0.6)
1 (0.3)
0 (0)
1 (0.4)
Proteus mirabilis
7 (1.5)
1 (0.3)
0 (0)
1 (0.4)
Pseudomonas aeruginosa
13 (2.8)
14 (3.6)
5 (3.0)
9 (3.9)
Legionella pneumophila*
1 (0.2)
9 (2.3)
5 (3.0)
4 (1.7)
Mycoplasma pneumoniae
0 (0)
0 (0)
0 (0)
0 (0)
Chlamydia pneumoniae
0 (0))
2 (0.5)
0 (0)
2 (0.9)
Mycobacterium tuberculosis £
3 (0.6)
6 (1.5)
5 (3.0)
1 (0.4)
Aspergillus fumigatus
0 (0)
3 (0.8)
2 (1.2)
1 (0.4)
6 (1.3)
15 (3.8)
7 (4.3)
8 (3.5)
6 (1.3)
6 (1.5)
1 (06)
5 (2.2)
Multiple organisms*
62 (13.2)
22 (5.6)
8 (4.9)
14 (6.1)
None identified*
182 (38.6)
207 (52.5)
77 (47.0)
130 (56.5)
74 (15.7)
42 (10.7)
15 (9.1)
27 (11.7)
Acquisition of MDR pathogens or nosocomial pneumonia, n (%)
MDR bacteria
52 (11.0)
44 (11.2)
19 (11.6)
25 (10.9)
12 (2.5)
12 (3.0)
5 (3.0)
7 (3)
Enterobacteriaceae ESBL
22 (4.7)
12 (3.0)
5 (3.0)
7 (3)
Nonfermentative GNB
25 (5.3)
25 (6.3)
14 (8.5)
11 (4.8)
Clostridium difficile
6 (1.3)
2 (0.5)
0 (0)
2 (0.9)
Nosocomial pneumonia
58 (12.3)
54 (13.7)
23 (14)
31 (13.5)
ICU stay in days, median [IQR]
6 [3; 15]
7 [3; 16]
7 [3.5; 15.5]
8 [3; 17]
Hospital stay in days, median [IQR]
15 [8; 33]
18 [10; 31]
17.5 [10.5; 35]
18 [9; 30]
Patients who died within 60 days, £ n (%)
123 (26.1)
107 (27.2)
35 (21.3)
72 (31.3)
Factors associated with 60-day mortality in the groups given monotherapy or dual therapy
Multivariate analysis
P- value
Dual therapy versus monotherapy
0.86 to 1.50
SAPSII (per 10 points)
1.54 to 1.79
Female gender
0.53 to 0.96
≥One co-morbidity
1.07 to 1.91
Antibiotic therapy on Day 2 versus Day 1
0.98 to 1.93
Antibiotic therapy on Day 3 versus Day 1
0.75 to 2.19
0.71 to 1.32
Multivariate sensitivity analysis*
P -value
Restricted to Streptococcus pneumoniae infection
0.73 to 2.77
Restricted to documented infection
0.89 to 1.89
Restricted to patients with septic shock
0.75 to 1.64
The following variables at admission were considered for entry into the model: gender, SAPSII, at least one co-morbidity, severe sepsis, septic shock, invasive ventilation, steroid therapy, day of antibiotic therapy initiation, steroids, hemodialysis-hemofiltration, bacteremia and pathogens yielding P- values <0.2 by univariate analysis.
Impact of one vs. two antibiotics on nosocomial pneumonia and multidrug-resistant bacteria rates
Nosocomial pneumonia developed in 127 patients, and MDR bacteria were identified in 105 patients. Neither the rate of nosocomial pneumonia nor the rate of MDR bacteria recovery differed significantly across the three antibiotic treatment groups (monotherapy, dual therapy with a macrolide and dual therapy with a fluoroquinolone; Table 3).
In a very large cohort of immunocompetent ICU patients with CAP, initial adequate antibiotic therapy improved 60-day survival and the improvement was greatest in the patients with S. pneumoniae infection or septic shock. Initial dual antibiotic therapy (β-lactam plus macrolide or fluoroquinolone) was associated with a higher frequency of adequate initial therapy but was not associated with better 60-day survival compared to β-lactam monotherapy. Dual therapy did not significantly affect the risk of nosocomial pneumonia or MDR bacteria compared to monotherapy.
Our study provides a good picture of the pathogens responsible for CAP requiring ICU admission. The distribution of the pathogens was consistent with previously published results, which vary widely, however, perhaps in relation to variations in case-mix [6]. Thus, the prevalence of S. pneumoniae infection in our study was only about half that found in a vast cohort of 3,523 patients in Spain [27], whereas the prevalence of Gram-negative bacilli was similar. The Spanish study included 15% of outpatients and 85% of inpatients admitted to wards or ICUs, whereas we studied only ICU patients, a population possibly characterized by greater bacterial virulence, greater bacterial resistance, and/or a longer time to treatment. Despite our restrictive inclusion criteria, Enterobacteriaceae and Pseudomonas aeruginosa were identified in 9.2% and 3% of patients, respectively. These pathogens, which raise specific treatment challenges, are typically found in healthcare-associated pneumonia [28]. However, 60-day mortality was independently related to acute illness severity, acute organ dysfunction, the presence of at least one co-morbidity and gender [29], but not to the nature of the pathogens, confirming our previous findings [30].
The better 60-day survival associated with initial adequate antibiotic therapy, particularly in the patients with the greatest disease severity, is consistent with many studies documenting the importance of very early adequate antibiotic administration in septic shock and severe pneumonia [2, 31, 32]. Dual therapy significantly increased the frequency of initial adequate therapy but did not increase survival. This apparent inconsistency in our findings may be ascribable to the fact that adequate therapy in patients without bacteriological documentation was defined in our study as compliance with guidelines. Another possible explanation is insufficient statistical power, although our cohort was large. So the effect of dual therapy in improving initial treatment adequacy may have been too small to induce a significant decrease in mortality.
Our finding that 60-day mortality was not significantly decreased by using two initial antibiotics instead of one, even in patients with septic shock or S. pneumoniae infection, may appear to contradict earlier studies [3, 8, 9, 21]. These discrepancies may be ascribable to differences in disease severity, causative organisms, antibiotics used, exclusion criteria and primary outcome measures. Thus, a prospective observational study of ICU patients found that dual therapy improved survival in the subgroup with shock, whereas no difference with monotherapy was noted in the subgroup without shock; however, survival was recorded at ICU discharge or on Day 28 [3]. In another prospective observational ICU study, in which 75.7% of the patients had shock; dual therapy, including a macrolide, was associated with better ICU survival compared to dual therapy with a fluoroquinolone [8], whereas we found no significant difference in 60-day mortality between these two groups. Although one of these studies excluded patients with COPD [3] and the other excluded patients with immunodeficiencies [8], neither used all the exclusion criteria used in our study. Two other studies focused on S. pneumoniae disease. One was a prospective observational study of patients with S. pneumoniae bacteremia showing that dual therapy improved 14-day survival in the subgroup requiring ICU admission but not in the subgroup managed on the wards [9]. In patients with S. pneumoniae CAP and bacteremia admitted to wards or ICUs, initial dual therapy with a macrolide was associated with better hospital survival compared to a β-lactam alone. Again, these studies had a different case-mix, as only 21.1% of our patients had S. pneumoniae infection and only 12.7% had bacteremia. Two studies found no difference between one and two initial antibiotics in patients with severe CAP [13, 14]. One was a post hoc analysis of data from two clinical trials of patients with severe pneumococcal sepsis and used ICU survival as the primary outcome, [13] whereas the other was a randomized trial comparing lefloxacin alone to ofloxacin plus cefotaxime in patients with severe CAP but with no shock and used clinical efficacy as the primary outcome [14]. Thus, neither study is closely similar to ours. A review article published in 2011 [7] showed that many studies supporting initial dual therapy in the most severe CAP requiring hospital admission were often retrospective, used a broad range of antibiotic regimens with some leading to conflicting results. As a result, the applicability of their results to everyday ICU practice can be challenged. In vitro resistance to macrolides has been associated with a higher clinical failure rate [33]. Despite consistent reports of increasing resistance to many antibiotics [33, 34], treatment failure remains extremely rare in patients with CAP. That β-lactams are not effective against L. pneumophila may seem to support dual therapy. However, L. pneumophila infection is rare and routinely sought by cultures or urine antigen testing (for type 1), with specific treatment being started at the slightest doubt, as this strategy has been shown to improve survival [35].
The main rationale for dual therapy is that the broader spectrum thus obtained covers atypical pathogens (other than Legionella pneumophila). However, only low-level evidence is available to support this rationale [19], as most studies were retrospective and had limited statistical power. The role for atypical pathogens in CAP has been extensively reviewed [5–7, 17, 18]. The absence of benefits from dual therapy on survival in our study may be partly due to the low frequency of atypical pathogens. A 2012 Cochrane review of randomized controlled trials in patients admitted to wards or ICUs for CAP found no benefit of atypical-pathogen coverage on clinical efficacy (the primary outcome) or survival, even in the subgroup of patients with atypical bacteria [36].
Another theoretical reason for using dual therapy is the possibility of improved effectiveness in patients with CAP due to resistant bacteria. We excluded patients with COPD and those admitted from long-term healthcare facilities, in whom repeated exposure to antibiotics increases the risk of bacterial resistance. The resulting low proportion of patients with initial bacterial resistance may have contributed to the absence of an effect of dual therapy on survival in our study.
Dual therapy might be expected to improve outcomes of patients with the most severe forms of CAP. Dual therapy was associated with better 28-day survival in patients with CAP and septic shock [3] and with better ICU survival in patients with severe CAP including 75.7% with septic shock [8]. In a retrospective study, treatment with a β-lactam and macrolide combination provided better 14-day and 30-day survival than did a fluoroquinolone alone in patients admitted for severe CAP [37]. In our study confined to ICU patients, dual therapy was not better than monotherapy, even when the second antibiotic was a macrolide. Patients with severe CAP usually undergo comprehensive investigations on an emergency basis, and their antibiotics are very quickly adapted to the microscopic smear results than to the susceptibility test results. This approach may decrease the impact of initial empirical dual antibiotic therapy.
Overuse of antibiotics, particularly fluoroquinolones [38, 39], might increase the risks of MDR bacteria selection and nosocomial pneumonia, although convincing clinical data to support these possibilities is lacking [40]. Secondary identification of MDR bacteria and nosocomial pneumonia occurred in similar proportions of patients in the monotherapy and dual therapy groups in our study. This finding should not be construed as evidence that unnecessary antibiotic use is harmless. Widespread antibiotic overuse does select MDR bacteria. Furthermore, both macrolides and fluoroquinolones can cause arrhythmias by prolonging the QT interval [41].
The strengths of our study are the large sample size, prospective data collection, patient identification based on clinical variables as opposed to codes [20], high quality of the database, and careful adjustment for confounding variables. Furthermore, to avoid including patients with healthcare-associated infections, which require specific treatment approaches, we excluded patients with immunodeficiencies, COPD or chronic dialysis as well as patients admitted from long-term healthcare facilities. The main limitation of our study is the observational design without random allocation of the initial antibiotic regimen. Randomized studies specifically evaluating β-lactam therapy alone or with a macrolide or fluoroquinolone would probably require very large sample sizes. Also, we had no information on antibiotic use in the six months preceding the CAP episode or on recent and/or repeated contact of the patients with healthcare professionals. This last factor may explain the high proportion of patients with gram-negative bacilli in our study. However, the possibility that patients with healthcare-associated pneumonia may be at increased risk of death because of their distinctive bacteriological features (including increased resistance) was challenged recently [28]. The higher mortality in these patients may be related instead to other factors, including functional impairments, malnutrition and a more restrictive ICU-admission policy. After careful adjustment for these factors, mortality was not significantly increased. Thus, there may be no sound rationale for modifying current guidelines for this particular population [28].
In conclusion, initial adequate therapy was associated with better 60-day survival in our patients with CAP requiring ICU admission and without COPD or immunodeficiency. Dual therapy (β-lactam plus macrolide or fluoroquinolone), compared to monotherapy (β-lactam alone), was associated with adequacy of initial antibiotic therapy but did not improve 60-day survival. Dual therapy did not increase the risks of nosocomial pneumonia or secondary bacterial multidrug resistance.
Key messages
● Initial adequate therapy was associated with better 60-day survival in ICU patients admitted for community-acquired pneumonia.
● Dual therapy with a β-lactam plus a macrolide or fluoroquinolone, although usually recommended as better than β-lactam monotherapy in severe community-acquired pneumonia, improved the adequacy of initial antibiotic therapy but did not improve 60-day survival.
● Dual therapy with a β-lactam plus a macrolide or fluoroquinolone did not increase the risk of nosocomial pneumonia or multidrug-resistant bacteria.
95% confidence interval
Community-acquired pneumonia
Chronic obstructive pulmonary disease
Confusion/Urea/Respiratory rate/Blood pressure score for individuals aged 65 years or over
Extended-spectrum beta-lactamase
Glasgow coma scale
Intensive care unit
Logistic organ dysfunction score
Multidrug resistant
Methicillin-resistant Staphylococcus aureus
Simplified acute physiology score version II
- sHR:
Subdistribution hazard ratio
Sequential organ failure assessment.
OUTCOMEREA is a non-profit organization supported by nonexclusive educational grants from four pharmaceutical companies (Aventis Pharma, France; Wyeth; Pfizer and MSD) and by research grants from three publicly funded French agencies (Centre National de la Recherche Scientifique (CNRS), Institut National pour la Santé et la Recherche Médicale (INSERM), and the French Ministry of Health).
The authors are indebted to A. Wolfe, M.D., for her help in preparing this manuscript.
Authors' Affiliations
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Godzilla 2014 HD TS XVID AC3-EVE
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text: PierpaoloRomani Pierpaolo Romani Firenze Musician playing both clarinet and bass clarinet, involved in classic music (chamber music, orchestral and solo) and in folk music (like the Metamorphosis Quartet project: www.soundcloud.com/metamorphosis-quartet). Biography Born in Abbadia San Salvatore (Italy) in 1987, in 2008 he brilliantly gradueted in clarinet under the guide of Fabio Battistelli at Louigi Cherubini Conservatory of Florence, studying also "Computer engineering" in the University of Florence. He studied chamber music repertoire with Tiziano Mealli and Rolando Russo, contemporary music with Mauro Ceccanti. He attended letions and after gradueted courses, both for clarinet and chamber music, with Jorge Riisi, Mirta Herrera, Teresa Carulli, Richard Stoltzman, Alessandro Carbonare, Antony Pay (at the Chigiana Accademy of Siena). He performed in several occasions in solistic, chamber and orchestral repertoire, like with Orchestra Regionale Toscana (Tuscany Regional Orchestra), Orchestra Giovanile Italiana (Italian Young Orchestra) and the Chernivetsk Philarmony Symphonic of Lviv (Ucraina). He performed, in addition, like soloist, the Aaron Copland's clarinet concert for solo clarinet, string orchestra, piano and harp and the Mozart's clarinet concert K622 for clarinet and orchestra. Very involved even in didattic activities he finished two years of apprendicesheep in the Fabio Battistelli's clarinet class in Luigi Cherubini Conservatory of Florence, he conducted didattic activities in School of Music of Fiesole, and he teaches in Artes School of Music of Prato and in School of Music of Monteroni d'Arbia. He collaborates with the Orchestra of the course of conduction of Dario Lucantoni of the Santa Cecilia Conservatory of Rome. He's continuing his studies with of Giovanni Riccucci (1st clarinet of the Maggio Musicale Fiorentino Orchestra) in School of Music of Fiesole and bass clarinet under the guide of Dario Goracci (bass clarinet of Santa Cecilia Orchestra of Rome). PierpaoloRomani's tracks Neleo Hora by PierpaoloRomani published on 2014/07/04 09:06:32 +0000 Sholem Alekhem by PierpaoloRomani published on 2012/07/03 13:51:50 +0000 Bach-Fensi - Transfiguration of Sarabanda from 2nd Cello Suite for bass clarinet by PierpaoloRomani published on 2011/12/05 20:49:57 +0000 Schubert - Der hirt auf dem felsen by PierpaoloRomani published on 2011/03/04 22:04:29 +0000 06 J.S. Bach - 2nd Cello suite BWV 1008 in D minor - Gigue by PierpaoloRomani published on 2011/02/26 13:39:34 +0000 05 J.S. Bach - 2nd Cello suite BWV 1008 in D minor - Menuetto I & II by PierpaoloRomani published on 2011/02/24 23:47:39 +0000 03 J.S. Bach - 2nd Cello suite BWV 1008 in D minor - Courante by PierpaoloRomani published on 2011/02/24 22:49:38 +0000 02 J.S. Bach - 2nd Cello suite BWV 1008 in D minor - Allemande by PierpaoloRomani published on 2011/02/15 00:17:19 +0000 Copland clarinet concerto performed by Pierpaolo Romani by PierpaoloRomani published on 2011/02/12 10:23:57 +0000 Mozart Clarinet Concerto k622 performed by Pierpaolo Romani - Rondò by PierpaoloRomani published on 2011/02/12 00:17:24 +0000


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Read GPD's response to a recent series of articles written by the Sarasota Herald-Tribune: RESPONSE
The Community Foundation of North Central Florida has established the Gainesville Police Department Foundation Fund to advance the mission of the Department by funding police specific projects and initiatives beyond the scope of the normal operating budget. Please visit the Community Foundation to donate by clicking here.
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The Starr Group Named 2014 Healthiest 100 Workplaces Award Winner by Healthiest Employers
MILWAUKEE, Wisc., January 15, 2014 – Healthiest Employers, the leader in employee health analytics, best practices and benchmark data, has announced the induction of The Starr Group into the 2014 Healthiest 100 Workplaces in America. Every one of these employers has achieved remarkable and sustainable success through a broad range of corporate wellness programs and employee wellness initiatives.
The Starr Group attained this recognition as the culmination of a year-long, highly selective two-stage assessment process spanning the United States to include companies of all sizes from all regions and industries.
"The Starr Group is both honored and humbled to be the recipient of this award. We consider wellness to be a very important business strategy for the overall success of our agency. It is because of a very involved and supportive group of employees who embrace our wellness initiatives that made this achievement possible," says Mary Starr Executive Vice-President.
These state and national awards recognize employers who have comprehensively incorporated the most effective employee wellness programs and practices. The Healthiest 100 have successfully implemented practical, effective and continuously improving corporate wellness strategies for creating a sustainably healthy workplace.
Rod Reasen II, President of Healthiest Employers, notes that "This highly selective award recognizes employers who demonstrate exceptional leadership in using wellness as a strategy to drive workplace productivity, employee health, and community wellbeing. As these employers demonstrate, every organization has a path to the Healthiest 100, regardless of size, industry or geography."
About Healthiest Employers
Healthiest Employers provides corporate wellness best practices and benchmark data and employee health analytics to employers, providers, carriers, brokers and consultants. This suite of proprietary tools includes Springbuk for intuitive health analytics (Spring 2014), the 360 Insight Series, and Corporate Wellness and Trend Reports for best practices and benchmark research. HE's national Directory helps employers select customer-ranked wellness vendors.
About The Starr Group
The Starr Group is an independent insurance and risk management agency with the capabilities of advising clients on everything from their business insurance, including group health, to personal insurance. The Starr Group also provides assistance in human resources compliance, loss control, workers' compensation claims administration, and e-services. For further information, please contact Lisa Simonson of The Starr Group at (414) 421-3800.
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· Volume capacity: 2.5 pounds per week of scraps.
· The
WormWatcher® Composting Bin includes an curtain, starter soil, video
set-up instructions, written instructions, trowel, moisture meter,
gloves, Vitamix, half pound of worms certificate, email reminders, email
coaching and a 60-day Warranty.
· Castings production: Approximately 25 pounds every 4 months with healthy conditions.
To add to learning:
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Deeper; Dusty and Daisy's Adventure into Composting - Children's Book
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Science and


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CLICK HERE to open our calendar in a new page.
From there, you can click on any event to see more information, band bios and start times.
BOOKING INFO: We are ROCKERS and we love to dance to rowdy, fun music!
If you are a full band with drums and bass and play classic rock, blues and
danceable covers, please email audio and/or video samples and fee information
to info @ bootstrapbrewing.com for consideration.


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The Gold Coast's star attraction is its beaches, including the world-renowned stretch of sand at Surfers Paradise. Beyond the beaches, discover laid-back neighbourhoods, a booming culinary scene and the Gold Coast's famous theme parks. And don't miss a trip into the subtropical hinterland for rainforest walks and waterfalls.
"Burleigh still has a bit of a country town feel about it and with a world-class surfing point break along with a growing number of great restaurants, bars and cafés it really is becoming one of the places to see."
– Sean Scott, Photographer


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Q From Barry Nordin; related questions came from Anne Cox, Nick Carrington, and William Hale: Shank's mare: I'm intrigued by this term for walking. However, my reference books, and a cursory AOL internet search, provide scant information on its derivation. I know you'll be much better informed.
A I am better informed, but it took more work than I expected, as it isn't in some of my standard references.
It's Scottish, dating from the eighteenth century. There was a verb, to shank or to shank it, meaning to go on foot. This is from standard English shank for the part of the leg from the knee to the ankle, which comes from Old English sceanca, the leg bone. This verb developed into shank's naig or shank's naigie (where the second words are local forms of nag, a horse) and later into shank's mare. It was a wry joke: I haven't got a horse of my own for the journey, so I'll use Shank's mare to get there, meaning I'll go on my own two feet. This supposed link with a person called Shank explains why the first word is often capitalised.
Another form, now more common in Britain, is shank's pony.
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Begging his pardon even so, but there is a unavoidable dichotomy between the Smith who sits comfortably in the familiar surroundings of Kingsholm talking about his life in (mainly Gloucester) rugby and the Caledonian alter ego who has done Five Nations rugby a service by blazing a trail on behalf of an endangered rugby species called the open-side flanker.
At nearly 32, Smith has been around long enough - more than 350 Gloucester games since making his debut as an 18-year-old - and dealt with enough aggravating inquisitors to know that curiosity about his provenance will continue as long as his Scotland career. "I get so irritated that people keep dragging it up," he complained. Sorry, Ian, but there is no escape.
"I know it's a fact of my past but it does get annoying when people harp on about it when they could be concentrating on the rugby or the game. There is nothing I can say that will make people think I'm a Scotsman. All I can do is go out and play, and if you think I play like an Englishman playing for Scotland, then so be it. The fact is I feel like a Scotsman and always have since I was a young boy."
But the fact is, too, that under present eligibility rules Smith would have committed himself to England - at least until a decent interval had passed - when he represented England B against Spain in 1989, and it is not widely remembered that in 1990 he was even in England's preliminary squad for the '91 World Cup.
But it was in 1990, on the very day that he dashed away from a Gloucester game at Nottingham for one of those England sessions, that the change of allegiance began to occur. Gloucester's defeat that day cost them the championship, but the consolation for Smith was a conversation he had before his departure with Chris Gray, the Nottingham captain.
Gray, an exile from the Lothians who had played in the Scotland second row against England when the Grand Slam had been won six weeks earlier, knew of Smith's Scottish connection and, as any good Scot would, tapped him up. A later phone call from Ian McGeechan, the persuasive Scotland coach, made up Smith's mind up for him; he made his Test debut in 1992 and will win his 16th cap for the land of his paternal grandparents against England this afternoon.
Smith's father Dick, an outstanding Gloucester flanker who appeared in the very first knock-out final at Twickenham in 1972, was Gloucester-born to a couple from Aberdeen which Smith Jnr insists gave him a Scottish allegiance from his earliest years. "I had always supported Scotland as a young boy and I always felt I wanted to switch," he said.
It was England's loss. Ask any back-row forward on the Courage league circuit and he will pay a sincere tribute to Smith's quality, bearing in mind also that he has sustained this individual excellence during a period - ever since that defeat at Nottingham was followed a week later by a cup-final annihilation by Bath - when Gloucester collectively have fallen far short of their traditional eminence.
Which perhaps helps explains why he has flourished in a different, less introspective and claustrophobic environment. In the Scottish chain of command Rob Wainwright, the captain, has this season had the good sense to use Smith, with his wisdom gained from long experience, as his first lieutenant.
And within the thrilling strategy of all-out movement with which Scotland have beaten Ireland, France and Wales, Smith as open-side flanker has more than any individual been responsible for its successful implementation. To think that not so long ago fleet-footed forwards of Smith's ilk were on the verge of extinction in the international game.
Not that Smith ever accepted its inevitability. "I've always said it: what goes round comes round. When you look at the successful teams, especially New Zealand and Australia, they have always picked a specialist open side and basically revolve the game around him. So it's been frustrating to see a game evolving here that involved big men playing an upright game, hitting up the middle.
"But I was always confident that it was a cyclical thing. Moves we used to use 10 years ago and which then petered out for a while have come back into use again and it's clear that the trend is back in the direction of players like me. But for the open side to be successful depends on the way other units work as well. A back row is only as good as the front five in front of it and the back line behind it."
Wales, with Gwyn Jones, and Ireland, by reinstating Denis McBride, are treading much the same path and even in the home of back-row mastodons, England, they have come to acknowledge the requirement for a specialist such as Smith, even if by choosing Lawrence Dallaglio they designedly have a player who must learn as he goes along.
None, one would suggest, has done it as well as Smith during this exhilarating Scottish season. "It is, quite simply, the natural way for me to play, what I've always done from when I was a young lad years ago," he said. "If I perform as I should, then the side functions as it should, and that's how it will be against England. That's a responsibility, I know, but I feel comfortable with it.
"I play against these blokes in English club rugby week-in week-out, so I know what they are like, what they can do, their strengths and weaknesses. I'm as confident as you can be going into a game like this and that's a deliberately ambiguous statement. If we - or should I say if we are allowed to - play as well as we can, then it could be a great day." A great day for Aberdeen no doubt, but would it be a great day for Gloucester?Reuse content


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- Details
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- Small group ensures personal service
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Traveling in a small group through
Your next stop is the 'Gandhi Memorial Museum', commonly known as 'National Gandhi Museum'. The origin of this museum dates back to the period soon after the assassination showcases personal relics, manuscripts, books, journals and documents as well as photographic and audio-visual material.
Continue to Raj Ghat. Located on the west bank of the
Your local guide will lead you through the life and times of Mahatma Gandhi, learning more about his message of truth, non violence and peace. Traveling in a small group, maximum 12 people, allows for an intimate and informative experience.
At the end of the trip you are free for personal exploration or alternatively your local guide can assist with arranging a taxi back to your hotel.
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Gandhi's Delhi Small Group Experience
- Local guide
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- Confirmation will be received at time of booking, unless booked within 2 days of travel. In this case confirmation will be received within 48 hours, subject to availability
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If you cancel between 3 and 6 day(s) in advance of the scheduled departure, there is a 50 percent cancellation fee.
If you cancel within 2 day(s) of the scheduled departure, there is a 100 percent cancellation fee.
Traveler Reviews
Reviewed by: Sankung S, August 2015
This was the highlight of our trip to India. We did a few tours during our brief five day stay in New Delhi. Visiting Gandhi's memorial sites was a very meaningful moment. Our tour guide was very knowledgeable and he speaks English which was helpful. He was patient and shows us everything we looked for in the visit. This is a tour we would like to do again when in New Delhi.
Reviewed by: smilinback88, June 2013
We saw all the major sites and our young guide was sooo nice.


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Philadelphia Asian American Film & Filmmakers
About us
Philadelphia Asian American Film & Filmmakers (PAAFF) is a volunteer run, multicultural organization founded in 2008 to support Asian American film and filmmakers throughout the Philadelphia region and educate and expose the region to films about Asian Americans through an annual film festival.
PAAFF organizes the Philadelphia Asian American Film Festival which is the first event of its kind in Philadelphia – a film festival celebrating and elevating the Asian American experience.
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Date Founded: 2008
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Philadelphia, PA, US


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Best Price Golf Clubs
The clubheads are stainless steel, with tungtsen weights in the toes, another nod to forgiveness. Distance control was a design goal in the set, Ping says, and thicker faces and stabilizer bars help in that area. The irons have a low-glare, satin chrome finish.
The Ping i20 irons come in 3-iron through 9-iron plus pitching wedge, sand wedge. The stock steel shaft is the Ping CFS, and the stock graphite shaft is the Ping TFC 169i.
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Mizuno have modeled the MP-68 on the classic MP-33 iron, which was universally agreed to be the best performing and
Mizuno golf clubs, a leader in golf technology and innovation, today announced the launch of the Grain Flow Forged Mizuno
The Mizuno MP-69 Iron Set, the next iconic Mizuno muscle-back iron, was created by blending Mizuno's PGA Tour Staff input
The latest release by Mizuno and their precision golf engineering masters is the wonderfully awaited MP-54 featuring a players-iron style
With feel and control as top priorities, Mizuno engineers relied heavily on the use of advanced simulation tools and input
The MP-4 is the purest of forged muscle backs for shot-makers seeking the ultimate control over their ball flight. he
The new Ping G20 Fairway Wood is designed to be the most forgiving wood that Ping has ever made. The
The all new TaylorMade Tour Preferred CB Irons are a precision-engineered cavity back design that offer the lastest in TaylorMade
TaylorMade Tour Preferred MC irons 2014 are the latest of the latest and loaded with a superb blend of art
Our patented SureFit® Tour hosel technology allows loft and lie to be independently adjusted to precisely fit your game. 913D3
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Express. Home of the Daily and Sunday Express.
CONFIRMED: Leeds United sign Peterborough striker Nicky Ajose
LEEDS UNITED have moved to replace departed striker Ross McCormack with the capture of Peterborough striker Nicky Ajose.
The Elland Road club confirmed Ajose has signed a three-year deal but will not disclose the fee paid to Posh.
Last season the 22-year-old scored 13 goals in League One but failed to find the net in any of his last 13 appearances.
His arrival will boost Leeds' forward ranks hit by the departure of McCormack to Fulham for £11million and manager Dave Hockaday revealed his keenness to bring in the former Manchester United youngster.
"Nicky was involved with a very good group of players in the Manchester United Academy and he was one of the high flyers in that group," Hockaday told Leedsunited.com.
"He can play up front in a number roles and he is very talented. He is a super professional and is an ideal addition to our squad."
DONE DEAL: We can now confirm the signing of Nicky Ajose from Peterborough United, he has signed a 3-year deal #lufc pic.twitter.com/CfELJG0F9D— Leeds United FC (@LUFC) August 5, 2014
Ajose is Hockaday's fifth permanent signing this summer, following goalkeeper Stuart Taylor, Chievo's Marco Silvestri, Tommaso Bianchi of Sassuolo and Sampdoria's Gaetano Berardi to Elland Road.
Leeds have also loaned in striker Souleymane Doukara with the potential of a permanent move from Catania, plus AC Milan midfielder Zan Benedicic.


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© Copyright 2017 middlechild274. All rights reserved.
Status: Finished
Genre: Other
Beautiful poem, love it. Keep up the great work d^_^b
'never fear to try..'
tama! xD
meaningful poem!:)
I love it. It's beautiful and also, it posses a great meaning. Nice poem.
I love it. You admitted what people are afraid to! Good job!
I WILL! Scaza, what an AMAZING poem, it's like you saw the world for what it is, you saw the people for what they become and your heart bleeds, you seek goodness yet all you see is a corrupt species. BEAUTIFUL, your dream of goodness is an admirable dream, a dream worth living for and ream worth fighting for. Thanks for the inspiration! ^^
It is a wonderful poem. You see both sides of life, the good and the bad. You want to find balance, and that's good. People often want to get to the top by simply wishing they could, or by not playing fair, but there are still people out there who want to get there in the right way and for the right reasons.
So, it was truly a lovely poem.
very true. i find myself wondering and worrying about those things from time to time, wanting to leave some sort of mark on the world rather than to just exist... then die.
this is beautiful
Short Story / Humor
Short Story / Memoir
Poem / Fantasy
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text: PC Makers to Microsoft: "Vista Is Not a Seller. You Suck"Jesus Diaz3/30/07 9:25amFiled to: SoftwareAcerGroundhog DayMicrosoftSamsungVista68EditPromoteShare to KinjaToggle Conversation toolsGo to permalink This may feel like Groundhog Day for you and Steve Ballmer, but according to computer and component manufacturers, Vista is not the hotcake that they were hoping for. The not-so-shiny-shiny-anymore OS is not helping sales at all and some companies may end with a whole bunch of unsold stuff in their warehouses. Take Acer's president, Gianfranco Lanci, who has just said that "PC makers are really not counting on Vista to drive high demands for the industry." Or Samsung Electronics, who now says that DRAM demand has not matched anyone's predictions based on Vista's now failed projections, something that is being echoed by the industry as a whole.So forget about Señor Gates' words on Vista pushing PC sales. You may want to punch us, Bill, but apparently those 20 million copies sold are indeed business as usual. Hasta la Vista baby, say PC makers [India Times]Reply68 repliesLeave a reply