Table 1.

Traditional versus alternative interpretation of clinical data on nosocomial infections and inflammation in ARDS

	Traditional interpretation	Alternative interpretation
Inflammation and bacteria	Inflammation kills bacteria	Regulated inflammation kills bacteria while excessive (unregulated) inflammation may enhance bacterial growth
Nosocomial infections	More frequent in nonsurvivors	More frequent in patients with persistent cytokine elevation
	Amplify inflammation (second hit hypothesis) and worsen multiple organ dysfunction syndrome	Do not amplify inflammation (downregulation, or LPS tolerance)
Systemic inflammation in ARDS	Progression is amplified by nosocomial infections (≥ day 3 of ARDS)	Progression is determined prior to day 3, by the success and/or failure of the host regulatory mechanisms
Glucocorticoid treatment in patients with unregulated systemic inflammation	Causes immunosuppression and enhances the risk for developing infections	If given in low doses for a prolonged period (≥ 7 days) may have an important immunomodulatory effect in regulating excessive inflammation and restoring homeostasis

ARDS, acute respiratory distress syndrome; LPS, lipopolysaccharide.