101
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Méndez R, Aldás I, Menéndez R. Biomarkers in Community-Acquired Pneumonia (Cardiac and Non-Cardiac). J Clin Med 2020; 9:jcm9020549. [PMID: 32085380 PMCID: PMC7073979 DOI: 10.3390/jcm9020549] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
Community-acquired pneumonia (CAP) remains the first cause of morbidity and mortality worldwide due to infection. Several aspects such as severity and host response are related to its clinical course and outcome. Beyond the acute implications that the infection provokes in the host, pneumonia also has long-term negative consequences. Among them, cardiovascular complications and mortality are the most outstanding. Therefore, an adequate recognition and stratification of the risk of complications and mortality is crucial. Many biomarkers have been studied for these reasons, considering that each biomarker mirrors a different aspect. Moreover, the clinical application of many of them is still being deliberated because of their limitations and the heterogeneity of the disease. In this review, we examine some of the most relevant biomarkers that we have classified as cardiac and non-cardiac. We discuss some classic biomarkers and others that are considered novel biomarkers, which are mainly involved in cardiovascular risk.
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Affiliation(s)
- Raúl Méndez
- Pneumology Department, Hospital Universitario y Politécnico La Fe/Instituto de Investigación Sanitaria (IIS) La Fe, 46026 Valencia, Spain; Pneumology Department, Hospital Universitario y Politécnico La Fe, Avda, Fernando Abril Martorell 106, 46026 Valencia, Spain;
| | - Irene Aldás
- University of Valencia, Medicine Faculty, 46026 Valencia, Spain;
- Pneumology Department, Hospital Germans Trias i Pujol, 08916 Badalona, Spain
| | - Rosario Menéndez
- Pneumology Department, Hospital Universitario y Politécnico La Fe/Instituto de Investigación Sanitaria (IIS) La Fe, 46026 Valencia, Spain; Pneumology Department, Hospital Universitario y Politécnico La Fe, Avda, Fernando Abril Martorell 106, 46026 Valencia, Spain;
- University of Valencia, Medicine Faculty, 46026 Valencia, Spain;
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
- Correspondence:
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102
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Paudel R, Dogra P, Montgomery-Yates AA, Coz Yataco A. Procalcitonin: A promising tool or just another overhyped test? Int J Med Sci 2020; 17:332-337. [PMID: 32132868 PMCID: PMC7053349 DOI: 10.7150/ijms.39367] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/19/2019] [Indexed: 12/24/2022] Open
Abstract
Sepsis is the leading cause of death worldwide. Timely administration of antibiotics is recognized as the cornerstone in the management of sepsis. However, inappropriate use of antibiotics may lead to adverse effects and the selection of drug-resistant pathogens. Microbiological cultures remain the gold standard to diagnose infection despite their low sensitivity and the intrinsic delay to obtain the results. Certain biomarkers have the benefit of rapid turnover, potentially providing an advantage in timely diagnosis leading to accurate treatment. Over the last few decades, there is an ongoing quest for the ideal biomarker in sepsis. Procalcitonin (PCT), when used alone or alongside additional clinical information, has shown to be a promising tool to aid in the diagnosis and management of patients with sepsis. In February 2017, the Food and Drug Administration (FDA) approved the use of PCT to guide antibiotic treatment in lower respiratory tract infections and sepsis. Despite a good negative predictive value for bacterial infection, the utility of PCT-guided antibiotic initiation is conflicting at best. On the other hand, the use of PCT-guided antibiotic discontinuation has shown to reduce the duration of antibiotic use, the associated adverse effects, and to decrease the overall mortality. The current review discusses the history and pathophysiology of procalcitonin, synthesizes its utility in the diagnosis and management of sepsis, highlights its limitations and compares it with other biomarkers in sepsis.
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Affiliation(s)
- Robin Paudel
- Division of Pulmonary and Critical Care, University of Kentucky, Lexington, Kentucky
| | - Prerna Dogra
- Division of Hospital Medicine, University of Kentucky, Lexington, Kentucky
| | | | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center, Lexington, Kentucky
- University of Kentucky College of Medicine
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103
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Baldirà J, Ruiz-Rodríguez JC, Wilson DC, Ruiz-Sanmartin A, Cortes A, Chiscano L, Ferrer-Costa R, Comas I, Larrosa N, Fàbrega A, González-López JJ, Ferrer R. Biomarkers and clinical scores to aid the identification of disease severity and intensive care requirement following activation of an in-hospital sepsis code. Ann Intensive Care 2020; 10:7. [PMID: 31940096 PMCID: PMC6962418 DOI: 10.1186/s13613-020-0625-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few validated biomarker or clinical score combinations exist which can discriminate between cases of infection and other non-infectious conditions following activation of an in-hospital sepsis code, as well as provide an accurate severity assessment of the corresponding host response. This study aimed to identify suitable blood biomarker (MR-proADM, PCT, CRP and lactate) or clinical score (SOFA and APACHE II) combinations to address this unmet clinical need. METHODS A prospective, observational study of patients activating the Vall d'Hebron University Hospital sepsis code (ISC) within the emergency department (ED), hospital wards and intensive care unit (ICU). Area under the receiver operating characteristic (AUROC) curves, logistic and Cox regression analysis were used to assess performance. RESULTS 148 patients fulfilled the Vall d'Hebron ISC criteria, of which 130 (87.8%) were retrospectively found to have a confirmed diagnosis of infection. Both PCT and MR-proADM had a moderate-to-high performance in discriminating between infected and non-infected patients following ISC activation, although the optimal PCT cut-off varied significantly across departments. Similarly, MR-proADM and SOFA performed well in predicting 28- and 90-day mortality within the total infected patient population, as well as within patients presenting with a community-acquired infection or following a medical emergency or prior surgical procedure. Importantly, MR-proADM also showed a high association with the requirement for ICU admission after ED presentation [OR (95% CI) 8.18 (1.75-28.33)] or during treatment on the ward [OR (95% CI) 3.64 (1.43-9.29)], although the predictive performance of all biomarkers and clinical scores diminished between both settings. CONCLUSIONS Results suggest that the individual use of PCT and MR-proADM might help to accurately identify patients with infection and assess the overall severity of the host response, respectively. In addition, the use of MR-proADM could accurately identify patients requiring admission onto the ICU, irrespective of whether patients presented to the ED or were undergoing treatment on the ward. Initial measurement of both biomarkers might therefore facilitate early treatment strategies following activation of an in-hospital sepsis code.
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Affiliation(s)
- Jaume Baldirà
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain. .,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain.
| | - Darius Cameron Wilson
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Alejandro Cortes
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Luis Chiscano
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Roser Ferrer-Costa
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Inma Comas
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department de Genètica i Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Fàbrega
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juan José González-López
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department de Genètica i Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
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104
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Torres A, Loeches IM, Sligl W, Lee N. Severe flu management: a point of view. Intensive Care Med 2020; 46:153-162. [PMID: 31912206 PMCID: PMC7095473 DOI: 10.1007/s00134-019-05868-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
Annual flu seasons are typically characterized by changes in types and subtypes of influenza, with variations in terms of severity. Despite remarkable improvements in the prevention and management of patients with suspected or laboratory-confirmed diagnosis of influenza, annual seasonal influenza continues to be associated with a high morbidity and mortality. Admission to the intensive care unit is required for patients with severe forms of seasonal influenza infection, with primary pneumonia being present in most of the cases. This review summarizes the most recent knowledge on the diagnosis and treatment strategies in critically ill patients with influenza, focused on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, and supportive measures. The review focuses on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, supportive measures and relevant existing evidence, in order to provide the non-expert clinician a useful overview. An enhanced understanding of current diagnostic and treatment aspects of influenza infection can contribute to improve outcomes and reduce mortality among ICU patients with influenza.
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Affiliation(s)
- Antoni Torres
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain.
| | - Ignacio-Martin- Loeches
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain.,Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Wendy Sligl
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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105
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Goodman D, Crocker ME, Pervaiz F, McCollum ED, Steenland K, Simkovich SM, Miele CH, Hammitt LL, Herrera P, Zar HJ, Campbell H, Lanata CF, McCracken JP, Thompson LM, Rosa G, Kirby MA, Garg S, Thangavel G, Thanasekaraan V, Balakrishnan K, King C, Clasen T, Checkley W. Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group. THE LANCET. RESPIRATORY MEDICINE 2019; 7:1068-1083. [PMID: 31591066 PMCID: PMC7164819 DOI: 10.1016/s2213-2600(19)30249-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.
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Affiliation(s)
- Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Mary E Crocker
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Division of Pediatric Pulmonology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Laura L Hammitt
- School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Heather J Zar
- Department of Pediatrics and Child Health, SA-MRC Unit on Child & Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M Thompson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ghislaine Rosa
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Vijayalakshmi Thanasekaraan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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106
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Ho VP, Kaafarani H, Rattan R, Namias N, Evans H, Zakrison TL. Sepsis 2019: What Surgeons Need to Know. Surg Infect (Larchmt) 2019; 21:195-204. [PMID: 31755816 DOI: 10.1089/sur.2019.126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.
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Affiliation(s)
- Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Haytham Kaafarani
- Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Boston, Massachusetts
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, Florida
| | - Heather Evans
- Division of General & Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Tanya L Zakrison
- Section for Trauma and Acute Care Surgery, The University of Chicago Medicine, Chicago, Illinois
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107
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Tosoni A, Paratore M, Piscitelli P, Addolorato G, De Cosmo S, Mirijello A. The use of procalcitonin for the management of sepsis in Internal Medicine wards: current evidence. Panminerva Med 2019; 62:54-62. [PMID: 31729202 DOI: 10.23736/s0031-0808.19.03809-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Procalcitonin (PCT) is a circulating polypeptide produced in response to bacterial infections. Studies conducted in the Intensive Care Unit (ICU) setting have demonstrated its utility as a biomarker of bacterial infection and sepsis. Thus, PCT is widely used to distinguish between sepsis and SIRS, and to guide antibiotic therapy. At present sepsis represents a frequent diagnosis among patients admitted to internal medicine (IM) departments. Basing on the knowledge derived from ICU studies, the use of PCT has become routine in non-intensive wards, contributing to improve the management of sepsis. However, some differences between the two populations of patients - the IM being older, affected by multiple chronic comorbidities and lacking of invasive monitoring - could limit the generalizability of ICU results. Most of the studies on PCT conducted in the IM setting have focused on chronic obstructive pulmonary disease, pneumonia and sepsis. Although PCT represents one of the best biomarker available in routine clinical practice, there are uncertainties on the optimal cut-offs to be used for starting or discontinuing antibiotic treatment in patients with suspected bacterial infection or sepsis, for predicting outcome and on the role of PCT variations during antibiotic treatment. Moreover, several diseases can produce an elevation of PCT levels, thus producing false positive results. This represents a narrative review summarizing current evidences on PCT for the management of sepsis in an Internal Medicine wards, highlighting differences with ICU, with a special focus on the role of PCT variations as predictor of outcomes in non-ICU wards.
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Affiliation(s)
- Alberto Tosoni
- Internal Medicine and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS Research Hospital, Rome, Italy
| | - Mattia Paratore
- Internal Medicine and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS Research Hospital, Rome, Italy
| | - Pamela Piscitelli
- Internal Medicine Unit, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Internal Medicine and Gastroenterology, A. Gemelli Hospital, Catholic University of Rome, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS Research Hospital, Rome, Italy
| | - Salvatore De Cosmo
- Internal Medicine Unit, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Antonio Mirijello
- Internal Medicine Unit, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy -
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108
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Tsalik EL, Khine A, Talebpour A, Samiei A, Parmar V, Burke TW, Mcclain MT, Ginsburg GS, Woods CW, Henao R, Alavie T. Rapid, Sample-to-Answer Host Gene Expression Test to Diagnose Viral Infection. Open Forum Infect Dis 2019; 6:ofz466. [PMID: 34150923 DOI: 10.1093/ofid/ofz466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022] Open
Abstract
Objective Distinguishing bacterial, viral, or other etiologies of acute illness is diagnostically challenging with significant implications for appropriate antimicrobial use. Host gene expression offers a promising approach, although no clinically useful test has been developed yet to accomplish this. Here, Qvella's FAST HR (Richmond Hill, Ontario, Canada) process was developed to quantify previously identified host gene expression signatures in whole blood in <45 minutes. Method Whole blood was collected from 128 human subjects (mean age 47, range 18-88) with clinically adjudicated, microbiologically confirmed viral infection, bacterial infection, noninfectious illness, or healthy controls. Stabilized mRNA was released from cleaned and stabilized RNA-surfactant complexes using e-lysis, an electrical process providing a quantitative real-time reverse transcription polymerase chain reaction-ready sample. Threshold cycle values (CT) for 10 host response targets were normalized to hypoxanthine phosphoribosyltransferase 1 expression, a control mRNA. The transcripts in the signature were specifically chosen to discriminate viral from nonviral infection (bacterial, noninfectious illness, or healthy). Classification accuracy was determined using cross-validated sparse logistic regression. Results Reproducibility of mRNA quantification was within 1 cycle as compared to the difference seen between subjects with viral versus nonviral infection (up to 5.0 normalized CT difference). Classification of 128 subjects into viral or nonviral etiologies demonstrated 90.6% overall accuracy compared to 82.0% for procalcitonin (P = .06). FAST HR achieved rapid and accurate measurement of the host response to viral infection in less than 45 minutes. Conclusions These results demonstrate the ability to translate host gene expression signatures to clinical platforms for use in patients with suspected infection. Clinical Trials Registration NCT00258869.
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Affiliation(s)
- Ephraim L Tsalik
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Ayeaye Khine
- Qvella Corporation, Richmond Hill, Ontario, Canada
| | | | | | - Vilcy Parmar
- Qvella Corporation, Richmond Hill, Ontario, Canada
| | - Thomas W Burke
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Micah T Mcclain
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Medicine Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Geoffrey S Ginsburg
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christopher W Woods
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Medicine Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Ricardo Henao
- Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Pratt School of Engineering, Duke University, Durham, North Carolina, USA
| | - Tino Alavie
- Qvella Corporation, Richmond Hill, Ontario, Canada
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109
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Bobillo-Perez S, Sole-Ribalta A, Balaguer M, Esteban E, Girona-Alarcon M, Hernandez-Platero L, Segura S, Felipe A, Cambra FJ, Launes C, Jordan I. Procalcitonin to stop antibiotics after cardiovascular surgery in a pediatric intensive care unit-The PROSACAB study. PLoS One 2019; 14:e0220686. [PMID: 31532769 PMCID: PMC6750599 DOI: 10.1371/journal.pone.0220686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/22/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction and objective Children admitted to the pediatric intensive care unit after cardiovascular surgery usually require treatment with antibiotics due to suspicion of infection. The aim of this study was to assess the effectiveness of procalcitonin in decreasing the duration of antibiotic treatment in children after cardiovascular surgery. Methods Prospective, interventional study carried out in a pediatric intensive care unit. Included patients under 18 years old admitted after cardiopulmonary bypass. Two groups were compared, depending on the implementation of the PCT-guided protocol to stop or de-escalate the antibiotic treatment (Group 1, 2011–2013 and group 2, 2014–2018). This new protocol was based on the decrease of the PCT value by 20% or 50% with respect to the maximum value of PCT. Primary endpoints were mortality, stewardship indication, duration of antibiotic treatment, and antibiotic-free days. Results 886 patients were recruited. There were 226 suspicions of infection (25.5%), and they were confirmed in 38 cases (16.8%). The global rate of infections was 4.3%. 102 patients received broad-spectrum antibiotic (4.7±1.7 days in group 1, 3.9±1 days in group 2 with p = 0.160). The rate of de-escalation was higher in group 2 (30/62, 48.4%) than in group 1 (24/92, 26.1%) with p = 0.004. A reduction of 1.1 days of antibiotic treatment (group 1, 7.7±2.2 and group 2, 6.7±2.2, with p = 0.005) and 2 more antibiotic free-days free in PICU in group 2 were observed (p = 0.001), without adverse outcomes. Conclusions Procalcitonin-guided protocol for stewardship after cardiac surgery seems to be safe and useful to decrease the antibiotic exposure. This protocol could help to reduce the duration of broad-spectrum antibiotics and the duration of antibiotics in total, without developing complications or adverse effects.
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Affiliation(s)
- Sara Bobillo-Perez
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Disorders of Immunity and Respiration of the Pediatric Critical Patients Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Anna Sole-Ribalta
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Monica Balaguer
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Elisabeth Esteban
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Monica Girona-Alarcon
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Lluisa Hernandez-Platero
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Aida Felipe
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Jose Cambra
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | - Cristian Launes
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Pediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Pediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
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110
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Damhorst GL, Tyburski EA, Brand O, Martin GS, Lam WA. Diagnosis of acute serious illness: the role of point-of-care technologies. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2019; 11:22-34. [PMID: 34079919 PMCID: PMC8168915 DOI: 10.1016/j.cobme.2019.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Access to rapid diagnostic information is a core value of point-of-care (POC) technology. This is particularly relevant in acute, emergency, and critical care settings where diagnostic speed and precision directly guide the management of patients with potentially life-threatening conditions. Many POC diagnostics described in the literature, however, remain largely unproven and have yet to enter the market entirely. Only a few have traversed the translation and commercialization pathways to reach widespread clinical adoption. Moreover, even technologies that have successfully translated to the patient bedside still frequently lack an evidence base showing improvement of clinical outcomes. In this review, we present aspects of diagnosis of acute life-threatening diseases and describe the potential role of POC technologies, emphasizing the available evidence of clinical outcomes. Finally, we discuss what is needed to identify clinically meaningful new technologies and translate them toward the long-promised goal of better health through rapid POC diagnosis.
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Affiliation(s)
| | - Erika A Tyburski
- Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA, USA
- The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, GA, USA
- Sanguina, LLC, Peachtree Corners, GA, USA
| | - Oliver Brand
- Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA, USA
- The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, GA, USA
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Greg S Martin
- The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, GA, USA
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
- Georgia Clinical and Translational Science Alliance, Atlanta, GA, USA
| | - Wilbur A Lam
- Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA, USA
- The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, GA, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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111
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Cole KA, Rivard KR, Dumkow LE. Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies. Curr Infect Dis Rep 2019; 21:33. [PMID: 31473861 DOI: 10.1007/s11908-019-0689-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance. RECENT FINDINGS In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.
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Affiliation(s)
- Kelli A Cole
- Department of Pharmacy Services, University of Toledo Medical Center, 3000 Arlington Ave. MS 1013, Toledo, OH, 43614, USA.
| | - Kaitlyn R Rivard
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Lisa E Dumkow
- Department of Pharmacy Services, Mercy Health Saint Mary's, 200 Jefferson SE, Grand Rapids, MI, 49503, USA.
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112
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Kuil SD, Hidad S, Fischer JC, Harting J, Hertogh CM, Prins JM, van Leth F, de Jong MD, Schneeberger C. Sensitivity of point-of-care testing C reactive protein and procalcitonin to diagnose urinary tract infections in Dutch nursing homes: PROGRESS study protocol. BMJ Open 2019; 9:e031269. [PMID: 31401614 PMCID: PMC6701568 DOI: 10.1136/bmjopen-2019-031269] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Suspected urinary tract infection (UTI) ranks among the most common reasons for antibiotic use in nursing homes. However, diagnosing UTI in this setting is challenging because UTI often presents with non-specific symptomatology. Moreover asymptomatic bacteriuria is common in elderly, which complicates attribution of causality to detection of bacteria in urine. These diagnostic challenges contribute to overuse of antibiotics and emergence of antimicrobial resistance in nursing homes. Given the diagnostic challenges, there is a need for point-of-care (POC) diagnostic tests to support clinical rules for diagnosing UTI. Procalcitonin (PCT) and C reactive protein (CRP) are inflammatory blood markers that have been proven useful to support diagnosis and monitoring of (bacterial) respiratory tract infections and sepsis. While limited studies suggest their usefulness in supporting UTI diagnosis, their utility has not been studied in elderly populations for this purpose. METHODS AND ANALYSIS In a 24-month matched prospective study, 'PROGRESS' will assess and compare the sensitivity of rapid POC measurements of blood CRP and PCT levels to support clinical rules for diagnosing UTI in nursing home residents. The primary outcome measure is sensitivity of the POC tests to identify patients with true UTI based on the predefined definition, as derived from receiver operating curves. ETHICS AND DISSEMINATION This study will be conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. The study protocol is approved by the Medical Ethical Committee of Amsterdam UMC location VUmc with reference number 2017.350 and National Central Committee on Research involving Human Subjects with reference number NL62067.029.17. TRIAL REGISTRATION NUMBER NTR6467.
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Affiliation(s)
- Sacha D Kuil
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Soemeja Hidad
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Johan C Fischer
- Clinical Chemistry, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke Harting
- Public Health, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Cees Mpm Hertogh
- General Practice and Elderly Care Medicine, Amsterdam UMC Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Internal Medicine, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Frank van Leth
- Global Health, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Menno D de Jong
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Caroline Schneeberger
- Medical Microbiology, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
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113
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Bloom AS, Suchindran S, Steinbrink J, McClain MT. Utility of predictive tools for risk stratification of elderly individuals with all-cause acute respiratory infection. Infection 2019; 47:617-627. [PMID: 30929142 DOI: 10.1007/s15010-019-01299-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE A number of scoring tools have been developed to predict illness severity and patient outcome for proven pneumonia, however, less is known about the utility of clinical prediction scores for all-cause acute respiratory infection (ARI), especially in elderly subjects who are at increased risk of poor outcomes. METHODS We retrospectively analyzed risk factors and outcomes of individuals ≥ 60 years of age presenting to the emergency department with a clinical diagnosis of ARI. RESULTS Of 276 individuals in the study, 40 had proven viral infection and 52 proven bacterial infection, but 184 patients with clinically adjudicated ARI (67%) remained without a proven microbial etiology despite extensive clinical (and expanded research) workup. Patients who were older, had multiple comorbidities, or who had proven bacterial infection were more likely to require hospital and ICU admission. We identified a novel model based on 11 demographic and clinical variables that were significant risk factors for ICU admission or mortality in elderly subjects with all-cause ARI. As comparators, a modified PORT score was found to correlate more closely with all-cause ARI severity than a modified CURB-65 score (r, 0.54, 0.39). Interestingly, modified Jackson symptom scores were found to inversely correlate with severity (r, - 0.34) but show potential for differentiating viral and bacterial etiologies. CONCLUSIONS Modified PORT, CURB-65, Jackson symptom scores, and a novel ARI scoring tool presented herein all offer predictive ability for all-cause ARI in elderly subjects. Such broadly applicable scoring metrics have the potential to assist in treatment and triage decisions at the point of care.
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Affiliation(s)
| | - Sunil Suchindran
- Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Julie Steinbrink
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Micah T McClain
- Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC, USA.
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA.
- Durham Veteran's Affairs Medical Center, Durham, NC, USA.
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114
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Walter JM, Ren Z, Yacoub T, Reyfman PA, Shah RD, Abdala-Valencia H, Nam K, Morgan VK, Anekalla KR, Joshi N, McQuattie-Pimentel AC, Chen CI, Chi M, Han S, Gonzalez-Gonzalez FJ, Soberanes S, Aillon RP, Watanabe S, Williams KJN, Lu Z, Paonessa J, Hountras P, Breganio M, Borkowski N, Donnelly HK, Allen JP, Amaral LA, Bharat A, Misharin AV, Bagheri N, Hauser AR, Budinger GRS, Wunderink RG. Multidimensional Assessment of the Host Response in Mechanically Ventilated Patients with Suspected Pneumonia. Am J Respir Crit Care Med 2019; 199:1225-1237. [PMID: 30398927 PMCID: PMC6519857 DOI: 10.1164/rccm.201804-0650oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 11/02/2018] [Indexed: 12/14/2022] Open
Abstract
Rationale: The identification of informative elements of the host response to infection may improve the diagnosis and management of bacterial pneumonia. Objectives: To determine whether the absence of alveolar neutrophilia can exclude bacterial pneumonia in critically ill patients with suspected infection and to test whether signatures of bacterial pneumonia can be identified in the alveolar macrophage transcriptome. Methods: We determined the test characteristics of alveolar neutrophilia for the diagnosis of bacterial pneumonia in three cohorts of mechanically ventilated patients. In one cohort, we also isolated macrophages from alveolar lavage fluid and used the transcriptome to identify signatures of bacterial pneumonia. Finally, we developed a humanized mouse model of Pseudomonas aeruginosa pneumonia to determine if pathogen-specific signatures can be identified in human alveolar macrophages. Measurements and Main Results: An alveolar neutrophil percentage less than 50% had a negative predictive value of greater than 90% for bacterial pneumonia in both the retrospective (n = 851) and validation cohorts (n = 76 and n = 79). A transcriptional signature of bacterial pneumonia was present in both resident and recruited macrophages. Gene signatures from both cell types identified patients with bacterial pneumonia with test characteristics similar to alveolar neutrophilia. Conclusions: The absence of alveolar neutrophilia has a high negative predictive value for bacterial pneumonia in critically ill patients with suspected infection. Macrophages can be isolated from alveolar lavage fluid obtained during routine care and used for RNA-Seq analysis. This novel approach may facilitate a longitudinal and multidimensional assessment of the host response to bacterial pneumonia.
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Affiliation(s)
- James M. Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Ziyou Ren
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Tyrone Yacoub
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Paul A. Reyfman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Raj D. Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Kiwon Nam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Vince K. Morgan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Kishore R. Anekalla
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Nikita Joshi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Ching-I Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Monica Chi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - SeungHye Han
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Saul Soberanes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Raul P. Aillon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Satoshi Watanabe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Ziyan Lu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Joseph Paonessa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Peter Hountras
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Madonna Breganio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Nicole Borkowski
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Helen K. Donnelly
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Jonathan P. Allen
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois; and
| | - Luis A. Amaral
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Feinberg School of Medicine, and
| | | | - Neda Bagheri
- Department of Chemical and Biological Engineering, Northwestern University, Evanston, Illinois
| | - Alan R. Hauser
- Department of Microbiology and Immunology, Northwestern University, Chicago, Illinois; and
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115
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[Diagnosis of sepsis and guidance of antibiotic therapy]. Med Klin Intensivmed Notfmed 2019; 114:286-289. [PMID: 30944943 DOI: 10.1007/s00063-019-0570-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/04/2019] [Indexed: 12/31/2022]
Abstract
There is a widespread use of biomarkers in modern intensive care. The potential benefit for the patients is, however, not fully investigated. This paper will discuss biomarkers regarding the diagnosis of infections and their potential use in antibiotic stewardship programs (ABS) in order to guide antimicrobial therapy. In the field of infections, procalcitonin (PCT) seems to be the most widespread marker. PCT is able to differentiate between inflammation and infection. Also, in the context of ABS rounds, PCT is well established.
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116
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Noviello S, Huang DB. The Basics and the Advancements in Diagnosis of Bacterial Lower Respiratory Tract Infections. Diagnostics (Basel) 2019; 9:E37. [PMID: 30987144 PMCID: PMC6627325 DOI: 10.3390/diagnostics9020037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/26/2019] [Accepted: 03/30/2019] [Indexed: 11/17/2022] Open
Abstract
Lower respiratory tract infections (LRTIs) are the leading infectious cause of death and the sixth-leading cause of death overall worldwide. Streptococcus pneumoniae, with more than 90 serotypes, remains the most common identified cause of community-acquired acute bacterial pneumonia. Antibiotics treat LRTIs with a bacterial etiology. With the potential for antibiotic-resistant bacteria, defining the etiology of the LRTI is imperative for appropriate patient treatment. C-reactive protein and procalcitonin are point-of-care tests that may differentiate bacterial versus viral etiologies of LRTIs. Major advancements are currently advancing the ability to make rapid diagnoses and identification of the bacterial etiology of LRTIs, which will continue to support antimicrobial stewardship, and is the focus of this review.
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Affiliation(s)
| | - David B Huang
- Motif BioSciences, Princeton, NJ 08540, USA.
- Department of Internal Medicine, Division of Infectious Diseases, Rutgers New Jersey Medical School, Trenton, NJ 07103, USA.
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117
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Leng Y, Chen C, Zhang Y, Luo C, Liu B. Ability of serum procalcitonin to distinguish focus of infection and pathogen types in patients with bloodstream infection. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:135. [PMID: 31157256 DOI: 10.21037/atm.2019.03.24] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Serum procalcitonin (PCT) is a widely recognized inflammatory marker which can distinguish systemic bacterial infection from other types of infections. The ability of PCT levels to distinguish different pathogens from different focus of infection is contradictory. Methods This study included 551 patients with bloodstream infection (BSI) diagnosed with positive blood culture (BC) during Jan 2013 and May 2018. The patients were divided into two groups with or without definite focus of infection. In this study, we analyzed PCT levels induced by Gram-positive bacteria, Gram-negative bacteria and fungal infection. Relationship of time between PCT peak and BC collection, and the impact of antibiotics usage on PCT peak distribution were examined. Results For patients without definite focus of infection, the serum PCT values of Gram-negative bacteria were higher than that of Gram-positive bacteria (P<0.05). A cut-off value of 7.54 ng/mL for PCT showed a sensitivity of 88.3%. For patients with definite focus of infection, the serum PCT values of Gram-negative bacteria were significantly higher than Gram-positive bacteria in patients with lower respiratory tract (P=0.003), abdominal (P=0.039), urinary tract infection (P=0.025), but not in patients with upper respiratory tract infection (P=0.664). The PCT values between multidrug-resistant organism (MDRO) and sensitive bacteria were not statistically significant (P>0.05) among all patients. Moreover, among patients who use antibiotics before BC collection, the longer antibiotics used, the higher trend of the proportion for PCT peak distribution after BC collection. The higher proportion of antibiotics combined before BC collection, the lower proportion of PCT peak distribution appeared before BC collection, and the higher the proportion of PCT peak distribution appeared after BC collection. Conclusions PCT value is determined by many factors. PCT value is related to not only Gram-positive bacteria or Gram-negative bacteria, but also related to specific pathogens, and specific of infection sites etc. The use of Antibiotics is also an important factor of PCT value.
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Affiliation(s)
- Yinzhi Leng
- Department of Infection Management Office, Nanjing Hospital of Chinese Medicine, Nanjing 210001, China.,Department of Infection Management Office, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Caiyun Chen
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yongxiang Zhang
- Department of Infection Management Office, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Can Luo
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Bo Liu
- Department of Infection Management Office, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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118
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Dong R, Wan B, Lin S, Wang M, Huang J, Wu Y, Wu Y, Zhang N, Zhu Y. Procalcitonin and Liver Disease: A Literature Review. J Clin Transl Hepatol 2019; 7:51-55. [PMID: 30944820 PMCID: PMC6441648 DOI: 10.14218/jcth.2018.00012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/02/2018] [Accepted: 10/23/2018] [Indexed: 12/23/2022] Open
Abstract
Procalcitonin (PCT) is a widely used biomarker for the diagnosis of bacterial infections. It is produced by various organs and the liver is considered to be the most important site of production. Severe liver dysfunction has been shown to influence PCT levels. Patients with no sources of infection who have liver disease are observed to have increased serum levels of PCT, thereby reducing the diagnostic utility and value within this particular patient subset. Here, we have summarized the relationship between PCT and liver disease, including liver cirrhosis, liver failure, and liver transplantation.
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Affiliation(s)
- Ruolin Dong
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Bo Wan
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Mingfang Wang
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jiaofeng Huang
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yinlian Wu
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yilong Wu
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Nanwen Zhang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yueyong Zhu
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- *Correspondence to: Yueyong Zhu, Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China. Tel: +86-591-87981660, Fax: +86-591-83356180, E-mail:
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119
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Subedi B, Louzon P, Zappas K, Onyia W, DeBoer K. Impact of Pharmacist-Led Procalcitonin-Guided Antibiotic Therapy in Critically Ill Patients With Pneumonia. Hosp Pharm 2019; 55:204-210. [PMID: 32508359 DOI: 10.1177/0018578719836643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Procalcitonin (PCT) is a peptide that is released in response to bacterial infections. The 2016 Infectious Diseases Society of America pneumonia guidelines recommend PCT monitoring to help guide antibiotic discontinuation. Utilization of PCT is well described in the literature; however, there is a paucity of literature regarding pharmacists' involvement for using PCT in antibiotic interventions. The objective of this study was to investigate the effect of pharmacist-led intervention with PCT-guided antibiotic therapy in critically ill patients with pneumonia. Methods: This was a pre-post study conducted at a 1368-bed community teaching hospital in the United States. A prospective cohort with pharmacist intervention utilizing PCT-algorithm guidance was compared with a retrospective historical cohort with standard therapy. Adult patients admitted to the intensive care unit (ICU) with pneumonia were included. The primary endpoint was duration of antibiotic therapy. Secondary endpoints included 28-day mortality, ICU and hospital length of stay, reinitiation of antibiotic therapy, and the incidence of Clostridium difficile infection. Results: From August 2016 to July 2017, 113 patients were screened in the PCT group and 123 patients in the standard therapy group. Of these, 37 patients were included in the PCT group and 37 patients in the standard therapy group. Baseline characteristics were similar between the 2 groups. The antibiotic duration of therapy was 6.3 days in the PCT group versus 9.7 days in the standard therapy group (P < .001). There were no differences in secondary endpoints between the 2 groups. Conclusion: Clinical pharmacists' intervention with PCT-guided antibiotic therapy led to a reduction in the duration of antibiotic therapy in critically ill patients with pneumonia without increasing complications.
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120
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Corrêa RDA, Costa AN, Lundgren F, Michelin L, Figueiredo MR, Holanda M, Gomes M, Teixeira PJZ, Martins R, Silva R, Athanazio RA, Silva RMD, Pereira MC. 2018 recommendations for the management of community acquired pneumonia. ACTA ACUST UNITED AC 2019; 44:405-423. [PMID: 30517341 PMCID: PMC6467584 DOI: 10.1590/s1806-37562018000000130] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022]
Abstract
Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.
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Affiliation(s)
- Ricardo de Amorim Corrêa
- . Faculdade de Medicina, Universidade Federal de Minas Gerais - UFMG - Belo Horizonte (MG) Brasil
| | - Andre Nathan Costa
- . Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP) Brasil
| | | | - Lessandra Michelin
- . Faculdade de Medicina, Universidade de Caxias do Sul, Caxias do Sul (RS) Brasil
| | | | - Marcelo Holanda
- . Faculdade de Medicina, Universidade Federal do Ceará - UFC - Fortaleza (CE) Brasil
| | - Mauro Gomes
- . Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo (SP) Brasil
| | | | - Ricardo Martins
- . Faculdade de Medicina, Universidade de Brasília - UnB - Brasília (DF) Brasil
| | - Rodney Silva
- . Faculdade de Medicina, Universidade Federal do Paraná - UFPR - Curitiba (PR) Brasil
| | | | | | - Mônica Corso Pereira
- . Faculdade de Medicina, Universidade Estadual de Campinas - Unicamp - Campinas (SP) Brasil
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Civljak R, Tot T, Falsey AR, Huljev E, Vranes J, Ljubin-Sternak S. Viral pathogens associated with acute respiratory illness in hospitalized adults and elderly from Zagreb, Croatia, 2016 to 2018. J Med Virol 2019; 91:1202-1209. [PMID: 30801727 PMCID: PMC7166480 DOI: 10.1002/jmv.25437] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/22/2022]
Abstract
Aims To investigate the viral etiology of acute respiratory infection (ARI) in hospitalized adults and elderly patients in Croatia, compare the prevalence of detected viruses, and to determine clinical characteristics and seasonal occurrence of investigated infections. Methods From January 2016 to June 2018, a total of 182 adult patients presented with symptoms of ARI and admitted to the hospital were tested for 15 respiratory viruses by multiplex reverse‐transcription polymerase chain reaction. Clinical data were collected by retrospective analysis of the patient's chart. Results A virus was identified in 106 (58.5%) of the patients. The most commonly detected virus was influenza virus (41.5%), followed by respiratory syncytial virus (13.8%), human metapneumovirus (13.0%), parainfluenza viruses (12.2%), rhinoviruses (11.4%), adenovirus and coronaviruses with equal frequencies (3.3%), and enterovirus (1.6%). The serum level of C‐reactive protein and white blood cell count were significantly lower in patients with respiratory viruses identified when compared with those in whom no virus was detected (P < 0.001 and
P = 0.007, respectively). There were no differences in clinical symptoms according to the type of the detected virus, except for more frequent illness exposure recall for influenza infection (
P = 0.010). Influenza, parainfluenza, and pneumoviruses were detected mostly in winter months, while rhinoviruses in autumn and spring. Conclusions In addition to influenza, pneumoviruses, rhinoviruses, and parainfluenza viruses play an important role in etiology of ARIs in adults. Fast and accurate laboratory diagnosis for respiratory viruses in routine practice is needed for clinicians optimally manage patients with ARI and potentially avoid the unnecessary use of antimicrobial drugs.
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Affiliation(s)
- Rok Civljak
- Department of Respiratory Tract Infections, Dr Fran Mihaljevic University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tatjana Tot
- Department of Microbiology, General Hospital Karlovac, Karlovac, Croatia
| | - Ann R Falsey
- Department of Medicine, Rochester General Hospital and University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eva Huljev
- Department of Respiratory Tract Infections, Dr Fran Mihaljevic University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Jasmina Vranes
- Department of Clinical Microbiology, Dr Andrija Stampar Teaching Institute of Public Health, Zagreb, Croatia.,Department of Medical Microbiology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Suncanica Ljubin-Sternak
- Department of Clinical Microbiology, Dr Andrija Stampar Teaching Institute of Public Health, Zagreb, Croatia.,Department of Medical Microbiology, University of Zagreb School of Medicine, Zagreb, Croatia
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Mathioudakis AG, Vestbo J. Was the implementation strategy of the ProACT trial adequately proactive? Breathe (Sheff) 2019; 15:77-80. [PMID: 30838064 PMCID: PMC6395982 DOI: 10.1183/20734735.0338-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Rising antimicrobial resistance rates represent an alarming threat to public health, currently causing over 25 000 and 23 000 deaths per year in European Union and the USA, respectively [1, 2]. The significant global overuse of antibiotics amplifies the development of resistant bacterial strains [1, 2]. A recent national audit in the USA estimated that almost half of all antibiotic prescriptions were issued for respiratory tract infections (221 antibiotic prescriptions per 1000 population per year) and half of them were inappropriate [3]. Extensive campaigns have been carried out to promote antibiotic stewardship guidance in an attempt to limit the administration of unneeded antibiotics, but their impact has been modest [4, 5]. The ProACT trial does not inform the evidence base regarding safety and clinical effectiveness of procalcitonin (PCT) as a biomarker to guide antibiotic administration for LRTIs, but reveals potential challenges in the introduction of PCT in real life.http://ow.ly/Enfr30n2TK6
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
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The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis. J Infect 2019; 78:339-348. [PMID: 30802469 PMCID: PMC7173077 DOI: 10.1016/j.jinf.2019.02.006] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the utility of the neutrophil:lymphocyte (NLR), lymphocyte:monocyte (LMR) and platelet:lymphocyte ratios (PLR) as infection biomarkers. METHODS PubMed/MEDLINE, Embase and Cochrane databases were searched to identify eligible articles. Studies of diagnosis, severity or outcome were included. PROSPERO systematic review registration CRD42017075032. RESULTS Forty studies were included, reporting on bacterial and viral infections, malaria, and critical illness due to sepsis. Ten studies reported an association of higher NLR with bacteraemia, supported by meta-analysis of patient-level data (five studies, n = 3320; AUC 0.72, p<0.0001) identifying a cut-off of >12.65. Two studies reported an association with lower LMR and diagnosis of influenza virus infection in patients with respiratory tract infection. Meta-analysis of patient-level data (n = 85; AUC 0.66, p = 0.01) identified a cut-off of ≤2.06. The directionality of associations between NLR and outcomes in heterogeneous cohorts of critically ill adults with sepsis varied. Potential clinical utility was also demonstrated in pneumonia (NLR), pertussis (NLR), urinary tract infection (NLR), diabetic foot infections (NLR) and Crimean Congo Haemorrhagic Fever (PLR). Longitudinal measurement of LMR during respiratory virus infection reflected symptoms and NLR during sepsis and bacteraemia predicted mortality. CONCLUSIONS Peripheral blood leucocyte ratios are useful infection biomarkers, with the most evidence related to diagnosis of bacteraemia and influenza virus infection. In critical illness due to sepsis, a signal towards an association with NLR and outcomes exists, and NLR should be evaluated in future stratification models. Longitudinal measurement of ratios during infection could be informative. Overall, these biomarkers warrant further recognition and study in infectious diseases.
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de Carvalho FT, Rabello Filho R, Bulgarelli L, Serpa Neto A, Deliberato RO. Procalcitonin as a Diagnostic, Therapeutic, and Prognostic Tool: a Critical Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0178-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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125
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Stalenhoef JE, van Nieuwkoop C, Wilson DC, van der Starre WE, van der Reijden TJK, Delfos NM, Leyten EMS, Koster T, Ablij HC, van 't Wout JJW, van Dissel JT. Procalcitonin, mid-regional proadrenomedullin and C-reactive protein in predicting treatment outcome in community-acquired febrile urinary tract infection. BMC Infect Dis 2019; 19:161. [PMID: 30764769 PMCID: PMC6376649 DOI: 10.1186/s12879-019-3789-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/07/2019] [Indexed: 12/22/2022] Open
Abstract
Background A reduction in duration of antibiotic therapy is crucial in minimizing the development of antimicrobial resistance, drug-related side effects and health care costs. The minimal effective duration of antimicrobial therapy for febrile urinary tract infections (fUTI) remains a topic of uncertainty, especially in male patients, those of older age or with comorbidities. Biomarkers have the potential to objectively identify the optimal moment for cessation of therapy. Methods A secondary analysis of a randomized placebo-controlled trial among 35 primary care centers and 7 emergency departments of regional hospitals in the Netherlands. Women and men aged ≥18 years with a diagnosis of fUTI were randomly assigned to receive antibiotic treatment for 7 or 14 days. Patients indicated to receive antimicrobial treatment for more than 14 days were excluded from randomization. The biomarkers procalcitonin (PCT), mid-regional proadrenomedullin (MR-proADM), and C-reactive protein (CRP) were compared in their ability to predict clinical cure or failure through the 10–18 day post-treatment visit. Results Biomarker concentrations were measured in 249 patients, with a clinical cure rate of 94% in the 165 randomized and 88% in the 84 non-randomized patients. PCT, MR-proADM and CRP concentrations did not differ between patients with clinical cure and treatment failure, and did not predict treatment outcome, irrespective of 7 or 14 day treatment duration (ROCAUC 0.521; 0.515; 0.512, respectively). PCT concentrations at presentation were positively correlated with bacteraemia (τ = 0.33, p < 0.001) and presence of shaking chills (τ = 0.25, p < 0.001), and MR-proADM levels with length of hospital stay (τ = 0.40, p < 0.001), bacteraemia (τ = 0.33, p < 0.001), initial intravenous treatment (τ = 0.22, p < 0.001) and time to defervescence (τ = 0.21, p < 0.001). CRP did not display any correlation to relevant clinical parameters. Conclusions Although the biomarkers PCT and MR-proADM were correlated to clinical parameters indicating disease severity, they did not predict treatment outcome in patients with community acquired febrile urinary tract infection who were treated for either 7 or 14 days. CRP had no added value in the management of patients with fUTI. Trial registration The study was registered at ClinicalTrials.gov [NCT00809913; December 16, 2008] and trialregister.nl [NTR1583; December 19, 2008].
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Affiliation(s)
- Janneke Evelyne Stalenhoef
- Department of Infectious Diseases, Leiden University Medical Center, PO, Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | | | | | - Tanny J K van der Reijden
- Department of Infectious Diseases, Leiden University Medical Center, PO, Box 9600, 2300 RC, Leiden, the Netherlands
| | | | | | - Ted Koster
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Jaap Tamino van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, PO, Box 9600, 2300 RC, Leiden, the Netherlands
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Fredman G, Kolpen M, Hertz FB, Petersen PT, Jensen AV, Baunbaek-Egelund G, Ravn P, Jensen PØ, Faurholt-Jepsen D. The inflamed sputum in lower respiratory tract infection: l-lactate levels are correlated to neutrophil accumulation. APMIS 2019; 127:72-79. [PMID: 30614067 PMCID: PMC7159756 DOI: 10.1111/apm.12913] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/26/2018] [Indexed: 11/30/2022]
Abstract
Lower respiratory tract infections (LRTI) are common, but little is known about the response of biomarkers of inflammation in the lungs. Therefore, our primary aim was to compare the concentration of l-lactate to the concentration of neutrophils in sputum and systemic markers of infection. Because it is difficult to differentiate viral and bacterial infection on the basis of clinical presentation in LRTI, our secondary aim was to evaluate if l- and d-lactate may serve as markers of local inflammation as representatives of neutrophils and bacteria, respectively. METHODS Patients with acute LRTI were prospectively recruited. Sputum samples were collected and analysed for neutrophil count, l-lactate and d-lactate. We had data on pathogens from sputum cultures and polymerase chain reaction (PCR) (atypical bacteria, virus) and C-reactive protein (CRP) from blood. RESULTS In 44 sputum samples from 32 patients, the median (interquartile range (IQR)) sputum neutrophil granulocyte count was 0.615 × 107 cells/mL (0.236-1.575). The sputum neutrophil granulocyte count was associated with sputum l-lactate (p = 0.011) and CRP (p = 0.018), but not with d-lactate (p = 0.177). There was a strong association between sputum d-lactate and l-lactate (p < 0.0001). CONCLUSION As l-lactate in sputum is closely correlated to sequestration of neutrophils in the lungs, l-lactate is a marker for local inflammation in LRTI and a potential biomarker in clinical management of LRTI. On expectorated sputum, d-lactate had no clinical relevance.
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Affiliation(s)
- Gabriella Fredman
- Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hillerød, Denmark
| | - Mette Kolpen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Pelle Trier Petersen
- Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hillerød, Denmark
| | | | | | - Pernille Ravn
- Department of Internal Medicine, Herlev-Gentofte Hospital, Hellerup
| | - Peter Østrup Jensen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark.,Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Faurholt-Jepsen
- Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hillerød, Denmark
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Khilnani, GC, Zirpe, K, Hadda, V, Mehta, Y, Madan, K, Kulkarni, A, Mohan, A, Dixit, S, Guleria, R, Bhattacharya, P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian J Crit Care Med 2019; 23:S1-S63. [PMID: 31516211 PMCID: PMC6734471 DOI: 10.5005/jp-journals-10071-23101] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.
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Affiliation(s)
- GC Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Vijay Hadda,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Yatin Mehta,
- Indian Society of Critical Care Medicine, Medanta Institute of Critical Care and Anesthesiology, Gurugram, Haryana, India
| | - Karan Madan,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Kulkarni,
- Department of Anaesthesiology, Division of Critical Care Medicine, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anant Mohan,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Subhal Dixit,
- Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Randeep Guleria,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Bhattacharya,
- Department of Anaesthesiology, Critical Care and Emergency Services, Bhopal, Madhya Pradesh, India
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128
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Abstract
Community-acquired pneumonia (CAP) is the third most common cause of death globally. Due to the complexity of CAP, it is widely accepted that, currently, clinical prognosis and diagnosis is inadequate for the assessment of the severity of the disease. With the aim to determining the initial treatment and the appropriate level of intervention, several clinical scores of severity and biomarkers have been developed. Both biomarkers and clinical scoring systems are expected to determine the different aspects of the host factor and the response to therapy, in order for physicians to be able to make an accurate benefit/risk assessment that will lead to proper diagnosis and correct prescription of antibiotics. This review aims to highlight the prognostic and diagnostic accuracy of various laboratory and clinical parameters in CAP and discuss the perspectives for the reduction of CAP mortality.
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Affiliation(s)
- Meropi Karakioulaki
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Daiana Stolz
- Department of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
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129
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Poore GD, Ko ER, Valente A, Henao R, Sumner K, Hong C, Burke TW, Nichols M, McClain MT, Huang ES, Ginsburg GS, Woods CW, Tsalik EL. A miRNA Host Response Signature Accurately Discriminates Acute Respiratory Infection Etiologies. Front Microbiol 2018; 9:2957. [PMID: 30619110 PMCID: PMC6298190 DOI: 10.3389/fmicb.2018.02957] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/16/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Acute respiratory infections (ARIs) are the leading indication for antibacterial prescriptions despite a viral etiology in the majority of cases. The lack of available diagnostics to discriminate viral and bacterial etiologies contributes to this discordance. Recent efforts have focused on the host response as a source for novel diagnostic targets although none have explored the ability of host-derived microRNAs (miRNA) to discriminate between these etiologies. Methods: In this study, we compared host-derived miRNAs and mRNAs from human H3N2 influenza challenge subjects to those from patients with Streptococcus pneumoniae pneumonia. Sparse logistic regression models were used to generate miRNA signatures diagnostic of ARI etiologies. Generalized linear modeling of mRNAs to identify differentially expressed (DE) genes allowed analysis of potential miRNA:mRNA relationships. High likelihood miRNA:mRNA interactions were examined using binding target prediction and negative correlation to further explore potential changes in pathway regulation in response to infection. Results: The resultant miRNA signatures were highly accurate in discriminating ARI etiologies. Mean accuracy was 100% [88.8-100; 95% Confidence Interval (CI)] in discriminating the healthy state from S. pneumoniae pneumonia and 91.3% (72.0-98.9; 95% CI) in discriminating S. pneumoniae pneumonia from influenza infection. Subsequent differential mRNA gene expression analysis revealed alterations in regulatory networks consistent with known biology including immune cell activation and host response to viral infection. Negative correlation network analysis of miRNA:mRNA interactions revealed connections to pathways with known immunobiology such as interferon regulation and MAP kinase signaling. Conclusion: We have developed novel human host-response miRNA signatures for bacterial and viral ARI etiologies. miRNA host response signatures reveal accurate discrimination between S. pneumoniae pneumonia and influenza etiologies for ARI and integrated analyses of the host-pathogen interface are consistent with expected biology. These results highlight the differential miRNA host response to bacterial and viral etiologies of ARI, offering new opportunities to distinguish these entities.
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Affiliation(s)
- Gregory D. Poore
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Emily R. Ko
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Hospital Medicine, Duke Regional Hospital, Durham, NC, United States
| | - Ashlee Valente
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Kelsey Sumner
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Christopher Hong
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Thomas W. Burke
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Marshall Nichols
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Micah T. McClain
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, United States
- Medicine Service, Durham VA Medical Center, Durham, NC, United States
| | - Erich S. Huang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical and Translational Science Institute, Durham, NC, United States
| | - Geoffrey S. Ginsburg
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Christopher W. Woods
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, United States
- Medicine Service, Durham VA Medical Center, Durham, NC, United States
| | - Ephraim L. Tsalik
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, United States
- Emergency Medicine Service, Durham VA Health Care System, Durham, NC, United States
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130
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Townsend J, Adams V, Galiatsatos P, Pearse D, Pantle H, Masterson M, Kisuule F, Jacob E, Kiruthi C, Ortiz P, Agbanlog A, Jurao R, Stern S, Nayak S, Melgar M, Sama J, Irwin J, Mazidi C, Psoter K, McKenzie R. Procalcitonin-Guided Antibiotic Therapy Reduces Antibiotic Use for Lower Respiratory Tract Infections in a United States Medical Center: Results of a Clinical Trial. Open Forum Infect Dis 2018; 5:ofy327. [PMID: 30619913 PMCID: PMC6306569 DOI: 10.1093/ofid/ofy327] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/14/2018] [Accepted: 11/29/2018] [Indexed: 01/09/2023] Open
Abstract
Background European trials using procalcitonin (PCT)-guided antibiotic therapy for patients with lower respiratory tract infections (LRTIs) have demonstrated significant reductions in antibiotic use without increasing adverse outcomes. Few studies have examined PCT for LRTIs in the United States. Methods In this study, we evaluated whether a PCT algorithm would reduce antibiotic exposure in patients with LRTI in a US hospital. We conducted a controlled pre-post trial comparing an intervention group of PCT-guided antibiotic therapy to a control group of usual care. Consecutive patients admitted to medicine services and receiving antibiotics for LRTI were enrolled in the intervention. Providers were encouraged to discontinue antibiotics according to a PCT algorithm. Control patients were similar patients admitted before the intervention. Results The primary endpoint was median antibiotic duration. Overall adverse outcomes at 30 days comprised death, transfer to an intensive care unit, antibiotic side effects, Clostridium difficile infection, disease-specific complications, and post-discharge antibiotic prescription for LRTI. One hundred seventy-four intervention patients and 200 controls were enrolled. Providers complied with the PCT algorithm in 75% of encounters. Procalcitonin-guided therapy reduced median antibiotic duration for pneumonia from 7 days to 6 (P = .045) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) from 4 days to 3 (P = .01). There was no difference in the rate of adverse outcomes in the PCT and control groups. Conclusions A PCT-guided algorithm safely reduced the duration of antibiotics for treating LRTI. Utilization of a PCT algorithm may aid antibiotic stewardship efforts. This clinical trial was a single-center, controlled, pre-post study of PCT-guided antibiotic therapy for LRTI. The intervention (incorporation of PCT-guided algorithms) started on April 1, 2017: the preintervention (control group) comprised patients admitted from November 1, 2016 to April 16, 2017, and the postintervention group comprised patients admitted from April 17, 2017 to November 29, 2017 (Supplementary Figure 1). The study comprised patients admitted to the internal medicine services to a medical ward, the Medical Intensive Care Unit (MICU), the Cardiac Intensive Care Unit (CICU), or the Progressive Care Unit (PCU) “step down unit”. The registration data for the trails are in the ClinicalTrials.gov database, number NCT0310910.
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Affiliation(s)
- Jennifer Townsend
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Victoria Adams
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - David Pearse
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Hardin Pantle
- Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Mary Masterson
- Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Flora Kisuule
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Elsen Jacob
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Catherine Kiruthi
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Paul Ortiz
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Albert Agbanlog
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Robert Jurao
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Sam Stern
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Seema Nayak
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Michael Melgar
- Division of Internal Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Jacob Sama
- Division of Internal Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Jillian Irwin
- Division of Internal Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Cyrus Mazidi
- Division of Internal Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Kevin Psoter
- Division of General Pediatrics and Adolescent Medicine, School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Robin McKenzie
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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131
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Abstract
Objective: Most positive studies in procalcitonin (PCT) utilization were done in large, tertiary medical centers. Furthermore, there is a paucity of data describing the implementation process. This article is the first to describe in detail the implementation process and initial outcomes after 6 months of PCT testing in a rural, 65-bed, primary hospital. Methods: Education before and during PCT implementation as well as facility rollout are described. Initial outcomes were assessed using a before and after quasi-experimental study design comparing 2 identical 6-month time periods: May to October 2016 and May to October 2017. Antibiotic consumption is described with days of therapy (DOT) per 1000 patient days (PD). Antimicrobial purchasing costs, admission rates, and length of stay (LOS) are also compared. Results: Antimicrobial consumption was variable with the greatest reduction at 6 months: 856 DOT/1000 PD before versus 576 DOT/1000 PD after (P < .0001). Admission rates and LOS were unaffected. There was no associated savings in antibiotic purchasing costs: $114 189.79 before and $139 829.26 after (difference +$25 639.47). Conclusion: Although implementation of PCT testing is feasible in a rural health care facility, after 6 months, it was associated with a marginal decrease in antibiotic consumption with no decrease in admission rates, LOS, or antibiotic cost savings.
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Affiliation(s)
- Jennifer L. Cole
- Veterans Health Care System of the
Ozarks, Fayetteville, AR, USA
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132
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Abstract
Influenza and other respiratory viruses are commonly identified in patients with community-acquired pneumonia, hospital-acquired pneumonia, and in immunocompromised patients with pneumonia. Clinically, it is difficult to differentiate viral from bacterial pneumonia. Similarly, the radiological findings of viral infection are nonspecific. The advent of polymerase chain reaction testing has enormously facilitated the identification of respiratory viruses, which has important implications for infection control measures and treatment. Currently, treatment options for patients with viral infection are limited, but there is ongoing research on the development and clinical testing of new treatment regimens and strategies.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, University of Louisville, 550 South Jackson Street, ACB, A3R27, Louisville, KY 40202, USA.
| | - Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Med Center One, 501 E. Broadway Suite 100, Louisville, KY 40202, USA
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Kip MMA, van Oers JA, Shajiei A, Beishuizen A, Berghuis AMS, Girbes AR, de Jong E, de Lange DW, Nijsten MWN, IJzerman MJ, Koffijberg H, Kusters R. Cost-effectiveness of procalcitonin testing to guide antibiotic treatment duration in critically ill patients: results from a randomised controlled multicentre trial in the Netherlands. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:293. [PMID: 30424796 PMCID: PMC6234639 DOI: 10.1186/s13054-018-2234-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/15/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Procalcitonin (PCT) testing can help in safely reducing antibiotic treatment duration in intensive care patients with sepsis. However, the cost-effectiveness of such PCT guidance is not yet known. METHODS A trial-based analysis was performed to estimate the cost-effectiveness of PCT guidance compared with standard of care (without PCT guidance). Patient-level data were used from the SAPS trial in which 1546 patients were randomised. This trial was performed in the Netherlands, which is a country with, on average, low antibiotic use and a short duration of hospital stay. As quality of life among sepsis survivors was not measured during the SAPS, this was derived from a Dutch follow-up study. Outcome measures were (1) incremental direct hospital cost and (2) incremental cost per quality-adjusted life year (QALY) gained from a healthcare perspective over a one-year time horizon. Uncertainty in outcomes was assessed with bootstrapping. RESULTS Mean in-hospital costs were €46,081/patient in the PCT group compared with €46,146/patient with standard of care (i.e. - €65 (95% CI - €6314 to €6107); - 0.1%). The duration of the first course of antibiotic treatment was lower in the PCT group with 6.9 vs. 8.2 days (i.e. - 1.2 days (95% CI - 1.9 to - 0.4), - 14.8%). This was accompanied by lower in-hospital mortality of 21.8% vs. 29.8% (absolute decrease 7.9% (95% CI - 13.9% to - 1.8%), relative decrease 26.6%), resulting in an increase in mean QALYs/patient from 0.47 to 0.52 (i.e. + 0.05 (95% CI 0.00 to 0.10); + 10.1%). However, owing to high costs among sepsis survivors, healthcare costs over a one-year time horizon were €73,665/patient in the PCT group compared with €70,961/patient with standard of care (i.e. + €2704 (95% CI - €4495 to €10,005), + 3.8%), resulting in an incremental cost-effectiveness ratio of €57,402/QALY gained. Within this time frame, the probability of PCT guidance being cost-effective was 64% at a willingness-to-pay threshold of €80,000/QALY. CONCLUSIONS Although the impact of PCT guidance on total healthcare-related costs during the initial hospitalisation episode is likely negligible, the lower in-hospital mortality may lead to a non-significant increase in costs over a one-year time horizon. However, since uncertainty remains, it is recommended to investigate the long-term cost-effectiveness of PCT guidance, from a societal perspective, in different countries and settings.
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Affiliation(s)
- Michelle M A Kip
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands.
| | - Jos A van Oers
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | - Arezoo Shajiei
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care, VU University Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands
| | - A M Sofie Berghuis
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands
| | - Armand R Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Evelien de Jong
- Department of Intensive Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Centre Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands
| | - Hendrik Koffijberg
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands
| | - Ron Kusters
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, P.O. Box 217, 7500 AE, Enschede, the Netherlands.,Laboratory for Clinical Chemistry and Hematology, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, the Netherlands
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135
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Abstract
The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
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136
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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137
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Crisafulli E, Barbeta E, Ielpo A, Torres A. Management of severe acute exacerbations of COPD: an updated narrative review. Multidiscip Respir Med 2018; 13:36. [PMID: 30302247 PMCID: PMC6167788 DOI: 10.1186/s40248-018-0149-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital. Main body In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD. Conclusion Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.
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Affiliation(s)
- Ernesto Crisafulli
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Enric Barbeta
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Antonella Ielpo
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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138
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González Del Castillo J, Candel FJ, de la Fuente J, Gordo F, Martín-Sánchez FJ, Menéndez R, Mujal A, Barberán J. [Integral approach to the acute exacerbation of chronic obstructive pulmonary disease]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:461-484. [PMID: 30284414 PMCID: PMC6194861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/04/2018] [Indexed: 11/12/2022]
Abstract
Chronic obstructive pulmonary disease is a set of clinical processes that have in common a chronic and progressive obstruction to airflow, with episodes of exacerbation. These exacerbations are more frequent and severe over time, deteriorating the lung function. The main cause of exacerbations is bacterial infection. There are multiple guidelines and documents that statement the management of this pathology. However, they focus primarily on the treatment during the stable phase. This document addresses the problem of acute exacerbation due to an infection from a multidisciplinary perspective, focusing on the integral approach to the process, and including etiology, microbiological studies, resistance to antimicrobials, risk stratification and initial empirical therapeutic management (antibiotic and concomitant). In addition, it includes an approach to more complex aspects such as the management of special populations (elderly and immunosuppressed) or therapeutic failure. Finally, more controversial topics such as prophylaxis of infection or palliative treatment are specifically discussed.
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Affiliation(s)
- J González Del Castillo
- Juan González del Castillo, Servicio de Urgencias. Hospital Clínico San Carlos. Calle Profesor Martín-Lagos s/n, 28040 Madrid. Spain.
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139
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Abstract
Pneumonia is a common cause of respiratory infection, accounting for more than 800,000 hospitalizations in the United States annually. Presenting symptoms of pneumonia are typically cough, pleuritic chest pain, fever, fatigue, and loss of appetite. Children and the elderly have different presenting features of pneumonia, which include headache, nausea, abdominal pain, and absence of one or more of the prototypical symptoms. Knowledge of local bacterial pathogens and their antibiotic susceptibility and resistance profiles is the key for effective pharmacologic selection and treatment of pneumonia.
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Affiliation(s)
- Samuel N Grief
- Clinical Family Medicine, Department of Family Medicine, University of Illinois at Chicago, 1919 West Taylor Street, Suite 143, Chicago, IL 60612, USA.
| | - Julie K Loza
- Department of Family Medicine, University of Illinois at Chicago, 1919 West Taylor Street, Chicago, IL 60612, USA
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140
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Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Schroeder S, Nobre V, Annane D, Reinhart K, Damas P, Nijsten M, Shajiei A, deLange DW, Deliberato RO, Oliveira CF, Shehabi Y, van Oers JAH, Beishuizen A, Girbes ARJ, de Jong E, Mueller B, Schuetz P. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018; 22:191. [PMID: 30111341 PMCID: PMC6092799 DOI: 10.1186/s13054-018-2125-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 07/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection. METHODS For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the "procalcitonin-guided" group) or the current standard of care (the "controls"). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay. RESULTS Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001). CONCLUSION Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
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Affiliation(s)
- Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Marc A. Meier
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Charles E. Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Florence Tubach
- Département d’Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Krankenhaus Dueren, Dueren, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, Garches, France
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | - Arezoo Shajiei
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | | | - Rodrigo O. Deliberato
- Laboratory for Critical Care Research, Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Carolina F. Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia
- Faculty of Medicine Nursing and Health Sciences, School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | | | | | | | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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141
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Feldman C, Richards G. Appropriate antibiotic management of bacterial lower respiratory tract infections. F1000Res 2018; 7:F1000 Faculty Rev-1121. [PMID: 30079235 PMCID: PMC6058472 DOI: 10.12688/f1000research.14226.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 01/05/2023] Open
Abstract
Lower respiratory tract infections are the leading cause of infectious disease deaths worldwide and are the fifth leading cause of death overall. This is despite conditions such as pneumococcal infections and influenza being largely preventable with the use of appropriate vaccines. The mainstay of treatment for the most important bacterial lower respiratory tract infections, namely acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP), is the use of antibiotics. Yet despite a number of recent publications, including clinical studies as well as several systematic literature reviews and meta-analyses, there is considerable ongoing controversy as to what the most appropriate antibiotics are for the empiric therapy of CAP in the different settings (outpatient, inpatient, and intensive care unit). Furthermore, in the case of AECOPD, there is a need for consideration of which of these exacerbations actually need antibiotic treatment. This article describes these issues and makes suggestions for appropriately managing these conditions, in the setting of the need for antimicrobial stewardship initiatives designed to slow current emerging rates of antibiotic resistance, while improving patient outcomes.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Guy Richards
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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142
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Huang DT, Yealy DM, Filbin MR, Brown AM, Chang CCH, Doi Y, Donnino MW, Fine J, Fine MJ, Fischer MA, Holst JM, Hou PC, Kellum JA, Khan F, Kurz MC, Lotfipour S, LoVecchio F, Peck-Palmer OM, Pike F, Prunty H, Sherwin RL, Southerland L, Terndrup T, Weissfeld LA, Yabes J, Angus DC. Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. N Engl J Med 2018; 379:236-249. [PMID: 29781385 PMCID: PMC6197800 DOI: 10.1056/nejmoa1802670] [Citation(s) in RCA: 267] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. METHODS In 14 U.S. hospitals with high adherence to quality measures for the treatment of pneumonia, we provided guidance for clinicians about national clinical practice recommendations for the treatment of lower respiratory tract infections and the interpretation of procalcitonin assays. We then randomly assigned patients who presented to the emergency department with a suspected lower respiratory tract infection and for whom the treating physician was uncertain whether antibiotic therapy was indicated to one of two groups: the procalcitonin group, in which the treating clinicians were provided with real-time initial (and serial, if the patient was hospitalized) procalcitonin assay results and an antibiotic use guideline with graded recommendations based on four tiers of procalcitonin levels, or the usual-care group. We hypothesized that within 30 days after enrollment the total antibiotic-days would be lower - and the percentage of patients with adverse outcomes would not be more than 4.5 percentage points higher - in the procalcitonin group than in the usual-care group. RESULTS A total of 1656 patients were included in the final analysis cohort (826 randomly assigned to the procalcitonin group and 830 to the usual-care group), of whom 782 (47.2%) were hospitalized and 984 (59.4%) received antibiotics within 30 days. The treating clinician received procalcitonin assay results for 792 of 826 patients (95.9%) in the procalcitonin group (median time from sample collection to assay result, 77 minutes) and for 18 of 830 patients (2.2%) in the usual-care group. In both groups, the procalcitonin-level tier was associated with the decision to prescribe antibiotics in the emergency department. There was no significant difference between the procalcitonin group and the usual-care group in antibiotic-days (mean, 4.2 and 4.3 days, respectively; difference, -0.05 day; 95% confidence interval [CI], -0.6 to 0.5; P=0.87) or the proportion of patients with adverse outcomes (11.7% [96 patients] and 13.1% [109 patients]; difference, -1.5 percentage points; 95% CI, -4.6 to 1.7; P<0.001 for noninferiority) within 30 days. CONCLUSIONS The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection. (Funded by the National Institute of General Medical Sciences; ProACT ClinicalTrials.gov number, NCT02130986 .).
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Affiliation(s)
- David T Huang
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Donald M Yealy
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael R Filbin
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Aaron M Brown
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Chung-Chou H Chang
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Yohei Doi
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael W Donnino
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Jonathan Fine
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael J Fine
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michelle A Fischer
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - John M Holst
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Peter C Hou
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - John A Kellum
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Feras Khan
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Michael C Kurz
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Shahram Lotfipour
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Frank LoVecchio
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Octavia M Peck-Palmer
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Francis Pike
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Heather Prunty
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Robert L Sherwin
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Lauren Southerland
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Thomas Terndrup
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Lisa A Weissfeld
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Jonathan Yabes
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
| | - Derek C Angus
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) - all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women's Hospital (P.C.H.) - all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
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143
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Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 2018; 20:31. [PMID: 29959545 DOI: 10.1007/s11908-018-0637-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions. RECENT FINDINGS AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.
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Affiliation(s)
- Jennifer Emberger
- Virginia Commonwealth University Medical Center, VMI Building, 2nd Floor, Room 204, Richmond, VA, 23298, USA.
| | - Dan Tassone
- Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - J Daniel Markley
- Department of Internal Medicine, Division of Infectious Diseases, Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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144
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Walter JM, Wunderink RG. Testing for Respiratory Viruses in Adults With Severe Lower Respiratory Infection. Chest 2018; 154:1213-1222. [PMID: 29908153 PMCID: PMC6224704 DOI: 10.1016/j.chest.2018.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 12/31/2022] Open
Abstract
Viral pathogens are a common cause of severe lower respiratory tract infection in adults. Our ability to rapidly and accurately identify viral infections has dramatically improved as slow culture-based techniques have been largely replaced by multiplex high-throughput systems. Given these advances, reevaluation of the role of respiratory viral testing in adults presenting with lower respiratory tract infection is important. This article reviews the potential benefits of testing, provides an overview of the most commonly used diagnostic techniques, and considers whether current evidence supports routine testing.
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Affiliation(s)
- James M Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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145
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Lee MS, Oh JY, Kang CI, Kim ES, Park S, Rhee CK, Jung JY, Jo KW, Heo EY, Park DA, Suh GY, Kiem S. Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia. Infect Chemother 2018; 50:160-198. [PMID: 29968985 PMCID: PMC6031596 DOI: 10.3947/ic.2018.50.2.160] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 01/07/2023] Open
Abstract
Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea.
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Affiliation(s)
- Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jee Youn Oh
- Division of Respiratory, Allergy and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Cheol In Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Ye Jung
- Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Wook Jo
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Eun Young Heo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Sungmin Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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146
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Abele-Horn M, Pantke E, Eckmanns T. Wege zum fachgerechten und verantwortungsvollen Umgang mit Antibiotika. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:572-579. [DOI: 10.1007/s00103-018-2723-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Joseph P, Godofsky E. Outpatient Antibiotic Stewardship: A Growing Frontier-Combining Myxovirus Resistance Protein A With Other Biomarkers to Improve Antibiotic Use. Open Forum Infect Dis 2018; 5:ofy024. [PMID: 29479553 PMCID: PMC5815119 DOI: 10.1093/ofid/ofy024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/29/2018] [Indexed: 12/20/2022] Open
Abstract
Background The majority of oral antibiotics are prescribed in outpatient primary and urgent care clinics for acute respiratory infections. Effective antibiotic stewardship must include proper prescribing for outpatients as well as for those in a hospital or long-term care facility. Methods Major databases, including MEDLINE and the Cochrane Library, were searched for prospective human clinical studies, including children and/or adults published between January 1966 and November 2017 that evaluated Myxovirus resistance protein A (MxA) as a biomarker for diagnosing viral infections as well as both C-reactive protein (CRP) and procalcitonin (PCT) as potential biomarkers for identifying and differentiating true bacterial upper respiratory infection (URI) from colonization. Results Ten prospective human studies, totaling 1683 patients, were identified that evaluated MxA as a viral biomarker in children and/or adults. Both systematic review articles, meta-analyses, and randomized controlled clinical trials that examined CRP and/or PCT as a biomarker for identifying clinically significant bacterial infections and supporting antibiotic stewardship were identified. Conclusions Quick and accurate differentiation between a viral and bacterial respiratory infection is critical to effectively combat antibiotic misuse. MxA expression in peripheral blood is a highly specific marker for viral infection. Combining MxA with other inflammatory biomarkers to test for respiratory infections offers enhanced sensitivity and specificity, forming an excellent tool for antibiotic stewardship in the outpatient setting.
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Affiliation(s)
- Patrick Joseph
- Private Practice to California Infection Control Consultants, San Ramon, California
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Levine AR, Riggott R, Vulaj K, Falcetti TR, Ali S, Singh G. A Collaborative Approach to Improve Consistent Use of Procalcitonin in Lower Respiratory Tract Infections. Ann Pharmacother 2018; 52:538-545. [PMID: 29322872 DOI: 10.1177/1060028017753411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Procalcitonin (PCT) is a biomarker that can help differentiate bacterial from viral infections and has been extensively studied in patients with sepsis and pneumonia to guide antibiotic therapy. However, there is poor adherence to prescribed algorithms when used to discontinue antibiotics in the real world. A quality improvement project was implemented to increase consistent use of PCT. OBJECTIVE To evaluate use of PCT and impact on antibiotic length of therapy (LOT) preimplementation and postimplementation of a quality improvement initiative. METHODS This was a single-center retrospective cohort study in patients with lower respiratory tract infections (LRTIs). RESULTS In all, 330 patients were included in this study. Following implementation of the quality improvement initiative, ordering PCT in the first 24 hours increased from 59.6% to 75.5% ( P = 0.011). Documentation to discontinue antibiotics in patients with low initial PCT values increased from 13.2% to 28.6% ( P = 0.100). Increased PCT use correlated with an overall mean reduction of 1.05 antibiotic days between cohorts (6.82 ± 3.88 vs 5.77 ± 3.43, P = 0.028). There was no difference in incidence of antibiotic-associated adverse effects or 30-day hospital readmission rates attributed to pneumonia. CONCLUSIONS Consistent use of PCT was achieved through a collaborative effort with the clinical pharmacy and hospitalist staff. Increased use of PCT was associated with a significant reduction in antibiotic LOT among patients with LRTIs. When controlling for other factors, low initial PCT values had the strongest influence on discontinuing antibiotics within 72 hours in the intervention group.
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Affiliation(s)
- Alexander R Levine
- 1 University of Saint Joseph School of Pharmacy, Hartford, CT, USA.,2 Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Robyn Riggott
- 1 University of Saint Joseph School of Pharmacy, Hartford, CT, USA
| | - Kristela Vulaj
- 1 University of Saint Joseph School of Pharmacy, Hartford, CT, USA
| | - Tera R Falcetti
- 2 Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Syed Ali
- 2 Saint Francis Hospital and Medical Center, Hartford, CT, USA.,3 University of Connecticut School of Medicine, Hartford, CT, USA
| | - Gagandeep Singh
- 2 Saint Francis Hospital and Medical Center, Hartford, CT, USA.,3 University of Connecticut School of Medicine, Hartford, CT, USA
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149
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Wirz Y, Branche A, Wolff M, Welte T, Nobre V, Reinhart K, Falsey AR, Damas P, Beishuizen A, Deliberato RO, Shehabi Y, Jensen JUS, Mueller B, Schuetz P. Management of Respiratory Infections with Use of Procalcitonin: Moving toward More Personalized Antibiotic Treatment Decisions. ACS Infect Dis 2017; 3:875-879. [PMID: 29120606 DOI: 10.1021/acsinfecdis.7b00199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Due to overlap of clinical findings and low sensitivity of bacterial diagnostic tests, differentiation between bacterial and viral respiratory tract infections remains challenging, ultimately leading to antibiotic overuse in this population of patients. Addition of procalcitonin, a blood biomarker expressed by epithelial cells in response to bacterial infections, to the clinical assessment leads to a reduction in inappropriate antibiotic initiation. Procalcitonin also provides prognostic information about the resolution of illness, and significant decreases over time are a strong signal for the discontinuation of antibiotics. Current evidence from randomized trials indicates that procalcitonin-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side effects, which importantly translates into improved survival of patients with respiratory infections. Inclusion of procalcitonin into antibiotic stewardship algorithms thus improves the diagnostic and therapeutic management of patients presenting with respiratory illnesses and holds great promise to mitigate the global bacterial resistance crisis.
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Affiliation(s)
- Yannick Wirz
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
| | - Angela Branche
- National Institute of Allergy and Infectious Diseases
Respiratory Pathogen Research Center, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, New York 14642, United States
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, 5 Rue Thomas Mann, 75013 Paris, France
| | - Tobias Welte
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, 110 Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brasil
| | - Konrad Reinhart
- Department
of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Ann R. Falsey
- National Institute of Allergy and Infectious Diseases
Respiratory Pathogen Research Center, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, New York 14642, United States
| | - Pierre Damas
- Department of General Intensive
Care, University Hospital of Liege, domaine universitaire du Sart Tilman,, 4000 Liège, Belgium
| | - Albertus Beishuizen
- Intensive
Care Center, Medisch Spectrum Twente, Koningsplein 1, 7512KZ, Enschede, The Netherlands
| | - Rodrigo O. Deliberato
- Critical
Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, São Paulo 05652-900, Brazil
| | - Yahya Shehabi
- Critical
Care and Peri-operative Medicine, Monash Health, Clayton Rd., Clayton, Victoria 3171, Australia
- School of Clinical
Sciences, Monash University, E Block, Level 5, Monash Medical Centre, Clayton, Victoria 3168, Australia
| | - Jens-Ulrik S. Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Finsencentret, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 København, Denmark
- Department of Internal Medicine, Respiratory Medicine, Herlev & Gentofte Hospital, Niels Andersens Vej 28, 2900 Hellerup, Denmark
| | - Beat Mueller
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
| | - Philipp Schuetz
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
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150
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Gkentzi D, Dimitriou G. Procalcitonin use for shorter courses of antibiotic therapy in suspected early-onset neonatal sepsis: are we getting there? J Thorac Dis 2017; 9:4899-4902. [PMID: 29312687 DOI: 10.21037/jtd.2017.11.80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Despoina Gkentzi
- Department of Paediatrics, University General Hospital of Patras, Medical School University of Patras, Patras, Greece
| | - Gabriel Dimitriou
- Department of Paediatrics, University General Hospital of Patras, Medical School University of Patras, Patras, Greece
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