Comparison of Four Days Versus Seven Days Duration of Antibiotic Therapy for Neonatal Pneumonia: A Randomized Controlled Trial

The spectrum of pneumonia among intubated neonates in the neonatal intensive care unit

We review the pathophysiology, epidemiology, diagnosis, treatment, and prevention of ventilator-associated pneumonia (VAP) in neonates. VAP has been studied primarily in adult ICU patients, although there has been more focus on pediatric and neonatal VAP (neo-VAP) in the last decade. The definition as well as diagnosis of VAP in neonates remains a challenge to date. The neonatal intensivist needs to be familiar with the current diagnostic tools and prevention strategies available to treat and reduce VAP to reduce neonatal morbidity and the emergence of antibiotic resistance. This review also highlights preventive strategies and old and emerging treatments available.

Efficacy of Antibiotic Regimens for Pneumonia in Young Infants Aged 0-59 Days: A Systematic Review

CONTEXT

Pneumonia is a leading cause of death in young infants.

OBJECTIVES

To evaluate the efficacy of different antibiotic regimens to treat young infant pneumonia on critical clinical outcomes.

DATA SOURCES

MEDLINE, Embase, CINAHL, World Health Organization (WHO) Global Index Medicus, Cochrane Central Registry of Trials.

STUDY SELECTION

We included randomized controlled trials of young infants aged 0 to 59 days with pneumonia (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes.

DATA EXTRACTION

We extracted data and assessed risk of bias in duplicate. We used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence.

LIMITATIONS

Trials were heterogeneous, which precluded data pooling.

RESULTS

Of 2601 publications screened, 10 randomized controlled trials were included. Seven trials were hospital-based (n = 869) and 3 were nonhospital-based (n = 4329). No hospital-based trials evaluated WHO-recommended first-choice regimens. One trial found the WHO-recommended second-choice antibiotic, cefotaxime, to have similar rates of treatment success as non-WHO-recommended regimens of either amoxicillin-clavulanate (RR 0.99, 95% confidence interval 0.82-1.10) or amoxicillin-clavulanate/cefotaxime (RR 1.02, 95% confidence interval 0.86-1.12). Among 3 nonhospital-based trials comparing oral amoxicillin to alternate regimens to treat isolated tachypnea among infants aged 7-59 days, there were no differences in treatment failure between amoxicillin and alternate regimens. Certainty of evidence was low or very low for all primary outcomes.

CONCLUSIONS

We found limited evidence to support the superiority of any single antibiotic regimen over alternate regimens to treat young infant pneumonia.

Efficacy and safety of short- vs. standard-course antibiotics for culture-negative neonatal sepsis: a systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis of evidence from randomized controlled trials (RCTs) comparing a short course of antibiotics (2-4 days), to a standard course (5-7 days), for the treatment of culture-negative neonatal sepsis.

METHODS

Relevant databases were searched for RCTs comparing short- vs. standard-course of antibiotics for culture-negative sepsis. The primary outcomes were mortality and treatment failure, defined as the reappearance of clinical signs suggestive of sepsis within 7 days of stoppage of antibiotics. Secondary outcomes included neurological impairment, duration of hospital stay, need for oxygen, respiratory support and double-volume exchange transfusion (DVET).

RESULTS

Seven RCTs were included in the review with 729 neonates >30 weeks gestational age at birth. No mortality occurred in either of the groups (2 studies; 276 neonates). Treatment failure rates were similar in the short- and standard-course antibiotic groups [7 studies; 729 neonates; risk ratio (RR) = 1.01; 95% confidence interval (CI), 0.55 to 1.86; very low certainty]. The short course of antibiotics resulted in a shorter hospital stay [3 studies; 293 neonates; mean difference (MD), -2.46 days; 95% CI, -3.16 to -1.75]. There was no difference in the need for oxygen supplementation (2 studies; 258 neonates; RR, 1.40; 95% CI, 0.40 to 4.91), any respiratory support (2 studies; 258 neonates; RR, 1.04; 95% CI, 0.92 to 1.17) or DVET (2 studies; 258 neonates; RR, 1.29; 95% CI, 0.56 to 2.95).

CONCLUSION

Very-low certainty evidence suggests that a short antibiotic course, compared to a standard course, does not affect treatment failure rates in culture-negative neonatal sepsis. There is a need for well-designed RCTs powered enough to assess critical outcomes such as mortality and neurological sequelae to generate stronger evidence and inform guidelines.

PROSPERO REGISTRATION NUMBER

CRD42023437199.

Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions

Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.

Assessment of mechanisms of infectious pneumonia based on expression of fibrinogen, procalcitonin, high-sensitivity C-reactive protein expression, T helper 17 cells, regulatory T cells interleukin-10, and interleukin-17

BACKGROUND

Infectious pneumonia is one of the important causes of neonatal death that can lead to the imbalance of T helper 17 cells (Th17) and T regulatory T cells (Treg) cells. The correlation between plasma fibrinogen (FIB), procalcitonin (PCT), C-reactive protein (CRP) and Th17/Treg-IL-10/IL-17 axis balance and their specific role in the occurrence and development of infectious pneumonia are not completely clear.

METHODS

Thirty specific-pathogen free Sprague Dawley (SD) rats were randomly divided into a control group for comparison and IPN model group. After the establishment of infectious pneumonia model, levels of FIB, PCT, hs-CRP, IL-10, and IL-17 in the serum of the two groups were measured using enzyme linked immunosorbent assay (ELISA), the pathological changes of lung tissue were observed using hematoxylin and eosin (HE) staining, the number of Treg and Th17 cells and the ratio of Th17/Treg in serum were detected using flow cytometry, and the levels of retinoic acid-related orphan receptor γt and forkhead box P3 (FOXP3) in lung tissue were detected using reverse transcription polymerase chain reaction (RT-PCR) and western blot.

RESULTS

The results showed that the serum levels of FIB, PCT, hs-CRP, Th17 cell number, Th17/Treg ratio, left lung dry and wet weight, lung tissue wet/dry ratio, lung pathology score and IL-17 level in the model group were significantly higher than those in the control group, while the number of Treg cells and the level of IL-10 in the model group were significantly lower than those in the control group. In addition, the expression of Foxp3mRNA and protein in lung tissue of model group decreased significantly, while the expression level of ROR- γ t mRNA and protein increased.

CONCLUSIONS

In infectious pneumonia, the expression levels of FIB, PCT and hs-CRP are up-regulated, and Th17 cells are activated, Treg cells are inhibited, proinflammatory cytokine IL-17 expression is up-regulated, anti-inflammatory cytokine IL-10 expression is down-regulated, resulting in increased inflammatory response, thus promoting the occurrence and development of infectious pneumonia.