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Athlin S, Magnuson A, Spindler C, Hedlund J, Strålin K, Nauclér P. Pneumococcal urinary antigen testing for antimicrobial guidance in community-acquired pneumonia: a register-based cohort study. J Infect 2022; 85:167-173. [PMID: 35618153 DOI: 10.1016/j.jinf.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 12/03/2021] [Accepted: 05/19/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the effect of pneumococcal urinary antigen test (UAT) usage on broad-spectrum antibiotic treatment in community-acquired pneumonia (CAP). METHODS Patients admitted to 32 Swedish hospitals between 2011-2014 were retrospectively included from the Swedish National Quality Register of CAP. Using propensity score matched data, stratified by CRB-65 score, we studied the effect of performing UAT and of positive test results on treatment with broad-spectrum β-lactam monotherapy (BSBM) and antibiotics with coverage for atypical bacteria compared to narrow-spectrum β-lactam monotherapy (NSBM). RESULTS UAT was performed for 4,995/14,590 (34.2%) patients, 603/4,995 (12.1%) of whom had positive test results. At day three, performing UAT was not associated with decreased use of BSBM (OR 1.07, 95% CI 0.94-1.23) but was associated with increased atypical coverage among patients with CRB-65 score 2 (OR 1.47, 95% CI 1.06-2.02). A positive UAT was associated with decreased BSBM use (OR 0.39, 95% CI 0.25-0.60) and decreased atypical coverage (OR 0.25, 95% CI 0.16-0.37), predominantly in non-severe CAP. At day one, performing UAT was associated with atypical coverage among patients with CRB-65 scores 2 (OR 2.60, 95% CI 1.69-3.98) and 3-4 (OR 3.69, 95% CI 1.55-8.79), and a positive test reduced the odds of BSBM treatment among CRB-65 score 3-4 patients (OR 3.49, 95% CI 1.02-12.0). CONCLUSIONS Performing UAT had no overall effect on decreasing the use of BSBM treatment by day three of hospitalization, yet non-severely ill patients with positive UAT results were less likely to be treated with BSBM and antibiotics with atypical coverage.
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Affiliation(s)
- Simon Athlin
- Department of Infectious Diseases, School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Carl Spindler
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Hedlund
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Kristoffer Strålin
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Pontus Nauclér
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Skoog Ståhlgren G, Grape M, Edlund C. The Swedish model for prioritising research on the use of antibiotics: Aligning public funding with research gaps. Health Policy 2022; 126:725-730. [DOI: 10.1016/j.healthpol.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 09/03/2021] [Accepted: 05/20/2022] [Indexed: 11/04/2022]
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Naucler P, Henriques-Normark B, Hedlund J, Galanis I, Granath F, Örtqvist Å. The changing epidemiology of community-acquired pneumonia: nationwide register-based study in Sweden. J Intern Med 2019; 286:689-701. [PMID: 31278792 DOI: 10.1111/joim.12956] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND There is limited evidence on the impact of pneumococcal conjugate vaccine childhood immunization programmes (PCV-CIP) on community-acquired pneumonia (CAP) in individuals with underlying diseases. METHODS A nationwide cohort study using Swedish health registers to assess the incidence of hospitalization with all-cause (AC-CAP) and pneumococcal or lobar (PL-CAP) CAP between 2005 and 2015, in relation to PCV-CIP introduction in 2007-09. RESULTS In total, 303 691 episodes of AC-CAP occurred, of which 14 225 were PL-CAP. Comparing before (2005-06) with after (2014-15) PCV-CIP, relative incidence reductions were 36% (95% Confidence Interval 32-40), 20% (14-25) and 16% (11-22) of AC-CAP for age groups < 2, 2-4 and 5-17 years, respectively, with similar reductions in young children with and without comorbidities. The reductions were more pronounced for PL-CAP. In the age groups 40-64, 65-74, 75-84 and ≥85 years there were relative increases of 11% (8-14), 18% (15-22), 15% (12-17) and 30% (27-34) of AC-CAP, respectively, but these increases were attenuated after adjustment for admittance practices using four control conditions. In adults with comorbidities, there was an increase in incidence of AC-CAP, and PL-CAP, in contrast to adults without reported underlying diseases where the incidence was stable or diminished for some age groups. Over the study period, there was an increased proportion of pneumonia patients with underlying diseases in all ages. CONCLUSION This emphasizes that direct preventive interventions should be targeted towards individuals with underlying diseases. Future studies should investigate reasons for the observed increased risk in adults with comorbidities, for example due to pneumococcal nonvaccine serotypes, or other pathogens, preferentially affecting subjects with underlying diseases.
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Affiliation(s)
- P Naucler
- From the, Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - B Henriques-Normark
- Public Health Agency of Sweden, Solna, Sweden.,Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,SCELSE and LKC, Nanyang Technological University, NTU, Singapore, Singapore
| | - J Hedlund
- From the, Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - I Galanis
- Public Health Agency of Sweden, Solna, Sweden
| | - F Granath
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Å Örtqvist
- From the, Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Communicable Disease Control and Prevention, Stockholm County Council, Stockholm, Sweden
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Benzylpenicillin versus wide-spectrum beta-lactam antibiotics as empirical treatment of Haemophilus influenzae-associated lower respiratory tract infections in adults; a retrospective propensity score-matched study. Eur J Clin Microbiol Infect Dis 2018; 37:1761-1775. [PMID: 29961165 PMCID: PMC6133041 DOI: 10.1007/s10096-018-3311-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/19/2018] [Indexed: 11/05/2022]
Abstract
There is consensus that definitive therapy for infections with H. influenzae should include antimicrobial agents with clinical breakpoints against the bacterium. In Scandinavia, benzylpenicillin is the recommended empirical treatment for community-acquired pneumonia (CAP) except in very severe cases. However, the effect of benzylpenicillin on H. influenzae infections has been debated. The aim of this study was to compare the outcomes of patients given benzylpenicillin with patients given wide-spectrum beta-lactams (WSBL) as empirical treatment of lower respiratory tract H. influenzae infections requiring hospital care. We identified 481 adults hospitalized with lower respiratory tract infection by H. influenzae, bacteremic and non-bacteremic. Overall, 30-day mortality was 9% (42/481). Thirty-day mortality, 30-day readmission rates, and early clinical response rates were compared in patients receiving benzylpenicillin (n = 199) and a WSBL (n = 213) as empirical monotherapy. After adjusting for potential confounders, empirical benzylpenicillin treatment was not associated with higher 30-day mortality neither in a multivariate logistic regression (aOR 2.03 for WSBL compared to benzylpenicillin, 95% CI 0.91–4.50, p = 0.082), nor in a propensity score-matched analysis (aOR 2.14, 95% CI 0.93–4.92, p = 0.075). Readmission rates did not significantly differ between the study groups, but early clinical response rates were significantly higher in the WSBL group (aOR 2.28, 95% CI 1.21–4.31, p = 0.011), albeit still high in both groups (84 vs 81%). In conclusion, despite early clinical response rates being slightly lower for benzylpenicillin compared to WSBL, we found no support for increased mortality or readmission rates in patients empirically treated with benzylpenicillin for lower respiratory tract infections by H. influenzae.
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Athlin S, Lidman C, Lundqvist A, Naucler P, Nilsson AC, Spindler C, Strålin K, Hedlund J. Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017. Infect Dis (Lond) 2017; 50:247-272. [PMID: 29119848 DOI: 10.1080/23744235.2017.1399316] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.
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Affiliation(s)
- Simon Athlin
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b Faculty of Medicin and Health , Örebro University , Örebro , Sweden
| | - Christer Lidman
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anders Lundqvist
- e Department of Infectious Diseases , Södra Älvsborgs Hospital , Borås , Sweden
| | - Pontus Naucler
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anna C Nilsson
- f Infectious Disease Research Unit, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Carl Spindler
- d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Kristoffer Strålin
- b Faculty of Medicin and Health , Örebro University , Örebro , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,g Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Hedlund
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
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Cazzola M, Rogliani P, Aliberti S, Blasi F, Matera MG. An update on the pharmacotherapeutic management of lower respiratory tract infections. Expert Opin Pharmacother 2017; 18:973-988. [PMID: 28480770 DOI: 10.1080/14656566.2017.1328497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment. Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described. Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.
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Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Stefano Aliberti
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Francesco Blasi
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , Università degli Studi della Campania "Luigi Vanvitelli" , Naples , Italy
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Simonetti AF, van Werkhoven CH, Schweitzer VA, Viasus D, Carratalà J, Postma DF, Oosterheert JJ, Bonten MJM. Predictors for individual patient antibiotic treatment effect in hospitalized community-acquired pneumonia patients. Clin Microbiol Infect 2017; 23:774.e1-774.e7. [PMID: 28336384 DOI: 10.1016/j.cmi.2017.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Our objective was to identify clinical predictors of antibiotic treatment effects in hospitalized patients with community-acquired pneumonia (CAP) who were not in the intensive care unit (ICU). METHODS Post-hoc analysis of three prospective cohorts (from the Netherlands and Spain) of adult patients with CAP admitted to a non-ICU ward having received either β-lactam monotherapy, β-lactam + macrolide, or a fluoroquinolone-based therapy as empirical antibiotic treatment. We evaluated candidate clinical predictors of treatment effects in multiple mixed-effects models by including interactions of the predictors with empirical antibiotic choice and using 30-day mortality, ICU admission and length of hospital stay as outcomes. RESULTS Among 8562 patients, empirical treatment was β-lactam in 4399 (51.4%), fluoroquinolone in 3373 (39.4%), and β-lactam + macrolide in 790 (9.2%). Older age (interaction OR 1.67, 95% CI 1.23-2.29, p 0.034) and current smoking (interaction OR 2.36, 95% CI 1.34-4.17, p 0.046) were associated with lower effectiveness of fluoroquinolone on 30-day mortality. Older age was also associated with lower effectiveness of β-lactam + macrolide on length of hospital stay (interaction effect ratio 1.14, 95% CI 1.06-1.22, p 0.008). CONCLUSIONS Older age and smoking could influence the response to specific antibiotic regimens. The effect modification of age and smoking should be considered hypothesis generating to be evaluated in future trials.
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Affiliation(s)
- A F Simonetti
- Hospital Universitari de Bellvitge, Institut D'investigació Biomèdica de Bellvitge, Barcelona, Spain.
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - D Viasus
- Division of Health Sciences, Faculty of Medicine, Universidad del Norte, and Hospital Universidad del Norte, Barranquilla, Colombia
| | - J Carratalà
- Hospital Universitari de Bellvitge, Institut D'investigació Biomèdica de Bellvitge, Barcelona, Spain; Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - D F Postma
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J J Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M J M Bonten
- Departments of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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