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Barreto JV, Dias CC, Cardoso T. Impact of the timing of initial antibiotic administration on community-onset pneumonia hospital mortality. Eur J Intern Med 2024; 124:145-146. [PMID: 38453572 DOI: 10.1016/j.ejim.2024.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Affiliation(s)
- J Vasco Barreto
- Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, Internal Medicine Service, Rua Dr. Eduardo Torres, Senhora da Hora 4464-513, Portugal; ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge de Viterbo Ferreira 228, Porto 4050-313, Portugal.
| | - Cláudia Camila Dias
- Knowledge Management Unit, Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
| | - Teresa Cardoso
- ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge de Viterbo Ferreira 228, Porto 4050-313, Portugal; CINTESIS@RISE, Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal; Intensive Care Department, Hospital Padre Américo, Tâmega e Sousa Local Health Unit, Avenida do Hospital Padre Américo 210, Guilhufe 4564-007, Portugal
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Méndez R, González-Jiménez P, Mengot N, Menéndez R. Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:225-236. [PMID: 38224700 DOI: 10.1055/s-0043-1778139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.
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Affiliation(s)
- Raúl Méndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula González-Jiménez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Noé Mengot
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Rosario Menéndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Kawecki D, Majewska A, Czerwinski J. Change for the Better: Severe Pneumonia at the Emergency Department. Pathogens 2022; 11:779. [PMID: 35890024 PMCID: PMC9325210 DOI: 10.3390/pathogens11070779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 12/03/2022] Open
Abstract
This is a single-centre observational study of adult patients with severe pneumonia requiring hospitalization conducted at the emergency department. During the observation period (94 weeks), 398 patients were diagnosed with severe pneumonia and required further treatment at the hospital. The median age of patients was 73 years. About 65% of patients had at least one chronic comorbidity. Almost 30% of patients had cardiovascular disorders, and 13% had diabetes mellitus. The average Emergency Department length of stay was 3.56 days. The average length of hospitalization was 15.8 days. Overall, 94% of patients treated for pneumonia received a beta-lactam antibiotic. The median time from ED admission to the administration of the first dose of antimicrobial agent was less than 6 h. Microbiology test samples were obtained from 48.7% patients. Gram-positive cocci were isolated most commonly (52.9%) from blood samples. Biological material from the lower respiratory tract was collected from 8.3% of patients, and from 47.2% of positive samples, fungi were cultured. The urine samples were obtained from 35.9% patients, and Gram-negative rods (76%) were isolated most commonly. Overall, 16.1% of patients died during the hospitalization. The mean age of patients who died was 79 years. This observational study is the first single-centre study conducted as part of the Polish Emergency Department Research Organization (PEDRO) project. It aims to provide up-to-date information about patients with pneumonia in order to improve medical care and develop local diagnostic and therapeutic recommendations.
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Affiliation(s)
- Dariusz Kawecki
- Department of Emergency, Medical University of Warsaw, 02-005 Warsaw, Poland; (D.K.); (J.C.)
- Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland
| | - Anna Majewska
- Department of Medical Microbiology, Medical University of Warsaw, 02-004 Warsaw, Poland
| | - Jarosław Czerwinski
- Department of Emergency, Medical University of Warsaw, 02-005 Warsaw, Poland; (D.K.); (J.C.)
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Fally M, Israelsen S, Benfield T, Tarp B, Ravn P. Time to antibiotic administration and patient outcomes in community-acquired pneumonia: results from a prospective cohort study. Clin Microbiol Infect 2020; 27:406-412. [PMID: 32896655 DOI: 10.1016/j.cmi.2020.08.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Community-acquired pneumonia (CAP) is a frequently occurring disease linked to high mortality and morbidity. Previous studies indicated that the administration of antibiotics within 4 hrs of admission can improve key patient outcomes associated with CAP, such as mortality and time to clinical stability. However, the results have been heterogeneous and may not be applicable to all healthcare settings. Therefore, we designed a cohort study to estimate the impact of timely antibiotic administration on outcomes in patients admitted with CAP. METHODS The impact of antibiotic administration within 4 hrs of admission and other covariates were estimated for 30-day mortality, stability within 72 hrs, 30-day readmission and time to discharge, using multivariable regression models. Sensitivity analyses were performed on a subset of patients with the most severe CAP and a propensity score matched cohort. RESULTS In total, 2264 patients were included. Of these, 273 (12.1%) died within 30 days of admission, 1277 (56.4%) were alive and stable within 72 hrs and 334 (14.8%) were discharged alive and readmitted within 30 days. Median length of hospital stay was 5 days (interquartile range 3-8). In all models, the administration of antibiotics within 4 hrs of admission had no significant effect on the outcomes. The adjusted odds ratios (OR) derived from the multivariable models for 30-day mortality, stability within 72 hrs and 30-day readmission were 1.01 (95% confidence interval (CI) 0.76; 1.33), 0.88 (95% CI 0.74; 1.05) and 1.05 (95% CI 0.82; 1.34). The adjusted hazard ratio (HR) for time to discharge was 1.00 (95% CI 0.91; 1.10). DISCUSSION A strict 4-hr threshold for antibiotic administration in all patients admitted with CAP is not reasonable. Instead, our results suggested that patients should be triaged and prioritized according to age, comorbidities, clinical condition and pneumonia severity.
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Affiliation(s)
- Markus Fally
- Department of Internal Medicine, Section for Pulmonary Diseases, Herlev Gentofte Hospital, Hellerup, Denmark.
| | - Simone Israelsen
- Department of Infectious Diseases, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Britta Tarp
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Pernille Ravn
- Department of Internal Medicine, Section for Infectious Diseases, Herlev Gentofte Hospital, Hellerup, Denmark
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Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship. Clin Microbiol Infect 2020; 27:175-181. [PMID: 32120032 DOI: 10.1016/j.cmi.2020.02.032] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/15/2020] [Accepted: 02/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock and bacterial meningitis, but may not be as important for other infectious syndromes. A better understanding of which patients can tolerate a delay in start of therapy is important for antibiotic stewardship purposes. OBJECTIVES To explore the existing evidence on the impact of time to antibiotics on clinical outcomes in patients presenting to the emergency department (ED) with bacterial infections of different severity of illness and source of infection. SOURCES A literature search was performed in the PubMed/MEDLINE database using combined search terms for various infectious syndromes (sepsis/septic shock, bacterial meningitis, lower respiratory tract infections, urinary tract infections, intra-abdominal infections and skin and soft tissue infections), time to antibiotic treatment, and clinical outcome. CONTENT The literature search generated 8828 hits. After screening titles and abstracts and assessing potentially relevant full-text papers, 60 original articles (four randomized controlled trials, 43 observational studies) were included. Most articles addressed sepsis/septic shock, while few studies evaluated early initiation of therapy in mild to moderate disease. The lack of randomized trials and the risk of confounding factors and biases in observational studies warrant caution in the interpretation of results. We conclude that the literature supports prompt administration of effective antibiotics for septic shock and bacterial meningitis, but there is no clear evidence showing that a delayed start of therapy is associated with worse outcome for less severe infectious syndromes. IMPLICATIONS For patients presenting with suspected bacterial infections, withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established (e.g. by 4-8 h) seems acceptable in most cases unless septic shock or bacterial meningitis are suspected. This approach promotes the use of ecologically favourable antibiotics in the ED, reducing the risks of side effects and selection of resistance.
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Abstract
PURPOSE OF REVIEW The primary challenges in the field of clinical research include a lack of support within existing infrastructure, insufficient number of clinical research training programs and a paucity of qualified mentors. Most medical centers offer infrastructure support for investigators working with industry sponsors or government-funded clinical trials, yet there are a significant amount of clinical studies performed in the field of pneumonia which are observational studies. For this type of research, which is frequently unfunded, support is usually lacking. RECENT FINDINGS In an attempt to optimize clinical research in pneumonia, at the University of Louisville, we developed a clinical research coordinating center (CRCC). The center manages clinical studies in the field of respiratory infections, with the primary focus being pneumonia. Other activities of the CRCC include the organization of an annual clinical research training course for physicians and other healthcare workers, and the facilitation of international research mentoring by a process of connecting new pneumonia investigators with established clinical investigators. SUMMARY To improve clinical research in pneumonia, institutions need to have the appropriate infrastructure in place to support investigators in all aspects of the clinical research process.
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López‐Alcalde J, Rodriguez‐Barrientos R, Redondo‐Sánchez J, Muñoz‐Gutiérrez J, Molero García JM, Rodríguez‐Fernández C, Heras‐Mosteiro J, Marin‐Cañada J, Casanova‐Colominas J, Azcoaga‐Lorenzo A, Hernandez Santiago V, Gómez‐García M. Short-course versus long-course therapy of the same antibiotic for community-acquired pneumonia in adolescent and adult outpatients. Cochrane Database Syst Rev 2018; 9:CD009070. [PMID: 30188565 PMCID: PMC6513237 DOI: 10.1002/14651858.cd009070.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a lung infection that can be acquired during day-to-day activities in the community (not while receiving care in a hospital). Community-acquired pneumonia poses a significant public health burden in terms of mortality, morbidity, and costs. Shorter antibiotic courses for CAP may limit treatment costs and adverse effects, but the optimal duration of antibiotic treatment is uncertain. OBJECTIVES To evaluate the efficacy and safety of short-course versus longer-course treatment with the same antibiotic at the same daily dosage for CAP in non-hospitalised adolescents and adults (outpatients). We planned to investigate non-inferiority of short-course versus longer-term course treatment for efficacy outcomes, and superiority of short-course treatment for safety outcomes. SEARCH METHODS We searched CENTRAL, which contains the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE, Embase, five other databases, and three trials registers on 28 September 2017 together with conference proceedings, reference checking, and contact with experts and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing short- and long-courses of the same antibiotic for CAP in adolescent and adult outpatients. DATA COLLECTION AND ANALYSIS We planned to use standard Cochrane methods. MAIN RESULTS Our searches identified 5260 records. We did not identify any RCTs that compared short- and longer-courses of the same antibiotic for the treatment of adolescents and adult outpatients with CAP.We excluded two RCTs that compared short courses (five compared to seven days) of the same antibiotic at the same daily dose because they evaluated antibiotics (gemifloxacin and telithromycin) not commonly used in practice for the treatment of CAP. In particular, gemifloxacin is no longer approved for the treatment of mild-to-moderate CAP due to its questionable risk-benefit balance, and reported adverse effects. Moreover, the safety profile of telithromycin is also cause for concern.We found one ongoing study that we will assess for inclusion in future updates of the review. AUTHORS' CONCLUSIONS We found no eligible RCTs that studied a short-course of antibiotic compared to a longer-course (with the same antibiotic at the same daily dosage) for CAP in adolescent and adult outpatients. The effects of antibiotic therapy duration for CAP in adolescent and adult outpatients remains unclear.
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Affiliation(s)
- Jesús López‐Alcalde
- Universidad Francisco de Vitoria (UFV) MadridFaculty of MedicineCtra. Pozuelo‐Majadahonda km. 1,800MadridSpain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)Clinical Biostatistics UnitCtra. Colmenar, km. 9.100MadridSpain28034
| | - Ricardo Rodriguez‐Barrientos
- Gerencia Asistencial de Atención Primaria, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)Unidad de apoyo a la InvestigaciónJátiva Nº23 2ºcMadridSpain28007
| | - Jesús Redondo‐Sánchez
- Gerencia Asistencial Atención PrimariaCentro de Salud Ramon y CajalJabonería 67MadridSpain28921
| | - Javier Muñoz‐Gutiérrez
- Gerencia Asistencial Atención PrimariaCentro de Salud Buenos AiresPio FelipeMadridSpain28038
| | - José María Molero García
- Gerencia Asistencial Atención PrimariaCentro de Salud San AndrésAlberto Palacios, nº 22MadridMadridSpain28021
| | | | - Julio Heras‐Mosteiro
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Jaime Marin‐Cañada
- Gerencia Asistencial Atencion Primaria de MadridCentro de Salud Villarejo de SalvanesCalle Hospital 7Villarejo de SalvanesMadridSpain28590
| | - Jose Casanova‐Colominas
- Gerencia Asistencial de Atención PrimariaCentro de Salud Ciudad de los PeriodistasValencia de don Juan 1028034 MadridMadridSpain28034
| | - Amaya Azcoaga‐Lorenzo
- Gerencia Asistencial Atención PrimariaCentro de Salud Los PintoresC/Prolongación Cordoba s/nParlaMadridSpain29981
| | - Virginia Hernandez Santiago
- University of St AndrewsDivision of Population and Behavioural Sciences, School of MedicineNorth HaughDundeeUKKY16 9TF
| | - Manuel Gómez‐García
- Gerencia Asistencial Atención PrimariaCentro de Salud MirasierraC/ Mirador de la Reina nº 117MadridSpain28035
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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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Burkett E, Macdonald SPJ, Carpenter CR, Arendts G, Hullick C, Nagaraj G, Osborn TM. Sepsis in the older person: The ravages of time and bacteria. Emerg Med Australas 2018; 30:249-258. [DOI: 10.1111/1742-6723.12949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital; Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - Stephen PJ Macdonald
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Emergency Department, Royal Perth Hospital; Perth Western Australia Australia
- Discipline of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute of Medical Research; Perth Western Australia Australia
- Discipline of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
| | - Carolyn Hullick
- Emergency Department; John Hunter Hospital; Newcastle New South Wales Australia
- Faculty of Health and Medicine; The University of Newcastle; Newcastle New South Wales Australia
| | - Guruprasad Nagaraj
- Emergency Department; Liverpool Hospital; Sydney New South Wales Australia
- School of Medicine, The University of Sydney; Sydney New South Wales Australia
| | - Tiffany M Osborn
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
- Department of Surgery; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
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