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Miyashita N, Nakamori Y, Ogata M, Fukuda N, Yamura A, Ishiura Y, Ito T. Is the JRS atypical pneumonia prediction score useful in detecting COVID-19 pneumonia under nursing or healthcare settings? Respir Investig 2024; 62:187-191. [PMID: 38185019 DOI: 10.1016/j.resinv.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND SARS-CoV-2 causes frequent outbreaks in elderly care facilities that meet the criteria for nursing and healthcare-associated pneumonia (NHCAP). We evaluated whether the Japanese Respiratory Society (JRS) atypical pneumonia prediction score could be adapted to the diagnosis of nursing and healthcare acquired COVID-19 (NHA-COVID-19) with pneumonia. METHODS We analyzed 516 pneumonia patients with NHA-COVID-19 and compared them with 1505 pneumonia patients with community-associated COVID-19 (CA-COVID-19). NHA-COVID-19 patients were divided into six groups; 80 cases had the ancestral strain, 76 cases had the Alfa variant, 30 cases had the Delta variant, 120 cases had the Omicron subvariant BA.1, 53 cases had the Omicron subvariant BA.2, and 157 cases had the Omicron subvariant BA.5. RESULTS The sensitivities of the diagnosis of atypical pneumonia in patients with NHA-COVID-19 based on four or more predictors were 22.8 % in the ancestral strain group, 32.0 % in the Alfa variant group, 34.5 % in the Delta variant group, 23.1 % in the BA.1 subvariant group, 32.7 % in the BA.2 subvariant group, and 30.4 % in the BA.5 subvariant group. The diagnostic sensitivity for the presumptive diagnosis of atypical pneumonia was significantly lower for NHA-COVID-19 than for CA-COVID-19 (28.2 % vs 64.1 %, p < 0.0001). CONCLUSIONS Our present study demonstrated that the JRS atypical pneumonia prediction score is not a useful tool in elderly patients even if there is a lot of atypical pneumonia in the NHCAP group. The caution is necessary that JRS atypical pneumonia prediction score was not fully applied to prediction for NHA-COVID-19 pneumonia.
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Affiliation(s)
- Naoyuki Miyashita
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
| | - Yasushi Nakamori
- Department of Emergency Medicine, Kansai Medical University Medical Center, 10-15 Bunen-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Makoto Ogata
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Naoki Fukuda
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Akihisa Yamura
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Yoshihisa Ishiura
- First Department of Internal Medicine, Division of Respiratory Medicine, Oncology and Allergology, Kansai Medical University Medical Center, 10-15 Bunen-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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Miyashita N, Nakamori Y, Ogata M, Fukuda N, Yamura A, Ishiura Y, Ito T. Nursing and healthcare-associated pneumonia due to SARS-CoV-2 Omicron variant. Respir Investig 2024; 62:252-257. [PMID: 38241958 DOI: 10.1016/j.resinv.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/05/2023] [Accepted: 12/22/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND There were many differences in the clinical characteristics between nursing and healthcare-associated pneumonia (NHCAP) and community-acquired pneumonia (CAP) due to the SARS-CoV-2 ancestral strain, Alpha variant and Delta variant. With the replacement of the Delta variant by the Omicron variant, the Omicron variant showed decreased infectivity to lung and was less pathogenic. We investigated the clinical differences between NHCAP and CAP due to the Omicron variant. METHODS We analyzed 516 NHCAP and 547 CAP patients with COVID-19 pneumonia. Of 516 patients with COVID-19 NHCAP, 330 cases were the Omicron variant (120 cases were BA.1, 53 cases were BA.2, and 157 cases were BA.5 subvariants) and 186 cases were non-Omicron variants. RESULTS The median age, frequency of comorbid illness, rates of intensive care unit (ICU) stay, and mortality rate were significantly higher in Omicron patients with NHCAP than in those with CAP. Rates of ICU stay and in-hospital mortality were significantly higher in NHCAP patients with non-Omicron variants compared with those in the Omicron variant group. No clinical differences were observed in patients with NHCAP among the Omicron BA.1, BA.2, and BA.5 subvariant groups. CONCLUSIONS The present study supported that the NHCAP category is necessary not only for bacterial pneumonia but also viral pneumonia. It is necessary to consider prevention and treatment strategies depending on the presence or absence of applicable criteria for NHCAP.
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Affiliation(s)
- Naoyuki Miyashita
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan.
| | - Yasushi Nakamori
- Department of Emergency Medicine, Kansai Medical University Medical Center, Japan
| | - Makoto Ogata
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan
| | - Naoki Fukuda
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan
| | - Akihisa Yamura
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan
| | - Yoshihisa Ishiura
- First Department of Internal Medicine, Division of Respiratory Medicine, Oncology and Allergology, Kansai Medical University Medical Center, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, Japan
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Ito A, Ishida T, Tachibana H, Nakanishi Y, Yamazaki A, Washio Y. Is antipseudomonal antibiotic treatment needed for all nursing and healthcare-associated pneumonia patients at risk for antimicrobial resistance? J Glob Antimicrob Resist 2020; 22:441-447. [PMID: 32339851 DOI: 10.1016/j.jgar.2020.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Nursing and healthcare-associated pneumonia (NHCAP) was proposed by the Japanese Respiratory Society to refer to healthcare-associated pneumonia. This study aimed to investigate whether antipseudomonal antibiotic therapy improved the prognosis of NHCAP patients at high risk for antimicrobial-resistant pathogens. METHODS Consecutive hospitalised NHCAP patients in Kurashiki Central Hospital between October 2010 and December 2016 were prospectively enrolled. NHCAP patients who were at high risk for antimicrobial resistance were defined as those who received antimicrobials in the preceding 90 days and/or were on tube feeding. The patients who received antipseudomonal antibiotics were defined as the guideline-concordant (GC) therapy group, and the others were defined as the guideline-discordant (GD) therapy group. The primary outcome was 30-day mortality. Inverse probability of treatment weighting (IPTW) analysis was used to reduce biases. RESULTS There were 277 patients with NHCAP; a majority (78.0%) were discharged from a hospital in the preceding 90 days. There were 52 patients in the GC group and 225 patients in the GD group. The 30-day mortality rate was significantly higher in the GC group than in the GD group (17.3%, 9/52 vs. 7.1%, 16/225; P = 0.03). After IPTW analysis, the GC therapy, compared with GD therapy, did not improve the 30-day mortality (OR 1.71, 95% CI 0.65-4.47; P = 0.28). CONCLUSIONS Not all NHCAP patients, even those at high risk for antimicrobial resistance, need antipseudomonal antimicrobial treatment. The treatment strategy for NHCAP patients should be individualised, according to the pneumonia severity, risk for antimicrobial-resistant pathogens, and antibiogram in each hospital.
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Affiliation(s)
- Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Hiromasa Tachibana
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Department of Respiratory Medicine, National Hospital Organization Minami Kyoto Hospital, Nakaashihara 11, Joyo, Kyoto, Japan.
| | - Yosuke Nakanishi
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Akio Yamazaki
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Department of Respiratory Medicine, Shiga University of Medical Science, Tsukinowa Seta-cho, Otsu, Shiga, Japan.
| | - Yasuyoshi Washio
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Higashiku Maidashi 3-1-1, Fukuoka, Japan.
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Ewig S, Kolditz M, Pletz MW, Chalmers J. Healthcare-associated pneumonia: is there any reason to continue to utilize this label in 2019? Clin Microbiol Infect 2019; 25:1173-1179. [PMID: 30825674 DOI: 10.1016/j.cmi.2019.02.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. OBJECTIVE To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. SOURCES The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). CONTENT Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. IMPLICATIONS HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Herne und Bochum, Germany.
| | - M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - M W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - J Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019; 8:35. [PMID: 30805182 PMCID: PMC6373132 DOI: 10.1186/s13756-019-0471-0] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.
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Affiliation(s)
- Dilip Nathwani
- 1Ninewells Hospital and Medical School, Dundee, DD19SY UK
| | - Della Varghese
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | - Jennifer Stephens
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | | | - Stephan Martin
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
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Affiliation(s)
- Kathryn A Connor
- Kathryn A. Connor is Associate Professor, Clinical Specialist, Critical Care, St John Fisher College of Pharmacy, 3690 East Avenue, Rochester, NY 14618
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Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study. Am J Infect Control 2017; 45:911-916. [PMID: 28385463 DOI: 10.1016/j.ajic.2017.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections. METHODS Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use. RESULTS Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing. CONCLUSIONS Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.
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Jwa H, Beom JW, Lee JH. Predictive Factors of Methicillin-Resistant Staphylococcus aureus Infection in Elderly Patients with Community-Onset Pneumonia. Tuberc Respir Dis (Seoul) 2017; 80:201-209. [PMID: 28416961 PMCID: PMC5392492 DOI: 10.4046/trd.2017.80.2.201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/13/2016] [Accepted: 02/09/2017] [Indexed: 11/24/2022] Open
Abstract
Background Methicillin-resistant Staphylococcus aureus (MRSA) infection is a severe and life-threatening disease in patients with community-onset (CO) pneumonia. However, the current guidelines lack specificity for a screening test for MRSA infection. Methods This study was retrospectively conducted in elderly patients aged ≥65 years, who had contracted CO-pneumonia during hospitalization at the Jeju National University Hospital, between January 2012 and December 2014. We analyzed the risk factors of MRSA in these patients and developed a scoring system to predict MRSA infection. Results A total of 762 patients were enrolled in this study, including 19 (2.4%) with MRSA infection. Healthcare-associated pneumonia (HCAP) showed more frequent MRSA infection compared to community-acquired pneumonia (4.4% vs. 1.5%, respectively; p=0.016). In a multivariate logistic regression analysis, admissions during the influenza season (odds ratio [OR], 2.896; 95% confidence interval [CI], 1.022–8.202; p=0.045), chronic kidney disease (OR, 3.555; 95% CI, 1.157–10.926; p=0.027), and intensive care unit admission (OR, 3.385; 95% CI, 1.035–11.075; p=0.044) were identified as predictive factors for MRSA infection. However, the presence of HCAP was not significantly associated with MRSA infection (OR, 1.991; 95% CI, 0.720–5.505; p=0.185). The scoring system consisted of three variables based on the multivariate analysis, and showed moderately accurate diagnostic prediction (area under curve, 0.790; 95% CI, 0.680–0.899; p<0.001). Conclusion MRSA infection would be considered in elderly CO-pneumonia patients, with three risk factors identified herein. When managing elderly patients with pneumonia, clinicians might keep in mind that these risk factors are associated with MRSA infection, which may help in selecting appropriate antibiotics.
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Affiliation(s)
- Hyeyoung Jwa
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Wook Beom
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Hoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
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