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Abelenda-Alonso G, Calatayud L, Rombauts A, Meije Y, Oriol I, Sopena N, Padullés A, Niubó J, Duarte A, Llaberia J, Aranda J, Gudiol C, Satorra P, Tebé C, Ardanuy C, Carratalà J. Multiplex real-time PCR in non-invasive respiratory samples to reduce antibiotic use in community-acquired pneumonia: a randomised trial. Nat Commun 2024; 15:7098. [PMID: 39154071 PMCID: PMC11330507 DOI: 10.1038/s41467-024-51547-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024] Open
Abstract
We assessed whether multiplex real-time PCR plus conventional microbiological testing is safe and more effective than conventional microbiological testing alone for reducing antibiotic use in community-acquired pneumonia (CAP). In this randomised trial, we recruited adults hospitalised with CAP at four Spanish hospitals. Patients were randomly assigned (1:1) to undergo either multiplex real-time PCR in non-invasive respiratory samples plus conventional microbiological testing or conventional microbiological testing alone. The primary endpoint was antibiotic use measured by days of antibiotic therapy (DOT). Between February 20, 2020, and April 24, 2023, 242 patients were enrolled; 119 were randomly assigned to multiplex real-time PCR plus conventional microbiological testing and 123 to conventional microbiological testing alone. All but one of the patients allocated to multiplex real-time PCR plus conventional microbiological testing underwent PCR, which was performed in sputum samples in 77 patients (65.2%) and in nasopharyngeal swabs in 41 (34.7%). The median DOT was 10.04 (IQR 7.98, 12.94) in the multiplex PCR plus conventional microbiological testing group and 11.33 (IQR 8.15, 16.16) in the conventional microbiological testing alone group (difference -1.04; 95% CI, -2.42 to 0.17; p = 0.093). No differences were observed in adverse events and 30-day mortality. Our findings do not support the routine implementation of multiplex real-time PCR in the initial microbiological testing in hospitalised patients with CAP. Clinicaltrials.gov registration: NCT04158492.
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Affiliation(s)
- Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Calatayud
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Microbiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Alexander Rombauts
- Department of Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Yolanda Meije
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de Barcelona, Societat Cooperativa d'Instal.lacions Sanitàries, Barcelona, Spain
| | - Isabel Oriol
- Department of Internal Medicine, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Nieves Sopena
- Infectious Diseases Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Ariadna Padullés
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacy, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Niubó
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Microbiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alejandra Duarte
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de Barcelona, Societat Cooperativa d'Instal.lacions Sanitàries, Barcelona, Spain
| | - Jaume Llaberia
- Department of Microbiology, Hospital de Barcelona, Societat Cooperativa d'Instal.lacions Sanitàries, Barcelona, Spain
| | - Judit Aranda
- Department of Internal Medicine, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Pau Satorra
- Biostatistics Unit, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristian Tebé
- Biostatistics Unit, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Carmen Ardanuy
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Microbiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.
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Froom P, Shimoni Z. Laboratory Tests, Bacterial Resistance, and Treatment Options in Adult Patients Hospitalized with a Suspected Urinary Tract Infection. Diagnostics (Basel) 2024; 14:1078. [PMID: 38893605 PMCID: PMC11172264 DOI: 10.3390/diagnostics14111078] [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: 03/21/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Patients treated for systemic urinary tract infections commonly have nonspecific presentations, and the specificity of the results of the urinalysis and urine cultures is low. In the following narrative review, we will describe the widespread misuse of urine testing, and consider how to limit testing, the disutility of urine cultures, and the use of antibiotics in hospitalized adult patients. Automated dipstick testing is more precise and sensitive than the microscopic urinalysis which will result in false negative test results if ordered to confirm a positive dipstick test result. There is evidence that canceling urine cultures if the dipstick is negative (negative leukocyte esterase, and nitrite) is safe and helps prevent the overuse of urine cultures. Because of the side effects of introducing a urine catheter, for patients who cannot provide a urine sample, empiric antibiotic treatment should be considered as an alternative to culturing the urine if a trial of withholding antibiotic therapy is not an option. Treatment options that will decrease both narrower and wider spectrum antibiotic use include a period of watching and waiting before antibiotic therapy and empiric treatment with antibiotics that have resistance rates > 10%. Further studies are warranted to show the option that maximizes patient comfort and safety.
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Affiliation(s)
- Paul Froom
- Clinical Utility Department, Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
- School of Public Health, University of Tel Aviv, Tel Aviv 6997801, Israel
| | - Zvi Shimoni
- The Adelson School of Medicine, Ariel University, Ariel 4070000, Israel;
- Sanz Medical Center, Laniado Hospital, Netanya 4244916, Israel
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3
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Vintila BI, Arseniu AM, Morgovan C, Butuca A, Bîrluțiu V, Dobrea CM, Rus LL, Ghibu S, Bereanu AS, Arseniu R, Roxana Codru I, Sava M, Gabriela Gligor F. A Real-World Study on the Clinical Characteristics, Outcomes, and Relationship between Antibiotic Exposure and Clostridioides difficile Infection. Antibiotics (Basel) 2024; 13:144. [PMID: 38391530 PMCID: PMC10885986 DOI: 10.3390/antibiotics13020144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Clostridioides difficile is a Gram-positive bacteria that causes nosocomial infections, significantly impacting public health. In the present study, we aimed to describe the clinical characteristics, outcomes, and relationship between antibiotic exposure and Clostridioides difficile infection (CDI) in patients based on reports from two databases. Thus, we conducted a retrospective study of patients diagnosed with CDI from Sibiu County Clinical Emergency Hospital (SCCEH), Romania, followed by a descriptive analysis based on spontaneous reports submitted to the EudraVigilance (EV) database. From 1 January to 31 December 2022, we included 111 hospitalized patients with CDI from SCCEH. Moreover, 249 individual case safety reports (ICSRs) from EVs were analyzed. According to the data collected from SCCEH, CDI was most frequently reported in patients aged 65-85 years (66.7%) and in females (55%). In total, 71.2% of all patients showed positive medical progress. Most cases were reported in the internal medicine (n = 30, 27%), general surgery (n = 26, 23.4%), and infectious disease (n = 22, 19.8%) departments. Patients were most frequently exposed to ceftriaxone (CFT) and meropenem (MER). Also, in the EV database, most CDI-related ADRs were reported for CFT, PIP/TAZ (piperacillin/tazobactam), MER, and CPX (ciprofloxacin). Understanding the association between previous antibiotic exposure and the risk of CDI may help update antibiotic stewardship protocols and reduce the incidence of CDI by lowering exposure to high-risk antibiotics.
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Affiliation(s)
- Bogdan Ioan Vintila
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Anca Maria Arseniu
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Morgovan
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Anca Butuca
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Victoria Bîrluțiu
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
- Clinical Medical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Carmen Maximiliana Dobrea
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Luca Liviu Rus
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Steliana Ghibu
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alina Simona Bereanu
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Rares Arseniu
- County Emergency Clinical Hospital "Pius Brînzeu", 300723 Timișoara, Romania
| | - Ioana Roxana Codru
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Mihai Sava
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Felicia Gabriela Gligor
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
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Gullì SP, Russo A. Considerations about antibiotic management for community-acquired pneumonia: unmet needs and future perspectives. Intern Emerg Med 2024; 19:9-11. [PMID: 37855968 DOI: 10.1007/s11739-023-03451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Sara Palma Gullì
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, Magna Graecia' University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, Magna Graecia' University of Catanzaro, Viale Europa, 88100, Catanzaro, Italy.
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Abubakar U, Awaisu A, Khan AH, Alam K. Impact of COVID-19 Pandemic on Healthcare-Associated Infections: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2023; 12:1600. [PMID: 37998802 PMCID: PMC10668951 DOI: 10.3390/antibiotics12111600] [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: 09/04/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/25/2023] Open
Abstract
This study investigated how the Coronavirus Disease 2019 (COVID-19) pandemic has affected the rate of healthcare-associated infections (HAIs). PubMed, Scopus and Google Scholar were searched to identify potentially eligible studies published from December 2019 to September 2022. A random effect model was used to determine the changes in the rate of HAIs during the pandemic. Thirty-seven studies, mostly from the United States (n = 13), were included. Fifteen studies described how the pandemic affected the rate of CLABSIs and CAUTIs, and eight of them showed a significant increase in CLABSIs. The risk of CLABSIs and CDIs was 27% (pooled odds ratio [OR]: 0.73; confidence interval [CI]: 0.61-0.89; p < 0.001) and 20% (pooled OR: 1.20; CI: 1.10-1.31; p < 0.001) higher during the pandemic compared to before the COVID-19 pandemic period, respectively. However, the overall risk of HAIs was unaffected by the pandemic (pooled OR: 1.00; 95 CI: 0.80-1.24; p = 0.990). Furthermore, there were no significant changes in the risk of CAUTIs (pooled OR: 1.01; 95 CI: 0.88-1.16; p = 0.890), and SSIs (pooled OR: 1.27; CI: 0.91-1.76; p = 0.16) between the two periods. The COVID-19 pandemic had no effect on the overall risk of HAIs among hospitalized patients, but an increased risk of CLABSIs and CDI were observed during the pandemic. Therefore, more stringent infection control and prevention measures and prudent interventions to promote the rational use of antibiotics are warranted across all healthcare facilities to reduce the burden of HAIs.
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Affiliation(s)
- Usman Abubakar
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha P.O. Box 2713, Qatar
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town 11800, Malaysia
| | - Khurshid Alam
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town 11800, Malaysia
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Rafey A, Jahan S, Farooq U, Akhtar F, Irshad M, Nizamuddin S, Parveen A. Antibiotics Associated With Clostridium difficile Infection. Cureus 2023; 15:e39029. [PMID: 37323360 PMCID: PMC10266117 DOI: 10.7759/cureus.39029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Clostridium difficile (C. difficile) is one of the major causes of diarrhea transmitted by the fecal-oral route. C. difficile type BI/NAP1/027 is responsible for the most severe C. difficile infection (CDI). It is a major cause of antibiotic-associated diarrhea followed by Clostridium perfringens, Staphylococcus aureus,and Klebsiella oxytoca. Historically, clindamycin, cephalosporins, penicillins, and fluoroquinolones were related to CDI. We conducted this study to evaluate the antibiotics associated with CDI in recent times. Methods We conducted a retrospective, single-center study over a period of eight years. A total of 58 patients were enrolled in the study. Patients with diarrhea and positive C. difficile toxin in stool were evaluated for antibiotics given, age, presence of malignancy, previous hospital stay for more than three days in the last three months, and any comorbidities. Results Among patients who developed CDI, prior antibiotics for at least four days duration were given in 93% (54/58) of patients. The most common antibiotics associated with C. difficile infection were piperacillin/tazobactam in 77.60% (45/58), meropenem in 27.60% (16/58), vancomycin in 20.70% (12/58), ciprofloxacin in 17.20% (10/58), ceftriaxone in 16% (9/58), and levofloxacin in 14% (8/58) of patients, respectively. Seven percent (7%) of patients with CDI did not receive any prior antibiotics. Solid organ malignancy was present in 67.20% and hematological malignancy in 27.60% of CDI patients. Ninety-eight percent (98%, 57/58) of patients treated with proton pump inhibitors, 93% of patients with a previous hospital stay for more than three days, 24% of patients with neutropenia, 20.1% of patients aged more than 65 years, 14% of patients with diabetes mellitus, and 12% of patients with chronic kidney disease also developed C. difficile infection. Conclusion The antibiotics associated with C. difficile infection are piperacillin/tazobactam, meropenem, vancomycin, ciprofloxacin, ceftriaxone, and levofloxacin. Other risk factors for CDI are proton pump inhibitor use, prior hospital admission, solid organ malignancy, neutropenia, diabetes mellitus (DM), and chronic kidney disease (CKD).
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Affiliation(s)
- Abdur Rafey
- Department of Internal Medicine and Infectious Diseases, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Shah Jahan
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Umer Farooq
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Furqana Akhtar
- Department of Infectious Diseases, Bahria International Hospital, Lahore, PAK
| | - Memoona Irshad
- Department of Infectious Diseases, Aga Khan University Hospital, Karachi, PAK
| | - Summiya Nizamuddin
- Department of Microbiology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Azra Parveen
- Department of Internal Medicine and Infectious Diseases, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
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High Prevalence of Clostridioides difficile Ribotype 176 in the University Hospital in Kosice. Pathogens 2023; 12:pathogens12030430. [PMID: 36986352 PMCID: PMC10055383 DOI: 10.3390/pathogens12030430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Dysbiosis of the gut microbiota, caused by antibiotics, plays a key role in the establishment of Clostridioides difficile CD). Toxin-producing strains are involved in the pathogenesis of Clostridioides difficile infection (CDI), one of the most common hospital-acquired infections. We cultured a total of 84 C. difficile isolates from stool samples of patients hospitalized at Louis Pasteur University Hospital in Kosice, Slovakia, that were suspected of CDI and further characterized by molecular methods. The presence of genes encoding toxin A, toxin B, and binary toxin was assessed by toxin-specific PCR. CD ribotypes were detected using capillary-based electrophoresis ribotyping. A total of 96.4% of CD isolates carried genes encoding toxins A and B, and 54.8% of them were positive for the binary toxin. PCR ribotyping showed the presence of three major ribotypes: RT 176 (n = 40, 47.6%); RT 001 (n = 23, 27.4%); and RT 014 (n = 7, 8.3%). Ribotype 176 predominated among clinical CD isolates in our hospital. The proportion of RT 176 and RT 001 in four hospital departments with the highest incidence of CDI cases was very specific, pointing to local CDI outbreaks. Based on our data, previous use of antibiotics represents a significant risk factor for the development of CDI in patients over 65 years of age.
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Maves RC, Kalil AC. Which trial do we need? Doxycycline in combination with ceftriaxone for the treatment of community-acquired pneumonia. Clin Microbiol Infect 2023:S1198-743X(23)00090-3. [PMID: 36870434 DOI: 10.1016/j.cmi.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Ryan C Maves
- Section of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Houshmand H, Porta C, Pradelli L, Pinciroli M, Sotgiu G. Cost-Impact Analysis of a Novel Diagnostic Test to Assess Community-Acquired Pneumonia Etiology in the Emergency Department Setting: A Multi-Country European Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3853. [PMID: 36900863 PMCID: PMC10001249 DOI: 10.3390/ijerph20053853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND We aimed to estimate the economic and clinical impacts of a novel diagnostic test called LIAISON® MeMed BV® (LMMBV), which can differentiate bacterial from viral infections, in patients with community-acquired pneumonia (CAP) in emergency departments. METHODS A cost-impact simulation model was developed to investigate the financial consequences of the introduction of LMMBV into the standard of care (SOC) diagnostic process in Italy, Germany, and Spain. Clinical outcomes were expressed as antibiotic patients and days saved, reduced hospital admissions, and shortened hospital length of stay (LOS). Cost savings were evaluated from the perspectives of third-party payers and hospitals. A deterministic sensitivity analysis (DSA) was carried out. RESULTS LMMBV was associated with a reduction in antibiotic prescriptions, treatment duration, and LOS. Furthermore, the adoption of LMMBV would allow savings per patient up to EUR 364 and EUR 328 for hospitals and EUR 91 and EUR 59 for payers in Italy and Germany, respectively. In Spain, average savings per patient could reach up to EUR 165 for both payers and hospitals. Savings were most sensitive to test accuracy, with DSA confirming the robustness of the results. CONCLUSIONS Combining LMMBV with the current SOC diagnostic process is expected to provide clinical and economic benefits in Italy, Germany, and Spain.
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Affiliation(s)
| | - Camilla Porta
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | | | - Giovanni Sotgiu
- Scienze Mediche Chirurgiche E Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy
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Garey KW, Rose W, Gunter K, Serio AW, Wilcox MH. Omadacycline and Clostridioides difficile: A Systematic Review of Preclinical and Clinical Evidence. Ann Pharmacother 2023; 57:184-192. [PMID: 35656828 PMCID: PMC9874691 DOI: 10.1177/10600280221089007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The objective of this systematic review is to summarize in vitro, preclinical, and human data related to omadacycline and Clostridioides difficile infection (CDI). DATA SOURCES PubMed and Google Scholar were searched for "omadacycline" AND ("Clostridium difficile" OR "C difficile" OR "Clostridioides difficile") for any studies published before February 15, 2022. The US Food and Drug Administration (FDA) Adverse Events Reporting System (AERS) was searched for omadacycline (for reports including "C. difficile" or "CDI" or "gastrointestinal infection"). The publications list publicly available at Paratek Pharmaceuticals, Inc. Web site was reviewed. STUDY SELECTION AND DATA EXTRACTION Publications presenting primary data on omadacycline and C. difficile published in English were included. DATA SYNTHESIS Preclinical and clinical evidence was extracted from 14 studies. No case reports in indexed literature and no reports on FDA AERS were found. Omadacycline has potent in vitro activity against many C. difficile clinical strains and diverse ribotypes. In phase 3 studies, there were no reports of CDI in patients who received omadacycline for either community-acquired bacterial pneumonia or acute bacterial skin and skin structure infection. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Omadacycline should be considered a low-risk antibiotic regarding its propensity to cause CDI. CONCLUSIONS Reducing the burden of CDI on patients and the health care system should be a priority. Patients with appropriate indications who are at heightened risk of CDI may be suitable candidates for omadacycline therapy. In these patients, omadacycline may be preferable to antibiotics with a high CDI risk.
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Affiliation(s)
- Kevin W. Garey
- University of Houston College of
Pharmacy, Houston, TX, USA
| | - Warren Rose
- School of Pharmacy, University of
Wisconsin–Madison, Madison, WI, USA
| | - Kyle Gunter
- Paratek Pharmaceuticals, Inc., King of
Prussia, PA, USA,Kyle Gunter, Director of Medical Science,
Paratek Pharmaceuticals, Inc., 1000 First Avenue, Suite 200, King of Prussia, PA
19406, USA.
| | | | - Mark H. Wilcox
- University of Leeds & Leeds
Teaching Hospitals, Leeds, UK
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Association of fluoroquinolones or cephalosporin plus macrolide with Clostridioides difficile infection (CDI) after treatment for community-acquired pneumonia. Infect Control Hosp Epidemiol 2023; 44:47-54. [PMID: 35440348 DOI: 10.1017/ice.2022.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) is the most common cause of gastroenteritis, and community-acquired pneumonia (CAP) is the most common infection treated in hospitals. American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) CAP guidelines recommend empiric therapy with a respiratory fluoroquinolone or cephalosporin plus macrolide combination, but the CDI risk of these regimens is unknown. We examined the association between each antibiotic regimen and the development of hospital-onset CDI. METHODS We conducted a retrospective cohort study using data from 638 US hospitals contributing administrative including 177 also contributing microbiologic data to Premier, Inc. We included adults admitted with pneumonia and discharged from July 2010 through June 2015 with a pneumonia diagnosis code who received ≥3 days of either empiric regimen. Hospital-onset CDI was defined by a diagnosis code not present on admission and positive laboratory test on day 4 or later or readmission for CDI. Mixed propensity-weighted multiple logistic regression was used to estimate the associations of CDI with antibiotic regimens. RESULTS Our sample included 58,060 patients treated with either cephalosporin plus macrolide (36,796 patients) or a fluoroquinolone alone (21,264 patients) and with microbiological data; 127 (0.35%) patients who received cephalosporin plus macrolide and 65 (0.31%) who received a fluoroquinolone developed CDI. After adjustment for patient demographics, comorbidities, risk factors for antimicrobial resistance, and hospital characteristics, CDI risks were similar for fluoroquinolones versus cephalosporin plus macrolide (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.70-1.38). CONCLUSION Among patients with CAP at US hospitals, CDI was uncommon, occurring in ∼0.33% of patients. We did not detect a significant association between the choice of empiric guideline recommended antibiotic therapy and the development of CDI.
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Kichloo A, El-Amir Z, Dahiya DS, Al-Haddad M, Singh J, Singh G, Corpuz C, Shaka H. Rate and predictors of 30-day readmission for clostridiodes difficile: a United States analysis. Ann Med 2022; 54:150-158. [PMID: 34989297 PMCID: PMC8741240 DOI: 10.1080/07853890.2021.2023211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Clostridiodes difficile is a leading cause of healthcare-associated diarrhea. In this study, we aimed to identify the rates and predictors for 30-day readmissions of Clostridiodes difficile Enterocolitis (CDE) in the United States. METHODS We conducted a retrospective study of the Nationwide Readmissions Database to identify adult hospitalizations with a principal diagnosis of CDE for 2018. Individuals <18 years old and elective hospitalizations were excluded. Primary outcomes included readmission rate and the top ten principal diagnosis on readmission, while the secondary outcomes were inpatient mortality, hospital costs and independent predictors of 30-day all-cause readmissions. Furthermore, we devised a scoring system to estimate the risk of CDE readmissions. Stata® Version 16 was used for statistical analysis and p-values ≤0.05 were statistically significant. RESULTS We identified 94,668 index hospitalizations and 18,296 readmissions at 30-days for CDE in 2018. The 30-day all-cause readmission rate was 25.7%. On readmission, CDE was the most common principal diagnosis (25.7%), followed by unspecified sepsis, and acute renal failure. A female predominance was also noted for index and 30-day readmissions of CDE. Compared to index admissions, we noted higher odds of inpatient mortality [4.4 vs 1.4%, Odds Ratio (OR):3.32, 95% Confidence Interval (CI):2.87-3.84, p < 0.001], longer mean length of stay (LOS) [6.4 vs 5.6 days, Mean Difference (MD):0.9, 95% CI:0.7-1.0, p < 0.001), and higher mean total hospital charge (THC) [$56,015 vs $40,871, MD:15,144, 95% CI:13,260-17,027, p < 0.001] for 30-day readmissions of CDE. Independent predictors for 30-day all-cause readmissions of CDE included discharged against medical advice (AMA) [Adjusd Hazard Ratio (aHR):2.01, 95% CI:1.73-2.53, p < 0.001], diabetes mellitus (DM) [aHR:1.22, 95% CI:1.16-1.29, p < 0.001], and chronic kidney disease (CKD) [aHR:1.29, 95% CI:1.21-1.37, p < 0.001]. CONCLUSION The all-cause 30-day readmission rate and inpatient mortality for CDE was 25.7% and 4.4%, respectively. Discharge AMA, DM and CKD were independent predictors for 30-day all-cause readmissions of CDE.KEY MESSAGEThe 30-day all-cause readmission rate for Clostridiodes difficile Enterocolitis was noted to be 21.4% in 2018.Independent predictors of 30-day all-cause readmissions for Clostridiodes difficile Enterocolitis include diabetes mellitus, discharged against medical advice and chronic kidney disease.Readmissions of Clostridiodes difficile Enterocolitis had higher mortality rates, healthcare cost and length of hospital stay compared to index admissions.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA.,Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jagmeet Singh
- Department of Nephrology, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Gurdeep Singh
- Department of Medicine and Endocrinology, Our Lady of Lourdes Memorial Hospital, Binghamton, NY, USA
| | - Carlos Corpuz
- Department of Internal Medicine, John H. Stronger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stronger Jr. Hospital of Cook County, Chicago, IL, USA
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Goff DA, Mangino JE, Trolli E, Scheetz R, Goff D. Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education From Infectious Diseases Experts. Open Forum Infect Dis 2022; 9:ofac361. [PMID: 35959211 PMCID: PMC9361170 DOI: 10.1093/ofid/ofac361] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.
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Affiliation(s)
- Debra A Goff
- Department of Pharmacy, The Ohio State University Wexner Medical Center, The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | - Julie E Mangino
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Elizabeth Trolli
- The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | | | - Douglas Goff
- Gilbert and Goff Prosthodontists, Columbus, Ohio, USA
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Johnson MD, Davis AP, Dyer AP, Jones TM, Spires SS, Ashley ED. Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine. Am J Med 2022; 135:828-835. [PMID: 35367180 DOI: 10.1016/j.amjmed.2022.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 11/01/2022]
Abstract
Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.
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Affiliation(s)
- Melissa D Johnson
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC.
| | - Angelina P Davis
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - April P Dyer
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - Travis M Jones
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - S Shaefer Spires
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
| | - Elizabeth Dodds Ashley
- Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC
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Leahy RG, Serio AW, Wright K, Traczewski MM, Tanaka SK. Activity of omadacycline in vitro against Clostridioides difficile and preliminary efficacy assessment in a hamster model of C. difficile-associated diarrhea. J Glob Antimicrob Resist 2022; 30:96-99. [DOI: 10.1016/j.jgar.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022] Open
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Analysis of recurrent urinary tract infection management in women seen in outpatient settings reveals opportunities for antibiotic stewardship interventions. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e8. [PMID: 36310787 PMCID: PMC9614978 DOI: 10.1017/ash.2021.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022]
Abstract
Objectives: We characterized antibiotic prescribing patterns and management practices among recurrent urinary tract infection (rUTI) patients, and we identified factors associated with lack of guideline adherence to antibiotic choice, duration of treatment, and urine cultures obtained. We hypothesized that prior resistance to nitrofurantoin or trimethoprim–sulfamethoxazole (TMP-SMX), shorter intervals between rUTIs, and more frequent rUTIs would be associated with fluoroquinolone or β-lactam prescribing, or longer duration of therapy. Methods: This study was a retrospective database study of adult women with International Classification of Diseases, Tenth Revision (ICD-10) cystitis codes meeting American Urological Association rUTI criteria at outpatient clinics within our academic medical center between 2016 and 2018. We excluded patients with ICD-10 codes indicative of complicated UTI or pyelonephritis. Generalized estimating equations were used for risk-factor analysis. Results: Among 214 patients with 566 visits, 61.5% of prescriptions comprised first-line agents of nitrofurantoin (39.7%) and TMP-SMX (21.5%), followed by second-line choices of fluoroquinolones (27.2%) and β-lactams (11%). Most fluoroquinolone prescriptions (86.7%), TMP-SMX prescriptions (72.2%), and nitrofurantoin prescriptions (60.2%) exceeded the guideline-recommended duration. Approximately half of visits lacked a urine culture. Receiving care through urology via telephone was associated with receiving a β-lactam (adjusted odds ratio [aOR], 6.34; 95% confidence interval [CI], 2.58–15.56) or fluoroquinolone (OR, 2.28; 95% CI, 1.07–4.86). Having >2 rUTIs during the study period and seeking care from a urology practice (RR, 1.28, 95% CI, 1.15–1.44) were associated with longer antibiotic duration. Conclusions: We found low guideline concordance for antibiotic choice, duration of therapy and cultures obtained among rUTI patients. These factors represent new targets for outpatient antibiotic stewardship interventions.
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Schneider JE, Cooper JT. Cost impact analysis of novel host-response diagnostic for patients with community-acquired pneumonia in the emergency department. J Med Econ 2022; 25:138-151. [PMID: 34994273 DOI: 10.1080/13696998.2022.2026686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is significant over-prescription of antibiotics for suspected community-acquired pneumonia (CAP) patients as bacterial and viral pathogens are difficult to differentiate. To address this issue, a host response diagnostic called MeMed BV (MMBV) was developed that accurately differentiates bacterial from viral infection at the point of need by integrating measurements of multiple biomarkers. A literature-based cost-impact model was developed that compared the cost impact and clinical benefits between using the standard of care diagnostics combined with MMBV relative to standard of care diagnostics alone. METHODS The patient population was stratified according to the pneumonia severity index, and cost savings were considered from payer and provider perspectives. Four scenarios were considered. The main analysis considers the cost impact of differences in antibiotic stewardship and resulting adverse events. The first, second, and third scenarios combine the impacts on antibiotic stewardship with changes in hospital admission probability, length of hospital stay and diagnosis related group (DRG) reallocation, and hospital admission probability, length of stay, and DRG reallocation in combination, respectively. RESULTS The main analysis results show overall per-patient savings of $37 for payers and $223 for providers. Scenarios 1, 2, and 3 produced savings of $137, $189, and $293 for payers, and $339, $713, and $809 for providers, respectively. LIMITATIONS Models are simulations of real-world clinical processes, and are not sensitive to variations in clinical practice driven by differences in physician practice styles, differences in facility-level practice patterns, and patient comorbidities expected to exacerbate the clinical impact of CAP. Hospital models are limited to costs and do not consider differences in revenue associated with each approach. CONCLUSIONS Introducing MMBV to the current SOC diagnostic process is likely to be cost-saving to both hospitals and payers when considering impacts on antibiotic distribution, hospital admission rate, hospital LOS, and DRG reallocation.
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Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis. Clin Microbiol Infect 2021; 28:479-490. [PMID: 34775072 DOI: 10.1016/j.cmi.2021.10.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/14/2021] [Accepted: 10/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is growing evidence supporting the efficacy of shorter courses of antibiotic therapy for common infections, however the risks of prolonged antibiotic duration are underappreciated. OBJECTIVES We sought to estimate the incremental daily risk of antibiotic-associated harms. METHODS We searched three major databases to retrieve systematic reviews from 2000 to July 30, 2020 in any language. ELIGIBILITY Systematic reviews were required to evaluate shorter versus longer antibiotic therapy with fixed durations between 3 and 14 days. RCTs included for meta-analysis were identified from the systematic reviews. PARTICIPANTS Adult and pediatric patients from any setting. INTERVENTIONS Primary outcomes were the proportion of patients experiencing adverse drug events, superinfections and antimicrobial resistance. Risk of Bias Assessment: Each RCT was evaluated for quality by extracting the assessment reported by each systematic review. DATA SYNTHESIS The daily odds ratio (OR) of antibiotic harm was estimated and pooled using random effects meta-analysis. RESULTS Thirty-five (35) systematic reviews encompassing 71 eligible randomized controlled trials were included. Studies most commonly evaluated duration of therapy for respiratory tract (n=36, 51%) and urinary tract infections (n=29, 41%). Overall, 23,174 patients were evaluated for antibiotic-associated harms. Adverse events (n=20,345), superinfections (n=5,776), and AMR (n=2,330) were identified in 19.9% (n=4,039), 4.8% (n=280), and 10.6% (n=246) of patients, respectively. Each day of antibiotic therapy was associated with 4% increased odds of experiencing an adverse event (OR 1.04, 95% CI [1.02 to 1.07]). Daily odds of severe adverse effects also increased (OR 1.09, 95% CI [1.00 to 1.19). The daily incremental odds of superinfection and AMR were OR 0.98 (0.92 to 1.06) and OR 1.03 (0.98 to 1.07), respectively. CONCLUSION Each additional day of antibiotic therapy is associated with measurable antibiotic harm, particularly adverse events. These data may provide additional context for clinicians when weighing benefits versus risks of prolonged antibiotic therapy.
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Uddin M, Mohammed T, Metersky M, Anzueto A, Alvarez CA, Mortensen EM. Effectiveness of Beta-Lactam plus Doxycycline for Patients Hospitalized with Community-Acquired Pneumonia. Clin Infect Dis 2021; 75:118-124. [PMID: 34751745 DOI: 10.1093/cid/ciab863] [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: 05/22/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite clinical practice guideline recommendations to use doxycycline as part of combination therapy for some patients hospitalized with pneumonia, there is minimal evidence supporting this recommendation. Our aim was to examine the association between beta-lactam plus doxycycline and mortality for patients hospitalized with community-acquired pneumonia. METHODS We identified patients > 65 years of age admitted to any United States Department of Veterans Affairs hospital in fiscal years 2002-2012 with a discharge diagnosis of pneumonia. We excluded those patients who did not receive antibiotic therapy concordant with the 2019 ATS/IDSA clinical practice guidelines. Using propensity score matching, we examined the association of doxycycline with 30- and 90-day mortality. RESULTS Our overall cohort was comprised of 70,533 patients and 5,282 (7.49%) received doxycycline. Unadjusted 30-day mortality was 6.4% for those who received a beta-lactam plus doxycycline vs. 9.1% in those who did not (p<0.0001), and 90-day mortality was 13.8% for those who received a beta-lactam + doxycycline vs. 16.8% for those who did not (p<0.0001). In the propensity score matched models, both 30- (odds ratio 0.72, 95% confidence interval, 0.63-0.84) and 90-day (0.83, 0.74-0.92) mortality were significantly lower for those who received doxycycline. CONCLUSIONS In this retrospective observational cohort study, we found that doxycycline use, as part of guideline-concordant antibiotic therapy, was associated with lower 30- and 90-day mortality than regimens without doxycycline. While this supports the safety and effectiveness of antibiotic regimes that include doxycycline, additional studies, especially randomized clinical trials, are needed to confirm this.
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Affiliation(s)
- Moe Uddin
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Turab Mohammed
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mark Metersky
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Antonio Anzueto
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Carlos A Alvarez
- VA North Texas Health Care System, Dallas, Texas, USA.,Department of Pharmacy Practice, Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, Texas, USA
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA.,VA North Texas Health Care System, Dallas, Texas, USA
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Potential Cost Savings Associated with Targeted Substitution of Current Guideline-Concordant Inpatient Agents with Omadacycline for the Treatment of Adult Hospitalized Patients with Community-Acquired Bacterial Pneumonia at High Risk for Clostridioides difficile Infections: Results of Healthcare-Decision Analytic Model from the United States Hospital Perspective. Antibiotics (Basel) 2021; 10:antibiotics10101195. [PMID: 34680776 PMCID: PMC8532985 DOI: 10.3390/antibiotics10101195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction: Approximately 3% of hospitalized patients with community-acquired bacterial pneumonia (CABP) develop healthcare-associated Clostridioides difficile infection (HCA-CDI). The validated Davis risk score (DRS) indicates that patients with a DRS ≥ 6 are at an increased risk of 30-day HCA-CDI. In the phase 3 OPTIC CABP study, 14% of CABP patients with DRS ≥ 6 who received moxifloxacin developed CDI vs. 0% for omadacycline. This study assessed the potential economic impact of substituting current guideline-concordant CABP inpatient treatments with omadacycline in hospitalized CABP patients with a DRS ≥ 6 across US hospitals. Methods: A deterministic healthcare-decision analytic model was developed. The model population was hospitalized adult CABP patients with a DRS ≥ 6 across US hospitals (100,000 patients). In the guideline-concordant arm, 14% of CABP patients with DRS ≥ 6 were assumed to develop an HCA-CDI, each costing USD 20,100. In the omadacycline arm, 5 days of therapy was calculated for the entire model population. Results: The use of omadacycline in place of guideline-concordant CABP inpatient treatments for CABP patients with DRS ≥ 6 was estimated to result in cost savings of USD 55.4 million annually across US hospitals. Conclusion: The findings of this simulated model suggest that prioritizing the use of omadacycline over current CABP treatments in hospitalized CABP with a DRS ≥ 6 may potentially reduce attributable HCA-CDI costs. The findings are not unique to omadacycline and could be applied to any antibiotic that confers a lower risk of HCA-CDI relative to current CABP inpatient treatments.
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Characterizing Risk Factors for Clostridioides difficile Infection among Hospitalized Patients with Community-Acquired Pneumonia. Antimicrob Agents Chemother 2021; 65:e0041721. [PMID: 33875439 DOI: 10.1128/aac.00417-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Hospitalized patients with community-acquired pneumonia (CAP) are at risk of developing Clostridioides difficile infection (CDI). We developed and tested clinical decision rules for identifying CDI risk in this patient population. The study was a single-center retrospective, case-control analysis of hospitalized adult patients empirically treated for CAP between 1 January 2014 and 3 March 2018. Differences between cases (CDI diagnosed within 180 days following admission) and controls (no test result indicating CDI during the study period) with respect to prehospitalization variables were modeled to generate propensity scores. Postadmission variables were used to predict case status on each postadmission day where (i) ≥1 additional case was identified and (ii) each model stratum contained ≥15 subjects. Models were developed and tested using optimal discriminant analysis and classification tree analysis. Forty-four cases and 181 controls were included. The median time to diagnosis was 50 days postadmission. After weighting, three models were identified (20, 117, and 165 days postadmission). The day 20 model yielded the greatest (weighted [w]) accuracy (weighted area under the receiver operating characteristic curve [wROC area] = 0.826) and the highest chance-corrected accuracy (weighted effect strength for sensitivity [wESS] = 65.3). Having a positive culture (odds, 1:4; P = 0.001), receipt of ceftriaxone plus azithromycin for a defined infection (odds, 3:5; P = 0.006), and continuation of empirical broad-spectrum antibiotics with activity against P. aeruginosa when no pathogen was identified (odds, 1:8; P = 0.013) were associated with CDI on day 20. Three models were identified that accurately predicted CDI in hospitalized patients treated for CAP. Antibiotic use increased the risk of CDI in all models, underscoring the importance of antibiotic stewardship.
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Solanki D, Kichloo A, El-Amir Z, Dahiya DS, Singh J, Wani F, Solanki S. Clostridium difficile Infection Hospitalizations in the United States: Insights From the 2017 National Inpatient Sample. Gastroenterology Res 2021; 14:87-95. [PMID: 34007350 PMCID: PMC8110239 DOI: 10.14740/gr1371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 03/25/2021] [Indexed: 12/27/2022] Open
Abstract
Background There is a paucity of contemporary national estimates for Clostridium difficile infection (CDI) hospitalizations by age group, sex, and region in the US population. Also, there is lack of contemporary national statistics on CDI hospitalizations with comorbidities. Methods We analyzed the 2017 National Inpatient Sample (NIS) to determine the population-based rates of CDI hospitalizations, characteristics of hospitalizations with CDI, and the rates of comorbidities associated with CDI hospitalizations. Results There were 329,460 CDI-related hospitalizations in 2017 (almost 1% of all hospitalizations). The average age for patients admitted with CDI as a principal or secondary diagnosis was 64.7 years (almost 20 years older when compared with all other hospitalizations). Patients 85 years and older had the highest rate of CDI hospitalizations (716 per 100,000 hospitalizations), and patients less than 18 years of age had the lowest rate (12 per 100,000 hospitalizations). There was a progressive increase in the CDI hospitalization rates with each successive age group. The hospitalization rates were higher in females (114 per 100,000 hospitalizations) than males (88 per 100,000 hospitalizations). The CDI hospitalization rate was highest in the Northeast (109 per 100,000 hospitalizations) and lowest in the West (84 per 100,000 hospitalizations). Fluid and electrolyte disturbance (63.3%) and renal failure (33.4%) were the two most common comorbidities associated with CDI hospitalizations. When CDI is a secondary diagnosis, major loss of function, extreme likelihood of dying, septicemia, and septic shock were more common in comparison to CDI as a principal diagnosis. Conclusions CDI hospitalization rates were highest in the elderly over 85 years old and declined with successive decreases in age. Women had higher CDI hospitalization rates than men, and fluid and electrolyte disturbances and renal failure were the most common comorbid conditions. The presence of CDI as a comorbid condition at the time of hospitalization for other principal diagnoses or development of CDI during a hospitalization for other principal diagnoses significantly increases the risk of in-hospital morbidity and mortality.
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Affiliation(s)
| | - Asim Kichloo
- Department of Medicine, Central Michigan University, Saginaw, MI, USA
| | - Zain El-Amir
- Department of Medicine, Central Michigan University, Saginaw, MI, USA
| | | | - Jagmeet Singh
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Farah Wani
- Department of Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Shantanu Solanki
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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Kichloo A, El-Amir Z, Dahiya DS, Singh J, Solanki D, Wani F, Shaka H. Impact of coexisting pneumonia in the patients admitted with Clostridium difficile infection: a retrospective study from a national inpatient database. J Investig Med 2021; 69:976-982. [PMID: 33785548 DOI: 10.1136/jim-2021-001820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/04/2022]
Abstract
Clostridium difficile is a gram-positive anaerobic spore forming bacillus that can cause infection in a setting of antibiotic use. Pneumonia is a major cause of morbidity and mortality in an inpatient setting and is frequently associated with significant antibiotic administration. This study aims to compare the outcomes of C. difficile infection (CDI) with and without pneumonia to determine the impact of pneumonia in hospitalized patients with CDI. This population-based retrospective observational propensity matched analysis study uses data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcomes were in-hospital mortality, total hospital charges, and mean length of stay. Secondary outcomes were the rates of sepsis, septic shock, non-ST elevation myocardial infarction (NSTEMI), acute renal failure, deep vein thrombosis, and pulmonary embolism. In-hospital mortality was noted to be higher in patients with pneumonia than those without (6.5% vs 1.2%, adjusted OR (aOR) 3.85; 95% CI 2.90 to 5.11, p<0.001). The following outcomes were more prevalent in patients with pneumonia compared with those without pneumonia: sepsis (9.8% vs 1.8%, aOR 4.69, 95% CI 3.73 to 5.87, p<0.001), septic shock (4.0% vs 0.5%, aOR 6.32, 95% CI 4.43 to 9.03, p<0.001), NSTEMI (1.9% vs 0.5%, aOR 2.95, 95% CI 1.85 to 4.71, p<0.001), and acute renal failure (31.5% vs 23.1%, aOR 1.23, 95% CI 1.07 to 1.40, p=0.003). In conclusion, patients with pneumonia were associated with significantly higher rates of system-based complications and higher in-hospital mortality rates.
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Affiliation(s)
- Asim Kichloo
- Department of Medicine, Samaritan Medical Center, Watertown, New York, USA .,Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Jagmeet Singh
- Department of Internal Medicine, Guthrie Healthcare System, Sayre, Pennsylvania, USA.,Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Dhanshree Solanki
- Department of Public Health, Rutgers University System, New Brunswick, New Jersey, USA
| | - Farah Wani
- Department of Medicine, Samaritan Medical Center, Watertown, New York, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
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Lodise TP, Mistry R, Young K, LaPensee K. Decision Analysis: Omadacycline Relative to Moxifloxacin Among Hospitalized Community-Acquired Bacterial Pneumonia Patients at Risk of Clostridioides difficile Infection. Clin Drug Investig 2021; 41:269-275. [PMID: 33604769 PMCID: PMC8079290 DOI: 10.1007/s40261-021-01005-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE: Omadacycline is an aminomethylcycline antibiotic approved in the USA as once-daily intravenous/oral monotherapy for adults with community-acquired bacterial pneumonia (CABP). Omadacycline demonstrated noninferiority to the fluoroquinolone moxifloxacin in a phase III CABP trial; adverse-event rates were similar between treatment groups except for Clostridioides difficile infection (CDI), which occurred in 2% of moxifloxacin-treated patients and 0% of patients on omadacycline. Conceptual healthcare-decision analytic models were developed to better understand the economic implications of antibiotic selection and CDI risk in acute-care facilities. METHODS A conceptual healthcare-decision analytic model was created to estimate incremental costs associated with treating 100 hospitalized CABP patients with an initial 5-day inpatient regimen of omadacycline instead of moxifloxacin. The underlying model assumption was that treatment with omadacycline has the potential to reduce CDI events relative to moxifloxacin. The model included excess costs associated with each treatment group from admission through discharge. Attributable CDI cost per case in the moxifloxacin group varied from $15,000 to $45,000 (US$). Omadacycline acquisition cost was $300-600/day for 5 days. RESULTS At a CDI attributable cost per case of $30,000 (base-case analyses), the incremental treatment cost (US$) per 100 patients ranged from $300,000 to $- 120,000 (cost savings). The excess CDI incidence in moxifloxacin-treated patients would need to be 5-10% for omadacycline to be cost-saving, assuming the attributable CDI cost is approximately $30,000. CONCLUSION Targeted omadacycline use may reduce economic burden associated with hospitalized CABP patients treated with moxifloxacin if it can reduce excess cases of moxifloxacin-associated CDI.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and the Health Sciences, 106 New Scotland Avenue, Albany, NY, 12189, USA.
| | | | - Kate Young
- PAREXEL Access Consulting, Waltham, MA, USA
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Zilberberg MD, Nathanson BH, Sulham K, Shorr AF. Multiple antimicrobial resistance and outcomes among hospitalized patients with complicated urinary tract infections in the US, 2013-2018: a retrospective cohort study. BMC Infect Dis 2021; 21:159. [PMID: 33557769 PMCID: PMC7869420 DOI: 10.1186/s12879-021-05842-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Complicated urinary tract infection (cUTI) is common among hospitalized patients. Though carbapenems are an effective treatment in the face of rising resistance, overuse drives carbapenem resistance (CR). We hypothesized that resistance to routinely used antimicrobials is common, and, despite frequent use of carbapenems, associated with an increased risk of inappropriate empiric treatment (IET), which in turn worsens clinical outcomes. Methods We conducted a retrospective cohort study of patients hospitalized with a culture-positive non-CR cUTI. Triple resistance (TR) was defined as resistance to > 3 of the following: 3rd generation cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, and nitrofurantoin. Multivariable models quantified the impact of TR and inappropriate empiric therapy (IET) on mortality, hospital LOS, and costs. Results Among 23,331 patients with cUTI, 3040 (13.0%) had a TR pathogen. Compared to patients with non-TR, those with TR were more likely male (57.6% vs. 47.7%, p < 0.001), black (17.9% vs. 13.6%, p < 0.001), and in the South (46.3% vs. 41.5%, p < 0.001). Patients with TR had higher chronic (median [IQR] Charlson score 3 [2, 4] vs. 2 [1, 4], p < 0.001) and acute (mechanical ventilation 7.0% vs. 5.0%, p < 0.001; ICU admission 22.3% vs. 18.6%, p < 0.001) disease burden. Despite greater prevalence of empiric carbapenem exposure (43.3% vs. 16.2%, p < 0.001), patient with TR were also more likely to receive IET (19.6% vs. 5.4%, p < 0.001) than those with non-TR. Although mortality was similar between groups, TR added 0.38 (95% CI 0.18, 0.49) days to LOS, and $754 (95% CI $406, $1103) to hospital costs. Both TR and IET impacted the outcomes among cUTI patients whose UTI was not catheter-associated (CAUTI), but had no effect on outcomes in CAUTI. Conclusions TR occurs in 1 in 8 patients hospitalized with cUTI. It is associated with an increase in the risk of IET exposure, as well as a modest attributable prolongation of LOS and increase in total costs, particularly in the setting of non-CAUTI. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05842-0.
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Affiliation(s)
| | | | - Kate Sulham
- Spero Therapeutics, 675 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Andrew F Shorr
- Washington Hospital Center, 110 Irving Street NW, Washington, DC, 20010, USA
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Khumra S, Mahony AA, Bergen PJ, Elliott RA. Evaluation of intravenous to oral antimicrobial switch at a hospital with a tightly regulated antimicrobial stewardship program. Br J Clin Pharmacol 2021; 87:3354-3358. [PMID: 33450086 DOI: 10.1111/bcp.14734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/10/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022] Open
Abstract
Timely intravenous (IV) to oral antimicrobial switch (IV-oral-switch) is a key antimicrobial stewardship (AMS) strategy. We aimed to explore concordance with IV-oral-switch guidelines in the context of a long-standing, tightly regulated AMS program. Data was retrospectively collected for 107 adult general medical and surgical patients in an Australian hospital. Median duration of IV antimicrobial courses before switching to oral therapy was 3 days (interquartile range [IQR] 2.25-5.00). Timely IV-oral-switch occurred in 57% (n = 61) of patients. The median delay to switching was 0 days (IQR 0 to 1.25). In most courses (92/106, 86.8%), the choice of oral alternative after switching was appropriate. In 45% (47/105) of courses, total duration of therapy (IV plus oral) exceeded the recommended duration by >1.0 day. Excessive IV antimicrobial duration was uncommon at a hospital with a tightly regulated AMS program. Total duration of therapy was identified as an AMS target for improvement.
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Affiliation(s)
- Sharmila Khumra
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew A Mahony
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne University, Melbourne, Victoria, Australia
| | - Phillip J Bergen
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Rohan A Elliott
- Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia.,Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
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Uranga A, Artaraz A, Bilbao A, Quintana JM, Arriaga I, Intxausti M, Lobo JL, García JA, Camino J, España PP. Impact of reducing the duration of antibiotic treatment on the long-term prognosis of community acquired pneumonia. BMC Pulm Med 2020; 20:261. [PMID: 33028293 PMCID: PMC7538840 DOI: 10.1186/s12890-020-01293-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) is not well established. The aim of this study was to assess the impact of reducing the duration of antibiotic treatment on long-term prognosis in patients hospitalized with CAP. Methods This was a multicenter study assessing complications developed during 1 year of patients previously hospitalized with CAP who had been included in a randomized clinical trial concerning the duration of antibiotic treatment. Mortality at 90 days, at 180 days and at 1 year was analyzed, as well as new admissions and cardiovascular complications. A subanalysis was carried out in one of the hospitals by measuring C-reactive protein (CRP), procalcitonin (PCT) and proadrenomedullin (proADM) at admission, at day 5 and at day 30. Results A total of 312 patients were included, 150 in the control group and 162 in the intervention group. Ninety day, 180 day and 1-year mortality in the per-protocol analysis were 8 (2.57%), 10 (3.22%) and 14 (4.50%), respectively. There were no significant differences between both groups in terms of 1-year mortality (p = 0.94), new admissions (p = 0.84) or cardiovascular events (p = 0.33). No differences were observed between biomarker level differences from day 5 to day 30 (CRP p = 0.29; PCT p = 0.44; proADM p = 0.52). Conclusions Reducing antibiotic treatment in hospitalized patients with CAP based on clinical stability criteria is safe, without leading to a greater number of long-term complications.
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Affiliation(s)
- Ane Uranga
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain.
| | - Amaia Artaraz
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Amaia Bilbao
- Research Unit, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Institute of Reasearch in Health Services Kronikgune, Barakaldo, Bizkaia, Spain
| | - Jose María Quintana
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Institute of Reasearch in Health Services Kronikgune, Barakaldo, Bizkaia, Spain.,Research Unit, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Ignacio Arriaga
- Department of Pneumology, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain
| | - Maider Intxausti
- Department of Pneumology, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain
| | - Jose Luis Lobo
- Department of Pneumology, Osakidetza, Universitary Hospital of Alava, Vitoria, Alava, Spain
| | - Julia Amaranta García
- Department of Pneumology, Osakidetza, Universitary Hospital of Alava, Vitoria, Alava, Spain
| | - Jesus Camino
- Department of Pneumology, Osakidetza, Hospital of San Eloy, Barakaldo, Bizkaia, Spain
| | - Pedro Pablo España
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
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Rzucidło-Hymczak A, Hymczak H, Olechowska-Jarząb A, Gorczyca A, Kapelak B, Drwiła R, Plicner D. Clostridioides difficile infection after cardiac surgery: Assessment of prevalence, risk factors and clinical outcomes-retrospective study. PeerJ 2020; 8:e9972. [PMID: 33062429 PMCID: PMC7531357 DOI: 10.7717/peerj.9972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is the most common cause of hospital-acquired diarrhea. There is little available data regarding risk factors of CDI for patients who undergo cardiac surgery. The study evaluated the course of CDI in patients after cardiac surgery. Methods Of 6,198 patients studied, 70 (1.1%) developed CDI. The control group consisted of 73 patients in whom CDI was excluded. Perioperative data and clinical outcomes were analyzed. Results Patients with CDI were significantly older in comparison to the control group (median age 73.0 vs 67.0, P = 0.005) and more frequently received proton pump inhibitors, statins, β-blockers and acetylsalicylic acid before surgery (P = 0.008, P = 0.012, P = 0.004, and P = 0.001, respectively). In addition, the presence of atherosclerosis, coronary disease and history of malignant neoplasms correlated positively with the development of CDI (P = 0.012, P = 0.036 and P = 0.05, respectively). There were no differences in the type or timing of surgery, aortic cross-clamp and cardiopulmonary bypass time, volume of postoperative drainage and administration of blood products between the studied groups. Relapse was more common among overweight patients with high postoperative plasma glucose or patients with higher C-reactive protein during the first episode of CDI, as well as those with a history of coronary disease or diabetes mellitus (P = 0.005, P = 0.030, P = 0.009, P = 0.049, and P = 0.025, respectively). Fifteen patients died (21.4%) from the CDI group and 7 (9.6%) from the control group (P = 0.050). Emergent procedures, prolonged stay in the intensive care unit, longer mechanical ventilation and high white blood cell count during the diarrhea were associated with higher mortality among patients with CDI (P = 0.05, P = 0.041, P = 0.004 and P = 0.007, respectively). Conclusions The study did not reveal any specific cardiac surgery-related risk factors for development of CDI.
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Affiliation(s)
| | - Hubert Hymczak
- Department of Anesthesiology, John Paul II Hospital, Krakow, Poland
| | | | - Anna Gorczyca
- Department of Infectious Diseases, John Paul II Hospital, Krakow, Poland
| | - Boguslaw Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Rafał Drwiła
- Medical College, Jagiellonian University, Krakow, Poland
| | - Dariusz Plicner
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
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Abelenda-Alonso G, Rombauts A, Gudiol C, Meije Y, Clemente M, Ortega L, Ardanuy C, Niubó J, Padullés A, Videla S, Tebe C, Carratalà J. Impact of comprehensive molecular testing to reduce antibiotic use in community-acquired pneumonia (RADICAP): a randomised, controlled, phase IV clinical trial protocol. BMJ Open 2020; 10:e038957. [PMID: 32819999 PMCID: PMC7443276 DOI: 10.1136/bmjopen-2020-038957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) continues to be a major health problem worldwide and is one of the main reasons for prescribing antibiotics. However, the causative agent is often not identified, resulting in antibiotic overtreatment, which is a key driver of antimicrobial resistance and adverse events. We aim to test the hypothesis that comprehensive molecular testing, compared with routine microbiological testing, would be effective in reducing antibiotic use in patients with CAP. METHODS AND ANALYSIS We will perform a randomised, controlled, open-label clinical trial with two parallel groups (1:1) at two tertiary hospitals between 2020 and 2022. Non-severely immunosuppressed adults hospitalised for CAP will be considered eligible. Patients will be randomly assigned to receive either the experimental diagnosis (comprehensive molecular testing plus routine microbiological testing) or standard diagnosis (only microbiological routine testing). The primary endpoint will be antibiotic consumption measured as days of antibiotic therapy per 1000 patient-days. Secondary endpoints will be de-escalation to narrower antibiotic treatment, time to switch from intravenous to oral antibiotics, days to reaching an aetiological diagnosis, antibiotic-related side effects, length of stay, days to clinical stability, intensive care unit admission, days of mechanical ventilation, hospital readmission up to 30 days after randomisation and death from any cause by 48 hours and 30 days after randomisation. We will need to include 440 subjects to be able to reject the null hypothesis that both groups have equal days of antibiotic therapy per 1000 patient-days with a probability >0.8. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethics Committee of Bellvitge Hospital (AC028/19) and from the Spanish Medicines and Medical Devices Agency, and it is valid for all participating centres under existing Spanish legislation. Results will be presented at international meetings and will be made available to patients, their caregivers and funders. TRIAL REGISTRATION NUMBER ClinicalTrials: NCT04158492. EudraCT: 2018-004880-29.
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Affiliation(s)
- Gabriela Abelenda-Alonso
- Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Institute for Biomedical Research, Barcelona, Spain
| | - Alexander Rombauts
- Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- Statistics Advisory Service, Institut d\'Investigacio Biomedica de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Carlota Gudiol
- Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- University of Barcelona, Barcelona, Catalunya, Spain
| | - Yolanda Meije
- Infectious Diseases Unit-Department of Internal Medicine, Hospital de Barcelona, Barcelona, Catalunya, Spain
| | - Mercedes Clemente
- Infectious Diseases Unit-Department of Internal Medicine, Hospital de Barcelona, Barcelona, Catalunya, Spain
| | - Lucía Ortega
- Infectious Diseases Unit-Department of Internal Medicine, Hospital de Barcelona, Barcelona, Catalunya, Spain
| | - Carmen Ardanuy
- Department of Clinical Microbiology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Niubó
- Department of Clinical Microbiology Unit, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Padullés
- Department of Farmacology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sebastian Videla
- Department of Clinical Farmacology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristian Tebe
- Statistics Advisory Service, Institut d\'Investigacio Biomedica de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Jordi Carratalà
- Infectious Diseases, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
- University of Barcelona, Barcelona, Catalunya, Spain
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Kokai-Kun JF, Le C, Trout K, Cope JL, Ajami NJ, Degar AJ, Connelly S. Ribaxamase, an Orally Administered β-Lactamase, Diminishes Changes to Acquired Antimicrobial Resistance of the Gut Resistome in Patients Treated with Ceftriaxone. Infect Drug Resist 2020; 13:2521-2535. [PMID: 32801790 PMCID: PMC7383106 DOI: 10.2147/idr.s260258] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Intravenous (IV) β-lactam antibiotics, excreted through bile into the gastrointestinal (GI) tract, may disrupt the gut microbiome by eliminating the colonization resistance from beneficial bacteria. This increases the risk for Clostridium difficile infection (CDI) and can promote antimicrobial resistance by selecting resistant organisms and eliminating competition by non-resistant organisms. Ribaxamase is an orally administered β-lactamase for use with IV β-lactam antibiotics (penicillins and cephalosporins) and is intended to degrade excess antibiotics in the upper GI before they can disrupt the gut microbiome and alter the resistome. Methods Longitudinal fecal samples (349) were collected from patients who participated in a previous Phase 2b clinical study with ribaxamase for prevention of CDI. In that previous study, patients were treated with ceftriaxone for a lower respiratory tract infection and received concurrent ribaxamase or placebo. Extracted fecal DNA from the samples was subjected to whole-genome shotgun sequencing and analyzed for the presence of antimicrobial resistance (AMR) genes by alignment of sequences against the Comprehensive Antibiotic Resistance Database. A qPCR assay was also used to confirm some of the results. Results Database alignment identified ~1300 acquired AMR genes and gene variants, including those encoding β-lactamases and vancomycin resistance which were significantly increased in placebo vs ribaxamase-treated patients following antibiotic exposure. qPCR corroborated the presence of these genes and supported both new acquisition and expansion of existing gene pools based on no detectable copy number or a low copy number in pre-antibiotic samples which increased post-antibiotics. Additional statistical analyses demonstrated significant correlations between changes in the gut resistome and clinical study parameters including study drug assignment and β-lactamase and vancomycin resistance gene frequency. Discussion These findings demonstrated that ribaxamase reduced changes to the gut resistome subsequent to ceftriaxone administration and may help limit the emergence of AMR.
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Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2020 Update. Arch Bronconeumol 2020. [PMID: 32139236 DOI: 10.1016/j.arbres.2020.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.
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Cannabis use and risk of Clostridioides difficile infection: Analysis of 59,824 hospitalizations. Anaerobe 2020; 61:102095. [DOI: 10.1016/j.anaerobe.2019.102095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/24/2019] [Accepted: 09/02/2019] [Indexed: 12/17/2022]
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Champredon D, Shoukat A, Moghadas SM. Effectiveness and cost-effectiveness of a Clostridium difficile vaccine candidate in a hospital setting. Vaccine 2020; 38:2585-2591. [PMID: 32014268 DOI: 10.1016/j.vaccine.2020.01.073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/18/2020] [Accepted: 01/23/2020] [Indexed: 11/27/2022]
Abstract
Toxoid vaccines against Clostridium difficile infections (CDI) appear promising in reducing the risk of developing toxin-mediated symptoms. We sought to evaluate the effectiveness and cost-effectiveness of a vaccine candidate in a hospital setting. We developed an agent-based simulation model of nosocomial CDI in a 300-bed hospital. Targeting high-risk patients for vaccination, we estimated the reduction of symptomatic CDI. Using the net reduction of CDI-associated isolation days, we evaluated the vaccine's cost-effectiveness from a healthcare provider perspective over a 2-year period with an average monthly incidence of 5 cases per 10,000 patient-days pre-vaccination. Assuming a vaccine efficacy in the range 60-90%, vaccinating 40% of high-risk patients pre-admission reduced symptomatic CDI by 16.6% (95% CI: 15.2, 17.9). When the vaccine coverage increased to 80%, the reduction of symptomatic CDI was 34.6% (95% CI: 33.7, 35.9). For a willingness to pay (WTP) of CDN$1000 (corresponding to the average costs of case isolation per day), vaccine was cost-effective for vaccination costs per individual (VCPI) up to CDN$111 in the scenario of 40% vaccine coverage. With the same WTP, vaccine was cost-effective for VCPI up to CDN$121 when the vaccine coverage increased to 80%. A significant portion (~80%) of hospital colonization is caused by environmental transmission of C. difficile, which markedly reduced the effectiveness of vaccine below its assumed efficacy. However, due to the number of CDI-associated isolation days averted, vaccination of high-risk patients can be cost-effective depending on the WTP and the VCPI.
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Affiliation(s)
- David Champredon
- Department of Pathology and Laboratory Medicine, University of Western Ontario, London, Ontario N6A 3K7, Canada; Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada
| | - Affan Shoukat
- Center for Infectious Disease Modelling and Analysis, Yale University, New Haven, CT 06510, USA; Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada
| | - Seyed M Moghadas
- Agent-Based Modelling Laboratory, York University, Toronto, Ontario M3J 1P3, Canada.
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Malik AT, Quatman CE, Phieffer LS, Ly TV, Khan SN. Clostridium difficile colitis in patients undergoing surgery for hip fractures: an analysis of 17,474 patients. Hip Int 2020; 30:22-32. [PMID: 30799640 DOI: 10.1177/1120700019831950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND We compiled evidence from a large national surgical database to identify the incidence, risk factors and postoperative impact of Clostridium difficile infection (CDI) in patients undergoing hip fracture repair. METHODS We identified 17,474 patients who underwent hip fracture repairs in 2015 using the ACS-NSQIP database. Interventions studied were open reduction/Internal fixation, total hip arthroplasty or hemiarthroplasty being performed for traumatic hip fractures. Outcomes studied were incidence, preoperative and postoperative risk factors for occurrence of CDI were studied using descriptive and statistical analysis. RESULTS A total of 92 patients (0.53%) developed CDI within 30 days of the operation. Following adjustment using multi-variate logistic regression, preoperative and hospital-associated factors associated with development of CDI were smoking (OR 1.75 [95% CI 1.03-2.99]), hypertension (OR 1.70 [95% CI 1.01-2.85]), hyponatraemia (OR 1.65 [95% CI 1.04-2.63]), prior systemic inflammatory response syndrome (SIRS) (OR 2.18 [95% CI 1.32-3.59]) and a length of stay >7 days (OR 1.98 [95% CI 1.11-3.53]. Postoperative factors associated with occurrence of CDI were occurrence of a deep surgical site infection (SSI) (OR 5.89 [95% CI 1.31-26.6]), a stay in the hospital >30 days (OR 6.56 [95% CI 2.56-16.9]) and unplanned reoperations (OR 2.78 [95% CI 1.29-5.99]). CONCLUSION As we move toward an era of bundled-payment models, identification of risk factors associated with the occurrence of postoperative complications, such as CDI, will help curb excess healthcare utilisation and costs associated with the management of this complication.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH, USA
| | - Carmen E Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH, USA
| | - Laura S Phieffer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH, USA
| | - Thuan V Ly
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH, USA
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A Generalizable, Data-Driven Approach to Predict Daily Risk of Clostridium difficile Infection at Two Large Academic Health Centers. Infect Control Hosp Epidemiol 2019; 39:425-433. [PMID: 29576042 DOI: 10.1017/ice.2018.16] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE An estimated 293,300 healthcare-associated cases of Clostridium difficile infection (CDI) occur annually in the United States. To date, research has focused on developing risk prediction models for CDI that work well across institutions. However, this one-size-fits-all approach ignores important hospital-specific factors. We focus on a generalizable method for building facility-specific models. We demonstrate the applicability of the approach using electronic health records (EHR) from the University of Michigan Hospitals (UM) and the Massachusetts General Hospital (MGH). METHODS We utilized EHR data from 191,014 adult admissions to UM and 65,718 adult admissions to MGH. We extracted patient demographics, admission details, patient history, and daily hospitalization details, resulting in 4,836 features from patients at UM and 1,837 from patients at MGH. We used L2 regularized logistic regression to learn the models, and we measured the discriminative performance of the models on held-out data from each hospital. RESULTS Using the UM and MGH test data, the models achieved area under the receiver operating characteristic curve (AUROC) values of 0.82 (95% confidence interval [CI], 0.80-0.84) and 0.75 ( 95% CI, 0.73-0.78), respectively. Some predictive factors were shared between the 2 models, but many of the top predictive factors differed between facilities. CONCLUSION A data-driven approach to building models for estimating daily patient risk for CDI was used to build institution-specific models at 2 large hospitals with different patient populations and EHR systems. In contrast to traditional approaches that focus on developing models that apply across hospitals, our generalizable approach yields risk-stratification models tailored to an institution. These hospital-specific models allow for earlier and more accurate identification of high-risk patients and better targeting of infection prevention strategies. Infect Control Hosp Epidemiol 2018;39:425-433.
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Pepper DJ, Sun J, Cui X, Welsh J, Natanson C, Eichacker PQ. Antibiotic- and Fluid-Focused Bundles Potentially Improve Sepsis Management, but High-Quality Evidence Is Lacking for the Specificity Required in the Centers for Medicare and Medicaid Service's Sepsis Bundle (SEP-1). Crit Care Med 2019; 47:1290-1300. [PMID: 31369426 PMCID: PMC10802116 DOI: 10.1097/ccm.0000000000003892] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To address three controversial components in the Centers for Medicare and Medicaid Service's sepsis bundle for performance measure (SEP-1): antibiotics within 3 hours, a 30 mL/kg fluid infusion for all hypotensive patients, and repeat lactate measurements within 6 hours if initially elevated. We hypothesized that antibiotic- and fluid-focused bundles like SEP-1 would probably show benefit, but evidence supporting specific antibiotic timing, fluid dosing, or serial lactate requirements would not be concordant. Therefore, we performed a meta-analysis of studies of sepsis bundles like SEP-1. DATA SOURCES PubMed, Embase, ClinicalTrials.gov through March 15, 2018. STUDY SELECTION Studies comparing survival in septic adults receiving versus not receiving antibiotic- and fluid-focused bundles. DATA EXTRACTION Two investigators (D.J.P., P.Q.E.). DATA SYNTHESIS Seventeen observational studies (11,303 controls and 4,977 bundle subjects) met inclusion criteria. Bundles were associated with increased odds ratios of survival (odds ratio [95% CI]) in 15 studies with substantial heterogeneity (I = 61%; p < 0.01). Survival benefits were consistent in the five largest (1,697-12,486 patients per study) (1.20 [1.11-1.30]; I = 0%) and six medium-sized studies (167-1,029) (2.03 [1.52-2.71]; I = 8%) but not the six smallest (64-137) (1.25 [0.42-3.66]; I = 57%). Bundles were associated with similarly increased survival benefits whether requiring antibiotics within 1 hour (n = 7 studies) versus 3 hours (n = 8) versus no specified time (n = 2); or 30 mL/kg fluid (n = 7) versus another volume (≥ 2 L, n = 1; ≥ 20 mL/kg, n = 2; 1.5-2 L or 500 mL, n = 1 each; none specified, n = 4) (p = 0.19 for each comparison). In the only study employing serial lactate measurements, survival was not increased versus others. No study had a low risk of bias or assessed potential adverse bundle effects. CONCLUSIONS Available studies support the notion that antibiotic- and fluid-focused sepsis bundles like SEP-1 improve survival but do not demonstrate the superiority of any specific antibiotic time or fluid volume or of serial lactate measurements. Until strong reproducible evidence demonstrates the safety and benefit of any fixed requirement for these interventions, the present findings support the revision of SEP-1 to allow flexibility in treatment according to physician judgment.
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Affiliation(s)
- Dominique J Pepper
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Judith Welsh
- NIH Library, National Institutes of Health, Bethesda, MD
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
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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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Abstract
The updated Infectious Disease Society of America guidelines for managing Clostridium difficile infections remove metronidazole as first-line therapy and add fecal microbiota transplants to the treatment options. This article reviews the new guidelines and strategies for diagnosis and infection control.
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Leslie JL, Vendrov KC, Jenior ML, Young VB. The Gut Microbiota Is Associated with Clearance of Clostridium difficile Infection Independent of Adaptive Immunity. mSphere 2019; 4:e00698-18. [PMID: 30700514 PMCID: PMC6354811 DOI: 10.1128/mspheredirect.00698-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/05/2019] [Indexed: 12/26/2022] Open
Abstract
Clostridium (Clostridioides) difficile, a Gram-positive, anaerobic bacterium, is the leading single cause of nosocomial infections in the United States. A major risk factor for Clostridium difficile infection (CDI) is prior exposure to antibiotics, as they increase susceptibility to CDI by altering the membership of the microbial community enabling colonization. The importance of the gut microbiota in providing protection from CDI is underscored by the reported 80 to 90% success rate of fecal microbial transplants in treating recurrent infections. Adaptive immunity, specifically humoral immunity, is also sufficient to protect from both acute and recurrent CDI. However, the role of the adaptive immune system in mediating clearance of C. difficile has yet to be resolved. Using murine models of CDI, we found that adaptive immunity is dispensable for clearance of C. difficile However, random forest analysis using only two members of the resident bacterial community correctly identified animals that would go on to clear the infection with 66.7% accuracy. These findings indicate that the indigenous gut microbiota independent of adaptive immunity facilitates clearance of C. difficile from the murine gastrointestinal tract.IMPORTANCEClostridium difficile infection is a major cause of morbidity and mortality in hospitalized patients in the United States. Currently, the role of the adaptive immune response in modulating levels of C. difficile colonization is unresolved. This work suggests that the indigenous gut microbiota is a main factor that promotes clearance of C. difficile from the GI tract. Our results show that clearance of C. difficile can occur without contributions from the adaptive immune response. This study also has implications for the design of preclinical studies testing the efficacy of vaccines on clearance of bacterial pathogens, as inherent differences in the baseline community structure of animals may bias findings.
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Affiliation(s)
- Jhansi L Leslie
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kimberly C Vendrov
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Matthew L Jenior
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Peyrani P, Mandell L, Torres A, Tillotson GS. The burden of community-acquired bacterial pneumonia in the era of antibiotic resistance. Expert Rev Respir Med 2018; 13:139-152. [PMID: 30596308 DOI: 10.1080/17476348.2019.1562339] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a significant global health problem and leading cause of death and hospitalization in both the US and abroad. Increasing macrolide resistance among Streptococcus pneumoniae and other pathogens results in a greater disease burden, along with changing demographics and a higher preponderance of comorbid conditions. Areas covered: This review summarizes current data on the clinical and economic burden of CAP, with particular focus on community-acquired bacterial pneumonia (CABP). Incidence, morbidity and mortality, and healthcare costs for the US and other regions of the world are among the topics covered. Major factors that are believed to be contributing to the increased impact of CABP, including antimicrobial resistance, the aging population, and the incidence of comorbidities are discussed, as well as unmet needs in current CABP management. Expert commentary: The clinical and economic burden of CABP is staggering, far-reaching, and expected to increase in the future as new antibiotic resistance mechanisms emerge and the world's population ages. Important measures must be initiated to stabilize and potentially decrease this burden. Urgent needs in CABP management include the development of new antimicrobials, adjuvant therapies, and rapid diagnostics.
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Affiliation(s)
- Paula Peyrani
- a Vaccine Clinical Research and Development , Pfizer Inc , Collegeville , PA , USA
| | - Lionel Mandell
- b Division of Infectious Diseases , McMaster University , Hamilton , Ontario , Canada
| | - Antoni Torres
- c Hospital Clinic, IDIBAPS, Ciberes , University of Barcelona , Barcelona , Spain
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ASID/ACIPC position statement - Infection control for patients with Clostridium difficile infection in healthcare facilities. Infect Dis Health 2018; 24:32-43. [PMID: 30691583 DOI: 10.1016/j.idh.2018.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2011, the Australasian Society for Infectious Diseases (ASID) and the Australian Infection Control Association (AICA), now known as the Australasian College of Infection Prevention and Control (ACIPC), produced a position statement on infection control requirements for preventing and controlling Clostridium difficile infection (CDI) in healthcare settings. METHODS The statement updated in 2017 to reflect new literature available .The authors reviewed the 2011 position statement and critically appraised new literature published between 2011 and 2017 and relevant current infection control guidelines to identify where new evidence had become available or best practice had changed. RESULTS The position statement was updated incorporating the new findings. A draft version of the updated position statement was circulated for consultation to members of ASID and ACIPC. The authors responded to all comments received and updated the position statement. CONCLUSIONS This updated position statement emphasizes the importance of health service organizations having evidence-based infection prevention and control programs and comprehensive antimicrobial stewardship programs, to ensure the risk of C. difficile acquisition, transmission and infection is minimised.
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Xu Q, Gu S, Chen Y, Quan J, Lv L, Chen D, Zheng B, Xu L, Li L. Protective Effect of Pediococcus pentosaceus LI05 Against Clostridium difficile Infection in a Mouse Model. Front Microbiol 2018; 9:2396. [PMID: 30356740 PMCID: PMC6189400 DOI: 10.3389/fmicb.2018.02396] [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: 06/06/2018] [Accepted: 09/19/2018] [Indexed: 12/26/2022] Open
Abstract
Clostridium difficile infection (CDI) is a major cause of infectious diarrhea among hospitalized patients. Probiotics could be instrumental in restoring the intestinal dysbiosis caused by CDI. Here, we examined the protective effect of Pediococcus pentosaceus LI05 in a mouse CDI model. C57BL/6 mice were administrated P. pentosaceus LI05 (LI05 group) or sterile anaerobic PBS (CDI group) everyday for 14 days. Mice were exposed to antibiotics cocktail for 5 days; then challenged with C. difficile strain VPI10463. Mice were monitored daily for survival and weight loss. Colonic tissue and serum samples were assessed for intestinal histopathology, intestinal barrier function and systemic inflammation. The oral administration of P. pentosaceus LI05 improved the survival rate and alleviated the histopathological impact of C. difficile. Compared to the CDI group, the levels of inflammatory mediators in the colon as well as inflammatory cytokines and chemokines in serum were substantially attenuated in the LI05 group. P. pentosaceus LI05 alleviated the CDI-induced of disruption of ZO-1, occludin and claudin-1. Additionally, fecal microbiome analysis showed an enrichment in the abundance of the Porphyromonadaceae and Rikenellaceae, while, the relative abundance of Enterobacteriaceae were decreased. Our results demonstrated that the preventive effect of P. pentosaceus LI05 against CDI was mediated via improving tight junction proteins and down-regulating the inflammatory response. Therefore, P. pentosaceus LI05 could be a promising probiotic in CDI.
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Affiliation(s)
- Qiaomai Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Silan Gu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiazheng Quan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Longxian Lv
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dazhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lichen Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Connelly S, Subramanian P, Hasan NA, Colwell RR, Kaleko M. Distinct consequences of amoxicillin and ertapenem exposure in the porcine gut microbiome. Anaerobe 2018; 53:82-93. [DOI: 10.1016/j.anaerobe.2018.04.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 01/12/2023]
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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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Selected Biomarkers Correlate with the Origin and Severity of Sepsis. Mediators Inflamm 2018; 2018:7028267. [PMID: 29769838 PMCID: PMC5892215 DOI: 10.1155/2018/7028267] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
The microbial etiology and source of sepsis influence the inflammatory response. Therefore, the plasma levels of cytokines (IL-6, IL-8, and IL-10), chemokines (CCL2/MCP-1, MIP-1β), heparin-binding protein (HBP), soluble CD14 (sCD14), and cortisol were analyzed in blood from septic patients obtained during the first 96 hours of intensive care unit hospitalization. The etiology was established in 56 out of a total of 62 patients enrolled in the study. Plasma concentrations of MCP-1, sCD14, IL-6, and IL-10 were significantly higher in patients with community-acquired pneumonia (CAP; n = 10) and infective endocarditis (IE; n = 11) compared to those with bacterial meningitis (BM; n = 18). Next, cortisol levels were higher in IE patients than in those with BM and CAP, and at one time point, cortisol was also higher in patients with gram-negative sepsis when compared to those with gram-positive infections. Furthermore, cortisol and MCP-1 levels correlated positively with the daily measured SOFA score. In addition, HBP levels were significantly higher in patients with IE than in those with BM. Our findings suggest that MCP-1, sCD14, IL-6, IL-10, cortisol, and HBP are modulated by the source of sepsis and that elevated MCP-1 and cortisol plasma levels are associated with sepsis-induced organ dysfunction.
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Abstract
PURPOSE OF REVIEW Increasing antimicrobial resistance is a worldwide phenomenon that is threatening public health. Lower respiratory infections are one of the leading causes of morbidity that contribute to antibiotic consumption and thus the emergence of multidrug-resistant microbial strains. The goal of shortening antibiotic regimens' duration in common bacterial infections has been prioritized by antimicrobial stewardship programs as an action against this problem. RECENT FINDINGS Data coming from randomized controlled trials, meta-analyses, and systematic reviews support the shortening of antimicrobial regimens in community-acquired, hospital-acquired, and ventilator-associated pneumonia. Short schedules have been proven at least as effective as long ones in terms of antimicrobial-free days and clinical cure. Procalcitonin-based algorithms have been validated as well tolerated and cost-effective tools for the duration of pneumonia therapy reduction. SUMMARY Shortening the duration of antibiotic regimens in pneumonia seems a reasonable strategy for reducing selective pressure driving antimicrobial resistance and costs provided that clinical cure is guaranteed. Procalcitonin-based protocols have been proven essentially helpful in this direction. VIDEO ABSTRACT.
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Oh SH, Kang HY. Identification of target risk groups for population-based Clostridium difficile infection prevention strategies using a population attributable risk approach. Int J Infect Dis 2017; 66:107-112. [PMID: 29162405 DOI: 10.1016/j.ijid.2017.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES We aimed to determine risk factors associated with Clostridium difficile infection (CDI) and assess the contributions of these factors on CDI burden. METHODS We conducted a 1:4 matched case-control study using a national claims dataset. Cases were incident CDI without a history of CDI in the previous 84 days, and were age- and sex-matched with control patients. We ascertained exposure, defined as a history of morbidities and drug use within 90 days. The population attributable risk (PAR) percent for risk factors was estimated using odds ratios (ORs) obtained from the case-control study. RESULTS Overall, the strongest CDI-associated risk factors, which have significant contributions to the CDI burden as well, were the experience of gastroenteritis (OR=5.08, PAR%=17.09%) and use of antibiotics (OR=1.69, PAR%=19.00%), followed by the experiences of female pelvic infection, irritable bowel syndrome, inflammatory bowel disease, and pneumonia, and use of proton-pump inhibitors (OR=1.52-2.37, PAR%=1.95-2.90). CONCLUSIONS The control of risk factors that had strong association with CDI and affected large proportions of total CDI cases would be beneficial for CDI prevention. We suggest performing CDI testing for symptomatic patients with gastroenteritis and implementing antibiotics stewardship.
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Affiliation(s)
- Sung-Hee Oh
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Hye-Young Kang
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea.
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Cotter KJ, Fan Y, Sieger GK, Weight CJ, Konety BR. Prevalence of Clostridium Difficile Infection in Patients After Radical Cystectomy and Neoadjuvant Chemotherapy. Bladder Cancer 2017; 3:305-310. [PMID: 29152554 PMCID: PMC5676759 DOI: 10.3233/blc-170132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Objectives: Clostridium Difficile is the most common cause of nosocomial infectious diarrhea. This study evaluates the prevalence and predictors of Clostridium Difficile infections in patients undergoing radical cystectomy with or without neoadjuvant chemotherapy. Methods: Retrospective chart review was performed of all patients undergoing cystectomy and urinary diversion at a single institution from 2011–2017. Infection was documented in all cases with testing for Clostridium Difficile polymerase chain reaction toxin B. Patient and disease related factors were compared for those who received neoadjuvant chemotherapy vs. those who did not in order to identify potential risk factors associated with C. Difficile infections. Chi squared test and logistic regression analysis were used to determine statistical significance. Results: Of 350 patients who underwent cystectomy, 41 (11.7%) developed Clostridium Difficile in the 30 day post-operative period. The prevalence of C. Difficile infection was higher amongst the patients undergoing cystectomy compared to the non-cystectomy admissions at our hospital (11.7 vs. 2.9%). Incidence was not significantly different among those who underwent cystectomy for bladder cancer versus those who underwent the procedure for other reasons. Median time to diagnosis was 6 days (range 3–28 days). The prevalence of C. Diff infections was not significantly different among those who received neoadjuvant chemotherapy vs. those who did not (11% vs. 10.4% p = 0.72). A significant association between C. Difficile infection was not seen with proton pump inhibitor use (p = 0.48), patient BMI (p = 0.67), chemotherapeutic regimen (p = 0.94), individual surgeon (p = 0.54), type of urinary diversion (0.41), or peri-operative antibiotic redosing (p = 0.26). Conclusions: Clostridium Difficile infection has a higher prevalence in patients undergoing cystectomy. No significant association between prevalence and exposure to neoadjuvant chemotherapy was seen.
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Affiliation(s)
| | - Yunhua Fan
- University of Minnesota Department of Urology, Minneapolis, MN, USA
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Chalmers J, Campling J, Ellsbury G, Hawkey PM, Madhava H, Slack M. Community-acquired pneumonia in the United Kingdom: a call to action. Pneumonia (Nathan) 2017; 9:15. [PMID: 29043150 PMCID: PMC5628444 DOI: 10.1186/s41479-017-0039-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/07/2017] [Indexed: 01/17/2023] Open
Abstract
Pneumococcal disease has a high burden in adults in the United Kingdom (UK); however, the total burden is underestimated, principally because most cases of community-acquired pneumonia (CAP) are non-invasive. Research into pneumonia receives poor funding relative to its disease burden (global mortality, disability-adjusted life years, and years lived with disability), ranking just 20 out of 25 for investment in infectious diseases in the UK. The current accuracy of data for establishing incidence rates is questionable, and it is a reflection of the paucity of research that much of the background information available derives from nearly 30 years ago. Given the relationship between CAP and mortality (pneumonia accounts for 29,000 deaths per annum in the UK, and 5-15% of patients hospitalised with CAP die within 30 days of admission), and the increasing threat of antimicrobial resistance associated with inappropriate antibiotic prescribing, such neglect of a highly prevalent problem is concerning. In this Call to Action, we explore the poorly understood burden of CAP in the UK, discuss the importance of an accurate diagnosis and appropriate treatment, and suggest how national collaboration could improve the management of an often life-threatening, yet potentially preventable disease.
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Affiliation(s)
- James Chalmers
- University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY UK
- Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY UK
| | | | | | - Peter M. Hawkey
- Institute of Microbiology and Infection, University of Birmingham, B15 2TT, Birmingham, UK
| | | | - Mary Slack
- School of Medicine, Griffith University, Campus, Gold Coast, QLD 4222 Australia
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Finch S, Keir HR, Dicker AJ, Chalmers JD. The past decade in bench research into pulmonary infectious diseases: What do clinicians need to know? Respirology 2017; 22:1062-1072. [PMID: 28657170 DOI: 10.1111/resp.13106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/07/2017] [Accepted: 05/14/2017] [Indexed: 12/12/2022]
Abstract
Respiratory infections are primarily treated with antibiotics, drugs that are mostly inexpensive and have been widely available since the 1940s and 1950s. Nevertheless, despite antibiotics, the burden of disease in pneumonia, bronchiectasis, cystic fibrosis, COPD and rare respiratory infections remains exceptionally high. There is an urgent need for translational studies to develop new treatments or new biomarkers to improve outcomes in these conditions. The 'translational gaps' between bench science and clinical practice are particularly challenging in respiratory infections. This is partly due to the poor representativeness of animal models of infection to human disease, and a long-term lack of investment into pulmonary infection research. The revolution in genomics and other omics technologies, however, is beginning to unlock clinically important information about the host response to infection, the behaviour of bacterial communities and the development of new antibiotics. It is not possible to review the extensive progress made in the last decade into the pathophysiology of the different respiratory infections and so here, we focus on major technologies that are now changing respiratory infection research, specifically bacterial whole-genome sequencing, the microbiota, personalized medicine with omics technologies, new antibiotic development and host inflammatory cell biology.
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Affiliation(s)
- Simon Finch
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Holly R Keir
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alison J Dicker
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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