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Candel FJ, Salavert M, Basaras M, Borges M, Cantón R, Cercenado E, Cilloniz C, Estella Á, García-Lechuz JM, Garnacho Montero J, Gordo F, Julián-Jiménez A, Martín-Sánchez FJ, Maseda E, Matesanz M, Menéndez R, Mirón-Rubio M, Ortiz de Lejarazu R, Polverino E, Retamar-Gentil P, Ruiz-Iturriaga LA, Sancho S, Serrano L. Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6864. [PMID: 37959328 PMCID: PMC10649000 DOI: 10.3390/jcm12216864] [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: 09/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology & Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain
| | - Miren Basaras
- Immunology, Microbiology and Parasitology Department, Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain;
| | - Marcio Borges
- Multidisciplinary Sepsis Unit, Intensive Medicine Department, University Hospital Son Llàtzer, 07198 Palma de Mallorca, Spain;
- Instituto de Investigación Sanitaria Islas Baleares (IDISBA), 07198 Mallorca, Spain
| | - Rafael Cantón
- Clinical Microbiology Service, University Hospital Ramón y Cajal, Institute Ramón y Cajal for Health Research (IRYCIS), 28034 Madrid, Spain;
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
| | - Emilia Cercenado
- Clinical Microbiology & Infectious Diseases Service, University Hospital Gregorio Marañón, 28009 Madrid, Spain;
| | - Catian Cilloniz
- IDIBAPS, CIBERES, 08007 Barcelona, Spain;
- Faculty of Health Sciences, Continental University, Huancayo 15304, Peru
| | - Ángel Estella
- Intensive Care Unit, INIBiCA, University Hospital of Jerez, Medicine Department, University of Cádiz, 11404 Jerez, Spain
| | | | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, 41013 Sevilla, Spain;
| | - Federico Gordo
- Intensive Medicine Department, University Hospital of Henares, 28802 Madrid, Spain;
| | - Agustín Julián-Jiménez
- Emergency Department, University Hospital Toledo, University of Castilla La Mancha, 45007 Toledo, Spain;
| | | | - Emilio Maseda
- Anesthesiology Department, Hospital Quirón Salud Valle del Henares, 28850 Madrid, Spain;
| | - Mayra Matesanz
- Hospital at Home Unit, Clinic University Hospital San Carlos, 28040 Madrid, Spain;
| | - Rosario Menéndez
- Pneumology Service, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain;
| | - Manuel Mirón-Rubio
- Hospital at Home Service, University of Torrejón, Torrejón de Ardoz, 28006 Madrid, Spain;
| | - Raúl Ortiz de Lejarazu
- National Influenza Center, Clinic University Hospital of Valladolid, University of Valladolid, 47003 Valladolid, Spain;
| | - Eva Polverino
- Pneumology Service, Hospital Vall d’Hebron, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health San Carlos III, 28029 Madrid, Spain
| | - Pilar Retamar-Gentil
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
- Infectious Diseases & Microbiology Clinical Management Unit, University Hospital Virgen Macarena, IBIS, University of Seville, 41013 Sevilla, Spain
| | - Luis Alberto Ruiz-Iturriaga
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
| | - Susana Sancho
- Intensive Medicine Department, University Hospital La Fe, 46015 Valencia, Spain;
| | - Leyre Serrano
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
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Thourani VH, Brennan JM, Edelman JJ, Chen Q, Boero IJ, Sarkar RR, Murphy SM, Leon MB, Kodali SK. Treatment Patterns, Disparities, and Management Strategies Impact Clinical Outcomes in Patients with Symptomatic Severe Aortic Regurgitation. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1988779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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3
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Radošević Quadranti N, Vlahović-Palčevski V, Popović B, Diminić-Lisica I. Impact of guidelines on antibiotic prescribing approach in primary care-a 10-year study. Fam Pract 2021; 38:259-264. [PMID: 33215207 DOI: 10.1093/fampra/cmaa125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Publication and implementation of clinical guidelines is an important educational measure that considerably helps physicians in choosing appropriate antimicrobial drug. OBJECTIVES To evaluate long-term changes in antimicrobial prescribing habits before and after publishing the guidelines and to determine the factors that influence physician's decision to prescribe an antimicrobial drug. METHODS The study among general practitioners in Primorsko-Goranska County was conducted in three periods (January 2009, January 2011 and April 2019) by using a structured questionnaire that included general data about the physician, questions about their habits in antibiotic prescribing, criteria that influenced decision to prescribe antibiotics and antimicrobial agent(s) preferred in treating common infections. RESULTS Concomitant chronic (non-pulmonary) disease was the most important factor influencing decision to prescribe an antimicrobial drug. Over 88% of physicians that completed the survey declared themselves as rational prescribers of antimicrobials but more than half of them (53.3%) sometimes prescribed an antibiotic even though it was not indicated compared to 75% of self-reported non-rational prescribers (P ˂ 0.05). Self-reported adherence to the guidelines increased from 34.6% in 2011 to 51.8% in 2019. CONCLUSION The research showed improvement in physicians' knowledge in choosing the right antibiotic based on the analysis of answers but indicated the necessity for improving communication skills and empowering physicians not to prescribe antibiotics 'just in case' because of diagnostic uncertainty or patient demand. Further qualitative research is needed to understand physicians' prescribing behaviour and decision-making processes in order to develop interventions that will effectively improve the use of antibiotics.
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Affiliation(s)
| | - Vera Vlahović-Palčevski
- Faculty of Health Studies, University of Rijeka, Rijeka.,Medical Faculty, University of Rijeka, Rijeka.,Department of Clinical Pharmacology, University Hospital Rijeka, Rijeka
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Abstract
Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.
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Menéndez R, Méndez R, Torres A. Respuesta a «Dual antibiotic therapy for outpatient management of community-acquired pneumonia?». Arch Bronconeumol 2020; 56:766-767. [DOI: 10.1016/j.arbres.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
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6
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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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O'Keefe C, Thompson A, McKenzie D, Lee K. Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy. Int J Clin Pract 2019; 73:e13427. [PMID: 31573741 DOI: 10.1111/ijcp.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 08/12/2019] [Accepted: 09/21/2019] [Indexed: 11/30/2022] Open
Abstract
Background Appropriate antibiotic prescribing improves patient outcomes and mitigates antimicrobial resistance. As the majority of antibiotics are used in the community, rational prescribing in this setting is of paramount importance. Objectives We aimed to (1) evaluate the concordance of community antibiotic prescribing with guidelines for three common infection types among patients who presented to hospital, and (2) identify relationships between guideline concordance and patient-related factors. Methods Medical records were evaluated from the Royal Hobart Hospital (Tasmania, Australia) for patients presenting with respiratory tract, urinary tract or skin and soft tissue infections within a 12-month period. Prior-to-hospital antibiotic therapy was assessed for concordance with prescribing guidelines based on presenting diagnosis. Concordance was assessed against first-line recommendations in the Australian Therapeutic Guidelines - Antibiotic, based on drug choice, dose, frequency and patient factors. Descriptive statistics were performed to address Objective 1. Multivariate logistic regressions were conducted to address Objective 2 with the following independent variables: infection type, age, allergies, diabetes status, gender and residential setting. Results A total of 285 patient records were eligible for data analysis; 28.8% (n = 82) were fully guideline concordant. The most common reason for non-concordance was inappropriate drug choice (n = 143, 50.2%). Patients with the following characteristics were less likely to receive concordant therapy: diabetes (OR = 0.3, 95% CI 0.1-0.8, P = .02) and increasing age (OR = 0.99, 95% CI 0.98-1.00, P = .04). Conclusions Almost three-quarters of patients received community-initiated antibiotic therapy that was not fully guideline concordant. Antimicrobial stewardship interventions are urgently needed to improve guideline concordance for community-initiated antibiotic therapy.
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Affiliation(s)
- Caitlan O'Keefe
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Angus Thompson
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Duncan McKenzie
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Faculty of Health and Medical Sciences, Division of Pharmacy, School of Allied Health, University of Western Australia, Crawley, Western Australia, Australia
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Abstract
"Health care-associated pneumonia (HCAP) was introduced into guidelines because of concerns about the increasing prevalence of drug-resistant pathogens (DRPs) not covered by standard empirical therapy. We now know that DRPs are very localized phenomena with low rates in most sites. Although HCAP risk factors are associated with a higher mortality, this is driven by comorbidities rather than the pathogens. Empirical coverage of DRPs has generally not resulted in better patient outcomes. A far more nuanced approach must be taken for patients with risk factors for DRPs taking into account the local cause and severity of disease.
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Affiliation(s)
- Grant W Waterer
- University of Western Australia, Royal Perth Hospital, Level 4, MRF Building, GPO Box X2213, Perth 6847, Australia; Northwestern University, Chicago, IL, USA.
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9
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Pickens CI, Wunderink RG. Principles and Practice of Antibiotic Stewardship in the ICU. Chest 2019; 156:163-171. [PMID: 30689983 DOI: 10.1016/j.chest.2019.01.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022] Open
Abstract
In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.
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Affiliation(s)
- Chiagozie I Pickens
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL.
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10
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Zimmerman DE, Covvey JR, Nemecek BD, Guarascio AJ, Wilson L, Freedy HR, Yassin MH. Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 27:279-285. [PMID: 30536468 DOI: 10.1111/ijpp.12497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 11/02/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP). METHODS An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts. KEY FINDINGS A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/β-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/β-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS). CONCLUSIONS The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.
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Affiliation(s)
- David E Zimmerman
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Jordan R Covvey
- Division of Pharmaceutical, Administrative and Social Sciences, Duquesne University School of Pharmacy, Pittsburgh, PA, USA
| | - Branden D Nemecek
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Anthony J Guarascio
- Division of Pharmacy Practice, Duquesne University School of Pharmacy, Pittsburgh, PA, USA.,Allegheny General Hospital, Pittsburgh, PA, USA
| | - Laura Wilson
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Henry R Freedy
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Mohamed H Yassin
- University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Haran JP, Volturo GA. Macrolide Resistance in Cases of Community-Acquired Bacterial Pneumonia in the Emergency Department. J Emerg Med 2018; 55:347-353. [DOI: 10.1016/j.jemermed.2018.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/11/2018] [Indexed: 11/17/2022]
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12
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Harnett G. Treatment of Community-Acquired Pneumonia: A Case Report and Current Treatment Dilemmas. Case Rep Emerg Med 2017; 2017:5045087. [PMID: 28698812 PMCID: PMC5494078 DOI: 10.1155/2017/5045087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/13/2017] [Indexed: 11/18/2022] Open
Abstract
Resistance to macrolides is rising in the USA and warrants careful consideration when confronted with a patient with suspected pneumonia in the urgent care clinic. This case study exemplifies the potentially serious consequences of treatment failure following prescription of a macrolide for community-acquired bacterial pneumonia. Furthermore, the consequential treatment dilemmas currently faced by physicians are briefly discussed.
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Affiliation(s)
- Glenn Harnett
- No Resistance Consulting Group, Mountain Brook, AL, USA
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13
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Beatty JA, Majumdar SR, Tyrrell GJ, Marrie TJ, Eurich DT. Prognostic factors associated with mortality and major in-hospital complications in patients with bacteremic pneumococcal pneumonia: Population-based study. Medicine (Baltimore) 2016; 95:e5179. [PMID: 27861340 PMCID: PMC5120897 DOI: 10.1097/md.0000000000005179] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Bacteremic pneumococcal pneumonia (BPP) causes considerable mortality and morbidity. We aimed to identify prognostic factors associated with mortality and major in-hospital complications in BPP.A prospective, population-based clinical registry of 1636 hospitalized adult patients (≥18 years) with BPP was established between 2000 and 2010 in Northern Alberta, Canada. Prognostic factors for mortality and major in-hospital complications (e.g., cardiac events, mechanical ventilation, aspiration) were evaluated using multivariable logistic regression.Average age was 54 (standard deviation 18) years, 57% males, and 59% had high case-fatality rate (CFR) serotypes. Overall, 14% (226/1636) of patients died and 22% (315/1410) of survivors developed at least 1 complication. Independent prognostic factors for mortality were age (adjusted odds ratio [aOR], 1.5 per decade; 95% confidence interval [CI], 1.3-1.7), nursing home residence (aOR, 3.7; 95% CI 1.8-7.4), community-dwelling dementia (aOR 3.7; 95% CI, 1.6-8.6), alcohol abuse (aOR, 2.2; 95% CI, 1.4-3.4), acid-suppressing drugs (aOR, 1.5; 95% CI, 1.0-2.3), guideline-discordant antibiotics (aOR, 3.4; 95% CI, 2.4-4.8), multilobe pneumonia (aOR, 2.6; 95% CI, 1.8-3.6), and high CFR serotypes (aOR, 1.8; 95% CI, 1.2-2.8). Similar prognostic factors were observed for major in-hospital complications. Pneumococcal vaccination was associated with reduced in-hospital mortality (aOR, 0.2; 95% CI, 0.05-0.9) but not major complications (P = 0.2).Older and frailer patients, and those who abuse alcohol or take acid-suppressing drugs, are at increased risk of BPP-related mortality and complications, as are those with high CFR serotypes. Beyond identifying those at highest risk, our findings demonstrate the importance of guideline-concordant antibiotics and pneumococcal vaccination in those with BPP.
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Affiliation(s)
- Jessica A. Beatty
- School of Public Health, University of Alberta
- ACHORD, 2-040 Li Ka Shing Center, University of Alberta
| | - Sumit R. Majumdar
- ACHORD, 2-040 Li Ka Shing Center, University of Alberta
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta
| | - Gregory J. Tyrrell
- Division of Diagnostic and Applied Microbiology, Laboratory Medicine and Pathology, University of Alberta
- Provincial Laboratory for Public Health, Edmonton, Alberta
| | - Thomas J. Marrie
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dean T. Eurich
- School of Public Health, University of Alberta
- ACHORD, 2-040 Li Ka Shing Center, University of Alberta
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14
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Current Smoking and Reduced Mortality in Bacteremic Pneumococcal Pneumonia. Chest 2016; 150:652-60. [DOI: 10.1016/j.chest.2016.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/15/2016] [Accepted: 04/18/2016] [Indexed: 11/22/2022] Open
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16
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Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis 2016; 20:2041-7. [PMID: 25418868 PMCID: PMC4257826 DOI: 10.3201/eid2012.140331] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Primary care providers were familiar with recommendations for antibiotic drug selection for common infections, but do not always comply with them. Appropriate selection of antibiotic drugs is critical to optimize treatment of infections and limit the spread of antibiotic resistance. To better inform public health efforts to improve prescribing of antibiotic drugs, we conducted in-depth interviews with 36 primary care providers in the United States (physicians, nurse practitioners, and physician assistants) to explore knowledge, attitudes, and self-reported practices regarding antibiotic drug resistance and antibiotic drug selection for common infections. Participants were generally familiar with guideline recommendations for antibiotic drug selection for common infections, but did not always comply with them. Reasons for nonadherence included the belief that nonrecommended agents are more likely to cure an infection, concern for patient or parent satisfaction, and fear of infectious complications. Providers inconsistently defined broad- and narrow-spectrum antibiotic agents. There was widespread concern for antibiotic resistance; however, it was not commonly considered when selecting therapy. Strategies to encourage use of first-line agents are needed in addition to limiting unnecessary prescribing of antibiotic drugs.
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17
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Li X, Wang M, Liu G, Ma J, Li C. Association of macrolides with overall mortality and cardiac death among patients with various infections: A meta-analysis. Eur J Intern Med 2016; 28:32-7. [PMID: 26412674 DOI: 10.1016/j.ejim.2015.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND A large body of evidences suggested that macrolide therapy could improve the survival of patients with various infections. While in the same time, macrolides are known to increase fatal arrhythmogenic risks and cause cardiac death. To assess the risks and benefits of macrolide therapy, we systematically reviewed all studies of macrolide use, cardiac death and mortality among patients with various infections. METHODS We searched Pubmed, Embase and Cochrane library and reviewed reference lists from 1980 through April 2015. Studies were included if they compared macrolides to other antibiotics in adults with various infections. The outcome measures were the overall mortality and the risk of cardiac death. RESULTS Overall, macrolide use was associated with a statistically significant mortality reduction compared with nonmacrolide use (OR: 0.65, 95% CI: 0.46-0.92). There was no difference in the risk of cardiac death between macrolide and nonmacrolide regimes (OR: 1.43, 95% CI: 0.86-2.40). In subgroup analyses, macrolide use was found to be associated with the decreased risk of mortality in a population of older individuals (age>48 years, OR: 0.69; 95% CI: 0.66-0.72). While in a general population of young and middle-aged adults, the use of macrolide-based regimens could not decrease the risk of death from any cause (age<48 years, OR: 0.42; 95% CI: 0.02-11.01). As for cardiac death, macrolide use was found to be associated with increased risk of cardiac death in a population of older individuals (age>48 years, OR: 1.99; 95% CI: 1.53-2.59). CONCLUSION Despite the potential cardiotoxic effects, there is a net benefit associated with macrolide use in older patients with various infections and macrolide use except roxithromycin was found to be associated with increased risk of cardiac death in a population of adults aged > 48 years.
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Affiliation(s)
- Xiang Li
- Department of Pharmacy, First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, China.
| | - Min Wang
- Medical Department, No. 263 Clinical Department, Beijing Military General Hospital, Beijing 101149, China
| | - Guiyang Liu
- Department of Pharmacy, First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, China
| | - Jianli Ma
- Department of Pharmacy, First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, China
| | - Chuntong Li
- Department of Pharmacy, First Affiliated Hospital of Chinese PLA General Hospital, Beijing 100048, China
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Trac MH, McArthur E, Jandoc R, Dixon SN, Nash DM, Hackam DG, Garg AX. Macrolide antibiotics and the risk of ventricular arrhythmia in older adults. CMAJ 2016; 188:E120-E129. [PMID: 26903359 DOI: 10.1503/cmaj.150901] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many respiratory tract infections are treated with macrolide antibiotics. Regulatory agencies warn that these antibiotics increase the risk of ventricular arrhythmia. We examined the 30-day risk of ventricular arrhythmia and all-cause mortality associated with macrolide antibiotics relative to nonmacrolide antibiotics. METHODS We conducted a population-based retrospective cohort study involving older adults (age > 65 yr) with a new prescription for an oral macrolide antibiotic (azithromycin, clarithromycin or erythromycin) in Ontario from 2002 to 2013. Our primary outcome was a hospital encounter with ventricular arrhythmia within 30 days after a new prescription. Our secondary outcome was 30-day all-cause mortality. We matched patients 1:1 using propensity scores to patients prescribed nonmacrolide antibiotics (amoxicillin, cefuroxime or levofloxacin). We used conditional logistic regression to measure the association between macrolide exposure and outcomes, and repeated the analysis in 4 subgroups defined by the presence or absence of chronic kidney disease, congestive heart failure, coronary artery disease and concurrent use of a drug known to prolong the QT interval. RESULTS Compared with nonmacrolide antibiotics, macrolide antibiotics were not associated with a higher risk of ventricular arrhythmia (0.03% v. 0.03%; relative risk [RR] 1.06, 95% confidence interval [CI] 0.83-1.36) and were associated with a lower risk of all-cause mortality (0.62% v. 0.76%; RR 0.82, 95% CI 0.78-0.86). These associations were similar in all subgroups. INTERPRETATION Among older adults, macrolide antibiotics were not associated with a higher 30-day risk of ventricular arrhythmia than nonmacrolide antibiotics. These findings suggest that current warnings from the US Food and Drug Administration may be overstated.
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Affiliation(s)
- Mai H Trac
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Eric McArthur
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Racquel Jandoc
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Stephanie N Dixon
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Danielle M Nash
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Daniel G Hackam
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Amit X Garg
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont.
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Levcovich A, Lazarovitch T, Moran-Gilad J, Peretz C, Yakunin E, Valinsky L, Weinberger M. Complex clinical and microbiological effects on Legionnaires' disease outcone; A retrospective cohort study. BMC Infect Dis 2016; 16:75. [PMID: 26864322 PMCID: PMC4748635 DOI: 10.1186/s12879-016-1374-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 01/22/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Legionnaires' disease (LD) is associated with high mortality rates and poses a diagnostic and therapeutic challenge. Use of the rapid urinary antigen test (UAT) has been linked to improved outcome. We examined the association between the method of diagnosis (UAT or culture) and various clinical and microbiological characteristics and outcome of LD. METHODS Consecutive patients with pneumonia and confirmation of Legionella infection by a positive UAT and/or a positive culture admitted between the years 2006-2012 to a university hospital were retrospectively studied. Isolated L. pneumophila strains were subject to serogrouping, immunological subtyping and sequence-based typing. Variables associated with 30-day all-cause mortality were analyzed using logistic regression as well as cox regression. RESULTS Seventy-two patients were eligible for mortality analyses (LD study group), of whom 15.5 % have died. Diagnosis based on positive L. pneumophila UAT as compared to positive culture (OR = 0.18, 95 % CI 0.03-0.98, p = 0.05) and administration of appropriate antibiotic therapy within 2 hospitalization days as compared to delayed therapy (OR = 0.16, 95 % CI 0.03-0.90, p = 0.04) were independently associated with reduced mortality. When controlling for intensive care unit (ICU) admissions, the method of diagnosis became non-significant. Survival analyses showed a significantly increased death risk for patients admitted to ICU compared to others (HR 12.90, 95 % CI 2.78-59.86, p = 0.001) and reduced risk for patients receiving appropriate antibiotic therapy within the first two admissions days compared to delayed therapy (HR 0.13, 95 % CI 0.04-0.05, p = 0.001). Legionella cultures were positive in 35 patients (including 29 patients from the LD study group), of whom 65.7 % were intubated and 37.1 % have died. Sequence type (ST) ST1 accounted for 50.0 % of the typed cases and ST1, OLDA/Oxford was the leading phenon (53.8 %). Mortality rate among patients in the LD study group infected with ST1 was 18.2 % compared to 42.9 % for non-ST1 genotypes (OR = 0.30, 95 % CI 0.05-1.91, p = 0.23). CONCLUSIONS The study confirms the importance of early administration of appropriate antibiotic therapy and at the same time highlights the complex associations of different diagnostic approaches with LD outcome. Infection with ST1 was not associated with increased mortality. Genotype effects on outcome mandate examination in larger cohorts.
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Affiliation(s)
- Ariela Levcovich
- Infectious Diseases Unit, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
| | - Tsilia Lazarovitch
- Microbiology Laboratory, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
| | - Jacob Moran-Gilad
- National Program for Legionellosis Control and Public Health Services, Israeli Ministry of Health, 39 Yermiyahu St., 5th Floor, Jerusalem, Israel.
- ESCMID Study Group for Legionella Infections (ESGLI), Basel, Switzerland.
- Faculty of Health Sciences, Ben-Gurion University of the Negev. Ben-Gurion Boulevard, Beer-Sheva, Israel.
| | - Chava Peretz
- School of Public Health, Epidemiology, Sackler School of Medicine, Tel Aviv University, POB 39040, Tel Aviv, 69978, Israel.
| | - Eugenia Yakunin
- Molecular Laboratory, Central Laboratories, Israel Ministry of Health, POB 34410, Jerusalem, 94467, Israel.
| | - Lea Valinsky
- Molecular Laboratory, Central Laboratories, Israel Ministry of Health, POB 34410, Jerusalem, 94467, Israel.
| | - Miriam Weinberger
- Infectious Diseases Unit, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
- Sackler School of Medicine, Tel Aviv University, POB 39040, Tel Aviv, 69978, Israel.
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Abstract
Macrolide antimicrobials are commonly prescribed, specifically for the treatment of respiratory tract infections. Although still effective, the development of widespread macrolide resistance has limited their use. Aside from their antimicrobial effects, macrolides are also known to possess immune-modulatory properties which may confer a survival benefit in both acute and chronic inflammatory states. This review discusses the efficacy, potential mechanisms, and adverse effects of macrolide therapy specifically in community-acquired pneumonia in outpatients, hospitalized ward patients, and those requiring intensive care unit admission. Challenges for ongoing research in this field are discussed and treatment recommendations offered.
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Abstract
PURPOSE OF REVIEW We are entering into a new era of healthcare wherein patient outcomes are increasingly being publicly reported, not just by institution, but by individual clinicians. This review focuses on the issue of quality of care of patients with community-acquired pneumonia (CAP), in particular the choice of outcome, quality of data needed and recommendations of the current bundle of care suggested by the available literature as delivering the best chance of favourable outcomes for patients. RECENT FINDINGS There is increasing evidence that pneumonia outcomes have improved over the past decade, particularly mortality. However, we have been oversimplistic in setting quality targets and that a bundle of care is required to deliver best outcomes, such as has been shown with the surviving sepsis campaign. Equally, the quality of data available to compare outcomes needs to be significantly improved on what is currently available. SUMMARY To achieve best outcomes for their patients, physicians must be actively comparing their outcomes against other institutions and not rely on historical data. A bundle of care that includes rapid administration of antibiotics, use of combination antibiotic therapy including a macrolide and early mobilization is a good starting point.
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Matuz M, Bognar J, Hajdu E, Doro P, Bor A, Viola R, Soos G, Benko R. Treatment of Community-Acquired Pneumonia in Adults: Analysis of the National Dispensing Database. Basic Clin Pharmacol Toxicol 2015; 117:330-4. [PMID: 26046802 DOI: 10.1111/bcpt.12426] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/28/2015] [Indexed: 11/29/2022]
Abstract
Crude national ambulatory antibiotic dispensing data (2007-2011) of adult patients (aged between 20 and below 65 years) with CAP were obtained and expressed as DDD per 1000 inhabitants and per day (DID). European quality indicators of antibiotic prescribing were calculated and adherence rate to the national CAP guideline was assessed. Antibiotic use for CAP in adults ranged between 0.27 and 0.30 DID in various years. The most frequently used antibacterials were levofloxacin, co-amoxiclav and clarithromycin. Antibiotic use in CAP was compliant with the European recommendations in 6.4% in 2007, which decreased to 4.9% by 2011, in contrast to the optimal compliant range of 80-100%. The consumption of fluoroquinolones mounted up to ~40% in both genders, which exceeded the recommended range (0-5%) substantially. National guideline also favoured the use of macrolides in the empiric therapy of CAP in otherwise healthy adults; hence, guideline-concordant antibiotic use ranged between 24.0-32.3%. Agents that were contra-indicated in the empiric therapy of CAP were also used in 6.5-9.0% in various years. These data reflect some worrisome figures and trends in the outpatient antibiotic treatment of adults with CAP. Clarified and updated national guidelines focusing on outpatients and incentives/regulations to increase guideline concordance are warranted.
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Affiliation(s)
- Maria Matuz
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | | | - Edit Hajdu
- First Internal Medicine, Infectiology Unit, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Peter Doro
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | - Andrea Bor
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | - Reka Viola
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | - Gyongyver Soos
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
| | - Ria Benko
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
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Cilloniz C, Albert RK, Liapikou A, Gabarrus A, Rangel E, Bello S, Marco F, Mensa J, Torres A. The Effect of Macrolide Resistance on the Presentation and Outcome of Patients Hospitalized forStreptococcus pneumoniaePneumonia. Am J Respir Crit Care Med 2015; 191:1265-72. [DOI: 10.1164/rccm.201502-0212oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Acute Pneumonia. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7151914 DOI: 10.1016/b978-1-4557-4801-3.00069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Feldman C, Anderson R. Recent advances in our understanding of Streptococcus pneumoniae infection. F1000PRIME REPORTS 2014; 6:82. [PMID: 25343039 PMCID: PMC4166932 DOI: 10.12703/p6-82] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A number of significant challenges remain with regard to the diagnosis, treatment, and prevention of infections with Streptococcus pneumoniae (pneumococcus), which remains the most common bacterial cause of community-acquired pneumonia. Although this infection is documented to be extremely common in younger children and in older adults, the burden of pneumonia it causes is considerably underestimated, since the incidence statistics are derived largely from bacteremic infections, because they are easy to document, and yet the greater burden of pneumococcal pneumonias is non-invasive. It has been estimated that for every bacteremic pneumonia that is documented, three non-bacteremic infections occur. Management of these infections is potentially complicated by the increasing resistance of the isolates to the commonly used antibiotics. Furthermore, it is well recognized that despite advances in medical care, the mortality of bacteremic pneumococcal pneumonia has remained largely unchanged over the past 50 years and averages approximately 12%. Much recent research interest in the field of pneumococcal infections has focused on important virulence factors of the organism, on improved diagnostic and prognostication tools, on defining risk factors for death, on optimal treatment strategies involving both antibiotics and adjunctive therapies, and on disease prevention. It is hoped that through these endeavors the outlook of pneumococcal infections will be improved.
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Affiliation(s)
- Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand7 York Road, Parktown, 2193Johannesburg, South Africa
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria5 Bophela Road, Arcadia, Pretoria, 0083South Africa
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Zhanel GG, Wolter KD, Calciu C, Hogan P, Low DE, Weiss K, Karlowsky JA. Clinical cure rates in subjects treated with azithromycin for community-acquired respiratory tract infections caused by azithromycin-susceptible or azithromycin-resistant Streptococcus pneumoniae: analysis of Phase 3 clinical trial data. J Antimicrob Chemother 2014; 69:2835-40. [PMID: 24920652 DOI: 10.1093/jac/dku207] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Community-acquired respiratory tract infections (CARTI) are commonly caused by Streptococcus pneumoniae (SPN) and empirically treated with azithromycin. This study assessed clinical cure rates in azithromycin-treated subjects with CARTI caused by azithromycin-susceptible (Azi-S) or azithromycin-resistant (Azi-R) SPN. METHODS 1127 subjects with CARTI (402 acute otitis media, 309 community-acquired pneumonia, 255 acute bacterial exacerbations of chronic bronchitis and 161 acute bacterial sinusitis) in 13 Phase 3 clinical trials (1993-2007) had a confirmed pathogen, received azithromycin and were assessed for clinical cure/failure. 34.4% of subjects (388/1127) had a positive culture for SPN; 33.4% (376/1127) had Azi-S or Azi-R SPN. RESULTS 28.9% (112/388) of subjects with SPN had Azi-R SPN: 35.7% (40/112) were low-level Azi-R SPN (LLAR; MIC 2-8 mg/L), while 64.3% (72/112) were high-level Azi-R SPN (HLAR; MIC ≥16 mg/L). Among Azi-S and Azi-R SPN CARTI subjects, clinical cure rates were: 86.2% (324/376) overall; 89.4% (236/264) for subjects with Azi-S SPN; 78.6% (88/112) for subjects with Azi-R SPN (P = 0.003, versus Azi-S); 77.5% (31/40) for subjects with LLAR SPN (P < 0.001); and 79.2% (57/72) for subjects with HLAR SPN (P = 0.122). CONCLUSIONS Clinical cure rates in CARTI subjects treated with azithromycin were higher for Azi-S SPN (89.4%) versus Azi-R SPN (78.6%; P = 0.003). However, cure rates were not different for subjects infected with LLAR-SPN versus HLAR-SPN. At the observed prevalence of Azi-R SPN of 28.9%, an additional 3.1 clinical failures would be predicted, as a consequence of azithromycin resistance (LLAR and HLAR), per 100 subjects treated empirically with azithromycin.
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Affiliation(s)
- George G Zhanel
- Department of Medical Microbiology and Infectious Diseases, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kevin D Wolter
- Established Products Clinical Development, Pfizer Inc., New York, NY, USA
| | | | - Patricia Hogan
- Specialty Care Business Unit, Pfizer Inc., New York, NY, USA
| | - Donald E Low
- Department of Microbiology, Mount Sinai Hospital, Toronto, Canada
| | - Karl Weiss
- Maisonneuve-Rosemont Hospital, Faculty of Medicine, University of Montreal, Montreal, Canada
| | - James A Karlowsky
- Department of Medical Microbiology and Infectious Diseases, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
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Halpape K, Sulz L, Schuster B, Taylor R. Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study). Can J Hosp Pharm 2014; 67:17-27. [PMID: 24634522 DOI: 10.4212/cjhp.v67i1.1317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality. OBJECTIVES The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used. METHODS An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared. RESULTS Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group. CONCLUSION An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.
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Affiliation(s)
- Katelyn Halpape
- , BSP, ACPR, is a PharmD student in the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia. She completed her pharmacy practice residency with the Regina Qu'Appelle Health Region, Regina, Saskatchewan, in 2012/2013
| | - Linda Sulz
- , BSP, PharmD, is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
| | - Brenda Schuster
- , BSP, ACPR, PharmD, FCSHP, is with Regina Qu'Appelle Health Region, and the Department of Academic Family Medicine, University of Saskatchewan, Regina, Saskatchewan
| | - Ron Taylor
- , MD, CCFP(EM), is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
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Kertland H, Kays MB. Should azithromycin no longer be considered a drug of choice for community-acquired pneumonia because of its potential to cause cardiovascular death? Can J Hosp Pharm 2013; 66:328-31. [PMID: 24159237 DOI: 10.4212/cjhp.v66i5.1292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Does empiric therapy for atypical pathogens improve outcomes for patients with CAP? Infect Dis Clin North Am 2013; 27:99-114. [PMID: 23398868 DOI: 10.1016/j.idc.2012.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The present controversy regarding the need to cover atypical pathogens in the empiric therapy of community-acquired pneumonia is related to several issues, including the relevance of terminology, imprecise diagnostic methods, and perceived contradictory results of published evidence. Studies evaluating the time to clinical recovery and the use of earlier endpoints for evaluation suggest that appropriate therapy provides a benefit if an atypical pathogen is a pathogen. Because recent surveillance studies suggest these pathogens are common and until there is the availability of accurate, cost-effective, and easily interpreted laboratory tests to provide the etiologic diagnosis at the time of point of care, empiric therapy of atypical pathogens is supported.
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Mosholder AD, Mathew J, Alexander JJ, Smith H, Nambiar S. Cardiovascular risks with azithromycin and other antibacterial drugs. N Engl J Med 2013; 368:1665-8. [PMID: 23635046 DOI: 10.1056/nejmp1302726] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew D Mosholder
- Office of Surveillance and Epidemiology, Division of Epidemiology II, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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Guideline adherence in management of stable chronic obstructive pulmonary disease. Respir Med 2013; 107:1046-52. [PMID: 23639271 DOI: 10.1016/j.rmed.2013.04.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/29/2013] [Accepted: 04/02/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is the only leading cause of death with rising morbidity and mortality. Clinical practice guidelines (CPGs) to optimize pharmacotherapy for patients with COPD have been updated based on promising results of randomized clinical trials. We examined the frequency of and factors associated with guideline adherence by physicians in clinical practice at an academic medical center. METHODS Patients with a clinical diagnosis of COPD, confirmed by spirometry, who presented to the ambulatory clinics, were enrolled. The primary outcome was provider's adherence to the 2007 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects were categorized as guideline-concordant who received a rescue inhaler (all patients), or at least one long-acting bronchodilator (stage II), or at least one long-acting bronchodilator plus an inhaled corticosteroid (stage III-IV). Demographics, clinical information and type of provider were recorded. Provider type was classified as primary care physician (PCP), pulmonologist, or co-management by both. RESULTS Among 450 subjects who met study criteria, 246 (54.7%) received guideline-concordant treatment. Age, sex, race, disease severity, and co-morbidities were not associated with guideline adherence. Multivariate analysis showed that patients co-managed by a PCP and pulmonologist had a higher likelihood of receiving guideline-concordant treatment than those managed by one or the other (Odds Ratio: 4.59; 95% Confidence Interval: 2.92, 7.22, p < 0.001). CONCLUSIONS Just over half of stable COPD patients receive guideline-concordant care. Co-management by a PCP and pulmonologist increases the likelihood of receiving guideline-concordant inhaler therapy.
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Yasutake T, Wada H, Higaki M, Nakamura M, Honda K, Watanabe M, Ishii H, Kamiya S, Takizawa H, Goto H. Anacardic acid, a histone acetyltransferase inhibitor, modulates LPS-induced IL-8 expression in a human alveolar epithelial cell line A549. F1000Res 2013; 2:78. [PMID: 24627774 PMCID: PMC3931454 DOI: 10.12688/f1000research.2-78.v1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2013] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE AND DESIGN The histone acetylation processes, which are believed to play a critical role in the regulation of many inflammatory genes, are reversible and regulated by histone acetyltransferases (HATs), which promote acetylation, and histone deacetylases (HDACs), which promote deacetylation. We studied the effects of lipopolysaccharide (LPS) on histone acetylation and its role in the regulation of interleukin (IL)-8 expression. MATERIAL A human alveolar epithelial cell line A549 was used in vitro. METHODS Histone H4 acetylation at the IL-8 promoter region was assessed by a chromatin immunoprecipitation (ChIP) assay. The expression and production of IL-8 were evaluated by quantitative polymerase chain reaction and specific immunoassay. Effects of a HDAC inhibitor, trichostatin A (TSA), and a HAT inhibitor, anacardic acid, were assessed. RESULTS Escherichia coli-derived LPS showed a dose- and time-dependent stimulatory effect on IL-8 protein production and mRNA expression in A549 cells in vitro. LPS showed a significant stimulatory effect on histone H4 acetylation at the IL-8 promoter region by ChIP assay. Pretreatment with TSA showed a dose-dependent stimulatory effect on IL-8 release from A549 cells as compared to LPS alone. Conversely, pretreatment with anacardic acid inhibited IL-8 production and expression in A549 cells. CONCLUSION These data suggest that LPS-mediated proinflammatory responses in the lungs might be modulated via changing chromatin remodeling by HAT inhibition.
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Affiliation(s)
- Tetsuo Yasutake
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Hiroo Wada
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Manabu Higaki
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Masuo Nakamura
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Kojiro Honda
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Masato Watanabe
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Haruyuki Ishii
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Shigeru Kamiya
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Hajime Takizawa
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
| | - Hajime Goto
- Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, 181-8611, Japan
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