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Kothari S, Ahmad SZ, Zhao MT, Teixeira-Barreira A, So M, Husain S. Assessing the quality of antimicrobial prescribing in solid organ transplant recipients: a new frontier in antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e72. [PMID: 38751941 PMCID: PMC11094401 DOI: 10.1017/ash.2024.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 05/18/2024]
Abstract
Background Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTRs) and local standardized antimicrobial treatment guidelines may contribute to improved clinical outcomes. Our study assessed the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes. Methods Consecutive adult SOTRs admitted to the transplant floor from January-September 2020 and were treated for an infectious syndrome were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records. Guideline compliance was characterized as either appropriate, effective but unnecessary, undertreatment, or inappropriate. Results Nine hundred and thirty-six SOTR were admitted to the transplant ward, of which 328 patients (35%) received treatment for infectious syndromes. Guidelines were applicable to 252 patients, constituting 275 syndromes: 86 pneumonias; 82 urinary tract infections; 40 intra-abdominal infections; 38 bloodstream infections; and 29 C. difficile infections. 200/246 (81%) of infectious syndromes received appropriate or effective but unnecessary empiric treatment. In addition, appropriate tailoring of antimicrobials resulted in a significant difference in 30-day all-cause mortality (adjusted OR of 0.07, 95% CI 0.01-0.38; P = .002). Lastly, we found that guideline-compliant empiric therapy was found to prevent the development of multi-drug resistance in a time-dependent analysis (adjusted HR of 0.21, 95% CI 0.08-0.52; P = .001). Conclusion Our data show that adherence to locally developed guidelines was associated with reduced mortality and resistant-organism development in our cohort of SOTR.
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Affiliation(s)
- Sagar Kothari
- Transplant Infectious Diseases, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Syed Z. Ahmad
- Transplant Infectious Diseases, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle T. Zhao
- Transplant Infectious Diseases, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, VIC, Australia
| | - Shahid Husain
- Transplant Infectious Diseases, Ajmera Transplant Center, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
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2
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Amati F, Bindo F, Stainer A, Gramegna A, Mantero M, Nigro M, Bussini L, Bartoletti M, Blasi F, Aliberti S. Identify Drug-Resistant Pathogens in Patients with Community-Acquired Pneumonia. Adv Respir Med 2023; 91:224-238. [PMID: 37366804 PMCID: PMC10295768 DOI: 10.3390/arm91030018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
A substantial increase in broad-spectrum antibiotics as empirical therapy in patients with community-acquired pneumonia (CAP) has occurred over the last 15 years. One of the driving factors leading to that has been some evidence showing an increased incidence of drug-resistant pathogens (DRP) in patients from a community with pneumonia, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Research has been published attempting to identify DRP in CAP through the implementation of probabilistic approaches in clinical practice. However, recent epidemiological data showed that the incidence of DRP in CAP varies significantly according to local ecology, healthcare systems and countries where the studies were performed. Several studies also questioned whether broad-spectrum antibiotic coverage might improve outcomes in CAP, as it is widely documented that broad-spectrum antibiotics overuse is associated with increased costs, length of hospital stay, drug adverse events and resistance. The aim of this review is to analyze the different approaches used to identify DRP in CAP patients as well as the outcomes and adverse events in patients undergoing broad-spectrum antibiotics.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Francesco Bindo
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mattia Nigro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Linda Bussini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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3
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Christensen MA, Nevers M, Ying J, Haroldsen C, Stevens V, Jones MM, Yarbrough PM, Goetz MB, Restrepo MI, Madaras-Kelly K, Samore MH, Jones BE. Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients. Clin Infect Dis 2021; 72:S59-S67. [PMID: 33512530 DOI: 10.1093/cid/ciaa1604] [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: 08/18/2020] [Accepted: 10/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients. METHODS For all VA acute hospitalizations for CAP from 2006-2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric "overcoverage" (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric "undercoverage" (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture). RESULTS Of 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P < .001. CONCLUSIONS Adoption of the 2019 CAP guidelines in this population would substantially change culturing and empiric antibiotic selection practices, with a decrease in overcoverage and slight increase in undercoverage for MRSA and P. aeruginosa.
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Affiliation(s)
| | - McKenna Nevers
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Jian Ying
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Candace Haroldsen
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Makoto M Jones
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Peter M Yarbrough
- Department of Internal Medicine, Veterans Affairs Salt Lake City Health Care System and University of Utah, Salt Lake City, Utah, USA
| | - Matthew Bidwell Goetz
- Division of Infectious Disease, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marcos I Restrepo
- Division of Pulmonary and Critical Care, South Texas Veterans Health Care System and UT Health San Antonio, San Antonio, Texas, USA
| | - Karl Madaras-Kelly
- Pharmacy Service, Veterans Affairs Boise Idaho and Idaho State University, Boise, Idaho, USA
| | - Matthew H Samore
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Barbara Ellen Jones
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, Utah, USA
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4
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Strategies for prediction of drug-resistant pathogens and empiric antibiotic selection in community-acquired pneumonia. Curr Opin Pulm Med 2021; 26:249-259. [PMID: 32101906 DOI: 10.1097/mcp.0000000000000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Although most patients with community-acquired pneumonia (CAP) are appropriately treated with narrow-spectrum antibiotics, predicting which patients require coverage of drug-resistant pathogens (DRP) remains a challenge. The 2019 American Thoracic Society/Infectious Diseases Society of America CAP guidelines endorse using locally validated prediction models for DRP. Here we review risk factors for DRP and provide a summary of available risk prediction models. RECENT FINDINGS Both inadequate initial empiric spectrum as well as unnecessary broad-spectrum antibiotic use are associated with poor outcomes in CAP. Multiple prediction models for DRP-based patient-level risk factors have been published, with some variation in included predictor variables and test performance characteristics. Seven models have been robustly externally validated, and implementation data have been published for two of these models. All models demonstrated better performance than the healthcare-associated pneumonia criteria, with most favoring sensitivity over specificity. We also report validation of the novel, risk factor-based treatment algorithm proposed in the American Thoracic Society/Infectious Diseases Society of America guidelines which strongly favors specificity over sensitivity, especially in nonsevere pneumonia. SUMMARY Using patient-level risk factors to guide the decision whether to prescribe broad-spectrum antibiotics is a rational approach to treatment. Several viable candidate prediction models are available. Hospitals should evaluate the local performance of existing scores before implementing in routine clinical practice.
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Yiang GT, Tzeng IS, Shui HA, Wu MY, Peng MY, Chan CY, Chan ED, Wu YK, Lan CC, Yang MC, Huang KL, Wu CW, Chang CH, Su WL. Early Screening of Risk for Multidrug-Resistant Organisms in the Emergency Department in Patients With Pneumonia and Early Septic Shock: Single-Center, Retrospective Cohort Study. Shock 2021; 55:198-209. [PMID: 32694392 DOI: 10.1097/shk.0000000000001599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Pneumonia is the fourth leading cause of death globally, with rapid progression during sepsis. Multidrug-resistant organisms (MDROs) are becoming more common with some healthcare-associated pneumonia events. Early detection of MDRO risk improves the outcomes; however, MDROs risk in pneumonia with sepsis is unknown. This study investigated the disease outcomes of pneumonia with septic shock in patients admitted in the emergency department (ED) intensive care unit (ICU), a population with a high prevalence of MDROs, after early screening of MDROs risk. METHODS In this retrospective cohort study, patients with pneumonia and early septic shock (n = 533) admitted to the ED at the Taipei Tzu Chi Hospital from 2013 to 2019 were selected. The study population was divided into four subgroups after the MDROs risk and screening procedure were completed within 1 or 6 h of admission. ICU mortality and multidrug antibiotic therapy were compared. RESULTS The high-risk MDROs groups had higher percentage of P aeruginosa than the low-risk group. Furthermore, the appropriate ED first antibiotics were higher in the 1-h subgroup than in the 6-h subgroup of the high-risk MDROs group. In multivariate analysis, the 6-h high-risk MDROs group had an adjusted odds ratio of 7.191 (95% CI: 2.911-17.767, P < 0.001) and 2.917 (95% CI: 1.456-5.847, P = 0.003) for ICU mortality and multidrug therapy in the ICU, respectively, after adjusting for other confounding factors. CONCLUSIONS MDRO screening within 1 h is recommended following admission of patients with pneumonia and early septic shock in the ED, especially in areas with a high prevalence of MDROs.
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Affiliation(s)
- Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - I-Shiang Tzeng
- Department of Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Yieh Peng
- Division of Infectious Disease, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Yu Chan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Edward D Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver at Anschutz Medical Center, Denver, Colorado
- Denver Veterans Affairs Medical Center, Denver, Colorado
- Department of Medicine, Division of the Mycobacterial and Respiratory Infections, National Jewish Health, Denver, Colorado
| | - Yao-Kuang Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chou-Chin Lan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Mei-Chen Yang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Kuo-Liang Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Wei Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chia-Hui Chang
- Divisions of Endocrine and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Wen-Lin Su
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
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6
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The potential economic value of sputum culture use in patients with community-acquired pneumonia and healthcare-associated pneumonia. Clin Microbiol Infect 2019; 25:1038.e1-1038.e9. [DOI: 10.1016/j.cmi.2018.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/07/2018] [Accepted: 11/17/2018] [Indexed: 11/24/2022]
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7
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Waterer GW. Potential antibiotic resistant pathogens in community-acquired pneumonia: playing it safe is anything but. Eur Respir J 2019; 54:54/1/1900870. [DOI: 10.1183/13993003.00870-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 11/05/2022]
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8
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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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Abstract
The use of next-generation sequencing and multiomic analysis reveals new insights on the identity of microbes in the lower airways blurring the lines between commensals and pathogens. Microbes are not found in isolation; rather they form complex metacommunities where microbe-host and microbe-microbe interactions play important roles on the host susceptibility to pathogens. In addition, the lower airway microbiota exert significant effects on host immune tone. Thus, this review highlights the roles that microbes in the respiratory tract play in the development of pneumonia.
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Affiliation(s)
- Benjamin G Wu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Human Microbiome Program, New York University School of Medicine, New York, NY 10028, USA
| | - Leopoldo N Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Human Microbiome Program, New York University School of Medicine, New York, NY 10028, USA.
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10
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Abstract
Few guidelines have greater acceptance than that for management of community-acquired pneumonia (CAP). Despite this, areas remain controversial, and new challenges continue to emerge. Current guidelines differ from those of northern European countries predominantly in need for macrolide combination with β-lactams for hospitalized, non-intensive care unit patients. A preponderance of evidence favors combination therapy. Challenges for current and future CAP guidelines include new antibiotic classes, emergence of viruses as major causes for CAP, new diagnostic modalities, alternative risk stratification for pathogens resistant to usual CAP antibiotics, and evidence-based management of severe CAP, including immunomodulatory therapy such as corticosteroids.
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Affiliation(s)
- Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, 240 East Huron Street, McGaw M-336, Chicago, IL 60611, USA.
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11
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Chou CC, Shen CF, Chen SJ, Chen HM, Wang YC, Chang WS, Chang YT, Chen WY, Huang CY, Kuo CC, Li MC, Lin JF, Lin SP, Ting SW, Weng TC, Wu PS, Wu UI, Lin PC, Lee SSJ, Chen YS, Liu YC, Chuang YC, Yu CJ, Huang LM, Lin MC. Recommendations and guidelines for the treatment of pneumonia in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:172-199. [PMID: 30612923 DOI: 10.1016/j.jmii.2018.11.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 01/19/2023]
Abstract
Pneumonia is a leading cause of death worldwide, ranking third both globally and in Taiwan. This guideline was prepared by the 2017 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group, formed under the auspices of the Infectious Diseases Society of Taiwan (IDST). A consensus meeting was held jointly by the IDST, Taiwan Society of Pulmonary and Critical Care Medicine (TSPCCM), the Medical Foundation in Memory of Dr. Deh-Lin Cheng, the Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines. The final guideline was endorsed by the IDST and TSPCCM. The major differences between this guideline and the 2007 version include the following: the use of GRADE methodology for the evaluation of available evidence whenever applicable, the specific inclusion of healthcare-associated pneumonia as a category due to the unique medical system in Taiwan and inclusion of recommendations for treatment of pediatric pneumonia. This guideline includes the epidemiology and recommendations of antimicrobial treatment of community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, healthcare-associated pneumonia in adults and pediatric pneumonia.
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Affiliation(s)
- Chih-Chen Chou
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ching-Fen Shen
- Division of Infectious Diseases, Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Su-Jung Chen
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsien-Meng Chen
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shuo Chang
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ya-Ting Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Yu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ching-Ying Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Ching-Chia Kuo
- Division of Infectious Diseases and Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Fu Lin
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shih-Ping Lin
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Wen Ting
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tzu-Chieh Weng
- Division of Holistic Care Unit, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ping-Sheng Wu
- Division of Infectious Diseases, Department of Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Un-In Wu
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Chin Lin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Yung-Ching Liu
- Division of Infectious Diseases, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan
| | - Yin-Ching Chuang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chong-Jen Yu
- National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ming Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
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12
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Heo JY, Song JY. Disease Burden and Etiologic Distribution of Community-Acquired Pneumonia in Adults: Evolving Epidemiology in the Era of Pneumococcal Conjugate Vaccines. Infect Chemother 2018; 50:287-300. [PMID: 30600652 PMCID: PMC6312904 DOI: 10.3947/ic.2018.50.4.287] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Indexed: 12/23/2022] Open
Abstract
Pneumonia is the leading cause of morbidity and mortality, particularly in old adults. The incidence and etiologic distribution of community-acquired pneumonia is variable both geographically and temporally, and epidemiology might evolve with the change of population characteristics and vaccine uptake rates. With the increasing prevalence of chronic medical conditions, a wide spectrum of healthcare-associated pneumonia could also affect the epidemiology of community-acquired pneumonia. Here, we provide an overview of the epidemiological changes associated with community-acquired pneumonia over the decades since pneumococcal conjugate vaccine introduction.
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Affiliation(s)
- Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Asian Pacific Influenza Institute, Korea University College of Medicine, Seoul, Korea.
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13
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Clinical Outcomes of Hospital-Acquired and Healthcare-Associated Pneumonia With and Without Empiric Vancomycin in a Noncritically Ill Population. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Horie H, Ito I, Konishi S, Yamamoto Y, Yamamoto Y, Uchida T, Ohtani H, Yoshida Y. Isolation of ESBL-producing Bacteria from Sputum in Community-acquired Pneumonia or Healthcare-associated Pneumonia Does Not Indicate the Need for Antibiotics with Activity against This Class. Intern Med 2018; 57:487-495. [PMID: 29021461 PMCID: PMC5849542 DOI: 10.2169/internalmedicine.8867-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective In the past decade, extended-spectrum β-lactamase (ESBL)-producing bacteria have increasingly frequently been isolated from various kinds of clinical specimens. However, the appropriate treatment of pneumonia in which ESBL-producing bacteria are isolated from sputum culture is poorly understood. To investigate whether or not ESBL-producing bacteria isolated from sputum in pneumonia cases should be treated as the causative bacteria. Methods and Patients In this retrospective study, we screened for patients, admitted between January 2009 and December 2015 in whom pneumonia was suspected and for whom sputum cultures yielded Escherichia coli or Klebsiella spp. isolates. We identified patients with community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) from whom ESBL-producing bacteria had been isolated from sputum culture and to whom antibiotic treatment had been given with a diagnosis of pneumonia. We analyzed the patients' backgrounds and the effect of the antibiotic treatment for the initial 3-5 days. Results From 400 patients initially screened, 27 with ESBL-producing bacteria were secondarily screened. In this subset of patients, 15 were diagnosed with pneumonia, including 7 with CAP (5 E. coli and 2 K. pneumoniae) and 8 with HCAP (8 E. coli). These patients exhibited an average age of 84.1 years old, and 9 of 15 were men. No patients were initially treated with antimicrobials that are effective against isolated ESBL-producing bacteria. However, 13 of 15 patients showed improvement of pneumonia following the initial antibiotic treatment. Conclusion ESBL-producing bacteria isolated from sputum are not likely to be the actual causative organisms of pneumonia.
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Affiliation(s)
- Hideyuki Horie
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
| | - Isao Ito
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
- Department of Respiratory Medicine, Kyoto University Hospital, Japan
| | - Satoshi Konishi
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
- Department of Respiratory Medicine, Kyoto University Hospital, Japan
| | - Yuki Yamamoto
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
- Department of Respiratory Medicine, Kyoto University Hospital, Japan
| | - Yuko Yamamoto
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
- Department of Respiratory Medicine, Kyoto University Hospital, Japan
| | - Tatsuya Uchida
- Departments of Laboratory Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
| | - Hideo Ohtani
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
| | - Yoshiharu Yoshida
- Departments of Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Japan
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15
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Attridge RT, Frei CR, Pugh MJV, Lawson KA, Ryan L, Anzueto A, Metersky ML, Restrepo MI, Mortensen EM. Health care-associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes. J Crit Care 2016; 36:265-271. [PMID: 27595461 PMCID: PMC5096991 DOI: 10.1016/j.jcrc.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/23/2016] [Accepted: 08/04/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with health care-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an intensive care unit (ICU) with HCAP. MATERIALS AND METHODS We performed a population-based cohort study of patients admitted to greater than 150 hospitals in the US Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model. RESULTS A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). Patients receiving GC-HCAP had higher 30-day patient mortality compared to GC-CAP patients (34% vs 22%; P< .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (odds ratio, 1.67; 95% confidence interval, 1.30-2.13), recent hospital admission (1.53; 1.15-2.02), and receipt of GC-HCAP therapy (1.51; 1.20-1.90). CONCLUSIONS Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.
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Affiliation(s)
- Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX 78209; Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229.
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mary Jo V Pugh
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712.
| | - Laurajo Ryan
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Antonio Anzueto
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mark L Metersky
- University of Connecticut School of Medicine, Farmington, CT 06030.
| | - Marcos I Restrepo
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Eric M Mortensen
- Section of General Internal Medicine, VA North Texas Health Care System, Dallas, TX 75216; Division of General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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Empiric antibiotic selection and risk prediction of drug-resistant pathogens in community-onset pneumonia. Curr Opin Infect Dis 2016; 29:167-77. [PMID: 26886179 DOI: 10.1097/qco.0000000000000254] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVEIW Empiric antibiotic selection in community-onset pneumonia is complicated by uncertainty regarding risk of drug-resistant pathogens (DRPs). The healthcare-associated pneumonia (HCAP) criteria have limited predictive value and lead to unnecessary antibiotic use. Better methods of predicting risk of DRP and selecting empiric antibiotics are needed. Here we give an update on risk factors for DRP, available risk prediction models, and treatment strategy in patients with pneumonia. RECENT FINDINGS Evidence supporting factors that contribute to risk of DRP has improved since the advent of HCAP. Many of these risk factors have been reproducibly identified in heterogeneous populations. Newer methods of predicting DRP based on these factors demonstrate better performance than HCAP. Recent innovations include the potential to discriminate between risk for methicillin-resistant Staphylococcus aureus and other DRP, and use of severity as a modifier of treatment threshold. However, there is wide variation in included predictor variables, and at proposed thresholds most scores still favor overtreatment. SUMMARY Until reliable molecular diagnostics are available, additional development and validation of decision support models integrating local resistance rates, estimated DRP risk, severity, and threshold for anti-DRP antibiotics are needed. Once optimized models are identified, implementation studies will be needed to confirm safety and efficacy.
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17
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Hong DY, Park SO, Kim JW, Lee KR, Baek KJ, Na JU, Choi PC, Lee YH. Serum Procalcitonin: An Independent Predictor of Clinical Outcome in Health Care-Associated Pneumonia. Respiration 2016; 92:241-251. [PMID: 27623169 DOI: 10.1159/000449005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 08/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early prediction of the clinical outcomes for health care-associated pneumonia (HCAP) patients is challenging. OBJECTIVES This is the first study to evaluate procalcitonin (PCT) as a predictor of outcomes in HCAP patients. METHODS We conducted an observational study based on data for HCAP patients prospectively collected between 2011 and 2014. Outcome variables were intensive care unit (ICU) admission and 30-day mortality. PCT was categorized into three groups: <0.5, 0.5-2.0, and >2.0 ng/ml. We analysed multiple variables including age, sex, comorbidities, clinical findings, and PCT group to assess their association with outcomes. RESULTS Of 245 HCAP patients, 99 (40.4%) were admitted to an ICU and 44 (18.0%) died within 30 days. The median PCT level was significantly higher in the ICU admission (1.19 vs. 0.4 ng/ml; p < 0.001) and 30-day mortality (3.3 vs. 0.4 ng/ml; p < 0.001) groups. In multivariate analysis, high PCT (>2.0 ng/ml) was strongly associated with ICU admission [odds ratio 3.734, 95% confidence interval (CI) 1.753-7.951; p = 0.001] and 30-day mortality (hazard ratio 2.254, 95% CI 1.250-5.340; p = 0.035). In receiver operating characteristic analysis, PCT had a poor discrimination power regarding ICU admission [0.695 of the area under the curve (AUC)] and a fair discrimination power regarding 30-day mortality in HCAP patients (0.768 of the AUC). CONCLUSIONS High PCT on admission was strongly associated with ICU admission and 30-day mortality in HCAP patients. However, application of PCT alone seems to be limited to predicting outcomes.
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Affiliation(s)
- Dae Young Hong
- Department of Emergency Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
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Matsuda S, Ogasawara T, Sugimoto S, Kato S, Umezawa H, Yano T, Kasamatsu N. Prospective open-label randomized comparative, non-inferiority study of two initial antibiotic strategies for patients with nursing- and healthcare-associated pneumonia: Guideline-concordant therapy versus empiric therapy. J Infect Chemother 2016; 22:400-6. [DOI: 10.1016/j.jiac.2016.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/13/2016] [Accepted: 03/09/2016] [Indexed: 11/25/2022]
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Roberts ET, DuGoff EH, Heins SE, Swedler DI, Castillo RC, Feldman DR, Wegener ST, Canudas‐Romo V, Anderson GF. Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data. Health Serv Res 2016; 51:953-80. [PMID: 26368813 PMCID: PMC4874815 DOI: 10.1111/1475-6773.12360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries. DATA SOURCES/STUDY SETTING Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer. STUDY DESIGN Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable. DATA COLLECTION Collected by the insurer from the time an injury was reported, through recovery or last follow-up. PRINCIPAL FINDINGS Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW. CONCLUSIONS There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.
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Affiliation(s)
- Eric T. Roberts
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
| | - Eva H. DuGoff
- Department of Population Health SciencesUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWI
| | - Sara E. Heins
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - David I. Swedler
- University of Illinois at Chicago School of Public HealthChicagoIL
| | - Renan C. Castillo
- METRC Coordinating CenterJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | | | | | - Vladimir Canudas‐Romo
- Department of Population, Family, and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Gerard F. Anderson
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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20
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Lee H, Park JY, Lee T, Lee YJ, Lim HJ, Park JS, Yoon HI, Lee JH, Lee CT, Cho YJ. Intermediate risk of multidrug-resistant organisms in patients who admitted intensive care unit with healthcare-associated pneumonia. Korean J Intern Med 2016; 31:525-34. [PMID: 26968189 PMCID: PMC4855101 DOI: 10.3904/kjim.2015.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/02/2015] [Accepted: 09/08/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Healthcare-associated pneumonia (HCAP) was proposed asa new pneumonia category in 2005, and treatment recommendations includebroad-spectrum antibiotics directed at multidrug-resistant (MDR) pathogens.However, this concept continues to be controversial, and microbiological data arelacking for HCAP patients in the intensive care unit (ICU). This study was conductedto determine the rate and type of antibiotic-resistant organisms and theclinical outcomes in patients with HCAP in the ICU, compared to patients withcommunity-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). METHODS We conducted a retrospective cohort analysis of patients with pneumonia(n = 195) who admitted to medical ICU in tertiary teaching hospital fromMarch 2011 to February 2013. Clinical characteristics, microbiological distributions,treatment outcomes, and prognosis of HCAP (n = 74) were compared tothose of CAP (n = 75) and HAP (n = 46). RESULTS MDR pathogens were significantly higher in HCAP patients (39.1%) thanin CAP (13.5%) and lower than in HAP (79.3%, p < 0.001). The initial use of inappropriateantibiotic treatment occurred more frequently in the HCAP (32.6%) andHAP (51.7%) groups than in the CAP group (11.8%, p = 0.006). There were no differencesin clinical outcomes. The significant prognostic factors were pneumoniaseverity and treatment response. CONCLUSIONS MDR pathogens were isolated in HCAP patients requiring ICU admissionat intermediate rates between those of CAP and HAP.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Young-Jae Cho
- Correspondence to Young-Jae Cho, M.D. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7058 Fax: +82-31-787-4051 E-mail:
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21
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Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score. Antimicrob Agents Chemother 2016; 60:2652-63. [PMID: 26856838 DOI: 10.1128/aac.03071-15] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/03/2016] [Indexed: 11/20/2022] Open
Abstract
The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.
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22
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Waterer GW. Healthcare-associated pneumonia: Can we salvage anything from the wreckage? Respirology 2015; 21:8-9. [DOI: 10.1111/resp.12695] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Grant W. Waterer
- School of Medicine and Pharmacology; Royal Perth Hospital; The University of Western Australia; Perth Western Australia Australia
- Department of Medicine; Northwestern University; Chicago Illinois USA
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23
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Metersky ML, Frei CR, Mortensen EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology 2015; 21:157-63. [PMID: 26682638 DOI: 10.1111/resp.12651] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/01/2015] [Accepted: 07/17/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with healthcare-associated pneumonia (HCAP) are at high risk of infection with multidrug-resistant (MDR) pathogens. Factors discriminating infection with MDR Gram-negative (MDR-GN) organism from infection with methicillin-resistant Staphylococcus aureus (MRSA) are not well understood and patients are often treated for both organisms. This study was performed to determine risk factors predicting pneumonia due to Pseudomonas versus MRSA. METHODS Veterans age ≥65 hospitalized with HCAP between 2002 and 2012 were identified from the Veterans Affairs administrative databases. Patients were identified with Pseudomonas pneumonia, MRSA pneumonia or neither according to the International Classification of Diseases, 9th Revision, Clinical Modification codes. We assessed unadjusted and adjusted associations of patient characteristics and HCAP due to Pseudomonas or MRSA. RESULTS Of the 61,651 patients with HCAP, 1156 (1.9%) were diagnosed with Pseudomonas pneumonia, 641 (1.0%) with MRSA pneumonia and 59,854 (97.1%) with neither. MRSA pneumonia was positively associated with male gender, age >74, diabetes, chronic obstructive pulmonary disease (COPD), recent nursing home or hospital stay, recent exposure to fluoroquinolone or antibiotics treating Gram-positive organisms, and severe pneumonia. MRSA pneumonia was negatively associated with complicated diabetes. Pseudomonas pneumonia was positively associated with recent hospital stay, immunocompromise, COPD, hemiplegia, recent exposure to inhaled corticosteroids, β-lactam/cephalosporin/carbapenem antibiotics, antibiotics against Gram-positive organisms, 'other antibiotics' and severe pneumonia. Pseudomonas pneumonia was negatively associated with age >84, higher socioeconomic status, drug abuse and diabetes. CONCLUSIONS Patient characteristics may assist in identifying patients at risk for HCAP due to Pseudomonas or MRSA.
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Affiliation(s)
- Mark L Metersky
- The Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, USA.,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center School of Medicine, San Antonio, USA
| | - Eric M Mortensen
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Rothberg MB, Zilberberg MD, Pekow PS, Priya A, Haessler S, Belforti R, Skiest D, Lagu T, Higgins TL, Lindenauer PK. Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia. J Antimicrob Chemother 2015; 70:1573-9. [PMID: 25558075 DOI: 10.1093/jac/dku533] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/30/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. PATIENTS AND METHODS We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. RESULTS Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT. CONCLUSIONS Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.
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Affiliation(s)
- Michael B Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Sarah Haessler
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
| | - Raquel Belforti
- Division of General Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Daniel Skiest
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Thomas L Higgins
- Division of Pulmonary/Critical Care Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
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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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26
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Webb BJ, Dascomb K, Stenehjem E, Dean N. Predicting risk of drug-resistant organisms in pneumonia: moving beyond the HCAP model. Respir Med 2014; 109:1-10. [PMID: 25468412 DOI: 10.1016/j.rmed.2014.10.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/19/2014] [Accepted: 10/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical management of community-acquired pneumonia (CAP) is increasingly complicated by antibiotic resistance. CAP due to pathogens resistant to guideline-recommended drugs (CAP-DRP) has increased. 2005 ATS/IDSA guidelines introduced a new category, healthcare-associated pneumonia (HCAP), and recommend extended-spectrum antibiotic treatment for patients meeting HCAP criteria. However, the predictive value of the HCAP model is limited and data suggest that outcomes are not improved using HCAP guideline-concordant therapy. Better methods to predict risk of CAP-DRP are needed. METHODS We reviewed currently published literature on the performance status of HCAP as a predictive tool and studies describing additional risk factors for CAP-DRP. We also summarize the performance characteristics of the currently published alternative clinical prediction scores and compare them to that of the HCAP model. RESULTS In addition to the five risk factors incorporated in HCAP, at least 13 other factors have been identified. The independent predictive value of any single factor is low, but accumulating factors results in increased risk of CAP-DRP. The performance characteristics of 9 clinical prediction scores are reviewed. Nearly all of the scores outperformed HCAP in their study populations. However, no single model has yet demonstrated adequate specificity to minimize unnecessary antibiotic use, while retaining sufficient sensitivity to prevent inadequate initial empiric antibiotic therapy when validated across a wide range of CAP-DRP prevalence. CONCLUSIONS Additional development and validation of prediction scores based upon more refined risk factors for CAP-DRP is needed. Once an accurate, adequately validated prediction score is available, an interventional trial will be needed to determine clinical impact.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Kristin Dascomb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Edward Stenehjem
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Nathan Dean
- Division of Pulmonary and Critical Care Medicine, at Intermountain Medical Center and the University of Utah, Salt Lake City, UT, USA
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Komiya K, Ishii H, Kadota JI. Healthcare-associated Pneumonia and Aspiration Pneumonia. Aging Dis 2014; 6:27-37. [PMID: 25657850 DOI: 10.14336/ad.2014.0127] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/24/2014] [Accepted: 01/27/2014] [Indexed: 12/13/2022] Open
Abstract
Healthcare-associated pneumonia (HCAP) is a new concept of pneumonia proposed by the American Thoracic Society/Infectious Diseases Society of America in 2005. This category is located between community-acquired pneumonia and hospital-acquired pneumonia with respect to the characteristics of the causative pathogens and mortality, and primarily targets elderly patients in healthcare facilities. Aspiration among such patients is recognized to be a primary mechanism for the development of pneumonia, particularly since the HCAP guidelines were published. However, it is difficult to manage patients with aspiration pneumonia because the definition of the condition is unclear, and the treatment is associated with ethical aspects. This review focused on the definition, prevalence and role of aspiration pneumonia as a prognostic factor in published studies of HCAP and attempted to identify problems associated with the concept of aspiration pneumonia.
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Affiliation(s)
- Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan ; Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Hiroshi Ishii
- Department of Respiratory Medicine, Fukuoka University Hospital, Jonan-ku, Fukuoka, Japan
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan
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Shindo Y, Ito R, Kobayashi D, Ando M, Ichikawa M, Shiraki A, Goto Y, Fukui Y, Iwaki M, Okumura J, Yamaguchi I, Yagi T, Tanikawa Y, Sugino Y, Shindoh J, Ogasawara T, Nomura F, Saka H, Yamamoto M, Taniguchi H, Suzuki R, Saito H, Kawamura T, Hasegawa Y. Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia. Am J Respir Crit Care Med 2013; 188:985-95. [PMID: 23855620 DOI: 10.1164/rccm.201301-0079oc] [Citation(s) in RCA: 203] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Identification of patients with drug-resistant pathogens at initial diagnosis is essential for treatment of pneumonia. OBJECTIVES To elucidate clinical features of community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP), and to clarify risk factors for drug-resistant pathogens in patients with CAP and HCAP. METHODS A prospective observational study was conducted in hospitalized patients with pneumonia at 10 institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin-sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP drug-resistant pathogens (CAP-DRPs). MEASUREMENTS AND MAIN RESULTS In total, 1,413 patients (887 CAP and 526 HCAP) were analyzed. CAP-DRPs were more frequently found in patients with HCAP (26.6%) than in patients with CAP (8.6%). Independent risk factors for CAP-DRPs were almost identical in patients with CAP and HCAP. These included prior hospitalization (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.23-3.43), immunosuppression (AOR, 2.31; 95% CI, 1.05-5.11), previous antibiotic use (AOR, 2.45; 95% CI, 1.51-3.98), use of gastric acid-suppressive agents (AOR, 2.22; 95% CI, 1.39-3.57), tube feeding (AOR, 2.43; 95% CI, 1.18-5.00), and nonambulatory status (AOR, 2.45; 95% CI, 1.40-4.30) in the combined patients with CAP and HCAP. The area under the receiver operating characteristic curve for counting the number of risk factors was 0.79 (95% CI, 0.74-0.84). CONCLUSIONS The clinical profile of HCAP was different from that of CAP. However, physicians can predict drug resistance in patients with either CAP or HCAP by taking account of the cumulative number of the risk factors. Clinical trial registered with https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000004001&language=E ; number UMIN000003306.
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Affiliation(s)
- Yuichiro Shindo
- 1 Institute for Advanced Research, Nagoya University, Nagoya, Japan
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Quartin AA, Scerpella EG, Puttagunta S, Kett DH. A comparison of microbiology and demographics among patients with healthcare-associated, hospital-acquired, and ventilator-associated pneumonia: a retrospective analysis of 1184 patients from a large, international study. BMC Infect Dis 2013; 13:561. [PMID: 24279701 PMCID: PMC4222644 DOI: 10.1186/1471-2334-13-561] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/12/2013] [Indexed: 11/10/2022] Open
Abstract
Background Acceptance of healthcare-associated pneumonia (HCAP) as an entity and the associated risk of infection by potentially multidrug-resistant (MDR) organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas and Acinetobacter have been debated. We therefore compared patients with HCAP, hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) enrolled in a trial comparing linezolid with vancomycin for treatment of pneumonia. Methods The analysis included all patients who received study drug. HCAP was defined as pneumonia occurring < 48 hours into hospitalization and acquired in a long-term care, subacute, or intermediate health care facility; following recent hospitalization; or after chronic dialysis. Results Data from 1184 patients (HCAP = 199, HAP = 379, VAP = 606) were analyzed. Compared with HAP and VAP patients, those with HCAP were older, had slightly higher severity scores, and were more likely to have comorbidities. Pseudomonas aeruginosa was the most common gram-negative organism isolated in all pneumonia classes [HCAP, 22/199 (11.1%); HAP, 28/379 (7.4%); VAP, 57/606 (9.4%); p = 0.311]. Acinetobacter spp. were also found with similar frequencies across pneumonia groups. To address potential enrollment bias toward patients with MRSA pneumonia, we grouped patients by presence or absence of MRSA and found little difference in frequencies of Pseudomonas and Acinetobacter. Conclusions In this population of pneumonia patients, the frequencies of MDR gram-negative pathogens were similar among patients with HCAP, HAP, or VAP. Our data support inclusion of HCAP within nosocomial pneumonia guidelines and the recommendation that empiric antibiotic regimens for HCAP should be similar to those for HAP and VAP.
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Affiliation(s)
- Andrew A Quartin
- Division of Pulmonary and Critical Care Medicine, Miller School of Medicine at the University of Miami, Jackson Memorial Hospital, 1611 NW 12th Avenue, C455A, Miami, FL 33156, USA.
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Troitino AX, Porhomayon J, El-Solh AA. Guideline-Concordant Antimicrobial Therapy for Healthcare-Associated Pneumonia: A Systematic Review and Meta-analysis. Lung 2013; 191:229-37. [DOI: 10.1007/s00408-013-9462-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
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A prospective comparison of nursing- and healthcare-associated pneumonia (NHCAP) with community-acquired pneumonia (CAP). J Infect Chemother 2013; 19:719-26. [DOI: 10.1007/s10156-013-0557-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
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