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Wei J, Uppal A, Nganjimi C, Warr H, Ibrahim Y, Gu Q, Yuan H, Rahman NM, Jones N, Walker AS, Eyre DW. No evidence of difference in mortality with amoxicillin versus co-amoxiclav for hospital treatment of community-acquired pneumonia. J Infect 2024; 88:106161. [PMID: 38663754 DOI: 10.1016/j.jinf.2024.106161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES Current guidelines recommend broad-spectrum antibiotics for high-severity community-acquired pneumonia (CAP), potentially contributing to antimicrobial resistance (AMR). We aim to compare outcomes in CAP patients treated with amoxicillin (narrow-spectrum) versus co-amoxiclav (broad-spectrum), to understand if narrow-spectrum antibiotics could be used more widely. METHODS We analysed electronic health records from adults (≥16 y) admitted to hospital with a primary diagnosis of pneumonia between 01-January-2016 and 30-September-2023 in Oxfordshire, United Kingdom. Patients receiving baseline ([-12 h,+24 h] from admission) amoxicillin or co-amoxiclav were included. The association between 30-day all-cause mortality and baseline antibiotic was examined using propensity score (PS) matching and inverse probability treatment weighting (IPTW) to address confounding by baseline characteristics and disease severity. Subgroup analyses by disease severity and sensitivity analyses with missing covariates imputed were also conducted. RESULTS Among 16,072 admissions with a primary diagnosis of pneumonia, 9685 received either baseline amoxicillin or co-amoxiclav. There was no evidence of a difference in 30-day mortality between patients receiving initial co-amoxiclav vs. amoxicillin (PS matching: marginal odds ratio 0.97 [0.76-1.27], p = 0.61; IPTW: 1.02 [0.78-1.33], p = 0.87). Results remained similar across stratified analyses of mild, moderate, and severe pneumonia. Results were also similar with missing data imputed. There was also no evidence of an association between 30-day mortality and use of additional macrolides or additional doxycycline. CONCLUSIONS There was no evidence of co-amoxiclav being advantageous over amoxicillin for treatment of CAP in 30-day mortality at a population-level, regardless of disease severity. Wider use of narrow-spectrum empirical treatment of moderate/severe CAP should be considered to curb potential for AMR.
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Affiliation(s)
- Jia Wei
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Aashna Uppal
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christy Nganjimi
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Hermione Warr
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Yasin Ibrahim
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Qingze Gu
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Hang Yuan
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK; The National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Nicola Jones
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; The National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, Oxford, UK
| | - David W Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK; The National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford, Oxford, UK.
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Markussen DL, Kommedal Ø, Knoop ST, Ebbesen MH, Bjørneklett RO, Ritz C, Heggelund L, Ulvestad E, Serigstad S, Grewal HMS. Microbial aetiology of community-acquired pneumonia in hospitalised adults: A prospective study utilising comprehensive molecular testing. Int J Infect Dis 2024; 143:107019. [PMID: 38582145 DOI: 10.1016/j.ijid.2024.107019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/08/2024] Open
Abstract
OBJECTIVES This study aimed to describe the microbial aetiology of community-acquired pneumonia (CAP) in adults admitted to a tertiary care hospital and assess the impact of syndromic polymerase chain reaction (PCR) panels on pathogen detection. METHODS Conducted at Haukeland University Hospital, Norway, from September 2020 to April 2023, this prospective study enrolled adults with suspected CAP. We analysed lower respiratory tract samples using both standard-of-care tests and the BIOFIRE® FILMARRAY® Pneumonia Plus Panel (FAP plus). The added value of FAP Plus in enhancing the detection of clinically relevant pathogens, alongside standard-of-care diagnostics, was assessed. RESULTS Of the 3238 patients screened, 640 met the inclusion criteria, with 384 confirmed to have CAP at discharge. In these patients, pathogens with proven or probable clinical significance were identified in 312 (81.3%) patients. Haemophilus influenzae was the most prevalent pathogen, found in 118 patients (30.7%), followed by SARS-CoV-2 in 74 (19.3%), and Streptococcus pneumoniae in 64 (16.7%). Respiratory viruses were detected in 186 (48.4%) patients. The use of FAP plus improved the pathogen detection rate from 62.8% with standard-of-care methods to 81.3%. CONCLUSIONS Pathogens were identified in 81% of CAP patients, with Haemophilus influenzae and respiratory viruses being the most frequently detected pathogens. The addition of the FAP plus panel, markedly improved pathogen detection rates compared to standard-of-care diagnostics alone.
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Affiliation(s)
- Dagfinn Lunde Markussen
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway; Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Øyvind Kommedal
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | | | | | - Rune Oskar Bjørneklett
- Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Christian Ritz
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Lars Heggelund
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway; Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Elling Ulvestad
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway; Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Sondre Serigstad
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway; Department of Emergency Medicine, Haukeland University Hospital, Bergen, Norway
| | - Harleen M S Grewal
- Department of Clinical Science, Bergen Integrated Diagnostic Stewardship Cluster, Faculty of Medicine, University of Bergen, Bergen, Norway; Department of Microbiology, Haukeland University Hospital, Bergen, Norway
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3
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Bai AD, Srivastava S, Digby GC, Girard V, Razak F, Verma AA. Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study. Chest 2024:S0012-3692(24)00260-5. [PMID: 38387648 DOI: 10.1016/j.chest.2024.02.025] [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: 12/12/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Antibiotics with extended anaerobic coverage are used commonly to treat aspiration pneumonia, which is not recommended by current guidelines. RESEARCH QUESTION In patients admitted to hospital for community-acquired aspiration pneumonia, does a difference exist between antibiotic therapy with limited anaerobic coverage (LAC) vs antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis? STUDY DESIGN AND METHODS We conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada, from January 1, 2015, to January 1, 2022. Patients were included if the physician diagnosed aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy to the patient within 48 h of admission. Patients then were categorized into the LAC group if they received ceftriaxone, cefotaxime, or levofloxacin. Patients were categorized into the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included incident C difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors. RESULTS The LAC and EAC groups included 2,683 and 1,316 patients, respectively. In hospital, 814 patients (30.3%) and 422 patients (32.1%) in the LAC and EAC groups died, respectively. C difficile colitis occurred in five or fewer patients (≤ 0.2%) and 11 to 15 patients (0.8%-1.1%) in the LAC and EAC groups, respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI, -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI, 0.3%-1.7%) for C difficile colitis. INTERPRETATION Extended anaerobic coverage likely is unnecessary in aspiration pneumonia because it is associated with no additional mortality benefit, only an increased risk of C difficile colitis.
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Affiliation(s)
- Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Siddhartha Srivastava
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Geneviève C Digby
- Division of Respirology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Vincent Girard
- Internal Medicine Residency Program, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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4
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Bai AD, Srivastava S, Wong BKC, Digby GC, Razak F, Verma AA. Comparative Effectiveness of First-Line and Alternative Antibiotic Regimens in Hospitalized Patients With Nonsevere Community-Acquired Pneumonia: A Multicenter Retrospective Cohort Study. Chest 2024; 165:68-78. [PMID: 37574164 DOI: 10.1016/j.chest.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/23/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND There are several antibiotic regimens to treat community-acquired pneumonia (CAP). RESEARCH QUESTION In patients hospitalized to a non-ICU ward setting with CAP, is there a difference between first-line and alternative antibiotic regimens (β-lactam plus macrolide [BL+M], β-lactam [BL] alone, respiratory fluoroquinolone [FQ], or β-lactam plus doxycycline [BL+D]) in terms of in-hospital mortality? STUDY DESIGN AND METHODS This retrospective cohort study included consecutive patients admitted with CAP at 19 Canadian hospitals from 2015 to 2021. Taking a target trial approach, patients were categorized into the four antibiotic groups based on the initial antibiotic treatment within 48 h of admission. Patients with severe CAP requiring ICU admission in the first 48 h were excluded. The primary outcome was all-cause in-hospital mortality. Secondary outcome included time to being discharged alive. Propensity score and overlap weighting were used to balance covariates. RESULTS Of 23,512 patients, 9,340 patients (39.7%) received BL+M, 9,146 (38.9%) received BL, 4,510 (19.2%) received FQ, and 516 (2.2%) received BL+D. The number of in-hospital deaths was 703 (7.5%) for the BL+M group, 888 (9.7%) for the BL group, 302 (6.7%) for the FQ group, and 31 (6.0%) for the BL+D group. The adjusted risk difference for in-hospital mortality when compared with BL+M was 1.5% (95% CI, -0.3% to 3.3%) for BL, -0.9% (95% CI, -2.9% to 1.1%) for FQ, and -1.9% (95% CI, -4.8% to 0.9%) for BL+D. Compared with BL+M, the subdistribution hazard ratio for being discharged alive was 0.90 (95% CI, 0.84-0.96) for BL, 1.07 (95% CI, 0.99-1.16) for FQ, and 1.04 (95% CI, 0.93-1.17) for BL+D. INTERPRETATION BL+M, FQ, and BL+D had similar outcomes and can be considered effective regimens for nonsevere CAP. Compared with BL+M, BL was associated with longer time to discharge and the CI for mortality cannot exclude a small but clinically important increase in risk.
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Affiliation(s)
- Anthony D Bai
- Divisions of Infectious Diseases, Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Siddhartha Srivastava
- General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Geneviève C Digby
- Division of Respirology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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5
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Morosawa M, Ueda T, Nakajima K, Inoue T, Toyama M, Ogasiwa H, Doi M, Nozaki Y, Murakami Y, Ishii M, Takesue Y. Comparison of antibiotic use and antibiotic resistance between a community hospital and tertiary care hospital for evaluation of the antimicrobial stewardship program in Japan. PLoS One 2023; 18:e0284806. [PMID: 37093821 PMCID: PMC10124824 DOI: 10.1371/journal.pone.0284806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/06/2023] [Indexed: 04/25/2023] Open
Abstract
Assessment of risk-adjusted antibiotic use (AU) is recommended to evaluate antimicrobial stewardship programs (ASPs). We aimed to compare the amount and diversity of AU and antimicrobial susceptibility of nosocomial isolates between a 266-bed community hospital (CH) and a 963-bed tertiary care hospital (TCH) in Japan. The days of therapy/100 bed days (DOT) was measured for four classes of broad-spectrum antibiotics predominantly used for hospital-onset infections. The diversity of AU was evaluated using the modified antibiotic heterogeneity index (AHI). With 10% relative DOT for fluoroquinolones and 30% for each of the remaining three classes, the modified AHI equals 1. Multidrug resistance (MDR) was defined as resistance to ≥ 3 anti-Pseudomonas antibiotic classes. The DOT was significantly higher in the TCH than in the CH (10.85 ± 1.32 vs. 3.89 ± 0.93, p < 0.001). For risk-adjusted AU, the DOT was 6.90 ± 1.50 for acute-phase medical wards in the CH, and 8.35 ± 1.05 in the TCH excluding the hematology department. In contrast, the DOT of antibiotics for community-acquired infections was higher in the CH than that in the TCH. As quality assessment of AU, higher modified AHI was observed in the TCH than in the CH (0.832 ± 0.044 vs. 0.721 ± 0.106, p = 0.003), indicating more diverse use in the TCH. The MDR rate in gram-negative rods was 5.1% in the TCH and 3.4% in the CH (p = 0.453). No significant difference was demonstrated in the MDR rate for Pseudomonas aeruginosa and Enterobacteriaceae species between hospitals. Broad-spectrum antibiotics were used differently in the TCH and CH. However, an increased antibiotic burden in the TCH did not cause poor susceptibility, possibly because of diversified AU. Considering the different patient populations, benchmarking AU according to the facility type is promising for inter-hospital comparisons of ASPs.
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Affiliation(s)
- Mika Morosawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoko Inoue
- Department of Pharmacy, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Masanobu Toyama
- Department of Pharmacy, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Hitoshi Ogasiwa
- Department of Clinical Technology, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Miki Doi
- Department of Clinical Technology, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Yasuhiro Nozaki
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Yasushi Murakami
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Makoto Ishii
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital, Tokoname, Japan
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6
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Kamiński K, Hąc-Wydro K, Skóra M, Tymecka M, Obłoza M. Preliminary Studies on the Mechanism of Antifungal Activity of New Cationic β-Glucan Derivatives Obtained from Oats and Barley. ACS OMEGA 2022; 7:40333-40343. [PMID: 36385808 PMCID: PMC9648169 DOI: 10.1021/acsomega.2c05311] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
New chemical structures with antifungal properties are highly desirable from the point of view of modern pharmaceutical science, especially due to the increasingly widespread instances of drug resistance in the case of these diseases. One way to solve this problem is to use polymeric drugs, widely described as biocidal, positively charged macromolecules. In this work, we present the synthesis of new cationic β-glucan derivatives that show selective antifungal activity and at the same time low toxicity toward animal and human cells. Two β-glucans isolated from oats and barley and modified using glycidyltrimethylammonium chloride were obtained and evaluated for biocidal properties on the cells of mammals and pathogenic fungi and bacteria. These compounds were found to be nontoxic to fibroblast and bacterial cells but showed selective toxicity to certain species of filamentous fungi (Scopulariopsis brevicaulis) and yeasts (Cryptococcus neoformans). The most important aspect of this work is the attempt to explain the mechanisms of action of these compounds by studying their interaction with biological membranes. This was achieved by examining the interactions with model biological membranes representative of given families of microorganisms using Langmuir monolayers. The data obtained partly show correlations between the results for model systems and biological experiments and allow indicating that the selective antifungal activity of cationic β-glucans is related to their interaction with fungal biological membranes and partly lack of such interaction toward cells of other organisms. In addition, the obtained macromolecules were characterized by spectral methods (Fourier transform infrared (FTIR) and 1H nuclear magnetic resonance (NMR) spectroscopies) to confirm that the desired structure was obtained, and their degree of modification and molecular weights were determined.
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Affiliation(s)
- Kamil Kamiński
- Faculty
of Chemistry, Jagiellonian University, Gronostajowa 2 Street, 30-387Kraków, Poland
| | - Katarzyna Hąc-Wydro
- Faculty
of Chemistry, Jagiellonian University, Gronostajowa 2 Street, 30-387Kraków, Poland
| | - Magdalena Skóra
- Department
of Infections Control and Mycology, Chair of Microbiology, Jagiellonian University Medical College, Czysta 18 Street, 31-121Kraków, Poland
| | - Małgorzata Tymecka
- Faculty
of Chemistry, Jagiellonian University, Gronostajowa 2 Street, 30-387Kraków, Poland
| | - Magdalena Obłoza
- Faculty
of Chemistry, Jagiellonian University, Gronostajowa 2 Street, 30-387Kraków, Poland
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7
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Waagsbø B, Tranung M, Damås JK, Heggelund L. Antimicrobial therapy of community-acquired pneumonia during stewardship efforts and a coronavirus pandemic: an observational study. BMC Pulm Med 2022; 22:379. [PMID: 36242006 PMCID: PMC9569007 DOI: 10.1186/s12890-022-02178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is the most frequent infection diagnosis in hospitals. Antimicrobial therapy for CAP is depicted in clinical practice guidelines, but adherence data and effect of antibiotic stewardship measures are lacking. Methods A dedicated antibiotic team pointed out CAP as a potential target for antimicrobial stewardship (AMS) measures at a 1.000-bed, tertiary care, teaching university hospital in Norway from March until May for the years 2016 throughout 2021. The aim of the AMS program was to increase diagnostic and antimicrobial therapy adherence to national clinical practice guideline recommendations through multiple and continuous AMS efforts. Descriptive statistics were retrospectively used to delineate antimicrobial therapy for CAP. The primary outcomes were proportions that received narrow-spectrum beta-lactams, and broad-spectrum antimicrobial therapy. Results 1.112 CAP episodes were identified. The annual proportion that received narrow-spectrum beta-lactams increased from 56.1 to 74.4% (p = 0.045). Correspondingly, the annual proportion that received broad-spectrum antimicrobial therapy decreased from 34.1 to 17.1% (p = 0.002). Trends were affected by the coronavirus pandemic. Mortality and 30-day readmission rates remained unchanged. De-escalation strategies were frequently unutilized, and overall therapy duration exceeded clinical practice guideline recommendations substantially. Microbiologically confirmed CAP episodes increased from 33.7 to 56.2% during the study period. Conclusion CAP is a suitable model condition that is sensitive to AMS measures. A continuous focus on improved microbiological diagnostics and antimicrobial therapy initiation is efficient in increasing adherence to guideline recommendations. There is an unmet need for better antimicrobial de-escalation strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02178-6.
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Affiliation(s)
- Bjørn Waagsbø
- St. Olavs Hospital, Regional centre for disease control in Central Norway Regional Health Authority, Trondheim University hospital, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Morten Tranung
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Central Norway Hospital Pharmacy Trust, Trondheim, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olavs Hospital, Trondheim University hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
| | - Lars Heggelund
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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8
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Bahrs C, Moeser A. Antibiotic Stewardship und Pneumonie. ZEITSCHRIFT FÜR PNEUMOLOGIE 2022. [PMCID: PMC9514178 DOI: 10.1007/s10405-022-00474-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Die Pneumonie ist eine sehr häufige und potenziell tödliche Erkrankung. Es werden 3 Entitäten (ambulant erworbenen = CAP, nosokomial erworben = HAP und Pneumonie unter Immunsuppression) unterschieden von denen insbesondere die CAP und die HAP für die Umsetzung von Antibiotic Stewardship(ABS)-Strategien, den rationalen Umgang mit Antibiotika, gut geeignet sind. Die Durchführung einer mikrobiologischen Diagnostik vor Start einer Antibiotikatherapie bei Pneumonie, die stationär behandelt werden muss, wird stark empfohlen. Eine Risikostratifizierung der Patienten und der Schweregrad der Erkrankung sind entscheidend für die kalkulierte Antibiotikaauswahl und die Applikationsform. Bei COVID-19-Patienten ohne septischen Schock kann aufgrund der niedrigen Rate von bakteriellen Superinfektionen auf eine empirische Antibiotikatherapie verzichtet werden. Eine Reevaluation der Antibiotikatherapie nach 48–72 h mit gezielter Deeskalation unter Beachtung der Klinik und Mikrobiologie, Absetzen bei Fehlindikation und die Begrenzung der Therapiedauer sind essenzielle ABS-Strategien zur Optimierung des klinischen Outcomes bei CAP und HAP mit dem Ziel, die Antibiotikaresistenzentwicklung sowie die Toxizität für den Patienten möglichst gering zu halten. Der Einsatz von Biomarkern wie Procalcitonin kann in bestimmten Situationen ein frühzeitiges Absetzen der Therapie begünstigen oder die Diagnose einer bakteriellen Superinfektion bei COVID-19 unterstützen.
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Affiliation(s)
- Christina Bahrs
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena – Friedrich-Schiller-Universität, Am Klinikum 1, 07747 Jena, Deutschland
- Universitätsklinik für Innere Medizin I, Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Währinger Gürtel 18–20, 1090 Wien, Österreich
| | - Anne Moeser
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena – Friedrich-Schiller-Universität, Am Klinikum 1, 07747 Jena, Deutschland
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9
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Dräger S, Giehl C, Søgaard KK, Egli A, de Roche M, Huber LC, Osthoff M. Do we need blood culture stewardship programs? A quality control study and survey to assess the appropriateness of blood culture collection and the knowledge and attitudes among physicians in Swiss hospitals. Eur J Intern Med 2022; 103:50-56. [PMID: 35715280 DOI: 10.1016/j.ejim.2022.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Guidance for blood culture (BC) collection is limited. Inappropriate BC collection may be associated with potentially harmful consequences for the patient such as unnecessary laboratory testing, treatment and additional costs. The aim of the study was to assess the appropriateness of BC collection and related knowledge and attitude of precribers. MATERIALS We conducted a single-center quality control study to assess the appropriateness of BC collection according to the local guidelines in a Swiss university hospital in 2020 by combining three different approaches: point prevalence, patient-individual longitudinal and diseases-related analysis. Second, we conducted a survey regarding BC collection practices and knowledge among physicians in two non-university and one university hospital using an 18-item electronic questionnaire. RESULTS We analyzed 1114 BC collected in 344 patients. Approximately 40% of the BCs were collected inappropriately, in particular in diseases with low pretest probability of bacteremia such as non-severe community acquired pneumonia (CAP). Follow-up blood culture (FUBC) collection was inappropriate in 60%. Growth of a relevant pathogen was more frequently observed in appropriately than in inappropriately collected BCs (18% vs. 3%, p < 0.001). In the survey, uncertainty concerning the need of index BC collection was high in non-severe CAP and uncomplicated cellulitis. CONCLUSIONS Almost half of the BCs was not collected according to the guidelines, especially in non-severe CAP and in case of FUBCs. Substantial uncertainty among physicians regarding BC ordering practices was identified. The implementation of diagnostic stewardship programs may improve BC collection practices, increase adherence to local guidelines, and may help reducing unnecessary diagnostics and treatment.
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Affiliation(s)
- Sarah Dräger
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland.
| | - Céline Giehl
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Kirstine Kobberøe Søgaard
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Biomedicine, University Hospital Basel, Hebelstrasse 20, 4031 Basel Switzerland.
| | - Adrian Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Biomedicine, University Hospital Basel, Hebelstrasse 20, 4031 Basel Switzerland.
| | - Mirjam de Roche
- Department of Internal Medicine, Hospital Thun, Krankenhausstrasse 12, 3600 Thun, Switzerland.
| | - Lars C Huber
- Department of Internal Medicine, City Hospital Triemli Zurich, Birmensdorferstrasse 497, 8063 Zurich, Switzerland; University of Zurich, Raemistrasse 71, 8006 Zurich, Switzerland.
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland.
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10
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Abelenda-Alonso G, Rombauts A, Gudiol C, García-Lerma E, Pallarés N, Ardanuy C, Calatayud L, Niubó J, Tebé C, Carratalà J. Effect of positive microbiological testing on antibiotic de-escalation and outcomes in community-acquired pneumonia: A propensity score analysis. Clin Microbiol Infect 2022; 28:1602-1608. [PMID: 35809784 DOI: 10.1016/j.cmi.2022.06.021] [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: 02/25/2022] [Revised: 06/03/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The usefulness of routine microbiological testing for rationalizing antibiotic use in hospitalized patients with community-acquired pneumonia (CAP) continues to be a subject of debate. We aim to determine the effect of positive microbiological testing on antimicrobial de-escalation and clinical outcomes in CAP. METHODS A retrospective analysis of a prospectively collected cohort of non-immunosuppressed adults hospitalized with CAP was performed. The primary study outcome was antimicrobial de-escalation. Secondary outcomes included 30-day case-fatality rate, adverse events, and CAP recurrence. Adjustment for confounders, was performed by inverse probability weighting propensity score (IPW-PS), logistic regression and cause-specific Cox model. RESULTS Of 3677 patients with CAP, 1924 (52.3%) had any positive microbiological test. Antimicrobial de-escalation was performed in 648/1924 (33.7%) of patients with positive microbiological testing and in 179/1753 (10.2%) of those with non positive results. When propensity score was entered into the multivariate analysis, positive microbiological testing (Adjusted Odds Ratio [AOR] 2.59 (1.96 - 3.41) and clinical stability at day 3 (AOR 1.87; 1.45 - 2.10) were two of the main factors independently associated with antimicrobial de-escalation. After applying an adjusted cause-specific Cox model, antimicrobial de-escalation was not associated with a higher 30-day case-fatality rate (Adjusted Hazard Ratio [AHR] 0.44; 0.14 - 1.43), higher frequency of adverse events (AHR 0.77; 0.53 - 1.12) or CAP recurrence (AHR 0.77; 0.45 - 1.28). CONCLUSIONS Antimicrobial de-escalation was more often performed in hospitalized patients with CAP who had positive microbiological tests than in those with non positive results, and it did not adversely affect relevant clinical outcomes.
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Affiliation(s)
- Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Alexander Rombauts
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | | | | | - Carmen Ardanuy
- University of Barcelona; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Calatayud
- Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Niubó
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain
| | | | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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11
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Pacios E. Antibiotic stewardship in the real world. THE LANCET. INFECTIOUS DISEASES 2022; 22:448-449. [PMID: 35338866 DOI: 10.1016/s1473-3099(22)00147-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/17/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Enrique Pacios
- Internal Medicine Department, Santa Cristina University Hospital, Madrid 28009, Spain.
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12
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van Heijl I, Schweitzer VA, van der Linden PD, van Werkhoven CH, Bonten MJM. Antibiotic stewardship in the real world - Authors' reply. THE LANCET. INFECTIOUS DISEASES 2022; 22:449. [PMID: 35338867 DOI: 10.1016/s1473-3099(22)00145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Inger van Heijl
- Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands; Department of Clinical Pharmacy, Tergooi Hospital, Hilversum, Netherlands
| | - Valentijn A Schweitzer
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, Netherlands.
| | | | | | - Marc J M Bonten
- Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, Netherlands
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