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Cannon CA, Menza TW, Reid TB, Lieberman NAP, Giacani L, Greninger AL. Comment on Callado et al: "Syphilis Treatment: Systematic Review and Meta-analysis Investigating Nonpenicillin Therapeutic Strategies". Open Forum Infect Dis 2024; 11:ofae324. [PMID: 38957685 PMCID: PMC11218762 DOI: 10.1093/ofid/ofae324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 07/04/2024] Open
Affiliation(s)
- Chase A Cannon
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Tim W Menza
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STI/HCV Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Tara B Reid
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nicole A P Lieberman
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Lorenzo Giacani
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Hixon AM, Micek S, Fraser VJ, Kollef M, Guillamet MCV. Impact of Gram-Negative Bacilli Resistance Rates on Risk of Death in Septic Shock and Pneumonia. Open Forum Infect Dis 2024; 11:ofae219. [PMID: 38770211 PMCID: PMC11103621 DOI: 10.1093/ofid/ofae219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/22/2024] Open
Abstract
Background Sepsis is a major cause of morbidity and mortality worldwide. When selecting empiric antibiotics for sepsis, clinicians are encouraged to use local resistance rates, but their impact on individual outcomes is unknown. Improved methods to predict outcomes are needed to optimize treatment selection and improve antibiotic stewardship. Methods We expanded on a previously developed theoretical model to estimate the excess risk of death in gram-negative bacilli (GNB) sepsis due to discordant antibiotics using 3 factors: the prevalence of GNB in sepsis, the rate of antibiotic resistance in GNB, and the mortality difference between discordant and concordant antibiotic treatments. We focused on ceftriaxone, cefepime, and meropenem as the anti-GNB treatment backbone in sepsis, pneumonia, and urinary tract infections. We analyzed both publicly available data and data from a large urban hospital. Results Publicly available data were weighted toward culture-positive cases. Excess risk of death with discordant antibiotics was highest in septic shock and pneumonia. In septic shock, excess risk of death was 4.53% (95% confidence interval [CI], 4.04%-5.01%), 0.6% (95% CI, .55%-.66%), and 0.19% (95% CI, .16%-.21%) when considering resistance to ceftriaxone, cefepime, and meropenem, respectively. Results were similar in pneumonia. Local data, which included culture-negative cases, showed an excess risk of death in septic shock of 0.75% (95% CI, .57%-.93%) for treatment with discordant antibiotics in ceftriaxone-resistant infections and 0.18% (95% CI, .16%-.21%) for cefepime-resistant infections. Conclusions Estimating the excess risk of death for specific sepsis phenotypes in the context of local resistance rates, rather than relying on population resistance data, may be more informative in deciding empiric antibiotics in GNB infections.
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Affiliation(s)
- Alison M Hixon
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy Practice, St Louis College of Pharmacy, St Louis, Missouri, USA
| | - Victoria J Fraser
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - M Cristina Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
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Sarink MJ, Bode LGM, Croughs P, de Steenwinkel JEM, Verkaik NJ, van Westreenen M, Vogel M, Yusuf E. Less Is More: When to Repeat Antimicrobial Susceptibility Testing. J Clin Microbiol 2023; 61:e0046323. [PMID: 37436180 PMCID: PMC10446856 DOI: 10.1128/jcm.00463-23] [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: 04/15/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023] Open
Abstract
This study investigated the frequency of change of the antimicrobial susceptibility pattern when the same isolate was found in the same patient in various situations. We used laboratory data collected over a period of 8 years (January 2014 to December 2021) at the clinical microbiology laboratory of a tertiary hospital for Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., Pseudomonas aeruginosa, and Staphylococcus aureus. Antimicrobial susceptibility tests (AST) were performed using Vitek 2 automated system. We determined essential agreement and categorical agreement, and introduced the new terms essential MIC increase and change from nonresistant to resistant to present changes in antimicrobial susceptibility over time. During the study period, 18,501 successive AST were included. The risk for S. aureus to be resistant to any antibiotic upon repeated culture was <10% during a follow-up of 30 days. For Enterobacterales, this risk was approximately 10% during a follow-up of 7 days. For P. aeruginosa, this risk was higher. The longer the follow-up period, the higher the risk that the bacteria would show phenotypic resistance. We also found that some drug-bug combinations were more likely to develop phenotypical resistance (i.e., E. coli/amoxicillin-clavulanic acid and E. coli/cefuroxime). A potential consequence of our finding is that if we regard a risk of resistance below 10% as acceptable, it may be feasible to omit follow-up AST within 7 days for the microorganisms investigated in this study. This approach saves money, time, and will reduce laboratory waste. Further studies are needed to determine whether these savings are in balance with the small possibility of treating patients with inadequate antibiotics.
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Affiliation(s)
- Maarten J. Sarink
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lonneke G. M. Bode
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter Croughs
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurriaan E. M. de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nelianne J. Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mireille van Westreenen
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marius Vogel
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Erlangga Yusuf
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
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A Broad Learning System to Predict the 28-Day Mortality of Patients Hospitalized with Community-Acquired Pneumonia: A Case-Control Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7003272. [PMID: 35281948 PMCID: PMC8916852 DOI: 10.1155/2022/7003272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
Abstract
This study was to conduct a model based on the broad learning system (BLS) for predicting the 28-day mortality of patients hospitalized with community-acquired pneumonia (CAP). A total of 1,210 eligible CAP cases from Chifeng Municipal Hospital were finally included in this retrospective case-control study. Random forest (RF) and an eXtreme Gradient Boosting (XGB) models were used to develop the prediction models. The data features extracted from BLS are utilized in RF and XGB models to predict the 28-day mortality of CAP patients, which established two integrated models BLS-RF and BLS-XGB. Our results showed the integrated model BLS-XGB as an efficient broad learning system (BLS) for predicting the death risk of patients, which not only performed better than the two basic models but also performed better than the integrated model BLS-RF and two well-known deep learning systems-deep neural network (DNN) and convolutional neural network (CNN). In conclusion, BLS-XGB may be recommended as an efficient model for predicting the 28-day mortality of CAP patients after hospital admission.
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Parra-Rodriguez L, Guillamet MCV. Antibiotic Decision-Making in the ICU. Semin Respir Crit Care Med 2022; 43:141-149. [PMID: 35172364 DOI: 10.1055/s-0041-1741014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
It is well established that Intensive Care Units (ICUs) are a focal point in antimicrobial consumption with a major influence on the ecological consequences of antibiotic use. With the high prevalence and mortality of infections in critically ill patients, and the clinical challenges of treating patients with septic shock, the impact of real life clinical decisions made by intensivists becomes more significant. Both under- and over-treatment with unnecessarily broad spectrum antibiotics can lead to detrimental outcomes. Even though substantial progress has been made in developing rapid diagnostic tests that can help guide antibiotic use, there is still a time window when clinicians must decide the empiric antibiotic treatment with insufficient clinical data. The continuous streams of data available in the ICU environment make antimicrobial optimization an ongoing challenge for clinicians but at the same time can serve as the input for sophisticated models. In this review, we summarize the evidence to help guide antibiotic decision-making in the ICU. We focus on 1) deciding IF: to start antibiotics, 2) choosing the spectrum of the empiric agents to use, and 3) de-escalating the chosen empiric antibiotics. We provide a perspective on the role of machine learning and artificial intelligence models for clinical decision support systems that can be incorporated seamlessly into clinical practice in order to improve the antibiotic selection process and, more importantly, current and future patients' outcomes.
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Affiliation(s)
- Luis Parra-Rodriguez
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - M Cristina Vazquez Guillamet
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Auzin A, Spits M, Tacconelli E, Rodríguez-Baño J, Hulscher M, Adang E, Voss A, Wertheim H. What is the evidence base of used aggregated antibiotic resistance percentages to change empiric antibiotic treatment? A scoping review. Clin Microbiol Infect 2021; 28:928-935. [PMID: 34906718 DOI: 10.1016/j.cmi.2021.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/08/2021] [Accepted: 12/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotic resistance requires continuous monitoring by experts to decide whether empiric antibiotic therapies (EAT) should be replaced by alternative antibiotics. The exact moment and criteria for this change is unclear and generally based on consensus between experts. OBJECTIVES This scoping review aims to identify from the literature the resistance thresholds used for a change in EAT and the criteria that they are based upon. METHODS Scoping review for which a comprehensive structured literature search was conducted. Rayyan, software for systematic reviews, was used for the screening of abstracts and titles. DATA SOURCES Pubmed and hand-searching of reference lists and grey literature. ELIGIBILITY Papers concerning any type of bacterial infectious disease and mentioning or defining antibiotic resistance thresholds for decision making purposes for EAT were included. The inclusion and analysis of articles was done by two researchers, any conflicts were resolved through discussion or by consulting a third reviewer. RESULTS We identified 3146 unique papers. Following title-abstract screening, 125 papers were comprehensively read, 16 papers included. The included papers gave thresholds for urinary tract infections, respiratory tract infections, meningitis, skin and soft tissue infections, gonorrhoea and bone and joint infections. Six criteria were found that were commonly used to base the thresholds on. These were: disease severity, efficacy of treatment, adverse drug events, risk of C. difficile infection, costs and increased resistance. The number of criteria used to define each threshold varied from 1 up to 6 criteria between papers. CONCLUSIONS The thresholds used for EATs are few, commonly based on expert opinion estimates and therefore can have broad ranges. Used criteria underlying reported thresholds are heterogenous and require standardization. Considering the rising trend in resistance there is a clear need for rigid tools to determine thresholds in order to support guideline development with the best and timely evidence.
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Affiliation(s)
- Ali Auzin
- Radboud university medical centre, Nijmegen, The Netherlands.
| | | | | | - José Rodríguez-Baño
- Infectious Diseases and Microbiology, Hospital Universitario Virgen Macarena and Medicine Department, University of Seville / Biomedicine Institute of Seville, Spain
| | - Marlies Hulscher
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud university medical centre, Nijmegen, The Netherlands
| | - Eddy Adang
- Radboud university medical centre, Nijmegen, The Netherlands
| | - Andreas Voss
- Canisius Wilhelmina Ziekenhuis (CWZ), Nijmegen, The Netherlands
| | - Heiman Wertheim
- Radboud university medical centre, Nijmegen, The Netherlands
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Lambregts M, Rump B, Ropers F, Sijbom M, Petrignani M, Visser L, de Vries M, de Boer M. Antimicrobial guidelines in clinical practice: incorporating the ethical perspective. JAC Antimicrob Resist 2021; 3:dlab074. [PMID: 34235435 PMCID: PMC8254525 DOI: 10.1093/jacamr/dlab074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/23/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Guidelines on antimicrobial therapy are subject to periodic revision to anticipate changes in the epidemiology of antimicrobial resistance and new scientific knowledge. Changing a policy to a broader spectrum has important consequences on both the individual patient level (e.g. effectiveness, toxicity) and population level (e.g. emerging resistance, costs). By combining both clinical data evaluation and an ethical analysis, we aim to propose a comprehensive framework to guide antibiotic policy dilemmas. Methods A preliminary framework for decision-making on antimicrobial policy was constructed based on existing literature and panel discussions. Antibiotic policy themes were translated into specific elements that were fitted into this framework. The adapted framework was evaluated in two moral deliberation groups. The moral deliberation sessions were analysed using ATLAS.ti statistical software to categorize arguments and evaluate completeness of the final framework. Results The final framework outlines the process of data evaluation, ethical deliberation and decision-making. The first phase is a factual data exploration. In the second phase, perspectives are weighed and the policy of moral preference is formulated. Judgments are made on three levels: the individual patient, the patient population and society. In the final phase, feasibility, implementation and re-evaluation are addressed. Conclusions The proposed framework facilitates decision-making on antibiotic policy by structuring existing data, identifying knowledge gaps, explicating ethical considerations and balancing interests of the individual and current and future generations.
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Affiliation(s)
- Merel Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Babette Rump
- National Institute of Public Health and the Environment, Centre for Infectious Diseases Control (RIVM-LCI), Antonie van Leeuwenhoeklaan 9, 3721MA, Bilthoven, The Netherlands
| | - Fabienne Ropers
- Department of Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Martijn Sijbom
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Mariska Petrignani
- Department of Infectious Diseases, Haaglanden Municipal Health Service, Westeinde 128, 2512HE Den Haag, The Netherlands
| | - Leo Visser
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Martine de Vries
- Leiden University Medical Center, Department of Medical Ethics and Law, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Mark de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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Should the Absence of Urinary Nitrite Influence Empiric Antibiotics for Urinary Tract Infection in Young Children? Pediatr Emerg Care 2020; 36:481-485. [PMID: 29135902 DOI: 10.1097/pec.0000000000001344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Screening for urinary tract infection (UTI) includes urinary nitrite testing by dipstick urinalysis. Gram-negative enteric organisms produce urinary nitrite and represent the most common uropathogens. Enterococcus, a less common uropathogen, does not produce nitrite and has a unique antibiotic resistance pattern. Whether to adjust empiric antibiotics in the absence of urinary nitrite has not been established. Our primary objective was to determine prevalence of enterococcal UTI among young children with a nitrite negative urinalysis. METHODS A retrospective study of children aged less than 2 years evaluated in the emergency department for possible UTI and had a paired urinalysis and urine culture was performed. Urinary tract infection was defined by catheterized culture yielding greater than or equal to 50,000 colony-forming units per milliliter of a single uropathogen. Prevalence of uropathogens among nitrite negative samples was studied. RESULTS A total of 7599 children were studied. Median (interquartile range) age was 5.6 (2.3-11.2) months, and 57% were female. Prevalence of UTI was 8.1%. Enterococcus was the uropathogen in 2.1% of UTIs, and all cases had negative dipstick nitrite. Among nitrite negative UTIs, 95.6% of uropathogens were gram-negative and only 3.2% (confidence interval, 1.8%-5.3%) were enterococcus. None of the 200 UTIs with positive nitrite yielded enterococcus (upper confidence interval, 1.4%). Among children with positive leukocyte esterase and negative nitrite, only 0.7% of cases had enterococcal UTI. CONCLUSIONS Only 3% of nitrite negative UTIs were caused by enterococcus. Given the low prevalence of enterococcal UTI, the absence of dipstick nitrite should not affect routine empiric antibiotic choice for presumptive UTI in young children.
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Tornheim JA, Intini E, Gupta A, Udwadia ZF. Clinical features associated with linezolid resistance among multidrug resistant tuberculosis patients at a tertiary care hospital in Mumbai, India. J Clin Tuberc Other Mycobact Dis 2020; 20:100175. [PMID: 32775702 PMCID: PMC7398971 DOI: 10.1016/j.jctube.2020.100175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Multidrug-resistant tuberculosis (MDR-TB) is an increasing problem worldwide, and 24% occurs in India. Linezolid is associated with improved MDR-TB treatment outcomes but causes significant side-effects and drug susceptibility testing (DST) is rarely available. This study assessed whether clinical factors could predict linezolid resistance. Methods An observational cohort of adults and adolescents with MDR-TB at a tertiary care hospital in Mumbai, India was analyzed for clinical, laboratory, and radiographic findings associated with linezolid resistance. Results In total, 343 MDR-TB patients had linezolid DST performed, and 23 (6.7%) had linezolid-resistant MDR-TB. Univariable analysis associated linezolid resistance with underweight (odds ratio (OR)–1.07, 95% confidence interval (CI):1.01–1.12); number of previous providers (OR:1.03, 95% CI:1.00–1.05); previous treatment with linezolid (OR:1.12, 95% CI:1.06–1.05), bedaquiline (OR:1.55, 95% CI:1.22–1.98), or clofazimine (OR:1.08 95% CI:1.03–1.16); cavitary disease (OR:1.10, 95% CI:1.04–1.16) and percent lung involvement (OR:1.02, 95% CI:1.01–1.03) on radiograph. DST associated linezolid resistance with resistance to fluoroquinolones (OR:1.08, 95% CI:1.01–1.14), injectables (OR:1.09, 95% CI:1.03–1.15), ethionamide (OR:1.09, 95% CI:1.03–1.15), and PAS (OR:1.13, 95% CI:1.06–1.21). In multivariate analysis, only prior linezolid and percent lung involvement were associated with linezolid resistance. Conclusion To maximize treatment benefits while minimizing toxicity, DST remains an important tool to identify linezolid resistance.
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Affiliation(s)
- J A Tornheim
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Intini
- Division of Respiratory Medicine, A. Gemelli University Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - A Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Z F Udwadia
- Department of Respiratory Medicine, P.D. Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 275] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 478] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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12
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Vazquez Guillamet MC, Vazquez R, Micek ST, Kollef MH. Reply to MacFadden et al. Clin Infect Dis 2019; 66:479-480. [PMID: 29020211 DOI: 10.1093/cid/cix776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Rodrigo Vazquez
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico, Albuquerque
| | - Scott T Micek
- Department of Pharmacy Practice, St Louis College of Pharmacy, St Louis, Missouri
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
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13
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Littmann J, Rid A, Buyx A. Tackling anti-microbial resistance: ethical framework for rational antibiotic use. Eur J Public Health 2019; 28:359-363. [PMID: 29036540 DOI: 10.1093/eurpub/ckx165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background To reduce the effect of antimicrobial resistance and to preserve antibiotic effectiveness, clinical guidelines and health policy documents call for the rational use of antibiotics, which aims to reduce unnecessary or minimally effective antibiotic use. Methods Through ethical analysis, we show that rational use programmes can lead to ethical conflicts, because they sometimes place patients at risk of harm-for example, a delayed switch to second-line antibiotics for community-acquired pneumonia can lead to substantial increases in mortality. Results Implementing the rational use of antibiotics can lead to conflicts between promoting patients' clinical interests and preserving antibiotic effectiveness for future use. The resulting ethical dilemma for clinicians, patients and policy makers has so far not been adequately addressed. Conclusions Existing guidance for acceptable risks in clinical research can help to define risk thresholds for the rational use of antibiotics. We develop an ethical framework that allows clinicians and policy-makers to evaluate policies for rational antibiotic use in six practical steps. This framework can help guide clinical practice and health policy.
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Affiliation(s)
| | - Annette Rid
- Department of Global Health and Social Medicine, King's College London, Strand, London, UK
| | - Alena Buyx
- Division of Bioethics, Institute of Experimental Medicine, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
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14
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Wagenlehner FME, Diemer T. Re: Acute Pyelonephritis in Adults. Eur Urol 2018; 74:676. [PMID: 30037528 DOI: 10.1016/j.eururo.2018.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/10/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Florian M E Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig University, Giessen, Germany.
| | - Thorsten Diemer
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig University, Giessen, Germany
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15
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Littmann J, Buyx A. [Rational use of antibiotics as an ethical challenge]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018. [PMID: 29536111 DOI: 10.1007/s00103-018-2716-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Antibiotics resistance presents one of the major challenges for health care in the twenty-first century. This paper examines the ethical problems that arise as a result of antibiotic resistance. Two main categories of ethical problems in infectious disease control are distinguished: those that are exacerbated by antibiotics resistance, and those that are a direct result of antibiotics resistance. The second category, which is considered in greater detail in this paper, includes, among others, issues of fair distribution of effective antibiotics, if they are considered a scarce resource. Of particular interest in this context is the concept of the rational use of antibiotics, which can have different ethical implications depending on its definition: either merely the elimination of antibiotics use that is not medically indicated, or a further limitation of antibiotics use to exclude treatment that only generates small benefits. The paper examines how a more far-reaching limitation can be justified with the aid of an analogy from the field of research ethics, and finally makes concrete suggestions of ways in which normative decisions can be taken into consideration in the prescription process for antibiotics.
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Affiliation(s)
- Jasper Littmann
- Robert Koch-Institut, Nordufer 20, 13553, Berlin, Deutschland.
| | - Alena Buyx
- Institut für Experimentelle Medizin, Christian-Albrechts-Universität zu Kiel, UKSH, Kiel, Deutschland
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16
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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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17
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Nielsen KM, Bøhn T, Townsend JP. Detecting rare gene transfer events in bacterial populations. Front Microbiol 2014; 4:415. [PMID: 24432015 PMCID: PMC3882822 DOI: 10.3389/fmicb.2013.00415] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/16/2013] [Indexed: 11/23/2022] Open
Abstract
Horizontal gene transfer (HGT) enables bacteria to access, share, and recombine genetic variation, resulting in genetic diversity that cannot be obtained through mutational processes alone. In most cases, the observation of evolutionary successful HGT events relies on the outcome of initially rare events that lead to novel functions in the new host, and that exhibit a positive effect on host fitness. Conversely, the large majority of HGT events occurring in bacterial populations will go undetected due to lack of replication success of transformants. Moreover, other HGT events that would be highly beneficial to new hosts can fail to ensue due to lack of physical proximity to the donor organism, lack of a suitable gene transfer mechanism, genetic compatibility, and stochasticity in tempo-spatial occurrence. Experimental attempts to detect HGT events in bacterial populations have typically focused on the transformed cells or their immediate offspring. However, rare HGT events occurring in large and structured populations are unlikely to reach relative population sizes that will allow their immediate identification; the exception being the unusually strong positive selection conferred by antibiotics. Most HGT events are not expected to alter the likelihood of host survival to such an extreme extent, and will confer only minor changes in host fitness. Due to the large population sizes of bacteria and the time scales involved, the process and outcome of HGT are often not amenable to experimental investigation. Population genetic modeling of the growth dynamics of bacteria with differing HGT rates and resulting fitness changes is therefore necessary to guide sampling design and predict realistic time frames for detection of HGT, as it occurs in laboratory or natural settings. Here we review the key population genetic parameters, consider their complexity and highlight knowledge gaps for further research.
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Affiliation(s)
- Kaare M Nielsen
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø Tromsø, Norway ; GenØk-Centre for Biosafety, The Science Park Tromsø, Norway
| | - Thomas Bøhn
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø Tromsø, Norway ; GenØk-Centre for Biosafety, The Science Park Tromsø, Norway
| | - Jeffrey P Townsend
- Department of Biostatistics, Yale University New Haven, CT, USA ; Program in Computational Biology and Bioinformatics, Yale University New Haven, CT, USA ; Program in Microbiology, Yale University New Haven, CT, USA
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18
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Low DE. What is the relevance of antimicrobial resistance on the outcome of community-acquired pneumonia caused by Streptococcus pneumoniae? (should macrolide monotherapy be used for mild pneumonia?). Infect Dis Clin North Am 2013; 27:87-97. [PMID: 23398867 DOI: 10.1016/j.idc.2012.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Multidrug-resistant pneumococci continue to increase worldwide. Although there are still questions regarding the relevance of β-lactam resistance, the recommendation for the use of the macrolides as monotherapy for mild community-acquired pneumonia should be revisited in view of high rates of resistance, the association of clinical failures with low-level and high-level resistance, and the lack of clinical data to support their need for empirical therapy for the atypicals.
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Affiliation(s)
- Donald E Low
- Department of Microbiology, Mount Sinai Hospital/University Health Network and University of Toronto, Toronto, Ontario, Canada.
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19
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Yezli S, Shibl AM, Livermore DM, Memish ZA. Antimicrobial resistance among Gram-positive pathogens in Saudi Arabia. J Chemother 2012; 24:125-36. [PMID: 22759756 DOI: 10.1179/1973947812y.0000000010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Several species of Gram-positive cocci are major nosocomial or community pathogens associated with morbidity and mortality. Here, we review the antimicrobial resistance among these pathogens in Saudi Arabia. In the last decades, antimicrobial resistance has increased among Staphylococcus aureus in the Kingdom with a growing prevalence of both nosocomial and community methicillin-resistant S. aureus (MRSA) isolates. As yet, no vancomycin-resistant MRSA have been reported, although isolates with reduced susceptibility to the drug have been noted. Currently, the prevalence of vancomycin-resistant entrococci (VRE) is low; however, VRE has been described in the Kingdom as well as Enterococcus faecalis and E. faecium isolates with high-level resistance to penicillin, sulfamethoxazole, macrolides, tetracycline, and aminoglycosides. In recent decades, the prevalence and rate of penicillin resistance and non-susceptibility among Streptococcus pneumoniae isolates have increased in Saudi Arabia. The organism remains, however, susceptible to other beta-lactams and to quinolones. On the other hand, resistance to co-trimoxazole and tetracyclines is high and resistance to macrolides is on the increase.
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20
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Valery PC, Morris PS, Grimwood K, Torzillo PJ, Byrnes CA, Masters IB, Bauert PA, McCallum GB, Mobberly C, Chang AB. Azithromycin for Indigenous children with bronchiectasis: study protocol for a multi-centre randomized controlled trial. BMC Pediatr 2012; 12:122. [PMID: 22891748 PMCID: PMC3445847 DOI: 10.1186/1471-2431-12-122] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/30/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The prevalence of chronic suppurative lung disease (CSLD) and bronchiectasis unrelated to cystic fibrosis (CF) among Indigenous children in Australia, New Zealand and Alaska is very high. Antibiotics are a major component of treatment and are used both on a short or long-term basis. One aim of long-term or maintenance antibiotics is to reduce the frequency of acute pulmonary exacerbations and symptoms. However, there are few studies investigating the efficacy of long-term antibiotic use for CSLD and non-CF bronchiectasis among children. This study tests the hypothesis that azithromycin administered once a week as maintenance antibiotic treatment will reduce the rate of pulmonary exacerbations in Indigenous children with bronchiectasis. METHODS/DESIGN We are conducting a multicentre, randomised, double-blind, placebo controlled clinical trial in Australia and New Zealand. Inclusion criteria are: Aboriginal, Torres Strait Islander, Maori or Pacific Island children aged 1 to 8 years, diagnosed with bronchiectasis (or probable bronchiectasis) with no underlying disease identified (such as CF or primary immunodeficiency), and having had at least one episode of pulmonary exacerbation in the last 12 months. After informed consent, children are randomised to receive either azithromycin (30 mg/kg once a week) or placebo (once a week) for 12-24 months from study entry. Primary outcomes are the rate of pulmonary exacerbations and time to pulmonary exacerbation determined by review of patient medical records. Secondary outcomes include length and severity of pulmonary exacerbation episodes, changes in growth, school loss, respiratory symptoms, forced expiratory volume in 1-second (FEV(1); for children ≥6 years), and sputum characteristics. Safety endpoints include serious adverse events. Antibiotic resistance in respiratory bacterial pathogens colonising the nasopharynx is monitored. Data derived from medical records and clinical assessments every 3 to 4 months for up to 24 months from study entry are recorded on standardised forms. DISCUSSION Should this trial demonstrate that azithromycin is efficacious in reducing the number of pulmonary exacerbations, it will provide a much-needed rationale for the use of long-term antibiotics in the medical management of bronchiectasis in Indigenous children. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12610000383066.
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Affiliation(s)
- Patricia C Valery
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Peter S Morris
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Darwin, NT, Australia
| | - Keith Grimwood
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Queensland Paediatric Infectious Diseases Laboratory, Royal Children’s Hospital, Brisbane, QLD, Australia
| | - Paul J Torzillo
- Royal Prince Alfred Hospital, and University of Sydney, Sydney, Australia
| | - Catherine A Byrnes
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
- Paediatric Respiratory Medicine, Starship Children’s Health, Auckland, New Zealand
| | - I Brent Masters
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Queensland Children’s Respiratory Centre, Royal Children’s Hospital, Brisbane, QLD, Australia
| | - Paul A Bauert
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Darwin, NT, Australia
| | - Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Charmaine Mobberly
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
- Paediatric Respiratory Medicine, Starship Children’s Health, Auckland, New Zealand
| | - Anne B Chang
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Queensland Children’s Respiratory Centre, Royal Children’s Hospital, Brisbane, QLD, Australia
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21
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Dalhoff A. Resistance surveillance studies: a multifaceted problem--the fluoroquinolone example. Infection 2012; 40:239-62. [PMID: 22460782 DOI: 10.1007/s15010-012-0257-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 03/09/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This review summarizes data on the fluoroquinolone resistance epidemiology published in the previous 5 years. MATERIALS AND METHODS The data reviewed are stratified according to the different prescription patterns by either primary- or tertiary-care givers and by indication. Global surveillance studies demonstrate that fluoroquinolone- resistance rates increased in the past several years in almost all bacterial species except Staphylococcus pneumoniae and Haemophilus influenzae causing community-acquired respiratory tract infections (CARTIs), as well as Enterobacteriaceae causing community-acquired urinary tract infections. Geographically and quantitatively varying fluoroquinolone resistance rates were recorded among Gram-positive and Gram-negative pathogens causing healthcare-associated respiratory tract infections. One- to two-thirds of Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) were fluoroquinolone resistant too, thus, limiting the fluoroquinolone use in the treatment of community- as well as healthcare-acquired urinary tract and intra-abdominal infections. The remaining ESBL-producing or plasmid-mediated quinolone resistance mechanisms harboring Enterobacteriaceae were low-level quinolone resistant. Furthermore, 10-30 % of H. influenzae and S. pneumoniae causing CARTIs harbored first-step quinolone resistance determining region (QRDR) mutations. These mutants pass susceptibility testing unnoticed and are primed to acquire high-level fluoroquinolone resistance rapidly, thus, putting the patient at risk. The continued increase in fluoroquinolone resistance affects patient management and necessitates changes in some current guidelines for the treatment of intra-abdominal infections or even precludes the use of fluoroquinolones in certain indications like gonorrhea and pelvic inflammatory diseases in those geographic areas in which fluoroquinolone resistance rates and/or ESBL production is high. Fluoroquinolone resistance has been selected among the commensal flora colonizing the gut, nose, oropharynx, and skin, so that horizontal gene transfer between the commensal flora and the offending pathogen as well as inter- and intraspecies recombinations contribute to the emergence and spread of fluoroquinolone resistance among pathogenic streptococci. Although interspecies recombinations are not yet the major cause for the emergence of fluoroquinolone resistance, its existence indicates that a large reservoir of fluoroquinolone resistance exists. Thus, a scenario resembling that of a worldwide spread of β-lactam resistance in pneumococci is conceivable. However, many resistance surveillance studies suffer from inaccuracies like the sampling of a selected patient population, restricted geographical sampling, and undefined requirements of the user, so that the results are biased. The number of national centers is most often limited with one to two participating laboratories, so that such studies are point prevalence but not surveillance studies. Selected samples are analyzed predominantly as either hospitalized patients or patients at risk or those in whom therapy failed are sampled; however, fluoroquinolones are most frequently prescribed by the general practitioner. Selected sampling results in a significant over-estimation of fluoroquinolone resistance in outpatients. Furthermore, the requirements of the users are often not met; the prescribing physician, the microbiologist, the infection control specialist, public health and regulatory authorities, and the pharmaceutical industry have diverse interests, which, however, are not addressed by different designs of a surveillance study. Tools should be developed to provide customer-specific datasets. CONCLUSION Consequently, most surveillance studies suffer from well recognized but uncorrected biases or inaccuracies. Nevertheless, they provide important information that allows the identification of trends in pathogen incidence and antimicrobial resistance.
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Affiliation(s)
- A Dalhoff
- Institute for Infection-Medicine, Christian-Albrechts University of Kiel and University Medical Center Schleswig-Holstein, Brunswiker Str. 4, 24105, Kiel, Germany.
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Townsend JP, Bøhn T, Nielsen KM. Assessing the probability of detection of horizontal gene transfer events in bacterial populations. Front Microbiol 2012; 3:27. [PMID: 22363321 PMCID: PMC3282476 DOI: 10.3389/fmicb.2012.00027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 01/16/2012] [Indexed: 11/23/2022] Open
Abstract
Experimental approaches to identify horizontal gene transfer (HGT) events of non-mobile DNA in bacteria have typically relied on detection of the initial transformants or their immediate offspring. However, rare HGT events occurring in large and structured populations are unlikely to be detected in a short time frame. Population genetic modeling of the growth dynamics of bacterial genotypes is therefore necessary to account for natural selection and genetic drift during the time lag and to predict realistic time frames for detection with a given sampling design. Here we draw on statistical approaches to population genetic theory to construct a cohesive probabilistic framework for investigation of HGT of exogenous DNA into bacteria. In particular, the stochastic timing of rare HGT events is accounted for. Integrating over all possible event timings, we provide an equation for the probability of detection, given that HGT actually occurred. Furthermore, we identify the key variables determining the probability of detecting HGT events in four different case scenarios that are representative of bacterial populations in various environments. Our theoretical analysis provides insight into the temporal aspects of dissemination of genetic material, such as antibiotic resistance genes or transgenes present in genetically modified organisms. Due to the long time scales involved and the exponential growth of bacteria with differing fitness, quantitative analyses incorporating bacterial generation time, and levels of selection, such as the one presented here, will be a necessary component of any future experimental design and analysis of HGT as it occurs in natural settings.
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Affiliation(s)
- Jeffrey P Townsend
- Department of Ecology and Evolutionary Biology, Yale University New Haven, CT, USA
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Integrated Multilevel Surveillance of the World's Infecting Microbes and Their Resistance to Antimicrobial Agents. Clin Microbiol Rev 2011; 24:281-95. [PMID: 21482726 DOI: 10.1128/cmr.00021-10] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Microbial surveillance systems have varied in their source of support; type of laboratory reporting (patient care or reference); inclusiveness of reports filed; extent of microbial typing; whether single hospital, multihospital, or multicountry; proportion of total medical centers participating; and types, levels, integration across levels, and automation of analyses performed. These surveillance systems variably support the diagnosis and treatment of patients, local or regional infection control, local or national policies and guidelines, laboratory capacity building, sentinel surveillance, and patient safety. Overall, however, only a small fraction of available data are under any surveillance, and very few data are fully integrated and analyzed. Advancing informatics and genomics can make microbial surveillance far more efficient and effective at preventing infections and improving their outcomes. The world's microbiology laboratories should upload their reports each day to programs that detect events, trends, and epidemics in communities, hospitals, countries, and the world.
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Falcó V, Sánchez A, Pahissa A, Rello J. Emerging drugs for pneumococcal pneumonia. Expert Opin Emerg Drugs 2011; 16:459-77. [DOI: 10.1517/14728214.2011.576669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Soriano F, Giménez MJ, Aguilar L. Cefditoren in upper and lower community-acquired respiratory tract infections. Drug Des Devel Ther 2011; 5:85-94. [PMID: 21340042 PMCID: PMC3038999 DOI: 10.2147/dddt.s9499] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Indexed: 11/23/2022] Open
Abstract
This article reviews and updates published data on cefditoren in the evolving scenario of resistance among the most prevalent isolates from respiratory tract infections in the community (Streptococcus pyogenes, Haemophilus influenzae, and Streptococcus pneumoniae). By relating the in vitro activity of cefditoren (in national and multinational surveillance and against isolates with emerging resistant genotypes/phenotypes) to its pharmacokinetics, the cefditoren pharmacodynamic activity predicting efficacy (in humans, animal models, and in vitro simulations) is analyzed prior to reviewing clinical studies (tonsillopharyngitis, sinusitis, acute exacerbations of chronic bronchitis, and community-acquired pneumonia) and the relationship between bacterial eradication and clinical efficacy. The high in vitro activity of cefditoren against the most prevalent respiratory isolates in the community, together with its pharmacokinetics (enabling a twice daily regimen) leading to adequate pharmacodynamic indexes covering all S. pyogenes, H. influenzae, and at least 95% S. pneumoniae isolates, makes cefditoren an antibiotic that will play a significant role in the treatment of respiratory tract infections in the community. In the clinical setting, studies carried out with cefditoren showed that treatments with the 400 mg twice daily regimen were associated with high rates of bacteriological response, even against penicillin-nonsusceptible S. pneumoniae, with good correlation between bacteriological efficacy/response and clinical outcome.
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Jones RN, Jacobs MR, Sader HS. Evolving trends in Streptococcus pneumoniae resistance: implications for therapy of community-acquired bacterial pneumonia. Int J Antimicrob Agents 2010; 36:197-204. [PMID: 20558045 DOI: 10.1016/j.ijantimicag.2010.04.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 04/07/2010] [Accepted: 04/08/2010] [Indexed: 10/19/2022]
Abstract
Pneumonia is a major infectious disease associated with significant morbidity, mortality and utilisation of healthcare resources. Streptococcus pneumoniae is the predominant pathogen in community-acquired pneumonia (CAP), accounting for 20-60% of bacterial cases. Emergence of multidrug-resistant S. pneumoniae has become a significant problem in the management of CAP. Although pneumococcal conjugate vaccine usage in children has led to significant decreases in morbidity and mortality due to S. pneumoniae in all age groups, disease management has been further complicated by the unexpected increase in resistant serotypes, such as 19A, in some regions. Until rapid and accurate diagnostic tests become available, initial treatment of CAP will remain empirical. Thus, selection of appropriate antimicrobial therapy for CAP must be based on prediction of the most likely pathogens and their local antimicrobial susceptibility patterns. This article reviews information on antimicrobial resistance patterns amongst S. pneumoniae and implications for managing CAP.
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Affiliation(s)
- Ronald N Jones
- JMI Laboratories, 345 Beaver Kreek Centre, Ste A, North Liberty, IA 52317, USA.
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Human antimicrobial peptide LL-37 induces MefE/Mel-mediated macrolide resistance in Streptococcus pneumoniae. Antimicrob Agents Chemother 2010; 54:3516-9. [PMID: 20498319 DOI: 10.1128/aac.01756-09] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Macrolide resistance is a major concern in the treatment of Streptococcus pneumoniae. Inducible macrolide resistance in this pneumococcus is mediated by the efflux pump MefE/Mel. We show here that the human antimicrobial peptide LL-37 induces the mefE promoter and confers resistance to erythromycin and LL-37. Such induction may impact the efficacy of host defenses and of macrolide-based treatment of pneumococcal disease.
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Ho PL, Cheng VCC, Chu CM. Antibiotic Resistance in Community-Acquired Pneumonia Caused by Streptococcus pneumoniae , Methicillin-Resistant Staphylococcus aureus , and Acinetobacter baumannii. Chest 2009; 136:1119-1127. [DOI: 10.1378/chest.09-0285] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hersh AL, Weintrub PS, Cabana MD. Antibiotic selection for purulent skin and soft-tissue infections in ambulatory care: a decision-analytic approach. Acad Pediatr 2009; 9:179-84. [PMID: 19450778 PMCID: PMC4394390 DOI: 10.1016/j.acap.2009.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 02/03/2009] [Accepted: 02/05/2009] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused a nationwide epidemic of skin and soft-tissue infections in ambulatory pediatrics. Antibiotic treatment recommendations suggest incorporating local epidemiology for the prevalence of CA-MRSA. We sought to identify the antibiotic strategy with the highest probability of activity and to identify threshold values for epidemiologic variables including bacterial prevalence and antibiotic resistance. METHODS We used decision analysis to evaluate 3 empiric antibiotic strategies: clindamycin, trimethoprim/sulfamethoxazole (T/S), and cephalexin. We calculated the probability of activity against the bacteria causing the infection (CA-MRSA, methicillin-sensitive S. aureus and group A Streptococcus [GAS]) by incorporating estimates of prevalence and antibiotic resistance to determine the optimal strategy. Sensitivity analysis was used to identify thresholds for prevalence and antibiotic resistance where 2 strategies were equal. RESULTS Clindamycin (0.95) and T/S (0.89) had substantially higher probability of activity than cephalexin (0.28) using baseline estimates for bacterial prevalence and antibiotic resistance. Cephalexin was the optimal antibiotic only when CA-MRSA prevalence was <10%. The probability of activity for clindamycin and T/S was highly sensitive to changes in the values for bacterial prevalence (both CA-MRSA and GAS) and CA-MRSA resistance to clindamycin. CONCLUSIONS Empiric treatment of skin and soft-tissue infections with either clindamycin or T/S maximizes the probability that the antibiotic will be active when CA-MRSA prevalence is >10%. Deciding between T/S and clindamycin requires consideration of antibiotic resistance and prevalence of GAS. This model can be customized to local communities and illustrates the importance of ongoing epidemiologic surveillance in primary care settings.
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Affiliation(s)
- Adam L. Hersh
- Division of Pediatric Infectious Diseases, University of California, San Francisco,Division of General Pediatrics, University of California, San Francisco
| | - Peggy S. Weintrub
- Division of Pediatric Infectious Diseases, University of California, San Francisco
| | - Michael D. Cabana
- Division of General Pediatrics, University of California, San Francisco
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File TM, Schentag JJ. What can we learn from the time course of untreated and partially treated community-onset Streptococcus pneumoniae pneumonia? A clinical perspective on superiority and noninferiority trial designs for mild community-acquired pneumonia. Clin Infect Dis 2008; 47 Suppl 3:S157-65. [PMID: 18986283 DOI: 10.1086/591398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
There are no well-designed placebo-controlled clinical trials in the recent era that precisely define the magnitude of the drug effect of antimicrobial therapy for mild community-acquired pneumonia (CAP). However, there is evidence that ineffective therapies, selected on the basis of the ratio of 24-h area under the concentration curve to minimum inhibitory concentration, associated with a discordant (nonsusceptible in vitro) specific agent (or no therapy) for mild CAP due to Streptococcus pneumoniae are associated with increased risk of progression to serious CAP. The relatively high rate of clinical success associated with appropriate antimicrobial treatment of mild CAP renders a standard outcome measure of clinical success an unlikely way to differentiate new agents. However, there may be an advantage in composite outcome assessments for mild CAP. Composite-outcomes end points that include time to resolution of morbidity, the use of patient reported-outcomes instruments, and biomarkers are recommended for future studies. Because the composite rate of success in recent randomized clinical trials exceeds 90%, it would seem that a noninferiority margin of 10% is reasonable for trials for mild CAP.
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Affiliation(s)
- Thomas M File
- Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, USA.
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Drug-Resistant Streptococcus pneumoniae for Community-Acquired Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2008. [DOI: 10.1097/ipc.0b013e31818db342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee B. Editorial Commentary:Digital Decision Making: Computer Models and Antibiotic Prescribing in the Twenty‐First Century. Clin Infect Dis 2008; 46:1139-41. [DOI: 10.1086/529441] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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