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Elsheikh R, Makram AM. Multidrug-Resistant Organisms: The Silent Plight of Burn Patients. J Burn Care Res 2024; 45:877-886. [PMID: 38695094 PMCID: PMC11303128 DOI: 10.1093/jbcr/irae075] [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: 02/27/2024] [Indexed: 07/20/2024]
Abstract
The global increasing spread of multidrug-resistant organisms (MDROs) is threatening the control of various infections in vulnerable populations and patient groups. One of the most affected groups is patients with burns, who are prone to hyperinfection as they suffer from a hypermetabolic state and weaken immune barriers. Those patients also share the infection risk of patients hospitalized for a long time, including ventilator-associated pneumonia and urinary tract infections. While some preventative and therapeutic management styles are still controversial, we discuss consensuses here. In this review, we aim to present the current knowledge on multidrug resistance with a special focus on patients with burns, discuss various causative organisms and their treatment options, and highlight the importance of antibiotic stewardship and teamwork in responding to an outbreak of MDROs.
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Affiliation(s)
- Randa Elsheikh
- Deanery of Biomedical Sciences at Edinburgh Medical School, University of Edinburgh, Edinburgh EH8 9YL, UK
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2
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Biney IN, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, Drummond MB, Johnson K, Kealing D, Kuehl PJ, Li J, Mahler DA, Martinez S, Ohar J, Radonovich LJ, Sood A, Suggett J, Tal-Singer R, Tashkin D, Yates J, Cambridge L, Dailey PA, Mannino DM, Dhand R. Guidance on Mitigating the Risk of Transmitting Respiratory Infections During Nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165:653-668. [PMID: 37977263 DOI: 10.1016/j.chest.2023.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Nebulizers are used commonly for inhaled drug delivery. Because they deliver medication through aerosol generation, clarification is needed on what constitutes safe aerosol delivery in infectious respiratory disease settings. The COVID-19 pandemic highlighted the importance of understanding the safety and potential risks of aerosol-generating procedures. However, evidence supporting the increased risk of disease transmission with nebulized treatments is inconclusive, and inconsistent guidelines and differing opinions have left uncertainty regarding their use. Many clinicians opt for alternative devices, but this practice could impact outcomes negatively, especially for patients who may not derive full treatment benefit from handheld inhalers. Therefore, it is prudent to develop strategies that can be used during nebulized treatment to minimize the emission of fugitive aerosols, these comprising bioaerosols exhaled by infected individuals and medical aerosols generated by the device that also may be contaminated. This is particularly relevant for patient care in the context of a highly transmissible virus. RESEARCH QUESTION How can potential risks of infections during nebulization be mitigated? STUDY DESIGN AND METHODS The COPD Foundation Nebulizer Consortium (CNC) was formed in 2020 to address uncertainties surrounding administration of nebulized medication. The CNC is an international, multidisciplinary collaboration of patient advocates, pulmonary physicians, critical care physicians, respiratory therapists, clinical scientists, and pharmacists from research centers, medical centers, professional societies, industry, and government agencies. The CNC developed this expert guidance to inform the safe use of nebulized therapies for patients and providers and to answer key questions surrounding medication delivery with nebulizers during pandemics or when exposure to common respiratory pathogens is anticipated. RESULTS CNC members reviewed literature and guidelines regarding nebulization and developed two sets of guidance statements: one for the health care setting and one for the home environment. INTERPRETATION Future studies need to explore the risk of disease transmission with fugitive aerosols associated with different nebulizer types in real patient care situations and to evaluate the effectiveness of mitigation strategies.
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Affiliation(s)
- Isaac N Biney
- University Pulmonary and Critical Care, The University of Tennessee Graduate School of Medicine, Knoxville, TN.
| | - Arzu Ari
- Department of Respiratory Care and Texas State Sleep Center, Texas State University, Round Rock, TX
| | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA; Division of Liver and Pancreas Transplantation, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | - Brian Carlin
- Sleep Medicine and Lung Health Consultants LLC, Pittsburgh, PA
| | - David C Christiani
- Harvard T.H. Chan School of Public Health, Harvard Medical School, Cambridge, MA; Pulmonary and Critical Care Division, Massachusetts General Hospital, Boston, MA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Jie Li
- Rush University, Chicago, IL
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH; Valley Regional Hospital, Claremont, NH
| | | | - Jill Ohar
- Bowman Gray Center for Medical Education, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Lewis J Radonovich
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | - Akshay Sood
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | | | | | - Donald Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles Health Sciences, Los Angeles, CA
| | | | - Lisa Cambridge
- Medical Science & Pharmaceutical Alliances, PARI, Inc., Midlothian, VA
| | | | | | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Tennessee Graduate School of Medicine, Knoxville, TN
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3
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Antimicrobial peptides for tackling cystic fibrosis related bacterial infections: a review. Microbiol Res 2022; 263:127152. [DOI: 10.1016/j.micres.2022.127152] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022]
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How to Manage Pseudomonas aeruginosa Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1386:425-445. [DOI: 10.1007/978-3-031-08491-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mitidieri E, Visaggio D, Frangipani E, Turnaturi C, Vanacore D, Provenzano R, Costabile G, Sorrentino R, Ungaro F, Visca P, d'Emmanuele di Villa Bianca R. Intra-tracheal administration increases gallium availability in lung: implications for antibacterial chemotherapy. Pharmacol Res 2021; 170:105698. [PMID: 34058327 DOI: 10.1016/j.phrs.2021.105698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 12/01/2022]
Abstract
The emergence of pan-resistant strains in nosocomial settings underscores the urgent need of novel therapies targeting vital bacterial functions. Bacterial iron metabolism is a fascinating target for new antimicrobials. Iron mimetic metal Ga(III) has been repurposed as an antimicrobial drug, in pre-clinical studies and recent clinical studies have raised the possibility of using Ga(III) for the treatment of P. aeruginosa pulmonary infection. Ga(III) has been approved by FDA for the treatment of cancer, autoimmune and bone resorption disorders. However, some critical issues affect the therapeutic schedule of Ga(III), principally the intra-venous (i.v.) administration, and the nephrotoxicity caused by prolonged administration. Ga(III) aerosolization could represent a viable alternative for treatment of lung infections, since delivery of antimicrobial agents to the airways maximizes drug concentration at the site of infection, improves the therapeutic efficacy, and alleviates systemic toxic effects. We demonstrate the advantage of inhaled vs i.v. administered Ga(III), in terms of bio-distribution and lung acute toxicity, by using a rat model. In vivo results support the use of Ga(III) for inhalation since intra-tracheal Ga(III) delivery improved its persistence in the lung, while the i.v. administration caused rapid clearance and did not allow to attain a significant Ga(III) concentration in this organ. Moreover, local and systemic acute toxicity following intra-tracheal administration was not observed, since no significant signs of inflammation were found. At this stage of evidence, the direct administration of Ga(III) to the lung appears feasible and safe, boosting the development of Ga(III)-based drugs for inhalation therapy.
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Affiliation(s)
- Emma Mitidieri
- Department of Pharmacy, School of Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | | | - Emanuela Frangipani
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Carlotta Turnaturi
- Department of Pharmacy, School of Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - Domenico Vanacore
- Department of Pharmacy, School of Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - Romina Provenzano
- Department of Pharmacy, School of Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - Gabriella Costabile
- Laboratory of Nanotechnology for Precision Medicine, Fondazione Istituto Italiano di Tecnologia, Via Morego 30, 16163 Genoa, Italy
| | - Raffaella Sorrentino
- Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, Italy.
| | - Francesca Ungaro
- Department of Pharmacy, School of Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - Paolo Visca
- Department of Science, Roma Tre University, Rome, Italy
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Liao Q, Lam JKW. Inhaled Antifungal Agents for the Treatment and Prophylaxis of Pulmonary Mycoses. Curr Pharm Des 2021; 27:1453-1468. [PMID: 33388013 DOI: 10.2174/1381612826666210101153547] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022]
Abstract
Pulmonary mycoses are associated with high morbidity and mortality. The current standard treatment by systemic administration is limited by inadequate local bioavailability and systemic toxic effects. Aerosolisation of antifungals is an attractive approach to overcome these problems, but no inhaled antifungal formulation is currently available for the treatment of pulmonary mycoses. Hence, the development of respirable antifungals formulations is of interest and in high demand. In this review, the recent advances in the development of antifungal formulations for pulmonary delivery are discussed, including both nebulised and dry powder formulations. Although the clinical practices of nebulised parenteral amphotericin B and voriconazole formulations (off-label use) are reported to show promising therapeutic effects with few adverse effects, there is no consensus about the dosage regimen (e.g. the dose, frequency, and whether they are used as single or combination therapy). To maximise the benefits of nebulised antifungal therapy, it is important to establish standardised protocol that clearly defines the dose and specifies the device and the administration conditions. Dry powder formulations of antifungal agents such as itraconazole and voriconazole with favourable physicochemical and aerosol properties are developed using various powder engineering technologies, but it is important to consider their suitability for use in patients with compromised lung functions. In addition, more biological studies on the therapeutic efficacy and pharmacokinetic profile are needed to demonstrate their clinical potential.
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Affiliation(s)
- Qiuying Liao
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong SAR, Hong Kong
| | - Jenny K W Lam
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong SAR, Hong Kong
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O’Toole C, Joyce M, McGrath JA, O’Sullivan A, Byrne MA, MacLoughlin R. Fugitive aerosols in the intensive care unit: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:592. [PMID: 33987290 PMCID: PMC8105852 DOI: 10.21037/atm-20-2280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/10/2020] [Indexed: 12/20/2022]
Abstract
The risk of unintended inhalation of fugitive aerosols is becoming a topic of increasing interest in the healthcare arena. These fugitive aerosols may be bioaerosols, generated by the patient themselves through cough or sneeze, or they may be therapeutic medical aerosols, generated by therapeutic medical aerosol generators with the intent of delivery to a specific patient's respiratory tract. This review focus' on therapeutic aerosols in the intensive care unit (ICU) only, those typically generated by nebulisers. In the intensive care environment, patients are generally in receipt of ventilatory support, and the literature suggests that these different support interventions influence fugitive therapeutic medical aerosol emissions in a variety of ways. Predominant ventilatory support interventions include, but are not limited to, invasive mechanical ventilation (MV), non-invasive mechanical ventilation (NIV), high flow nasal therapy (HFNT), and supplemental oxygen delivery in spontaneously breathing patients. Further, factors such as nebuliser type, patient interface, patient breathing pattern, nebuliser position in the patient breathing circuit and medication formulation characteristics also have been shown to exert influence on aerosol concentrations and distance from the source. Here we present the state of the art knowledge in this, as yet, poorly described field of research, and identify the key risks, and subsequently, opportunities to mitigate the risks of unintended exposure of both patients and bystanders during and for periods following the administration of therapeutic aerosols.
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Affiliation(s)
- Ciarraí O’Toole
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Mary Joyce
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - James A. McGrath
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | | | - Miriam A. Byrne
- School of Physics & Ryan Institute’s Centre for Climate & Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - Ronan MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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Chorepsima S, Kechagias KS, Kalimeris G, Triarides NA, Falagas ME. Spotlight on inhaled ciprofloxacin and its potential in the treatment of non-cystic fibrosis bronchiectasis. Drug Des Devel Ther 2018; 12:4059-4066. [PMID: 30568427 PMCID: PMC6267620 DOI: 10.2147/dddt.s168014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Non-cystic fibrosis bronchiectasis (NCFB) is a severe chronic illness characterized by irreversible dilation of airways and thickening of bronchial walls, chronic inflammation, repeated infections, and progressive obstruction of the airways. In contrast to cystic fibrosis bronchiectasis (CFB), which is a well-defined genetic disorder, NCFB is a heterogeneous disease caused by many different medical entities. Inhaled antibiotics are effective for patients with CFB, but their efficacy in NCFB has not been proven. The main pathogens involved in the colonization of patients with bronchiectasis are Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa. The latter is associated with increased morbidity and mortality. In addition, in NCFB, P. aeruginosa strains are frequently more resistant than those in CFB. At present, there are no approved inhaled antibiotic therapies for NCFB patients. Inhaled ciprofloxacin has been under investigation in the last few years. In two phase II randomized, double-blind, placebo-controlled trials, the use of inhaled ciprofloxacin was significantly associated with reduction in sputum bacterial density and greater eradication rates. In four phase III randomized, double-blind, placebo-controlled trials, the results regarding the time of the first exacerbation and the rate of exacerbations were inconsistent. Specifically, ORBIT-4 and RESPIRE-1 trials showed clinical benefit (prolongation of the time of the first exacerbation and reduced rate of exacerbations in the treatment group compared to the placebo group), whereas the ORBIT-3 and RESPIRE-2 failed to achieve their primary endpoints. The RESPIRE-1 was the first trial that examined the 14-days on/off course separate from the standard 28-days on/off regimen, which is based on CFB protocol treatments. The current data on the efficacy of inhaled ciprofloxacin are encouraging, but further evaluation is needed to determine the appropriate target group and the ideal duration of treatment.
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Affiliation(s)
- Stamatia Chorepsima
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | | | - Georgios Kalimeris
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Nikolaos A Triarides
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece, .,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA,
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Lachiewicz AM, Hauck CG, Weber DJ, Cairns BA, van Duin D. Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance. Clin Infect Dis 2018; 65:2130-2136. [PMID: 29194526 DOI: 10.1093/cid/cix682] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/11/2017] [Indexed: 12/14/2022] Open
Abstract
Patients who are admitted to the hospital after sustaining a large burn injury are at high risk for developing hospital-associated infections. If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death. Ventilator-associated pneumonia is the most important infection in this patient population. The risk of infections caused by multidrug-resistant bacterial pathogens increases with hospital length of stay in burn patients. In the first days of the postburn hospitalization, more susceptible, Gram-positive organisms predominate, whereas later more resistant Gram-negative organisms are found. These findings impact the choice of empiric antibiotics in critically ill burn patients. A proactive infection control approach is essential in burn units. Furthermore, a multidisciplinary approach to burn patients with a team that includes an infectious disease specialist and a pharmacist in addition to the burn surgeon is highly recommended.
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Affiliation(s)
- Anne M Lachiewicz
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Christopher G Hauck
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - David J Weber
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Bruce A Cairns
- Department of Surgery, University of North Carolina at Chapel Hill.,North Carolina Jaycee Burn Center, Chapel Hill
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
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How to translate the new hospital-acquired and ventilator-associated pneumonia guideline to the bedside. Curr Opin Crit Care 2018; 23:355-363. [PMID: 28858915 DOI: 10.1097/mcc.0000000000000434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Hospital-acquired pneumonia and ventilator-associated pneumonia remain significant causes of morbidity, mortality, and financial burden in the United States and around the globe. Although guidelines for the management of patients with these conditions have been available for several years, implementation remains challenging. Here, we review the most common barriers faced by clinicians in implementing the current guidelines and offer suggestions for improved adherence. RECENT FINDINGS Recent studies have identified barriers to the implementation of the guidelines regarding management of hospital-acquired and ventilator-associated pneumonia. The most common difficulties encountered are lack of awareness of the guidelines, practice variation among providers delivering care to affected patients, lack of antibiogram information, and lack of antibiotic stewardship programs. SUMMARY Translating the current hospital-acquired and ventilator-associated pneumonia guidelines to the bedside requires understanding of the current barriers affecting care of patients with these conditions. Adopting clinical guidelines facilitates the management of these patients and improves outcomes. Dissemination of the guidelines, provider education, antibiotic stewardship programs, access to local antibiogram information, audit and feedback, electronic tools and leadership commitment are likely to play important roles in guideline implementation. More studies on hospital-acquired and ventilator-associated pneumonia guideline implementation are necessary to identify the most effective interventions.
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Cazzola M, Rogliani P, Aliberti S, Blasi F, Matera MG. An update on the pharmacotherapeutic management of lower respiratory tract infections. Expert Opin Pharmacother 2017; 18:973-988. [PMID: 28480770 DOI: 10.1080/14656566.2017.1328497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment. Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described. Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.
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Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Stefano Aliberti
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Francesco Blasi
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , Università degli Studi della Campania "Luigi Vanvitelli" , Naples , Italy
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