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Komiya K, Yamatani I, Kadota JI. Treatment strategy for older patients with pneumonia independent of the risk of drug resistance in the world's top country for longevity. Respir Investig 2024; 62:710-716. [PMID: 38823190 DOI: 10.1016/j.resinv.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/05/2024] [Accepted: 05/26/2024] [Indexed: 06/03/2024]
Abstract
The number of older people with impaired swallowing function increases with aging population. Aspiration pneumonia is one of the most cases of pneumonia developing among older people. As aspiration pneumonia may develop as a result of age-related deterioration, it is crucial to consider it as an unavoidable event with aging. While pneumonia is diagnosed based on respiratory symptoms and radiological features, the lung involvement of aspiration pneumonia may be undetectable via a frontal chest radiograph in some cases. Bacterial profiles show the predominance of drug-resistant bacteria, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), but isolated bacteria from respiratory samples do not necessarily indicate causative pathogens. Furthermore, there is no evidence regarding treatment superiority using broad-spectrum antibiotics compared with narrow-spectrum antibiotics. Even if isolated pathogens are a causative factor for pneumonia among older patients, the use of broad-spectrum antibiotics covering the bacteria may not improve their outcomes. Therefore, we propose a treatment strategy independent of the risk of drug resistance focusing on the discrimination of patients who are unlikely to respond to broad-spectrum antibiotics. An aspiration risk is associated with increased in-hospital mortality in patients with pneumonia, which could also lead to a greater risk of poor long-term outcomes with increased 1-year mortality. Advance care planning is now recognized as a process for communication and medical decision-making across the life course. This approach would be widely recommended for older people with aspiration risk.
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Affiliation(s)
- Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan; Research Center for Global and Local Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Izumi Yamatani
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan; Department of Mycobacterium Reference and Research, the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan.
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
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Seo C, Corrado M, Lim R, Thornton CS. Guideline-Concordant Therapy for Community-Acquired Pneumonia in the Hospitalized Population: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2024; 11:ofae336. [PMID: 38966853 PMCID: PMC11222985 DOI: 10.1093/ofid/ofae336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/12/2024] [Indexed: 07/06/2024] Open
Abstract
Background A commonly used guideline for community-acquired pneumonia (CAP) is the joint American Thoracic Society and Infectious Diseases Society of America practice guideline. We aimed to investigate the effect of guideline-concordant therapy in the treatment of CAP. Methods We systematically searched MEDLINE, Embase, CENTRAL, Web of Science, and Scopus from 2007 to December 2023. We screened citations, extracted data, and assessed risk of bias in duplicate. Primary outcomes were mortality rates, intensive care unit (ICU) admission, and length of stay. Secondary outcomes were guideline adherence, readmission, clinical cure rate, and adverse complications. We performed random-effect meta-analysis to estimate the overall effect size and assessed heterogeneity using the I2 statistics. Results We included 17 observational studies and 82 240 patients, of which 10 studies were comparative and pooled in meta-analysis. Overall guideline adherence rate was 65.2%. Guideline-concordant therapy was associated with a statistically significant reduction in 30-day mortality rate (crude odds ratio [OR], 0.49 [95% confidence interval .34-.70; I2 = 60%]; adjusted OR, 0.49 [.37-.65; I2 = 52%]) and in-hospital mortality rate (crude OR, 0.63 [.43-.92]; I2 = 61%). Due to significant heterogeneity, we could not assess the effect of guideline-concordant therapy on length of stay, ICU admission, readmission, clinical cure rate, and adverse complications. Conclusions In hospitalized patients with CAP, guideline-concordant therapy was associated with a significant reduction in mortality rate compared with nonconcordant therapy; however, there was limited evidence to support guideline-concordant therapy for other clinical outcomes. Future studies are needed to assess the clinical efficacy and safety of current guideline recommendations.
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Affiliation(s)
- Chanhee Seo
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mario Corrado
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Lim
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christina S Thornton
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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3
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Heffernan AJ, Smedley A, Stickley T, Oomen S, Carrigan B, Heffernan R, Woodall H, Pinidiyapathirage J, Brumpton K. Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments. Aust J Rural Health 2024; 32:179-187. [PMID: 38158634 DOI: 10.1111/ajr.13079] [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: 12/05/2022] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 01/03/2024] Open
Abstract
DESIGN/PARTICIPANTS This was a multicentre retrospective cohort study of adult patients (≥18 years) presenting with a process associated International Classification of Diseases code (ICD-AM-10) pertaining to sepsis between January 2017 and July 2020 to rural Emergency Departments. MAIN OUTCOME MEASURES Our primary outcome was antibiotic appropriateness as defined by the Australian Therapeutic Guidelines (for antibiotic selection relative to infecting source) and the National Antimicrobial Prescribing Survey tool. Our secondary outcome was in-hospital mortality. METHODS Relevant clinical and non-clinical, physiological and laboratory data were collected retrospectively. Multivariate logistic regression was used to estimate the odds of both inappropriate antibiotic prescribing and in-hospital mortality based on clinical and non-clinical factors. RESULTS A total of 378 patients were included who primarily presented with sepsis of unknown origin (36.8%), a genitourinary (22.22%) or respiratory (18.78%) source. Antibiotics were appropriately prescribed in 59% of patients. A positive Quick Sequential Organ Failure Assessment score (qSOFA) (odds ratio [OR] = 0.49; 95% confidence interval [CI], 0.29-0.83), a respiratory infection source (OR = 0.5; 95% CI, 0.29-0.86) and documented allergy (OR = 0.42; 95% CI, 0.25-0.72) were associated with a lower risk of appropriate prescribing in multivariate analysis. Forty-one percent of patients received antibiotics within 1 h of presentation. Inappropriate antibiotic prescribing was not associated with in-hospital mortality. CONCLUSION The rates of appropriate antibiotic prescribing in rural Emergency Departments for patients presenting with sepsis is low, but comparable to other referral metropolitan centres.
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Affiliation(s)
- A J Heffernan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - A Smedley
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - T Stickley
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - S Oomen
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - B Carrigan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Rural Medical Education Australia, Toowoomba, Queensland, Australia
| | - R Heffernan
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Rural Medical Education Australia, Toowoomba, Queensland, Australia
| | - H Woodall
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Rural Medical Education Australia, Toowoomba, Queensland, Australia
| | - J Pinidiyapathirage
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Rural Medical Education Australia, Toowoomba, Queensland, Australia
| | - K Brumpton
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
- Rural Medical Education Australia, Toowoomba, Queensland, Australia
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Scheithauer S, Karasimos B, Manamayil D, Häfner H, Lewalter K, Mischke K, Heintz B, Tacke F, Brücken D, Lüring C, Heidenhain C, Tewarie L, Hilgers RD, Lemmen SW. A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc14. [PMID: 37405250 PMCID: PMC10316282 DOI: 10.3205/dgkh000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Aim To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial. Methods An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality. Results In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed. Discussion ABQ can be improved significantly by intervention bundles with apparent sustainable effects.
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Affiliation(s)
- Simone Scheithauer
- Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany
| | - Britta Karasimos
- Clinic for Orthopedics and Trauma Surgery, Hospital Düren, Düren, Germany
| | - David Manamayil
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Helga Häfner
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Lewalter
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Mischke
- Medical Clinic 1, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Bernhard Heintz
- Clinic for Nephrology, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte (CCM)/Campus Virchow-Klinikum (CVK, Charité – University Medical Center Berlin, Berlin, Germany
| | - David Brücken
- Clinic for Traumatology, University Hospital Aachen, Aachen, Germany
| | | | - Christoph Heidenhain
- Clinic for Visceral Surgery, AGAPLESION MARKUS Krankenhaus Frankfurt, Frankfurt/Main, Germany
| | | | | | - Sebastian W. Lemmen
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
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Covington EW, Rufe A. Identification of Risk Factors for Multidrug-Resistant Organisms in Community-Acquired Bacterial Pneumonia at a Community Hospital. J Pharm Pract 2021; 36:303-308. [PMID: 34406082 DOI: 10.1177/08971900211039700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The 2019 Infectious Disease Society of America (IDSA) guidelines for the management of community-acquired bacterial pneumonia encourage the identification of locally validated risk factors for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa to guide empiric therapy decisions for patients with community-acquired pneumonia (CAP). The guidelines urge clinicians to perform local validation to determine prevalence and risk factors pertinent to their institution. Objective: To determine the percentage of community-acquired pneumonia caused by multidrug-resistant organisms (MDROs) and assess risk factors potentially associated with multidrug-resistant organisms CAP at our hospital. Methods: This was a retrospective case control study analyzing patients admitted to the 344-bed community hospital with bacterial community-acquired pneumonia between January 1, 2019 and December 31, 2019. Univariate analysis and multivariate regression were performed to assess potential risk factors for MDRO pathogens. Results: MDROs were isolated in 41.3% of patients with culture-positive CAP (n=19/46), and 3.6% of patients with microbiological culture data within 48 hours of admission (19/527). Among patients with culture-positive CAP, hospitalization in the previous 90 days and receipt of antibiotics in the previous 90 days occurred more frequently in MDRO patients than non-MDRO patients (37% vs 11%, P=.032). No risk factors reached statistical significance in the multivariate regression. There were no differences in clinical outcomes between MDRO and non-MDRO patients. Conclusions: This study demonstrated a low overall prevalence of MDRO pathogens in patients with CAP. Potential risk factors for MDRO included hospitalization within the past 90 days and antibiotic use within the past 90 days.
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Affiliation(s)
| | - Alanna Rufe
- Department of Pharmacy, Jackson Hospital and Clinic, Montgomery, AL, USA
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6
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Stodghill J, Finnigan A, Newcomb AB, Lita E, Liu C, Teicher E. Predictive Value of the Methicillin-Resistant Staphylococcus aureus Nasal Swab for Methicillin-Resistant Staphylococcus aureus Ventilator-Associated Pneumonia in the Trauma Patient. Surg Infect (Larchmt) 2021; 22:889-893. [PMID: 33872057 DOI: 10.1089/sur.2020.477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Many trauma centers have empiric treatment algorithms for ventilator-associated pneumonia (VAP) treatment prior to culture results that include antibiotic agents for methicillin-resistant Staphylococcus aureus (MRSA) coverage that can have adverse effects. This is the only study to evaluate risk factors and MRSA nasal swabs to risk-stratify trauma patients for MRSA VAP, thereby potentially limiting the need for empiric vancomycin. Patients and Methods: This was a single institution retrospective cohort study. Adult patients admitted to the trauma intensive care unit (ICU) between January 2013 and December 2017 who had a MRSA nasal swab and subsequently met criteria for VAP were included. Demographics, risk factors for MRSA pneumonia, and culture results were collected. Results: A total of 140 patients met inclusion criteria. The negative predictive value (NPV) of MRSA nasal swab at predicting subsequent MRSA pneumonia was 97%. The sensitivity, specificity, and positive predictive value were 50.0%, 96.2%, and 44.4%, respectively. Smokers were more likely to develop MRSA pneumonia, odds ratio: 7.0 (p = 0.02). When considering non-smokers with a negative MRSA nasal swab, NPV was 100%. Conclusions: This is the only study to date that assesses the utility of MRSA nasal swab and risk factor data to guide empiric VAP antibiotic therapy in trauma patients. Smoking was found to be a risk factor for MRSA pneumonia. The use of MRSA nasal swabs in combination with smoking status to guide empiric use of MRSA coverage antibiotic agents is recommended because of a 100% NPV. When utilized, as many as 68% of patients may safely be spared MRSA coverage antibiotic agents and the related adverse effects.
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Affiliation(s)
- Joshua Stodghill
- Department of Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - April Finnigan
- Department of Pharmacy Department, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Anna B Newcomb
- Department of Section of Acute Care Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Elena Lita
- Department of Section of Acute Care Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Chang Liu
- Department of Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Erik Teicher
- Department of Section of Acute Care Surgery, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
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7
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Talagtag M, Patel TS, Scappaticci GB, Perissinotti AJ, Schepers AJ, Petty LA, Pettit KM, Burke PW, Bixby DL, Marini BL. Utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in patients with acute myeloid leukemia (AML). Transpl Infect Dis 2021; 23:e13612. [PMID: 33825279 DOI: 10.1111/tid.13612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/22/2021] [Accepted: 03/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current literature has demonstrated the utility of the MRSA nasal screen as a de-escalation tool to decrease unnecessary anti-MRSA antibiotic therapy. However, data on the applicability of this test in patients with hematologic malignancy is lacking. METHODS This is a single-center, retrospective cohort study of patients with acute myeloid leukemia (AML) with or without a history of hematopoietic cell transplant (HCT), with pneumonia and MRSA nasal screening with respiratory cultures obtained. The primary outcome was to determine the negative predictive value (NPV) of the MRSA nasal screen for MRSA pneumonia. Secondary outcomes included sensitivity, specificity, positive predictive value (PPV) of the MRSA nasal screen and prevalence of MRSA pneumonia. RESULTS Of 98 patients with AML and pneumonia, the prevalence of MRSA pneumonia was 4.1% with confirmed positive MRSA respiratory cultures observed in 4 patient cases. In patients with confirmed MRSA pneumonia, 3 had positive MRSA nasal screens while 1 had a false negative result, possibly due to a long lag time (21 days) between MRSA nasal screen and pneumonia diagnosis. Overall, the MRSA nasal screen demonstrated 75% sensitivity and 100% specificity, with a PPV of 100% and a NPV of 98.9%. CONCLUSIONS Given the low prevalence, empiric use of anti-MRSA therapy in those AML and HCT patients with pneumonia may not be warranted in clinically stable patients. For patients in whom empiric anti-MRSA antibiotics are initiated, nasal screening for MRSA may be utilized to de-escalate anti-MRSA antibiotics in patients with AML with or without HCT.
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Affiliation(s)
- Millicynth Talagtag
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Gianni B Scappaticci
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Allison J Schepers
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Ann Arbor, MI, USA
| | - Kristen M Pettit
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Patrick W Burke
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dale L Bixby
- Department of Internal Medicine, Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Michigan Medicine and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Pharmacy, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Sellarès-Nadal J, Burgos J, Falcó V, Almirante B. Investigational and Experimental Drugs for Community-Acquired Pneumonia: the Current Evidence. J Exp Pharmacol 2020; 12:529-538. [PMID: 33239925 PMCID: PMC7682597 DOI: 10.2147/jep.s259286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022] Open
Abstract
Community-acquired pneumonia (CAP) is a common infection with a constantly evolving etiological spectrum. This changing etiology conditions the adequate selection of optimal therapeutic regimens, both in empirical and definitive treatments. In recent years, new antimicrobials have been approved by regulatory authorities for use in CAP, although it is necessary to continue incorporating new antimicrobial agents that improve the activity profile in relation to the appearance of bacterial resistance in certain pathogens, such as pneumococcus, Staphylococcus aureus or Pseudomonas aeruginosa. Delafloxacin, omadacycline and lefamulin are the most recently approved antibiotics for CAP. These three antibiotics have shown non-inferiority to their comparators for the treatment of CAP with an excellent safety profile. However, in the 2019 ATS/IDSA guidelines, it has been considered that more information is needed to incorporate these new drugs into community-based treatment. New antimicrobials, such as solithromycin and nemonoxacin, are currently being studied in Phase III clinical trials. Both drugs have shown non-inferiority against the comparators and an acceptable safety profile; however, they have not yet been approved by the regulatory authorities. Several drugs are being tested in Phase I and II clinical trials. These include zabofloxacin, aravofloxacin, nafithromycin, TP-271, gepotidacin, radezolid, delpazolid, and CAL02. The preliminary results of these clinical trials allow us to assure that most of these drugs may play a role in the future treatment of CAP.
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Affiliation(s)
- Juilia Sellarès-Nadal
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Joaquin Burgos
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Vicenç Falcó
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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9
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Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments. Appl Clin Inform 2020; 11:589-597. [PMID: 32906153 DOI: 10.1055/s-0040-1715893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions. METHODS Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis. RESULTS Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing. DISCUSSION The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization). CONCLUSION Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Noel Metcalf
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Larissa S May
- Department of Emergency Medicine, UC Davis Health, Davis, California, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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10
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Lewis PO. Risk Factor Evaluation for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Community-Acquired Pneumonia. Ann Pharmacother 2020; 55:36-43. [PMID: 32545992 DOI: 10.1177/1060028020935106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The 2019 community-acquired pneumonia guidelines recommend using recent respiratory cultures and locally validated epidemiology plus risk factor assessment to determine empirical coverage of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. OBJECTIVE To develop a methodology for evaluating local epidemiology and validating local risk factors for P aeruginosa and MRSA. METHODS This multicenter, retrospective cohort evaluated adult patients admitted for pneumonia. Risk factors for MRSA and P aeruginosa were evaluated using multivariable logistic regression and reported as adjusted odds ratios (aORs). RESULTS There were 10 723 cases evaluated. Lung abscess/empyema had the highest odds associated with MRSA (aOR = 4.24; P < 0.0001), followed by influenza (aOR = 2.34; P = 0.01), end-stage renal disease (ESRD; aOR = 2.09; P = 0.006), illicit substance use (aOR = 1.7; P = 0.007), and chronic obstructive pulmonary disease (COPD; aOR = 1.26; P = 0.04). For P aeruginosa, the highest odds were in bronchiectasis (aOR = 6.13; P < 0.0001), lung abscess/empyema (aOR = 3.36; P = 0.005), and COPD (aOR = 1.84; P < 0.0001). Isolated COPD without other risk factors did not pose an increased risk of either organism. CONCLUSION AND RELEVANCE Influenza, ESRD, lung abscess/empyema, and illicit substance use were local risk factors for MRSA. Bronchiectasis and lung abscess/empyema were risk factors for Pseudomonas. COPD was associated with MRSA and Pseudomonas. However, isolated COPD had similar rates of MRSA and Pseudomonas pneumonia compared with the total population. This study established a feasible methodology for evaluating local risk factors.
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Affiliation(s)
- Paul O Lewis
- Johnson City Medical Center, Johnson City, TN, USA
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11
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Ito A, Ishida T, Tachibana H, Nakanishi Y, Yamazaki A, Washio Y. Is antipseudomonal antibiotic treatment needed for all nursing and healthcare-associated pneumonia patients at risk for antimicrobial resistance? J Glob Antimicrob Resist 2020; 22:441-447. [PMID: 32339851 DOI: 10.1016/j.jgar.2020.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Nursing and healthcare-associated pneumonia (NHCAP) was proposed by the Japanese Respiratory Society to refer to healthcare-associated pneumonia. This study aimed to investigate whether antipseudomonal antibiotic therapy improved the prognosis of NHCAP patients at high risk for antimicrobial-resistant pathogens. METHODS Consecutive hospitalised NHCAP patients in Kurashiki Central Hospital between October 2010 and December 2016 were prospectively enrolled. NHCAP patients who were at high risk for antimicrobial resistance were defined as those who received antimicrobials in the preceding 90 days and/or were on tube feeding. The patients who received antipseudomonal antibiotics were defined as the guideline-concordant (GC) therapy group, and the others were defined as the guideline-discordant (GD) therapy group. The primary outcome was 30-day mortality. Inverse probability of treatment weighting (IPTW) analysis was used to reduce biases. RESULTS There were 277 patients with NHCAP; a majority (78.0%) were discharged from a hospital in the preceding 90 days. There were 52 patients in the GC group and 225 patients in the GD group. The 30-day mortality rate was significantly higher in the GC group than in the GD group (17.3%, 9/52 vs. 7.1%, 16/225; P = 0.03). After IPTW analysis, the GC therapy, compared with GD therapy, did not improve the 30-day mortality (OR 1.71, 95% CI 0.65-4.47; P = 0.28). CONCLUSIONS Not all NHCAP patients, even those at high risk for antimicrobial resistance, need antipseudomonal antimicrobial treatment. The treatment strategy for NHCAP patients should be individualised, according to the pneumonia severity, risk for antimicrobial-resistant pathogens, and antibiogram in each hospital.
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Affiliation(s)
- Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Hiromasa Tachibana
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Department of Respiratory Medicine, National Hospital Organization Minami Kyoto Hospital, Nakaashihara 11, Joyo, Kyoto, Japan.
| | - Yosuke Nakanishi
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan.
| | - Akio Yamazaki
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Department of Respiratory Medicine, Shiga University of Medical Science, Tsukinowa Seta-cho, Otsu, Shiga, Japan.
| | - Yasuyoshi Washio
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, Japan; Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Higashiku Maidashi 3-1-1, Fukuoka, Japan.
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12
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1774] [Impact Index Per Article: 443.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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13
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The potential economic value of sputum culture use in patients with community-acquired pneumonia and healthcare-associated pneumonia. Clin Microbiol Infect 2019; 25:1038.e1-1038.e9. [DOI: 10.1016/j.cmi.2018.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/07/2018] [Accepted: 11/17/2018] [Indexed: 11/24/2022]
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14
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Abstract
"Health care-associated pneumonia (HCAP) was introduced into guidelines because of concerns about the increasing prevalence of drug-resistant pathogens (DRPs) not covered by standard empirical therapy. We now know that DRPs are very localized phenomena with low rates in most sites. Although HCAP risk factors are associated with a higher mortality, this is driven by comorbidities rather than the pathogens. Empirical coverage of DRPs has generally not resulted in better patient outcomes. A far more nuanced approach must be taken for patients with risk factors for DRPs taking into account the local cause and severity of disease.
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Affiliation(s)
- Grant W Waterer
- University of Western Australia, Royal Perth Hospital, Level 4, MRF Building, GPO Box X2213, Perth 6847, Australia; Northwestern University, Chicago, IL, USA.
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15
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Heo JY, Song JY. Disease Burden and Etiologic Distribution of Community-Acquired Pneumonia in Adults: Evolving Epidemiology in the Era of Pneumococcal Conjugate Vaccines. Infect Chemother 2018; 50:287-300. [PMID: 30600652 PMCID: PMC6312904 DOI: 10.3947/ic.2018.50.4.287] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Indexed: 12/23/2022] Open
Abstract
Pneumonia is the leading cause of morbidity and mortality, particularly in old adults. The incidence and etiologic distribution of community-acquired pneumonia is variable both geographically and temporally, and epidemiology might evolve with the change of population characteristics and vaccine uptake rates. With the increasing prevalence of chronic medical conditions, a wide spectrum of healthcare-associated pneumonia could also affect the epidemiology of community-acquired pneumonia. Here, we provide an overview of the epidemiological changes associated with community-acquired pneumonia over the decades since pneumococcal conjugate vaccine introduction.
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Affiliation(s)
- Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Asian Pacific Influenza Institute, Korea University College of Medicine, Seoul, Korea.
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16
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Clinical Outcomes of Hospital-Acquired and Healthcare-Associated Pneumonia With and Without Empiric Vancomycin in a Noncritically Ill Population. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting. Curr Probl Pediatr Adolesc Health Care 2018; 48:289-305. [PMID: 30322711 DOI: 10.1016/j.cppeds.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.
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18
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Kobayashi D, Shindo Y, Ito R, Iwaki M, Okumura J, Sakakibara T, Yamaguchi I, Yagi T, Ogasawara T, Sugino Y, Taniguchi H, Saito H, Saka H, Kawamura T, Hasegawa Y. Validation of the prediction rules identifying drug-resistant pathogens in community-onset pneumonia. Infect Drug Resist 2018; 11:1703-1713. [PMID: 30349327 PMCID: PMC6188199 DOI: 10.2147/idr.s165669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Appropriate initial antibiotic treatment and avoiding administration of unnecessary broad-spectrum antibiotics are important for the treatment of pneumonia. To achieve this, assessment of risk for drug-resistant pathogens (DRPs) at diagnosis is essential. Purpose The aim of this study was to validate a predictive rule for DRPs that we previously proposed (the community-acquired pneumonia drug-resistant pathogen [CAP-DRP] rule), comparing several other predictive methods. Patients and methods A prospective observational study was conducted in hospitalized patients with community-onset pneumonia at four institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin–sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP-DRPs. Results CAP-DRPs were identified in 73 (10.1%) of 721 patients analyzed. The CAP-DRP rule differentiated low vs high risk of CAP-DRP at the threshold of ≥3 points or 2 points plus any of methicillin-resistant Staphylococcus aureus specific factors with a sensitivity of 0.45, specificity of 0.87, positive predictive value of 0.47, negative predictive value of 0.87, and accuracy of 0.79. Its discrimination performance, area under the receiver operating characteristic curve, was 0.73 (95% confidence interval 0.66–0.79). Specificity of the CAP-DRP rule against CAP-DRPs was the highest among the six predictive rules tested. Conclusion The performance of the predictive rules and criteria for CAP-DRPs was limited. However, the CAP-DRP rule yielded high specificity and could specify patients who should be treated with non-broad-spectrum antibiotics, eg, a non-pseudomonal β-lactam plus a macrolide, more precisely.
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Affiliation(s)
- Daisuke Kobayashi
- Kyoto University Health Service, Kyoto, Japan.,Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Ryota Ito
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mai Iwaki
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Respiratory Medicine, Kasugai Municipal Hospital, Kasugai, Japan
| | - Junya Okumura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Toshihiro Sakakibara
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Ikuo Yamaguchi
- Department of Central Laboratory, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan
| | - Tomohiko Ogasawara
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | | | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
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19
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Lat I, Daley MJ, Shewale A, Pangrazzi MH, Hammond D, Olsen KM. A Multicenter, Prospective, Observational Study to Determine Predictive Factors for Multidrug-Resistant Pneumonia in Critically Ill Adults: The DEFINE Study. Pharmacotherapy 2018; 39:253-260. [PMID: 30101412 DOI: 10.1002/phar.2171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This study was conducted to describe the prevalence, epidemiology, and clinical outcomes of multidrug-resistant (MDR) organism (MDRO) pneumonia in critically ill patients. METHODS A multicenter, prospective, observational study of patients admitted to 60 intensive care units (ICUs), from 34 hospitals, in the United States from November to December 2016. Adults (> 18 yrs) receiving antimicrobial therapy at least 5 days for pneumonia were included. Patients were classified into two categories, with or without MDRO, and subcategorized by pneumonia type. MEASUREMENTS AND MAIN RESULTS Demographics, medication histories, and health care exposure were collected during ICU admission and compared using t test and chi-square tests. Multivariate logistic regression was used to determine predictive factors for MDRO pneumonia and hospital mortality. Of 652 patients, 92 patients (14.1%) developed MDR pneumonia. Predictors of MDRO pneumonia were acid suppression therapy within the previous 90 days (odds ratio [OR] 1.88 [1.14-3.09]; p=0.013), mechanical ventilation (OR 1.96 [1.14-3.35]; p<0.001), and history of MDRO infection (OR 4.74 [2.21-10.18]; p<0.001). Appropriate initial antimicrobial selection occurred in 58 patients (63%) with MDRO pneumonia compared to 464 patients (82.7%) in patients without MDRO pneumonia (p<0.001). MDRO pneumonia was not associated with hospital mortality (18.5% vs 17.6%, p=0.087). CONCLUSIONS In a broad cohort of critically ill patients, MDRO pneumonia is infrequent, and associated with factors describing the intensity of health care provided. Presence of MDRO pneumonia is not associated with hospital mortality. Further study is needed to clarify risk factors for multidrug-resistant pneumonia in critically ill patients.
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Affiliation(s)
- Ishaq Lat
- Shirley Ryan Abilitylab, Chicago, Illinois
| | | | - Anand Shewale
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mark H Pangrazzi
- Detroit Medical Center - Sinai Grace Hospital, Detroit, Michigan
| | | | - Keith M Olsen
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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20
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François-Fasille V, Monsuez JJ, Varennes G, Reuter PG, Lapostolle F. Risk score-guided treatment for hospitalized pneumonia in older patients. Eur Geriatr Med 2018; 9:509-513. [DOI: 10.1007/s41999-018-0069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/12/2018] [Indexed: 10/28/2022]
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21
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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22
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Frei CR, Rehani S, Lee GC, Boyd NK, Attia E, Pechal A, Britt RS, Mortensen EM. Application of a Risk Score to Identify Older Adults with Community-Onset Pneumonia Most Likely to Benefit From Empiric Pseudomonas Therapy. Pharmacotherapy 2017; 37:195-203. [PMID: 28035692 DOI: 10.1002/phar.1891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE To assess the impact of empiric Pseudomonas pharmacotherapy on 30-day mortality in hospitalized patients with community-onset pneumonia stratified according to their risk (low, medium, or high) of drug-resistant pathogens. DESIGN Retrospective cohort study. DATA SOURCE Veterans Health Administration database. PATIENTS A total of 50,119 patients who were at least 65 years of age, hospitalized with pneumonia, and received antibiotics within 48 hours of admission between fiscal years 2002 and 2007. Patients were stratified into empiric Pseudomonas therapy (31,027 patients) and no Pseudomonas therapy (19,092 patients) groups based on antibiotics received during their first 48 hours of admission. MEASUREMENTS AND MAIN RESULTS A clinical prediction scoring system developed in 2014 that stratifies patients with community-onset pneumonia according to their risk of drug-resistant pathogens was used to identify patients who were likely to benefit from empiric Pseudomonas therapy as well as those in whom antipseudomonal therapy could be spared; patients were classified into low-risk (68%), medium-risk (21%), and high-risk (11%) groups. Of the 50,119 patients, 62% received Pseudomonas therapy. All-cause 30-day mortality was the primary outcome. Empiric Pseudomonas therapy (adjusted odds ratio 0.72, 95% confidence interval 0.62-0.84) was associated with lower 30-day mortality in the high-risk group but not the low- or medium-risk groups. CONCLUSION Application of a risk score for patients with drug-resistant pathogens can identify patients likely to benefit from empiric Pseudomonas therapy. Widespread use of this score could reduce overuse of anti-Pseudomonas antibiotics in low- to medium-risk patients and improve survival in high-risk patients.
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Affiliation(s)
- Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,South Texas Veterans Health Care System, San Antonio, Texas
| | - Sylvie Rehani
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Grace C Lee
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Natalie K Boyd
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Erene Attia
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ashley Pechal
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Rachel S Britt
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas.,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Eric M Mortensen
- VA North Texas Health Care System, Dallas, Texas.,The University of Texas Southwestern Medical Center, Dallas, Texas
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23
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Qi F, Zhang GX, She DY, Liang ZX, Wang RT, Yang Z, Chen LA, Cui JC. Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years. Chin Med J (Engl) 2016; 128:2707-13. [PMID: 26481734 PMCID: PMC4736886 DOI: 10.4103/0366-6999.167294] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis. Methods: Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk). Results: Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP. Conclusion: Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality.
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Affiliation(s)
| | | | | | | | | | | | - Liang-An Chen
- Department of Respiratory Medicine, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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24
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Komiya K, Rubin BK, Kadota JI, Mukae H, Akaba T, Moro H, Aoki N, Tsukada H, Noguchi S, Shime N, Takahashi O, Kohno S. Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta-analysis. Sci Rep 2016; 6:38097. [PMID: 27924871 PMCID: PMC5141412 DOI: 10.1038/srep38097] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 11/04/2016] [Indexed: 12/18/2022] Open
Abstract
Aspiration pneumonia is thought to be associated with a poor outcome in patients with community acquired pneumonia (CAP). However, there has been no systematic review regarding the impact of aspiration pneumonia on the outcomes in patients with CAP. This review was conducted using the MOOSE guidelines: Patients: patients defined CAP. Exposure: aspiration pneumonia defined as pneumonia in patients who have aspiration risk. Comparison: confirmed pneumonia in patients who were not considered to be at high risk for oral aspiration. Outcomes: mortality, hospital readmission or recurrent pneumonia. Three investigators independently identified published cohort studies from PubMed, CENTRAL database, and EMBASE. Nineteen studies were included for this systematic review. Aspiration pneumonia increased in-hospital mortality (relative risk, 3.62; 95% CI, 2.65–4.96; P < 0.001, seven studies) and 30-day mortality (3.57; 2.18–5.86; P < 0.001, five studies). In contrast, aspiration pneumonia was associated with decreased ICU mortality (relative risk, 0.40; 95% CI, 0.26–0.60; P < 0.00001, four studies). Although there are insufficient data to perform a meta-analysis on long-term mortality, recurrent pneumonia, and hospital readmission, the few reported studies suggest that aspiration pneumonia is also associated with these poor outcomes. In conclusion, aspiration pneumonia was associated with both higher in-hospital and 30-day mortality in patients with CAP outside ICU settings.
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Affiliation(s)
- Kosaku Komiya
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA.,Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.,Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, 5956 Nihongi, Nakahetsugi, Oita, 879-7761, Japan
| | - Bruce K Rubin
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Hiroshi Mukae
- Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomohiro Akaba
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA
| | - Hiroshi Moro
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 757 Asahi-machi, Chuo-ku, Niigata, 951-8510, Japan
| | - Nobumasa Aoki
- Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 757 Asahi-machi, Chuo-ku, Niigata, 951-8510, Japan
| | - Hiroki Tsukada
- Department of Respiratory Medicine/Infectious Disease, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, 950-1197, Japan
| | - Shingo Noguchi
- Department of Respiratory Medicine, University of Occupational and Environmental Health, 1-1 Idaigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical &Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, St. Luke's Life Science Institute, 10-1 Akashicho, Chuo-ku, Tokyo, 104-0044, Japan
| | - Shigeru Kohno
- Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Attridge RT, Frei CR, Pugh MJV, Lawson KA, Ryan L, Anzueto A, Metersky ML, Restrepo MI, Mortensen EM. Health care-associated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes. J Crit Care 2016; 36:265-271. [PMID: 27595461 PMCID: PMC5096991 DOI: 10.1016/j.jcrc.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/23/2016] [Accepted: 08/04/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with health care-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an intensive care unit (ICU) with HCAP. MATERIALS AND METHODS We performed a population-based cohort study of patients admitted to greater than 150 hospitals in the US Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model. RESULTS A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). Patients receiving GC-HCAP had higher 30-day patient mortality compared to GC-CAP patients (34% vs 22%; P< .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (odds ratio, 1.67; 95% confidence interval, 1.30-2.13), recent hospital admission (1.53; 1.15-2.02), and receipt of GC-HCAP therapy (1.51; 1.20-1.90). CONCLUSIONS Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.
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Affiliation(s)
- Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX 78209; Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229.
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mary Jo V Pugh
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Kenneth A Lawson
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712.
| | - Laurajo Ryan
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712; Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Antonio Anzueto
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Mark L Metersky
- University of Connecticut School of Medicine, Farmington, CT 06030.
| | - Marcos I Restrepo
- Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX 78229; Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229.
| | - Eric M Mortensen
- Section of General Internal Medicine, VA North Texas Health Care System, Dallas, TX 75216; Division of General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390.
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Empiric antibiotic selection and risk prediction of drug-resistant pathogens in community-onset pneumonia. Curr Opin Infect Dis 2016; 29:167-77. [PMID: 26886179 DOI: 10.1097/qco.0000000000000254] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVEIW Empiric antibiotic selection in community-onset pneumonia is complicated by uncertainty regarding risk of drug-resistant pathogens (DRPs). The healthcare-associated pneumonia (HCAP) criteria have limited predictive value and lead to unnecessary antibiotic use. Better methods of predicting risk of DRP and selecting empiric antibiotics are needed. Here we give an update on risk factors for DRP, available risk prediction models, and treatment strategy in patients with pneumonia. RECENT FINDINGS Evidence supporting factors that contribute to risk of DRP has improved since the advent of HCAP. Many of these risk factors have been reproducibly identified in heterogeneous populations. Newer methods of predicting DRP based on these factors demonstrate better performance than HCAP. Recent innovations include the potential to discriminate between risk for methicillin-resistant Staphylococcus aureus and other DRP, and use of severity as a modifier of treatment threshold. However, there is wide variation in included predictor variables, and at proposed thresholds most scores still favor overtreatment. SUMMARY Until reliable molecular diagnostics are available, additional development and validation of decision support models integrating local resistance rates, estimated DRP risk, severity, and threshold for anti-DRP antibiotics are needed. Once optimized models are identified, implementation studies will be needed to confirm safety and efficacy.
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Risk factors for drug-resistant pathogens in immunocompetent patients with pneumonia: Evaluation of PES pathogens. J Infect Chemother 2016; 23:23-28. [PMID: 27729192 DOI: 10.1016/j.jiac.2016.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/08/2016] [Accepted: 09/12/2016] [Indexed: 11/23/2022]
Abstract
RATIONALE The new acronym, PES pathogens (Pseudomonas aeruginosa, Enterobacteriaceae extended-spectrum beta-lactamase-positive, and methicillin-resistant Staphylococcus aureus), was recently proposed to identify drug-resistant pathogens associated with community-acquired pneumonia. OBJECTIVES To evaluate the risk factors for antimicrobial-resistant pathogens in immunocompetent patients with pneumonia and to validate the role of PES pathogens. METHODS A retrospective analysis of a prospective observational study of immunocompetent patients with pneumonia between March 2009 and June 2015 was conducted. We clarified the risk factors for PES pathogens. RESULTS Of the total 1559 patients, an etiological diagnosis was made in 705 (45.2%) patients. PES pathogens were identified in 51 (7.2%) patients, with 53 PES pathogens (P. aeruginosa, 34; ESBL-positive Enterobacteriaceae, 6; and MRSA, 13). Patients with PES pathogens had tendencies toward initial treatment failure, readmission within 30 days, and a prolonged hospital stay. Using multivariate analysis, female sex (adjusted odds ratio [AOR] 1.998, 95% confidence interval [CI] 1.047-3.810), admission within 90 days (AOR 2.827, 95% CI 1.250-6.397), poor performance status (AOR 2.380, 95% CI 1.047-5.413), and enteral feeding (AOR 5.808, 95% CI 1.813-18.613) were independent risk factors for infection with PES pathogens. The area under the receiver operating characteristics curve for the risk factors was 0.66 (95% CI 0.577-0.744). CONCLUSIONS We believe the definition of PES pathogens is an appropriate description of drug-resistant pathogens associated with pneumonia in immunocompetent patients. The frequency of PES pathogens is quite low. However, recognition is critical because they can cause refractory pneumonia and different antimicrobial treatment is required.
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Abstract
PURPOSE OF REVIEW Identification of patients with multidrug-resistant (MDR) pathogens at initial diagnosis is essential for the appropriate selection of empiric treatment of patients with pneumonia coming from the community. The term Healthcare-Associated Pneumonia (HCAP) is controversial for this purpose. Our goal is to summarize and interpret the data addressing the association of MDR pathogens and community-onset pneumonia. RECENT FINDINGS Most recent clinical studies conclude that HCAP risk factor does not accurately identify resistant pathogens. Several risk factors related to MDR pathogens, including new ones that were not included in the original HCAP definition, have been described and different risk scores have been proposed. The present review focuses on the most recent literature assessing the importance of different risk factors for MDR pathogens in patients with pneumonia coming from the community. These included generally MDR risk factors, specific risk factors related to methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa and clinical scoring systems develop to assess the MDR risk factors and its application in clinical practice. SUMMARY Different MDR risk factors and prediction scores have been recently developed. However, further research is needed in order to help clinicians in distinguishing between different MDR pathogens causing pneumonia.
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Safdar N, Musuuza JS, Xie A, Hundt AS, Hall M, Wood K, Carayon P. Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence. BMC Infect Dis 2016; 16:349. [PMID: 27448800 PMCID: PMC4957386 DOI: 10.1186/s12879-016-1665-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 06/24/2016] [Indexed: 01/28/2023] Open
Abstract
Background Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of ventilator-associated pneumonia (VAP). However, the mere presence of guidelines is rarely sufficient to promote widespread adoption and uptake. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model framework, we undertook a study to understand barriers and facilitators to the adoption of the IDSA/ATS guidelines. Methods We conducted surveys and focus group discussions of different health care providers involved in the management of VAP. The setting was medical-surgical ICUs at a tertiary academic hospital and a large multispecialty rural hospital in Wisconsin, USA. Results Overall, we found that 55 % of participants indicated that they were aware of the IDSA/ATS guideline. The top ranked barriers to VAP management included: 1) having multiple physician groups managing VAP, 2) variation in VAP management by differing ICU services, 3) physicians and level of training, and 4) renal failure complicating doses of antibiotics. Facilitators to VAP management included presence of multidisciplinary rounds that include nurses, pharmacist and respiratory therapists, and awareness of the IDSA/ATS guideline. This awareness was associated with receiving effective training on management of VAP, keeping up to date on nosocomial infection literature, and belief that performing a bronchoscopy to diagnose VAP would help with expeditious diagnosis of VAP. Conclusions Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.
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Affiliation(s)
- Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA. .,Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Department of Infectious Disease, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
| | - Jackson S Musuuza
- Institute for Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ann Schoofs Hundt
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA
| | - Matthew Hall
- Department of Infectious Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - Kenneth Wood
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA
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30
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Metersky ML, Frei CR, Mortensen EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology 2015; 21:157-63. [PMID: 26682638 DOI: 10.1111/resp.12651] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/01/2015] [Accepted: 07/17/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with healthcare-associated pneumonia (HCAP) are at high risk of infection with multidrug-resistant (MDR) pathogens. Factors discriminating infection with MDR Gram-negative (MDR-GN) organism from infection with methicillin-resistant Staphylococcus aureus (MRSA) are not well understood and patients are often treated for both organisms. This study was performed to determine risk factors predicting pneumonia due to Pseudomonas versus MRSA. METHODS Veterans age ≥65 hospitalized with HCAP between 2002 and 2012 were identified from the Veterans Affairs administrative databases. Patients were identified with Pseudomonas pneumonia, MRSA pneumonia or neither according to the International Classification of Diseases, 9th Revision, Clinical Modification codes. We assessed unadjusted and adjusted associations of patient characteristics and HCAP due to Pseudomonas or MRSA. RESULTS Of the 61,651 patients with HCAP, 1156 (1.9%) were diagnosed with Pseudomonas pneumonia, 641 (1.0%) with MRSA pneumonia and 59,854 (97.1%) with neither. MRSA pneumonia was positively associated with male gender, age >74, diabetes, chronic obstructive pulmonary disease (COPD), recent nursing home or hospital stay, recent exposure to fluoroquinolone or antibiotics treating Gram-positive organisms, and severe pneumonia. MRSA pneumonia was negatively associated with complicated diabetes. Pseudomonas pneumonia was positively associated with recent hospital stay, immunocompromise, COPD, hemiplegia, recent exposure to inhaled corticosteroids, β-lactam/cephalosporin/carbapenem antibiotics, antibiotics against Gram-positive organisms, 'other antibiotics' and severe pneumonia. Pseudomonas pneumonia was negatively associated with age >84, higher socioeconomic status, drug abuse and diabetes. CONCLUSIONS Patient characteristics may assist in identifying patients at risk for HCAP due to Pseudomonas or MRSA.
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Affiliation(s)
- Mark L Metersky
- The Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, USA.,Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center School of Medicine, San Antonio, USA
| | - Eric M Mortensen
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
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31
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Mahboub B, Al Zaabi A, Al Ali OM, Ahmed R, Niederman MS, El-Bishbishi R. Real life management of community-acquired Pneumonia in adults in the Gulf region and comparison with practice guidelines: a prospective study. BMC Pulm Med 2015; 15:112. [PMID: 26424530 PMCID: PMC4591061 DOI: 10.1186/s12890-015-0108-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 09/23/2015] [Indexed: 11/25/2022] Open
Abstract
Background Very few data exist on the management of community-acquired pneumonia (CAP) in patients admitted to hospitals in the Gulf region. The objectives of this study were to describe treatment patterns for CAP in 38 hospitals in five Gulf countries (United Arab Emirates, Kuwait, Bahrain, Oman, and Qatar) and to compare the findings to the most recent Infectious Diseases Society of America (IDSA) / American Thoracic Society (ATS) guidelines. Methods This was a prospective, observational study conducted between January 2009 and February 2011. Adult patients hospitalised (excluding intensive care units) for CAP and subsequently discharged were included. Data were collected retrospectively at hospital discharge, and prospectively during two follow-up visits. Data on medical history, mortality-risk scores, diagnostic criteria, antibiotic treatment, isolated pathogens and clinical and radiographic outcomes were collected. Care practices were compared to the IDSA/ATS guidelines. Results A total of 684 patients were included. The majority (82.9 %) of patients were classified as low risk for mortality (pneumonia severity index II and III). The majority of patients fulfilled criteria for treatment success at discharge, although only 77.6 % presented a normalised leukocyte count. Overall, the management of CAP in Gulf countries is in line with the IDSA/ATS guidelines. This applied to the diagnosis of CAP, to the identification of high-risk CAP patients, to the identification of etiologic agent responsible for CAP and to the type of treatment despite the fact that combinations of antimicrobial agents were not consistent with the guidelines in 10 % of patients. In all patients, information about Gram’s staining was not captured as recommended by the IDSA/ATS and in the majority of patients (>85 %) chest radiography was not systematically performed at the post-discharge follow-up visits. Discussion The management of CAP in the Gulf region is globally in line with current IDSA/ATS guidelines, although rates of pathogen characterisation and post-discharge follow-up need to be improved. Conclusion Compliance with established guidelines should be encouraged in order to improve the management of the disease in this region.
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Affiliation(s)
- Bassam Mahboub
- Rashid Hospital, Oud Metha Road, Umm Hurair Area 2, PO Box 4545, Dubai, UAE.
| | | | - Ola Mohamed Al Ali
- Rashid Hospital, Oud Metha Road, Umm Hurair Area 2, PO Box 4545, Dubai, UAE.
| | - Raees Ahmed
- Rashid Hospital Trauma Center, Dubai, United Arab Emirates.
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Teshome BF, Lee GC, Reveles KR, Attridge RT, Koeller J, Wang CP, Mortensen EM, Frei CR. Application of a methicillin-resistant Staphylococcus aureus risk score for community-onset pneumonia patients and outcomes with initial treatment. BMC Infect Dis 2015; 15:380. [PMID: 26385225 PMCID: PMC4575496 DOI: 10.1186/s12879-015-1119-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 09/10/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is an evolving problem, and there is a great need for a reliable method to assess MRSA risk at hospital admission. A new MRSA prediction score classifies CO-pneumonia patients into low, medium, and high-risk groups based on objective criteria available at baseline. Our objective was to assess the effect of initial MRSA therapy on mortality in these three risk groups. METHODS We conducted a retrospective cohort study using data from the Veterans Health Administration (VHA). Patients were included if they were hospitalized with pneumonia and received antibiotics within the first 48 h of admission. They were stratified into MRSA therapy and no MRSA therapy treatment arms based on antibiotics received in the first 48 h. Multivariable logistic regression was used to adjust for potential confounders. RESULTS A total of 80,330 patients met inclusion criteria, of which 36% received MRSA therapy and 64% did not receive MRSA therapy. The majority of patients were classified as either low (51%) or medium (47%) risk, with only 2% classified as high-risk. Multivariable logistic regression analysis demonstrated that initial MRSA therapy was associated with a lower 30-day mortality in the high-risk group (adjusted odds ratio 0.57; 95% confidence interval 0.42-0.77). Initial MRSA therapy was not beneficial in the low or medium-risk groups. CONCLUSIONS This study demonstrated improved survival with initial MRSA therapy in high-risk CO-pneumonia patients. The MRSA risk score might help spare MRSA therapy for only those patients who are likely to benefit.
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Affiliation(s)
- Besu F Teshome
- St. Louis College of Pharmacy, St. Louis, MO, USA.
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
- Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Grace C Lee
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
- Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
- Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Russell T Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA.
- South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Jim Koeller
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
- Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
| | - Chen-pin Wang
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, TX, USA.
| | - Eric M Mortensen
- The VA North Texas Health Care System, Dallas, TX, USA.
- The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
- Pharmacotherapy Education and Research Center, School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
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Jones BE, Jones MM, Huttner B, Stoddard G, Brown KA, Stevens VW, Greene T, Sauer B, Madaras-Kelly K, Rubin M, Goetz MB, Samore M. Trends in Antibiotic Use and Nosocomial Pathogens in Hospitalized Veterans With Pneumonia at 128 Medical Centers, 2006-2010. Clin Infect Dis 2015. [PMID: 26223995 DOI: 10.1093/cid/civ629] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In 2005, pneumonia practice guidelines recommended broad-spectrum antibiotics for patients with risk factors for nosocomial pathogens. The impact of these recommendations on the ability of providers to match treatment with nosocomial pathogens is unknown. METHODS Among hospitalizations with a principal diagnosis of pneumonia at 128 Department of Veterans Affairs medical centers from 2006 through 2010, we measured annual trends in antibiotic selection; initial blood or respiratory cultures positive for methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species; and alignment between antibiotic coverage and culture results for MRSA and P. aeruginosa, calculating sensitivity, specificity, and diagnostic odds ratio using a 2 × 2 contingency table. RESULTS In 95 511 hospitalizations for pneumonia, initial use of vancomycin increased from 16% in 2006 to 31% in 2010, and piperacillin-tazobactam increased from 16% to 27%, and there was a decrease in both ceftriaxone (from 39% to 33%) and azithromycin (change from 39% to 36%) (P < .001 for all). The proportion of hospitalizations with cultures positive for MRSA decreased (from 2.5% to 2.0%; P < .001); no change was seen for P. aeruginosa (1.9% to 2.0%; P = .14) or Acinetobacter spp. (0.2% to 0.2%; P = .17). For both MRSA and P. aeruginosa, sensitivity increased (from 46% to 65% and 54% to 63%, respectively; P < .001) and specificity decreased (from 85% to 69% and 76% to 68%; P < .001), with no significant changes in diagnostic odds ratio (decreases from 4.6 to 4.1 [P = .57] and 3.7 to 3.2 [P = .95], respectively). CONCLUSIONS Between 2006 and 2010, we found a substantial increase in the use of broad-spectrum antibiotics for pneumonia despite no increase in nosocomial pathogens. The ability of providers to accurately match antibiotic coverage to nosocomial pathogens remains low.
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Affiliation(s)
| | | | - Benedikt Huttner
- Infection Control Program and Division of Infectious Diseases, Geneva University Hospital, Switzerland
| | | | | | - Vanessa W Stevens
- Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah and Salt Lake City VA Health System
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City
| | | | - Karl Madaras-Kelly
- Boise VA Medical Center and Idaho State University College of Pharmacy, Pocatello
| | | | - Matthew Bidwell Goetz
- Division of Infectious Disease, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, California
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Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28:603-61. [PMID: 26016486 PMCID: PMC4451395 DOI: 10.1128/cmr.00134-14] [Citation(s) in RCA: 2701] [Impact Index Per Article: 300.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
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Affiliation(s)
- Steven Y C Tong
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Joshua S Davis
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Emily Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas L Holland
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Matsunuma R, Asai N, Ohkuni Y, Nakashima K, Iwasaki T, Misawa M, Norihiro K. I-ROAD could be efficient in predicting severity of community-acquired pneumonia or healthcare-associated pneumonia. Singapore Med J 2015; 55:318-24. [PMID: 25017407 DOI: 10.11622/smedj.2014082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The ability to predict the prognosis of patients with pneumonia is critical, especially when making decisions regarding treatment regimens and sites of care. However, prognostic guidelines for healthcare-associated pneumonia (HCAP) have yet to be established. I-ROAD is the prognostic guideline of the Japanese Respiratory Society for hospital-acquired pneumonia (HAP). This study compared available prognostic guidelines to determine the usefulness of I-ROAD as a prognostic tool for patients with HCAP. METHODS We conducted a retrospective review of all patients with pneumonia admitted to Kameda Medical Center, Japan, from January 2006 to September 2009. Patients were categorised into two groups, namely those with community acquired pneumonia (CAP) and those with HCAP. We compared the baseline characteristics, laboratory findings, identified pathogens, antibiotic regimens, clinical outcomes, pneumonic severity and prognostic accuracy of each guideline between the two patient groups. The severity of each disease was assessed on admission using the A-DROP, CURB-65, PSI and I-ROAD guidelines. RESULTS Of the 302 patients evaluated, 228 (75.5%) were diagnosed with CAP and 74 (24.5%) with HCAP. Patients with HCAP were older and had a higher performance status than patients with CAP. The mortality rate in the CAP group tended to rise with increasing severity scores of prognostic guidelines. Although the severity scores of all prognostic guidelines could predict 30-day mortality in patients with CAP, I-ROAD exhibited a higher discriminatory power for patients with HCAP based on analysis of receiver-operating characteristic curves. CONCLUSION I-ROAD could be more accurate than other prognostic guidelines for evaluating the severity of HCAP.
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Affiliation(s)
- R Matsunuma
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba Prefecture, Japan 296-8602.
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Bjarnason A, Asgeirsson H, Baldursson O, Kristinsson KG, Gottfredsson M. Mortality in healthcare-associated pneumonia in a low resistance setting: a prospective observational study. Infect Dis (Lond) 2015; 47:130-6. [PMID: 25664503 PMCID: PMC4688572 DOI: 10.3109/00365548.2014.980842] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/20/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The classification of pneumonia as community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) has implications for selection of initial antimicrobial therapy. HCAP has been associated with an increased prevalence of multidrug-resistant (MDR) pathogens and with high mortality leading to recommendations for broad empiric therapy. METHODS We performed a prospective, population-based study on consecutive adults (≥ 18 years) admitted for pneumonia over 1 calendar year. Patients were classified by pneumonia type and severity. Microbial etiologic testing was performed on all patients. Treatment, length of stay, and mortality rates were compared. RESULTS A total of 373 admissions were included, 94% of all eligible patients. They were classified as CAP (n = 236, 63%) or HCAP (n = 137, 37%). Chronic underlying disease was more commonly found among patients with HCAP compared with CAP (74% vs 51%, p < 0.001). Mycoplasma pneumoniae was more common among CAP patients (p < 0.01), while gram-negative bacteria were more often found among HCAP patients (p = 0.02). No MDR pathogens were detected, and rates of Staphylococcus aureus were similar in the two groups. HCAP patients were not more likely to receive ineffective initial antimicrobial therapy. HCAP patients had worse prognostic scores on admission and higher in-house mortality than CAP patients (10% vs 1%, respectively, p < 0.01). CONCLUSIONS Even in a low resistance setting, patients with HCAP have increased mortality compared with patients with CAP. This is most likely explained by a higher prevalence of co-morbidities. Our data do not support broad-spectrum empiric antibiotic therapy for HCAP.
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Affiliation(s)
- Agnar Bjarnason
- From the Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Hilmir Asgeirsson
- Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Olafur Baldursson
- Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Karl G. Kristinsson
- From the Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Clinical Microbiology, Landspitali University Hospital, Reykjavik, Iceland
| | - Magnus Gottfredsson
- From the Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland
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Rothberg MB, Zilberberg MD, Pekow PS, Priya A, Haessler S, Belforti R, Skiest D, Lagu T, Higgins TL, Lindenauer PK. Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia. J Antimicrob Chemother 2015; 70:1573-9. [PMID: 25558075 DOI: 10.1093/jac/dku533] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/30/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. PATIENTS AND METHODS We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. RESULTS Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT. CONCLUSIONS Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.
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Affiliation(s)
- Michael B Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Sarah Haessler
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
| | - Raquel Belforti
- Division of General Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Daniel Skiest
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Thomas L Higgins
- Division of Pulmonary/Critical Care Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
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Komiya K, Oka H, Ohama M, Uchida M, Miyajima H, Iwashita T, Okabe E, Shuto O, Matsumoto T, Ishii H, Kadota JI. Evaluation of prognostic differences in elderly patients with pneumonia treated by between pulmonologists and non-pulmonologists: a propensity score analysis. CLINICAL RESPIRATORY JOURNAL 2014; 10:462-8. [PMID: 25402005 DOI: 10.1111/crj.12245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 10/21/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The incidence of pneumonia among elderly people is increasing in aged countries, and both pulmonologists and non-pulmonologists treat such patients. OBJECTIVES The aim of this study was to assess prognostic differences between elderly patients treated by pulmonologists and those treated by non-pulmonologists. METHODS This study was a retrospective cohort using a propensity score analysis. Patients 65 years of age or over with pneumonia were consecutively included. The propensity score was estimated based on the patient's background and severity of pneumonia. The difference in 30-day and 90-day mortality depending on the attending physician's specialty was analyzed after adjusting for other variables, including the propensity score. RESULTS We assessed 68 and 182 patients treated by pulmonologists and non-pulmonologists, respectively. The pulmonologists tended to be in charge of patients with hypoxemia, chronic obstructive pulmonary disease or dementia without aspiration pneumonia or renal dysfunction (area under receiver operating characteristic curve to predict treatment by a pulmonologist according to the propensity score = 0.737, P < 0.001). In the multivariate analysis, white blood count cell (adjusted hazard ratio, 1.000, P = 0.030) and the serum albumin level (0.382, P = 0.001) were associated with 30-day mortality, and a bedridden status (3.000, P = 0.013) and the serum albumin level (0.382, P < 0.001) were associated with 90-day mortality; however, the attending physician's specialty was not associated with these prognoses. CONCLUSIONS The overall prognosis of pneumonia in elderly patients may not necessarily improve, irrespective of treatment by pulmonologists, and host factors seemed to be associated with mortality.
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Affiliation(s)
- Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan.,Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Hiroaki Oka
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan.,Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Minoru Ohama
- Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Masahiro Uchida
- Gastrointestinal Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Hajime Miyajima
- Gastrointestinal Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | | | - Eiji Okabe
- Nephrology, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Osamu Shuto
- Internal Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | | | - Hiroshi Ishii
- Respiratory Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan
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Webb BJ, Dascomb K, Stenehjem E, Dean N. Predicting risk of drug-resistant organisms in pneumonia: moving beyond the HCAP model. Respir Med 2014; 109:1-10. [PMID: 25468412 DOI: 10.1016/j.rmed.2014.10.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/19/2014] [Accepted: 10/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical management of community-acquired pneumonia (CAP) is increasingly complicated by antibiotic resistance. CAP due to pathogens resistant to guideline-recommended drugs (CAP-DRP) has increased. 2005 ATS/IDSA guidelines introduced a new category, healthcare-associated pneumonia (HCAP), and recommend extended-spectrum antibiotic treatment for patients meeting HCAP criteria. However, the predictive value of the HCAP model is limited and data suggest that outcomes are not improved using HCAP guideline-concordant therapy. Better methods to predict risk of CAP-DRP are needed. METHODS We reviewed currently published literature on the performance status of HCAP as a predictive tool and studies describing additional risk factors for CAP-DRP. We also summarize the performance characteristics of the currently published alternative clinical prediction scores and compare them to that of the HCAP model. RESULTS In addition to the five risk factors incorporated in HCAP, at least 13 other factors have been identified. The independent predictive value of any single factor is low, but accumulating factors results in increased risk of CAP-DRP. The performance characteristics of 9 clinical prediction scores are reviewed. Nearly all of the scores outperformed HCAP in their study populations. However, no single model has yet demonstrated adequate specificity to minimize unnecessary antibiotic use, while retaining sufficient sensitivity to prevent inadequate initial empiric antibiotic therapy when validated across a wide range of CAP-DRP prevalence. CONCLUSIONS Additional development and validation of prediction scores based upon more refined risk factors for CAP-DRP is needed. Once an accurate, adequately validated prediction score is available, an interventional trial will be needed to determine clinical impact.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Kristin Dascomb
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Edward Stenehjem
- Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA; Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Nathan Dean
- Division of Pulmonary and Critical Care Medicine, at Intermountain Medical Center and the University of Utah, Salt Lake City, UT, USA
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Jeong BH, Koh WJ, Yoo H, Park HY, Suh GY, Chung MP, Kwon OJ, Jeon K. Risk factors for acquiring potentially drug-resistant pathogens in immunocompetent patients with pneumonia developed out of hospital. Respiration 2014; 88:190-8. [PMID: 24994099 DOI: 10.1159/000362673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 04/01/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The concept of healthcare-associated pneumonia (HCAP) exists to identify patients infected with highly resistant pathogens who are exposed to the healthcare environment. However, many studies have included immunosuppressed patients who were excluded from the original concept. OBJECTIVES The risk factors of potentially drug-resistant (PDR) pathogens in patients with pneumonia developed outside the hospital were reevaluated after excluding the patients who had immunosuppression. METHODS This was a retrospective study of prospectively collected data from all consecutive patients with pneumonia who were admitted to hospital via the emergency department between January 2008 and December 2011. RESULTS Pathogens were isolated in a total of 315 patients with pneumonia from our cohort; 33% with PDR pathogens did not meet the criteria for HCAP, but 44% without PDR pathogens did meet the criteria. Variables independently associated with PDR included nursing home residency, hospitalization in the preceding 90 days, antibiotics in the 30 days prior to pneumonia, poor function status and chronic lung disease. The new predictive scoring system based on the logistic regression model had a higher predictive power for the risk of PDR pathogens than the presence of the risk factors or the HCAP criteria. CONCLUSIONS Functional status, pulmonary comorbidity and previous exposure to the healthcare environment were significantly associated with acquiring PDR pathogens in immunocompetent patients with pneumonia that developed out of hospital. However, a risk stratification model was more accurate than the presence of the risk factors or the HCAP criteria for assessing the probability of PDR pathogens.
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Affiliation(s)
- Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother 2014; 58:5262-8. [PMID: 24957843 DOI: 10.1128/aac.02582-14] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
There are limited U.S. data describing the risk factors for multidrug-resistant organism (MDRO) isolation in community-acquired pneumonia (CAP) and health care-associated pneumonia (HCAP). However, concern for the presence of these pathogens drives the prescribing of empiric broad-spectrum antibiotics for CAP and HCAP. A retrospective study of all adults hospitalized with community-onset pneumonia (CAP and HCAP) at a large U.S. medical center from January 2010 to December 2011 was conducted. The objective was to ascertain the rate of pneumonia caused by MDROs and to evaluate whether HCAP is a risk factor for MDRO pneumonia. Univariate and propensity score-adjusted multivariate analyses were performed. A total of 521 patients (50.5% CAP and 49.5% HCAP) were included. The most common etiologies of pneumonia were primary viral and Streptococcus pneumoniae. MDROs were isolated in 20 (3.8%) patients overall, and MDROs occurred in 5.9% and 1.9% of HCAP and CAP patients, respectively. The presence of an MDRO was not associated with HCAP classification (odds ratio [OR]=1.95; 95% confidence interval [95% CI], 0.66 to 5.80; P=0.23) or with most of its individual components (hemodialysis, home infusion, home wound care, and ≥48-h hospitalization in the last 90 days). Independent predictors of MDRO included the following: Pseudomonas aeruginosa colonization/infection in the previous year (OR=7.43; 95% CI, 2.24 to 24.61; P<0.001), antimicrobial use in the previous 90 days (OR=2.90; 95% CI, 1.13 to 7.45; P=0.027), admission from a nursing home (OR=4.19; 95% CI, 1.55 to 11.31; P=0.005), and duration of hospitalization in the previous 90 or 180 days (P=0.013 and P=0.002, respectively). MDROs were uncommon in HCAP and CAP. HCAP did not predict MDRO isolation. Local etiology of community onset pneumonia and specific MDRO risk factors should be integrated into therapeutic decisions to prevent empirical overprescribing of antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) and P. aeruginosa.
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Dobler CC, Waterer G. Healthcare-associated pneumonia: a US disease or relevant to the Asia Pacific, too? Respirology 2014; 18:923-32. [PMID: 23714303 DOI: 10.1111/resp.12132] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 04/22/2013] [Indexed: 11/30/2022]
Abstract
The term 'health care-associated pneumonia' (HCAP) was introduced by the American Thoracic Society and the Infectious Diseases Society of America in 2005 to describe a distinct entity of pneumonia that resembles hospital-acquired pneumonia rather than community-acquired pneumonia (CAP) in terms of occurrence of drug-resistant pathogens and mortality in patients that--while not hospitalized in the traditional sense--have been in recent contact with the health-care system. It was proposed that HCAP should be treated empirically with therapy for drug-resistant pathogens. Over the last few years, there has been increasing controversy over whether HCAP is a helpful definition, or leads to unnecessary and potentially problematic overtreatment. The term HCAP has been extensively criticized in Europe. While most studies have shown that HCAP is associated with more frequent drug-resistant pathogens and higher mortality than CAP, there is no clear evidence that this is due to inappropriate antibiotic therapy. Therapy consistent with HCAP treatment guidelines has also not been found to improve mortality. Based on current evidence, we suggest broad-spectrum antibiotic therapy to treat possible pathogens not usually covered in CAP be based on assessment of individual risk factors rather than applying a HCAP classification system in the Asia-Pacific Region.
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Affiliation(s)
- Claudia C Dobler
- Department of Respiratory Medicine, Liverpool Hospital, University of New South Wales, New South Wales, Australia
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Vallés J, Martin-Loeches I, Torres A, Diaz E, Seijas I, López MJ, Garro P, Castillo C, Garnacho-Montero J, Martin MDM, de la Torre MV, Olaechea P, Cilloniz C, Almirall J, García F, Jiménez R, Seoane E, Soriano C, Mesalles E, Posada P. Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study. Intensive Care Med 2014; 40:572-81. [PMID: 24638939 PMCID: PMC7094988 DOI: 10.1007/s00134-014-3239-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/04/2014] [Indexed: 12/04/2022]
Abstract
Purpose Information about healthcare-associated pneumonia (HCAP) in critically ill patients is scarce. Methods This prospective study compared clinical presentation, outcomes, microbial etiology, and treatment of HCAP, community-acquired pneumonia (CAP), and immunocompromised patients (ICP) with severe pneumonia admitted to 34 Spanish ICUs. Results A total of 726 patients with pneumonia (449 CAP, 133 HCAP, and 144 ICP) were recruited during 1 year from April 2011. HCAP patients had more comorbidities and worse clinical status (Barthel score). HCAP and ICP patients needed mechanical ventilation and tracheotomy more frequently than CAP patients. Streptococcus pneumoniae was the most frequent pathogen in all three groups (CAP, 34.2 %; HCAP, 19.5 %; ICP, 23.4 %; p = 0.001). The overall incidence of Gram-negative pathogens, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa was low, but higher in HCAP and ICP patients than CAP. Empirical treatment was in line with CAP guidelines in 73.5 % of patients with CAP, in 45.5 % of those with HCAP, and in 40 % of those with ICP. The incidence of inappropriate empirical antibiotic therapy was 6.5 % in CAP, 14.4 % in HCAP, and 21.8 % in ICP (p < 0.001). Mortality was highest in ICP (38.6 %) and did not differ between CAP (18.4 %) and HCAP (21.2 %). Conclusions HCAP accounts for one-fifth of cases of severe pneumonia in patients admitted to Spanish ICUs. The empirical antibiotic therapy recommended for CAP would be appropriate for 90 % of patients with HCAP in our population, and consequently the decision to include coverage of multidrug-resistant pathogens for HCAP should be cautiously judged in order to prevent the overuse of antimicrobials. Electronic supplementary material The online version of this article (doi:10.1007/s00134-014-3239-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jordi Vallés
- Area de Patología Crítica, Critical Care Department, Hospital de Sabadell, Corporació Sanitaria Universitaria Parc Taulí, Parc Taulí s/n, Sabadell, Spain,
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Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis. Crit Care Med 2014; 42:420-32. [PMID: 24158175 DOI: 10.1097/ccm.0b013e3182a66b9b] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Some studies suggest better outcomes with macrolide therapy for critically ill patients with community-acquired pneumonia. To further explore this, we performed a systematic review of studies with mortality endpoints that compared macrolide therapy with other regimens in critically ill patients with community-acquired pneumonia. DATA SOURCES Studies were identified via electronic databases, grey literature, and conference proceedings through May 2013. STUDY SELECTION Using prespecified criteria, two reviewers selected studies; studies of outpatients and hospitalized noncritically ill patients were excluded. DATA EXTRACTION Two reviewers extracted data and evaluated bias using the Newcastle-Ottawa Scale. Random effects models were used to generate pooled risk ratios and evaluate heterogeneity (I). DATA SYNTHESIS Twenty-eight observational studies (no randomized control trials) were included. Average age ranged from 58 to 78 years and 14-49% were women. In our primary analysis of 9,850 patients, macrolide use was associated with statistically significant lower mortality compared with nonmacrolides (21% [846 of 4,036 patients] vs 24% [1,369 of 5,814]; risk ratio, 0.82; 95% CI, 0.70-0.97; p = 0.02; I = 63%). When macrolide monotherapy was excluded, the macrolide mortality benefit was maintained (21% [737 of 3,447 patients] vs 23% [1,245 of 5,425]; risk ratio, 0.84; 95% CI, 0.71-1.00; p = 0.05; I = 60%). When broadly guideline-concordant regimens were compared, there was a trend to improved mortality and heterogeneity was reduced (20% [511 of 2,561 patients] mortality with beta-lactam/macrolide therapy vs 23% [386 of 1,680] with beta-lactam/fluoroquinolone; risk ratio, 0.83; 95% CI, 0.67-1.03; p = 0.09; I = 25%). When adjusted risk estimates were pooled from eight studies, macrolide therapy was still associated with a significant reduction in mortality (risk ratio, 0.75; 95% CI, 0.58-0.96; p = 0.02; I = 57%). CONCLUSIONS In observational studies of almost 10,000 critically ill patients with community-acquired pneumonia, macrolide use was associated with a significant 18% relative (3% absolute) reduction in mortality compared with nonmacrolide therapies. After pooling data from studies that provided adjusted risk estimates, an even larger mortality reduction was observed. These results suggest that macrolides be considered first-line combination treatment in critically ill patients with community-acquired pneumonia and support current guidelines.
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Halpape K, Sulz L, Schuster B, Taylor R. Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study). Can J Hosp Pharm 2014; 67:17-27. [PMID: 24634522 DOI: 10.4212/cjhp.v67i1.1317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality. OBJECTIVES The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used. METHODS An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared. RESULTS Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group. CONCLUSION An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.
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Affiliation(s)
- Katelyn Halpape
- , BSP, ACPR, is a PharmD student in the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia. She completed her pharmacy practice residency with the Regina Qu'Appelle Health Region, Regina, Saskatchewan, in 2012/2013
| | - Linda Sulz
- , BSP, PharmD, is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
| | - Brenda Schuster
- , BSP, ACPR, PharmD, FCSHP, is with Regina Qu'Appelle Health Region, and the Department of Academic Family Medicine, University of Saskatchewan, Regina, Saskatchewan
| | - Ron Taylor
- , MD, CCFP(EM), is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
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Cardoso T, Almeida M, Friedman ND, Aragão I, Costa-Pereira A, Sarmento AE, Azevedo L. Classification of healthcare-associated infection: a systematic review 10 years after the first proposal. BMC Med 2014; 12:40. [PMID: 24597462 PMCID: PMC4016612 DOI: 10.1186/1741-7015-12-40] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/11/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ten years after the first proposal, a consensus definition of healthcare-associated infection (HCAI) has not been reached, preventing the development of specific treatment recommendations. A systematic review of all definitions of HCAI used in clinical studies is made. METHODS The search strategy focused on an HCAI definition. MEDLINE, SCOPUS and ISI Web of Knowledge were searched for articles published from earliest achievable data until November 2012. Abstracts from scientific meetings were searched for relevant abstracts along with a manual search of references from reports, earlier reviews and retrieved studies. RESULTS The search retrieved 49,405 references: 15,311 were duplicates and 33,828 were excluded based on title and abstract. Of the remaining 266, 43 met the inclusion criteria. The definition more frequently used was the initial proposed in 2002--in infection present at hospital admission or within 48 hours of admission in patients that fulfilled any of the following criteria: received intravenous therapy at home, wound care or specialized nursing care in the previous 30 days; attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the previous 30 days; were hospitalized in an acute care hospital for ≥2 days in the previous 90 days, resided in a nursing home or long-term care facility. Additional criteria founded in other studies were: immunosuppression, active or metastatic cancer, previous radiation therapy, transfer from another care facility, elderly or physically disabled persons who need healthcare, previous submission to invasive procedures, surgery performed in the last 180 days, family member with a multi-drug resistant microorganism and recent treatment with antibiotics. CONCLUSIONS Based on the evidence gathered we conclude that the definition initially proposed is widely accepted. In a future revision, recent invasive procedures, hospitalization in the last year or previous antibiotic treatment should be considered for inclusion in the definition. The role of immunosuppression in the definition of HCAI still requires ongoing discussion.
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Affiliation(s)
- Teresa Cardoso
- Intensive Care Unit, Unidade de Cuidados Intensivos Polivalente, Hospital de Santo António, University of Porto, Largo Prof, Abel Salazar, 4099-001 Porto, Portugal.
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Seong GM, Kim M, Lee J, Lee JH, Jeong SY, Choi Y, Kim WJ. Healthcare-Associated Pneumonia among Hospitalized Patients: Is It Different from Community Acquired Pneumonia? Tuberc Respir Dis (Seoul) 2014; 76:66-74. [PMID: 24624215 PMCID: PMC3948854 DOI: 10.4046/trd.2014.76.2.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 01/20/2014] [Accepted: 01/29/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The increasing number of outpatients with multidrug-resistant (MDR) pathogens has led to a new category of pneumonia, termed healthcare-associated pneumonia (HCAP). We determined the differences in etiology and outcomes between patients with HCAP and those with community-acquired pneumonia (CAP) to clarify the risk factors for HCAP mortality. METHODS A retrospective study comparing patients with HCAP and CAP at Jeju National University Hospital. The primary outcome was 30-day mortality. RESULTS A total of 483 patients (208 patients HCAP, 275 patients with CAP) were evaluated. Patients with HCAP were older than those with CAP (median, 74 years; interquartile range [IQR], 65-81 vs. median, 69 years; IQR, 52-78; p<0.0001). Streptococcus pneumoniae was the major pathogen in both groups, and MDR pathogens were isolated more frequently from patients with HCAP than with CAP (18.8% vs. 4.9%, p<0.0001). Initial pneumonia severity was greater in patients with HCAP than with CAP. The total 30-day mortality rate was 9.9% and was higher in patients with HCAP based on univariate analysis (16.3% vs. 5.1%; odds ratio (OR), 3.64; 95% confidence interval (CI), 1.90-6.99; p<0.0001). After adjusting for age, sex, comorbidities, and initial severity, the association between HCAP and 30-day mortality became non-significant (OR, 1.98; 95% CI, 0.94-4.18; p=0.167). CONCLUSION HCAP was a common cause of hospital admissions and was associated with a high mortality rate. This increased mortality was related primarily to age and initial clinical vital signs, rather than combination antibiotic therapy or type of pneumonia.
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Affiliation(s)
- Gil Myung Seong
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Miok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Hoo Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Sun Young Jeong
- Department of Radiology, Jeju National University School of Medicine, Jeju, Korea
| | - Yunsuk Choi
- Department of Anesthesia and Pain Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Woo Jeong Kim
- Department of Emergency Medicine, Jeju National University School of Medicine, Jeju, Korea
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Komiya K, Ishii H, Kadota JI. Healthcare-associated Pneumonia and Aspiration Pneumonia. Aging Dis 2014; 6:27-37. [PMID: 25657850 DOI: 10.14336/ad.2014.0127] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/24/2014] [Accepted: 01/27/2014] [Indexed: 12/13/2022] Open
Abstract
Healthcare-associated pneumonia (HCAP) is a new concept of pneumonia proposed by the American Thoracic Society/Infectious Diseases Society of America in 2005. This category is located between community-acquired pneumonia and hospital-acquired pneumonia with respect to the characteristics of the causative pathogens and mortality, and primarily targets elderly patients in healthcare facilities. Aspiration among such patients is recognized to be a primary mechanism for the development of pneumonia, particularly since the HCAP guidelines were published. However, it is difficult to manage patients with aspiration pneumonia because the definition of the condition is unclear, and the treatment is associated with ethical aspects. This review focused on the definition, prevalence and role of aspiration pneumonia as a prognostic factor in published studies of HCAP and attempted to identify problems associated with the concept of aspiration pneumonia.
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Affiliation(s)
- Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan ; Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
| | - Hiroshi Ishii
- Department of Respiratory Medicine, Fukuoka University Hospital, Jonan-ku, Fukuoka, Japan
| | - Jun-Ichi Kadota
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan
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Aikman KL, Hobbs MR, Ticehurst R, Karmakar GC, Wilsher ML, Thomas MG. Adherence to Guidelines for Treating Community-Acquired Pneumonia at a New Zealand Hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00273.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | | | - Mark G Thomas
- Infectious Disease Physician, Auckland City Hospital; Auckland
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50
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Quartin AA, Scerpella EG, Puttagunta S, Kett DH. A comparison of microbiology and demographics among patients with healthcare-associated, hospital-acquired, and ventilator-associated pneumonia: a retrospective analysis of 1184 patients from a large, international study. BMC Infect Dis 2013; 13:561. [PMID: 24279701 PMCID: PMC4222644 DOI: 10.1186/1471-2334-13-561] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 11/12/2013] [Indexed: 11/10/2022] Open
Abstract
Background Acceptance of healthcare-associated pneumonia (HCAP) as an entity and the associated risk of infection by potentially multidrug-resistant (MDR) organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas and Acinetobacter have been debated. We therefore compared patients with HCAP, hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) enrolled in a trial comparing linezolid with vancomycin for treatment of pneumonia. Methods The analysis included all patients who received study drug. HCAP was defined as pneumonia occurring < 48 hours into hospitalization and acquired in a long-term care, subacute, or intermediate health care facility; following recent hospitalization; or after chronic dialysis. Results Data from 1184 patients (HCAP = 199, HAP = 379, VAP = 606) were analyzed. Compared with HAP and VAP patients, those with HCAP were older, had slightly higher severity scores, and were more likely to have comorbidities. Pseudomonas aeruginosa was the most common gram-negative organism isolated in all pneumonia classes [HCAP, 22/199 (11.1%); HAP, 28/379 (7.4%); VAP, 57/606 (9.4%); p = 0.311]. Acinetobacter spp. were also found with similar frequencies across pneumonia groups. To address potential enrollment bias toward patients with MRSA pneumonia, we grouped patients by presence or absence of MRSA and found little difference in frequencies of Pseudomonas and Acinetobacter. Conclusions In this population of pneumonia patients, the frequencies of MDR gram-negative pathogens were similar among patients with HCAP, HAP, or VAP. Our data support inclusion of HCAP within nosocomial pneumonia guidelines and the recommendation that empiric antibiotic regimens for HCAP should be similar to those for HAP and VAP.
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Affiliation(s)
- Andrew A Quartin
- Division of Pulmonary and Critical Care Medicine, Miller School of Medicine at the University of Miami, Jackson Memorial Hospital, 1611 NW 12th Avenue, C455A, Miami, FL 33156, USA.
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