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Geilen J, Kainz M, Zapletal B, Schweiger T, Jäger W, Maier-Salamon A, Zeitlinger M, Stamm T, Ritschl V, Geleff S, Schultz MJ, Tschernko E. Effects of lung inflammation and injury on pulmonary tissue penetration of meropenem and vancomycin in a model of unilateral lung injury. Int J Antimicrob Agents 2024; 64:107180. [PMID: 38649034 DOI: 10.1016/j.ijantimicag.2024.107180] [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: 01/16/2024] [Revised: 03/23/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE The timing and dosing of antimicrobial therapy are key in the treatment of pneumonia in critically ill patients. It is uncertain whether the presence of lung inflammation and injury affects tissue penetration of intravenously administered antimicrobial drugs. The effects of lung inflammation and injury on tissue penetration of two antimicrobial drugs commonly used for pneumonia were determined in an established model of unilateral lung injury. METHODS Unilateral lung injury was induced in the left lung of 13 healthy pigs through cyclic rinsing; the right healthy lung served as control. Infusions of meropenem and vancomycin were administered and concentrations of these drugs in lung tissue, blood, and epithelial lining fluid (ELF) were compared over a period of 6 h. RESULTS Median vancomycin lung tissue concentrations and penetration ratio were higher in inflamed and injured lungs compared with uninflamed and uninjured lungs (AUC0-6h: P = 0.003 and AUCdialysate/AUCplasma ratio: P = 0.003), resulting in higher AUC0-24/MIC. Median meropenem lung tissue concentrations and penetration ratio in inflamed and injured lungs did not differ from that in uninflamed and uninjured lungs (AUC0-6: P = 0.094 and AUCdialysate/AUCplasma ratio: P = 0.173). The penetration ratio for both vancomycin and meropenem into ELF was similar in injured and uninjured lungs. CONCLUSION Vancomycin penetration into lung tissue is enhanced by acute inflammation and injury, a phenomenon barely evident with meropenem. Therefore, inflammation in lung tissue influences the penetration into interstitial lung tissue, depending on the chosen antimicrobial drug. Measurement of ELF levels alone might not identify the impact of inflammation and injury.
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Affiliation(s)
- Johannes Geilen
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Kainz
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernhard Zapletal
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Jäger
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | | | - Markus Zeitlinger
- Department of Clinical Pharmacology, Clinical Pharmacokinetics/Pharmacogenetics and Imaging, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Institute of Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Valentin Ritschl
- Institute of Outcomes Research, Centre for Medical Data Science, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Silvana Geleff
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Marcus J Schultz
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria; Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Amsterdam University Medical Centres, location 'AMC', Amsterdam, The Netherlands
| | - Edda Tschernko
- Department of Anaesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
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Tanha N, Areskog Lejbman I, De Bus L, De Pascale G, Garnacho-Montero J, Leone M, Fujitan S, De Waele JJ, Torisson G, Sjövall F. Clinical outcomes in combination versus mono antibiotic therapy in ICU admitted patients with a suspected infection - A substudy of the DIANA study. J Crit Care 2024; 80:154501. [PMID: 38128219 DOI: 10.1016/j.jcrc.2023.154501] [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: 10/22/2023] [Revised: 12/02/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE In a retrospective cohort study of intensive care unit (ICU) admitted adult patients with suspected or confirmed infection, associations between combination versus mono empirical antibiotic therapy and clinical cure at day 7 as well as mortality at day 7 and 28, were investigated. MATERIALS AND METHODS Patients from the DIANA study were grouped and analysed by combination versus mono antibiotic therapy. Clinical cure was defined as survival and resolution of all signs and symptoms related to the infection. Odds ratios (ORs) were calculated by logistic regression analyses. RESULTS Of the 1398 included patients, 568 patients (41%) received combination therapy. In total, 641(46%) patients achieved clinical cure and 135 (10%) patients had died as of day 7. There were no significant associations between combination and mono therapy relating to clinical cure and mortality. CONCLUSIONS This study found no differences in clinical cure and mortality between empirical combination versus mono therapy in a large cohort of ICU patients with a suspected infection.
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Affiliation(s)
- Nima Tanha
- Department of Perioperative Medicine and Intensive Care Medicine, Skåne University Hospital, Malmö, Sweden.
| | - Ilja Areskog Lejbman
- Department of Perioperative Medicine and Intensive Care Medicine, Skåne University Hospital, Malmö, Sweden.
| | - Liesbet De Bus
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Gennaro De Pascale
- Department of Basic Biotechnological Sciences, Intensive Clinics and Perioperatives, Cattolica del Sacro Cuore University, Rome, Italy
| | | | - Marc Leone
- Department of Anesthesiology and Intensive care unit, Nord Hospital, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France.
| | - Shigeki Fujitan
- Department of Emergency medicine and Critical care medicine, St. Marianna University, Kanagawa, Japan
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Gustav Torisson
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden.
| | - Fredrik Sjövall
- Department of Perioperative Medicine and Intensive Care Medicine, Skåne University Hospital, Malmö, Sweden.
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Barbier F, Dupuis C, Buetti N, Schwebel C, Azoulay É, Argaud L, Cohen Y, Hong Tuan Ha V, Gainnier M, Siami S, Forel JM, Adrie C, de Montmollin É, Reignier J, Ruckly S, Zahar JR, Timsit JF. Single-drug versus combination antimicrobial therapy in critically ill patients with hospital-acquired pneumonia and ventilator-associated pneumonia due to Gram-negative pathogens: a multicenter retrospective cohort study. Crit Care 2024; 28:10. [PMID: 38172969 PMCID: PMC10765858 DOI: 10.1186/s13054-023-04792-0] [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: 09/27/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024] Open
Abstract
KEY MESSAGES In this study including 391 critically ill patients with nosocomial pneumonia due to Gram-negative pathogens, combination therapy was not associated with a reduced hazard of death at Day 28 or a greater likelihood of clinical cure at Day 14. No over-risk of AKI was observed in patients receiving combination therapy. BACKGROUND The benefits and harms of combination antimicrobial therapy remain controversial in critically ill patients with hospital-acquired pneumonia (HAP), ventilated HAP (vHAP) or ventilator-associated pneumonia (VAP) involving Gram-negative bacteria. METHODS We included all patients in the prospective multicenter OutcomeRea database with a first HAP, vHAP or VAP due to a single Gram-negative bacterium and treated with initial adequate single-drug or combination therapy. The primary endpoint was Day-28 all-cause mortality. Secondary endpoints were clinical cure rate at Day 14 and a composite outcome of death or treatment-emergent acute kidney injury (AKI) at Day 7. The average effects of combination therapy on the study endpoints were investigated through inverse probability of treatment-weighted regression and multivariable regression models. Subgroups analyses were performed according to the resistance phenotype of the causative pathogens (multidrug-resistant or not), the pivotal (carbapenems or others) and companion (aminoglycosides/polymyxins or others) drug classes, the duration of combination therapy (< 3 or ≥ 3 days), the SOFA score value at pneumonia onset (< 7 or ≥ 7 points), and in patients with pneumonia due to non-fermenting Gram-negative bacteria, pneumonia-related bloodstream infection, or septic shock. RESULTS Among the 391 included patients, 151 (38.6%) received single-drug therapy and 240 (61.4%) received combination therapy. VAP (overall, 67.3%), vHAP (16.4%) and HAP (16.4%) were equally distributed in the two groups. All-cause mortality rates at Day 28 (overall, 31.2%), clinical cure rate at Day 14 (43.7%) and the rate of death or AKI at Day 7 (41.2%) did not significantly differ between the groups. In inverse probability of treatment-weighted analyses, combination therapy was not independently associated with the likelihood of all-cause death at Day 28 (adjusted odd ratio [aOR], 1.14; 95% confidence interval [CI] 0.73-1.77; P = 0.56), clinical cure at Day 14 (aOR, 0.79; 95% CI 0.53-1.20; P = 0.27) or death or AKI at Day 7 (aOR, 1.07; 95% CI 0.71-1.63; P = 0.73). Multivariable regression models and subgroup analyses provided similar results. CONCLUSIONS Initial combination therapy exerts no independent impact on Day-28 mortality, clinical cure rate at Day 14, and the hazard of death or AKI at Day 7 in critically ill patients with mono-bacterial HAP, vHAP or VAP due to Gram-negative bacteria.
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Affiliation(s)
- François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, Orléans, France.
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, 14, Avenue de L'Hôpital, 45000, Orléans, France.
| | - Claire Dupuis
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | - Niccolò Buetti
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
- IAME UMR 1137, INSERM, Université Paris-Cité, Paris, France
| | - Carole Schwebel
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Grenoble - Alpes, La Tronche, France
| | - Élie Azoulay
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Saint-Louis, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Yves Cohen
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | | | - Marc Gainnier
- Réanimation des Urgences, Centre Hospitalier Universitaire La Timone, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Shidasp Siami
- Réanimation Polyvalente, Centre Hospitalier Sud-Essonne, Étampes, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Nord, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Christophe Adrie
- Réanimation Polyvalente, Centre Hospitalier Delafontaine, Saint-Denis, France
| | - Étienne de Montmollin
- Service de Médecine Intensive et Réanimation Infectieuse, Centre Hospitalier Universitaire Bichat - Claude Bernard, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean Reignier
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Jean-Ralph Zahar
- IAME UMR 1137, INSERM, Université Paris-Cité, Paris, France
- Département de Microbiologie Clinique, Centre Hospitalier Universitaire Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | - Jean-François Timsit
- IAME UMR 1137, INSERM, Université Paris-Cité, Paris, France
- Service de Médecine Intensive et Réanimation Infectieuse, Centre Hospitalier Universitaire Bichat - Claude Bernard, Assistance Publique - Hôpitaux de Paris, Paris, France
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Li L, Huang L, Liu X, Ye Y, Sai F, Huang H. Intensive care unit-acquired pneumonia caused by Klebsiella pneumoniae in China: Risk factors and prediction model of mortality. Medicine (Baltimore) 2023; 102:e33269. [PMID: 36961194 PMCID: PMC10035998 DOI: 10.1097/md.0000000000033269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023] Open
Abstract
Intensive care unit (ICU)-acquired pneumonia (ICUAP) is a major concern owing to its associated high mortality rate. Few studies have focused on ICUAP caused by Klebsiella pneumoniae (KP). This study aimed to investigate the risk factors for ICUAP-associated death due to KP and to develop a mortality prediction model. Patients with KP-associated ICUAP at Renji Hospital were enrolled from January 2012 to December 2017. The patients were registered from the ICU units of the Surgery, Gynecology and Obstetrics, Neurosurgery, Emergency and Geriatric Departments, and were followed for 30 days. A multivariate analysis was performed to analyze the differences between 30-day survivors and nonsurvivors, and to determine the independent risk factors. Receiver operator characteristic (ROC) curves were also used to determine the predictive power of the model. Among the 285 patients with KP-associated ICUAP, the median age was 70.55 years, and 61.6% were men. Fifty patients died. The nonsurvivors had a lower Glasgow coma score (GCS), platelet count, and albumin concentrations, but higher lactate concentrations, than the survivors. The nonsurvivors were also more likely to be admitted to the ICU for respiratory failure and surgery, and they received less appropriate empirical antimicrobial therapy than the survivors. A lower GCS (odds ratio [OR] = 0.836, 95% confidence interval [CI]: 0.770-0.907), lower albumin concentrations (OR = 0.836, 95% CI: 0.770-0.907), higher lactate concentrations (OR = 1.167, 95% CI: 1.0013-1.344) and inappropriate empirical treatment (OR = 2.559, 95% CI: 1.080-6.065) were independent risk factors for mortality in patients with KP-associated ICUAP. ROC curve analysis showed that the risk of death was higher in patients with 2 or more independent risk factors. The predictive model was effective, with an area under the ROC curve of 0.823 (95% CI: 0.773-0.865). The number of independent risk factors is positively correlated with the risk of death. Our model shows excellent predictive performance.
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Affiliation(s)
- Lanyu Li
- Department of Emergency Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Liying Huang
- Department of General Practice, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiaolei Liu
- Department of Emergency Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yan Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Fangfang Sai
- Department of General Practice, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Huan Huang
- Department of Emergency Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Methods to appraise available evidence and adequacy of data from a systematic literature review to conduct a robust network meta-analysis of treatment options for patients with hospital-acquired or ventilator-associated bacterial pneumonia. PLoS One 2023; 18:e0279844. [PMID: 36598902 DOI: 10.1371/journal.pone.0279844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023] Open
Abstract
We aimed to determine if available evidence from a previously conducted systematic literature review was sufficient to conduct a robust network meta-analysis (NMA) using the International Society for Pharmacoeconomics and Outcomes Research Good Practice Task Force NMA study questionnaire to evaluate suitability, relevance, and credibility of available randomized-controlled trials (RCT) of antibacterial therapies for treatment of patients with hospital-acquired or ventilator-associated bacterial pneumonia (HABP/VABP). We assessed feasibility and reliability of an NMA for a connected network of RCTs, and then relevance and credibility of the connected network for informing decision-making. This previously conducted systematic literature review using Cochrane dual-reviewer methodology, Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and PICOTS (population, interventions, comparators, outcomes, timing, and setting) criteria identified 25 citations between 2001 and 2018; 18 were unique RCTs. Trial design characteristics, outcome definitions, assessment time points, and analyses populations varied across studies. Using "clinical response," an efficacy end point to health technology assessment agencies, we assessed potential network credibility, which collapsed from the overall data set to four studies and five interventions. This did not include closed loop(s) needed to assess consistency. Of the studies reporting clinical response, >70% of patients were ventilated at baseline with mean Acute Physiologic Assessment and Chronic Health Evaluation II scores from 14.7 to 17.5. Pseudomonas aeruginosa (range, 18.4-64.1%) and Klebsiella spp. (range, 1.6-49%) were the most common causative pathogens. We identified relevant RCTs for most standard-of-care agents approved for HABP/VABP, which provided a comprehensive evidence base. In summary, our appraisal of available evidence for the clinical response outcome among adult patients with HABP/VABP does not support the conduct of a scientifically robust and clinically meaningful NMA. Although this data is vital to registration, there are significant limitations in these trials for health technology assessments, payor decisions, guidelines, and protocol decisions.
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Timing and Spectrum of Antibiotic Treatment for Suspected Sepsis and Septic Shock: Why so Controversial? Infect Dis Clin North Am 2022; 36:719-733. [PMID: 36328632 DOI: 10.1016/j.idc.2022.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sepsis guidelines and mandates encourage increasingly aggressive time-to-antibiotic targets for broad-spectrum antimicrobials for suspected sepsis and septic shock. This has caused considerable controversy due to weaknesses in the underlying evidence and fear that overly strict antibiotic deadlines may harm patients by perpetuating or escalating overtreatment. Indeed, a third or more of patients currently treated for sepsis and septic shock have noninfectious or nonbacterial conditions. These patients risk all the potential harms of antibiotics without their possible benefits. Updated Surviving Sepsis Campaign guidelines now emphasize the importance of tailoring antibiotics to each patient's likelihood of infection, risk for drug-resistant pathogens, and severity-of-illness.
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Relationship between Pharmacokinetic/Pharmacodynamic Target Attainment and Microbiological Outcome in Critically Ill COVID-19 Patients with Documented Gram-Negative Superinfections Treated with TDM-Guided Continuous-Infusion Meropenem. Pharmaceutics 2022; 14:pharmaceutics14081585. [PMID: 36015211 PMCID: PMC9412264 DOI: 10.3390/pharmaceutics14081585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/23/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives: The objective of this study was to explore the relationship between pharmacokinetic/pharmacodynamic (PK/PD) target attainment of continuous-infusion (CI) meropenem and microbiological outcome in critical COVID-19 patients with documented Gram-negative superinfections. Methods: Patients receiving CI meropenem for documented Gram-negative infections at the COVID ICU of the IRCCS Azienda Ospedaliero-Universitaria di Bologna and undergoing therapeutic drug monitoring from January 2021 to February 2022 were retrospectively assessed. Average steady-state meropenem concentrations (Css) were calculated and the Css/MIC ratio was selected as a pharmacodynamic parameter of meropenem efficacy. The Css/MIC ratio was defined as optimal if ≥4, quasi-optimal if between 1 and 4, and suboptimal if <1. The relationship between Css/MIC and microbiological outcome was assessed. Results: Overall, 43 critical COVID-19 patients with documented Gram-negative infections were retrieved. Combination therapy was implemented in 26 cases. Css/MIC ratios were optimal in 27 (62.8%), quasi-optimal in 7 (16.3%), and suboptimal in 9 cases (20.9%). Microbiological failure occurred in 21 patients (48.8%), with no difference between monotherapy and combination therapy (43.8% vs. 53.8%; p = 0.53). The microbiological failure rate was significantly lower in patients with an optimal Css/MIC ratio compared to those with a quasi-optimal or suboptimal Css/MIC ratio (33.3% vs. 75.0%; p = 0.01). Conclusion: Suboptimal attainment of meropenem PK/PD targets may be a major determinant impacting on microbiological failure in critical COVID-19 patients with Gram-negative superinfections.
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Alkhawaldeh R, Abu Farha R, Abu Hammour K, Alefishat E. The Appropriateness of Empiric Treatment of Urinary Tract Infections in a Tertiary Teaching Hospital in Joran: A Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11050629. [PMID: 35625272 PMCID: PMC9137745 DOI: 10.3390/antibiotics11050629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
This is a cross-sectional study that was conducted at Jordan University Hospital (JUH) to evaluate the appropriateness of Urinary Tract Infection (UTI) empiric treatment based on microbial culture data and susceptibility testing. All urine cultures requested for adult patients (≥18 years) admitted to JUH within the period from January 2019–July 2021 were reviewed and only those cultures with positive episodes of infection were considered. In this study, 6950 urine culture episodes were screened; among them, 34.5% (n = 2400) revealed positive results. Among those patients with positive culture episodes, 1600 patients (66.7%) were discharged before the availability of culture results and were excluded. Of the remaining eligible 800 patients, 701 (87.6%) received empiric treatment. In 26.8% of the eligible cases (n = 214), the prescribed empiric agents failed to have appropriate coverage of the identified pathogens, and in 14.6% of the cases (n = 117) the identified microorganisms were reported as resistant to the prescribed empiric agents. Furthermore, only 13.4% of the patients (n = 107) were appropriately treated for their UTI with empiric antibacterial agents. We were not able to judge the appropriateness of UTI treatment for one third (n = 263, 32.9%) of the patients, because they did not have susceptibility reports performed. This study revealed an alarmingly high rate of inappropriate treatment of UTIs, which encourages the emergence of bacterial resistance and affects health-related outcomes negatively. Therefore, antimicrobial stewardship programs must be applied to optimize antibiotic consumption in hospital settings.
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Affiliation(s)
- Rama Alkhawaldeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan; (R.A.); (R.A.F.)
| | - Rana Abu Farha
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan; (R.A.); (R.A.F.)
| | - Khawla Abu Hammour
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman 11942, Jordan;
| | - Eman Alefishat
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman 11942, Jordan;
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi 127788, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi 127788, United Arab Emirates
- Correspondence: ; Tel.: +97-15-018-466
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Lynch JP, Zhanel GG. Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy. Semin Respir Crit Care Med 2022; 43:191-218. [PMID: 35062038 DOI: 10.1055/s-0041-1740109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Pan D, Niederman MS. Risk Factors and Algorithms for the Empirical Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:183-190. [PMID: 35042262 DOI: 10.1055/s-0041-1740335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to be major concerns for morbidity and mortality, especially in patients treated in the intensive care unit. With the rise in multidrug-resistant organisms, HAP and VAP treatment is challenged by the need for early appropriate treatment, with broad-spectrum agents, while still being aware of the principles of antibiotic stewardship. The two major society guidelines proposed a series of risk factors in their most recent guidelines to help identify patients who can most benefit from narrow- or broad-spectrum initial empiric antibiotic therapy. The guidelines reveal differences in the proposed risk factors and treatment approaches, as well as major similarities.
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Affiliation(s)
- Di Pan
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Michael S Niederman
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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Korang SK, Maagaard M, Feinberg JB, Perner A, Gluud C, Jakobsen JC. The effects of adding quinolones to beta-lactam antibiotics for sepsis. Acta Anaesthesiol Scand 2021; 65:1023-1032. [PMID: 33864250 DOI: 10.1111/aas.13831] [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: 03/10/2021] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sepsis is common, deadly, and a major challenge to treat. Quinolones added to beta-lactam antibiotics are currently recommended as a second-line empiric regimen in sepsis, but the evidence regarding their benefits and harms is unclear. OBJECTIVE To assess the benefits and harms of adding quinolones to standard care for sepsis. DATA SOURCES We conducted a systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-Expanded, and BIOSIS. STUDY SELECTION Randomized clinical trials assessing the effects of adding any quinolone to standard care for children and adults with sepsis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened studies and extracted data. The certainty of the evidence was assessed by GRADE. RESULTS We included three trials randomizing 995 adults. All trials were at overall "high risk of bias." All trials compared a quinolone (moxifloxacin, levofloxacin, or ciprofloxacin) and a beta-lactam antibiotic versus the same beta-lactam antibiotic. We found no evidence of an effect of adding quinolones to beta-lactam antibiotics when assessing all-cause mortality (RR 1.07, 95% CI 0.86 to 1.33; 2 trials; 915 participants; very low certainty of evidence) and serious adverse events (RR 1.00, 95% CI 0.67 to 1.50; 977 participants; two trials; very low certainty of evidence). No trials reported on quality of life. CONCLUSIONS The effects of adding quinolones to beta-lactam antibiotics for the treatment of sepsis were unclear for all outcomes. Additional trial data are warranted to support the recommendation of empirical use of quinolones for sepsis.
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Affiliation(s)
- Steven K. Korang
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - Mathias Maagaard
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Anaesthesiology Centre for Anaesthesiological Research Zealand University HospitalThe Zealand Region of Denmark Koge Denmark
| | - Joshua B. Feinberg
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care RigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine The Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- The Cochrane Hepato‐Biliary Group Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Regional Health Research The Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Regional Health Research The Faculty of Health Sciences University of Southern Denmark Odense Denmark
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Impact of Cardiovascular Failure in Intensive CareUnit-Acquired Pneumonia: A Single-Center, Prospective Study. Antibiotics (Basel) 2021; 10:antibiotics10070798. [PMID: 34209181 PMCID: PMC8300830 DOI: 10.3390/antibiotics10070798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Cardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to determine the impact of CVF on outcome in patients with ICUAP. Methods: A prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS. Results: 358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa02/FiO2 improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. Conclusions: Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.
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Strich JR, Heil EL, Masur H. Considerations for Empiric Antimicrobial Therapy in Sepsis and Septic Shock in an Era of Antimicrobial Resistance. J Infect Dis 2020; 222:S119-S131. [PMID: 32691833 PMCID: PMC7372215 DOI: 10.1093/infdis/jiaa221] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order.
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Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Henry Masur
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Ott SR, Bodmann KF, Grabein B, Höffken G, Kolditz M, Lode H, Pletz MW, Thalhammer F. Calculated parenteral initial treatment of bacterial infections: Respiratory infections. GMS INFECTIOUS DISEASES 2020; 8:Doc15. [PMID: 32373440 PMCID: PMC7186806 DOI: 10.3205/id000059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This is the fifth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. It provides recommendations for the empirical and targeted antimicrobial treatment of lower respiratory tract infections, with a special emphasis on the treatment of acute exacerbation of COPD, community-acquired pneumonia and hospital-acquired pneumonia.
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Affiliation(s)
| | - Klaus-Friedrich Bodmann
- Klinik für Internistische Intensiv- und Notfallmedizin und Klinische Infektiologie, Klinikum Barnim GmbH, Werner Forßmann Krankenhaus, Eberswalde, Germany
| | - Béatrice Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Munich, Germany
| | | | - Martin Kolditz
- Pneumologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | | | - Mathias W. Pletz
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Germany
| | - Florian Thalhammer
- Klinische Abteilung für Infektiologie und Tropenmedizin, Medizinische Universität Wien, Vienna, Austria
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Hyzy RC, McSparron J. Ventilator-Associated Pneumonia. EVIDENCE-BASED CRITICAL CARE 2020. [PMCID: PMC7120513 DOI: 10.1007/978-3-030-26710-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventilator-associated pneumonia occurs in patients who have been intubated for at least 2–3 days with significant exposure to hospital-acquired organisms. Treatment should be initiated rapidly and cover Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumonia, and methicillin-resistant Staphylococcus aureus(MRSA). Within 72 h or with the availability of culture results, antibiotics should be narrowed. Active research is on-going to identify patients at risk for ventilator-associated complications and to minimize the likelihood of infection in these patients.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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Which Multicenter Randomized Controlled Trials in Critical Care Medicine Have Shown Reduced Mortality? A Systematic Review. Crit Care Med 2019; 47:1680-1691. [DOI: 10.1097/ccm.0000000000004000] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Cisneros JM, Rosso-Fernández CM, Roca-Oporto C, De Pascale G, Jiménez-Jorge S, Fernández-Hinojosa E, Matthaiou DK, Ramírez P, Díaz-Miguel RO, Estella A, Antonelli M, Dimopoulos G, Garnacho-Montero J. Colistin versus meropenem in the empirical treatment of ventilator-associated pneumonia (Magic Bullet study): an investigator-driven, open-label, randomized, noninferiority controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:383. [PMID: 31779711 PMCID: PMC6883535 DOI: 10.1186/s13054-019-2627-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/27/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Colistin is recommended in the empirical treatment of ventilator-associated pneumonia (VAP) with a high prevalence of carbapenem-resistant gram-negative bacilli (CR-GNB). However, the efficacy and safety of colistin are not well defined. METHODS A multicenter prospective randomized trial conducted in 32 European centers compared the efficacy and safety of colistin (4.5 million unit loading dose followed by a maintenance dose of 3 million units every 8 h) versus meropenem (2 g every 8 h), both in combination with levofloxacin (500 mg every 12 h) for 7-14 days in patients with late VAP. Between May 2012 and October 2015, 232 patients were randomly assigned to the 2 treatment groups. The primary endpoint was mortality at 28 days after randomization in the microbiologically modified intention-to-treat (mMITT) population. Secondary outcomes included clinical and microbiological cure, renal function at the end of the treatment, and serious adverse events. The study was interrupted after the interim analysis due to excessive nephrotoxicity in the colistin group; therefore, the sample size was not achieved. RESULTS A total of 157 (67.7%) patients were included in the mMITT population, 36 of whom (22.9%) had VAP caused by CR-GNB. In the mMITT population, no significant difference in mortality between the colistin group (19/82, 23.2%) and the meropenem group (19/75, 25.3%) was observed, with a risk difference of - 2.16 (- 15.59 to 11.26, p = 0.377); the noninferiority of colistin was not demonstrated due to early termination and limited number of patients infected by carbapenem-resistant pathogens. Colistin plus levofloxacin increased the incidence of renal failure (40/120, 33.3%, versus 21/112, 18.8%; p = 0.012) and renal replacement therapy (11/120, 9.1%, versus 2/112, 1.8%; p = 0.015). CONCLUSIONS This study did not demonstrate the noninferiority of colistin compared with meropenem, both combined with levofloxacin, in terms of efficacy in the empirical treatment of late VAP but demonstrated the greater nephrotoxicity of colistin. These findings do not support the empirical use of colistin for the treatment of late VAP due to early termination. TRIAL REGISTRATION ClinicalTrials.gov, NCT01292031. Registered 9 February 2011.
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Affiliation(s)
- José M Cisneros
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocio CSIC, University of Seville, Avenida Manuel Siurot s/n, 41013, Seville, Spain.
| | - Clara María Rosso-Fernández
- Clinical Trial Unit, Hospital Universitario Virgen del Rocío, Avenida Manuel Siurot s/n, 41013, Seville, Spain
| | - Cristina Roca-Oporto
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocio CSIC, University of Seville, Avenida Manuel Siurot s/n, 41013, Seville, Spain
| | | | - Silvia Jiménez-Jorge
- Clinical Trial Unit, Hospital Universitario Virgen del Rocío, Avenida Manuel Siurot s/n, 41013, Seville, Spain
| | - Esteban Fernández-Hinojosa
- Intensive Care Clinical Unit, Hospital Universitario Virgen del Rocío, Avenida Manuel Siurot s/n, 41013, Seville, Spain
| | - Dimitrios K Matthaiou
- Department of Critical Care, University Hospital ATTIKON, National and Kapodistrian University of Athens, Athens, Greece
| | - Paula Ramírez
- Intensive Medicine Unit, Hospital Universitario y Politécnico La Fe, Avinguda de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Ramón Ortiz Díaz-Miguel
- Intensive Medicine Unit, Hospital General Universitario de Ciudad Real, Calle Obispo Rafael Torija s/n, 13005, Ciudad Real, Spain
| | - Angel Estella
- Intensive Care Unit, Hospital Universitario de Jerez, Carretera Nacional IV s/n, 11407, Jerez de la Frontera, Cádiz, Spain
| | - Massimo Antonelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, National and Kapodistrian University of Athens, Athens, Greece
| | - José Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Calle Dr. Fedriani, 3, 41009, Seville, Spain
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Obodozie-Ofoegbu OO, Teng C, Mortensen EM, Frei CR. Antipseudomonal monotherapy or combination therapy for older adults with community-onset pneumonia and multidrug-resistant risk factors: a retrospective cohort study. Am J Infect Control 2019; 47:1053-1058. [PMID: 30904374 PMCID: PMC6710104 DOI: 10.1016/j.ajic.2019.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Infectious Diseases Society of America guidelines recommend empiric antipseudomonal combination therapy when Pseudomonas is suspected. However, combination antipseudomonal therapy is controversial. This study compares all-cause 30-day mortality in older patients who received antipseudomonal monotherapy (PMT) or antipseudomonal combination therapy (PCT) for the treatment of community-onset pneumonia. METHODS This population-based, retrospective cohort study used data from over 150 Veterans Health Administration hospitals. Patients were classified as being at low, medium, or high risk of drug-resistant pathogens. In total, 31,027 patients were assigned to PCT or PMT treatment arms based on antibiotics received in the first 48 hours of hospital admission. RESULTS The unadjusted 30-day mortality difference between PCT and PMT was most pronounced in the low-risk group (18% vs 8%), followed by the medium-risk group (24% vs 18%) and then the high-risk group (39% vs 33%). PCT was associated with higher 30-day mortality than PMT overall (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.43-1.66) in all 3 risk groups: low (aOR, 1.69; 95% CI, 1.50-1.89), medium (aOR, 1.30; 95% CI, 1.14-1.48), and high (aOR, 1.21; 95% CI, 1.04-1.40). CONCLUSIONS Older adults who received combination antipseudomonal therapy for community-onset pneumonia fared worse than those who received monotherapy. Empiric combination antipseudomonal therapy should not be routinely offered to all patients suspected of having pseudomonal pneumonia.
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Affiliation(s)
- Obiageri O Obodozie-Ofoegbu
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
| | - Chengwen Teng
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX
| | - Eric M Mortensen
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX.
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Ventilator-Associated Pneumonia and PaO 2/F IO 2 Diagnostic Accuracy: Changing the Paradigm? J Clin Med 2019; 8:jcm8081217. [PMID: 31416285 PMCID: PMC6722826 DOI: 10.3390/jcm8081217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023] Open
Abstract
Background: Ventilator-associated pneumonia (VAP) is associated to longer stay and poor outcomes. Lacking definitive diagnostic criteria, worsening gas exchange assessed by PaO2/FIO2 ≤ 240 in mmHg has been proposed as one of the diagnostic criteria for VAP. We aim to assess the adequacy of PaO2/FIO2 ≤ 240 to diagnose VAP. Methods: Prospective observational study in 255 consecutive patients with suspected VAP, clustered according to PaO2/FIO2 ≤ 240 vs. > 240 at pneumonia onset. The primary analysis was the association between PaO2/FIO2 ≤ 240 and quantitative microbiologic confirmation of pneumonia, the most reliable diagnostic gold-standard. Results: Mean PaO2/FIO2 at VAP onset was 195 ± 82; 171 (67%) cases had PaO2/FIO2 ≤ 240. Patients with PaO2/FIO2 ≤ 240 had a lower APACHE-II score at ICU admission; however, at pneumonia onset they had higher CPIS, SOFA score, acute respiratory distress syndrome criteria and incidence of shock, and less microbiological confirmation of pneumonia (117, 69% vs. 71, 85%, p = 0.008), compared to patients with PaO2/FIO2 > 240. In multivariate logistic regression, PaO2/FIO2 ≤ 240 was independently associated with less microbiological confirmation (adjusted odds-ratio 0.37, 95% confidence interval 0.15–0.89, p = 0.027). The association between PaO2/FIO2 and microbiological confirmation of VAP was poor, with an area under the ROC curve 0.645. Initial non-response to treatment and length of stay were similar between both groups, while hospital mortality was higher in patients with PaO2/FIO2 ≤ 240. Conclusion: Adding PaO2/FIO2 ratio ≤ 240 to the clinical and radiographic criteria does not help in the diagnosis of VAP. PaO2/FIO2 ratio > 240 does not exclude this infection. Using this threshold may underestimate the incidence of VAP.
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sarda C, Fazal F, Rello J. Management of ventilator-associated pneumonia (VAP) caused by resistant gram-negative bacteria: which is the best strategy to treat? Expert Rev Respir Med 2019; 13:787-798. [PMID: 31210549 DOI: 10.1080/17476348.2019.1632195] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Treatment of ventilator-associated pneumonia (VAP) is a major challenge. The increase in multi-drug resistant bacteria has not been accompanied by the validation of new drugs, or by any new antimicrobial strategies to exploit the available agents. VAP due to Gram-negative bacteria has increased mortality, both due to the resistant pathogens themselves and due to inappropriate treatment. Local epidemiology, patients' characteristics and clinical responses provide the most important information for therapeutic decision-making. Moreover, data on VAP therapy due to resistant bacteria are lacking, and the choice of treatment is often based on clinical practice and individual experience. Areas covered: This review summarizes the strategies available for treating the three most prevalent resistant Gram-negative organisms causing VAP: Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae. The review covers the results of a Pubmed search, clinical practice guidelines and reviews, and the authors' experience. Expert opinion: The existing evidence focuses on bloodstream infections or other sites rather than pneumonia and there are no recommendations for the treatment of VAP by multi-drug resistant Gram-negative bacteria, especially for combination regimens. The approval of new drugs is needed to provide effective and safe alternatives for treating carbapenemase-producing strains. Precision medicine and personalized approach are also fundamental in future research.
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Affiliation(s)
- Cristina Sarda
- a Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia , Pavia , Italy
| | - Farhan Fazal
- b Department of Medicine and Microbiology (Infectious Disease), All India Institute of Medical Science (AIIMS) New Delhi , New Delhi , India
| | - Jordi Rello
- c Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Stewart SD, Allen S. Antibiotic use in critical illness. J Vet Emerg Crit Care (San Antonio) 2019; 29:227-238. [PMID: 31021520 DOI: 10.1111/vec.12842] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 05/17/2017] [Accepted: 06/12/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a review on the current use of antimicrobials with a discussion on the pharmacokinetic and pharmacodynamic profiles of antimicrobials in critically ill patients, the challenges of drug resistance, the use of diagnostic testing to direct therapy, and the selection of the most likely efficacious antimicrobial protocol. ETIOLOGY Patients in the intensive care unit often possess profound pathophysiologic changes that can complicate antimicrobial therapy. Although many antimicrobials have known pharmacodynamic profiles, critical illness can cause wide variations in their pharmacokinetics. The two principal factors affecting pharmacokinetics are volume of distribution and drug clearance. Understanding the interplay between critical illness, drug pharmacokinetics, and antimicrobial characteristics (ie, time-dependent vs concentration-dependent) may improve antimicrobial efficacy and patient outcome. DIAGNOSIS Utilizing bacterial culture and susceptibility can aid in identifying drug resistant infections, selecting the most appropriate antimicrobials, and hindering the future development of drug resistance. THERAPY Having a basic knowledge of antimicrobial function and how to use diagnostics to direct therapeutic treatment is paramount in managing this patient population. Diagnostic testing is not always available at the time of initiation of antimicrobial therapy, so empiric selections are often necessary. These empiric choices should be made based on the location of the infection and the most likely infecting bacteria. PROGNOSIS Studies have demonstrated the importance of moving away from a "one dose fits all" approach to antimicrobial therapy. Instead there has been a move toward an individualized approach that takes into consideration the pharmacokinetic and pharmacodynamic variabilities that can occur in critically ill patients.
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Affiliation(s)
- Samuel D Stewart
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
| | - Sarah Allen
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
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Burgos J, Falcó V, Almirante B. Chemical pharmacotherapy for hospital-acquired pneumonia in the elderly. Expert Opin Pharmacother 2019; 20:423-434. [PMID: 30614744 DOI: 10.1080/14656566.2018.1559820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Hospital-acquired pneumonia (HAP) is a potentially serious infection that primarily affects older patients. The number of patients affected by multidrug-resistant (MDR) bacteria is increasing, including infection from strains of Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa. AREAS COVERED This article focuses specifically on HAP, excluding patients afflicted by ventilator-associated pneumonia (VAP). The pathogenesis and clinical features of HAP in the elderly are discussed as well as specific drug pharmacokinetic and pharmacodynamic considerations in elderly patients. The current recommended guidelines for the management of HAP are also discussed. Finally, the authors provide evidence on the empirical therapy used for the treatment of HAP and widely consider specific-pathogen treatment of HAP in elderly patients. EXPERT OPINION In patients not at risk of MDR organism infection, antibiotics including piperacillin-tazobactam, cefepime, carbapenems or fluorquinolones are recommended. However, the emergence of MDR organisms as causal agents of HAP makes it necessary to accurately assess risk factors to these pathogens and revise our knowledge on specific antimicrobial susceptibility patterns from each institution. The authors believe that broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are best recommended in elderly patients at risk of HAP infection by MDR strains.
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Affiliation(s)
- Joaquin Burgos
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
| | - Vicenç Falcó
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
| | - Benito Almirante
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
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Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 34:215-220. [PMID: 28248705 DOI: 10.1097/eja.0000000000000595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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El Chakhtoura NG, Saade E, Iovleva A, Yasmin M, Wilson B, Perez F, Bonomo RA. Therapies for multidrug resistant and extensively drug-resistant non-fermenting gram-negative bacteria causing nosocomial infections: a perilous journey toward 'molecularly targeted' therapy. Expert Rev Anti Infect Ther 2018; 16:89-110. [PMID: 29310479 PMCID: PMC6093184 DOI: 10.1080/14787210.2018.1425139] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/04/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Non-fermenting Gram-negative bacilli are at the center of the antimicrobial resistance epidemic. Acinetobacter baumannii and Pseudomonas aeruginosa are both designated with a threat level to human health of 'serious' by the Centers for Disease Control and Prevention. Two other major non-fermenting Gram-negative bacilli, Stenotrophomonas maltophilia and Burkholderia cepacia complex, while not as prevalent, have devastating effects on vulnerable populations, such as those with cystic fibrosis, as well as immunosuppressed or hospitalized patients. Areas covered: In this review, we summarize the clinical impact, presentations, and mechanisms of resistance of these four major groups of non-fermenting Gram-negative bacilli. We also describe available and promising novel therapeutic options and strategies, particularly combination antibiotic strategies, with a focus on multidrug resistant variants. Expert commentary: We finally advocate for a therapeutic approach that incorporates in vitro antibiotic susceptibility testing with molecular and genotypic characterization of mechanisms of resistance, as well as pharmacokinetics and pharmacodynamics (PK/PD) parameters. The goal is to begin to formulate a precision medicine approach to antimicrobial therapy: a clinical-decision making model that integrates bacterial phenotype, genotype and patient's PK/PD to arrive at rationally-optimized combination antibiotic chemotherapy regimens tailored to individual clinical scenarios.
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Affiliation(s)
- Nadim G. El Chakhtoura
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Elie Saade
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Medicine, University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alina Iovleva
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohamad Yasmin
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Medicine, University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brigid Wilson
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Federico Perez
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert A. Bonomo
- Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Services Case Western Reserve University School of Medicine, Cleveland, Ohio
- Geriatrics Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Medicine, University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine, Cleveland, Ohio
- Departments of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Nowak J, Zander E, Stefanik D, Higgins PG, Roca I, Vila J, McConnell MJ, Cisneros JM, Seifert H. High incidence of pandrug-resistant Acinetobacter baumannii isolates collected from patients with ventilator-associated pneumonia in Greece, Italy and Spain as part of the MagicBullet clinical trial. J Antimicrob Chemother 2017; 72:3277-3282. [PMID: 28961773 PMCID: PMC5890771 DOI: 10.1093/jac/dkx322] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To investigate the molecular epidemiology, antimicrobial susceptibility and carbapenem resistance determinants of Acinetobacter baumannii isolates from respiratory tract samples of patients diagnosed with ventilator-associated pneumonia (VAP) who were enrolled in the MagicBullet clinical trial. METHODS A. baumannii isolates were prospectively cultured from respiratory tract samples from 65 patients from 15 hospitals in Greece, Italy and Spain. Susceptibility testing was performed by broth microdilution. Carbapenem resistance determinants were identified by PCR and sequencing. Molecular epidemiology was investigated using rep-PCR (DiversiLab) and international clones (IC) were identified using our in-house database. RESULTS Of 65 isolates, all but two isolates (97%) were resistant to imipenem and these were always associated with an acquired carbapenemase, OXA-23 (80%), OXA-40 (4.6%), OXA-58 (1.5%) or OXA-23/58 (1.5%). Resistance to colistin was 47.7%. Twenty-two isolates were XDR, and 20 isolates were pandrug-resistant (PDR). The majority of isolates clustered with IC2 (n = 54) with one major subtype comprising isolates from 12 hospitals in the three countries, which included 19 XDR and 16 PDR isolates. CONCLUSIONS Carbapenem resistance rates were very high in A. baumannii recovered from patients with VAP. Almost half of the isolates were colistin resistant, and 42 (64.6%) isolates were XDR or PDR. Rep-PCR confirmed IC2 is the predominant clonal lineage in Europe and suggests the presence of an epidemic XDR/PDR A. baumannii clone that has spread in Greece, Italy and Spain. These data highlight the difficulty in empirical treatment of patients with A. baumannii VAP in centres with a high prevalence of carbapenem-resistant A. baumannii.
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Affiliation(s)
- J Nowak
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstraße 19-21, 50935 Cologne, Germany
| | - E Zander
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstraße 19-21, 50935 Cologne, Germany
| | - D Stefanik
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstraße 19-21, 50935 Cologne, Germany
| | - P G Higgins
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstraße 19-21, 50935 Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - I Roca
- Department of Clinical Microbiology and ISGlobal, Barcelona Ctr. Int. Health Res. CRESIB, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - J Vila
- Department of Clinical Microbiology and ISGlobal, Barcelona Ctr. Int. Health Res. CRESIB, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - M J McConnell
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocío, Seville, Spain
| | - J M Cisneros
- Clinical Unit of Infectious Diseases, Microbiology, and Preventive Medicine Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocío, Seville, Spain
| | - H Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstraße 19-21, 50935 Cologne, Germany
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, Germany
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Modeling antibiotic treatment in hospitals: A systematic approach shows benefits of combination therapy over cycling, mixing, and mono-drug therapies. PLoS Comput Biol 2017; 13:e1005745. [PMID: 28915236 PMCID: PMC5600366 DOI: 10.1371/journal.pcbi.1005745] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/28/2017] [Indexed: 12/30/2022] Open
Abstract
Multiple treatment strategies are available for empiric antibiotic therapy in hospitals, but neither clinical studies nor theoretical investigations have yielded a clear picture when which strategy is optimal and why. Extending earlier work of others and us, we present a mathematical model capturing treatment strategies using two drugs, i.e the multi-drug therapies referred to as cycling, mixing, and combination therapy, as well as monotherapy with either drug. We randomly sample a large parameter space to determine the conditions determining success or failure of these strategies. We find that combination therapy tends to outperform the other treatment strategies. By using linear discriminant analysis and particle swarm optimization, we find that the most important parameters determining success or failure of combination therapy relative to the other treatment strategies are the de novo rate of emergence of double resistance in patients infected with sensitive bacteria and the fitness costs associated with double resistance. The rate at which double resistance is imported into the hospital via patients admitted from the outside community has little influence, as all treatment strategies are affected equally. The parameter sets for which combination therapy fails tend to fall into areas with low biological plausibility as they are characterised by very high rates of de novo emergence of resistance to both drugs compared to a single drug, and the cost of double resistance is considerably smaller than the sum of the costs of single resistance.
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Weiss E, Essaied W, Adrie C, Zahar JR, Timsit JF. Treatment of severe hospital-acquired and ventilator-associated pneumonia: a systematic review of inclusion and judgment criteria used in randomized controlled trials. Crit Care 2017; 21:162. [PMID: 28655326 PMCID: PMC5488424 DOI: 10.1186/s13054-017-1755-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) are often selected for randomized clinical trials (RCTs) aiming at new drug approval. Guidelines for the design of such RCTs have been repeatedly updated by regulatory agencies. We hypothesized that large variability in the enrolled populations, the endpoints assessed and the HAP/VAP definition criteria may impact the results of these studies, and addressed this through a systematic review of HAP/VAP RCTs. METHODS A search (Pubmed-Embase-ICAAC-ECCMID) of all RCTs published between 1994 and 2016 comparing antimicrobial treatment for HAP/VAP in the intensive care unit was conducted. The populations enrolled, inclusion/exclusion criteria, statistical design and endpoints assessed were recorded. All unpublished RCTs recorded on the ClinicalTrials.gov registry were also screened. RESULTS From the 93 abstracts reviewed, 39 potentially relevant studies were inspected, leading to 27 studies being included. As expected, illness severity or the proportion with VAP (27-100%) differed greatly among the enrolled populations. The HAP/VAP definition used various clinical and biological criteria, and only 55% of studies required a microbiological sample. The mandatory duration of prior hospital stay was variable; the mechanical ventilation duration was an inclusion criterion in only 41% of VAP studies. Nine studies had non-inferiority design, but nine studies (33%) did not have a pre-specified statistical hypothesis. Clinical cure was the primary endpoint in 24 studies, but was recorded in several populations or as the co-primary endpoint in 13 studies. The definition of clinical cure and the timing of its assessment greatly differed. This variability slightly improved over time but remained significant in the 13 registered but currently unpublished RCTs that we screened. CONCLUSION Our study provides a description of populations and endpoints of RCTs evaluating antimicrobials for treatment of HAP/VAP in the ICU. There was significant heterogeneity in enrollment criteria, endpoints and statistical design, which may influence the ability of studies to demonstrate differences between studied drugs.
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Affiliation(s)
- Emmanuel Weiss
- Department of Anesthesiology and Critical Care, HUPNVS, Hôpital Beaujon, APHP, 92110 Clichy, France
- Paris Diderot University, Paris, France
- Inserm UMR_S 1149 Center for Research On Inflammation Inserm/University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - Wafa Essaied
- UMR 1137 - IAME Team 5 – DeSCID: Decision SCiences in Infectious Diseases, control and care Inserm/University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | | | - Jean-Ralph Zahar
- UMR 1137 - IAME Team 5 – DeSCID: Decision SCiences in Infectious Diseases, control and care Inserm/University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
- Microbiology and infection control unit, APHP, Hôpital Avicenne, Paris, France
| | - Jean-François Timsit
- Paris Diderot University, Paris, France
- UMR 1137 - IAME Team 5 – DeSCID: Decision SCiences in Infectious Diseases, control and care Inserm/University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
- Medical and Infectious Intensive Care Unit, AP-HP, Hôpital Bichat Claude Bernard, Paris Diderot University, Paris, F-75018 France
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Lyu Y, Yang X, Goswami S, Gorityala BK, Idowu T, Domalaon R, Zhanel GG, Shan A, Schweizer F. Amphiphilic Tobramycin-Lysine Conjugates Sensitize Multidrug Resistant Gram-Negative Bacteria to Rifampicin and Minocycline. J Med Chem 2017; 60:3684-3702. [PMID: 28409644 DOI: 10.1021/acs.jmedchem.6b01742] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chromosomally encoded low membrane permeability and highly efficient efflux systems are major mechanisms by which Pseudomonas aeruginosa evades antibiotic actions. Our previous reports have shown that amphiphilic tobramycin-fluoroquinolone hybrids can enhance efficacy of fluoroquinolone antibiotics against multidrug-resistant (MDR) P. aeruginosa isolates. Herein, we report on a novel class of tobramycin-lysine conjugates containing an optimized amphiphilic tobramycin-C12 tether that sensitize Gram-negative bacteria to legacy antibiotics. Combination studies indicate the ability of these conjugates to synergize rifampicin and minocycline against MDR and extensively drug resistant (XDR) P. aeruginosa isolates and enhance efficacy of both antibiotics in the Galleria mellonella larvae in vivo infection model. Mode of action studies indicate that the amphiphilic tobramycin-lysine adjuvants enhance outer membrane cell penetration and affect the proton motive force, which energizes efflux pumps. Overall, this study provides a strategy for generating effective antibiotic adjuvants that overcome resistance of rifampicin and minocycline in MDR and XDR Gram-negative bacteria including P. aeruginosa.
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Affiliation(s)
- Yinfeng Lyu
- Institute of Animal Nutrition, Northeast Agricultural University , Harbin, Heilongjiang 150030, P.R. China.,Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada
| | - Xuan Yang
- Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada
| | - Sudeep Goswami
- Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada
| | | | - Temilolu Idowu
- Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada
| | - Ronald Domalaon
- Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba , Winnipeg, MB R3T 1R9, Canada
| | - Anshan Shan
- Institute of Animal Nutrition, Northeast Agricultural University , Harbin, Heilongjiang 150030, P.R. China
| | - Frank Schweizer
- Department of Chemistry, University of Manitoba , Winnipeg, MB R3T 2N2, Canada.,Department of Medical Microbiology/Infectious Diseases, University of Manitoba , Winnipeg, MB R3T 1R9, Canada
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Empirical mono- versus combination antibiotic therapy in adult intensive care patients with severe sepsis – A systematic review with meta-analysis and trial sequential analysis. J Infect 2017; 74:331-344. [DOI: 10.1016/j.jinf.2016.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
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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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Deconinck L, Meybeck A, Patoz P, Van Grunderbeeck N, Boussekey N, Chiche A, Delannoy PY, Georges H, Leroy O. Impact of combination therapy and early de-escalation on outcome of ventilator-associated pneumonia caused by Pseudomonas aeruginosa. Infect Dis (Lond) 2017; 49:396-404. [DOI: 10.1080/23744235.2016.1277035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Laurène Deconinck
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France
| | - Agnès Meybeck
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France
| | - Pierre Patoz
- Laboratoire de microbiologie, Centre Hospitalier de Tourcoing, Tourcoing, France
| | | | - Nicolas Boussekey
- Service de réanimation, Centre Hospitalier de Tourcoing, Tourcoing, France
| | - Arnaud Chiche
- Service de réanimation, Centre Hospitalier de Tourcoing, Tourcoing, France
| | | | - Hugues Georges
- Service de réanimation, Centre Hospitalier de Tourcoing, Tourcoing, France
| | - Olivier Leroy
- Service de réanimation, Centre Hospitalier de Tourcoing, Tourcoing, France
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Kochanek M, Böll B, Vornhagen AS, Michels G, Cornely O, Fätkenheuer G, Aurbach U, Seifert H, Gutschow C, Waldschmidt D, Rybniker J, Skouras E, Vehreschild MJGT, Vehreschild JJ, Kaase M, Scheithauer S. Infektiologie. REPETITORIUM INTERNISTISCHE INTENSIVMEDIZIN 2017. [PMCID: PMC7193718 DOI: 10.1007/978-3-662-53182-2_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Das Kapitel Infektiologie stellt die neue Sepsis-3-Definition, Management und die letzten Sepsisleitlinien von 2012 vor und beleuchtet auch die neuen Entwicklungen seitdem. Darüber hinaus werden Therapievorschläge für die wichtigsten infektiösen Erkrankungen (intraabdominelle Infektionen, akute Pankreatitis, Harnwegsinfekt mit Urosepsis, Pneumonie etc.) auf der Intensivstation gegeben und auch auf spezielle Erkrankungen wie komplizierte Malaria, opportunistische Infektionserkrankungen bei immunsupprimierten Patienten (u. a. HIV) eingegangen. Besonderer Wert wurde auf die mikrobiologische Erregerdiagnostik gelegt (Behälter, Transportmedien, Lagerung der Proben wie auch die richtige Probengewinnung). Zuletzt wird neben den Pilzinfektionen und deren Behandlung jedes der gängigsten Antibiotika und Antimykotika steckbriefartig zusammengefasst.
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Ventilator-Associated Pneumonia and Other Complications. EVIDENCE-BASED CRITICAL CARE 2017. [PMCID: PMC7120823 DOI: 10.1007/978-3-319-43341-7_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ventilator-associated pneumonia occurs in patients who have been intubated for two to three days with significant exposure to hospital-acquired organisms. Treatment should be initiated rapidly and cover P. aeruginosa, Escheriochia coli, Klebsiella pneumonia, and Acinetobacter species as well as methicillin-resistant S. aureus. Within 72 h or with the availability of culture results, antibiotics should be narrowed. Active research is on-going to identify patients at risk for ventilator-associated complications and to minimize the likelihood of infection in these patients.
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Abstract
PURPOSE OF REVIEW Infections are common complications in critically ill patients and are frequently treated with antibiotics. Unfortunately, delivery of optimal therapy is complicated because efficacy of antimicrobials is influenced by the timing of treatment initiation, the use of combination therapy, and the optimization of drug dosing. RECENT FINDINGS Early diagnosis of infection is mandatory to provide a rapid and appropriate antibiotic therapy. The presence of less susceptible strains, in particular for hospital-acquired infections, or patients with severe disease, such as the presence of septic shock, may need combination antibiotic therapy. Antibiotic pharmacokinetics, notably volume of distribution and total body clearance, are significantly altered in these critically ill patients and can influence the attainment of adequate circulating levels when standard dosage regimens are administered. Higher dosing should be considered in such patients, although in case of renal impairment and reduced clearance, drug accumulation could also result in some side-effects. Nebulized antibiotics may provide a better clinical response than systemic antibiotics in ventilator-associated pneumonia because of multidrug-resistant pathogens. SUMMARY The optimal use of antibiotics in the management of severe infections is an important challenge for ICU physicians. Antimicrobial therapy needs to be individualized according to specific patient characteristics, infecting organisms, and susceptibility patterns.
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Fernández-Barat L, Ferrer M, De Rosa F, Gabarrús A, Esperatti M, Terraneo S, Rinaudo M, Li Bassi G, Torres A. Intensive care unit-acquired pneumonia due to Pseudomonas aeruginosa with and without multidrug resistance. J Infect 2016; 74:142-152. [PMID: 27865895 DOI: 10.1016/j.jinf.2016.11.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/04/2016] [Accepted: 11/11/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pseudomonas aeruginosa often presents multi-drug resistance (MDR) in intensive care unit (ICU)-acquired pneumonia (ICUAP), possibly resulting in inappropriate empiric treatment and worse outcomes. We aimed to identify patients with ICUAP at risk for these pathogens in order to improve treatment selection and outcomes. METHODS We prospectively assessed 222 consecutive immunocompetent ICUAP patients confirmed microbiologically. We determined the characteristics, risk factors, systemic inflammatory response and outcomes of P. aeruginosa pneumonia (Pa-ICUAP), compared to other aetiologies. We also compared patients with MDR vs. non-MDR Pa-ICUAP. RESULTS Pseudomonas aeruginosa was the most frequent aetiology (64, 29%); 22 (34%) cases had MDR. Independent predictors for Pa-ICUAP were prior airway colonization by P. aeruginosa, previous antibiotic treatment, solid cancer and shock; alcohol abuse and pleural effusion were independently associated to lower risk for Pa-ICUAP. Chronic liver disease independently predicted MDR among Pa-ICUAP. The inflammatory biomarkers were similar between all groups. Patients with Pa-ICUAP had lower unadjusted 90-day survival (p = 0.049). However, the 90-day survival adjusted for confounding factors using a propensity score did not differ between all groups. CONCLUSION Pseudomonas aeruginosa remains the most frequent aetiology of ICUAP, with high prevalence of MDR. These risk factors should be taken into account to avoid inappropriate empiric antibiotics for Pa-ICUAP. Pseudomonas aeruginosa, regardless multidrug resistance, was not associated with different propensity-adjusted survival.
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Affiliation(s)
- Laia Fernández-Barat
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Miquel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain.
| | - Francesca De Rosa
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Dipartmento di Anestesia e Rianimazione, Università degli studi di Milano, Milan, Italy
| | - Albert Gabarrús
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Mariano Esperatti
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Silvia Terraneo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Mariano Rinaudo
- Department of Pneumology, Respiratory Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Gianluigi Li Bassi
- Department of Pneumology, Respiratory Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
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Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality, complicating the medical course of approximately 10% of mechanically-ventilated patients, with an estimated attributable mortality of 13%. To treat VAP empirically, the American Thoracic Society currently recommends antibiotic therapy based on the patients' risk of colonisation by an organism with multidrug resistance. The selection of initial antibiotic therapy in VAP is important, as inappropriate initial antimicrobial treatment is associated with higher mortality and longer hospital stay in intensive care unit (ICU) patients.While guidelines exist for the antibiotic treatment of hospital-acquired pneumonia (HAP) from the American Thoracic Society and the British Society for Antimicrobial Chemotherapy, there are many limitations in the quality of available evidence. This systematic review aimed to summarise the results of all randomised controlled trials (RCTs) that compare empirical antibiotic regimens for VAP. OBJECTIVES The primary objective of this review was to assess the effect of different empirical antimicrobial therapies on the survival and clinical cure of adult patients with ventilator-associated pneumonia (VAP). Secondary objectives included reporting the incidence of adverse events, new superinfections, length of hospital stay, and length of intensive care unit (ICU) stay associated with these therapies. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CINAHL and Web of Science to December 2015; we searched ClinicalTrials.gov to September 2016. SELECTION CRITERIA Two review authors independently assessed RCTs comparing empirical antibiotic treatments of VAP in adult patients, where VAP was defined as new-onset pneumonia that developed more than 48 hours after endotracheal intubation. Physicians and researchers were not required to be blinded for inclusion in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study data. We pooled studies and analysed them in two ways. We examined monotherapy, or a single experimental antimicrobial drug, versus combination therapy, or multiple experimental antimicrobial drugs. We also examined carbapenem therapy versus non-carbapenem therapy. MAIN RESULTS We included 12 studies with 3571 participants. All included studies examined the empiric use of one antimicrobial regimen versus another for the treatment of adults with VAP, but the particular drug regimens examined by each study varied. There was potential for bias because some studies did not report outcomes for all participants. All but one study reported sources of funding or author affiliations with pharmaceutical companies.We found no statistical difference in all-cause mortality between monotherapy and combination therapy (N = 4; odds ratio (OR) monotherapy versus combination 0.97, 95% confidence interval (CI) 0.73 to 1.30), clinical cure (N = 2; OR monotherapy versus combination 0.88, 95% CI 0.56 to 1.36), length of stay in ICU (mean difference (MD) 0.65, 95% CI 0.07 to 1.23) or adverse events (N = 2; OR monotherapy versus combination 0.93, 95% CI 0.68 to 1.26). We downgraded the quality of evidence for all-cause mortality, adverse events, and length of ICU stay to moderate for this comparison. We determined clinical cure for this comparison to be of very low-quality evidence.For our second comparison of combination therapy with optional adjunctives only one meta-analysis could be performed due to a lack of trials comparing the same antibiotic regimens. Two studies compared tigecycline versus imipenem-cilastatin for clinical cure in the clinically evaluable population and there was a statistically significant increase in clinical cure for imipenem-cilastatin (N = 2; OR tigecycline versus imipenem-cilastatin 0.44, 95% CI 0.23 to 0.84). Of importance, this effect was due to a single study.We found no statistical difference in all-cause mortality between carbapenem and non-carbapenem therapies (N = 1; OR carbapenem versus non-carbapenem 0.59, 95% CI 0.30 to 1.19) or adverse events (N = 3; OR carbapenem versus non-carbapenem 0.78, 95% CI 0.56 to 1.09), but we found that carbapenems are associated with a statistically significant increase in the clinical cure (N = 3; OR carbapenem versus non-carbapenem 1.53, 95% CI 1.11 to 2.12 for intention-to-treat (ITT) analysis and N = 2; OR carbapenem versus non-carbapenem 2.29, 95% CI 1.19 to 4.43 for clinically evaluable patients analysis). For this comparison we downgraded the quality of evidence for mortality, and clinical cure (ITT and clinically evaluable populations) to moderate. We determined the quality of evidence for adverse events to be low. AUTHORS' CONCLUSIONS We did not find a difference between monotherapy and combination therapy for the treatment of people with VAP. Since studies did not identify patients with increased risk for multidrug-resistant bacteria, these data may not be generalisable to all patient groups. However, this is the largest meta-analysis comparing monotherapy to multiple antibiotic therapies for VAP and contributes further evidence to the safety of using effective monotherapy for the empiric treatment of VAP.Due to lack of studies, we could not evaluate the best antibiotic choice for VAP, but carbapenems as a class may result in better clinical cure than other tested antibiotics.
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Affiliation(s)
- Lauren E Arthur
- School of Medicine, University of QueenslandOchsner Clinical SchoolNew OrleansLAUSA
| | - Russell S Kizor
- The University of QueenslandSchool of Medicine16/205 Coronation DriveMiltonBrisbaneQueenslandAustralia4064
| | - Adrian G Selim
- Bond UniversityFaculty of Health Sciences and MedicineGold CoastQldAustralia4229
| | - Mieke L van Driel
- The University of QueenslandDiscipline of General Practice, School of MedicineBrisbaneQueenslandAustralia4029
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
- Ghent UniversityDepartment of Family Medicine and Primary Health Care1K3, De Pintelaan 185GhentBelgium9000
| | - Leonardo Seoane
- Ochsner Health SystemDepartment of Pulmonary/Critical Care Medicine1514 Jefferson HwyNew OrleansLAUSA70121
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Uhle F, Chousterman BG, Grützmann R, Brenner T, Weber GF. Pathogenic, immunologic, and clinical aspects of sepsis - update 2016. Expert Rev Anti Infect Ther 2016; 14:917-27. [PMID: 27530423 DOI: 10.1080/14787210.2016.1224971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Sepsis is a major cause of death worldwide but its orchestrating components remain incompletely understood. On the one hand, development of sepsis results from an infectious focus that cannot be controlled by the immune system, but on the other, responding immune cells that can eliminate the infection inflict damage to the host by contributing to complications such as endothelial leakage, septic shock, and multiorgan failure. AREAS COVERED In this review we give a comprehensive overview of how sepsis occurs, which exogenous and endogenous factors might affect the immune-pathophysiological course of sepsis and finally how this knowledge translates into up-to-date definitions and therapeutic approaches. Expert commentary: Although new immunological mechanisms altering the course of sepsis have been identified recently, future research needs to address the limitations of experimental approaches, redirect the research focus into translational approaches, and finally evaluate personalized treatment strategies.
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Affiliation(s)
- Florian Uhle
- a Department of Anesthesiology , Heidelberg University Hospital , Heidelberg , Germany
| | - Benjamin G Chousterman
- b Department of Anesthesia, Intensive Care and SAMU , Hôpital Lariboisière, AP-HP, and Université Paris Diderot , Paris , France
| | - Robert Grützmann
- c Department of Surgery , University Hospital Erlangen-Nürnberg , Erlangen , Germany
| | - Thorsten Brenner
- a Department of Anesthesiology , Heidelberg University Hospital , Heidelberg , Germany
| | - Georg F Weber
- c Department of Surgery , University Hospital Erlangen-Nürnberg , Erlangen , Germany
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 PMCID: PMC4981759 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 2042] [Impact Index Per Article: 255.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C. Kalil
- Departmentof Internal Medicine, Division of Infectious Diseases,
University of Nebraska Medical Center,
Omaha
| | - Mark L. Metersky
- Division of Pulmonary and Critical Care Medicine,
University of Connecticut School of Medicine,
Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School
- Harvard Pilgrim Health Care Institute, Boston,
Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program,Queens University, Kingston, Ontario,
Canada
| | - Daniel A. Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine,
University of California, San
Diego
| | - Lucy B. Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep
Medicine, State University of New York at Stony
Brook
| | - Lena M. Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency
Surgery, University of Michigan, Ann
Arbor
| | - Naomi P. O'Grady
- Department of Critical Care Medicine, National
Institutes of Health, Bethesda
| | - John G. Bartlett
- Johns Hopkins University School of Medicine,
Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari
de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in
Infectious Diseases, University of Barcelona,
Spain
| | - Ali A. El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep
Medicine, University at Buffalo, Veterans Affairs Western New
York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious
Diseases, EVK Herne and Augusta-Kranken-Anstalt
Bochum, Germany
| | - Paul D. Fey
- Department of Pathology and Microbiology, University of
Nebraska Medical Center, Omaha
| | | | - Marcos I. Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care
Medicine, South Texas Veterans Health Care System and University
of Texas Health Science Center at San Antonio
| | - Jason A. Roberts
- Burns, Trauma and Critical Care Research Centre, The
University of Queensland
- Royal Brisbane and Women's Hospital,
Queensland
| | - Grant W. Waterer
- School of Medicine and Pharmacology, University of
Western Australia, Perth,
Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Shandra L. Knight
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Jan L. Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
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O'Horo JC, Kashyap R, Sevilla Berrios R, Herasevich V, Sampathkumar P. Differentiating infectious and noninfectious ventilator-associated complications: A new challenge. Am J Infect Control 2016; 44:661-5. [PMID: 26899526 DOI: 10.1016/j.ajic.2015.12.032] [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] [Received: 09/08/2015] [Revised: 12/10/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of this study was to develop an electronic search algorithm which reliably differentiates infectious and noninfectious ventilator-associated events (VAEs). This was a retrospective cohort study used to derive a predictive model. It took place at a tertiary care hospital campus. METHODS Participants included all ventilated patients who met the Centers for Disease Control and Prevention's National Health Safety Network definitions for VAEs between January 1, 2012, and December 31, 2013. There were 164 patients who experienced 185 VAEs in the study period. RESULTS The most predictive variables were fever 2 days before VAE onset, oxygenation changes, and appearance of respiratory secretions. No other variable, including laboratory tests, radiologic findings, and vital sign values, reached statistical significance. A multivariate regression model was constructed, with 68% sensitivity and 75% specificity (receiver operator characteristic area under the curve [ROC-AUC], 0.83). This was modestly better than the clinical pulmonary infection score (CPIS), which had sensitivity of 50%, specificity of 59%, and ROC-AUC of 0.60. CONCLUSIONS Although diagnosis of VAEs remains challenging, our data indicate that clinical signs and symptoms of a VAE may be present up to 2 days before they screen positive. Sputum, fever, and oxygenation requirements all were indicative, but aggregate models failed to create a sensitive and specific model for differentiation of VAEs. The existing clinical tool, the CPIS, is also insufficiently sensitive and specific. Further research is needed to create a clinically viable tool for differentiating VAE types at the bedside.
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Vincent JL, Bassetti M, François B, Karam G, Chastre J, Torres A, Roberts JA, Taccone FS, Rello J, Calandra T, De Backer D, Welte T, Antonelli M. Advances in antibiotic therapy in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:133. [PMID: 27184564 PMCID: PMC4869332 DOI: 10.1186/s13054-016-1285-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infections occur frequently in critically ill patients and their management can be challenging for various reasons, including delayed diagnosis, difficulties identifying causative microorganisms, and the high prevalence of antibiotic-resistant strains. In this review, we briefly discuss the importance of early infection diagnosis, before considering in more detail some of the key issues related to antibiotic management in these patients, including controversies surrounding use of combination or monotherapy, duration of therapy, and de-escalation. Antibiotic pharmacodynamics and pharmacokinetics, notably volumes of distribution and clearance, can be altered by critical illness and can influence dosing regimens. Dosing decisions in different subgroups of patients, e.g., the obese, are also covered. We also briefly consider ventilator-associated pneumonia and the role of inhaled antibiotics. Finally, we mention antibiotics that are currently being developed and show promise for the future.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, 33100, Udine, Italy
| | - Bruno François
- Service de Réanimation Polyvalente, CHU de Dupuytren, 87042, Limoges, France
| | - George Karam
- Infectious Disease Section, Louisiana State University School of Medicine, 70112, New Orleans, LA, USA
| | - Jean Chastre
- Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
| | - Antoni Torres
- Department of Pulmonary Medicine, Hospital Clinic of Barcelona, IDIBAPS-Ciberes, 08036, Barcelona, Spain
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Royal Brisbane and Women's Hospital, 4029 Herston, Brisbane, Australia
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jordi Rello
- Department of Intensive care, CIBERES, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, 08035, Barcelona, Spain
| | - Thierry Calandra
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, 1011, Lausanne, Switzerland
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, 1420, Braine L'Alleud, Belgium
| | - Tobias Welte
- Department of Respiratory Medicine, Medizinische Hochschule, 30625, Hannover, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
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Die schwere Pneumonie auf der Intensivstation. Med Klin Intensivmed Notfmed 2016; 111:279-89. [DOI: 10.1007/s00063-016-0165-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
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Khan R, Al-Dorzi HM, Tamim HM, Rishu AH, Balkhy H, El-Saed A, Arabi YM. The impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia. J Infect Public Health 2016; 9:161-71. [DOI: 10.1016/j.jiph.2015.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 07/28/2015] [Accepted: 09/04/2015] [Indexed: 01/08/2023] Open
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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Ferrer M, Difrancesco LF, Liapikou A, Rinaudo M, Carbonara M, Li Bassi G, Gabarrus A, Torres A. Polymicrobial intensive care unit-acquired pneumonia: prevalence, microbiology and outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:450. [PMID: 26703094 PMCID: PMC4699341 DOI: 10.1186/s13054-015-1165-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Microbial aetiology of intensive care unit (ICU)-acquired pneumonia (ICUAP) determines antibiotic treatment and outcomes. The impact of polymicrobial ICUAP is not extensively known. We therefore investigated the characteristics and outcomes of polymicrobial aetiology of ICUAP. METHOD Patients with ICUAP confirmed microbiologically were prospectively compared according to identification of 1 (monomicrobial) or more (polymicrobial) potentially-pathogenic microorganisms. Microbes usually considered as non-pathogenic were not considered for the etiologic diagnosis. We assessed clinical characteristics, microbiology, inflammatory biomarkers and outcome variables. RESULTS Among 441 consecutive patients with ICUAP, 256 (58%) had microbiologic confirmation, and 41 (16%) of them polymicrobial pneumonia. Methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, and several Enterobacteriaceae were more frequent in polymicrobial pneumonia. Multi-drug and extensive-drug resistance was similarly frequent in both groups. Compared with monomicrobial, patients with polymicrobial pneumonia had less frequently chronic heart disease (6, 15% vs. 71, 33%, p = 0.019), and more frequently pleural effusion (18, 50%, vs. 54, 25%, p = 0.008), without any other significant difference. Appropriate empiric antimicrobial treatment was similarly frequent in the monomicrobial (185, 86%) and the polymicrobial group (39, 95%), as were the initial response to the empiric treatment, length of stay and mortality. Systemic inflammatory response was similar comparing monomicrobial with polymicrobial ICUAP. CONCLUSION The aetiology of ICUAP confirmed microbiologically was polymicrobial in 16% cases. Pleural effusion and absence of chronic heart disease are associated with polymicrobial pneumonia. When empiric treatment is frequently appropriate, polymicrobial aetiology does not influence the outcome of ICUAP.
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Affiliation(s)
- Miquel Ferrer
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
| | - Leonardo Filippo Difrancesco
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Department of Internal Medicine, Ospedale Sant'Andrea, "Sapienza" University, Via di Grottarossa 1035-1039, Rome, Italy.
| | - Adamantia Liapikou
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Sotiria Chest Diseases Hospital, 6rd Respiratory Department, Mesogion 152, Athens, Greece.
| | - Mariano Rinaudo
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain.
| | - Marco Carbonara
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Department of Anesthesia, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda Milano, Milan, Italy.
| | - Gianluigi Li Bassi
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
| | - Albert Gabarrus
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
| | - Antoni Torres
- Department of Pneumology, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-Instituto de Salud Carlos III (ISCiii), Madrid, Spain.
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50
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Combined therapy for multi-drug-resistant Acinetobacter baumannii infection – is there evidence outside the laboratory? J Med Microbiol 2015. [DOI: 10.1099/jmm.0.000144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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