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Kurotschka PK, Bentivegna M, Hulme C, Ebell MH. Identifying the Best Initial Oral Antibiotics for Adults with Community-Acquired Pneumonia: A Network Meta-Analysis. J Gen Intern Med 2024; 39:1214-1226. [PMID: 38360961 PMCID: PMC11116361 DOI: 10.1007/s11606-024-08674-1] [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: 10/24/2023] [Accepted: 02/02/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The objective of this network meta-analysis was to compare rates of clinical response and mortality for empiric oral antibiotic regimens in adults with mild-moderate community-acquired pneumonia (CAP). METHODS We searched PubMed, Cochrane, and the reference lists of systematic reviews and clinical guidelines. We included randomized trials of adults with radiologically confirmed mild to moderate CAP initially treated orally and reporting clinical cure or mortality. Abstracts and studies were reviewed in parallel for inclusion in the analysis and for data abstraction. We performed separate analyses by antibiotic medications and antibiotic classes and present the results through network diagrams and forest plots sorted by p-scores. We assessed the quality of each study using the Cochrane Risk of Bias framework, as well as global and local inconsistency. RESULTS We identified 24 studies with 9361 patients: six at low risk of bias, six at unclear risk, and 12 at high risk. Nemonoxacin, levofloxacin, and telithromycin were most likely to achieve clinical response (p-score 0.79, 0.71, and 0.69 respectively), while penicillin and amoxicillin were least likely to achieve clinical response. Levofloxacin, nemonoxacin, azithromycin, and amoxicillin-clavulanate were most likely to be associated with lower mortality (p-score 0.85, 0.75, 0.74, and 0.68 respectively). By antibiotic class, quinolones and macrolides were most effective for clinical response (0.71 and 0.70 respectively), with amoxicillin-clavulanate plus macrolides and beta-lactams being less effective (p-score 0.11 and 0.22). Quinolones were most likely to be associated with lower mortality (0.63). All confidence intervals were broad and partially overlapping. CONCLUSION We observed trends toward a better clinical response and lower mortality for quinolones as empiric antibiotics for CAP, but found no conclusive evidence of any antibiotic being clearly more effective than another. More trials are needed to inform guideline recommendations on the most effective antibiotic regimens for outpatients with mild to moderate CAP.
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Affiliation(s)
- Peter K Kurotschka
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Michelle Bentivegna
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Cassie Hulme
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.
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Giamarellos-Bourboulis EJ, Siampanos A, Bolanou A, Doulou S, Kakavoulis N, Tsiakos K, Katopodis S, Schinas G, Skorda L, Alexiou Z, Armenis K, Katsaounou P, Chrysos G, Masgala A, Poulakou G, Antonakos N, Safarika A, Kyprianou M, Dakou K, Gerakari S, Papanikolaou IC, Milionis H, Marangos M, Dalekos GN, Tzavara V, Akinosoglou K, Hatziaggelaki E, Sympardi S, Kontopoulou T, Mouktaroudi M, Papadopoulos A, Niederman MS. Clarithromycin for early anti-inflammatory responses in community-acquired pneumonia in Greece (ACCESS): a randomised, double-blind, placebo-controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:294-304. [PMID: 38184008 DOI: 10.1016/s2213-2600(23)00412-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/06/2023] [Accepted: 10/27/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Addition of macrolide antibiotics to β-lactam antibiotics for the treatment of patients in hospital with community-acquired pneumonia is based on results from observational studies and meta-analyses rather than randomised clinical trials. We investigated if addition of the macrolide clarithromycin to treatment with a β-lactam antibiotic in this population could improve early clinical response-the new regulatory endpoint for community-acquired pneumonia-and explored the possible contribution of modulation of the inflammatory host response to that outcome. METHODS The ACCESS trial was a phase 3 prospective, double-blind, randomised controlled trial, in which adults in hospital with community-acquired pneumonia who had systemic inflammatory response syndrome, Sequential Organ Failure Assessment (SOFA) score of 2 or more, and procalcitonin 0·25 ng/mL or more were enrolled in 18 internal medicine departments of public Greek hospitals. Patients were randomly assigned (1:1) by computer-generated block randomisation to standard of care medication (including intravenous administration of a third-generation cephalosporin or intravenous administration of β-lactam plus β-lactamase inhibitor combination) plus either oral placebo or oral clarithromycin 500 mg twice daily for 7 days. Investigators, staff, and patients were masked to group allocation. The primary composite endpoint required that patients fulfilled both of the following conditions after 72 hours (ie, day 4 of treatment): (1) decrease in respiratory symptom severity score of 50% or more as an indicator of early clinical response and (2) decrease in SOFA score of at least 30% or favourable procalcitonin kinetics (defined as ≥80% decrease from baseline or procalcitonin <0·25 ng/mL), or both, as an indicator of early inflammatory response. Participants who were randomly assigned and received allocated treatment were included in the primary analysis population. This trial is complete and is registered with the EU Clinical Trials Register (2020-004452-15) and ClinicalTrials.gov (NCT04724044). FINDINGS Patients were enrolled between Jan 25, 2021, and April 11, 2023, and 278 individuals were randomly allocated to receive standard of care in combination with either clarithromycin (n=139) or placebo (n=139). 134 patients in the clarithromycin group (five withdrew consent) and 133 patients in the placebo group (six withdrew consent) were included in the analysis of the primary endpoint. The primary endpoint was met in 91 (68%) patients in the clarithromycin group and 51 (38%) patients in the placebo group (difference 29·6% [95% CI 17·7-40·3]; odds ratio [OR] 3·40 [95% CI 2·06-5·63]; p<0·0001). Serious treatment-emergent adverse events (TEAEs) occurred in 58 (43%) patients in the clarithromycin group and 70 (53%) patients in the placebo group (difference 9·4% [95% CI -2·6 to 20·9]; OR 0·67 [95% CI 0·42 to 1·11]; p=0·14). None of the serious TEAEs was judged to be related to treatment assignment. INTERPRETATION Addition of clarithromycin to standard of care enhances early clinical response and attenuates the inflammatory burden of community-acquired pneumonia. The mechanism of benefit is associated with changes in the immune response. These findings suggest the importance of adding clarithromycin to β-lactams for treatment of patients in hospital with community-acquired pneumonia to achieve early clinical response and early decrease of the inflammatory burden. FUNDING Hellenic Institute for the Study of Sepsis and Abbott Products Operations.
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Affiliation(s)
- Evangelos J Giamarellos-Bourboulis
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece.
| | - Athanasios Siampanos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Amalia Bolanou
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Sarantia Doulou
- Fifth Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece
| | - Nikolaos Kakavoulis
- First Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Konstantinos Tsiakos
- Third Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sokratis Katopodis
- Second Department of Propedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Schinas
- Department of Internal Medicine, University of Patras, Rion, Greece
| | - Lamprini Skorda
- Third Department of Internal Medicine and Infectious Diseases Unit, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | - Zoi Alexiou
- Second Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Konstantinos Armenis
- First Department of Internal Medicine, G Gennimatas General Hospital of Athens, Athens, Greece
| | - Paraskevi Katsaounou
- First Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Chrysos
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Aikaterini Masgala
- Second Department of Internal Medicine, Konstantopouleio General Hospital, Athens, Greece
| | - Garyphalia Poulakou
- Third Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Antonakos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Asimina Safarika
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Styliani Gerakari
- Emergency Department, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Ilias C Papanikolaou
- Department of Pulmonary Medicine, General Hospital of Corfu "Agia Eirini", Greece
| | - Haralampos Milionis
- First Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Markos Marangos
- Department of Internal Medicine, University of Patras, Rion, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Vasiliki Tzavara
- First Department of Internal Medicine, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | | | - Eryfilli Hatziaggelaki
- Second Department of Propedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Styliani Sympardi
- First Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Theano Kontopoulou
- Fifth Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece; First Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece
| | - Maria Mouktaroudi
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Antonios Papadopoulos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Weil Cornell Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
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Kyprianou M, Dakou K, Aktar A, Aouina H, Behbehani N, Dheda K, Juvelekian G, Khattab A, Mahboub B, Nyale G, Oraby S, Sayiner A, Shibl A, El Deen MAT, Unal S, Zubairi ABS, Davidson R, Giamarellos-Bourboulis EJ. Macrolides for better resolution of community-acquired pneumonia: A global meta-analysis of clinical outcomes with focus on microbial aetiology. Int J Antimicrob Agents 2023; 62:106942. [PMID: 37541531 DOI: 10.1016/j.ijantimicag.2023.106942] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/06/2023] [Accepted: 07/29/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVES This meta-analysis examined the effect of macrolides on resolution of community-acquired pneumonia (CAP) and interpretation of clinical benefit according to microbiology; emphasis is given to data under-reported countries (URCs). METHODS This meta-analysis included 47 publications published between 1994 and 2022. Publications were analysed for 30-d mortality (58 759 patients) and resolution of CAP (6465 patients). A separate meta-analysis was done for the prevalence of respiratory pathogens in URCs. RESULTS Mortality after 30 d was reduced by the addition of macrolides (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.51-0.82). The OR for CAP resolution when macrolides were added to the treatment regimen was 1.23 (95% CI 1.00-1.52). In the CAP resolution analysis, the most prevalent pathogen was Streptococcus pneumoniae (12.68%; 95% CI 9.36-16.95%). Analysis of the pathogen epidemiology from the URCs included 12 publications. The most prevalent pathogens were S. pneumoniae (24.91%) and Klebsiella pneumoniae (12.90%). CONCLUSION The addition of macrolides to the treatment regimen led to 35% relative decrease of 30-d mortality and to 23% relative increase in resolution of CAP.
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Affiliation(s)
| | | | - Aftab Aktar
- Department of Pulmonary and Critical Care Medicine, Shifa International Hospital, Islamabad, Pakistan
| | | | - Naser Behbehani
- Department of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Georges Juvelekian
- Department of Pulmonary, Critical Care and Sleep Division at Saint George Hospital University Medical Centre, Beirut, Lebanon
| | - Adel Khattab
- Department of Pulmonary Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassam Mahboub
- Department of Pulmonary Medicine, Rashid Hospital, Dubai, United Arab Emirates
| | | | - Sayed Oraby
- Department of Pulmonary and Respiratory Care Unit, Erfan Hospital, Jeddah, Saudi Arabia
| | - Abdullah Sayiner
- Department of Chest Diseases, Ege University Medical Faculty Hospital, Bornova/İzmir, Turkey
| | - Atef Shibl
- Department of Microbiology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Serhat Unal
- Department of Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ali Bin Sarwar Zubairi
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ross Davidson
- Departments of Pathology, Microbiology, Immunology and Medicine, Dalhousie University, Halifax, Canada
| | - Evangelos J Giamarellos-Bourboulis
- Hellenic Institute for the Study of Sepsis, Athens, Greece; Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
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4
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Tokito T, Kido T, Muramatsu K, Tokutsu K, Okuno D, Yura H, Takemoto S, Ishimoto H, Takazono T, Sakamoto N, Obase Y, Ishimatsu Y, Fujino Y, Yatera K, Fushimi K, Matsuda S, Mukae H. Impact of Administering Intravenous Azithromycin within 7 Days of Hospitalization for Influenza Virus Pneumonia: A Propensity Score Analysis Using a Nationwide Administrative Database. Viruses 2023; 15:1142. [PMID: 37243228 PMCID: PMC10222596 DOI: 10.3390/v15051142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
The potential antimicrobial and anti-inflammatory effectiveness of azithromycin against severe influenza is yet unclear. We retrospectively investigated the effect of intravenous azithromycin administration within 7 days of hospitalization in patients with influenza virus pneumonia and respiratory failure. Using Japan's national administrative database, we enrolled and classified 5066 patients with influenza virus pneumonia into severe, moderate, and mild groups based on their respiratory status within 7 days of hospitalization. The primary endpoints were total, 30-day, and 90-day mortality rates. The secondary endpoints were the duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. The inverse probability of the treatment weighting method with estimated propensity scores was used to minimize data collection bias. Use of intravenous azithromycin was proportional to the severity of respiratory failure (mild: 1.0%, moderate: 3.1%, severe: 14.8%). In the severe group, the 30-day mortality rate was significantly lower with azithromycin (26.49% vs. 36.65%, p = 0.038). In the moderate group, the mean duration of invasive mechanical ventilation after day 8 was shorter with azithromycin; there were no significant differences in other endpoints between the severe and moderate groups. These results suggest that intravenous azithromycin has favorable effects in patients with influenza virus pneumonia using mechanical ventilation or oxygen.
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Affiliation(s)
- Takatomo Tokito
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-0804, Japan
| | - Kei Tokutsu
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-0804, Japan
| | - Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Hirokazu Yura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Shinnosuke Takemoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Science, University of Occupational and Environmental Health, Japan, Kitakyushu 807-0804, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-0804, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan, Tokyo 113-8519, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, University of Occupational and Environmental Health, Japan, Kitakyushu 807-0804, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
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Efficacy of empiric macrolides versus fluoroquinolones in community-acquired pneumonia associated with atypical bacteria: A meta-analysis. Respir Med Res 2022; 82:100931. [DOI: 10.1016/j.resmer.2022.100931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/11/2022] [Accepted: 06/04/2022] [Indexed: 11/22/2022]
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6
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Xu L, Wang C, Peng X, Jiao Y, Zhao C, Zhang L, Ma L. Empirical Antibiotic Treatment Strategies for Community-Acquired Pneumonia: A Network Meta-analysis. J Glob Antimicrob Resist 2022; 30:1-9. [DOI: 10.1016/j.jgar.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 11/15/2022] Open
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Abstract
Community-acquired pneumonia is an important cause of morbidity and mortality. It can be caused by bacteria, viruses, or fungi and can be prevented through vaccination with pneumococcal, influenza, and COVID-19 vaccines. Diagnosis requires suggestive history and physical findings in conjunction with radiographic evidence of infiltrates. Laboratory testing can help guide therapy. Important issues in treatment include choosing the proper venue, timely initiation of the appropriate antibiotic or antiviral, appropriate respiratory support, deescalation after negative culture results, switching to oral therapy, and short treatment duration.
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8
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Cortés JA, Cuervo-Maldonado SI, Nocua-Báez LC, Valderrama MC, Sánchez EA, Saavedra A, Torres JV, Forero DP, Álvarez CA, Leal AL, Pérez JE, Rodríguez IA, Guevara FO, Saavedra CH, Vergara EP, Montúfar FE, Espinosa T, Chaves W, Carrizosa JA, Meléndez SDM, Espinosa CJ, García F, Guzmán IJ, Cortés SL, Díaz JA, González N. Guía de práctica clínica para el manejo de la neumonía adquirida en la comunidad. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v70n2.93814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
La neumonía sigue siendo una de las principales causas de consulta y de hospitalización a la que, además de su un alto impacto en términos de morbilidad y mortalidad, se suma la actual problemática de resistencia a los antimicrobianos, por lo que establecer directrices que permitan su adecuado diagnóstico y tratamiento es de gran importancia para obtener mejores desenlaces clínicos y promover un uso racional de antibióticos en estos pacientes. La presente guía de práctica clínica (GPC) contiene recomendaciones basadas en la evidencia para el diagnóstico y tratamiento de la neumonía adquirida en la comunidad en adultos, las cuales fueron realizadas mediante el proceso de adaptación de GPC basadas en la evidencia para el contexto colombiano.
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9
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Su R, Zhang Y, Zhang J, Wang H, Luo Y, Chan HF, Tao Y, Chen Z, Li M. Nanomedicine to advance the treatment of bacteria-induced acute lung injury. J Mater Chem B 2021; 9:9100-9115. [PMID: 34672317 DOI: 10.1039/d1tb01770e] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bacteria-induced acute lung injury (ALI) is associated with a high mortality rate due to the lack of an effective treatment. Patients often rely on supportive care such as low tidal volume ventilation to alleviate the symptoms. Nanomedicine has recently received much attention owing to its premium benefits of delivering drugs in a sustainable and controllable manner while minimizing the potential side effects. It can effectively improve the prognosis of bacteria-induced ALI through targeted delivery of drugs, regulation of multiple inflammatory pathways, and combating antibiotic resistance. Hence, in this review, we first discuss the pathogenesis of ALI and its potential therapeutics. In particular, the state-of-the-art nanomedicines for the treatment of bacteria-induced ALI are highlighted, including their administration routes, in vivo distribution, and clearance. Furthermore, the available bacteria-induced ALI animal models are also summarized. In the end, future perspectives of nanomedicine for ALI treatment are proposed.
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Affiliation(s)
- Ruonan Su
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China. .,Laboratory of Biomaterials and Translational Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Yu Zhang
- Department of Biological and Environmental Engineering, Cornell University, Ithaca 14853, USA
| | - Jiabin Zhang
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China.
| | - Haixia Wang
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China. .,Laboratory of Biomaterials and Translational Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Yun Luo
- Department of Urology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510630, China
| | - Hon Fai Chan
- Institute for Tissue Engineering and Regenerative Medicine, School of Biomedical Science, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Yu Tao
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China. .,Laboratory of Biomaterials and Translational Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Zhuanggui Chen
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China.
| | - Mingqiang Li
- Center for Nanomedicine, Department of Pediatrics and Department of Allergy, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China. .,Laboratory of Biomaterials and Translational Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China.,Guangdong Provincial Key Laboratory of Liver Disease Research, Guangzhou 510630, China
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10
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Miyashita N. Atypical pneumonia: Pathophysiology, diagnosis, and treatment. Respir Investig 2021; 60:56-67. [PMID: 34750083 DOI: 10.1016/j.resinv.2021.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/19/2022]
Abstract
Atypical pneumonia is caused by atypical pathogens that are not detectable with Gram stain and cannot be cultured using standard methods. The most common causative organisms of atypical pneumonia are Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species. The therapeutic approach for atypical pneumonias is different than that for typical pneumonia. Typical bacterial pathogens classically respond to β-lactam antimicrobial therapy because they have a cell wall amenable to β-lactam disruption. On the contrary, most atypical pathogens do not have a bacterial cell wall, some are intracellular (e.g., Legionella), and some are paracellular (e.g., M. pneumoniae). To prevent an increase in the number of antimicrobial-resistant strains, the Japanese pneumonia guidelines have proposed a differential diagnosis for typical bacterial pneumonia and atypical pneumonia to select an appropriate antibiotic for the management of mild-to-moderate pneumonia. The guidelines have set up six parameters and criteria based on the clinical symptoms, physical signs, and laboratory data. However, in the elderly individuals and patients with underlying diseases, the differential diagnosis may be difficult or a mixed infection may be latent. Therefore, in these individuals, the administration of a β-lactam drug plus a macrolide or tetracycline, or only fluoroquinolone should be considered from the beginning to cover bacterial and atypical pneumonia.
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Affiliation(s)
- Naoyuki Miyashita
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
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11
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A personalised approach to antibiotic pharmacokinetics and pharmacodynamics in critically ill patients. Anaesth Crit Care Pain Med 2021; 40:100970. [PMID: 34728411 DOI: 10.1016/j.accpm.2021.100970] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 01/01/2023]
Abstract
Critically ill patients admitted to intensive care unit (ICU) with severe infections, or those who develop nosocomial infections, have poor outcomes with substantial morbidity and mortality. Such patients commonly have suboptimal antibiotic exposures at routinely used antibiotic doses related to an increased volume of distribution and altered clearance due to their underlying altered physiology. Furthermore, the use of extracorporeal devices such as renal replacement therapy and extracorporeal membrane oxygenation in these group of patients also has the potential to alter in vivo drug concentrations. Moreover, ICU patients are likely to be infected with less-susceptible pathogens. Therefore, one potential contributing cause to the poor outcomes observed in critically ill patients may be related to subtherapeutic antibiotic exposures. Newer concepts include the clinician considering optimised dosing based on a blood antibiotic exposure defined by pharmacokinetic modelling and therapeutic drug monitoring, combined with a knowledge of the antibiotic penetration into the site of infection, thereby achieving optimal bacterial killing. Such optimised dosing is likely to improve patient outcomes. The aim of this review is to highlight key aspects of antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in critically ill patients and provide a PK/PD approach to tailor antibiotic dosing to the individual patient.
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Wu M, Yang X, Tian J, Fan H, Zhang Y. Antibiotic Treatment of Pulmonary Infections: An Umbrella Review and Evidence Map. Front Pharmacol 2021; 12:680178. [PMID: 34737694 PMCID: PMC8560894 DOI: 10.3389/fphar.2021.680178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Considering the global burden of pulmonary infections, there is an urgent need for optimal empirical antimicrobial therapy strategies for pulmonary infections, which should rely on reliable evidence. Therefore, we aim to investigate the optimal treatment options for pulmonary infections in adults and assess the strength of that evidence. Methods: We searched PubMed, Embase, the Cochrane Library, and China Biology Medicine disc to identify systematic reviews and meta-analyses of randomized controlled trials (RCTs) focusing on antimicrobial treatments for pulmonary infections. The outcomes of the included meta-analyses should include all-cause mortality or clinical treatment success. For each meta-analysis, we estimated relative risk (RR) with 95% CI. We also created an evidence map to show the efficacy of each antimicrobial treatment strategy and the certainty of the evidence. Results: Twenty-six meta-analyses and two new RCTs were included that contained 31 types of antimicrobial therapy strategies. We found that carbapenems were related to lower mortality than other β-lactams or fluoroquinolones alone or in combination with aminoglycosides for HAP patients (RR 0.76, 95% CI: 0.58-0.99). There was no statistical difference in all-cause mortality between the other antimicrobial therapy strategies. As for clinical cure, treatment with fluoroquinolones was associated with better success versus macrolides or β-lactams alone for CAP patients in both the intention-to-treat (ITT) population (RR 1.22, 95% CI: 1.02-1.47) and clinically evaluable (CE) population (RR 1.37, 95% CI: 1.11-1.68). Treatment with carbapenems showed a better clinical cure over non-carbapenems for VAP patients (RR 1.21, 95% CI: 1.05-1.4). Adjunctive inhaled antibiotics compared with intravenous antibiotics alone showed a benefit for VAP (RR 1.2, 95% CI: 1.05-1.35). In addition, adjunctive nebulized aminoglycoside for nosocomial pneumonia was associated with a higher cure rate versus intravenous antibiotics alone in the ITT population (RR 1.28, 95% CI: 1.04-1.57), while no statistical difference in clinical cure was observed between other intervention groups. Conclusions: We cannot evaluate which antibiotic is the best choice for the treatment of pulmonary infection. Carbapenems or adjunctive inhaled antibiotics showed a reasonable choice for HAP or VAP. However, we do not find a statistical difference between most antimicrobial therapy strategies for CAP patients.
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Affiliation(s)
- Man Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xue Yang
- Department of Respiratory and Critical Care Medicine, Shenzhen People’s Hospital, Shenzhen, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Yonggang Zhang
- Department of Periodical Press, West China Hospital, Sichuan University, Chengdu, China
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13
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Feng DY, Ren Y, Zhou M, Zou XL, Wu WB, Yang HL, Zhou YQ, Zhang TT. Deep Learning-Based Available and Common Clinical-Related Feature Variables Robustly Predict Survival in Community-Acquired Pneumonia. Risk Manag Healthc Policy 2021; 14:3701-3709. [PMID: 34512057 PMCID: PMC8427836 DOI: 10.2147/rmhp.s317735] [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: 04/27/2021] [Accepted: 08/14/2021] [Indexed: 01/16/2023] Open
Abstract
Background Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Although there are many predictors of death for CAP, there are still some limitations. This study aimed to build a simple and accurate model based on available and common clinical-related feature variables for predicting CAP mortality by adopting machine learning techniques. Methods This was a single-center retrospective study. The data used in this study were collected from all patients (≥18 years) with CAP admitted to research hospitals between January 2012 and April 2020. Each patient had 62 clinical-related features, including clinical diagnostic and treatment features. Patients were divided into two endpoints, and by using Tensorflow2.4.1 as the modeling framework, a three-layer fully connected neural network (FCNN) was built as a base model for classification. For a comprehensive comparison, seven classical machine learning methods and their integrated stacking patterns were introduced to model and compare the same training and test data. Results A total of 3997 patients with CAP were included; 205 (5.12%) died in the hospital. After performing deep learning methods, this study established an ensemble FCNN model based on 12 FCNNs. By comparing with seven classical machine learning methods, the area under the curve of the ensemble FCNN was 0.975 when using deep learning algorithms to classify poor from good prognosis based on available and common clinical-related feature variables. The predicted outcome was poor prognosis if the ControlNet's poor prognosis score was greater than the cutoff value of 0.50. To confirm the scientificity of the ensemble FCNN model, this study analyzed the weight of random forest features and found that mainstream prognostic features still held weight, although the model is perfect after integrating other factors considered less important by previous studies. Conclusion This study used deep learning algorithms to classify prognosis based on available and common clinical-related feature variables in patients with CAP with high accuracy and good generalizability. Every clinical-related feature is important to the model.
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Affiliation(s)
- Ding-Yun Feng
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yong Ren
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, People's Republic of China
| | - Mi Zhou
- Department of Surgery Intensive Care Unit, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xiao-Ling Zou
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Wen-Bin Wu
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Hai-Ling Yang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yu-Qi Zhou
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Institute of Respiratory Diseases of Sun Yat-Sen University, Guangzhou, People's Republic of China
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Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet 2021; 398:906-919. [PMID: 34481570 DOI: 10.1016/s0140-6736(21)00630-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.
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Affiliation(s)
- Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy.
| | - Charles S Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale School of Medicine, New Haven, CT, USA
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Marcos I Restrepo
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
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15
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Giamarellos-Bourboulis EJ, Daikos GL, Gargalianos P, Gogos C, Lazanas M, Panagopoulos P, Poulakou G, Sambatakou H, Samarkos M. The Role of Macrolides for the Management of Community-Acquired Pneumonia and Pneumonia by the Novel Coronavirus SARS-CoV-2 (COVID-19): A Position Paper by Four Medical Societies from Greece. Infect Dis Ther 2021; 10:1-15. [PMID: 34155472 PMCID: PMC8208612 DOI: 10.1007/s40121-021-00471-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/26/2021] [Indexed: 10/28/2022] Open
Abstract
In light of the accumulating evidence for survival benefit coming from the use of macrolides for community-acquired pneumonia (CAP), a group of experts from the field of internal medicine and infectious diseases frame a position statement on the use of macrolides for the management of bacterial CAP and for infection by the novel coronavirus (COVID-19). The statement is framed taking into consideration existing publications and own research experience. The main content of this statement is that the combination of one β-lactam and a macrolide should be the first treatment of choice for patients with severe bacterial CAP. Severity is assessed as scoring 2 or more points on the CURB65 scoring system of severity or as pneumonia severity index III to V or C-reactive protein more than 150 mg/l; the suggested macrolide is either azithromycin or clarithromycin. The experts also suggest that in COVID-19 pneumonia, the combination of one β-lactam and a macrolide should be reserved only when there is strong suspicion of bacterial co-infection.
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Affiliation(s)
| | - George L. Daikos
- 1st Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Charalambos Gogos
- Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Marios Lazanas
- Department of Internal Medicine, Iaso General Athens Hospital, Athens, Greece
| | - Periklis Panagopoulos
- 2nd Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Garyphallia Poulakou
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Sambatakou
- 2nd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Samarkos
- 1st Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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16
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Han X, Chen L, Wang Y, Li H, Wang H, Xing X, Zhang C, Suo L, Wang J, Yu G, Wang G, Yao X, Yu H, Wang L, Liu X, Cao B. Cost Effectiveness of Different Initial Antimicrobial Regimens for Elderly Community-Acquired Pneumonia Patients in General Ward. Infect Drug Resist 2021; 14:1845-1853. [PMID: 34040398 PMCID: PMC8140887 DOI: 10.2147/idr.s302852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/26/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose The cost-effectiveness of different guideline-concordant antimicrobial regimens for elderly patients with community-acquired pneumonia (CAP) was rarely discussed. This study attempts to explore the most appropriate cost-effectiveness of guideline-concordant antimicrobial regimen for elderly patients with CAP in general wards. Patients and Methods This was a multicenter, retrospective, 4:2:1 matched study enrolling 511 elderly patients with CAP hospitalized in general wards. Two hundred ninety-two patients prescribed with β-lactam monotherapy (group A), 146 patients prescribed with fluoroquinolone monotherapy (group B) and 73 patients prescribed with β-lactam/macrolide combination therapy (group C). Clinical outcomes and medical costs were analyzed by χ2 test for categorical variables or Kruskal–Wallis H-test for continuous variables. Results There were no statistical differences in imaging features, etiology and complications during hospitalization among these three groups. The rates of clinical failure occurrence, in-hospital mortality, 30-day mortality and 60-day mortality also had no significant differences among group A, B and C patients; however, the median length of stay (LOS) in group A patients was 12.0 days, which was significantly higher than that in group B and C patients (both 10.0 days, p<0.02). The median total, drug, and antibiotic costs for one elderly CAP episode in group B patients were RMB 10368.4, RMB 3874.8, and RMB 1796.3, respectively, which were significantly lower than those in group A and C patients (p<0.01). Conclusion Non-inferiority of clinical failure occurrence and short-term mortality was observed in different guideline-concordant antimicrobial regimens for elderly patients with CAP in general wards; however, the median LOS and hospitalization-associated costs for one elderly CAP episode with fluoroquinolone monotherapy were significantly lowest, and this strategy was considered to be the most cost-effective strategy in general wards.
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Affiliation(s)
- Xiudi Han
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, People's Republic of China
| | - Liang Chen
- Department of Infectious Disease, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Yimin Wang
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Hui Li
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Hong Wang
- Department of Nosocomial Infection, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, People's Republic of China
| | - Xiqian Xing
- Department of Pulmonary and Critical Care Medicine, Yan'an Hospital Affiliated to Kunming Medical University, Kunming City, Yunnan Province, People's Republic of China
| | - Chunxiao Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Huimin Hospital, Beijing, People's Republic of China
| | - Lijun Suo
- Department of Pulmonary and Critical Care Medicine, Zibo Municipal Hospital, Zibo City, Shandong Province, People's Republic of China
| | - Jinxiang Wang
- Department of Pulmonary and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guohua Yu
- Department of Pulmonary and Critical Care Medicine, Weifang No. 2 People's Hospital, Weifang City, Shandong Province, People's Republic of China
| | - Guangqiang Wang
- Department of Respiratory Medicine, Shandong University Affiliated Qilu Hospital (Qingdao), Qingdao City, Shandong Province, People's Republic of China
| | - Xuexin Yao
- Department of Respiratory Medicine, The 2nd Hospital of Beijing Corps, Chinese Armed Police Forces, Beijing, People's Republic of China
| | - Hongxia Yu
- Department of Infectious Disease, Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai City, Shandong Province, People's Republic of China
| | - Lei Wang
- Department of Pulmonary and Critical Care Medicine, Rizhao Chinese Medical Hospital Affiliated to Shandong Chinese Medical University, Rizhao City, Shandong Province, People's Republic of China
| | - Xuedong Liu
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital Group, Qingdao City, Shandong Province, People's Republic of China
| | - Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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18
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Llor C, Moragas A, Vevatne K. Dual Antibiotic Therapy for Outpatient Management of Community-acquired Pneumonia? Arch Bronconeumol 2020. [DOI: 10.1016/j.arbres.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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19
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Menéndez R, Méndez R, Torres A. Respuesta a «Dual antibiotic therapy for outpatient management of community-acquired pneumonia?». Arch Bronconeumol 2020; 56:766-767. [DOI: 10.1016/j.arbres.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
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20
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1805] [Impact Index Per Article: 451.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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York JA, Varadarajan M, Barlow G. When are combinations of antibiotics clinically useful? Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32097069 DOI: 10.12968/hmed.2019.0348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antimicrobial resistance is a global crisis. Prescribing antibacterial combinations may be one way of reducing the development of resistance in target pathogens, as in the treatment of tuberculosis. Combinations may be useful for ascertaining synergy, broadening antimicrobial cover to reduce the risk of non-susceptibility, antimicrobial stewardship reasons, and immune modulation. The current research literature and/or prevailing global standards of clinical care suggest that combination therapy may be advantageous in: severe community-acquired pneumonia; severe hospital-acquired or ventilator-associated pneumonia or when there is a high risk of resistance in hospital-acquired or ventilator-associated pneumonia; multi-drug or extensively drug-resistant Gram-negative infections; and severe group A streptococcal infections. In other situations, combinations may be harmful. Overall, outside of tuberculosis, combination antibacterial therapy is likely to improve outcomes only in specific circumstances and there is little evidence to suggest that this prevents the development of bacterial resistance. Further high-quality research is essential.
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Affiliation(s)
- Joshua A York
- Hull York Medical School, York, UK.,Department of Infection, Hull University Teaching Hospitals, Hull, UK
| | - Maithili Varadarajan
- Department of Infection, Hull University Teaching Hospitals, Hull, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | - Gavin Barlow
- Hull York Medical School, York, UK.,Department of Infection, Hull University Teaching Hospitals, Hull, UK
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22
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Azithromycin combination therapy for community-acquired pneumonia: propensity score analysis. Sci Rep 2019; 9:18406. [PMID: 31804572 PMCID: PMC6895050 DOI: 10.1038/s41598-019-54922-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 11/21/2019] [Indexed: 11/10/2022] Open
Abstract
Whether macrolide combination therapy reduces the mortality of patients with severe community-acquired pneumonia (CAP) hospitalized in the non-intensive care unit (ICU) remains unclear. Therefore, we investigated the efficacy of adding azithromycin to β-lactam antibiotics for such patients. This prospective cohort study enrolled consecutive patients with CAP hospitalized in the non-ICU between October 2010 and November 2016. The 30-day mortality between β-lactam and azithromycin combination therapy and β-lactam monotherapy was compared in patients classified as mild to moderate and severe according to the CURB-65, Pneumonia Severity Index (PSI), and Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) criteria. Inverse probability of treatment weighting (IPTW) analysis was used to reduce biases. Based on the CURB-65 and PSI, combination therapy did not significantly reduce the 30-day mortality in either group (179 patients in the combination group, 952 in the monotherapy group). However, based on the IDSA/ATS criteria, combination therapy significantly reduced the 30-day mortality in patients with severe (odds ratio [OR] 0.12, 95% confidence interval [CI] 0.007–0.57), but not non-severe pneumonia (OR 1.85, 95% CI 0.51–5.40); these results were similar after IPTW analysis. Azithromycin combination therapy significantly reduced the mortality of patients with severe CAP who met the IDSA/ATS criteria.
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Survival benefit associated with clarithromycin in severe community-acquired pneumonia: A matched comparator study. Int J Antimicrob Agents 2019; 55:105836. [PMID: 31704213 DOI: 10.1016/j.ijantimicag.2019.10.017] [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] [Received: 08/26/2019] [Revised: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 01/12/2023]
Abstract
Although analysis of retrospective studies has documented survival benefit from the addition of a macrolide to the treatment regimen for community-acquired pneumonia (CAP), no data are available to determine if there is differential efficacy between members of the macrolide family. In order to investigate this, an analysis was undertaken of data from 1174 patients with CAP who met the new Sepsis-3 definitions and were enrolled prospectively in the data registry of the Hellenic Sepsis Study Group. Four well-matched treatment groups were identified with 130 patients per group: clarithromycin and β-lactam; azithromycin and β-lactam; respiratory fluoroquinolone and β-lactam monotherapy. The primary endpoint was comparison of the effects of clarithromycin with β-lactam monotherapy on 28-day mortality. The secondary endpoint was resolution of CAP. Mortality rates for the clarithromycin, azithromycin, respiratory fluoroquinolone and β-lactam groups were 20.8%, 33.8% (P=0.026 vs clarithromycin), 32.3% (P=0.049 vs clarithromycin) and 36.2% (P=0.009 vs clarithromycin), respectively. After stepwise Cox regression analysis among all groups, clarithromycin was the only treatment modality associated with a favourable outcome (hazard ratio 0.61; P=0.021). CAP resolved in 73.1%, 65.9% (P=0.226 vs clarithromycin), 58.5% (P=0.009 vs clarithromycin) and 61.5% (P=0.046 vs clarithromycin) of patients, respectively. It is concluded that the addition of clarithromycin to the treatment regimen of patients with severe CAP leads to better survival rates.
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Smith CJ, Heal C, Vail A, Jeans AR, Westendorp WF, Nederkoorn PJ, van de Beek D, Kalra L, Montaner J, Woodhead M, Meisel A. Antibiotic Class and Outcome in Post-stroke Infections: An Individual Participant Data Pooled Analysis of VISTA-Acute. Front Neurol 2019; 10:504. [PMID: 31156537 PMCID: PMC6527959 DOI: 10.3389/fneur.2019.00504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction: Antibiotics used to treat post-stroke infections have differing antimicrobial and anti-inflammatory effects. Our aim was to investigate whether antibiotic class was associated with outcome after post-stroke infection. Methods: We analyzed pooled individual participant data from the Virtual International Stroke Trials Archive (VISTA)-Acute. Patients with ischemic stroke and with an infection treated with systemic antibiotic therapy during the first 2 weeks after stroke onset were eligible. Antibiotics were grouped into eight classes, according to antimicrobial mechanism and prevalence. The primary analysis investigated whether antibiotic class for any infection, or for pneumonia, was independently associated with a shift in 90 day modified Rankin Scale (mRS) using ordinal logistic regression. Results: 2,708 patients were eligible (median age [IQR] = 74 [65 to 80] y; 51% female; median [IQR] NIHSS score = 15 [11 to 19]). Pneumonia occurred in 35%. Treatment with macrolides (5% of any infections; 9% of pneumonias) was independently associated with more favorable mRS distribution for any infection [OR (95% CI) = 0.59 (0.42 to 0.83), p = 0.004] and for pneumonia [OR (95% CI) = 0.46 (0.29 to 0.73), p = 0.001]. Unfavorable mRS distribution was independently associated with treatment of any infection either with carbapenems, cephalosporins or monobactams [OR (95% CI) = 1.62 (1.33 to 1.97), p < 0.001], penicillin plus β-lactamase inhibitors [OR (95% CI) = 1.26 (1.03 to 1.54), p = 0.025] or with aminoglycosides [OR (95% CI) = 1.73 (1.22 to 2.46), p = 0.002]. Conclusion: This retrospective study has several limitations including effect modification and confounding by indication. Macrolides may have favorable immune-modulatory effects in stroke-associated infections. Prospective evaluation of the impact of antibiotic class on treatment of post-stroke infections is warranted.
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Affiliation(s)
- Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Calvin Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andy Vail
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Adam R Jeans
- Division of Clinical Support Services and Tertiary Medicine, Department of Microbiology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Willeke F Westendorp
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lalit Kalra
- Clinical Neurosciences, King's College Hospital NHS Foundation Trust London, London, United Kingdom
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d' Hebron Institute of Research, Barcelona, Spain.,Stroke Research Program, Department of Neurology, Institute de Biomedicine of Seville, Hospital Universitario Virgen Macarena, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Mark Woodhead
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andreas Meisel
- Department of Neurology, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité Universitaetsmedizin Berlin, Berlin, Germany
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25
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Pharmacological management of sepsis in adults with a focus on the current gold standard treatments and promising adjunctive strategies: evidence from the last five years. Expert Opin Pharmacother 2019; 20:991-1007. [DOI: 10.1080/14656566.2019.1589451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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26
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Chou CC, Shen CF, Chen SJ, Chen HM, Wang YC, Chang WS, Chang YT, Chen WY, Huang CY, Kuo CC, Li MC, Lin JF, Lin SP, Ting SW, Weng TC, Wu PS, Wu UI, Lin PC, Lee SSJ, Chen YS, Liu YC, Chuang YC, Yu CJ, Huang LM, Lin MC. Recommendations and guidelines for the treatment of pneumonia in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:172-199. [PMID: 30612923 DOI: 10.1016/j.jmii.2018.11.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 01/19/2023]
Abstract
Pneumonia is a leading cause of death worldwide, ranking third both globally and in Taiwan. This guideline was prepared by the 2017 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group, formed under the auspices of the Infectious Diseases Society of Taiwan (IDST). A consensus meeting was held jointly by the IDST, Taiwan Society of Pulmonary and Critical Care Medicine (TSPCCM), the Medical Foundation in Memory of Dr. Deh-Lin Cheng, the Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines. The final guideline was endorsed by the IDST and TSPCCM. The major differences between this guideline and the 2007 version include the following: the use of GRADE methodology for the evaluation of available evidence whenever applicable, the specific inclusion of healthcare-associated pneumonia as a category due to the unique medical system in Taiwan and inclusion of recommendations for treatment of pediatric pneumonia. This guideline includes the epidemiology and recommendations of antimicrobial treatment of community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, healthcare-associated pneumonia in adults and pediatric pneumonia.
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Affiliation(s)
- Chih-Chen Chou
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ching-Fen Shen
- Division of Infectious Diseases, Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Su-Jung Chen
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsien-Meng Chen
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shuo Chang
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ya-Ting Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Yu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ching-Ying Huang
- Department of Pediatrics, MacKay Children's Hospital and MacKay Memorial Hospital, Taipei, Taiwan
| | - Ching-Chia Kuo
- Division of Infectious Diseases and Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Fu Lin
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shih-Ping Lin
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Wen Ting
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tzu-Chieh Weng
- Division of Holistic Care Unit, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ping-Sheng Wu
- Division of Infectious Diseases, Department of Pediatrics, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Un-In Wu
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Chin Lin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Yao-Shen Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Yung-Ching Liu
- Division of Infectious Diseases, Taipei Medical University Shuang Ho Hospital, Taipei, Taiwan
| | - Yin-Ching Chuang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chong-Jen Yu
- National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ming Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
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27
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Feldman C, Richards G. Appropriate antibiotic management of bacterial lower respiratory tract infections. F1000Res 2018; 7:F1000 Faculty Rev-1121. [PMID: 30079235 PMCID: PMC6058472 DOI: 10.12688/f1000research.14226.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 01/05/2023] Open
Abstract
Lower respiratory tract infections are the leading cause of infectious disease deaths worldwide and are the fifth leading cause of death overall. This is despite conditions such as pneumococcal infections and influenza being largely preventable with the use of appropriate vaccines. The mainstay of treatment for the most important bacterial lower respiratory tract infections, namely acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP), is the use of antibiotics. Yet despite a number of recent publications, including clinical studies as well as several systematic literature reviews and meta-analyses, there is considerable ongoing controversy as to what the most appropriate antibiotics are for the empiric therapy of CAP in the different settings (outpatient, inpatient, and intensive care unit). Furthermore, in the case of AECOPD, there is a need for consideration of which of these exacerbations actually need antibiotic treatment. This article describes these issues and makes suggestions for appropriately managing these conditions, in the setting of the need for antimicrobial stewardship initiatives designed to slow current emerging rates of antibiotic resistance, while improving patient outcomes.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Guy Richards
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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28
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Okumura J, Shindo Y, Takahashi K, Sano M, Sugino Y, Yagi T, Taniguchi H, Saka H, Matsui S, Hasegawa Y. Mortality in patients with community-onset pneumonia at low risk of drug-resistant pathogens: Impact of β-lactam plus macrolide combination therapy. Respirology 2017; 23:526-534. [PMID: 29239493 DOI: 10.1111/resp.13232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 09/01/2017] [Accepted: 11/07/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Drug-resistant pathogen (DRP) risk stratification is important for choosing a treatment strategy for community-onset pneumonia. Evidence for benefits of non-antipseudomonal β-lactam plus macrolide combination therapy (BLM) on mortality is limited in patients at low DRP risk. Risk factors for mortality remain to be clarified. METHODS Post hoc analysis using a prospective multicentre study cohort of community-onset pneumonia was performed to assess 30-day differences in mortality between non-antipseudomonal β-lactam monotherapy (BL) and BLM groups. Logistic regression analysis was performed to assess the therapeutic effect and risk factors for mortality in patients at low DRP risk. RESULTS In total, 594 patients with community-onset pneumonia at low DRP risk (369 BL and 225 BLM) were analysed. The 30-day mortality in BL and BLM was 13.8% and 1.8%, respectively (P < 0.001). Multivariate analysis showed that BLM reduced the 30-day mortality (adjusted odds ratio: 0.28, 95% CI: 0.09-0.87) compared with BL. Independent prognostic factors for 30-day mortality included arterial partial pressure of carbon dioxide (PaCO2 ) > 50 mm Hg, white blood cell count < 4000/mm3 , non-ambulatory status, albumin < 3.0 g/dL, haematocrit < 30%, age ≥ 80 years, respiratory rate > 25/min and body temperature < 36°C. CONCLUSION In patients with community-onset pneumonia at low DRP risk, BLM treatment reduced 30-day mortality compared with BL. Independent risk factors for mortality are potential confounding factors when assessing antibiotic effects in randomized clinical trials.
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Affiliation(s)
- Junya Okumura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Sano
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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29
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Ceftriaxone versus ceftriaxone plus a macrolide for community-acquired pneumonia in hospitalized patients with HIV/AIDS: a randomized controlled trial. Clin Microbiol Infect 2017. [PMID: 28648859 DOI: 10.1016/j.cmi.2017.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate if treatment with ceftriaxone and a macrolide, improved patient outcome when compared with monotherapy with ceftriaxone, in hospitalized patients with human immunodeficiency virus/acquired immunodeficient syndrome (HIV/AIDS) with community-acquired pneumonia (CAP). METHODS Adult patients with HIV hospitalized due to suspected CAP were randomized to receive one of two regimens, ceftriaxone plus macrolide or ceftriaxone plus placebo, at a 1:1 proportion (Brazilian Clinical Trials Registry: RBR-8wtq2b). The primary outcome was in-hospital mortality and the secondary outcomes were mortality within 14 days, need for vasoactive drugs, need for mechanical ventilation, time to clinical stability and length of hospitalization. RESULTS A total of 227 patients were randomized, two were excluded after randomization; 225 patients were analysed (112 receiving ceftriaxone plus placebo and 113 receiving ceftriaxone plus macrolide). The frequency of the primary outcome, in-hospital mortality, was not statistically different between the regimens: 12/112 (11%) patients who received ceftriaxone plus placebo and 17/113 (15%) who received ceftriaxone plus macrolide died during hospitalization (hazard ratio 1.22, 95% CI 0.57-2.59). We did not find differences between the regimens for any of the secondary outcomes, including mortality within 14 days, which occurred in 5/112 (4%) patients with ceftriaxone plus placebo and in 12/113 (11%) patients with ceftriaxone plus macrolide (relative risk 2.38, 95% CI 0.87-6.53). CONCLUSIONS Among hospitalized patients with HIV/AIDS with CAP, treatment with ceftriaxone and a macrolide did not improve patient outcomes, when compared with ceftriaxone monotherapy.
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30
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Eljaaly K, Alshehri S, Aljabri A, Abraham I, Al Mohajer M, Kalil AC, Nix DE. Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis 2017; 17:385. [PMID: 28576117 PMCID: PMC5457549 DOI: 10.1186/s12879-017-2495-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/25/2017] [Indexed: 11/18/2022] Open
Abstract
Background Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints). Methods We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I2) was observed. Results Five RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732–0.99; P = 0.037]; I2 = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259–1.165, P = 0.118], I2 = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523–1.272, P = 0.369], I2 = 0%), diarrhea (RR = 0.746 [95% CI, 0.311–1.790, P = 0.512], I2 = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542–1.270, P = 0.39], I2 = 0%). Conclusions Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2495-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khalid Eljaaly
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia. .,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA.
| | - Samah Alshehri
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia.,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Ahmed Aljabri
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia.,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Ivo Abraham
- College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - David E Nix
- College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA.,Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, AZ, USA
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31
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Restrepo MI, Chalmers JD, Song Y, Mallow C, Hewlett J, Maldonado F, Yarmus L. Year in review 2016: Respiratory infections, acute respiratory distress syndrome, pleural diseases, lung cancer and interventional pulmonology. Respirology 2017; 22:602-611. [PMID: 28244617 PMCID: PMC5889848 DOI: 10.1111/resp.13016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/06/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Marcos I Restrepo
- South Texas Veterans Health Care System and University of Texas Health, San Antonio, TX, USA
| | - James D Chalmers
- Scottish Centre for Respiratory Research, Dundee, UK
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Justin Hewlett
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Lonny Yarmus
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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32
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Anderson R, Feldman C. Pneumolysin as a potential therapeutic target in severe pneumococcal disease. J Infect 2017; 74:527-544. [PMID: 28322888 DOI: 10.1016/j.jinf.2017.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/09/2017] [Accepted: 03/11/2017] [Indexed: 12/13/2022]
Abstract
Acute pulmonary and cardiac injury remain significant causes of morbidity and mortality in those afflicted with severe pneumococcal disease, with the risk for early mortality often persisting several years beyond clinical recovery. Although remaining to be firmly established in the clinical setting, a considerable body of evidence, mostly derived from murine models of experimental infection, has implicated the pneumococcal, cholesterol-binding, pore-forming toxin, pneumolysin (Ply), in the pathogenesis of lung and myocardial dysfunction. Topics covered in this review include the burden of pneumococcal disease, risk factors, virulence determinants of the pneumococcus, complications of severe disease, antibiotic and adjuvant therapies, as well as the structure of Ply and the role of the toxin in disease pathogenesis. Given the increasing recognition of the clinical potential of Ply-neutralisation strategies, the remaining sections of the review are focused on updates of the types, benefits and limitations of currently available therapies which may attenuate, directly and/or indirectly, the injurious actions of Ply. These include recently described experimental therapies such as various phytochemicals and lipids, and a second group of more conventional agents the members of which remain the subject of ongoing clinical evaluation. This latter group, which is covered more extensively, encompasses macrolides, statins, corticosteroids, and platelet-targeted therapies, particularly aspirin.
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Affiliation(s)
- Ronald Anderson
- Department of Immunology and Institute of Cellular and Molecular Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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