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Johansen E, Nielsen H, Gillespie D, Aabenhus R, Hansen MP. The optimal antibiotic treatment duration for community-acquired pneumonia in adults diagnosed in general practice in Denmark (CAP-D): an open-label, pragmatic, randomised controlled trial. Trials 2024; 25:627. [PMID: 39334468 PMCID: PMC11429885 DOI: 10.1186/s13063-024-08477-z] [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: 05/27/2024] [Accepted: 09/17/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Use of antibiotics is the main driver of antimicrobial resistance which is considered one of the biggest threats to human health. In Denmark, most antibiotics are prescribed in general practice. Acute lower respiratory tract infections, including community-acquired pneumonia (CAP), are among the most frequent indications for antibiotic prescribing. Phenoxymethylpenicillin is established as first-line treatment in general practice in Denmark. However, the treatment duration with phenoxymethylpenicillin is mostly based on traditions. Both 5 and 7 days of treatment is recommended in Danish guidelines, and when asking the general practitioners about what treatment duration, they prescribe the variation is even bigger. Several hospital-based studies have proven short course (≤ 6 days) antibiotic treatment non-inferior to long course (≥ 7 days) treatment of CAP. No evidence exists on the optimal treatment duration for CAP in non-hospitalised patients. This randomised controlled trial aim to investigate the optimal treatment duration with phenoxymethylpenicillin for CAP in adults diagnosed in general practice in Denmark. METHODS This is an open-label, pragmatic, randomised controlled, five-arm DURATIONS trial. Participants will be recruited from at least 24 general practices in Denmark. Eligible participants are adults, with no pre-existing lung disease, presenting with symptoms of CAP, and in whom the general practitioner finds it relevant to treat with antibiotics. The study will compare treatment with phenoxymethylpenicillin 1.2 MIE q.i.d. in 3, 4, 5, 6, and 7 days. DISCUSSION This study will provide evidence for the optimal antibiotic treatment duration of CAP in general practice and inform future guidelines on CAP in all countries using phenoxymethylpenicillin for the treatment of acute respiratory tract infections in adults. The results of this study might also be used to guide treatment recommendations in other countries using phenoxymethylpenicillin. Moreover, a (potential) reduction in antibiotic use might lower the development of antimicrobial resistance, increase patient treatment adherence, reduce risks of adverse events, and lower the economical exp TRIAL REGISTRATION: ClinicalTrials.gov: NCT06295120. Registered 28 February 2024. The Scientific Ethics Committee for the North Denmark Region: N-20230039.
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Affiliation(s)
- Eskild Johansen
- Center for General Practice, Aalborg University, Aalborg, Denmark.
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David Gillespie
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Rune Aabenhus
- The Research Unit for General Practice, Copenhagen, Denmark
- Section of General Practice, Institute of Public Health, Copenhagen University, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Center for General Practice, Aalborg University, Aalborg, Denmark
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
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de Barros GM, Borges IN, Ravetti CG, Diniz PH, Ferreira SR, De Mori LH, Castro R, Okamura GH, Gatto F, Nobre V. Significant drop in serum C-reactive protein in patients with solid neoplasia and bacterial infection is associated with a better prognosis and identifies candidates for short-course antibiotic therapy. BMC Infect Dis 2024; 24:974. [PMID: 39272020 PMCID: PMC11401243 DOI: 10.1186/s12879-024-09544-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/20/2024] [Indexed: 09/15/2024] Open
Abstract
INTRODUCTION The greater predisposition to infections, as well as the possibility of a worse response to treatment, can lead to the excessive use of antimicrobials among cancer patients. C-reactive protein (CRP) has gained prominence as a tool for monitoring therapeutic responses and reducing the duration of antibiotic therapy; however, few studies have analyzed this protein in cancer patient populations. We hypothesize that cancer patients with a good response to antibiotic therapy show a faster decline in serum CRP levels, which would allow us to identify candidates for short-course treatments. OBJECTIVE To evaluate the behavior of serum CRP levels among adult cancer patients using antibiotic therapy, and its association with the duration of this treatment, therapeutic response, and clinical recurrence. METHODS This work consisted of a retrospective study with cancer patients admitted to a university hospital between September 2018 and December 2019. Adults (age ≥ 18 years) who underwent at least one course of antibiotic therapy were included. CRP behavior over the first 7 days of treatment was classified as: i) good response: when the CRP value on the fifth day of therapy reached 50% or less of the peak value detected in the first 48 h of treatment, and ii) poor response: Maintenance, within the same interval, of a CRP value > 50% of the peak value in the first 48 h. The duration of antibiotic therapy was categorized as up to seven full days or more. Outcomes were assessed by events that occurred during the 30 days of hospitalization or until hospital discharge. PRIMARY OUTCOME Clinical recurrence of the index infection. SECONDARY OUTCOMES i) Death from any cause; ii) microbiological recurrence; iii) therapeutic response; iv) colitis associated with Clostridioides difficile; and v) isolation of multi-resistant bacteria, whether in clinical or surveillance samples. RESULTS The final analysis consisted of 212 patients, with a median age (IQ) of 59.2 (48 - 67) years old and a predominance of females (65%), who were hypertensive (35%), smokers (21%), and diabetics (17.8%). There was no difference in clinical recurrence between the two groups (8.1% vs. 12.2%; p = 0.364), with a lower 30-day mortality in the good CRP response group (32.2% vs. 14.5%; p = 0.002). Despite the tendency towards a lower occurrence of other secondary outcomes in the good response group, these differences were not statistically significant. In the poor CRP response group, outcomes like clinical recurrence, mortality, and therapeutic response were significantly worse, regardless of the duration of antibiotic treatment. CONCLUSION In this study, cancer patients with a good CRP response during antibiotic therapy presented lower mortality and a higher proportion of satisfactory therapeutic responses. CRP can be a useful tool when combined with other clinical information in optimizing the duration of antimicrobial treatment in a hospitalized cancer population.
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Affiliation(s)
- Guilherme Monteiro de Barros
- Graduate Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte MG, CEP: 30130-100, Brazil.
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil.
| | - Isabela Nascimento Borges
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil
| | - Cecilia Gómez Ravetti
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil
| | - Paulo Henrique Diniz
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Samuel Rosa Ferreira
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Lara Hemerly De Mori
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Rafael Castro
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Getúlio H Okamura
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Felipe Gatto
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
| | - Vandack Nobre
- Graduate Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte MG, CEP: 30130-100, Brazil
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Prof. Alfredo Balena, Santa Efigênia, Belo Horizonte MG, 190CEP: 30130-100, Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil
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Kuijpers SME, Buis DTP, Ziesemer KA, van Hest RM, Schade RP, Sigaloff KCE, Prins JM. The evidence base for the optimal antibiotic treatment duration of upper and lower respiratory tract infections: an umbrella review. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00456-0. [PMID: 39243792 DOI: 10.1016/s1473-3099(24)00456-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Many trials, reviews, and meta-analyses have been performed on the comparison of short versus long antibiotic treatment in respiratory tract infections, generally supporting shorter treatment. The aim of this umbrella review is to assess the soundness of the current evidence base for optimal antibiotic treatment duration. METHODS A search in Ovid MEDLINE, Embase, and Clarivate Analytics Web of Science Core Collection was performed on May 1, 2024, without date and language restrictions. Systematic reviews addressing treatment durations in community-acquired pneumonia (CAP), acute exacerbation of chronic obstructive pulmonary disease (AECOPD), hospital-acquired pneumonia (HAP), acute sinusitis, and streptococcal pharyngitis, tonsillitis, or pharyngotonsillitis were included. Studies from inpatient and outpatient settings were included; reviews in paediatric populations were excluded. Outcomes of interest were clinical and bacteriological cure, microbiological eradication, mortality, relapse rate, and adverse events. The quality of the reviews was assessed using the AMSTAR 2 tool, risk of bias of all included randomised controlled trials (RCTs) using the Cochrane risk-of-bias tool (version 1), and overall quality of evidence according to GRADE. FINDINGS We identified 30 systematic reviews meeting the criteria; they were generally of a low to critically low quality. 21 reviews conducted a meta-analysis. For CAP outside the intensive care unit (ICU; 14 reviews, of which eight did a meta-analysis) and AECOPD (eight reviews, of which five did a meta-analysis), there was sufficient evidence supporting a treatment duration of 5 days; evidence for shorter durations is scarce. Evidence on non-ventilator-associated HAP is absent, despite identifying three reviews (of which one did a meta-analysis), since no trials were conducted exclusively in this population. For sinusitis the evidence appears to support a shorter regimen, but more evidence is needed in the population who actually require antibiotic treatment. For pharyngotonsillitis (eight reviews, of which six did a meta-analysis), sufficient evidence exists to support short-course cephalosporin but not short-course penicillin when dosed three times a day. INTERPRETATION The available evidence for non-ICU CAP and AECOPD supports a short-course treatment duration of 5 days in patients who have clinically improved. Efforts of the scientific community should be directed at implementing this evidence in daily practice. High-quality RCTs are needed to underpin even shorter treatment durations for CAP and AECOPD, to establish the optimal treatment duration of HAP and acute sinusitis, and to evaluate shorter duration using an optimal penicillin dosing schedule in patients with pharyngotonsillitis. FUNDING None.
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Affiliation(s)
- Suzanne M E Kuijpers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David T P Buis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Reinier M van Hest
- Department of Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Rogier P Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.
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Sellarès-Nadal J, Burgos J, Martín-Gómez MT, Romero-Herrero D, Sánchez-Montalvá A, Falcó V. Real Life Experience in Short Treatments for Community-Acquired Pneumonia: An Observational Propensity Cohort Study. Arch Bronconeumol 2024; 60:582-584. [PMID: 38744545 DOI: 10.1016/j.arbres.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Júlia Sellarès-Nadal
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Infectious Diseases Department, Vall d'Hebron, Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Malalties Infeccioses Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Joaquín Burgos
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Infectious Diseases Department, Vall d'Hebron, Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Malalties Infeccioses Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
| | - María Teresa Martín-Gómez
- Microbiology Department, Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Daniel Romero-Herrero
- Microbiology Department, Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Infectious Diseases Department, Vall d'Hebron, Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Malalties Infeccioses Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - Vicenç Falcó
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Infectious Diseases Department, Vall d'Hebron, Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain; Malalties Infeccioses Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Vall d'Hebron Hospital Universitari, Barcelona, Spain
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Tucker E, O'Sullivan M, Waddell L. Controversies in the management of community-acquired pneumonia in adults. Aust Prescr 2024; 47:80-84. [PMID: 38962379 PMCID: PMC11216909 DOI: 10.18773/austprescr.2024.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Community-acquired pneumonia (CAP) is a common infectious syndrome in Australia and a leading global cause of morbidity and mortality. It drives a significant amount of antimicrobial prescribing in Australia. Accurate assessment and stratification of CAP severity is important. However, adequate evaluation is challenging and controversy remains about the optimal method. Streptococcus pneumoniae is the most commonly identified bacterial pathogen causing CAP. As such, oral amoxicillin monotherapy is the mainstay of empirical therapy for low-severity CAP. The need to start empirical therapy for pathogens such as Mycoplasma pneumoniae and Legionella species in low-severity CAP remains controversial; evaluating the causative pathogen on clinical grounds alone is difficult. Oral antibiotics recommended for CAP (e.g. amoxicillin, doxycycline) have excellent bioavailability and may be used instead of intravenous therapy in some hospitalised patients. A duration of 5 days of antibiotic therapy is recommended in clinical practice guidelines for patients with uncomplicated CAP who meet stability criteria at follow-up.
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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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Almajid A, Almuyidi S, Alahmadi S, Bohaligah S, Alfaqih L, Alotaibi A, Almarzooq A, Alsarihi A, Alrawi Z, Althaqfan R, Alamoudi R, Albaqami S, Alali AH. ''Myth Busting in Infectious Diseases'': A Comprehensive Review. Cureus 2024; 16:e57238. [PMID: 38686221 PMCID: PMC11056812 DOI: 10.7759/cureus.57238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
Antibiotics have played a pivotal role in modern medicine, drastically reducing mortality rates associated with bacterial infections. Despite their significant contributions, the emergence of antibiotic resistance has become a formidable challenge, necessitating a re-evaluation of antibiotic use practices. The widespread belief in clinical practice that bactericidal antibiotics are inherently superior to bacteriostatic ones lacks consistent support from evidence in randomized controlled trials (RCTs). With the latest evidence, certain infections have demonstrated equal or even superior efficacy with bacteriostatic agents. Furthermore, within clinical practice, there is a tendency to indiscriminately order urine cultures for febrile patients, even in cases where alternative etiologies might be present. Consequently, upon obtaining a positive urine culture result, patients often receive antimicrobial prescriptions despite the absence of clinical indications warranting such treatment. Furthermore, it is a prevailing notion among physicians that extended durations of antibiotic therapy confer potential benefits and mitigate the emergence of antimicrobial resistance. Contrary to this belief, empirical evidence refutes such assertions. This article aims to address common myths and misconceptions within the field of infectious diseases.
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Affiliation(s)
- Ali Almajid
- Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Shatha Alahmadi
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Sarah Bohaligah
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | | | | | - Asmaa Alsarihi
- Applied Medical Sciences, Taibah University, AlMadinah, SAU
| | - Zaina Alrawi
- Medicine, King Abdulaziz University, Jeddah, SAU
| | - Rahaf Althaqfan
- Applied Medical Sciences, King Khalid University, Khamis Mushait, SAU
| | - Rahma Alamoudi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | | | - Alaa H Alali
- Infectious Diseases, King Saud Medical City, Riyadh, SAU
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Rafeq R, Igneri LA. Infectious Pulmonary Diseases. Infect Dis Clin North Am 2024; 38:1-17. [PMID: 38280758 DOI: 10.1016/j.idc.2023.12.006] [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] [Indexed: 01/29/2024]
Abstract
Pneumonia is a lower respiratory tract infection caused by the inability to clear pathogens from the lower airway and alveoli. Cytokines and local inflammatory markers are released, causing further damage to the lungs through the accumulation of white blood cells and fluid congestion, leading to pus in the parenchyma. The Infectious Diseases Society of America defines pneumonia as the presence of new lung infiltrate with other clinical evidence supporting infection, including new fever, purulent sputum, leukocytosis, and decline in oxygenation. Importantly, lower respiratory infections remain the most deadly communicable disease. Pneumonia is subdivided into three categories: (1) community acquired, (2) hospital acquired, and (3) ventilator associated. Therapy for each differs based on the severity of the disease and the presence of risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa.
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Affiliation(s)
- Rachel Rafeq
- Emergency Medicine, Department of Pharmacy, Cooper University Healthcare, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Lauren A Igneri
- Critical Care, Department of Pharmacy, Cooper University Healthcare, 1 Cooper Plaza, Camden, NJ 08103, USA
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Candel FJ, Salavert M, Basaras M, Borges M, Cantón R, Cercenado E, Cilloniz C, Estella Á, García-Lechuz JM, Garnacho Montero J, Gordo F, Julián-Jiménez A, Martín-Sánchez FJ, Maseda E, Matesanz M, Menéndez R, Mirón-Rubio M, Ortiz de Lejarazu R, Polverino E, Retamar-Gentil P, Ruiz-Iturriaga LA, Sancho S, Serrano L. Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6864. [PMID: 37959328 PMCID: PMC10649000 DOI: 10.3390/jcm12216864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology & Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain
| | - Miren Basaras
- Immunology, Microbiology and Parasitology Department, Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain;
| | - Marcio Borges
- Multidisciplinary Sepsis Unit, Intensive Medicine Department, University Hospital Son Llàtzer, 07198 Palma de Mallorca, Spain;
- Instituto de Investigación Sanitaria Islas Baleares (IDISBA), 07198 Mallorca, Spain
| | - Rafael Cantón
- Clinical Microbiology Service, University Hospital Ramón y Cajal, Institute Ramón y Cajal for Health Research (IRYCIS), 28034 Madrid, Spain;
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
| | - Emilia Cercenado
- Clinical Microbiology & Infectious Diseases Service, University Hospital Gregorio Marañón, 28009 Madrid, Spain;
| | - Catian Cilloniz
- IDIBAPS, CIBERES, 08007 Barcelona, Spain;
- Faculty of Health Sciences, Continental University, Huancayo 15304, Peru
| | - Ángel Estella
- Intensive Care Unit, INIBiCA, University Hospital of Jerez, Medicine Department, University of Cádiz, 11404 Jerez, Spain
| | | | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, 41013 Sevilla, Spain;
| | - Federico Gordo
- Intensive Medicine Department, University Hospital of Henares, 28802 Madrid, Spain;
| | - Agustín Julián-Jiménez
- Emergency Department, University Hospital Toledo, University of Castilla La Mancha, 45007 Toledo, Spain;
| | | | - Emilio Maseda
- Anesthesiology Department, Hospital Quirón Salud Valle del Henares, 28850 Madrid, Spain;
| | - Mayra Matesanz
- Hospital at Home Unit, Clinic University Hospital San Carlos, 28040 Madrid, Spain;
| | - Rosario Menéndez
- Pneumology Service, La Fe (IIS) Health Research Institute, University Hospital La Fe, 46015 Valencia, Spain;
| | - Manuel Mirón-Rubio
- Hospital at Home Service, University of Torrejón, Torrejón de Ardoz, 28006 Madrid, Spain;
| | - Raúl Ortiz de Lejarazu
- National Influenza Center, Clinic University Hospital of Valladolid, University of Valladolid, 47003 Valladolid, Spain;
| | - Eva Polverino
- Pneumology Service, Hospital Vall d’Hebron, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health San Carlos III, 28029 Madrid, Spain
| | - Pilar Retamar-Gentil
- CIBER of Infectious Diseases (CIBERINFEC), National Institute of Health San Carlos III, 28034 Madrid, Spain;
- Infectious Diseases & Microbiology Clinical Management Unit, University Hospital Virgen Macarena, IBIS, University of Seville, 41013 Sevilla, Spain
| | - Luis Alberto Ruiz-Iturriaga
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
| | - Susana Sancho
- Intensive Medicine Department, University Hospital La Fe, 46015 Valencia, Spain;
| | - Leyre Serrano
- Pneumology Service, University Hospital Cruces, 48903 Barakaldo, Spain; (L.A.R.-I.); (L.S.)
- Faculty of Medicine and Nursing, University of País Vasco, 48940 Bizkaia, Spain
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Saatchi A, Reid JN, Shariff SZ, Povitz M, Silverman M, Patrick DM, Morris AM, McCormack J, Haverkate MR, Marra F. Retrospective cohort analysis of outpatient antibiotic prescribing for community-acquired pneumonia in Canadian older adults. PLoS One 2023; 18:e0292899. [PMID: 37831711 PMCID: PMC10575505 DOI: 10.1371/journal.pone.0292899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND This retrospective cohort study is the first in North America to examine population-level appropriate antibiotic use for community-acquired pneumonia (CAP) in older adults, by agent, dose and duration. With the highest rates of CAP reported in the elderly populations, appropriate antibiotic use is essential to improve clinical outcomes. Given the ongoing crisis of antimicrobial resistance, understanding inappropriate antibiotic prescribing is integral to direct community stewardship efforts. METHODS All outpatient primary care visits for CAP (aged ≥65 years) were identified using physician billing codes between January 1 2014 to December 31 2018 in British Columbia (BC) and Ontario (ON). Categories of prescribing were derived from existing literature, and constructed for clinical relevance using Canadian and international guidelines available during the study period. Categories were mutually exclusive and included: guideline adherent (first-line agent, adherent dose/duration), clinically appropriate (non-first line agent, presence of comorbidities), effective but unnecessary (first-line agent, excess dose/duration), undertreatment (first-line agent, subtherapeutic dose/duration), and not recommended (non-first line agent, absence of comorbidities). Proportions of prescribing were examined by category. Temporal trends in prescribing were examined using Poisson regression. RESULTS A total of 436,441 episodes of CAP were identified, with 46% prescribed an antibiotic in BC, and 52% in Ontario. Guideline adherent prescribing was minimal for both provinces (BC: 2%; ON: 1%) however the largest magnitude of increase was reported in this category by the final study year (BC-Rate Ratio [RR]: 3.4, 95% Confidence Interval [CI]: 2.7-4.3; ON-RR: 4.62, 95% CI: 3.4-6.5). Clinically appropriate prescribing accounted for the most antibiotics issued, across all study years (BC: 61%; ON: 74%) (BC-RR: 0.8, 95% CI: 0.8-0.8; ON-RR: 0.9, 95% CI: 0.8-0.9). Excess duration of therapy was the hallmark characteristic for effective but unnecessary prescribing (BC: 92%; ON: 99%). The most common duration prescribed was 7 days, followed by 10. Not recommended prescribing was minimal in both provinces (BC: 4%; ON: 7%) and remained stable by the final study year (BC-RR: 1.1, 95% CI: 0.9-1.2; ON-RR: 0.9, 95% CI: 0.9-1.1). CONCLUSION Three quarters of antibiotic prescribing for CAP was appropriate in Ontario, but only two thirds in BC. Shortening durations-in line with evidence for 3 to 5-day treatment presents a focused target for stewardship efforts.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer N. Reid
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Salimah Z. Shariff
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Marcus Povitz
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - David M. Patrick
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew M. Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manon R. Haverkate
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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11
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Iovino G, Nadeau L. Effect of Pharmacist-Initiated Interventions on Duration of Antibiotic Therapy for Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Community-Acquired Pneumonia. Can J Hosp Pharm 2023; 76:296-301. [PMID: 37767382 PMCID: PMC10522359 DOI: 10.4212/cjhp.3421] [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: 09/29/2023]
Abstract
Background Current guidelines for the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP) recommend 5 days of antimicrobial therapy. Despite these recommendations, the duration of therapy exceeds 5 days for up to 70% of patients, with most superfluous prescribing occurring upon discharge from hospital. Shortening the duration of antibiotic therapy could decrease adverse events, resistance, and costs. Objective To determine whether a pharmacist-initiated modification to the duration of antibiotic therapy prescribed for the treatment of AECOPD or CAP reduced the duration of antibiotic prescriptions. Methods In this prospective, single-centre study of adult inpatients receiving antibiotics for the treatment of AECOPD or CAP between October 2020 and March 2021, pharmacists assigned a 5-day duration to antimicrobials prescribed for these indications. For patients discharged before completion of therapy, the antibiotic start date and intended duration were included on the discharge prescription. Study patients were matched 1:1 with historical controls to compare the total duration of antibiotic therapy with and without the intervention. Results A total of 100 patients (66 with CAP and 34 with AECOPD) met the inclusion criteria and had their antibiotic treatment duration modified to 5 days. Mean total duration of antibiotic therapy was 5.31 days in the intervention group and 7.11 days in the control group (p < 0.001). Outpatient antibiotic prescribing was 0.86 days in the intervention group and 3.2 days in the control group (p < 0.001). In both groups, the rates of readmission at 30 and 90 days were 19% and 31%, respectively. Conclusions Pharmacist-initiated modification of antimicrobial therapy resulted in shortening of the duration of therapy by almost 2 days. Including information about treatment duration on the discharge prescription reduced outpatient prescribing without affecting readmission rates.
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Affiliation(s)
- Giovanni Iovino
- , PharmD, ACPR, BSC, is with the Windsor Regional Hospital, Windsor, Ontario
| | - Lynn Nadeau
- , PharmD, is with the Windsor Regional Hospital, Windsor, Ontario
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12
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Mponponsuo K, Pinto R, Fowler R, Rogers B, Daneman N. Fixed versus individualized treatment for five common bacterial infectious syndromes: a survey of the perspectives and practices of clinicians. JAC Antimicrob Resist 2023; 5:dlad087. [PMID: 37533760 PMCID: PMC10391701 DOI: 10.1093/jacamr/dlad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/26/2023] [Indexed: 08/04/2023] Open
Abstract
Background Traditionally, bacterial infections have been treated with fixed-duration antibiotic courses; however, some have advocated for individualized durations. It is not known which approach currently predominates. Methods We conducted a multinational clinical practice survey asking prescribers their approach to treating skin and soft tissue infection (SSTI), community-acquired pneumonia (CAP), pyelonephritis, cholangitis and bloodstream infection (BSI) of an unknown source. The primary outcome was self-reported treatment approach as being fully fixed duration, fixed minimum, fixed maximum, fixed minimum and maximum, or fully individualized durations. Secondary questions explored factors influencing duration of therapy. Multivariable logistic regression with generalized estimating equations was used to examine predictors of use of fully fixed durations. Results Among 221 respondents, 170 (76.9%) completed the full survey; infectious diseases physicians accounted for 60.6%. Use of a fully fixed duration was least common for SSTI (8.5%) and more common for CAP (28.3%), BSI (29.9%), cholangitis (35.7%) and pyelonephritis (36.3%). Fully individualized therapy, with no fixed minimum or maximum, was used by only a minority: CAP (4.9%), pyelonephritis (5.0%), cholangitis (9.9%), BSI (13.6%) and SSTI (19.5%). In multivariable analyses, a fully fixed duration approach was more common among Canadian respondents [adjusted OR (aOR) 1.76 (95% CI 1.12-2.76)] and for CAP (aOR 4.25, 95% CI 2.53-7.13), cholangitis (aOR 6.01, 95% CI 3.49-10.36), pyelonephritis (aOR 6.08, 95% CI 3.56-10.39) and BSI (aOR 4.49, 95% CI 2.50-8.09) compared with SSTI. Conclusions There is extensive practice heterogeneity in fixed versus individualized treatment; clinical trials would be helpful to compare these approaches.
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Affiliation(s)
| | - Ruxandra Pinto
- Sunnybrook Research Institute, Toronto, Canada
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Robert Fowler
- Sunnybrook Research Institute, Toronto, Canada
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ben Rogers
- Division of Infectious Diseases, Monash Health, Clayton, VIC, Australia
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13
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Israelsen SB, Tingsgård S, Thorlacius-Ussing L, Knudsen A, Lindegaard B, Johansen IS, Mygind LH, Ravn P, Benfield T. Short-course antibiotic therapy of 5 days in community-acquired pneumonia (CAP5): study protocol for a randomised controlled trial. BMJ Open 2023; 13:e069013. [PMID: 37479519 PMCID: PMC10364160 DOI: 10.1136/bmjopen-2022-069013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION The optimal duration of antibiotic therapy for community-acquired pneumonia (CAP) is unsettled. Short-course therapy has proved successful in clinical trials but is not yet implemented in everyday clinical practice. Validation of results from randomised controlled trials is crucial to evaluate existing evidence and provide clinicians with assurance of using new treatment strategies. In a pragmatic framework, we aim to assess the use of short-course antibiotic therapy guided by the onset of clinical stability in patients hospitalised with CAP. METHODS AND ANALYSIS This study is a randomised controlled trial with a non-inferiority design that will examine the efficacy of short-course antibiotic therapy in patients hospitalised with CAP. From six hospitals across Denmark, we plan to enrol 564 patients between 2019 and 2024. Within 3-5 days after initiating antibiotic therapy, participants will be randomised 1:1 to parallel treatment arms: (1) short-course antibiotic therapy of 5 days or (2) antibiotic therapy of at least 7 days. The primary outcome will be 90-day readmission-free survival and will be estimated as an absolute risk difference with a predefined non-inferiority margin of -6%. Secondary outcomes will comprise other safety measures including new antibiotics, adverse events, length of hospital stay and postdischarge outpatient visits. Both intention-to-treat and per-protocol analyses will be performed. ETHICS AND DISSEMINATION This study has been approved by the Health Research Ethics Committee of the Capital Region of Denmark (identifier number: H-19014479). Trial data will be made available in anonymous form when the trial has ended. TRIAL REGISTRATION NUMBER NCT04089787, ClinicalTrials.Gov.
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Affiliation(s)
- Simone Bastrup Israelsen
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Sandra Tingsgård
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Louise Thorlacius-Ussing
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Andreas Knudsen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Birgitte Lindegaard
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Isik S Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Lone Hagens Mygind
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Pernille Ravn
- Department of Internal Medicine, Section for Infectious Diseases, Copenhagen University Hospital, Herlev and Gentofte, Hellerup, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
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14
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Dinh A, Crémieux AC, Guillemot D. Short treatment duration for community-acquired pneumonia. Curr Opin Infect Dis 2023; 36:140-145. [PMID: 36718940 DOI: 10.1097/qco.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Lower respiratory tract infections are one of the most common indications for antibiotic use in community and hospital settings. Usual guidelines for adults with community-acquired pneumonia (CAP) recommend 5-7 days of antibiotic treatment. In daily practice, physicians often prescribe 9-10 days of antibiotic treatment. Among available strategies to decrease antibiotic use, possibly preventing the emergence of bacterial resistance, reducing treatment durations is the safest and the most acceptable to clinicians. We aim to review data evaluating the efficacy of short antibiotic duration in adult CAP and which criteria can help clinicians to reduce antibiotic treatment. RECENT FINDINGS Several studies and meta-analyses demonstrated that the treatment duration of 7 days or less was sufficient for CAP. Two trials found that 3-day treatments were effective, even in hospitalized CAP.To customize and shorten duration, clinical and biological criteria have been studied and reflect patient's response. Indeed, stability criteria were recently shown to be effective to discontinue antibiotic treatment. Procalcitonin was also studied but never compared with clinical criteria. SUMMARY Treatment duration for CAP is still under debate, but several studies support short durations. Clinical criteria could be possibly used to discontinue antibiotic treatment.
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Affiliation(s)
- Aurélien Dinh
- Infectious Diseases Unit, University Hospital Raymond-Poincaré, AP-HP, Garches
- Paris Saclay University, UVSQ, Inserm, CESP, Antiinfective Evasion and Pharmacoepidemiology Team, Montigny-Le-Bretonneux
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE)
| | - Anne-Claude Crémieux
- Infectious Diseases Department, Saint-Louis University Hospital, AP-HP, University of Paris, Paris, France
| | - Didier Guillemot
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE)
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15
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Furukawa Y, Luo Y, Funada S, Onishi A, Ostinelli E, Hamza T, Furukawa TA, Kataoka Y. Optimal duration of antibiotic treatment for community-acquired pneumonia in adults: a systematic review and duration-effect meta-analysis. BMJ Open 2023; 13:e061023. [PMID: 36948555 PMCID: PMC10040075 DOI: 10.1136/bmjopen-2022-061023] [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] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVES To find the optimal treatment duration with antibiotics for community-acquired pneumonia (CAP) in adults. DESIGN Systematic review and duration-effect meta-analysis. DATA SOURCES MEDLINE, Embase and CENTRAL through 25 August 2021. ELIGIBILITY CRITERIA All randomised controlled trials comparing the same antibiotics used at the same daily dosage but for different durations for CAP in adults. Both outpatients and inpatients were included but not those admitted to intensive care units. We imposed no date, language or publication status restriction. DATA EXTRACTION AND SYNTHESIS Data extraction by two independent reviewers. We conducted a random-effects, one-stage duration-effect meta-analysis with restricted cubic splines. We tested the non-inferiority with the prespecified non-inferiority margin of 10% examined against 10 days . The primary outcome was clinical improvement on day 15 (range 7-45 days). SECONDARY OUTCOMES all-cause mortality, serious adverse events and clinical improvement on day 30 (15-60 days). RESULTS We included nine trials (2399 patients with a mean (SD) age of 61.2 (22.1); 39% women). The duration-effect curve was monotonic with longer duration leading to a lower probability of improvement, and shorter treatment duration (3-9 days) was likely to be non-inferior to 10-day treatment. Harmful outcome curves indicated no association. The weighted average percentage of the primary outcome in the 10-day treatment arms was 68%. Using that average, the absolute clinical improvement rates of the following durations were: 3-day treatment 75% (95% CI: 68% to 81%), 5-day treatment 72% (95% CI: 66% to 78%) and 7-day treatment 69% (95% CI: 61% to 76%). CONCLUSIONS Shorter treatment duration (3-5 days) probably offers the optimal balance between efficacy and treatment burden for treating CAP in adults if they achieved clinical stability. However, the small number of included studies and the overall moderate-to-high risk of bias may compromise the certainty of the results. Further research on the shorter duration range is required. PROSPERO REGISTRATION NUMBER CRD 42021273357.
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Affiliation(s)
- Yuki Furukawa
- Department of Psychiatry, Tokyo Musashino Hospital, Tokyo, Japan
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Yan Luo
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Funada
- Department of Urology, Kyoto University, Kyoto, Japan
- Health Promotion and Human Behavior, Kyoto University, Kyoto, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Tasnim Hamza
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Toshi A Furukawa
- Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Community Medicine, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
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16
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Lee RA, Stripling JT, Spellberg B, Centor RM. Short-course antibiotics for common infections: what do we know and where do we go from here? Clin Microbiol Infect 2023; 29:150-159. [PMID: 36075498 DOI: 10.1016/j.cmi.2022.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over the past 25 years, researchers have performed >120 randomized controlled trials (RCTs) illustrating short courses to be non-inferior to long courses of antibiotics for common bacterial infections. OBJECTIVE We sought to determine whether clinical data from RCTs affirm the mantra of 'shorter is better' for antibiotic durations in 7 common infections: pneumonia, urinary tract infection, intra-abdominal infection, bacteraemia, skin and soft tissue infection, bone and joint infections, pharyngitis and sinusitis. SOURCES Published RCTs comparing short- versus long-course antibiotic durations were identified through searches of PubMed and clinical guideline documents. CONTENT Short-course antibiotic durations consistently result in similar treatment success rates as longer antibiotic courses among patients with community-acquired pneumonia, complicated urinary tract infections in women, gram-negative bacteraemia, and skin and soft tissue infections when the diagnosis is confirmed, appropriate antimicrobials are used, and patients show clinical signs of improvement. For patients with osteomyelitis, 6 weeks of antibiotics is adequate for the treatment of osteomyelitis in the absence of implanted foreign bodies and surgical debridement. Whether durations can be further shortened with debridement is unclear, although small studies are promising. IMPLICATIONS With few exceptions, short courses were non-inferior to long courses; future research should focus on appropriately defining the patient population, ensuring the correct choice and dose of antimicrobials and developing meaningful outcomes relevant for frontline clinicians.
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Affiliation(s)
- Rachael A Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama Heersink School of Medicine, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Joshua T Stripling
- Department of Medicine, Division of Infectious Diseases, University of Alabama Heersink School of Medicine, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Robert M Centor
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA; Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham, AL, USA
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Berk Cam H. Treatment of Chlamydial Infections. Infect Dis (Lond) 2023. [DOI: 10.5772/intechopen.109648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Sexually transmitted infections (STIs) are a major health problem with an estimated burden of disease transmission as high as one million new cases per day globally. Chlamydia trachomatis, a member of the genus Chlamydia, is one of the most common and curable causative agents of STIs. C. trochomatis infections usually affect sexually active young adults and adolescents; and are composed of a broad spectrum of diseases varying from asymptomatic infection to severe genito-urinary infection leading to infertility and acute or chronic ocular infection (trachoma), which may result in blindness and pneumonia. Among the members of the genus Chlamydia, there are also two pathogenic species, Chlamydia pneumoniae and Chlamydia psittaci which are responsible for acute respiratory tract infections and febrile illness in humans. The incidence, pathophysiology, and diagnostic methods are discussed in detail in the previous chapters. The purpose of this chapter is to elucidate the management of infections due to C. trachomatis, C. pneumoniae, and C. psittaci including antibiotic susceptibility and resistance mechanisms, treatment recommendations for ocular infections, genito-urinary and respiratory tract infections, and management of sex partners, pregnant women, neonates, and children according to the latest data.
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Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses. Antibiotics (Basel) 2023; 12:antibiotics12020224. [PMID: 36830137 PMCID: PMC9952143 DOI: 10.3390/antibiotics12020224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.
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Israelsen SB, Fally M, Tarp B, Kolte L, Ravn P, Benfield T. Short-course antibiotic therapy for hospitalized patients with early clinical response in community-acquired pneumonia: a multicentre cohort study. Clin Microbiol Infect 2023; 29:54-60. [PMID: 35988851 DOI: 10.1016/j.cmi.2022.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To explore whether short-course antibiotic therapy is efficient and safe in routine clinical settings among patients hospitalized with community-acquired pneumonia (CAP) who achieve an early clinical response. METHODS During 2017-2019, we conducted a cohort study of patients admitted with CAP to four hospitals in Denmark. Data were prospectively gathered from medical records and enriched with data from nationwide registries. In the present study, we included patients with early clinical response and divided them into treatment groups based on antibiotic duration, as decided by the attending physician: short-course (4-7 days) or prolonged-course (8-14 days). The primary outcome was post-treatment mortality within 30 days. Secondary outcomes included readmissions or new antibiotics. Logistic regression models were used to estimate ORs with 95% CIs, and inverse probability weighting was applied to adjust for confounding. RESULTS The study cohort included 1151 patients with a median age of 74 years, predominantly presenting with mild-moderate disease. The 30-day post-treatment mortality was 3.36% (11/327) in the short-course group and 3.40% (28/824) in the prolonged-course group (adjusted OR 1.05, 95% CI 0.38-1.88). Readmission occurred in 15.6% (42/269) vs. 14.0% (102/727) (adjusted OR 1.07, 95% CI 0.75-1.69) and new prescription of antibiotics in 11.9% (32/269) vs. 12.1% (88/727) (adjusted OR 0.99, 95% CI 0.61-1.49). DISCUSSION In patients hospitalized with CAP and early clinical response, similar outcomes were observed between short-course and prolonged-course therapies. These results support the use of short-course therapy in routine clinical settings.
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Affiliation(s)
- Simone Bastrup Israelsen
- Center of Research and Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.
| | - Markus Fally
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Britta Tarp
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Lilian Kolte
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Nordsjaelland, Hilleroed, Denmark
| | - Pernille Ravn
- Department of Internal Medicine, Section for Infectious Diseases, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Thomas Benfield
- Center of Research and Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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20
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Sheppard D. Short-course antibiotic therapy: The next frontier in antimicrobial stewardship. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2022; 48:496-501. [PMID: 38173469 PMCID: PMC10763651 DOI: 10.14745/ccdr.v48i1112a01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ensuring appropriate use of antibiotics is critical to preserving their effectiveness through limiting the development and spread of antimicrobial resistance. Evidence is accumulating that shorter courses of antibiotics are as effective as traditional longer regimens for many common infections and can reduce the risk of adverse events. Despite the availability of evidence and guidelines supporting short-course antibiotic therapy for these conditions, prolonged use of antibiotics remains common. This article will review the origins and evolution of our approach regarding antimicrobial prescription duration, the evidence for the use of short-course therapy for selected infections, barriers to the uptake of this practice and potential approaches that can be taken to reduce inappropriately long antibiotic use.
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Affiliation(s)
- Donald Sheppard
- Antimicrobial Resistance Task Force, Public Health Agency of Canada, Ottawa, ON
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, QC
- Infectious Disease and Immunity in Global Health, Research Institute of McGill University Health Center, Montréal, QC
- McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, QC
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21
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Waagsbø B, Tranung M, Damås JK, Heggelund L. Antimicrobial therapy of community-acquired pneumonia during stewardship efforts and a coronavirus pandemic: an observational study. BMC Pulm Med 2022; 22:379. [PMID: 36242006 PMCID: PMC9569007 DOI: 10.1186/s12890-022-02178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is the most frequent infection diagnosis in hospitals. Antimicrobial therapy for CAP is depicted in clinical practice guidelines, but adherence data and effect of antibiotic stewardship measures are lacking. Methods A dedicated antibiotic team pointed out CAP as a potential target for antimicrobial stewardship (AMS) measures at a 1.000-bed, tertiary care, teaching university hospital in Norway from March until May for the years 2016 throughout 2021. The aim of the AMS program was to increase diagnostic and antimicrobial therapy adherence to national clinical practice guideline recommendations through multiple and continuous AMS efforts. Descriptive statistics were retrospectively used to delineate antimicrobial therapy for CAP. The primary outcomes were proportions that received narrow-spectrum beta-lactams, and broad-spectrum antimicrobial therapy. Results 1.112 CAP episodes were identified. The annual proportion that received narrow-spectrum beta-lactams increased from 56.1 to 74.4% (p = 0.045). Correspondingly, the annual proportion that received broad-spectrum antimicrobial therapy decreased from 34.1 to 17.1% (p = 0.002). Trends were affected by the coronavirus pandemic. Mortality and 30-day readmission rates remained unchanged. De-escalation strategies were frequently unutilized, and overall therapy duration exceeded clinical practice guideline recommendations substantially. Microbiologically confirmed CAP episodes increased from 33.7 to 56.2% during the study period. Conclusion CAP is a suitable model condition that is sensitive to AMS measures. A continuous focus on improved microbiological diagnostics and antimicrobial therapy initiation is efficient in increasing adherence to guideline recommendations. There is an unmet need for better antimicrobial de-escalation strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02178-6.
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Affiliation(s)
- Bjørn Waagsbø
- St. Olavs Hospital, Regional centre for disease control in Central Norway Regional Health Authority, Trondheim University hospital, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Morten Tranung
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Central Norway Hospital Pharmacy Trust, Trondheim, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olavs Hospital, Trondheim University hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
| | - Lars Heggelund
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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22
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Arteche-Eguizabal L, Corcuera-Martínez de Tobillas I, Melgosa-Latorre F, Domingo-Echaburu S, Urrutia-Losada A, Eguiluz-Pinedo A, Rodriguez-Piacenza NV, Ibarrondo-Olaguenaga O. Multidisciplinary Collaboration for the Optimization of Antibiotic Prescription: Analysis of Clinical Cases of Pneumonia between Emergency, Internal Medicine, and Pharmacy Services. Antibiotics (Basel) 2022; 11:1336. [PMID: 36289994 PMCID: PMC9598292 DOI: 10.3390/antibiotics11101336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/13/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pneumonia is a lung parenchyma acute infection usually treated with antibiotics. Increasing bacterial resistances force the review and control of antibiotic use criteria in different health departments. OBJECTIVE Evaluate the adequacy of antibiotic treatment in community-acquired pneumonia in patients initially attended at the emergency department and then admitted to the internal medicine service of the Alto Deba Hospital-Osakidetza Basque Country Health Service (Spain). METHODS Observational, retrospective study, based on the review of medical records of patients with community-acquired pneumonia attended at the hospital between January and May 2021. The review was made considering the following items: antimicrobial treatment indication, choice of antibiotic, time of administration of the first dose, adequacy of the de-escalation-sequential therapy, duration of treatment, monitoring of efficacy and adverse effects, and registry in the medical records. The review was made by the research team (professionals from the emergency department, internal medicine, and pharmacy services). RESULTS Fifty-five medical records were reviewed. The adequacy of the treatments showed that antibiotic indication, time of administration of the first dose, and monitoring of efficacy and adverse effects were the items with the greatest agreement between the three departments. This was not the case with the choice of antibiotic, de-escalation/sequential therapy, duration of treatment, and registration in the medical record, which have been widely discussed. The choice of antibiotic was optimal in 63.64% and might have been better in 25.45%. De-escalation/oral sequencing might have been better in 50.91%. The treatment duration was optimal in 45.45% of the patients and excessive in 45.45%. DISCUSSION The team agreed to disseminate these data among the hospital professionals and to propose audits and feedback through an antibiotic stewardship program. Besides this, implementing the local guideline and defining stability criteria to apply sequential therapy/de-escalation was considered essential.
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Affiliation(s)
- Lorea Arteche-Eguizabal
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Pharmacy Service, 20500 Arrasate/Mondragón, Spain
| | | | - Federico Melgosa-Latorre
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Emergency Service, 20500 Arrasate/Mondragón, Spain
| | - Saioa Domingo-Echaburu
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Pharmacy Service, 20500 Arrasate/Mondragón, Spain
| | - Ainhoa Urrutia-Losada
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Pharmacy Service, 20500 Arrasate/Mondragón, Spain
| | - Amaia Eguiluz-Pinedo
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Internal Medicine Service, 20500 Arrasate/Mondragón, Spain
| | | | - Oliver Ibarrondo-Olaguenaga
- Osakidetza Basque Health Service, Debagoiena Integrated Health Organization, Research Unit, 20500 Arrasate/Mondragón, Spain
- Biodonostia Health Research Institute, 20014 Donostia-San Sebastián, Spain
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23
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Rafeq R, Igneri LA. Infectious Pulmonary Diseases. Emerg Med Clin North Am 2022; 40:503-518. [DOI: 10.1016/j.emc.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Agarwal A, Gao Y, Colunga Lozano LE, Asif S, Bakaa L, Ghadimi M, Basmaji J, Das A, Loeb M, Guyatt G. Shorter versus longer durations of antibiotic treatment for patients with community-acquired pneumonia: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e062428. [PMID: 35750458 PMCID: PMC9234800 DOI: 10.1136/bmjopen-2022-062428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Community-acquired pneumonia (CAP), frequently encountered in both outpatient and inpatient settings, is the leading cause of infectious disease-related mortality. While equipoise regarding the optimal duration of antimicrobial therapy to treat CAP remains, recent studies suggest shorter durations of therapy may achieve optimal outcomes. We have therefore planned a systematic review and meta-analysis evaluating the impact of shorter versus longer durations of antibiotic therapy for patients with CAP. METHODS AND ANALYSIS We searched Ovid MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials from inception to September 2021 for randomised controlled trials evaluating shorter versus longer duration of antibiotics. Eligible studies will compare durations with a minimum difference of two days of antibiotic therapy, irrespective of antibiotic agent, class, route, frequency or dosage, and will report on any patient-important outcome of benefit or harm. Paired reviewers working independently will conduct title and abstract screening, full-text screening, data extraction and risk of bias (RoB) evaluation using a modified Cochrane RoB 2.0 tool. We will perform random-effects modelling for meta-analyses, with study weights generated using the inverse variance method, and will assess certainty in effect estimates using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The Instrument for assessing the Credibility of Effect Modification Analyses (ICEMAN) tool will inform assessments of credibility of subgroup effects based on severity of illness, drug class, duration of therapy, setting of CAP acquisition and RoB. ETHICS AND DISSEMINATION The results will be of importance to general practitioners and internists managing CAP, and may directly inform international clinical guidance. Where concerns regarding antimicrobial resistance continue to grow internationally, this evidence summary may motivate new recommendations regarding shorter durations of therapy. We intend to disseminate our findings via national and international conferences, and publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021283990.
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Affiliation(s)
- Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | | | - Saad Asif
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Layla Bakaa
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, Ontario, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Western University, London, Ontario, Canada
| | - Aninditee Das
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther 2022; 11:973-986. [PMID: 35505000 PMCID: PMC9124264 DOI: 10.1007/s40121-022-00635-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Legionellosis is the infection caused by bacteria of the genus Legionella, including a non-pneumonic influenza-like syndrome, and Legionnaires’ disease is a more serious illness characterized by pneumonia. Legionellosis is becoming increasingly important as a public health problem throughout the world; although it is an underreported disease, studies have consistently documented a high incidence. In addition, health costs associated with the disease are high. Diagnosis of Legionnaires’ disease is based mainly on the detection of Legionella pneumophila serogroup 1 antigen in urine. However, there have been advances in detection tests for patients with legionellosis. New methodologies show greater sensitivity and specificity, detect more species and serogroups of Legionella spp., and have the potential for use in epidemiological studies. Testing for Legionella spp. is recommended at hospital admission for severe community-acquired pneumonia, and antibiotics directed against Legionella spp. should be included early as empirical therapy. Inadequate or delayed antibiotic treatment in Legionella pneumonia has been associated with a worse prognosis. Either a fluoroquinolone (levofloxacin or moxifloxacin) or a macrolide (azithromycin preferred) is the recommended first-line therapy for Legionnaires’ disease; however, little information is available regarding adverse events or complications, or about the duration of antibiotic therapy and its association with clinical outcomes. Most published studies evaluating antibiotic treatment for Legionnaires’ disease are observational and consequently susceptible to bias and confounding. Well-designed studies are needed to assess the usefulness of diagnostic tests regarding clinical outcomes, as well as randomized trials comparing fluoroquinolones and macrolides or combination therapy that evaluate outcomes and adverse events.
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26
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Furlan L, Francesco PD, Costantino G, Montano N. Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care. J Intern Med 2022; 291:397-407. [PMID: 35307902 PMCID: PMC9314697 DOI: 10.1111/joim.13472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient-centered care. Such initiatives have paved the way to a new "way of thinking." Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients' needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while "thinking wisely," physicians should also "act wisely," being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Di Francesco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Anaesthesia-Intensive Care Unit, Emergency Department and Emergency Medicine Unit, IRCCS Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Internal Medicine, General Medicine Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
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27
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Graham DY, Hernaez R, Rokkas T. Cross-roads for meta-analysis and network meta-analysis of H. pylori therapy. Gut 2022; 71:643-650. [PMID: 34750206 PMCID: PMC8828664 DOI: 10.1136/gutjnl-2021-326170] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
Helicobacter pylori infections are responsible for tremendous morbidity and mortality worldwide, leading to efforts to eradicate the organism. However, the effectiveness of antimicrobial therapy has been undermined by the progressive development of antimicrobial resistance. Treatments and treatment guidelines have been based on traditional pairwise meta-analyses of randomised controlled trials. More recently, network meta-analyses have also been used in an attempt to provide useful information to the clinician regarding which therapies appear best and which to avoid as the least efficacious. However, both forms of meta-analysis have been undermined by the same problems including the poor quality of the clinical trials using unoptimised regimens and incomparable comparisons related to marked geographic and ethnic genotypic and phenotypic heterogeneity. In addition, the comparator regimens often consist of invalid strawman comparisons. New approaches concerning H. pylori treatment and analysis of therapies are needed. H. pylori therapies should be based on antimicrobial stewardship, as in other infectious diseases. This approach requires the use of only optimised therapies proven to be reliably highly effective in the local population (eg, a cure rate of >90%) for both the study and the comparator regimens. Meta-analyses should be restricted to regimens that meet these criteria and must take into account the presence of marked geographical and host genetic and phenotypic heterogeneity. In addition, to provide clinically relevant results, treatment outcomes should focus on, and present, actual cure rates in addition to odd ratios.
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Affiliation(s)
- David Y Graham
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Ruben Hernaez
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Theodore Rokkas
- Department of Gastroenterology, Henry Dunant Hospital, Athens, Greece
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28
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Esposito S, Argentiero A, Rebecchi F, Fainardi V, Pisi G, Principi N. The remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia. Expert Opin Pharmacother 2022; 23:497-505. [PMID: 35094614 DOI: 10.1080/14656566.2022.2028773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite availability of several official guidelines, not all the problems related to the most effective and safe use of antibiotics in children with community-acquired pneumonia (CAP) have been solved. Presently, too many children receive unneeded antibiotics or, when antibiotics are mandatory, the choice of the drug is not appropriate. AREAS COVERED In this paper, the authors discuss the remaining unsolved problems for rational antibiotic therapy use in pediatric community-acquired pneumonia and provide their expert perspectives. EXPERT OPINION Further improvement in pediatric CAP management could be derived from physician education on antibiotic use and a larger use, particularly in office practice, of point of care testing or new technologies (i.e. artificial intelligence) to define etiology of a lower respiratory infection. However, recommendations regarding the duration of antibiotic therapy vary largely because of the absence of reliable data on the optimal CAP treatment according to the bacterial etiology of the disease, its severity, and child characteristics. Available evidence seems to confirm that a short course of antibiotics, approximately 5 days, can be effective and lead to results not substantially different from those obtained with prolonged-course antibiotic therapy, at least in patients with mild to moderate disease.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesca Rebecchi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
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29
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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30
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Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis. Clin Microbiol Infect 2021; 28:479-490. [PMID: 34775072 DOI: 10.1016/j.cmi.2021.10.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/14/2021] [Accepted: 10/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is growing evidence supporting the efficacy of shorter courses of antibiotic therapy for common infections, however the risks of prolonged antibiotic duration are underappreciated. OBJECTIVES We sought to estimate the incremental daily risk of antibiotic-associated harms. METHODS We searched three major databases to retrieve systematic reviews from 2000 to July 30, 2020 in any language. ELIGIBILITY Systematic reviews were required to evaluate shorter versus longer antibiotic therapy with fixed durations between 3 and 14 days. RCTs included for meta-analysis were identified from the systematic reviews. PARTICIPANTS Adult and pediatric patients from any setting. INTERVENTIONS Primary outcomes were the proportion of patients experiencing adverse drug events, superinfections and antimicrobial resistance. Risk of Bias Assessment: Each RCT was evaluated for quality by extracting the assessment reported by each systematic review. DATA SYNTHESIS The daily odds ratio (OR) of antibiotic harm was estimated and pooled using random effects meta-analysis. RESULTS Thirty-five (35) systematic reviews encompassing 71 eligible randomized controlled trials were included. Studies most commonly evaluated duration of therapy for respiratory tract (n=36, 51%) and urinary tract infections (n=29, 41%). Overall, 23,174 patients were evaluated for antibiotic-associated harms. Adverse events (n=20,345), superinfections (n=5,776), and AMR (n=2,330) were identified in 19.9% (n=4,039), 4.8% (n=280), and 10.6% (n=246) of patients, respectively. Each day of antibiotic therapy was associated with 4% increased odds of experiencing an adverse event (OR 1.04, 95% CI [1.02 to 1.07]). Daily odds of severe adverse effects also increased (OR 1.09, 95% CI [1.00 to 1.19). The daily incremental odds of superinfection and AMR were OR 0.98 (0.92 to 1.06) and OR 1.03 (0.98 to 1.07), respectively. CONCLUSION Each additional day of antibiotic therapy is associated with measurable antibiotic harm, particularly adverse events. These data may provide additional context for clinicians when weighing benefits versus risks of prolonged antibiotic therapy.
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31
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Bielicki JA, Stöhr W, Barratt S, Dunn D, Naufal N, Roland D, Sturgeon K, Finn A, Rodriguez-Ruiz JP, Malhotra-Kumar S, Powell C, Faust SN, Alcock AE, Hall D, Robinson G, Hawcutt DB, Lyttle MD, Gibb DM, Sharland M. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial. JAMA 2021; 326:1713-1724. [PMID: 34726708 PMCID: PMC8564579 DOI: 10.1001/jama.2021.17843] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The optimal dose and duration of oral amoxicillin for children with community-acquired pneumonia (CAP) are unclear. OBJECTIVE To determine whether lower-dose amoxicillin is noninferior to higher dose and whether 3-day treatment is noninferior to 7 days. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, 2 × 2 factorial noninferiority trial enrolling 824 children, aged 6 months and older, with clinically diagnosed CAP, treated with amoxicillin on discharge from emergency departments and inpatient wards of 28 hospitals in the UK and 1 in Ireland between February 2017 and April 2019, with last trial visit on May 21, 2019. INTERVENTIONS Children were randomized 1:1 to receive oral amoxicillin at a lower dose (35-50 mg/kg/d; n = 410) or higher dose (70-90 mg/kg/d; n = 404), for a shorter duration (3 days; n = 413) or a longer duration (7 days; n = 401). MAIN OUTCOMES AND MEASURES The primary outcome was clinically indicated antibiotic re-treatment for respiratory infection within 28 days after randomization. The noninferiority margin was 8%. Secondary outcomes included severity/duration of 9 parent-reported CAP symptoms, 3 antibiotic-related adverse events, and phenotypic resistance in colonizing Streptococcus pneumoniae isolates. RESULTS Of 824 participants randomized into 1 of the 4 groups, 814 received at least 1 dose of trial medication (median [IQR] age, 2.5 years [1.6-2.7]; 421 [52%] males and 393 [48%] females), and the primary outcome was available for 789 (97%). For lower vs higher dose, the primary outcome occurred in 12.6% with lower dose vs 12.4% with higher dose (difference, 0.2% [1-sided 95% CI -∞ to 4.0%]), and in 12.5% with 3-day treatment vs 12.5% with 7-day treatment (difference, 0.1% [1-sided 95% CI -∞ to 3.9]). Both groups demonstrated noninferiority with no significant interaction between dose and duration (P = .63). Of the 14 prespecified secondary end points, the only significant differences were 3-day vs 7-day treatment for cough duration (median 12 days vs 10 days; hazard ratio [HR], 1.2 [95% CI, 1.0 to 1.4]; P = .04) and sleep disturbed by cough (median, 4 days vs 4 days; HR, 1.2 [95% CI, 1.0 to 1.4]; P = .03). Among the subgroup of children with severe CAP, the primary end point occurred in 17.3% of lower-dose recipients vs 13.5% of higher-dose recipients (difference, 3.8% [1-sided 95% CI, -∞ to10%]; P value for interaction = .18) and in 16.0% with 3-day treatment vs 14.8% with 7-day treatment (difference, 1.2% [1-sided 95% CI, -∞ to 7.4%]; P value for interaction = .73). CONCLUSIONS AND RELEVANCE Among children with CAP discharged from an emergency department or hospital ward (within 48 hours), lower-dose outpatient oral amoxicillin was noninferior to higher dose, and 3-day duration was noninferior to 7 days, with regard to need for antibiotic re-treatment. However, disease severity, treatment setting, prior antibiotics received, and acceptability of the noninferiority margin require consideration when interpreting the findings. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN76888927.
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Affiliation(s)
- Julia A. Bielicki
- Pediatric Infectious Diseases Research Group, Medical Research Council Clinical Trial Unit at University College London, Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Wolfgang Stöhr
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Sam Barratt
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - David Dunn
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Nishdha Naufal
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Damian Roland
- Pediatric Emergency Medicine Leicester Academic (PEMLA) Group, Emergency Department, Leicester, United Kingdom
- SAPPHIRE Group, University of Leicester, Department of Health Sciences, Leicester, United Kingdom
| | - Kate Sturgeon
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Adam Finn
- Bristol Children’s Vaccine Centre, Schools of Population Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Juan Pablo Rodriguez-Ruiz
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Colin Powell
- Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Saul N. Faust
- National Institute for Health Research Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Anastasia E. Alcock
- Pediatric Emergency Medicine, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Dani Hall
- Pediatric Emergency Medicine, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- Pediatric Emergency Medicine, Children’s Health Ireland at Crumlin, Ireland
| | - Gisela Robinson
- Pediatric Emergency Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
| | - Daniel B. Hawcutt
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Pediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Mark D. Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom
- Faculty of Health and Applied Science, University of the West of England, Bristol, United Kingdom
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Mike Sharland
- Pediatric Infectious Diseases Research Group, Medical Research Council Clinical Trial Unit at University College London, Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
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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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Grant J, Saux NL. Duration of antibiotic therapy for common infections. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:181-197. [PMID: 36337760 PMCID: PMC9615468 DOI: 10.3138/jammi-2021-04-29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 06/16/2023]
Affiliation(s)
- Jennifer Grant
- Division of Medical Microbiology and Infectious Diseases, Vancouver General Hospital, Vancouver Costal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Horowitz HW. Use of an Electronic Medical Record Alert. Clin Infect Dis 2021; 73:e523. [PMID: 33411907 DOI: 10.1093/cid/ciab009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Harold W Horowitz
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
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35
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King LM, Hersh AL, Hicks LA, Fleming-Dutra KE. Duration of Outpatient Antibiotic Therapy for Common Outpatient Infections, 2017. Clin Infect Dis 2021; 72:e663-e666. [PMID: 32936884 DOI: 10.1093/cid/ciaa1404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/14/2020] [Indexed: 11/14/2022] Open
Abstract
Our objective was to describe the duration of antibiotic therapy for the management of common outpatient conditions. The median duration of antibiotic courses for most common conditions, except for acute cystitis, was 10 days, in many cases exceeding guideline-recommended durations.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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36
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Shapiro DJ, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children. J Pediatr 2021; 234:205-211.e1. [PMID: 33745996 DOI: 10.1016/j.jpeds.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics. STUDY DESIGN We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course. RESULTS The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively. CONCLUSIONS Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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Lee RA, Centor RM, Humphrey LL, Jokela JA, Andrews R, Qaseem A, Akl EA, Bledsoe TA, Forciea MA, Haeme R, Kansagara DL, Marcucci M, Miller MC, Obley AJ. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians. Ann Intern Med 2021; 174:822-827. [PMID: 33819054 DOI: 10.7326/m20-7355] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections. METHODS The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence. BEST PRACTICE ADVICE 1 Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). BEST PRACTICE ADVICE 2 Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. BEST PRACTICE ADVICE 3 In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility. BEST PRACTICE ADVICE 4 In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.
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Affiliation(s)
- Rachael A Lee
- University of Alabama at Birmingham, Birmingham, Alabama (R.A.L.)
| | - Robert M Centor
- Birmingham Veterans Affairs Medical Center and University of Alabama at Birmingham, Birmingham, Alabama (R.M.C.)
| | - Linda L Humphrey
- Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland, Oregon (L.L.H.)
| | - Janet A Jokela
- University of Illinois College of Medicine at Urbana-Champaign, Urbana, Illinois (J.A.J.)
| | - Rebecca Andrews
- University of Connecticut Health Center, Farmington, Connecticut (R.A.)
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
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Sánchez Fabra D, Ger Buil A, Torres Courchoud I, Martínez Murgui R, Matía Sanz MT, Fiteni Mera I, Rubio Obanos T. Antimicrobial management in community acquired pneumonia in hospital at home: Is there room for improvement? ACTA ACUST UNITED AC 2021; 39:271-275. [PMID: 34088446 DOI: 10.1016/j.eimce.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/01/2020] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Community Acquired Pneumonia (CAP) is common disease that can be treated in Hospital At Home (HAH). In this paper we evaluate the room of improvement in the use of antibiotics in CAP in HH. METHODS Patients with CAP were retrospectively recruited in two Spanish hospitals from 1/1/18 to 10/30/19. Demographic, clinical and quality of antibiotic prescription variables were recorded. Subsequently, we created a new variable that collected six quality of care indicator, categorizing and comparing patients into two groups: good quality of care (4 or more indicators performed) or poor quality of care (3 or less indicators performed). RESULTS We recruited 260 patients. The request for diagnostic tests and the adequacy to Clinical Practice Guidelines were 85.4% and 85.8% respectively. Percentages of de-escalation (53.7%) and sequential therapy (57.7%) when indicated were low. The average length of treatment was 7.3 days for intravenous and 9.5 days for total. Quality of prescription was good in 134 (63.2%) patients, being more frequent in those who were admitted directly to HAD from the emergency room. It was also associated with less readmission at 30 days. CONCLUSION There is a wide room for improvement in some fields of antimicrobials use in HAH that could stimulate the implementation of Antimicrobial Stewardship Programs.
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Affiliation(s)
- David Sánchez Fabra
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, Spain.
| | - Adriana Ger Buil
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, Spain
| | | | - Raúl Martínez Murgui
- Servicio de Medicina Interna del Hospital Royo Villanova de Zaragoza, Zaragoza, Spain
| | | | - Isabel Fiteni Mera
- Servicio de Medicina Interna del Hospital Royo Villanova de Zaragoza, Zaragoza, Spain
| | - Teresa Rubio Obanos
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, Spain
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Gauzit R, Castan B, Bonnet E, Bru JP, Cohen R, Diamantis S, Faye A, Hitoto H, Issa N, Lebeaux D, Lesprit P, Maulin L, Poitrenaud D, Raymond J, Strady C, Varon E, Verdon R, Vuotto F, Welker Y, Stahl JP. Anti-infectious treatment duration: The SPILF and GPIP French guidelines and recommendations. Infect Dis Now 2021; 51:114-139. [PMID: 34158156 DOI: 10.1016/j.idnow.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- R Gauzit
- Infectiologie transversale, CHU Cochin, AP-HP, 75014 Paris, France.
| | - B Castan
- Maladies infectieuses et tropicales, CHG, 24000 Périgueux, France
| | - E Bonnet
- Équipe Mobile d'Infectiologie, Hôpital Joseph-Ducuing, Clinique Pasteur, 31300 Toulouse, France
| | - J P Bru
- Maladies Infectieuses, CH Annecy-Genevois, 74374 Pringy, France
| | - R Cohen
- Unité petits nourrissons, CHI, 94000 Créteil, France
| | - S Diamantis
- Maladies Infectieuses et Tropicales, groupe hospitalier Sud Île-de-France, 77000 Melun, France
| | - A Faye
- Pédiatrie Générale et maladies infectieuses, Hôpital Robert-Debré, Université de Paris, AP-HP, 75019 Paris, France
| | - H Hitoto
- Maladies Infectieuses et Tropicales, CH, 72037 Le Mans, France
| | - N Issa
- Réanimation médicale et maladies infectieuses, Hôpital Saint-André, CHU, 33000 Bordeaux, France
| | - D Lebeaux
- Université de Paris, 75006 Paris, France; Microbiologie, Unité Mobile d'Infectiologie, HEGP, AP-HP, 75015 Paris, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, Service de Biologie Clinique, Hôpital Foch, 92150 Suresnes, France
| | - L Maulin
- Maladies Infectieuses et tropicales, CHIAP, 13616 Aix-en-Provence, France
| | - D Poitrenaud
- Unité fonctionnelle d'Infectiologie Régionale, CH Ajaccio, 20303 Ajaccio, France
| | - J Raymond
- Bactériologie, Centre Hospitalier Bicêtre, 94270 Kremlin-Bicêtre, France
| | - C Strady
- Cabinet d'infectiologie, Groupe Courlancy, 51100 Reims, France
| | - E Varon
- Laboratoire de Biologie Médicale et Centre National de Référence des Pneumocoques, CHIC, 94000 Créteil, France
| | - R Verdon
- Maladies Infectieuses et Tropicales, CHU, 14033 Caen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Univ, UNICAEN, UNIROUEN, GRAM 2.0, 14000 Caen, France
| | - F Vuotto
- Maladies Infectieuses, CHU, Hôpital Huriez, 59000 Lille, France
| | - Y Welker
- Maladies Infectieuses, CHI, 78100 Saint-Germain-en-Laye, France
| | - J P Stahl
- Infectiologie, CHU Grenoble Alpes, 38043 Grenoble, France
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Abstract
PURPOSE OF REVIEW We highlight the recent advances in the guidelines for treating patients with severe community-acquired pneumonia (sCAP). RECENT FINDINGS sCAP is a significant cause of hospital admissions. We performed an extensive review of the literature, covering studies from the last several years, to summarise the most important points in the diagnosis and treatment of patients hospitalised with sCAP. SUMMARY sCAP is associated with a high clinical burden. Therefore, deep knowledge is necessary for its management. In general, diagnosis, treatment and management are based on many published guidelines. However, the mortality rate is still unacceptably high, indicating the need for clear recommendations in the management of patients with sCAP. The choice of empirical antibiotic therapy for sCAP depends on multiple factors, such as national and local antimicrobial susceptibility data and the characteristics of the patients, including their risk factors for acquiring infections caused by multidrug-resistant pathogens. Currently, there are several published international guidelines. The aim of this review is to explore the areas that require further knowledge and new recommendations for current clinical practice.
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Moniz P, Coelho L, Póvoa P. Antimicrobial Stewardship in the Intensive Care Unit: The Role of Biomarkers, Pharmacokinetics, and Pharmacodynamics. Adv Ther 2021; 38:164-179. [PMID: 33216323 PMCID: PMC7677101 DOI: 10.1007/s12325-020-01558-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/31/2020] [Indexed: 02/06/2023]
Abstract
The high prevalence of infectious diseases in the intensive care unit (ICU) and consequently elevated pressure for immediate and effective treatment have led to increased antimicrobial therapy consumption and misuse. Moreover, the emerging global threat of antimicrobial resistance and lack of novel antimicrobials justify the implementation of judicious antimicrobial stewardship programs (ASP) in the ICU. However, even though the importance of ASP is generally accepted, its implementation in the ICU is far from optimal and current evidence regarding strategies such as de-escalation remains controversial. The limitations of clinical guidance for antimicrobial therapy initiation and discontinuation have led to multiple studies for the evaluation of more objective tools, such as biomarkers as adjuncts for ASP. C-reactive protein and procalcitonin can be adequate for clinical use in acute infectious diseases, the latter being the most studied for ASP purposes. Although promising, current evidence highlights challenges in biomarker application and interpretation. Furthermore, the physiological alterations in the critically ill render pharmacokinetics and pharmacodynamics crucial parameters for adequate antimicrobial therapy use. Individual pharmacokinetic and pharmacodynamic targets can reduce antimicrobial therapy misuse and risk of antimicrobial resistance.
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Affiliation(s)
- Patrícia Moniz
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Luís Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.
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Hughes S, Kamranpour P, Gibani MM, Mughal N, Moore LSP. Short-course Antibiotic Therapy: A Bespoke Approach Is Required. Clin Infect Dis 2020; 70:1793-1794. [PMID: 32274513 DOI: 10.1093/cid/ciz711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Stephen Hughes
- Chelsea and Westminster National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Pegah Kamranpour
- Chelsea and Westminster National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Malick M Gibani
- Chelsea and Westminster National Health Service (NHS) Foundation Trust, London, United Kingdom.,North West London Pathology, Imperial College Healthcare NHS Trust, United Kingdom.,Imperial College London, United Kingdom
| | - Nabeela Mughal
- Chelsea and Westminster National Health Service (NHS) Foundation Trust, London, United Kingdom.,North West London Pathology, Imperial College Healthcare NHS Trust, United Kingdom.,Imperial College London, United Kingdom
| | - Luke S P Moore
- Chelsea and Westminster National Health Service (NHS) Foundation Trust, London, United Kingdom.,North West London Pathology, Imperial College Healthcare NHS Trust, United Kingdom.,Imperial College London, United Kingdom
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Lan SH, Lai CC, Chang SP, Lu LC, Hung SH, Lin WT. Five-day antibiotic treatment for community-acquired bacterial pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Glob Antimicrob Resist 2020; 23:94-99. [DOI: 10.1016/j.jgar.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/17/2020] [Accepted: 08/07/2020] [Indexed: 10/23/2022] Open
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Fally M, Diernaes E, Israelsen S, Tarp B, Benfield T, Kolte L, Ravn P. The impact of a stewardship program on antibiotic administration in community-acquired pneumonia: Results from an observational before-after study. Int J Infect Dis 2020; 103:208-213. [PMID: 33232831 DOI: 10.1016/j.ijid.2020.11.172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A majority of patients with community-acquired pneumonia (CAP) receive antibiotics. According to the evidence, 5-7 days of treatment should be sufficient for most patients. Many, however, are treated longer than recommended. We have previously conducted a quality improvement study to ensure guideline-conform treatment for CAP. However, the impact of the interventions on antibiotic use has not been investigated. OBJECTIVE To estimate the impact of an eight-month stewardship program on antibiotic use. METHODS We conducted a before-after study comparing a four-month baseline period with data from a corresponding follow-up period. We performed univariable and multivariable logistic regression to compare odds for ≤7 days of total antibiotic treatment, ≤3 days of intravenous treatment and the proportion of correct empiric antibiotics. As sensitivity analysis, we repeated the univariable logistic regression on a propensity score-matched cohort by using the same variables we used for adjustments in the multivariable analysis. We also performed subgroup analyses for patients stable ≤72 h of admission. RESULTS In total, 771 patients were included. Compared to preintervention, the unadjusted odds ratio (OR) for ≤7 days of total antibiotic treatment were 1.84 (95% CI 1.34-2.54) for the whole population and 2.08 (1.41-3.10) for the stable patients. The OR for ≤3 days of intravenous antibiotics were 1.16 (0.87-1.54) and 1.38 (0.87-2.22), respectively. The OR for correct empiric antibiotics were 1.96 (1.45-2.68) and 1.82 (1.23-2.69). Comparable results regarding all outcomes were derived from the other analyses. CONCLUSION The program resulted in a significantly lower overall antibiotic exposure and a higher proportion of patients treated with the recommended antibiotics without a the reduction of exposure to intravenous antibiotics significantly.
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Affiliation(s)
- Markus Fally
- Department of Internal Medicine, Section for Pulmonary Diseases, Herlev Gentofte Hospital, Hellerup, Denmark.
| | - Emma Diernaes
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Simone Israelsen
- Department of Infectious Diseases, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Britta Tarp
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Lilian Kolte
- Department of Respiratory Medicine and Infectious Diseases, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Pernille Ravn
- Department of Internal Medicine, Section for Infectious Diseases, Herlev Gentofte Hospital, Hellerup, Denmark
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Sánchez Fabra D, Ger Buil A, Torres Courchoud I, Martínez Murgui R, Matía Sanz MT, Fiteni Mera I, Rubio Obanos T. Antimicrobial management in community acquired pneumonia in hospital at home: Is there room for improvement? Enferm Infecc Microbiol Clin 2020. [PMID: 33162224 DOI: 10.1016/j.eimc.2020.10.002] [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: 11/30/2022]
Abstract
INTRODUCTION Community Acquired Pneumonia (CAP) is common disease that can be treated in Hospital At Home (HAH). In this paper we evaluate the room of improvement in the use of antibiotics in CAP in HH. METHODS Patients with CAP were retrospectively recruited in two Spanish hospitals from 1/1/18 to 10/30/19. Demographic, clinical and quality of antibiotic prescription variables were recorded. Subsequently, we created a new variable that collected six quality of care indicator, categorizing and comparing patients into two groups: good quality of care (4 or more indicators performed) or poor quality of care (3 or less indicators performed). RESULTS We recruited 260 patients. The request for diagnostic tests and the adequacy to Clinical Practice Guidelines were 85.4% and 85.8% respectively. Percentages of de-escalation (53.7%) and sequential therapy (57.7%) when indicated were low. The average length of treatment was 7.3 days for intravenous and 9.5 days for total. Quality of prescription was good in 134 (63.2%) patients, being more frequent in those who were admitted directly to HAD from the emergency room. It was also associated with less readmission at 30 days. CONCLUSION There is a wide room for improvement in some fields of antimicrobials use in HAH that could stimulate the implementation of Antimicrobial Stewardship Programs.
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Affiliation(s)
- David Sánchez Fabra
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, España.
| | - Adriana Ger Buil
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, España
| | | | - Raúl Martínez Murgui
- Servicio de Medicina Interna del Hospital Royo Villanova de Zaragoza, Zaragoza, España
| | | | - Isabel Fiteni Mera
- Servicio de Medicina Interna del Hospital Royo Villanova de Zaragoza, Zaragoza, España
| | - Teresa Rubio Obanos
- Servicio de Medicina Interna del Hospital Reina Sofía de Tudela, Tudela, Navarra, España
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Uranga A, Artaraz A, Bilbao A, Quintana JM, Arriaga I, Intxausti M, Lobo JL, García JA, Camino J, España PP. Impact of reducing the duration of antibiotic treatment on the long-term prognosis of community acquired pneumonia. BMC Pulm Med 2020; 20:261. [PMID: 33028293 PMCID: PMC7538840 DOI: 10.1186/s12890-020-01293-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background The optimal duration of antibiotic treatment for community-acquired pneumonia (CAP) is not well established. The aim of this study was to assess the impact of reducing the duration of antibiotic treatment on long-term prognosis in patients hospitalized with CAP. Methods This was a multicenter study assessing complications developed during 1 year of patients previously hospitalized with CAP who had been included in a randomized clinical trial concerning the duration of antibiotic treatment. Mortality at 90 days, at 180 days and at 1 year was analyzed, as well as new admissions and cardiovascular complications. A subanalysis was carried out in one of the hospitals by measuring C-reactive protein (CRP), procalcitonin (PCT) and proadrenomedullin (proADM) at admission, at day 5 and at day 30. Results A total of 312 patients were included, 150 in the control group and 162 in the intervention group. Ninety day, 180 day and 1-year mortality in the per-protocol analysis were 8 (2.57%), 10 (3.22%) and 14 (4.50%), respectively. There were no significant differences between both groups in terms of 1-year mortality (p = 0.94), new admissions (p = 0.84) or cardiovascular events (p = 0.33). No differences were observed between biomarker level differences from day 5 to day 30 (CRP p = 0.29; PCT p = 0.44; proADM p = 0.52). Conclusions Reducing antibiotic treatment in hospitalized patients with CAP based on clinical stability criteria is safe, without leading to a greater number of long-term complications.
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Affiliation(s)
- Ane Uranga
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain.
| | - Amaia Artaraz
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Amaia Bilbao
- Research Unit, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Institute of Reasearch in Health Services Kronikgune, Barakaldo, Bizkaia, Spain
| | - Jose María Quintana
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Institute of Reasearch in Health Services Kronikgune, Barakaldo, Bizkaia, Spain.,Research Unit, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Ignacio Arriaga
- Department of Pneumology, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain
| | - Maider Intxausti
- Department of Pneumology, Osakidetza, Universitary Hospital of Basurto, Bilbao, Bizkaia, Spain
| | - Jose Luis Lobo
- Department of Pneumology, Osakidetza, Universitary Hospital of Alava, Vitoria, Alava, Spain
| | - Julia Amaranta García
- Department of Pneumology, Osakidetza, Universitary Hospital of Alava, Vitoria, Alava, Spain
| | - Jesus Camino
- Department of Pneumology, Osakidetza, Hospital of San Eloy, Barakaldo, Bizkaia, Spain
| | - Pedro Pablo España
- Department of Pneumology, Osakidetza, Universitary Hospital of Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
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Abstract
While the world is grappling with the consequences of a global pandemic related to SARS-CoV-2 causing severe pneumonia, available evidence points to bacterial infection with Streptococcus pneumoniae as the most common cause of severe community acquired pneumonia (SCAP). Rapid diagnostics and molecular testing have improved the identification of co-existent pathogens. However, mortality in patients admitted to ICU remains staggeringly high. The American Thoracic Society and Infectious Diseases Society of America have updated CAP guidelines to help streamline disease management. The common theme is use of timely, appropriate and adequate antibiotic coverage to decrease mortality and avoid drug resistance. Novel antibiotics have been studied for CAP and extend the choice of therapy, particularly for those who are intolerant of, or not responding to standard treatment, including those who harbor drug resistant pathogens. In this review, we focus on the risk factors, microbiology, site of care decisions and treatment of patients with SCAP.
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Affiliation(s)
- Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Michael S Niederman
- Weill Cornell Medical College, Pulmonary and Critical Care, New York Presbyterian/ Weill Cornell Medical Center, New York, NY, USA.
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Same RG, Amoah J, Hsu AJ, Hersh AL, Sklansky DJ, Cosgrove SE, Tamma PD. The Association of Antibiotic Duration With Successful Treatment of Community-Acquired Pneumonia in Children. J Pediatric Infect Dis Soc 2020; 10:267-273. [PMID: 32525203 PMCID: PMC8023315 DOI: 10.1093/jpids/piaa055] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia (CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been evaluated. METHODS We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins Hospital who received short-course (5-7 days) vs prolonged-course (8-14 days) antibiotic therapy for uncomplicated CAP between 2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheostomies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after completing antibiotic therapy. RESULTS Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (median, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio, 0.48; 95% confidence interval, .18-1.30). CONCLUSIONS A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure compared with longer courses for hospitalized children with uncomplicated CAP.
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Affiliation(s)
- Rebecca G Same
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Correspondence: Rebecca G. Same, Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N. Wolfe St., Room 3150, Baltimore, Maryland, USA ()
| | - Joe Amoah
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alice J Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Daniel J Sklansky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sara E Cosgrove
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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