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Kuo LK, Chang HT, Hsueh SC, Liu IM, Hsieh PC, Jean SS. Bacterial profile, and independent predictors for healthcare-associated pneumonia persistently caused by multidrug-resistant Gram-negative bacteria for patients with the preceding multidrug-resistant Gram-negative pneumonia in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00121-X. [PMID: 39147627 DOI: 10.1016/j.jmii.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 06/18/2024] [Accepted: 07/15/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES To understand the microbial profile and investigate the independent predictors for healthcare-associated pneumonia (HCAP) pertinaciously caused by isolates of multidrug-resistant (MDR) Gram-negative bacteria (GNB). METHODS Multicenter ICU patients who received appropriate antibiotic treatments for preceding pneumonia due to MDR GNB isolates and subsequently developed HCAP caused by either MDR GNB (n = 126) or non-MDR GNB (n = 40) isolates in Taiwan between 2018 and 2023 were enrolled. Between the groups of patients with HCAP due to MDR GNB and non-MDR GNB, the proportions of the following variables, including demographic characteristics, important co-morbidities, nursing home residence, physiological severity, intervals between two hospitalizations, steroid use, the tracheostomy tube use alone, ventilator support, and the predominant GNB species involving HCAP, were analyzed using the chi-square test. Logistic regression was employed to explore the independent predictors for HCAP persistently caused by MDR GNB in the aforementioned variables with a P-value of <0.15 in the univariate analysis. RESULTS MDR-Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii complex were the three predominant species causing HCAP. Chronic structural lung disorders, diabetes mellitus, intervals of ≤30 days between two hospitalizations, use of the tracheostomy tube alone, and prior pneumonia caused by MDR A. baumannii complex were shown to independently predict the HCAP tenaciously caused by MDR GNB. Conversely, the preceding pneumonia caused by MDR P. aeruginosa was a negative predictor. CONCLUSION Identifying predictors for HCAP persistently caused by MDR GNB is crucial for prescribing appropriate antibiotics.
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Affiliation(s)
- Li-Kuo Kuo
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Critical Care Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Hou-Tai Chang
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Industrial Engineering and Management, Yuan Ze University, Taoyuan, Taiwan
| | - Shun-Chung Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Min Liu
- Department of Pharmacy, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan
| | - Po-Chuen Hsieh
- Department of Pharmacy, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan
| | - Shio-Shin Jean
- Department of Pharmacy, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan; Departments of Internal Medicine and Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan.
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Ding H, Mang NS, Loomis J, Ortwine JK, Wei W, O’Connell EJ, Shah NJ, Prokesch BC. Incidence of drug-resistant pathogens in community-acquired pneumonia at a safety net hospital. Microbiol Spectr 2024; 12:e0079224. [PMID: 39012119 PMCID: PMC11302006 DOI: 10.1128/spectrum.00792-24] [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: 03/28/2024] [Accepted: 06/17/2024] [Indexed: 07/17/2024] Open
Abstract
The 2019 Infectious Diseases Society of America guideline for the management of community-acquired pneumonia (CAP) emphasizes the need for clinician to understand local epidemiological data to guide selection of appropriate treatment. Currently, the local distribution of causative pathogens and their associated resistance patterns in CAP is unknown. A retrospective observational study was performed of patients admitted to an 870-bed safety net hospital between March 2016 and March 2021 who received a diagnosis of CAP or healthcare-associated pneumonia within the first 48 hours of admission. The primary outcome was the incidence of CAP caused by methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PsA) as determined by comparing the number of satisfactory sputum cultures or blood cultures with these drug-resistant organisms to the total number of reviewed patients. Secondary outcomes studied included risk factors associated with CAP caused by drug-resistant organisms, utilization of broad-spectrum antibiotics, appropriate antibiotic de-escalation within 72 hours, and treatment duration. In this 220-patient cohort, MRSA or PsA was isolated from three sputum cultures and no blood cultures. The local incidence of drug-resistant pathogens among the analyzed sample of CAP patients was 1.4% (n = 3/220). The overall incidence of CAP caused by MRSA or PsA among admitted patients is low at our safety-net county hospital. Future research is needed to identify local risk factors associated with the development of CAP caused by drug-resistant pathogens.IMPORTANCEThis study investigates the incidence of drug-resistant pathogens including methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa among community-acquired pneumonia (CAP) patients at a safety net hospital. Understanding local bacteria resistance patterns when treating CAP is essential and supported by evidence-based guidelines. Our findings empower other clinicians to investigate resistance patterns at their own institutions and identify methods to improve antibiotic use. This has the potential to reduce the unnecessary use of broad-spectrum antibiotic agents and combat the development of antibiotic resistance.
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Affiliation(s)
- Helen Ding
- Department of Pharmacy, Parkland Health, Dallas, Texas, USA
| | - Norman S. Mang
- Department of Pharmacy, Parkland Health, Dallas, Texas, USA
| | - Jordan Loomis
- Department of Pharmacy, Parkland Health, Dallas, Texas, USA
| | | | - Wenjing Wei
- Department of Pharmacy, Parkland Health, Dallas, Texas, USA
| | - Ellen J. O’Connell
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nainesh J. Shah
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bonnie C. Prokesch
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Bone H, Diamond-Fox S. Assessment and examination of the respiratory system. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:606-611. [PMID: 38954452 DOI: 10.12968/bjon.2021.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
This article aims to outline the fundamental principles of consultations with and clinical assessments of patients with symptoms that may be indicative of respiratory system pathology. The article explores how to perform a respiratory system-focused patient history and physical examination. An evaluation of clinical 'red flags' to reduce the risk of omitting serious illness is also considered, alongside the exploration of features of respiratory pathology and evidence-based clinical decision-making tools that may be used to support clinical diagnosis.
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Affiliation(s)
- Helen Bone
- was Advanced Critical Care Practitioner, South Tees Hospitals NHS Foundation Trust when this article was written
| | - Sadie Diamond-Fox
- Subject Co-Lead for Advanced Practice, Assistant Professor in Advanced Critical Care Practice and PhD Student (ImpACCPt study), Northumbria University, Newcastle upon Tyne
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Calabretta D, Martìn-Loeches I, Torres A. New Guidelines for Severe Community-acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:274-286. [PMID: 38428839 DOI: 10.1055/s-0043-1777797] [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: 03/03/2024]
Abstract
In 2023, the new European guidelines on severe community-acquired pneumonia, providing clinical practice recommendations for the management of this life-threatening infection, characterized by a high burden of mortality, morbidity, and costs for the society. This review article aims to summarize the principal evidence related to eight different questions covered in the guidelines, by also highlighting the future perspectives for research activity.
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Affiliation(s)
- Davide Calabretta
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ignacio Martìn-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Campaña-Duel E, Camprubí-Rimblas M, Areny-Balagueró A, Quero S, Artigas A, Ceccato A. Risk of Multidrug-Resistant Pathogens in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:246-254. [PMID: 38301713 DOI: 10.1055/s-0043-1778138] [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: 02/03/2024]
Abstract
Severe community-acquired pneumonia (SCAP) is difficult to treat when caused by difficult-to-treat (DTR) pathogens because of limited treatment options and poorer clinical outcomes. Over time, several predictive scoring systems based on risk factors for infection with multidrug resistant pathogens have been developed. We reviewed the available tools for identifying DTR pathogens as the cause of SCAP, both predictive scoring systems and rapid diagnostic methods, to develop management strategies aimed at early identification of DTR pathogens, reducing broad-spectrum antibiotic use and improving clinical outcomes. The scoring systems reviewed show considerable heterogeneity among them at the level of the region studied, the definition of risk factors, as well as which DTR pathogens are the target pathogens. The models described have shown limited effectiveness in reducing inappropriate antibiotic treatment or improving patient outcomes by themselves. However, predictive models could serve as a first step in identifying DTR pathogen infections as part of a larger detection algorithm. Rapid diagnostic tools, such as multiplex polymerase chain reaction, would be useful for the rapid identification of pneumonia-causing pathogens and their resistance mechanisms. In resource-limited settings, rapid tests should be limited to patients at high risk of developing SCAP due to DTR pathogens. We propose an integrative algorithm based on the different scores, taking into account local epidemiological data, where ideally each center should have an antimicrobial stewardship program.
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Affiliation(s)
- E Campaña-Duel
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
| | - M Camprubí-Rimblas
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
| | - A Areny-Balagueró
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
| | - Sara Quero
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
| | - A Artigas
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
| | - Adrian Ceccato
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
- Intensive Care Unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain
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6
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Frazee BW, Singh A, Labreche M, Imani P, Ha K, Furszyfer Del Rio J, Kreys E, Mccabe R. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa community acquired pneumonia: Prevalence and locally derived risk factors in a single hospital system. J Am Coll Emerg Physicians Open 2023; 4:e13061. [PMID: 37927447 PMCID: PMC10620376 DOI: 10.1002/emp2.13061] [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: 05/04/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Objectives Current American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) community-acquired pneumonia (CAP) guidelines expand the CAP definition to include infections occurring in patients with recent health care exposure. The guidelines now recommend that hospital systems determine their own local prevalence and predictors of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) among patients satisfying this new broader CAP definition. We sought to carry out these recommendations in our system, focusing on the emergency department, where CAP diagnosis and initial empiric antibiotic selection usually ooccur. Methods We performed a retrospective cohort study of patients admitted with CAP through any of 3 EDs in our hospital system in Northern California between November 2019 and October 2021. Inclusion criteria included an ED admission diagnosis of pneumonia or sepsis, fever or hypothermia, leukocytosis or leukopenia, and consistent chest imaging result. SARS-CoV-2-positive cases were excluded. We abstracted variables historically associated with P. aeruginosa and MRSA. Outcome measures were prevalence of P. aeruginosa and MRSA in the overall clinically defined cohort and among microbiologically confirmed cases and predictors of P. aeruginosa or MRSA isolation, as determined by univariate logistic regression, bootstrapped least absolute shrinkage and selection operator, and random forest analyses. Additionally, we describe the iterative process used and challenges encountered in carrying out the new ATS/IDSA guideline recommendations. Results There were 1133 unique patients who satisfied our definition of clinically defined CAP, of whom 109 (9.6%) had a bacterial pathogen isolated. There were 24 P. aeruginosa isolates and 11 MRSA isolates in 33 patients. Thus, the prevalence P. aeruginosa and MRSA was 2.9% in the overall CAP cohort, but 30.3% in the microbiologically confirmed cohort. The most important predictors of either P. aeruginosa or MRSA isolation were tracheostomy (odds ratio [OR] 22.08; 95% confidence interval [CI] 10.39-46.96) and gastrostomy tube (OR 14.7; 95% CI 7.14-30.26). Challenges included determining the suspected infection type in patients admitted simply for "sepsis"; interpreting dictated radiology reports; determining functional status, presence of indwelling lines and tubes, and long-term care facility residence from the electronic health record; and correctly attributing culture results to pneumonia. Conclusion Prevalence of MRSA and P. aeruginosa was low among patients admitted in our medical system with CAP - now broadly defined - but high among those with a microbiologically confirmed bacterial etiology. Our locally derived predictors of MRSA and P. aeruginosa can be used to aid our emergency physicians in empiric antibiotic selection for CAP. Findings from this project might inform efforts at other institutions.
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Affiliation(s)
- Bradley W. Frazee
- Department of Emergency MedicineAlameda Health SystemHighland HospitalOaklandCaliforniaUSA
| | - Amarinder Singh
- Department of Emergency MedicineAlameda Health SystemHighland HospitalOaklandCaliforniaUSA
| | - Matt Labreche
- Pharmacy DepartmentAlameda Health SystemHighland HospitalOaklandCaliforniaUSA
| | - Partow Imani
- School of Public HealthDivision of BiostatisticsUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Kevin Ha
- Department of Internal MedicineAlameda Health SystemHighland HospitalOaklandCaliforniaUSA
| | | | - Eugene Kreys
- Department of Clinical and Administrative SciencesCalifornia Northstate University College of PharmacyElk GroveCaliforniaUSA
| | - Robert Mccabe
- Department of Internal MedicineInfectious Disease DivisionAlameda Health SystemHighland HospitalOaklandCaliforniaUSA
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Candel FJ, Salavert M, Estella A, Ferrer M, Ferrer R, Gamazo JJ, García-Vidal C, del Castillo JG, González-Ramallo VJ, Gordo F, Mirón-Rubio M, Pérez-Pallarés J, Pitart C, del Pozo JL, Ramírez P, Rascado P, Reyes S, Ruiz-Garbajosa P, Suberviola B, Vidal P, Zaragoza R. Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6526. [PMID: 37892664 PMCID: PMC10607368 DOI: 10.3390/jcm12206526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology and 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, Hospital Universitario y Politécnico La Fe, 46026 València, Spain
| | - Angel Estella
- Intensive Medicine Service, Hospital Universitario de Jerez, 11407 Jerez, Spain
- Departamento de Medicina, INIBICA, Universidad de Cádiz, 11003 Cádiz, Spain
| | - Miquel Ferrer
- UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic de Barcelona, IDIBAPS, CibeRes (CB06/06/0028), Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Ricard Ferrer
- Intensive Medicine Service, Hospital Universitario Valle de Hebrón, 08035 Barcelona, Spain;
| | - Julio Javier Gamazo
- Servicio de Urgencias, Hospital Universitario de Galdakao, 48960 Bilbao, Spain;
| | | | | | | | - Federico Gordo
- Intensive Medicine Service, Hospital Universitario del Henares, 28822 Coslada, Spain;
| | - Manuel Mirón-Rubio
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Torrejón, 28850 Torrejón de Ardoz, Spain;
| | - Javier Pérez-Pallarés
- Division of Respiratory Medicine, Hospital Universitario Santa Lucía, 30202 Cartagena, Spain;
| | - Cristina Pitart
- Department of Clinical Microbiology, ISGlobal, Hospital Clínic-University of Barcelona, CIBERINF, 08036 Barcelona, Spain;
| | - José Luís del Pozo
- Servicio de Enfermedades Infecciosas, Servicio de Microbiología, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Paula Ramírez
- Intensive Medicine Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Pedro Rascado
- Intensive Care Unit, Complejo Hospitalario Universitario Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Soledad Reyes
- Neumology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Borja Suberviola
- Intensive Medicine Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria IDIVAL, 39011 Santander, Spain;
| | - Pablo Vidal
- Intensive Medicine Service, Complexo Hospitalario Universitario de Ourense, 32005 Ourense, Spain;
| | - Rafael Zaragoza
- Intensive Care Unit, Hospital Dr. Peset, 46017 Valencia, Spain;
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Pan D, Nielsen E, Chung S, Niederman MS. Management of pneumonia in the critically ill. Minerva Med 2023; 114:667-682. [PMID: 36700925 DOI: 10.23736/s0026-4806.22.08467-1] [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: 01/27/2023]
Abstract
Pneumonias continue to be major public health issues and are commonly encountered in the intensive care setting. The most common types of pneumonia leading to critical illness include severe community acquired pneumonia, hospital acquired pneumonia, and ventilator associated pneumonia. Early evaluation, diagnosis, and escalation to appropriate levels of care are imperative to improving survival. Treatment remains challenging with the need to balance antibiotic stewardship and minimizing patient harm. As evidenced in the most recent society guidelines, the identification of risk factors for severe disease and the causative pathogens are crucial in guiding the most appropriate therapy.
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Affiliation(s)
- Di Pan
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Erik Nielsen
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Samuel Chung
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA -
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Cilloniz C, Pericas JM, Curioso WH. Interventions to improve outcomes in community-acquired pneumonia. Expert Rev Anti Infect Ther 2023; 21:1071-1086. [PMID: 37691049 DOI: 10.1080/14787210.2023.2257392] [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: 06/22/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a common infection associated with high morbimortality and a highly deleterious impact on patients' quality of life and functionality. We comprehensively review the factors related to the host, the causative microorganism, the therapeutic approach and the organization of health systems (e.g. setting for care and systems for allocation) that might have an impact on CAP-associated outcomes. Our main aims are to discuss the most controversial points and to provide some recommendations that may guide further research and the management of patients with CAP, in order to improve their outcomes, beyond mortality. AREA COVERED In this review, we aim to provide a critical account of potential measures to improve outcomes of CAP and the supporting evidence from observational studies and clinical trials. EXPERT OPINION CAP is associated with high mortality and a highly deleterious impact on patients' quality of life. To improve CAP-associated outcomes, it is important to understand the factors related to the patient, etiology, therapeutics, and the organization of health systems.
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Affiliation(s)
- Catia Cilloniz
- IDIBAPS, Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Barcelona, Spain
- Facultad de Ciencias de la Salud, Universidad Continental, Huancayo, Peru
| | - Juan Manuel Pericas
- Liver Unit, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute for Research (VHIR), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Walter H Curioso
- Facultad de Ciencias de la Salud, Universidad Continental, Huancayo, Peru
- Health Services Administration, Continental University of Florida, Margate, FL, USA
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Rothberg MB, Haessler S, Deshpande A, Yu PC, Lindenauer PK, Zilberberg MD, Higgins TL, Imrey PB. Derivation and validation of a risk assessment model for drug-resistant pathogens in hospitalized patients with community-acquired pneumonia. Infect Control Hosp Epidemiol 2023; 44:1143-1150. [PMID: 36172877 PMCID: PMC10050215 DOI: 10.1017/ice.2022.229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To derive and validate a model for risk of resistance to first-line community-acquired pneumonia (CAP) therapy. DESIGN We developed a logistic regression prediction model from a large multihospital discharge database and validated it versus the Drug Resistance in Pneumonia (DRIP) score in a holdout sample and another hospital system outside that database. Resistance to first-line CAP therapy (quinolone or third generation cephalosporin plus macrolide) was based on blood or respiratory cultures. SETTING This study was conducted using data from 177 Premier Healthcare database hospitals and 11 Cleveland Clinic hospitals. PARTICIPANTS Adults hospitalized for CAP. EXPOSURE Risk factors for resistant infection. RESULTS Among 138,762 eligible patients in the Premier database, 12,181 (8.8%) had positive cultures and 5,200 (3.8%) had organisms resistant to CAP therapy. Infection with a resistant organism in the previous year was the strongest predictor of resistance; markers of acute illness (eg, receipt of mechanical ventilation or vasopressors) and chronic illness (eg, pressure ulcer, paralysis) were also associated with resistant infections. Our model outperformed the DRIP score with a C-statistic of 0.71 versus 0.63 for the DRIP score (P < .001) in the Premier holdout sample, and 0.65 versus 0.58 (P < .001) in Cleveland Clinic hospitals. Clinicians at Premier facilities used broad-spectrum antibiotics for 20%-30% of patients. In discriminating between patients with and without resistant infections, physician judgment slightly outperformed the DRIP instrument but not our model. CONCLUSIONS Our model predicting infection with a resistant pathogen outperformed both the DRIP score and physician practice in an external validation set. Its integration into practice could reduce unnecessary use of broad-spectrum antibiotics.
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Affiliation(s)
- Michael B. Rothberg
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | - Sarah Haessler
- Division of Infectious Diseases, University of Massachusetts Medical School – Baystate, Springfield, Massachusetts
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pei-Chun Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
| | - Marya D. Zilberberg
- University of Massachusetts, Amherst, Massachusetts, and EviMed Research Group, Goshen, Massachusetts
| | - Thomas L. Higgins
- Division of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts
- The Center for Case Management, Natick, Massachusetts
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos LD, Chalmers JD, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna CM, Menendez R, Niederman MS, Ponomarev D, Restrepo MI, Rigau D, Schultz MJ, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med 2023; 49:615-632. [PMID: 37012484 PMCID: PMC10069946 DOI: 10.1007/s00134-023-07033-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/01/2022] [Indexed: 04/05/2023]
Abstract
PURPOSE Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and whilst European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP. METHODS The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations. RESULTS Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions. CONCLUSIONS In these international guidelines, ERS, ESICM, ESCMID, and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment, and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland.
- Trinity College Dublin, Dublin, Ireland.
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain.
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain.
| | - Antoni Torres
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
| | - Blin Nagavci
- Faculty of Medicine, Institute for Evidence in Medicine, Medical Centre-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Matteo Bassetti
- Infectious Disease Clinic, Department of Health Sciences, Ospedale Policlinico San Martino IRCCS, University of Genoa, Genoa, Italy
| | - Lieuwe D Bos
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carlos M Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Rosario Menendez
- Pneumology Service, Universitary and Politechnic Hospital La Fe, Valencia, Spain
| | - Michael S Niederman
- Pneumology Service, Universitary and Politechnic Hospital La Fe, Valencia, Spain
| | - Dmitry Ponomarev
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX, USA
| | - David Rigau
- Centre Cochrane Iberoamericà-Institut d'Investigació Biomèdica Sant Pau, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Hôpital Beaujon, DMU PARABOL, AP-HP Nord and Université de Paris, Clichy, France
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Member of the German Center of Lung Research, Hannover School of Medicine, Hannover, Germany
| | - Richard Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Amati F, Bindo F, Stainer A, Gramegna A, Mantero M, Nigro M, Bussini L, Bartoletti M, Blasi F, Aliberti S. Identify Drug-Resistant Pathogens in Patients with Community-Acquired Pneumonia. Adv Respir Med 2023; 91:224-238. [PMID: 37366804 PMCID: PMC10295768 DOI: 10.3390/arm91030018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
A substantial increase in broad-spectrum antibiotics as empirical therapy in patients with community-acquired pneumonia (CAP) has occurred over the last 15 years. One of the driving factors leading to that has been some evidence showing an increased incidence of drug-resistant pathogens (DRP) in patients from a community with pneumonia, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Research has been published attempting to identify DRP in CAP through the implementation of probabilistic approaches in clinical practice. However, recent epidemiological data showed that the incidence of DRP in CAP varies significantly according to local ecology, healthcare systems and countries where the studies were performed. Several studies also questioned whether broad-spectrum antibiotic coverage might improve outcomes in CAP, as it is widely documented that broad-spectrum antibiotics overuse is associated with increased costs, length of hospital stay, drug adverse events and resistance. The aim of this review is to analyze the different approaches used to identify DRP in CAP patients as well as the outcomes and adverse events in patients undergoing broad-spectrum antibiotics.
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Affiliation(s)
- Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Francesco Bindo
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mattia Nigro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Linda Bussini
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Infectious Diseases Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, 20089 Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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13
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Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos L, Chalmers J, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna C, Menendez R, Niederman M, Ponomarev D, Restrepo M, Rigau D, Schultz M, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Eur Respir J 2023; 61:13993003.00735-2022. [PMID: 37012080 DOI: 10.1183/13993003.00735-2022] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/01/2022] [Indexed: 04/05/2023]
Abstract
BACKGROUND Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and while European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP. MATERIALS AND METHODOLOGY The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations. RESULTS Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions. CONCLUSIONS In these international guidelines, ERS, ESICM, ESCMID and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
- Authors contributed equally to this work
| | - Antoni Torres
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
- Authors contributed equally to this work
| | - Blin Nagavci
- Faculty of Medicine, Institute for Evidence in Medicine, Medical Centre - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Matteo Bassetti
- Infectious Disease Clinic, Ospedale Policlinico San Martino IRCCS, Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Lieuwe Bos
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - James Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carlos Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Rosario Menendez
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Michael Niederman
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Dimitry Ponomarev
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Marcos Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX, USA
| | - David Rigau
- Centre Cochrane Iberoamericà - Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marcus Schultz
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emmanuele Weiss
- Department of Anaesthesiology and Critical Care, Hôpital Beaujon, DMU PARABOL, AP-HP Nord and Université de Paris, Clichy, France
| | | | - Richard Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Rhodes NJ, Rohani R, Yarnold PR, Pawlowski AE, Malczynski M, Qi C, Sutton SH, Zembower TR, Wunderink RG. Machine Learning To Stratify Methicillin-Resistant Staphylococcus aureus Risk among Hospitalized Patients with Community-Acquired Pneumonia. Antimicrob Agents Chemother 2023; 67:e0102322. [PMID: 36472425 PMCID: PMC9872682 DOI: 10.1128/aac.01023-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon but serious cause of community-acquired pneumonia (CAP). A lack of validated MRSA CAP risk factors can result in overuse of empirical broad-spectrum antibiotics. We sought to develop robust models predicting the risk of MRSA CAP using machine learning using a population-based sample of hospitalized patients with CAP admitted to either a tertiary academic center or a community teaching hospital. Data were evaluated using a machine learning approach. Cases were CAP patients with MRSA isolated from blood or respiratory cultures within 72 h of admission; controls did not have MRSA CAP. The Classification Tree Analysis algorithm was used for model development. Model predictions were evaluated in sensitivity analyses. A total of 21 of 1,823 patients (1.2%) developed MRSA within 72 h of admission. MRSA risk was higher among patients admitted to the intensive care unit (ICU) in the first 24 h who required mechanical ventilation than among ICU patients who did not require ventilatory support (odds ratio [OR], 8.3; 95% confidence interval [CI], 2.4 to 32). MRSA risk was lower among patients admitted to ward units than among those admitted to the ICU (OR, 0.21; 95% CI, 0.07 to 0.56) and lower among ICU patients without a history of antibiotic use in the last 90 days than among ICU patients with antibiotic use in the last 90 days (OR, 0.03; 95% CI, 0.002 to 0.59). The final machine learning model was highly accurate (receiver operating characteristic [ROC] area = 0.775) in training and jackknife validity analyses. We identified a relatively simple machine learning model that predicted MRSA risk in hospitalized patients with CAP within 72 h postadmission.
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Affiliation(s)
- Nathaniel J. Rhodes
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, Illinois, USA
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Roxane Rohani
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, Illinois, USA
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | | | - Anna E. Pawlowski
- Clinical Translational Sciences Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Malczynski
- Department of Microbiology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Chao Qi
- Department of Pathology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Sarah H. Sutton
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Teresa R. Zembower
- Department of Pathology, Northwestern Memorial Hospital, Chicago, Illinois, USA
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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15
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Cavallazzi R, Ramirez JA. How and when to manage respiratory infections out of hospital. Eur Respir Rev 2022; 31:31/166/220092. [PMID: 36261157 DOI: 10.1183/16000617.0092-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022] Open
Abstract
Lower respiratory infections include acute bronchitis, influenza, community-acquired pneumonia, acute exacerbation of COPD and acute exacerbation of bronchiectasis. They are a major cause of death worldwide and often affect the most vulnerable: children, elderly and the impoverished. In this paper, we review the clinical presentation, diagnosis, severity assessment and treatment of adult outpatients with lower respiratory infections. The paper is divided into sections on specific lower respiratory infections, but we also dedicate a section to COVID-19 given the importance of the ongoing pandemic. Lower respiratory infections are heterogeneous entities, carry different risks for adverse events, and require different management strategies. For instance, while patients with acute bronchitis are rarely admitted to hospital and generally do not require antimicrobials, approximately 40% of patients seen for community-acquired pneumonia require admission. Clinicians caring for patients with lower respiratory infections face several challenges, including an increasing population of patients with immunosuppression, potential need for diagnostic tests that may not be readily available, antibiotic resistance and social aspects that place these patients at higher risk. Management principles for patients with lower respiratory infections include knowledge of local surveillance data, strategic use of diagnostic tests according to surveillance data, and judicious use of antimicrobials.
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Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care Medicine, and Sleep Disorders, University of Louisville, Louisville, KY, USA
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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16
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Niederman MS, Torres A. Severe community-acquired pneumonia. Eur Respir Rev 2022; 31:220123. [PMID: 36517046 PMCID: PMC9879347 DOI: 10.1183/16000617.0123-2022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022] Open
Abstract
Severe community-acquired pneumonia is the most life-threatening form of community-acquired pneumonia, characterised by intensive care unit admission and high morbidity and mortality. In this review article, we cover in depth six aspects of severe community-acquired pneumonia that are still controversial: use of PCR molecular techniques for microbial diagnosis; the role of biomarkers for initial management; duration of treatment, macrolides or quinolones in the initial empirical antibiotic therapy; the use of prediction scores for drug-resistant pathogens to modify initial empiric therapy; the use of noninvasive mechanical ventilation and high-flow nasal oxygen; and the use of corticosteroids as adjunctive therapy in severe community-acquired pneumonia.
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Affiliation(s)
- Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY, USA
- Both authors contributed equally
| | - Antoni Torres
- Dept of Pulmonology, Hospital Clinic, University of Barcelona, IDIBAPS, ICREA, CIBERES, Barcelona, Spain
- Both authors contributed equally
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17
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Kobayashi H, Shindo Y, Kobayashi D, Sakakibara T, Murakami Y, Yagi M, Matsuura A, Sato K, Matsui K, Emoto R, Yagi T, Saka H, Matsui S, Hasegawa Y. Extended-Spectrum Antibiotics for Community-Acquired Pneumonia with a Low Risk of Drug-Resistant Pathogens. Int J Infect Dis 2022; 124:124-132. [PMID: 36116670 DOI: 10.1016/j.ijid.2022.09.015] [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: 07/03/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The potential hazards of extended-spectrum antibiotic therapy for patients with community-acquired pneumonia (CAP) with low risk of drug-resistant pathogens (DRPs) remains unclear, although risk assessment for DRPs is essential to determine the initial antibiotics to be administered. The study objective is to assess the effect of unnecessary extended-spectrum therapy on mortality of such patients. METHODS A post-hoc analysis was conducted after a prospective multicenter observational study for CAP. Multivariable logistic regression analysis was performed to assess the effect of extended-spectrum therapy on 30-day mortality. Three sensitivity analyses, including propensity score analysis to confirm the robustness of findings, were also performed. RESULTS Among 750 patients with CAP, 416 with CAP with a low risk of DRPs were analyzed; of these, 257 underwent standard therapy and 159 underwent extended-spectrum therapy. The 30-day mortality was 3.9% and 13.8% in the standard and extended-spectrum therapy groups, respectively. Primary analysis revealed that extended-spectrum therapy was associated with increased 30-day mortality compared with standard therapy (adjusted odds ratio, 2.82; 95% confidence interval, 1.20-6.66). The results of the sensitivity analyses were consistent with those of the primary analysis. CONCLUSIONS Physicians should assess the risk of DRPs when determining the empirical antibiotic therapy and should refrain from administering unnecessary extended-spectrum antibiotics for patients with CAP with a low risk of DRPs.
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Affiliation(s)
- Hironori Kobayashi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Daisuke Kobayashi
- Kyoto University Health Service, Yoshida-Honmachi, Sakyo-ku, Kyoto 606-8501, Japan.
| | - Toshihiro Sakakibara
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Yasushi Murakami
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Mitsuaki Yagi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Akinobu Matsuura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Kenta Sato
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Kota Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Ryo Emoto
- Department of Biostatistics, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Hideo Saka
- Department of Respiratory Medicine, Matsunami General Hospital, 185-1 Dendai, Kasamatsu, Hashima District, Gifu 501-6062, Japan; National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya 460-0001, Japan.
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan; National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya 460-0001, Japan.
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18
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Amin AN, Dellinger EP, Harnett G, Kraft BD, LaPlante KL, LoVecchio F, McKinnell JA, Tillotson G, Valentine S. It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States. Front Med (Lausanne) 2022; 9:901980. [PMID: 35966853 PMCID: PMC9363693 DOI: 10.3389/fmed.2022.901980] [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: 03/22/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.
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Affiliation(s)
- Alpesh N. Amin
- Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | | | - Glenn Harnett
- No Resistance Consulting, Birmingham, AL, United States
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kerry L. LaPlante
- College of Pharmacy, University of Rhode Island, Kingston, RI, United States
| | - Frank LoVecchio
- Department of Emergency Medicine, Valleywise Health, Arizona State University, Phoenix, AZ, United States
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Lundquist Research Institute at Harbor-UCLA, Torrance, CA, United States
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Derivation and Validation of a Clinical Prediction Score to Identify the Isolation of Pseudomonas in Pneumonia. Microbiol Spectr 2022; 10:e0042422. [PMID: 35604182 PMCID: PMC9241902 DOI: 10.1128/spectrum.00424-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Given the focus of existing clinical prediction scores on identifying drug-resistant pathogens as a whole, the application to individual pathogens and other institutions may yield weaker performance. This study aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. This retrospective study included patients ≥18 years of age who were admitted to an academic medical center between 1 July 2010 and 31 July 2020 with a CDC National Healthcare Safety Network confirmed pneumonia diagnosis and were receiving antimicrobials during the index encounter, with a positive respiratory culture. Cystic fibrosis patients were excluded. Logistic regression analysis identified risk factors associated with the isolation of Pseudomonas aeruginosa from respiratory cultures within the derivation cohort (n = 186), which were weighted to generate a prediction score that was applied to the derivation and internal validation (n = 95) cohorts. A total of 281 patients met the inclusion criteria. Five predictor variables were identified, namely, tracheostomy status (4 points), chronic obstructive pulmonary disease (5 points), enteral nutrition (9 points), chronic steroid use (11 points), and Pseudomonas aeruginosa isolation from any culture in the prior 6 months (14 points). At a score of >11, the prediction score demonstrated a sensitivity of 52.4% (95% confidence interval [CI], 36.4 to 68.0%) and a specificity of 84.9% (95% CI, 72.4 to 93.35%) in the validation cohort. Score accuracy was 70.5% (95% CI, 60.3 to 79.4%), and the area under the receiver operating characteristic curve (AUROC) was 0.77 (95% CI, 0.68 to 0.87) in the validation cohort. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics. Validation with larger and external cohorts is necessary. IMPORTANCE In this study, we aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. Utilizing a locally validated prediction score may help direct therapeutic management and be generalizable to other clinical settings and similar populations for the selection of appropriate antimicrobial coverage when data are lacking. Our study highlights a unique patient population, including immunocompromised, structural lung disease, and transplant patients. Five predictor variables were identified, namely, tracheostomy status, chronic obstructive pulmonary disease, enteral nutrition, chronic steroid use, and Pseudomonas aeruginosa isolation from any culture in the prior 6 months. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics, although validation with larger and external cohorts is necessary.
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Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”. Antibiotics (Basel) 2022; 11:antibiotics11030359. [PMID: 35326822 PMCID: PMC8944836 DOI: 10.3390/antibiotics11030359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/26/2022] Open
Abstract
Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.
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21
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Risk factors for antibiotic resistance in hospital-acquired and ventilator-associated pneumonia. J Infect Chemother 2022; 28:745-752. [DOI: 10.1016/j.jiac.2022.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/11/2022] [Accepted: 02/10/2022] [Indexed: 02/08/2023]
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Barreto JV, Dias CC, Cardoso T. Risk factors for community-onset pneumonia caused by drug-resistant pathogens: A prospective cohort study. Eur J Intern Med 2022; 96:66-73. [PMID: 34670681 DOI: 10.1016/j.ejim.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/30/2021] [Accepted: 10/07/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There is no consensual definition of risk factors for drug resistant pathogens (DRP) in community-onset pneumonia (COP). Healthcare-associated pneumonia criteria have been abandoned because they were found to have weak discriminative power. Our aim was to identify risk factors for DRP in COP. METHODS Prospective cohort study, conducted over a two years' period, in a community-based hospital, including all adult patients with COP criteria. Univariate and multivariate logistic regression modeling were performed to understand the association of risk factors (demographic, clinical and epidemiological) with COP by a DRP (PES: Pseudomonas aeruginosa, extended-spectrum ß-lactamase producing Enterobacteriaceae, Methicillin-resistant Staphylococcus aureus; and other non-fermenting gram-negative bacteria, namely Acinetobacter baumannii). RESULTS A total of 660 cases of COP were included, with a mean (±SD) age of 74±15 years and 58.9% of males. Microbiological documentation was possible in 32.6% of the cases. There were 197 cases selected for further analysis, of which 37 were cases of PES. The multivariate logistic regression model retained antibiotic use in the previous 90 days (adjusted OR=4.411, 95%CI [1.745-11.148]) and being bed-ridden (adjusted OR=5.492, 95%CI [2.121-14.222]), adjusted for Charlson's Index, CURB 65 and provenience from a long-term care facility. The area under the ROC curve for this model was 0.832, 95%CI [0.756-0.908], higher than the application of the HCAP criteria (AUROC = 0.676, 95%CI [0.582-0.770]). CONCLUSION In this study, antibiotic use in the previous 90 days and being bed-ridden were independently associated with COP caused by DRP, after adjustment for Charlson's Index, CURB 65 and provenience from a long-term care facility.
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Affiliation(s)
- J Vasco Barreto
- Internal Medicine Service, Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, Rua Dr. Eduardo Torres, 4464-513 Senhora da Hora, Portugal; ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal.
| | - Cláudia Camila Dias
- Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Teresa Cardoso
- ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Rua Jorge de Viterbo Ferreira 228, 4050-313 Porto, Portugal; Intensive Care Unit (UCIP) and Hospital Infection Control Committee, Hospital de Santo António, Oporto University Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
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23
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Carr JR, Jones BE, Collingridge DS, Webb BJ, Vines C, Zobell B, Allen TL, Srivastava R, Rubin J, Dean NC. Deploying an Electronic Clinical Decision Support Tool for Diagnosis and Treatment of Pneumonia Into Rural and Critical Access Hospitals: Utilization, Effect on Processes of Care, and Clinician Satisfaction. J Rural Health 2022; 38:262-269. [PMID: 33244803 PMCID: PMC8149487 DOI: 10.1111/jrh.12543] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Electronic clinical decision support (CDS) for treatment of community-acquired pneumonia (ePNa) is associated with improved guideline adherence and decreased mortality. How rural providers respond to CDS developed for urban hospitals could shed light on extending CDS to resource-limited settings. METHODS ePNa was deployed into 10 rural and critical access hospital emergency departments (EDs) in Utah and Idaho in 2018. We reviewed pneumonia cases identified through ICD-10 codes after local deployment to measure ePNa utilization and guideline adherence. ED providers were surveyed to assess quantitative and qualitative aspects of satisfaction. FINDINGS ePNa was used in 109/301 patients with pneumonia (36%, range 0%-67% across hospitals) and was associated with appropriate antibiotic selection (93% vs 65%, P < .001). Fifty percent of survey recipients responded, 87% were physicians, 87% were men, and the median ED experience was 10 years. Mean satisfaction with ePNa was 3.3 (range 1.7-4.8) on a 5-point Likert scale. Providers with a favorable opinion of ePNa were more likely to favor implementation of additional CDS (P = .005). Satisfaction was not associated with provider type, age, years of experience or experience with ePNa. Ninety percent of respondents provided qualitative feedback. The most common theme in high and low utilization hospitals was concern about usability. Compared to high utilization hospitals, low utilization hospitals more frequently identified concerns about adaptation for local needs. CONCLUSIONS ePNa deployment to rural and critical access EDs was moderately successful and associated with improved antibiotic use. Concerns about usability and adapting ePNa for local use predominated the qualitative feedback.
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Affiliation(s)
- Jason R. Carr
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah
| | - Barbara E. Jones
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah,Salt Lake City Veterans Affairs Health Care System, Salt Lake City, Utah
| | | | - Brandon J. Webb
- Intermountain Health Care, Division of Infectious Diseases, Salt Lake City, Utah
| | - Caroline Vines
- LDS Hospital, Department of Emergency Medicine, Salt Lake City, Utah
| | - Blake Zobell
- Senior Medical Director for Intermountain Rural Hospitals, Richfield, Utah
| | - Todd L. Allen
- Intermountain Healthcare Delivery Institute, Murray, Utah
| | - Rajendu Srivastava
- Intermountain Healthcare Delivery Institute, Murray, Utah,University of Utah School of Medicine, Department of Pediatrics, Division of Inpatient Medicine, Salt Lake City, Utah
| | - Jenna Rubin
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah
| | - Nathan C. Dean
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah,Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
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Diagnosis of Multidrug-Resistant Pathogens of Pneumonia. Diagnostics (Basel) 2021; 11:diagnostics11122287. [PMID: 34943524 PMCID: PMC8700525 DOI: 10.3390/diagnostics11122287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/09/2021] [Accepted: 11/26/2021] [Indexed: 12/15/2022] Open
Abstract
Hospital-acquired pneumonia and ventilator-associated pneumonia that are caused by multidrug resistant (MDR) pathogens represent a common and severe problem with increased mortality. Accurate diagnosis is essential to initiate appropriate antimicrobial therapy promptly while simultaneously avoiding antibiotic overuse and subsequent antibiotic resistance. Here, we discuss the main conventional phenotypic diagnostic tests and the advanced molecular tests that are currently available to diagnose the primary MDR pathogens and the resistance genes causing pneumonia.
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25
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Matlock A, Garcia JA, Moussavi K, Long B, Liang SYT. Advances in novel antibiotics to treat multidrug-resistant gram-negative bacterial infections. Intern Emerg Med 2021; 16:2231-2241. [PMID: 33956311 PMCID: PMC8100742 DOI: 10.1007/s11739-021-02749-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/16/2021] [Indexed: 01/01/2023]
Abstract
Antimicrobial resistance is a growing threat to public health and an increasingly common problem for acute care physicians to confront. Several novel antibiotics have been approved in the past decade to combat these infections; however, physicians may be unfamiliar with how to appropriately utilize them. The purpose of this review is to evaluate novel antibiotics active against resistant gram-negative bacteria and highlight clinical information regarding their use in the acute care setting. This review focuses on novel antibiotics useful in the treatment of infections caused by resistant gram-negative organisms that may be seen in the acute care setting. These novel antibiotics include ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilistatin/relebactam, cefiderocol, plazomicin, eravacycline, and omadacycline. Acute care physicians should be familiar with these novel antibiotics so they can utilize them appropriately.
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Affiliation(s)
- Aaron Matlock
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234 USA
| | - Joshua Allan Garcia
- Assistant Professor, Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA USA
| | - Kayvan Moussavi
- Assistant Professor, Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234 USA
| | - Stephen Yuan-Tung Liang
- Department of Emergency Medicine and Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO USA
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Too Much or Too Little Empiric Treatment for Pseudomonas aeruginosa in Community-acquired Pneumonia? Ann Am Thorac Soc 2021; 18:1456-1458. [PMID: 34468288 PMCID: PMC8489867 DOI: 10.1513/annalsats.202107-762ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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27
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Validation of a Prediction Score for Drug-Resistant Microorganisms in Community-acquired Pneumonia. Ann Am Thorac Soc 2021; 18:257-265. [PMID: 32915057 DOI: 10.1513/annalsats.202005-558oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Recommended initial empiric antimicrobial treatment covers the most common bacterial pathogens; however, community-acquired pneumonia (CAP) may be caused by microorganisms not targeted by this treatment. Developed in 2015, the PES (Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus) score was developed in 2015 to predict the microbiological etiology of CAP caused by PES microorganisms.Objective: To validate the usefulness of the PES score for predicting PES microorganisms in two cohorts of patients with CAP from Valencia and Mataró.Methods: We analyzed two prospective observational cohorts of patients with CAP from Valencia and Mataró. Patients in the Mataró cohort were all admitted to an intensive care unit (ICU).Results: Of the 1,024 patients in the Valencia cohort, 505 (51%) had a microbiological etiology and 31 (6%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.81 (95% confidence interval [95% CI], 0.74-0.88). For a PES score ≥5, sensitivity, specificity, the negative and positive predictive values as well as the negative and positive likelihood ratios were 72%, 74%, 98%, 14%, 0.38, and 2.75, respectively. Of the 299 patients in the Mataró cohort, 213 (71%) had a microbiological etiology and 11 (5%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.73 (95% CI 0.61-0.86). For a PES score ≥ 5, sensitivity, specificity, the negative and positive predictive values, and the negative and positive likelihood ratios were 36%, 83%, 96%, 11%, 0.77, and 2.09, respectively. The best cutoff for patients admitted to the ICU was 4 points, which improved sensitivity to 86%. The hypothetical application of the PES score showed high rates of overtreatment in both cohorts (26% and 35%, respectively) and similar rates of undertreatment.Conclusions: The PES score showed good accuracy in predicting the risk for microorganisms that required different empirical therapy; however, its use as a single strategy for detecting noncore pathogens could lead to high rates of overtreatment. Given its high negative predictive value, the PES score may be used as a first step of a wider strategy that includes subsequent advanced diagnostic tests.
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28
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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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Haessler S, Lindenauer PK, Zilberberg MD, Imrey PB, Yu PC, Higgins T, Deshpande A, Rothberg MB. Blood Cultures Versus Respiratory Cultures: 2 Different Views of Pneumonia. Clin Infect Dis 2021; 71:1604-1612. [PMID: 31665249 DOI: 10.1093/cid/ciz1049] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/25/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Choice of empiric therapy for pneumonia depends on risk for antimicrobial resistance. Models to predict resistance are derived from blood and respiratory culture results. We compared these results to understand if organisms and resistance patterns differed by site. We also compared characteristics and outcomes of patients with positive cultures by site. METHODS We studied adult patients discharged from 177 US hospitals from July 2010 through June 2015, with principal diagnoses of pneumonia, or principal diagnoses of respiratory failure, acute respiratory distress syndrome, respiratory arrest, or sepsis with a secondary diagnosis of pneumonia, and who had blood or respiratory cultures performed. Demographics, treatment, microbiologic results, and outcomes were examined. RESULTS Among 138 561 hospitalizations of patients with pneumonia who had blood or respiratory cultures obtained at admission, 12 888 (9.3%) yielded positive cultures: 6438 respiratory cultures, 5992 blood cultures, and 458 both respiratory and blood cultures. Forty-two percent had isolates resistant to first-line therapy for community-acquired pneumonia. Isolates from respiratory samples were more often resistant than were isolates from blood (54.2% vs 26.6%; P < .001). Patients with both culture sites positive had higher case-fatality, longer lengths of stay, and higher costs than patients who had only blood or respiratory cultures positive. Among respiratory cultures, the most common pathogens were Staphylococcus aureus (34%) and Pseudomonas aeruginosa (17%), whereas blood cultures most commonly grew Streptococcus pneumoniae (33%), followed by S. aureus (22%). CONCLUSIONS Patients with positive respiratory tract cultures are clinically different from those with positive blood cultures, and resistance patterns differ by source. Models of antibiotic resistance should account for culture source.
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Affiliation(s)
- Sarah Haessler
- Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Marya D Zilberberg
- EviMed Research Group, LLC, Goshen, Massachusetts, USA.,Division of Pulmonary and Critical Medicine, University of Massachusetts School of Public Health and Health Sciences, Amherst, Massachusetts, USA
| | - Peter B Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Pei-Chun Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tom Higgins
- Center for Case Management, Natick, Massachusetts, USA
| | - Abhishek Deshpande
- Medicine Institute Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.,Medicine Institute Center for Value Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.
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A "resistance calculator": Simple stewardship intervention for refining empiric practices of antimicrobials in acute-care hospitals. Infect Control Hosp Epidemiol 2021; 42:1082-1089. [PMID: 33736724 PMCID: PMC8459314 DOI: 10.1017/ice.2020.1372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: In the era of widespread resistance, there are 2 time points at which most empiric prescription errors occur among hospitalized adults: (1) upon admission (UA) when treating patients at risk of multidrug-resistant organisms (MDROs) and (2) during hospitalization, when treating patients at risk of extensively drug-resistant organisms (XDROs). These errors adversely influence patient outcomes and the hospital’s ecology. Design and setting: Retrospective cohort study, Shamir Medical Center, Israel, 2016. Patients: Adult patients (aged >18 years) hospitalized with sepsis. Methods: Logistic regressions were used to develop predictive models for (1) MDRO UA and (2) nosocomial XDRO. Their performances on the derivation data sets, and on 7 other validation data sets, were assessed using the area under the receiver operating characteristic curve (ROC AUC). Results: In total, 4,114 patients were included: 2,472 patients with sepsis UA and 1,642 with nosocomial sepsis. The MDRO UA score included 10 parameters, and with a cutoff of ≥22 points, it had an ROC AUC of 0.85. The nosocomial XDRO score included 7 parameters, and with a cutoff of ≥36 points, it had an ROC AUC of 0.87. The range of ROC AUCs for the validation data sets was 0.7–0.88 for the MDRO UA score and was 0.66–0.75 for nosocomial XDRO score. We created a free web calculator (https://assafharofe.azurewebsites.net). Conclusions: A simple electronic calculator could aid with empiric prescription during an encounter with a septic patient. Future implementation studies are needed to evaluate its utility in improving patient outcomes and in reducing overall resistances.
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Community-acquired Pneumonia Owing to Multidrug-Resistant Pathogens: A Step toward an Early Identification. Ann Am Thorac Soc 2021; 18:211-213. [PMID: 33522876 PMCID: PMC7869783 DOI: 10.1513/annalsats.202009-1207ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Strategies for prediction of drug-resistant pathogens and empiric antibiotic selection in community-acquired pneumonia. Curr Opin Pulm Med 2021; 26:249-259. [PMID: 32101906 DOI: 10.1097/mcp.0000000000000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Although most patients with community-acquired pneumonia (CAP) are appropriately treated with narrow-spectrum antibiotics, predicting which patients require coverage of drug-resistant pathogens (DRP) remains a challenge. The 2019 American Thoracic Society/Infectious Diseases Society of America CAP guidelines endorse using locally validated prediction models for DRP. Here we review risk factors for DRP and provide a summary of available risk prediction models. RECENT FINDINGS Both inadequate initial empiric spectrum as well as unnecessary broad-spectrum antibiotic use are associated with poor outcomes in CAP. Multiple prediction models for DRP-based patient-level risk factors have been published, with some variation in included predictor variables and test performance characteristics. Seven models have been robustly externally validated, and implementation data have been published for two of these models. All models demonstrated better performance than the healthcare-associated pneumonia criteria, with most favoring sensitivity over specificity. We also report validation of the novel, risk factor-based treatment algorithm proposed in the American Thoracic Society/Infectious Diseases Society of America guidelines which strongly favors specificity over sensitivity, especially in nonsevere pneumonia. SUMMARY Using patient-level risk factors to guide the decision whether to prescribe broad-spectrum antibiotics is a rational approach to treatment. Several viable candidate prediction models are available. Hospitals should evaluate the local performance of existing scores before implementing in routine clinical practice.
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Christensen MA, Nevers M, Ying J, Haroldsen C, Stevens V, Jones MM, Yarbrough PM, Goetz MB, Restrepo MI, Madaras-Kelly K, Samore MH, Jones BE. Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients. Clin Infect Dis 2021; 72:S59-S67. [PMID: 33512530 DOI: 10.1093/cid/ciaa1604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients. METHODS For all VA acute hospitalizations for CAP from 2006-2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric "overcoverage" (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric "undercoverage" (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture). RESULTS Of 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P < .001. CONCLUSIONS Adoption of the 2019 CAP guidelines in this population would substantially change culturing and empiric antibiotic selection practices, with a decrease in overcoverage and slight increase in undercoverage for MRSA and P. aeruginosa.
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Affiliation(s)
| | - McKenna Nevers
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Jian Ying
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Candace Haroldsen
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Makoto M Jones
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Peter M Yarbrough
- Department of Internal Medicine, Veterans Affairs Salt Lake City Health Care System and University of Utah, Salt Lake City, Utah, USA
| | - Matthew Bidwell Goetz
- Division of Infectious Disease, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marcos I Restrepo
- Division of Pulmonary and Critical Care, South Texas Veterans Health Care System and UT Health San Antonio, San Antonio, Texas, USA
| | - Karl Madaras-Kelly
- Pharmacy Service, Veterans Affairs Boise Idaho and Idaho State University, Boise, Idaho, USA
| | - Matthew H Samore
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Barbara Ellen Jones
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, Utah, USA
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Validation of a Community-Acquired Pneumonia Score To Improve Empiric Antibiotic Selection at an Academic Medical Center. Antimicrob Agents Chemother 2021; 65:AAC.01482-20. [PMID: 33257449 DOI: 10.1128/aac.01482-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/23/2020] [Indexed: 11/20/2022] Open
Abstract
The 2019 American Thoracic Society and the Infectious Diseases Society of America community-acquired pneumonia (CAP) guidelines recommend that drug-resistant pathogens (DRP) be empirically covered if locally validated risk factors are present. This retrospective case-control validation study evaluated the performance of the drug resistance in pneumonia (DRIP) clinical prediction score. Two hundred seventeen adult patients with ICD-10 (https://www.who.int/classifications/classification-of-diseases) pneumonia diagnosis, positive confirmed microbiologic data, and clinical signs and symptoms were included. A DRIP score of ≥4 was used to assess model performance. Logistic regression was used to select for significant predictors and create a modified DRIP score, which was evaluated to define clinical application. The DRIP score predicted pneumonia due to a DRP with a sensitivity of 67% and specificity of 73%. The area under the receiver operating characteristic (AUROC) curve was 0.76 (95% confidence interval [CI], 0.69 to 0.82). From regression analysis, prior infection with a DRP and antibiotics in the last 60 days, yielding scores of 2 points and 1 point, respectively, remained local risk factors in predicting drug-resistant pneumonia. Sensitivity (47%) and specificity (94%) were maximized at a threshold of ≥2 in the modified DRIP model. Therefore, prior infection with a DRP remained the only clinically relevant predictor for drug-resistant pneumonia. The original DRIP score demonstrated a decreased performance in our patient population and behaved similarly to other clinical prediction models. Empiric CAP therapy without anti-methicillin-resistant Staphylococcus aureus and antipseudomonal coverage should be considered for noncritically ill patients without a drug resistant pathogen infection in the past year. Our data support the necessity of local validation to authenticate clinical risk predictors for drug-resistant pneumonia.
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Validation of the Drip Score at A Community-Teaching Hospital. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ciarkowski CE, Timbrook TT, Kukhareva PV, Edholm KM, Hatton ND, Hopkins CL, Thomas F, Sanford MN, Igumnova E, Benefield RJ, Kawamoto K, Spivak ES. A Pathway for Community-Acquired Pneumonia With Rapid Conversion to Oral Therapy Improves Health Care Value. Open Forum Infect Dis 2020; 7:ofaa497. [PMID: 33269294 PMCID: PMC7686657 DOI: 10.1093/ofid/ofaa497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background Evidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable, and the best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care. Methods This is a retrospective, observational pre–post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in 3 sequential 6-month phases; Phase 1: education alone; Phase 2: education and a CDS-driven CAP pathway coupled with active antimicrobial stewardship and provider feedback; and Phase 3: education and a CDS-driven CAP pathway without active stewardship. The 12 months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process, and cost outcomes were also measured. Results The study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization, and a 20% cost reduction compared with baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared with baseline. Conclusions A CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.
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Affiliation(s)
- Claire E Ciarkowski
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Polina V Kukhareva
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Karli M Edholm
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nathan D Hatton
- Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Christy L Hopkins
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Frank Thomas
- Value Engineering, University of Utah, Salt Lake City, Utah, USA
| | | | - Elena Igumnova
- Decision Support, University of Utah, Salt Lake City, Utah, USA
| | | | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Maruyama T, Fujisawa T, Ishida T, Ito A, Oyamada Y, Fujimoto K, Yoshida M, Maeda H, Miyashita N, Nagai H, Imamura Y, Shime N, Suzuki S, Amishima M, Higa F, Kobayashi H, Suga S, Tsutsui K, Kohno S, Brito V, Niederman MS. A Therapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Therapy. Clin Infect Dis 2020; 68:1080-1088. [PMID: 30084884 DOI: 10.1093/cid/ciy631] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/31/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. METHODS We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumonia (HAP), or 55 ventilator-associated pneumonia (VAP). RESULTS Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. The frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Those with ≥2 MDR risks had MDR pathogens more often than those with 0-1 MDR risk (25.8% vs 5.3%, P < .001). The 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0-1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hematocrit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were significantly correlated with 30-day mortality, whereas the classification of pneumonia type (VAP, HAP, HCAP, CAP) was not. CONCLUSIONS Individual MDR risk factors can be used in a unified algorithm to guide and simplify empiric therapy for all pneumonia patients, and were more important than the classification of site of pneumonia acquisition in determining 30-day mortality. CLINICAL TRIALS REGISTRATION JMA-IIA00146.
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Affiliation(s)
- Takaya Maruyama
- Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu
| | - Takao Fujisawa
- Department of Pediatrics, National Hospital Organization, Mie National Hospital, Tsu
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama
| | - Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama
| | - Yoshitaka Oyamada
- Department of Respiratory Medicine, National Hospital Organization, Tokyo Medical Center, Meguro-ku
| | - Kazuyuki Fujimoto
- Department of Respiratory Medicine, National Hospital Organization, Tokyo Medical Center, Meguro-ku
| | - Masamichi Yoshida
- Department of Respiratory Medicine, Mie Prefectural General Medical Center, Yokkaichi
| | - Hikaru Maeda
- Department of Respiratory Medicine, Mie Prefectural General Medical Center, Yokkaichi
| | | | - Hideaki Nagai
- Center for Pulmonary Diseases, National Hospital Organization, Tokyo National Hospital, Kiyose-shi
| | - Yoshifumi Imamura
- Second Department of Internal Medicine, Nagasaki University School of Medicine
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical and Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, Minami-ku
| | - Shoji Suzuki
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo
| | - Masaru Amishima
- Department of Respiratory Medicine, National Hospital Organization, Hokkaido Medical Center, Nishi-ku, Sapporo-shi
| | - Futoshi Higa
- Department of Respiratory Medicine, National Hospital Organization, Okinawa National Hospital, Ginowan-shi
| | - Hiroyasu Kobayashi
- Department of Respiratory Medicine, Suzuka General Hospital, Yasuzuka-cho, Mie, Japan
| | - Shigeru Suga
- Department of Pediatrics, National Hospital Organization, Mie National Hospital, Tsu
| | - Kiyoyuki Tsutsui
- Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu
| | - Shigeru Kohno
- Second Department of Internal Medicine, Nagasaki University School of Medicine
| | - Veronica Brito
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor Scott and White Health, Dallas, Texas
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian-Weill Cornell Medical Center
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Wilke M, Hübner C, Kämmerer W. Calculated parenteral initial treatment of bacterial infections: Economic aspects of antibiotic treatment. GMS INFECTIOUS DISEASES 2020; 8:Doc03. [PMID: 32373428 PMCID: PMC7186923 DOI: 10.3205/id000047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This is the seventeenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. This chapter analyses economic aspects of antiinfective therapy. Any treatment decision is also a cost decision. In this chapter the authors particularly analyse whether or not there is evidence that certain clinically effective strategies as Antimicrobial Stewardship programs (AMS), guideline adherent initial therapy, early diagnostics, De-escalation, sequence therapy or therapeutic drug monitoring also have benficial economic effects. These can be direct savings or shortening of length of stay to free resources.
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Affiliation(s)
| | - Claudia Hübner
- Lehrstuhl für Allgemeine Betriebswirtschaftslehre und Gesundheitsmanagement, Universität Greifswald, Germany
| | - Wolfgang Kämmerer
- Klinische Pharmazie, Apotheke des Universitätsklinikums Augsburg, Germany
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1837] [Impact Index Per Article: 459.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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Dean NC, Vines CG, Rubin J, Collingridge DS, Mankivsky M, Srivastava R, Jones BE, Kuttler KG, Walker M, Jenson N, Webb BJ, Allen TL, Haug PJ. Implementation of Real-Time Electronic Clinical Decision Support for Emergency Department Patients with Pneumonia Across a Healthcare System. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2020; 2019:353-362. [PMID: 32308828 PMCID: PMC7153076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A real-time electronic CDS for pneumonia (ePNa) identifies possible pneumonia patients, measures severity and antimicrobial resistance risk, and then recommends disposition, antibiotics, and microbiology studies. Use is voluntary, and clinicians may modify treatment recommendations. ePNa was associated with lower mortality in emergency department (ED) patients versus usual care (Annals EM 66:511). We adapted ePNa for the Cerner EHR, and implemented it across Intermountain Healthcare EDs (Utah, USA) throughout 2018. We introduced ePNa through didactic, interactive presentations to ED clinicians; follow-up visits identified barriers and facilitators to use. Email reminded clinicians and answered questions. Hospital admitting clinicians encouraged ePNa use to smooth care transitions. Audit-and-feedback measured utilization, showing variations from best practice when ePNa and associated electronic order sets were not used. Use was initially low, but gradually increased especially at larger hospitals. A user-friendly interface, frequent reminders, audit-and- feedback, a user survey, a nurse educator, and local physician champions are additive towards implementation success.
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Truong WR, Hsu DI, Yamaki J. Oral Antibiotic Prescribing in Healthcare-associated Pneumonia Patients at Hospital Discharge. Clin Infect Dis 2019; 69:2042-2043. [PMID: 31211833 DOI: 10.1093/cid/ciz340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Donald I Hsu
- Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, Pomona
| | - Jason Yamaki
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California
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Farkas A, Sassine J, Mathew JP, Stavropoulos C, Stern R, Mckinley G. Outcomes associated with the use of a revised risk assessment strategy to predict antibiotic resistance in community-onset pneumonia: a stewardship perspective. J Antimicrob Chemother 2019; 73:2555-2558. [PMID: 29897465 DOI: 10.1093/jac/dky202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/01/2018] [Indexed: 12/21/2022] Open
Abstract
Objectives There is growing evidence that patients with community-onset pneumonia and recent healthcare exposure are not at equally high risk of infection with MDR organisms. An individualized approach is necessary with regard to risk assessment and choice of antibiotics. Methods We reviewed the records of 102 patients admitted for community-onset pneumonia, before and after the implementation of a revised risk assessment programme for MDR organisms using the drug resistance in pneumonia (DRIP) score. The primary aim of the study was to identify the effects of this intervention on antibiotic days of therapy (DOT), and secondary outcomes included all-cause readmissions and time to clinical improvement. Statistical analysis was performed using generalized linear regression and Cox hazards models. Results Implementation of the programme resulted in a decrease in anti-MRSA (-1.44 DOT, P = 0.007) and anti-pseudomonal (-2.03 DOT, P < 0.001) antibiotic utilization, but was not associated with a significant difference in the odds of readmissions (OR 0.64, 95% CI 0.16-2.57) or in time to clinical improvement (HR 1.19, 95% CI 0.62-2.21). Conclusions An individualized MDR organism risk assessment strategy using a clinical prediction score for community-onset pneumonia can decrease the utilization of broad-spectrum antibiotics without an increase in adverse outcomes.
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Affiliation(s)
- Andras Farkas
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, USA
| | - Joseph Sassine
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Joseph P Mathew
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Christine Stavropoulos
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Infectious Diseases, Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
| | - Ron Stern
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, USA
| | - George Mckinley
- Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA.,Division of Infectious Diseases, Department of Medicine, Mount Sinai West and Mount Sinai St. Luke's, New York, NY, USA
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Webb BJ, Sorensen J, Jephson A, Mecham I, Dean NC. Broad-spectrum antibiotic use and poor outcomes in community-onset pneumonia: a cohort study. Eur Respir J 2019; 54:13993003.00057-2019. [PMID: 31023851 DOI: 10.1183/13993003.00057-2019] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/01/2019] [Indexed: 01/29/2023]
Abstract
QUESTION Is broad-spectrum antibiotic use associated with poor outcomes in community-onset pneumonia after adjusting for confounders? METHODS We performed a retrospective, observational cohort study of 1995 adults with pneumonia admitted from four US hospital emergency departments. We used multivariable regressions to investigate the effect of broad-spectrum antibiotics on 30-day mortality, length of stay, cost and Clostridioides difficile infection (CDI). To address indication bias, we developed a propensity score using multilevel (individual provider) generalised linear mixed models to perform inverse-probability of treatment weighting (IPTW) to estimate the average treatment effect in the treated. We also manually reviewed a sample of mortality cases for antibiotic-associated adverse events. RESULTS 39.7% of patients received broad-spectrum antibiotics, but drug-resistant pathogens were recovered in only 3%. Broad-spectrum antibiotics were associated with increased mortality in both the unweighted multivariable model (OR 3.8, 95% CI 2.5-5.9; p<0.001) and IPTW analysis (OR 4.6, 95% CI 2.9-7.5; p<0.001). Broad-spectrum antibiotic use by either analysis was also associated with longer hospital stay, greater cost and increased CDI. Healthcare-associated pneumonia was not associated with mortality independent of broad-spectrum antibiotic use. In manual review we identified antibiotic-associated events in 17.5% of mortality cases. CONCLUSION Broad-spectrum antibiotics appear to be associated with increased mortality and other poor outcomes in community-onset pneumonia.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, USA
| | - Jeff Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Al Jephson
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Ian Mecham
- Division of Pulmonary and Critical Care, Utah Valley Regional Medical Center, Intermountain Healthcare, Provo, UT, USA
| | - Nathan C Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
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Antibiotic Use and Outcomes After Implementation of the Drug Resistance in Pneumonia Score in ED Patients With Community-Onset Pneumonia. Chest 2019; 156:843-851. [PMID: 31077649 DOI: 10.1016/j.chest.2019.04.093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/19/2019] [Accepted: 04/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To guide rational antibiotic selection in community-onset pneumonia, we previously derived and validated a novel prediction tool, the Drug-Resistance in Pneumonia (DRIP) score. In 2015, the DRIP score was integrated into an existing electronic pneumonia clinical decision support tool (ePNa). METHODS We conducted a quasi-experimental, pre-post implementation study of ePNa with DRIP score (2015) vs ePNa with health-care-associated pneumonia (HCAP) logic (2012) in ED patients admitted with community-onset pneumonia to four US hospitals. Using generalized linear models, we used the difference-in-differences method to estimate the average treatment effect on the treated with respect to ePNa with DRIP score on broad-spectrum antibiotic use, mortality, hospital stay, and cost, adjusting for available patient-level confounders. RESULTS We analyzed 2,169 adult admissions: 1,122 in 2012 and 1,047 in 2015. A drug-resistant pathogen was recovered in 3.2% of patients in 2012 and 2.8% in 2015; inadequate initial empirical antibiotics were prescribed in 1.1% and 0.5%, respectively (P = .12). A broad-spectrum antibiotic was administered in 40.1% of admissions in 2012 and 33.0% in 2015 (P < .001). Vancomycin days of therapy per 1,000 patient days in 2012 were 287.3 compared with 238.8 in 2015 (P < .001). In the primary analysis, the average treatment effect among patients using the DRIP score was a reduction in broad-spectrum antibiotic use (OR, 0.62; 95% CI, 0.39-0.98; P = .039). However, the average effects for ePNa with DRIP on mortality, length of stay, and cost were not statistically significant. CONCLUSIONS Electronic calculation of the DRIP score was more effective than HCAP criteria for guiding appropriate broad-spectrum antibiotic use in community-onset pneumonia.
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Ewig S, Kolditz M, Pletz MW, Chalmers J. Healthcare-associated pneumonia: is there any reason to continue to utilize this label in 2019? Clin Microbiol Infect 2019; 25:1173-1179. [PMID: 30825674 DOI: 10.1016/j.cmi.2019.02.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. OBJECTIVE To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. SOURCES The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). CONTENT Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. IMPLICATIONS HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Herne und Bochum, Germany.
| | - M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - M W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - J Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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Cillóniz C, Dominedò C, Nicolini A, Torres A. PES Pathogens in Severe Community-Acquired Pneumonia. Microorganisms 2019; 7:microorganisms7020049. [PMID: 30759805 PMCID: PMC6406253 DOI: 10.3390/microorganisms7020049] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/09/2019] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Worldwide, there is growing concern about the burden of pneumonia. Severe community-acquired pneumonia (CAP) is frequently complicated by pulmonary and extra-pulmonary complications, including sepsis, septic shock, acute respiratory distress syndrome, and acute cardiac events, resulting in significantly increased intensive care admission rates and mortality rates. Streptococcus pneumoniae (Pneumococcus) remains the most common causative pathogen in CAP. However, several bacteria and respiratory viruses are responsible, and approximately 6% of cases are due to the so-called PES (Pseudomonas aeruginosa, extended-spectrum β-lactamase Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus) pathogens. Of these, P. aeruginosa and methicillin-resistant Staphylococcus aureus are the most frequently reported and require different antibiotic therapy to that for typical CAP. It is therefore important to recognize the risk factors for these pathogens to improve the outcomes in patients with CAP.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)-SGR 911-Ciber de Enfermedades Respiratorias (Ciberes), 08036 Barcelona, Spain.
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Antonello Nicolini
- Respiratory Diseases Unit, Hospital of Sestri Levante, 16039 Sestri Levante, Italy.
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB)-SGR 911-Ciber de Enfermedades Respiratorias (Ciberes), 08036 Barcelona, Spain.
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Farkas A, Lin F, Bui K, Liu F, An GL, Pakholskiy A, Stavropoulos CF, Lantis JC, Yassin A. Development of predictive nomograms for clinical use to quantify the risk of isolating resistance prone organisms in patients with infected foot ulcers. Epidemiol Infect 2019; 147:e157. [PMID: 31063087 PMCID: PMC6518461 DOI: 10.1017/s0950268818003667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/02/2018] [Accepted: 12/23/2018] [Indexed: 01/22/2023] Open
Abstract
Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) have been considered prevalent pathogens in foot infections. However, whether empiric therapy directed against these organisms is necessary, and in whom to consider treatment, is rather unclear. The aim of this study was to develop predictive algorithms for forecasting the probability of isolating these organisms in the infected wounds of patients in a population where the prevalence of resistant pathogens is low. This was a retrospective study of regression model-based risk factor analysis that included 140 patients who presented with infected, culture positive foot ulcers to two urban hospitals. A total of 307 bacteria were identified, most frequently MRSA (11.1%). P. aeruginosa prevalence was 6.5%. In the multivariable analysis, amputation (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.48-27.63), renal disease (OR 5.46, 95% CI 1.43-25.16) and gangrene (OR 2.78, 95% CI 0.82-9.59) were identified as risk factors associated with higher while diabetes (OR 0.07, 95% CI 0.01-0.34) and Infectious Diseases Society of America infection severity >3 (OR 0.18, 95% CI 0.03-0.65) were associated with lower odds of P. aeruginosa isolation (C statistic 0.81). Similar analysis for MRSA showed that amputation was associated with significantly lower (OR 0.29, 95% CI 0.09-0.79) risk, while history of MRSA infection (OR 5.63, 95% CI 1.56-20.63) and osteomyelitis (OR 2.523, 95% CI 1.00-6.79) was associated with higher odds of isolation (C statistic 0.69). We developed two predictive nomograms with reasonable to strong ability to discriminate between patients who were likely of being infected with P. aeruginosa or MRSA and those who were not. These analyses confirm the association of some, but also question the significance of other frequently described risk factors in predicting the isolation of these organisms.
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Affiliation(s)
- A. Farkas
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, 10019, USA
| | - F. Lin
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, 10019, USA
| | - K. Bui
- Department of Pharmacy, Mount Sinai St. Luke's Hospital, New York, NY, 10025, USA
| | - F. Liu
- Department of Pharmacy, Mount Sinai St. Luke's Hospital, New York, NY, 10025, USA
| | - G. L. An
- Department of Pharmacy, Mount Sinai St. Luke's Hospital, New York, NY, 10025, USA
| | - A. Pakholskiy
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, 10019, USA
| | - C. F. Stavropoulos
- Division of Infectious Diseases, Department of Medicine, Mount Sinai West and St. Luke's Hospitals, New York, NY, 10019, USA
| | - J. C. Lantis
- Division of Vascular and Endovascular Surgery, Mt. Sinai West and St. Luke's Hospitals, New York, NY, 10019, USA
| | - A. Yassin
- Department of Pharmacy, Mount Sinai St. Luke's Hospital, New York, NY, 10025, USA
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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Kobayashi D, Shindo Y, Ito R, Iwaki M, Okumura J, Sakakibara T, Yamaguchi I, Yagi T, Ogasawara T, Sugino Y, Taniguchi H, Saito H, Saka H, Kawamura T, Hasegawa Y. Validation of the prediction rules identifying drug-resistant pathogens in community-onset pneumonia. Infect Drug Resist 2018; 11:1703-1713. [PMID: 30349327 PMCID: PMC6188199 DOI: 10.2147/idr.s165669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Appropriate initial antibiotic treatment and avoiding administration of unnecessary broad-spectrum antibiotics are important for the treatment of pneumonia. To achieve this, assessment of risk for drug-resistant pathogens (DRPs) at diagnosis is essential. Purpose The aim of this study was to validate a predictive rule for DRPs that we previously proposed (the community-acquired pneumonia drug-resistant pathogen [CAP-DRP] rule), comparing several other predictive methods. Patients and methods A prospective observational study was conducted in hospitalized patients with community-onset pneumonia at four institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin–sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP-DRPs. Results CAP-DRPs were identified in 73 (10.1%) of 721 patients analyzed. The CAP-DRP rule differentiated low vs high risk of CAP-DRP at the threshold of ≥3 points or 2 points plus any of methicillin-resistant Staphylococcus aureus specific factors with a sensitivity of 0.45, specificity of 0.87, positive predictive value of 0.47, negative predictive value of 0.87, and accuracy of 0.79. Its discrimination performance, area under the receiver operating characteristic curve, was 0.73 (95% confidence interval 0.66–0.79). Specificity of the CAP-DRP rule against CAP-DRPs was the highest among the six predictive rules tested. Conclusion The performance of the predictive rules and criteria for CAP-DRPs was limited. However, the CAP-DRP rule yielded high specificity and could specify patients who should be treated with non-broad-spectrum antibiotics, eg, a non-pseudomonal β-lactam plus a macrolide, more precisely.
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Affiliation(s)
- Daisuke Kobayashi
- Kyoto University Health Service, Kyoto, Japan.,Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Ryota Ito
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mai Iwaki
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Respiratory Medicine, Kasugai Municipal Hospital, Kasugai, Japan
| | - Junya Okumura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Toshihiro Sakakibara
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan, .,Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Ikuo Yamaguchi
- Department of Central Laboratory, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan
| | - Tomohiko Ogasawara
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | | | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan,
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