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Barratt S, Bielicki JA, Dunn D, Faust SN, Finn A, Harper L, Jackson P, Lyttle MD, Powell CV, Rogers L, Roland D, Stöhr W, Sturgeon K, Vitale E, Wan M, Gibb DM, Sharland M. Amoxicillin duration and dose for community-acquired pneumonia in children: the CAP-IT factorial non-inferiority RCT. Health Technol Assess 2021; 25:1-72. [PMID: 34738518 DOI: 10.3310/hta25600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Data are limited regarding the optimal dose and duration of amoxicillin treatment for community-acquired pneumonia in children. OBJECTIVES To determine the efficacy, safety and impact on antimicrobial resistance of shorter (3-day) and longer (7-day) treatment with amoxicillin at both a lower and a higher dose at hospital discharge in children with uncomplicated community-acquired pneumonia. DESIGN A multicentre randomised double-blind 2 × 2 factorial non-inferiority trial in secondary care in the UK and Ireland. SETTING Paediatric emergency departments, paediatric assessment/observation units and inpatient wards. PARTICIPANTS Children aged > 6 months, weighing 6-24 kg, with a clinical diagnosis of community-acquired pneumonia, in whom treatment with amoxicillin as the sole antibiotic was planned on discharge. INTERVENTIONS Oral amoxicillin syrup at a dose of 35-50 mg/kg/day compared with a dose of 70-90 mg/kg/day, and 3 compared with 7 days' duration. Children were randomised simultaneously to each of the two factorial arms in a 1 : 1 ratio. MAIN OUTCOME MEASURES The primary outcome was clinically indicated systemic antibacterial treatment prescribed for respiratory tract infection (including community-acquired pneumonia), other than trial medication, up to 28 days after randomisation. Secondary outcomes included severity and duration of parent/guardian-reported community-acquired pneumonia symptoms, drug-related adverse events (including thrush, skin rashes and diarrhoea), antimicrobial resistance and adherence to trial medication. RESULTS A total of 824 children were recruited from 29 hospitals. Ten participants received no trial medication and were excluded. Participants [median age 2.5 (interquartile range 1.6-2.7) years; 52% male] were randomised to either 3 (n = 413) or 7 days (n = 401) of trial medication at either lower (n = 410) or higher (n = 404) doses. There were 51 (12.5%) and 49 (12.5%) primary end points in the 3- and 7-day arms, respectively (difference 0.1%, 90% confidence interval -3.8% to 3.9%) and 51 (12.6%) and 49 (12.4%) primary end points in the low- and high-dose arms, respectively (difference 0.2%, 90% confidence interval -3.7% to 4.0%), both demonstrating non-inferiority. Resolution of cough was faster in the 7-day arm than in the 3-day arm for cough (10 days vs. 12 days) (p = 0.040), with no difference in time to resolution of other symptoms. The type and frequency of adverse events and rate of colonisation by penicillin-non-susceptible pneumococci were comparable between arms. LIMITATIONS End-of-treatment swabs were not taken, and 28-day swabs were collected in only 53% of children. We focused on phenotypic penicillin resistance testing in pneumococci in the nasopharynx, which does not describe the global impact on the microflora. Although 21% of children did not attend the final 28-day visit, we obtained data from general practitioners for the primary end point on all but 3% of children. CONCLUSIONS Antibiotic retreatment, adverse events and nasopharyngeal colonisation by penicillin-non-susceptible pneumococci were similar with the higher and lower amoxicillin doses and the 3- and 7-day treatments. Time to resolution of cough and sleep disturbance was slightly longer in children taking 3 days' amoxicillin, but time to resolution of all other symptoms was similar in both arms. FUTURE WORK Antimicrobial resistance genotypic studies are ongoing, including whole-genome sequencing and shotgun metagenomics, to fully characterise the effect of amoxicillin dose and duration on antimicrobial resistance. The analysis of a randomised substudy comparing parental electronic and paper diary entry is also ongoing. TRIAL REGISTRATION Current Controlled Trials ISRCTN76888927, EudraCT 2016-000809-36 and CTA 00316/0246/001-0006. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 60. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sam Barratt
- MRC Clinical Trials Unit, University College London, London, UK
| | - Julia A Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - David Dunn
- MRC Clinical Trials Unit, University College London, London, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Adam Finn
- Bristol Children's Vaccine Centre, School of Population Health Sciences/School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Lynda Harper
- MRC Clinical Trials Unit, University College London, London, UK
| | - Pauline Jackson
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Colin Ve Powell
- Paediatric Emergency Medicine Department, Sidra Medicine, Doha, The State of Qatar.,School of Medicine, Cardiff University, Cardiff, UK
| | - Louise Rogers
- Research and Development Nursing Team, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK.,SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Wolfgang Stöhr
- MRC Clinical Trials Unit, University College London, London, UK
| | - Kate Sturgeon
- MRC Clinical Trials Unit, University College London, London, UK
| | - Elia Vitale
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Mandy Wan
- Evelina Pharmacy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
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Lyttle MD, Bielicki JA, Barratt S, Dunn D, Finn A, Harper L, Jackson P, Powell CVE, Roland D, Stohr W, Sturgeon K, Wan M, Little P, Faust SN, Robotham J, Hay AD, Gibb DM, Sharland M. Efficacy, safety and impact on antimicrobial resistance of duration and dose of amoxicillin treatment for young children with Community-Acquired Pneumonia: a protocol for a randomIsed controlled Trial (CAP-IT). BMJ Open 2019; 9:e029875. [PMID: 31123008 PMCID: PMC6538022 DOI: 10.1136/bmjopen-2019-029875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/08/2019] [Accepted: 03/14/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a common indication for antibiotic treatment in young children. Data are limited regarding the ideal dose and duration of amoxicillin, leading to practice variation which may impact on treatment failure and antimicrobial resistance (AMR). Community-Acquired Pneumonia: a randomIsed controlled Trial (CAP-IT) aims to determine the optimal amoxicillin treatment strategies for CAP in young children in relation to efficacy and AMR. METHODS AND ANALYSIS The CAP-IT trial is a multicentre, randomised, double-blind, placebo-controlled 2×2 factorial non-inferiority trial of amoxicillin dose and duration. Children are enrolled in paediatric emergency and inpatient environments, and randomised to receive amoxicillin 70-90 or 35-50 mg/kg/day for 3 or 7 days following hospital discharge. The primary outcome is systemic antibacterial treatment for respiratory tract infection (including CAP) other than trial medication up to 4 weeks after randomisation. Secondary outcomes include adverse events, severity and duration of parent-reported CAP symptoms, adherence and antibiotic resistance. The primary analysis will be by intention to treat. Assuming a 15% primary outcome event rate, 8% non-inferiority margin assessed against an upper one-sided 95% CI, 90% power and 15% loss to follow-up, 800 children will be enrolled to demonstrate non-inferiority for the primary outcome for each of duration and dose. ETHICS AND DISSEMINATION The CAP-IT trial and relevant materials were approved by the National Research Ethics Service (reference: 16/LO/0831; 30 June 2016). The CAP-IT trial results will be published in peer-reviewed journals, and in a report published by the National Institute for Health Research Health Technology Assessment programme. Oral and poster presentations will be given to national and international conferences, and participating families will be notified of the results if they so wish. Key messages will be constructed in partnership with families, and social media will be used in their dissemination. TRIAL REGISTRATION NUMBER ISRCTN76888927, EudraCT2016-000809-36.
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Affiliation(s)
- Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Science, University of the West of England, Bristol, UK
| | - Julia A Bielicki
- Paediatric Infectious Diseases Research Group, MRC Clinical Trial Unit at UCL, Institute for Infection and Immunity, St George's University of London, London, UK
| | | | - David Dunn
- MRC Clinical Trials Unit at UCL, London, UK
| | - Adam Finn
- Bristol Children's Vaccine Centre, Schools of Population Sciences and Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | | | - Pauline Jackson
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Colin V E Powell
- Paediatric Emergency Medicine Department, Sidra Medicine, Doha, Qatar
- School of Medicine, Cardiff University, Cardiff, UK
| | - Damian Roland
- Emergency Department, Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
- SAPPHIRE group, University of Leicester Department of Health Sciences, Leicester, UK
| | | | | | - Mandy Wan
- NIHR CRN: Children, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul Little
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Saul N Faust
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Julie Robotham
- HCAI and AMR Division, National Infection Service, Public Health England, London, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, MRC Clinical Trial Unit at UCL, Institute for Infection and Immunity, St George's University of London, London, UK
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Cao B, Huang Y, She DY, Cheng QJ, Fan H, Tian XL, Xu JF, Zhang J, Chen Y, Shen N, Wang H, Jiang M, Zhang XY, Shi Y, He B, He LX, Liu YN, Qu JM. Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association. CLINICAL RESPIRATORY JOURNAL 2017; 12:1320-1360. [PMID: 28756639 PMCID: PMC7162259 DOI: 10.1111/crj.12674] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/25/2017] [Indexed: 02/05/2023]
Abstract
Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.
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Affiliation(s)
- Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Yi Huang
- Department of Respiratory and Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai 200433, China
| | - Dan-Yang She
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi-Jian Cheng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Xin-Lun Tian
- Department of Pulmonary Medicine, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yu Chen
- Department of Respiratory and Critical Care Medicine, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Hui Wang
- Department of Laboratory Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xiang-Yan Zhang
- Department of Respiratory and Critical Care Medicine, Guizhou Provincial People's Hospital, Guizhou 550002, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing 210002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
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Hoover JL, Lewandowski TF, Mininger CL, Singley CM, Sucoloski S, Rittenhouse S. A Robust Pneumonia Model in Immunocompetent Rodents to Evaluate Antibacterial Efficacy against S. pneumoniae, H. influenzae, K. pneumoniae, P. aeruginosa or A. baumannii. J Vis Exp 2017. [PMID: 28117818 PMCID: PMC5408714 DOI: 10.3791/55068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Efficacy of candidate antibacterial treatments must be demonstrated in animal models of infection as part of the discovery and development process, preferably in models which mimic the intended clinical indication. A method for inducing robust lung infections in immunocompetent rats and mice is described which allows for the assessment of treatments in a model of serious pneumonia caused by S. pneumoniae, H. influenzae, P. aeruginosa, K. pneumoniae or A. baumannii. Animals are anesthetized, and an agar-based inoculum is deposited deep into the lung via nonsurgical intratracheal intubation. The resulting infection is consistent, reproducible, and stable for at least 48 h and up to 96 h for most isolates. Studies with marketed antibacterials have demonstrated good correlation between in vivo efficacy and in vitro susceptibility, and concordance between pharmacokinetic/pharmacodynamic targets determined in this model and clinically accepted targets has been observed. Although there is an initial time investment when learning the technique, it can be performed quickly and efficiently once proficiency is achieved. Benefits of the model include elimination of the neutropenic requirement, increased robustness and reproducibility, ability to study more pathogens and isolates, improved flexibility in study design and establishment of a challenging infection in an immunocompetent host.
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Lewis SJ, Mueller BA. Antibiotic Dosing in Patients With Acute Kidney Injury: "Enough But Not Too Much". J Intensive Care Med 2014; 31:164-76. [PMID: 25326429 DOI: 10.1177/0885066614555490] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 08/25/2014] [Indexed: 12/21/2022]
Abstract
Increasing evidence suggests that antibiotic dosing in critically ill patients with acute kidney injury (AKI) often does not achieve pharmacodynamic goals, and the continued high mortality rate due to infectious causes appears to confirm these findings. Although there are compelling reasons why clinicians should use more aggressive antibiotic dosing, particularly in patients receiving aggressive renal replacement therapies, concerns for toxicity associated with higher doses are real. The presence of multisystem organ failure and polypharmacy predispose these patients to drug toxicity. This article examines the pharmacokinetic and pharmacodynamic consequences of critical illness, AKI, and renal replacement therapy and describes potential solutions to help clinicians give "enough but not too much" in these very complicated patients.
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Affiliation(s)
- Susan J Lewis
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Bruce A Mueller
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Tanigawara Y, Kaku M, Totsuka K, Tsuge H, Saito A. Population pharmacokinetics and pharmacodynamics of sitafloxacin in patients with community-acquired respiratory tract infections. J Infect Chemother 2013; 19:858-66. [PMID: 23529500 PMCID: PMC3824208 DOI: 10.1007/s10156-013-0580-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/26/2013] [Indexed: 11/29/2022]
Abstract
An optimal dosage regimen of sitafloxacin was considered based on a pharmacokinetics and pharmacodynamics (PK–PD) analysis in patients with community-acquired respiratory tract infections (RTI). A population pharmacokinetic analysis of sitafloxacin was conducted using clinical data of five clinical pharmacology studies and one clinical PK–PD study in patients with RTIs. The pharmacokinetic parameters in individual patients were estimated by the Bayesian method to examine any correlation between pharmacokinetics and bacteriological efficacy. Efficacy data were obtained from the clinical PK–PD study, in which 50 or 100 mg sitafloxacin was administered twice daily for 7 days. In addition, an efficacy was simulated for a hypothetical dose regimen of 100 mg once daily. The fAUC0–24h/MIC and the fCmax/MIC of sitafloxacin at a dose of 50 mg twice daily were 117.5 ± 78.0 and 7.3 ± 4.7 (mean ± SD), respectively. As a result of the univariate logistic regression analysis, the larger the value of fAUC0–24h/MIC or fCmax/MIC becomes, the higher the bacteriological efficacies. The eradication rates for fAUC0–24h/MIC ≥ 30 and for fCmax/MIC ≥ 2 were 96.4 % and 96.3 %, respectively. The PK–PD target values of sitafloxacin for the treatment of mild to moderate RTIs were considered to be fAUC0–24h/MIC ≥ 30 and fCmax/MIC ≥ 2. The PK–PD parameters at the regimen of 50 or 100 mg twice daily in patients with RTIs reached the target values. Furthermore, a 100 mg once-daily regimen was expected to show similar efficacy based on the PK–PD simulations.
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Affiliation(s)
- Yusuke Tanigawara
- Department of Clinical Pharmacokinetics and Pharmacodynamics, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan,
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Antibiotic therapy for pediatric community-acquired pneumonia: do we know when, what and for how long to treat? Pediatr Infect Dis J 2012; 31:e78-85. [PMID: 22466326 DOI: 10.1097/inf.0b013e318255dc5b] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Community-acquired pneumonia (CAP) is a common cause of morbidity among children in developed countries and accounts for an incidence of 10-40 cases per 1000 children in the first 5 years of life. Given the clinical, social and economic importance of CAP, there is general agreement that prompt and adequate therapy is essential to reduce the impact of the disease. The aim of this discussion paper is to consider critically the available data concerning the treatment of uncomplicated pediatric CAP and to consider when, how and for how long it should be treated. This review has identified the various reasons that make it difficult to establish a rational approach to the treatment of pediatric CAP, including the definition of CAP, the absence of a pediatric CAP severity score, the difficulty of identifying the etiology, limited pharmacokinetic (PK)/pharmacodynamic (PD) studies, the high resistance of the most frequent respiratory pathogens to the most widely used anti-infectious agents and the lack of information concerning the changes in CAP epidemiology following the introduction of new vaccines against respiratory pathogens. More research is clearly required in various areas, such as the etiology of CAP and the reasons for its complications, the better definition of first- and second-line antibiotic therapies (including the doses and duration of parenteral and oral antibiotic treatment), the role of antiviral treatment and on how to follow-up patients with CAP. Finally, further efforts are needed to increase vaccination coverage against respiratory pathogens and to conduct prospective studies of their impact.
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Septimus EJ, Owens RC. Need and potential of antimicrobial stewardship in community hospitals. Clin Infect Dis 2011; 53 Suppl 1:S8-S14. [PMID: 21795728 DOI: 10.1093/cid/cir363] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Preventing, reducing, and controlling the emergence of antimicrobial-resistant organisms is a major public health challenge requiring the participation of the entire medical community and public health agencies. Antimicrobial stewardship programs (ASPs) have the potential to integrate the many and sometimes disparate individuals and organizations that rely on antimicrobial agents in an effort to better control antimicrobial prescribing, possibly minimizing the emergence of resistant organisms. Developing and implementing ASPs can be a major challenge for community-based hospitals. In addition to specific and localized patterns of resistance-a consideration for every hospital-community hospitals must develop strategies that appropriately conform to their size, staffing, personnel, and infrastructure. This article reviews the ASP strategies and resources currently available to community hospitals for improving if, when, and how antimicrobial agents are prescribed and delivered.
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Affiliation(s)
- Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center, Infection Prevention and Epidemiology, HCA Healthcare System, Houston, Texas 59107, USA.
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Canut A, Martin-Herrero JE, Maortua H, Labora A, Isla A, Rodriguez-Gascon A. Impact of acute otitis media pathogen shifts on the clinical efficacy of several antibiotics: a therapeutic outcomes model. J Chemother 2009; 21:408-13. [PMID: 19622459 DOI: 10.1179/joc.2009.21.4.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The aim of this study was to predict the clinical efficacy of different antimicrobials in the treatment of patients with acute otitis media (AOM), before and after the change in the proportion of middle ear pathogens observed after the introduction of the new conjugated heptavalent penumococcal vaccine (pPCV-7). The therapeutic Outcomes model was used to predict the likelihood of clinical success. According to this mathematical model the obtained rank order of predicted clinical efficacy was similar in the pre-PVC7 period and the post-PVC period. The results suggest that ceftriaxone and amoxicillin/clavulanate are the antibiotics with the highest predicted clinical efficacy, whereas cefaclor, azithromycin, erythromycin and clarithromycin are those with the lowest predicted clinical efficacy. The differences between antibiotics with good and those with low antibacterial activity were greater when only cases of bacterial AOM were considered. Antibiotics for which the highest clinical efficacy was predicted should maximize the likelihood of cure in outpatient antibiotic treatment of AOM.
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Affiliation(s)
- A Canut
- Department of Clinical Microbiology, Hospital Santiago Apóstol, Vitoria, Spain.
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Owens RC, Shorr AF. Rational dosing of antimicrobial agents: Pharmacokinetic and pharmacodynamic strategies. Am J Health Syst Pharm 2009; 66:S23-30. [DOI: 10.2146/090087d] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Robert C. Owens
- Antimicrobial Stewardship Program, Department of Pharmacy, and Clinical Pharmacy Specialist, Infectious Diseases, Division of Infectious Diseases, Maine Medical Center, Portland, ME
| | - Andrew F. Shorr
- Pulmonary Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC
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Canut A, Martín-Herrero JE, Labora A, Maortua H. What are the most appropriate antibiotics for the treatment of acute exacerbation of chronic obstructive pulmonary disease? A therapeutic outcomes model. J Antimicrob Chemother 2007; 60:605-12. [PMID: 17595285 DOI: 10.1093/jac/dkm228] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To predict the clinical efficacy of several antimicrobials in the treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS A probability model (therapeutic outcomes model) was used to predict the likelihood of clinical success with particular antimicrobial agents in the treatment of patients with AECOPD, both in those clinically diagnosed (total patients with an AECOPD diagnosis regardless of the cause) and in those with bacterial AECOPD. The model took into account the following variables: (i) the proportion of patients with a clinical diagnosis of AECOPD and non-bacterial disease; (ii) likelihood of spontaneous resolution of a non-bacterial infection; (iii) prevalence of subcauses (different bacterial species) in bacterial AECOPD; (iv) rates of spontaneous resolution of bacterial AECOPD; and (v) antimicrobial efficacy of each antibiotic against each bacterial species (susceptibility based on PK/PD breakpoints). RESULTS Fluoroquinolones (levofloxacin, ciprofloxacin and moxifloxacin), a new third-generation oral cephalosporin (cefditoren) and high doses of amoxicillin/clavulanate were the antimicrobials with the highest predicted clinical efficacy both in mild-moderate AECOPD and in severe AECOPD (rates of 89.2% to 90.5% and 80.3% to 88.1%, respectively), whereas cefaclor, azithromycin, erythromycin and clarithromycin had the lowest predicted clinical efficacy (rates of 79.1% to 81.3% and 51.8% to 55.6% for mild-moderate and severe AECOPD, respectively), which was not much higher than that predicted for placebo (73.6% and 45.5%, respectively). CONCLUSIONS According to our model, fluoroquinolones (levofloxacin, ciprofloxacin and moxifloxacin), cefditoren and amoxicillin/clavulanate are the most appropriate antibiotics for the treatment of patients with AECOPD in terms of predicted clinical efficacy, with wide differences with respect to other antibiotics commonly used in the treatment of these patients, such as clarithromycin and azithromycin.
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Affiliation(s)
- Andrés Canut
- Department of Clinical Microbiology, Hospital Santiago Apóstol, Vitoria, Spain.
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