Assessment of the intensive care unit treatment of pneumonia at a veterans affairs facility

INTRODUCTION

Pneumonia is a common cause of morbidity and mortality in the critically ill. Clinicians use a range of duration for antibiotic treatment from 7 to 14 days or longer. Failure to de-escalate antimicrobial therapy in a timely manner may lead to increased antimicrobial resistance, increased risk of side effects, and increased cost.

OBJECTIVE

To investigate potential methods to improve treatment of pneumonia for patients in 4 intensive care units (ICUs).

METHODS

A retrospective descriptive chart review was conducted at the Veterans Affairs North Texas Health Care System (VANTHCS). Veterans aged 18 to 90 years admitted to the ICU with a diagnosis of pneumonia were included. Descriptive statistics were used to interpret the data. Current management was reviewed to identify markers such as length of antibiotic therapy, ICU length of stay, and inpatient mortality. Secondary objectives included appropriateness and accuracy of the empiric regimen.

RESULTS

Of the 1,854 Veterans admitted, 107 met inclusion criteria. Antibiotic choices for positive cultures were appropriate in 45 out of 46 (98%) patients, with an average length of therapy of 8.6 ± 6.3 days. De-escalation of antibiotics based on sensitivity data occurred in 73% of positive cultures.

CONCLUSIONS

Pneumonia in the VANTHCS ICUs is initially treated with empiric antibiotics. Empiric antibiotic therapy for pneumonia was appropriate and accurate over this time period. Opportunities exist for de-escalation in patients with or without positive cultures. The procalcitonin assay is now being utilized at VANTHCS to optimize patient care.

Modeling antibiotic resistance in hospitals: the impact of minimizing treatment duration

Infections caused by antibiotic-resistant pathogens are a global public health problem. Numerous individual- and population-level factors contribute to the emergence and spread of these pathogens. An individual-based model (IBM), formulated as a system of stochastically determined events, was developed to describe the complexities of the transmission dynamics of antibiotic-resistant bacteria. To simplify the interpretation and application of the model's conclusions, a corresponding deterministic model was created, which describes the average behavior of the IBM over a large number of simulations. The integration of these two model systems provides a quantitative analysis of the emergence and spread of antibiotic-resistant bacteria, and demonstrates that early initiation of treatment and minimization of its duration mitigates antibiotic resistance epidemics in hospitals.

Gemifloxacin once daily for 5 days versus 7 days for the treatment of community-acquired pneumonia: a randomized, multicentre, double-blind study

OBJECTIVES

Short-course therapy has been advocated for the treatment of community-acquired pneumonia (CAP). We compared the efficacy and safety of 5 and 7 day courses of gemifloxacin for outpatient treatment of mild-moderate CAP.

PATIENTS AND METHODS

In a multicentre, double-blind, parallel group study, patients were randomized to receive 320 mg of oral gemifloxacin once daily for 5 or 7 days. Over 95% of all patients in each cohort had a Fine score of <or=III. The primary efficacy endpoint was clinical cure at follow-up (days 24-30). Secondary outcomes were clinical and bacteriological responses at the end of therapy (days 7-9) and bacteriological and radiological responses at follow-up. Adverse events (AEs) were also monitored.

RESULTS

In a total of 469 per protocol (PP) patients, clinical resolution at follow-up was 95% and 92% for 5 and 7 day treatments, respectively [95% confidence interval (CI) -1.48, 7.42], indicating non-inferiority of 5 day treatment. Clinical resolution at the end of therapy was 96% for both regimens (95% CI -3.85, 3.42). Bacteriological response rates in PP patients at the end of therapy were 94% and 96% for 5 and 7 day groups, respectively (95% CI -8.27, 3.25) and 91% for both groups at follow-up (95% CI -6.89, 7.93). Radiological success in PP patients at follow-up was 98% and 93% in 5 and 7 day groups, respectively (95% CI 0.35, 7.91). Pre-therapy pathogens were identified in 242 (47.3%) patients, most commonly Streptococcus pneumoniae. Frequency of treatment-related AEs was 21% in both cohorts with discontinuation rates of 1.2% and 2% in the 5 and 7 day groups, respectively. A lower incidence of rash was observed in the 5 day cohort (0.4%) versus the 7 day cohort (2.8%) (P=0.04).

CONCLUSIONS

Gemifloxacin once daily for 5 days is not inferior to 7 days in the PP population with respect to clinical, bacteriological and radiological efficacy. Further work is needed, however, to explore whether fewer treatment days would improve patient compliance and reduce the incidence of AEs.