Treating nosocomial pneumonia: what's new

Distribution and antibacterial susceptibility pattern of isolated bacteria from endotracheal aspirates among ventilator-assisted pneumonia patients in Indonesia

An accurate and timely identification of causative microorganisms as well as determination of their antibiotic susceptibility patterns will help in the selection of proper antibiotics and prevention of their misuse in pneumonia patients. The aim of this study was to determine the distribution and antibiotic susceptibility pattern of bacteria isolated from endotracheal aspirates of ventilator-assisted pneumonia patients in Indonesia. A retrospective cross-sectional study was conducted at Dr. Zainoel Abidin Hospital, a provincial reference hospital in Banda Aceh, Indonesia, from January to December 2021. Ventilator-assisted pneumonia patients aged ≥17 years treated in the hospital were considered eligible. Antibiotic susceptibility was valuated using Kirby-Bauer disc-diffusion followed with VITEK 2 Compact. We included 57 patients of which 73.7% males and 26.3% aged 56-65 years (represent the majority group of the patients). Each patient reported at least one comorbidity and the average duration of receiving mechanical ventilation was 8.68 days, and more than half (59.7%) of the patients had a poor clinical outcome (died). A total 57 bacteria isolates (consisting nine species) were recovered; 68.5% Gram-negative and 31.5% Gram-positive bacteria. Among 57 patients, Acinetobacter baumannii was the most frequent isolated Gram-negative bacteria (19.3%), followed by Klebsiella pneumoniae (17.5%), Pseudomonas aeruginosa (15.8%), and Achromobacter denitrificans (12.3%). A. baumannii exhibited <70% sensitivity to aminoglycoside and carbapenem antibiotics and 100% resistance to third-generation cephalosporins. The most abundant Gram-positive bacteria was Staphylococcus aureus (17.5%), followed by S. haemolyticus (10.5%) and S. epidermidis (3.5%). All S. aureus were sensitive to linezolid, tigecycline, vancomycin, and macrolide antibiotics (azithromycin, clarithromycin, clindamycin, and erythromycin), whereas 50% were sensitive to some beta-lactams. However, 50% of S. aureus were methicillin resistant S. aureus (MRSA). Given the magnitude of multi-drug resistance, an empiric antimicrobial therapy in particular to specific settings and implementation of antibiotic stewardship programs are crucial.

Pulmonary Infections, Including Ventilator-Associated Pneumonia

Pneumonia is a leading cause of morbidity and mortality and a primary cause of hospitalizations. Guidelines have been established through the American Thoracic Society and Infectious Diseases Society of America in 2016 focusing on the causative pathogen for antibiotic selection. In 2017 an International European task force provided guidelines of specific antibiotic selections based on drug resistance and mortality risk. Improving patient outcomes is based not only on the appropriate treatment, which should not be delayed, but also on implementation and adherence to evidence-based strategies to reduce the increased risk of mortality.

Systematic Literature Review of Real-world Evidence of Ceftolozane/Tazobactam for the Treatment of Respiratory Infections

Introduction

Gram-negative nosocomial pneumonia (NP), including hospital-acquired bacterial pneumonia (HABP), ventilated HABP (vHABP), and ventilator-associated bacterial pneumonia (VABP), is a significant cause of morbidity and mortality. Common pathogens, including Enterobacterales and Pseudomonas aeruginosa, are prevalent in healthcare settings and have few effective treatment options due to high rates of antibacterial resistance. Resistant pathogens are associated with significantly worse outcomes, relative to patients with susceptible infections. Ceftolozane/tazobactam (C/T) has established efficacy in clinical trials of patients with NP. This review aims to collate data on C/T use for HABP/vHABP/VABP infections in real-world clinical practice.

Methods

This systematic literature review searched online biomedical databases for real-world studies of C/T used to treat Gram-negative respiratory tract infections (RTIs) between January 2009 and June 2020.

Results

Thirty-three studies comprising 658 patients were identified. Pneumonia was the most common infection treated with C/T (85%), with a smaller number of unspecified RTIs (9%) and tracheobronchitis (5%) reported. The majority of patients had respiratory infections caused by P. aeruginosa (92.8%), of which 88.1% were multidrug-resistant. Examination of these studies demonstrated an increase in the percentage of patients receiving the recommended dose of C/T for respiratory infections (3 g q8h or renal impairment-adjusted) over time (36.8% of patients in 2017 to 71.5% in 2020). Clinical success rates ranged from 51.4 to 100%, with 10 studies (55.6% of studies reporting clinical success) reporting clinical success rates of > 70%; microbiological success rates ranged from 57.0 to 100.0%, with three studies (60.0% of studies reporting microbiological success) reporting microbiological success rates of > 70%. Thirty-day mortality ranged from 0.0 to 33.0%, with nine studies (90% of studies reporting mortality) reporting 30-day mortality of < 30%.

Conclusions

The studies identified in this review demonstrate that C/T shows similar outcomes as those seen in clinical trials, despite the higher frequency of multidrug-resistant pathogens, and comorbidities that may have been excluded from the trials.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00491-x.

Modern approaches to pharmacotherapy of Community-Acquired Pneumonia

Introduction: The study presents current views on the pharmacotherapy of community-acquired pneumonia (CAP). This study also describes in general terms the current pharmacoepidemiological situation of the CAP in Russia and abroad, which can both help medical professionals make an informed choice when choosing a pharmacotherapy, and inspire them to follow-up research and observations.

The aim of the study is to conduct an analysis of the available research on the pharmacotherapy of CAP in order to accelerate the accumulation and assimilation of knowledge in the field of this pathology.

Materials and methods: The following databases of medical publications and electronic libraries were used to search for the relevant sources of information: PubMed, Medline, Google Scholar, Crossref, and eLIBRARY.RU.

Results and discussion: The choice of a rational antimicrobial therapy (AMT) for CAP is of high relevance due to the widespread of the pathology. The article highlights modern approaches to the pharmacotherapy of CAP in adults, including a review of promising new drugs, and presents the main problematic issues related to the emergence of antibiotic resistance of pathogens, as well as methods to combat it.

Conclusion: The analyzed and generalized results of the conducted research allow the authors to make a conclusion about the feasibility of a more detailed study and raising the level of awareness of medical professionals in this pathology.

Healthcare Resource Utilization of Ceftolozane/Tazobactam Versus Meropenem for Ventilated Nosocomial Pneumonia from the Randomized, Controlled, Double-Blind ASPECT-NP Trial

Introduction

Hospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP) are associated with significant healthcare resource utilization (HCRU). This a priori, exploratory, secondary analysis from the ASPECT-NP clinical trial evaluated resource utilization among patients with ventilated HABP (vHABP)/VABP treated with ceftolozane/tazobactam or meropenem.

Methods

This analysis used data from the randomized, double-blind, noninferiority phase 3 ASPECT-NP trial of patients with vHABP/VABP randomized to receive ceftolozane/tazobactam 3 g (ceftolozane 2 g/tazobactam 1 g) or meropenem 1 g for 8–14 days. Day 28 outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, and time to mechanical ventilation extubation in the microbiological intention-to-treat (mITT) population and in an HCRU population. The HCRU population, a subset of patients from the mITT population that were alive at day 28, was used to remove resource use bias influenced by mortality rates.

Results

Ceftolozane/tazobactam-treated versus meropenem-treated patients, respectively, had fewer deaths (20.1% vs. 25.5%), fewer hospital discharges (30.7% vs. 32.4%), and higher ICU discharges (60.0% vs. 58.3%) and extubations (51.9% vs. 48.2%) by day 28. In the HCRU population, adjusted LOS differences (95% confidence intervals) for ceftolozane/tazobactam compared with meropenem were 0.1 (− 1.4 to 1.6) hospitalization days, − 1.4 (− 2.9 to 0.2) ICU days, and − 0.9 (− 2.4 to 0.7) mechanical ventilation days. Patterns were similar among the VABP and Pseudomonas aeruginosa subgroups.

Conclusion

Similar 28-day resource utilization outcomes were observed between ceftolozane/tazobactam and meropenem in the mITT population of patients from ASPECT-NP with vHABP/VABP due to gram-negative pathogens. ASPECT-NP was not powered to detect differences in resource utilization outcomes between treatment groups; however, numerical differences in ICU LOS and duration of mechanical ventilation were noted. Further study is needed to assess resource utilization in the real-world practice setting, especially among patients excluded from ASPECT-NP, including those with resistant P. aeruginosa infections.

Trial Registrations

ClinicalTrials.gov: NCT02070757, registered February 25, 2014; EudraCT: 2012-002862-11.

Electronic supplementary material

The online version of this article (10.1007/s40121-020-00343-0) contains supplementary material, which is available to authorized users.

Evaluating the Saliva of Burn ICU Patients for Resistant Infections Harbor Metallo-β-Lactamase Genes

Pseudomonas aeruginosa and Acinetobacter baumannii are the bacteria which increasingly account for nosocomial infections. Due to high virulence, the rate of Multi-Drug Resistance (MDR) and limited availability of new agents, these infections create significant clinical burdens, making it important to identify the possible sources of their occurrence. The aim of this study was to assess non-lactose fermenting bacteria and their metallo-β-lactamase (MBLs) genes expression in the Burn Intensive Care Unit (BICU) patients' saliva samples. This cross-sectional study was conducted from 2017 to 2018 on 124 saliva samples of BICU patients. Identified isolates were evaluated for drug susceptibility by disc diffusion method. MBLs production isolates were detected by Modified Hodge test and Imipenem-EDTA Combined disk. MBLs related genes were evaluated by polymerase chain reaction (PCR). A total of 86 Gram negative non-lactose fermenting bacteria (38; A. baumannii) and (48; P. aeruginosa), were detected. All of the A. baumannii isolates were resistant to Carbapenems, while more than 90% of them were sensitive to Colistin. However, the highest sensitivity in P. aeruginosa isolates was related to Carbapenems and Colistin. More than 95% of A. baumannii and 32% of P. aeruginosa were detected MDR. MBLs production was confirmed in 9 (33.33%) P. aeruginosa and 18 (66.67%) A. baumannii isolates. The blaVIM was the most prevalent gene, while this gene was detected in all of MBLs positive strains. This study confirmed the prevalence of carbapenemase producer Gram-negative bacilli in the saliva of BICU patients. The results of the present study provide a new data set about saliva infection source that could lead to the proper antibiotic regimen and better control of drug resistance.