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Póvoa P, Coelho L, Cidade JP, Ceccato A, Morris AC, Salluh J, Nobre V, Nseir S, Martin-Loeches I, Lisboa T, Ramirez P, Rouzé A, Sweeney DA, Kalil AC. Biomarkers in pulmonary infections: a clinical approach. Ann Intensive Care 2024; 14:113. [PMID: 39020244 PMCID: PMC11254884 DOI: 10.1186/s13613-024-01323-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/27/2024] [Indexed: 07/19/2024] Open
Abstract
Severe acute respiratory infections, such as community-acquired pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia, constitute frequent and lethal pulmonary infections in the intensive care unit (ICU). Despite optimal management with early appropriate empiric antimicrobial therapy and adequate supportive care, mortality remains high, in part attributable to the aging, growing number of comorbidities, and rising rates of multidrug resistance pathogens. Biomarkers have the potential to offer additional information that may further improve the management and outcome of pulmonary infections. Available pathogen-specific biomarkers, for example, Streptococcus pneumoniae urinary antigen test and galactomannan, can be helpful in the microbiologic diagnosis of pulmonary infection in ICU patients, improving the timing and appropriateness of empiric antimicrobial therapy since these tests have a short turnaround time in comparison to classic microbiology. On the other hand, host-response biomarkers, for example, C-reactive protein and procalcitonin, used in conjunction with the clinical data, may be useful in the diagnosis and prediction of pulmonary infections, monitoring the response to treatment, and guiding duration of antimicrobial therapy. The assessment of serial measurements overtime, kinetics of biomarkers, is more informative than a single value. The appropriate utilization of accurate pathogen-specific and host-response biomarkers may benefit clinical decision-making at the bedside and optimize antimicrobial stewardship.
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Affiliation(s)
- Pedro Póvoa
- Department of Intensive Care, Hospital de São Francisco Xavier, ULSLO, Lisbon, Portugal.
- NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056, Lisbon, Portugal.
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.
| | - Luís Coelho
- Department of Intensive Care, Hospital de São Francisco Xavier, ULSLO, Lisbon, Portugal
- Pulmonary Department, CDP Dr. Ribeiro Sanches, ULS Santa Maria, Lisbon, Portugal
| | - José Pedro Cidade
- Department of Intensive Care, Hospital de São Francisco Xavier, ULSLO, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Adrian Ceccato
- Critical Care Center, Institut d'Investigació i Innovació Parc Taulí I3PT-CERCA, Hospital Universitari Parc Taulí, Univeristat Autonoma de Barcelona, Sabadell, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Intensive Care Unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
- JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Jorge Salluh
- Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
| | - Vandack Nobre
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Saad Nseir
- 1Univ. Lille, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, 59000, Lille, France
- CNRS, UMR 8576, 59000, Lille, France
- INSERM, U1285, 59000, Lille, France
- CHU Lille, Service de Médecine Intensive Réanimation, 59000, Lille, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James Hospital, Dublin, Ireland
- Department of Pneumology, Hospital Clinic of Barcelona-August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Thiago Lisboa
- Postgraduate Program Pulmonary Science, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Paula Ramirez
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Department of Critical Care Medicine, Hospital Universitario Y Politécnico La Fe, Valencia, Spain
| | - Anahita Rouzé
- 1Univ. Lille, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, 59000, Lille, France
- CNRS, UMR 8576, 59000, Lille, France
- INSERM, U1285, 59000, Lille, France
- CHU Lille, Service de Médecine Intensive Réanimation, 59000, Lille, France
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, La Jolla, San Diego, CA, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
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2
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Plaisance CJ, Borne GE, Daniel CP, Wagner MJ, Shelvan A, Mathew J, Ahmadzadeh S, Paladini A, Varrassi G, Shekoohi S, Kaye AD. Cefiderocol (Fetroja) as a Treatment for Hospital-Acquired Pneumonia. Cureus 2024; 16:e52230. [PMID: 38352089 PMCID: PMC10863518 DOI: 10.7759/cureus.52230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/13/2024] [Indexed: 02/16/2024] Open
Abstract
With increasing resistance to conventional antibiotic treatments, especially among gram-negative bacilli, the search for new antibiotics has become critical on a global scale. Among infections with multidrug-resistant bacteria is hospital-acquired pneumonia (HAP), which is nosocomial pneumonia in patients who have been hospitalized for more than 48 hours. HAP carries a high mortality rate and continues to be a challenge with regard to adequate treatment. The typical multidrug-resistant gram negatives found in HAP include Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Many new antibiotics have been studied and tested against these pathogens as possible solutions, and the search continues. Cefiderocol, a novel siderophore cephalosporin, is effective against these pathogens. Cefiderocol is an iron-chelating agent that makes use of iron pumps on the membrane of bacteria via a catechol moiety on the C3 side chain of the molecule. This allows for easy access into the cytoplasm, where it can inhibit peptidoglycan synthesis by binding to penicillin-binding proteins. Cefiderocol displays linear pharmacokinetics and is mainly excreted through the kidneys. It is well tolerated in healthy individuals but may need adjustments of dosage in patients with impaired renal function. Studies have shown that both healthy subjects and those with impaired renal function experienced some adverse effects, including nausea, diarrhea, abdominal pain, and increased creatinine kinase; however, these adverse effects were limited and experienced in placebo groups. It has demonstrated efficacy in treating infections caused by many multidrug-resistant gram-negative pathogens and has demonstrated high stability against many classes of b-lactamases. There have been multiple phase 3 trials, such as the CREDIBLE-CR trial and the APEKS-NP trial, that demonstrated efficacy in treated nosocomial pneumonia caused by multidrug-resistant gram negatives, such as carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, compared to the best available treatment. While clinical data remain limited, a few studies are showing clinical efficacy and few adverse effects. Cefiderocol demonstrated effectivity in treating multidrug-resistant gram-negative pneumonia in patients with multiple comorbidities, such as chronic kidney disease, chronic-obstructive pulmonary disease, and diabetes mellitus. Cefiderocol shows promise as a novel antimicrobial agent in treating multidrug-resistant gram-negative in HAP.
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Affiliation(s)
- Connor J Plaisance
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Grant E Borne
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Charles P Daniel
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Maxwell J Wagner
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Anitha Shelvan
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jibin Mathew
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Antonella Paladini
- Department of Life, Health & Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | | | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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3
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Heitz M, Levrat A, Lazarevic V, Barraud O, Bland S, Santiago-Allexant E, Louis K, Schrenzel J, Hauser S. Metagenomics for the microbiological diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia (HAP/VAP) in intensive care unit (ICU): a proof-of-concept study. Respir Res 2023; 24:285. [PMID: 37968636 PMCID: PMC10648381 DOI: 10.1186/s12931-023-02597-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated-pneumonia (HAP/VAP) are one of the most prevalent health-care associated infections in the intensive care unit (ICU). Culture-independent methods were therefore developed to provide faster route to diagnosis and treatment. Among these, metagenomic next-generation sequencing (mNGS) has shown considerable promise. METHODS This proof-of-concept study describes the technical feasibility and evaluates the clinical validity of the mNGS for the detection and characterization of the etiologic agents causing hospital-acquired and ventilator-associated pneumonia. We performed a prospective study of all patients with HAP/VAP hospitalized in our intensive care unit for whom a bronchoalveolar lavage (BAL) was performed between July 2017 and November 2018. We compared BAL fluid culture and mNGS results of these patients. RESULTS A total of 32 BAL fluids were fully analyzed. Of these, 22 (69%) were positive by culture and all pathogens identified were also reported by mNGS. Among the culture-positive BAL samples, additional bacterial species were revealed by mNGS for 12 patients, raising the issue of their pathogenic role (colonization versus coinfection). Among BALF with culture-negative test, 5 were positive in mNGS test. CONCLUSIONS This study revealed concordant results for pneumonia panel pathogens between mNGS and culture-positive tests and identified additional pathogens potentially implicated in pneumonia without etiologic diagnosis by culture. mNGS has emerged as a promising methodology for infectious disease diagnoses to support conventional methods. Prospective studies with real-time mNGS are warranted to examine the impact on antimicrobial decision-making and clinical outcome.
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Affiliation(s)
- Morgane Heitz
- Intensive Care Unit, Annecy-Genevois Hospital, Site d'Annecy, 1 Avenue de L'hôpital, 74370, Metz Tessy, France.
| | - Albrice Levrat
- Intensive Care Unit, Annecy-Genevois Hospital, Site d'Annecy, 1 Avenue de L'hôpital, 74370, Metz Tessy, France
| | - Vladimir Lazarevic
- Genomic Research Laboratory, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Barraud
- Genomic Research Laboratory, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphane Bland
- Bacteriology Laboratory, Annecy-Genevois Hospital, Metz Tessy, France
| | | | - Karen Louis
- BIOASTER Microbiology Technology Institute, 40 Avenue Tony Garnier, 69007, Lyon, France
| | - Jacques Schrenzel
- Genomic Research Laboratory, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Bacteriology Laboratory, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sébastien Hauser
- bioMérieux Grenoble, Centre Christophe Mérieux, 5 Rue Des Berges, 38024, Grenoble Cedex 01, France
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4
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Simon S, Rademacher J. [Antibiotic treatment of community-acquired and hospital-acquired pneumonia]. Med Klin Intensivmed Notfmed 2023; 118:454-463. [PMID: 37405418 DOI: 10.1007/s00063-023-01033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 07/06/2023]
Abstract
Community-acquired and nosocomial bacterial pneumonia are among the most common infectious diseases in Germany. Knowledge of possible pathogens and therapeutic implications thereof are essential to be able to provide adequate, differentiated antimicrobial therapy with the appropriate drugs, form of application, dose, and duration. New diagnostics that include multiplex polymerase chain reaction, correct interpretation of the biomarker procalcitonin, and treatment of multidrug-resistant bacteria are becoming increasingly import.
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Affiliation(s)
- Susanne Simon
- Klinik für Pneumologie und Infektiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Jessica Rademacher
- Klinik für Pneumologie und Infektiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
- German Center for Lung Research (DZL), Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Deutschland
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5
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Flick H, Hermann M, Urban M, Meilinger M. Nosokomiale Pneumonien und beatmungsassoziierte Krankenhauserreger. ANÄSTHESIE NACHRICHTEN 2022. [PMCID: PMC9645741 DOI: 10.1007/s44179-022-00108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Holger Flick
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Klinische Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, LKH-Univ. Klinikum Graz, Medizinische Universität Graz, Graz, Österreich
| | - Maria Hermann
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Klinische Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, LKH-Univ. Klinikum Graz, Medizinische Universität Graz, Graz, Österreich
| | - Matthias Urban
- Abteilung für Innere Medizin und Pneumologie, Klinik Floridsdorf, Wien, Österreich
- ÖGP-Arbeitskreis „Beatmung und Intensivmedizin“, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und pneumologische Onkologie, Wien, Österreich
| | - Michael Meilinger
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Abteilung für Innere Medizin und Pneumologie, Klinik Floridsdorf, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und pneumologische Onkologie, Wien, Österreich
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6
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Bassetti M, Mularoni A, Giacobbe DR, Castaldo N, Vena A. New Antibiotics for Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:280-294. [PMID: 35088403 DOI: 10.1055/s-0041-1740605] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) represent one of the most common hospital-acquired infections, carrying a significant morbidity and risk of mortality. Increasing antibiotic resistance among the common bacterial pathogens associated with HAP and VAP, especially Enterobacterales and nonfermenting gram-negative bacteria, has made the choice of empiric treatment of these infections increasingly challenging. Moreover, failure of initial empiric therapy to cover the causative agents associated with HAP and VAP has been associated with worse clinical outcomes. This review provides an overview of antibiotics newly approved or in development for the treatment of HAP and VAP. The approved antibiotics include ceftobiprole, ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, and cefiderocol. Their major advantages include their high activity against multidrug-resistant gram-negative pathogens.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Alessandra Mularoni
- Department of Infectious Diseases, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS), Palermo, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Nadia Castaldo
- Division of Infectious Diseases, Department of Medicine, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.,Department of Pulmonology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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7
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Enne VI, Aydin A, Baldan R, Owen DR, Richardson H, Ricciardi F, Russell C, Nomamiukor-Ikeji BO, Swart AM, High J, Colles A, Barber J, Gant V, Livermore DM, O'Grady J. Multicentre evaluation of two multiplex PCR platforms for the rapid microbiological investigation of nosocomial pneumonia in UK ICUs: the INHALE WP1 study. Thorax 2022; 77:1220-1228. [PMID: 35027473 DOI: 10.1136/thoraxjnl-2021-216990] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/29/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Culture-based microbiological investigation of hospital-acquired or ventilator-associated pneumonia (HAP or VAP) is insensitive, with aetiological agents often unidentified. This can lead to excess antimicrobial treatment of patients with susceptible pathogens, while those with resistant bacteria are treated inadequately for prolonged periods. Using PCR to seek pathogens and their resistance genes directly from clinical samples may improve therapy and stewardship. METHODS Surplus routine lower respiratory tract samples were collected from intensive care unit patients about to receive new or changed antibiotics for hospital-onset lower respiratory tract infections at 15 UK hospitals. Testing was performed using the BioFire FilmArray Pneumonia Panel (bioMérieux) and Unyvero Pneumonia Panel (Curetis). Concordance analysis compared machine and routine microbiology results, while Bayesian latent class (BLC) analysis estimated the sensitivity and specificity of each test, incorporating information from both PCR panels and routine microbiology. FINDINGS In 652 eligible samples; PCR identified pathogens in considerably more samples compared with routine microbiology: 60.4% and 74.2% for Unyvero and FilmArray respectively vs 44.2% by routine microbiology. PCR tests also detected more pathogens per sample than routine microbiology. For common HAP/VAP pathogens, FilmArray had sensitivity of 91.7%-100.0% and specificity of 87.5%-99.5%; Unyvero had sensitivity of 50.0%-100.0%%, and specificity of 89.4%-99.0%. BLC analysis indicated that, compared with PCR, routine microbiology had low sensitivity, ranging from 27.0% to 69.4%. INTERPRETATION Conventional and BLC analysis demonstrated that both platforms performed similarly and were considerably more sensitive than routine microbiology, detecting potential pathogens in patient samples reported as culture negative. The increased sensitivity of detection realised by PCR offers potential for improved antimicrobial prescribing.
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Affiliation(s)
- Virve I Enne
- Division of Infection and Immunity, University College London, London, UK
| | - Alp Aydin
- Division of Infection and Immunity, University College London, London, UK
| | - Rossella Baldan
- Centre for Clinical Infection and Diagnostic Research, King's College London, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Dewi R Owen
- Division of Infection and Immunity, University College London, London, UK
| | | | - Federico Ricciardi
- Department of Statistical Science, University College London, London, UK
| | | | | | - Ann-Marie Swart
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Juliet High
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Antony Colles
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - Vanya Gant
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK.,NIHR Biomedical research Centre, University College London Hospitals, London, UK
| | | | - Justin O'Grady
- Norwich Medical School, University of East Anglia, Norwich, UK.,Quadram Institute Bioscience, Norwich, UK
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8
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Póvoa P, Coelho L. Which Biomarkers Can Be Used as Diagnostic Tools for Infection in Suspected Sepsis? Semin Respir Crit Care Med 2021; 42:662-671. [PMID: 34544183 DOI: 10.1055/s-0041-1735148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The diagnosis of infection in patients with suspected sepsis is frequently difficult to achieve with a reasonable degree of certainty. Currently, the diagnosis of infection still relies on a combination of systemic manifestations, manifestations of organ dysfunction, and microbiological documentation. In addition, the microbiologic confirmation of infection is obtained only after 2 to 3 days of empiric antibiotic therapy. These criteria are far from perfect being at least in part responsible for the overuse and misuse of antibiotics, in the community and in hospital, and probably the main drive for antibiotic resistance. Biomarkers have been studied and used in several clinical settings as surrogate markers of infection to improve their diagnostic accuracy as well as in the assessment of response to antibiotics and in antibiotic stewardship programs. The aim of this review is to provide a clear overview of the current evidence of usefulness of biomarkers in several clinical scenarios, namely, to diagnose infection to prescribe antibiotics, to exclude infection to withhold antibiotics, and to identify the causative pathogen to target antimicrobial treatment. In recent years, new evidence with "old" biomarkers, like C-reactive protein and procalcitonin, as well as new biomarkers and molecular tests, as breathomics or bacterial DNA identification by polymerase chain reaction, increased markedly in different areas adding useful information for clinical decision making at the bedside when adequately used. The recent evidence shows that the information given by biomarkers can support the suspicion of infection and pathogen identification but also, and not less important, can exclude its diagnosis. Although the ideal biomarker has not yet been found, there are various promising biomarkers that represent true evolutions in the diagnosis of infection in patients with suspected sepsis.
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Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Luis Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal
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9
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Koulenti D, Armaganidis A, Arvaniti K, Blot S, Brun-Buisson C, Deja M, De Waele J, Du B, Dulhunty JM, Garcia-Diaz J, Judd M, Paterson DL, Putensen C, Reina R, Rello J, Restrepo MI, Roberts JA, Sjovall F, Timsit JF, Tsiodras S, Zahar JR, Zhang Y, Lipman J. Protocol for an international, multicentre, prospective, observational study of nosocomial pneumonia in intensive care units: the PneumoINSPIRE study. CRIT CARE RESUSC 2021; 23:59-66. [PMID: 38046390 PMCID: PMC10692553 DOI: 10.51893/2021.1.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Nosocomial pneumonia in the critical care setting is associated with increased morbidity, significant crude mortality rates and high health care costs. Ventilator-associated pneumonia represents about 80% of nosocomial pneumonia cases in intensive care units (ICUs). Wide variance in incidence of nosocomial pneumonia and diagnostic techniques used has been reported, while successful treatment remains complex and a matter of debate. Objective: To describe the epidemiology, diagnostic strategies and treatment modalities for nosocomial pneumonia in contemporary ICU settings across multiple countries around the world. Design, setting and patients: PneumoINSPIRE is a large, multinational, prospective cohort study of adult ICU patients diagnosed with nosocomial pneumonia. Participating ICUs from at least 20 countries will collect data on 10 or more consecutive ICU patients with nosocomial pneumonia. Site-specific information, including hospital policies on antibiotic therapy, will be recorded along with patient-specific data. Variables that will be explored include: aetiology and antimicrobial resistance patterns, treatment-related parameters (including time to initiation of antibiotic therapy, and empirical antibiotic choice, dose and escalation or de-escalation), pneumonia resolution, ICU and hospital mortality, and risk factors for unfavourable outcomes. The concordance of ventilator-associated pneumonia diagnosis with accepted definitions will also be assessed. Results and conclusions: PneumoINSPIRE will provide valuable information on current diagnostic and management practices relating to ICU nosocomial pneumonia, and identify research priorities in the field. Trial registration:ClinicalTrials.gov identifier NCT02793141.
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Affiliation(s)
- Despoina Koulenti
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
| | - Apostolos Armaganidis
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
| | - Kostoula Arvaniti
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
| | - Stijn Blot
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - Christian Brun-Buisson
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Mixed Research Unit (French Institute for Medical Research [INSERM], Université de Versailles Saint Quentin Medical School and Institut Pasteur), Paris-Saclay University, Montigny-Le-Bretonneux, France
| | - Maria Deja
- Lumbeck Klinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitatsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Joel M. Dulhunty
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Research and Medical Education, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Julia Garcia-Diaz
- Infectious Diseases Department, Ochsner Clinic Foundation, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, New Orleans, LA, USA
| | - Matthew Judd
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - David L. Paterson
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Infectious Diseases Unit, Royal Brisbane and Women’s Hospital,Brisbane, QLD, Australia
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Rosa Reina
- Critical Care Department, Hospital San Martin de la Plata, Buenos Aires, Argentina
| | - Jordi Rello
- Clinical Research/Innovation in Pneumonia and Sepsis Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Efermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research Department, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Marcos I. Restrepo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Pulmonary and Critical Care Fellowship Program, University of Texas Health Science Center, San Antonio, TX, USA
- Medical Intensive Care Unit, South Texas Veterans Health Care System, Audie L Murphy Division, San Antonio, TX, USA
- INnovation Science in Pulmonary Infections REsearch Network, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Fredrik Sjovall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
| | - Jean-Francois Timsit
- Infection, Antimicrobials, Modelling, Evolution Research Centre, French Institute for Medical Research (INSERM), Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit (MI2), Hôpital Bichat, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, Assistance Publique — Hôpitaux de Paris, Bobigny, France
- Infection, Antimicrobials, Modelling, Evolution Research Centre, Unité Mixte de Recherche 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
| | - Yuchi Zhang
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Anesthesiology and Critical Care Department, Centre Hospitalier Universitaire de Nîmes, University of Montpellier, Nîmes, France
| | - On behalf of the Working Group on Pneumonia of the European Society of Intensive Care Medicine
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Second Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Athens, Greece
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
- Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Mixed Research Unit (French Institute for Medical Research [INSERM], Université de Versailles Saint Quentin Medical School and Institut Pasteur), Paris-Saclay University, Montigny-Le-Bretonneux, France
- Lumbeck Klinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitatsklinikum Schleswig-Holstein, Campus Lübeck, Universität zu Lübeck, Lübeck, Germany
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
- Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Research and Medical Education, Redcliffe Hospital, Brisbane, QLD, Australia
- Infectious Diseases Department, Ochsner Clinic Foundation, New Orleans, LA, USA
- Ochsner Clinical School, The University of Queensland, New Orleans, LA, USA
- Infectious Diseases Unit, Royal Brisbane and Women’s Hospital,Brisbane, QLD, Australia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Critical Care Department, Hospital San Martin de la Plata, Buenos Aires, Argentina
- Clinical Research/Innovation in Pneumonia and Sepsis Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Efermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research Department, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Pulmonary and Critical Care Fellowship Program, University of Texas Health Science Center, San Antonio, TX, USA
- Medical Intensive Care Unit, South Texas Veterans Health Care System, Audie L Murphy Division, San Antonio, TX, USA
- INnovation Science in Pulmonary Infections REsearch Network, Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Infection, Antimicrobials, Modelling, Evolution Research Centre, French Institute for Medical Research (INSERM), Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit (MI2), Hôpital Bichat, Assistance Publique – Hôpitaux de Paris, Paris, France
- Fourth Department of Internal Medicine, Attikon University Hospital, Athens, Greece
- Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, Assistance Publique — Hôpitaux de Paris, Bobigny, France
- Infection, Antimicrobials, Modelling, Evolution Research Centre, Unité Mixte de Recherche 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Anesthesiology and Critical Care Department, Centre Hospitalier Universitaire de Nîmes, University of Montpellier, Nîmes, France
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10
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El-Mokhtar MA, Daef E, Mohamed Hussein AAR, Hashem MK, Hassan HM. Emergence of Nosocomial Pneumonia Caused by Colistin-Resistant Escherichia coli in Patients Admitted to Chest Intensive Care Unit. Antibiotics (Basel) 2021; 10:antibiotics10030226. [PMID: 33668302 PMCID: PMC7996192 DOI: 10.3390/antibiotics10030226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Colistin is a last-resort antibiotic used in treating multidrug-resistant Gram-negative infections. The growing emergence of colistin resistance in Escherichia coli (E. coli) represents a serious health threat, particularly to intensive care unit (ICU) patients. (2) Methods: In this work, we investigated the emergence of colistin resistance in 140 nosocomial E. coli isolated from patients with pneumonia and admitted to the chest ICU over 36 months. Virulence and resistance-related genes and E. coli pathotypes in colistin-resistant and colistin-sensitive isolates were determined. (3) Results: Colistin resistance was observed in 21/140 (15%) of the nosocomial E. coli isolates. The MIC50 of the resistant strains was 4 mg/L, while MIC90 was 16 mg/L. Colistin-resistant isolates were also co-resistant to amoxicillin, amoxicillin/clavulanic, aztreonam, ciprofloxacin, and chloramphenicol. The mechanism of colistin resistance was represented by the presence of mcr-1 in all resistant strains. Respectively, 42.9% and 36.1% of colistin-resistant and colistin-sensitive groups were extended-spectrum β-lactamase (ESBL) producers, while 23.8% and 21% were metallo β-lactamase (MBL) producers. blaTEM-type was the most frequently detected ESBL gene, while blaIMP-type was the most common MBL in both groups. Importantly, most resistant strains showed a significantly high prevalence of astA (76.2%), aggR (76.2%), and pic (52.4%) virulence-related genes. Enteroaggregative E. coli (76%) was the most frequently detected genotype among the colistin-resistant strains. (4) Conclusion: The high colistin resistance rate observed in E. coli strains isolated from patients with nosocomial pneumonia in our university hospital is worrisome. These isolates carry different drug resistance and virulence-related genes. Our results indicate the need for careful monitoring of colistin resistance in our university hospital. Furthermore, infection control policies restricting the unnecessary use of extended-spectrum cephalosporins and carbapenems are necessary.
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Affiliation(s)
- Mohamed A. El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt; (M.A.E.-M.); (E.D.)
- Microbiology and Immunology Department, Faculty of Pharmacy, Sphinx University, Assiut 71515, Egypt
| | - Enas Daef
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt; (M.A.E.-M.); (E.D.)
| | | | - Maiada K. Hashem
- Chest Department, Faculty of Medicine, Assiut University, Assiut 71515, Egypt; (A.A.R.M.H.); (M.K.H.)
| | - Hebatallah M. Hassan
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt; (M.A.E.-M.); (E.D.)
- Correspondence: ; Tel.: +2-010-2218-2086
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11
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Short-Term Effects of Appropriate Empirical Antimicrobial Treatment with Ceftolozane/Tazobactam in a Swine Model of Nosocomial Pneumonia. Antimicrob Agents Chemother 2021; 65:AAC.01899-20. [PMID: 33168605 DOI: 10.1128/aac.01899-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 11/20/2022] Open
Abstract
The rising frequency of multidrug-resistant and extensively drug-resistant (MDR/XDR) pathogens is making more frequent the inappropriate empirical antimicrobial therapy (IEAT) in nosocomial pneumonia, which is associated with increased mortality. We aim to determine the short-term benefits of appropriate empirical antimicrobial treatment (AEAT) with ceftolozane/tazobactam (C/T) compared with IEAT with piperacillin/tazobactam (TZP) in MDR Pseudomonas aeruginosa pneumonia. Twenty-one pigs with pneumonia caused by an XDR P. aeruginosa strain (susceptible to C/T but resistant to TZP) were ventilated for up to 72 h. Twenty-four hours after bacterial challenge, animals were randomized to receive 2-day treatment with either intravenous saline (untreated) or 25 to 50 mg of C/T per kg body weight (AEAT) or 200 to 225 mg of TZP per kg (IEAT) every 8 h. The primary outcome was the P. aeruginosa burden in lung tissue and the histopathology injury. P. aeruginosa burden in tracheal secretions and bronchoalveolar lavage (BAL) fluid, the development of antibiotic resistance, and inflammatory markers were secondary outcomes. Overall, P. aeruginosa lung burden was 5.30 (range, 4.00 to 6.30), 4.04 (3.64 to 4.51), and 4.04 (3.05 to 4.88) log10CFU/g in the untreated, AEAT, and IEAT groups, respectively (P = 0.299), without histopathological differences (P = 0.556). In contrast, in tracheal secretions (P < 0.001) and BAL fluid (P = 0.002), bactericidal efficacy was higher in the AEAT group. An increased MIC to TZP was found in 3 animals, while resistance to C/T did not develop. Interleukin-1β (IL-1β) was significantly downregulated by AEAT in comparison to other groups (P = 0.031). In a mechanically ventilated swine model of XDR P. aeruginosa pneumonia, appropriate initial treatment with C/T decreased respiratory secretions' bacterial burden, prevented development of resistance, achieved the pharmacodynamic target, and may have reduced systemic inflammation. However, after only 2 days of treatment, P. aeruginosa tissue concentrations were moderately affected.
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12
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Jovanovic B, Djuric O, Hadzibegovic A, Jovanovic S, Stanisavljevic J, Milenkovic M, Rajkovic M, Ratkovic S, Markovic-Denic L. Trauma and Antimicrobial Resistance Are Independent Predictors of Inadequate Empirical Antimicrobial Treatment of Ventilator-Associated Pneumonia in Critically Ill Patients. Surg Infect (Larchmt) 2021; 22:730-737. [PMID: 33439780 DOI: 10.1089/sur.2020.306] [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: 12/20/2022] Open
Abstract
Background: We aimed to assess independent risk factors for inadequate initial antimicrobial treatment (IAT) in critically ill patients with ventilator-associated pneumonia (VAP) treated in intensive care units (ICU) and to determine whether IAT is associated with adverse outcomes in patients with VAP. Patients and Methods: A prospective cohort study was performed and included 152 patients with VAP treated in an ICU for more than 48 hours. The main outcomes of interest were all-cause ICU mortality and VAP-related mortality. Other outcomes considered were: intra-hospital mortality, VAP-related sepsis, relapse, re-infection, length of stay in ICU (ICU LOS), and number of days on mechanical ventilation (MV). Results: One-third of patients (35.5%) received inadequate antimicrobial therapy. Trauma (odds ratio [OR], 3.55; 95% confidence interval [CI], 1.25-10.06) and extensively drug-resistant (XDR) causative agent (OR, 3.09; 95% CI, 1.23-7.74) were independently associated with inadequate IAT. Inadequate IAT was associated with a higher mortality rate (OR, 3.08; 95% CI, 1.30-7.26), VAP-related sepsis (OR, 2.39; 95% CI, 1.07-5.32), relapse (OR, 3.25; 95% CI, 1.34-7.89), re-infection (OR, 6.06; 95% CI, 2.48-14.77), and ICU LOS (β 4.65; 95% CI, 0.93-8.36). Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella/Enterobacter spp. were the most common bacteria in patients with IAT and those with adequate antimicrobial therapy. Conclusions: This study demonstrated that inadequate IAT is associated with a higher risk of the majority of adverse outcomes in patients with VAP treated in ICUs. Trauma and XDR strains of bacteria are independent predictors of inadequate IAT of VAP in critically ill patients.
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Affiliation(s)
- Bojan Jovanovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Olivera Djuric
- Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Center for Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Adi Hadzibegovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Snezana Jovanovic
- Department of Microbiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jovana Stanisavljevic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Milenkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Rajkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Sanja Ratkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Ljiljana Markovic-Denic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia
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13
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Performance and comparison of assessment models to predict 30-day mortality in patients with hospital-acquired pneumonia. Chin Med J (Engl) 2020; 133:2947-2952. [PMID: 33278090 PMCID: PMC7752693 DOI: 10.1097/cm9.0000000000001252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) is the most common hospital-acquired infection in China with substantial morbidity and mortality. But no specific risk assessment model has been well validated in patients with HAP. The aim of this study was to investigate the published risk assessment models that could potentially be used to predict 30-day mortality in HAP patients in non-surgical departments. METHODS This study was a single-center, retrospective study. In total, 223 patients diagnosed with HAP from 2012 to 2017 were included in this study. Clinical and laboratory data during the initial 24 hours after HAP diagnosis were collected to calculate the pneumonia severity index (PSI); consciousness, urea nitrogen, respiratory rate, blood pressure, and age ≥65 years (CURB-65); Acute Physiology and Chronic Health Evaluation II (APACHE II); Sequential Organ Failure Assessment (SOFA); and Quick Sequential Organ Failure Assessment (qSOFA) scores. The discriminatory power was tested by constructing receiver operating characteristic (ROC) curves, and the areas under the curve (AUCs) were calculated. RESULTS The all-cause 30-day mortality rate was 18.4% (41/223). The PSI, CURB-65, SOFA, APACHE II, and qSOFA scores were significantly higher in non-survivors than in survivors (all P < 0.001). The discriminatory abilities of the APACHE II and SOFA scores were better than those of the CURB-65 and qSOFA scores (ROC AUC: APACHE II vs. CURB-65, 0.863 vs. 0.744, Z = 3.055, P = 0.002; APACHE II vs. qSOFA, 0.863 vs. 0.767, Z = 3.017, P = 0.003; SOFA vs. CURB-65, 0.856 vs. 0.744, Z = 2.589, P = 0.010; SOFA vs. qSOFA, 0.856 vs. 0.767, Z = 2.170, P = 0.030). The cut-off values we defined for the SOFA, APACHE II, and qSOFA scores were 4, 14, and 1. CONCLUSIONS These results suggest that the APACHE II and SOFA scores determined during the initial 24 h after HAP diagnosis may be useful for the prediction of 30-day mortality in HAP patients in non-surgical departments. The qSOFA score may be a simple tool that can be used to quickly identify severe infections.
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14
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Leclerc QJ, Naylor NR, Aiken AM, Coll F, Knight GM. Feasibility of informing syndrome-level empiric antibiotic recommendations using publicly available antibiotic resistance datasets. Wellcome Open Res 2020; 4:140. [PMID: 32656364 PMCID: PMC7327722 DOI: 10.12688/wellcomeopenres.15477.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Antibiotics are often prescribed empirically to treat infection syndromes before causative bacteria and their susceptibility to antibiotics are identified. Guidelines on empiric antibiotic prescribing are key to effective treatment of infection syndromes, and need to be informed by likely bacterial aetiology and antibiotic resistance patterns. We aimed to create a clinically-relevant composite index of antibiotic resistance for common infection syndromes to inform recommendations at the national level. Methods: To create our index, we used open-access antimicrobial resistance (AMR) surveillance datasets, including the ECDC Surveillance Atlas, CDDEP ResistanceMap, WHO GLASS and the newly-available Pfizer ATLAS dataset. We integrated these with data on aetiology of common infection syndromes, existing empiric prescribing guidelines, and pricing and availability of antibiotics. Results: The ATLAS dataset covered many more bacterial species (287) and antibiotics (52) than other datasets (ranges = 8-11 and 16-32 respectively), but had a similar number of samples per country per year. Using these data, we were able to make empiric prescribing recommendations for bloodstream infection, pneumonia and cellulitis/skin abscess in up to 44 countries. There was insufficient data to make national-level recommendations for the other six syndromes investigated. Results are presented in an interactive web app, where users can visualise underlying resistance proportions to first-line empiric antibiotics for infection syndromes and countries of interest. Conclusions: We found that whilst the creation of a composite resistance index for empiric antibiotic therapy was technically feasible, the ATLAS dataset in its current form can only inform on a limited number of infection syndromes. Other open-access AMR surveillance datasets are largely limited to bloodstream infection specimens and cannot directly inform treatment of other syndromes. With improving availability of international AMR data and better understanding of infection aetiology, this approach may prove useful for informing empiric prescribing decisions in settings with limited local AMR surveillance data
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Affiliation(s)
- Quentin J Leclerc
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Centre for Mathematical Modelling of Infectious Diseases (CMMID), London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Nichola R Naylor
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Alexander M Aiken
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Francesc Coll
- Department of Infection Biology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Gwenan M Knight
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Centre for Mathematical Modelling of Infectious Diseases (CMMID), London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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15
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16
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Xue LY, Gaowa S, Wang W, Zhao F, Zhu HC, Yu XY, Gong Y. Ventilator-associated pneumonia in patients with cerebral hemorrhage: Impact on mortality and microbiological characterization. Med Clin (Barc) 2020; 154:400-405. [PMID: 32197859 DOI: 10.1016/j.medcli.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/24/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a major complication among critically ill patients who depend on mechanical ventilation. Few reports have focused on intracerebral hemorrhage patients with VAP. Our main objective was to investigate the bacteria distribution characteristics and the impact of ventilator-associated pneumonia mortality in critical cerebral hemorrhage patients. This retrospective study included 89 cases of cerebral hemorrhage patients with VAP admitted to the ICU of Huashan Hospital. We used the chi-square test to compare qualitative variables and Student's t-test to compare means between groups of normally distributed quantitative variables. Multiple logistic regression analysis was used to assess mortality-independent predictors in the ICU. A total of 42% patients with cerebral hemorrhage were diagnosed with VAP in the ICU during the study period, and the mortality rate was 18%. Acinetobacter baumannii (n=58), Klebsiella pneumoniae (n=52), and Pseudomonas aeruginosa (n=21) were the most common pathogenic bacteria. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were independent factors associated with increased mortality. Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the time from bleeding to intubation were other potentially important factors. While the number of infecting bacteria may not be directly related to death, it can increase antibiotic consumption and length of intensive care unit (ICU) stays. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were directly related to the death of critical cerebral hemorrhage patients with ventilator-associated pneumonia.
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Affiliation(s)
- Lu Yu Xue
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Saren Gaowa
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei Wang
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Zhao
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - He Chen Zhu
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao Yan Yu
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Ye Gong
- Department of Intensive Care Unit, Huashan Hospital, Fudan University, Shanghai, China.
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17
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Burillo A, de Egea V, Onori R, Martín-Rabadán P, Cercenado E, Jiménez-Navarro L, Muñoz P, Bouza E. Gradient diffusion antibiogram used directly on bronchial aspirates for a rapid diagnosis of ventilator-associated pneumonia. Antimicrob Resist Infect Control 2019; 8:176. [PMID: 31807286 PMCID: PMC6857332 DOI: 10.1186/s13756-019-0640-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background In patients with suspected ventilator-associated pneumonia, a rapid etiological diagnosis is crucial as incorrect or delayed treatment in the first few hours leads to a worse prognosis and a higher mortality rate. This study examines the efficacy of a rapid antibiogram on bronchial aspirates in patients with suspected ventilator-associated pneumonia (VAP). Methods The direct gradient diffusion susceptibility testing method (GDM) on respiratory samples was compared with a standard broth microdilution method (BMD) after quantitative cultures in patients with suspicion of VAP. Samples were preselected by Gram staining (for good quality microbiological samples with a predominant single bacterial morphotype). The antibiotics tested were ceftazidime, ceftobiprole, ceftolozane-tazobactam, meropenem, doripenem, and tedizolid. Results Over a 16-month study period, 445 bronchial aspirate samples were selected from 1376 samples received at our laboratory from 672 adult patients. By direct plating on Mueller-Hinton agar, we recovered 504 (95.5%) of the 528 microorganisms identified by the standard semiquantitative method. Antimicrobial susceptibility testing by GDM was compared with the BMD method in 472 strains (216 Enterobacteriaceae, 138 P. aeruginosa and 118 S. aureus.) and 1652 individual microorganism-antimicrobial agent combinations. There was total agreement between both methods in 98% of combinations. The Kappa index between both techniques was excellent (over 80%). There was only one potential major error for P. aeruginosa susceptibility to ceftazidime. Conclusions The six GDM strips directly placed on plated bronchial aspirates obtained from patients with a suspicion of VAP provided accurate and reliable susceptibility results within 24 h.
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Affiliation(s)
- Almudena Burillo
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Viviana de Egea
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Raffaella Onori
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Pablo Martín-Rabadán
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Emilia Cercenado
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Laura Jiménez-Navarro
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Patricia Muñoz
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Emilio Bouza
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
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Subramanian M, Hirschkorn C, Eyerly-Webb SA, Solomon RJ, Hodgman EI, Sanchez RE, Davare DL, Pigneri DA, Kiffin C, Rosenthal AA, Pedraza Taborda FE, Arenas JD, Hennessy SA, Minei JP, Minshall CT, Hranjec T. Clinical Diagnosis of Infection in Surgical Intensive Care Unit: You're Not as Good as You Think! Surg Infect (Larchmt) 2019; 21:122-129. [PMID: 31553271 DOI: 10.1089/sur.2019.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Because of the everincreasing costs and the complexity of institutional medical reimbursement policies, the necessity for extensive laboratory work-up of potentially infected patients has come into question. We hypothesized that intensivists are able to differentiate between infected and non-infected patients clinically, without the need to pan-culture, and are able to identify the location of the infection clinically in order to administer timely and appropriate treatment. Methods: Data collected prospectively on critically ill patients suspected of having an infection in the surgical intensive care unit (SICU) was obtained over a six-month period in a single tertiary academic medical center. Objective evidence of infection derived from laboratory or imaging data was compared with the subjective answers of the three most senior physicians' clinical diagnoses. Results: Thirty-nine critically ill surgical patients received 52 work-ups for suspected infections on the basis of signs and symptoms (e.g., fever, altered mental status). Thirty patients were found to be infected. Clinical diagnosis differentiated infected and non-infected patients with only 61.5% accuracy (sensitivity 60.3%; specificity 64.4%; p = 0.0049). Concordance between physicians was poor (κ = 0.33). Providers were able to predict the infectious source correctly only 60% of the time. Utilization of culture/objective data and SICU antibiotic protocols led to overall 78% appropriate initiation of antibiotics compared with 48% when treatment was based on clinical evaluation alone. Conclusion: Clinical diagnosis of infection is difficult, inaccurate, and unreliable in the absence of culture and sensitivity data. Infection suspected on the basis of signs and symptoms should be confirmed via objective and thorough work-up.
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Affiliation(s)
- Madhu Subramanian
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Trauma, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Carol Hirschkorn
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie A Eyerly-Webb
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Rachele J Solomon
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Erica I Hodgman
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Medicine, Pediatric Surgery, University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee
| | - Rafael E Sanchez
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Dafney L Davare
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Danielle A Pigneri
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Chauniqua Kiffin
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Andrew A Rosenthal
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Fernando E Pedraza Taborda
- Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Juan D Arenas
- Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Sara A Hennessy
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph P Minei
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian T Minshall
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tjasa Hranjec
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida.,Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
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19
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Leclerc QJ, Naylor NR, Aiken AM, Coll F, Knight GM. Feasibility of informing syndrome-level empiric antibiotic recommendations using publicly available antibiotic resistance datasets. Wellcome Open Res 2019; 4:140. [DOI: 10.12688/wellcomeopenres.15477.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Antibiotics are most often prescribed empirically, meaning that they are used to treat infection syndromes prior to identification of the causative bacteria and their susceptibility to antibiotics. The effectiveness of antibiotic therapies is now compromised by the emergence and spread of antibiotic-resistant bacteria. Guidelines on empiric antibiotic therapy are a key component of effective clinical care for infection syndromes, as treatment needs to be informed by knowledge of likely aetiology and bacterial resistance patterns. Methods: We used open-access antimicrobial resistance (AMR) surveillance datasets, including the newly available ATLAS dataset from Pfizer, to derive a composite index of antibiotic resistance for common infection syndromes. Results: We developed a framework that integrated data on antibiotic prescribing guidelines, aetiology of infections, access to and cost of antibiotics, with antibiotic susceptibilities from global AMR surveillance datasets to create an empirical prescribing index. The results are presented in an interactive web app to allow users to visualise underlying resistance rates to first-line empiric antibiotics for their infection syndromes and countries of interest. Conclusions: We found that whilst an index for empiric antibiotic therapy based on resistance data can technically be created, the ATLAS dataset in its current form can only inform on a limited number of infection syndromes. Other open-access AMR surveillance datasets (ECDC Surveillance Atlas, CDDEP ResistanceMap and WHO GLASS datasets) are largely limited to bacteraemia-derived specimens and cannot directly inform treatment of other infection syndromes. With improving data availability on international rates of AMR and better understanding of infection aetiology, our approach may prove useful for informing empiric prescribing decisions in settings with limited local AMR surveillance data. Syndrome-level resistance could be a more clinically relevant measure of resistance to inform on the appropriateness of empiric antibiotic therapies at the country-level.
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20
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Shi Y, Huang Y, Zhang TT, Cao B, Wang H, Zhuo C, Ye F, Su X, Fan H, Xu JF, Zhang J, Lai GX, She DY, Zhang XY, He B, He LX, Liu YN, Qu JM. Chinese guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition). J Thorac Dis 2019; 11:2581-2616. [PMID: 31372297 PMCID: PMC6626807 DOI: 10.21037/jtd.2019.06.09] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Shi
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Hui Wang
- Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Fu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Guo-Xiang Lai
- Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China
| | - Dan-Yang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Yan Zhang
- Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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21
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Roberts KL, Micek ST, Juang P, Kollef MH. Controversies and advances in the management of ventilator associated pneumonia. Expert Rev Respir Med 2017; 11:875-884. [PMID: 28891372 DOI: 10.1080/17476348.2017.1378574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although national surveillance data suggests that the incidence of ventilator associated pneumonia (VAP) is down-trending, it remains one of the most commonly encountered hospital acquired infections in the United States and worldwide. Its association with increased healthcare costs and worsened patient outcomes warrants continued effort to improve the care of patients with VAP. Areas covered: The increasing prevalence of multi-drug resistant bacteria further drives the need to explore advances in diagnostic and treatment options. In this review, controversies pertaining to the definition and diagnosis of VAP as well as empiric treatment strategies will be discussed along with several developments related to rapid microbiologic testing methods and the use of non-traditional antimicrobial agents. Expert commentary: The application of rapid diagnostic techniques to identify microbial pathogens is perhaps one of the most impactful advancements in the treatment of serious nosocomial infections. This technology has the potential to reduce inappropriate initial antimicrobial therapy, unnecessary antimicrobial exposure, and mortality in patients with VAP. In addition, the anticipated approval of new antimicrobial agents within the next several years will provide a much-needed expansion of available treatment options in an era of growing antimicrobial resistance.
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Affiliation(s)
| | - Scott T Micek
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Paul Juang
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Marin H Kollef
- c Division of Pulmonary and Critical Care Medicine , Washington University School of Medicine , St Louis , MO , USA
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22
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Schreiber MP, Shorr AF. Challenges and opportunities in the treatment of ventilator-associated pneumonia. Expert Rev Anti Infect Ther 2016; 15:23-32. [DOI: 10.1080/14787210.2017.1250625] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 PMCID: PMC4981759 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 1981] [Impact Index Per Article: 247.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C. Kalil
- Departmentof Internal Medicine, Division of Infectious Diseases,
University of Nebraska Medical Center,
Omaha
| | - Mark L. Metersky
- Division of Pulmonary and Critical Care Medicine,
University of Connecticut School of Medicine,
Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School
- Harvard Pilgrim Health Care Institute, Boston,
Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program,Queens University, Kingston, Ontario,
Canada
| | - Daniel A. Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine,
University of California, San
Diego
| | - Lucy B. Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep
Medicine, State University of New York at Stony
Brook
| | - Lena M. Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency
Surgery, University of Michigan, Ann
Arbor
| | - Naomi P. O'Grady
- Department of Critical Care Medicine, National
Institutes of Health, Bethesda
| | - John G. Bartlett
- Johns Hopkins University School of Medicine,
Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari
de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in
Infectious Diseases, University of Barcelona,
Spain
| | - Ali A. El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep
Medicine, University at Buffalo, Veterans Affairs Western New
York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious
Diseases, EVK Herne and Augusta-Kranken-Anstalt
Bochum, Germany
| | - Paul D. Fey
- Department of Pathology and Microbiology, University of
Nebraska Medical Center, Omaha
| | | | - Marcos I. Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care
Medicine, South Texas Veterans Health Care System and University
of Texas Health Science Center at San Antonio
| | - Jason A. Roberts
- Burns, Trauma and Critical Care Research Centre, The
University of Queensland
- Royal Brisbane and Women's Hospital,
Queensland
| | - Grant W. Waterer
- School of Medicine and Pharmacology, University of
Western Australia, Perth,
Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Shandra L. Knight
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Jan L. Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
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Souza-Oliveira AC, Cunha TM, Passos LBDS, Lopes GC, Gomes FA, Röder DVDDB. Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates. Braz J Infect Dis 2016; 20:437-43. [PMID: 27473893 PMCID: PMC9425467 DOI: 10.1016/j.bjid.2016.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 11/16/2022] Open
Abstract
Ventilator-associated pneumonia is the most prevalent nosocomial infection in intensive care units and is associated with high mortality rates (14–70%). Aim This study evaluated factors influencing mortality of patients with Ventilator-associated pneumonia (VAP), including bacterial resistance, prescription errors, and de-escalation of antibiotic therapy. Methods This retrospective study included 120 cases of Ventilator-associated pneumonia admitted to the adult adult intensive care unit of the Federal University of Uberlândia. The chi-square test was used to compare qualitative variables. Student's t-test was used for quantitative variables and multiple logistic regression analysis to identify independent predictors of mortality. Findings De-escalation of antibiotic therapy and resistant bacteria did not influence mortality. Mortality was 4 times and 3 times higher, respectively, in patients who received an inappropriate antibiotic loading dose and in patients whose antibiotic dose was not adjusted for renal function. Multiple logistic regression analysis revealed the incorrect adjustment for renal function was the only independent factor associated with increased mortality. Conclusion Prescription errors influenced mortality of patients with Ventilator-associated pneumonia, underscoring the challenge of proper Ventilator-associated pneumonia treatment, which requires continuous reevaluation to ensure that clinical response to therapy meets expectations.
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Affiliation(s)
- Ana Carolina Souza-Oliveira
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Programa de Pós Graduação em Ciências da Saúde, Uberlândia, MG, Brazil; Universidade Federal de Uberlândia (UFU), Hospital de Clínicas, Uberlândia, MG, Brazil.
| | - Thúlio Marquez Cunha
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Programa de Pós Graduação em Ciências da Saúde, Uberlândia, MG, Brazil; Universidade Federal de Uberlândia (UFU), Hospital de Clínicas, Uberlândia, MG, Brazil
| | | | - Gustavo Camargo Lopes
- Universidade Federal de Uberlândia (UFU), Hospital de Clínicas, Uberlândia, MG, Brazil
| | - Fabiola Alves Gomes
- Universidade Federal de Uberlândia (UFU), Hospital de Clínicas, Uberlândia, MG, Brazil
| | - Denise Von Dolinger de Brito Röder
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Programa de Pós Graduação em Ciências da Saúde, Uberlândia, MG, Brazil; Instituto de Ciências Biomédicas, Uberlândia, MG, Brazil
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25
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Park SY, Oh WS, Kim YS, Yeom JS, Choi HK, Kwak YG, Jun JB, Chung JW, Rhee JY, Kim BN. Health care–associated acute pyelonephritis is associated with inappropriate empiric antibiotic therapy in the ED. Am J Emerg Med 2016; 34:1415-20. [DOI: 10.1016/j.ajem.2016.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 11/16/2022] Open
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26
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Lacy MK, Stryjewski ME, Wang W, Hardin TC, Nogid B, Luke DR, Shorr AF, Corey GR, Barriere SL. Telavancin hospital-acquired pneumonia trials: impact of Gram-negative infections and inadequate Gram-negative coverage on clinical efficacy and all-cause mortality. Clin Infect Dis 2016; 61 Suppl 2:S87-93. [PMID: 26316562 DOI: 10.1093/cid/civ536] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND When hospital-acquired or ventilator-associated bacterial pneumonia (HABP/VABP) is caused by gram-positive and gram-negative pathogens or both (mixed infections), the adequacy of gram-negative coverage (GNC) can confound the assessment of a gram-positive agent under study. This analysis examines the influence of gram-negative infections and the adequacy of GNC on clinical efficacy and all-cause mortality in the telavancin HABP/VABP phase 3 ATTAIN trials (Assessment of Telavancin for Treatment of Hospital-Acquired Pneumonia). METHODS This post hoc analysis evaluated 3 patient groups from ATTAIN: (1) gram-positive-only infections, (2) gram-positive-only and mixed infections-adequate GNC, and (3) gram-negative-only infections and mixed infections with inadequate GNC. For each, clinical efficacy at test of cure and all-cause mortality at day 28 were compared for telavancin and vancomycin. RESULTS/CONCLUSIONS In the ATTAIN safety population there were 16 more deaths in the telavancin arms than in the vancomycin arms. Of these, 13 were in patients with gram-negative-only infections (n = 9) or with mixed infections and inadequate GNC (n = 4) and all had estimated baseline creatinine clearances of <30ml/min. Based on this analysis, clinical response and all-cause mortality could be confounded because there were more patients with gram-negative pathogens at baseline and more patients received inadequate treatment of these gram-negative infections in the telavancin groups.
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Affiliation(s)
- Melinda K Lacy
- Theravance Biopharma US, South San Francisco, California
| | - Martin E Stryjewski
- Department of Medicine, Section of Infectious Diseases, Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), Ciudad Autónoma de Buenos Aires, Argentina
| | - Whedy Wang
- Theravance Biopharma US, South San Francisco, California
| | | | - Boris Nogid
- Theravance Biopharma US, South San Francisco, California
| | - David R Luke
- Theravance Biopharma US, South San Francisco, California
| | - Andrew F Shorr
- Pulmonary and Critical Care Medicine, Washington Hospital Center, Washington D.C
| | - G Ralph Corey
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina
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Clinical predictors and microbiology of ventilator-associated pneumonia in the intensive care unit: a retrospective analysis in six Italian hospitals. Eur J Clin Microbiol Infect Dis 2016; 35:1531-9. [PMID: 27272120 DOI: 10.1007/s10096-016-2694-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/23/2016] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to assess the main clinical predictors and microbiological features of ventilator-associated pneumonia (VAP) in the Intensive Care Unit (ICU) environment. This work is a retrospective analysis over one year from September 2010 to September 2011. Patients' risk factors, causes of admission, comorbidities and respiratory specimens collected in six Italian ICUs were reviewed. Incidence and case fatality rate of VAP were evaluated. After stratification for VAP development, univariate and multivariate analyses were performed to assess the impact of patients' conditions on the onset of this infection. A total of 1,647 ICU patients (pts) were considered. Overall, 115 patients (6.9 %) experienced at least one episode of VAP. The incidence rate for VAP was 5.82/1,000 pts-days, with a case fatality rate of 44.3 %. Multivariate analysis showed that admission for neurological disorders (aIRR 4.12, CI 1.24-13.68, p = 0.02) and emergency referral to ICU from other hospitals (aIRR 2.11, CI 1.03-4.31, p = 0.04) were associated with higher risk of VAP, whereas a tendency to a higher risk of infection was detected for admission due to respiratory disease, cardiac disease, trauma and for having obesity or renal failure. A total of 372 microbiological isolates from respiratory specimens were collected in VAP patients. The most common species were Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa, showing high resistance rates to carbapenems. Neurological disorders and emergency referral at the admission into the ICU are significantly associated with the onset of VAP. A high incidence of multi-drug resistant Gram- species was detected in the respiratory specimens.
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Falcó V, Burgos J, Papiol E, Ferrer R, Almirante B. Investigational drugs in phase I and phase II clincial trials for the treatment of hospital-acquired pneumonia. Expert Opin Investig Drugs 2016; 25:653-65. [PMID: 26998623 DOI: 10.1517/13543784.2016.1168803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Hospital acquired pneumonia (HAP) is one of the main infections acquired by patients during a stay in hospital. The main issue when dealing with patients with HAP and ventilator associated pneumonia (VAP) is the increasing role of multi-drug resistant organisms (MDROs). AREAS COVERED In this review the authors summarize the actual situation of MDROs as a cause of HAP and VAP. They also review the current treatment options stated in the most important international guidelines. Finally, they focus on the investigational drugs that have reached the phase III stage of development and the novel compounds that are being studied in phase I and II clinical trials. EXPERT OPINION Thanks to their excellent activity against MDROs, drugs in development for the treatment of HAP and VAP can significantly improve the therapeutic options available. In selected patients, the possibility to administer directed therapy with monoclonal antibodies to specific pathogens is an exciting strategy in the fight against widespread resistance.
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Affiliation(s)
- Vicenç Falcó
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Joaquin Burgos
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Elisabeth Papiol
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Ricard Ferrer
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Benito Almirante
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
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29
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Ruppé E, Baud D, Schicklin S, Guigon G, Schrenzel J. Clinical metagenomics for the management of hospital- and healthcare-acquired pneumonia. Future Microbiol 2016; 11:427-39. [PMID: 26934540 DOI: 10.2217/fmb.15.144] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The increasing burden of multidrug-resistant bacteria affects the management of several infections. In order to prescribe adequate antibiotics, clinicians facing severe infections such as hospital-acquired pneumonia (HAP) need to promptly identify the pathogens and know their antibiotic susceptibility profiles (AST), which with conventional microbiology currently requires 24 and 48 h, respectively. Clinical metagenomics, based on whole genome sequencing of clinical samples, could improve the diagnosis of HAP, however, many obstacles remain to be overcome, namely the turn-around time, the quantification of pathogens, the choice of antibiotic resistance determinants (ARDs), the inference of the AST from metagenomic data and the linkage between ARDs and their host. Here, we propose to tackle those issues in a bottom-up, clinically driven approach.
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Affiliation(s)
- Etienne Ruppé
- Genomic Research Laboratory, Service of Infectious Diseases, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Damien Baud
- Genomic Research Laboratory, Service of Infectious Diseases, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Stéphane Schicklin
- Bioinformatics Research Department, bioMérieux, 69280 Marcy l'Etoile, France
| | - Ghislaine Guigon
- Bioinformatics Research Department, bioMérieux, 69280 Marcy l'Etoile, France
| | - Jacques Schrenzel
- Genomic Research Laboratory, Service of Infectious Diseases, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.,Bacteriology Lab, Service of Laboratory Medicine, Department of Genetics & Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland
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Pseudomonas aeruginosa nosocomial pneumonia: impact of pneumonia classification. Infect Control Hosp Epidemiol 2015; 36:1190-7. [PMID: 26190444 DOI: 10.1017/ice.2015.167] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe and compare the mortality associated with nosocomial pneumonia due to Pseudomonas aeruginosa (Pa-NP) according to pneumonia classification (community-onset pneumonia [COP], hospital-acquired pneumonia [(HAP], and ventilator-associated pneumonia [VAP]). DESIGN We conducted a retrospective cohort study of adults with Pa-NP. We compared mortality for Pa-NP among patients with COP, HAP, and VAP and used logistic regression to identify risk factors for hospital mortality and inappropriate initial antibiotic therapy (IIAT). SETTING Twelve acute care hospitals in 5 countries (United States, 3; France, 2; Germany, 2; Italy, 2; and Spain, 3). PATIENTS/PARTICIPANTS A total of 742 patients with Pa-NP. RESULTS Hospital mortality was greater for those with VAP (41.9%) and HAP (40.1%) compared with COP (24.5%) (P<.001). In multivariate analyses, independent predictors of hospital mortality differed by pneumonia classification (COP: need for mechanical ventilation and intensive care; HAP: multidrug-resistant isolate; VAP: IIAT, increasing age, increasing Charlson comorbidity score, bacteremia, and use of vasopressors). Presence of multidrug resistance was identified as an independent predictor of IIAT for patients with COP and HAP, whereas recent antibiotic administration was protective in patients with VAP. CONCLUSIONS Among patients with Pa-NP, pneumonia classification identified patients with different risks for hospital mortality. Specific risk factors for hospital mortality also differed by pneumonia classification and multidrug resistance appeared to be an important risk factor for IIAT. These findings suggest that pneumonia classification for P. aeruginosa identifies patients with different mortality risks and specific risk factors for outcome and IIAT.
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Inchai J, Pothirat C, Bumroongkit C, Limsukon A, Khositsakulchai W, Liwsrisakun C. Prognostic factors associated with mortality of drug-resistant Acinetobacter baumannii ventilator-associated pneumonia. J Intensive Care 2015; 3:9. [PMID: 27408726 PMCID: PMC4940762 DOI: 10.1186/s40560-015-0077-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/16/2015] [Indexed: 12/29/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) caused by drug-resistant Acinetobacter baumannii is associated with high mortality in critically ill patients. We identified the prognostic factors of 30-day mortality in patients with VAP caused by drug-resistant A. baumannii and compared survival outcomes among multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) A. baumannii VAP. Methods A retrospective cohort study was conducted in the Medical Intensive Care Unit at Chiang Mai University Hospital, Thailand. All adult patients diagnosed with A. baumannii VAP between 2005 and 2011 were eligible. Univariable and multivariable Cox’s proportional hazards regression were performed to identify the prognostic factors of 30-day mortality. Results A total of 337 patients with microbiologically confirmed A. baumannii VAP were included. The proportion of drug-sensitive (DS), MDR, XDR, and PDR A. baumannii were 9.8%, 21.4%, 65.3%, and 3.6%, respectively. The 30-day mortality rates were 21.2%, 31.9%, 56.8%, and 66.7%, respectively. The independent prognostic factors were SOFA score >5 (hazard ratio (HR) = 3.33, 95% confidence interval (CI) 1.94–5.72, P < 0.001), presence of septic shock (HR = 2.66, 95% CI 1.71–4.12, P < 0.001), Simplified Acute Physiology Score (SAPS) II >45 (HR = 1.58, 95% CI 1.01–2.46, P = 0.045), and inappropriate initial antibiotic treatment (HR = 1.53, 95% CI 1.08–2.20, P = 0.016). Conclusions Drug-resistant A. baumannii, particularly XDR and PDR, was associated with a high mortality rate. Septic shock, high SAPS II, high SOFA score, and inappropriate initial antibiotic treatment were independent prognostic factors for 30-day mortality.
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Affiliation(s)
- Juthamas Inchai
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Chaicharn Pothirat
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Chaiwat Bumroongkit
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Atikun Limsukon
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | | | - Chalerm Liwsrisakun
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
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Mishra SK, Shrestha R, Rijal BP, Pokhrel BM. The bad, the ugly and the demon: a tale of extensively drug-resistant, extended-spectrum-beta-lactamase- and metallo-beta-lactamase-producing superbugs associated with nosocomial pneumonia. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2015. [DOI: 10.1016/s2222-1808(14)60630-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nair GB, Niederman MS. Ventilator-associated pneumonia: present understanding and ongoing debates. Intensive Care Med 2015; 41:34-48. [PMID: 25427866 PMCID: PMC7095124 DOI: 10.1007/s00134-014-3564-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 11/11/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention. RESULTS Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a 'ventilator bundle' can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies. CONCLUSION The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.
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Affiliation(s)
- Girish B. Nair
- Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
| | - Michael S. Niederman
- Department of Medicine, Winthrop-University Hospital, 222 Station Plaza N., Suite 509, Mineola, NY 11501 USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
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Schulte B, Eickmeyer H, Heininger A, Juretzek S, Karrasch M, Denis O, Roisin S, Pletz MW, Klein M, Barth S, Lüdke GH, Thews A, Torres A, Cillóniz C, Straube E, Autenrieth IB, Keller PM. Detection of pneumonia associated pathogens using a prototype multiplexed pneumonia test in hospitalized patients with severe pneumonia. PLoS One 2014; 9:e110566. [PMID: 25397673 PMCID: PMC4232251 DOI: 10.1371/journal.pone.0110566] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 09/23/2014] [Indexed: 11/18/2022] Open
Abstract
Severe pneumonia remains an important cause of morbidity and mortality. Polymerase chain reaction (PCR) has been shown to be more sensitive than current standard microbiological methods – particularly in patients with prior antibiotic treatment – and therefore, may improve the accuracy of microbiological diagnosis for hospitalized patients with pneumonia. Conventional detection techniques and multiplex PCR for 14 typical bacterial pneumonia-associated pathogens were performed on respiratory samples collected from adult hospitalized patients enrolled in a prospective multi-center study. Patients were enrolled from March until September 2012. A total of 739 fresh, native samples were eligible for analysis, of which 75 were sputa, 421 aspirates, and 234 bronchial lavages. 276 pathogens were detected by microbiology for which a valid PCR result was generated (positive or negative detection result by Curetis prototype system). Among these, 120 were identified by the prototype assay, 50 pathogens were not detected. Overall performance of the prototype for pathogen identification was 70.6% sensitivity (95% confidence interval (CI) lower bound: 63.3%, upper bound: 76.9%) and 95.2% specificity (95% CI lower bound: 94.6%, upper bound: 95.7%). Based on the study results, device cut-off settings were adjusted for future series production. The overall performance with the settings of the CE series production devices was 78.7% sensitivity (95% CI lower bound: 72.1%) and 96.6% specificity (95% CI lower bound: 96.1%). Time to result was 5.2 hours (median) for the prototype test and 43.5 h for standard-of-care. The Pneumonia Application provides a rapid and moderately sensitive assay for the detection of pneumonia-causing pathogens with minimal hands-on time. Trial Registration Deutsches Register Klinischer Studien (DRKS) DRKS00005684
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Affiliation(s)
- Berit Schulte
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Holm Eickmeyer
- Heart and Diabetes Center North Rhine-Westphalia, Institute for Laboratory- and Transfusion Medicine, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
- Heart and Diabetes Center North Rhine-Westphalia, Clinic for Thoracic and Cardiovascular Surgery, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Alexandra Heininger
- German Centre for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
- Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
| | - Stephanie Juretzek
- University Hospital Jena, Institute of Medical Microbiology, Jena, Germany
| | - Matthias Karrasch
- University Hospital Jena, Institute of Medical Microbiology, Jena, Germany
| | - Olivier Denis
- Université Libre de Bruxelles, Laboratory of Microbiology, Bruxelles, Belgium
| | - Sandrine Roisin
- Université Libre de Bruxelles, Laboratory of Microbiology, Bruxelles, Belgium
| | - Mathias W. Pletz
- University Hospital Jena, Center for Infectious Diseases and Infection Control, and Center for Sepsis Care and Control, Jena, Germany
| | | | | | | | | | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Catia Cillóniz
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Eberhard Straube
- University Hospital Jena, Institute of Medical Microbiology, Jena, Germany
- University Hospital Jena, Center for Infectious Diseases and Infection Control, and Center for Sepsis Care and Control, Jena, Germany
| | - Ingo B. Autenrieth
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Peter M. Keller
- University Hospital Jena, Institute of Medical Microbiology, Jena, Germany
- University Hospital Jena, Center for Infectious Diseases and Infection Control, and Center for Sepsis Care and Control, Jena, Germany
- * E-mail:
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Charles MVP, Easow JM, Joseph NM, Ravishankar M, Kumar S, Umadevi S. Role of Appropriate Therapy in Combating Mortality among the Ventilated Patients. J Clin Diagn Res 2014; 8:DC01-3. [PMID: 25300335 DOI: 10.7860/jcdr/2014/7995.4666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 04/13/2014] [Indexed: 11/24/2022]
Abstract
CONTEXT Ventilator associated pneumonia (VAP) is a nosocomial infection prevalent among the intensive care unit (ICU) patients despite proper infection control practices. The diagnosis of VAP still remains controversial and hence the mortality rate is higher among this group of patients. AIM The aim of our study was to identify the antibiotic pattern and the appropriateness of treatment followed in the ICU in relation with the clinical pulmonary infection score (CPIS) as a tool to diagnose VAP. This was compared with patients who had an inappropriate treatment in comparison to the CPIS and the clinical outcome. RESULTS Out of the 18 VAP patients, 12 (66.7%) received appropriate therapy based on the antibiotic susceptibility pattern of the causative organism, while 1 (5.5%) received partially inappropriate therapy and 5 (27.8%) received totally inappropriate therapy. Nine of the 18 (50%) VAP patients died, while only 5 of the 58 (8.6%) patients without VAP died. 72.2% patients with VAP received appropriate treatment based on the sensitivity of the isolates. The mortality rate in VAP patients receiving inappropriate therapy was 80%, while in those receiving appropriate therapy the mortality rate was 38.5%. The mortality rate among VAP patients with blood culture positivity was 100%, while it was 43.75% among those with negative blood culture. CONCLUSION The mortality rate among the patients receiving inappropriate therapy is high compared to other group of patients. Hence, a proper evaluation and administration of appropriate antibiotics can curb mortality among the ventilated patients.
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Affiliation(s)
- M V Pravin Charles
- Assistant Professor, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - Joshy M Easow
- Professor, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - Noyal M Joseph
- Assistant Professor, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - M Ravishankar
- Professor Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - Shailesh Kumar
- Professor, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
| | - Sivaraman Umadevi
- Professor, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute , Pondicherry, India
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Piazza O, Wang X. A translational approach to ventilator associated pneumonia. Clin Transl Med 2014; 3:26. [PMID: 25097729 PMCID: PMC4118201 DOI: 10.1186/2001-1326-3-26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/14/2014] [Indexed: 01/22/2023] Open
Abstract
The management of Ventilator Associated Pneumonia (VAP) presents many difficulties because of the heterogeneity of the disease; the way the immunocompromised host and the aggressive ICU environment interact is only partially discovered, the available biomarkers for diagnosis are not sufficient to ensure prompt differentiation between sick patients and patients at risk, the microbiological cultures require invasive techniques and time consuming methods. A translational medicine and bio-informatics approach can enable the identification of the main players of pathology, which may represent novel therapeutic targets or biomarker candidates. Analysis of proteome i.e. allows to individuate proteins that act as biomarkers, for patient-centered research strategies. Similarly, the genomic approach has proved useful to individuate those patients who are prone to develop VAP, and, in the future, we could be able to immunomodulate their responses to save them from nosocomial infections.
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Affiliation(s)
| | - Xiangdong Wang
- Fudan University, Shanghai, China ; Zhongshan Hospital, Fudan University, Shanghai, China
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Randhawa V, Sarwar S, Walker S, Elligsen M, Palmay L, Daneman N. Weighted-incidence syndromic combination antibiograms to guide empiric treatment of critical care infections: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R112. [PMID: 24887215 PMCID: PMC4075242 DOI: 10.1186/cc13901] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/15/2014] [Indexed: 01/14/2023]
Abstract
Introduction Empiric antimicrobial selection for critical care infections must balance the need for timely adequate coverage with the resistance pressure exerted by broadspectrum agents. We estimated the potential of weighted incidence syndromic combination antibiograms (WISCAs) to improve time to adequate coverage for critical care infections. In contrast to traditional antibiograms, WISCAs display the likelihood of coverage for a specific infectious syndrome (rather than individual pathogens), and also take into account the potential for poly-microbial infections and the use of multi-drug regimens. Methods Cases of ventilator-associated pneumonia (VAP) and catheter-related bloodstream infection (CRBSI) were identified over three years using stringent surveillance criteria. Based on the susceptibility profile of the culprit pathogens, we calculated the WISCA percentages of infections that would have been adequately covered by common antimicrobial(s). We then computed the excess percentage coverage offered by WISCA regimens compared to the actual antimicrobials administered to patients by 12 h, 24 h, and 48 h from culture collection. Results Among 163 patients with critical care infection, standard practice only resulted in adequate coverage of 35% of patients by 12 h, 52% by 24 h, and 75% by 48 h. No WISCA mono-therapy regimen offered greater than 85% adequate overall coverage for VAP and CRBSI. A wide range of dual therapy regimens would have conferred greater than 90% adequate coverage, with excess coverage estimated to be as high as +56%, +42% and +18% at 12 h, 24 h and 48 h, respectively. We did not detect a decrease in mortality associated with early adequate treatment, and so could not estimate potential downstream benefits. Conclusions WISCA-derived empiric antimicrobial regimens can be calculated for patients with intensive care unit (ICU)-acquired infections, and have the potential to reduce time to adequate treatment. Prospective research must confirm whether implementation of WISCA prescribing aids facilitate timely adequate treatment and improved ICU outcomes.
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A rapid, real-time quantitative polymerase chain reaction test for the identification of pathogens in bronchoalveolar lavage samples. J Trauma Acute Care Surg 2014; 76:651-9; discussion 659-60. [PMID: 24553531 DOI: 10.1097/ta.0000000000000157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard bacteriologic culture techniques offer results within 2 days to 3 days, precluding a focused and timely antibiotic therapy in ventilated trauma patients. Our laboratory developed a real-time quantitative polymerase chain reaction (qPCR) test that can detect 25 different bacteria and fungi and methicillin resistance and offers results within 3 hours. The objective of this study was to compare the qPCR method to standard culture techniques. METHODS This was a prospective observational cohort study at a Level I trauma center from 2009 to 2012. Adult trauma patients on ventilation, receiving at least one bronchoalveolar lavage (BAL) with culture results were eligible for inclusion. DNA was isolated from the BAL samples and analyzed in 96-well plates using qPCR. Student's t tests were used to examine differences in mean qPCR cycle counts. Sensitivities, specificities, negative predictive values, and positive predictive values were calculated for the qPCR primer sets. RESULTS There were 28 BALs in the study. The qPCR method detected a total of 165 organisms, and culture methods found 54. The qPCR test had an overall sensitivity of 85%, specificity of 74%, negative predictive value of 98%, and positive predictive value of 27%. Those organisms that were only identified through qPCR had significantly less DNA than those identified through both qPCR and quantitative culture (28.8 vs. 23.3, p < 0.001). Concurrent antibiotic therapy was found to decrease the qPCR specificity in some primer sets, and methicillin resistance was only found in BAL samples that were concurrent with antibiotics. CONCLUSION The qPCR method shows promising initial diagnostic value. Many of the organisms not identified by quantitative culture had late cycle calls, suggesting that they might have been in quantities too low to result in culture identification. Once refined, our qPCR method has the potential to identify pathogens faster and earlier than standard quantitative culture methods, allowing for targeted antibiotic therapy within 3 hours. LEVEL OF EVIDENCE Diagnostic test, level II.
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Borgatta B, Rello J. How to approach and treat VAP in ICU patients. BMC Infect Dis 2014; 14:211. [PMID: 25430899 PMCID: PMC4304084 DOI: 10.1186/1471-2334-14-211] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/17/2014] [Indexed: 01/03/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is one of the most frequent clinical problems in ICU with an elevated morbidity and costs associated with it, in addition to prolonged MV, ICU-length of stay (LOS) and hospital-length of stay. Current challenges in VAP management include the absence of a diagnostic gold standard; the lack of evidence regarding contamination vs. airway colonization vs. infection; and the increasing antibiotic resistance. We performed a Pubmed search of articles addressing the management of ventilator-associated pneumonia (VAP). Immunocompromised patients, children and VAP due to multi-drug resistant pathogens were excluded from the analysis. When facing a patient with VAP, it’s important to address a few key questions for the patient’s optimal management: when should antibiotics be started?; what microorganisms should be covered?; is there risk for multirresistant microorganisms?; how to choose the initial agent?; how microbiological tests determine antibiotic changes?; and lastly, which dose and for how long?. It’s important not to delay adequate treatment, since outcomes improve when empirical treatment is early and effective. We recommend short course of broad-spectrum antibiotics, followed by de-escalation when susceptibilities are available. Individualization of treatment is the key to optimal management.
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Affiliation(s)
- Bárbara Borgatta
- Critical Care Department, Hospital Universitario Vall d'Hebron, Barcelona, Spain.
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Drusano GL, Liu W, Fikes S, Cirz R, Robbins N, Kurhanewicz S, Rodriquez J, Brown D, Baluya D, Louie A. Interaction of drug- and granulocyte-mediated killing of Pseudomonas aeruginosa in a murine pneumonia model. J Infect Dis 2014; 210:1319-24. [PMID: 24760199 DOI: 10.1093/infdis/jiu237] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Killing of bacterial pathogens by granulocytes is a saturable process, as previously demonstrated. There is virtually no quantitative information about how granulocytes interact with antimicrobial chemotherapy to kill bacterial cells. METHODS We performed a dose-ranging study with the aminoglycoside plazomicin against Pseudomonas aeruginosa ATCC27853 in a granulocyte-replete murine pneumonia model. Plazomicin was administered in a humanized fashion (ie, administration of decrementing doses 5 times over 24 hours, mimicking a human daily administration profile). Pharmacokinetic profiling was performed in plasma and epithelial lining fluid. All samples were simultaneously analyzed with a population model. Mouse cohorts were treated for 24 hours; other cohorts treated with the same therapy were observed for another 24 hours after therapy cessation, allowing delineation of the therapeutic effect necessary to reduce the bacterial burden to a level below the half-saturation point. RESULTS The mean bacterial burden (±SD) at which granulocyte-mediated kill was half saturable was 2.45 × 10(6) ± 6.84 × 10(5) colony-forming units of bacteria per gram of tissue (CFU/g). Higher levels of plazomicin exposure reduced the bacterial burden to <5 log10 CFU/g, allowing granulocytes to kill an additional 1.0-1.5 log CFU/g over the subsequent 24 hours. CONCLUSIONS For patients with large bacterial burdens (eg, individuals with ventilator-requiring hospital-acquired pneumonia), it is imperative to kill ≥2 log10 CFU/g early after treatment initiation, to allow the granulocytes to contribute optimally to bacterial clearance.
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Affiliation(s)
- George Louis Drusano
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Weiguo Liu
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Steven Fikes
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | | | - Nichole Robbins
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Stephanie Kurhanewicz
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Jaime Rodriquez
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - David Brown
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Dodge Baluya
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
| | - Arnold Louie
- Institute for Therapeutic Innovation, Department of Medicine, College of Medicine, University of Florida Research and Academic Center, Lake Nona
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Tuon FF, Rocha JL, Leite TM, Dias C. A simple mathematical model to determine the ideal empirical antibiotic therapy for bacteremic patients. Braz J Infect Dis 2014; 18:360-3. [PMID: 24594099 PMCID: PMC9427507 DOI: 10.1016/j.bjid.2013.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 10/30/2013] [Accepted: 11/06/2013] [Indexed: 11/26/2022] Open
Abstract
Background Local epidemiological data are always helpful when choosing the best antibiotic regimen, but it is more complex than it seems as it may require the analysis of multiple combinations. The aim of this study was to demonstrate a simplified mathematical calculation to determine the most appropriate antibiotic combination in a scenario where monotherapy is doomed to failure. Methods The susceptibility pattern of 11 antibiotics from 216 positive blood cultures from January 2012 to January 2013 was analyzed based on local policy. The length of hospitalization before bacteremia and the unit (ward or intensive care unit) were the analyzed variables. Bacteremia was classified as early, intermediate or late. The antibiotics were combined according to the combination model presented herein. Results A total of 55 possible mathematical associations were found combining 2 by 2, 165 associations with 3 by 3 and 330 combinations with 4 by 4. In the intensive care unit, monotherapy never reached 80% of susceptibility. In the ward, only carbapenems covered more than 90% of early bacteremia. Only three drugs combined reached a susceptibility rate higher than 90% anywhere in the hospital. Several regimens using four drugs combined reached 100% of susceptibility. Conclusions Association of three drugs is necessary for adequate coverage of empirical treatment of bacteremia in both the intensive care unit and the ward.
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Affiliation(s)
- Felipe F Tuon
- Division of Infectious Diseases, Universidade Federal do Paraná, Curitiba, PR, Brazil; Division of Infectious and Parasitic Diseases, Hospital Evangélico de Curitiba, Curitiba, PR, Brazil.
| | - Jaime L Rocha
- Division of Microbiology, Frischmann Aisengart/DASA Medicina Diagnóstica, Curitiba, PR, Brazil
| | - Talita M Leite
- Division of Infectious and Parasitic Diseases, Hospital Evangélico de Curitiba, Curitiba, PR, Brazil
| | - Camila Dias
- Division of Infectious and Parasitic Diseases, Hospital Evangélico de Curitiba, Curitiba, PR, Brazil
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Wilke M, Grube R. Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy. Infect Drug Resist 2013; 7:1-7. [PMID: 24379684 PMCID: PMC3872224 DOI: 10.2147/idr.s25985] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective Nosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT). Material and methods We conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined. Results All guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022). Conclusion We conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.
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Lin HL, Chao CM, Lai CC. The association between prior antibiotics and outcome. Am J Med 2013; 126:e35. [PMID: 24157303 DOI: 10.1016/j.amjmed.2013.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Hsin-Lan Lin
- Department of Nursing, Chi Mei Medical Center, Liouying, Tainan, Taiwan
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Abstract
PURPOSE OF REVIEW Pneumonia continues to be a common reason for, or complication of, ICU admission. Associated morbidity and mortality remain high, with an increasing incidence of multidrug-resistant organisms. Appropriate antibiotic therapy, both in terms of spectrum of cover and dose, remains the cornerstone of effective management. RECENT FINDINGS Critically ill patients will frequently manifest significantly altered end-organ function, as compared with an ambulatory or ward-based setting. Such changes can have profound effects on antibiotic drug handling, promoting subtherapeutic concentrations, treatment failure or the selection of resistant organisms. Standard antibiotic regimens typically fail to consider such issues, with recent literature highlighting the need for improved dosing to achieve sufficient intrapulmonary concentrations, particularly in the setting of augmented elimination. Although recent clinical trials utilizing strategies that optimize drug exposure (either through the use of agents with improved penetration, or continuous infusions) demonstrate superior surrogate outcomes, a mortality benefit is still uncertain. SUMMARY Antibiotic dosing strategies that are adapted to a critical care environment are urgently needed, both to improve clinical outcomes and ensure therapeutic longevity. Similarly, study protocols investigating emerging antibiotics must also be designed accordingly, to prevent potential setbacks in drug availability.
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Empirical Antibiotic Therapy for Ventilator-Associated Pneumonia. Antibiotics (Basel) 2013; 2:339-51. [PMID: 27029307 PMCID: PMC4790268 DOI: 10.3390/antibiotics2030339] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/15/2013] [Accepted: 06/18/2013] [Indexed: 12/29/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common infectious complication in the intensive care unit. It can increase duration of mechanical ventilation, length of stay, costs, and mortality. Improvements in the administration of empirical antibiotic therapy have potential to reduce the complications of VAP. This review will discuss the current data addressing empirical antibiotic therapy and the effect on mortality in patients with VAP. It will also address factors that could improve the administration of empirical antibiotics and directions for future research.
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Bercault N. Pneumonie acquise sous ventilation mécanique et mortalité : réelle implication ou simple association ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0672-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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