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Fally M, Haseeb F, Kouta A, Hansel J, Robey RC, Williams T, Welte T, Felton T, Mathioudakis AG. Unravelling the complexity of ventilator-associated pneumonia: a systematic methodological literature review of diagnostic criteria and definitions used in clinical research. Crit Care 2024; 28:214. [PMID: 38956655 PMCID: PMC11221085 DOI: 10.1186/s13054-024-04991-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a prevalent and grave hospital-acquired infection that affects mechanically ventilated patients. Diverse diagnostic criteria can significantly affect VAP research by complicating the identification and management of the condition, which may also impact clinical management. OBJECTIVES We conducted this review to assess the diagnostic criteria and the definitions of the term "ventilator-associated" used in randomised controlled trials (RCTs) of VAP management. SEARCH METHODS Based on the protocol (PROSPERO 2019 CRD42019147411), we conducted a systematic search on MEDLINE/PubMed and Cochrane CENTRAL for RCTs, published or registered between 2010 and 2024. SELECTION CRITERIA We included completed and ongoing RCTs that assessed pharmacological or non-pharmacological interventions in adults with VAP. DATA COLLECTION AND SYNTHESIS Data were collected using a tested extraction sheet, as endorsed by the Cochrane Collaboration. After cross-checking, data were summarised in a narrative and tabular form. RESULTS In total, 7,173 records were identified through the literature search. Following the exclusion of records that did not meet the eligibility criteria, 119 studies were included. Diagnostic criteria were provided in 51.2% of studies, and the term "ventilator-associated" was defined in 52.1% of studies. The most frequently included diagnostic criteria were pulmonary infiltrates (96.7%), fever (86.9%), hypothermia (49.1%), sputum (70.5%), and hypoxia (32.8%). The different criteria were used in 38 combinations across studies. The term "ventilator-associated" was defined in nine different ways. CONCLUSIONS When provided, diagnostic criteria and definitions of VAP in RCTs display notable variability. Continuous efforts to harmonise VAP diagnostic criteria in future clinical trials are crucial to improve quality of care, enable accurate epidemiological assessments, and guide effective antimicrobial stewardship.
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Affiliation(s)
- Markus Fally
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.
| | - Faiuna Haseeb
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Ahmed Kouta
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Jan Hansel
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- North West School of Intensive Care Medicine, Health Education England North West, Manchester, UK
| | - Rebecca C Robey
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Thomas Williams
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Timothy Felton
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alexander G Mathioudakis
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
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Moore LSP, Baltas I, Amos J, Cooray M, Hughes S, Freeman R, Ashfield T. Antimicrobial stewardship markers and healthcare-associated pneumonia threshold criteria in UK hospitals: analysis of the MicroGuide Tm application. JAC Antimicrob Resist 2024; 6:dlae058. [PMID: 38633221 PMCID: PMC11022069 DOI: 10.1093/jacamr/dlae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Background To address antimicrobial resistance, antimicrobial stewardship (AMS) principles must be implemented and adhered to. Clinical decision aids such as the MicroGuideTM app are an important part of these efforts. We sought to evaluate the consistency of core AMS information and the diversity of classification thresholds for healthcare-associated pneumonia (HAP) in the MicroGuide app. Methods Guidelines in the MicroGuide app were extracted and analysed for content related to AMS and HAP. Guidelines were characterized according to HAP naming classification; community-acquired pneumonia (CAP) classifications were analysed to serve as a comparator group. Results In total, 115 trusts (119 hospitals) were included. Nearly all hospitals had developed MicroGuide sections on AMS (n = 112/119, 94%) and sepsis management (n = 117/119, 98%). Other AMS sections were outpatient parenteral antimicrobial therapy (47%), antifungal stewardship (70%), critical care (23%) and IV to oral switch therapy (83%). Only 9% of hospitals included guidance on the maximum six key AMS sections identified. HAP definitions varied widely across hospitals with some classifying by time to onset and some classifying by severity or complexity. The largest proportion of HAP guidelines based classification on severity/complexity (n = 69/119, 58%). By contrast, definitions in CAP guidelines were uniform. Conclusions The high heterogeneity in HAP classification identified suggests inconsistency of practice in identifying thresholds for HAP in the UK. This complicates HAP management and AMS practices. To address HAP in alignment with AMS principles, a comprehensive strategy that prioritizes uniform clinical definitions and thresholds should be developed.
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Affiliation(s)
- Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Ioannis Baltas
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, UK
- Department of Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Stephen Hughes
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Hammoudi Halat D, Ayoub Moubareck C. Hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative pathogens: Understanding epidemiology, resistance patterns, and implications with COVID-19. F1000Res 2024; 12:92. [PMID: 38915769 PMCID: PMC11195619 DOI: 10.12688/f1000research.129080.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 06/26/2024] Open
Abstract
The ongoing spread of antimicrobial resistance has complicated the treatment of bacterial hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Gram-negative pathogens, especially those with multidrug-resistant profiles, including Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter spp., are important culprits in this type of infections. Understanding the determinants of resistance in pathogens causing pneumonia is ultimately stressing, especially in the shadows of the COVID-19 pandemic, when bacterial lung infections are considered a top priority that has become urgent to revise. Globally, the increasing prevalence of these pathogens in respiratory samples represents a significant infection challenge, with major limitations of treatment options and poor clinical outcomes. This review will focus on the epidemiology of HAP and VAP and will present the roles and the antimicrobial resistance patterns of implicated multidrug-resistant (MDR) Gram-negative pathogens like carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Enterobacterales (CRE), as well as colistin-resistant Gram-negative pathogens and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales. While emerging from the COVID-19 pandemic, perspectives and conclusions are drawn from findings of HAP and VAP caused by MDR Gram-negative bacteria in patients with COVID-19.
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Mathioudakis AG, Fally M, Hansel J, Robey RC, Haseeb F, Williams T, Kouta A, Welte T, Wootton DG, Clarke M, Waterer G, Dark P, Williamson PR, Vestbo J, Felton TW. Clinical trials of pneumonia management assess heterogeneous outcomes and measurement instruments. J Clin Epidemiol 2023; 164:88-95. [PMID: 37898460 DOI: 10.1016/j.jclinepi.2023.10.011] [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: 05/30/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVES To inform clinical practice guidelines, randomized controlled trials (RCTs) of the management of pneumonia need to address the outcomes that are most important to patients and health professionals using consistent instruments, to enable results to be compared, contrasted, and combined as appropriate. This systematic review describes the outcomes reported in clinical trials of pneumonia management and the instruments used to measure these outcomes. STUDY DESIGN AND SETTING Based on a prospective protocol, we searched MEDLINE/PubMed, Cochrane CENTRAL and clinical trial registries for ongoing or completed clinical trials evaluating pneumonia management in adults in any clinical setting. We grouped reported outcomes thematically and classified them following the COMET Initiative's taxonomy. We describe instruments used for assessing each outcome. RESULTS We found 280 eligible RCTs of which 115 (41.1%) enrolled critically ill patients and 165 (58.9%) predominantly noncritically ill patients. We identified 43 distinct outcomes and 108 measurement instruments, excluding nonvalidated scores and questionnaires. Almost all trials reported clinical/physiological outcomes (97.5%). Safety (63.2%), mortality (56.4%), resource use (48.6%) and life impact (11.8%) outcomes were less frequently addressed. The most frequently reported outcomes were treatment success (60.7%), mortality (56.4%) and adverse events (41.1%). There was significant variation in the selection of measurement instruments, with approximately two-thirds used in less than 10 of the 280 RCTs. None of the patient-reported outcomes were used in 10 or more RCTs. CONCLUSION This review reveals significant variation in outcomes and measurement instruments reported in clinical trials of pneumonia management. Outcomes that are important to patients and health professionals are often omitted. Our findings support the need for a rigorous core outcome set, such as that being developed by the European Respiratory Society.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Markus Fally
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jan Hansel
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; North West School of Intensive Care Medicine, Health Education England North West, Manchester, UK
| | - Rebecca C Robey
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Faiuna Haseeb
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Thomas Williams
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ahmed Kouta
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
| | - Dan G Wootton
- Institute of Infection, Veterinary and Ecological Sciences, NIHR HPRU in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
| | - Mike Clarke
- Centre of Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Grant Waterer
- School of Medicine and Pharmacology, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Paula R Williamson
- Department of Health Data Science, MRC/NIHR Trials Methodology Research Partnership, University of Liverpool, Liverpool, UK
| | - Jørgen Vestbo
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Timothy W Felton
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK; North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Stepanenko E, Bondareva N, Sheremet A, Fedina E, Tikhomirov A, Gerasimova T, Poberezhniy D, Makarova I, Tarantul V, Zigangirova N, Nenasheva V. Identification of Key TRIM Genes Involved in Response to Pseudomonas aeruginosa or Chlamydia spp. Infections in Human Cell Lines and in Mouse Organs. Int J Mol Sci 2023; 24:13290. [PMID: 37686095 PMCID: PMC10487655 DOI: 10.3390/ijms241713290] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Bacterial infections represent an unsolved problem today since bacteria can evade antibiotics and suppress the host's immune response. A family of TRIM proteins is known to play a role in antiviral defense. However, the data on the involvement of the corresponding genes in the antibacterial response are limited. Here, we used RT-qPCR to profile the transcript levels of TRIM genes, as well as interferons and inflammatory genes, in human cell lines (in vitro) and in mice (in vivo) after bacterial infections caused by Pseudomonas aeruginosa and Chlamydia spp. As a result, the genes were identified that are involved in the overall immune response and associated primarily with inflammation in human cells and in mouse organs when infected with both pathogens (TRIM7, 8, 14, 16, 17, 18, 19, 20, 21, 47, 68). TRIMs specific to the infection (TRIM59 for P. aeruginosa, TRIM67 for Chlamydia spp.) were revealed. Our findings can serve as a basis for further, more detailed studies on the mechanisms of the immune response to P. aeruginosa and Chlamydia spp. Studying the interaction between bacterial pathogens and the immune system contributes to the search for new ways to successfully fight bacterial infections.
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Affiliation(s)
- Ekaterina Stepanenko
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
| | - Natalia Bondareva
- Laboratory for Chlamydiosis, National Research Center for Epidemiology and Microbiology Named after N. F. Gamaleya, Russian Health Ministry, Moscow 123098, Russia
| | - Anna Sheremet
- Laboratory for Chlamydiosis, National Research Center for Epidemiology and Microbiology Named after N. F. Gamaleya, Russian Health Ministry, Moscow 123098, Russia
| | - Elena Fedina
- Laboratory for Chlamydiosis, National Research Center for Epidemiology and Microbiology Named after N. F. Gamaleya, Russian Health Ministry, Moscow 123098, Russia
| | - Alexei Tikhomirov
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
- Department of Chemistry and Technology of Biomedical Pharmaceuticals, D. Mendeleev University of Chemical Technology of Russia, Moscow 125047, Russia
| | - Tatiana Gerasimova
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
| | - Daniil Poberezhniy
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
| | - Irina Makarova
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
| | - Vyacheslav Tarantul
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
| | - Nailya Zigangirova
- Laboratory for Chlamydiosis, National Research Center for Epidemiology and Microbiology Named after N. F. Gamaleya, Russian Health Ministry, Moscow 123098, Russia
| | - Valentina Nenasheva
- Laboratory of Molecular Neurogenetics and Innate Immunity, National Research Centre “Kurchatov Institute”, Moscow 123182, Russia; (E.S.)
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Pickens CI, Gao CA, Bodner J, Walter JM, Kruser JM, Donnelly HK, Donayre A, Clepp K, Borkowski N, Wunderink RG, Singer BD. An Adjudication Protocol for Severe Pneumonia. Open Forum Infect Dis 2023; 10:ofad336. [PMID: 37520413 PMCID: PMC10372865 DOI: 10.1093/ofid/ofad336] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Background Clinical end points that constitute successful treatment in severe pneumonia are difficult to ascertain and vulnerable to bias. The utility of a protocolized adjudication procedure to determine meaningful end points in severe pneumonia has not been well described. Methods This was a single-center prospective cohort study of patients with severe pneumonia admitted to the medical intensive care unit. The objective was to develop an adjudication protocol for severe bacterial and/or viral pneumonia. Each episode of pneumonia was independently reviewed by 2 pulmonary and critical care physicians. If a discrepancy occurred between the 2 adjudicators, a third adjudicator reviewed the case. If a discrepancy remained after all 3 adjudications, consensus was achieved through committee review. Results Evaluation of 784 pneumonia episodes during 593 hospitalizations achieved only 48.1% interobserver agreement between the first 2 adjudicators and 78.8% when agreement was defined as concordance between 2 of 3 adjudicators. Multiple episodes of pneumonia and presence of bacterial/viral coinfection in the initial pneumonia episode were associated with lower interobserver agreement. For an initial episode of bacterial pneumonia, patients with an adjudicated day 7-8 clinical impression of cure (compared with alternative impressions) were more likely to be discharged alive (odds ratio, 6.3; 95% CI, 3.5-11.6). Conclusions A comprehensive adjudication protocol to identify clinical end points in severe pneumonia resulted in only moderate interobserver agreement. An adjudicated end point of clinical cure by day 7-8 was associated with more favorable hospital discharge dispositions, suggesting that clinical cure by day 7-8 may be a valid end point to use in adjudication protocols.
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Affiliation(s)
- Chiagozie I Pickens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Catherine A Gao
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Justin Bodner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James M Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacqueline M Kruser
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Helen K Donnelly
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alvaro Donayre
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Katie Clepp
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nicole Borkowski
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Benjamin D Singer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Ventilator-Associated Pneumonia in COVID-19 Patients Admitted in Intensive Care Units: Relapse, Therapeutic Failure and Attributable Mortality-A Multicentric Observational Study from the OutcomeRea Network. J Clin Med 2023; 12:jcm12041298. [PMID: 36835834 PMCID: PMC9961155 DOI: 10.3390/jcm12041298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/24/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction: Ventilator-associated pneumonia (VAP) incidence is high among critically ill COVID-19 patients. Its attributable mortality remains underestimated, especially for unresolved episodes. Indeed, the impact of therapeutic failures and the determinants that potentially affect mortality are poorly evaluated. We assessed the prognosis of VAP in severe COVID-19 cases and the impact of relapse, superinfection, and treatment failure on 60-day mortality. Methods: We evaluated the incidence of VAP in a multicenter prospective cohort that included adult patients with severe COVID-19, who required mechanical ventilation for ≥48 h between March 2020 and June 2021. We investigated the risk factors for 30-day and 60-day mortality, and the factors associated with relapse, superinfection, and treatment failure. Results: Among 1424 patients admitted to eleven centers, 540 were invasively ventilated for 48 h or more, and 231 had VAP episodes, which were caused by Enterobacterales (49.8%), P. aeruginosa (24.8%), and S. aureus (22%). The VAP incidence rate was 45.6/1000 ventilator days, and the cumulative incidence at Day 30 was 60%. VAP increased the duration of mechanical ventilation without modifying the crude 60-day death rate (47.6% vs. 44.7% without VAP) and resulted in a 36% increase in death hazard. Late-onset pneumonia represented 179 episodes (78.2%) and was responsible for a 56% increase in death hazard. The cumulative incidence rates of relapse and superinfection were 45% and 39.5%, respectively, but did not impact death hazard. Superinfection was more frequently related to ECMO and first episode of VAP caused by non-fermenting bacteria. The risk factors for treatment failure were an absence of highly susceptible microorganisms and vasopressor need at VAP onset. Conclusions: The incidence of VAP, mainly late-onset episodes, is high in COVID-19 patients and associated with an increased risk of death, similar to that observed in other mechanically ventilated patients. The high rate of VAP due to difficult-to-treat microorganisms, pharmacokinetic alterations induced by renal replacement therapy, shock, and ECMO likely explains the high cumulative risk of relapse, superinfection, and treatment failure.
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Taushiba A, Dwivedi S, Zehra F, Shukla PN, Lawrence AJ. Assessment of indoor air quality and their inter-association in hospitals of northern India-a cross-sectional study. AIR QUALITY, ATMOSPHERE, & HEALTH 2023; 16:1023-1036. [PMID: 37213469 PMCID: PMC9985081 DOI: 10.1007/s11869-023-01321-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 02/01/2023] [Indexed: 05/23/2023]
Abstract
This study was commenced to evaluate the indoor and outdoor air quality concentrations of PM2.5, sub-micron particles (PM>2.5, PM1.0-2.5, PM0.50 -1.0, PM0.25-0.50, and PM<0.25), heavy metals, and microbial contaminants along with their identification in three different hospitals of Lucknow City. The study was conducted from February 2022 to April 2022 in hospitals situated in the commercial, residential, and industrial belts of the city. The indoor concentration trend of particulate matter as observed during the study suggested that most of the highest concentrations belonged to the hospital situated in an industrial area. The highest obtained indoor and outdoor concentrations for PM1.0-2.5, PM0.50-1.0, PM0.25-0.50, and PM<0.25 are 40.44 µg/m3, 56.08 µg/m3, 67.20 µg/m3, 74.50 µg/m3, 61.9 µg/m3, 79.3 µg/m3, 82.0 µg/m3, and 93.9 µg/m3, respectively, which belonged to hospital C situated in the industrial belt. However, for PM>2.5, the highest indoor concentration obtained belonged to hospital B, i.e., 30.7 µg/m3, which is situated in the residential belt of the city. Regarding PM2.5, the highest indoor and outdoor concentrations obtained are 149.41 µg/m3 and 227.45 µg/m3, which were recorded at hospital A and hospital C, respectively. The present study also observed that a high bacterial load of 1389.21 CFU/m3 is recorded in hospital B, and the fungi load was highest in hospital C with 786.34 CFU/m3. Henceforth, the present study offers thorough information on the various air pollutants in a crucial indoor setting, which will further aid the researchers in the field to identify and mitigate the same more precisely.
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Affiliation(s)
- Anam Taushiba
- Department of Chemistry, Isabella Thoburn College, Lucknow, India
- Department of Environmental Science, Integral University, Lucknow, India
| | - Samridhi Dwivedi
- Department of Chemistry, Isabella Thoburn College, Lucknow, India
| | - Farheen Zehra
- Department of Chemistry, Isabella Thoburn College, Lucknow, India
| | - Pashupati Nath Shukla
- Department of Pharmacology & Microbial Technology, National Botanical Research Institute, Lucknow, India
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9
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Palmer LB, Smaldone GC. The Unfulfilled Promise of Inhaled Therapy in Ventilator-Associated Infections: Where Do We Go from Here? J Aerosol Med Pulm Drug Deliv 2022; 35:11-24. [PMID: 35099284 PMCID: PMC8867107 DOI: 10.1089/jamp.2021.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Respiratory infection is common in intubated/tracheotomized patients and systemic antibiotic therapy is often unrewarding. In 1967, the difficulty in treating Gram-negative respiratory infections led to the use of inhaled gentamicin, targeting therapy directly to the lungs. Fifty-three years later, the effects of topical therapy in the intubated patient remain undefined. Clinical failures with intravenous antibiotics persist and instrumented patients are now infected by many more multidrug-resistant Gram-negative species as well as methicillin-resistant Staphylococcus aureus. Multiple systematic reviews and meta-analyses suggest that there may be a role for inhaled delivery but “more research is needed.” Yet there is still no Food and Drug Administration (FDA) approved inhaled antibiotic for the treatment of ventilator-associated infection, the hallmark of which is the foreign body in the upper airway. Current pulmonary and infectious disease guidelines suggest using aerosols only in the setting of Gram-negative infections that are resistant to all systemic antibiotics or not to use them at all. Recently two seemingly well-designed large randomized placebo-controlled Phase 2 and Phase 3 clinical trials of adjunctive inhaled therapy for the treatment of ventilator-associated pneumonia failed to show more rapid resolution of pneumonia symptoms or effect on mortality. Despite evolving technology of delivery devices and more detailed understanding of the factors affecting delivery, treatment effects were no better than placebo. What is wrong with our approach to ventilator- associated infection? Is there a message from the large meta-analyses and these two large recent multisite trials? This review will suggest why current therapies are unpredictable and have not fulfilled the promise of better outcomes. Data suggest that future studies of inhaled therapy, in the milieu of worsening bacterial resistance, require new approaches with completely different indications and endpoints to determine whether inhaled therapy indeed has an important role in the treatment of ventilated patients.
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Affiliation(s)
- Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Gerald C Smaldone
- Pulmonary, Critical Care and Sleep Division, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
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Wicky PH, Martin-Loeches I, Timsit JF. "HAP and VAP after Guidelines". Semin Respir Crit Care Med 2022; 43:248-254. [PMID: 35042265 DOI: 10.1055/s-0041-1740246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.
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Affiliation(s)
- Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.,UMR 1137, IAME, Université Paris Diderot, Paris, France
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11
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Jung EH, Yang JH, Mun SJ, Han SY. Detection of nosocomial pneumonia pathogens using a fluorescence-based device. Photodiagnosis Photodyn Ther 2021; 37:102621. [PMID: 34749000 DOI: 10.1016/j.pdpdt.2021.102621] [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: 06/12/2021] [Revised: 10/13/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early detection of nosocomial pneumonia pathogens is a significant factor in hospital-acquired pneumonia care. This study aimed to determine the autofluorescence properties of five nosocomial pneumonia pathogens using a fluorescence-based device and to establish evidence for clinical guidelines. METHODS The following bacterial strains were assessed: Acinetobacter baumannii (AB), Escherichia coli (EC), Enterococcus faecalis (EF), Klebsiella pneumoniae (KP), and Staphylococcus aureus (SA). The bacteria were cultured separately on tryptic soy agar at 37°C under aerobic conditions for 168 h. Fluorescence photographs of each species were captured every 24 h using a fluorescence-based device with fixed camera settings. The images were analyzed by measuring the red and green values (R/G ratio) at a central point in each colony, and the R/G ratios were analyzed using the Kruskal-Wallis non-parametric test. RESULTS KP and SA showed red fluorescence with their R/G values, which were significantly higher than those of the other strains (p < 0.001). In particular, the R/G ratio of KP increased steadily until 72 h of incubation, peaking at 3.65. In addition, AB and EC showed orange fluorescence with higher red ratios than green ratios. EF and SA showed green fluorescence all through 168 h of incubation, with R/G values less than 1.0. CONCLUSIONS Nosocomial pneumonia pathogens can be identified and classified via bacterial autofluorescence emission. It is possible to develop a rapid and easy-to-use identification technology based on bacterial autofluorescence for clinical applications.
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Affiliation(s)
- Eun-Ha Jung
- Department of Dental Hygiene, Yonsei University, 1, Yonseidae-gil, Wonju, Gangwon-do, 26493, Korea
| | - Ji-Hye Yang
- Department of Dental Hygiene, Yonsei University, 1, Yonseidae-gil, Wonju, Gangwon-do, 26493, Korea
| | - So-Jung Mun
- Department of Dental Hygiene, Yonsei University, 1, Yonseidae-gil, Wonju, Gangwon-do, 26493, Korea; HaimBio Co., Ltd., 703-2, TechnoComplex Building, 145, Anam-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Sun-Young Han
- Department of Dental Hygiene, Yonsei University, 1, Yonseidae-gil, Wonju, Gangwon-do, 26493, Korea.
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12
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Monajati M, Ala S, Aliyali M, Ghasemian R, Heidari F, Ahanjan M, Moradi S, Sharifpour A, Mojtahedzadeh M, Salehifar E. Clinical Effectiveness of a High Dose Versus the Standard Dose of Meropenem in Ventilator-associated Pneumonia Caused by Multidrugresistant Bacteria: A Randomized, Single-blind Clinical Trial. Infect Disord Drug Targets 2021; 21:274-283. [PMID: 32106807 DOI: 10.2174/1871526520666200227102013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/01/2020] [Accepted: 02/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Meropenem standard doses are based on the minimum inhibitory concentration of sensitive pathogens and the pharmacokinetic parameter of not critically ill patients. We compared the efficacy of high versus standard dose of meropenem in ventilator-associated pneumonia (VAP). ; Methods: 24 out of 34 eligible patients were randomized to receive meropenem 3 g q8h (high dose group, 11 patients) or 2 g q8h (standard-dose group, 13 patients) as a 3h infusion. The primary outcome was considered as clinical success that was defined as stable hemodynamic, improved sequential organ failure assessment (SOFA) score, stable or improved PaO2/FiO2 after 7 days. Sputum culture was taken before the intervention. ; Results: Clinical success rate was not significantly different between the high and standard-dose group (54.5% vs. 38.5%, P= 0.431). There was a significant difference in the reduction of clinical pulmonary infection score (CPIS) compared to a high dose to the standard group (P=0.038). SOFA score declined significantly in the high dose group throughout the study (P=0.006). A shorter duration of VAP treatment was recorded in the high dose group (P=0.061). We did not observe any significant adverse event related to meropenem. Acinetobacter spp. (34.8%), Klebsiella spp. (32.6%) and Pseudomonas aeruginosa (19.5%) isolated more frequently from sputum cultures. ; Conclusion: Treatment with the high dose of meropenem seems to be safe. However, it did not provide a significantly higher clinical success rate in comparison with the standard dose, but could be considered as an appropriate empirical treatment in patients with severe infection due to reduction in SOFA and CPIS. ; The trial protocol was registered with IRCT.ir (registration number IRCT2010010700 3014N19 in April 2018).
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Affiliation(s)
- Mahila Monajati
- Department of Clinical Pharmacy, Faculty of Pharmacy, Pharmaceutical Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Shahram Ala
- Department of Clinical Pharmacy, Faculty of Pharmacy, Pharmaceutical Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Masoud Aliyali
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Roya Ghasemian
- Department of Infectious Disease, Razi Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Heidari
- Department of Anesthesiology and Critical Care, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Ahanjan
- Department of Microbiology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Siavash Moradi
- Education Development Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Sharifpour
- Toxoplasmosis Research Center, Iranian National Registry Center for Lophmaniasis (INRCL), Mazandaran University of Medical Sciences, PO Box 48471-91971, Sari, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Salehifar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Pharmaceutical Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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13
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Rouyer M, Strazzulla A, Youbong T, Tarteret P, Pitsch A, de Pontfarcy A, Cassard B, Vignier N, Pourcine F, Jochmans S, Monchi M, Diamantis S. Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study. Antibiotics (Basel) 2021; 10:antibiotics10080988. [PMID: 34439038 PMCID: PMC8388913 DOI: 10.3390/antibiotics10080988] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Aim of this study is to analyse the characteristics of ventilator-associated pneumonia (VAP) inpatients infected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). MATERIALS AND METHODS A retrospective study was conducted, including coronavirus infectious disease 2019 (COVID-19) patients who developed VAP from March to May 2020 (VAP COVID-19). They were compared to non-COVID-19 patients who developed VAP from January 2011 to December 2019 (VAP NO COVID-19) and COVID-19 patients who did not develop VAP (NO VAP COVID-19). RESULTS Overall, 42 patients were included in the VAP COVID-19group, 37 in the NO VAP COVID-19 group, and 188 in the VAP NO COVID-19 group. VAP COVID-19 had significantly higher rates of shock (71% vs. 48%, p = 0.009), death in ICU (52% vs. 30%, p = 0.011), VAP recurrence (28% vs. 4%, p < 0.0001), positive blood culture (26% vs. 13%, p = 0.038), and polymicrobial culture (28% vs. 13%, p = 0.011) than VAP NO COVID-19. At the multivariate analysis, death in patients with VAP was associated with shock (p = 0.032) and SARS-CoV-2 (p = 0.008) infection. CONCLUSIONS VAP in COVID-19 patients is associated with shock, bloodstream, and polymicrobial infections.
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Affiliation(s)
- Maxence Rouyer
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Alessio Strazzulla
- Internal Medicine Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France
- Correspondence: ; Tel.: +33-181742070
| | - Tracie Youbong
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Paul Tarteret
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Aurélia Pitsch
- Medical Biology Laboratory, Groupe Hospitalier Sud Ile de France, 77000 Melun, France;
| | - Astrid de Pontfarcy
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Bruno Cassard
- Pharmacy Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France;
| | - Nicolas Vignier
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Franck Pourcine
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Sébastien Jochmans
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Mehran Monchi
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Sylvain Diamantis
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
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14
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Bart SM, Rubin D, Kim P, Farley JJ, Nambiar S. Trends in Hospital-Acquired and Ventilator-Associated Bacterial Pneumonia Trials. Clin Infect Dis 2021; 73:e602-e608. [PMID: 33173946 DOI: 10.1093/cid/ciaa1712] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND New drug development for hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) is critical. Challenges remain in the conduct of HABP/VABP trials, especially in the contexts of enrollment, endpoints, nonstudy antibacterial drug therapy, and antimicrobial resistance. METHODS Four Phase 3 noninferiority trials (n = 2433 participants) submitted to the Food and Drug Administration after 2015 were analyzed for enrollment statistics, participant characteristics associated with 28-day all-cause mortality (ACM), microbiology, and receipt of nonstudy antibacterial drugs. All trials primarily enrolled patients with gram-negative bacterial infections. RESULTS The mean trial length was 2.7 years and the mean recruitment rate was 0.17 participants/site/month. ACM at 28 days was 17.1% and was higher among participants diagnosed with ventilated HABP (31.9%) or VABP (19.0%) than nonventilated HABP (9.9%). VABP participants tended to be younger, less likely to have chronic obstructive pulmonary disease, and more likely to have previously sustained an injury. Age, South American residence, diagnosis of ventilated HABP or VABP, and Acinetobacter baumannii infection were all associated with 28-day ACM in a multivariate logistic regression model. Infection by A. baumannii was most common in Eastern European and Asia/Pacific participants, and Eastern European isolates exhibited the highest levels of meropenem resistance. Concomitant nonstudy antibacterial drug therapy most commonly included beta-lactams and was initiated earliest in Western Europe. CONCLUSION This analysis of recent trials may assist in trial considerations for HABP/VABP development programs and promote needed antibacterial drug development for patients with serious infections.
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Affiliation(s)
- Stephen M Bart
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daniel Rubin
- Division of Biometrics IV, Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Peter Kim
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - John J Farley
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sumathi Nambiar
- Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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15
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Naik J, Puzniak L, Critchlow S, Elsea D, Dillon RJ, Yang J. Cost Effectiveness of Ceftolozane/Tazobactam Compared with Meropenem for the Treatment of Patients with Ventilated Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Infect Dis Ther 2021; 10:939-954. [PMID: 33837518 PMCID: PMC8034281 DOI: 10.1007/s40121-021-00436-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction The clinical efficacy and safety of ceftolozane/tazobactam for the treatment of ventilated hospital-acquired bacterial pneumonia (vHABP) and ventilator-associated bacterial pneumonia (VABP) has been demonstrated in the phase III randomised controlled trial ASPECT-NP. However, there are no published data on the cost-effectiveness of ceftolozane/tazobactam for vHABP/VABP. These nosocomial infections are associated with high rates of morbidity and mortality, and are increasingly complicated by growing rates of resistance and the inappropriate use of antimicrobials. This study is to assess the cost-effectiveness of ceftolozane/tazobactam compared with meropenem for the treatment of vHABP/VABP in a US hospital setting. Methods A short-term decision tree followed by a long-term Markov model was developed to estimate lifetime costs and quality-adjusted life-years associated with ceftolozane/tazobactam and meropenem in the treatment of patients with vHABP/VABP. Pathogen susceptibility and clinical efficacy were informed by the Program to Assess Ceftolozane/Tazobactam Susceptibility (PACTS) database and ASPECT-NP, respectively. A US healthcare sector perspective was adopted, capturing direct costs borne by third-party payers or integrated health systems, and direct health effects for patients. Results In the confirmed treatment setting (post-susceptibility results), the incremental cost-effectiveness ratio for ceftolozane/tazobactam compared to meropenem was US$12,126 per quality-adjusted life-year (QALY); this reduced when used in the early treatment setting (before susceptibility results) at $4775/QALY. Conclusion Ceftolozane/tazobactam represents a highly cost-effective treatment option for patients with vHABP/VABP versus meropenem when used in either the confirmed or early treatment setting; with increased cost-effectiveness shown in the early setting. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00436-4.
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Affiliation(s)
- Jaesh Naik
- BresMed Health Solutions Ltd, Sheffield, UK
| | | | | | | | | | - Joe Yang
- Merck & Co., Inc., Kenilworth, NJ, USA.
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16
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Fowler VG, Das AF, Lipka-Diamond J, Schuch R, Pomerantz R, Jáuregui-Peredo L, Bressler A, Evans D, Moran GJ, Rupp ME, Wise R, Corey GR, Zervos M, Douglas PS, Cassino C. Exebacase for patients with Staphylococcus aureus bloodstream infection and endocarditis. J Clin Invest 2021; 130:3750-3760. [PMID: 32271718 DOI: 10.1172/jci136577] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDNovel therapeutic approaches are critically needed for Staphylococcus aureus bloodstream infections (BSIs), particularly for methicillin-resistant S. aureus (MRSA). Exebacase, a first-in-class antistaphylococcal lysin, is a direct lytic agent that is rapidly bacteriolytic, eradicates biofilms, and synergizes with antibiotics.METHODSIn this superiority-design study, we randomly assigned 121 patients with S. aureus BSI/endocarditis to receive a single dose of exebacase or placebo. All patients received standard-of-care antibiotics. The primary efficacy endpoint was clinical outcome (responder rate) on day 14.RESULTSClinical responder rates on day 14 were 70.4% and 60.0% in the exebacase + antibiotics and antibiotics-alone groups, respectively (difference = 10.4, 90% CI [-6.3, 27.2], P = 0.31), and were 42.8 percentage points higher in the prespecified exploratory MRSA subgroup (74.1% vs. 31.3%, difference = 42.8, 90% CI [14.3, 71.4], ad hoc P = 0.01). Rates of adverse events (AEs) were similar in both groups. No AEs of hypersensitivity to exebacase were reported. Thirty-day all-cause mortality rates were 9.7% and 12.8% in the exebacase + antibiotics and antibiotics-alone groups, respectively, with a notable difference in MRSA patients (3.7% vs. 25.0%, difference = -21.3, 90% CI [-45.1, 2.5], ad hoc P = 0.06). Among MRSA patients in the United States, median length of stay was 4 days shorter and 30-day hospital readmission rates were 48% lower in the exebacase-treated group compared with antibiotics alone.CONCLUSIONThis study establishes proof of concept for exebacase and direct lytic agents as potential therapeutics and supports conduct of a confirmatory study focused on exebacase to treat MRSA BSIs.TRIAL REGISTRATIONClinicaltrials.gov NCT03163446.FUNDINGContraFect Corporation.
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Affiliation(s)
- Vance G Fowler
- Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Anita F Das
- AD Stat Consulting, Guerneville, California, USA
| | | | | | | | | | - Adam Bressler
- Infectious Disease Specialists of Atlanta, Georgia, USA
| | - David Evans
- The Ohio State University, Columbus, Ohio, USA
| | | | - Mark E Rupp
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Robert Wise
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - G Ralph Corey
- Duke University Medical Center, Durham, North Carolina, USA
| | | | - Pamela S Douglas
- Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
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17
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Affiliation(s)
- Melinda M Pettigrew
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Windy Tanner
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore Maryland, USA
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18
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Alonso B, Fernández-Barat L, Di Domenico EG, Marín M, Cercenado E, Merino I, de Pablos M, Muñoz P, Guembe M. Characterization of the virulence of Pseudomonas aeruginosa strains causing ventilator-associated pneumonia. BMC Infect Dis 2020; 20:909. [PMID: 33261585 PMCID: PMC7706020 DOI: 10.1186/s12879-020-05534-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Background The objective of this study was to evaluate the virulence of P. aeruginosa ventilator-associated pneumonia (VAP) strains (cases) in terms of biofilm production and other phenotypic and genotypic virulence factors compared to P. aeruginosa strains isolated from other infections (controls). Methods Biofilm production was tested to assess biomass production and metabolic activity using crystal violet binding assay and XTT assay, respectively. Pigment production (pyocyanin and pyoverdine) was evaluated using cetrimide agar. Virulence genes were detected by conventional multiplex PCR and virulence was tested in an in vivo model in Galleria mellonella larvae. Results We did not find statistically significant differences between VAP and no-VAP strains (p > 0.05) regarding biofilm production. VAP strains had no production of pyocyanin after 24 h of incubation (p = 0.023). The distribution of virulence genes between both groups were similar (p > 0.05). VAP strains were less virulent than non-VAP strains in an in vivo model of G. mellonella (p < 0.001). Conclusion The virulence of VAP-Pseudomonas aeruginosa does not depend on biofilm formation, production of pyoverdine or the presence of some virulence genes compared to P. aeruginosa isolated from non-invasive locations. However, VAP strains showed attenuated virulence compared to non-VAP strains in an in vivo model of G. mellonella. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12879-020-05534-1.
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Affiliation(s)
- Beatriz Alonso
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | - Laia Fernández-Barat
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Center for Biomedical Research CELLEX, School of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilia Cercenado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Irene Merino
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain.,Group For Biomedical Research in Sepsis (BioSepsis) Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Centro de Investigación Biomedica En Red - Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain.,National Health System, SACYL/IECSCYL, Valladolid, Spain
| | - Manuela de Pablos
- Servicio de Microbiología y Parasitología Hospital Universitario La Paz, Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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19
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Weiss E, Zahar JR, Alder J, Asehnoune K, Bassetti M, Bonten MJM, Chastre J, De Waele J, Dimopoulos G, Eggimann P, Engelhardt M, Ewig S, Kollef M, Lipman J, Luna C, Martin-Loeches I, Pagani L, Palmer LB, Papazian L, Poulakou G, Prokocimer P, Rello J, Rex JH, Shorr AF, Talbot GH, Thamlikitkul V, Torres A, Wunderink RG, Timsit JF. Elaboration of Consensus Clinical Endpoints to Evaluate Antimicrobial Treatment Efficacy in Future Hospital-acquired/Ventilator-associated Bacterial Pneumonia Clinical Trials. Clin Infect Dis 2020; 69:1912-1918. [PMID: 30722013 DOI: 10.1093/cid/ciz093] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/26/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Randomized clinical trials (RCTs) in hospital-acquired and ventilator-associated bacterial pneumonia (HABP and VABP, respectively) are important for the evaluation of new antimicrobials. However, the heterogeneity in endpoints used in RCTs evaluating treatment of HABP/VABP may puzzle clinicians. The aim of this work was to reach a consensus on clinical endpoints to consider in future clinical trials evaluating antimicrobial treatment efficacy for HABP/VABP. METHODS Twenty-six international experts from intensive care, infectious diseases, and the pharmaceutical industry were polled using the Delphi method. RESULTS The panel recommended a hierarchical composite endpoint including, by priority order, (1) survival at day 28, (2) mechanical ventilation-free days through day 28, and (3) clinical cure between study days 7 and 10 for VABP; and (1) survival (day 28) and (2) clinical cure (days 7-10) for HABP. Clinical cure was defined as the combination of resolution of signs and symptoms present at enrollment and improvement or lack of progression of radiological signs. More than 70% of the experts agreed to assess survival and mechanical ventilation-free days though day 28, and clinical cure between day 7 and day 10 after treatment initiation. Finally, the hierarchical order of endpoint components was reached after 3 Delphi rounds (72% agreement). CONCLUSIONS We provide a multinational expert consensus on separate hierarchical composite endpoints for VABP and HABP, and on a definition of clinical cure that could be considered for use in future HABP/VABP clinical trials.
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Affiliation(s)
- Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris (AP-HP), Beaujon Hospital, Clichy.,Unité Mixte de Recherche (UMR) 1149, Centre for Research on Inflammation, Institut national de la santé et de la recherche médicale (INSERM)/Université Paris Diderot, Paris
| | - Jean-Ralph Zahar
- Department of Clinical Microbiology and Infection Control Unit, Avicennes Hospital, AP-HP, Bobigny.,Infection, Antibiotics, Modelisation, Epidemiology (IAME), UMR 1137, Université Paris 13, Sorbonne Paris Cité, France
| | | | - Karim Asehnoune
- University Hospital of Nantes, Intensive Care Unit, Anesthesia and Critical Care Department, Hôtel Dieu, Nantes, France
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Italy
| | - Marc J M Bonten
- Department of Medical Microbiology and Julius Center for Health Science and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Belgium
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Greece
| | - Philippe Eggimann
- Department of Critical Care, Centre Hospitalier Universitaire Vaudois, Lausanne
| | | | - Santiago Ewig
- Department of Respiratory Medicine and Infectious Diseases, Evangelic Hospital in Herne and Augusta Hospital, Bochum, Germany
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey Lipman
- Royal Brisbane and Womens Hospital, Australia.,University of the Witwatersrand, Johannesburg, South Africa
| | - Carlos Luna
- Department of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Argentina
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | | | - Lucy B Palmer
- Pulmonary, Critical Care and Sleep Division, State University of New York at Stony Brook, France
| | - Laurent Papazian
- Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, France
| | - Garyphallia Poulakou
- Third Department of Medicine, Sotiria General Hospital, Greece.,Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Jordi Rello
- Centro Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Barcelona Hospital Campus, Spain
| | | | - Andrew F Shorr
- Medstar Washington Hospital Center, Washington, District of Columbia
| | | | - Visanu Thamlikitkul
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona, Institut De Investigacio Biomedica Agusti Pi i Sunyer, CIBERES, Spain
| | | | - Jean-François Timsit
- AP-HP, Medical and Infectious Diseases Intensive Care Unit, Bichat Hospital, Paris.,UMR 1137 IAME, INSERM, Université Paris Diderot, France
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20
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Paling FP, Hazard D, Bonten MJM, Goossens H, Jafri HS, Malhotra-Kumar S, Sifakis F, Weber S, Kluytmans JAJW. Association of Staphylococcus aureus Colonization and Pneumonia in the Intensive Care Unit. JAMA Netw Open 2020; 3:e2012741. [PMID: 32997125 PMCID: PMC7527877 DOI: 10.1001/jamanetworkopen.2020.12741] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Carriage of Staphylococcus aureus is associated with S aureus infection. However, associations between S aureus carriage and the development of S aureus intensive care unit (ICU) pneumonia (SAIP) have not been quantified accurately, and interpretation of available data is hampered because of variations in definitions. OBJECTIVE To quantify associations of patient-related and contextual factors, including S aureus colonization status, with the occurrence of SAIP. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted in ICUs of 30 hospitals in 11 European countries, geographically spread across 4 regions. Among patients with an anticipated length of stay 48 hours or longer who were undergoing mechanical ventilation at ICU admission, S aureus colonization was ascertained in the nose and lower respiratory tract. From this group, S aureus-colonized and noncolonized patients were enrolled into the study cohort in a 1:1 ratio. Data analysis was performed from May to November 2019. MAIN OUTCOMES AND MEASURES SAIP was defined as any pneumonia during the ICU stay developing 48 hours or more after ICU admission with S aureus isolated from lower respiratory tract specimens or blood samples. The incidence of SAIP was derived in the study cohort and estimated on the weighted incidence calculation for the originating overarching population, while taking competing events into account. Weighted risk factor analysis was performed using Cox multivariable regression. RESULTS The study cohort consisted of 1933 patients (mean [SD] age, 62.0 [16.0] years); 1252 patients (64.8%) were men, and 950 patients (49.1%) were S aureus carriers at ICU admission. In all, 304 patients (15.7%) developed ICU-acquired pneumonia, of whom 131 patients (6.8%) had SAIP. Weighted SAIP incidences were 11.7 events per 1000 patient-days in the ICU for S aureus-colonized patients and 2.9 events per 1000 patient-days in the ICU for noncolonized patients (overall incidence, 4.9 events per 1000 patient-days in the ICU). The only factor independently associated with SAIP was S aureus colonization status at ICU admission (cause-specific hazard ratio, 3.6; 95% CI, 2.2-6.0; P < .001). There were marked regional differences in SAIP incidence and cause-specific hazard ratios for colonization status. CONCLUSIONS AND RELEVANCE SAIP incidence was 4.9 events per 1000 ICU patient-days for patients undergoing mechanical ventilation at ICU admission (or shortly thereafter). The daily risk of SAIP was 3.6 times higher in patients colonized with S aureus at ICU admission compared with noncolonized patients.
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Affiliation(s)
- Fleur P. Paling
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Derek Hazard
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Freiburg, Germany
| | - Marc J. M. Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Hasan S. Jafri
- Microbial Sciences, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Frangiscos Sifakis
- Microbial Sciences, R&D BioPharmaceuticals, AstraZeneca, Gaithersburg, Maryland
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Susanne Weber
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Freiburg, Germany
| | - Jan A. J. W. Kluytmans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Infection Control, Amphia Hospital, Breda, the Netherlands
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21
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Sheremet AB, Nesterenko LN, Zigangirova NA. The Type Three Secretion System of Pseudomonas aeruginosa as a Target for Development of Antivirulence Drugs. MOLECULAR GENETICS, MICROBIOLOGY AND VIROLOGY 2020. [DOI: 10.3103/s0891416820010073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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22
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Roquilly A, Jacqueline C, Davieau M, Mollé A, Sadek A, Fourgeux C, Rooze P, Broquet A, Misme-Aucouturier B, Chaumette T, Vourc'h M, Cinotti R, Marec N, Gauttier V, McWilliam HEG, Altare F, Poschmann J, Villadangos JA, Asehnoune K. Alveolar macrophages are epigenetically altered after inflammation, leading to long-term lung immunoparalysis. Nat Immunol 2020; 21:636-648. [PMID: 32424365 DOI: 10.1038/s41590-020-0673-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/30/2020] [Indexed: 12/21/2022]
Abstract
Sepsis and trauma cause inflammation and elevated susceptibility to hospital-acquired pneumonia. As phagocytosis by macrophages plays a critical role in the control of bacteria, we investigated the phagocytic activity of macrophages after resolution of inflammation. After resolution of primary pneumonia, murine alveolar macrophages (AMs) exhibited poor phagocytic capacity for several weeks. These paralyzed AMs developed from resident AMs that underwent an epigenetic program of tolerogenic training. Such adaptation was not induced by direct encounter of the pathogen but by secondary immunosuppressive signals established locally upon resolution of primary infection. Signal-regulatory protein α (SIRPα) played a critical role in the establishment of the microenvironment that induced tolerogenic training. In humans with systemic inflammation, AMs and also circulating monocytes still displayed alterations consistent with reprogramming six months after resolution of inflammation. Antibody blockade of SIRPα restored phagocytosis in monocytes of critically ill patients in vitro, which suggests a potential strategy to prevent hospital-acquired pneumonia.
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Affiliation(s)
- Antoine Roquilly
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France. .,Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France. .,Department of Microbiology and Immunology, Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Parkville, Victoria, Australia.
| | - Cedric Jacqueline
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France
| | - Marion Davieau
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France
| | - Alice Mollé
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR1064, ITUN, Nantes, France
| | - Abderrahmane Sadek
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR1064, ITUN, Nantes, France.,Department of Biology, Faculty of Science, Moulay Ismail University, Zitoune, Meknes, Morocco
| | - Cynthia Fourgeux
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR1064, ITUN, Nantes, France
| | - Paul Rooze
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France.,Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Alexis Broquet
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France
| | - Barbara Misme-Aucouturier
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France
| | - Tanguy Chaumette
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France
| | - Mickael Vourc'h
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France.,Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Raphael Cinotti
- Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Nadege Marec
- Plateforme Cytocell, SFR François Bonamy, Nantes, France
| | - Vanessa Gauttier
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR1064, ITUN, Nantes, France
| | - Hamish E G McWilliam
- Department of Microbiology and Immunology, Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Parkville, Victoria, Australia.,Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Frederic Altare
- CRCINA, INSERM, Université de Nantes, CHU de Nantes, Nantes, France
| | - Jeremie Poschmann
- Université de Nantes, CHU Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR1064, ITUN, Nantes, France.
| | - Jose A Villadangos
- Department of Microbiology and Immunology, Peter Doherty Institute of Infection and Immunity, The University of Melbourne, Parkville, Victoria, Australia. .,Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, Victoria, Australia.
| | - Karim Asehnoune
- Université de Nantes, EA3826 Thérapeutiques Anti-Infectieuses, Institut de Recherche en Santé 2 Nantes Biotech, Nantes, France. .,Université de Nantes, CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France.
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23
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de Kraker MEA, Sommer H, de Velde F, Gravestock I, Weiss E, McAleenan A, Nikolakopoulos S, Amit O, Ashton T, Beyersmann J, Held L, Lovering AM, MacGowan AP, Mouton JW, Timsit JF, Wilson D, Wolkewitz M, Bettiol E, Dane A, Harbarth S. Optimizing the Design and Analysis of Clinical Trials for Antibacterials Against Multidrug-resistant Organisms: A White Paper From COMBACTE's STAT-Net. Clin Infect Dis 2019; 67:1922-1931. [PMID: 30107400 PMCID: PMC6260160 DOI: 10.1093/cid/ciy516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/15/2018] [Indexed: 01/08/2023] Open
Abstract
Innovations are urgently required for clinical development of antibacterials against multidrug-resistant organisms. Therefore, a European, public-private working group (STAT-Net; part of Combatting Bacterial Resistance in Europe [COMBACTE]), has reviewed and tested several innovative trials designs and analytical methods for randomized clinical trials, which has resulted in 8 recommendations. The first 3 focus on pharmacokinetic and pharmacodynamic modeling, emphasizing the pertinence of population-based pharmacokinetic models, regulatory procedures for the reassessment of old antibiotics, and rigorous quality improvement. Recommendations 4 and 5 address the need for more sensitive primary end points through the use of rank-based or time-dependent composite end points. Recommendation 6 relates to the applicability of hierarchical nested-trial designs, and the last 2 recommendations propose the incorporation of historical or concomitant trial data through Bayesian methods and/or platform trials. Although not all of these recommendations are directly applicable, they provide a solid, evidence-based approach to develop new, and established, antibacterials and address this public health challenge.
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Affiliation(s)
- Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Harriet Sommer
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany
| | - Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isaac Gravestock
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Emmanuel Weiss
- Université Paris Diderot, Paris, France.,APHP Anesthesiology and Critical Care Department, Beaujon Hospital, Paris, France
| | - Alexandra McAleenan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Stavros Nikolakopoulos
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Ohad Amit
- GlaxoSmithKline, Collegeville, Pennsylvania
| | | | | | - Leonhard Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Andrew M Lovering
- Bristol Centre for Antibiotic Research and Evaluation, Infection Sciences, North Bristol NHS Trust, Southmead Hospital, United Kingdom
| | - Alasdair P MacGowan
- Bristol Centre for Antibiotic Research and Evaluation, Infection Sciences, North Bristol NHS Trust, Southmead Hospital, United Kingdom
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Rotterdam, The Netherlands
| | - Jean-François Timsit
- UMR 1137 IAME Inserm/Université Paris Diderot.,APHP Medical and Infectious Diseases ICU, Bichat Hospital, Paris, France
| | | | - Martin Wolkewitz
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany
| | - Esther Bettiol
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Aaron Dane
- DaneStat Consulting Limited, Macclesfield, United Kingdom
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
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24
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Microbial cause of ICU-acquired pneumonia: hospital-acquired pneumonia versus ventilator-associated pneumonia. Curr Opin Crit Care 2019; 24:332-338. [PMID: 30036192 DOI: 10.1097/mcc.0000000000000526] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Successful treatment of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains a difficult and complex undertaking. Better knowledge of the pathogens involved in that setting may allow reassessment of our current modalities of therapy and definition of better protocols. RECENT FINDINGS Microorganisms responsible for HAP/VAP differ according to geographic areas, ICU patients' specific characteristics, durations of hospital and ICU stays before onset of the disease, and risk factors for MDR pathogens. However, a number of studies have shown that Gram-negative bacilli (GNB) - particularly Pseudomonas aeruginosa and Enterobacteriaceae - cause many of the respiratory infections in this setting, with minimal differences between HAP and VAP, indicating that the cause depends more on the underlying clinical condition of patients rather than previous intubation. SUMMARY When selecting initial antimicrobial therapy in patients with HAP/VAP, more attention should be paid to individual risk factors for MDR pathogens, severity of the clinical situation, and the local epidemiology than to the type of pneumonia.
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25
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Scquizzato T, Gazzato A. Adopting a smart toothbrush with artificial intelligence may improve oral care in patients admitted to the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:223. [PMID: 31215441 PMCID: PMC6582490 DOI: 10.1186/s13054-019-2512-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCSS San Raffaele Scientific Institute, Milan, Italy. .,Vita-Salute San Raffaele University, Milan, Italy.
| | - Arianna Gazzato
- Azienda ULSS 3 Serenissima - Ospedale di Mirano, Venice, Italy
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26
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Aerosol Therapy for Pneumonia in the Intensive Care Unit. Clin Chest Med 2019; 39:823-836. [PMID: 30390752 DOI: 10.1016/j.ccm.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antibiotic aerosolization in patients with ventilator-associated pneumonia (VAP) allows very high concentrations of antimicrobial agents in the respiratory secretions, far more than those achievable using the intravenous route. However, data in critically ill patients with pneumonia are limited. Administration of aerosolized antibiotics might increase the likelihood of clinical resolution, but no significant improvements in important outcomes have been consistently documented. Thus, aerosolized antibiotics should be restricted to the treatment of extensively resistant gram-negative pneumonia. In these cases, the use of a vibrating-mesh nebulizer seems to be more efficient, but specific settings and conditions are required to improve lung delivery.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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27
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Roquilly A, Torres A, Villadangos JA, Netea MG, Dickson R, Becher B, Asehnoune K. Pathophysiological role of respiratory dysbiosis in hospital-acquired pneumonia. THE LANCET RESPIRATORY MEDICINE 2019; 7:710-720. [PMID: 31182406 DOI: 10.1016/s2213-2600(19)30140-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
Abstract
Hospital-acquired pneumonia is a major cause of morbidity and mortality. The incidence of hospital-acquired pneumonia remains high globally and treatment can often be ineffective. Here, we review the available data and unanswered questions surrounding hospital-acquired pneumonia, discuss alterations of the respiratory microbiome and of the mucosal immunity in patients admitted to hospital, and explore potential approaches to stratify patients for tailored treatments. The lungs have been considered a sterile organ for decades because microbiological culture techniques had shown negative results. Culture-independent techniques have shown that healthy lungs harbour a diverse and dynamic ecosystem of bacteria, changing our comprehension of respiratory physiopathology. Understanding dysbiosis of the respiratory microbiome and altered mucosal immunity in patients with critical illness holds great promise to develop targeted host-directed immunotherapy to reduce ineffective treatment, to improve patient outcomes, and to tackle the global threat of resistant bacteria that cause these infections.
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Affiliation(s)
- A Roquilly
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes, France; Department of Microbiology and Immunology, Faculty of Medicine, University of Nantes, Nantes, France
| | - A Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona Institut d'investigació Biomédica August Pi i Sunyer, Centro de Investigación Biomédica en Red.Enfermedades Respiratorias, Barcelona, Spain
| | - J A Villadangos
- Department of Microbiology and Immunology, Doherty Institute of Infection and Immunity and Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Parkville, VIC, Australia
| | - M G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - R Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - B Becher
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - K Asehnoune
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes, France; Department of Microbiology and Immunology, Faculty of Medicine, University of Nantes, Nantes, France.
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28
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Zhou Y, Chen X, Xu P, Zhu Y, Wang K, Xiang D, Wang F, Banh HL. Clinical experience with tigecycline in the treatment of hospital-acquired pneumonia caused by multidrug resistant Acinetobacter baumannii. BMC Pharmacol Toxicol 2019; 20:19. [PMID: 31023357 PMCID: PMC6482491 DOI: 10.1186/s40360-019-0300-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 04/10/2019] [Indexed: 12/20/2022] Open
Abstract
Background Tigecycline, with broad in vitro antibacterial activity, has been widely used off-label for nosocomial pneumonia caused by multi-drug resistant Acinetobacter baumannii (MDRAB). However, many concerns have been raised about the efficacy of tigecycline treatment as the inconsistent results from previous clinical studies. Methods This retrospective study evaluated the outcome of adult patients with monomicrobial MDRAB nosocomial pneumonia treated with tigecycline between 2015 and 2017. Results. A total of 77 patients was eligible for this study, and the overall clinical success and 30-day survival rates were 70.03 and 70.13%, respectively, however, the microbiological eradication rate was relatively low (48%). Multivariate analysis indicated that shorter duration of tigecycline use associated with increased clinical failure, whereas higher CURB65 scores, mechanical ventilation and tigecycline resistant to MDRAB have significant association with 30-day mortality. Conclusions Our results suggest that tigecycline is one of the potential choices for the treatment of hospital-acquired pneumonia caused by MDRAB, especially with a MIC≤2 mg/L. In addition, a longer duration of tigecycline treatment may be required to insure better clinical outcomes.
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Affiliation(s)
- Yangang Zhou
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Xumin Chen
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Ping Xu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China. .,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China.
| | - Yan Zhu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Kuangguo Wang
- The Traditional Chinese Medicine hospital of Longhui, Changsha, Hunan, People's Republic of China
| | - Daxiong Xiang
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Feng Wang
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Hoan Linh Banh
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, No.139 Middle Renmin Road, Changsha, Hunan, 410011, People's Republic of China.,Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China.,Department of Family Medicine, University of Alberta, Edmonton, Canada
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Torres A, Rank D, Melnick D, Rekeda L, Chen X, Riccobene T, Critchley IA, Lakkis HD, Taylor D, Talley AK. Randomized Trial of Ceftazidime-Avibactam vs Meropenem for Treatment of Hospital-Acquired and Ventilator-Associated Bacterial Pneumonia (REPROVE): Analyses per US FDA-Specified End Points. Open Forum Infect Dis 2019; 6:ofz149. [PMID: 31041348 PMCID: PMC6483139 DOI: 10.1093/ofid/ofz149] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background Hospital-acquired and ventilator-associated pneumonia (HAP/VAP; nosocomial pneumonia) due to Gram-negative pathogens are associated with significant morbidity and mortality; treatment options for multidrug-resistant infections are limited. The pivotal phase III REPROVE trial evaluated the efficacy of ceftazidime-avibactam (CAZ-AVI) vs meropenem in the treatment of patients with HAP/VAP. Study results for prespecified analyses per US Food and Drug Administration–recommended trial end points are reported here. Methods Hospitalized adults with HAP/VAP proven or suspected to be caused by a Gram-negative pathogen were randomized 1:1 to receive CAZ-AVI or meropenem for 7 to 14 days. The primary outcome was 28-day all-cause mortality in the intent-to-treat (ITT) population. Secondary outcomes included clinical cure at test of cure (TOC) in the ITT and microbiological ITT (micro-ITT) populations, and safety and tolerability throughout the study. Results hundred seventy randomized patients received treatment and were included in the ITT population (CAZ-AVI, n = 436; meropenem, n = 434). CAZ-AVI was noninferior to meropenem for the primary end point (28-day all-cause mortality; ITT) based on the prespecified 10% noninferiority margin (CAZ-AVI, 9.6%; meropenem, 8.3%; difference, 1.5%; 95% confidence interval [CI], –2.4% to 5.3%) and for the clinical cure end point in the ITT population based on a prespecified –10% noninferiority margin (CAZ-AVI, 67.2%; meropenem, 69.1%; difference, −1.9%; 95% CI, –8.1% to 4.3%). Clinical cure rates at TOC for patients infected with CAZ-nonsusceptible pathogens were similar (CAZ-AVI, 75.5%; meropenem, 71.2%; micro-ITT). Safety data were consistent with established safety profiles for both agents. Conclusions CAZ-AVI provides an important new treatment option for HAP/VAP due to Gram-negative pathogens, including CAZ-nonsusceptible strains.
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Affiliation(s)
- Antoni Torres
- Servei de Pneumologia, University of Barcelona, IDIBAPS, CIBERES, ICREA Academia, Hospital Clinic, Barcelona, Spain
| | - Doug Rank
- Clinical Development, Allergan plc, Madison, New Jersey
| | - David Melnick
- Clinical Development, Allergan plc, Madison, New Jersey
| | | | - Xiang Chen
- Biostatistics, Allergan plc, Madison, New Jersey
| | - Todd Riccobene
- Clinical Pharmacology, Allergan plc, Madison, New Jersey
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Why have trials of inhaled antibiotics for ventilator-associated infections failed? Curr Opin Infect Dis 2019; 32:163-168. [DOI: 10.1097/qco.0000000000000525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Wojak JF, Ditz C, Abusamha A, Smith E, Gliemroth J, Tronnier V, Küchler J. The Impact of Extubation Failure in Patients with Good-Grade Subarachnoid Hemorrhage. World Neurosurg 2018; 117:e335-e340. [PMID: 29908380 DOI: 10.1016/j.wneu.2018.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/05/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the clinical impact of extubation failure (EF) in patients with good-grade subarachnoid hemorrhage (SAH), in whom a good clinical course usually is expected. PATIENTS AND METHODS We reviewed the clinical data from 141 patients with SAH and 1) initial Hunt & Hess grade 1-3; 2) induction of general anesthesia for intervention; and 3) the presence of data about the functional outcome. Patients were divided into 3 groups: 1) primary tracheotomized patients (PT); 2) patients with successful extubation (ES); and 3) patients with EF (reintubation within 48 hours). RESULTS EF occurred with a rate of 0.12. The leading cause of EF was respiratory insufficiency (n = 7), followed by impaired consciousness (n = 5). Multivariate logistic regression did not show any neurologic predictor of EF. Patients with ES showed an excellent outcome after 6 months (favorable outcome: 95.7%), whereas the outcome of patients with EF and PT was significantly (P < 0.05) poorer. The case fatality rate was nonsignificantly greater in the EF group (0.15 vs. 0.03). Hospitalization was significantly reduced for patients with ES, whereas the occurrence of symptomatic cerebral vasospasms and vasospastic cerebral infarction was similar between patients with EF, ES, or PT. CONCLUSIONS We showed that EF is a frequent condition in good grade-SAH but is not predictable using common neurologic parameters. Regarding the functional outcome, we were able to show that the result of an extubation trial clearly delineates the patients in 2 distinct groups, in which ES predicts an excellent outcome.
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Affiliation(s)
- Jann F Wojak
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | | | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Volker Tronnier
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany.
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Sommer H, Bluhmki T, Beyersmann J, Schumacher M. Assessing Noninferiority in Treatment Trials for Severe Infectious Diseases: an Extension to the Entire Follow-Up Period Using a Cure-Death Multistate Model. Antimicrob Agents Chemother 2018; 62:e01691-17. [PMID: 29061757 PMCID: PMC5740315 DOI: 10.1128/aac.01691-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/17/2017] [Indexed: 12/18/2022] Open
Abstract
In current and former clinical trials for the development of antibacterial drugs, various primary endpoints have been used, and treatment effects are evaluated mostly in noninferiority analyses at the end of follow-up, which varies between studies. A more convincing and highly patient-relevant statement would be a noninferiority assessment over the entire follow-up period with cure and death as coprimary endpoints, while preserving the desired alpha level for statistical testing. To account for the time-dynamic pattern of cure and death, we apply a cure-death multistate model. The endpoint of interest is "get cured and stay alive over time." Noninferiority between treatments over the entire follow-up period is studied by means of one-sided confidence bands provided by a flexible resampling technique. We illustrate the technique by applying it to a recently published study and establish noninferiority in being cured and alive over a time frame of interest for the entire population, patients with hospital-acquired pneumonia, but not for the subset of patients with ventilator-associated pneumonia. Our analysis improves the original results in the sense that our endpoint is more patient benefiting, a stronger noninferiority statement is demonstrated, and the time dependency of cure and death, competing events, and different follow-up times is captured. Multistate methodology combined with confidence bands adds a valuable statistical tool for clinical trials in the context of infection control. The framework is not restricted to the cure-death model but can be adapted to more complex multistate endpoints and equivalence or superiority analyses.
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Affiliation(s)
- Harriet Sommer
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
| | | | | | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center-University of Freiburg, Freiburg, Germany
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Abstract
Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7-8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.
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Affiliation(s)
- Jean-Francois Timsit
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Wafa Esaied
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France
| | - Mathilde Neuville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Lila Bouadma
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Bruno Mourvllier
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
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