Adherence to guidelines for hospitalized community-acquired pneumonia over time and its impact on health outcomes and mortality

The social experience of uncertainty: a qualitative analysis of emergency department care for suspected pneumonia for the design of decision support

BACKGROUND

This study sought to understand the process of clinical decision-making for suspected pneumonia by emergency departments (ED) providers in Veterans Affairs (VA) Medical Centers. The long-term goal of this work is to create clinical decision support tools to reduce unwarranted variation in diagnosis and treatment of suspected pneumonia.

METHODS

Semi-structured qualitative interviews were conducted with 16 ED clinicians from 9 VA facilities demonstrating variation in antibiotic and hospitalization decisions. Interviews of ED providers focused on understanding decision making for provider-selected pneumonia cases and providers' organizational contexts.

RESULTS

Thematic analysis identified four salient themes: i) ED decision-making for suspected pneumonia is a social process; ii) the "diagnosis drives treatment" paradigm is poorly suited to pneumonia decision-making in the ED; iii) The unpredictability of the ED requires deliberate and effortful information management by providers in CAP decision-making; and iv) the emotional stakes and high uncertainty of pneumonia care drive conservative decision making.

CONCLUSIONS

Ensuring CDS reflects the realities of clinical work as a socially organized process with high uncertainty may ultimately improve communication between ED and admitting providers, continuity of care and patient outcomes.

Duration of Antimicrobial Treatment in Adult Patients with Pneumonia: A Narrative Review

Pneumonia remains a major global health concern, causing significant morbidity and mortality among adults. This narrative review assesses the optimal duration of antimicrobial treatment in adults with community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Current evidence about the impact of treatment duration on clinical outcomes demonstrates that shorter antibiotic courses are non-inferior, regarding safety and efficacy, compared to longer courses, particularly in patients with mild to moderate CAP, which is in line with the recommendations of international guidelines. Data are limited regarding the optimal antimicrobial duration in HAP patients, and it should be individually tailored to each patient, taking into account the causative pathogen and the clinical response. Shorter courses are found to be as effective as longer courses in the management of VAP, except for pneumonia caused by non-fermenting Gram-negative bacteria; however, duration should be balanced between the possibility of higher recurrence rates and the documented benefits with shorter courses. Additionally, the validation of reliable biomarkers or clinical predictors that identify patients who would benefit from shorter therapy is crucial. Insights from this review may lead to future research on personalized antimicrobial therapies in pneumonia, in order to improve patient outcomes.

European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists)

SCOPE

This European Society of Clinical Microbiology and Infectious Diseases guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are (a) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? (b) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? (c) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? (d) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing?

METHODS

An expert panel was convened by European Society of Clinical Microbiology and Infectious Diseases and the guideline chair. The panel selected in consensus the four most relevant antimicrobial stewardship topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes and stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively.

RECOMMENDATIONS

The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e. withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very low and low certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.

The Adequacy of Current Legionnaires' Disease Diagnostic Practices in Capturing the Epidemiology of Clinically Relevant Legionella: A Scoping Review

Legionella is an underdiagnosed and underreported etiology of pneumonia. Legionella pneumophila serogroup 1 (LpSG1) is thought to be the most common pathogenic subgroup. This assumption is based on the frequent use of a urinary antigen test (UAT), only capable of diagnosing LpSG1. We aimed to explore the frequency of Legionella infections in individuals diagnosed with pneumonia and the performance of diagnostic methods for detecting Legionella infections. We conducted a scoping review to answer the following questions: (1) "Does nucleic acid testing (NAT) increase the detection of non-pneumophila serogroup 1 Legionella compared to non-NAT?"; and (2) "Does being immunocompromised increase the frequency of pneumonia caused by non-pneumophila serogroup 1 Legionella compared to non-immunocompromised individuals with Legionnaires' disease (LD)?". Articles reporting various diagnostic methods (both NAT and non-NAT) for pneumonia were extracted from several databases. Of the 3449 articles obtained, 31 were included in our review. The most common species were found to be L. pneumophila, L. longbeachae, and unidentified Legionella species appearing in 1.4%, 0.9%, and 0.6% of pneumonia cases. Nearly 50% of cases were caused by unspecified species or serogroups not detected by the standard UAT. NAT-based techniques were more likely to detect Legionella than non-NAT-based techniques. The identification and detection of Legionella and serogroups other than serogroup 1 is hampered by a lack of application of broader pan-Legionella or pan-serogroup diagnostics.

What Is the Value Proposition of Evidence-Based Guidelines? An Application of the Operative Value Index for Lumbar Fusions

BACKGROUND

Elective lumbar fusions have received criticism for inappropriate utilization. Here, we use a novel Operative Value Index (OVI) to assess whether "indicated," evidence-based lumbar fusions are associated with increased value (outcomes per dollar spent).

METHODS

This study is a retrospective analysis of a prospective observational cohort of 294 patients undergoing elective lumbar fusions at a single large academic institution. All patients were preoperatively evaluated by a panel of neurosurgeons for concordance with evidence-based medicine (EBM), determined through guidelines from the North American Spine Society. Oswestry Disability Index (ODI) scores were collected for all patients both preoperatively and at 6-months postoperatively. Time-driven activity-based costing was employed to determine both direct and indirect intraoperative costs. The OVI was defined as the percent improvement in ODI per $1000 spent intraoperatively. Generalized linear mixed model regression, adjusting for confounders, was performed to assess whether EBM-concordant surgeries were associated with higher OVI.

RESULTS

Of 294 elective lumbar fusions, 92.9% (n = 273) were EBM-concordant. The average total cost of an EBM-concordant lumbar fusion was $17,932 (supplies: $13,020; personnel: $4314), compared to $20,616 (supplies: $15,467; personnel: $4758) for an EBM-discordant fusion. Average OVI was 2.27 for a concordant fusion, compared to 0.11 for a discordant fusion. Generalized linear mixed model analysis revealed that EBM-concordant cases were associated with significantly higher OVI (β-coefficient 2.0, P < 0.001).

CONCLUSIONS

EBM-concordant fusions were associated with 2% greater improvement in ODI scores from baseline for every $1000 spent intraoperatively. Systematic methods for increasing guideline adherence for lumbar fusions could therefore improve value at scale.

Severe aspiration pneumonia in the elderly

The global population is aging at an unprecedented rate, resulting in a growing and vulnerable elderly population in need of efficient comprehensive healthcare services that include long-term care and skilled nursing facilities. In this context, severe aspiration pneumonia, a condition that carries substantial morbidity, mortality, and financial burden, especially among elderly patients requiring admission to the intensive care unit, has attracted greater concern. Aspiration pneumonia is defined as a pulmonary infection related to aspiration or dysphagia in etiology. Prior episodes of coughing on food or liquid intake, a history of relevant underlying conditions, abnormalities on videofluoroscopy or water swallowing, and gravity-dependent shadow distribution on chest imaging are among the clues that suggest aspiration. Patients with aspiration pneumonia tend to be elderly, frail, and suffering from more comorbidities than those without this condition. Here, we comprehensively address the epidemiology, clinical characteristics, diagnosis, treatment, prevention, and prognosis of severe aspiration community-acquired pneumonia in the elderly to optimize care of this high-risk demographic, enhance outcomes, and minimize the healthcare costs associated with this illness. Emphasizing preventive measures and effective management strategies is vital in ensuring the well-being of our aging population.

Practicing Medicine Wisely: Routine Use of Urine Legionella in Suspicious Pneumonia - Are we Overdoing?

ABSTRACT

Legionella spp. is an underreported cause of Community Acquired pneumonia that affects significant population specially in urban areas and its prevalence is on an increasing trend. The routine practice of testing for urinary antigen of Legionella in all suspected cases of pneumonia is prevalent is resource rich western countries. Although several studies have shown no distinct advantage of performing routine urinary antigen testing, this practice continues to be preferred by clinicians. In this viewpoint, we have discussed the advantages and disadvantages of urinary antigen testing, its relevance in current practice and its impact on clinical outcomes.

Assessing the quality of antimicrobial prescribing in solid organ transplant recipients: a new frontier in antimicrobial stewardship

Background

Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTRs) and local standardized antimicrobial treatment guidelines may contribute to improved clinical outcomes. Our study assessed the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes.

Methods

Consecutive adult SOTRs admitted to the transplant floor from January-September 2020 and were treated for an infectious syndrome were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records. Guideline compliance was characterized as either appropriate, effective but unnecessary, undertreatment, or inappropriate.

Results

Nine hundred and thirty-six SOTR were admitted to the transplant ward, of which 328 patients (35%) received treatment for infectious syndromes. Guidelines were applicable to 252 patients, constituting 275 syndromes: 86 pneumonias; 82 urinary tract infections; 40 intra-abdominal infections; 38 bloodstream infections; and 29 C. difficile infections. 200/246 (81%) of infectious syndromes received appropriate or effective but unnecessary empiric treatment. In addition, appropriate tailoring of antimicrobials resulted in a significant difference in 30-day all-cause mortality (adjusted OR of 0.07, 95% CI 0.01-0.38; P = .002). Lastly, we found that guideline-compliant empiric therapy was found to prevent the development of multi-drug resistance in a time-dependent analysis (adjusted HR of 0.21, 95% CI 0.08-0.52; P = .001).

Conclusion

Our data show that adherence to locally developed guidelines was associated with reduced mortality and resistant-organism development in our cohort of SOTR.

Microbiology of Severe Community-Acquired Pneumonia and the Role of Rapid Molecular Techniques

The microbiology of severe community acquired pneumonia (SCAP) has implications on management, clinical outcomes and public health policy. Therefore, knowledge of the etiologies of SCAP and methods to identify these microorganisms is key. Bacteria including Streptococcus pneumoniae, Staphylococcus aureus and Enterobacteriaceae continue to be important causes of SCAP. Viruses remain the most commonly identified etiology of SCAP. Atypical organisms are also important etiologies of SCAP and are critical to identify for public health. With the increased number of immunocompromised individuals, less common pathogens may also be found as the causative agent of SCAP. Traditional diagnostic tests, including semi-quantitative respiratory cultures, blood cultures and urinary antigens continue to hold an important role in the evaluation of patients with SCAP. Many of the limitations of the aforementioned tests are addressed by rapid, molecular diagnostic tests. Molecular diagnostics utilize culture-independent technology to identify species-specific genetic sequences. These tests are often semi-automated and provide results within hours, which provides an opportunity for expedient antibiotic stewardship. The existing literature suggests molecular diagnostic techniques may improve antibiotic stewardship in CAP, and future research should investigate optimal methods for implementation of these assays into clinical practice.

Compliance with guideline recommendations in the management of patients with hospitalized community-acquired pneumonia

Compliance with guidelines in the empirical treatment for community-acquired pneumonia (CAP) is very important to increase treatment success and reduce mortality. This study aimed to determine compliance with guideline recommendations for CAP and define the role of the clinical pharmacist (CP). Patients diagnosed with CAP were evaluated retrospectively between January 2018 and January 2020 and prospectively between February 2020 and February 2021. Compliance with guidelines was evaluated according to the local, national (Turkish Thoracic Society), and international (American Thoracic Society and Infectious Disease Society of America, European Society of Clinical Microbiology and Infectious Diseases) guidelines. A total of 751 patients (423 in the retrospective and 328 in the prospective period) were included. It was determined that the 30-day mortality and length of stay were higher in patients who were not treated according to the guidelines. The compliance for empirical treatments was 16.3%-59.1% and 7.8%-30.1% in retrospective and prospective periods, respectively. During the prospective period, a total of 603 recommendations were made by CP, and 578 (95.9%) were accepted and implemented. In the prospective period, treatment duration was shortened, inappropriate fluoroquinolone use was decreased, the switch to oral treatment was increased, and the number of potential drug-drug interactions was decreased (p < 0.001). Compliance with guidelines is essential to be improved to reduce mortality, shorten the length of stay, determine the appropriate antimicrobial duration, and reduce the use of fluoroquinolones and broad-spectrum antibiotics unless necessary. CP intervention contributes to the rational selection of antimicrobials, limiting drug-drug interactions, avoiding toxicities, and compliance with guidelines.

Clinical Characteristics and Microorganisms Isolated in Community-Acquired Pneumonia in the COVID-19 Period

Introduction

Community-acquired pneumonia is a leading cause of mortality and hospital admissions. The aetiology remains unknown in 30-65% of the cases. Molecular tests are available for multiple pathogen detection and are under research to improve the causal diagnosis.

Methods

We carried out a prospective study to describe the clinical characteristics and aetiology of community-acquired pneumonia during the COVID-19 pandemic and to assess the diagnostic effectivity of the microbiological tests, including a molecular test of respiratory pathogens (FilmArray™ bioMérieux).

Results

From the 1st of February 2021 until the 31st of March 2022, 225 patients were included. Failure in microorganism identification occurred in approximately 70% of patients. Streptococcus pneumoniae was the most common isolate. There were 5 cases of viral pneumonia. The tested FilmArray exhibited a low positivity rate of 7% and mainly aided in the diagnosis of viral coinfections.

Conclusions

Despite our extensive diagnostic protocol, there is still a low rate of microorganism identification. We have observed a reduction in influenza and other viral pneumoniae during the COVID-19 pandemic. Having a high NEWS2 score on arrival at the emergency department, an active oncohematological disease or chronic neurological conditions and a positive microbiological test result were related to worse outcomes. Further research is needed to determine the role of molecular tests in the microbiological diagnosis of pneumonia.

Diagnosis and Therapy of Community-Acquired Pneumonia in the Emergency Department: A Retrospective Observational Study and Medical Audit

BACKGROUND

Despite advances in therapy, community-acquired pneumonia (CAP) is still associated with significant morbidity and mortality. Several studies conducted in different countries have reported suboptimal adherence to the guidelines. However, there are currently no available data on adherence to CAP guidelines specifically in Switzerland.

OBJECTIVES

The aim of this study was to audit the quality of diagnosis and therapy of CAP at a Swiss general hospital.

METHODS

A retrospective, observational, single-center cohort study was conducted, including patients older than 18 years diagnosed with CAP and admitted to a medical ward throughout 2019 without prior antibiotic therapy prescribed by their general practitioner (GP). The baseline characteristics of the patients were analyzed, and the diagnostic workup and treatment were compared to the Swiss guidelines for CAP.

RESULTS

A total of 254 patients diagnosed with CAP were included in this study (median age 78 years, 51.6% males). Atypical pneumonia was diagnosed in 4% of patients, while an organism was identified in 33% of cases, with Streptococcus pneumoniae being the most frequently detected pathogen (57%). A chest image was taken in almost all patients. Documentation of respiratory rate was missing in 23% of cases. Procalcitonin was measured in 23.2% of cases. Pneumococcal and legionella urinary antigen testing was performed on approximately 90% of all patients and blood cultures were drawn in approximately 80% of patients. In 39% of cases, arterial blood gas analysis was performed. Guideline adherence for the administration of empiric antibiotics was documented/recorded in 75% of cases. Twelve different antibiotic regimens were administered, and they were mostly amoxicillin/clavulanate with or without macrolides, as suggested by the guidelines. In particular, the use of ceftriaxone was higher (19.7%) compared to the Swiss guidelines. The average length of antibiotic therapy was longer (8.2 days) compared to the guidelines (5-7 days). Oral steroid therapy was administered to 29.1% of patients, including to 75% of those diagnosed with COPD.

CONCLUSION

Overall, guideline adherence was moderately low, especially with regards to the assessment of respiratory rate, performance of arterial blood gas analysis, and sputum collection. Regarding antibiotic therapy, the use of ceftriaxone and the length of antibiotic therapy should be reduced. Further research is needed to identify the reasons for guideline non-adherence, and to find effective measures for the improvement of guideline adherence.

Clinical effects of bacteremia in sepsis patients with community-acquired pneumonia

BACKGROUND

Data regarding the clinical effects of bacteremia on severe community-acquired pneumonia (CAP) are limited. Thus, we investigated clinical characteristics and outcomes of severe CAP patients with bacteremia compared with those of subjects without bacteremia. In addition, we evaluated clinical factors associated with bacteremia at the time of sepsis awareness.

METHODS

We enrolled sepsis patients diagnosed with CAP at emergency departments (EDs) from an ongoing nationwide multicenter observational registry, the Korean Sepsis Alliance, between September 2019 and December 2020. For evaluation of clinical factors associated with bacteremia, we divided eligible patients into bacteremia and non-bacteremia groups, and logistic regression analysis was performed using the clinical characteristics at the time of sepsis awareness.

RESULT

During the study period, 1,510 (47.9%) sepsis patients were caused by CAP, and bacteremia was identified in 212 (14.0%) patients. Septic shock occurred more frequently in the bacteremia group than in the non-bacteremia group (27.4% vs. 14.8%; p < 0.001). In multivariable analysis, hematologic malignancies and septic shock were associated with an increased risk of bacteremia. However, chronic lung disease was associated with a decreased risk of bacteremia. Hospital mortality was significantly higher in the bacteremia group than in the non-bacteremia group (27.3% vs. 40.6%, p < 0.001). The most prevalent pathogen in blood culture was Klebsiella pneumoniae followed by Escherichia coli in gram-negative pathogens.

CONCLUSION

The incidence of bacteremia in severe CAP was low at 14.0%, but the occurrence of bacteremia was associated with increased hospital mortality. In severe CAP, hematologic malignancies and septic shock were associated with an increased risk of bacteremia.

Derivation and external validation of a prediction model for pneumococcal urinary antigen test positivity in patients with community-acquired pneumonia

Objective

Derive and externally validate a prediction model for pneumococcal urinary antigen test (pUAT) positivity.

Methods

Retrospective cohort study of adults admitted with community-acquired pneumonia (CAP) to 177 U.S. hospitals in the Premier Database (derivation and internal validation samples) or 12 Cleveland Clinic hospitals (external validation sample). We utilized multivariable logistic regression to predict pUAT positivity in the derivation dataset, followed by model performance evaluation in both validation datasets. Potential predictors included demographics, comorbidities, clinical findings, and markers of disease severity.

Results

Of 198,130 Premier patients admitted with CAP, 27,970 (14.1%) underwent pUAT; 1962 (7.0%) tested positive. The strongest predictors of pUAT positivity were history of pneumococcal infection in the previous year (OR 6.99, 95% CI 4.27-11.46), severe CAP on admission (OR 1.76, 95% CI 1.56-1.98), substance abuse (OR 1.57, 95% CI 1.27-1.93), smoking (OR 1.23, 95% CI 1.09-1.39), and hyponatremia (OR 1.35, 95% CI 1.17-1.55). Negative predictors included IV antibiotic use in past year (OR 0.65, 95% CI 0.52-0.82), congestive heart failure (OR 0.72, 95% CI 0.63-0.83), obesity (OR 0.71, 95% CI 0.60-0.85), and admission from skilled nursing facility (OR 0.60, 95% CI 0.45-0.78). Model c-statistics were 0.60 and 0.67 in the internal and external validation cohorts, respectively. Compared to guideline-recommended testing of severe CAP patients, our model would have detected 23% more cases with 5% fewer tests.

Conclusion

Readily available data can identify patients most likely to have a positive pUAT. Our model could be incorporated into automated clinical decision support to improve test efficiency and antimicrobial stewardship.

Impact of severe lymphopenia on the early prediction of clinical outcome in hospitalized patients with pneumococcal community-acquired pneumonia

PURPOSE

To evaluate the impact of an optimal and reproducible cutoff value set according to a predefined lymphopenia scale as an early predictor of in-hospital mortality and other outcomes in patients hospitalized with pneumococcal pneumonia and positive urinary antigen at admission to the emergency department.

METHODS

An observational cohort study was conducted based on analysis of a prospective registry of consecutive immunocompetent adults hospitalized for pneumococcal pneumonia in two tertiary hospitals. Generalized additive models were constructed to assess the smooth relationship between in-hospital mortality and lymphopenia.

RESULTS

We included 1173 patients. Lymphopenia on admission was documented in 686 (58.4%). No significant differences were observed between groups regarding the presence of comorbidities. Overall, 299 (25.5%) patients were admitted to intensive care and 90 (7.6%) required invasive mechanical ventilation. Fifty-nine (5%) patients died, among them 23 (38.9%) in the first 72 h after admission. A lymphocyte count < 500/μL, documented in 282 (24%) patients, was the predefined cutoff point that best predicted in-hospital mortality. After adjustment, these patients had higher rates of intensive care admission (OR 2.9; 95% CI 1.9-4.3), invasive mechanical ventilation (OR 2.2; 95% CI 1.2-3.9), septic shock (OR 1.8; 95% CI 1.1-2.9), treatment failure (OR 2.1; 95% CI 1.2-3.5), and in-hospital mortality (OR 2.2; 95% 1.1-4.9). Severe lymphopenia outperformed PSI score in predicting early and 30-day mortality in patients classified in the higher-risk classes.

CONCLUSION

Lymphocyte count < 500/μL could be used as a reproducible predictor of complicated clinical course in patients with an early diagnosis of pneumococcal pneumonia.

Adherence to evidence-based guidelines for the management of pneumonia in a tertiary teaching hospital in Riyadh

Background

Adherence to therapeutic guidelines is crucial when treating pneumonia, as it reduces mortality rate, length of hospital stay and duration of antibiotic therapy. However, the high non-adherence rate to treatment guidelines, in general, and to the Infectious Disease Society of America (IDSA) guidelines, are still reported globally. According to our knowledge, no existing data is available regarding the rate of physicians' adherence to the IDSA guidelines for managing pneumonia in Saudi Arabia. Therefore, we aim to assess the adherence rate and the clinical outcomes among patients treated according to the IDSA guidelines, in a tertiary care center in Riyadh.

Methods

A single-centered, retrospective, cross-sectional, observational study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. All data were extracted from the hospital's electronic information system, known as Esihi. Adult patients (≥18 years old) diagnosed and treated in the hospital for community-acquired pneumonia, hospital-acquired pneumonia, or ventilator-associated pneumonia from Nov 2019 to Nov 2021 were included.

Results

A total of 148 patients were included in this study, and the management of 50% of them (74 patients) adhered to the guidelines' recommendations. Even though the patients who received guidelines-adhered management were older (70 ± 16 vs 59 ± 22; p = 0.001), and had a higher CURB-65 score for pneumonia severity (1.86 ± 1.03 vs 1.39 ± 1.26; p = 0.026) and an average calculated Charlson comorbidity index (4.62 ± 2.19 vs 3.28 ± 2.80; p = 0.001) than patients who were treated irrespectively of the guidelines, yet they had a better cure rate (95% vs 84%; adjusted OR, 3.9; 95% CI, 0.82-18.58), lower mortality (5% vs 14%; adjusted OR, 0.38; 95% CI, 0.04-4.05) and shorter length of hospital stay (LOS) (6.5 vs 8 days; p = 0.082); compared to patients who were treated irrespectively of the guidelines.

Conclusions

Comparable to previous literature, non-adherence to evidence-based guidelines has been observed in 50% of patients treated for pneumonia. Despite being nonsignificant, higher clinical cure rates, shorter LOS, and lower mortality rates have been observed in patients who were treated based on evidence-based guidelines. Further measures to improve guidelines compliance in pneumonia treatment are needed.

Adherence to use of blood cultures according to current national guidelines and their impact in patients with community acquired pneumonia: A retrospective cohort

BACKGROUND

Community acquired pneumonia (CAP) is the most frequent cause of mortality secondary to infectious etiologies. Recommendations about the use of blood cultures in the diagnosis and treatment of CAP has been a contentious topic of debate and ever-changing recommendations.

METHODS

A cohort study was conducted in a community teaching hospital. All the patients that were admitted with a diagnosis of CAP, between January and December of 2019 were included. Sociodemographic and clinical characteristics were obtained. Blood cultures results were obtained, and it was evaluated if they were done in compliance with current recommendations by the Infectious Disease Society of America (IDSA).

RESULTS

721 patients were included in the study. Median age was 68 years and 50% of the patients were male (n = 293). Patients presented from home (84%) and the most common comorbidities were hypertension and diabetes (68% and 31%). 96 patients had positive blood culture and 34% (n = 247) of all the blood cultures were adequately ordered. 80 patients died or went to hospice and the median length of hospital stay in our cohort was 7 days. The multivariate model showed that mortality was associated with positive blood cultures (OR = 3.1 95%CI 1.63-5.87) and appropriateness of blood cultures (OR = 2.96 95% CI 1.2-5.7).

CONCLUSION

Adequate use of blood cultures in patients with CAP might have some association with the outcomes of this disease. However, a prospective study evaluating the utility of this test following current IDSA recommendations is needed to understand their impact in mortality and morbidity.

Utility of Blood Culture in Patients with Community-Acquired Pneumonia: A Propensity Score-Matched Analysis Based on a Japanese National Health Insurance Database

Community-acquired pneumonia (CAP) is an acute pulmonary parenchymal infection acquired outside the hospital. The utility of blood cultures in inpatients with CAP to reduce mortality and length of hospital stay is controversial. This study aimed to determine the utility of blood cultures on the first day of hospitalization for CAP inpatients and its influence on mortality, length of hospital stay, and antibiotics use. We conducted a fact-finding survey on the implementation of blood culture in inpatients with CAP in Japan. A propensity score (PS)-matched analysis based on the National Database of Health Insurance Claims and Specific Health Check-ups of Japan database was conducted. Overall, 163173 patients were included in the analysis, and PS matching extracted 68104 pairs. The results of the comparison between the PS-matched blood culture group and PS-matched control group were as follows: mortality and length of hospital stay were significantly lower in the PS-matched blood culture group than in the control group. The adjusted odds ratio (OR) (95% confidence interval (CI)) for in-hospital mortality with blood culture test was 0.73 (0.68-0.79). Moreover, for days of antibiotic usage, number of antibiotics used were significantly higher in the PS-matched blood culture group than that in the control group. Our findings indicated that performing a blood culture on the first day of hospitalization for inpatients with CAP was associated with reduced mortality. To our knowledge, this is the largest epidemiological study to assess the utility of blood culture in Japanese inpatients with CAP. This testing method shows potential for application in clinical practice.

Urinary Antigen Testing for Respiratory Infections: Current Perspectives on Utility and Limitations

Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (>90%) and moderate sensitivity (<80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.

New testing guidelines for community-acquired pneumonia

PURPOSE OF REVIEW

The purpose of this article is to review diagnostic testing recommendations outlined in the current American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) community-acquired pneumonia (CAP) guideline and the 2021 ATS guideline for noninfluenza respiratory viruses.

RECENT FINDINGS

Diagnostic testing in CAP with gram stain, lower respiratory and blood cultures, Streptococcal and Legionella urinary antigens are not routinely recommended unless identified as severe CAP or with risk factors for Methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa infection. Influenza virus testing remains a strong recommendation during periods of community viral spread.An additional 2021 ATS clinical practice guideline reviewed the use of molecular testing for noninfluenza viral pathogens in adults with suspected CAP and recommended testing in those hospitalized with severe CAP and/or various immunocompromising conditions.

SUMMARY

Diagnostic testing remains an important component of confirming and treating CAP. The CAP guideline includes recommendations surrounding diagnostic testing with lower respiratory gram stain and culture, blood cultures, Legionella and Pneumococcal urinary antigen, influenza viral testing and serum procalcitonin.There is a strong recommendation to obtain influenza virus testing during periods of community spread. However, the use of other diagnostics such as gram stain, lower respiratory and blood culture, and urinary antigen testing are dependent on severity of illness and whether a patient has been identified as having strong risk factors for MRSA or P. aeruginosa infection. The 2021 ATS clinical practice document did not routinely recommend testing noninfluenza respiratory viruses unless identified as having severe CAP and/or various immunocompromising conditions.

Use of a smartphone app to inform healthcare workers of hospital policy during a pandemic such as COVID-19: A mixed methods observational study

Objective

To evaluate the use of a COVID-19 app containing relevant information for healthcare workers (HCWs) in hospitals and to determine user experience.

Methods

A smartphone app (Firstline) was adapted to exclusively contain local COVID-19 policy documents and treatment protocols. This COVID-19 app was offered to all HCWs of a 900-bed tertiary care hospital. App use was evaluated with user analytics and user experience in an online questionnaire.

Results

A total number of 1168 HCWs subscribed to the COVID-19 app which was used 3903 times with an average of 1 minute and 20 seconds per session during a three-month period. The number of active users peaked in April 2020 with 1017 users. Users included medical specialists (22.3%), residents (16.5%), nurses (22.2%), management (6.2%) and other (26.5%). Information for HCWs such as when to test for SARS-CoV-2 (1214), latest updates (1181), the COVID-19 telephone list (418) and the SARS-CoV-2 / COVID-19 guideline (280) were the most frequently accessed advice. Seventy-one users with a mean age of 46.1 years from 19 different departments completed the questionnaire. Respondents considered the COVID-19 app clear (54/59; 92%), easy-to-use (46/55; 84%), fast (46/52; 88%), useful (52/56; 93%), and had faith in the information (58/70; 83%). The COVID-19 app was used to quickly look up something (43/68; 63%), when no computer was available (15/68; 22%), look up / dial COVID-related phone numbers (15/68; 22%) or when walking from A to B (11/68; 16%). Few respondents felt app use cost time (5/68; 7%).

Conclusions

Our COVID-19 app proved to be a relatively simple yet innovative tool that was used by HCWs from all disciplines involved in taking care of COVID-19 patients. The up-to-date app was used for different topics and had high user satisfaction amongst questionnaire respondents. An app with local hospital policy could be an invaluable tool during a pandemic.

Impact of Streptococcus pneumoniae Urinary Antigen Testing in Patients With Community-Acquired Pneumonia Admitted Within a Large Academic Health System

Background

Limited data support use of pneumococcal urinary antigen testing (PUAT) for patients with community-acquired pneumonia (CAP) as an antimicrobial stewardship tool. At our institution, CAP guidelines and admission order set were standardized to include universal PUAT.

Methods

This was a retrospective study of adults hospitalized in 2019 who had PUAT performed. We compared incidence and timing of de-escalation in PUAT- positive vs -negative groups and described patients’ outcomes.

Results

We evaluated 910 patients, 121 (13.3%) of whom were PUAT positive. No difference in baseline characteristics, including severity of illness, was observed between groups. Initial de-escalation occurred in 82.9% and 81.2% of PUAT-positive and -negative patients, respectively (P = .749). Median time to de-escalation was shorter in the PUAT-positive group (1 [interquartile range {IQR}, 0–2] day vs 1 [IQR, 1–2] day, P = .01). Within 24 hours of PUAT, more patients in the PUAT-positive group had atypical coverage discontinued (61.3% vs 47.2%, P = .026) without difference in methicillin-resistant Staphylococcus aureus (MRSA) agent discontinuation (or antipseudomonal de-escalation). Among the PUAT-positive group, unadjusted analysis demonstrated shorter median length of stay in patients who were de-escalated compared to those who were not (6 [IQR, 4–10] vs 8 [IQR, 7–12] days, P = .0005), without difference in the incidence of Clostridioides difficile, in-hospital mortality, or 30-day infection-related readmission.

Conclusions

We observed earlier de-escalation in the PUAT-positive group. This seems to be due to discontinuation of atypical rather than anti-MRSA or antipseudomonal coverage. Further antimicrobial stewardship interventions are warranted.

Guía de práctica clínica para el manejo de la neumonía adquirida en la comunidad

La neumonía sigue siendo una de las principales causas de consulta y de hospitalización a la que, además de su un alto impacto en términos de morbilidad y mortalidad, se suma la actual problemática de resistencia a los antimicrobianos, por lo que establecer directrices que permitan su adecuado diagnóstico y tratamiento es de gran importancia para obtener mejores desenlaces clínicos y promover un uso racional de antibióticos en estos pacientes. La presente guía de práctica clínica (GPC) contiene recomendaciones basadas en la evidencia para el diagnóstico y tratamiento de la neumonía adquirida en la comunidad en adultos, las cuales fueron realizadas mediante el proceso de adaptación de GPC basadas en la evidencia para el contexto colombiano.

Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.

Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.

Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.

Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region

OBJECTIVE

The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations.

PATIENTS AND METHODS

An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED.

RESULTS

A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients.

CONCLUSION

Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion.

Health Care-Associated Pneumonia: Is It Still a Useful Concept?

"Health care-associated pneumonia (HCAP) was introduced into guidelines because of concerns about the increasing prevalence of drug-resistant pathogens (DRPs) not covered by standard empirical therapy. We now know that DRPs are very localized phenomena with low rates in most sites. Although HCAP risk factors are associated with a higher mortality, this is driven by comorbidities rather than the pathogens. Empirical coverage of DRPs has generally not resulted in better patient outcomes. A far more nuanced approach must be taken for patients with risk factors for DRPs taking into account the local cause and severity of disease.

Use of an innovative and non-invasive device for virologic sampling of cough aerosols in patients with community and hospital acquired pneumonia: a pilot study

BACKGROUND

The aetiology of lower respiratory tract infections is challenging to investigate. Despite the wide array of diagnostic tools, invasive techniques, such as bronchoalveolar lavage (BAL), are often required to obtain adequate specimens. PneumoniaCheckTM is a new device that collects aerosol particles from cough, allowing microbiological analyses. Up to now it has been tested only for bacteria detection, but no study has investigated its usefulness for virus identification.

METHODS

In this pilot study we included 12 consecutive patients with pneumonia. After testing cough adequacy via a peak flow meter, a sampling with PneumoniaCheckTM was collected and a BAL was performed in each patient. Microbiological analyses for virus identification were performed on each sample and concordance between the two techniques was tested (sensitivity, specificity and positive/negative predictive values), taking BAL results as reference.

RESULTS

BAL was considered adequate in 10 patients. Among them, a viral pathogen was identified by PneumoniaCheckTM 6 times, each on different samples, whereas BAL allowed to detect the presence of a virus on 7 patients (14 positivities). Overall, the specificity for PneumoniaCheckTM to detect a virus was 100%, whereas the sensitivity was 66%. When considering only herpes viruses, PneumoniaCheckTM showed a lower sensitivity, detecting a virus in 1/4 of infected patients (25%).

CONCLUSIONS

In this pilot study PneumoniaCheckTM showed a good correlation with BAL for non-herpes virologic identification in pneumonia patients, providing excellent specificity. Further studies on larger population are needed to confirm these results and define its place in the panorama of rapid diagnostic tests for lower respiratory tract infections.

Determining best outcomes from community-acquired pneumonia and how to achieve them

Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.

Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study

BACKGROUND

The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections.

METHODS

Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use.

RESULTS

Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing.

CONCLUSIONS

Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.