Initial management of and outcome in patients with pneumococcal bacteremia: a retrospective study at a Swiss university hospital, 2003-2009

The coverage of influenza and pneumococcal vaccinations among people living with HIV in Denmark: A single-center cross-sectional survey

Annual influenza vaccination is recommended for all people living with HIV (PLWH), and so is pneumococcal vaccination at least once. This is due to higher incidence rates for both infections among PLWH, compared to HIV negative, even in the later highly active antiretroviral therapy era. To clarify the uptake of and attitude toward both vaccines among PLWH in Denmark, a survey on self-reported vaccine uptake was performed during 2017. Analyses identifying factors associated with vaccine uptake in the latest season for 203 participants were performed. Both influenza and pneumococcal vaccination uptake are low among PLWH in Denmark, 31.0% and 4.4%, respectively. Previous vaccination against influenza had the highest impact on influenza vaccine uptake, and lack of immunization guidance lowers the likelihood. Interventions to improve vaccination coverage are needed, such as increased awareness about guidelines and physician education.

Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures

BACKGROUND

Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes.

METHODS

We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days.

RESULTS

We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups.

CONCLUSIONS

Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes.

LEVEL OF EVIDENCE

Level III prognostic.

A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Outcomes of Patients With Severe Bacterial Infections

BACKGROUND

Patients with severe bacterial infections often experience delay in receiving appropriate treatment. Consolidated evidence of the impact of delayed appropriate treatment is needed to guide treatment and improve outcomes.

RESEARCH QUESTION

What is the impact of delayed appropriate antibacterial therapy on clinical outcomes in patients with severe bacterial infections?

STUDY DESIGN AND METHODS

Literature searches of MEDLINE and Embase, conducted on July 24, 2018, identified studies published after 2007 reporting the impact of delayed appropriate therapy on clinical outcomes for hospitalized adult patients with bacterial infections. Where appropriate, results were pooled and analyzed with delayed therapy modeled three ways: delay vs no delay in receiving appropriate therapy; duration of delay; and inappropriate vs appropriate initial therapy. This article reports meta-analyses on the effect of delay and duration of delay.

RESULTS

The eligibility criteria were met by 145 studies, of which 37 contributed data to analyses of effect of delay. Mortality was significantly lower in patients receiving appropriate therapy without delay compared with those experiencing delay (OR, 0.57; 95% CI, 0.45-0.72). Mortality was also lower in the no-delay group compared with the delay group in subgroups of studies reporting mortality at 20 to 30 days, during ICU stay, or in patients with bacteremia (OR, 0.57 [95% CI, 0.43-0.76]; OR, 0.47 [95% CI, 0.27-0.80]; and OR, 0.54 [95% CI, 0.40-0.75], respectively). No difference was found in time to appropriate therapy between those who died and those who survived (P = .09), but heterogeneity between studies was high.

INTERPRETATION

Avoiding delayed appropriate therapy is essential to reduce mortality in patients with severe bacterial infections.

CLINICAL TRIAL REGISTRATION

PROSPERO; No.: CRD42018104669; URL: www.crd.york.ac.uk/prospero/.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

OBJECTIVE

To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012."

DESIGN

A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

METHODS

The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

RESULTS

The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.

CONCLUSIONS

Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

OBJECTIVE

To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".

DESIGN

A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

METHODS

The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.

RESULTS

The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.

CONCLUSIONS

Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

The Roles of the Charlson Comorbidity Index and Time to First Antibiotic Dose as Predictors of Outcome in Pneumococcal Community-Acquired Pneumonia

PURPOSE

In this retrospective study, we aimed to investigate the role of comorbidities using the Charlson comorbidity index (CCI) and time to first antibiotic dose (TFAD) in patients with pneumococcal community-acquired pneumonia (PCAP).

METHODS

All consecutive ER admissions with PCAP who were hospitalized in the University Hospital, Zurich between 2006 and 2012 were included. The primary outcome was to determine possible determinants of all-cause in-hospital mortality (ACIHM). The second endpoint was to detect risk factors for adverse events (AEs) and determinants of length of stay (LOS).

RESULTS

108 subjects (mean age 57.6 years) were included. The median (IQR) CCI was 4 (1, 8). The median (IQR) TFAD was 210 (150, 280) min. ACIHM was 6.5 % (7/108), and median (IQR) LOS was 9 (6, 14) days. PCAP-related AEs were observed in 57 cases (52.8 %). In the multivariable analysis, neither CCI nor TFAD was associated with the outcome measures. Pneumonia severity index (PSI) was the only statistically significant predictor of ACIHM (HR 1.31/10 point increase, 95 % CI 1.12-1.53, p = 0.001) and AE rate (OR 1.31, 95 % CI 1.15-1.50, p < 0.001).

CONCLUSIONS

In this study including comparatively young patients with rather mild disease severity, we found no strong evidence supporting that CCI or TFAD influenced short-term outcome measures of PCAP. Yet, pneumonia severity appears to be the most important factor for the outcome.

Management of severe non-TB bacterial infection in HIV-infected adults

Despite widespread antiretroviral therapy use, severe bacterial infections (SBI) in HIV-infected adults continue to cause significant morbidity and mortality globally. Four main pathogens account for the majority of documented SBI: Streptococcus pneumoniae, non-typhoidal strains of Salmonella enterica, Escherichia coli and Staphylococcus aureus. The epidemiology of SBI is dynamic, both in developing countries where, despite dramatic successes in antiretroviral therapy, coverage is far from complete, and in settings in both resource-poor and resource-rich countries where antiretroviral therapy failure is becoming increasingly common. Throughout the world, this complexity is further compounded by rapidly emerging antimicrobial resistance, making management of SBI very challenging in these vulnerable patients. We review the causes and treatment of SBI in HIV-infected people and discuss future developments in this field.

Alcoholism: A systemic proinflammatory condition

Excessive ethanol consumption affects virtually any organ, both by indirect and direct mechanisms. Considerable research in the last two decades has widened the knowledge about the paramount importance of proinflammatory cytokines and oxidative damage in the pathogenesis of many of the systemic manifestations of alcoholism. These cytokines derive primarily from activated Kupffer cells exposed to Gram-negative intestinal bacteria, which reach the liver in supra-physiological amounts due to ethanol-mediated increased gut permeability. Reactive oxygen species (ROS) that enhance the inflammatory response are generated both by activation of Kupffer cells and by the direct metabolic effects of ethanol. The effects of this increased cytokine secretion and ROS generation lie far beyond liver damage. In addition to the classic consequences of endotoxemia associated with liver cirrhosis that were described several decades ago, important research in the last ten years has shown that cytokines may also induce damage in remote organs such as brain, bone, muscle, heart, lung, gonads, peripheral nerve, and pancreas. These effects are even seen in alcoholics without significant liver disease. Therefore, alcoholism can be viewed as an inflammatory condition, a concept which opens the possibility of using new therapeutic weapons to treat some of the complications of this devastating and frequent disease. In this review we examine some of the most outstanding consequences of the altered cytokine regulation that occurs in alcoholics in organs other than the liver.

Pneumococcal vertebral osteomyelitis at three teaching hospitals in Japan, 2003-2011: analysis of 14 cases and a review of the literature

BACKGROUND

Pneumococcal vertebral osteomyelitis (PVO) is a rare disease whose clinical characteristics have not been clarified. This study aimed to investigate the clinical features and outcomes of patients with PVO.

METHODS

We retrospectively evaluated all adult patients diagnosed with PVO at three teaching hospitals in Japan from January 2003 to December 2011. All cases were identified through a review of the medical records of patients with invasive pneumococcal disease (IPD).

RESULTS

Among 208 patients with IPD, we identified 14 with PVO (6.4%; 95% CI, 3.5-10%). All 14 patients (nine male, five female; median age 69 years) had acquired PVO outside the hospital and had no recent history of an invasive procedure or back injury. Five patients (36%) had diabetes mellitus, and four (29%) had heavy alcohol intake. Fever (n = 13; 93%) or back pain/neck pain (n = 12; 86%) were present in most patients. The lumbar spine was affected in nine patients (64%) but the cervical spine was the site of infection in four patients (29%). All patients except one had a positive blood culture for Streptococcus pneumoniae, and there were no distant infected sites in most patients (n = 10; 71%). Intravenous beta-lactam therapy was initiated within 1 week after the onset of symptoms in 11 patients (79%). No patients died within 30 days, but one patient died from aspiration pneumonia on day 37 after admission.

CONCLUSIONS

PVO was relatively common among adult patients with IPD, and mortality was low in this study. S. pneumoniae may be the causative pathogen of vertebral osteomyelitis, especially among community-onset cases without a history of invasive procedures or back injury.

An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy

The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.

Pneumococcal infection--low awareness as a potential barrier to vaccination: results of a European study

INTRODUCTION

Elderly people and adults with chronic disease or compromised immune status are at increased risk of pneumococcal infection, with pneumonia being the most common serious presentation and a significant cause of morbidity and mortality. Most European countries have recommendations for pneumococcal vaccination but vaccination rates have remained low. In the present article, the authors present the results of a European survey that investigated the current level of awareness of pneumococcal infection among primary care physicians and specialists, and attitudes to vaccination in these physicians and members of the general public aged >50 years.

METHODS

Primary care physicians (n = 1,300) and specialists (n = 926) from 13 Western European countries participated in online/face-to-face interviews, and a further 6,534 individuals aged >50 years from a population sample reflecting local socio-demographic structure participated in telephone/face-to-face interviews.

RESULTS

Pneumonia was the most well-known of the pneumococcal infections amongst primary care physicians and specialists. However, there was a relatively low awareness of the term invasive pneumococcal disease (IPD), with only 50% of primary care physicians and 71% of specialists reporting knowledge of the term IPD. Key factors influencing a physician's decision to prescribe pneumococcal vaccination were the patient's health condition, recommendations from health authorities, and the tolerability of the vaccine. Perceptions regarding vaccination were good amongst the members of the general public; individuals did not fear vaccines or their side effects. The main drivers for vaccination were recommendations from a healthcare professional and, to a lesser extent, that vaccination provides reassurance against contracting a disease.

CONCLUSION

These findings highlight the low awareness of the term IPD in comparison with individual pneumococcal conditions. Given the importance of physician recommendations in encouraging patients to be vaccinated, primary care physicians need to be vigilant of patients at risk of pneumococcal infections in order to increase vaccination rates.

Association of levofloxacin resistance with mortality in adult patients with invasive pneumococcal diseases: a post hoc analysis of a prospective cohort

OBJECTIVE

This study was conducted to identify risk factors for mortality and to evaluate the impact of antimicrobial resistance on outcome in adult patients with invasive pneumococcal disease (IPD).

METHODS

A post hoc analysis of an observational cohort study on community-acquired pneumococcal infections was conducted and a total of 136 adult patients with IPD were analyzed in this study.

RESULTS

Pneumonia was the most common type of infection (n = 84, 61.8 %), followed by primary bacteremia (n = 15, 11.0 %) and meningitis (n = 15, 11.0 %). One hundred and three patients (75.7 %) had concomitant pneumococcal bacteremia. The overall 30-day mortality rate was 26.5 % (36/136), and factors associated with 30-day mortality were corticosteroid use, presentation with septic shock, and development of acute respiratory distress syndrome (ARDS) (all P < 0.05). While penicillin and erythromycin resistance were associated with a lower mortality, an association between levofloxacin resistance and increased mortality was found in the univariate analysis; however, statistical significance was not reached (P = 0.083). Multivariable analysis showed that presentation with septic shock, corticosteroid use, development of ARDS, and levofloxacin resistance were independent factors associated with 30-day mortality. Of the five patients with IPD caused by levofloxacin-resistant Streptococcus pneumoniae, three (60 %) died within 30 days of diagnosis.

CONCLUSION

Levofloxacin resistance was associated with increased mortality, along with septic shock, prior use of corticosteroids, and development of ARDS, in adult patients with IPD. Our data suggest that the emergence of levofloxacin resistance among invasive pneumococcal isolates is now becoming a challenge for clinicians managing community-acquired bacterial infections.