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Fisher JE, Shaheen S, Yau E, Gavigan P. Significance of Procalcitonin in Hospitalized Children With Respiratory Syncytial Virus. Pediatr Infect Dis J 2024; 43:e381-e382. [PMID: 38986000 DOI: 10.1097/inf.0000000000004460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Affiliation(s)
- James E Fisher
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Eric Yau
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Patrick Gavigan
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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Williams A, Repetto E, Lebbie I, Khalife M, Jensen TO. Are C-reactive protein and procalcitonin safe and useful for antimicrobial stewardship purposes in patients with COVID-19? A scoping review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e129. [PMID: 39290622 PMCID: PMC11406566 DOI: 10.1017/ash.2024.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 09/19/2024]
Abstract
Objective The primary objectives of this study were to assess the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) in the diagnosis of bacterial co-infections in coronavirus disease 2019 (COVID-19) and if their incorporation in antimicrobial stewardship (AMS) programs is safe and useful, stratified by severity of disease as level of care, intensive care unit (ICU) or non-ICU. Our secondary objectives were to identify cut-off values for antibiotic decision-making and identify reported results from low- and middle-income countries (LMICs). Design A scoping review of published literature, adhering to the PRISMA statement for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. The last search was performed in January 2024. Results Fifty-nine studies were included in this scoping review: 20 studies reporting predictive values and/or sensitivity/specificity results for PCT, 8 reporting clear objectives on AMS, and 3 studies from LMICs. Conclusion In the context of non-ICU hospitalized COVID-19 patients in high-income countries, a PCT value below 0.25 mg/L can be a useful tool to rule out bacterial co-infection. The wide range of reported negative predictive values suggests that PCT should be interpreted in the context of other clinical findings. Our results do not support the use of CRP in the same manner as PCT. There is a clear need for more studies in LMICs.
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Affiliation(s)
- Anita Williams
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
- Middle East Medical Unit, Médecins Sans Frontières, Beirut, Lebanon
- Luxembourg Operational Research (LuxOR) Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - Ernestina Repetto
- Infectious Diseases Department, Université Libre de Bruxelles (ULB), CHU Saint-Pierre, Brussels, Belgium
| | - Ishmael Lebbie
- Kenema Project, Médecins Sans Frontières, Operational Centre Brussels, Kenema City, Sierra Leone
| | - Mohamad Khalife
- Middle East Medical Unit, Médecins Sans Frontières, Beirut, Lebanon
| | - Tomas Oestergaard Jensen
- Medical Department, Médecins Sans Frontières, Operational Center Paris, Paris, France
- Center of Excellence for Health, Immunity, and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Sandoe JAT, Grozeva D, Albur M, Bond SE, Brookes-Howell L, Dark P, Euden J, Hamilton R, Hellyer TP, Henley J, Hopkins S, Howard P, Howdon D, Knox-Macaulay C, Llewelyn MJ, Maboshe W, McCullagh IJ, Ogden M, Parsons HK, Partridge DG, Powell N, Prestwich G, Shaw D, Shinkins B, Szakmany T, Thomas-Jones E, Todd S, West RM, Carrol ED, Pallmann P. A retrospective propensity-score-matched cohort study of the impact of procalcitonin testing on antibiotic use in hospitalized patients during the first wave of COVID-19. J Antimicrob Chemother 2024:dkae246. [PMID: 39248146 DOI: 10.1093/jac/dkae246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/14/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Procalcitonin (PCT) is a blood marker used to help diagnose bacterial infections and guide antibiotic treatment. PCT testing was widely used/adopted during the COVID-19 pandemic in the UK. OBJECTIVES Primary: to measure the difference in length of early (during first 7 days) antibiotic prescribing between patients with COVID-19 who did/did not have baseline PCT testing during the first wave of the pandemic. Secondary: to measure differences in length of hospital/ICU stay, mortality, total days of antibiotic prescribing and resistant bacterial infections between these groups. METHODS Multi-centre, retrospective, observational, cohort study using patient-level clinical data from acute hospital Trusts/Health Boards in England/Wales. Inclusion: patients ≥16 years, admitted to participating Trusts/Health Boards and with a confirmed positive COVID-19 test between 1 February 2020 and 30 June 2020. RESULTS Data from 5960 patients were analysed: 1548 (26.0%) had a baseline PCT test and 4412 (74.0%) did not. Using propensity-score matching, baseline PCT testing was associated with an average reduction in early antibiotic prescribing of 0.43 days [95% confidence interval (CI): 0.22-0.64 days, P < 0.001) and of 0.72 days (95% CI: 0.06-1.38 days, P = 0.03] in total antibiotic prescribing. Baseline PCT testing was not associated with increased mortality or hospital/ICU length of stay or with the rate of antimicrobial-resistant secondary bacterial infections. CONCLUSIONS Baseline PCT testing appears to have been an effective antimicrobial stewardship tool early in the pandemic: it reduced antibiotic prescribing without evidence of harm. Our study highlights the need for embedded, rapid evaluations of infection diagnostics in the National Health Service so that even in challenging circumstances, introduction into clinical practice is supported by evidence for clinical utility. STUDY REGISTRATION NUMBER ISRCTN66682918.
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Affiliation(s)
- Jonathan A T Sandoe
- Department of Microbiology, The General Infirmary at Leeds, Leeds, UK
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Detelina Grozeva
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mahableshwar Albur
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Stuart E Bond
- Pharmacy Department, Mid Yorkshire Teaching NHS Trust, Wakefield, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Joanne Euden
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Ryan Hamilton
- Antibiotic Research UK, York, UK
- School of Pharmacy, De Montfort University, Leicester, UK
| | - Thomas P Hellyer
- Royal Victoria Infirmary, Newcastle and Freeman Hospital, Newcastle-upon-Tyne Hospital NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Josie Henley
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Philip Howard
- NHS England and NHS Improvement, North-East and Yorkshire Region, UK
| | - Daniel Howdon
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Chikezie Knox-Macaulay
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Wakunyambo Maboshe
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Iain J McCullagh
- Royal Victoria Infirmary, Newcastle and Freeman Hospital, Newcastle-upon-Tyne Hospital NHS Foundation Trust, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Margaret Ogden
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Helena K Parsons
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David G Partridge
- Department of Microbiology, Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Foundation Trust, Truro, UK
| | - Graham Prestwich
- Public and Patient Involvement Representative, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Dominick Shaw
- Leicester NIHR Biomedical Research Centre and Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Bethany Shinkins
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tamas Szakmany
- Critical Care Directorate, Aneurin Bevan University Health Board, Cwmbran, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Stacy Todd
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Robert M West
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Behal ML, Flannery AH, Miano TA. The times are changing: A primer on novel clinical trial designs and endpoints in critical care research. Am J Health Syst Pharm 2024; 81:890-902. [PMID: 38742701 PMCID: PMC11383190 DOI: 10.1093/ajhp/zxae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Michael L Behal
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Todd A Miano
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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5
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Kwak H, Kwon WY, Jo YH, Kim S, Suh GJ, Kim KS, Jung YS, Lee HJ, Kim JY. Afebrile status at the time of emergency department visit is associated with delayed antibiotic therapy in patients with sepsis (revised). Am J Emerg Med 2024; 83:69-75. [PMID: 38976929 DOI: 10.1016/j.ajem.2024.06.031] [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: 02/15/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 07/10/2024] Open
Abstract
OBJECTIVES To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients. METHODS This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records. RESULTS We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46-2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34-2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01). CONCLUSIONS Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients.
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Affiliation(s)
- Hyeongkyu Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Public Health and Medical Service, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Sola Kim
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea; Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hui Jai Lee
- SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Adami ME, Giamarellos-Bourboulis EJ, Polyzogopoulou E. Towards improved point-of-care (POC) testing for patients with suspected sepsis: POC tests for host biomarkers and possible microbial pathogens. Expert Rev Mol Diagn 2024:1-11. [PMID: 39135402 DOI: 10.1080/14737159.2024.2392283] [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: 06/12/2024] [Accepted: 08/11/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Sepsis is a heterogeneous syndrome often misdiagnosed. Point-of-care (POC) diagnostic tests are commonly used to guide decision and include host biomarkers and molecular diagnostics. AREAS COVERED The diagnostic and prognostic accuracy of established and emerging biomarkers for sepsis, including procalcitonin (PCT) soluble urokinase plasminogen activator receptor (suPAR), presepsin, TRAIL/IP-10/CRP, MxA, and MxA-CRP, are analyzed in this review. The clinical utility of the two prevalent molecular techniques for pathogens identification using polymerase chain reaction (PCR) assays is also presented: FILMARRAY and QIAstat-Dx RP. EXPERT OPINION The rising benefits of the combined use of POC biomarkers with molecular diagnostics in daily clinical routine appear to outperform conventional practices in terms of reduced turnaround time, timely diagnosis, and prompt administration of the appropriate treatment. Yet, this must be further demonstrated in future investigations. However, the cost-effectiveness of POC tests and the high rate of false positive and negative results, indicate the need for a comprehensive clinical evaluation.
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Affiliation(s)
- Maria-Evangelia Adami
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Effie Polyzogopoulou
- Department of Emergency Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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7
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Clauss S, Bourlet S, Jaffal K, Duran C, D'Anglejan E, Perronne V, Bouchand F, Noussair L, Dahmane L, Dinh A. Real-life impact on antimicrobial prescription of Syndromic Molecular Testing in adults hospitalized in infectious disease departments. Respiratory Syndromic Molecular Testing panel: Is it worth it? Infect Dis Now 2024; 54:104933. [PMID: 38801977 DOI: 10.1016/j.idnow.2024.104933] [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: 04/10/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND While sensitive molecular diagnostic tests enable accurate and rapid diagnosis of many respiratory viruses, their impact on antibiotic management remains uncertain. Our study aimed to evaluate the impact of respiratory syndromic molecular testing panel in real-life clinical practice. METHOD Retrospective descriptive study involving consecutive hospitalized patients in an infectious disease department who had been prescribed a respiratory syndromic molecular testing panel on nasopharyngeal swab samples (FilmArray Respiratory Panel 2 plus) during hospitalization from October 1st, 2021, to February 28th, 2023. RESULTS All in all, 94 out of 210 screened patients were included in the study. Syndromic molecular testing results influenced antibiotic treatment in seven cases: discontinuation in four cases (three virus identifications), changes in two (Mycoplasma pneumoniae positive cases), and initiation in two (negative viral PCRs and one positive bacterial culture). CONCLUSION In our study, respiratory syndromic molecular testing had low impact on antibiotic modification.
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Affiliation(s)
- Séverine Clauss
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Stéphane Bourlet
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Karim Jaffal
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Clara Duran
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Emma D'Anglejan
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Véronique Perronne
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Frédérique Bouchand
- Pharmacy, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Latifa Noussair
- Microbiological Laboratory, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Lotfi Dahmane
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University
| | - Aurélien Dinh
- Infectious disease department, University R. Poincaré Hospital, Garches, APHP, Paris Saclay University.
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8
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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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9
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Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J. European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists). Clin Microbiol Infect 2024:S1198-743X(24)00251-9. [PMID: 39029872 DOI: 10.1016/j.cmi.2024.05.014] [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: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/21/2024]
Abstract
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.
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Affiliation(s)
- Teske Schoffelen
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany; Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Khalid Eljaaly
- Department of Pharmacy Practice, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pharmacy, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mical Paul
- Infectious Diseases, Rambam Health Care Campus, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Emma Keuleyan
- Department of Clinical Microbiology and Virology, University Hospital Lozenetz, Sofia, Bulgaria; Ministry of Health, Sofia, Bulgaria
| | | | - Nathan Peiffer-Smadja
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, IAME, Paris, France; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Carlos Palos
- Infection Control and Antimicrobial Resistance Committee, Hospital da Luz, Lisbon, Portugal
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, WI, USA
| | - Bojana Beovic
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eric Batard
- Emergency Department, CHU Nantes, Nantes, France; Cibles et Médicaments des Infections et du Cancer, IICiMed UR1155, Nantes Université, Nantes, France
| | - Fredrik Resman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Marlies Hulscher
- IQ Health Science Department, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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10
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Halder A, Liesenfeld O, Whitfield N, Uhle F, Schenz J, Mehrabi A, Schmitt FCF, Weigand MA, Decker SO. A 29-mRNA host-response classifier identifies bacterial infections following liver transplantation - a pilot study. Langenbecks Arch Surg 2024; 409:185. [PMID: 38865015 PMCID: PMC11169022 DOI: 10.1007/s00423-024-03373-1] [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: 03/09/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Infections are common complications in patients following liver transplantation (LTX). The early diagnosis and prognosis of these infections is an unmet medical need even when using routine biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT). Therefore, new approaches are necessary. METHODS In a prospective, observational pilot study, we monitored 30 consecutive patients daily between days 0 and 13 following LTX using the 29-mRNA host classifier IMX-BVN-3b that determine the likelihood of bacterial infections and viral infections. True infection status was determined using clinical adjudication. Results were compared to the accuracy of CRP and PCT for patients with and without bacterial infection due to clinical adjudication. RESULTS Clinical adjudication confirmed bacterial infections in 10 and fungal infections in 2 patients. 20 patients stayed non-infected until day 13 post-LTX. IMX-BVN-3b bacterial scores were increased directly following LTX and decreased until day four in all patients. Bacterial IMX-BVN-3b scores detected bacterial infections in 9 out of 10 patients. PCT concentrations did not differ between patients with or without bacterial, whereas CRP was elevated in all patients with significantly higher levels in patients with bacterial infections. CONCLUSION The 29-mRNA host classifier IMX-BVN-3b identified bacterial infections in post-LTX patients and did so earlier than routine biomarkers. While our pilot study holds promise future studies will determine whether these classifiers may help to identify post-LTX infections earlier and improve patient management. CLINICAL TRIAL NOTATION German Clinical Trials Register: DRKS00023236, Registered 07 October 2020, https://drks.de/search/en/trial/DRKS00023236.
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Affiliation(s)
- Amelie Halder
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | | | | | - Florian Uhle
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Judith Schenz
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Heidelberg University, Medical Faculty Heidelberg, Department of General, Visceral & Transplantation Surgery, Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Felix C F Schmitt
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sebastian O Decker
- Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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11
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Li J, Xiong A, Wang J, Wu X, Bai L, Zhang L, He X, Li G. Deciphering the microbial landscape of lower respiratory tract infections: insights from metagenomics and machine learning. Front Cell Infect Microbiol 2024; 14:1385562. [PMID: 38846353 PMCID: PMC11153674 DOI: 10.3389/fcimb.2024.1385562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/29/2024] [Indexed: 06/09/2024] Open
Abstract
Background Lower respiratory tract infections represent prevalent ailments. Nonetheless, current comprehension of the microbial ecosystems within the lower respiratory tract remains incomplete and necessitates further comprehensive assessment. Leveraging the advancements in metagenomic next-generation sequencing (mNGS) technology alongside the emergence of machine learning, it is now viable to compare the attributes of lower respiratory tract microbial communities among patients across diverse age groups, diseases, and infection types. Method We collected bronchoalveolar lavage fluid samples from 138 patients diagnosed with lower respiratory tract infections and conducted mNGS to characterize the lung microbiota. Employing various machine learning algorithms, we investigated the correlation of key bacteria in patients with concurrent bronchiectasis and developed a predictive model for hospitalization duration based on these identified key bacteria. Result We observed variations in microbial communities across different age groups, diseases, and infection types. In the elderly group, Pseudomonas aeruginosa exhibited the highest relative abundance, followed by Corynebacterium striatum and Acinetobacter baumannii. Methylobacterium and Prevotella emerged as the dominant genera at the genus level in the younger group, while Mycobacterium tuberculosis and Haemophilus influenzae were prevalent species. Within the bronchiectasis group, dominant bacteria included Pseudomonas aeruginosa, Haemophilus influenzae, and Klebsiella pneumoniae. Significant differences in the presence of Pseudomonas phage JBD93 were noted between the bronchiectasis group and the control group. In the group with concomitant fungal infections, the most abundant genera were Acinetobacter and Pseudomonas, with Acinetobacter baumannii and Pseudomonas aeruginosa as the predominant species. Notable differences were observed in the presence of Human gammaherpesvirus 4, Human betaherpesvirus 5, Candida albicans, Aspergillus oryzae, and Aspergillus fumigatus between the group with concomitant fungal infections and the bacterial group. Machine learning algorithms were utilized to select bacteria and clinical indicators associated with hospitalization duration, confirming the excellent performance of bacteria in predicting hospitalization time. Conclusion Our study provided a comprehensive description of the microbial characteristics among patients with lower respiratory tract infections, offering insights from various perspectives. Additionally, we investigated the advanced predictive capability of microbial community features in determining the hospitalization duration of these patients.
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Affiliation(s)
- Jiahuan Li
- Clinical Medicine Department, North Sichuan Medical College, Nanchong, China
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Anying Xiong
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Chengdu third people’s hospital branch of National Clinical Research Center for Respiratory Disease, Affiliated Hospital of ChongQing Medical University, Chengdu, China
| | - Junyi Wang
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Chengdu third people’s hospital branch of National Clinical Research Center for Respiratory Disease, Affiliated Hospital of ChongQing Medical University, Chengdu, China
| | - Xue Wu
- Clinical Medicine Department, North Sichuan Medical College, Nanchong, China
| | - Lingling Bai
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Lei Zhang
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Chengdu third people’s hospital branch of National Clinical Research Center for Respiratory Disease, Affiliated Hospital of ChongQing Medical University, Chengdu, China
| | - Xiang He
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Chengdu third people’s hospital branch of National Clinical Research Center for Respiratory Disease, Affiliated Hospital of ChongQing Medical University, Chengdu, China
- National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guoping Li
- Clinical Medicine Department, North Sichuan Medical College, Nanchong, China
- Laboratory of Allergy and Precision Medicine, Chengdu Institute of Respiratory Health, the Third People’s Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, Chengdu third people’s hospital branch of National Clinical Research Center for Respiratory Disease, Affiliated Hospital of ChongQing Medical University, Chengdu, China
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12
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Diehl-Wiesenecker E, Galtung N, Dickescheid J, Prpic M, Somasundaram R, Kappert K, Bauer W. Blood calprotectin as a biomarker for infection and sepsis - the prospective CASCADE trial. BMC Infect Dis 2024; 24:496. [PMID: 38755564 PMCID: PMC11100246 DOI: 10.1186/s12879-024-09394-x] [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: 02/07/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Early in the host-response to infection, neutrophils release calprotectin, triggering several immune signalling cascades. In acute infection management, identifying infected patients and stratifying these by risk of deterioration into sepsis, are crucial tasks. Recruiting a heterogenous population of patients with suspected infections from the emergency department, early in the care-path, the CASCADE trial aimed to evaluate the accuracy of blood calprotectin for detecting bacterial infections, estimating disease severity, and predicting clinical deterioration. METHODS In a prospective, observational trial from February 2021 to August 2022, 395 patients (n = 194 clinically suspected infection; n = 201 controls) were enrolled. Blood samples were collected at enrolment. The accuracy of calprotectin to identify bacterial infections, and to predict and identify sepsis and mortality was analysed. These endpoints were determined by a panel of experts. RESULTS The Area Under the Receiver Operating Characteristic (AUROC) of calprotectin for detecting bacterial infections was 0.90. For sepsis within 72 h, calprotectin's AUROC was 0.83. For 30-day mortality it was 0.78. In patients with diabetes, calprotectin had an AUROC of 0.94 for identifying bacterial infection. CONCLUSIONS Calprotectin showed notable accuracy for all endpoints. Using calprotectin in the emergency department could improve diagnosis and management of severe infections, in combination with current biomarkers. CLINICAL TRIAL REGISTRATION NUMBER DRKS00020521.
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Affiliation(s)
- Eva Diehl-Wiesenecker
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Benjamin Franklin Campus, Zentrale Notaufnahme und Aufnahmestation, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Noa Galtung
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Benjamin Franklin Campus, Zentrale Notaufnahme und Aufnahmestation, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Johannes Dickescheid
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Benjamin Franklin Campus, Zentrale Notaufnahme und Aufnahmestation, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Monika Prpic
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Benjamin Franklin Campus, Zentrale Notaufnahme und Aufnahmestation, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Kai Kappert
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Wolfgang Bauer
- Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Benjamin Franklin Campus, Zentrale Notaufnahme und Aufnahmestation, Hindenburgdamm 30, 12203, Berlin, Germany.
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13
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Hunold KM, Rozycki E, Brummel N. Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department. Emerg Med Clin North Am 2024; 42:231-247. [PMID: 38641389 PMCID: PMC11212456 DOI: 10.1016/j.emc.2024.02.001] [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] [Indexed: 04/21/2024]
Abstract
Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.
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Affiliation(s)
- Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, 376 W 10th Avenue, 760 Prior Hall, Columbus, OH 43220, USA.
| | - Elizabeth Rozycki
- Emergency Medicine, Department of Pharmacy, The Ohio State University, 376 W 10th Avenue, 760 Prior Hall, Columbus, OH 43220, USA
| | - Nathan Brummel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University, 376 W 10th Avenue, 760 Prior Hall, Columbus, OH 43220, USA
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14
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Jiang J, Shu H, Wang DW, Hui R, Li C, Ran X, Wang H, Zhang J, Nie S, Cui G, Xiang D, Shao Q, Xu S, Zhou N, Li Y, Gao W, Chen Y, Bian Y, Wang G, Xia L, Wang Y, Zhao C, Zhang Z, Zhao Y, Wang J, Chen S, Jiang H, Chen J, Du X, Chen M, Sun Y, Li S, Ding H, Ma X, Zeng H, Lin L, Zhou S, Ma L, Tao L, Chen J, Zhou Y, Guo X. Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis. SCIENCE CHINA. LIFE SCIENCES 2024; 67:913-939. [PMID: 38332216 DOI: 10.1007/s11427-023-2421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/25/2023] [Indexed: 02/10/2024]
Abstract
Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.
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Affiliation(s)
- Jiangang Jiang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hongyang Shu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dao Wen Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Rutai Hui
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chenze Li
- Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Xiao Ran
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jing Zhang
- Fuwai Huazhong Cardiovascular Hospital, Zhengzhou, 450003, China
| | - Shaoping Nie
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Guanglin Cui
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dingcheng Xiang
- Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qun Shao
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Shengyong Xu
- Union Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ning Zhou
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yuming Li
- Taida Hospital, Tianjin, 300457, China
| | - Wei Gao
- Peking University Third Hospital, Beijing, 100191, China
| | - Yuguo Chen
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Yuan Bian
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Guoping Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Liming Xia
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yan Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chunxia Zhao
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhiren Zhang
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Yuhua Zhao
- Kanghua Hospital, Dongguan, Guangzhou, 523080, China
| | - Jianan Wang
- Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shaoliang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Hong Jiang
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Jing Chen
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Xianjin Du
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Mao Chen
- West China Hospital, Sichuan University, Chengdu, 610044, China
| | - Yinxian Sun
- First Hospital of China Medical University, Shenyang, 110002, China
| | - Sheng Li
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hu Ding
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xueping Ma
- General Hospital of Ningxia Medical University, Yinchuan, 750003, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li Lin
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shenghua Zhou
- The Second Xiangya Hospital, Central South University, Changsha, 410012, China
| | - Likun Ma
- The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230002, China
| | - Ling Tao
- The First Affiliated Hospital of Air Force Medical University, Xi'an, 710032, China
| | - Juan Chen
- Central Hospital of Wuhan City, Wuhan, 430014, China
| | - Yiwu Zhou
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaomei Guo
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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15
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Allel K, Hernández-Leal MJ, Naylor NR, Undurraga EA, Abou Jaoude GJ, Bhandari P, Flanagan E, Haghparast-Bidgoli H, Pouwels KB, Yakob L. Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review. BMJ Glob Health 2024; 9:e013205. [PMID: 38423548 PMCID: PMC10910705 DOI: 10.1136/bmjgh-2023-013205] [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: 06/22/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs CONCLUSION Robust information on ABR interventions is critical for efficient resource allocation. We highlight cost-effective strategies for mitigating ABR in hospitals, emphasising substantial knowledge gaps, especially in low-income and middle-income countries. Our study serves as a resource for guiding future cost-effectiveness study design and analyses.PROSPERO registration number CRD42020341827 and CRD42022340064.
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Affiliation(s)
- Kasim Allel
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
- Institute for Global Health, University College London, London, UK
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - María José Hernández-Leal
- Department of Community, Maternity and Paediatric Nursing, University of Navarra, Pamplona, Spain
- Millennium Nucleus on Sociomedicine, Santiago, Chile
| | - Nichola R Naylor
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London, UK
| | - Eduardo A Undurraga
- Escuela de Gobierno, Pontificia Universidad Catolica de Chile, Santiago, Chile
- CIFAR Azrieli Global Scholars program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
| | | | - Priyanka Bhandari
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ellen Flanagan
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Koen B Pouwels
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- The National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Laith Yakob
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
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16
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Bessat C, Bingisser R, Schwendinger M, Bulaty T, Fournier Y, Della Santa V, Pfeil M, Schwab D, Leuppi JD, Geigy N, Steuer S, Roos F, Christ M, Sirova A, Espejo T, Riedel H, Atzl A, Napieralski F, Marti J, Cisco G, Foley RA, Schindler M, Hartley MA, Fayet A, Garcia E, Locatelli I, Albrich WC, Hugli O, Boillat-Blanco N. PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial. Trials 2024; 25:86. [PMID: 38273319 PMCID: PMC10809691 DOI: 10.1186/s13063-023-07795-y] [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: 07/19/2023] [Accepted: 11/09/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.
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Affiliation(s)
- Cécile Bessat
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Roland Bingisser
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | | | - Tim Bulaty
- Emergency Department, Cantonal Hospital of Baden, Baden, Switzerland
| | - Yvan Fournier
- Emergency Department, Intercantonal Hospital of Broye, Payerne, Switzerland
| | | | - Magali Pfeil
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Dominique Schwab
- Emergency Department, Hospital Riviera-Chablais, Rennaz, Switzerland
| | - Jörg D Leuppi
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department and University Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Stephan Steuer
- Emergency Department, St Claraspital, Basel, Switzerland
| | | | - Michael Christ
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Adriana Sirova
- Emergency Department, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Henk Riedel
- Emergency Department, University Hospital of Basel, Basel, Switzerland
| | - Alexandra Atzl
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Fabian Napieralski
- Emergency Department, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Joachim Marti
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Giulio Cisco
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Rose-Anna Foley
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- School of Health Sciences HESAV, University of Applied sciences of Western Switzerland, HES-SO, Lausanne, Switzerland
| | - Melinée Schindler
- Qualitative research platform, social sciences sector, Department of Epidemiology and Health Services, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Mary-Anne Hartley
- Intelligent Global Health Research Group, Machine Learning and Optimization Laboratory, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Aurélie Fayet
- Clinical Research Center (CRC), University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Elena Garcia
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- Health Economics and Policy Unit, Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases & Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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17
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Lüthi-Corridori G, Roth AI, Boesing M, Jaun F, Tarr PE, Leuppi-Taegtmeyer AB, Leuppi JD. Diagnosis and Therapy of Community-Acquired Pneumonia in the Emergency Department: A Retrospective Observational Study and Medical Audit. J Clin Med 2024; 13:574. [PMID: 38276080 PMCID: PMC10816545 DOI: 10.3390/jcm13020574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 01/27/2024] Open
Abstract
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.
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Affiliation(s)
- Giorgia Lüthi-Corridori
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Andrea I. Roth
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Maria Boesing
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Fabienne Jaun
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
| | - Philip E. Tarr
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
- University Center for Internal Medicine, Infectious Diseases and Hospital Epidemiology Service, Cantonal Hospital Baselland, 4101 Bruderholz, Switzerland
| | - Anne B. Leuppi-Taegtmeyer
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
- Department of Patient Safety, Medical Directorate, University Hospital Basel, 4031 Basel, Switzerland
| | - Jörg D. Leuppi
- University Institute of Internal Medicine (UIIM), Cantonal Hospital Baselland, 4410 Liestal, Switzerland; (G.L.-C.); (A.I.R.); (M.B.); (F.J.); (A.B.L.-T.)
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland;
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18
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Salachas C, Gounane C, Beduneau G, Lopinto J, Turpin M, Amiel C, Cuvelier A, Gueudin M, Voiriot G, Fartoukh M. Diagnostic yield of viral multiplex PCR during acute exacerbation of COPD admitted to the intensive care unit: a pilot study. Sci Rep 2024; 14:1057. [PMID: 38212620 PMCID: PMC10784589 DOI: 10.1038/s41598-024-51465-1] [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: 03/09/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024] Open
Abstract
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is one of the leading causes of admission to the intensive care unit, often triggered by a respiratory tract infection of bacterial or viral aetiology. Managing antibiotic therapy in this context remains a challenge. Respiratory panel molecular tests allow identifying viral aetiologies of AECOPD. We hypothesized that the systematic use of a respiratory multiplex PCR (mPCR) would help antibiotics saving in severe AECOPD. Our objectives were to describe the spectrum of infectious aetiologies of severe AECOPD, using a diagnostic approach combining conventional diagnostic tests and mPCR, and to measure antibiotics exposure. The study was bicentric, prospective, observational, and included 105 critically ill patients with a severe AECOPD of presumed infectious aetiology, in whom a respiratory mPCR with a viral panel was performed in addition to conventional microbiological tests. Altogether, the microbiological documentation rate was 50%, including bacteria alone (19%), respiratory viruses alone (16%), and mixed viruses and bacterial species (16%). The duration of antibiotic therapy was shorter in patients without documented bacterial infection (5.6 vs. 9 days; P = 0.0006). This pilot study suggests that molecular tests may help for the proper use of anti-infective treatments in critically ill patients with severe AECOPD.
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Affiliation(s)
- Costa Salachas
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France
| | - Cherifa Gounane
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France
| | - Gaëtan Beduneau
- Département de Médecine Intensive Réanimation, Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, 76000, Rouen, France
| | - Julien Lopinto
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France
| | - Matthieu Turpin
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France
| | - Corinne Amiel
- Assistance Publique - Hôpitaux de Paris, Département de Virologie, Hôpital Tenon, 75020, Paris, France
| | - Antoine Cuvelier
- Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, Service de Soins Intensifs Respiratoires, Rouen, France
| | - Marie Gueudin
- Département de Virologie, Normandie Univ, UNIROUEN, UNICAEN, UMR1311 INSERM DYNAMICURE, CHU Rouen, Rouen, France
| | - Guillaume Voiriot
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France
- Sorbonne Université, Paris, France
| | - Muriel Fartoukh
- Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 4, Rue de La Chine, 75020, Paris, France.
- Sorbonne Université, Paris, France.
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19
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Rogers MB, Harner A, Buhay M, Firek B, Methé B, Morris A, Palmer OMP, Promes SB, Sherwin RL, Southerland L, Vieira AR, Yende S, Morowitz MJ, Huang DT. The salivary microbiota of patients with acute lower respiratory tract infection-A multicenter cohort study. PLoS One 2024; 19:e0290062. [PMID: 38206940 PMCID: PMC10783762 DOI: 10.1371/journal.pone.0290062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/01/2023] [Indexed: 01/13/2024] Open
Abstract
The human microbiome contributes to health and disease, but the oral microbiota is understudied relative to the gut microbiota. The salivary microbiota is easily accessible, underexplored, and may provide insight into response to infections. We sought to determine the composition, association with clinical features, and heterogeneity of the salivary microbiota in patients with acute lower respiratory tract infection (LRTI). We conducted a multicenter prospective cohort study of 147 adults with acute LRTI presenting to the emergency department of seven hospitals in three states (Pennsylvania, Michigan, and Ohio) between May 2017 and November 2018. Salivary samples were collected in the emergency department, at days 2-5 if hospitalized, and at day 30, as well as fecal samples if patients were willing. We compared salivary microbiota profiles from patients to those of healthy adult volunteers by sequencing and analyzing bacterial 16-rRNA. Compared to healthy volunteers, the salivary microbiota of patients with LRTI was highly distinct and strongly enriched with intestinal anaerobes such as Bacteroidaceae, Ruminococcaceae, and Lachnospiraceae (e.g., mean 10% relative abundance of Bacteroides vs < 1% in healthy volunteers). Within the LRTI population, COPD exacerbation was associated with altered salivary microbiota composition compared to other LRTI conditions. The largest determinant of microbiota variation within the LRTI population was geography (city in which the hospital was located).
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Affiliation(s)
- Matthew B. Rogers
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Ashley Harner
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Megan Buhay
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Brian Firek
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Barbara Methé
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Alison Morris
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | | | - Susan B. Promes
- Pennsylvania State University, State College, Pennsylvania, United States of America
| | | | - Lauren Southerland
- The Ohio State University Wexner Medical Center, Columbus, Ohio, United States of America
| | - Alexandre R. Vieira
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Sachin Yende
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Michael J. Morowitz
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - David T. Huang
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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20
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Schuetz P. The Value of a Biomarker Should be Judged on What it Adds to the Clinical Assessment: Not the Area Under the Curve. Crit Care Med 2024; 52:e30-e31. [PMID: 38095530 DOI: 10.1097/ccm.0000000000006035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Department of Clinical Research (DKF), University of Basel, Basel, Switzerland
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21
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Kwa ALH, Aninda Sidharta BR, Son DN, Zirpe K, Periyasamy P, Plongla R, Swaminathan S, Loho T, Van Giap V, Apisarnthanarak A. Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations. Expert Rev Anti Infect Ther 2024; 22:45-58. [PMID: 38112181 DOI: 10.1080/14787210.2023.2296066] [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: 05/29/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions. AREAS COVERED Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges. EXPERT OPINION Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.
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Affiliation(s)
- Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases Program, Duke-National University of Singapore Medical School, Singapore, Singapore
| | | | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital; Hanoi Medical University; School of Medicine and Pharmacy, Hanoi National University, Hanoi, Vietnam
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, India
| | - Petrick Periyasamy
- Infectious Diseases Unit, Medical Department, Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia
| | - Rongpong Plongla
- Division of Infectious Diseases, Department of Medicine and Center of Excellence in Antimicrobial Resistance and Stewardship; Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Tonny Loho
- Department of Clinical Pathology, Medistra Hospital; Medicine and Health Sciences, Universitas Kristen Krida Wacana, Jakarta, Indonesia
| | - Vu Van Giap
- Training and Direction of Healthcare Activities Center; Internal Medicine Department, Hanoi Medical University; Vietnam Respiratory Society; Vietnam Society of Sleep Medicine; Respiratory Center, Bach Mai Hospital, Hanoi, Vietnam
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22
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Wee LE, Lye DC, Lee V. Developments in pneumonia and priorities for research. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1046-1047. [PMID: 38030373 DOI: 10.1016/s2213-2600(23)00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Liang En Wee
- National Centre for Infectious Diseases, Singapore; Duke-NUS Graduate Medical School, National University of Singapore, Singapore; Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - David Chien Lye
- National Centre for Infectious Diseases, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Vernon Lee
- National Centre for Infectious Diseases, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Communicable Diseases Group, Ministry of Health, 169854, Singapore.
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23
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Heren JE, Lund BC, Alexander B, Livorsi DJ. Procalcitonin Monitoring and Antibiotic Duration in Presumed Lower Respiratory Tract Infections: A Propensity Score-Matched Cohort Across the Veterans Health Administration. Open Forum Infect Dis 2023; 10:ofad520. [PMID: 37942465 PMCID: PMC10629903 DOI: 10.1093/ofid/ofad520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
Background Randomized controlled trials have shown that procalcitonin-guided algorithms can reduce antibiotic duration for lower respiratory tract infections (LRTIs). The goal of this study was to compare antibiotic duration for LRTIs with and without procalcitonin testing in real-life practice. Methods This retrospective cohort study included all acute care hospital admissions for presumed LRTIs between 1/2018 and 12/2021 at 81 Veterans Affairs facilities with on-site procalcitonin testing. The exposure was procalcitonin testing; the primary outcome was antibiotic duration. We used 1:1 nearest-neighbor propensity score matching to estimate the difference in outcome between procalcitonin-tested and nontested patients. Results A total of 35 610 patients with LRTIs were included (6015 [16.9%] with procalcitonin testing; 29 595 [83.1%] without testing). In tested patients, the median number of procalcitonin levels checked (interquartile range) was 2 (1-3). The mean antibiotic duration was 10.0 days in the procalcitonin group compared with 8.3 days in nontested patients (unadjusted difference, 1.7 days; P < .0001). After propensity score matching with 3903 pairs, antibiotic duration remained greater in the procalcitonin group (9.6 days vs 9.2 days; P < .0001). In a subgroup analysis of 2241 tested patients with a procalcitonin value at the standard threshold for antibiotic discontinuation, antibiotic duration was shorter in tested vs nontested patients, with a mean difference of 0.1 days (P < .01). Conclusions In this retrospective propensity-matched cohort of patients with presumed LRTIs across a geographically diverse group of hospitals, patients who underwent procalcitonin testing did not have a meaningful reduction in antibiotic duration compared with those who were not tested. Poor implementation of procalcitonin testing may have undermined its effectiveness.
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Affiliation(s)
- Jamie E Heren
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brian C Lund
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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24
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Miyazaki T, Fukushima K, Hashiguchi K, Ide S, Kobayashi T, Sawai T, Yatera K, Kohno Y, Fukuda Y, Futsuki Y, Matsubara Y, Koga H, Mihara T, Sasaki E, Ashizawa N, Hirayama T, Takazono T, Yamamoto K, Imamura Y, Kaku N, Kosai K, Morinaga Y, Yanagihara K, Mukae H. A high α1-antitrypsin/interleukin-10 ratio predicts bacterial pneumonia in adults with community-acquired pneumonia: a prospective cohort study. Pneumonia (Nathan) 2023; 15:16. [PMID: 37876022 PMCID: PMC10599029 DOI: 10.1186/s41479-023-00118-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Current microbiological tests fail to identify the causative microorganism in more than half of all pneumonia cases. We explored biomarkers that could be used for differentiating between bacterial and viral pneumonia in patients with community-acquired pneumonia (CAP). METHODS In this prospective cohort study conducted in Japan, data obtained from adult patients with bacterial pneumonia, including bacterial and viral coinfections (bacterial pneumonia [BP] group), and purely viral pneumonia (VP group) at diagnosis were analyzed using multivariate logistic regression analysis to identify predictors of bacterial pneumonia. Furthermore, a decision tree was developed using the predictors. RESULTS A total of 210 patients were analyzed. The BP and VP groups comprised 108 and 18 patients, respectively. The other 84 patients had no identified causative microorganism. The two groups shared similar characteristics, including disease severity; however, a significant difference (p < 0.05) was observed between the two groups regarding sputum type; sputum volume score; neutrophil counts; and serum levels of interleukin (IL)-8, IL-10, and α1-antitrypsin (AAT). Sputum volume score (p < 0.001), IL-10 (p < 0.001), and AAT (p = 0.008) were ultimately identified as predictors of BP. The area under the curve for these three variables on the receiver operating characteristic (ROC) curve was 0.927 (95% confidence interval [CI]: 0.881-0.974). The ROC curve for sputum volume score and an AAT/IL-10 ratio showed a diagnostic cutoff of 1 + and 65, respectively. Logistic regression analysis using dichotomized variables at the cutoff values showed that the odds ratios for the diagnosis of BP were 10.4 (95% CI: 2.2-50.2) for sputum volume score (absence vs. presence) and 19.8 (95% CI: 4.7-83.2) for AAT/IL-10 ratio (< 65 vs. ≥ 65). CONCLUSIONS Considering that obtaining a definitive etiologic diagnosis with the current testing methods is difficult and time consuming, a decision tree with two predictors, namely sputum volume and the AAT/IL-10 ratio, can be useful in predicting BP among patients diagnosed with CAP and facilitating the appropriate use of antibiotics. TRIAL REGISTRATION UMIN000034673 registered on November 29, 2018.
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Affiliation(s)
- Taiga Miyazaki
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan.
| | | | | | - Shotaro Ide
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Isahaya General Hospital, Isahaya, Japan
| | | | | | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | | | | | | | | | | | | | | | - Nobuyuki Ashizawa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuro Hirayama
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuko Yamamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- First Department of Internal Medicine, Division of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus Graduate School of Medicine, Okinawa, Japan
| | - Yoshifumi Imamura
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Medical Education Development Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Norihito Kaku
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kosuke Kosai
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoshitomo Morinaga
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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25
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Hanson KE, Banerjee R, Doernberg SB, Evans SR, Komarow L, Satlin MJ, Schwager N, Simner PJ, Tillekeratne LG, Patel R. Priorities and Progress in Diagnostic Research by the Antibacterial Resistance Leadership Group. Clin Infect Dis 2023; 77:S314-S320. [PMID: 37843119 PMCID: PMC10578045 DOI: 10.1093/cid/ciad541] [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] [Indexed: 10/17/2023] Open
Abstract
The advancement of infectious disease diagnostics, along with studies devoted to infections caused by gram-negative and gram-positive bacteria, is a top scientific priority of the Antibacterial Resistance Leadership Group (ARLG). Diagnostic tests for infectious diseases are rapidly evolving and improving. However, the availability of rapid tests designed to determine antibacterial resistance or susceptibility directly in clinical specimens remains limited, especially for gram-negative organisms. Additionally, the clinical impact of many new tests, including an understanding of how best to use them to inform optimal antibiotic prescribing, remains to be defined. This review summarizes the recent work of the ARLG toward addressing these unmet needs in the diagnostics field and describes future directions for clinical research aimed at curbing the threat of antibiotic-resistant bacterial infections.
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Affiliation(s)
- Kimberly E Hanson
- Division of Infectious Diseases, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Division of Clinical Microbiology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Scott R Evans
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Lauren Komarow
- George Washington University Biostatistics Center, Rockville, Maryland, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Nyssa Schwager
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Patricia J Simner
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - L Gayani Tillekeratne
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Papp M, Kiss N, Baka M, Trásy D, Zubek L, Fehérvári P, Harnos A, Turan C, Hegyi P, Molnár Z. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis. Crit Care 2023; 27:394. [PMID: 37833778 PMCID: PMC10576288 DOI: 10.1186/s13054-023-04677-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients. METHODS We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes. RESULTS We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively). CONCLUSIONS PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.
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Affiliation(s)
- Márton Papp
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Saint John's Hospital, Budapest, Hungary
| | - Nikolett Kiss
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Máté Baka
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - Domonkos Trásy
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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Chew CR, Patel D, Rynarzewska AI, Jones L. Procalcitonin Use for Predicting Mortality and Morbidity of Patients Diagnosed With Sepsis Within the Intensive Care Unit. Cureus 2023; 15:e48080. [PMID: 38046497 PMCID: PMC10690065 DOI: 10.7759/cureus.48080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Objective Infections leading to severe sepsis and septic shock are among the top five causes requiring admission to the intensive care unit (ICU). Up to 40% of ICU admissions contain a sepsis diagnosis. Without a clear marker to diagnose and manage sepsis, procalcitonin has been extensively studied for its usefulness in the management of bacterial infections. These studies, however, have been focused toward how it can be used to help guide when antibiotics should be initiated and de-escalated. There, however, has not been a study on how this biomarker could be used to predict mortality, and morbidity and help guide a need for antibiotic escalation. Design A retrospective chart review was conducted on patients admitted to the ICU at Northeast Georgia Medical Center between January 1, 2019, to June 30, 2021. Inclusion criteria were all patients above the age of 18 admitted to the ICU with a diagnosis of sepsis and having at least two procalcitonin drawn within 10 days of each other. Exclusion criteria were any patient with a diagnosis of COVID-19. Data Analysis was conducted to identify how delta procalcitonin could identify mortality and morbidity and if there was any change in antibiotics based on the delta procalcitonin. Conclusion There was a statistically significant association between a delta positive procalcitonin and increased ICU length of stay. There was no statistical significance in expiration based on the antibiotic change in relationship to delta positive change in procalcitonin.
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Affiliation(s)
- Christopher R Chew
- Critical Care, Louisiana State University (LSU) Shreveport, Shreveport, USA
| | - Dhaval Patel
- Critical Care, Northeast Georgia Medical Center Gainsville, Gainesville, USA
| | | | - Louise Jones
- Research, Northeast Georgia Medical Center Gainsville, Gainesville, USA
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Halabi S, Shiber S, Paz M, Gottlieb TM, Barash E, Navon R, Ilan-Ber T, Shani L, Petersiel N, Grupper M, Simon E, Kirshner D, Haber D, Stein M, Maor Y, Guetta C, Lishtzinsky Y, Yanai S, Drescher MJ, Oved K, Eden E, Neuberger A, Paul M. Host test based on tumor necrosis factor-related apoptosis-inducing ligand, interferon gamma-induced protein-10 and C-reactive protein for differentiating bacterial and viral respiratory tract infections in adults: diagnostic accuracy study. Clin Microbiol Infect 2023; 29:1159-1165. [PMID: 37270059 DOI: 10.1016/j.cmi.2023.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 05/10/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To assess the performance of a test (called BV), integrating the blood levels of three immune proteins into a score, to differentiate bacterial from viral infection among adults with suspected lower respiratory tract infection (LRTI). METHODS Prospective diagnostic accuracy study, enrolling febrile adults >18 years with LRTI signs or symptoms for less than 7 days presenting to several hospitals' emergency departments in Israel. The main exclusion criterion was immunodeficiency. Reference standard diagnosis (bacterial/viral/indeterminate) was based on three experts independently reviewing comprehensive patient data including follow-up data. BV generated three results: viral infection or other nonbacterial condition (0 ≤ score < 35), equivocal (35 ≤ score ≤ 65) and bacterial infection including co-infection (65 < score ≤ 100). BV performance was assessed against the reference standard with indeterminate reference standard and equivocal BV cases removed. RESULTS Of 490 enrolled patients, 415 met eligibility criteria (median age 56 years, interquartile range 35). The reference standard classified 104 patients as bacterial, 210 as viral and 101 as indeterminate. BV was equivocal in 9.6% (30/314). Excluding indeterminate reference standard diagnoses and equivocal BV results, BV's sensitivity for bacterial infection was 98.1% (101/103; 95% confidence interval 95.4-100), specificity 88.4% (160/181; 83.7-93.1) and negative predictive value 98.8% (160/162; 97.1-100). DISCUSSION BV exhibited high diagnostic performance for febrile adults with suspected LRTI among patients with reference standard diagnoses of bacterial or viral LRTI.
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Affiliation(s)
- Salim Halabi
- Emergency Department, Carmel Medical Center, Haifa, Israel
| | - Shachaf Shiber
- Emergency Department, Rabin Medical Center, Petah Tikvah, Israel
| | | | | | | | | | | | | | - Neta Petersiel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Mordechai Grupper
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | | | - Daniel Kirshner
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Haber
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | | | - Yasmin Maor
- Infectious Disease Unit, Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claire Guetta
- Emergency Department, Rabin Medical Center, Petah Tikvah, Israel
| | - Ynon Lishtzinsky
- Emergency Department, Rabin Medical Center, Petah Tikvah, Israel
| | - Shirly Yanai
- Emergency Department, Rabin Medical Center, Petah Tikvah, Israel
| | | | | | | | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Raupach D, Joean O, Fuge J, Welte T, Rademacher J. Point-of-care procalcitonin testing for lower respiratory tract infection in pulmonary outpatient care has limited value. Pneumologie 2023; 77:550-553. [PMID: 37315574 DOI: 10.1055/a-2095-3321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Lower respiratory tract infections (LRTI) are frequently the reasons for patients to visit their general practitioners or lung specialists; however, physicians tend to prescribe antibiotics less frequently than necessary. A readily available biomarker could help distinguish between viral and bacterial cause of LRTI. The primary objective of our study was to determine the diagnostic accuracy of point-of-care testing (POCT) of procalcitonin (PCT) in identifying bacterial pneumonia in outpatients with LRTI. All patients aged 18 years or older with signs and symptoms of LRTI who visited a respiratory physician were included in the study and their PCT levels were measured. In 110 patients enrolled in the study, three patients (2.7%) had PCT values above the threshold of 0.25 µg/L without proven bacterial infection, in contrast to seven patients with typical radiological signs of pneumonia without elevated POCT PCT levels. The AUC for PCT for the detection of pneumonia was 0.56 (p=0.685). POCT PCT showed limited specificity and sensitivity in distinguishing pneumonia from bronchitis or exacerbation of chronic respiratory diseases. PCT is a marker of severe bacterial infections and not suitable for milder infections in outpatient care.
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Affiliation(s)
- David Raupach
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
| | - Oana Joean
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
- BREATH, German Center for Lung Research, Hannover, Germany
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jessica Rademacher
- Respiratory medicine and Infectious disease, Hannover Medical School, Hannover, Germany
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Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [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: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
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Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
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Montes-Moreno S, Climent F, Fraga M, Luis Patier J, Robles-Marhuenda Á, García-Sanz R, Ocio EM, González García A, Navarro JT. Expert consensus on the integrated diagnosis of idiopathic multicentric Castleman disease. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2023; 56:158-167. [PMID: 37419554 DOI: 10.1016/j.patol.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 07/09/2023]
Abstract
Idiopathic multicentric Castleman disease (iMCD) is rare. The differential diagnosis includes inflammatory, autoimmune and neoplastic disease. The identification of the histopathological features of Castleman disease in the lymph node is the main diagnostic criterion. Fifty-three experts from three medical societies (SEMI, SEHH and SEAP) have created a multi-disciplinary consensus document in order to standardise the diagnosis of Castleman disease. Using the Delphi method, specific recommendations for the initial clinical, laboratory and imaging studies have been made for an integrated diagnosis of iMCD as well as for the best way to obtain samples for histopathological confirmation, correct laboratory procedure and interpretation and reporting of results.
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Affiliation(s)
- Santiago Montes-Moreno
- Servicio de Anatomía Patológica y Laboratorio Hematopatología Traslacional, Hospital Universitario Marqués de Valdecilla/IDIVAL, Centro para la Investigación Biomédica CIBERONC, Santander, Spain.
| | - Fina Climent
- Departmento de Anatomía Patológica, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Máximo Fraga
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Santiago de Compostela, Departamento Forense, Anatomía Patológica, Ginecología, Obstetricia y Pediatría, Facultad de Medicina de Santiago de Compostela, Spain
| | - José Luis Patier
- Unidad de Enfermedades Autoinmune Sistémicas y Minoritarias, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá de Henares, Madrid, Spain
| | | | - Ramón García-Sanz
- Departmento de Hematología, Hospital Universitario de Salamanca, Centro para la Investigación del Cáncer (CiC-IBMCC, CSIC/USAL), Centro para la Investigación Médica CIBERONC, Instituto de Investigación Biomédica de Salamanca (IBSAL), Spain
| | - Enrique M Ocio
- Departamento de Hematologia, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Andrés González García
- Unidad de Enfermedades Autoinmune Sistémicas y Minoritarias, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - José-Tomás Navarro
- Laboratorio de Hematología, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Instituto para la Investigación de la Leucemia Josep Carreras, Spain
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Saura O, Luyt CE. Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections. Expert Rev Respir Med 2023; 17:651-661. [PMID: 37639716 DOI: 10.1080/17476348.2023.2251394] [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: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms. AREAS COVERED In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure. EXPERT OPINION Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMRS_1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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Su P, Hu P, Xu L, Zhang B. Diagnostic and prognostic value of deregulated long non-coding RNA RPPH1 in patients with severe community-acquired pneumonia: a retrospective cohort study. BMC Pulm Med 2023; 23:201. [PMID: 37291525 DOI: 10.1186/s12890-023-02507-3] [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: 02/09/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Severe community-acquired pneumonia (SCAP) is one of the most common critical and acute diseases in the respiratory and acute medicine department. The expression and significance of lncRNA RPPH1 (RPPH1) in SCAP were assessed aiming to explore a biomarker assisting in the screening and management of SCAP. METHODS This study is a retrospective study enrolled 97 SCAP patients, 102 mild community-acquired pneumonia (MCAP) patients, and 65 healthy individuals. The serum expression of RPPH1 of study subjects was evaluated using PCR. The diagnostic and prognostic significance of RPPH1 in SCAP was evaluated by ROC and Cox analyses. Meanwhile, the correlation of RPPH1 with patients' clinicopathological features was evaluated by spearman correlation analysis to evaluate its role in assessing disease severity. RESULTS A significant downregulation of RPPH1 was observed in the serum of SCAP patients compared with MCAP and healthy individuals. RPPH1 was positively correlated with ALB (r = 0.74) and negatively correlated with C-reactive protein (r = -0.69), neutrophil-to-lymphocyte ratio (r = -0.88), procalcitonin (r = -0.74), and neutrophil (r = -0.84) of SCAP patients, which are associated with the development and severity of SCAP. Additionally, reduced RPPH1 was closely associated with the 28-day development-free survival of SCAP patients and served as an adverse prognostic indicator together with procalcitonin. CONCLUSIONS Downregulated RPPH1 in SCAP could act as a diagnostic biomarker screening SCAP from healthy and MCAP individuals and act as a prognostic biomarker predicting patients' disease conditions and outcomes. The demonstrated significance of RPPH1 in SCAP could assist the clinical antibiotic therapies of SCAP patients.
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Affiliation(s)
- Pengtao Su
- Department of Emergency, Binzhou Medical University Hospital, No.661 Huanghe 2nd Road, Binzhou, 256600, China
| | - Pengbo Hu
- Department of Emergency, Binzhou Medical University Hospital, No.661 Huanghe 2nd Road, Binzhou, 256600, China
| | - Ling Xu
- Department of Respiratory Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Bing Zhang
- Department of Emergency, Binzhou Medical University Hospital, No.661 Huanghe 2nd Road, Binzhou, 256600, China.
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Geis D, Canova N, Lhopitallier L, Kronenberg A, Meuwly JY, Senn N, Mueller Y, Fasseur F, Boillat-Blanco N. Exploration of the Acceptance of the Use of Procalcitonin Point-of-Care Testing and Lung Ultrasonography by General Practitioners to Decide on Antibiotic Prescriptions for Lower Respiratory Infections: A Qualitative Study. BMJ Open 2023; 13:e063922. [PMID: 37169498 PMCID: PMC10186440 DOI: 10.1136/bmjopen-2022-063922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 04/12/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES We aimed to explore the acceptance and opinions of general practitioners (GPs) on the use of procalcitonin point-of-care and lung ultrasonography for managing patients with lower respiratory tract infections in primary care. We suppose that there are several factors that can influence the physician's antibiotic prescribing decision, and the implementation of a new tool will only be possible when it can be inserted into the physician's daily practice, helping him/her in the decision-making process. DESIGN Semistructured interviews; data analysis using the grounded theory method. SETTING Lausanne, Switzerland. PARTICIPANTS 12 GPs who participated in the randomised clinical trial UltraPro, which evaluated the impact of the use of procalcitonin only or an algorithm combining procalcitonin and lung ultrasonography on antibiotic prescription. RESULTS GPs had mostly positive attitudes towards the use of point-of-care procalcitonin in lower respiratory tract infections and uncertainties regarding the usefulness of ultrasonography. Physicians' prescribing decisions result from interactions between three kinds of TrustS (core category): 'self-confidence', 'trust in the results' and 'trust in the doctor-patient relationship'. Procalcitonin reinforced the three levels of trust, while ultrasonography only strengthened the physician-patient relationship. To facilitate implementation of procalcitonin, physicians pointed out the need of coverage by insurance and of clear guidelines describing the targeted patient population. CONCLUSIONS Our data show that there is a preference for the implementation of procalcitonin rather than lung ultrasonography for the management of patients with lower respiratory tract infections in primary care. Coverage by insurance plans and updated guidelines are prerequisite to the successful implementation of procalcitonin testing in primary care. TRIAL REGISTRATION NUMBER NCT03191071.
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Affiliation(s)
- Daniel Geis
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Nina Canova
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Loïc Lhopitallier
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
- gare10 medical practice, Lausanne, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Medix General Practice, Bern, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Fabienne Fasseur
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
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Jordan A, Sivapalan P, Rømer V, Jensen JU. Time-Updated Phenotypic Guidance of Corticosteroids and Antibiotics in COPD: Rationale, Perspective and a Proposed Method. Biomedicines 2023; 11:biomedicines11051395. [PMID: 37239067 DOI: 10.3390/biomedicines11051395] [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: 04/01/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with distinct phenotypes, each having distinct treatment needs. Eosinophilic airway inflammation is present in a subset of COPD patients in whom it can act as a driver of exacerbations. Blood eosinophil counts are a reliable way to identify patients with an eosinophilic phenotype, and these measurements have proven to be successful in guiding the use of corticosteroids in moderate and severe COPD exacerbations. Antibiotic use in COPD patients induces a risk of Clostridium difficile infection, diarrhea, and antibiotic resistance. Procalcitonin could possibly guide antibiotic treatment in patients admitted with AECOPD. Current studies in COPD patients were successful in reducing exposure to antibiotics with no changes in mortality or length of stay. Daily monitoring of blood eosinophils is a safe and effective way to reduce oral corticosteroid exposure and side effects for acute exacerbations. No evidence on time-updated treatment guidance for stable COPD exists yet, but a current trial is testing an eosinophil-guided approach on inhaled corticosteroid use. Procalcitonin-guided antibiotic treatment in AECOPD shows promising results in safely and substantially reducing antibiotic exposure both in time-independent and time-updated algorithms.
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Affiliation(s)
- Alexander Jordan
- Section of Respiratory Medicine, Herlev-Gentofte University Hospital, 2900 Hellerup, Denmark
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Herlev-Gentofte University Hospital, 2900 Hellerup, Denmark
| | - Valdemar Rømer
- Section of Respiratory Medicine, Herlev-Gentofte University Hospital, 2900 Hellerup, Denmark
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Herlev-Gentofte University Hospital, 2900 Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [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: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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Chambliss AB, Patel K, Colón-Franco JM, Hayden J, Katz SE, Minejima E, Woodworth A. AACC Guidance Document on the Clinical Use of Procalcitonin. J Appl Lab Med 2023; 8:598-634. [PMID: 37140163 DOI: 10.1093/jalm/jfad007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Procalcitonin (PCT), a peptide precursor of the hormone calcitonin, is a biomarker whose serum concentrations are elevated in response to systemic inflammation caused by bacterial infection and sepsis. Clinical adoption of PCT in the United States has only recently gained traction with an increasing number of Food and Drug Administration-approved assays and expanded indications for use. There is interest in the use of PCT as an outcomes predictor as well as an antibiotic stewardship tool. However, PCT has limitations in specificity, and conclusions surrounding its utility have been mixed. Further, there is a lack of consensus regarding appropriate timing of measurements and interpretation of results. There is also a lack of method harmonization for PCT assays, and questions remain regarding whether the same clinical decision points may be used across different methods. CONTENT This guidance document aims to address key questions related to the use of PCT to manage adult, pediatric, and neonatal patients with suspected sepsis and/or bacterial infections, particularly respiratory infections. The document explores the evidence for PCT utility for antimicrobial therapy decisions and outcomes prediction. Additionally, the document discusses analytical and preanalytical considerations for PCT analysis and confounding factors that may affect the interpretation of PCT results. SUMMARY While PCT has been studied widely in various clinical settings, there is considerable variability in study designs and study populations. Evidence to support the use of PCT to guide antibiotic cessation is compelling in the critically ill and in some lower respiratory tract infections but is lacking in other clinical scenarios, and evidence is also limited in the pediatric and neonatal populations. Interpretation of PCT results requires guidance from multidisciplinary care teams of clinicians, pharmacists, and clinical laboratorians.
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Affiliation(s)
- Allison B Chambliss
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Khushbu Patel
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Joshua Hayden
- Department of Laboratories, Norton Healthcare, Louisville, KY, United States
| | - Sophie E Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Emi Minejima
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, United States
| | - Alison Woodworth
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY, United States
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Janković R, Stojanović M, Božov H, Domi R, Ivančan V, Karišik M, Mojsova Mijovska M, Jakupović Smajić J, Šoštarič M. PROCALCITONIN GUIDED ANTIBIOTIC STEWARDSHIP: A BALKAN EXPERT CONSENSUS STATEMENT. Acta Clin Croat 2023; 62:36-44. [PMID: 38304372 PMCID: PMC10829966 DOI: 10.20471/acc.2023.62.01.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/22/2023] [Indexed: 02/03/2024] Open
Abstract
Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program.
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Affiliation(s)
- Radmilo Janković
- University Clinical Center Niš, Department of Anesthesia and Intensive Therapy, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Milena Stojanović
- University Clinical Center Niš, Department of Anesthesia and Intensive Therapy, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Hristo Božov
- Department of Anesthesiology, Maritime and Intensive Medicine, Naval Hospital, Varna, Bulgaria
| | - Rudin Domi
- University of Medicine, Tirana Faculty of Medicine, Tirana, Albania
| | | | - Marijana Karišik
- Department of Anesthesiology and Intensive Care, Institute for Children’s Disease, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Maja Mojsova Mijovska
- Department of Anesthesia, Resuscitation and Intensive Care (KARIL), Skopje, North Macedonia
| | - Jasmina Jakupović Smajić
- Tuzla University Clinical Center, Tuzla University, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | - Maja Šoštarič
- Ljubljana University Medical Center, University of Ljubljana, Ljubljana, Slovenia
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Tsalik EL, Rouphael NG, Sadikot RT, Rodriguez-Barradas MC, McClain MT, Wilkins DM, Woods CW, Swamy GK, Walter EB, El Sahly HM, Keitel WA, Mulligan MJ, Tuyishimire B, Serti E, Hamasaki T, Evans SR, Ghazaryan V, Lee MS, Lautenbach E. Efficacy and safety of azithromycin versus placebo to treat lower respiratory tract infections associated with low procalcitonin: a randomised, placebo-controlled, double-blind, non-inferiority trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:484-495. [PMID: 36525985 PMCID: PMC10040424 DOI: 10.1016/s1473-3099(22)00735-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lower respiratory tract infections are frequently treated with antibiotics, despite a viral cause in many cases. It remains unknown whether low procalcitonin concentrations can identify patients with lower respiratory tract infection who are unlikely to benefit from antibiotics. We aimed to compare the efficacy and safety of azithromycin versus placebo to treat lower respiratory tract infections in patients with low procalcitonin. METHODS We conducted a randomised, placebo-controlled, double-blind, non-inferiority trial at five health centres in the USA. Adults aged 18 years or older with clinically suspected non-pneumonia lower respiratory tract infection and symptom duration from 24 h to 28 days were eligible for enrolment. Participants with a procalcitonin concentration of 0·25 ng/mL or less were randomly assigned (1:1), in blocks of four with stratification by site, to receive over-encapsulated oral azithromycin 250 mg or matching placebo (two capsules on day 1 followed by one capsule daily for 4 days). Participants, non-study clinical providers, investigators, and study coordinators were masked to treatment allocation. The primary outcome was efficacy of azithromycin versus placebo in terms of clinical improvement at day 5 in the intention-to-treat population. The non-inferiority margin was -12·5%. Solicited adverse events (abdominal pain, vomiting, diarrhoea, allergic reaction, or yeast infections) were recorded as a secondary outcome. This trial is registered with ClinicalTrials.gov, NCT03341273. FINDINGS Between Dec 8, 2017, and March 9, 2020, 691 patients were assessed for eligibility and 499 were enrolled and randomly assigned to receive azithromycin (n=249) or placebo (n=250). Clinical improvement at day 5 was observed in 148 (63%, 95% CI 54 to 71) of 238 participants with full data in the placebo group and 155 (69%, 61 to 77) of 227 participants with full data in the azithromycin group in the intention-to-treat analysis (between-group difference -6%, 95% CI -15 to 2). The 95% CI for the difference did not meet the non-inferiority margin. Solicited adverse events and the severity of solicited adverse events were not significantly different between groups at day 5, except for increased abdominal pain associated with azithromycin (47 [23%, 95% CI 18 to 29] of 204 participants) compared with placebo (35 [16%, 12 to 21] of 221; between-group difference -7% [95% CI -15 to 0]; p=0·066). INTERPRETATION Placebo was not non-inferior to azithromycin in terms of clinical improvement at day 5 in adults with lower respiratory tract infection and a low procalcitonin concentration. After accounting for both the rates of clinical improvement and solicited adverse events at day 5, it is unclear whether antibiotics are indicated for patients with lower respiratory tract infection and a low procalcitonin concentration. FUNDING National Institute of Allergy and Infectious Diseases, bioMérieux.
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Affiliation(s)
- Ephraim L Tsalik
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA; Emergency Medicine Service, Durham VA Health Care System, Durham, NC, USA.
| | - Nadine G Rouphael
- Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ruxana T Sadikot
- Atlanta VA Health Care System, Atlanta, GA, USA; Medical Service, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Micah T McClain
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA; Medical Service, Durham VA Health Care System, Durham, NC, USA
| | | | - Christopher W Woods
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA; Medical Service, Durham VA Health Care System, Durham, NC, USA
| | - Geeta K Swamy
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA; Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Emmanuel B Walter
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA; Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hana M El Sahly
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Wendy A Keitel
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mark J Mulligan
- Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Division of Infectious Diseases and Immunology, NYU Langone Health, New York, NY, USA
| | | | | | - Toshimitsu Hamasaki
- Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA; Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Scott R Evans
- Biostatistics Center, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA; Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD, USA
| | - Varduhi Ghazaryan
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Marina S Lee
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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40
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Sivapalan P, Jensen JUS. Procalcitonin to reduce antimicrobial overuse in patients with lower respiratory tract infection: time for re-evaluation of our prescription culture? THE LANCET. INFECTIOUS DISEASES 2023; 23:390-391. [PMID: 36525986 DOI: 10.1016/s1473-3099(22)00757-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Jens-Ulrik Stæhr Jensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen DK-2100, Denmark.
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Andrade A, Bang H, Reddick K, Villaseñor B, Tran NK, May L. Evaluation of pharmacist guided intervention using procalcitonin and respiratory virus testing. Am J Emerg Med 2023; 66:146-151. [PMID: 36773457 PMCID: PMC10038929 DOI: 10.1016/j.ajem.2023.01.041] [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: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Acute respiratory infections make up a sizable percentage of emergency department (ED) visits and many result in antibiotics being prescribed. Procalcitonin (PCT) has been found to reduce antibiotic use in both outpatient and critical care settings, yet remains underused in the ED. This study aimed to evaluate whether point of care molecular influenza and Respiratory Syncytial Virus (RSV) testing, PCT, and a pharmacist driven educational intervention in aggregate optimizes antibiotic and antiviral prescribing in the ED setting. METHODS A randomized trial of the Cobas Liat Flu/RSV Assay, procalcitonin, and the use of pharmacist-led education in patients 0-50 years of age being seen in the ED for Influenza Like Illness (ILI) or acute respiratory illness. The study enrolled 200 ED patients between March 2018 and April 2022. RESULTS There was little difference in antibiotic or antiviral prescribing between the intervention and control groups in this study (39%-32% = 7.0%, 95% CI: -6.2, 20.2, P = 0.30). However, a post-hoc analysis of the use of procalcitonin showed results were used as indicated in the ED (P = 0.001). CONCLUSION PCT can be used in both adult and pediatric populations to help guide the decision of whether to treat with antibiotics in the ED setting. Pharmacist guided education may not be a driving factor.
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Affiliation(s)
- Amia Andrade
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Heejung Bang
- Department of Public Health Sciences, School of Medicine, One Shields Ave., Med-Sci 1C, Davis, CA 95616, United States of America.
| | - Katie Reddick
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Bryan Villaseñor
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 3435 Tupper Hall, Davis, CA 95616, United States of America.
| | - Larissa May
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
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The Role of Procalcitonin as an Antimicrobial Stewardship Tool in Patients Hospitalized with Seasonal Influenza. Antibiotics (Basel) 2023; 12:antibiotics12030573. [PMID: 36978440 PMCID: PMC10044820 DOI: 10.3390/antibiotics12030573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Up to 60% of the antibiotics prescribed to patients hospitalized with seasonal influenza are unnecessary. Procalcitonin (PCT) has the potential as an antimicrobial stewardship program (ASP) tool because it can differentiate between viral and bacterial etiology. We aimed to explore the role of PCT as an ASP tool in hospitalized seasonal influenza patients. Methods: We prospectively included 116 adults with seasonal influenza from two influenza seasons, 2018–2020. All data was obtained from a single clinical setting and analyzed by descriptive statistics and regression models. Results: In regression analyses, we found a positive association of PCT with 30 days mortality and the amount of antibiotics used. Influenza diagnosis was associated with less antibiotic use if the PCT value was low. Patients with a low initial PCT (<0.25 µg/L) had fewer hospital and intensive care unit (ICU) days and fewer positive chest X-rays. PCT had a negative predictive value of 94% for ICU care stay, 98% for 30 days mortality, and 88% for bacterial coinfection. Conclusion: PCT can be a safe rule-out test for bacterial coinfection. Routine PCT use in seasonal influenza patients with an uncertain clinical picture, and rapid influenza PCR testing, may be efficient as ASP tools.
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Claeys KC, Johnson MD. Leveraging diagnostic stewardship within antimicrobial stewardship programmes. Drugs Context 2023; 12:dic-2022-9-5. [PMID: 36843619 PMCID: PMC9949764 DOI: 10.7573/dic.2022-9-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Practice Science and Health Outcomes Research, Baltimore, MD, USA
| | - Melissa D Johnson
- Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA,Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center Durham, NC, USA
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de la Fuente A, García-Mateo N, Bermejo-Martin JF. Prime-time for clinical use of transcriptomics for differentiating viral from bacterial respiratory infection. Eur J Clin Invest 2023; 53:e13967. [PMID: 36748118 DOI: 10.1111/eci.13967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/08/2023]
Affiliation(s)
- Amanda de la Fuente
- Group for Biomedical Research in Sepsis (BioSepsis), Instituto de Investigación Biomédica de Salamanca (IBSAL), Gerencia Regional de Salud de Castilla y León, Salamanca, Spain.,CIBER de Enfermedades Respiratorias, CB22/06/00035, Instituto de Salud Carlos III, Madrid, Spain
| | - Nadia García-Mateo
- Group for Biomedical Research in Sepsis (BioSepsis), Instituto de Investigación Biomédica de Salamanca (IBSAL), Gerencia Regional de Salud de Castilla y León, Salamanca, Spain
| | - Jesús F Bermejo-Martin
- Group for Biomedical Research in Sepsis (BioSepsis), Instituto de Investigación Biomédica de Salamanca (IBSAL), Gerencia Regional de Salud de Castilla y León, Salamanca, Spain.,CIBER de Enfermedades Respiratorias, CB22/06/00035, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad de Salamanca, Salamanca, Spain
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Antimicrobial Stewardship Techniques for Critically Ill Patients with Pneumonia. Antibiotics (Basel) 2023; 12:antibiotics12020295. [PMID: 36830205 PMCID: PMC9952097 DOI: 10.3390/antibiotics12020295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Pneumonia is common in the intensive care unit (ICU), infecting 27% of all critically ill patients. Given the high prevalence of this disease state in the ICU, optimizing antimicrobial therapy while minimizing toxicities is of utmost importance. Inappropriate antimicrobial use can increase the risk of antimicrobial resistance, Clostridiodes difficile infection, allergic reaction, and other complications from antimicrobial use (e.g., QTc prolongation, thrombocytopenia). This review article aims to discuss methods to optimize antimicrobial treatment in patients with pneumonia, including the following: procalcitonin use, utilization of methicillin-resistant Staphylococcus aureus nares testing to determine need for vancomycin therapy, utilization of the Biofire® FilmArray® pneumonia polymerase chain reaction (PCR), and microbiology reporting techniques.
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Gao CA, Pickens CI, Morales-Nebreda L, Wunderink RG. Clinical Features of COVID-19 and Differentiation from Other Causes of CAP. Semin Respir Crit Care Med 2023; 44:8-20. [PMID: 36646082 DOI: 10.1055/s-0042-1759889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, one of the most common reasons for infection-related death worldwide. Causes of CAP include numerous viral, bacterial, and fungal pathogens, though frequently no specific organism is found. Beginning in 2019, the COVID-19 pandemic has caused incredible morbidity and mortality. COVID-19 has many features typical of CAP such as fever, respiratory distress, and cough, and can be difficult to distinguish from other types of CAP. Here, we highlight unique clinical features of COVID-19 pneumonia such as olfactory and gustatory dysfunction, lymphopenia, and distinct imaging appearance.
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Affiliation(s)
- Catherine A Gao
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chiagozie I Pickens
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Luisa Morales-Nebreda
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Shojaei M, Chen UI, Midic U, Thair S, Teoh S, McLean A, Sweeney TE, Thompson M, Liesenfeld O, Khatri P, Tang B. Multisite validation of a host response signature for predicting likelihood of bacterial and viral infections in patients with suspected influenza. Eur J Clin Invest 2023; 53:e13957. [PMID: 36692131 DOI: 10.1111/eci.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Indiscriminate use of antimicrobials and antimicrobial resistance is a public health threat. IMX-BVN-1, a 29-host mRNA classifier, provides two separate scores that predict likelihoods of bacterial and viral infections in patients with suspected acute infections. We validated the performance of IMX-BVN-1 in adults attending acute health care settings with suspected influenza. METHOD We amplified 29-host response genes in RNA extracted from blood by NanoString nCounter. IMX-BVN-1 calculated two scores to predict probabilities of bacterial and viral infections. Results were compared against the infection status (no infection; highly probable/possible infection; confirmed infection) determined by clinical adjudication. RESULTS Amongst 602 adult patients (74.9% ED, 16.9% ICU, 8.1% outpatients), 7.6% showed in-hospital mortality and 15.5% immunosuppression. Median IMX-BVN-1 bacterial and viral scores were higher in patients with confirmed bacterial (0.27) and viral (0.62) infections than in those without bacterial (0.08) or viral (0.21) infection, respectively. The AUROC distinguishing bacterial from nonbacterial illness was 0.81 and 0.87 when distinguishing viral from nonviral illness. The bacterial top quartile's positive likelihood ratio (LR) was 4.38 with a rule-in specificity of 88%; the bacterial bottom quartile's negative LR was 0.13 with a rule-out sensitivity of 96%. Similarly, the viral top quartile showed an infinite LR with rule-in specificity of 100%; the viral bottom quartile had a LR of 0.22 and a rule-out sensitivity of 85%. CONCLUSION IMX-BVN-1 showed high accuracy for differentiating bacterial and viral infections from noninfectious illness in patients with suspected influenza. Clinical utility of IMX-BVN will be validated following integration into a point of care system.
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Affiliation(s)
- Maryam Shojaei
- Department of Medicine, Sydney Medical School Nepean, Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia.,Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.,Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Uan-I Chen
- Inflammatix, Inc., Sunnyvale, California, USA
| | - Uros Midic
- Inflammatix, Inc., Sunnyvale, California, USA
| | | | - Sally Teoh
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | - Anthony McLean
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | | | | | | | | | - Benjamin Tang
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.,Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
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Malley BE, Yabes JG, Gimbel E, Chang CCH, Yealy DM, Fine MJ, Angus DC, Huang DT. Impact of adherence to procalcitonin antibiotic prescribing guideline recommendations for low procalcitonin levels on antibiotic use. BMC Infect Dis 2023; 23:30. [PMID: 36658543 PMCID: PMC9850552 DOI: 10.1186/s12879-022-07923-0] [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: 06/11/2022] [Accepted: 12/05/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The Procalcitonin Antibiotic Consensus Trial (ProACT) found provision of a procalcitonin antibiotic prescribing guideline to hospital-based clinicians did not reduce antibiotic use. Possible reasons include clinician reluctance to follow the guideline, with an observed 64.8% adherence rate. In this study we sought to determine the threshold adherence rate for reduction in antibiotic use, and to explore opportunities to increase adherence. METHODS This study is a retrospective analysis of ProACT data. ProACT randomized 1656 patients presenting to 14 U.S. hospitals with suspected lower respiratory tract infection to usual care or provision of procalcitonin assay results and an antibiotic prescribing guideline to the treating clinicians. We simulated varying adherence to guideline recommendations for low procalcitonin levels and determined which threshold adherence rate could have resulted in rejection of the null hypothesis of no difference between groups at alpha = 0.05. We also performed sensitivity analyses within specific clinical settings and grouped patients initially prescribed antibiotics despite low procalcitonin into low, medium, and high risk of illness severity or bacterial infection. RESULTS Our primary outcome was number of antibiotic-days by day 30 using an intention-to-treat approach and a null hypothesis of no difference in antibiotic use. We determined that an 84% adherence rate in the hospital setting (emergency department and inpatient) for low procalcitonin could have allowed rejection of the null hypothesis (3.7 vs 4.3 antibiotic-days, p = 0.048). The threshold adherence rate was 76% for continued guideline adherence after discharge. Even 100% adherence in the emergency department alone failed to reduce antibiotic-days. Of the 218 patients prescribed antibiotics in the emergency department despite low procalcitonin, 153 (70.2%) were categorized as low or medium risk. CONCLUSIONS High adherence in the hospital setting to a procalcitonin antibiotic prescribing guideline is necessary to reduce antibiotic use in suspected lower respiratory tract infection. Continued guideline adherence after discharge and withholding of antibiotics in low and medium risk patients with low procalcitonin may offer impactful potential opportunities for antibiotic reduction. Trial registration Procalcitonin Antibiotic Consensus Trial (ProACT), ClinicalTrials.gov Identifier: NCT02130986. First posted May 6, 2014.
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Affiliation(s)
- Brian E. Malley
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Jonathan G. Yabes
- grid.21925.3d0000 0004 1936 9000Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Elizabeth Gimbel
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Chung-Chou H. Chang
- grid.21925.3d0000 0004 1936 9000Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Donald M. Yealy
- grid.21925.3d0000 0004 1936 9000Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Michael J. Fine
- grid.413935.90000 0004 0420 3665Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - Derek C. Angus
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000The MACRO (Multidisciplinary Acute Care Research Organization) Center, University of Pittsburgh, Pittsburgh, PA USA
| | - David T. Huang
- grid.21925.3d0000 0004 1936 9000The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000The MACRO (Multidisciplinary Acute Care Research Organization) Center, University of Pittsburgh, Pittsburgh, PA USA ,grid.21925.3d0000 0004 1936 9000University of Pittsburgh, 606B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
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Peng Y, Wu Q, Liu H, Zhang J, Han Q, Yin F, Wang L, Chen Q, Zhang F, Feng C, Zhu H. An immune-related gene signature predicts the 28-day mortality in patients with sepsis. Front Immunol 2023; 14:1152117. [PMID: 37033939 PMCID: PMC10076848 DOI: 10.3389/fimmu.2023.1152117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Sepsis is the leading cause of death in intensive care units and is characterized by multiple organ failure, including dysfunction of the immune system. In the present study, we performed an integrative analysis on publicly available datasets to identify immune-related genes (IRGs) that may play vital role in the pathological process of sepsis, based on which a prognostic IRG signature for 28-day mortality prediction in patients with sepsis was developed and validated. Methods Weighted gene co-expression network analysis (WGCNA), Cox regression analysis and least absolute shrinkage and selection operator (LASSO) estimation were used to identify functional IRGs and construct a model for predicting the 28-day mortality. The prognostic value of the model was validated in internal and external sepsis datasets. The correlations of the IRG signature with immunological characteristics, including immune cell infiltration and cytokine expression, were explored. We finally validated the expression of the three IRG signature genes in blood samples from 12 sepsis patients and 12 healthy controls using qPCR. Results We established a prognostic IRG signature comprising three gene members (LTB4R, HLA-DMB and IL4R). The IRG signature demonstrated good predictive performance for 28-day mortality on the internal and external validation datasets. The immune infiltration and cytokine analyses revealed that the IRG signature was significantly associated with multiple immune cells and cytokines. The molecular pathway analysis uncovered ontology enrichment in myeloid cell differentiation and iron ion homeostasis, providing clues regarding the underlying biological mechanisms of the IRG signature. Finally, qPCR detection verified the differential expression of the three IRG signature genes in blood samples from 12 sepsis patients and 12 healthy controls. Discussion This study presents an innovative IRG signature for 28-day mortality prediction in sepsis patients, which may be used to facilitate stratification of risky sepsis patients and evaluate patients' immune state.
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Affiliation(s)
- Yaojun Peng
- Department of Graduate Administration, Medical School of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qiyan Wu
- Institute of Oncology, The Fifth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Hongyu Liu
- Department of Graduate Administration, Medical School of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- Department of Neurosurgery, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- Department of Neurosurgery, Hainan Hospital of Chinese People's Liberation Army (PLA) General Hospital, Sanya, Hainan, China
| | - Jinying Zhang
- Department of Basic Medicine, Medical School of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qingru Han
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Fan Yin
- Department of Oncology, The Second Medical Center & National Clinical Research Center of Geriatric Disease, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lingxiong Wang
- Institute of Oncology, The Fifth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qi Chen
- Department of Traditional Chinese Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Fei Zhang
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Fei Zhang, ; Cong Feng, ; Haiyan Zhu,
| | - Cong Feng
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Fei Zhang, ; Cong Feng, ; Haiyan Zhu,
| | - Haiyan Zhu
- Department of Emergency, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
- *Correspondence: Fei Zhang, ; Cong Feng, ; Haiyan Zhu,
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Pereira JG, Fernandes J, Duarte AR, Fernandes SM. β-Lactam Dosing in Critical Patients: A Narrative Review of Optimal Efficacy and the Prevention of Resistance and Toxicity. Antibiotics (Basel) 2022; 11:antibiotics11121839. [PMID: 36551496 PMCID: PMC9774837 DOI: 10.3390/antibiotics11121839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Antimicrobial prescription in critically ill patients represents a complex challenge due to the difficult balance between infection treatment and toxicity prevention. Underexposure to antibiotics and therapeutic failure or, conversely, drug overexposure and toxicity may both contribute to a worse prognosis. Moreover, changes in organ perfusion and dysfunction often lead to unpredictable pharmacokinetics. In critically ill patients, interindividual and intraindividual real-time β-lactam antibiotic dose adjustments according to the patient's condition are critical. The continuous infusion of β-lactams and the therapeutic monitoring of their concentration have both been proposed to improve their efficacy, but strong data to support their use are still lacking. The knowledge of the pharmacokinetic/pharmacodynamic targets is poor and is mostly based on observational data. In patients with renal or hepatic failure, selecting the right dose is even more tricky due to changes in drug clearance, distribution, and the use of extracorporeal circuits. Intermittent usage may further increase the dosing conundrum. Recent data have emerged linking overexposure to β-lactams to central nervous system toxicity, mitochondrial recovery delay, and microbiome changes. In addition, it is well recognized that β-lactam exposure facilitates resistance selection and that correct dosing can help to overcome it. In this review, we discuss recent data regarding real-time β-lactam antibiotic dose adjustment, options in special populations, and the impacts on mitochondria and the microbiome.
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Affiliation(s)
- João Gonçalves Pereira
- Hospital Vila Franca de Xira, 2600-009 Vila Franca de Xira, Portugal
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Correspondence: ; Tel.: +351-96-244-1546
| | - Joana Fernandes
- Centro Hospitalar de Trás-os-Montes e Alto Douro, 5000-508 Vila Real, Portugal
| | - Ana Rita Duarte
- Nova Medical School, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal
| | - Susana Mendes Fernandes
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina, Universidade de Lisboa, 1649-004 Lisboa, Portugal
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