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Pereira JM, Xu S, Leong JM, Sousa S. The Yin and Yang of Pneumolysin During Pneumococcal Infection. Front Immunol 2022; 13:878244. [PMID: 35529870 PMCID: PMC9074694 DOI: 10.3389/fimmu.2022.878244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/23/2022] [Indexed: 12/15/2022] Open
Abstract
Pneumolysin (PLY) is a pore-forming toxin produced by the human pathobiont Streptococcus pneumoniae, the major cause of pneumonia worldwide. PLY, a key pneumococcal virulence factor, can form transmembrane pores in host cells, disrupting plasma membrane integrity and deregulating cellular homeostasis. At lytic concentrations, PLY causes cell death. At sub-lytic concentrations, PLY triggers host cell survival pathways that cooperate to reseal the damaged plasma membrane and restore cell homeostasis. While PLY is generally considered a pivotal factor promoting S. pneumoniae colonization and survival, it is also a powerful trigger of the innate and adaptive host immune response against bacterial infection. The dichotomy of PLY as both a key bacterial virulence factor and a trigger for host immune modulation allows the toxin to display both "Yin" and "Yang" properties during infection, promoting disease by membrane perforation and activating inflammatory pathways, while also mitigating damage by triggering host cell repair and initiating anti-inflammatory responses. Due to its cytolytic activity and diverse immunomodulatory properties, PLY is integral to every stage of S. pneumoniae pathogenesis and may tip the balance towards either the pathogen or the host depending on the context of infection.
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Affiliation(s)
- Joana M. Pereira
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Molecular and Cellular (MC) Biology PhD Program, ICBAS - Instituto de Ciência Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Shuying Xu
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA, United States
- Graduate Program in Immunology, Tufts Graduate School of Biomedical Sciences, Boston, MA, United States
| | - John M. Leong
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA, United States
| | - Sandra Sousa
- i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
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Sundaresh B, Xu S, Noonan B, Mansour MK, Leong JM, van Opijnen T. Host-informed therapies for the treatment of pneumococcal pneumonia. Trends Mol Med 2021; 27:971-989. [PMID: 34376327 DOI: 10.1016/j.molmed.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
Over the past two decades, traditional antimicrobial strategies have lost efficacy due to a rapid rise in antibiotic resistance and limited success in developing new antibiotics. Rather than relying on therapeutics solely targeting the bacterial pathogen, therapies are emerging that simultaneously focus on host responses. Here, we describe the most promising 'host-informed therapies' (HITs) in two categories: those that aid patients with fully functional immune systems, and those that aid patients with perturbed immune processes. Using Streptococcus pneumoniae, the leading cause of bacterial pneumonia, as a case study, we show HITs as an attractive option for supplementing infection management. However, to broaden their applicability and design new strategies, targeted research and clinical trials will be essential.
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Affiliation(s)
| | - Shuying Xu
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA, USA; Graduate Program in Immunology, Tufts Graduate School of Biomedical Sciences, Boston, MA, USA
| | - Brian Noonan
- Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance, Tufts Medical Center, Boston, MA, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John M Leong
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, MA, USA; Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance, Tufts Medical Center, Boston, MA, USA.
| | - Tim van Opijnen
- Department of Biology, Boston College, Chestnut Hill, MA, USA; Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance, Tufts Medical Center, Boston, MA, USA.
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Kim L, McGee L, Tomczyk S, Beall B. Biological and Epidemiological Features of Antibiotic-Resistant Streptococcus pneumoniae in Pre- and Post-Conjugate Vaccine Eras: a United States Perspective. Clin Microbiol Rev 2016; 29:525-52. [PMID: 27076637 PMCID: PMC4861989 DOI: 10.1128/cmr.00058-15] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Streptococcus pneumoniae inflicts a huge disease burden as the leading cause of community-acquired pneumonia and meningitis. Soon after mainstream antibiotic usage, multiresistant pneumococcal clones emerged and disseminated worldwide. Resistant clones are generated through adaptation to antibiotic pressures imposed while naturally residing within the human upper respiratory tract. Here, a huge array of related commensal streptococcal strains transfers core genomic and accessory resistance determinants to the highly transformable pneumococcus. β-Lactam resistance is the hallmark of pneumococcal adaptability, requiring multiple independent recombination events that are traceable to nonpneumococcal origins and stably perpetuated in multiresistant clonal complexes. Pneumococcal strains with elevated MICs of β-lactams are most often resistant to additional antibiotics. Basic underlying mechanisms of most pneumococcal resistances have been identified, although new insights that increase our understanding are continually provided. Although all pneumococcal infections can be successfully treated with antibiotics, the available choices are limited for some strains. Invasive pneumococcal disease data compiled during 1998 to 2013 through the population-based Active Bacterial Core surveillance program (U.S. population base of 30,600,000) demonstrate that targeting prevalent capsular serotypes with conjugate vaccines (7-valent and 13-valent vaccines implemented in 2000 and 2010, respectively) is extremely effective in reducing resistant infections. Nonetheless, resistant non-vaccine-serotype clones continue to emerge and expand.
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Affiliation(s)
- Lindsay Kim
- Epidemiology Section, Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lesley McGee
- Streptococcus Laboratory, Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sara Tomczyk
- Epidemiology Section, Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Bernard Beall
- Streptococcus Laboratory, Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1-S39. [PMID: 25832968 DOI: 10.1177/0194599815572097] [Citation(s) in RCA: 481] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. ACTION STATEMENTS The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA
| | | | - Itzhak Brook
- Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Kaparaboyna Ashok Kumar
- Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Maggie Kramper
- Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard R Orlandi
- Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James N Palmer
- Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Zara M Patel
- Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Anju Peters
- Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA
| | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Davis, California, USA
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Wattal C, Goel N, Khanna S, Byotra SP, Laxminarayan R, Easton A. Impact of informational feedback to clinicians on antibiotic-prescribing rates in a tertiary care hospital in Delhi. Indian J Med Microbiol 2015; 33:255-9. [DOI: 10.4103/0255-0857.153582] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Najafi Mosleh M, Gharibi M, Alikhani MY, Saidijam M, Kalantarian G. Antimicrobial Susceptibilities and Distribution of Resistance Genes for β-Lactams in Streptococcus pneumoniae Isolated in Hamadan. Jundishapur J Microbiol 2014; 7:e12714. [PMID: 25632328 PMCID: PMC4295318 DOI: 10.5812/jjm.12714] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 03/05/2014] [Accepted: 04/15/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND β-lactams resistant Streptococcus pneumoniae are an emerging problem throughout the world. Several resistance mechanisms have been reported, including expression of drug-destroying enzymes such as β-lactamases, altered drug targets such as conformational changes in PBPs, decreased bacterial permeability, and increased drug efflux. OBJECTIVES The present study aimed to determine the relationship between the results of polymerase chain reaction identification of the Pbp1a, Pbp2b and Pbp2x genes (penicillin-binding proteins) and susceptibilities of β-lactam antibiotics against S. pneumoniae. MATERIALS AND METHODS Fifty five isolates of S. pneumoniae were obtained from clinical samples with antimicrobial tests. The susceptibilities of isolates to benzylpenicillin, imipenem, oxacillin, ceftazidime were determined. The resistance genotype was determined by the polymerase chain reaction with primers designed for the PBP genes. RESULTS The number of S. pneumoniae isolates resistant to benzylpenicillin, imipenem, oxacillin and ceftazidime were 94.5%, 100%, 100%, and 21.8%, respectively. Analysis of mutation in the genes for pbp showed that 85% of isolates had mutations in pbp2x, pbp2b and pbp1a. Susceptibility to benzylpenicillin was decreased once the number of mutated pbp genes in S. pneumonia increased. According to the results of this study, S. pneumoniae isolates showed reduced susceptibility due to accumulation of resistance genes. CONCLUSIONS We suggest that studies should be performed to evaluate changes in Minimum Inhibitory Concentration (MIC) values as well as genetic mutations in order to determine prevalence of S. pneumoniae resistance against antimicrobial agents.
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Affiliation(s)
- Mohammad Najafi Mosleh
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Marzieh Gharibi
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Mohammad Yousef Alikhani
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Massoud Saidijam
- Department of Molecular Medicine and Genetics, Hamadan University of Medical Sciences, Hamadan,IR Iran
| | - Giti Kalantarian
- Department of Biochemistry, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran
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Factors associated with ceftriaxone nonsusceptibility of Streptococcus pneumoniae: analysis of South African national surveillance data, 2003 to 2010. Antimicrob Agents Chemother 2014; 58:3293-305. [PMID: 24687499 DOI: 10.1128/aac.02580-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is important to monitor β-lactam antimicrobial nonsusceptibility trends for Streptococcus pneumoniae to inform empirical treatment guidelines. In this study, we describe penicillin and ceftriaxone susceptibility trends using national laboratory-based pneumococcal surveillance data from 2003 to 2010. A sentinel enhanced-site patient subset (2009 to 2010) contributed to the risk factor and mortality analyses. We included 9,218 invasive pneumococcal disease (IPD) cases for trend analyses and 2,854 IPD cases for risk factor and mortality analyses. Overall, we detected no significant changes in penicillin (patients <5 years of age, P = 0.50; patients ≥ 5 years of age, P = 0.05) or ceftriaxone nonsusceptibility rates (patients <5 years of age, P = 0.21; patients ≥ 5 years of age, P = 0.60). Factors associated with ceftriaxone nonsusceptibility on multivariate analysis were an age of <5 years (<1 year of age: adjusted odds ratio [aOR], 2.87; 95% confidence interval [CI], 1.70 to 4.86; 1 to 4 years of age: aOR, 2.58; 95% CI, 1.53 to 4.35, versus 25 to 44 years of age), province (Gauteng [aOR, 2.46; 95% CI, 1.26 to 4.84], and Northern Cape [aOR, 4.52; 95% CI, 1.95 to 10.52] versus KwaZulu-Natal), β-lactam use within 24 h preceding admission (aOR, 2.52; 95% CI, 1.41 to 4.53), and 13-valent vaccine serotypes (aOR, 51.64; 95% CI, 7.18 to 371.71). Among patients ≥ 5 years of age with meningitis who were treated according to current guidelines, HIV-infected patients (aOR, 2.94; 95% CI, 1.32 to 6.54) and patients infected with ceftriaxone-nonsusceptible isolates (aOR, 3.17; 95% CI, 1.27 to 7.89) had increased mortality rates. Among children <5 years of age with meningitis, mortality was increased in HIV-infected patients (aOR, 3.04; 95% CI, 1.40 to 6.56) but not in those with ceftriaxone-nonsusceptible isolates. Penicillin and ceftriaxone nonsusceptibility remained stable over the study period. Ceftriaxone nonsusceptibility was associated with increased mortality among patients ≥5 years of age with meningitis. The introduction of a pneumococcal conjugate vaccine may reduce ceftriaxone-nonsusceptible meningitis.
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Grenón SL, Salvi Grabulosa MC, Regueira MM, Fossati MS, von Specht MH. Meningitis neumocócica en niños menores de 15 años. Dieciséis años de vigilancia epidemiológica en Misiones, Argentina. Rev Argent Microbiol 2014; 46:14-23. [DOI: 10.1016/s0325-7541(14)70042-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 02/07/2014] [Indexed: 11/16/2022] Open
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Garau J, Aguilar L, Rodríguez-Créixems M, Dal-Ré R, Pérez-Trallero E, Rodríguez M, Bouza E. Influence of Comorbidity and Severity on the Clinical Outcome of Bacteremic Pneumococcal Pneumonia Treated with β-lactam Monotherapy. J Chemother 2013. [DOI: 10.1179/joc.1999.11.3.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Updated antibiotic resistance and clinical spectrum of infections caused by Streptococcus pneumoniae in Taiwan: Emphasis on risk factors for penicillin nonsusceptibilities. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012; 46:345-51. [PMID: 22992392 DOI: 10.1016/j.jmii.2012.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/01/2012] [Accepted: 07/17/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE(S) Streptococcus pneumoniae is one of the leading pathogens causing community-acquired infection with high mortality rates in elderly patients. Emerging antibiotic resistance was found in past decades. Continuous surveillance to monitor changes in antibiotic resistance of S. pneumoniae and associated risk factors are important clinical issues. METHODS Isolates of S. pneumoniae collected from six hospitals participating in the Taiwan Surveillance of Antimicrobial Resistance (TSAR) program III (2002) - VI (2008) were enrolled in this study. Bacterial susceptibilities were determined by minimum inhibitory concentration. The clinical data of source patients were collected retrospectively. RESULTS A total of 330 nonduplicate S. pneumoniae isolates were enrolled in this study. Sputum was the most common specimen source, followed by pus. The mean age of the source patients was 38 years among these 330 patients, and 247 had various infections caused by S. pneumoniae. The overall in-hospital mortality rate was 6% and most (60%)of the mortality occurred in patients older than 65 years. The mortality rates among the patients age 65 years and older and those age 5 years and younger were 12.9% (9 of 70) and 2.4% (2 of 83), respectively. The rates of nonsusceptibility to penicillin by the meningitis criteria (PNSP-M) were 69.0% in 2002, 81.0% in 2004, 73.7% in 2006, and 74.5% in 2008. Resistance to erythromycin and trimethoprim/sulfamethoxazole remained high. Using multivariate analysis, patients with PNSP isolates were more likely to have a history of antibiotic exposure within the previous 15 days compared with patients with penicillin-susceptible (PSSP) isolates (nonmeningitis criteria: 29.70% vs. 18.34%, p = 0.0288; meningitis criteria: 25.30% vs. 9.88%, p = 0.006). Shock at presentation was the risk factor for in-hospital mortality. CONCLUSION Our study demonstrated that the rates of penicillin nonsusceptibility among S. pneumoniae remained high in Taiwan during the study period. Previous antibiotic exposure was the only risk factor for subsequent acquisition of penicillin- nonsusceptible S. pneumoniae compared with penicillin-susceptible S. pneumoniae. Judicious antibiotic use is important to control the spread of drug nonsusceptible S. pneumoniae.
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Jenkins TC, Sakai J, Knepper BC, Swartwood CJ, Haukoos JS, Long JA, Price CS, Burman WJ. Risk factors for drug-resistant Streptococcus pneumoniae and antibiotic prescribing practices in outpatient community-acquired pneumonia. Acad Emerg Med 2012; 19:703-6. [PMID: 22632455 DOI: 10.1111/j.1553-2712.2012.01365.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Due to antimicrobial resistance in Streptococcus pneumoniae, national guidelines recommend a respiratory fluoroquinolone or combination antimicrobial therapy for outpatient treatment of community-acquired pneumonia (CAP) associated with risk factors for drug-resistant S. pneumoniae (DRSP). The objectives of this study were to assess the prevalence of these risk factors and antibiotic prescribing practices in cases of outpatient CAP treated in the acute care setting. METHODS This was a retrospective cohort study of adult outpatients treated for CAP in the emergency department (ED) or urgent care center of an urban, academic medical center from May 1, 2009, through October 31, 2009, and comparison of antibiotic therapy in cases with and without DRSP risk factors. RESULTS Of 175 patients, 90 (51%) had at least one DRSP risk factor, most commonly asthma (n = 28, 16%), alcohol abuse (n = 24, 14%), diabetes mellitus (n = 18, 10%), chronic obstructive pulmonary disease (n = 16, 9%), age > 65 years (n = 16, 9%), and use of antibiotics within 3 months (15, 9%). Antibiotic prescriptions were similar among cases with and without DRSP risk factors: a macrolide (62% vs. 59%, respectively, p = 0.65), doxycycline (27% vs. 28%, p = 0.82), or a respiratory fluoroquinolone (9% vs. 9%, p = 0.90). Concordance with national guideline treatment recommendations was significantly lower in cases with DRSP risk factors (9% vs. 87%, p < 0.0001). CONCLUSIONS DRSP risk factors were present in approximately half of outpatient CAP cases treated in the acute care setting; however, guideline-concordant antibiotic therapy was infrequent. Strict adherence to current guidelines would substantially increase use of fluoroquinolones or combination therapy. Whether the potential risks associated with these broad-spectrum regimens are justified by improved clinical outcomes requires further study.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine, the Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA.
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Desai H, Richter S, Doern G, Heilmann K, Dohrn C, Johnson A, Brauer A, Murphy T, Sethi S. Antibiotic resistance in sputum isolates of Streptococcus pneumoniae in chronic obstructive pulmonary disease is related to antibiotic exposure. COPD 2011; 7:337-44. [PMID: 20854048 DOI: 10.3109/15412555.2010.510162] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Streptococcus pneumoniae (S. pneumoniae) is recovered from sputum of patients with chronic obstructive pulmonary disease (COPD) during stable disease and exacerbations. In patients with community acquired pneumonia, antibiotic exposure in the prior 3-6 months is associated with recovery of antibiotic resistant isolates of S. pneumoniae. Whether the same relationship is seen in COPD is not known. From April 1994 to June 2004, 127 adults with COPD were enrolled in a prospective longitudinal study. Sputum isolates of S. pneumoniae were characterized with susceptibility testing and pulsed-field gel electrophoresis (PFGE). The relationship between antibiotic use in the previous 3 and 6 months with either new acquisition of a resistant pneumococcal isolate or development of resistance (4-fold increase in MIC) in a pre-existing colonizing pneumococcal strain was determined. A total of 194 pneumococcal isolates were recovered from 38 patients. Among 71 newly acquired and 4 resistance-emergent strains analyzed further, rates of resistance to penicillin (MIC ≥2), erythromycin (MIC ≥1), tetracycline (MIC ≥8) and trimethoprim/sulfamethoxazole (MIC ≥4) were 8%, 24%, 17% and 16% respectively. Flouroquinolone resistance was not seen. Among strains isolated from patients exposed to a macrolide within 6 months, 53.6% displayed erythromycin resistance vs. 14% of strains without such exposure (p = 0.00085). Similar associations were not seen for other antibiotics. Macrolide use in the previous 6 months is associated with macrolide resistance in sputum isolates of S. pneumoniae. Recent antibiotic exposure may help in determining appropriate antibiotic treatment in these patients.
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Comparison of clinical features, antimicrobial susceptibility, serotype distribution and outcomes of patients with hospital- and community-associated invasive pneumococcal disease. Int J Antimicrob Agents 2010; 36:119-23. [DOI: 10.1016/j.ijantimicag.2010.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/16/2010] [Accepted: 04/16/2010] [Indexed: 11/19/2022]
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Corrêa RDA, Lundgren FLC, Pereira-Silva JL, Frare e Silva RL, Cardoso AP, Lemos ACM, Rossi F, Michel G, Ribeiro L, Cavalcanti MADN, de Figueiredo MRF, Holanda MA, Valery MIBDA, Aidê MA, Chatkin MN, Messeder O, Teixeira PJZ, Martins RLDM, da Rocha RT. Brazilian guidelines for community-acquired pneumonia in immunocompetent adults - 2009. J Bras Pneumol 2010; 35:574-601. [PMID: 19618038 DOI: 10.1590/s1806-37132009000600011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 04/23/2009] [Indexed: 01/30/2023] Open
Abstract
Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.
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Affiliation(s)
- Ricardo de Amorim Corrêa
- Universidade Federal de Minas Gerais - UFMG, Federal University of Minas Gerais - School of Medicine, Belo Horizonte, Brazil
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Risk Factors for Multidrug-Resistant Pneumococcal Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2008. [DOI: 10.1097/ipc.0b013e31817eec69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Falagas ME, Giannopoulou KP, Vardakas KZ, Dimopoulos G, Karageorgopoulos DE. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. THE LANCET. INFECTIOUS DISEASES 2008; 8:543-52. [DOI: 10.1016/s1473-3099(08)70202-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care 2008; 46:847-62. [PMID: 18665065 DOI: 10.1097/mlr.0b013e318178eabd] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. RESEARCH DESIGN AND METHODS We searched the Cochrane Collaboration's Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. RESULTS Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair. CONCLUSIONS QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.
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Abstract
CONTEXT Large-scale strategies are needed to reduce overuse of antibiotics in US communities. OBJECTIVES To evaluate the impact of a mass media campaign-"Get Smart Colorado"-on public exposure to campaign, antibiotic use, and office visit rates. DESIGN Nonrandomized controlled trial. SETTING Two metropolitan communities in Colorado, United States. SUBJECTS The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. INTERVENTION : The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. PRINCIPAL MEASURES Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. RESULTS After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. CONCLUSIONS A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.
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Aspa J, Rajas O, de Castro FR. Pneumococcal antimicrobial resistance: therapeutic strategy and management in community-acquired pneumonia. Expert Opin Pharmacother 2008; 9:229-41. [PMID: 18201146 DOI: 10.1517/14656566.9.2.229] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Streptococcus pneumoniae has been consistently shown to represent the most frequent causative agent of community-acquired pneumonia (CAP) and pneumococcal antibiotic resistance towards different families of antibiotics continues to be a much-debated issue. Microbial resistance causes a great deal of confusion in choosing an empirical treatment for pneumonia and this makes it necessary to know which factors actually determine the real impact of antimicrobial resistance on the outcome of pneumococcal infections. Several different aspects have to be taken into account when analyzing this matter, such as the study design, the condition of the patient at the time of diagnosis, the choice of the initial antimicrobial regimen (combination or monotherapy) and the pharmacokinetic/pharmacodynamic variables of the chosen antibiotic. It is generally accepted that in the treatment of beta-lactam-resistant pneumococcal infections, the use of standard antipneumococcal beta-lactam agents is unlikely to impact negatively on the outcome of CAP when appropriate agents are given in sufficient doses. As a general rule, for infections with penicillin-sensitive strains, penicillin or an aminopenicillin in a standard dosage will be effective; in the cases of strains with intermediate resistance, beta-lactam agents are still considered appropriate treatment although higher dosages are recommended; finally, infections with isolates of high-level penicillin resistance should be treated with alternative agents such as the third-generation cephalosporins or the new antipneumococcal fluoroquinolones. In areas of high prevalence of high-level macrolide resistance, empirical monotherapy with a macrolide is not optimal for the treatment of hospitalised patients with moderate or moderately-severe CAP. Fluoroquinolones are considered to be excellent antibiotics in the treatment of pneumococcal CAP in adults, but their general recommendation has been withheld due to fears of a widespread development of resistance. Most international guidelines recommend combination therapy (beta-lactam plus a macrolide) for the treatment of hospitalised patients with CAP.
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Affiliation(s)
- Javier Aspa
- Universidad Autónoma de Madrid, Servicio de Neumología, Hospital Universitario de la Princesa, Madrid, Spain.
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Limited efficacy of a nonrestricted intervention on antimicrobial prescription of commonly used antibiotics in the hospital setting: results of a randomized controlled trial. Eur J Clin Microbiol Infect Dis 2008; 27:597-605. [PMID: 18392866 DOI: 10.1007/s10096-008-0482-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 02/01/2008] [Indexed: 10/22/2022]
Abstract
Most interventions aimed at diminishing the use of antimicrobials in hospitals have focussed on newly introduced antibiotics and very few have been randomly controlled. We evaluated the impact on antibiotic consumption of an intervention without restrictions in antibiotic use, focussed on commonly used antibiotics with a controlled randomized trial. All new prescriptions of levofloxacin, carbapenems, or vancomycin in hospitalized patients were randomized to an intervention or a control group. Intervention consisted of an antibiotic regimen counselling targeted to match local antibiotic guidelines, performed using only patients' charts. Clinical charts of patients assigned to the control group were reviewed daily by a pharmacist. The primary endpoint was a reduction in consumption of the targeted antibiotics. Two hundred seventy-eight prescriptions corresponding to 253 patients were included: 146 were assigned to the intervention and 132 to the control group. Total consumption of the targeted antibiotics (median [IQR]) was slightly lower in the intervention (8 [4-12] defined daily doses [DDDs] per patient) than in the control group (10 [6-16] DDDs per patient; p = 0.04). No differences in number of DDDs were observed when antibiotics of substitution were included (11.05 [6-18.2] vs 10 [6-16.5] in the intervention and control groups, respectively, p = 0.13). The total number of days on treatment with the targeted antibiotics was lower in the intervention (4 [3-7] days per patient) than in the control group (6 [4-10] days per patient; p = 0.002). Differences in number of days on treatment only reached statistical significance in the prescriptions of carbapenems. There were no differences between intervention and control groups in terms of number of deaths, hospital readmissions, length of hospital stay, or antibiotic costs. In this trial, an intervention without restrictions focussed on antimicrobial prescriptions of commonly used antibiotics in the hospital setting had a limited efficacy to reduce consumption and did not save costs. Future strategies to promote a more rational antimicrobial use should be evaluated with a randomized controlled design.
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ISHIDA T, MANIWA K, KAGIOKA H, HIRABAYASHI M, ONARU K, TOMIOKA H, HAYASHI M, TOMII K, GOHMA I, ITO Y, HIRAI T, ITO I, MISHIMA M. Antimicrobial susceptibilities of Streptococcus pneumoniae isolated from adult patients with community-acquired pneumonia in Japan. Respirology 2008; 13:240-6. [DOI: 10.1111/j.1440-1843.2007.01214.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJP, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007; 137:S1-31. [PMID: 17761281 DOI: 10.1016/j.otohns.2007.06.726] [Citation(s) in RCA: 626] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Revised: 06/20/2007] [Accepted: 06/20/2007] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This guideline provides evidence-based recommendations on managing sinusitis, defined as symptomatic inflammation of the paranasal sinuses. Sinusitis affects 1 in 7 adults in the United States, resulting in about 31 million individuals diagnosed each year. Since sinusitis almost always involves the nasal cavity, the term rhinosinusitis is preferred. The guideline target patient is aged 18 years or older with uncomplicated rhinosinusitis, evaluated in any setting in which an adult with rhinosinusitis would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with sinusitis. PURPOSE The primary purpose of this guideline is to improve diagnostic accuracy for adult rhinosinusitis, reduce inappropriate antibiotic use, reduce inappropriate use of radiographic imaging, and promote appropriate use of ancillary tests that include nasal endoscopy, computed tomography, and testing for allergy and immune function. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of allergy, emergency medicine, family medicine, health insurance, immunology, infectious disease, internal medicine, medical informatics, nursing, otolaryngology-head and neck surgery, pulmonology, and radiology. RESULTS The panel made strong recommendations that 1) clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions, and a clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening), and 2) the management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain. The panel made a recommendation against radiographic imaging for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected. The panel made recommendations that 1) if a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin as first-line therapy for most adults, 2) if the patient worsens or fails to improve with the initial management option by 7 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications, 3) clinicians should distinguish chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms, 4) clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation, 5) the clinician should corroborate a diagnosis and/or investigate for underlying causes of CRS and recurrent acute rhinosinusitis, 6) the clinician should obtain computed tomography of the paranasal sinuses in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 7) clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures. The panel offered as options that 1) clinicians may prescribe symptomatic relief in managing viral rhinosinusitis, 2) clinicians may prescribe symptomatic relief in managing ABRS, 3) observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness (mild pain and temperature <38.3 degrees C or 101 degrees F) and assurance of follow-up, 4) the clinician may obtain nasal endoscopy in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis, and 5) the clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent acute rhinosinusitis. DISCLAIMER This clinical practice guideline is not intended as a sole source of guidance for managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center and Long Island College Hospital, Brooklyn, NY 11201-5514, USA.
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Falagas ME, Siempos II, Bliziotis IA, Panos GZ. Impact of initial discordant treatment with beta-lactam antibiotics on clinical outcomes in adults with pneumococcal pneumonia: a systematic review. Mayo Clin Proc 2006; 81:1567-74. [PMID: 17165635 DOI: 10.4065/81.12.1567] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To systematically examine the available evidence regarding the effect of initial discordant therapy with beta-lactam antibiotics on mortality, clinical success, and bacteriological eradication in patients with pneumococcal pneumonia. METHODS We analyzed prospective studies that compared the clinical effectiveness of concordant (active in vitro) beta-lactam monotherapy with discordant (inactive in vitro) monotherapy with the same beta-lactam in patients with pneumococcal pneumonia. Relevant studies were identified from searches of the PubMed database (1950 to November 2005) and references from articles. Outcomes between groups of patients who received concordant and discordant treatment were compared by simple pooling of data and by estimation of pooled odds ratios or risk difference (RD), when applicable. RESULTS Six prospective studies were included in our analysis. No statistically significant difference was found in mortality of patients treated with beta-Iactam concordant and discordant therapy (51/275 [19%] vs 9/42 [21%]; P = .66; data from 6 studies; RD, -0.05; 95% confidence interval [CI], -0.23 to 0.12; data from 5 studies). In addition, no statistically significant difference was found regarding clinical success (37/42 [88%] vs 5/6 [83%]; P = .57; odds ratio, 2.57; 95% CI, 0.46 to 14.34; RD, 0.07; 95% CI, -0.36 to 0.50; data from 3 studies) or bacteriological success (24/30 [80%] vs 3/3 [100%]; P = .99; and RD, -0.18; 95% CI, -0.79 to 0.42; data from 2 studies) between concordant and discordant therapy. CONCLUSION The initial discordant treatment with beta-lactam antibiotics was not associated with a statistically significant Increase in mortality or clinical or bacteriological failure of therapy for pneumococcal pneumonia.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos St, 151 23 Marousi, Athens, Greece.
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Metlay JP, Fishman NO, Joffe MM, Kallan MJ, Chittams JL, Edelstein PH. Macrolide resistance in adults with bacteremic pneumococcal pneumonia. Emerg Infect Dis 2006; 12:1223-30. [PMID: 16965701 PMCID: PMC3291219 DOI: 10.3201/eid1708.060017] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We conducted a case-control study of adults with bacteremic pneumococcal pneumonia to identify factors associated with macrolide resistance. Study participants were identified through population-based surveillance in a 5-county region surrounding Philadelphia. Forty-three hospitals contributed 444 patients, who were interviewed by telephone regarding potential risk factors. In multivariable analyses, prior exposure to a macrolide antimicrobial agent (odds ratio [OR] 2.8), prior flu vaccination (OR 2.0), and Hispanic ethnicity (OR 4.1) were independently associated with an increased probability of macrolide resistance, and a history of stroke was independently associated with a decreased probability of macrolide resistance (OR 0.2). Fifty-five percent of patients with macrolide-resistant infections reported no antimicrobial drug exposure in the preceding 6 months. Among patients who reported taking antimicrobial agents in the 6 months preceding infection, failure to complete the course of prescribed drugs was associated with an increased probability of macrolide resistance (OR 3.4).
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Affiliation(s)
- Joshua P Metlay
- Center for Clinical Epidemiology and Biostatistics, Philadelphia Veterans Affairs Medical Center, 423 Guardian Drive, Philadelphia, PA 19104, USA.
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Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/ebch.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Neumonías comunitarias graves del adulto. EMC - ANESTESIA-REANIMACIÓN 2006. [PMCID: PMC7158989 DOI: 10.1016/s1280-4703(06)45316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Las neumonías agudas comunitarias son causa frecuente de hospitalización y mortalidad. El reconocimiento inmediato de las formas graves según criterios simples, clínicos, radiológicos y de laboratorio, es una etapa esencial para un tratamiento rápido en el servicio de reanimación con el fin de controlar los fallos orgánicos. La obtención de muestras apropiadas para realizar estudios microbiológicos precede al tratamiento antibiótico, que se debe instaurar con rapidez después de diagnosticar la neumonía. Pese a las técnicas de identificación, sólo la mitad de las neumonías se documentan adecuadamente. El tratamiento antibiótico, en principio empírico, integra los gérmenes patógenos, tanto extracelulares como intracelulares, que producen neumonías con mayor frecuencia; siempre debe ser activo contra el neumococo, la bacteria implicada más a menudo. La asociación de un betalactámico y un macrólido o una fluoroquinolona es la que mejor responde a este objetivo. En las recomendaciones más comunes, las fluoroquinolonas activas contra los neumococos sustituyen a los fármacos precedentes. En el caso excepcional de los pacientes con factores de riesgo especiales, el tratamiento empírico debe tener en cuenta Pseudomonas aeruginosa. La gravedad de parte de las neumonías comunitarias justifica el que se recurra a tratamientos complementarios. Se debe evaluar de nuevo el tratamiento antibiótico en las 72 horas siguientes a su instauración, a fin de valorar su eficacia, adaptar el tratamiento en caso necesario y simplificarlo. El mantenimiento de antibióticos de amplio espectro expone al paciente a efectos secundarios y contribuye a producir resistencias bacterianas. En cuanto a las neumonías neumocócicas, las fluoroquinolonas activas contra el neumococo podrían representar una alternativa en caso de que el neumococo desarrolle resistencia a los betalactámicos. La mortalidad persistente de las neumonías sigue siendo notable. Esto debe fomentar la mejora del tratamiento inicial y la búsqueda de nuevas opciones terapéuticas.
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Luna CM, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez AR, Mera J. [Clinical guidelines for the treatment of nosocomial pneumonia in Latin America: an interdisciplinary consensus document. Recommendations of the Latin American Thoracic Society]. Arch Bronconeumol 2005; 41:439-56. [PMID: 16117950 DOI: 10.1016/s1579-2129(06)60260-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- C M Luna
- Asociación Argentina de Medicina Respiratoria, Buenos Aires, Argentina.
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Abstract
BACKGROUND The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well-documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately. OBJECTIVES To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files. SELECTION CRITERIA We included all randomised and quasi-randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient-based intervention. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. MAIN RESULTS Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention. AUTHORS' CONCLUSIONS The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.
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Affiliation(s)
- S R Arnold
- University of Tennessee, Pediatrics, Le Bonheur Children's Medical Center, 50 N Dunlap St., Memphis, TN 38103, USA.
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Luna C, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez A, Mera J. Neumonía intrahospitalaria: guía clínica aplicable a Latinoamérica preparada en común por diferentes especialistas. Arch Bronconeumol 2005. [DOI: 10.1157/13077956] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Belongia EA, Knobloch MJ, Kieke BA, Davis JP, Janette C, Besser RE. Impact of statewide program to promote appropriate antimicrobial drug use. Emerg Infect Dis 2005; 11:912-20. [PMID: 15963287 PMCID: PMC3367605 DOI: 10.3201/eid1106.050118] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.
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Affiliation(s)
- Edward A Belongia
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin 54449, USA.
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Pneumonies communautaires graves de l'adulte. EMC - ANESTHÉSIE-RÉANIMATION 2005. [PMCID: PMC7148697 DOI: 10.1016/j.emcar.2005.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Les pneumonies aiguës communautaires sont des causes fréquentes d'hospitalisation et de mortalité. La reconnaissance immédiate des formes sévères sur des critères simples, cliniques, radiologiques et biologiques, est une étape importante pour une prise en charge rapide en réanimation afin de contrôler les défaillances d'organes. Les prélèvements appropriés microbiologiques précèdent l'antibiothérapie qui doit être instituée très rapidement après le diagnostic de pneumonie. Malgré les techniques d'identification, la moitié seulement des pneumonies sont documentées. Cette antibiothérapie, initialement probabiliste, intègre les germes pathogènes les plus souvent responsables, extra- et intracellulaires ; elle doit toujours être active sur le pneumocoque, bactérie la plus fréquente. L'association d'une β-lactamine et d'un macrolide ou d'une fluoroquinolone répond le mieux à cet objectif. Les fluoroquinolones actives sur le pneumocoque se sont substituées aux précédentes dans les plus récentes recommandations. Dans le cas exceptionnel des patients ayant des facteurs de risque particuliers, le traitement probabiliste doit prendre en compte Pseudomonas aeruginosa. La gravité d'une partie des pneumonies communautaires justifie le recours à des traitements adjuvants. L'antibiothérapie doit être réévaluée dans les 72 heures dans le but d'apprécier son efficacité, de l'adapter éventuellement et de la simplifier. La poursuite des antibiotiques à large spectre expose le patient à des effets indésirables et contribue aux résistances bactériennes. Pour les pneumonies dues au pneumocoque, les fluoroquinolones actives sur le pneumocoque pourront constituer une alternative en cas d'évolution importante des résistances du pneumocoque aux β-lactamines. La mortalité persistante des pneumonies reste sévère. Ceci doit stimuler l'amélioration de la prise en charge initiale et faire rechercher de nouvelles thérapeutiques.
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Current Perspectives on Streptococcus pneumoniae Antibiotic Resistance, With Particular Reference to Isolates From Spain. ACTA ACUST UNITED AC 2005. [DOI: 10.1097/01.cpm.0000171507.28715.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kiang KM, Kieke BA, Como-Sabetti K, Lynfield R, Besser RE, Belongia EA. Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug use. Emerg Infect Dis 2005; 11:904-11. [PMID: 15963286 PMCID: PMC3367606 DOI: 10.3201/eid1106.050144] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.
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Affiliation(s)
- Karen M Kiang
- Minnesota Department of Health, Minneapolis, Minnesota, USA
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Gonzales R, Corbett KK, Leeman-Castillo BA, Glazner J, Erbacher K, Darr CA, Wong S, Maselli JH, Sauaia A, Kafadar K. The "minimizing antibiotic resistance in Colorado" project: impact of patient education in improving antibiotic use in private office practices. Health Serv Res 2005; 40:101-16. [PMID: 15663704 PMCID: PMC1361128 DOI: 10.1111/j.1475-6773.2005.00344.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practices. DATA SOURCES/STUDY SETTING Antibiotic prescription rates based on claims data from four managed care organizations in Colorado during baseline (winter 2000) and study (winter 2001) periods. STUDY DESIGN A nonrandomized controlled trial of a household and office-based patient educational intervention was performed. During both periods, Colorado physicians were mailed antibiotic prescribing profiles and practices guidelines as part of an ongoing quality improvement program. Intervention practices (n=7) were compared with local and distant control practices. DATA COLLECTION/EXTRACTION METHODS Office visits were extracted by managed care organizations using International Classification of Diseases-9-Clinical Modification codes for acute respiratory tract infections, and merged with pharmacy claims data based on visit and dispensing dates coinciding within 2 days. PRINCIPAL FINDINGS Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practices, and decreased from 39 to 37 percent at the local control practices, and from 34 to 30 percent at the intervention practices (p=.18 compared with distant control practices). Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practices, from 55 to 45 percent at the local control practices, and from 60 to 36 percent at the intervention practices (p<.002 and p=.006 compared with distant and local control practices, respectively). CONCLUSIONS In office practices, there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis. In contrast, patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts.
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Affiliation(s)
- Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA 94118, USA
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Stivers T. Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance. Soc Sci Med 2005; 60:949-64. [PMID: 15589666 DOI: 10.1016/j.socscimed.2004.06.040] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study draws on a database of 570 community-based acute pediatric encounters in the USA and uses conversation analysis as a methodology to identify two formats physicians use to recommend non-antibiotic treatment in acute pediatric care (using a subset of 309 cases): recommendations for particular treatment (e.g., "I'm gonna give her some cough medicine.") and recommendations against particular treatment (e.g., "She doesn't need any antibiotics."). The findings are that the presentation of a specific affirmative recommendation for treatment is less likely to engender parent resistance to a non-antibiotic treatment recommendation than a recommendation against particular treatment even if the physician later offers a recommendation for particular treatment. It is suggested that physicians who provide a specific positive treatment recommendation followed by a negative recommendation are most likely to attain parent alignment and acceptance when recommending a non-antibiotic treatment for a viral upper respiratory illness.
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Affiliation(s)
- Tanya Stivers
- Max Planck Institute for Psycholinguistics, Language and Cognition Group, PB 310, 6500 AH Nijmegen, The Netherlands.
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Álvarez-Rocha L, Alós J, Blanquer J, Álvarez-Lerma F, Garau J, Guerrero A, Torres A, Cobo J, Jordá R, Menéndez R, Olaechea P, Rodríguez de castro F. [Guidelines for the management of community pneumonia in adult who needs hospitalization]. Med Intensiva 2005; 29:21-62. [PMID: 38620135 PMCID: PMC7131443 DOI: 10.1016/s0210-5691(05)74199-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2004] [Indexed: 11/01/2022]
Abstract
Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention.
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Affiliation(s)
- L. Álvarez-Rocha
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - J.I. Alós
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - J. Blanquer
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - F. Álvarez-Lerma
- Grupo de Estudio de la Infección en el Paciente Crítico. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIPC de la SEIMC)
| | - J. Garau
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Guerrero
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Torres
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - J. Cobo
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - R. Jordá
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - R. Menéndez
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - P. Olaechea
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - F. Rodríguez de castro
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
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Abstract
Acute respiratory infections (ARIs) are the most common infections in humans, accounting for half of all acute conditions each year in the United States. Acute bronchitis episodes represent a significant portion of these illnesses. This article focuses on acute bronchitis in otherwise healthy individuals.
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Stivers T. Parent resistance to physicians' treatment recommendations: one resource for initiating a negotiation of the treatment decision. HEALTH COMMUNICATION 2005; 18:41-74. [PMID: 15918790 DOI: 10.1207/s15327027hc1801_3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This article examines pediatrician-parent interaction in the context of acute pediatric encounters for children with upper respiratory infections. Parents and physicians orient to treatment recommendations as normatively requiring parent acceptance for physicians to close the activity. Through acceptance, withholding of acceptance, or active resistance, parents have resources with which to negotiate for a treatment outcome that is in line with their own wants. This article offers evidence that even in acute care, shared decision making not only occurs but, through normative constraints, is mandated for parents and physicians to reach accord in the treatment decision.
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Affiliation(s)
- Tanya Stivers
- Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands.
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Abstract
The seriousness of community-acquired pneumonia (CAP), despite being a reasonably common and potentially lethal disease, often is under estimated by physicians and patients alike. CAP results in more than 10 million visits to physicians, 64 million days of restricted activity, and 600,000 hospitalizations. This article discusses the epidemiology and bacterial causes of CAP in immunocompetent adults and the severe acute respiratory syndrome coronavirus.
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Affiliation(s)
- Lionel A Mandell
- Division of Infectious Diseases, Department of Medicine, McMaster University, Henderson Site, 711 Concession Street, 40 Wing, 5th Floor, Room 503, Hamilton, ON Canada L8V 1C3.
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Hiramatsu K, Ohama M, Mijajima Y, Kishi K, Mizunoe S, Tokimatsu I, Nagai H, Kadota JI, Saikawa T, Nasu M. Antimicrobial susceptibilities and analysis of genes related to penicillin or macrolide resistance in Streptococcus pneumoniae. Int J Antimicrob Agents 2004; 24:125-9. [PMID: 15288310 DOI: 10.1016/j.ijantimicag.2004.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2003] [Accepted: 02/04/2004] [Indexed: 11/26/2022]
Abstract
One hundred and seventy-seven strains of Streptococcus pneumoniae derived from respiratory specimens between 1987 and 2001 were evaluated for their antimicrobial susceptibilities and distribution of genes related to penicillin and macrolide resistance. Resistance rates tended to be higher for the 1996-2001 isolates than for the 1987-1995 isolates for all beta-lactams tested. For benzylpenicillin the MIC(90) value of the isolates derived between 1996 and 2001 was 1.56 mg/L, while that of strains isolated between 1987 and 1990 was 0.05 mg/L. Furthermore, the number of strains susceptible to macrolides also decreased, but only two strains isolated in 1993 were resistant to levofloxacin of the 177 S. pneumoniae strains tested. When of genes relating to penicillin resistance were analysed using PCR with primers specific to susceptible alleles, although more than 50% of strains from 1987 to 1990 and 1991 to 1995 revealed no mutations in the pbp 1a, 2x and 2b genes, only 30.0% of strains derived between 1996 and 2001 showed no mutations in the pbp gene. Strains having mutations in all three pbp genes (1a, 2x and 2b) by the PCR method increased from only 2.2% in the 1987-1990 derived strains to 27.5% in the 1996-2001 strains. Furthermore, 64.1 and 60.0% of the isolates from 1987 to 1990 and 1991 to 1995, respectively, did not possess either the mefA or ermB by PCR analysis. Conversely, 75.0% of isolates from 1996 to 2001 possessed mefA and/or ermB. These genetic changes may explain the increase in the number of penicillin and macrolide resistant strains. We believe that it is important to evaluate changes in MIC as well as genetic mutations in order to select the most appropriate therapy for S. pneumoniae infections.
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Affiliation(s)
- Kazufumi Hiramatsu
- Clinical Laboratory Center, Oita University Faculty of Medicine, Hasama, Oita 879-5593, Japan
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Barahona Rondón L, Soriano García F, Granizo Martínez JJ, Santos O'Connor F, López Durán JC, Fernández Roblas R. Factores relacionados con la mortalidad de la enfermedad neumocócica invasiva. Med Clin (Barc) 2004; 123:575-7. [PMID: 15535939 DOI: 10.1016/s0025-7753(04)74601-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE To analyze the risk factors associated with mortality in invasive pneumococcal disease in the university hospital Fundación Jiménez Díaz (Madrid, Spain) during 11 years. PATIENTS AND METHOD We performed a retrospective study of patients attending the emergency service of the hospital from January 1993 to August 2003. We registered data on mortality, clinical and microbiological evolution and relapses. RESULTS We studied 263 patients with pneumococcal baceteremia and invasive disease caused by Streptococcus pneumoniae (pneumonia, meningitis, sepsis, bacteremia of unknown origin and oligoarthritis). Mortality was 12.5%. Variables associated with mortality in a logistic regression analysis included absence of leukocytosis (p = 0.04), acidosis (p < 0.01), respiratory signs and symptoms (tachypnea, pleuritic pain) (p = 0.02), and neurologic manifestations (decreased consciousness level; (p < 0.01). CONCLUSION Patients at highest risk of death because of invasive pneumococcal disease are critically ill, with no leukocytosis, with severe respiratory or neurological symptoms and undergoing invasive procedures such as mechanical ventilation and tracheostomy.
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Coenen S, Van Royen P, Michiels B, Denekens J. Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial. J Antimicrob Chemother 2004; 54:661-72. [PMID: 15282232 DOI: 10.1093/jac/dkh374] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough. METHODS In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures. RESULTS Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution. CONCLUSIONS An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.
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Affiliation(s)
- Samuel Coenen
- Centre for General Practice, University of Antwerp, BE 2610 Antwerp, Belgium.
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Aspa J, Rajas O, Rodríguez de Castro F, Blanquer J, Zalacain R, Fenoll A, de Celis R, Vargas A, Rodríguez Salvanés F, España PP, Rello J, Torres A. Drug‐Resistant Pneumococcal Pneumonia: Clinical Relevance and Related Factors. Clin Infect Dis 2004; 38:787-98. [PMID: 14999620 DOI: 10.1086/381886] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Accepted: 11/03/2003] [Indexed: 11/03/2022] Open
Abstract
A multicenter study of 638 cases of community-acquired pneumonia due to Streptococcus pneumoniae (SP-CAP) was performed to assess current levels of resistance. Of the pneumococcal strains, 35.7% had an minimum inhibitory concentration (MIC) of penicillin of > or =0.12 microg/mL (3 isolates had an MIC of 4 microg/mL), 23.8% had an MIC of erythromycin of 128 microg/mL, and 22.2% were multidrug resistant. Logistic regression determined that chronic pulmonary disease (odds ratio [OR], 1.44], human immunodeficiency virus infection (OR, 1.98), clinically suspected aspiration (OR, 2.12), and previous hospital admission (OR, 1.69) were related to decreased susceptibility to penicillin, and previous admission (OR, 1.89) and an MIC of penicillin of MIC > or =0.12 microg/mL (OR, 15.85) were related to erythromycin resistance (MIC, > or =1 microg/mL). The overall mortality rate was 14.4%. Disseminated intravascular coagulation, empyema, and bacteremia were significantly more frequent among patients with penicillin-susceptible SP-CAP. Among isolates with MICs of penicillin of > or =0.12 microg/mL, serotype 19 was predominant and was associated with a higher mortality rate. In summary, the rate of resistance to beta -lactams and macrolides among S. pneumoniae that cause CAP remains high, but such resistance does not result in increased morbidity.
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Affiliation(s)
- Javier Aspa
- Servicio de Neumologia, Hospital de la Princesa, Madrid, Spain.
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Lujan M, Gallego M, Fontanals D, Mariscal D, Rello J. Prospective observational study of bacteremic pneumococcal pneumonia: Effect of discordant therapy on mortality*. Crit Care Med 2004; 32:625-31. [PMID: 15090938 DOI: 10.1097/01.ccm.0000114817.58194.bf] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of discordant empirical therapy on outcome in bacteremic pneumococcal community-acquired pneumonia. DESIGN Prospective observational study. SETTING A 600-bed teaching hospital with a reference area of 400,000 inhabitants. PATIENTS All patients aged > or =18 yrs with a diagnosis of community-acquired pneumonia whose blood cultures, obtained within the first 48 hrs of hospitalization, demonstrated growth of Streptococcus pneumoniae were included in the study. METHODS Discordant therapy was defined as failure to administer an antibiotic with in vitro activity against the isolated strain within 24 hrs of hospital admission. The 2002 breakpoints recommended for respiratory infections by the National Committee for Clinical Laboratory Standards were used to classify therapy. RESULTS A total of 100 patients with bacteremic pneumococcal pneumonia were identified. Penicillin- and macrolide-resistant strains were identified in 29 and 18 cases, respectively. Only two strains had minimum inhibitory concentrations of >2 microg/mL for cephalosporins. Discordant therapy was documented in ten patients, five of whom died. Mortality in patients receiving concordant therapy was 14% (13 of 90). Nursing home residence (odds ratio [OR] = 14.8) and immunocompromise (OR = 11.5) were independently (p <.05) associated with discordant therapy. Risk of discordant therapy was significantly higher (p <.05) when empirical therapy did not include cefotaxime or ceftriaxone (OR = 10.4). Discordant therapy (OR = 27.3), multilobar involvement (OR = 14.2), underlying chronic obstructive pulmonary disease (OR = 9.1), and hospitalization during the previous 12 wks (OR = 7.9) were independently associated (p <.05) with death. The excess mortality for initial discordant therapy was estimated to be 35.6% (95% confidence interval, 3.73-67.4). CONCLUSIONS Survival in patients with bacteremic community-acquired pneumococcal pneumonia can be improved by avoiding suboptimal therapy. Using the 2002 breakpoints, it is very unlikely that discordant therapy would be given with ceftriaxone or cefotaxime. Clinical outcome is worse in those patients receiving antimicrobial therapy that in vitro testing suggests would be ineffective.
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Affiliation(s)
- Manel Lujan
- Pulmonary Department, Corporació Parc Taulí, Sabadell, Barcelona, Spain
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Ruhe JJ, Myers L, Mushatt D, Hasbun R. High‐Level Penicillin‐NonsusceptibleStreptococcus pneumoniaeBacteremia: Identification of a Low‐Risk Subgroup. Clin Infect Dis 2004; 38:508-14. [PMID: 14765343 DOI: 10.1086/381197] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2003] [Accepted: 10/11/2003] [Indexed: 11/03/2022] Open
Abstract
High-level penicillin resistance has been associated with treatment failure in patients with Streptococcus pneumoniae infections. To identify a subgroup of patients at low risk for high-level penicillin-nonsusceptible S. pneumoniae bacteremia, a cross-sectional study of 303 patients was performed. For the total study population, penicillin resistance was observed in 98 (32%) of 303 patients; high-level resistance was seen in 33 (11%). A predictive model was created by using 3 baseline variables that were independently associated with high-level penicillin resistance: previous beta -lactam antibiotic use, previous stay in a risk area (defined as stay in day care facilities, prisons, homeless shelters, nursing homes, or other long-term care facilities), and previous respiratory tract infection. The model was used to identify patients at low and high risk for high-level penicillin-resistant pneumococcal bacteremia. None of the isolates of patients in the low-risk subgroup had ceftriaxone resistance. Patients in the low-risk subgroup could be empirically treated with fluoroquinolone-sparing regimens.
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Affiliation(s)
- Jörg J Ruhe
- Department of Medicine, Infectious Diseases Section, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA
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Altclas J, Salgueira C, Di Martino A. Pneumococcal bacteremia in a single center in Argentina. Int J Infect Dis 2004; 8:53-8. [PMID: 14690781 DOI: 10.1016/j.ijid.2003.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To determine the clinical and microbiologic characteristics of pneumococcal bacteremia at Sanatorio Mitre, Buenos Aires, Argentina. METHODS One-hundred-and-seven episodes of pneumococcal bacteremia were prospectively analyzed from 1993 to 1998. Demographics, clinical and microbiological variables were studied. RESULTS Eighty-one patients (76%) were adults and 26 children (24%). Most cases (98%) were acquired in the community. Seventy-nine patients (74%) had at least one underlying condition. The primary source of bacteremia was found in 91 patients (85%), the lungs being the most common source. Streptococcus pneumoniae was isolated from one sterile site other than the primary focus in 25 patients (23%). Eighty-five (79%) of the Streptococcus pneumoniae were susceptible to penicillin and 22 (21%) showed intermediate or high resistance to penicillin and 2% were additionally resistant to ceftriaxone. Initial antimicrobial therapy was appropriate in 95% of the cases. The overall mortality was 21%, however adults admitted to the intensive care unit (ICU) had higher mortality (81%). No patients under 14 years old died. Multivariate analysis showed that age and recovery of the organisms from a sterile site other than the primary focus were statistically significant predictors of mortality. CONCLUSION Bacteremic pneumococcal infections continue to be an important worldwide problem causing morbidity and high mortality despite supportive care and appropriate antimicrobial therapy.
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Affiliation(s)
- Javier Altclas
- Division of Infectious Diseases, Sanatorio Mitre, Buenos Aires, Argentina.
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Pallares R, Fenoll A, Liñares J. The epidemiology of antibiotic resistance in Streptococcus pneumoniae and the clinical relevance of resistance to cephalosporins, macrolides and quinolones. Int J Antimicrob Agents 2003; 22 Suppl 1:S15-24; discussion S25-6. [PMID: 14512221 DOI: 10.1016/j.ijantimicag.2003.08.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Invasive non-meningeal pneumococcal infections remain a major cause of morbidity and mortality worldwide. The factors affecting the epidemiology and mortality of pneumococcal infections are discussed. The increase and spread of resistance to antimicrobial agents among pneumococci is a cause of concern to the clinician. There are links between the usage of antibacterial agents and the development of resistance. Resistance to penicillin and other beta-lactams has become widespread but this does not appear to have decreased the efficacy of some of these agents against non-meningeal infections. There is evidence that the good pharmacokinetic and pharmacodynamic features of the third generation cephalosporins (cefotaxime and ceftriaxone) contribute to their efficacy in vivo. New breakpoints for cefotaxime and ceftriaxone against non-meningeal pneumococcal isolates were proposed by the National Committee for Clinical Laboratory Standard (NCCLS, US), based on the clinical evidence of the efficacy of these drugs. In contrast there is increasing evidence that resistance to macrolides can lead to a poor clinical response. Fluoroquinolones have been widely used to treat respiratory tract infections among others, and pneumococcal resistance to these agents in vitro, although currently low, is increasing. There are reports that resistance to fluoroquinolones can develop during treatment and may be reflected in a lack of clinical response. Several clinical and epidemiological variables (e.g. prior antibiotic use) can be useful to identify patients at risk from infections with antibiotic-resistant pneumococci. These patients would be those who would benefit the most from a pneumococcal vaccination programme.
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Affiliation(s)
- Roman Pallares
- Infectious Diseases Department, Hospital de Bellvitge, University of Barcelona, Barcelona, Spain.
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Sirinavin S, Vorachit M, Thakkinstian A, Hongsanguensri S, Wittayawongsruji P. Pediatric invasive pneumococcal disease in a teaching hospital in Bangkok. Int J Infect Dis 2003; 7:183-9. [PMID: 14563221 DOI: 10.1016/s1201-9712(03)90050-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Increased problems with drug-resistant Streptococcus pneumoniae (SP) and the dearth of epidemiologic and clinical information on invasive pneumococcal disease in children in Asia formed the basis for this study. METHODS A periodic retrospective review of the records of 0-15-year-old patients was conducted at a teaching hospital in Bangkok, during 1971-2000. RESULTS Infections with penicillin-non-susceptible SP (PNSSP) strains rapidly increased after they first appeared in 1988, and they accounted for 71% (29/41) of the total cases during 1996-2000. Of 137 patients, 74% were <60 months old, and 66% had an underlying condition. Infections included: bacteremia without focus 51; pneumonia 38; meningitis 35; peritonitis 13; and bone/joint infection 2. Two patients had two foci of infection. Eight of 10 episodes in patients with AIDS were bacteremic pneumonia. Median ages (range) in months for patients with and without an underlying condition were 24 (1-174) and 10 (0-160); and for the patients without an underlying condition they were: pneumonia 23 (4-156); bacteremia without focus 12 (0-160); and meningitis 7 (2-156). Case-fatality rates were 18% and 2% for patients with and without an underlying condition. The study also examined factors associated with PNSSP infection and death. During 1991-2000, 74% (43/58) of the total cases occurred from November to April, which are dry months. CONCLUSIONS This study population contained a high proportion with both an underlying condition and infection with PNSSP, and a moderately low proportion with bacteremia without focus. The disease was two to three times more common in dry months than in rainy months.
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Affiliation(s)
- Sayomporn Sirinavin
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Waterer GW, Buckingham SC, Kessler LA, Quasney MW, Wunderink RG. Decreasing beta-lactam resistance in Pneumococci from the Memphis region: analysis of 2,152 isolates From 1996 to 2001. Chest 2003; 124:519-25. [PMID: 12907537 DOI: 10.1378/chest.124.2.519] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The Memphis region historically has had high pneumococcal antibiotic resistance rates. In recent years, we have seen a significant shift in antibiotic use away from beta-lactams toward the newer quinolones and macrolides. We hypothesized that these changes would cause a shift in pneumococcal antibiotic resistance patterns. DESIGN Retrospective cohort study. SETTING A large private hospital system. PATIENTS AND METHODS We analyzed the antibiotic susceptibility patterns of 2,152 pneumococcal isolates obtained in the Memphis area from 1996 to 2001. Isolates were categorized as invasive or noninvasive and antibiotic resistance was classified according to the 2000 guidelines of the National Committee for Clinical Laboratory Standards. RESULTS Over the study period, the proportion of penicillin-susceptible noninvasive pneumococcal isolates taken from children increased from 22 to 44% (p = 0.0004 [for trend across the 6-year period]). In noninvasive isolates taken from adults, penicillin susceptibility increased from 22 to 55% (p = 0.002), with a trend toward increasing sensitivity to cefotaxime (p = 0.02) in noninvasive isolates over the same period. The proportion of isolates with high-level penicillin resistance (ie, minimum inhibitory concentration, > or = 4 microg/mL) also decreased between 1996 and 2001 (p = 0.003). Clindamycin resistance in adult noninvasive isolates also declined (p = 0.002). The only adverse trend observed over this period was an increase in erythromycin resistance in noninvasive isolates from adults (p = 0.01). Resistance rates were significantly higher in children than in adults and were higher in noninvasive isolates than in invasive isolates. CONCLUSIONS The stabilization of beta-lactam resistance rates in our region suggests that a continuous increase in pneumococcal resistance to antibiotics is not inevitable and may be avoidable.
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Affiliation(s)
- Grant W Waterer
- Department of Medicine, University of Western Australia, Crawley, Australia
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Yu VL, Chiou CCC, Feldman C, Ortqvist A, Rello J, Morris AJ, Baddour LM, Luna CM, Snydman DR, Ip M, Ko WC, Chedid MBF, Andremont A, Klugman KP. An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotics administered, and clinical outcome. Clin Infect Dis 2003; 37:230-7. [PMID: 12856216 DOI: 10.1086/377534] [Citation(s) in RCA: 321] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2002] [Accepted: 06/12/2003] [Indexed: 12/17/2022] Open
Abstract
We performed a prospective, international, observational study of 844 hospitalized patients with blood cultures positive for Streptococcus pneumoniae. Fifteen percent of isolates had in vitro intermediate susceptibility to penicillin (minimum inhibitory concentration [MIC], 0.12-1 microg/mL), and 9.6% of isolates were resistant (MIC, >or=2 microg/mL). Age, severity of illness, and underlying disease with immunosuppression were significantly associated with mortality; penicillin resistance was not a risk factor for mortality. The impact of concordant antibiotic therapy (i.e., receipt of a single antibiotic with in vitro activity against S. pneumoniae) versus discordant therapy (inactive in vitro) on mortality was assessed at 14 days. Discordant therapy with penicillins, cefotaxime, and ceftriaxone (but not cefuroxime) did not result in a higher mortality rate. Similarly, time required for defervescence and frequency of suppurative complications were not associated with concordance of beta-lactam antibiotic therapy. beta-Lactam antibiotics should still be useful for treatment of pneumococcal infections that do not involve cerebrospinal fluid, regardless of in vitro susceptibility, as determined by current NCCLS breakpoints.
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Affiliation(s)
- Victor L Yu
- Division of Infectious Disease, University of Pittsburgh, PA, USA. vly+@pitt.edu
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