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Leung LY, Huang HL, Hung KK, Leung CY, Lam CC, Lo RS, Yeung CY, Tsoi PJ, Lai M, Brabrand M, Walline JH, Graham CA. Door-to-antibiotic time and mortality in patients with sepsis: Systematic review and meta-analysis. Eur J Intern Med 2024:S0953-6205(24)00262-0. [PMID: 39034174 DOI: 10.1016/j.ejim.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/02/2024] [Accepted: 06/12/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To evaluate whether the timing of initial antibiotic administration in patients with sepsis in hospital affects mortality. METHODS This systematic review and meta-analysis included studies from inception up to 19 May 2022. Interventional and observational studies including adult human patients with suspected or confirmed sepsis and reported time of antibiotic administration with mortality were included. Data were extracted by two independent reviewers. Summary estimates were calculated by using random-effects model. The primary outcome was mortality. RESULTS We included 42 studies comprising 190,896 patients with sepsis. Pooled data showed that the OR for patient mortality who received antibiotics ≤1 hr was 0.83 (95 %CI: 0.67 to 1.04) when compared with patients who received antibiotics >1hr. Significant reductions in the risk of death in patients with earlier antibiotic administration were observed in patients ≤3 hrs versus >3 hrs (OR: 0.80, 95 %CI: 0.68 to 0.94) and ≤6 hrs vs 6 hrs (OR: 0.57, 95 %CI: 0.39 to 0.82). CONCLUSIONS Our findings show an improvement in mortality in sepsis patients with early administration of antibiotics at <3 and <6 hrs. Thus, these results suggest that antibiotics should be administered within 3 hrs of sepsis recognition or ED arrival regardless of the presence or absence of shock.
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Affiliation(s)
- Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Hsi-Lan Huang
- Department of Global Health Policy, The University of Tokyo, Japan
| | - Kevin Kc Hung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Chi Yan Leung
- Department of Global Health Policy, The University of Tokyo, Japan
| | - Cherry Cy Lam
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Ronson Sl Lo
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Chun Yu Yeung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Peter Joseph Tsoi
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China; James Cook University, Townsville, Australia
| | - Michael Lai
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China; Department of Emergency Medicine, University of British Columbia, Canada
| | - Mikkel Brabrand
- Department of Emergency Medicine, University of Southern Denmark, Denmark
| | - Joseph H Walline
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China
| | - Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, PR China.
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Bassetti M, Giacobbe DR, Magnasco L, Fantin A, Vena A, Castaldo N. Antibiotic Strategies for Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:187-199. [PMID: 38301712 DOI: 10.1055/s-0043-1778641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Despite advancements in health systems and intensive care unit (ICU) care, along with the introduction of novel antibiotics and microbiologic techniques, mortality rates in severe community-acquired pneumonia (sCAP) patients have not shown significant improvement. Delayed admission to the ICU is a major risk factor for higher mortality. Apart from choosing the appropriate site of care, prompt and appropriate antibiotic therapy significantly affects the prognosis of sCAP. Treatment regimens involving ceftaroline or ceftobiprole are currently considered the best options for managing patients with sCAP. Additionally, several other molecules, such as delafloxacin, lefamulin, and omadacycline, hold promise as therapeutic strategies for sCAP. This review aims to provide a comprehensive summary of the key challenges in managing adults with severe CAP, focusing on essential aspects related to antibiotic treatment and investigating potential strategies to enhance clinical outcomes in sCAP patients.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Policlinico San Martino Hospital, IRCCS, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Daniele R Giacobbe
- Infectious Diseases Unit, Policlinico San Martino Hospital, IRCCS, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Laura Magnasco
- Infectious Diseases Unit, Policlinico San Martino Hospital, IRCCS, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Alberto Fantin
- Department of Pulmonology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Policlinico San Martino Hospital, IRCCS, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Nadia Castaldo
- Department of Pulmonology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
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Houshmand H, Porta C, Pradelli L, Pinciroli M, Sotgiu G. Cost-Impact Analysis of a Novel Diagnostic Test to Assess Community-Acquired Pneumonia Etiology in the Emergency Department Setting: A Multi-Country European Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3853. [PMID: 36900863 PMCID: PMC10001249 DOI: 10.3390/ijerph20053853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND We aimed to estimate the economic and clinical impacts of a novel diagnostic test called LIAISON® MeMed BV® (LMMBV), which can differentiate bacterial from viral infections, in patients with community-acquired pneumonia (CAP) in emergency departments. METHODS A cost-impact simulation model was developed to investigate the financial consequences of the introduction of LMMBV into the standard of care (SOC) diagnostic process in Italy, Germany, and Spain. Clinical outcomes were expressed as antibiotic patients and days saved, reduced hospital admissions, and shortened hospital length of stay (LOS). Cost savings were evaluated from the perspectives of third-party payers and hospitals. A deterministic sensitivity analysis (DSA) was carried out. RESULTS LMMBV was associated with a reduction in antibiotic prescriptions, treatment duration, and LOS. Furthermore, the adoption of LMMBV would allow savings per patient up to EUR 364 and EUR 328 for hospitals and EUR 91 and EUR 59 for payers in Italy and Germany, respectively. In Spain, average savings per patient could reach up to EUR 165 for both payers and hospitals. Savings were most sensitive to test accuracy, with DSA confirming the robustness of the results. CONCLUSIONS Combining LMMBV with the current SOC diagnostic process is expected to provide clinical and economic benefits in Italy, Germany, and Spain.
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Affiliation(s)
| | - Camilla Porta
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, 10121 Torino, Italy
| | | | - Giovanni Sotgiu
- Scienze Mediche Chirurgiche E Sperimentali, Università degli Studi di Sassari, 07100 Sassari, Italy
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Ryu S, Ni K, Wang C, Sivanantham A, Carnino JM, Ji HL, Jin Y. Bacterial Outer Membrane Vesicles Promote Lung Inflammatory Responses and Macrophage Activation via Multi-Signaling Pathways. Biomedicines 2023; 11:568. [PMID: 36831104 PMCID: PMC9953134 DOI: 10.3390/biomedicines11020568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Emerging evidence suggests that Gram-negative bacteria release bacterial outer membrane vesicles (OMVs) and that these play an important role in the pathogenesis of bacterial infection-mediated inflammatory responses and organ damage. Despite the fact that scattered reports have shown that OMVs released from Gram-negative bacteria may function via the TLR2/4-signaling pathway or induce pyroptosis in macrophages, our study reveals a more complex role of OMVs in the development of inflammatory lung responses and macrophage pro-inflammatory activation. We first confirmed that various types of Gram-negative bacteria release similar OMVs which prompt pro-inflammatory activation in both bone marrow-derived macrophages and lung alveolar macrophages. We further demonstrated that mice treated with OMVs via intratracheal instillation developed significant inflammatory lung responses. Using mouse inflammation and autoimmune arrays, we identified multiple altered cytokine/chemokines in both bone marrow-derived macrophages and alveolar macrophages, suggesting that OMVs have a broader spectrum of function compared to LPS. Using TLR4 knock-out cells, we found that OMVs exert more robust effects on activating macrophages compared to LPS. We next examined multiple signaling pathways, including not only cell surface antigens, but also intracellular receptors. Our results confirmed that bacterial OMVs trigger both surface protein-mediated signaling and intracellular signaling pathways, such as the S100-A8 protein-mediated pathway. In summary, our studies confirm that bacterial OMVs strongly induced macrophage pro-inflammatory activation and inflammatory lung responses via multi-signaling pathways. Bacterial OMVs should be viewed as a repertoire of pathogen-associated molecular patterns (PAMPs), exerting more robust effects than Gram-negative bacteria-derived LPS.
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Affiliation(s)
- Sunhyo Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
| | - Kareemah Ni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
| | - Chenghao Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
| | - Ayyanar Sivanantham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
| | - Jonathan M. Carnino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
| | - Hong-Long Ji
- Department of Cellular and Molecular Biology, University of Texas at Tyler Health Science Center, 11937 US Hwy 271, BMR, Lab D-11, Tyler, TX 75708, USA
| | - Yang Jin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA 02118, USA
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Cao L, Ji Z, Zhang P, Wang J. Epidemiology and mortality predictors for severe childhood community-acquired pneumonia in ICUs: A retrospective observational study. Front Pediatr 2023; 11:1031423. [PMID: 37033191 PMCID: PMC10076704 DOI: 10.3389/fped.2023.1031423] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background To identify the epidemiology and mortality predictors of severe childhood community-acquired pneumonia (CAP) and evaluate the influence of medications on clinical outcomes in the real world. Methods We conducted a multicenter retrospective observational study among children aged ≤5 years with severe CAP, separately comparing the detailed information between those who experienced in-hospital death and those who survived in three different age groups. A multivariate logistic regression model was used to determine mortality predictors. Results A total of 945 children were recruited: 341 young children aged 2-59 months, 47 infants aged 29 days to 2 months, and 557 neonates aged less than 28 days. A total of 88 deaths occurred (9.3%). There was low adherence to antimicrobial guidelines in the group aged 2-59 months, and carbapenems widely served as initial empirical regimens. However, analysis of all three age groups showed that the efficacy of antibacterial drugs with initial empirical selection grades higher than those recommended by the guidelines was not better than that of antibacterial drugs with grades recommended by the guidelines. In multivariate analyses, very severe pneumonia (odds ratio (OR): 3.48; 95% confidence interval (CI): 1.36-8.93), lower birth weight (OR: 4.64; 95% CI: 1.78-12.20), severe underweight (OR: 6.06; 95% CI: 2.34-15.63), mechanical ventilation (OR: 2.58; 95% CI: 1.00-6.62; OR: 15.63; 95% CI 3.25-76.92), a higher number of comorbidities (OR: 8.40; 95% CI: 1.89-37.04), comorbidities including anemia (OR: 5.24; 95% CI: 2.33-11.76) and gastrointestinal hemorrhage (OR: 3.79; 95% CI: 1.36-10.53), and the use of sedative-hypnotics (OR: 2.60; 95% CI: 1.14-5.95) were independent risk factors for death; infants treated with probiotics had a lower mortality rate (OR: 0.14; 95% CI: 0.06-0.33). Conclusions Severe CAP remains a primary cause of death in children under 5 years of age. Clinical characteristics, comorbidities and medications are evidently associated with death. Importantly, we should pay particular attention to the identification of mortality predictors and establish prophylactic measures to reduce mortality.
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Affiliation(s)
- Lu Cao
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Zhaohua Ji
- Department of Epidemiology and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, China
| | - Peng Zhang
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
- Correspondence: Peng Zhang Jingwen Wang
| | - Jingwen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, China
- Correspondence: Peng Zhang Jingwen Wang
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de Hond TAP, Hamelink WJ, de Groot MCH, Hoefer IE, Oosterheert JJ, Haitjema S, Kaasjager KAH. Axial light loss of monocytes as a readily available prognostic biomarker in patients with suspected infection at the emergency department. PLoS One 2022; 17:e0270858. [PMID: 35816504 PMCID: PMC9273078 DOI: 10.1371/journal.pone.0270858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/19/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives To evaluate the prognostic value of the coefficient of variance of axial light loss of monocytes (cv-ALL of monocytes) for adverse clinical outcomes in patients suspected of infection in the emergency department (ED). Methods We performed an observational, retrospective monocenter study including all medical patients ≥18 years admitted to the ED between September 2016 and June 2019 with suspected infection. Adverse clinical outcomes included 30-day mortality and ICU/MCU admission <3 days after presentation. We determined the additional value of monocyte cv-ALL and compared to frequently used clinical prediction scores (SIRS, qSOFA, MEWS). Next, we developed a clinical model with routinely available parameters at the ED, including cv-ALL of monocytes. Results A total of 3526 of patients were included. The OR for cv-ALL of monocytes alone was 2.21 (1.98–2.47) for 30-day mortality and 2.07 (1.86–2.29) for ICU/MCU admission <3 days after ED presentation. When cv-ALL of monocytes was combined with a clinical score, the prognostic accuracy increased significantly for all tested scores (SIRS, qSOFA, MEWS). The maximum AUC for a model with routinely available parameters at the ED was 0.81 to predict 30-day mortality and 0.81 for ICU/MCU admission. Conclusions Cv-ALL of monocytes is a readily available biomarker that is useful as prognostic marker to predict 30-day mortality. Furthermore, it can be used to improve routine prediction of adverse clinical outcomes at the ED. Clinical trial registration Registered in the Dutch Trial Register (NTR) und number 6916.
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Affiliation(s)
- Titus A. P. de Hond
- Department of Internal Medicine and Acute Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- * E-mail:
| | - Wout J. Hamelink
- Department of Internal Medicine and Acute Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark C. H. de Groot
- Central Diagnostic Laboratory, Division Laboratory, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Imo E. Hoefer
- Central Diagnostic Laboratory, Division Laboratory, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, Division Laboratory, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karin A. H. Kaasjager
- Department of Internal Medicine and Acute Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Sakakibara T, Shindo Y, Kobayashi D, Sano M, Okumura J, Murakami Y, Takahashi K, Matsui S, Yagi T, Saka H, Hasegawa Y. A prediction rule for severe adverse events in all inpatients with community-acquired pneumonia: a multicenter observational study. BMC Pulm Med 2022; 22:34. [PMID: 35022026 PMCID: PMC8753951 DOI: 10.1186/s12890-022-01819-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prediction of inpatients with community-acquired pneumonia (CAP) at high risk for severe adverse events (SAEs) requiring higher-intensity treatment is critical. However, evidence regarding prediction rules applicable to all patients with CAP including those with healthcare-associated pneumonia (HCAP) is limited. The objective of this study is to develop and validate a new prediction system for SAEs in inpatients with CAP. Methods Logistic regression analysis was performed in 1334 inpatients of a prospective multicenter study to develop a multivariate model predicting SAEs (death, requirement of mechanical ventilation, and vasopressor support within 30 days after diagnosis). The developed ALL-COP-SCORE rule based on the multivariate model was validated in 643 inpatients in another prospective multicenter study. Results The ALL-COP SCORE rule included albumin (< 2 g/dL, 2 points; 2–3 g/dL, 1 point), white blood cell (< 4000 cells/μL, 3 points), chronic lung disease (1 point), confusion (2 points), PaO2/FIO2 ratio (< 200 mmHg, 3 points; 200–300 mmHg, 1 point), potassium (≥ 5.0 mEq/L, 2 points), arterial pH (< 7.35, 2 points), systolic blood pressure (< 90 mmHg, 2 points), PaCO2 (> 45 mmHg, 2 points), HCO3− (< 20 mmol/L, 1 point), respiratory rate (≥ 30 breaths/min, 1 point), pleural effusion (1 point), and extent of chest radiographical infiltration in unilateral lung (> 2/3, 2 points; 1/2–2/3, 1 point). Patients with 4–5, 6–7, and ≥ 8 points had 17%, 35%, and 52% increase in the probability of SAEs, respectively, whereas the probability of SAEs was 3% in patients with ≤ 3 points. The ALL-COP SCORE rule exhibited a higher area under the receiver operating characteristic curve (0.85) compared with the other predictive models, and an ALL-COP SCORE threshold of ≥ 4 points exhibited 92% sensitivity and 60% specificity. Conclusions ALL-COP SCORE rule can be useful to predict SAEs and aid in decision-making on treatment intensity for all inpatients with CAP including those with HCAP. Higher-intensity treatment should be considered in patients with CAP and an ALL-COP SCORE threshold of ≥ 4 points. Trial registration This study was registered with the University Medical Information Network in Japan, registration numbers UMIN000003306 and UMIN000009837. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01819-0.
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Schneider JE, Cooper JT. Cost impact analysis of novel host-response diagnostic for patients with community-acquired pneumonia in the emergency department. J Med Econ 2022; 25:138-151. [PMID: 34994273 DOI: 10.1080/13696998.2022.2026686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is significant over-prescription of antibiotics for suspected community-acquired pneumonia (CAP) patients as bacterial and viral pathogens are difficult to differentiate. To address this issue, a host response diagnostic called MeMed BV (MMBV) was developed that accurately differentiates bacterial from viral infection at the point of need by integrating measurements of multiple biomarkers. A literature-based cost-impact model was developed that compared the cost impact and clinical benefits between using the standard of care diagnostics combined with MMBV relative to standard of care diagnostics alone. METHODS The patient population was stratified according to the pneumonia severity index, and cost savings were considered from payer and provider perspectives. Four scenarios were considered. The main analysis considers the cost impact of differences in antibiotic stewardship and resulting adverse events. The first, second, and third scenarios combine the impacts on antibiotic stewardship with changes in hospital admission probability, length of hospital stay and diagnosis related group (DRG) reallocation, and hospital admission probability, length of stay, and DRG reallocation in combination, respectively. RESULTS The main analysis results show overall per-patient savings of $37 for payers and $223 for providers. Scenarios 1, 2, and 3 produced savings of $137, $189, and $293 for payers, and $339, $713, and $809 for providers, respectively. LIMITATIONS Models are simulations of real-world clinical processes, and are not sensitive to variations in clinical practice driven by differences in physician practice styles, differences in facility-level practice patterns, and patient comorbidities expected to exacerbate the clinical impact of CAP. Hospital models are limited to costs and do not consider differences in revenue associated with each approach. CONCLUSIONS Introducing MMBV to the current SOC diagnostic process is likely to be cost-saving to both hospitals and payers when considering impacts on antibiotic distribution, hospital admission rate, hospital LOS, and DRG reallocation.
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Kang SH, Jo YH, Lee JH, Jang DH, Kim YJ, Park I. Antibiotic prescription consistent with guidelines in emergency department is associated with 30-day survival in severe community-acquired pneumonia. BMC Emerg Med 2021; 21:108. [PMID: 34579649 PMCID: PMC8477488 DOI: 10.1186/s12873-021-00505-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The selection of initial empirical antibiotics is an important issue in the treatment of severe community-acquired pneumonia (CAP). This study aimed to investigate whether empirical antibiotic prescription concordant with guidelines in the emergency department (ED) affects 30-day mortality in patients with severe CAP. METHODS We conducted a retrospective analysis of adult patients with severe CAP who were hospitalized in the ED. Severe CAP was defined according to the criteria of the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Patients were divided into two groups according to whether they were prescribed empirical antibiotics concordant with guidelines. Multivariable Cox proportional hazard regression analysis was performed to identify the independent association between the prescription of initial empirical antibiotics concordant with the guidelines and 30-day mortality. Propensity score matching was performed to reduce selection bias between groups and Kaplan-Meier survival analysis was performed to analyze the time-to-event of 30-day survival. RESULTS In total, 630 patients were hospitalized in the ED for severe CAP, and 179 (28.4%) died within 30 days. Antibiotics consistent with guidelines were prescribed to 359 (57.0%) patients. The 30-day mortality was significantly higher in the guideline-discordant group (p = 0.003) and multivariable Cox proportional hazard regression analysis revealed that the prescription of antibiotics discordant with the guidelines was independently associated with 30-day mortality (hazard ratio 1.43, 95% CI 1.05-1.93). After propensity score matching, there were 255 patients in each group. The 30-day mortality was lower in the group prescribed guideline-concordant antibiotics than in the group prescribed guideline-discordant antibiotics (23.9% vs. 33.3%, p = 0.024). Kaplan-Meier survival analysis showed that antibiotic prescription concordant with the guidelines resulted in higher survival rates at 30 days (p = 0.002). CONCLUSIONS The prevalence of antibiotic prescription consistent with guidelines for severe CAP seemed to be low in the ED, and this variable was independently associated with 30-day survival.
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Affiliation(s)
- Seung Hyun Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
| | - Dong-Hyun Jang
- Department of Emergency Medicine, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
| | - Inwon Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
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Ewig S, Kolditz M, Pletz M, Altiner A, Albrich W, Drömann D, Flick H, Gatermann S, Krüger S, Nehls W, Panning M, Rademacher J, Rohde G, Rupp J, Schaaf B, Heppner HJ, Krause R, Ott S, Welte T, Witzenrath M. [Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]. Pneumologie 2021; 75:665-729. [PMID: 34198346 DOI: 10.1055/a-1497-0693] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
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Affiliation(s)
- S Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Kranken-Anstalt Bochum
| | - M Kolditz
- Universitätsklinikum Carl-Gustav Carus, Klinik für Innere Medizin 1, Bereich Pneumologie, Dresden
| | - M Pletz
- Universitätsklinikum Jena, Institut für Infektionsmedizin und Krankenhaushygiene, Jena
| | - A Altiner
- Universitätsmedizin Rostock, Institut für Allgemeinmedizin, Rostock
| | - W Albrich
- Kantonsspital St. Gallen, Klinik für Infektiologie/Spitalhygiene
| | - D Drömann
- Universitätsklinikum Schleswig-Holstein, Medizinische Klinik III - Pulmologie, Lübeck
| | - H Flick
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Lungenkrankheiten, Graz
| | - S Gatermann
- Ruhr Universität Bochum, Abteilung für Medizinische Mikrobiologie, Bochum
| | - S Krüger
- Kaiserswerther Diakonie, Florence Nightingale Krankenhaus, Klinik für Pneumologie, Kardiologie und internistische Intensivmedizin, Düsseldorf
| | - W Nehls
- Helios Klinikum Erich von Behring, Klinik für Palliativmedizin und Geriatrie, Berlin
| | - M Panning
- Universitätsklinikum Freiburg, Department für Medizinische Mikrobiologie und Hygiene, Freiburg
| | - J Rademacher
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - G Rohde
- Universitätsklinikum Frankfurt, Medizinische Klinik I, Pneumologie und Allergologie, Frankfurt/Main
| | - J Rupp
- Universitätsklinikum Schleswig-Holstein, Klinik für Infektiologie und Mikrobiologie, Lübeck
| | - B Schaaf
- Klinikum Dortmund, Klinik für Pneumologie, Infektiologie und internistische Intensivmedizin, Dortmund
| | - H-J Heppner
- Lehrstuhl Geriatrie Universität Witten/Herdecke, Helios Klinikum Schwelm, Klinik für Geriatrie, Schwelm
| | - R Krause
- Medizinische Universität Graz, Universitätsklinik für Innere Medizin, Klinische Abteilung für Infektiologie, Graz
| | - S Ott
- St. Claraspital Basel, Pneumologie, Basel, und Universitätsklinik für Pneumologie, Universitätsspital Bern (Inselspital) und Universität Bern
| | - T Welte
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover
| | - M Witzenrath
- Charité, Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie, Berlin
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Zhang J, Hu W, Huang Y, Qu J. Blind Spots of Traditional Microbiological Tests for Severe Community-Acquired Pneumonia in Adults and Availability of Nonculture Techniques: A Nationwide Survey of Physicians in China. J Infect Dis 2021; 221:S198-S205. [PMID: 32176798 DOI: 10.1093/infdis/jiz636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In China, no national survey has been conducted to evaluate physicians' attitudes and compliance with guidelines in the management of adult patients with community-acquired pneumonia (CAP). Therefore, this study aimed to evaluate physicians' awareness of the use of microbiological tests in the management of severe CAP (SCAP) and to investigate the availability of nonculture tests in China. METHODS A nationwide electronic questionnaire survey was conducted among Chinese physicians between March and July 2018, which assessed their viewpoints concerning the issues in the management of SCAP. RESULTS A total of 6333 physicians completed this survey, evenly covering all career stages. Among these, 3208 (50.6%) and 1936 (30.6%) had blind spots in the application of blood and sputum cultures in the management of SCAP, respectively. Nonteaching hospital, nonrespirologists, and junior career stage were independently associated with misunderstandings. Regarding nonculture methods, 52.7% of the facilities had no access to polymerase chain reaction-based pathogen detection tests. The accessibility of urinary antigen tests for Streptococcus pneumoniae (42.5%) and Legionella pneumophila (38.5%) was also low. The main barriers were inland and remote region, lower hospital level, and nonteaching hospital. CONCLUSIONS Insufficient use of sputum and blood cultures, together with low accessibility of major nonculture techniques, were noticeable barriers to achieving microbiological diagnosis of SCAP in China. To help curb the overuse of broad-spectrum antibiotics, further measures should be taken to raise awareness among nonspecialists and promote rapid nonculture tests, especially in nonteaching hospitals and developing regions.
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Affiliation(s)
- Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weiping Hu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Changhai Hospital of Shanghai, Second Military Medical University, Shanghai, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
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Wilke M, Heinlein W, Stiefenhofer L, Bodmann KF. Clinical and economical improvements after introducing rapid identification of bacteria and early antibiotic susceptibility testing in sepsis and bloodstream infections. Results of the PHENOMENON study. GMS INFECTIOUS DISEASES 2020; 8:Doc25. [PMID: 33376664 PMCID: PMC7745702 DOI: 10.3205/id000069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background: Sepsis and bloodstream infections pose severe challenges in intensive care. Early reliable diagnosis is the key to successful therapy. The objective of the study presented here was to investigate the clinical and economical effects of the new PhenoTM BC test, which allows bacteria identification (ID) and antimicrobial susceptibility testing (AST) in approximately 7 hours after a blood culture becomes positive (BC+). Methods: Historically controlled interventional study. Population: patients with BC+ and ICU admission. Inadequate initial antimicrobial therapy (IAT) is need of therapy change based on result. Prospectively the new test was used in addition. Primary endpoint: time-to-result in hours. Contribution margin (CM) i.e. revenue - costs was computed. All patients formed the intention-to-treat population (ITT). Patients with complete cost data formed the modified ITT group (mITT). CM results were calculated for mITT and PP. Further analyses: length-of-stay (LOS) and mortality. Results: 223 historical and 200 prospective patients were included. Time to result (ITT) was shortened by 51.1 hours (83 vs. 31.9; p<0.001). Overall savings (mITT) were 257,100 € (-301,264 € vs. -44,164 €). 143 of 181 (79%) patients had a test performed, 126 of 143 (88%) having a clinically useable result. 40 (32%) had IAT vs. 65 (29%) in the historic cohort. Median time to AST in PP was shortened by 61.7 hours (89.5 vs. 27.8; p<0.001). LOS was shortened 7 days (28 vs. 19; p=0.226) and mortality was 8% (40.5% vs. 32.5%; p=0.440) lower. Median CM +3,074.80 € per case (-2,350.50 € vs. +724.70 €; p=0.040). Conclusion: The new PhenoTM ID+AST test leads to faster and clinically meaningful results and saves money by shortening LOS on the ICU.
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Affiliation(s)
- Michael Wilke
- inspiring-health GmbH, Munich, Germany,*To whom correspondence should be addressed: Michael Wilke, inspiring-health GmbH, Waldmeisterstrasse 72, 80935 Munich, Germany, Phone: +49 (0)89 1890 8376-1, Fax: +49 (0)89 1890 8376-9, E-mail:
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13
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McKenzie KE, Mayorga ME, Miller KE, Singh N, Arnold RC, Romero-Brufau S. Notice to comply: A systematic review of clinician compliance with guidelines surrounding acute hospital-based infection management. Am J Infect Control 2020; 48:940-947. [PMID: 32192754 DOI: 10.1016/j.ajic.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To identify and characterize studies evaluating clinician compliance with infection-related guidelines, and to explore trends in guideline design and implementation strategies. DATA SOURCES PubMed database, April 2017. Followed the PRISMA Statement for systematic reviews. STUDY SELECTION Scope was limited to studies reporting compliance with guidelines pertaining to the prevention, detection, and/or treatment of acute hospital-based infections. Initial search (1,499 titles) was reduced to 49 selected articles. DATA EXTRACTION Extracted publication and guideline characteristics, outcome measures reported, and any results related to clinician compliance. Primary summary measures were frequencies and distributions of characteristics. Interventions that led to improved compliance results were analyzed to identify trends in guideline design and implementation. RESULTS OF DATA SYNTHESIS Of the 49 selected studies, 18 (37%), 13 (27%), and 10 (20%) focused on sepsis, pneumonia, and general infection, respectively. Six (12%), 17 (35%), and 26 (53%) studies assessed local, national, and international guidelines, respectively. Twenty studies (41%) reported 1-instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or control group studies), and 1 study (2%) described compliance qualitatively. Average absolute change in compliance for minimal, decision support, and multimodal interventions was 10%, 14%, and 25%, respectively. Twelve studies (24%) reported no patient outcome alongside compliance. CONCLUSIONS Multimodal interventions and quality improvement initiatives seem to produce the greatest improvement in compliance, but trends in other factors were inconsistent. Additional research is required to investigate these relationships and understand the implications behind various approaches to guideline design, communication, and implementation, in addition to effectiveness of protocol impact on relevant patient outcomes.
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14
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Frühe Optimierung der Antibiotikatherapie durch den schnellen Nachweis von Erregern und Empfindlichkeit. Med Klin Intensivmed Notfmed 2020; 115:420-427. [DOI: 10.1007/s00063-020-00680-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/06/2019] [Accepted: 03/08/2020] [Indexed: 11/25/2022]
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15
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Zasowski EJ, Bassetti M, Blasi F, Goossens H, Rello J, Sotgiu G, Tavoschi L, Arber MR, McCool R, Patterson JV, Longshaw CM, Lopes S, Manissero D, Nguyen ST, Tone K, Aliberti S. A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Outcomes of Patients With Severe Bacterial Infections. Chest 2020; 158:929-938. [PMID: 32446623 DOI: 10.1016/j.chest.2020.03.087] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/20/2020] [Accepted: 03/30/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Patients with severe bacterial infections often experience delay in receiving appropriate treatment. Consolidated evidence of the impact of delayed appropriate treatment is needed to guide treatment and improve outcomes. RESEARCH QUESTION What is the impact of delayed appropriate antibacterial therapy on clinical outcomes in patients with severe bacterial infections? STUDY DESIGN AND METHODS Literature searches of MEDLINE and Embase, conducted on July 24, 2018, identified studies published after 2007 reporting the impact of delayed appropriate therapy on clinical outcomes for hospitalized adult patients with bacterial infections. Where appropriate, results were pooled and analyzed with delayed therapy modeled three ways: delay vs no delay in receiving appropriate therapy; duration of delay; and inappropriate vs appropriate initial therapy. This article reports meta-analyses on the effect of delay and duration of delay. RESULTS The eligibility criteria were met by 145 studies, of which 37 contributed data to analyses of effect of delay. Mortality was significantly lower in patients receiving appropriate therapy without delay compared with those experiencing delay (OR, 0.57; 95% CI, 0.45-0.72). Mortality was also lower in the no-delay group compared with the delay group in subgroups of studies reporting mortality at 20 to 30 days, during ICU stay, or in patients with bacteremia (OR, 0.57 [95% CI, 0.43-0.76]; OR, 0.47 [95% CI, 0.27-0.80]; and OR, 0.54 [95% CI, 0.40-0.75], respectively). No difference was found in time to appropriate therapy between those who died and those who survived (P = .09), but heterogeneity between studies was high. INTERPRETATION Avoiding delayed appropriate therapy is essential to reduce mortality in patients with severe bacterial infections. CLINICAL TRIAL REGISTRATION PROSPERO; No.: CRD42018104669; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Evan J Zasowski
- Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Internal Medicine Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem and Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Jordi Rello
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Clinical Research and Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Mick R Arber
- York Health Economics Consortium, University of York, York, United Kingdom
| | - Rachael McCool
- York Health Economics Consortium, University of York, York, United Kingdom
| | - Jacoby V Patterson
- York Health Economics Consortium, University of York, York, United Kingdom
| | | | | | | | | | | | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Internal Medicine Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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Wilke M, Hübner C, Kämmerer W. Calculated parenteral initial treatment of bacterial infections: Economic aspects of antibiotic treatment. GMS INFECTIOUS DISEASES 2020; 8:Doc03. [PMID: 32373428 PMCID: PMC7186923 DOI: 10.3205/id000047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This is the seventeenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. This chapter analyses economic aspects of antiinfective therapy. Any treatment decision is also a cost decision. In this chapter the authors particularly analyse whether or not there is evidence that certain clinically effective strategies as Antimicrobial Stewardship programs (AMS), guideline adherent initial therapy, early diagnostics, De-escalation, sequence therapy or therapeutic drug monitoring also have benficial economic effects. These can be direct savings or shortening of length of stay to free resources.
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Affiliation(s)
| | - Claudia Hübner
- Lehrstuhl für Allgemeine Betriebswirtschaftslehre und Gesundheitsmanagement, Universität Greifswald, Germany
| | - Wolfgang Kämmerer
- Klinische Pharmazie, Apotheke des Universitätsklinikums Augsburg, Germany
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17
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Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2020 Update. Arch Bronconeumol 2020. [PMID: 32139236 DOI: 10.1016/j.arbres.2020.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.
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Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship. Clin Microbiol Infect 2020; 27:175-181. [PMID: 32120032 DOI: 10.1016/j.cmi.2020.02.032] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/15/2020] [Accepted: 02/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock and bacterial meningitis, but may not be as important for other infectious syndromes. A better understanding of which patients can tolerate a delay in start of therapy is important for antibiotic stewardship purposes. OBJECTIVES To explore the existing evidence on the impact of time to antibiotics on clinical outcomes in patients presenting to the emergency department (ED) with bacterial infections of different severity of illness and source of infection. SOURCES A literature search was performed in the PubMed/MEDLINE database using combined search terms for various infectious syndromes (sepsis/septic shock, bacterial meningitis, lower respiratory tract infections, urinary tract infections, intra-abdominal infections and skin and soft tissue infections), time to antibiotic treatment, and clinical outcome. CONTENT The literature search generated 8828 hits. After screening titles and abstracts and assessing potentially relevant full-text papers, 60 original articles (four randomized controlled trials, 43 observational studies) were included. Most articles addressed sepsis/septic shock, while few studies evaluated early initiation of therapy in mild to moderate disease. The lack of randomized trials and the risk of confounding factors and biases in observational studies warrant caution in the interpretation of results. We conclude that the literature supports prompt administration of effective antibiotics for septic shock and bacterial meningitis, but there is no clear evidence showing that a delayed start of therapy is associated with worse outcome for less severe infectious syndromes. IMPLICATIONS For patients presenting with suspected bacterial infections, withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established (e.g. by 4-8 h) seems acceptable in most cases unless septic shock or bacterial meningitis are suspected. This approach promotes the use of ecologically favourable antibiotics in the ED, reducing the risks of side effects and selection of resistance.
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Wongsurakiat P, Chitwarakorn N. Severe community-acquired pneumonia in general medical wards: outcomes and impact of initial antibiotic selection. BMC Pulm Med 2019; 19:179. [PMID: 31619219 PMCID: PMC6794881 DOI: 10.1186/s12890-019-0944-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 09/20/2019] [Indexed: 12/31/2022] Open
Abstract
Background Most international guidelines recommend empirical therapy for community-acquired pneumonia (CAP) to be based on site of care. Some patients with severe CAP are managed in general wards because of limited intensive care unit (ICU) bed or because of unrecognition of the pneumonia severity. Appropriate initial antibiotic treatment for severe CAP outside ICU has not yet been established. This study aimed to determine the prevalence and the impact of initial antibiotic selection on the outcomes of patients with severe CAP who were admitted and managing in general wards. Methods This prospective observational study included consecutive patients hospitalized for presumed CAP in general wards over a 1-year period. Severe CAP was identified using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) criteria. Initial antibiotic treatment in the first 24 h were collected. The primary outcome was the rate of unfavorable outcome (composite outcome of treatment failure and in-hospital death). The secondary outcome was the number of hospital-free days assessed 30 days after enrollment into the study. Results There were 94 patients hospitalized with CAP of which 50 (53.2%) patients were compatible with severe CAP. An etiologic diagnosis was found in 43 (45.8%) patients. The most common pathogens identified in patients with severe CAP were Staphylococcus aureus (28.6%) and Klebsiella pneumoniae (28.6%), followed by Pseudomonas aeruginosa (17.9%). Patients with severe CAP had significantly more positive blood culture than patients with non-severe CAP (24% VS 4.5%; p = .008). Initial antibiotic treatment were discordant with the IDSA/ATS guidelines in 42% of all patients hospitalized with CAP, and 52% of patients with severe CAP. Multivariate analysis revealed that age (OR 1.1, 95% CI 1.01–1.1) and initial antibiotic treatment discordant to guidelines for severe CAP in ICU (OR 4.6, 95% CI 1.3–17.1) were independent risk factors of the unfavorable outcome of patients with severe CAP. Patients with unfavorable outcome had lower number of hospital-free days than patients with favorable outcome (5.2 ± 8 days VS 18 ± 7.1 days; p < .001). Conclusions Patients with severe CAP outside ICU should be recognized for appropriate initial antibiotic selection to improve outcomes.
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Affiliation(s)
- Phunsup Wongsurakiat
- Division of Respiratory Disease, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Napat Chitwarakorn
- Bamrasnaradura Infectious Disease Institute, Tiwanon Road, Amphur Mueng, Nonthaburi, 11000, Thailand
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Simultaneous Depression of Immunological Synapse and Endothelial Injury is Associated with Organ Dysfunction in Community-Acquired Pneumonia. J Clin Med 2019; 8:jcm8091404. [PMID: 31500177 PMCID: PMC6780106 DOI: 10.3390/jcm8091404] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/02/2019] [Accepted: 09/04/2019] [Indexed: 01/07/2023] Open
Abstract
Rationale: A depressed expression of antigen presentation is, along with endothelial dysfunction, a recognized signature of severe community-acquired pneumonia (CAP). We aimed to evaluate the expression of a number of genes involved in the immunological synapse in non-critically ill CAP patients with or without organ dysfunction and to profile endothelial biomarkers such as proendothelin-1 (proET1) and proadrenomedullin (proADM). Methods: A nested study in a prospective cohort in CAP patients was performed. Expression levels of major histocompatibility complex class II DR alpha (HLA-DRA), CD40 ligand (CD40LG), CD3E, CD28, and inducible T-cell costimulator (ICOS) were quantified by using droplet digital polymerase chain reaction and endothelial biomarkers by immunofluorescence. Results: Ninety-four patients were included, 44.7% of whom had organ failure in one or more organs. A significant decrease in the expression of the five genes with increased levels of proadrenomedullin (proADM) and proendothelin-1 (proET1) was found in CAP with organ failure. The depressed expression of HLA-DRA (odds ratio (OR), 2.94), CD40LG (OR, 3.90), and CD28 (OR, 3.48) was independently associated with organ failure after adjustment for age, Charlson score, and severity. Conclusions. CAP with organ failure showed depressed expression of immunological synapse genes with increased levels of biomarkers denoting endothelial damage. Simultaneous profiling of immunological and endothelial signatures could help in the early identification of organ failure in CAP and in the implementation of personalized treatment.
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Pereira JM, Laszczyńska O, Azevedo A, Basílio C, Sousa-Dias C, Mergulhão P, Paiva JA. Early prediction of treatment failure in severe community-acquired pneumonia: The PRoFeSs score. J Crit Care 2019; 53:38-45. [PMID: 31177029 DOI: 10.1016/j.jcrc.2019.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 05/17/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To identify a single/panel of biomarkers and to provide a point score that, after 48 h of treatment, could early predict treatment failure at fifth day of Intensive Care Unit (ICU) stay in severe community-acquired pneumonia (SCAP) patients. MATERIALS AND METHODS Single-center, prospective cohort study of 107 ICU patients with SCAP. Primary outcome included death or absence of improvement in Sequential Organ Failure Assessment score by ≥2 points within 5 days of treatment. Biomarkers were evaluated within 12 h of first antibiotic dose (D1) and 48 h after the first assessment (D3). RESULTS A model based on Charlson's score and a panel of biomarkers (procalcitonin on D1 and D3, B-natriuretic peptide on D1, D-dimer and lactate on D3) had good discrimination for primary outcome in both derivation (AUC 0.82) and validation (AUC 0.76) samples and was well calibrated (X2 = 0.98; df = 1; p = .32). A point score system (PRoFeSs score) built on the estimates of regression coefficients presented good discrimination (AUC 0.81; 95% Confidence Interval 0.72-0.89) for primary outcome. CONCLUSIONS In SCAP, a combination of biomarkers measured at admission and 48 h later may early predict treatment failure. PRoFeSs score may recognize patients with poor short-term prognosis.
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Affiliation(s)
- José Manuel Pereira
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Olga Laszczyńska
- EPIUnit - Institute of Public Health, University of Porto, Portugal
| | - Ana Azevedo
- EPIUnit - Institute of Public Health, University of Porto, Portugal; Hospital Epidemiology Centre, Centro Hospitalar São João EPE, Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, University of Porto Medical School, Portugal.
| | - Carla Basílio
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal
| | - Conceição Sousa-Dias
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal
| | - Paulo Mergulhão
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Artur Paiva
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Valade S, Biard L, Lemiale V, Argaud L, Pène F, Papazian L, Bruneel F, Seguin A, Kouatchet A, Oziel J, Rouleau S, Bele N, Razazi K, Lesieur O, Boissier F, Megarbane B, Bigé N, Brulé N, Moreau AS, Lautrette A, Peyrony O, Perez P, Mayaux J, Azoulay E. Severe atypical pneumonia in critically ill patients: a retrospective multicenter study. Ann Intensive Care 2018; 8:81. [PMID: 30105627 PMCID: PMC6089852 DOI: 10.1186/s13613-018-0429-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/02/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Chlamydophila pneumoniae (CP) and Mycoplasma pneumoniae (MP) patients could require intensive care unit (ICU) admission for acute respiratory failure. METHODS Adults admitted between 2000 and 2015 to 20 French ICUs with proven atypical pneumonia were retrospectively described. Patients with MP were compared to Streptococcus pneumoniae (SP) pneumonia patients admitted to ICUs. RESULTS A total of 104 patients were included, 71 men and 33 women, with a median age of 56 [44-67] years. MP was the causative agent for 76 (73%) patients and CP for 28 (27%) patients. Co-infection was documented for 18 patients (viruses for 8 [47%] patients). Median number of involved quadrants on chest X-ray was 2 [1-4], with alveolar opacities (n = 61, 75%), interstitial opacities (n = 32, 40%). Extra-pulmonary manifestations were present in 34 (33%) patients. Mechanical ventilation was required for 75 (72%) patients and vasopressors for 41 (39%) patients. ICU length of stay was 16.5 [9.5-30.5] days, and 11 (11%) patients died in the ICU. Compared with SP patients, MP patients had more extensive interstitial pneumonia, fewer pleural effusion, and a lower mortality rate [6 (8%) vs. 17 (22%), p = 0.013]. According MCA analysis, some characteristics at admission could discriminate MP and SP. MP was more often associated with hemolytic anemia, abdominal manifestations, and extensive chest radiograph abnormalities. SP-P was associated with shock, confusion, focal crackles, and focal consolidation. CONCLUSION In this descriptive study of atypical bacterial pneumonia requiring ICU admission, mortality was 11%. The comparison with SP pneumonia identified clinical, laboratory, and radiographic features that may suggest MP or CP pneumonia.
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Affiliation(s)
- S. Valade
- AP-HP, Medical ICU, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France
| | - L. Biard
- UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France
- AP-HP, DBIM, Hôpital Saint-Louis, Paris, France
| | - V. Lemiale
- AP-HP, Medical ICU, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France
| | - L. Argaud
- Hôpital Edouard Herriot, Service de Réanimation Médicale, Hospices Civils de Lyon, Lyon, France
| | - F. Pène
- AP-HP, Réanimation médicale, Hôpital Cochin, Paris, France
| | - L. Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - F. Bruneel
- Service de Réanimation, Centre Hospitalier de Versailles, Le Chesnay, France
| | - A. Seguin
- Department of Medical Intensive Care, CHU de Caen, Caen, France
| | - A. Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, Hôpital Angers, Angers, France
| | - J. Oziel
- AP-HP, Medical-Surgical Intensive Care Unit, Avicenne University Hospital, Bobigny, France
| | - S. Rouleau
- Service de Réanimation polyvalente, Angoulême, France
| | - N. Bele
- Intensive Care Unit, Draguignan Hospital, Draguignan, France
| | - K. Razazi
- AP-HP, Groupe Henri Mondor-Albert Chenevier, Service de Réanimation Médicale, Hôpital Henri Mondor, Créteil, France
| | - O. Lesieur
- Service de Réanimation, CH Saint-Louis, La Rochelle, France
| | - F. Boissier
- AP-HP, Réanimation médicale, Hôpital Européen Georges Pompidou, Paris, France
| | - B. Megarbane
- AP-HP, Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris, France
| | - N. Bigé
- AP-HP, Medical Intensive Care Unit, Hôpital Saint-Antoine, Paris, France
| | - N. Brulé
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - A. S. Moreau
- Centre de réanimation, Hôpital Salengro, CHU-Lille, Lille, France
| | - A. Lautrette
- Service de Réanimation Médicale Polyvalente, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - O. Peyrony
- AP-HP, Service des urgences, Hôpital Saint-Louis, Paris, France
| | - P. Perez
- Service de Réanimation médicale, Hôpital Brabois, Nancy, France
| | - J. Mayaux
- AP-HP, Pneumology and Critical Care Medicine Department, Universitary Hospital La Pitié Salpêtrière-Charles Foix, Paris, France
| | - E. Azoulay
- AP-HP, Medical ICU, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- UFR de Médecine, University Paris-7 Paris-Diderot, Paris, France
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Abstract
Appropriate antimicrobial therapy is essential to ensuring positive patient outcomes. Inappropriate or suboptimal utilization of antibiotics can lead to increased length of stay, multidrug-resistant infections, and mortality. Critically ill intensive care patients, particularly those with severe sepsis and septic shock, are at risk of antibiotic failure and secondary infections associated with incorrect antibiotic use. Through the initiation of active empiric antibiotic therapy based upon local susceptibilities, daily evaluation of signs and symptoms of infection and narrowing of antibiotic therapy when feasible, providers can streamline the treatment of common intensive care unit (ICU) infections. Optimizing antibiotic dosing through prolonged infusions can be beneficial in intensive care populations with altered pharmacokinetics. Antimicrobial stewardship teams can assist ICU providers in managing and implementing these tactics. This review will discuss the current literature on antibiotic use in the ICU applying antimicrobial stewardship strategies. Based upon the most recent evidence, ICUs would benefit from employing empiric guidelines for antibiotic use, collecting appropriate specimens and implementing molecular diagnostics, optimizing the dosing of antibiotics, and reducing the duration of total therapy. These strategies for antibiotic use have the potential to enhance patient care while preventing adverse outcomes.
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Affiliation(s)
- Maureen Campion
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gail Scully
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
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Vardakas KZ, Trigkidis KK, Apiranthiti KN, Falagas ME. The dilemma of monotherapy or combination therapy in community-acquired pneumonia. Eur J Clin Invest 2017; 47. [PMID: 29027205 DOI: 10.1111/eci.12845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
Abstract
SCOPE To study the factors associated with mortality in hospitalized patients with community-acquired pneumonia treated with monotherapy or combination therapy. METHODS PubMed and Scopus were searched. Patients receiving macrolides, β-lactams and fluoroquinolones, as monotherapy or in combination, were included. Meta-analyses and meta-regressions were performed. RESULTS Fifty studies were included. Overall, monotherapy was not associated with higher mortality than combination (RR 1.14, 95% CI 0.99-1.32, I2 84%). Monotherapy was associated with higher mortality than combination in North American and retrospective studies. β-lactam monotherapy was associated with higher mortality than β-lactam/macrolide combination in the primary (1.32, 1.12-1.56, I2 85%) and most sensitivity analyses. There was no difference in mortality between fluoroquinolone monotherapy and β-lactam/macrolide combination (0.98, 0.78-1.23, I2 73%). In meta-regressions, the moderators that could partially explain the observed statistical heterogeneity were the frequency of cancer patients (P = .03) and Pneumonia Severity Index score IV (P = .008). CONCLUSION Due to the considerable heterogeneity and inclusion of unadjusted data, it is difficult to recommend a specific antibiotic regimen over another. Specific antibiotic regimens, study design and the characteristics of the population under study seem to influence the reported outcomes.
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Affiliation(s)
- Konstantinos Z Vardakas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece
| | - Kyriakos K Trigkidis
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Katerina N Apiranthiti
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece.,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Cao B, Huang Y, She DY, Cheng QJ, Fan H, Tian XL, Xu JF, Zhang J, Chen Y, Shen N, Wang H, Jiang M, Zhang XY, Shi Y, He B, He LX, Liu YN, Qu JM. Diagnosis and treatment of community-acquired pneumonia in adults: 2016 clinical practice guidelines by the Chinese Thoracic Society, Chinese Medical Association. CLINICAL RESPIRATORY JOURNAL 2017; 12:1320-1360. [PMID: 28756639 PMCID: PMC7162259 DOI: 10.1111/crj.12674] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 07/25/2017] [Indexed: 02/05/2023]
Abstract
Community‐acquired pneumonia (CAP) in adults is an infectious disease with high morbidity in China and the rest of the world. With the changing pattern in the etiological profile of CAP and advances in medical techniques in diagnosis and treatment over time, Chinese Thoracic Society of Chinese Medical Association updated its CAP guideline in 2016 to address the standard management of CAP in Chinese adults. Extensive and comprehensive literature search was made to collect the data and evidence for experts to review and evaluate the level of evidence. Corresponding recommendations are provided appropriately based on the level of evidence. This updated guideline covers comprehensive topics on CAP, including aetiology, antimicrobial resistance profile, diagnosis, empirical and targeted treatments, adjunctive and supportive therapies, as well as prophylaxis. The recommendations may help clinicians manage CAP patients more effectively and efficiently. CAP in pediatric patients and immunocompromised adults is beyond the scope of this guideline. This guideline is only applicable for the immunocompetent CAP patients aged 18 years and older. The recommendations on selection of antimicrobial agents and the dosing regimens are not mandatory. The clinicians are recommended to prescribe and adjust antimicrobial therapies primarily based on their local etiological profile and results of susceptibility testing, with reference to this guideline.
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Affiliation(s)
- Bin Cao
- National Clinical Research Center of Respiratory Diseases, Center for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Yi Huang
- Department of Respiratory and Critical Care Medicine, Changhai Hospital, the Second Military Medical University, Shanghai 200433, China
| | - Dan-Yang She
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Qi-Jian Cheng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Sichuan 610041, China
| | - Xin-Lun Tian
- Department of Pulmonary Medicine, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yu Chen
- Department of Respiratory and Critical Care Medicine, Shengjing Hospital, China Medical University, Shenyang 110004, China
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Hui Wang
- Department of Laboratory Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xiang-Yan Zhang
- Department of Respiratory and Critical Care Medicine, Guizhou Provincial People's Hospital, Guizhou 550002, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing 210002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Respiratory and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
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Amaro R, Sellarés J, Polverino E, Cillóniz C, Ferrer M, Fernández-Barat L, Mensa J, Niederman MS, Torres A. Antibiotic therapy prior to hospital admission is associated with reduced septic shock and need for mechanical ventilation in patients with community-acquired pneumonia. J Infect 2017; 74:442-449. [PMID: 28130142 DOI: 10.1016/j.jinf.2017.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/09/2017] [Accepted: 01/14/2017] [Indexed: 11/27/2022]
Abstract
A subgroup of patients admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP) have received antibiotic therapy prior to admission for the current episode of pneumonia. The objective of this study was to assess the clinical course of patients receiving antibiotics prior to admission, compared to patients not previously treated. An observational cohort of 3364 CAP patients consecutively admitted to our hospital, and prospectively included, were studied. We collected clinical, microbiological and biochemical parameters, focusing on recent antibiotics received prior to admission. 610 (18%) patients received antibiotics prior to hospital admission for the current CAP episode. Patients with previous antibiotic use developed septic shock less frequently (4% vs. 7%, p = 0.007) and required invasive ventilation less often (3% vs. 6%, p = 0.002). After adjustment by different covariate factors and propensity score, antibiotic therapy was still independently associated with a lower incidence of septic shock at admission (OR 0.54 [95% CI 0.31-0.95], p = 0.03) and less need for invasive ventilation (OR 0.38 [95% CI 0.16-0.91], p = 0.03). In this cohort, recent use of antibiotics before hospital admission in CAP seems to be associated with a lower incidence of septic shock on admission and a lower need for invasive ventilation.
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Affiliation(s)
- Rosanel Amaro
- Department of Pneumology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Jacobo Sellarés
- Department of Pneumology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Eva Polverino
- Department of Pneumology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Catia Cillóniz
- Department of Pneumology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Miquel Ferrer
- Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Laia Fernández-Barat
- Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain
| | - Josep Mensa
- Department of Infectious Disease, Hospital Clinic of Barcelona, Spain
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian- Weill Cornell Medical Center, New York, NY, USA
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain.
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Fluoroquinolones or macrolides in combination with β-lactams in adult patients hospitalized with community acquired pneumonia: a systematic review and meta-analysis. Clin Microbiol Infect 2016; 23:234-241. [PMID: 27965070 DOI: 10.1016/j.cmi.2016.12.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/23/2016] [Accepted: 12/03/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The best treatment option for hospitalized patients with community-acquired pneumonia (CAP) has not been defined. The effectiveness of β-lactam/fluoroquinolone (BLFQ) versus β-lactam/macrolide (BLM) combinations for the treatment of patients with CAP was evaluated. METHODS PubMed, Scopus and the Cochrane Library were searched for observational cohort studies, non-randomized and randomized controlled trials providing data for patients with CAP receiving BLM or BLFQ. Mortality was the primary outcome. A meta-analysis was performed. MINORS and GRADE were used for data quality assessment. RESULTS Seventeen studies (16 684 patients) were included. Randomized trials were not identified. A variety of β-lactams, fluoroquinolones and macrolides were used within and between the studies. Mortality was reported at different time points. The available body of evidence had very low quality. In the analysis of unadjusted data, mortality with BLFQ was higher than with BLM (risk ratio 1.33, 95% CI 1.15-1.54, I2 28%). BLFQ was associated with higher mortality regardless of the study design, mortality recording time, study period and study BLM group mortality. BLFQ was associated with higher mortality in American but not European studies. No difference was observed in patients with bacteraemia and septic shock. In the meta-analysis of adjusted mortality data, a non-significant difference between the two regimens was observed (eight studies, adjusted risk ratio 1.26, 95% CI 0.95-1.67, I2 43%). CONCLUSION In the absence of data from randomized controlled trials recommendations cannot be made for or against either of the studied regimens in this group of hospitalized patients with CAP. Well designed randomized controlled trials comparing the two regimens are warranted.
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29
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Pneumonia presenting with organ dysfunctions: Causative microorganisms, host factors and outcome. J Infect 2016; 73:419-426. [PMID: 27506395 DOI: 10.1016/j.jinf.2016.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/25/2016] [Accepted: 08/02/2016] [Indexed: 11/23/2022]
Abstract
Community-acquired pneumonia (CAP) is a serious infection that may occasionally rapidly evolve provoking organ dysfunctions. We aimed to characterize CAP presenting with organ dysfunctions at the emergency room, with regard to host factors and causative microorganisms, and its impact on 30-day mortality. 460 of 4070 (11.3%) CAP patients had ≥2 dysfunctions at diagnosis, with a 30-day mortality of 12.4% vs. 3.4% in those with one or no dysfunctions. Among them, the most frequent causative microorganisms were Streptococcus pneumoniae, gram-negatives and polymicrobial etiology. Independent host risk factors for presenting with ≥2 dysfunctions were: liver (OR 2.97) and renal diseases (OR 3.91), neurological disorders (OR 1.86), and COPD (OR 1.30). Methicillin-resistant Staphylococcus aureus (OR 6.41) and bacteraemic episodes (OR 1.68) had the higher independent risk among microorganisms. The number of organ dysfunctions vs. none increased at 30-day mortality: three organs (OR 11.73), two organs (OR 4.29), and one organ (OR 2.42) whereas Enterobacteria (OR 3.73) were also independently related to mortality. The number of organ dysfunctions was the strongest 30-day mortality risk factor while Enterobacteriaceae was also associated with poorer outcome. The assessment of organ dysfunctions in CAP should be implemented for management, allocation and treatment decisions on initial evaluation.
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30
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Sahuquillo-Arce JM, Menéndez R, Méndez R, Amara-Elori I, Zalacain R, Capelastegui A, Aspa J, Borderías L, Martín-Villasclaras JJ, Bello S, Alfageme I, de Castro FR, Rello J, Molinos L, Ruiz-Manzano J, Torres A. Age-related risk factors for bacterial aetiology in community-acquired pneumonia. Respirology 2016; 21:1472-1479. [PMID: 27417291 DOI: 10.1111/resp.12851] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/01/2016] [Accepted: 05/09/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of this study was to evaluate the effect of age and comorbidities, smoking and alcohol use on microorganisms in patients with community-acquired pneumonia (CAP). METHODS A prospective multicentre study was performed with 4304 patients. We compared microbiological results, bacterial aetiology, smoking, alcohol abuse and comorbidities in three age groups: young adults (<45 years), adults (45-64 years) and seniors (>65 years). RESULTS Bacterial aetiology was identified in 1522 (35.4%) patients. In seniors, liver disease was independently associated with Gram-negative bacteria (Haemophilus influenzae and Enterobacteriaceae), COPD with Pseudomonas aeruginosa (OR = 2.69 (1.46-4.97)) and Staphylococcus aureus (OR = 2.8 (1.24-6.3)) and neurological diseases with S. aureus. In adults, diabetes mellitus (DM) was a risk factor for Streptococcus pneumoniae and S. aureus, and COPD for H. influenzae (OR = 3.39 (1.06-10.83)). In young adults, DM was associated with S. aureus. Smoking was a risk factor for Legionella pneumophila regardless of age. Alcohol intake was associated with mixed aetiology and Coxiella burnetii in seniors, and with S. pneumoniae in young adults. CONCLUSION It should be considered that the bacterial aetiology may differ according to the patient's age, comorbidities, smoking and alcohol abuse. More extensive microbiological testing is warranted in those with risk factors for infrequent microorganisms.
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Affiliation(s)
| | - Rosario Menéndez
- Pneumology Service, IIS/ University and Politechnic Hospital La Fe, Valencia, Spain. .,CIBERES, Valencia, Spain.
| | - Raúl Méndez
- Pneumology Service, IIS/ University and Politechnic Hospital La Fe, Valencia, Spain.,CIBERES, Valencia, Spain
| | - Isabel Amara-Elori
- Pneumology Service, IIS/ University and Politechnic Hospital La Fe, Valencia, Spain.,CIBERES, Valencia, Spain
| | - Rafael Zalacain
- Pneumology Service, University Hospital Cruces, Bilbao, Spain
| | | | - Javier Aspa
- Pneumology Service, University Hospital of Princesa, Madrid, Spain
| | | | | | - Salvador Bello
- Pneumology Service, University Hospital Miguel Servet, Zaragoza, Spain
| | | | | | - Jordi Rello
- Critical Care Unit, University Hospital Joan XXIII, Tarragona, Spain.,Critical Care Unit, University Hospital Vall Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Luis Molinos
- Pneumology Service, University Hospital Central, Oviedo, Spain
| | | | - Antoni Torres
- CIBERES, Valencia, Spain.,Pneumology Service, Clinic Hospital, IDIBAPS, University of Barcelona, Barcelona, Spain
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Abdelaziz H, Richardson S, Walsh K, Nodzon J, Schwartz B. Evaluation of STAT medication ordering process in a community hospital. Pharm Pract (Granada) 2016; 14:647. [PMID: 27382418 PMCID: PMC4930852 DOI: 10.18549/pharmpract.2016.02.647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: In most health care facilities, problems related to delays in STAT medication order processing time are of common concern. Objective: The purpose of this study was to evaluate processing time for STAT orders at Kimball Medical Center. Methods: All STAT orders were reviewed to determine processing time; order processing time was also stratified by physician order entry (physician entered (PE) orders vs. non-physician entered (NPE) orders). Collected data included medication ordered, indication, time ordered, time verified by pharmacist, time sent from pharmacy, and time charted as given to the patient. Results: A total of 502 STAT orders were reviewed and 389 orders were included for analysis. Overall, median time was 29 minutes, IQR 16–63; p<0.0001.). The time needed to process NPE orders was significantly less than that needed for PE orders (median 27 vs. 34 minutes; p=0.026). In terms of NPE orders, the median total time required to process STAT orders for medications available in the Automated Dispensing Devices (ADM) was within 30 minutes, while that required to process orders for medications not available in the ADM was significantly greater than 30 minutes. For PE orders, the median total time required to process orders for medications available in the ADM (i.e., not requiring pharmacy involvement) was significantly greater than 30 minutes. [Median time = 34 minutes (p<0.001)]. Conclusion: We conclude that STAT order processing time may be improved by increasing the availability of medications in ADM, and pharmacy involvement in the verification process.
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Affiliation(s)
| | | | - Kim Walsh
- Barnabas Health. West Orange, NJ ( United States ).
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Ricard JD, Messika J. Low-dose corticosteroids during severe community-acquired pneumonia: end of the story. Eur Respir J 2016; 45:305-7. [PMID: 25653260 DOI: 10.1183/09031936.00225414] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-chirurgicale, Hôpital Louis Mourier, Colombes, France INSERM, IAME, 1137, Paris, France Univ Paris Diderot, IAME, 1137, Sorbonne Paris Cité, Paris, France
| | - Jonathan Messika
- AP-HP, Service de Réanimation Médico-chirurgicale, Hôpital Louis Mourier, Colombes, France INSERM, IAME, 1137, Paris, France Univ Paris Diderot, IAME, 1137, Sorbonne Paris Cité, Paris, France
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Rello J, Perez A. Precision medicine for the treatment of severe pneumonia in intensive care. Expert Rev Respir Med 2016; 10:297-316. [PMID: 26789703 DOI: 10.1586/17476348.2016.1144477] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite advances in its management, community-acquired pneumonia (CAP) remains the most important cause of sepsis-related mortality and the reason for many ICU admissions. Severity assessment is the cornerstone of CAP patient management and the attempts to ensure the best site of care and therapy. Survival depends on a combination of host factors (genetic, age, comorbidities, defenses), pathogens (virulence, serotypes) and drugs. To reduce CAP mortality, early adequate antibiotic therapy is fundamental. The use of combination therapy with a macrolide seems to improve the clinical outcome in the subset of patients with high inflammation due to immunomodulation. Guidelines on antibiotic therapy have been associated with beneficial effects, and studies of newer adjunctive drugs have produced promising results. This paper discusses the current state of knowledge regarding of precision medicine and the treatment of severe CAP patients.
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Affiliation(s)
- Jordi Rello
- a CIBERES , Barcelona , Spain.,b School of Medicine , Universitat Autonoma de Barcelona , Barcelona , Spain
| | - Antonio Perez
- a CIBERES , Barcelona , Spain.,b School of Medicine , Universitat Autonoma de Barcelona , Barcelona , Spain
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34
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Montull B, Menéndez R, Torres A, Reyes S, Méndez R, Zalacaín R, Capelastegui A, Rajas O, Borderías L, Martin-Villasclaras J, Bello S, Alfageme I, Rodríguez de Castro F, Rello J, Molinos L, Ruiz-Manzano J. Predictors of Severe Sepsis among Patients Hospitalized for Community-Acquired Pneumonia. PLoS One 2016; 11:e0145929. [PMID: 26727202 PMCID: PMC4699794 DOI: 10.1371/journal.pone.0145929] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 12/10/2015] [Indexed: 11/18/2022] Open
Abstract
Background Severe sepsis, may be present on hospital arrival in approximately one-third of patients with community-acquired pneumonia (CAP). Objective To determine the host characteristics and micro-organisms associated with severe sepsis in patients hospitalized with CAP. Results We performed a prospective multicenter cohort study in 13 Spanish hospital, on 4070 hospitalized CAP patients, 1529 of whom (37.6%) presented with severe sepsis. Severe sepsis CAP was independently associated with older age (>65 years), alcohol abuse (OR, 1.31; 95% CI, 1.07–1.61), chronic obstructive pulmonary disease (COPD) (OR, 1.75; 95% CI, 1.50–2.04) and renal disease (OR, 1.57; 95% CI, 1.21–2.03), whereas prior antibiotic treatment was a protective factor (OR, 0.62; 95% CI, 0.52–0.73). Bacteremia (OR, 1.37; 95% CI, 1.05–1.79), S pneumoniae (OR, 1.59; 95% CI, 1.31–1.95) and mixed microbial etiology (OR, 1.65; 95% CI, 1.10–2.49) were associated with severe sepsis CAP. Conclusions CAP patients with COPD, renal disease and alcohol abuse, as well as those with CAP due to S pneumonia or mixed micro-organisms are more likely to present to the hospital with severe sepsis.
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Affiliation(s)
- Beatriz Montull
- Pneumology Department, ISS/Hospital Universitario y Politecnico La Fe, CIBER Enfermedades Respiratorias (CIBERES), Valencia, Spain
| | - Rosario Menéndez
- Pneumology Department, ISS/Hospital Universitario y Politecnico La Fe, CIBER Enfermedades Respiratorias (CIBERES), Valencia, Spain
- * E-mail:
| | - Antoni Torres
- Pneumology Department, Hospital Clínico y Provincial, IDIBAPS, CIBER Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Soledad Reyes
- Pneumology Department, ISS/Hospital Universitario y Politecnico La Fe, CIBER Enfermedades Respiratorias (CIBERES), Valencia, Spain
| | - Raúl Méndez
- Pneumology Department, ISS/Hospital Universitario y Politecnico La Fe, CIBER Enfermedades Respiratorias (CIBERES), Valencia, Spain
| | | | | | - Olga Rajas
- Pneumology Department, Hospital La Princesa, Madrid, Spain
| | - Luis Borderías
- Pneumology Department, Hospital San Jorge, Huesca, Spain
| | | | - Salvador Bello
- Pneumology Department, Hospital Miguel Servet, Zaragoza, Spain
| | | | | | - Jordi Rello
- Critical Care Department, Hospital Joan XXII of Tarragona and Hospital Vall Hebron, Universtitat Autonoma de Barcelona, Barcelona, Spain
| | - Luis Molinos
- Pneumology Department, Hospital Central Asturias, Oviedo, Asturias, Spain
| | - Juan Ruiz-Manzano
- Pneumology Department, Hospital Germans Trias i Pujol Badalona, Barcelona, Spain
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Adoption of a national antimicrobial guide (SWAB-ID) in the Netherlands. Eur J Clin Pharmacol 2015; 72:249-52. [DOI: 10.1007/s00228-015-1969-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/16/2015] [Indexed: 10/22/2022]
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Abstract
PURPOSE OF REVIEW We are entering into a new era of healthcare wherein patient outcomes are increasingly being publicly reported, not just by institution, but by individual clinicians. This review focuses on the issue of quality of care of patients with community-acquired pneumonia (CAP), in particular the choice of outcome, quality of data needed and recommendations of the current bundle of care suggested by the available literature as delivering the best chance of favourable outcomes for patients. RECENT FINDINGS There is increasing evidence that pneumonia outcomes have improved over the past decade, particularly mortality. However, we have been oversimplistic in setting quality targets and that a bundle of care is required to deliver best outcomes, such as has been shown with the surviving sepsis campaign. Equally, the quality of data available to compare outcomes needs to be significantly improved on what is currently available. SUMMARY To achieve best outcomes for their patients, physicians must be actively comparing their outcomes against other institutions and not rely on historical data. A bundle of care that includes rapid administration of antibiotics, use of combination antibiotic therapy including a macrolide and early mobilization is a good starting point.
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Liapikou A, Rosales-Mayor E, Torres A. The management of severe community acquired pneumonia in the intensive care unit. Expert Rev Respir Med 2015; 8:293-303. [PMID: 24838089 DOI: 10.1586/17476348.2014.896202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Severe CAP (SCAP), accounting for 6% of admissions to intensive care units (ICUs) needs early diagnosis and aggressive interventions at the most proximal point of disease presentation. The prognostic scores as the ATS/IDSA rule, the systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen and pH or SCAP system are appropriate in early identification of eligible patients requiring admission to ICU. Then the recommended initial resuscitation in SCAP in the ICU consists of fluid volume intake titrated to specific goals after a fluid challenge and hemodynamic optimization. The first selection of antimicrobial therapy should be started in the first hour and would be broad enough to cover all likely pathogens. Combination therapy may be useful in patients with non refractory septic shock and severe sepsis pneumococcal bacteremia as well. After 6 hours the patient would be reevaluated in terms of hemodynamic stability and antibiotic and therapy. Future developments will focus on sepsis biomarkers, molecular diagnostic techniques and the development of novel therapeutic immunomodulaty agents.
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Affiliation(s)
- Adamantia Liapikou
- 6th Respiratory Department, Sotiria Hospital, Mesogion 152, 11527, Athens, Greece
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Bello S, Menéndez R, Antoni T, Reyes S, Zalacain R, Capelastegui A, Aspa J, Borderías L, Martin-Villasclaras JJ, Alfageme I, Rodríguez de Castro F, Rello J, Luis M, Ruiz-Manzano J. Tobacco smoking increases the risk for death from pneumococcal pneumonia. Chest 2014; 146:1029-1037. [PMID: 24811098 DOI: 10.1378/chest.13-2853] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Active smoking increases the risk of developing community-acquired pneumonia (CAP) and invasive pneumococcal disease, although its impact on mortality in pneumococcal CAP outcomes remains unclear. The aim of this study was to investigate the influence of current smoking status on pneumococcal CAP mortality. METHODS We performed a multicenter, prospective, observational cohort study in 4,288 hospitalized patients with CAP. The study group consisted of 892 patients with pneumococcal CAP: 204 current smokers (22.8%), 387 nonsmokers (43.4%), and 301 exsmokers (33.7%). RESULTS Mortality at 30 days was 3.9%: 4.9% in current smokers vs 4.3% in nonsmokers and 2.6% in exsmokers. Current smokers with CAP were younger (51 years vs 74 years), with more alcohol abuse and fewer cardiac, renal, and asthma diseases. Current smokers had lower CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) scores, although 40% had severe sepsis at diagnosis. Current smoking was an independent risk factor (OR, 5.0; 95% CI, 1.8-13.5; P = .001) for 30-day mortality of pneumococcal CAP after adjusting for age (OR, 1.06; P = .001), liver disease (OR, 4.5), sepsis (OR, 2.3), antibiotic adherence to guidelines, and first antibiotic dose given < 6 h. The independent risk effect of current smokers remained when compared only with nonsmokers (OR, 4.0; 95% CI, 1.3-12.6; P = .015) or to exsmokers (OR, 3.9; 95% CI, 1.09-4.95; P = .02). CONCLUSIONS Current smokers with pneumococcal CAP often develop severe sepsis and require hospitalization at a younger age, despite fewer comorbid conditions. Smoking increases the risk of 30-day mortality independently of tobacco-related comorbidity, age, and comorbid conditions. Current smokers should be actively targeted for preventive strategies.
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Affiliation(s)
- Salvador Bello
- The Servicio de Neumología, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - Rosario Menéndez
- Servicio de Neumología, IIS Hospital Universitario la Fe, Valencia, Spain
| | - Torres Antoni
- Servei de Pneumologia, Institut Clinic del Torax, Universitat de Barcelona, Ciberes GRS, Barcelona, Spain
| | - Soledad Reyes
- Servicio de Neumología, IIS Hospital Universitario la Fe, Valencia, Spain
| | | | | | - Javier Aspa
- Servicio de Neumología, Hospital de la Princesa Spain, Madrid, Spain
| | - Luis Borderías
- Servicio de Neumología, Hospital San Jorge, Huesca, Spain
| | | | | | | | - Jordi Rello
- Critical Care, Hospital Vall d'Hebron, Institut de Recerca Vall d'Hebron-UAB, CIBERES, Barcelona, Spain
| | - Molinos Luis
- Servicio de Neumología, Hospital Central de Asturias, Oviedo, Spain
| | - Juan Ruiz-Manzano
- Servicio de Neumología, Hospital Germans Trias i Pujol, Badalona, Spain
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van den Bosch CMA, Geerlings SE, Natsch S, Prins JM, Hulscher MEJL. Quality indicators to measure appropriate antibiotic use in hospitalized adults. Clin Infect Dis 2014; 60:281-91. [PMID: 25266285 DOI: 10.1093/cid/ciu747] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An important requirement for an effective antibiotic stewardship program is the ability to measure appropriateness of antibiotic use. The aim of this study was to develop quality indicators (QIs) that can be used to measure appropriateness of antibiotic use in the treatment of all bacterial infections in hospitalized adult patients. METHODS A RAND-modified Delphi procedure was used to develop a set of QIs. Potential QIs were retrieved from the literature. In 2 questionnaire mailings with an in-between face-to-face consensus meeting, an international multidisciplinary expert panel of 17 experts appraised and prioritized these potential QIs. RESULTS The literature search resulted in a list of 24 potential QIs. Nine QIs describing recommended care at patient level were selected: (1) take 2 blood cultures, (2) take cultures from suspected sites of infection, (3) prescribe empirical antibiotic therapy according to local guideline, (4) change empirical to pathogen-directed therapy, (5) adapt antibiotic dosage to renal function, (6) switch from intravenous to oral, (7) document antibiotic plan, (8) perform therapeutic drug monitoring, and (9) discontinue antibiotic therapy if infection is not confirmed. Two QIs describing recommended care at the hospital level were also selected: (1) a local antibiotic guideline should be present, and (2) these local guidelines should correspond to the national antibiotic guidelines. CONCLUSIONS The selected QIs can be used in antibiotic stewardship programs to determine for which aspects of antibiotic use there is room for improvement. At this moment we are testing the clinimetric properties of these QIs in 1800 hospitalized patients, in 22 Dutch hospitals.
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Affiliation(s)
- Caroline M A van den Bosch
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
| | | | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam
| | - Marlies E J L Hulscher
- Department of Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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Gattarello S, Borgatta B, Solé-Violán J, Vallés J, Vidaur L, Zaragoza R, Torres A, Rello J. Decrease in mortality in severe community-acquired pneumococcal pneumonia: impact of improving antibiotic strategies (2000-2013). Chest 2014; 146:22-31. [PMID: 24371840 DOI: 10.1378/chest.13-1531] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE The objective of the present study was to compare antibiotic prescribing practices and survival in the ICU for patients with pneumococcal severe community-acquired pneumonia (SCAP) between 2000 and 2013. METHODS This was a matched case-control study of two prospectively recorded cohorts in Europe. Eighty patients from the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos (CAPUCI) II study (case group) were matched with 80 patients from CAPUCI I (control group) based on the following: shock at admission, need of mechanical ventilation, COPD, immunosuppression, and age. RESULTS Demographic data were comparable in the two groups. Combined antibiotic therapy increased from 66.2% to 87.5% (P < .01), and the percentage of patients receiving the first dose of antibiotic within 3 h increased from 27.5% to 70.0% (P < .01). ICU mortality was significantly lower (OR, 0.82; 95% CI, 0.68-0.98) in cases, both in the whole population and in the subgroups of patients with shock (OR, 0.67; 95% CI, 0.50-0.89) or receiving mechanical ventilation (OR, 0.73; 95% CI, 0.55-0.96). In the multivariate analysis, ICU mortality increased in patients requiring mechanical ventilation (OR, 5.23; 95% CI, 1.60-17.17) and decreased in patients receiving early antibiotic treatment (OR, 0.36; 95% CI, 0.15-0.87) and combined therapy (OR, 0.19; 95% CI, 0.07-0.51). CONCLUSIONS In pneumococcal SCAP, early antibiotic prescription and use of combination therapy increased. Both were associated with improved survival.
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Affiliation(s)
- Simone Gattarello
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona.
| | - Bárbara Borgatta
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona
| | - Jordi Solé-Violán
- Intensive Care Unit, Dr Negrin University Hospital, Las Palmas de Gran Canaria, Sabadell; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Jordi Vallés
- Critical Care Center, Sabadell Hospital, Consorci Hospitalari Universitari Parc Taulí, Sabadell; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Loreto Vidaur
- Intensive Care Department, Donostia Hospital, Donostia; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Dr Peset University Hospital, Valencia
| | - Antoni Torres
- Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, University of Barcelona, Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Jordi Rello
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
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Thellier D, Georges H, Leroy O. [Which samples to obtain in the emergency department for the microbiological diagnosis of community-acquired pneumonia in the immunocompetent patient?]. MEDECINE INTENSIVE REANIMATION 2014; 23:490-497. [PMID: 32288739 PMCID: PMC7117809 DOI: 10.1007/s13546-014-0923-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/08/2014] [Indexed: 11/01/2022]
Abstract
Current diagnostic methods allow microbial identification in 50% of patients admitted with severe community-acquired pneumonia (CAP). Guidelines derived from epidemiological data help physicians to start empirical antimicrobial therapy. Definitive microbial diagnosis is useful to guide further pathogen-directed therapy. Blood cultures, cultures of respiratory specimens and urine antigen tests are recommended to determine the causative bacterial pathogen. Positive blood cultures range from 15 to 25% of CAP patients according to severity. Whether sputum specimens represent or not lower respiratory secretions determines its accuracy in CAP microbial diagnosis. In intubated patients, endotracheal aspirates are often of interest. Detection of positive pneumococcal or legionella urinary antigen is often associated with CAP severity. The sensitivity of this test is not decreased in patients who have received antibiotics prior to sampling. Viral pneumonia account for 10 to 40% of severe CAP. Nasal swabs are recommended for influenza identification using polymerase chain reaction (PCR) in order to deliver oseltamivir treatment. In the emergency department, atypical pneumonia serology is less useful than respiratory specimens obtained using fiberoptic bronchoscopy. Serum PCR to diagnose bacterial CAP is not superior to the other usual methods.
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Affiliation(s)
- D. Thellier
- Service de réanimation médicale et maladies infectieuses, centre hospitalier Chatilliez, 135 rue du Président Coty, F-59208 Tourcoing, France
| | - H. Georges
- Service de réanimation médicale et maladies infectieuses, centre hospitalier Chatilliez, 135 rue du Président Coty, F-59208 Tourcoing, France
| | - O. Leroy
- Service de réanimation médicale et maladies infectieuses, centre hospitalier Chatilliez, 135 rue du Président Coty, F-59208 Tourcoing, France
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van den Bosch CMA, Hulscher MEJL, Natsch S, Gyssens IC, Prins JM, Geerlings SE. Development of quality indicators for antimicrobial treatment in adults with sepsis. BMC Infect Dis 2014; 14:345. [PMID: 24950718 PMCID: PMC4078010 DOI: 10.1186/1471-2334-14-345] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 06/09/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Outcomes in patients with sepsis are better if initial empirical antimicrobial use is appropriate. Several studies have shown that adherence to guidelines dictating appropriate antimicrobial use positively influences clinical outcome, shortens length of hospital stay and contributes to the containment of antibiotic resistance.Quality indicators (QIs) can be systematically developed from these guidelines to define and measure appropriate antimicrobial use. We describe the development of a concise set of QIs to assess the appropriateness of antimicrobial use in adult patients with sepsis on a general medical ward or Intensive Care Unit (ICU). METHODS A RAND-modified, five step Delphi procedure was used. A multidisciplinary panel of 14 experts appraised and prioritized 40 key recommendations from within the Dutch national guideline on antimicrobial use for adult hospitalized patients with sepsis (http://www.swab.nl/guidelines). A procedure to select QIs relevant to clinical outcome, antimicrobial resistance and costs was performed using two rounds of questionnaires with a face-to-face consensus meeting between the rounds over a period of three months. RESULTS The procedure resulted in the selection of a final set of five QIs, namely: obtain cultures; prescribe empirical antimicrobial therapy according to the national guideline; start intravenous drug therapy; start antimicrobial treatment within one hour; and streamline antimicrobial therapy. CONCLUSION This systematic, stepwise method, which combined evidence and expert opinion, led to a concise and therefore feasible set of QIs for optimal antimicrobial use in hospitalized adult patients with sepsis. The next step will entail subjecting these quality indicators to an applicability test for their clinimetric properties and ultimately, using these QIs in quality-improvement projects. This information is crucial for antimicrobial stewardship teams to help set priorities and to focus improvement.
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Affiliation(s)
- Caroline MA van den Bosch
- Department of Internal Medicine, division of Infectious Diseases, Center for Infection and Immunity Amsterdam (CINIMA) Academic Medical Center, Meibergdreef 9, 1105, AZ Amsterdam Zuidoost, The Netherlands
| | - Marlies EJL Hulscher
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephanie Natsch
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
- Hasselt University, Hasselt, Belgium
| | - Jan M Prins
- Department of Internal Medicine, division of Infectious Diseases, Center for Infection and Immunity Amsterdam (CINIMA) Academic Medical Center, Meibergdreef 9, 1105, AZ Amsterdam Zuidoost, The Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, division of Infectious Diseases, Center for Infection and Immunity Amsterdam (CINIMA) Academic Medical Center, Meibergdreef 9, 1105, AZ Amsterdam Zuidoost, The Netherlands
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Macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis. Crit Care Med 2014; 42:420-32. [PMID: 24158175 DOI: 10.1097/ccm.0b013e3182a66b9b] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Some studies suggest better outcomes with macrolide therapy for critically ill patients with community-acquired pneumonia. To further explore this, we performed a systematic review of studies with mortality endpoints that compared macrolide therapy with other regimens in critically ill patients with community-acquired pneumonia. DATA SOURCES Studies were identified via electronic databases, grey literature, and conference proceedings through May 2013. STUDY SELECTION Using prespecified criteria, two reviewers selected studies; studies of outpatients and hospitalized noncritically ill patients were excluded. DATA EXTRACTION Two reviewers extracted data and evaluated bias using the Newcastle-Ottawa Scale. Random effects models were used to generate pooled risk ratios and evaluate heterogeneity (I). DATA SYNTHESIS Twenty-eight observational studies (no randomized control trials) were included. Average age ranged from 58 to 78 years and 14-49% were women. In our primary analysis of 9,850 patients, macrolide use was associated with statistically significant lower mortality compared with nonmacrolides (21% [846 of 4,036 patients] vs 24% [1,369 of 5,814]; risk ratio, 0.82; 95% CI, 0.70-0.97; p = 0.02; I = 63%). When macrolide monotherapy was excluded, the macrolide mortality benefit was maintained (21% [737 of 3,447 patients] vs 23% [1,245 of 5,425]; risk ratio, 0.84; 95% CI, 0.71-1.00; p = 0.05; I = 60%). When broadly guideline-concordant regimens were compared, there was a trend to improved mortality and heterogeneity was reduced (20% [511 of 2,561 patients] mortality with beta-lactam/macrolide therapy vs 23% [386 of 1,680] with beta-lactam/fluoroquinolone; risk ratio, 0.83; 95% CI, 0.67-1.03; p = 0.09; I = 25%). When adjusted risk estimates were pooled from eight studies, macrolide therapy was still associated with a significant reduction in mortality (risk ratio, 0.75; 95% CI, 0.58-0.96; p = 0.02; I = 57%). CONCLUSIONS In observational studies of almost 10,000 critically ill patients with community-acquired pneumonia, macrolide use was associated with a significant 18% relative (3% absolute) reduction in mortality compared with nonmacrolide therapies. After pooling data from studies that provided adjusted risk estimates, an even larger mortality reduction was observed. These results suggest that macrolides be considered first-line combination treatment in critically ill patients with community-acquired pneumonia and support current guidelines.
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Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence 2013; 5:80-97. [PMID: 24184742 PMCID: PMC3916387 DOI: 10.4161/viru.26913] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.
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Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine; Section of Infectious Diseases; Health Sciences Centre; Winnipeg, MB Canada
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Spoorenberg V, Hulscher MEJL, Akkermans RP, Prins JM, Geerlings SE. Appropriate Antibiotic Use for Patients With Urinary Tract Infections Reduces Length of Hospital Stay. Clin Infect Dis 2013; 58:164-9. [DOI: 10.1093/cid/cit688] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) contributes significantly to morbidity and mortality, especially in the elderly. Recent advances aimed at improving outcomes and reducing CAP disease burden are summarized. RECENT FINDINGS Emerging data suggests that newer CAP risk stratification indices based on disease severity hold promise in predicting intensive care need. Additional evidence supports a role of procalcitonin and pro-adrenomedullin as biomarkers of disease severity and for guiding antimicrobial therapy. New diagnostic tools have greatly contributed to early diagnosis and better-targeted therapy. There is increasing recognition of the role of coinfections in CAP. In patients with severe disease, therefore, current guidelines advise against monotherapy. Although inclusion of coverage for atypical pathogens in nonsevere CAP has been challenged, evidence suggests that such coverage is beneficial in patients with severe disease. Use of steroids as adjunctive therapy for CAP, however, is associated with complications and prolonged hospitalization. Updated prevention strategies include approval of pneumococcal conjugate vaccine (PCV13) for adults at risk. SUMMARY Despite these developments research aimed at further reducing CAP-related morbidity and mortality is required. Increasing global life expectancy is likely to expand the at-risk population; therefore, research directed at CAP prevention in view of changing demography is essential.
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Asrar Khan W, Woodhead M. Major advances in managing community-acquired pneumonia. F1000PRIME REPORTS 2013; 5:43. [PMID: 24167724 PMCID: PMC3790563 DOI: 10.12703/p5-43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This article is a non-systematic review of selected recent publications in community-acquired pneumonia, including a comparison of various guidelines. Risk stratification of patients has recently been advanced by the addition of several useful biomarkers. The issue of single versus dual antibiotic treatment remains controversial and awaits a conclusive randomized controlled trial. However, in the meantime, there is a working consensus that more severe patients should receive dual therapy.
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Sialer S, Liapikou A, Torres A. What is the best approach to the nonresponding patient with community-acquired pneumonia? Infect Dis Clin North Am 2013; 27:189-203. [PMID: 23398874 DOI: 10.1016/j.idc.2012.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Treatment failure in community-acquired pneumonia (CAP) is the failure to normalize the clinical features (eg, fever, cough, sputum production), or nonresolving image in chest radiograph, despite antimicrobial therapy. The incidence of treatment failure in CAP has not been clearly established; according to several studies it ranges between 6% and 15%. The rate of mortality increases significantly, especially in those patients with severe CAP. It is important to be able to identify what patients are at risk for progressive or treatment failure pneumonia that may make them candidates for a more careful monitoring.
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Affiliation(s)
- Salvador Sialer
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Barcelona 08036, Spain
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Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. Management decisions regarding site of care, extent of assessment and level of treatment are based primarily on disease severity (outpatient, inpatient and ICU admission). Despite the developments in antibiotic therapy, CAP is still the most common infectious cause of death. AREAS COVERED There are several challenges with the management of CAP, from the accurate diagnosis, decisions about place of therapy and the choice of appropriate antibiotics. An extensive literature review of manuscripts, in PubMed, published in the past 10 years has been performed, using combinations of words and terms appropriate to the concepts of CAP, treatment, guidelines and corticoids. Some empirical antimicrobial regimens, such as macrolides, are still being debated; some new antibiotics and adjunctive therapies (corticoids) have recently been tested. This is a review of current recommended antimicrobials regimens, novel approaches and adjunctive drugs for the treatment of CAP. EXPERT OPINION Effective management of CAP requires risk stratification of patients by severity and proper place of therapy. Additional therapeutic interventions along with antibiotics may help to improve outcome in patients with CAP, especially in severe CAP.
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Affiliation(s)
- Adamantia Liapikou
- Sotiria Chest Diseases Hospital, 3rd Respiratory Department, Mesogion 152, Athens, Greece.
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