Predictors of treatment failure and clinical stability in patients with community acquired pneumonia

Comparison of Empiric Antibiotic Treatment Regimens for Hospitalized, Non-severe Community-acquired Pneumonia: A Retrospective, Multicenter Cohort Study

PURPOSE

Consensus guidelines for hospitalized, non-severe community-acquired pneumonia (CAP) recommend empiric macrolide + β-lactam or respiratory fluoroquinolone monotherapy in patients with no risk factors for resistant organisms. In patients with allergies or contraindications, doxycycline + β-lactam is a recommended alternative. The purpose of this study was to compare differences in outcomes among guideline-recommended regimens in this population.

METHODS

This retrospective, multicenter cohort study included patients ≥18 years of age with CAP who received respiratory fluoroquinolone monotherapy, empiric macrolide + β-lactam, or doxycycline + β-lactam. Major exclusion criteria included patients with immunocompromising conditions, requiring vasopressors or invasive mechanical ventilation within 48 hours of admission, and receiving less than 2 days of total antibiotic therapy. The primary outcome was in-hospital mortality. Secondary outcomes included clinical failure, 14- and 30-day hospital readmission, and hospital length of stay. Safety outcomes included incidence of new Clostridioides difficile infection and aortic aneurysm ruptures.

FINDINGS

Of 4685 included patients, 1722 patients received empiric respiratory fluoroquinolone monotherapy, 159 received empiric doxycycline + β-lactam, and 2804 received empiric macrolide + β-lactam. Incidence of in-hospital mortality was not observed to be significantly different among empiric regimens (doxycycline + β-lactam group: 1.9% vs macrolide + β-lactam: 1.9% vs respiratory fluoroquinolone monotherapy: 1.5%, P = 0.588). No secondary outcomes were observed to differ significantly among groups.

IMPLICATIONS

We observed no differences in clinical or safety outcomes among three guideline-recommended empiric CAP regimens. Empiric doxycycline + β-lactam may be a safe empiric regimen for hospitalized CAP patients with non-severe CAP, although additional research is needed to corroborate these observations with larger samples.

Childhood Pneumonia: What's Unchanged, and What's New?

Childhood pneumonia is still a significant clinical and public health problem. India contributes the highest number of deaths due to pneumonia, accounts for about 20% of global mortality among under five children. Various etiologic agents including bacteria, viruses and atypical organism are responsible for childhood pneumonia. Recent studies suggest that viruses are one of the major causes of childhood pneumonia. Among viruses, respiratory syncytial virus has got great attention and several recent studies are reporting it as an important organism for pneumonia. Lack of exclusive breast feeding during first six months, improper timing of start and content of complimentary feeding, anemia, undernutrition, indoor pollution due to tobacco smoking and use of coal and wood for cooking food and lack of vaccinations are important risk factors. X-ray chest is not routinely performed to diagnose pneumonia while use of lung ultrasound is increasing to detect consolidation, pleural effusion, pneumothorax and pulmonary edema (interstitial syndrome). Role of C-reactive protein (CRP) and procalcitonin is similar, to differentiate between viral and bacterial pneumonia, however duration of antibiotics is better guided by procalcitonin. Newer biomarkers like IL-6, presepsin and triggering receptor expressed on myeloid cells 1 are needed to be evaluated for their use in children. Hypoxia is significantly associated with childhood pneumonia. Therefore, use of pulse oximetry should be encouraged for early detection and prompt treatment of hypoxia to prevent adverse outcomes. Among the available tools for risk of mortality assessment in children due to pneumonia, PREPARE score is the best but external validation will be needed.

Evaluation of Plasma Lipocalin-2 as a Predictor of Etiology and Severity in Adult Patients with Community-Acquired Pneumonia

The aim of this study was to evaluate the diagnostic performance of plasma Lipocalin-2 (LCN2) concentration in adult patients with community-acquired pneumonia (CAP) to determine its etiology, severity and prognosis. A prospective observational study involving adults with CAP from November 2015 to May 2017 was conducted. Plasma LCN2 concentration was measured upon admission by a modified enzyme immunoassay coupled with chemiluminescence (Architect, Abbott Laboratories). The diagnostic performance of LCN2, C-reactive protein (CRP) and white blood cell to predict bacterial CAP was assessed. A total of 130 patients with CAP were included: 71 (54.6%) bacterial CAP, 42 (32.3%) unknown origin CAP and 17 (13.1%) viral CAP. LCN2 was higher in bacterial CAP than in non-bacterial CAP (122.0 vs. 89.7 ng/mL, respectively) (p = 0.03) with a limited ability to distinguish bacterial and non-bacterial CAP (AUROC: 0.62 [95% CI 0.52-0.72]). The LCN2 cutoff ≥ 204 ng/mL predicted the presence of pneumococcal bacteremia with an AUROC of 0.74 (sensitivity 70%, specificity 79.1%). Regarding severity, as defined by CURB-65 and PSI scores, there was a significant linear trend in the mean concentration of LCN2, exhibiting a shift from the low-risk to the intermediate-risk and high-risk group (p < 0.001 and 0.001, respectively). LCN2 concentration was associated with severity in adult patients with CAP. However, its utility as a biomarker to discriminate viral and bacterial etiology in CAP is limited.

Clinical Characteristics and Microbial Profiles of Paediatric Patients with Methicillin-Resistant Staphylococcus aureus Pneumonia in China

Background: Staphylococcus aureus can cause fatal pneumonia. The evolution of bacteria and the overuse of antibiotics have enhanced the drug resistance of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA). Objectives: This study aimed to recapitulate the microbiological profile and clinical characteristics of paediatric patients with MRSA. Methods: This retrospective study was conducted to investigate 1372 paediatric patients with S. aureus pneumonia from January 2017 to December 2021. Sputum specimens were collected and processed for performing bacterial culture and drug sensitivity tests. Medical records of patients were reviewed for clinical characteristics and laboratory examination results. Results: The MRSA and MSSA pneumonia mainly occurred in infants; however, comparisons of sex, age, and sampling time between patients with MRSA and MSSA pneumonia showed no significant differences (P > 0.05). The results of drug sensitivity in sputum culture revealed that all MRSA and MSSA isolates were susceptible to vancomycin, tigecycline, linezolid, teicoplanin, and ceftaroline. Methicillin-sensitive Staphylococcus aureus was completely sensitive to rifampicin and oxacillin. Methicillin-resistant Staphylococcus aureus was completely resistant to penicillin and oxacillin, while MSSA was less sensitive to penicillin. Methicillin-resistant Staphylococcus aureus and MSSA both maintained high sensitivity rates to gentamicin, sulfamethoxazole-trimethoprim, levofloxacin, and moxifloxacin, with the exception of clindamycin and erythromycin. According to our results, moreover, the sensitivity of MRSA to gentamicin and sulfamethoxazole-trimethoprim was significantly higher than that of MSSA (P < 0.05). The common symptoms of patients with S. aureus pneumonia were fever, cough, and wheezing. patients with MRSA pneumonia had significantly higher counts of white blood cells (WBCs), C-reactive protein (CRP), and procalcitonin (PCT) than patients with MSSA pneumonia (P < 0.05). Conclusions: The results of antimicrobial sensitivity test in sputum culture of MRSA and MSSA isolates can reflect the sensitivity of antibiotics and guide the use of clinical antibiotics. Infectious biomarkers can reflect the severity of infection and guide prognosis.

Choosing antibiotic therapy for severe community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) is known as a major worldwide health concern considering it has been shown to account for 78% of infection-related deaths in the USA. It is a common cause for hospitalization with a continued incidence rise in the elderly, high mortality rate and long-term sequelae in critically ill patients. Severe CAP (sCAP) is an accepted terminology used to describe ICU admitted patients with CAP. The aim of this review is to further report on the major advances in treatment for patients with sCAP including new antibiotic treatments despite macrolide resistance as seen in the ICU, and multifaceted antibiotic stewardship interventions that may lead to the reduction broad-spectrum antibiotic use in CAP.

RECENT FINDINGS

We aim to examine the most recent findings in order to determine appropriate empirical antibiotic choices, timing regimens and evidence for clinical effectiveness. This will be addressed by focusing on the use combination therapies, the usefulness of severity scores and the difficulty to treat multidrug-resistant pathogens, including gram negatives such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Relevant reports referenced within included randomized controlled trials, meta-analyses, observational studies, systematic reviews and international guidelines where applicable.

SUMMARY

New antibiotics have been recently launched with direct agent-specific properties that have been shown to avoid the overuse of previous broad-spectrum antibiotics when treating patients sCAP. Although narrow-spectrum antibiotics are now recommended and imperative in improving a patients' prognosis, there are also some considerations when prescribing antibiotics that are beyond the spectrum. There is a need to implement effective policies of de-escalation to avoid antibiotic resistance and the risk for developing subsequent infections by combining informed clinical judgement and the application of biomarkers. Reaching clinical stability and avoidance of treatment failure are the most important pillars in treatment success.

Controlling Nutritional Status score: A novel prognostic marker for patients with community-acquired pneumonia

Objective:

We aimed to investigate the prevalence and prognostic value of malnutrition assessed by Controlling Nutritional Status score in community-acquired pneumonia patients.

Methods:

All adult patients admitted to our emergency department and hospitalized for community-acquired pneumonia were prospectively followed-up until hospital discharge or death. Nutritional status was assessed with the Controlling Nutritional Status score, which is based on serum albumin levels, total cholesterol levels, and lymphocyte counts. The primary study endpoint was complicated hospital course defined as need for mechanical ventilation, mortality, or intensive care unit admission.

Results:

Three hundred and five patients (mean age 68.6 ± 11.2 years and 51.8% female) were enrolled, and 40 patients (13.1%) had complicated hospitalizations. Older patients, patients with more comorbidities, and patients with higher Controlling Nutritional Status scores on admission were tended to have a higher rate of complications during their hospitalization. Multivariate analysis showed that older age (odds ratio 2.55, 95% confidence interval 1.41–4.64, p < 0.001), presence of diabetes (odds ratio 1.54; 95% confidence interval 1.09–3.65; p = 0.004), pneumonia severity index ⩾ 3 (odds ratio 1.27, 95% confidence interval 0.524–3.725, p = 0.035), and Controlling Nutritional Status score > 4 (odds ratio 2.23, 95% confidence interval 1.129–3.657, p = 0.001) were independent predictors of complicated hospitalizations.

Conclusion:

Malnutrition determined by Controlling Nutritional Status score predicts complications in hospitalized patients with community-acquired pneumonia.

Calprotectin: An Ignored Biomarker of Neutrophilia in Pediatric Respiratory Diseases

Calprotectin (CP) is a non-covalent heterodimer formed by the subunits S100A8 (A8) and S100A9 (A9). When neutrophils become activated, undergo disruption, or die, this abundant cytosolic neutrophil protein is released. By fervently chelating trace metal ions that are essential for bacterial development, CP plays an important role in human innate immunity. It also serves as an alarmin by controlling the inflammatory response after it is released. Extracellular concentrations of CP increase in response to infection and inflammation, and are used as a biomarker of neutrophil activation in a variety of inflammatory diseases. Although it has been almost 40 years since CP was discovered, its use in daily pediatric practice is still limited. Current evidence suggests that CP could be used as a biomarker in a variety of pediatric respiratory diseases, and could become a valuable key factor in promoting diagnostic and therapeutic capacity. The aim of this study is to re-introduce CP to the medical community and to emphasize its potential role with the hope of integrating it as a useful adjunct, in the practice of pediatric respiratory medicine.

Utility of procalcitonin as a predictor of bloodstream infections and supportive modality requirements in critically ill cancer patients

BACKGROUND

We evaluated the diagnostic utility of procalcitonin (PCT) in predicting bacterial bloodstream infections (BSI) in critically ill cancer patients with and without neutropenia. We also investigated the role of PCT as a prognostic marker of supportive modalities (vasopressors, invasive mechanical ventilation, and renal replacement therapy (RRT)) in the intensive care unit (ICU).

METHODS

We retrospectively analyzed 2200 PCT and blood cultures from adult cancer patients with suspected sepsis. Primary outcome was BSI, defined by positive blood culture, collected within 72 h of PCT collection.

RESULTS

Median PCT values were higher in encounters with BSI (3.2 vs 0.5 ng/ml, p < 0.001). The area under the ROC curve (AUC) was 0.726 (95%CI 0.698, 0.754). PCT > 2.0 ng/ml was significantly associated with greater likelihood of BSI and this effect was significantly stronger for neutropenic (OR 9.09, 95%CI: 4.39, 18.79) compared with non-neutropenic patients (OR 4.00 (95% CI: 3.13, 5.10), interaction p = 0.036). PCT > 2.0 was associated with vasopressor requirement on ICU admission (OR 1.82 (95% CI 1.31, 2.53), p < 0.001) and RRT (OR 2.20 (95% CI 1.24, 3.91), p = 0.007).

CONCLUSIONS

Procalcitonin is a fair discriminator of BSI in critically ill cancer patients with and without neutropenia and a PCT > 2.0 ng/ml was significantly more likely to require vasopressors and RRT in the ICU.

Predictors of urinary tract infection in acute stroke patients: A cohort study

Patients with stroke have a high risk of infection which may be predicted by age, procalcitonin, interleukin-6, C-reactive protein, National Institute of Health stroke scale (NHSS) score, diabetes, etc. These prediction methods can reduce unfavourable outcome by preventing the occurrence of infection.We aim to identify early predictors for urinary tract infection in patients after stroke.In 186 collected acute stroke patients, we divided them into urinary tract infection group, other infection type groups, and non-infected group. Data were recorded at admission. Independent risk factors and infection prediction model were determined using Logistic regression analyses. Likelihood ratio test was used to detect the prediction effect of the model. Receiver operating characteristic curve and the corresponding area under the curve were used to measure the predictive accuracy of indicators for urinary tract infection.Of the 186 subjects, there were 35 cases of urinary tract infection. Elevated interleukin-6, higher NIHSS, and decreased hemoglobin may be used to predict urinary tract infection. And the predictive model for urinary tract infection (including sex, NIHSS, interleukin-6, and hemoglobin) have the best predictive effect.This study is the first to discover that decreased hemoglobin at admission may predict urinary tract infection. The prediction model shows the best accuracy.

Non-bacteremic pneumococcal pneumonia: general characteristics and early predictive factors for poor outcome

Purpose: Nowadays, most cases of pneumococcal community-acquired pneumonia (PCAP) are diagnosed by positive urinary antigen. Our aims were to analyse process of care in patients hospitalised with non-bacteremic PCAP (NB-PCAP) and identify factors associated with poor outcome (PO) in this population.Methods: We conducted a prospective study, including patients hospitalised for NB-PCAP (positive urinary antigen and negative blood culture) over a 15 year period. We performed multivariate analysis of predisposing factors for PO, defined as need for mechanical ventilation and/or shock and/or in-hospital death.Results: Of the 638 patients included, 4.1% died in hospital and 12.8% had PO. Host-related factors were similar in patients with and without PO, but patients with PO had higher illness severity on admission. Adjusted analysis revealed the following independent factors associated with PO: being a nursing home resident (OR: 6.156; 95% CI: 1.827-20.750; p = .003), respiratory rate ≥30 breaths/min (OR: 3.030; 95% CI: 1.554-5.910; p = .001), systolic blood pressure <90 mmHg (OR: 4.789; 95% CI: 1.967-11.660; p = .001), diastolic blood pressure <60 mmHg (OR: 2.820; 95% CI: 1.329-5.986; p = .007), pulse rate ≥125 beats/min (OR: 3.476; 95% CI: 1.607-7.518; p = .002), pH <7.35 (OR: 9.323; 95% CI: 3.680-23.622; p < .001), leukocytes <4000/µL (OR: 10.007; 95% CI: 2.960-33.835; p < .001), and severe inflammation (OR: 2.364; 95% CI 1.234-4.526; p = .009). The area under the curve for predicting PO was 0.890 (95% CI: 0.851-0.929).Conclusions: Since patients with PO seem different and had worse in-hospital course, we identified eight independent risk factors for PO measurable on admission.

Diagnostic markers for community-acquired pneumonia

Community-acquired pneumonia (CAP) is one of the respiratory infectious diseases caused by not only bacteria, but also viruses. Antibiotic agents are needed to treat only bacterial but not viral CAP. In addition, there are some non-infectious respiratory diseases in the differential diagnosis of CAP, such as malignant diseases, interstitial lung diseases, pulmonary edema, and pulmonary hemorrhage. We usually diagnose patients having CAP by comprehensive evaluation of symptoms, vital signs, laboratory examinations, and radiographic examinations. However, symptoms and vital signs are not specific for the diagnosis of CAP; therefore, we also use inflammatory biomarkers for differentiating bacterial from viral CAP and non-infectious respiratory diseases. We have used the white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate as common inflammatory biomarkers, but they are not specific for bacterial infection because they could be increased by malignant diseases and collagen diseases. Recently, some inflammatory biomarkers such as procalcitonin (PCT), soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), pro-adrenomedullin (proADM), and presepsin have been developed as relatively specific biomarkers for bacterial infection. Many reports have evaluated the usefulness of PCT for diagnosing CAP. In this review, the characteristics of each biomarker are discussed based on previous studies.

Pretreatment of nafithromycin attenuates inflammatory response in murine lipopolysaccharide induced acute lung injury

Acute respiratory distress syndrome following an acute lung injury (ALI) is a life threatening inflammatory condition predominantly characterized by vascular protein leakage, neutrophil recruitment and overexpression of proinflammatory cytokines. Pulmonary and systemic bacterial infections are the major cause of ALI wherein the bacterial cell components play a crucial role. Macrolide/ketolide antibiotics are reported to possess immunomodulatory activity; as a result improved survival has been noted in pneumonia patients. Hence immunomodulatory activity of nafithromycin, a novel lactone ketolide antibacterial agent was assessed in the murine LPS induced ALI model. Vehicle, nafithromycin (100 mg/kg), azithromycin (600 mg/kg) and dexamethasone (20 mg/kg) were administered orally, 1 h prior to LPS challenge and bronchoalveolar lavage (BAL) fluid was collected thereafter at 18, 24 and 48 h to determine the total cell count, total protein, myeloperoxidase (MPO), tumor necrosis factor (TNF)-α and interleukin (IL)-6. Results from the current study showed that pretreatment with nafithromycin significantly reduced the total cell count, total protein, MPO, TNF-α and IL-6 levels in BAL fluid compared to LPS control group. Histopathological evaluations also suggest significant reduction in neutrophil infiltration by nafithromycin. Dexamethasone, a positive reference standard as expected exhibited potent anti-inflammatory activity. The immunomodulatory effect of nafithromycin at dose of 100 mg/kg was comparable to azithromycin dosed at 600 mg/kg. As a result of immunomodulatory activity, nafithromycin is expected to provide additional clinical benefits by resolving the secondary complications associated with severe pneumonia and thereby improving survival in such patients.

Lactate dehydrogenase as a prognostic marker of renal transplant recipients with severe community-acquired pneumonia: a 10-year retrospective study

BACKGROUND

Lactate dehydrogenase (LDH) is an easily accessible biological marker that has been associated with several pulmonary disorders. The aim of this study was to investigate the prognostic value of serum LDH in renal transplant recipients with severe community-acquired pneumonia (CAP).

METHODS

A total of 77 renal transplant recipients with severe CAP admitted to the intensive care unit (ICU) were screened for eligibility in this retrospective study. Patient characteristics and laboratory tests, such as LDH on day 1 (LDH_{day 1}) and day 3 (LDH_{day 3}) were recorded. Cox regression models were used to assess the performance of LDH to predict 90-day mortality.

RESULTS

Median LDH level was higher on day 1 in 90-day nonsurvivors (440 U/L, IQR, 362-1,055 U/L) than in survivors (334 U/L, IQR, 265-432 U/L; P<0.001); median LDH level on day 3 in nonsurvivors was 522.5 U/L (IQR, 457.5-1,058.5 U/L) and in survivors 290 U/L (IQR, 223-387.5 U/L; P<0.001). Analysis of LDH kinetics from day 1 to day 3 showed an increase in nonsurvivors and a decrease in survivors. Moreover, Multivariate Cox analysis showed that LDH_{day 1} (increase per 100 U/L), LDH_{day 3} (increase per 100 U/L) and LDH kinetics (increase per 10%) were independently associated with 90-day mortality.

CONCLUSIONS

Serum LDH levels and LDH kinetics early were independently associated with 90-day mortality in renal transplant recipients with severe CAP. In future, the prognostic role of LDH needs to be warranted.

Future Research Directions in Pneumonia. NHLBI Working Group Report

Pneumonia is a complex pulmonary disease in need of new clinical approaches. Although triggered by a pathogen, pneumonia often results from dysregulations of host defense that likely precede infection. The coordinated activities of immune resistance and tissue resilience then dictate whether and how pneumonia progresses or resolves. Inadequate or inappropriate host responses lead to more severe outcomes such as acute respiratory distress syndrome and to organ dysfunction beyond the lungs and over extended time frames after pathogen clearance, some of which increase the risk for subsequent pneumonia. Improved understanding of such host responses will guide the development of novel approaches for preventing and curing pneumonia and for mitigating the subsequent pulmonary and extrapulmonary complications of pneumonia. The NHLBI assembled a working group of extramural investigators to prioritize avenues of host-directed pneumonia research that should yield novel approaches for interrupting the cycle of unhealthy decline caused by pneumonia. This report summarizes the working group's specific recommendations in the areas of pneumonia susceptibility, host response, and consequences. Overarching goals include the development of more host-focused clinical approaches for preventing and treating pneumonia, the generation of predictive tools (for pneumonia occurrence, severity, and outcome), and the elucidation of mechanisms mediating immune resistance and tissue resilience in the lung. Specific areas of research are highlighted as especially promising for making advances against pneumonia.

Cytokines and Cortisol - predictors of treatment response to corticosteroids in community-acquired pneumonia?

BACKGROUND

A previous study found community-acquired pneumonia (CAP) patients with imbalance of high inflammation and discordantly low cortisol levels to benefit most from adjunctive corticosteroid treatment. Our aim was to validate this hypothesis in a preplanned secondary analysis of the randomized controlled STEP trial.

METHODS

Patients included in the STEP trial receiving 50 mg prednisone or placebo for 5 days were categorized based on pro-inflammatory cytokines (Interleukin-6/8/MCP-1), CRP and cortisol levels on admission into four groups (high/low inflammation and high/low cortisol). The primary combined end-point was mortality or ICU admission within 30 days.

RESULTS

In total, 632 patients (315 prednisone, 317 placebo) were included in this analysis. Prednisone did not significantly reduce the risk for the primary end-point in patients with high cytokines/low cortisol and in any other subgroups. However, we noted some differences in the strength of corticosteroid effect in the different subgroups with stronger effects in patients with high cytokines [OR 0.44 (0.10,1.72)] compared to patients with low cytokines [OR 0.68 (0.30,1.5)] (P-interaction = 0.600). The effects did not differ according to cortisol levels.

CONCLUSION

The imbalance of high inflammation state and low cortisol levels did not predict treatment response to corticosteroids in patients with CAP. However, in line to previous research, inflammation as measured by cytokine levels irrespective of cortisol tended to predict treatment response to corticosteroids in CAP. Whether this concept may help to personalize corticosteroids to patients most likely benefitting from this treatment needs to be tested in future intervention trials.

Personalizing the Management of Pneumonia

Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.

Biomarkers in Pneumonia-Beyond Procalcitonin

Pneumonia is the leading infectious cause of mortality worldwide and one of the most common lower respiratory tract infections that is contributing significantly to the burden of antibiotic consumption. Due to the complexity of its pathophysiology, it is widely accepted that clinical diagnosis and prognosis are inadequate for the accurate assessment of the severity of the disease. The most challenging task for a physician is the risk stratification of patients with community-acquired pneumonia. Herein, early diagnosis is essential in order to reduce hospitalization and mortality. Procalcitonin and C-reactive protein remain the most widely used biomarkers, while interleukin 6 has been of particular interest in the literature. However, none of them appear to be ideal, and the search for novel biomarkers that will most sufficiently predict the severity and treatment response in pneumonia has lately intensified. Although our insight has significantly increased over the last years, a translational approach with the application of genomics, metabolomics, microbiomics, and proteomics is required to better understand the disease. In this review, we discuss this rapidly evolving area and summarize the application of novel biomarkers that appear to be promising for the accurate diagnosis and risk stratification of pneumonia.

Plasma Soluble Urokinase-Type Plasminogen Activator Receptor Level as a Predictor of the Severity of Community-Acquired Pneumonia

The urokinase-type plasminogen activator receptor (uPAR) mediates various cellular activities and is involved in proteolysis, angiogenesis, and inflammation. The objective of this study was to investigate the association between soluble uPAR (suPAR) levels and community-acquired pneumonia (CAP) severity. A commercial enzyme-linked immunosorbent assay (ELISA) was performed to measure the plasma suPAR levels in 67 healthy controls and 75 patients with CAP. Our results revealed that plasma suPAR levels were significantly elevated in patients with CAP compared with the controls, and antibiotic treatment was effective in reducing suPAR levels. The plasma suPAR levels were correlated with the severity of CAP based on the pneumonia severity index (PSI) scores. Furthermore, lipopolysaccharide (LPS)-stimulation significantly increased uPAR expression in RAW 264.7 macrophages. In conclusion, plasma suPAR levels may play a role in the clinical assessment of CAP severity; these findings may provide information on new targets for treatment of CAP.

Budget Impact of Omadacycline for the Treatment of Patients with Community-Acquired Bacterial Pneumonia in the United States from the Hospital Perspective

BACKGROUND

Community-acquired bacterial pneumonia (CABP) is an acute, lower respiratory bacterial infection. Despite advances in medical care, CABP remains associated with considerable morbidity, mortality, and healthcare costs; early empiric treatment is recommended by the Infectious Diseases Society of America and by the American Thoracic Society. Omadacycline is an oral and intravenous (IV) once-daily aminomethylcycline antibiotic that is approved in the United States for the treatment of adult patients with CABP.

OBJECTIVE

To estimate the budget impact of introducing omadacycline as a treatment option among patients with suspected or documented CABP from a US hospital perspective.

METHODS

A budget impact model was developed in Microsoft Excel^® 2010. Population, clinical, and cost inputs were based on the available literature, clinical trial data, and real-world evidence databases. Emergency departments and observation units were assumed to be hospital-owned as part of the analyses. Sensitivity analyses assessed the impact of key parameters on the model results, and scenario analyses were explored to analyze the budget impact of reducing length of hospital stay and avoiding hospitalization.

RESULTS

The introduction of omadacycline as a treatment resulted in a total budget increase of $20,643 over 3 years. This increase was mainly attributed to treatment acquisition costs. In a scenario where the length of hospital stay was reduced by 1 day (under the assumption that an antibiotic with IV and oral formulations can facilitate earlier discharge from inpatient care), the 3-year total budget decreased to $2384; reducing the hospital stay by 2 days resulted in 3-year cost-savings of $15,875. Shifting inpatient care to the outpatient setting with omadacycline resulted in 3-year cumulative cost-savings of $112,843.

CONCLUSION

This is the first omadacycline budget impact model developed for adult patients with suspected or documented CABP. The model projected a modest budget increase with the introduction of omadacycline, mainly due to treatment acquisition costs.

Efficacy and safety of antimicrobial de-escalation as a clinical strategy

INTRODUCTION

De-escalation is a widely recommended strategy in regard to guidelines, with an associated adherence to guidelines being around 50%. This review discusses data supporting de-escalation and possible obstacles for its implementation. Areas covered: Although it does not have a consensual definition, de-escalation consists of reducing the spectrum of empirical antimicrobial treatment based on the microbiological findings. Many observational studies have suggested that this strategy is likely safe and efficient for treating various types of infection. However, randomized controlled trials published as of now have not shown any improvement on the outcomes. Regarding the adverse effects of de-escalation on ecological pressure and multidrug resistance emergence, the data are contradictory. The implementation of new techniques, such as rapid diagnosis, can help guide clinicians. Expert opinion: De-escalation should be included as part of a large antibiotic stewardship program to balance the risk and benefit of each administration, and each physician prescribing antibiotics should be challenged for the quality of her/his prescription on a daily basis. In the future, one of our duties will involve determining whether a delay of antimicrobial treatment - making it possible to improve diagnostic performance and obtain the first laboratory results - is either safe or unsafe for our patients.