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De Alba I, Amin A. Hospital Readmissions in Pneumonia Patients: Quality of Care and Cost Containment. Curr Emerg Hosp Med Rep 2016; 4:172-6. [DOI: 10.1007/s40138-016-0111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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DiDiodato G, McArthur L, Beyene J, Smieja M, Thabane L. Evaluating the impact of an antimicrobial stewardship program on the length of stay of immune-competent adult patients admitted to a hospital ward with a diagnosis of community-acquired pneumonia: A quasi-experimental study. Am J Infect Control 2016; 44:e73-9. [PMID: 26899527 DOI: 10.1016/j.ajic.2015.12.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 12/09/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of this study was to demonstrate an antimicrobial stewardship intervention can reduce length of stay for patients admitted to hospital with community-acquired pneumonia (CAP). METHODS Starting April 1, 2013, consecutive adult patients with CAP admitted to an acute care community hospital in Barrie, Ontario, Canada, were eligible for enrollment until March 31, 2015. The antimicrobial stewardship intervention was a prospective audit and feedback recommendation implemented in a stepped-wedge design across 4 wards. The primary outcome was time to hospital discharge, and secondary outcomes included time to antibiotic discontinuation and a composite outcome of 30-day readmission or all-cause mortality. The intervention effect was estimated by survival (time to discharge and antibiotic discontinuation) and logistic (30-day readmission or all-cause mortality) regression analyses. RESULTS Complete data were available for 763 patients. The primary outcome was observed in 196 (82%) control patients and 402 (77%) intervention patients. Length of stay was reduced by 11% (95% confidence interval [CI], -9% to 35%). Time to antibiotic discontinuation was shortened by 29% (95% CI, 10%-52%). Odds ratio for 30-day readmission or all-cause mortality was 0.79 (95% CI, 0.49-1.29). CONCLUSIONS A prospective audit and feedback intervention did not significantly reduce length of hospital stay in CAP patients despite reducing overall antibiotic utilization.
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Falcó V, Burgos J, Papiol E, Ferrer R, Almirante B. Investigational drugs in phase I and phase II clincial trials for the treatment of hospital-acquired pneumonia. Expert Opin Investig Drugs 2016; 25:653-65. [PMID: 26998623 DOI: 10.1517/13543784.2016.1168803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Hospital acquired pneumonia (HAP) is one of the main infections acquired by patients during a stay in hospital. The main issue when dealing with patients with HAP and ventilator associated pneumonia (VAP) is the increasing role of multi-drug resistant organisms (MDROs). AREAS COVERED In this review the authors summarize the actual situation of MDROs as a cause of HAP and VAP. They also review the current treatment options stated in the most important international guidelines. Finally, they focus on the investigational drugs that have reached the phase III stage of development and the novel compounds that are being studied in phase I and II clinical trials. EXPERT OPINION Thanks to their excellent activity against MDROs, drugs in development for the treatment of HAP and VAP can significantly improve the therapeutic options available. In selected patients, the possibility to administer directed therapy with monoclonal antibodies to specific pathogens is an exciting strategy in the fight against widespread resistance.
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Affiliation(s)
- Vicenç Falcó
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Joaquin Burgos
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Elisabeth Papiol
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Ricard Ferrer
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Benito Almirante
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
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DiDiodato G, McArthur L, Beyene J, Smieja M, Thabane L. Can an antimicrobial stewardship program reduce length of stay of immune-competent adult patients admitted to hospital with diagnosis of community-acquired pneumonia? Study protocol for pragmatic controlled non-randomized clinical study. Trials 2015; 16:355. [PMID: 26272324 PMCID: PMC4535257 DOI: 10.1186/s13063-015-0871-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 07/16/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pneumonia is responsible for a large proportion of hospital admissions and antibiotic utilization. Physician adherence to evidence-based pneumonia management guidelines is poor. Antimicrobial stewardship programs (ASPs) are an effective intervention to mitigate against unwarranted variation from these guidelines. Despite this benefit, ASPs have not been shown to reduce the length of stay of hospitalized patients with pneumonia. In immune-competent adult patients admitted to a hospital ward with a diagnosis of community-acquired pneumonia, does a multi-faceted ASP utilizing prospective chart audit and feedback reduce the length of stay, compared with usual care, without increasing the risk of death or readmission 30 days after discharge from hospital? METHODS/DESIGN Starting on 1 April 2013, all consecutive immune-competent adult patients (>18 years old) admitted to a hospital ward with a positive febrile respiratory illness screening questionnaire and a diagnosis of pneumonia by the attending physician will be eligible for inclusion in this non-randomized study. All eligible patients who fulfill the ASP review criteria will undergo a prospective chart audit, followed by an ASP recommendation provided to the attending physician. The attending physician is responsible for implementing or rejecting the ASP recommendation. This is a modified stepped-wedge design with a baseline data collection period of 3 months, followed by non-random sequential introduction of the ASP intervention on each of four hospital wards in a single community-based, academic-affiliated 339-bed acute-care hospital in Barrie, ON, Canada. The primary outcome measure is hospital length of stay; secondary outcome measures include days and duration of antibiotic therapy, and inadvertent adverse outcomes of 30 day post-discharge mortality and hospital readmission rates. Differences in outcome measures will be assessed using extended Cox regression analysis. Time to ASP intervention is included as a time-dependent covariate in the final model, to account for time-dependent bias. DISCUSSION By designing a pragmatic clinical trial with unique design and analytic features, we not only expect to demonstrate the effectiveness of a real-world ASP, but also provide a model for program evaluation that can be used more broadly to improve patient safety and quality of care. TRIAL REGISTRATION ClinicalTrials.gov NCT02264756 .
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Affiliation(s)
- Giulio DiDiodato
- Department of Critical Care Medicine, Royal Victoria Regional Health Centre, Barrie, Ontario, L4M 6M2, Canada.
| | - Leslie McArthur
- Pharmacy, Royal Victoria Regional Health Centre, Barrie, Ontario, L4M 6M2, Canada.
| | - Joseph Beyene
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Marek Smieja
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
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Gattarello S, Ramírez S, Almarales JR, Borgatta B, Lagunes L, Encina B, Rello J. Causes of non-adherence to therapeutic guidelines in severe community-acquired pneumonia. Rev Bras Ter Intensiva 2015; 27:44-50. [PMID: 25909312 PMCID: PMC4396896 DOI: 10.5935/0103-507x.20150008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/24/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To assess the adherence to Infectious Disease Society of America/American Thoracic Society guidelines and the causes of lack of adherence during empirical antibiotic prescription in severe pneumonia in Latin America. METHODS A clinical questionnaire was submitted to 36 physicians from Latin America; they were asked to indicate the empirical treatment in two fictitious cases of severe respiratory infection: community-acquired pneumonia and nosocomial pneumonia. RESULTS In the case of community acquired pneumonia, 11 prescriptions of 36 (30.6%) were compliant with international guidelines. The causes for non-compliant treatment were monotherapy (16.0%), the unnecessary prescription of broad-spectrum antibiotics (40.0%) and the use of non-recommended antibiotics (44.0%). In the case of nosocomial pneumonia, the rate of adherence to the Infectious Disease Society of America/American Thoracic Society guidelines was 2.8% (1 patient of 36). The reasons for lack of compliance were monotherapy (14.3%) and a lack of dual antibiotic coverage against Pseudomonas aeruginosa (85.7%). If monotherapy with an antipseudomonal antibiotic was considered adequate, the antibiotic treatment would be adequate in 100% of the total prescriptions. CONCLUSION The compliance rate with the Infectious Disease Society of America/American Thoracic Society guidelines in the community-acquired pneumonia scenario was 30.6%; the most frequent cause of lack of compliance was the indication of monotherapy. In the case of nosocomial pneumonia, the compliance rate with the guidelines was 2.8%, and the most important cause of non-adherence was lack of combined antipseudomonal therapy. If the use of monotherapy with an antipseudomonal antibiotic was considered the correct option, the treatment would be adequate in 100% of the prescriptions.
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Affiliation(s)
- Simone Gattarello
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Sergio Ramírez
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - José Rafael Almarales
- Servicio de Medicina Intensiva, Clínica Comfamiliar, Universidad Tecnológica de Pereira, Risaralda, Colombia
| | - Bárbara Borgatta
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Leonel Lagunes
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Belén Encina
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Jordi Rello
- Servicio de Medicina Intensiva, Institut de Recerca Vall d'Hebron (VHIR); Hospital Universitario Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kadota JI. [Diagnosis, treatment and prevention of infectious diseases. Editorial: elderly society and clinical practice of pneumonia]. Nihon Naika Gakkai Zasshi 2013; 102:2799-2800. [PMID: 24450114 DOI: 10.2169/naika.102.2799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Lee JH, Kim SW, Kim JH, Ryu YJ, Chang JH. High-dose levofloxacin in community-acquired pneumonia: a randomized, open-label study. Clin Drug Investig 2012; 32:569-76. [PMID: 22765645 DOI: 10.1007/BF03261911] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The conventional treatment for community-acquired pneumonia (CAP) involves combination therapy consisting of a β-lactam penicillin or a cephalosporin with a macrolide. Alternatively, high-dose levofloxacin treatment has been used as single-agent therapy for treating CAP, covering atypical pathogens. OBJECTIVE This study compared the clinical efficacy and safety of high-dose levofloxacin with combined ceftriaxone and azithromycin for the treatment of CAP. PATIENTS AND METHODS This phase IV, prospective, randomized, open-label trial enrolled patients admitted to a tertiary referral hospital for CAP treatment from 2010 to 2011. Hospital admission was decided based on clinical judgement and the pneumonia severity index. Forty subjects were enrolled and assigned to two treatment arms using a random numbers table. The 20 subjects in the experimental group were given levofloxacin 750 mg intravenously once daily, followed by the same dose of oral levofloxacin at discharge when clinically improved and the 20 subjects in the control group were given ceftriaxone 2.0 g intravenously once daily plus oral azithromycin 500 mg for 3 consecutive days, followed by oral cefpodoxime 200 mg per day at discharge after clinical improvement. The primary outcome was the clinical success rate. Secondary outcomes were the microbiological success rate and adverse events during the study. RESULTS Of the 40 subjects enrolled, 36 completed the study: 17 in the experimental group and 19 in the control group. The groups did not differ in terms of demographic factors or clinical findings at baseline. The clinical success rate (cured + improved) was 94% in the experimental (levofloxacin) group and 84% in the control group (p > 0.05). The microbiological success rate and overall adverse events were also similar in both groups. CONCLUSION Single-agent, high-dose levofloxacin treatment exhibited excellent clinical and microbiological efficacy with a safety profile comparable to that of ceftriaxone plus azithromycin therapy. Large-scale clinical trials are required to verify these results. CLINICAL TRIAL REGISTRATION WHO International Clinical Trials Registry: KCT0000374; Daiichi-Sankyo Korea study code: T11-13-V1.
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Lee JH, Kim SW, Kim JH, Ryu YJ, Chang JH. High-dose levofloxacin in community-acquired pneumonia: a randomized, open-label study. Clin Drug Investig 2012. [PMID: 22765645 DOI: 10.2165/11634640-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The conventional treatment for community-acquired pneumonia (CAP) involves combination therapy consisting of a β-lactam penicillin or a cephalosporin with a macrolide. Alternatively, high-dose levofloxacin treatment has been used as single-agent therapy for treating CAP, covering atypical pathogens. OBJECTIVE This study compared the clinical efficacy and safety of high-dose levofloxacin with combined ceftriaxone and azithromycin for the treatment of CAP. PATIENTS AND METHODS This phase IV, prospective, randomized, open-label trial enrolled patients admitted to a tertiary referral hospital for CAP treatment from 2010 to 2011. Hospital admission was decided based on clinical judgement and the pneumonia severity index. Forty subjects were enrolled and assigned to two treatment arms using a random numbers table. The 20 subjects in the experimental group were given levofloxacin 750 mg intravenously once daily, followed by the same dose of oral levofloxacin at discharge when clinically improved and the 20 subjects in the control group were given ceftriaxone 2.0 g intravenously once daily plus oral azithromycin 500 mg for 3 consecutive days, followed by oral cefpodoxime 200 mg per day at discharge after clinical improvement. The primary outcome was the clinical success rate. Secondary outcomes were the microbiological success rate and adverse events during the study. RESULTS Of the 40 subjects enrolled, 36 completed the study: 17 in the experimental group and 19 in the control group. The groups did not differ in terms of demographic factors or clinical findings at baseline. The clinical success rate (cured + improved) was 94% in the experimental (levofloxacin) group and 84% in the control group (p > 0.05). The microbiological success rate and overall adverse events were also similar in both groups. CONCLUSION Single-agent, high-dose levofloxacin treatment exhibited excellent clinical and microbiological efficacy with a safety profile comparable to that of ceftriaxone plus azithromycin therapy. Large-scale clinical trials are required to verify these results. CLINICAL TRIAL REGISTRATION WHO International Clinical Trials Registry: KCT0000374; Daiichi-Sankyo Korea study code: T11-13-V1.
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Affiliation(s)
- Jin Hwa Lee
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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