Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States

PURPOSE

To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States.

METHODS

We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, β-lactam + macrolide, β-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.).

RESULTS

Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location.

CONCLUSIONS

Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.

Validation of the Hospital Frailty Risk Score in older adults hospitalized with community-acquired pneumonia

AIM

Frailty results from age-associated declines in physiological reserve and function and is prevalent in older people. Our aim is to examine the association of the Hospital Frailty Risk Score (HFRS) with adverse events in older patients hospitalized with community-acquired pneumonia (CAP) and hypothesise that frailty is a comparable predictor of outcomes in CAP versus traditional severity indices such as CURB-65.

METHODS

Retrospective review of electronic medical records in patients ≥65 years with CAP admitted to a tertiary hospital from 1 January to 30 April 2021. Patients were identified using ICD codes for CAP and categorized as high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using the HFRS.

RESULTS

Of 429 patients with CAP, 53.8% male, mean age of 82.9 years, older patients (85 vs. 79.7 years, P < 0.001) were at higher risk of frailty. Using the HFRS, 47.6% were deemed at high risk, 35.9% at intermediate risk, and 16.6% at low risk of frailty. Multivariate logistic regression shows that HFRS was more strongly associated (≥7 days, OR 1.042, CI 1.017-1.069) than CURB-65 (OR 0.995, CI 0.810-1.222) with long hospital length of stay (LOS), while CURB-65 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure, age => 65 years old) was more strongly associated with mortality at 30, 90 and 365 days, compared with the HFRS. Comparing the values for the area under the receiver operator characteristic curve, the HFRS was found to be a better predictor of long LOS, while CURB-65 remains a better predictor of mortality.

CONCLUSIONS

Patients with high risk of frailty have higher healthcare utilization and HFRS is a better predictor of long LOS than CURB-65 but CURB-65 was a better predictor of mortality. Geriatr Gerontol Int 2024; 24: 135-141.

The levels of vitamins and cytokines in serum of elderly patients with community-acquired pneumonia: A case-control study

Background and Aims

The community acquired pneumonia (CAP) is a common disease with high incidence rate and mortality among the elderly. This study aims to explore the association between vitamins, cytokines, and CAP infected by different pathogens in Handan First Hospital.

Methods

The subjects of this study were elderly patients with community-acquired pneumonia in Handan First Hospital and healthy elderly people in the community from February 2018 to December 2019. The study include 234 CAP patients and 180 healthy elderly people. The differences between the healthy and CAP groups were analyzed by blood routine test, urine routine test, Liquid chromatography tandem mass spectrometry (LC-MS/MS) detection of vitamin level, and Enzyme linked immunosorbent assay (ELISA) detection of cytokine level. Sputum culture was used to detect pathogens.

Results

According to our results, there was no significant difference in the contents of vitamin A, vitamin D, vitamin E, and vitamin C in serum between the healthy and CAP elderly. However, compared with the control group, the levels of serum cytokines of IL-2, IL-17, and TGF-β in the CAP patients were significantly increased. In addition, IL-17 was positively correlated with white blood cells, neutrophils, platelet/lymphocyte ratio and neutrophil/lymphocyte ratio of CAP patients, and negatively correlated with lymphocytes. The four pathogens with the highest positive rates were Streptococcus pneumoniae, Klebsiella pneumoniae, Mycoplasma pneumoniae and H. influenza. In patients with S. pneumoniae infection, the IL-2, IL-17, and TGF-β levels were significantly higher than the levels in the control group; IL-17 was also significantly increased in the serum of patients infected with M. pneumoniae, K. pneumoniae, and H. influenza.

Conclusions

There is no direct association between vitamins in serum and community acquired pneumonia (CAP). However, the cytokines are closely related to the clinical indicators and pathogens of CAP patients, which can provide references for the diagnosis, prognosis and treatment of CAP patients.

Community-Acquired Pneumonia and Risk of Cardiovascular Events in People Living With HIV

Background Hospitalization with community-acquired pneumonia (CAP) is associated with an increased risk of cardiovascular disease (CVD) events in patients uninfected with HIV. We evaluated whether people living with HIV (PLWH) have a higher risk of CVD or mortality than individuals uninfected with HIV following hospitalization with CAP. Methods and Results We analyzed data from the Veterans Aging Cohort Study on US veterans admitted with their first episode of CAP from April 2003 through December 2014. We used Cox regression analyses to determine whether HIV status was associated with incident CVD events and mortality from date of admission through 30 days after discharge (30-day mortality), adjusting for known CVD risk factors. We included 4384 patients (67% [n=2951] PLWH). PLWH admitted with CAP were younger, had less severe CAP, and had fewer CVD risk factors than patients with CAP who were uninfected with HIV. In multivariable-adjusted analyses, CVD risk was similar in PLWH compared with HIV-uninfected (hazard ratio [HR], 0.89; 95% CI, 0.70-1.12), but HIV infection was associated with higher mortality risk (HR, 1.49; 95% CI, 1.16-1.90). In models stratified by HIV status, CAP severity was significantly associated with incident CVD and 30-day mortality in PLWH and patients uninfected with HIV. Conclusions In this study, the risk of CVD events during or after hospitalization for CAP was similar in PLWH and patients uninfected with HIV, after adjusting for known CVD risk factors and CAP severity. HIV infection, however, was associated with increased 30-day mortality after CAP hospitalization in multivariable-adjusted models. PLWH should be included in future studies evaluating mechanisms and prevention of CVD events after CAP.

Cavitary lesions emerged rapidly in Pseudomonas aeruginosa pneumonia

Pseudomonas aeruginosa should be highly considered as a causative pathogen, when patients deteriorate rapidly despite community-acquired pathogen, and the radiological findings display a rapid emergence of cavitary lung lesions especially among patients at high risk of P aeruginosa pneumonia.

An atypical case of atypical pneumonia

Atypical pneumonia has been thought to account for 7%-20% of community-acquired pneumonia (CAP). The treatment for the pathogens that cause atypical pneumonia is different from that of other bacterial pneumonia. Therefore, identification of the causative pathogen in a primary care situation is crucial for adequate treatment of CAP. Mycoplasma infection is prevalent in the general population, but Mycoplasma pneumoniae with extrapulmonary symptoms is relatively rare. Herein, we report a case of CAP because of M. pneumoniae that presented with a wide variety of extrapulmonary diseases. Delayed administration of appropriate antibiotics may contribute to development of extrapulmonary manifestations.

Influenza C virus–associated community-acquired pneumonia in children

To evaluate the impact of influenza C (ICV) infection in children with community-acquired pneumonia (CAP), all of the children consecutively seen during 4 influenza seasons with respiratory symptoms and radiographically confirmed CAP were prospectively evaluated. ICV was identified in the respiratory secretions of five of 391 patients (1·3%). In children with ICV-associated CAP, clinical data were similar to those observed in children with IAV-associated CAP and worse than those observed in children with IBV-associated. The phylogenetic tree showed that the sequenced strains clustered in two of the six ICV lineages. These findings highlight that ICV can be a cause of CAP of children and that this can be severe enough to require hospitalization.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.