Impact of antibiotic therapy in severe community-acquired pneumonia:

Antibiotic therapy (AT) is the cornerstone of the management of severe community-acquired pneumonia (CAP). However, the best treatment strategy is far from being established | Journal of Critical Care

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Highlights:

  • In SCAP patients, the use of combination of antibiotics that includes a macrolide is associated a better hospital and long term (6 months) survival.
  • Courses of antibiotic therapy longer than 7 days are not associated with survival benefit but lead to longer ICU and hospital LOS.
  • Serum lactate showed to be a good prognostic marker of hospital mortality in SCAP patients.

Full reference: Pereira, J.M. et al. (2017) Impact of antibiotic therapy in severe community-acquired pneumonia: Data from the Infauci study. Journal of Critical Care. Published online: 4 September 2017

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Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department

New risk factors and occurrence in patients coming directly from the community | Journal of Hospital Infection

Aim: To investigate the prevalence of patients harboring CRE on hospital admission, risk factors associated and the acquisition rate within the emergency department (ED).

Methods: We conducted a cross-sectional with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain-reaction (RT-PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE.

Findings: Forty-six patients were colonized, all positive RT-PCR were KPC. The acquisition rate was 18%. Patients CRE colonized presented a higher mortality rate. Previous exposure to healthcare in the last year, liver disease and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community.

Conclusion: Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Full reference: Salomão, M.C. et al. (2017) Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department: new risk factors and occurrence in patients coming directly from the community. Journal of Hospital Infection. Published online: 18 August 2017

Risk Factors for Community-Associated Clostridium difficile Infection in Children

Adams, D.J. et al. The Journal of Pediatrics | Published online: 7 April 2017

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Objective: To characterize the medication and other exposures associated with pediatric community-associated Clostridium difficile infections (CA-CDIs).

Conclusions: CA-CDI is associated with medications regularly prescribed in pediatric practice, along with exposure to outpatient healthcare clinics and family members with CDI. Our findings provide additional support for the judicious use of these medications and for efforts to limit spread of CDI in ambulatory healthcare settings and households.

Read the full abstract here

Severe community-acquired pneumonia: timely management measures in the first 24 hours

Phua, J. et al. Critical Care. Published online: 28 August 2016

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.

These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

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While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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Compliance with the current recommendations for prescribing antibiotics for paediatric community-acquired pneumonia is improving

Launay, E. at al. BMC Pediatrics | Published online: 12 August 2016

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Image shows electron micrograph of klebsiella pneumoniae bacteria 

Background: Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP).

Methods: We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors.

Results: A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4–5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p < 0.001).

Conclusions: We observed a significant increase in the compliance with recommendations, with a reduction in the prescription of broad-spectrum antibiotics, efforts to improve antibiotic prescriptions must continue.

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