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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Antibiotic Therapy for Nearly 1 in 4 Adults with Pneumonia Does Not Work

Approximately 1 in 4 (22.1 percent) adults prescribed an antibiotic in an outpatient setting for community-acquired pneumonia does not respond to treatment, according to a new study presented at the 2017 American Thoracic Society International Conference | Infection Control Today

B0007348 Streptococcus pneumoniae

Image source: Debbie Marshall – Wellcome Images // CC BY 4.0

Image shows colour enhanced scanning electron micrograph of a colony of Streptococcus pneumoniae, the species of bacterium that is the commonest cause of pneumonia.

McKinnell and colleagues conducted this study because current community-acquired pneumonia guidelines from the American Thoracic Society and the Infectious Disease Society of America, published in 2007, provide some direction, but large-scale, real-world data are needed to better understand and optimize antibiotic choices and to better define clinical risk factors that may be associated with treatment failure.

The researchers examined databases containing records for 251,947 adult patients who were treated between 2011 and 2015 with a single class of antibiotics (beta-lactam, macrolide, tetracycline, or fluoroquinolone) following a visit to their physician for treatment for community-acquired pneumonia.  The scientists defined treatment failure as either the need to refill antibiotic prescriptions, antibiotic switch, ER visit or hospitalization within 30 days of receipt of the initial antibiotic prescription.  The total antibiotic failure rate was 22.1 percent, while patients with certain characteristics — such as older age, or having certain other diseases in addition to pneumonia — had higher rates of drug failure.  After adjusting for patient characteristics, the failure rates by class of antibiotic were:  beta-lactams (25.7 percent), macrolides (22.9 percent), tetracyclines (22.5 percent), and fluoroquinolones (20.8 percent).

Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU

Swan, J.T. et al. (2016) Critical Care Medicine. 44(10) pp. 1822–1832

rubber-duck-1390639_960_720Objective: To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.

Design: This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.

Setting: Twenty-four–bed surgical ICU at a quaternary academic medical center.

Patients: Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.

Interventions: Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).

Measurements and Main Results: The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309–0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5–16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).

Conclusions: Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

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).

CC flow chart

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.

Read the full article here

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.

Read the full article here

Healthcare-Associated Pneumonia in the ICU: Guideline-Concordant Antibiotics and Outcome

Attridge, R.T. et al. Journal of Critical Care | Published online: August 11, 2016

L0075034 An intensive care unit in a hospital.

Image source: Robert Priseman – Wellcome Library // CC BY-NC-ND 4.0

Purpose: Recent data have not demonstrated improved outcomes when guideline-concordant (GC) antibiotics are given to patients with healthcare-associated pneumonia (HCAP). This study was designed to evaluate the relationship between health outcomes and GC therapy in patients admitted to an ICU with HCAP.

Materials and Methods: We performed a population-based cohort study of patients admitted to >150 hospitals in the U.S. Veterans Health Administration system to compare baseline characteristics, bacterial pathogens, and health outcomes in ICU patients with HCAP receiving either GC-HCAP therapy, GC community-acquired pneumonia (GC-CAP) therapy, or non-GC therapy. The primary outcome was 30-day patient mortality. Risk factors for the primary outcome were assessed in a multivariable logistic regression model.

Results: A total of 3593 patients met inclusion criteria and received GC-HCAP therapy (26%), GC-CAP therapy (23%), or non-GC therapy (51%). GC-HCAP patients had higher 30-day patient mortality compared to GC-CAP patients (34% vs. 22%, P < .0001). After controlling for confounders, risk factors for 30-day patient mortality were vasopressor use (OR, 95% CI; 1.67, 1.30–2.13), recent hospital admission (1.53, 1.15–2.02), and receipt of GC-HCAP therapy (1.51, 1.20–1.90).

Conclusions: Our data do not demonstrate improved outcomes among ICU patients with HCAP who received GC-HCAP therapy.

Read the abstract here

Prevention of ventilator-associated pneumonia: Use of the care bundle approach

Alcan, A.O. et al. American Journal of Infection Control. Published online: 4 July 2016

Highlights

  • Ventilator-associated pneumonia is one of the most common nosocomial infections for critical care patients.
  • This study investigates the effect of using the care bundle on ventilator-associated pneumonia rates.
  • Implementation of the care bundle through nurse education is effective at reducing the rate of ventilator-associated pneumonia.

Image shows colour enhanced scanning electron micrograph of a colony of Streptococcus pneumoniae

Background: The ventilator-associated pneumonia (VAP) care bundle consists of evidence-based practices to improve the outcomes of patients receiving mechanical ventilatory therapy. This study aimed to investigate the implementation of the care bundle on VAP rates in this quasiexperimental study.

Methods: The protocol of this study consisted of 3 phases. In the initial phase, observations were made to determine the VAP care bundle adherence of intensive care unit (ICU) nurses. In the second phase, education was provided to ICU nurses on the subject of the VAP care bundle. For the third phase, the effect of VAP care bundle adherence on the VAP rates after education was investigated.

Results: The nurses’ VAP care bundle adherence improved after education from 10.8% (n = 152) to 89.8% (n = 1,324) and showed statistically significant improvement (P = .0001 and P < .05). In this study, the VAP rates were determined as 15.91/103 ventilator-days before education and 8.50/103 ventilator days after education. It was found that the VAP rates after the education period were significantly lower than the VAP rates before education.

Conclusion: VAP care bundle implementation with education prepared according to evidence-based guidelines decreased VAP rates. Thus, implementation of the VAP care bundle on mechanically ventilated patients care is recommended.

Read the abstract here