Community-acquired Pneumonia Guidelines Research Articles

1494. Validation of Methicillin-Resistant Staphylococcus aureus (MRSA) Risk Factors in Predicting MRSA Community-Acquired Pneumonia at an Academic Medical Center

BackgroundThe 2019 Infectious Diseases Society of America community-acquired pneumonia (CAP) guidelines recommend anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy in patients with CAP based on previously identified risk factors for MRSA with an emphasis on local epidemiology and institutional validation of risk. Thus, we sought to assess the ability of guideline-recognized risk factors to predict MRSA CAP at our institution.MethodsThis was a single-center, retrospective cohort study from January 2016 to March 2020. Patients were included if they were >18 years old, diagnosed with CAP, and had a MRSA nasal screen and a respiratory culture obtained on admission. Patients were excluded if CAP diagnosis was not met, respiratory cultures were not obtained within 48 hours of antibiotic initiation, or they had cystic fibrosis. Sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios (LR) were calculated using Vassar Stats 2019. Pre/post-test odds and pre/post-test probabilities were calculated using Microsoft Excel 2019.ResultsOf 705 screened patients, 221 were included. MRSA prevalence in CAP patients at our institution was 3.6%. History of MRSA isolated from a respiratory specimen had high specificity (98%), high positive LR of 20 (95% CI 5.3 – 74.8), and high post-test probability of 42.8%. Receipt of IV antibiotics during hospitalization within the past 90 days had a positive LR of 1.9 (95% CI 0.74 – 4.84). A positive MRSA nasal screen on admission had a positive LR of 6.9 (95% CI 4.0 – 12.1), negative LR 0.28 (95% CI 0.08 – 0.93), positive post-test probability of 20.7%, and negative post-test probability of 1.04%.ConclusionOur study utilized institutional data to validate guideline-recognized risk factors for MRSA CAP specifically at our institution. Risk factors including history of MRSA isolated from a respiratory specimen, and positive post-admission MRSA nasal screen were validated as significant risk factors; receipt of IV antibiotics during hospitalization within the past 90 days was not shown to be a risk factor for MRSA CAP based on our institutional data. Validated risk factors may help providers discern which patients with CAP at our institution would benefit most from empiric MRSA treatment.Disclosures Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member) Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member)

94. Appropriate Urine Legionella Antigen Testing: A Step Towards Diagnostic Stewardship

BackgroundPneumonia is a leading cause of sepsis and hospitalization. Infectious Diseases Society of America and American Thoracic Society (IDSA/ATS) published 2019 practice guidelines for community-acquired pneumonia (CAP), recommending urinary antigen testing (UAT) for Legionella pneumophila (LP) only in patients with severe pneumonia or having epidemiological risk factors. In the last 20 years, there has been no Legionella outbreak in Nebraska. Currently, the urine antigen test is considered based on the discretion of the ordering provider. However, this usually results in over-utilization of the test and associated financial burden.MethodsRetrospective chart review of patients admitted to Bergan Mercy Medical Center, Creighton University, Omaha with the admission diagnosis of community-acquired pneumonia in the year 2019, by using electronic medical records. The charts were reviewed for baseline characteristics, admission diagnoses, and clinical outcomes. The project was submitted to and reviewed by the institutional review board.ResultsFrom January to December 2019, 4738 patients were admitted to the general medical floors with the diagnosis of community-acquired pneumonia. Among those patients, 826 patients (17.43%) had urine Legionella antigen tests done, only 11 (0.23%) were tested positive. Moreover, 140 patients (2.95%) had urine Legionella antigen tests in the absence of a documented diagnosis of community-acquired pneumonia. Patients admitted to intensive care units were not included in the study as guidelines do not restrict from ordering urine Legionella tests in patients with severe sepsis secondary to community-acquired pneumonia.ConclusionA diagnostic stewardship approach should be considered for urine Legionella antigen testing. Moreover, such a retrospective review provides an opportunity for quality improvement initiatives at the academic medical facilities with lower Legionella outbreaks.Disclosures All Authors: No reported disclosures

Use of Oral Tetracyclines in the Treatment of Adult Patients with Community-Acquired Bacterial Pneumonia: A Literature Review on the Often-Overlooked Antibiotic Class.

Oral tetracyclines have been used in clinical practice for over 60 years. Overall, one of the most common indications for use of oral tetracyclines is for treatment of adult outpatients with lower respiratory tract infections, including community-acquired pneumonia (CAP). Despite the longstanding use of oral tetracyclines, practice patterns indicate that they are often considered after other guideline-concordant oral CAP treatment options (namely macrolides, fluoroquinolones, and β-lactams). However, there are growing resistance or safety concerns with the available oral agents listed for outpatients with CAP in the updated American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) CAP guidelines, especially among patients with comorbidities or notable risk factors for resistant pathogens. Given the need for alternative oral agents to macrolides, fluoroquinolones, and beta-lactams for adult outpatients with CAP, this review summarizes the literature on the use of oral tetracyclines (i.e., doxycycline, minocycline, and omadacycline) for this indication. As part of this review, we described their mechanism of action, common mechanisms of resistance, susceptibility profiles against common CAP pathogens, pharmacokinetics, pharmacodynamics, clinical data, and safety. The intent of the review is to highlight the important considerations when deciding between doxycycline, minocycline, and omadacycline for an adult outpatient with CAP in situations in which use of an oral tetracycline is warranted.

Risk factors for COVID-19 patients with cardiac injury: pulmonary ventilation dysfunction and oxygen inhalation insufficiency are not the direct causes.

Background: Cardiac injury in patients with coronavirus disease 2019 (COVID-19) has been reported in recent studies. However, reports on the risk factors for cardiac injury and their prognostic value are limited.Results: In total, 15.9% of all cases were defined as cardiac injury in our study. Patients with severe COVID-19 were significantly associated with older age and higher respiratory rates, Sequential Organ Failure Assessment (SOFA) scores, cardiac injury biomarkers and PaO2/FiO2 ratios. Male patients with chest distress and dyspnea were more likely to have severe disease. Patients with cardiac injury were significantly more likely to have a severe condition and have an outcome of death. However, no significant difference was found in respiratory rates, dyspnea or PaO2/FiO2 ratio between patients with or without cardiac injury. In the logistic regression model, pre-existing hypertension and higher SOFA score were independent risk factors for patients with COVID-19 developing cardiac injury.Conclusions: Our study revealed that cardiac injury was an important predictor for patients having a severe or fatal outcome. Patients with pre-existing hypertension and higher SOFA scores upon admission were more likely to develop cardiac injury. Nevertheless, pulmonary ventilation dysfunction and oxygen inhalation insufficiency were not the main causes of cardiac injury in patients with COVID-19.Methods: A total of 113 confirmed cases were included in our study. Severe patients were defined according to American Thoracic Society guidelines for community-acquired pneumonia. Cardiac injury was defined as a serum cTnI above the 99th-percentile of the upper reference limit. Patient characteristics, clinical laboratory data and treatment details were collected and analyzed. The risk factors for patients with and without cardiac injury were analyzed.

A pharmacist-led prospective antibiotic stewardship intervention improves compliance to community-acquired pneumonia guidelines in 39 public and private hospitals across South Africa

Introduction: Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals.Methods: This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared.Results: In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40).Conclusion: Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

Influenza With an Infiltrate: Investigating the New Community-Acquired Pneumonia Guidelines

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (&lt;0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P &lt; .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None

Community-acquired Pneumonia Guideline Recommendations-Impact of a Consensus-based Process versus Systematic Reviews.

The American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) Community-acquired Pneumonia (CAP) guidelines were developed using systematic reviews to inform every recommendation, as suggested by the Institute of Medicine Standards for Trustworthy Guidelines. Recent studies suggest that an expert consensus-based approach, called the Convergence of Opinion on Recommendations and Evidence (CORE) process, can produce recommendations that are concordant with recommendations informed by systematic reviews. The goal of the study was to evaluate the efficacy of the CORE process had it been used to develop the ATS/IDSA CAP guidelines. Experts in CAP who were not on the guideline panel and had no knowledge of the guideline's systematic reviews or recommendations were recruited to participate in the CORE process, addressing the same questions asked by the guideline panel. Recommendations derived from the CORE process were compared to the guideline recommendations. Concordance of the course of action, strength of recommendation, and quality of evidence were determined. Using a threshold of 70% of experts selecting the same course of action to make a recommendation, the CORE process yielded a recommendation for 20 of 31 (65%) questions. Among the 20 CORE-derived recommendations, 19 (95%) were concordant with the guideline recommendations (kappa agreement 0.88, 95% CI .64-1.00). There was less agreement among the strength of recommendations (58%) and quality of evidence (42%). If the CORE process had been used, 11 systematic reviews would have been necessary rather than 31, with minimal impact on the recommended courses of action.

Hospital Admission Patterns in Adult Patients with Community-Acquired Pneumonia Who Received Ceftriaxone and a Macrolide by Disease Severity across United States Hospitals

(1) Objective: There are limited data regarding community-acquired pneumonia (CAP) admissions patterns in US hospitals. Current expert CAP guidelines advocate for outpatient treatment or an abbreviated hospital stay for CAP patients in pneumonia severity index (PSI) risk classes I–III (low risk); however, the extent of compliance with this recommendation is unclear. This study sought to estimate the proportion of admissions among CAP patients who received ceftriaxone and macrolide therapy, one of the most commonly prescribed guideline-concordant CAP regimens, by PSI risk class and Charlson comorbidity index (CCI) score. (2) Methods: A retrospective cross-sectional study of patients in the Vizient® (MedAssets, Irving, Texas) database between 2012 and 2015 was performed. Patients were included if they were aged ≥ 18 years, had a primary diagnosis for CAP, and received ceftriaxone and a macrolide on hospital day 1 or 2. Baseline demographics and admitting diagnoses were used to calculate the PSI score. Patients in the final study population were grouped into categories by their PSI risk class and CCI score. Hospital length of stay, 30-day mortality rates, and 30-day CAP-related readmissions were calculated across resulting PSI–CCI strata. (3) Results: Overall, 32,917 patients met the study criteria. Approximately 70% patients were in PSI risk classes I–III and length of stay ranged between 4.9 and 6.2 days, based on CCI score. The 30-day mortality rate was <0.5% and <1.4% in patients with PSI risk classes I and II, respectively. (4) Conclusions: Over two-thirds of hospitalized patients with CAP who received ceftriaxone and a macrolide were in PSI risk classes I–III. Although the findings should be interpreted with caution, they suggest that there is a potential opportunity to improve the efficiency of healthcare delivery for CAP patients by shifting inpatient care to the outpatient setting in appropriate patients.

Abstract P134: ASSOCIATION OF HYPERTENSION WITH MORTALITY RISK IN PATIENTS WITH COVID 19 PNEUMONIA IN A HOSPITAL IN MEXICO CITY

Introduction: The world is currently suffering from the outbreak of a pandemic caused by the SARS-CoV-2 coronavirus, which causes the disease called COVID-19. This disease was reported for the first time in Wuhan, Hubei Province, China, on December 31, 2019. Hypertension, diabetes and cardiovascular disease are common among patients with COVID-19. In Mexico, information on the association between COVID-19 and hypertension is scarce. Methods: This investigation was a descriptive, observational and cross-sectional study that included patients over 18 years of age who had been hospitalized with laboratory-confirmed COVID-19 between April 6, 2020, and May 6, 2020, and exhibited chest X-ray abnormalities (ground-glass opacity, interstitial alterations and/or multilobar infiltrate). Severity of pneumonia (severe vs. nonsevere) at the time of admission was defined using the community-acquired pneumonia guidelines of the American Thoracic Society (ATS). Results: Information was collected from 89 patients with COVID-19 pneumonia, 34 of whom (38.2%) were hypertensive. When studying risk factors in hypertensive patients and their degree of statistical association with risk of mortality, only the severity of pneumonia stood out. The association between severe pneumonia and mortality was statistically significant (OR: 10.9, CI 1.19-99.6, p value = 0.034). Conclusions: Severity of pneumonia upon admission can be regarded as a marker of adverse clinical outcome in hypertensive COVID-19 patients. Among hypertensive COVID-19 patients, in-hospital mortality was high (68%); such mortality was higher in our study than has been reported in other series worldwide.

An audit of community-acquired pneumonia antimicrobial compliance using an intervention bundle in an Irish hospital

ObjectivesHospitalisations with community-acquired pneumonia (CAP) are often not managed in accordance with antimicrobial guidelines. This study aimed to assess whether guideline-driven antimicrobial prescribing for CAP can be improved using an intervention bundle. Secondary measures assessed were hospital length of stay (LOS), mortality, duration of intravenous antibiotics and total antibiotics, improved uptake of appropriate investigations, and documentation of CURB-65 score. MethodsA retrospective cohort of hospitalised CAP patients from August–September 2018 was compared with a post-intervention prospective cohort from May–June 2019. The intervention bundle included a mobile audience response system, promotion of the antimicrobial app, development of a physical card with local guidelines, and incorporating CURB-65 into the unscheduled admission proforma. Local guidelines are in keeping with British Thoracic Society CAP guidelines. ResultsA total of 69 adult patients (aged >18 years) were included in the study (37 retrospective, 32 prospective). Overall compliance with local CAP guidelines improved from 21.6% to 62.5% (P < 0.001). No difference in initial intravenous antibiotic duration was seen (median 4 days vs. 4 days; P = 0.70) and total antibiotic duration was significantly shorter in the post-intervention group (median 9 days vs. 7 days; P = 0.01). No difference in LOS or mortality was seen between the groups. Documentation of CURB-65 improved from 5.4% to 46.9% (P < 0.001). Uptake of streptococcal urinary antigen testing improved from 18.9% to 40.6% (P = 0.024). ConclusionsA simple, low-cost quality improvement bundle can significantly increase appropriate antimicrobial prescribing and shorten the total antibiotic duration.

Antibiotic use in patients with COVID-19: a 'snapshot' Infectious Diseases International Research Initiative (ID-IRI) survey.

BackgroundAntibiotics may be indicated in patients with COVID-19 due to suspected or confirmed bacterial superinfection.ObjectivesTo investigate antibiotic prescribing practices in patients with COVID-19.MethodsWe performed an international web-based survey and investigated the pattern of antibiotic use as reported by physicians involved in treatment of COVID-19. SPSS Statistics version 25 was used for data analysis.ResultsThe survey was completed by 166 participants from 23 countries and 82 different hospitals. Local guidelines for antibiotic use in COVID-19 patients were reported by 61.8% (n = 102) of participants and for 82.9% (n = 136) they did not differ from local community-acquired pneumonia guidelines. Clinical presentation was recognized as the most important reason for the start of antibiotics (mean score = 4.07 and SD = 1.095 on grading scale from 1 to 5). When antibiotics were started, most respondents rated as the highest the need for coverage of atypical pathogens (mean score = 2.8 and SD = 0.99), followed by Staphylococcus aureus (mean score = 2.67 and SD = 1.05 on bi-modal scale, with values 1 and 2 for disagreement and values 3 and 4 for agreement). In the patients on the ward, 29.1% of respondents chose not to prescribe any antibiotic. Combination of β-lactams and macrolides or fluoroquinolones was reported by 52.4% (n = 87) of respondents. In patients in the ICU, piperacillin/tazobactam was the most commonly prescribed antibiotic. The mean reported duration of antibiotic treatment was 7.12 (SD = 2.44) days.ConclusionsThe study revealed widespread broad-spectrum antibiotic use in patients with COVID-19. Implementation of antimicrobial stewardship principles is warranted to mitigate the negative consequences of antibiotic therapy.

Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016.

Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP). Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children's Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day. Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] -0.2, 39.9%) and decreased by 37.6% per year (95% CI -56.1, -11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials. Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.

Risk Factor Evaluation for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Community-Acquired Pneumonia.

The 2019 community-acquired pneumonia guidelines recommend using recent respiratory cultures and locally validated epidemiology plus risk factor assessment to determine empirical coverage of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. To develop a methodology for evaluating local epidemiology and validating local risk factors for P aeruginosa and MRSA. This multicenter, retrospective cohort evaluated adult patients admitted for pneumonia. Risk factors for MRSA and P aeruginosa were evaluated using multivariable logistic regression and reported as adjusted odds ratios (aORs). There were 10 723 cases evaluated. Lung abscess/empyema had the highest odds associated with MRSA (aOR = 4.24; P < 0.0001), followed by influenza (aOR = 2.34; P = 0.01), end-stage renal disease (ESRD; aOR = 2.09; P = 0.006), illicit substance use (aOR = 1.7; P = 0.007), and chronic obstructive pulmonary disease (COPD; aOR = 1.26; P = 0.04). For P aeruginosa, the highest odds were in bronchiectasis (aOR = 6.13; P < 0.0001), lung abscess/empyema (aOR = 3.36; P = 0.005), and COPD (aOR = 1.84; P < 0.0001). Isolated COPD without other risk factors did not pose an increased risk of either organism. Influenza, ESRD, lung abscess/empyema, and illicit substance use were local risk factors for MRSA. Bronchiectasis and lung abscess/empyema were risk factors for Pseudomonas. COPD was associated with MRSA and Pseudomonas. However, isolated COPD had similar rates of MRSA and Pseudomonas pneumonia compared with the total population. This study established a feasible methodology for evaluating local risk factors.

Management of patients with SARS-CoV-2 infections and of patients with chronic lung diseases during the COVID-19 pandemic (as of 9 May 2020) : Statement of the Austrian Society of Pneumology (ASP).

SummaryThe coronavirus disease 2019 (COVID-19) pandemic is currently a challenge worldwide. In Austria, a crisis within the healthcare system has so far been prevented. The treatment of patients with community-acquired pneumonia (CAP), including SARS-CoV‑2 infections, should continue to be based on evidence-based CAP guidelines during the pandemic; however, COVID-19 specific adjustments are useful. The treatment of patients with chronic lung diseases has to be adapted during the pandemic but must still be guaranteed.

Statement of the Austrian Society of Pneumology (ASP)

Die COVID-19-Pandemie stellt derzeit weltweit eine Herausforderung dar. In Österreich konnte eine Krise innerhalb des medizinischen Versorgungssystems bisher verhindert werden. Die Behandlung von Patienten mit ambulant erworbener Pneumonie („community acquired pneumonia“, CAP), inklusive durch SARS-CoV-2-Infektionen, sollte sich auch während der Pandemie weiterhin an evidenzbasierten CAP-Leitlinien orientieren. COVID-19-spezifische Anpassungen sind jedoch sinnvoll. Die Behandlung von Patienten mit chronischen Lungenerkrankungen muss während der Pandemie angepasst werden, ist aber weiterhin zu gewährleisten.

Strategies for prediction of drug-resistant pathogens and empiric antibiotic selection in community-acquired pneumonia

Although most patients with community-acquired pneumonia (CAP) are appropriately treated with narrow-spectrum antibiotics, predicting which patients require coverage of drug-resistant pathogens (DRP) remains a challenge. The 2019 American Thoracic Society/Infectious Diseases Society of America CAP guidelines endorse using locally validated prediction models for DRP. Here we review risk factors for DRP and provide a summary of available risk prediction models. Both inadequate initial empiric spectrum as well as unnecessary broad-spectrum antibiotic use are associated with poor outcomes in CAP. Multiple prediction models for DRP-based patient-level risk factors have been published, with some variation in included predictor variables and test performance characteristics. Seven models have been robustly externally validated, and implementation data have been published for two of these models. All models demonstrated better performance than the healthcare-associated pneumonia criteria, with most favoring sensitivity over specificity. We also report validation of the novel, risk factor-based treatment algorithm proposed in the American Thoracic Society/Infectious Diseases Society of America guidelines which strongly favors specificity over sensitivity, especially in nonsevere pneumonia. Using patient-level risk factors to guide the decision whether to prescribe broad-spectrum antibiotics is a rational approach to treatment. Several viable candidate prediction models are available. Hospitals should evaluate the local performance of existing scores before implementing in routine clinical practice.

COVID-19: don't neglect antimicrobial stewardship principles!

COVID-19: don't neglect antimicrobial stewardship principles!

Bacterial etiology of community-acquired pneumonia in immunocompetent hospitalized patients and appropriateness of empirical treatment recommendations: an international point-prevalence study.

An accurate knowledge of the epidemiology of community-acquired pneumonia (CAP) is key for selecting appropriate antimicrobial treatments. Very few etiological studies assessed the appropriateness of empiric guideline recommendations at a multinational level. This study aims at the following: (i) describing the bacterial etiologic distribution of CAP and (ii) assessing the appropriateness of the empirical treatment recommendations by clinical practice guidelines (CPGs) for CAP in light of the bacterial pathogens diagnosed as causative agents of CAP. Secondary analysis of the GLIMP, a point-prevalence international study which enrolled adults hospitalized with CAP in 2015. The analysis was limited to immunocompetent patients tested for bacterial CAP agents within 24 h of admission. The CAP CPGs evaluated included the following: the 2007 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA), the European Respiratory Society (ERS), and selected country-specific CPGs. Among 2564 patients enrolled, 35.3% had an identifiable pathogen. Streptococcus pneumoniae (8.2%) was the most frequently identified pathogen, followed by Pseudomonas aeruginosa (4.1%) and Klebsiella pneumoniae (3.4%). CPGs appropriately recommend covering more than 90% of all the potential pathogens causing CAP, with the exception of patients enrolled from Germany, Pakistan, and Croatia. The 2019 ATS/IDSA CPGs appropriately recommend covering 93.6% of the cases compared with 90.3% of the ERS CPGs (p < 0.01). S. pneumoniae remains the most common pathogen in patients hospitalized with CAP. Multinational CPG recommendations for patients with CAP seem to appropriately cover the most common pathogens and should be strongly encouraged for the management of CAP patients.Electronic supplementary materialThe online version of this article (10.1007/s10096-020-03870-3) contains supplementary material, which is available to authorized users.

Neumonía adquirida en la comunidad. Normativa de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Actualización 2020

The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.

Sticking by an Imperfect Standard: Chest Radiography for Pediatric Community-Acquired Pneumonia.

* Abbreviations: CAP — : community-acquired pneumonia CXR — : chest radiography ED — : emergency department PCV13 — : 13-valent pneumococcal conjugate vaccine PHIS — : Pediatric Health Information System PIDS/IDSA — : Pediatric Infectious Diseases Society and Infectious Diseases Society of America For decades, chest radiography (CXR) was considered to be the reference standard for diagnosis of community-acquired pneumonia (CAP). Studies of CAP diagnostics in children have used CXR as both a reference standard and an index test, with disagreement over how and when it should be used.1 Although frequently obtained, CXR has low sensitivity and only fair interrater reliability in diagnosing CAP.2 Radiography cannot differentiate bacterial from viral CAP and does not have substantial impact on outcomes.3 Furthermore, access to CXR is limited in many settings. Given these limitations, the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric CAP guideline recommends against routine CXR to confirm suspected CAP in children managed in the outpatient setting, a strong recommendation citing high-quality evidence.4 Despite this, among children 1 to 6 years of age managed as outpatients in the United States from 2008 to 2015, 83% of children with CAP received CXR in the emergency department (ED) compared with 22% in the primary care setting, with no change after guideline publication.5 This suggests that there is still room to improve, especially in the ED. In this issue of Pediatrics , Geanacopoulos et al6 used the Pediatric Health Information System (PHIS), an administrative database, to evaluate CXR use in 30 pediatric EDs from 2008 to 2018 … Address correspondence to Todd A. Florin, MD, MSCE, Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62, Chicago, IL 60611. E-mail: taflorin{at}luriechildrens.org