Therapy For Community-acquired Pneumonia Research Articles

La terapia breve per la polmonite acquisita in comunità è superiore alla terapia tradizionale: i risultati del RCT SCOUT-CAP

Brief therapy for community-acquired pneumonia is superior to traditional therapy: findings from SCOUT-CAP RCT This US multicenter study of good methodological quality, with an innovative method of enrollment of 380 uncomplicated cases of community-acquired pneumonia (CAP) on the third day of antibiotic therapy, is the first one to demonstrate the superiority a short antibiotic therapy (5 days) in children aged 6-71 months compared to the traditional one. The RADAR score used by the authors to assess superiority considers not only the clinical response to therapy and resolution of symptoms but also the presence and severity of adverse effects of antibiotic therapy (box.1). Slightly less than 10% of children in each strategy have an inadequate clinical response. Short therapy has a 69% probability (95% CI, 63-75) of presenting a more desirable RADAR score than standard therapy. In addition, the authors performed antibiotic resistance (resistoma) gene analysis for a group of 171 children. The average number of antibiotic resistance genes per prokaryotic cell (RGPC) was significantly lower with short therapy and thus helpful in counteracting the problematic phenomenon of antibiotic resistance.

Analysis of antibacterials for systemic use recommended for the treatment of patients with community-acquired pneumonia in Ukraine according to the modern approach to preventing the development of antimicrobial resistance

BACKGROUND. According to a 2019 epidemiological study, antibiotic resistance (AR) caused about 1.27 million deaths worldwide, with lower respiratory tract infections (particularly pneumonia) dominating the global disease burden caused by resistant microorganisms.
 OBJECTIVE. To determine the compliance of antibiotics (J01), which are recommended by the guidelines of the National Academy of Medical Sciences of Ukraine for the empiric therapy of community-acquired pneumonia (CAP) in adults, with World Health Organization (WHO) recommendations based on the prevention of the development of AR.
 MATERIALS AND METHODS. Objects – antibiotics (J01) recommended by the guideline and their belonging to the access, watch and reserve groups according to the WHO AWaRe classification of antibiotics. Methods: system overview, analytical, comparison and generalization.
 RESULTS AND DISCUSSION. In the guidelines for empiric therapy of CAP in adults, antibiotics of 7 groups are recommended, from which 36 international non-proprietary names (INNs) were selected and analyzed. Of these, 7 INNs belong to the access group, of which only 4 antibiotics (amoxicillin, amoxicillin / clavulanic acid, gentamicin, doxycycline) are recommended by WHO experts for empiric treatment of CAP in adults; 26 INNs belong to the watch group, but only 3 antibiotics (cefotaxime, ceftriaxone, clarithromycin) according to the WHO database are recommended as empiric therapy for the severe CAP in adults. Ceftaroline, according to the WHO AWaRe antibiotic classification, belongs to the reserve group and should be used to fight multiresistant microorganisms. No antibiotic of the reserve group is recommended by WHO for empiric therapy of CAP.
 CONCLUSIONS. The results of the analysis can be used in updating the recommendations for rational empiric antibiotic therapy of CAP, taking into account the mechanisms of resistance to the development and spread of AR.

Retrospective Analysis of the Initial Empirical Antibiotic Therapy Effectiveness for Community-Acquired Pneumonia in Young Individuals in Moscow Multidisciplinary Hospital

Despite the fact that the incidence of community-acquired pneumonia (CAP) among young people is significantly lower than among older patients, the frequency of hospitalizations for severe CAP among people under 45 years of age remains high. The effectiveness and duration of treatment directly depend on the rationally selected initial empirical antibacterial therapy (ABT).The aim of the study is to analyze the factors influencing the effectiveness of initial empiric antibacterial therapy for CAP in young people in multidisciplinary medical institutions.Materials and methods. The study was designed as a retrospective observational study; it analyzes 105 medical records of young patients with CAP admitted to one of the multidisciplinary hospitals in Moscow from 2017 to 2019.Results. The empiric ceftriaxone + azithromycin ABT regimen (70% of all prescriptions) was ineffective in 13.7% of cases; monotherapy with ceftriaxone (13% of all prescriptions) was ineffective in 57% cases. Severe CAP, acute respiratory failure, systemic inflammatory response syndrome, and exudative pleurisy were diagnosed with significantly higher frequency in the group of patients with ineffective initial empirical ABT. There was no predominance of any comorbid pathology and Charlson Comorbidity Index in groups where the initial ABT was changed and in groups without a change in initial ABT. The microbiological spectrum of CAP pathogens did not significantly differ in young patients between groups with a changed initial empirical ABT and a group without changing initial ABT.Conclusion. The reasons for the ineffectiveness of the initial empirical ABT could be such factors as: underestimation of the risk of the presence of multidrug-resistant pathogens; underestimation of the risk of viral genesis of CAP; underestimation of the severity of CAP, as well as the severity of CAP complications.

Evaluation of Current Practice of Antibiotic Use and Clinical Outcomes of Community-Acquired Pneumonia Patients with Type 2 Diabetes Mellitus in Indonesia

Impaired immunity in diabetes mellitus (DM) causes reduced lung function, which increases the incidence of various types of infections, including community-acquired pneumonia (CAP). The main principle of CAP therapy is the administration of antibiotics. This study aims to assess the appropriate use of antibiotics according to existing clinical practice guidelines using the Gyssen algorithm, and to determine its effect on clinical outcomest in hospitalized patients. It is an observational study with a retrospective cohort design and total sampling technique. The research was conducted at Dr. Cipto Mangunkusumo Hospital Jakarta, with the research subjects being 98 hospitalized CAP patients with type 2 DM (T2DM) over the period January 2018 - December 2019. The collection of data on patient characteristics and clinical outcomes was made through patient medical records. 28.6% of the subjects were in the severe category of CAP. The results of the evaluation using the Gyssen algorithm showed that 59.2% of the subjects receive the appropriate antibiotics, while 40.8% receive non appropriate antibiotics. The clinical outcomes in the group receiving appropriate antibiotics (70.7%) was significantly higher than the non-appropriate group (42.5%). The results of the multivariate analysis show that the group receiving appropriate antibiotics experienced 2.7 times greater clinical outcomes (RR 2.683, 95% CI: 1.102-6.592), after controlling for the degree of CAP and the onset of antibiotic administration. The use of appropriate antibiotics in CAP patients with T2DM significantly enhanced clinical outcomes.

1803. Pediatric Antimicrobial Stewardship: Beyond the Core Elements

Abstract Background Facility treatment guidelines for antibiotic choice and duration are a priority in the CDC Core Elements of hospital antimicrobial stewardship (AMS). Urinary tract infection (UTI) and community acquired pneumonia (CAP) are common pediatric diagnoses with potential for AMS impact in both inpatient and outpatient settings. We describe a project at a free-standing children’s hospital that was implemented through a collaboration of multidisciplinary providers who participated in the national Value in Inpatient Pediatrics (VIP) program. One aim of this project is to evaluate baseline and improve antibiotic duration for CAP and UTI. Methods This is a retrospective/prospective chart review study that compares baseline and post-intervention duration of antibiotic prescribing for UTI and CAP cases from July 2019-December 2021 based on data collected through the VIP program. Figure 1 describes the timeline of events and results. Patients included were identified by diagnosis code for CAP and UTI. Each case was randomized for inclusion and manually reviewed to ensure it met the diagnosis clinical definition. Cases with underlying chronic medical conditions were excluded from this analysis. Duration of antibiotics prescribed was compared for each group using Wilcoxon rank-sum testing. Figure 1.Timeline of guideline implementation and evaluation Results Among the 351 patients included, 163 had a diagnosis of CAP (98 pre-, 65 post- implementation); 188 with UTI (121 pre-, 67 post- implementation). Post Implementation, there was a significant decrease in median duration of antibiotic prescribing from 10 to 7 days in both groups (p< 0.001). Figure 2.Median duration of antibiotics pre and post program implementation (p<0.001) Conclusion Institutional implementation of guidelines is an important step in local AMS. Guideline implementation alone is not enough to ensure practice change and going beyond the CDC core elements has become important. In our case, participation in a national project with local multidisciplinary involvement was successful in improving duration of therapy for CAP and UTI not previously achieved by the local guidelines. Changes were made to the electronic medical record in the ED to ensure sustainability of this change. Disclosures All Authors: No reported disclosures.

2172. Closing the CAP Gap: Improving the Management of Community Acquired Pneumonia (CAP)

Abstract Background In October 2019 updated community acquired pneumonia (CAP) guidelines were published, highlighting indications for empiric anti-MRSA and antipseudomonal antibiotics and use of MRSA nares screens. During a review of patients receiving vancomycin and piperacillin-tazobactam at our institution in 2020 we noted frequent use of anti-MRSA and antipseudomonal antibiotics and infrequent use of MRSA nares screens for CAP. In May 2020 we initiated a multifaceted intervention, including prospective audit and feedback, an updated pneumonia order set, and system-wide education. In this study we sought to describe gaps in the care of patients with CAP at our institution and to evaluate the impact of a multifaceted intervention on those gaps in care. Methods We performed a retrospective cohort study on a random sample of unique adult patients admitted with pneumonia from January 1, 2020 through June 30, 2021. Exclusion criteria included COVID infection within 4 weeks of admission, no antibiotics for pneumonia given during admission, immunocompromised condition, and diagnosis of hospital-acquired or ventilator-associated pneumonia. The primary objective was to describe the percentage of patients receiving appropriate anti-MRSA and antipseudomonal therapy and MRSA nares testing during the study period. The secondary objective was to compare appropriateness of these outcomes before and after the intervention. Study groups Results For the 126 patients reviewed, 68.3% received the appropriate empiric spectrum of activity for MRSA and Pseudomonas aeruginosa, improving from 60% to 80% before and after the intervention respectively. The percentage of patients screened for MRSA increased from 6 to 34%; however, the percentage of appropriate MRSA screens decreased from 71 to 54% because screens were often collected despite absence of MRSA risk factors. Results Conclusion The percentage of patients receiving appropriate anti-MRSA and antipseudomonal therapy for CAP improved after a multifaceted stewardship intervention. The percentage of patients for whom appropriate MRSA nares screens was performed worsened, mainly due to use of MRSA nares screens when not needed. Disclosures All Authors: No reported disclosures.

Derivation and validation of a risk assessment model for drug-resistant pathogens in hospitalized patients with community-acquired pneumonia.

To derive and validate a model for risk of resistance to first-line community-acquired pneumonia (CAP) therapy. We developed a logistic regression prediction model from a large multihospital discharge database and validated it versus the Drug Resistance in Pneumonia (DRIP) score in a holdout sample and another hospital system outside that database. Resistance to first-line CAP therapy (quinolone or third generation cephalosporin plus macrolide) was based on blood or respiratory cultures. This study was conducted using data from 177 Premier Healthcare database hospitals and 11 Cleveland Clinic hospitals. Adults hospitalized for CAP. Risk factors for resistant infection. Among 138,762 eligible patients in the Premier database, 12,181 (8.8%) had positive cultures and 5,200 (3.8%) had organisms resistant to CAP therapy. Infection with a resistant organism in the previous year was the strongest predictor of resistance; markers of acute illness (eg, receipt of mechanical ventilation or vasopressors) and chronic illness (eg, pressure ulcer, paralysis) were also associated with resistant infections. Our model outperformed the DRIP score with a C-statistic of 0.71 versus 0.63 for the DRIP score (P < .001) in the Premier holdout sample, and 0.65 versus 0.58 (P < .001) in Cleveland Clinic hospitals. Clinicians at Premier facilities used broad-spectrum antibiotics for 20%-30% of patients. In discriminating between patients with and without resistant infections, physician judgment slightly outperformed the DRIP instrument but not our model. Our model predicting infection with a resistant pathogen outperformed both the DRIP score and physician practice in an external validation set. Its integration into practice could reduce unnecessary use of broad-spectrum antibiotics.

Impact of a Medication Reconciliation Pharmacist Program on Appropriateness of Community-Acquired Pneumonia Treatment Durations at Hospital Discharge.

Antimicrobial stewardship programs have made large efforts to minimize the inappropriate use of antibiotics. Implementation of these programs can be challenging, since many institutions have limited resources. Utilizing resources that already exist may be beneficial, including medication reconciliation pharmacist (MRP) programs. This study aims to evaluate the impact of a MRP program on appropriateness of community-acquired pneumonia (CAP) treatment durations at hospital discharge. This study was a retrospective, observational, single-center study comparing the total days of antibiotic therapy for CAP in the preintervention period (9/2020-11/2020) versus the post-intervention period (9/2021-11/2021). Implementation of a new clinical intervention occurred between the 2 periods and included education to MRPs on appropriate CAP treatment durations and on documentation of recommendations. Data was collected utilizing a chart review of the electronic medical record of patients diagnosed with CAP using ICD-10 codes. The primary objective of this study was to compare the total days of antibiotic therapy in the pre-intervention period versus the postintervention period. One-hundred fifty-five patients were included in the primary analysis. When observing total days of antibiotic therapy, there was no change from the pre-intervention period at 8 days compared to the postintervention period (P = .109). When analyzing antibiotic days of therapy at discharge, there was a decrease from 4.55 days in the preintervention period compared to 3.8 days in the post-intervention period (P = .109). The incidence of those with appropriate treatment durations, defined as 5 to 7 days of antibiotic therapy, was higher in the post-intervention period (26.5% in the pre-intervention group vs 37.9% in the post-intervention group, P = .460). There was a non-statistically significant decrease in median days of antimicrobial therapy for CAP at hospital discharge after implementation of a new clinical intervention targeting antibiotic days of therapy. Though median total antibiotic days of therapy were similar between both time periods, patients had an overall increase in incidence of appropriate duration of therapy, defined as 5 to 7 days, after intervention. Further studies are necessary to show how MRPs have a positive impact on improving outpatient antibiotic prescribing at hospital discharge.

Comparison between Ceftriaxone and Sulbactam-Ampicillin as Initial Treatment of Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis.

Current guidelines recommend the use of ceftriaxone and sulbactam-ampicillin for the initial treatment of community-acquired pneumonia (CAP). However, there are no clear data on these guidelines. Therefore, this systematic review and meta-analysis aims to evaluate the effectiveness of ceftriaxone and sulbactam-ampicillin in the initial treatment of CAP. The Embase, Scopus, PubMed, Ichushi, and Cumulative Index to Nursing and Allied Health Literature databases were systematically searched from inception to July 2022. The studies included patients who received ceftriaxone or sulbactam-ampicillin as the initial antibiotic therapy for CAP. The mortality and clinical cure rates were evaluated. Of the 2152 citations identified for screening, four studies were included. Results of the pooled analysis indicated no significant differences in the mortality and clinical cure rates between patients treated with ceftriaxone and those treated with sulbactam-ampicillin (mortality, odds ratio [OR]: 1.85, 95% confidence interval [CI]: 0.57–5.96; clinical cure rate, OR: 1.08, 95% CI: 0.18–6.44). This study supports the guidelines for CAP treatment, though further studies are needed to obtain a deeper understanding.

Effect of Ginseng Extract Supplementation on Procalcitonin Level, Neutrophil, and Length of Stay In Patients With Community Acquired Pneumonia

Background: Pneumonia is an acute inflammation of the lung parenchyma caused by microorganisms (bacteria, viruses, fungi, parasites) and causes of high morbidity and mortality. Ginsenoside in ginseng have anti-inflammatory effects, potentially as adjunctive therapy in community-acquired pneumonia (CAP) patients. As much as 43% of patients at dr. Moewardi Hospital in 2016 were hospitalized have passed away. The aim of this study was to determine the effect of ginseng extract on levels of procalcitonin, neutrophils, and length of stay of community-acquired pneumonia patients. Method: The quasi-experimental clinical trial with the pretest posttest design approach was conducted on 26 community acquired pneumonia patients who were hospitalized in Dr. Moewardi Hospital Surakarta from October until November 2019 using consecutive sampling. The control group (n=13) received standard antibiotics while the treatment group (n=13) received additional ginseng extract 2x100 mg/day for 14 days. Procalcitonin was measured at admission, third and fourteenth day; neutrophils are measured at admission and third day; length of stay is based on the number of days of treatment in hospital. Results: There was a significant difference (P=0.001) towards decreased of serum procalcitonin levels between treatment group (-0.63±0.06) compared to control group (-0.38±0.07). There was a significant difference (P&lt;0.001) towards decreased of neutrophil levels between treatment group (-6.68±1.34) compared to control group (-3.51±0.88). There was a significant difference (P=0.001) towards decreased of length of stay between treatment group (5.69±0.95) compared to control group (7.15±0.99). Conclusion: Ginseng extract containing ginsenoside as its main ingredient, can act as an anti-inflammatory which can be used as adjunctive therapy in community-acquired pneumonia patients who are hospitalized to accelerate clinical improvement and shorten the length of stay.

Effect of zinc versus vitamin A supplementation on pediatric patients with community-acquired pneumonia.

Background: Community-acquired pneumonia (CAP) is one of the most common infectious diseases affecting the respiratory tract and is responsible for a high mortality rate in children less than 5 years of age. The mortality rate due to CAP is much higher in low/middle-income countries than in high-income countries due to malnutrition and different micronutrient deficiencies that weaken the immune system. Aim: The aim of this study was to compare the effects of zinc and vitamin A, as two elements of micronutrient agents, on the recovery rate of children suffering from CAP aged from 6 months to 5 years. The length of hospital stays was also investigated. Method: A comparative, randomized, open-label, controlled, interventional study was carried out among children less than 5 years of age in the pediatric intensive care unit (PICU) diagnosed with CAP who were randomly divided into three groups. In addition to the standard therapy, group 1 was given zinc, group 2 was given vitamin A, and group 3 was the control group, given the standard therapy only. We compared the three groups in terms of recovery rate and hospital stay. Result: The duration of hospitalization following zinc and vitamin A supplementation was reduced by an average of 3.21 days (95% CI: 5.01–1.41, p = 0.01) and 2.43 days (95% CI: 4.29–0.57, p = 0.01), respectively, compared to the control group. In addition, the two groups of vitamin A and zinc supplementation were associated with a shorter duration of pneumonic effusion (p < 0.001) in comparison to the control group. Additionally, there was no significant difference between the effects of zinc and vitamin A when compared to each other in terms of duration of hospital stay and pneumatic effusion. Conclusion: The administration of zinc or vitamin A supplementation proved to be useful as an add-on therapy in community-acquired pneumonia, where it reduced the length of hospital stay and the duration of pneumonic effusion in pneumonic children less than 5 years of age.

Drivers of Prolonged Outpatient Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia.

Variability exists in treatment duration for community-acquired pneumonia (CAP) and urinary tract infection (UTI) in children and may be associated with non-clinical factors. A retrospective study was conducted of patients treated for outpatient CAP and UTI in a children's hospital network from 2016 to 2019. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (≥10 days). Hospitalization within 30 days was determined. Overall, 2124 prescriptions for CAP and 1116 prescriptions for UTI were included. Prescriptions were ≥10 days in 59.9% and 47.6% for CAP and UTI, respectively. Long durations were more common in the emergency department (ED) than in clinics for UTI's (P = .0082), and more common in convenient care for CAP (P = .045). In UTI's, Asian and Hispanic patients received shorter durations than white patients. Younger children had greater odds of long duration for both diagnoses. Medicaid insurance was associated with long therapy for UTI (OR: 1.660, P = .0042) and CAP (OR: 1.426, P = .0169). Residents and fellows were less likely to give long durations than attending physicians (P < .0001). APNs were more likely to administer long therapies in CAP (P = .0062). Subsequent hospitalizations were uncommon for UTI (n = 10) and CAP (n = 20). Younger age, Medicaid insurance, ED, and convenient care visits were associated with a long duration of therapy. Residents and fellows were less likely to give long durations.

Assessment of Antibiotic Pharmacokinetics, Molecular Biomarkers and Clinical Status in Critically Ill Adults Diagnosed with Community-Acquired Pneumonia and Receiving Intravenous Piperacillin/Tazobactam and Hydrocortisone over the First Five Days of Intensive Care: An Observational Study (STROBE Compliant).

Severe community-acquired pneumonia (CAP) is a condition that frequently requires intensive care and, eventually, can cause to death. Piperacillin/tazobactam antibiotic therapy is employed as an empiric intravenous regimen, in many cases supplemented with intravenous bolus hydrocortisone treatment. The individual and condition-dependent pharmacokinetic properties of these drugs may lead to therapeutic failure. The impact of systemic inflammation, as well as of hydrocortisone on the altered pharmacokinetics of piperacillin is largely unknown. The protocol of a clinical study aimed at the characterization of the pharmacokinetics of piperacillin and tazobactam and its association with the concentrations of inflammatory markers and adrenal steroids during CAP therapy will be investigated in up to 40 critically ill patients. The serum concentrations of piperacillin and tazobactam, cortisol, cortisone, corticosterone and 11-deoxycortisol and interleukin-6 levels, as well as routine clinical chemistry and hematology parameters will be monitored from the beginning of treatment for up to five days. Nonparametric population pharmacokinetic modeling and Monte-Carlo simulations will be performed to make estimates of the pharmacokinetics of piperacillin and tazobactam and the probability of pharmacokinetic-pharmacodynamic target attainment. The observed individual characteristics and changes will be correlated with clinical and laboratory findings. The protocol of the observational study will be designed following the STROBE guideline.

Defining effective durations of antibiotic therapy for community-acquired pneumonia and urinary tract infections in hospitalized children.

Community-acquired pneumonia (CAP) and urinary tract infections (UTI) are two common childhood infections often leading to hospital admission. National guidelines for CAP and UTI in children recommend durations of antibiotic therapy of 10 days and 7-14 days, respectively. Due to concerns of rising antimicrobial resistance and an increased awareness of harms associated with prolonged courses of antibiotics, there is a renewed emphasis on reevaluating commonly prescribed durations of antibiotic therapy across bacterial infections. We describe recent clinical trials and observational studies evaluating durations of therapy for CAP and UTI in adults and children and translate the findings to our suggested approach for selecting durations of antibiotic therapy in hospitalized children. There is a growing body of evidence, primarily in adults, that shorter durations of therapy than are commonly prescribed are just as effective as longer durations for CAP and UTIs. Combining clinical trial data from adults with available data in children, we believe it is reasonable to consider 5 days of therapy for CAP, 3-5 days of therapy for cystitis, and 7 days of therapy for pyelonephritis for most hospitalized children with uncomplicated infections.

Evaluation of the Efficacy and Safety of Initial Empirical Antibiotic Therapy for Community-Acquired Pneumonia in Middle-Aged People

β-lactam antibiotics, including cephalosporins, are the drugs of choice for empirical antibiotic therapy (ABT) in patients with community-acquired pneumonia. Unreasonable and irrational use of antibiotics leads to an increased risk of adverse reactions, contributes to the growth of antibiotic resistance.The aim of the study was to analyse data on the efficacy and safety of initial empirical ABT using cephalosporins for community-acquired pneumonia in middle-aged patients of multidisciplinary hospitals in Moscow.Materials and methods: the authors analysed 177 archived medical records of the patients admitted to three multidisciplinary hospitals (I.V. Davydovsky City Clinical Hospital, City Clinical Hospital 52 and City Clinical Hospital 4) in Moscow from 2017 to 2019 and prescribed mono- and/or combination therapy including a cephalosporin antibiotic as a starting therapy for community-acquired pneumonia. The initial ABT was considered effective if a patient’s body temperature normalised within 48–72 h following initiation of treatment and safe if no adverse reactions developed during the period of inpatient treatment.Results: the combination of ceftriaxone and azithromycin was the most frequently prescribed ABT regimen; its effectiveness was 71.9%. Ceftriaxone monotherapy was the second in frequency of prescription; its effectiveness amounted to 77.2%. The third regimen included cefotaxime and azithromycin and was effective in 70% of cases. The patients who needed a change in initial ABT had a significantly higher incidence of developing severe community-acquired pneumonia and complications. The study results indicate that the structure of comorbidity did not affect the effectiveness of initial empirical ABT. Streptococcus pneumoniae was found to be the most common causative agent of community-acquired pneumonia in the studied population (44.8% of cases). Only 13% of the patients faced adverse reactions associated with the use of antibiotics as part of the initial empirical ABT; the most common were leukopenia and diarrhoea.Сonclusions: the results of the study indicate the feasibility of mono- and/or combination ABT including a cephalosporin antibiotic as a starting empirical therapy for community-acquired pneumonia due to its effectiveness and favourable safety profile.

Evaluation of the Effect of Comorbidity on the Efficacy and Safety of β-Lactam Antibiotics in Patients with Community-Acquired Pneumonia

Lower respiratory tract infections, which include community-acquired pneumonia (CAP), are the most common cause of death among all infectious diseases. The presence of a comorbid pathology in a patient with CAP suggests a possibility of mutual influence and changes in the course of both the underlying disease and comorbidities, as well as changes in the effectiveness and safety of ongoing drug therapy. The aim of the study was to analyse literature data on the structure of comorbidity in CAP patients and its impact on the efficacy and safety of therapy with β-lactam antibiotics. It has been established that CAP most often occurs in patients with chronic obstructive pulmonary disease, cardiovascular diseases (ischemic heart disease, arterial hypertension, and chronic heart failure), cerebrovascular disease, chronic kidney disease, diabetes mellitus, bronchial asthma, leukemia, anemia, dementia, neurological disorders, and cancer. The most common causative agent of CAP, regardless of the patient’s age and comorbidity, is pneumococcus (Streptococcus pneumoniae), followed by intracellular pathogens (mycoplasmas, chlamydia) and Haemophilus influenzae, as well as respiratory viruses. With this in mind, the initial empiric therapy for CAP mainly includes β-lactam antibiotics, which are effective against pneumococcus. If patients with CAP have concomitant chronic diseases and conditions, the spectrum of pneumonia pathogens may differ from that in the general population and include rare pathogens and multidrug-resistant strains. The effectiveness of antibiotic therapy in such patients is reduced, which leads to a worsening of the course of both CAP and concomitant diseases. This patient population may require longer treatment with antibiotics, including β-lactams, or the use of antibiotics at doses that provide a higher minimum inhibitory concentration, which is associated with a high risk of adverse reactions and a decrease in the safety of antibiotic therapy.

Impact of Guideline Adherence on Outcomes in Patients Hospitalized with Community-Acquired Pneumonia (CAP) in Hungary: A Retrospective Observational Study.

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. This retrospective observational study evaluated the antibiotic prescription patterns and associations between guideline adherence and outcomes in patients hospitalized with CAP in Hungary. Main outcome measures were adherence to national and international CAP guidelines (agent choice, dose) when using empirical antibiotics, antibiotic exposure, and clinical outcomes. Demographic and clinical characteristics of patients with CAP in the 30-day mortality and 30-day survival groups were compared. Fisher’s exact test and t-test were applied to compare categorical and continuous variables, respectively. Adherence to the national CAP guideline for initial empirical therapies was 30.61% (45/147) for agent choice and 88.89% (40/45) for dose. Average duration of antibiotic therapy for CAP was 7.13 ± 4.37 (mean ± SD) days, while average antibiotic consumption was 11.41 ± 8.59 DDD/patient (range 1–44.5). Adherence to national guideline led to a slightly lower 30-day mortality rate than guideline non-adherence (15.56% vs. 16.67%, p > 0.05). In patients aged ≥ 85 years, 30-day mortality was 3 times higher than in those aged 65–84 years (30.43% vs. 11.11%). A significant difference was found between 30-day non-survivors and 30-day survivors regarding the average CRP values on admission (177.28 ± 118.94 vs. 112.88 ± 93.47 mg/L, respectively, p = 0.006) and CCI score (5.71 ± 1.85 and 4.67 ± 1.83, p = 0.012). We found poor adherence to the national and international CAP guidelines in terms of agent choice. In addition, high CRP values on admission were markedly associated with higher mortality in CAP.

Cost-effectiveness analysis of empiric antibiotics in hospitalized community-acquired Pneumonia

Community-Acquired Pneumonia (CAP) remains an important infectious disease due to its impact on patient outcomes.  This study aimed to investigate the clinical outcome and especially costs of hospitalization for community-acquired pneumonia (CAP) concerning empirical antibiotics. This research was conducted to estimate the cost-effectiveness of levofloxacin, ceftriaxone, and a combination of ceftriaxone and azithromycin aiming to improve the clinical outcome of CAP. A retrospective observational study was conducted in secondary care, University Hospital in Surakarta, Central Java, Indonesia. The study enrolled all CAP patients hospitalized in the period January until December 2018, with ages≥ 18 years old, and at least used antibiotic for three days. We compared cost-effectiveness, as measured by total cost and proportion of patients successfully treated, of 3 empirical antibiotics for inpatient CAP, involving ceftriaxone, levofloxacin, or combination ceftriaxone + azithromycin. Our analyses were conducted based on a healthcare perspective. In all groups were analyzed based on severity classification (Pneumonia Severity Index score). The use of levofloxacin instead of ceftriaxone improved clinical response, but it is more expensive. Levofloxacin was the most cost-effective based on ACER value. Treatment using a combination of ceftriaxone + azithromycin was more expensive without added benefit. Based on this study, the use of levofloxacin as the first-line therapy for CAP could be maintained because it was more cost-effective than other alternatives. Since the limitations, a study on a broader population is needed to confirm these findings.

Beta-Lactam Plus Macrolide for Patients Hospitalized With Community-Acquired Pneumonia: Difference Between Autumn and Spring.

The 2017 Korean guideline on community-acquired pneumonia (CAP) recommended beta-lactam plus macrolide combination therapy for patients hospitalized with severe pneumonia, and beta-lactam monotherapy for mild-to-moderate pneumonia. However, antibiotic treatment regimen for mild-to-moderate CAP has never been evaluated for Korean patients. In this retrospective cohort study, study patients were selected from three evaluation periods (October 1 to December 31, 2014; April 1 to June 30, 2016; October 1 to December 31, 2017) of the National Quality Assessment Program for CAP management and the National Health Insurance data on the selected patients was extracted from 1 year before the first patient enrollment and 1 year after the last patient enrollment at each evaluation period for the analysis of risk adjustment and outcomes. The survival rates between beta-lactam plus macrolide (BM) groups and beta-lactam monotherapy (B) were compared using a Kaplan-Meier survival analysis after propensity score matching by age, gender, confusion, urea, respiratory rate, blood pressure at age of 65 years or older (CURB-65), and Charlson comorbidity index for risk adjustment. The differences between autumn and spring season were also evaluated. A total of 30,053 patients were enrolled. Mean age and the male-to-female ratio were 64.7 ± 18.4 and 14,197:15,856, respectively. After matching, 2,397 patients in each group were analyzed. The 30-day survival rates did not differ between the BM and B groups (97.3% vs. 96.5%, P = 0.081). In patients with CURB-65 ≥ 2, the 30-day survival rate was higher in the BM than in the B group (93.7% vs. 91.0%, P = 0.044). Among patients with CURB-65 ≥ 2, the 30-day survival rate was higher in the BM than in the B group (93.3% vs. 88.5%, P = 0.009) during autumn season, which was not observed during spring (94.2% vs. 94.1%, P = 0.986). Beta-lactam plus macrolide combination therapy shows potential as an empirical therapy for CAP with CURB-65 ≥ 2, especially in autumn.

146. Predictors of Long Duration Antibiotic Therapy for Urinary Tract Infections and Community-Acquired Pneumonia in Pediatric Ambulatory Care Settings

BackgroundSignificant variation exists in the duration of antibiotic therapy for children in ambulatory care settings. Understanding drivers of variation for common conditions such as community-acquired pneumonia (CAP) and urinary tract infection (UTI) is important to informing antimicrobial stewardship interventions. MethodsA retrospective observational study was conducted of patients with CAP and UTI seen in outpatient clinics or discharged from the emergency room (ER) of a tertiary care children’s hospital network from 2016 – 2019. Diagnoses CAP and UTI were identified via ICD-10 coding. Only oral medications ordered for ≥ 3 and < 28 days were included. Multivariable logistic regression was performed to identify predictors of long antibiotic duration (defined as ≥ 10 days). Potential non-clinical drivers of longer duration included race, ethnicity, sex, primary language, and insurance status. ResultsA total of 2,104 prescriptions for CAP from 442 prescribers and 1,070 prescriptions for UTI from 314 prescribers were included. Antibiotic durations were ≥ 10 days in 59.9% and 47.6% of prescriptions for CAP and UTI, respectively. Long duration of therapy was more common in children discharged from the ER when compared to clinics for both CAP (OR 1.795, 95% CI: 1.107 - 2.929), and UTI (OR 5.149, 95% CI: 1.933 - 16.373). The proportion of patients with long duration of therapy increased with younger age for both diagnoses and decreased overall in the final year of the study. Race, gender, ethnicity, and primary language were not associated with prolonged duration of therapy. However, patients with Medicaid insurance were more likely to receive long duration of therapy for CAP (OR 1.337, 95% CI: 1.062 - 1.682) and UTI (1.654, 95%, CI: 1.181 - 2.325). ConclusionIn pediatric patients in ambulatory care settings, younger age, care in the ER, and being insured through Medicaid were independently associated with prolonged duration of therapy for both UTI and CAP.Disclosures All Authors: No reported disclosures