Empirical Treatment Of Community-acquired Pneumonia Research Articles

Compliance with guideline recommendations in the management of patients with hospitalized community-acquired pneumonia.

Compliance with guidelines in the empirical treatment for community-acquired pneumonia (CAP) is very important to increase treatment success and reduce mortality. This study aimed to determine compliance with guideline recommendations for CAP and define the role of the clinical pharmacist (CP). Patients diagnosed with CAP were evaluated retrospectively between January 2018 and January 2020 and prospectively between February 2020 and February 2021. Compliance with guidelines was evaluated according to the local, national (Turkish Thoracic Society), and international (American Thoracic Society and Infectious Disease Society of America, European Society of Clinical Microbiology and Infectious Diseases) guidelines. A total of 751 patients (423 in the retrospective and 328 in the prospective period) were included. It was determined that the 30-day mortality and length of stay were higher in patients who were not treated according to the guidelines. The compliance for empirical treatments was 16.3%-59.1% and 7.8%-30.1% in retrospective and prospective periods, respectively. During the prospective period, a total of 603 recommendations were made by CP, and 578 (95.9%) were accepted and implemented. In the prospective period, treatment duration was shortened, inappropriate fluoroquinolone use was decreased, the switch to oral treatment was increased, and the number of potential drug-drug interactions was decreased (p < 0.001). Compliance with guidelines is essential to be improved to reduce mortality, shorten the length of stay, determine the appropriate antimicrobial duration, and reduce the use of fluoroquinolones and broad-spectrum antibiotics unless necessary. CP intervention contributes to the rational selection of antimicrobials, limiting drug-drug interactions, avoiding toxicities, and compliance with guidelines.

Empiric antibiotic selection for community-acquired pneumonia in US hospitals, 2013–2020

Background: Community-acquired pneumonia (CAP) is a common indication for antibiotic prescribing in hospitalized patients. Professional societies’ clinical guidelines recommend specific antibiotics for empiric treatment of CAP based on clinical factors. Manual assessments of appropriateness are time-consuming and are often conducted on a smaller scale. We evaluated empiric antibiotic selection among a large cohort of adults hospitalized with CAP using electronic health records. Methods: In this study, we used the PINC-AI healthcare database to define a cohort of adults hospitalized with CAP from 2013 to 2020. CAP was identified by International Classification of Diseases (ICD) diagnosis codes. Exclusions were applied to identify uncomplicated CAP (Fig. 1). Treatment was only evaluated if a chest radiograph or computerized tomography (CT) scan was charged during the first 2 days of hospitalization, otherwise it was considered an inadequate CAP evaluation. Administrative billing data were used to identify antibiotics charged within the first 2 days of hospitalization. Empiric guideline-recommended treatment was determined based on 2019 CAP guidelines and more recent studies. Patients who received nonrecommended treatment were evaluated for antibiotic allergies in the current hospitalization or methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in the year prior or on admission using International Classification of Disease, Tenth Revision (ICD-10) diagnosis codes. Results: We identified 4.47 million adult hospitalizations with CAP from 2013 to 2020; 32% (1.43 million) were included in this analysis (Fig. 1). Among discharges with adequate CAP evaluation (1.37 million), 59.7% received recommended antibiotics in the first 2 days of hospitalization, ranging from 62.6% in 2013 to 57.5% in 2019. Overall, 34.8% of our study population received a nonrecommended antibiotic without documentation of an antibiotic allergy or MRSA colonization (2013: 32.5%; 2018: 36.7%) (Fig. 2). Most patients in our study population received &gt;1 antibiotic (92.3%) in the first 2 days of hospitalization. The most common antibiotics among patients receiving recommended treatment were ceftriaxone (74.2% of patients receiving recommended treatment), azithromycin (67.2%), and levofloxacin (31.8%) (Fig. 3a). The most common nonrecommended antibiotics were vancomycin (57.2% of patients receiving nonrecommended treatment), piperacillin-tazobactam (48.1%), and cefepime (25.7%) (Fig. 3b). From 2013 to 2020, cefepime charges consistently increased among CAP patients treated with nonrecommended antibiotics, whereas levofloxacin charges consistently decreased among CAP patients treated with only recommended antibiotics. Conclusions: Approximately one-third of patients with uncomplicated CAP received nonrecommended empiric antibiotics, and from 2013 to 2020 that proportion increased by 9%. Additional strategies are needed to help identify opportunities to optimize antibiotic selection among patients with CAP.Disclosures: None

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.

Efficacy of erythromycin compared to clarithromycin and azithromycin in adults or adolescents with community-acquired pneumonia: A Systematic Review and meta-analysis of randomized controlled trials

BackgroundIt is debatable whether erythromycin has similar efficacy to other macrolides in treating community-acquired pneumonia (CAP). The aim of this meta-analysis is to compare the efficacy of erythromycin with clarithromycin and azithromycin. MethodsWe performed this meta-analysis of randomized controlled trials (RCTs) of adults or adolescents with CAP which compared the efficacy of erythromycin monotherapy to either azithromycin or clarithromycin. We searched PubMed and EMBASE and Cochrane Library databases and three clinical trial registries up to November 02, 2021. We evaluated heterogeneity and used random-effects models to perform risk ratios with 95% confidence intervals. ResultsWe included four RCTs (total of 472 patients), which compared the clinical efficacy of erythromycin versus clarithromycin. No studies comparing monotherapy of erythromycin versus azithromycin were found. Erythromycin use was associated with significantly lower rates of clinical success (RR, 0.79; 95% CI, 0.64 to 0.98; P-value = 0.033; I2 = 20.27%), clinical cure (RR,0.67; 95% CI, 0.48 to 0.92; P-value = 0.014; I2 = 8.75%), and radiological success (RR, 0.84; 95% CI, 0.71 to 0.996; P-value = 0.045; I2 = 20.12%) than clarithromycin. ConclusionErythromycin is less effective than clarithromycin as empiric treatment of CAP in adults and adolescents. Because of this and the higher rate of adverse reactions, erythromycin should not be used in the majority of CAP patients when azithromycin and clarithromycin are available.

Clinical Benefits and Cost-Effectiveness of Moxifloxacin as Initial Treatment for Community-Acquired Pneumonia: A Meta-Analysis and Economic Evaluation

Moxifloxacin and levofloxacin are currently recommended as empirical initial treatment options for community-acquired pneumonia (CAP) in China according to guidelines. Most studies that evaluated the efficacy and safety of moxifloxacin and levofloxacin in treating CAP as initial empirical treatment were single-centered trials assessing different clinical end points. In addition, there is limited research investigating moxifloxacin's clinical benefits in the context of health care resource utilization and reimbursement from the payer's perspective in China. Hence, this study was aimed at comparing the clinical efficacy of moxifloxacin and levofloxacin by conducting a meta-analysis and assessing their economic value from the China payer's perspective through a cost-utility analysis model. For the meta-analysis, 6 bibliographic databases were searched for relevant publications from January 2000 to August 2020, and studies were assessed for eligibility under predetermined criteria. Meta-analysis was performed by using a random effects model when analyses included >2 trials. For the economic evaluation, a decision-tree model was constructed to investigate the cost-utility of moxifloxacin versus levofloxacin as initial regimens in the treatment of CAP inpatients. Parameter values were derived from meta-analysis, published literature, and clinician survey. The outcome was reported in the form of an incremental cost-effectiveness ratio. One-way sensitivity analysis and probabilistic sensitivity analysis were undertaken to assess the robustness of the model. Twenty-seven randomized controlled trials were included in the meta-analysis. Results indicated that the clinical response rate at the test-of-cure visit with initial treatment of moxifloxacin was significantly higher than that of levofloxacin (3441 patients; random effects model; I2=49%; odds ratio, 3.35; 95% CI, 2.35-4.77; P < 0.001). In terms of the safety profile, total adverse events were not significantly different between the 2 groups (2770 patients; random effects model; I2=40%; odds ratio, 0.77; 95% CI, 0.56-1.06; P=0.11). Output of the cost-utility model showed that under the willingness-to-pay threshold of one-time China gross domestic product per capita, moxifloxacin is dominant over levofloxacin, being less costly and more efficacious (0.002 quality-adjusted life year gained, CNY 844 [US$131] saved in total cost, negative incremental cost-effectiveness ratio). Sensitivity analyses indicated the robustness of the model as moxifloxacin remained dominant when model parameter values fluctuated. Moxifloxacin is more efficacious than levofloxacin as the initial empirical treatment for CAP. In addition, treatment of CAP with moxifloxacin instead of levofloxacin is expected to be cost-saving from the perspective of payers in China. However, for the cost-utility analysis, in the absence of a national representative database on costs for hospitalization in China, inputs in the cost-utility model could be underestimated or overestimated due to estimating errors applied to both treatment arms.

Bacterial etiology and risk factors of Community acquired pneumonia (CAP) among adult patients in a Tertiary Care Hospital in South India

Background: Community acquired pneumonia (CAP) is a significant cause of morbidity and mortality among adult patients worldwide. In India, data on the bacterial etiology of CAP, antimicrobial resistance profiles, risk factors and outcomes is limited. This study was aimed at determining the bacterial etiology of CAP, their antimicrobial resistance profile, and outcomes since the choice of empirical treatment of CAP often remains challenging due to the development of drug resistant pathogens. Methods and materials: A prospective pilot study was carried out among 100 adult subjects ≥18 years of age admitted to a tertiary care hospital in South India with the diagnosis of CAP for a period of 1 year. Blood, sputum, endotracheal tip and pleural fluid were obtained for microbiological investigations within 48 h of admission. Antimicrobial susceptibility testing was performed on culture positive isolates by Kirby Bauer disk diffusion technique. Descriptive statistics and odds ratio with its 95% confidence interval was conducted using SPSS statistical software package, version 22.0. Results: A total of 100 subjects diagnosed for CAP were enrolled in the study. Majority of patients were males (63%), aged >45 years (79%), and resided in a rural area (57%). Most patients had a severe clinical course including intensive care admission (46%), ventilatory support (15%) on admission with 16% mortality. Bacterial pathogens could be identified only among 30% of the participants. 13(43%) of the isolates were multidrug resistant. Klebsiella pneumoniae [n = 16(53%)] was the most predominant isolate followed by Pseudomonas aeruginosa, Streptococcus pneumoniae, and Staphylococcus aureus. Chronic cardiovascular disease [OR 5.76 (95%CI: 1.75-18.88)], chronic liver disease [OR 6.67(95%CI: 1.47-30.27)], chronic kidney disease [OR 3.79 (95%CI: 0.97-11.7)], altered sensorium [OR 6.6(95%CI: 1.85-23.6)], sepsis and septic shock [OR 8.53 (95%CI: 2.64-27.59)] were found to be significantly associated with mortality. Conclusion: Gram negative bacteria were the predominant etiological agent responsible for CAP in our setting with multidrug resistant strains and severe clinical course. Chronic comorbid conditions must be monitored in order to increase the chance of survival among CAP patients.

Azithromycin in COVID-19 Patients: Pharmacological Mechanism, Clinical Evidence and Prescribing Guidelines.

The global COVID-19 pandemic has led to a race to find medications that can improve the prognosis of the disease. Azithromycin, in association with hydroxychloroquine or chloroquine, has been proposed as one such medication. The aim of this review is to describe the pharmacological mechanism, clinical evidence and prescribing guidelines concerning azithromycin in COVID-19 patients. There is weak evidence on the antiviral and immunomodulating effects of azithromycin, which in addition is not based on results from COVID-19 patients specifically. Therefore, this antibacterial should be considered only as empirical treatment of community-acquired pneumonia (CAP), although not all current treatment guidelines are in agreement. After the initial expectations raised by a small trial, more recent evidence has raised serious safety concerns on the use of hydroxychloroquine or chloroquine with azithromycin to treat COVID-19 patients, as all these drugs have arrhythmogenic potential. The World Health Organization has not made recommendations suggesting the use of azithromycin with hydroxychloroquine or chloroquine as treatment for COVID-19, but some national organisations have taken a different position, recommending this as first-line treatment. Several scientific societies, including the American College of Cardiology, have cautioned about the risks of this treatment in view of the lack of evidence concerning its benefits.

Effect of β-Lactam Plus Macrolide Versus Fluoroquinolone on 30-Day Readmissions for Community-Acquired Pneumonia.

Antibiotic therapy with a macrolide and β-lactam or a fluoroquinolone for the empirical treatment of community-acquired pneumonia (CAP) in an inpatient non-intensive care setting is recommended per guidelines. Studies show that these treatments have similar outcomes, including death, adverse effects, and bacterial eradication. However, a comparison of 30-day readmission rates between these treatments is limited. To determine whether 30-day readmissions for patients treated for CAP in a regional hospital differed between a fluoroquinolone monotherapy and a β-lactam plus macrolide combination therapy. Retrospective cohort study of patients aged ≥18 years with a CAP diagnosis who were admitted to the same regional hospital from December 1, 2011, through December 1, 2016. Patients receiving a third-generation cephalosporin plus macrolide were compared with those receiving a respiratory fluoroquinolone. Exclusion criteria were concurrent or recent use of the study antibiotics; death, transfer, or transition to hospice; and diagnosis of hospital-acquired pneumonia or health care-associated pneumonia. The collected data were 30-day readmission rates, antibiotic regimens, demographic characteristics, and pneumonia severity index and comorbidity scores. Association between treatment group and readmissions was assessed with logistic regression. Association between readmissions and individual data points between the 2 treatment groups was calculated with multivariate regression and odds ratio (95% confidence interval). Of 432 patients, 171 met inclusion criteria (fluoroquinolone group, n = 101; β-lactam plus macrolide group, n = 70). Thirty-day readmissions were not significantly different between the fluoroquinolone group and β-lactam plus macrolide group (P = 0.58). Increased 30-day readmissions were independently associated with male sex and hospital length of stay (P < 0.05). Length of stay was approximately 3 days and did not differ between treatment groups. No difference was seen in 30-day readmissions between CAP patients who received fluoroquinolone monotherapy and those who received β-lactam plus macrolide combination therapy.

Ceftobiprole medocaril for the treatment of community-acquired pneumonia

ABSTRACTIntroduction: Ceftobiprole is a novel broad-spectrum cephalosporin with excellent activity against a broad range of pathogens that are important in community-acquired pneumonia (CAP), including drug-resistant pneumococci, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa.Areas covered: This article reviews the spectrum of activity, the main pharmacological and pharmacodynamic characteristics of ceftobiprole as well its clinical efficacy and safety in the treatment of CAP in adult patients.Expert opinion: Taking into account that the current treatment guidelines for CAP recommend the use of an adequate empirical therapy to improve its prognosis, ceftobiprole shows a profile of antimicrobial activity that would cover most etiological agents in patients with risk factors for infection caused by multidrug resistant organisms. The results of the pivotal clinical trial of patients hospitalized with CAP treated with ceftobiprole showed a high rate of clinical cure. The clinical tolerance of ceftobiprole in clinical trials was generally very good. These findings make ceftobiprole a good parenteral therapeutic alternative for the empirical treatment of CAP that requires hospitalization, especially in patients with risk factors for CAP caused by resistant microorganisms.

Benzylpenicillin versus wide-spectrum beta-lactam antibiotics as empirical treatment of Haemophilus influenzae-associated lower respiratory tract infections in adults; a retrospective propensity score-matched study

There is consensus that definitive therapy for infections with H. influenzae should include antimicrobial agents with clinical breakpoints against the bacterium. In Scandinavia, benzylpenicillin is the recommended empirical treatment for community-acquired pneumonia (CAP) except in very severe cases. However, the effect of benzylpenicillin on H. influenzae infections has been debated. The aim of this study was to compare the outcomes of patients given benzylpenicillin with patients given wide-spectrum beta-lactams (WSBL) as empirical treatment of lower respiratory tract H. influenzae infections requiring hospital care. We identified 481 adults hospitalized with lower respiratory tract infection by H. influenzae, bacteremic and non-bacteremic. Overall, 30-day mortality was 9% (42/481). Thirty-day mortality, 30-day readmission rates, and early clinical response rates were compared in patients receiving benzylpenicillin (n = 199) and a WSBL (n = 213) as empirical monotherapy. After adjusting for potential confounders, empirical benzylpenicillin treatment was not associated with higher 30-day mortality neither in a multivariate logistic regression (aOR 2.03 for WSBL compared to benzylpenicillin, 95% CI 0.91–4.50, p = 0.082), nor in a propensity score-matched analysis (aOR 2.14, 95% CI 0.93–4.92, p = 0.075). Readmission rates did not significantly differ between the study groups, but early clinical response rates were significantly higher in the WSBL group (aOR 2.28, 95% CI 1.21–4.31, p = 0.011), albeit still high in both groups (84 vs 81%). In conclusion, despite early clinical response rates being slightly lower for benzylpenicillin compared to WSBL, we found no support for increased mortality or readmission rates in patients empirically treated with benzylpenicillin for lower respiratory tract infections by H. influenzae.

Reducing inappropriate third-generation cephalosporin use for community-acquired pneumonia in a small Australian emergency department.

Antimicrobial stewardship is a key component of hospital accreditation in Australia and contributes to the prevention and containment of antimicrobial resistance. The Second Australian Report on Antimicrobial Use and Resistance in Human Health (AURA Report) 2017 calls for greater participation by small hospitals in antimicrobial stewardship activities. Community acquired pneumonia (CAP) and third generation cephalosporin (3GCs) use is a known target for intervention. This paper reports the results of an educational intervention for reducing inappropriate prescribing of 3GCs in the empiric treatment of CAP. The intervention was based on a leadership and education campaign in an Emergency Department (ED) in a 96 bed acute rural hospital in New South Wales, Australia. A two-point retrospective audit within (April-June 2010, April-June 2011) was conducted comparing pre-intervention and post-intervention antibiotic prescribing trends for CAP from ED presentations. Data was collected via audit tool and appropriateness was assessed against endorsed guidelines. The main outcome measures were improved prescribing appropriateness and decreased utilisation. Whilst statistically insignificant, a reduction (6.4%) in inappropriate prescribing and a reduction in 3GC utilisation (16.7%) was demonstrated. Small hospitals have active contributions to make to prevent and contain antimicrobial resistance via antimicrobial stewardship. The challenge is collecting this data for national data sets whilst instituting local benefits in the context of limited resources. Our results suggest change can occur in antibiotic prescribing, studies such as this model a targeted strategy for resource poor facilities to contribute to national AU data whilst instituting local AMS change.

Guideline recommendations and antimicrobial resistance: the need for a change

ObjectivesAntimicrobial resistance has become a global burden for which inappropriate antimicrobial use is an important contributing factor. Any decisions on the selection of antibiotics use should consider their effects on...

Bacterial Etiology and Antibiotic Sensitivity Pattern of Community Acquired Pneumonia in Diabetic Patients: Experience in a Tertiary Care Hospital in Bangladesh

Background: Diabetes mellitus (DM) is an immunosuppressive condition and uncontrolled diabetes is associated with increased susceptibility to various infections like pneumonia. Community acquired pneumonia (CAP) in diabetic patients is often caused by more virulent or atypical organisms and associated with increased resistance to conventional antibiotics. The aims of this study were to identify the bacterial etiology of CAP in patients with DM and to see their antibiotic sensitivity pattern.Methods: This was a cross-sectional, observational study conducted in the Department of Internal Medicine &amp; Pulmonology of BIRDEM General Hospital, Dhaka, Bangladesh, from January 2013 to December 2015. A total of 120 hospitalized diabetic patients diagnosed with CAP and with a positive sputum culture growth of any bacteria were included in the study.Results: Majority (67%) of the patients were male. Mean age of the patients was - 55.69 ±10.5 years. Mean duration of diabetes was - 7.35 ±1.3 years. Mean HbA1c was - 8.6 ±1.89%. Sputum for culture showed that out of 120 (100%) patients, Klebsiella pneumoniae was detected in 53 (44.2%) patients, Staphylococcus aureus in 18 (15.0%), Pseudomonas species in 16 (13.3%) patients, Acinetobacter in 10 (8.3%), Escherichia coli in 9 (7.5%) patients and 14 (11.7%) patients had growth of other organisms. Sensitivity pattern of different bacterial growth in sputum to commonly used antibiotics like ceftriaxone, ciprofloxacin, amikacin and imipenem were as follows – Klebsiella (19%, 47%, 74%, 96% respectively), Staph aureus (11%, 33%, 78%, 67% respectively), Pseudomonas (19%, 75%, 81%, 88% respectively), Acinetobacter (0%, 0%, 20%, 50% respectively), E. coli (22%, 22%, 100%, 100% respectively). All (100%) of the Pseudomonas and Acinetobacter were sensitive to colistin. Most of the growth of all the bacteria (Klebsiella 94%, Staphylococcus 78%, Pseudomonas 81%, Acinetobacter 100%, E. coli 100%) occurred in patients with poor glycemic control (HbA1c ? 7.0%).Conclusion: This study results suggest that CAP in diabetic patients are more frequently due to Klebsiella pneumoniae, Staphylococcus aureus and Pseudomonas species and mostly they are less sensitive to commonly used antibiotics like ceftriaxone and ciprofloxacin. So, whenever possible, treatment of CAP should be guided by sputum culture and sensitivity test and for empirical treatment of CAP in diabetic patients, alternative antibiotics like imipenem and amikacin should be considered.Birdem Med J 2017; 7(2): 101-105

Moxifloxacin pharmacokinetic profile and efficacy evaluation in empiric treatment of community-acquired pneumonia.

When antimicrobials are used empirically, pathogen MICs equal to clinical breakpoints or epidemiological cutoff values must be considered. This is to ensure that the most resistant pathogen subpopulation is appropriately targeted to prevent emergence of resistance. Accordingly, we determined the pharmacokinetic (PK) profile of moxifloxacin at 400 mg/day in 18 patients treated empirically for community-acquired pneumonia. We developed a population pharmacokinetic model to assess the potential efficacy of moxifloxacin and to simulate the maximal MICs for which recommended pharmacokinetic-pharmacodynamic (PK-PD) estimates are obtained. Moxifloxacin plasma concentrations were determined the day after therapy initiation using ultra-high-performance liquid chromatography. Peak drug concentrations (Cmax) and area under the free drug concentration-time curve from 0 to 24 h (fAUC0-24) values predicted for each patient were evaluated against epidemiological cutoff MIC values for Streptococcus pneumoniae, Haemophilus influenzae, and Legionella pneumophila. PK-PD targets adopted were a Cmax/MIC of ≥12.2 for all pathogens, an fAUC0-24/MIC of >34 for S. pneumoniae, and an fAUC0-24/MIC of >75 for H. influenzae and L. pneumophila. Individual predicted estimates for Cmax/MIC and fAUC0-24/MIC as well as simulated maximal MICs resulting in target attainment for oral and intravenous administration of the drug were suitable for S. pneumoniae and H. influenzae but not for L. pneumophila. These results indicate that caution must be taken when moxifloxacin is used as monotherapy to treat community-acquired pneumonia caused by L. pneumophila. In conclusion, this report reveals key information relevant to the empirical treatment of community-acquired pneumonia while highlighting the robust and flexible nature of this population pharmacokinetic model to predict therapeutic success. (Clinical Trials Registration no. NCT01983839.).

Sputum bacteriology and antibiotic sensitivity patterns of community-acquired pneumonia in hospitalized adult patients in Nigeria: a 5-year multicentre retrospective study.

A clear knowledge of the pathogens responsible for community-acquired pneumonia (CAP) in a given region and their antibiotic sensitivity patterns is necessary for optimal treatment. We determined the common bacterial pathogens causing CAP in Nigeria and further reviewed their antibiotic senstivity patterns with a view to providing recommendations to improve antibiotic management of CAP. Case notes of all adult patients who were 18 years or more admitted to four major tertiary hospitals in South East Nigeria with a diagnosis of CAP between 2008 and 2012 were retrospectively studied. To be eligible, patients were required to have sputum culture and sensitivity results available. Socio-demographic, clinical, pre-admission and in-hospital treatment data were also obtained. Of 400 patients with a radiologically confirmed diagnosis of CAP, 232 fulfilled the study criteria; 122 (52.6%) were women and the mean age was 50.6 ± 18.8 years. Aetiological agents were identified from sputum in 189 (81.5%) patients. Streptococcus pneumoniae (n = 90, 47.6%) was the most frequent isolate followed by Klebsiella pneumoniae (n = 62, 32.8%), Staphylococcus aureus (n = 24, 12.7%) and Streptococcus pyogenes (n = 13, 6.9%). The pathogens were most sensitive to levofloxacin (77%), ceftazidime (75.5%) and ofloxacin (55.8%). The susceptibility of the isolates to antibiotics most frequently presecribed for empirical therapy was low (co-amoxiclav, 47.6%; ciprofloxacin, 45.9% and ceftriaxone, 47.6%) and this was associated with higher mortality and/or longer duration of hospital stay in survivors. Strep. pneumoniae and K. pneumoniae were the most common causes of CAP. The pathogens were most sensitive to levofloxacin and ceftazidime. We suggest that these antibiotics should increasingly be considered as superior options for empirical treatment of CAP in Nigeria.

Infecciones por neumococo

S. pneumoniae infections are a major cause of infection in patients seen in primary care and emergency services. The main table associated with pneumococcal infection is pneumonia, the severity is highly variable, depending on the age of the patient, underlying diseases and the extent and complications thereof (bilateral, pleural effusion, empyema, shock, etc.). Other common but less serious cases are otitis and sinusitis, which very frequently affect children. Less frequently but conditioning can be observed high mortality tables meningitis, bacteremia and endocarditis. Microbiological diagnosis revolves around three pillars: Gram stain, culture of sterile fluids (blood, pleural fluid, cerebrospinal, joint, peritoneal.) and immunochromatography to determine the capsular polysaccharide C (urine and CSF). The treatment is based on amoxicillin or amoxicillin-clavulanic noninvasive pictures (otitis and sinusitis), third-generation cephalosporins associated with macrolides in the empiric treatment of community-acquired pneumonia; cephalosporins and vancomycin associated with meningeal tables (where there are high rates of resistance to penicillins and cephalosporins).

Ceftaroline—An Anti-MRSA Cephalosporin and Its Implications for Singapore

Ceftaroline is a fifth-generation cephalosporin with activity against methicillin-resistant Staphylococcus aureus (MRSA) that was recently launched in Singapore. It received approval from the United States (US) Food Drug Administration (FDA) and European Commission for the treatment of adult patients with community-acquired pneumonia (CAP) and complicated skin and soft tissue infections (cSSTI). This study aimed to review current published data and determine its clinical role, particularly in the local setting. A literature review on published articles in English on ceftaroline, focusing in particular on clinical trials and other clinical reports. Susceptibility testing was also performed on a limited sample of local MRSA and Streptococcus pneumoniae isolates. Ceftaroline has an extensive spectrum of activity, including coverage of MRSA and multidrug-resistant S. pneumoniae. However, it has limited activity against non-fermenting Gram-negative bacteria and is susceptible to hydrolysis by extended spectrum beta-lactamases. It is only available for intravenous delivery, with a reconstituted stability of just 6 hours, rendering it unavailable for use for outpatient antibiotic therapy. Clinical trials demonstrate non-inferiority compared to first-line comparators in the treatment of CAP and cSSTI. Published case reports/series suggest a potential greater role in the treatment of MRSA bacteremia and endocarditis. No resistance was found among local archived MRSA and S. pneumoniae isolates. We believe ceftaroline will occupy primarily niche roles for culture-directed treatment of various infections--in particular those caused by MRSA--until further clinical trial data become available. A variety of factors render it less useful or appealing for empirical treatment of CAP or healthcare-associated infections.

A 2011-2012 Survey of Doctors' Perceptions of Korean Guidelines and Empirical Treatment of Community-Acquired Pneumonia

BackgroundThe causative pathogens of and prevalence of antibiotic resistance in community-acquired pneumonia (CAP) varies across countries. We evaluated the patterns of antibiotic prescriptions for adult CAP patients, and physician satisfaction with the form and content of the 2009 Korean CAP treatment guidelines.Materials and MethodsWe designed an online survey for clinical physicians who treat CAP (infectious disease specialists, pulmonologists, and other physicians). We e-mailed the online survey to physicians and gathered results from December 2011 to January 2012, and then analyzed their responses.ResultsA total of 157 physicians responded to our survey: 61 (38.9%) infectious disease specialists, 33 (21.0%) pulmonologists, and 63 (40.1%) other physicians. Two-thirds (96/157, 61.2%) had positions in tertiary and secondary hospitals; the others (61, 38.8%) worked in primary clinics (hospitals and private clinics). One hundred and eight (68.8%) were aware of the Korean CAP clinical guidelines; of these, 98 (62.4%) applied the guidelines to their practice. Among physicians using them, 86.7% (85/98) reported the guidelines to be most useful for empirical selection of antibiotics, and 75.2% (118/157) said the guidelines were useful and satisfactory. Sixty-eight (43.3%) respondents indicated that they had not used aminoglycosides as an initial empirical CAP treatment, while 51 (32.5%) had combined aminoglycosides with other antibiotics to treat patients with CAP. Seventy-three (46.5%) physicians often combined macrolides with β-lactam antibiotics for empirical treatment of CAP, and 21 (13.4%) reported using macrolide monotherapy (which is not recommended in the 2009 Korean CAP treatment guidelines) for CAP patients. The most commonly used β-lactams were third-generation cephalosporins (72, 45.9%) and ampicillin/sulbactam or amoxicillin/clavulanate (28, 17.8%).ConclusionsSome physicians remain unaware of the 2009 Korean treatment guidelines for CAP and do not use them in clinical practice. In addition, aminoglycoside combination therapy is frequently and inappropriately used in practice. In some cases, CAP is treated with macrolide monotherapy. Thus, the Korean CAP clinical guidelines must be more aggressively and continuously publicized.

Commentary on: Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

Commentary on: Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

The role of fluoroquinolones (FQs) as empirical therapy for community-acquired pneumonia (CAP) remains controversial in countries with high tuberculosis (TB) endemicity owing to the possibility of delayed TB diagnosis and treatment and the emergence of FQ resistance in Mycobacterium tuberculosis. Although the rates of macrolide-resistant Streptococcus pneumoniae and amoxicillin/clavulanic acid-resistant Haemophilus influenzae have risen to alarming levels, the rates of respiratory FQ (RFQ) resistance amongst these isolates remain relatively low. It is reported that ca. 1–7% of CAP cases are re-diagnosed as pulmonary TB in Asian countries. A longer duration (≥7 days) of symptoms, a history of night sweats, lack of fever (>38°C), infection involving the upper lobe, presence of cavitary infiltrates, opacity in the lower lung without the presence of air, low total white blood cell count and the presence of lymphopenia are predictive of pulmonary TB. Amongst patients with CAP who reside in TB-endemic countries who are suspected of having TB, imaging studies as well as aggressive microbiological investigations need to be performed early on. Previous exposure to a FQ for >10 days in patients with TB is associated with the emergence of FQ-resistant M. tuberculosis isolates. However, rates of M. tuberculosis isolates with FQ resistance are significantly higher amongst multidrug-resistant M. tuberculosis isolates than amongst susceptible isolates. Consequently, in Taiwan and also in other countries with TB endemicity, a short-course (5-day) regimen of a RFQ is still recommended for empirical therapy for CAP patients if the patient is at low risk for TB.