Management Of Hospital-acquired Pneumonia Research Articles

A multiplex pneumonia panel for diagnosis of hospital-acquired and ventilator-associated pneumonia in the era of emerging antimicrobial resistance.

BackgroundAntimicrobial resistance (AMR), including multidrug (MDR) and extensively drug-resistant (XDR) bacteria, is an essential consideration in the prevention and management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). In the AMR era, the clinical utility of the BioFire FilmArray Pneumonia Panel Plus (BFPP) to diagnose HAP/VAP has not been thoroughly evaluated.MethodsWe enrolled adult hospitalized patients with HAP or VAP at Siriraj Hospital and Saraburi Hospital from July 2019–October 2021. Respiratory samples were collected for standard microbiological assays, antimicrobial susceptibility testing (AST), and the BFPP analysis.ResultsOf 40 subjects, 21 were men. The median duration of HAP/VAP diagnoses was 10.5 (5, 21.5) days, and 36 endotracheal aspirate and 4 sputum samples were collected. Standard cultures isolated 54 organisms—A. baumannii (37.0%), P. aeruginosa (29.6%), and S. maltophilia (16.7%). 68.6% of Gram Negatives showed an MDR or XDR profile. BFPP detected 77 bacterial targets—A. baumannii 32.5%, P. aeruginosa 26.3%, and K. pneumoniae 17.5%. Of 28 detected AMR gene targets, CTX-M (42.5%), OXA-48-like (25%), and NDM (14.3%) were the most common. Compared with standard testing, the BFPP had an overall sensitivity of 98% (88-100%), specificity of 81% (74-87%), positive predictive value of 60% (47-71%), negative predictive value of 99% (96-100%), and kappa (κ) coefficient of 0.64 (0.53-0.75). The concordance between phenotypic AST and detected AMR genes in Enterobacterales was 0.57. There was no concordance among A. baumannii, P. aeruginosa, and S. aureus ConclusionsThe BFPP has excellent diagnostic sensitivity to detect HAP/VAP etiology. The absence of S. maltophilia and discordance of AMR gene results limit the test performance.

Classical and Molecular Techniques to Diagnose HAP/VAP.

Nosocomial pneumonia, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), are the most common nosocomial infections occurring in critically ill patients requiring intensive care. However, challenges exist in making a timely and accurate diagnosis of HAP and VAP. Under diagnosis of HAP and VAP can result in greater mortality risk, especially if accompanied by delays in the administration of appropriate antimicrobial treatment. Over diagnosis of HAP and VAP results in the unnecessary administration of broad spectrum antibiotics that can lead to further escalation of antibiotic resistance. Optimal diagnosis and management of HAP and VAP require a systematic approach that combines clinical and radiographic assessments along with proper microbiologic techniques. The use of more invasive sampling methods (bronchoalveolar lavage and protected specimen brush) may enhance specimen collection resulting in more specific diagnoses to limit unnecessary antibiotic exposure. Molecular techniques, currently in use and investigational technique, may improve the diagnosis of HAP and VAP by allowing more rapid identification of offending pathogens, if present, thus increasing both appropriate antibiotic treatment and avoiding unnecessary drug exposure.

Utility of Procalcitonin in the Management of Hospital-Acquired Pneumonia - A Review

Utility of Procalcitonin in the Management of Hospital-Acquired Pneumonia - A Review

국내 병원획득 폐렴 원인균의 경험적 항균제에 대한 내성 현황

Background : Although the prevalence of antibiotic resistance may vary according to region, there is no guidance developed in Korea on the use of empirical antibiotics for the treatment of hospitalacquired pneumonia (HAP). The purpose of this study was to investigate the patterns of empiric antibiotic therapy and resistance of the isolated pathogens to the empirical antibiotics in the management of HAP in Korea. Methods : A retrospective analysis was conducted using the electronic medical records of the HAP patients January 2014-December 2015 in Korea. The patterns of prescribing empirical antibiotics and resistance of the isolated pathogens to the empirical antibiotics were examined. Results : A total of 170 patients was analyzed. Piperacillin/tazobactam was the key agent in the empirical antibiotics. The most common pathogen was Staphylococcus aureus (27.9%) followed by Acinetobacter baumannii (21.6%), Klebsiella pneumoniae (11.1%), Pseudomonas aeruginosa (6.3%), Stenotrophomonas maltophilia (5.8%), Enterobacter aerogenes (5.3%), and Escherichia coli (5.3%). The resistance rates of S. aureus to ciprofloxacin was 76%. E. coli had high level of resistance rate to ciprofloxacin (80%) and low resistance rate to imipenem (10%). K. pneumoniae and P. aeruginosa showed very high level of sensitivity to imipenem (100%) and cefepime (91.7%), respectively. To piperacillin/tazobactam, E. coli, E. erogenes, K. pneumoniae, and P. aeruginosa showed high level of sensitivity (52.4-100%). A. baumannii exhibited high-level resistance rates (63.4-85.4%) to the empirical antibiotics, including cefepime, ceftazidime, ciprofloxacin, imipenem, and piperacillin/tazobactam. Conclusion : The empirical antibiotic therapy was appropriate for the initial treatment of HAP owing to the adequate antibiotic coverage. Piperacillin/tazobactam was used in most patients and the most common pathogens including Pseudomonas aeruginosa had high level of sensitivity to the drug. The high level of resistance of A. baumannii to the empirical antibiotics is one of the major challenges in treating HAP.

Diagnosis and management of hospital-acquired pneumonia in older adults

Diagnosis and management of hospital-acquired pneumonia in older adults

Diagnosis and management of hospital-acquired pneumonia in older adults

Diagnosis and management of hospital-acquired pneumonia in older adults

Utility of procalcitonin in predicting mortality among cases of hospital-acquired pneumonia: a North Indian study

Bckground Data regarding the role of biomarkers like procalcitonin (PCT) in predicting treatment outcomes in hospital-acquired pneumonia (HAP) are limited in an Indian setting. We set out to determine the usefulness of PCT in predicting mortality among the cases of nosocomial pneumonia, at an 800-bed, apex tertiary care centre, in Kashmir (North India). Patients and methods Of the 318 confirmed cases of HAP, 60 consenting cases were selected randomly. Quantitative determination of PCT was done using immunofluorescence assays. Levels greater than 0.5 ng/ml were taken as positive. Data were collected on clinical parameters, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores pneumonia severity index were calculated. Appropriate blood and respiratory cultures were performed. Results Of the 60 cases included in the study, 19 (32%) died during the hospital stay, of which 14 (74%) deaths occurred in PCT-positive cases (P=0.001). The median PCT level was higher in the in-hospital mortality group (1.07 vs. 0.25), with a mean value of 1.2±2.8 vs. 1.2±2.5 in the group with no mortality (P=0.000). Using multivariate analysis, positive PCT level was strongly associated with in-hospital mortality (odds ratio: 6.767, 95%CI: 1.992–22.984, P=0.002) and APACHE-II score greater than 20 (n=14, odds ratio=4.5, 95%CI=1.448–13.984, P=0.009). Using receiver operating characteristic analysis, PCT had apropos discrimination power for in-hospital mortality (0.713 of area under the curve) and higher APACHE-II scores (0.753 of area under the curve). Using Cox regression model for mortality in PCT-positive group, the calculated hazard ratio was 3.273 (95%CI: 1.076–9.951, P=0.037). Conclusion PCT might have a vital role in the management of HAP, as a predictor of the poor treatment outcome.

Pulmonary infections in critical/intensive care - rapid diagnosis and optimizing antimicrobial usage.

Diagnosis of pulmonary infection, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in the critically ill patient remains a common and therapeutically challenging diagnosis with significant attributable morbidity, mortality, and cost. Current clinical approaches to surveillance, early detection and, conventional culture-based microbiology are inadequate for optimal targeted antibiotic treatment and stewardship. Efforts to enhance diagnosis of HAP and VAP and the impact of these novel approaches on rational antimicrobial selection and stewardship are the focus of recent studies reviewed here. Recent consensus guidelines for diagnosis and management of HAP and VAP are relatively silent on the potential role of novel rapid microbiological techniques and reply heavily on conventional culture strategies of noninvasively obtained (including endotracheal aspirate samples). Novel rapid microbiological diagnostics, including nucleic acid amplification, mass spectrometry, and fluorescence microscopy-based technologies are promising approaches for the future. Exhaled breath biomarkers, including measurement of VOC represent a future approach. Further validation of novel diagnostic technology platforms will be required to evaluate their utility for enhancing diagnosis and guiding treatment of pulmonary infections in the critically ill. However, the integration of novel diagnostics for rapid microbial identification, resistance phenotyping, and antibiotic sensitivity testing into usual care practice could significantly transform the care of patients and potentially inform improved targeted antimicrobial selection, de-escalation, and stewardship.

Clinical outcomes of extended versus intermittent administration of piperacillin/tazobactam for the treatment of hospital-acquired pneumonia: a randomized controlled trial

The purpose of this study was to assess the pharmacokinetic (PK) characteristics, clinical efficiency, and pharmacoeconomic parameters of piperacillin/tazobactam administered by extended infusion (EI) or intermittent infusion (II) in the treatment of hospital-acquired pneumonia (HAP) in critically ill patients with low illness severity in China. Fifty patients completed the study, with 25 patients receiving 4/0.5 g piperacillin/tazobactam over 30 min as the II group and 25 patients receiving 4/0.5 g piperacillin/tazobactam over 3 h every 6 h as the EI group. Drug assay was performed using high-performance liquid chromatography (HPLC). The percentage of the dosing interval for which the free piperacillin concentration (%fT) exceeds the minimum inhibitory concentration (MIC) was calculated. The patients’ therapy cost, clinical efficiency, and adverse effects were also recorded. %fT>MIC was about 100, 98.73, and 93.04 % in the EI arm versus 81.48, 53.29, and 42.15 % in the II arm, respectively, when the microorganism responsible for HAP had an MIC of 4, 8, and 16 mg/L. The therapy cost in the EI group was lower than that of the II group ($1351.72 ± 120.39 vs. $1782.04 ± 164.51, p = 0.001). However, the clinical success rate, clinical failure rate, and drug-related adverse events did not significantly differ between groups. EI treatment with piperacillin/tazobactam was a cost-effective approach to the management of HAP, being equally clinically effective to conventional II.

Telavancin in the treatment of Staphylococcus aureus hospital-acquired and ventilator-associated pneumonia: clinical evidence and experience.

Telavancin (TLV) is a lipoglycopeptide derivative of vancomycin (VAN), which has activity against Gram-positive aerobic bacteria, and is especially effective against methicillin-resistant Staphylococcus aureus (MRSA) and Gram-positive bacteria resistant to VAN. Comparative clinical studies of TLV have demonstrated noninferiority compared with VAN in the treatment of hospital-acquired Gram-positive pneumonia, with high cure rates for TLV-treated patients with monomicrobial S. aureus infection, including isolates with reduced VAN susceptibility. The results based on the patients' clinical response were supported by supplemental post-hoc analyses of 28-day mortality. In Europe and the USA, TLV is approved as a useful alternative for patients with difficult-to-treat, hospital-acquired MRSA pneumonia when there are very few alternatives. The present article reviews TLV's pharmacological characteristics and clinical efficacy resulting from clinical trials giving a detailed picture of its properties and position in the management of hospital-acquired pneumonia.

The predictive rule for the management of hospital-acquired pneumonia in adults by the Japanese Respiratory Society, I-ROAD, could correctly estimate the severity of Pneumcystis Pneumonia without human immunodeficiency virus infection

The predictive rule for the management of hospital-acquired pneumonia in adults by the Japanese Respiratory Society, I-ROAD, could correctly estimate the severity of Pneumcystis Pneumonia without human immunodeficiency virus infection

Clinical efficacy of carbapenems on hospital-acquired pneumonia in accordance with the Japanese Respiratory Society Guidelines for management of HAP

Hospital-acquired pneumonia (HAP) is the second most common cause of hospital-acquired infection and is the leading cause of death. In 2002, the Japanese Respiratory Society (JRS) published guidelines for the diagnosis and treatment of HAP (JRS GL 2002). In these guidelines, treatment with carbapenems is recommended for all disease types of HAP, excluding cases of mild or moderate pneumonia with no risk factors, and cases with early-onset ventilation-acquired pneumonia. To evaluate the efficacy of carbapenems on HAP in accordance with JRS GL 2002, we conducted a prospective study of HAP patients treated with carbapenems based on JRS GL 2002. The results of this study were also analyzed based on the revised guidelines published in June 2008 (JRS GL 2008), and the validity of the new guidelines was examined. Of the 33 subjects, 19 were judged as responders to the treatment, corresponding to a response rate of 57.6%. There were 3 deaths, corresponding to a mortality rate of 9.1%. The efficacy of carbapenems for the treatment of HAP based on JRS GL 2002 was confirmed. The severity rating system in JRS GL 2002 has a tendency to overestimate the severity of the cases and may lead to overtreatment in some cases. On the other hand, the severity rating system by JRS GL 2008 seemed to be more accurate and closely correlated with the efficacy of the treatment. It is suggested that JRS GL 2008 is more useful in clinical practice for accurately judging the severity of the disease and initiating appropriate subsequent antibiotic therapy.

Comment on: Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy

Sir, I appreciated the recent and very comprehensive guidelines for managing hospital-acquired pneumonia by Masterton et al. Malnutrition can greatly increase pneumonia morbidity and mortality rates in both children and adults. Malnutrition is responsible for an estimated 52% of the 2 million impoverished children who die annually worldwide due to pneumonia. However, the relationship between malnutrition and pneumonia in adults in the developed world is often overlooked. Various studies have reported malnutrition for hospitalized elderly to range from 42% to 91% in the developed world. Several studies have reported that rates of both hospital-acquired pneumonia and nosocomial infections, in general, are significantly higher in malnourished versus well-nourished patients. A study of 578 nursing home elderly reported that rates of both pneumonia infection and antibiotic consumption were significantly higher in residents with low serum zinc levels. Many acutely ill patients require enteral tube feeding, which may present some aspiration risk. A study of 4049 mechanically ventilated patients reported that enteral feeding within 48 h of intubation was associated with a significant reduction in hospital mortality (27.8% versus 34.2%, P 1⁄4 0.0005), even though rates of aspiration pneumonia were increased (12.6% versus 9.5%, P 1⁄4 0.007) when compared with patients who received later enteral feeding. Use of ‘immunonutrition’ enteral formulas containing omega 3 fatty acids and extra levels of glutamine, zinc, copper, selenium and vitamins may reduce the risk of pneumonia among the acutely ill. Meta-analysis of 11 studies reported that the use of such ‘immunonutrition’ formulas was associated with a 46% reduced risk of hospital-acquired pneumonia when compared with standard formulas (P 1⁄4 0.007). A study of 165 mechanically ventilated patients with severe sepsis reported that use of an enteral formula with omega 3 fatty acids and extra vitamins was associated with significantly lower mortality and significantly fewer days on mechanical ventilation when compared with patients on standard formula. Good nutrition can play a major role in preventing and treating hospital-acquired pneumonia. Much more research on the relationship between nutrition and pneumonia should be published and the results incorporated into future pneumonia guidelines.

Management of Hospital-Acquired Pneumonia

Management of Hospital-Acquired Pneumonia

Management of Hospital-Acquired Pneumonia in Adults

Target Audience: Internists, pulmonologists, critical care specialists, and infectious diseases specialistsSponsoring Organizations: The American

Clinical effect of intravenous ciprofloxacin on hospital-acquired pneumonia

The effect of intravenous ciprofloxacin (CPFX) on hospital-acquired pneumonia was examined. The subjects were 32 patients with hospital-acquired pneumonia classified as being in group I, group II, and group III, based on The Japanese Respiratory Society Guidelines for management of hospital-acquired pneumonia. None of the patients had received antibiotic treatment for the pneumonia. CPFX 300 mg was intravenously infused twice daily for 3-14 days, and its clinical effect, bacterological effect, and side effects were examined. Intravenous CPEX was clinically effective in 21 of the 32 patients, with an efficacy rate of 65.6%. With regard to bacteriological efficacy, 4 of 5 strains of methicillin-sensitive Staphylococcus aureus, 2 of 3 strains of Klebsiella pneumoniae, 1 of 2 strains of Streptococcus pneumoniae, 1 of 2 strains of Streptococcus agalactiae, 1 of 2 strains of Pseudomonas aeruginosa, 1 of 2 strains of Serratia marcescens, and the 1 strain of Klebsiella oxytoca were eradicated, with an eradication rate of 42.3% (11 of 26 strains whose fate was confirmed eradicated). Abnormal laboratory findings (side effects) were observed in 11 of the 32 patients (34.4%), but all side effects were mild. Based on the above data, intravenous CPFX may be the drug which should be recommended as the first choice for hospital-acquired pneumonia.

Management of hospital-acquired pneumonia

Management of hospital-acquired pneumonia