Risk Factors For Drug-resistant Pathogens Research Articles

2187. Validation of Local Risk Factors for Antibiotic-resistant Pathogens in Community-acquired Pneumonia at an Urban Community-based Medical Center

Abstract Background The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend to abandon the term healthcare-associated pneumonia (HCAP) and to base the use of broad-spectrum antibiotics on local epidemiology and risk factors. Jamaica, NY represents a unique population of ethnically diverse, largely immigrant patients. Several nursing homes, an international airport, along with a low socioeconomic status population feed into the hospital. The purpose of this study is to determine prevalent risk factors for drug-resistant pathogens (DRP) in CAP within an urban population. The secondary objective is to validate the Drug Resistance in Pneumonia (DRIP) score in this population. Methods A retrospective study was conducted on adults admitted from August 2018-December 2019 with a diagnosis of CAP, including aspiration pneumonia. Patients with a DRP respiratory culture (collected within 48 hours of admission) were selected, the next consecutively admitted patient with a non-resistant culture was included as a control. Results A total of 227 patients were included (114 in the DRP group and 113 in the control group). The DRP group had more patients with tracheostomies (30% vs 3%, p < .001) and chronic pulmonary disease (37% vs 16%, p < .001) (Table 1). Approximately 40% of the DRP patients were admitted from a long term care (LTC) facility compared to 8.8% in the control group (p < .001). Isolation of P. aeruginosa was not associated with LTC residence (Odds Ratio: 0.75) in our population (Table 2). All DRIP score components were associated with the isolation of DRP in our patient population, except for methicillin-resistant S. aureus (MRSA) colonization (Table 3). In our population 50% of the DRP had a DRIP score < 3. DRIP scores > 2, > 3 and > 4 had low negative predictive values (NPV) for the isolation of DRP in CAP (71.9%, 67.4% and 64.2%, respectively). Conclusion Demographic risk factors may exist for DRP in CAP, e.g. tracheostomy, pulmonary disease. Using a DRIP score cut off of > 4 missed 50% of the DRP in our study population. Despite a DRIP score > 4 having a specificity of 90.3%, with a NPV of 64.2% this scoring tool may underestimate the prevalence of DRP in our patient population. Based on our findings, institutions should consider local validation of the DRIP score prior to implementing use at their site. Disclosures All Authors: No reported disclosures.

Новая высокодозная форма амоксициллина/клавуланата в терапии острых инфекций дыхательных путей и лор-органов у детей

A significant growth of bacterial resistance to antimicrobial agents has been reported globally over the past decades. Pneumococcus and Haemophilus influenzae are the major respiratory and ENT pathogens among children in the Russian Federation. To date, the problem of rational and effective bacterial respiratory tract infections therapy remains unsettled. The emergence of the new high-dose amoxicillin with clavulanate provides additional opportunities for respiratory disease therapy in children with risk factors for drug-resistant pathogens.

Risk factors for drug-resistant pathogens in immunocompetent patients with pneumonia: Evaluation of PES pathogens.

The new acronym, PES pathogens (Pseudomonas aeruginosa, Enterobacteriaceae extended-spectrum beta-lactamase-positive, and methicillin-resistant Staphylococcus aureus), was recently proposed to identify drug-resistant pathogens associated with community-acquired pneumonia. To evaluate the risk factors for antimicrobial-resistant pathogens in immunocompetent patients with pneumonia and to validate the role of PES pathogens. A retrospective analysis of a prospective observational study of immunocompetent patients with pneumonia between March 2009 and June 2015 was conducted. We clarified the risk factors for PES pathogens. Of the total 1559 patients, an etiological diagnosis was made in 705 (45.2%) patients. PES pathogens were identified in 51 (7.2%) patients, with 53 PES pathogens (P.aeruginosa, 34; ESBL-positive Enterobacteriaceae, 6; and MRSA, 13). Patients with PES pathogens had tendencies toward initial treatment failure, readmission within 30 days, and a prolonged hospital stay. Using multivariate analysis, female sex (adjusted odds ratio [AOR] 1.998, 95% confidence interval [CI] 1.047-3.810), admission within 90 days (AOR 2.827, 95% CI 1.250-6.397), poor performance status (AOR 2.380, 95% CI 1.047-5.413), and enteral feeding (AOR 5.808, 95% CI 1.813-18.613) were independent risk factors for infection with PES pathogens. The area under the receiver operating characteristics curve for the risk factors was 0.66 (95% CI 0.577-0.744). We believe the definition of PES pathogens is an appropriate description of drug-resistant pathogens associated with pneumonia in immunocompetent patients. The frequency of PES pathogens is quite low. However, recognition is critical because they can cause refractory pneumonia and different antimicrobial treatment is required.

Empiric antibiotic selection and risk prediction of drug-resistant pathogens in community-onset pneumonia.

Empiric antibiotic selection in community-onset pneumonia is complicated by uncertainty regarding risk of drug-resistant pathogens (DRPs). The healthcare-associated pneumonia (HCAP) criteria have limited predictive value and lead to unnecessary antibiotic use. Better methods of predicting risk of DRP and selecting empiric antibiotics are needed. Here we give an update on risk factors for DRP, available risk prediction models, and treatment strategy in patients with pneumonia. Evidence supporting factors that contribute to risk of DRP has improved since the advent of HCAP. Many of these risk factors have been reproducibly identified in heterogeneous populations. Newer methods of predicting DRP based on these factors demonstrate better performance than HCAP. Recent innovations include the potential to discriminate between risk for methicillin-resistant Staphylococcus aureus and other DRP, and use of severity as a modifier of treatment threshold. However, there is wide variation in included predictor variables, and at proposed thresholds most scores still favor overtreatment. Until reliable molecular diagnostics are available, additional development and validation of decision support models integrating local resistance rates, estimated DRP risk, severity, and threshold for anti-DRP antibiotics are needed. Once optimized models are identified, implementation studies will be needed to confirm safety and efficacy.

Healthcare-associated Pneumonia

Background:Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis.Methods:Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk).Results:Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP.Conclusion:Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality.

Risk Factors for Drug-Resistant Pathogens in Community-acquired and Healthcare-associated Pneumonia

Identification of patients with drug-resistant pathogens at initial diagnosis is essential for treatment of pneumonia. To elucidate clinical features of community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP), and to clarify risk factors for drug-resistant pathogens in patients with CAP and HCAP. A prospective observational study was conducted in hospitalized patients with pneumonia at 10 institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin-sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP drug-resistant pathogens (CAP-DRPs). In total, 1,413 patients (887 CAP and 526 HCAP) were analyzed. CAP-DRPs were more frequently found in patients with HCAP (26.6%) than in patients with CAP (8.6%). Independent risk factors for CAP-DRPs were almost identical in patients with CAP and HCAP. These included prior hospitalization (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.23-3.43), immunosuppression (AOR, 2.31; 95% CI, 1.05-5.11), previous antibiotic use (AOR, 2.45; 95% CI, 1.51-3.98), use of gastric acid-suppressive agents (AOR, 2.22; 95% CI, 1.39-3.57), tube feeding (AOR, 2.43; 95% CI, 1.18-5.00), and nonambulatory status (AOR, 2.45; 95% CI, 1.40-4.30) in the combined patients with CAP and HCAP. The area under the receiver operating characteristic curve for counting the number of risk factors was 0.79 (95% CI, 0.74-0.84). The clinical profile of HCAP was different from that of CAP. However, physicians can predict drug resistance in patients with either CAP or HCAP by taking account of the cumulative number of the risk factors. Clinical trial registered with https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000004001&language=E ; number UMIN000003306.

Community-Acquired Pneumonia with Risk for Drug-Resistant Pathogens

Pneumonia is a leading infectious cause of morbidity and mortality in the United States. The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) have published treatment guidelines for community-acquired pneumonia (CAP) based upon the site of acquisition and specific pathogen risk. The literature demonstrates improved outcomes with guideline-concordant empiric therapy. A subset of patients with CAP has risk factors for drug-resistant pathogens (DRPs). IDSA/ATS treatment guidelines do not provide clear recommendations for empiric treatment, and clinical studies have not provided descriptive data for this group. A retrospective chart review of all admissions between January 1, 2008 and April 19, 2009 with an International Classification of Diseases-9 code and physician-documented diagnosis of pneumonia at two community hospitals were performed. IDSA pneumonia type and presence of risk factors for DRP were recorded for each patient, and the empiric antibiotic therapy received was evaluated. Admissions were excluded if immunosuppression or pregnancy was present. Of the 400 admissions reviewed, 343 patients were included. A total of 228 patients (71%) had CAP. Forty-three percent of patients with CAP had risk factors for DRP. Only 2% of this group received an antibiotic regimen with coverage of the specific DRP risk factor present. The most common DRPs not receiving coverage in this group were Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. P. aeruginosa and methicillin-resistant S. aureus occurred more commonly in culture-positive patients with CAP with DRP risk factors but did not achieve statistical significance. A larger sample size would be needed to determine whether this difference is significant. Risk factors for DRP occurred commonly in our CAP population. Patients with CAP with risk for DRP may be a distinct group who are without clear guidance on treatment. Future studies are needed to define the risk of DRP and the impact upon empiric therapy for patients with CAP.