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Best therapy of healthcare-associated pneumonia: narrow vs broad spectrum antimicrobials?
Michele Bartoletti Infectious Diseases Unit S. Orsola Teaching Hospital
ESCMID COURSE - Ferney-Voltaire (France) November 5 -6 2015
“Moving antimicrobial stewardship forward in special patient populations”
A New Strategy for Healthcare-Associated Pneumonia: A 2-Year Prospective MulticenterCohort Study Using Risk Factors for Multidrug- Resistant Pathogens to Select InitialEmpiric Therapy. T.Maruyama et al. Clin Infect Dis 2013
124 CAP
321 HCAP
n=110 n=92 n=41 n=78
93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, 92.9% received appropriate therapy for the identified pathogen
De-escalation therapy among bacteraemic patients withcommunity-acquired pneumonia
Carugati M Clin Microbiol Infect 2015; 21: 936.e11–936.e18
METHODS:Secondary analysis of the Community-Acquired Pneumonia Organization database
DET was defined as changing an appropriate empirical broad-spectrum regimen toa narrower-spectrum regimen according to culture results within 7 days from hospital admission
Study population: 261 patients with bacteriemic CAP
165 DET gropup 96 N-DET gropup
There was a significantly lower 30-day mortality rate in the DET group than in the N-DET group in univariate analysis ( 15.1% vs. 25.0%, p 0.04)
After adjustment for confounders, DET was not associated with an increased risk of 30-day mortality RR 0.78 (95% CI 0.47–1.27), p 0.32)
Safety and clinical outcomes of carbapenem de-escalation as part ofan antimicrobial stewardship programme in an ESBL-endemic setting
Lew KY et al JAC. 2015 Apr;70(4):1219-25
Criteria for de-escalation
Empirical therapy Definitive therapy
•Afebrile
•Not on inotropes
•Systolic blood pressure returned to baseline
•Not mechanically ventilated or fraction of inspired oxygen ≤0.4
•Respiratory rate < 25 bpm
Microbiology-driven
Patients receiving meropenem or imipenem underwent a prospective ASP review for eligibility for de-escalation.
Patients in whom carbapenem was de-escalated or not de-escalated, representing the acceptance and rejection of the ASP recommendation, respectively, were compared
Predictive Value of Methicillin-Resistant Staphylococcusaureus (MRSA) Nasal Swab PCR Assay for MRSA Pneumonia
Dangerfield B. et alAntimicrob Agents Chemother. 2014;58(2):859-64
All patients with confirmed pneumonia who had both a nasal swab MRSA PCR test and a bacterial culture within predefined time intervals were included in the study
435 patients enrolled
54% cases were calssified as HCAP
14% of cases had a nasal swab culturepositive for MRSA
5.7% of cases had bloodculture or sputum positive for MRSA
Ability of nasal swab MRSA PCR assay in predicting MRSA pneumonia
Association Between Hospitalization With Community-Acquired Laboratory-Confirmed Influenza Pneumonia andPrior Receipt of Influenza Vaccination
Grijalva G et al JAMA. 2015;314(14):1488-1497.
METHODSThe Etiology of Pneumonia in the Community (EPIC) study was a prospectiveobservational multicenter study of hospitalizations for community-acquiredpneumonia
In this case-control study, authors used EPIC data from patients 6 months or older withlaboratory-confirmed influenza infection and verified vaccination status during theinfluenza seasons
RESULTSOverall, 2767 patients hospitalized for pneumonia were eligible for the study; 162(5.9%) had laboratory-confirmed influenza. Twenty-eight of 162 cases (17%) withinfluenza-associated pneumonia and 766 of 2605 controls (29%) with influenza-negativepneumonia had been vaccinated.
The adjusted odds ratio of prior influenza vaccination between cases and controlswas 0.43 (95% CI, 0.28-0.68; estimated vaccine effectiveness, 56.7%; 95% CI, 31.9%-72.5%).