Duration Of Antibiotic Therapy For Outpatients And Inpatients With Cap
The optimal duration of antibiotic therapy for the treatment of CAP has yet to be definitively established. Short-term antibiotic therapy seems to be the most appropriate, given that it provides less patient exposure to the effects of antibiotics, reduces the occurrence of adverse effects, reduces the development of drug resistance by microorganisms, improves patient adherence, and can minimize length of hospital stay and financial costs. In addition, very long-term treatments favor the development of bacterial resistance and the occurrence of potentially severe adverse effects, such as infections with Clostridium difficile. However, short-term treatment should be as effective as longer-term treatments in terms of rates of mortality, complications, and disease recurrence.
Recommendations regarding the optimal duration of antibiotic therapy have changed over time, and there are discrepancies on this issue across guidelines .
Question 1: In Adults With Cap Who Test Positive For Influenza Should The Treatment Regimen Include Antiviral Therapy
Recommendation
We recommend that antiinfluenza treatment, such as oseltamivir, be prescribed for adults with CAP who test positive for influenza in the inpatient setting, independent of duration of illness before diagnosis .
We suggest that antiinfluenza treatment be prescribed for adults with CAP who test positive for influenza in the outpatient setting, independent of duration of illness before diagnosis .
Summary of the evidence
No clinical trials have evaluated the effect of treatment with antiinfluenza agents in adults with influenza pneumonia, and data are lacking on the benefits of using antiinfluenza agents in the outpatient setting for patients with CAP who test positive for influenza virus. Several observational studies suggest that treatment with oseltamivir is associated with reduced risk of death in patients hospitalized for CAP who test positive for influenza virus . Treatment within 2 days of symptom onset or hospitalization may result in the best outcomes , although there may be benefits up to 4 or 5 days after symptoms begin .
The use of antiinfluenza agents in the outpatient setting reduces duration of symptoms and the likelihood of lower respiratory tract complications among patients with influenza , with most benefit if therapy is received within 48 hours after onset of symptoms .
Rationale for the recommendation
Research needed in this area
Recurrent C Difficile Infection:
a View renal dosing hereb Non-severe reaction: simple rash, intolerance or unknown. c Severe reaction: Those with clear Ig-E mediated reaction including Anaphylaxis, Angioedema, Wheezing, Laryngeal edema, Hives/urticaria or those with severe non-IgE mediated reactions including Serum sickness, Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, Acute Interstitial Nephritis , Drug Rash Eosinophilia Systemic Symptoms Syndrome, Hemolytic anemia.
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Study Setting Design And Participants
We conducted a multicenter, retrospective study on hospitalized patients with CAP aged 65 years or older data were extracted from the CAP-China network. Data of patients that met the inclusion and exclusion criteria were collected from 13 centers in seven cities in three provinces between January 1, 2014, and December 31, 2014 . The study was approved by the Human Subject Protection Program Institutional Review Board at China-Japan Friendship Hospital. Additional approval obtained from the local institutional review board of each participating hospital. Patient consent was waived owing to the retrospective study design. The initial antimicrobial regimen for each patient was evaluated and categorized as concordance, overtreatment, or undertreatment according to the 2016 Chinese CAP guidelines as previously described.6 Guideline-concordant patients admitted to the general ward constituted the main research population in this study. The following treatment regimens are recommended for patients with CAP aged 65 years who require non-ICU hospitalization: 1) penicillin/-lactamase-inhibitor combinations 2) third-generation cephalosporins or their enzyme inhibitor combinations, cephamycins, oxycephalosporins, carbapenems such as ertapenem 3) monotherapy of the above drugs or in combination with macrolides and 4) respiratory quinolones. All the detailed antimicrobial regimes are available from supplementary material .
Cost Of Antimicrobial Therapy
Economic pressures have accentuated the focus on reducing health care costs and utilizing resources while maintaining or improving quality of care.31 These pressures are exacerbated by the growing resistance of S. pneumoniae to penicillin.31,32 This pattern of resistance increases the cost of treatment because of prolonged hospitalization, relapses, and the use of more expensive antibacterial agents.3337
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D Necrotizing Skin And Soft Tissue Infection
- May be caused by Group A streptococci or mixed aerobes/anaerobes or other rare etiologies
- Urgent Infectious Diseases and Surgical consultation is strongly suggested in all suspected cases
Microbiological Diagnostic Evaluation In The Hospital
It is recommended in the German guideline that, as soon as a patient is hospitalized for CAP, blood cultures should be drawn , Legionella and pneumococcal antigens should be measured in the urine, and purulent sputum should be examined microscopically and cultured . If the epidemiological setting is suggestive, patients with severe CAP should also be tested for influenza viruses with the polymerase chain reaction . If mycoplasma pneumonia is suspected, mycoplasma IgM or PCR can be measured however, the measurement of mycoplasma IgG and IgA is of no diagnostic value, and Chlamydia serology is of no diagnostic value either . If there is a pleural effusion that can be punctured and aspirated, a rapid diagnostic puncture followed by microbiological evaluation and pH measurement is indicated.
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Question : Should A Clinical Prediction Rule For Prognosis Plus Clinical Judgment Versus Clinical Judgment Alone Be Used To Determine Inpatient General Medical Versus Higher Levels Of Inpatient Treatment Intensity For Adults With Cap
Recommendation
We recommend direct admission to an ICU for patients with hypotension requiring vasopressors or respiratory failure requiring mechanical ventilation .
For patients not requiring vasopressors or mechanical ventilator support, we suggest using the IDSA/ATS 2007 minor severity criteria together with clinical judgment to guide the need for higher levels of treatment intensity .
Summary of the evidence
The PSI and CURB-65 were not designed to help select the level of care needed by a patient who is hospitalized for CAP. Several prognostic models have been designed to predict the need for higher levels of inpatient treatment intensity using severity-of-illness parameters based on patient outcomes . Studies of prognostic models have used different end points, including inpatient mortality , ICU admission , receipt of intensive respiratory or vasopressor support , or ICU admission plus receipt of a critical therapy . In comparative studies, these prognostic models yield higher overall accuracy than the PSI or CURB-65 when using illness outcomes other than mortality .
Rationale for the recommendation
Research needed in this area
Controlled studies are needed to study the effectiveness and safety of using illness severity tools as decision aids to guide the intensity of treatment in adults hospitalized for pneumonia.
B Empiric Therapy For Patients Who Require Inpatient Management
- Obtain urine culture to confirm susceptibility
- First-line empiric therapy*:
- Ceftriaxone 1g IV Q24H +/- Ampicillin 2 g IV Q6H
- Step down to appropriate oral antibiotics when patient is afebrile and hemodynamically stable, based on culture and susceptibility results
- Usual duration of therapy is 7 days for uncomplicated pyelonephritis complicated infections require 10-14 days of therapy and occasionally longer, in consultation with Urology and Infectious Diseases
*Suggest coverage for extended-spectrum beta-lactamase producing organisms in the following circumstances:
- Known ESBL colonization
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Study Design And Subjects
A secondary analysis of the Community-Acquired Pneumonia Organization database was performed. The database contains data retrospectively collected from 43 hospitals in 12 countries, between June 2001 and June 2005. In each participating centre, primary investigators selected adult nonconsecutively hospitalised patients diagnosed with CAP. All data were collected on a case report form and transferred electronically to the CAPO coordinating centre at the University of Louisville . Local institutional review board approval was obtained for each study site.
Diagnosis And Treatment Of Community
M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S., University of Illinois College of Medicine at Rockford, Rockford, Illinois
STEPHANIE WESSEL REYBURN, M.D., M.P.H., Mayo School of Graduate Medical Education, Rochester, Minnesota
Am Fam Physician. 2006 Feb 1 73:442-450.
Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneumonia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Consensus guidelines from several organizations recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline. Patients who are hospitalized should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to tolerate oral medications. Clinical pathways are important tools to improve care and maximize cost-effectiveness in hospitalized patients.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Patients with suspected community-acquired pneumonia should receive chest radiography.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Patients with suspected community-acquired pneumonia should receive chest radiography.
Overview of Community-Acquired Pneumonia
Definition
Definition
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Clinical Response And Duration Of Therapy
Duration of total, intravenous and oral antibiotic therapy is depicted in , based on the day in which patients reached clinical stability. Using a regression analysis, a linear relationship was found between TCS and duration of intravenous antibiotic therapy . Conversely, no linear relationship was identified between TCS and neither the duration of oral antibiotic therapy nor the total duration of antibiotic therapy .
Relationship between time to clinical stability and the mean duration of total , intravenous and oral antibiotic therapy in the study population, with p-values for linear trend.
When we applied logistic regression in order to identify variables that could potentially discriminate between a total duration of therapy < 10 days versus 10 days, neither TCS nor any other findings were found to be significantly associated with total duration of therapy .
Question 1: In The Inpatient Setting Should Adults With Cap And Risk Factors For Mrsa Or P Aeruginosa Be Treated With Extended
Recommendation
We recommend abandoning use of the prior categorization of healthcare-associated pneumonia to guide selection of extended antibiotic coverage in adults with CAP .
We recommend clinicians only cover empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present . Empiric treatment options for MRSA include vancomycin or linezolid . Empiric treatment options for P. aeruginosa include piperacillin-tazobactam , cefepime , ceftazidime , aztreonam , meropenem , or imipenem .
If clinicians are currently covering empirically for MRSA or P. aeruginosa in adults with CAP on the basis of published risk factors but do not have local etiological data, we recommend continuing empiric coverage while obtaining culture data to establish if these pathogens are present to justify continued treatment for these pathogens after the first few days of empiric treatment .
Summary of the evidence
Unfortunately, no validated scoring systems exist to identify patients with MRSA or P. aeruginosa with sufficiently high positive predictive value to determine the need for empiric extended-spectrum antibiotic treatment. Scoring system development and validation are complicated by varying prevalence of MRSA and P. aeruginosa in different study populations. Moreover, no scoring system has been demonstrated to improve patient outcomes or reduce overuse of broad-spectrum antibiotics.
Rationale for the recommendation
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Question : Should A Clinical Prediction Rule For Prognosis Plus Clinical Judgment Versus Clinical Judgment Alone Be Used To Determine Inpatient Versus Outpatient Treatment Location For Adults With Cap
Recommendation
In addition to clinical judgement, we recommend that clinicians use a validated clinical prediction rule for prognosis, preferentially the Pneumonia Severity Index over the CURB-65 , to determine the need for hospitalization in adults diagnosed with CAP.
Summary of the evidence
Both the PSI and CURB-65 were developed as prognostic models in immunocompetent patients with pneumonia, using patient demographic and clinical variables from the time of diagnosis to predict 30-day mortality . When compared with CURB-65, PSI identifies larger proportions of patients as low risk and has a higher discriminative power in predicting mortality .
Two multicenter, cluster-randomized trials demonstrated that use of the PSI safely increases the proportion of patients who can be treated in the outpatient setting . These trials and one additional randomized controlled trial support the safety of using the PSI to guide the initial site of treatment of patients without worsening mortality or other clinically relevant outcomes . Consistent evidence from three prepost intervention studies and one prospective controlled observational study support the effectiveness and safety of using the PSI to guide the initial site of treatment .
The PSI may underestimate illness severity among younger patients and oversimplify how clinicians interpret continuous variables . Therefore, when used as a decision aid, the PSI should be used in conjunction with clinical judgment.
Outpatient Vs Inpatient Treatment
Choosing between outpatient and inpatient treatment is a crucial decision because of the possible risk of death.9,15,16 This decision not only influences diagnostic testing and medication choices, it can have a psychological impact on patients and their families. On average, the estimated cost for inpatient care of patients with CAP is $7,500. Outpatient care can cost as little as $150 to $350.1719 Hospitalization of a patient should depend on patient age, comorbidities, and the severity of the presenting disease.9,20
Physicians tend to overestimate a patients risk of death14 therefore, many low-risk patients who could be safely treated as out-patients are admitted for more costly inpatient care. The Pneumonia Severity Index was developed to assist physicians in identifying patients at a higher risk of complications and who are more likely to benefit from hospitalization.9,15,16 Investigators developed a risk model based on a prospective cohort study16 of 2,287 patients with CAP in Pittsburgh, Boston, and Halifax, Nova Scotia. By using the model, the authors found that 26 to 31 percent of the hospitalized patients were good outpatient candidates, and an additional 13 to 19 percent only needed brief hospital observation. They validated this model using data17 from more than 50,000 patients with CAP in 275 U.S. and Canadian hospitals.1517,21,22
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Inpatient |
Information from reference 15.
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Diagnosis And Management Of Community
RICHARD R. WATKINS, MD, MS, Akron General Medical Center, Akron, Ohio
TRACY L. LEMONOVICH, MD, University Hospitals Case Medical Center, Cleveland, Ohio
Am Fam Physician. 2011 Jun 1 83:1299-1306.
Community-acquired pneumonia is a significant cause of morbidity and mortality in adults. CAP is defined as an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other recent contact with the health care system. Table 1 includes common etiologies of CAP.13 This article discusses the important studies and guidelines for CAP that have been published since the topic was last reviewed in American Family Physician.4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
In patients with clinically suspected CAP, chest radiography should be obtained to confirm the diagnosis.
| Clinical recommendations | ||
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Evaluation for specific pathogens that would alter standard empiric therapy should be performed when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues this testing usually is not required in outpatients. |
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Mortality and severity prediction scores should be used to determine inpatient versus outpatient care for patients with CAP. |
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All patients with CAP who are admitted to the intensive care unit should be treated with dual therapy. |
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Prevention of CAP should focus on universal influenza vaccination and pneumococcal vaccination for patients at high risk of pneumococcal disease. |
Duration Of Antibiotic Treatment And Follow
- Antibiotic treatment in patients who are improving should be continued until the patient achieves stability and for no less than a total of 5 days
- Evidence of clinical stability includes
- Resolution and stabilization of vital signs
- Ability to eat
- Normal mentation
- Based on the literature, patients with lung cancer would have been candidates for routine screening and were generally current or ex-smokers
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Initiative Improves Antibiotic Prescribing For Community
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An initiative launched in dozens of Michigan hospitals more than doubled the rate of appropriate antibiotic prescribing for patients hospitalized with community-acquired pneumonia, researchers reported.
Such patients often receive more than 5 days of antibiotic treatment, resulting in a higher risk for adverse events, the researchers said.
Valerie M. Vaughn
Since 2017, weve been seeking to improve care for hospitalized patients with infections. We found that patients often receive antibiotic therapy in excess of what they need and that this can lead to immediate, direct patient harm in terms of adverse events but also in long-term harm, like antibiotic resistance,Valerie M. Vaughn, MD, MSc, assistant professor of medicine and director of hospital medicine research at the University of Utah School of Medicine, told Healio.
So, we wanted to help hospitals improve their antibiotic prescribing, Vaughn said.
Vaughn and colleagues performed a prospective collaborative quality initiative that included patients hospitalized with uncomplicated community-acquired pneumonia who qualified for a 5-day antibiotic duration.
Most hospitalized patients with community-acquired pneumonia should get no more than 5 days of antibiotic therapy, Vaughn said.