Julio A. Ramirez

Clinical Efficacy of Intravenous followed by Oral Azithromycin Monotherapy in Hospitalized Patients with Community-Acquired Pneumonia

ABSTRACT The purpose of this study was to evaluate intravenous (i.v.) azithromycin followed by oral azithromycin as a monotherapeutic regimen for community-acquired pneumonia (CAP). Two trials of i.v. azithromycin used as initial monotherapy in hospitalized CAP patients are summarized. Clinical efficacy is reported from an open-label randomized trial of azithromycin compared to cefuroxime with or without erythromycin. Bacteriologic and clinical efficacy results are also presented from a noncomparative trial of i.v. azithromycin that was designed to give additional clinical experience with a larger number of pathogens. Azithromycin was administered to 414 patients: 202 and 212 in the comparative and noncomparative trials, respectively. The comparator regimen was used as treatment for 201 patients; 105 were treated with cefuroxime alone and 96 were given cefuroxime plus erythromycin. In the comparative trial, clinical outcome data were available for 268 evaluable patients with confirmed CAP at the 10- to 14-day visit, with 106 (77%) of the azithromycin patients cured or improved and 97 (74%) of the comparator patients cured or improved. Mean i.v. treatment duration and mean total treatment duration (i.v. and oral) for the clinically evaluable patients were significantly (P < 0.05) shorter for the azithromycin group (3.6 days for the i.v. group and 8.6 days for the i.v. and oral group) than for the evaluable patients given cefuroxime plus erythromycin (4.0 days for the i.v. group and 10.3 days for the i.v. and oral group). The present comparative study demonstrates that initial therapy with i.v. azithromycin for hospitalized patients with CAP is associated with fewer side effects and is equal in efficacy to a 1993 American Thoracic Society-suggested regimen of cefuroxime plus erythromycin when the erythromycin is deemed necessary by clinicians.

Adults Hospitalized With Pneumonia in the United States: Incidence, Epidemiology, and Mortality

BackgroundnUnderstanding the burden of community-acquired pneumonia (CAP) is critical to allocate resources for prevention, management, and research. The objectives of this study were to define incidence, epidemiology, and mortality of adult patients hospitalized with CAP in the city of Louisville, and to estimate burden of CAP in the US adult population.nnnMethodsnThis was a prospective population-based cohort study of adult residents in Louisville, Kentucky, from 1 June 2014 to 31 May 2016. Consecutive hospitalized patients with CAP were enrolled at all adult hospitals in Louisville. The annual population-based CAP incidence was calculated. Geospatial epidemiology was used to define ecological associations among CAP and income level, race, and age. Mortality was evaluated during hospitalization and at 30 days, 6 months, and 1 year after hospitalization.nnnResultsnDuring the 2-year study, from a Louisville population of 587499 adults, 186384 hospitalizations occurred. A total of 7449 unique patients hospitalized with CAP were documented. The annual age-adjusted incidence was 649 patients hospitalized with CAP per 100000 adults (95% confidence interval, 628.2-669.8), corresponding to 1591825 annual adult CAP hospitalizations in the United States. Clusters of CAP cases were found in areas with low-income and black/African American populations. Mortality during hospitalization was 6.5%, corresponding to 102821 annual deaths in the United States. Mortality at 30 days, 6 months, and 1 year was 13.0%, 23.4%, and 30.6%, respectively.nnnConclusionsnThe estimated US burden of CAP is substantial, with >1.5 million unique adults being hospitalized annually, 100000 deaths occurring during hospitalization, and approximately 1 of 3 patients hospitalized with CAP dying within 1 year.

The order of administration of macrolides and beta-lactams may impact the outcomes of hospitalized patients with community-acquired pneumonia: results from the community-acquired pneumonia organization

Abstract Background: The beneficial effect of macrolides for the treatment of community-acquired pneumonia (CAP) in combination with beta-lactams may be due to their anti-inflammatory activity. In patients with pneumococcal meningitis, the use of steroids improves outcomes only if they are administered before beta-lactams. The objective of this study was to compare outcomes in hospitalized patients with CAP when macrolides were administered before, simultaneously with, or after beta-lactams. Methods: Secondary data analysis of the Community-Acquired Pneumonia Organization (CAPO) International Cohort Study database. Study groups were defined based on the sequence of administration of macrolides and beta-lactams. The study outcomes were time to clinical stability (TCS), length of stay (LOS) and in-hospital mortality. Accelerated failure time models were used to evaluate the adjusted impact of sequential antibiotic administration and time-to-event outcomes, while a logistic regression model was used to evaluate their adjusted impact on mortality. Results: A total of 99 patients were included in the macrolide before group and 305 in the macrolide after group. Administration of a macrolide before a beta-lactam compared to after a beta-lactam reduced TCS (3 vs. 4 days, pu2009=u2009.011), LOS (6 vs. 7 days, pu2009=u2009.002) and mortality (3 vs. 7.2%, pu2009=u2009.228). Conclusions: The administration of macrolides before beta-lactams was associated with a statistically significant decrease in TCS and LOS and a non-statistically significant decrease in mortality. The beneficial effect of macrolides in hospitalized patient with CAP may occur only if administered before beta-lactams.

Infection prevention and control and the refugee population: Experiences from the University of Louisville Global Health Center

Background: During 2016, approximately 140,000 individuals entered the United States as part of the federal government refugee resettlement program and established themselves in communities in virtually every state. No national database regarding refugee health currently exists; therefore, little is known about existing infectious diseases, conditions, and cultural practices that impact successful acculturation. The objective of this report is to identify what is currently known about refugees and circumstances important to infection prevention and control with respect to their roles as new community members, employees, and consumers of health care. Methods: Using data from the University of Louisville Global Health Centers Newly Arriving Refugee Surveillance System, health issues affecting refugees from the perspective of a community member, an employee, and a patient were explored. Results: Lack of immunity to vaccine‐preventable diseases is the most widespread issue impacting almost every adult, adolescent, and child refugee resettled in Kentucky. Health issues of concern from an infection prevention and control perspective include latent tuberculosis infection, HIV, hepatitis B, hepatitis C, syphilis, and parasites. Other health conditions that may also be important include anemia, obesity, oral health, diabetes, and cardiovascular disease. Conclusions: Refugee resettlement provides motivation for collaborative work among those responsible for infection prevention and control in all settings, their public health partners, and those responsible for and interested in community workforce concerns.

Individualizing duration of antibiotic therapy in community-acquired pneumonia

International experts suggest tailoring antibiotic duration in community-acquired pneumonia (CAP) according to patients characteristics. We aimed to assess the effectiveness of an individualized approach to antibiotic duration based on time in which CAP patients reach clinical stability during hospitalization. In a multicenter, non-inferiority, randomized, controlled trial hospitalized adult patients with CAP reaching clinical stability within 5 days after hospitalization were randomized to a standard vs. individualized antibiotic duration. In the Individualized group, antibiotics were discontinued 48xa0h after the patient reached clinical stability, with at least five days of total antibiotic treatment. Early failure within 30 days was the primary composite outcome. 135 patients were randomized to the Standard group and 125 to the Individualized group. The trial was interrupted by the safety committee because of an apparent inferiority of the Individualized group over the Standard treatment: 14 (11.2%) patients in the Individualized group experienced early failure vs. 10 (7.4%) patients in the Standard group, pxa0=xa00.200, at the intention-to-treat analysis. 30-day mortality rate was four-time higher in the Individualized group than the Standard group. Shortening antibiotic duration according to patients characteristics still remains an open question.

Macrolide therapy is associated with lower mortality in community-acquired bacteraemic pneumonia

BACKGROUNDnCommunity-acquired pneumonia (CAP) has a potential complication of bacteremia. The objective of this study was to define the clinical outcomes of patients with CAP and bacteremia treated with and without a macrolide.nnnMATERIALS AND METHODSnSecondary analysis of the Community-Acquired Pneumonia Organization database of hospitalized patients with CAP. Patients with a positive blood culture were categorized based on the presence or absence of a macrolide in their initial antimicrobial regimen, and severity of their CAP. Outcomes included in-hospital all-cause mortality, 30-day mortality, length of stay, and time to clinical stability.nnnRESULTSnAmong 549 patients with CAP and bacteremia, 247 (45%) were treated with a macrolide and 302 (55%) were not. The primary pathogen was Streptococcus pneumoniae (74%). Poisson regression with robust error variance models were used to compare the adjusted effects of each study group on the outcomes. The unadjusted 30-day mortality was 18.4% in the macrolide group, and 29.6% in the non-macrolide group (adjusted relative risk (aRR)0.81; 95% confidence interval (CI)0.50-1.33; Pu202f=u202f0.41). Unadjusted in-hospital all-cause mortality was 7.3% in the macrolide group, and 18.9% in the non-macrolide group (aRR 0.54, 95% CI 0.30-0.98; Pu202f=u202f0.043). Length of stay and time to clinical stability were not significantly different.nnnCONCLUSIONSnIn-hospital mortality, but not 30-day mortality, was significantly better in the macrolide group. Our data support the use of a macrolide in hospitalized patients with CAP and bacteraemia.

Future Research Directions in Pneumonia. NHLBI Working Group Report

&NA; Pneumonia is a complex pulmonary disease in need of new clinical approaches. Although triggered by a pathogen, pneumonia often results from dysregulations of host defense that likely precede infection. The coordinated activities of immune resistance and tissue resilience then dictate whether and how pneumonia progresses or resolves. Inadequate or inappropriate host responses lead to more severe outcomes such as acute respiratory distress syndrome and to organ dysfunction beyond the lungs and over extended time frames after pathogen clearance, some of which increase the risk for subsequent pneumonia. Improved understanding of such host responses will guide the development of novel approaches for preventing and curing pneumonia and for mitigating the subsequent pulmonary and extrapulmonary complications of pneumonia. The NHLBI assembled a working group of extramural investigators to prioritize avenues of host‐directed pneumonia research that should yield novel approaches for interrupting the cycle of unhealthy decline caused by pneumonia. This report summarizes the working groups specific recommendations in the areas of pneumonia susceptibility, host response, and consequences. Overarching goals include the development of more host‐focused clinical approaches for preventing and treating pneumonia, the generation of predictive tools (for pneumonia occurrence, severity, and outcome), and the elucidation of mechanisms mediating immune resistance and tissue resilience in the lung. Specific areas of research are highlighted as especially promising for making advances against pneumonia.

Methods for computational disease surveillance in infection prevention and control: Statistical process control versus Twitter's anomaly and breakout detection algorithms

HighlightsWe compared traditional Statistical Process Control (SPC) charts with novel Anomaly/Breakout Detection (ABD) charts using Twitters Anomaly and Breakout detection algorithms for detecting out of control or anomalous HAI data.ABD charts appeared to work better than SPC charts in the context of seasonality and autocorrelation, two well‐known statistical issues with HAI data.These new charts may be useful for trending of HAI data and for other quality improvement data monitoring.An open‐access web application is provided for users to apply their own datasets to generate ABD and SPC charts. Background: Although not all health care‐associated infections (HAIs) are preventable, reducing HAIs through targeted intervention is key to a successful infection prevention program. To identify areas in need of targeted intervention, robust statistical methods must be used when analyzing surveillance data. The objective of this study was to compare and contrast statistical process control (SPC) charts with Twitters anomaly and breakout detection algorithms. Methods: SPC and anomaly/breakout detection (ABD) charts were created for vancomycin‐resistant Enterococcus, Acinetobacter baumannii, catheter‐associated urinary tract infection, and central line‐associated bloodstream infection data. Results: Both SPC and ABD charts detected similar data points as anomalous/out of control on most charts. The vancomycin‐resistant Enterococcus ABD chart detected an extra anomalous point that appeared to be higher than the same time period in prior years. Using a small subset of the central line‐associated bloodstream infection data, the ABD chart was able to detect anomalies where the SPC chart was not. Discussion: SPC charts and ABD charts both performed well, although ABD charts appeared to work better in the context of seasonal variation and autocorrelation. Conclusions: Because they account for common statistical issues in HAI data, ABD charts may be useful for practitioners for analysis of HAI surveillance data.

Googling your hand hygiene data: Using Google Forms, Google Sheets, and R to collect and automate analysis of hand hygiene compliance monitoring

HighlightsWe created an easy‐to‐use, platform‐independent hand hygiene data collection process using Google Forms and Google Spreadsheets.Using R and RStudio Shiny, we built an online analytics engine to provide on‐demand, automated reporting directly from the Google Spreadsheet.By reducing the workload of data collection and analysis, more time may be spent on improving hand hygiene adherence. Background: Hand hygiene is one of the most important interventions in the quest to eliminate healthcare‐associated infections, and rates in healthcare facilities are markedly low. Since hand hygiene observation and feedback are critical to improve adherence, we created an easy‐to‐use, platform‐independent hand hygiene data collection process and an automated, on‐demand reporting engine. Methods: A 3‐step approach was used for this project: 1) creation of a data collection form using Google Forms, 2) transfer of data from the form to a spreadsheet using Google Spreadsheets, and 3) creation of an automated, cloud‐based analytics platform for report generation using R and RStudio Shiny software. Results: A video tutorial of all steps in the creation and use of this free tool can be found on our YouTube channel: https://www.youtube.com/watch?v=uFatMR1rXqU&t. The on‐demand reporting tool can be accessed at: https://crsp.louisville.edu/shiny/handhygiene. Conclusions: This data collection and automated analytics engine provides an easy‐to‐use environment for evaluating hand hygiene data; it also provides rapid feedback to healthcare workers. By reducing some of the data management workload required of the infection preventionist, more focused interventions may be instituted to increase global hand hygiene rates and reduce infection.

Long-term Mortality in Hospitalized Patients With Community-Acquired Pneumonia

In this issue of the American Journal of the Medical Sciences, Ajayi et al present data on the lifespan of 155 adults who recovered from an invasive pneumococcal pneumonia (IPD). These subjects were hospitalized between 1983 and 2003 and mortality rate was assessed for up to 32 years with a mean of 7 years after the episode of IPD. The authors reported increased longterm mortality in hospitalized patients with IPD with an estimated 10 years of potential life lost. This research adds to the body of evidence indicating that hospitalized patients with community-acquired pneumonia (CAP) have an increased rate of mortality, even several years after the initial episode. Various investigators have evaluated long-term mortality comparing hospitalized patients with CAP to patients hospitalized for other causes or controls from the general population. Although the study designs and follow-up periods differed among the studies, increased mortality compared to controls remained statistically significant even after adjusting for comorbidities including cardiovascular disease, chronic pulmonary disease, diabetes mellitus, renal disease, liver disease, neoplastic disease, cerebrovascular disease and pneumococcal vaccination status. Ajayi et al found no association between any specific Streptococcus pneumoniae serotype and increased mortality. In fact, the literature published on this topic has failed to find an association between long-term mortality and a specific pathogen causing pneumonia. This suggests that the outcome is not necessarily determined by the pathogen; instead, outcomes might be driven by the host response. Considering the above, in which way may the host response influence long-term mortality? It has been