Marco Mantero

Stratifying Risk Factors for Multidrug-Resistant Pathogens in Hospitalized Patients Coming From the Community With Pneumonia

BACKGROUND  Not all risk factors for acquiring multidrug-resistant (MDR) organisms are equivalent in predicting pneumonia caused by resistant pathogens in the community. We evaluated risk factors for acquiring MDR bacteria in patients coming from the community who were hospitalized with pneumonia. Our evaluation was based on actual infection with a resistant pathogen and clinical outcome during hospitalization. METHODS  An observational, prospective study was conducted on consecutive patients coming from the community who were hospitalized with pneumonia. Data on admission and during hospitalization were collected. Logistic regression models were used to evaluate risk factors for acquiring MDR bacteria independently associated with the actual presence of a resistant pathogen and in-hospital mortality. RESULTS  Among the 935 patients enrolled in the study, 473 (51%) had at least 1 risk factor for acquiring MDR bacteria on admission. Of all risk factors, hospitalization in the preceding 90 days (odds ratio [OR], 4.87 95% confidence interval {CI}, 1.90-12.4]; P = .001) and residency in a nursing home (OR, 3.55 [95% CI, 1.12-11.24]; P = .031) were independent predictors for an actual infection with a resistant pathogen. A score able to predict pneumonia caused by a resistant pathogen was computed, including comorbidities and risk factors for MDR. Hospitalization in the preceding 90 days and residency in a nursing home were also independent predictors for in-hospital mortality. CONCLUSIONS  Risk factors for acquiring MDR bacteria should be weighted differently, and a probabilistic approach to identifying resistant pathogens among patients coming from the community with pneumonia should be embraced.

Understanding the burden of pneumococcal disease in adults

Streptococcus pneumoniae causes different types of acute, invasive and non-invasive clinical infections, being the most frequently detected pathogen responsible for community-acquired pneumonia. Pneumococcal pneumonia is accompanied by bacteraemia in 10-30% of cases. Streptococcus pneumoniae is gaining resistance to the in vitro activity of several antimicrobial agents and, even if questions remain regarding the clinical impact of this phenomenon, more and more reports indicate that antibiotic resistance can lead to more treatment failures if not higher mortality. Use of the 23-valent anti-pneumococcal vaccine appears to offer subpotimal protection against pneumococcal disease, particularly among high-risk adult populations. Vaccination against S. pneumoniae with new conjugate vaccines seems to be the most promising field for real improvement in the management of pneumococcal infections in adults.

The role of vaccination in preventing pneumococcal disease in adults

Pneumococcal infections, including pneumonia and invasive disease, are major sources of morbidity and mortality worldwide. Prevention of the first acquisition of Streptococcus pneumoniae through the use of vaccines represents an effective method to reduce the burden of the disease in both children and adults. Two vaccines are currently available in adults: a pneumococcal polysaccharide vaccine (PPV23) that includes 23 purified capsular polysaccharide antigens and a pneumococcal protein-conjugate vaccine (PCV13) that includes capsular polysaccharide antigens covalently linked to a non-toxic protein. The PPV23 induces a humoral immune response and since it has been licensed has been the subject of debates and controversies. Numerous studies and meta-analyses have shown that PPV23 protects against invasive pneumococcal disease, although there are conflicting data regarding its efficacy for the prevention of pneumonia. Vaccination with PCV13 stimulates good antibody responses as well as mucosal immunity and suppresses colonization. A conjugate vaccine can be expected to have benefits over a polysaccharide vaccine because of the characteristics of a T-cell-dependent response in terms of affinity, maturation of antibodies with repeated exposure, induction of immunological memory and long-lasting immunity. PCV13 has demonstrated all of these characteristics in children and fundamental differences in adults are not expected. The efficacy in adults is currently being investigated and results will be available soon.

Quality standards for the management of bronchiectasis in Italy: A national audit

Although historically considered a neglected disease, bronchiectasis has become a disease of renewed interest over recent decades in light of an increase in prevalence and a substantial burden on healthcare systems [1–3]. In 2010, the British Thoracic Society (BTS) published guidelines on the management of bronchiectasis in adults, along with specific quality standards [4, 5]. To date, these represent the only quality standards available in Europe. These have been tested over a number of years in the UK with progressive improvements in the standard of care [6]. No national guidelines are available in Italy and no indications on which guideline should be followed have been given by the Italian Society of Respiratory Medicine (SIP). There are limited published data on the quality of bronchiectasis care in Europe outside of the UK. The BTS standards have not been tested in continental Europe or in Italy, where information on characteristics and management of bronchiectasis patients are lacking. The majority of the quality standards for the management of bronchiectasis in adults are not met in Italy http://ow.ly/YKMpU

Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis

Acute osteomyelitis and septic arthritis are two infections whose frequencies are increasing in pediatric patients. Acute osteomyelitis and septic arthritis need to be carefully assessed, diagnosed, and treated to avoid devastating sequelae. Traditionally, the treatment of acute osteoarticular infection in pediatrics was based on prolonged intravenous anti-infective therapy. However, results from clinical trials have suggested that in uncomplicated cases, a short course of a few days of parenteral antibiotics followed by oral therapy is safe and effective. The aim of this review is to provide clinicians an update on recent controversies and advances regarding the management of acute osteomyelitis and septic arthritis in children. In recent years, the emergence of bacterial species resistant to commonly used antibiotics that are particularly aggressive highlights the necessity for further research to optimize treatment approaches and to develop new molecules able to fight the war against acute osteoarticular infection in pediatric patients.

Antibiotics as immunomodulant agents in COPD

It is widely accepted that some antibiotics have activities beyond their direct antibacterial effects. Macrolide is the antibiotic class with more convincing studies and evidence on its immunomodulatory and anti-inflammatory activities. Different clinical studies have shown that macrolide prophylaxis in patients with moderate-severe chronic obstructive pulmonary disease (COPD) can have a significant impact on the exacerbation rate reducing morbidity and, potentially, mortality of the disease. Other antibiotics, such as fluoroquinolones, demonstrate a variety of immunomodulatory effects but only few clinical data are available in COPD. New macrolide derivatives devoid of antibacterial activity have been synthetized. This review analyses the relevance of immunomodulatory and anti-inflammatory effects of antibiotics in the management of COPD.

Compliance with anti‐H1N1 vaccine among healthcare workers and general population

Population protection through vaccination against infectious diseases has been one of the major achievements of public health care. The recent H1N1 influenza virus pandemic reopened the discussion on the strategic arrangements for vaccination in the face of spreading infection. Even though vaccination against a pandemic strain is considered to be one of the most effective countermeasures for protecting individuals, the general acceptance of H1N1 influenza vaccination has been low worldwide. The understanding of the potential health risks of the novel influenza A (H1N1) strain, the distrust of vaccinations and concerns about vaccine safety are the main reasons reported by the public for not undergoing vaccination. Concern about vaccine safety and distrust of health authorities are the commonest reasons given for low compliance with vaccination by healthcare workers. Better communication strategies to improve vaccination acceptance by the general population and by healthcare workers are required.

Non-Intensive Care Unit Acquired Pneumonia: A New Clinical Entity?

Hospital-acquired pneumonia (HAP) is a frequent cause of nosocomial infections, responsible for great morbidity and mortality worldwide. The majority of studies on HAP have been conducted in patients hospitalized in the intensive care unit (ICU), as mechanical ventilation represents a major risk factor for nosocomial pneumonia and specifically for ventilator-associated pneumonia. However, epidemiological data seem to be different between patients acquiring HAP in the ICU vs. general wards, suggesting the importance of identifying non ICU-acquired pneumonia (NIAP) as a clinical distinct entity in terms of both etiology and management. Early detection of NIAP, along with an individualized management, is needed to reduce antibiotic use and side effects, bacterial resistance and mortality. The present article reviews the pathophysiology, diagnosis, treatment and prevention of NIAP.

Assessment of Sarcoidosis Activity by 67Gallium Lung Scan

71 consecutive patients with histologically confirmed sarcoidosis, in various clinical stages of activity, were submitted to 67Ga lung scan, and 23 of them were studied with two or more scans at intervals of 4-6 months. In patients on steroid therapy, the drug was suspended 7 days before scan to avoid the steroids interfering with the gallium (Ga) uptake mechanism. In order to assess the usefulness of 67Ga in the evaluation of sarcoid activity, six other parameters of activity were considered, ranging from angiotensin-converting enzyme levels to progressive symptoms, from deteriorating X-ray or pulmonary function tests to clinical or laboratory evidence of prominent extra thoracic involvement. Our work suggests that Ga scan is more sensitive than chest X-ray in determining the degree and variation of pulmonary sarcoidosis activity, in evaluating the response to therapy, and in foreseeing the relapses. In some cases it gives information not detectable with other noninvasive criteria. The detection of patients with active disease, after discontinuation of steroids 7 days before scan, raises doubts about the opportunities of scanning patients on steroids, and suggests that further studies on this point are needed.

The evidence on tiotropium bromide in asthma: From the rationale to the bedside

Severe and poorly controlled asthma still accounts for a great portion of the patients affected. Disease control and future risk management have been identified by international guidelines as the main goals in patients with asthma. The need for new treatment approaches has led to reconsider anticholinergic drugs as an option for asthma treatment. Tiotropium is the first anticholinergic drug that has been approved for children and adults with poorly controlled asthma and is currently considered as an option for steps 4 and 5 of the Global Initiative for Asthma. In large randomized clinical trials enrolling patients with moderate to severe asthma, add-on therapy with tiotropium has demonstrated to be efficacious in improving lung function, decreasing risk of exacerbation and slowing the worsening of disease; accordingly, tiotropium demonstrated to be non inferior compared to long acting beta-agonists in the maintenance treatment along with medium to high inhaled corticosteroids. In view of the numerous ancillary effects acting on inflammation, airway remodeling, mucus production and cough reflex, along with the good safety profile and the broad spectrum of efficacy demonstrated in different disease phenotypes, tiotropium can represent a beneficial alternative in the therapeutic management of poorly controlled asthma. The present extensive narrative review presents the pharmacological and pathophysiological basis that guided the rationale for the introduction of tiotropium in asthma treatment algorithm, with a particular focus on its conventional and unconventional effects; finally, data on tiotropium efficacy and safety. from recent randomized clinical trials performed in all age categories will be extensively discussed.