Clinical evaluation of the need for carbapenems to treat community-acquired and healthcare-associated pneumonia

Abstract

Carbapenems have an overall broad antibacterial spectrum and should be protected against from the acquisition of drug resistance. The clinical advantages of carbapenem in cases of pneumonia have not been certified and the need for antipseudomonal antimicrobial agents to treat healthcare-associated pneumonia (HCAP) remains controversial. We introduced an antimicrobial stewardship program for carbapenem and tazobactam/piperacillin use and investigated the effects of this program on the clinical outcomes of 591 pneumonia cases that did not require intensive care unit management, mechanical ventilation or treatment with vasopressor agents [221 patients with community-acquired pneumonia (CAP) and 370 patients with HCAP]. Compared with the pre-intervention period, age, comorbidities and the severity and etiology of pneumonia did not differ during the intervention period. Carbapenems were rarely used during the intervention period in cases of pneumonia (CAP: 12% vs. 1%, HCAP: 13% vs. 1%), while antipseudomonal beta-lactam use was reduced from 33% to 8% among cases with HCAP. This reduction in the rate of carbapenem administration did not have an impact on the prognosis in the cases of CAP, and the in-hospital mortality was lower among the patients with HCAP during the intervention period (15% vs. 5%, p = 0.013). The causes of death in the cases of HCAP were not directly related to pneumonia during the intervention period. The current study shows that carbapenem use can be avoided in cases of CAP or HCAP that are not in a critical condition. The frequent use of antipseudomonal beta-lactams does not improve the clinical outcomes of HCAP.

Epidemiology and antimicrobial resistance of Escherichia coli in broiler chickens, farmworkers, and farm sewage in Bangladesh

“…However, in a recent study, 31.66% and 10% resistance to meropenem and imipenem, respectively, were found in E. coli isolated from cloacal swab of poultry (Sobur et al., 2019 ). Carbapenem antibiotics are considered as ‘last‐line agents’ as they are used to treat infections due to MDR bacteria that are non‐responsive to other classes of antibiotics (Kamata et al., 2015 ). Generally, the emergence of carbapenem‐resistant strain could occur through the acquisition of carbapenem‐resistance genes via plasmid‐mediated horizontal gene transfer.…”

Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients

“…However, even patients admitted to ICUs may have just as great 1 a risk of harm from over-coverage with these agents, including renal toxicity and secondary infection [34]. In pneumonia, anti-MRSA and antipseudomonal therapy has not been associated with improved outcomes in observational cohort studies [8,10], or pre-post analyses of antimicrobial stewardship programs [35]. For the VA population, we previously failed to establish a benefit of empiric anti-MRSA therapy, even when used in those with elevated risk for MRSA pneumonia [36].…”

Disease Burden and Etiologic Distribution of Community-Acquired Pneumonia in Adults: Evolving Epidemiology in the Era of Pneumococcal Conjugate Vaccines

“…Based on this evidence, the 2005 ATS/IDSA guidelines for nosocomial pneumonia included recommendations for HCAP treatment, suggesting empirical coverage of MDR pathogens [3]. Since then, subsequent studies were conducted in South Korea, Japan, and Spain, but most studies showed that S. pneumoniae is the most common causative agent of HCAP, similar to CAP (Table 3) [567894445464954556162636465]. In addition, although the proportion of MDR pathogens is higher in HCAP, some studies revealed indistinguishable etiologic distribution of causative agents between HCAP and CAP [56789].…”

“…In comparison, the disease burden of pneumococcal pneumonia might be persistent among at-risk HCAP populations particularly residing in LTCF with missed opportunity of vaccination [70], as pneumococcal pneumonia outbreaks have been reported among unvaccinated nursing home residents [7172]. In some studies conducted in Japan, the proportion of pneumococcal pneumonia in HCAP was similar or rather higher compared to that of CAP (Table 3) [689]. The concerning point is that MDR S. pneumoniae might be transmitted among LTCF residents with repeated antibiotic exposure.…”

“…Similar to patients with CAP, most HCAP cases present from the community followed by frequent emergency room visits during acute disease phase. Furthermore, increasing evidence shows that the causative pathogens of HCAP cases are more closely related to pathogens associated with CAP than HAP [56789].…”