Guidelines for the management of adult lower respiratory tract infections - Summary

Woodhead, Mark; Blasi, Francesco; Ewig, Santiago; Garau, Javier; Huchon, G.; Ieven, Margareta; Örtqvist, Åke; Schaberg, T.; Torres, Antoni; Heijden, G. H. M. van der; Read, Robert C.; Verheij, Theo

doi:10.1111/j.1469-0691.2011.03602.x

Cited by 305 publications

(154 citation statements)

References 464 publications

(377 reference statements)

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“…96 The price per day for antibiotic treatment were calculated based on the dosage recommended in the treatment guidelines. LRTI treatment guidelines were used for the hospitalised non-ICU setting, 98 and treatment guidelines for suspected or confirmed sepsis were used for the ICU settings. 99 The prices of different antibiotic treatment strategies (recommended by the guideline for a specific setting) were averaged.…”

Section: Resource Use and Costsmentioning

confidence: 99%

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

116

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BackgroundDetermination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection.ObjectivesTo assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection.MethodsTwelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using theI2andQstatistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months’ time horizon.ResultsEighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD –3.19 days, 95% confidence interval (CI) –5.44 to –0.95 days,I2 = 95.2%; four studies], hospital stay (WMD –3.85 days, 95% CI –6.78 to –0.92 days,I2 = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD –2.03 days, 95% CI –4.19 to 0.13 days,I2 = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms.Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY).ConclusionsThe limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK.Study registrationThis study is registered as PROSPERO CRD42014010822.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Resource Use and Costsmentioning

confidence: 99%

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

116

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“…In particular, for hospitalized patients with S. pneumoniae-related CAP, combination therapy with ␤-lactams plus macrolides is the preferred choice in several guidelines (3)(4)(5). Although accumulating clinical evidence has shown the efficacy of combination therapies incorporating macrolides, the efficacy of combination therapies with quinolones or tetracyclines has not been demonstrated (6)(7)(8)(9).…”

mentioning

confidence: 99%

Efficacy of β-Lactam-plus-Macrolide Combination Therapy in a Mouse Model of Lethal Pneumococcal Pneumonia

Yoshioka

Kajiwara

Ishii

et al. 2016

Antimicrob Agents Chemother

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b Community-acquired pneumonia is a common disease with considerable morbidity and mortality, for which Streptococcus pneumoniae is accepted as a leading cause. Although ␤-lactam-plus-macrolide combination therapy for this disease is recommended in several guidelines, the clinical efficacy of this strategy against pneumococcal pneumonia remains controversial. In this study, we examined the effects of ␤-lactam-plus-macrolide combination therapy on lethal mouse pneumococcal pneumonia and explored the mechanisms of action in vitro and in vivo. We investigated survival, lung bacterial burden, and cellular host responses in bronchoalveolar lavage fluids obtained from mice infected with pneumonia and treated with ceftriaxone, azithromycin, or both in combination. Although in vitro synergy was not observed, significant survival benefits were demonstrated with combination treatment. Lung neutrophil influx was significantly lower in the ceftriaxone-plus-azithromycin-treated group than in the ceftriaxone-treated group, whereas no differences in the lung bacterial burden were observed on day 3 between the ceftriaxone-plus-azithromycin-treated group and the ceftriaxone-treated group. Notably, the analysis of cell surface markers in the ceftriaxone-plus-azithromycin combination group exhibited upregulation of presumed immune checkpoint ligand CD86 and major histocompatibility complex class II in neutrophils and CD11b-positive CD11c-positive (CD11b ؉ CD11c ؉ ) macrophages and dendritic cells, as well as downregulation of immune checkpoint receptors cytotoxic-T lymphocyte-associated antigen 4 and programmed death 1 in T helper and T regulatory cells. Our data demonstrate that the survival benefits of ceftriaxoneplus-azithromycin therapy occur through modulation of immune checkpoints in mouse pneumococcal pneumonia. In addition, immune checkpoint molecules may be a novel target class for future macrolide research.

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“…[51,52] In contrast, where there is diagnostic uncertainty, measurement of CRP levels can assist the physician in the management of patients presenting with features of ARTI. Recommendations for the use of CRP are based on reports from two large research groups: the IMPAC3T programme and the [ [40][41][42] GRACE consortium study. These studies, incorporated into the 2014 NICE guidelines, [53] are very useful in providing evidence to support the clinician who is uncertain as to whether to include antibiotics in the management of LRTI or not.…”

Section: Communityacquired Pneumoniamentioning

confidence: 99%

The role of appropriate diagnostic testing in acute respiratory tract infections: An antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care

et al. 2016

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Guidelines for the management of adult lower respiratory tract infections - Summary

Cited by 305 publications

References 464 publications

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Efficacy of β-Lactam-plus-Macrolide Combination Therapy in a Mouse Model of Lethal Pneumococcal Pneumonia

The role of appropriate diagnostic testing in acute respiratory tract infections: An antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care

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