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103. Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia.

Author

Deshpande, Abhishek, Klompas, Michael, Guo, Ning, Imrey, Peter B, Pallotta, Andrea M, Higgins, Thomas, Haessler, Sarah, Zilberberg, Marya D, Lindenauer, Peter K, and Rothberg, Michael B

Subjects
HOSPITALS, LENGTH of stay in hospitals, INTENSIVE care units, INTRAVENOUS therapy, ORAL drug administration, RETROSPECTIVE studies, FLUOROQUINOLONES, TREATMENT duration, MEDICAL care costs, COST control, PATIENTS, TREATMENT effectiveness, HOSPITAL mortality, HOSPITAL admission & discharge, HOSPITAL care, DESCRIPTIVE statistics, RESEARCH funding, COMMUNITY-acquired pneumonia, ANTIBIOTICS, LONGITUDINAL method
Abstract

Background Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. Methods We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. Results Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low–risk patients were switched early. Conclusions Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low–risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes. [ABSTRACT FROM AUTHOR]

Published
2023
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139. Urinary Antigen Testing for Respiratory Infections: Current Perspectives on Utility and Limitations

Author

Kim,Priscilla, Deshpande,Abhishek, and Rothberg,Michael B

Subjects
Infection and Drug Resistance, respiratory tract diseases
Abstract

Priscilla Kim,1 Abhishek Deshpande,2 Michael B Rothberg2 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; 2Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USACorrespondence: Michael B Rothberg, Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, Mail Code G10, Cleveland, OH, 44195, USA, Tel +1 216-445-5556, Email rothbem@ccf.orgAbstract: Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (> 90%) and moderate sensitivity (< 80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.Keywords: urinary antigen test, Streptococcus pneumoniae, Legionella pneumophila, pneumonia, impact

Published
2022

141. Derivation and validation of a risk assessment model for drug-resistant pathogens in hospitalized patients with community-acquired pneumonia

Author

Rothberg, Michael B., Haessler, Sarah, Deshpande, Abhishek, Yu, Pei-Chun, Lindenauer, Peter K., Zilberberg, Marya D., Higgins, Thomas L., and Imrey, Peter B.

Abstract

AbstractObjective:To derive and validate a model for risk of resistance to first-line community-acquired pneumonia (CAP) therapy.Design:We developed a logistic regression prediction model from a large multihospital discharge database and validated it versus the Drug Resistance in Pneumonia (DRIP) score in a holdout sample and another hospital system outside that database. Resistance to first-line CAP therapy (quinolone or third generation cephalosporin plus macrolide) was based on blood or respiratory cultures.Setting:This study was conducted using data from 177 Premier Healthcare database hospitals and 11 Cleveland Clinic hospitals.Participants:Adults hospitalized for CAP.Exposure:Risk factors for resistant infection.Results:Among 138,762 eligible patients in the Premier database, 12,181 (8.8%) had positive cultures and 5,200 (3.8%) had organisms resistant to CAP therapy. Infection with a resistant organism in the previous year was the strongest predictor of resistance; markers of acute illness (eg, receipt of mechanical ventilation or vasopressors) and chronic illness (eg, pressure ulcer, paralysis) were also associated with resistant infections. Our model outperformed the DRIP score with a C-statistic of 0.71 versus 0.63 for the DRIP score (P< .001) in the Premier holdout sample, and 0.65 versus 0.58 (P< .001) in Cleveland Clinic hospitals. Clinicians at Premier facilities used broad-spectrum antibiotics for 20%–30% of patients. In discriminating between patients with and without resistant infections, physician judgment slightly outperformed the DRIP instrument but not our model.Conclusions:Our model predicting infection with a resistant pathogen outperformed both the DRIP score and physician practice in an external validation set. Its integration into practice could reduce unnecessary use of broad-spectrum antibiotics.

Published
2023
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147. A Validated Model to Identify Patients With Low Likelihood of High-Risk Coronary Artery Disease Anatomy

Author

Barakat, Amr F., primary, Amuthan, Ram, additional, Hariri, Essa, additional, Chana, Rajdeep, additional, Gupta, Niyati, additional, Ibrahim, Joseph, additional, Bashir, Zubair S., additional, Hu, Bo, additional, Sezer, Ahmet, additional, Thoma, Floyd, additional, Soman, Prem, additional, Mulukutla, Suresh, additional, Barzilai, Benico, additional, Ellis, Stephen G., additional, Jaber, Wael, additional, and Rothberg, Michael B., additional

Published
2022
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150. sj-docx-1-mdm-10.1177_0272989X221121350 – Supplemental material for Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation

Author

Martinez, Kathryn A., Linfield, Debra T., Shaker, Victoria, and Rothberg, Michael B.

Subjects
111708 Health and Community Services, 111799 Public Health and Health Services not elsewhere classified, 160807 Sociological Methodology and Research Methods, FOS: Health sciences, FOS: Sociology
Abstract

Supplemental material, sj-docx-1-mdm-10.1177_0272989X221121350 for Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation by Kathryn A. Martinez, Debra T. Linfield, Victoria Shaker and Michael B. Rothberg in Medical Decision Making

Published
2022
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