Hayato Yamana1, Hiroki Matsui2, Takashi Tagami3, Junko Hirashima4, Kiyohide Fushimi5, Hideo Yasunaga2. 1. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan. Electronic address: yamana-tky@umin.ac.jp. 2. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan. 3. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan; Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 2068512, Japan. 4. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 1130033, Japan; Department of Respiratory Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 1628655, Japan. 5. Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138510, Japan.
Abstract
OBJECTIVES: To compare mortality between de-escalation and continued empirical treatment in patients with community-acquired pneumonia. METHODS: Using a nationwide administrative database, we identified adult patients with community-acquired pneumonia caused by Streptococcus pneumoniae, other streptococci, Haemophilus influenzae, Klebsiella pneumoniae, or Escherichia coli (n = 10,231) or of unknown etiology (n = 8247), discharged between July 2010 and March 2013. De-escalation was determined by the spectrum and number of antimicrobials at day 4. We used propensity score matching to obtain 489 pairs of de-escalation and continuation groups among pathogen-identified patients and 278 pairs among culture-negative patients to compare mortalities. RESULTS: In the pathogen-identified patients, de-escalation was noninferior to continuation in 15-day mortality [5.3% in de-escalation versus 4.3% in continuation, a difference of 1.0% (95% confidence interval, -1.7% to 3.7%)] and in-hospital mortality [8.0% in de-escalation versus 8.8% in continuation, a difference of -0.8% (95% confidence interval, -4.3% to 2.7%)]. In the culture-negative cases, de-escalation was noninferior to continuation in terms of 15-day mortality but not in terms of in-hospital mortality. CONCLUSIONS: Among patients with community-acquired pneumonia of specific etiology, de-escalation was noninferior to continuation of empirical treatment, suggesting that de-escalation is a safe strategy and supporting current recommendations. Safety of de-escalation in culture-negative cases is questionable.
OBJECTIVES: To compare mortality between de-escalation and continued empirical treatment in patients with community-acquired pneumonia. METHODS: Using a nationwide administrative database, we identified adult patients with community-acquired pneumonia caused by Streptococcus pneumoniae, other streptococci, Haemophilus influenzae, Klebsiella pneumoniae, or Escherichia coli (n = 10,231) or of unknown etiology (n = 8247), discharged between July 2010 and March 2013. De-escalation was determined by the spectrum and number of antimicrobials at day 4. We used propensity score matching to obtain 489 pairs of de-escalation and continuation groups among pathogen-identified patients and 278 pairs among culture-negative patients to compare mortalities. RESULTS: In the pathogen-identified patients, de-escalation was noninferior to continuation in 15-day mortality [5.3% in de-escalation versus 4.3% in continuation, a difference of 1.0% (95% confidence interval, -1.7% to 3.7%)] and in-hospital mortality [8.0% in de-escalation versus 8.8% in continuation, a difference of -0.8% (95% confidence interval, -4.3% to 2.7%)]. In the culture-negative cases, de-escalation was noninferior to continuation in terms of 15-day mortality but not in terms of in-hospital mortality. CONCLUSIONS: Among patients with community-acquired pneumonia of specific etiology, de-escalation was noninferior to continuation of empirical treatment, suggesting that de-escalation is a safe strategy and supporting current recommendations. Safety of de-escalation in culture-negative cases is questionable.
Authors: Inger van Heijl; Valentijn A Schweitzer; C H Edwin Boel; Jan Jelrik Oosterheert; Susanne M Huijts; Wendelien Dorigo-Zetsma; Paul D van der Linden; Marc J M Bonten; Cornelis H van Werkhoven Journal: PLoS One Date: 2019-09-27 Impact factor: 3.240
Authors: Joshua P Metlay; Grant W Waterer; Ann C Long; Antonio Anzueto; Jan Brozek; Kristina Crothers; Laura A Cooley; Nathan C Dean; Michael J Fine; Scott A Flanders; Marie R Griffin; Mark L Metersky; Daniel M Musher; Marcos I Restrepo; Cynthia G Whitney Journal: Am J Respir Crit Care Med Date: 2019-10-01 Impact factor: 21.405
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