Beta-lactam plus Macrolide vs Fluoroquinolone for Empiric Therapy of Hospitalized Patients with CAP: Results from the University of Louisville Pneumonia Study

Background Current guidelines recommend a β-lactam plus a macrolide or fluoroquinolone monotherapy as initial empiric antibiotic therapy for treatment of patients hospitalized with community-acquired pneumonia (CAP). Multiple studies have shown different results comparing the two regimens for the treatment of CAP. Our objective, in a city-wide prospective study, was to compare outcomes among hospitalized patients with CAP who received empiric treatment either with a β-lactam plus a macrolide or fluoroquinolone monotherapy. Methods This was a propensity score matched case-control study of the University of Louisville Pneumonia Study. It was a prospective population-based cohort study of all hospitalized adults with CAP. Patients were divided into two groups and propensity score matched based on empiric therapy; a β-lactam plus a macrolide compared to fluoroquinolone monotherapy. Study outcomes were time to clinical stability, length of stay, and in-hospital, 30-day and 1-year mortality. Stratified Cox proportional hazards regression was performed to analyze continuous variable differences between groups. Conditional logistic regression was performed to analyze dichotomous variable differences in mortality. Results An association was not found between the two groups for time to clinical stability (aHR: 1.06; 95% CI: 0.93-1.22), length of stay (aHR: 1.14; 95% CI: 0.99-1.32) or mortality. Conclusion The present study did not show any difference in short or long-term outcomes for hospitalized patients with CAP who were treated with either a β-lactam plus a macrolide or fluoroquinolone monotherapy. Hence, our study does not support the superiority of one treatment over other

Association of Urine Levels of C-Reactive Protein with Clinical Outcomes in Patients with Pneumonia: A Pilot Study

Finding relevant biomarkers as a potential predictor of severity for patients hospitalized with community acquired pneumonia (CAP), in addition to the clinical scoring system, could advance progress towards more effective patient management. The inflammatory marker, C-reactive protein (CRP), which is elevated in the pathogenesis of many infectious diseases, may be a key biomarker target for CAP. Previous studies have shown that serum CRP may be a useful diagnostic marker for pneumonia in hospitalized patients with acute respiratory symptoms. The main aims of this study were to determine the correlation between serum and urine CRP levels in hospitalized patients with CAP, and any correlation with patient outcomes. Our laboratory employed a commercially available human high sensitive CRP ELISA kit to check the level of CRP in the corresponding patient urine sample. The results showed that there was a positive correlation between patient serum and urine CRP levels. In addition, we showed the correlation of urine CRP levels with certain patient comorbidities, time to clinical stability, length of patient hospital stay, and mortality

Clinical Outcomes for Patients with Community-Acquired Pneumonia are Worse in Those with a History of Stroke

Background: Stroke is one of the most prevalent neurological diseases in the United States. Community-acquired pneumonia (CAP) is the leading cause of infections in survivors of stroke. There is limited research evaluating the clinical outcomes of CAP in patients with stroke. The objective of this study was to evaluate the clinical characteristics and outcomes of hospitalized patients with CAP and a history of stroke. Methods: This was a secondary analysis of the University of Louisville Pneumonia Study database. Patients were divided into two groups based on the presence or absence of a history of stroke. Clinical outcomes were length of stay, time to clinical stability, and one-year mortality, which were assessed via stratified Cox proportional hazards regression. Differences in risk of clinical outcomes were reported as adjusted hazard ratios. Results: We found no significant differences in time to clinical stability between the two groups. The median length of stay for patients with a history of stroke hospitalized with CAP was six days and for patients without stroke was five days (P=0.01). We observed a 16% higher risk of mortality in stroke patients with CAP than in the non-stroke population (P=0.001). Conclusions: This study indicates that hospitalized patients with CAP have a longer hospital stay and higher mortality than those without stroke

COVID-19 is Associated with Increased Severity in Pregnant Women

Background: COVID-19 pandemic originated in China in late 2019, the number of cases are increasing with 2,104,346 cases and 116,140 deaths in the United States, as of June 16, 2020. Pregnant women are a vulnerable population in epidemics or Pandemics. This Review is designed to look in detail the severity of COVID-19 in pregnant women in comparison to non-pregnant women of reproductive age. Methods: Literature search on PubMed, Google Scholar, Lancet, and Web of Science were conducted. Results: We have found the evidence of increased risk for severe disease and distinctive symptoms among pregnant women diagnosed with COVID-19 as compared to non-pregnant women. Conclusions: COVID-19 presents in an atypical fashion in pregnant women with comparatively increased severity of symptoms, compared to COVID-19 positive non pregnant women of reproductive age. These findings can help clinicians to recognize the risk posed by COVID-19 in pregnant women

Characteristics and Clinical Outcomes of Hospitalized Patients with Community-Acquired Pneumonia who are Active Intravenous Drug Users

Background: Intravenous drug users (IVDU) have a 10-fold increased risk of community-acquired pneumonia (CAP) compared to the general population. There is scarce data available evaluating the clinical outcomes of IVDU hospitalized patients with CAP and that data mostly focuses on mortality. The objective of this study was to evaluate the clinical characteristics, incidence and outcomes of hospitalized patients with CAP in active intravenous drug users in Louisville, Kentucky. Methods: This was a secondary data analysis of the University of Louisville Pneumonia study. IVDU patients were propensity score matched to a non-IVDU group. Study outcomes were time to clinical stability (TCS), length of stay (LOS), mortality at discharge, and mortality at 1 year. Stratified Cox proportional hazard regression was performed to evaluate TCS and LOS. Conditional logistic regression was performed to evaluate mortality. Statistical significance was defined as p ≤ 0.05. Results:From a total of 8,284 hospitalized patients with CAP reviewed, 113 patients were matched per group. Median (IQR) age for the IVDU was 33 (28-43) versus 36 (28-48) for the matched non-IVDU group (p Conclusions: This study shows that active IVDU hospitalized patients with CAP do not have worse outcomes when compared with non-IVDU hospitalized patients with CAP. Patients in the IVDU group were significantly younger. Since severity scores commonly used are heavily influenced by age, these will not likely be useful tools to assist the physicians with the site for care and management

Comparing Outcomes for Community-Acquired Pneumonia Between Females and Males: Results from the University of Louisville Pneumonia Study

Introduction: Male sex is currently considered to be a risk factor for worsened community-acquired pneumonia (CAP) outcomes compared to female sex; hence, female sex equates to a lower score on the Pneumonia Severity Index. There is no recent update on sex-based outcomes of patients with CAP. The objective of this study was to compare the outcomes of CAP between females and males. Methods: This was a secondary analysis of the University of Louisville Pneumonia Study database. It was a prospective population-based cohort study of all hospitalized adults with CAP who were residents of Jefferson County in the city of Louisville, Kentucky. The study included data from June 1, 2014, to May 31, 2016, and data from October 1, 2016, to May 31, 2017. The study population was divided into two groups: females and males. Results: Female patients had a 13% lower mortality at one year compared to males (aHR 1.13 [95% CI 1.05–1.23], P=0.002). There was no significant difference in mortality between the two groups during hospitalization or at 30-day or six-month follow-up. The median time to discharge for both female and male patients hospitalized with CAP was five days (interquartile range [IQR] 3, 9 days). The median time to clinical stability for both female and male patients hospitalized with CAP was two days (IQR 1, 4 days). Conclusion: This study shows that female patients had significantly lower one-year mortality compared to males. There was no significant difference between females and males in time to clinical stability or length of stay. Further investigation is needed to examine whether risk factors associated with female and male sex predict outcomes among hospitalized patients due to CAP

Age, Comorbidities, and Mortality Correlation in COVID-19 Patients: A Review

Background: The risk of death due to COVID-19 among hospitalized patients is known to be higher in older adults and those with underlying health conditions. Understanding the percentage of patients who are at increased risk of death due COVID-19 and how this varies between age groups will inform the healthcare community how to evaluate the risk of COVID-19, and better design healthcare and economic policies. Methods: We conducted a literature search for studies published between December 2019 until May 16, 2020 in PubMed, Embase, and Cochrane (CENTRAL). Descriptive statistics were performed. Results: We reviewed 14 studies of which 13 were retrospective and one was prospective. Eleven studies were conducted in Wuhan, China. A grand total of 11,938 COVID-19 confirmed patients were reviewed. Among these patients, 7637 (64%) were males. Our review reported hypertension (41%), diabetes (21%), cardiac diseases (14%), COPD (8%), chronic kidney disease (4%) and cerebrovascular disease (10%) as the most common underlying diseases among patients who died during hospitalization due to COVID-19. The total number of patients died in the hospital was 1744 (15%). Among patients who died in the hospital, 1% patients were 30-39 years, 16% patients were 40-59 years and 83% patients were more than 60 years of age. Conclusions: Older patients with underlying diseases appear to be at higher risk of mortality from COVID-19. Comorbidities are significant predictors of mortality in COVID-19 patients. There is an urgent need to know the epidemiology of the novel virus and characterize its potential impact

Outcomes of Patients Hospitalized with Community-Acquired Pneumonia with Liver Disease or Cirrhosis.

Introduction: Liver disease and cirrhosis are common causes of mortality worldwide. Community-acquired pneumonia is recognized as a significant cause of morbidity and mortality in this population of adults. There is a lack of data regarding outcomes or prognosis in patients with liver dysfunction who develop CAP. The objective of this study was to evaluate the clinical characteristics, incidence, and outcomes of hospitalized patients with CAP and liver disease. Methods: This was a secondary analysis of the University of Louisville Pneumonia Study, which was a prospective population-based cohort study of adults hospitalized with community-acquired pneumonia. All patients were divided into three groups: 1) patients without liver disease, 2) patients with liver disease, and 3) patients with cirrhosis. Short and long-term outcomes were analyzed. Results: Among 9,201 patients, 8,566 patients did not have liver disease, 515 patients had liver disease, and 120 patients had cirrhosis. The median age of patients with liver disease or cirrhosis was approximately 10 years younger than the median age of overall population, and a higher proportion was admitted directly to the ICU. Compared to patients without liver disease, we found no significant difference in time to clinical stability for patients with liver diseases (adjusted hazard ratio [aHR] 1.01 [95% CI 0.92–1.12]; P=0.790) or cirrhosis (aHR 0.85 [95% CI 0.69–1.05]; P=0.127). There were also no differences in median length of stay (LOS) between any two groups. Patients with cirrhosis had a 35% higher risk of death at any time compared to patients with no liver disease (aHR 1.35 [95% CI 1.00–1.82]; P=0.049) but did not have significantly increased risk compared to patients with liver disease (aHR 1.37 [95% CI 0.97–1.93], P=0.070). Conclusion: In this study of hospitalized adults with CAP, patients with cirrhosis had a significantly higher risk of death compared to patients without liver disease

Compliance with Guidelines for Treatment of Staphylococcus aureus Bacteremia is Associated with Decreased Mortality in Patients Hospitalized for Community-Acquired Pneumonia with Staphylococcus aureus Bacteremia

Introduction: Staphylococcus aureus bacteremia has a minimum treatment duration of two weeks, while S. aureus community-acquired pneumonia (CAP) treatment is at least five days. Treatment failure, persistent bacteremia, and recurrence are common among patients with community-acquired S. aureus bacteremia. There is conflicting information in the current Infectious Diseases Society of America (IDSA) guidelines for the treatment of S.aureus bacteremia patients with CAP. Therefore, the appropriate treatment duration and modality for S. aureus CAP with bacteremia is unclear. The objective of this study was to compare outcomes among patients with S. aureus CAP and bacteremia treated in compliance versus non-compliance with IDSA S. aureus bacteremia guidelines. Methods: This was a secondary data analysis of the Community-Acquired Pneumonia Organization (CAPO) study database. Logistic regression was used to compare outcomes. Results: A total of 117 patients with S. aureus CAP and bacteremia were included in the study. Compliance with S. aureus bacteremia guidelines was documented in 67 patients, and non-compliance was documented in 50 patients. Compliance with IDSA S. aureus bacteremia guidelines resulted in a decrease in odds of re-hospitalization of 30% after adjusting for confounding variables between the compliant and non-compliant groups (adjusted odds ratio (aOR) 0.70 [95% CI 0.29–1.70]; P=0.42). The 30-day mortality for the compliant group was 6% and for the non-compliant group was 10%; P=0.576. The 1-year mortality for the compliant group was 19% and for the non-compliant group was 44%; P=0.011. Conclusion: The present study demonstrated that when treated in compliance with IDSA guidelines for S. aureus bacteremia, there was decreased 1-year mortality for patients hospitalized for S. aureus CAP with bacteremia. In this case, the IDSA S. aureus bacteremia guidelines recommend treating uncomplicated S. aureus bacteremia with CAP for at least two weeks of antimicrobials and at least four weeks of antimicrobials for complicated S. aureus bacteremia with CAP

Implementing a Clinical Research Program in Long Term Care Facilities: Experiences from the University of Louisville Center Excellence for Research in Infectious Diseases [CERID]

Background: According to the US Census Bureau International Report, in 2015, almost nine percent of the world’s population was aged 65 and over. As the worldwide population ages, there is a need to understand how to best care for those individuals. Developing clinical research programs focusing on long term care (LTC) will be critical to defining best practice. Objectives: The objectives of this manuscript are to: 1) outline the challenges identified in performing clinical research in long term care facilities (LTCF), and 2) offer solutions for future clinical research in the LTC environment based upon our experiences. Methods: A research feasibility study was performed in 14 LTCFs in Louisville, Kentucky during 2018. Research questions involving identification of LTCF residents experiencing diarrhea were used as the basis for determining challenges and abilities to perform research in the LTC environment. Results: Challenges to performing clinical research involving an infectious disease were gathered throughout the twenty-week feasibility assessment period and organized into eight distinct yet inter-related areas. These included: 1) facility recruitment; 2) engagement of facility leadership; 3) engagement of facility personnel; 4) identification of research candidates; 5) consenting processes; 6) management of clinical samples; 7) navigating the medical record systems; and 8) study team workflow. Conclusions: This feasibility assessment found that conducting research in LTCFs was very different in almost every aspect from research conducted in the hospital setting. Results from this feasibility assessment will be used as a basis to determine a more comprehensive population-based incidence of C. difficile infection through the City of Louisville Diarrhea (CLOUD) study