Skip to main content Accessibility help
×
Home
Hostname: page-component-55597f9d44-qcsxw Total loading time: 0.447 Render date: 2022-08-12T04:25:47.637Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia

Published online by Cambridge University Press:  01 December 2020

Michael Klompas*
Affiliation:
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Peter B. Imrey
Affiliation:
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
Pei-Chun Yu
Affiliation:
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
Chanu Rhee
Affiliation:
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Abhishek Deshpande
Affiliation:
Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
Sarah Haessler
Affiliation:
Department of Medicine, Division of Infectious Diseases, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
Marya D. Zilberberg
Affiliation:
EviMed Research Group, LLC, Goshen, Massachusetts
Michael B. Rothberg
Affiliation:
Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
*
Author for correspondence: Michael Klompas, E-mail: mklompas@bwh.harvard.edu

Abstract

Objective:

Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.

Design:

Retrospective cohort study.

Setting:

The study included 179 US hospitals.

Patients:

Adults admitted with pneumonia between July 2010 and June 2015.

Methods:

We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.

Results:

Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001).

Conclusions:

A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.

Type
Original Article
Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Fridkin, S, Baggs, J, Fagan, R, et al. Vital signs: improving antibiotic use among hospitalized patients. Morbid Mortal Wkly Rep 2014;63:194200.Google ScholarPubMed
Magill, SS, Edwards, JR, Beldavs, ZG, et al. Prevalence of antimicrobial use in US acute care hospitals, May–September 2011. JAMA 2014;312:14381446.Google Scholar
Klompas, M, Ochoa, A, Ji, W, et al. Prevalence of clinical signs within reference ranges among hospitalized patients prescribed antibiotics for pneumonia. JAMA Netw Open 2020;3:e2010700.CrossRefGoogle ScholarPubMed
Burk, M, El-Kersh, K, Saad, M, Wiemken, T, Ramirez, J, Cavallazzi, R. Viral infection in community-acquired pneumonia: a systematic review and meta-analysis. Eur Respir Rev 2016;25:178188.CrossRefGoogle ScholarPubMed
Piralla, A, Mariani, B, Rovida, F, Baldanti, F. Frequency of respiratory viruses among patients admitted to 26 intensive care units in seven consecutive winter–spring seasons (2009–2016) in northern Italy. J Clin Virol 2017;92:4851.CrossRefGoogle Scholar
Jain, S, Self, WH, Wunderink, RG, et al. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med 2015;373:415427.CrossRefGoogle Scholar
van Someren Greve, F, Juffermans, NP, Bos, LDJ, et al. Respiratory viruses in invasively ventilated critically ill patients—a prospective multicenter observational study. Crit Care Med 2018;46:2936.CrossRefGoogle ScholarPubMed
Voiriot, G, Visseaux, B, Cohen, J, et al. Viral-bacterial coinfection affects the presentation and alters the prognosis of severe community-acquired pneumonia. Crit Care (London, England) 2016;20:375.CrossRefGoogle ScholarPubMed
Legoff, J, Zucman, N, Lemiale, V, et al. Clinical significance of upper airway virus detection in critically ill hematology patients. Am J Respir Crit Care Med 2018.Google Scholar
Murdoch, DR. Indications for microbiological testing in pneumonia: which patients should be tested? Clin Infect Dis 2019;68:20342035.CrossRefGoogle Scholar
Silverman, M, Povitz, M, Sontrop, JM, et al. Antibiotic prescribing for nonbacterial acute upper respiratory infections in elderly persons. Ann Intern Med 2017;166:765774.CrossRefGoogle ScholarPubMed
Timbrook, T, Maxam, M, Bosso, J. Antibiotic discontinuation rates associated with positive respiratory viral panel and low procalcitonin results in proven or suspected respiratory infections. Infect Dis Ther 2015;4:297306.CrossRefGoogle ScholarPubMed
Lowe, CF, Payne, M, Puddicombe, D, et al. Antimicrobial stewardship for hospitalized patients with viral respiratory tract infections. Am J Infect Control 2017;45:872875.CrossRefGoogle ScholarPubMed
Premier Healthcare Database White Paper: Data that informs and performs, July 29, 2018. Premier Applied Sciences website. https://learn.premierinc.com/white-papers/premier-healthcare-database-whitepaper.https://learn.premierinc.com/white-papers/premier-healthcare-database-whitepaper. Published July, 29, 2018. Accessed November 6, 2020.Google Scholar
Lindenauer, PK, Lagu, T, Shieh, MS, Pekow, PS, Rothberg, MB. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003–2009. JAMA 2012;307:14051413.CrossRefGoogle Scholar
Stroup, WW. Generalized Linear Mixed Models: Modern Concepts, Methods, and Applications. Boca Raton, FL: CRC Press; 2012.Google Scholar
Manning, WG, Basu, A, Mullahy, J. Generalized modeling approaches to risk adjustment of skewed outcomes data. J Health Econ 2005;24:465488.CrossRefGoogle ScholarPubMed
Elixhauser, A, Steiner, C, Harris, DR, Coffey, RM. Comorbidity measures for use with administrative data. Med Care 1998;36:827.CrossRefGoogle ScholarPubMed
Gagne, JJ GR, Avorn, J, Levin, R, Schneeweiss, S. A combined comorbidity score predicted mortality in elderly patients better than existing scores. Clin Epidemiol 2011;64:749759.CrossRefGoogle ScholarPubMed
Timsit, JF, Chevret, S, Valcke, J, et al. Mortality of nosocomial pneumonia in ventilated patients: influence of diagnostic tools. Am J Respir Crit Care Med 1996;154:116123.CrossRefGoogle ScholarPubMed
Rothberg, MB, Pekow, PS, Priya, A, et al. Using highly detailed administrative data to predict pneumonia mortality. PLoS One 2014;9:e87382.CrossRefGoogle ScholarPubMed
Cilloniz, C, Dominedo, C, Magdaleno, D, Ferrer, M, Gabarrus, A, Torres, A. Pure viral sepsis secondary to community-acquired pneumonia in adults: risk and prognostic factors. J Infect Dis 2019;220:11661171.CrossRefGoogle ScholarPubMed
Uyeki, TM, Bernstein, HH, Bradley, JS, et al. Clinical practice guidelines by the Infectious Diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenzaa. Clin Infect Dis 2019;68:895902.CrossRefGoogle Scholar
Shorr, AF, Fisher, K, Micek, ST, Kollef, MH. The burden of viruses in pneumonia associated with acute respiratory failure: an underappreciated issue. Chest 2018;154:8490.CrossRefGoogle ScholarPubMed
Tamma, PD, Avdic, E, Li, DX, Dzintars, K, Cosgrove, SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017;177:13081315.CrossRefGoogle ScholarPubMed
Schuetz, P, Christ-Crain, M, Thomann, R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009;302:10591066.CrossRefGoogle ScholarPubMed
Huang, DT, Yealy, DM, Filbin, MR, et al. Procalcitonin-guided use of antibiotics for lower respiratory tract infection. N Engl J Med 2018;379:236249.CrossRefGoogle ScholarPubMed
Montassier, E, Javaudin, F, Moustafa, F, et al. Guideline-based clinical assessment versus procalcitonin-guided antibiotic use in pneumonia: a pragmatic randomized trial. Ann Emerg Med 2019;74:580591.CrossRefGoogle ScholarPubMed
Branche, AR, Walsh, EE, Vargas, R, et al. Serum procalcitonin measurement and viral testing to guide antibiotic use for respiratory infections in hospitalized adults: a randomized controlled trial. J Infect Dis 2015;212:16921700.CrossRefGoogle ScholarPubMed
Rodriguez, AH, Aviles-Jurado, FX, Diaz, E, et al. Procalcitonin (PCT) levels for ruling-out bacterial coinfection in ICU patients with influenza: a CHAID decision-tree analysis. J Infect 2016;72:143151.CrossRefGoogle ScholarPubMed
Minnaard, MC, de Groot, JAH, Hopstaken, RM, et al. The added value of C-reactive protein measurement in diagnosing pneumonia in primary care: a meta-analysis of individual patient data. CMAJ 2017;189:E56E63.CrossRefGoogle ScholarPubMed
Do, NT, Ta, NT, Tran, NT, et al. Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial. Lancet Glob Health 2016;4:e633e641.CrossRefGoogle ScholarPubMed
Butler, CC, Gillespie, D, White, P, et al. C-reactive protein testing to guide antibiotic prescribing for COPD exacerbations. N Engl J Med 2019;381:111120.CrossRefGoogle ScholarPubMed
Vaughn, VM, Flanders, SA, Snyder, A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med 2019;171:153163.CrossRefGoogle ScholarPubMed
Supplementary material: File

Klompas et al. supplementary material

Tables S1-S4

Download Klompas et al. supplementary material(File)
File 35 KB

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *