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Semin Respir Crit Care Med 2024; 45(02): 246-254
DOI: 10.1055/s-0043-1778138
Review Article

Risk of Multidrug-Resistant Pathogens in Severe Community-Acquired Pneumonia

E. Campaña-Duel
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
,
M. Camprubí-Rimblas
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
,
A. Areny-Balagueró
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
,
Sara Quero
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
,
A. Artigas
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
,
Adrian Ceccato
1   Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
2   Centro de Investigación Biomedica En Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Barcelona, Spain
3   Intensive Care Unit, Hospital Universitari Sagrat Cor, Grupo Quironsalud, Barcelona, Spain
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Abstract

Severe community-acquired pneumonia (SCAP) is difficult to treat when caused by difficult-to-treat (DTR) pathogens because of limited treatment options and poorer clinical outcomes. Over time, several predictive scoring systems based on risk factors for infection with multidrug resistant pathogens have been developed. We reviewed the available tools for identifying DTR pathogens as the cause of SCAP, both predictive scoring systems and rapid diagnostic methods, to develop management strategies aimed at early identification of DTR pathogens, reducing broad-spectrum antibiotic use and improving clinical outcomes. The scoring systems reviewed show considerable heterogeneity among them at the level of the region studied, the definition of risk factors, as well as which DTR pathogens are the target pathogens. The models described have shown limited effectiveness in reducing inappropriate antibiotic treatment or improving patient outcomes by themselves. However, predictive models could serve as a first step in identifying DTR pathogen infections as part of a larger detection algorithm. Rapid diagnostic tools, such as multiplex polymerase chain reaction, would be useful for the rapid identification of pneumonia-causing pathogens and their resistance mechanisms. In resource-limited settings, rapid tests should be limited to patients at high risk of developing SCAP due to DTR pathogens. We propose an integrative algorithm based on the different scores, taking into account local epidemiological data, where ideally each center should have an antimicrobial stewardship program.

Keywords

community-acquired pneumonia - risk factors - difficult-to-treat pathogens - multidrug-resistant pathogens - antibiotic therapy - infection - management strategies


Publication History

Article published online:
01 February 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Aliberti S, Dela Cruz CS, Amati F, Sotgiu G, Restrepo MI. Community-acquired pneumonia. Lancet 2021; 398 (10303): 906-919
    CrossrefPubMedSearch in Google Scholar
  • 2 Murray CJ, Ikuta KS, Sharara F. et al; Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022; 399 (10325): 629-655
    CrossrefPubMedSearch in Google Scholar
  • 3 Jain S, Williams DJ, Arnold SR. et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med 2015; 372 (09) 835-845
    CrossrefPubMedSearch in Google Scholar
  • 4 Ferrer M, Travierso C, Cilloniz C. et al. Severe community-acquired pneumonia: characteristics and prognostic factors in ventilated and non-ventilated patients. PLoS One 2018; 13 (01) e0191721
    CrossrefPubMedSearch in Google Scholar
  • 5 Cillóniz C, Ewig S, Polverino E. et al. Microbial aetiology of community-acquired pneumonia and its relation to severity. Thorax 2011; 66 (04) 340-346
    CrossrefPubMedSearch in Google Scholar
  • 6 McCabe C, Kirchner C, Zhang H, Daley J, Fisman DN. Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: playing by the rules. Arch Intern Med 2009; 169 (16) 1525-1531
    CrossrefPubMedSearch in Google Scholar
  • 7 Webb BJ, Sorensen J, Jephson A, Mecham I, Dean NC. Broad-spectrum antibiotic use and poor outcomes in community-onset pneumonia: a cohort study. Eur Respir J 2019; 54 (01) 1900057
    CrossrefPubMedSearch in Google Scholar
  • 8 Jones BE, Ying J, Stevens V. et al. Empirical anti-MRSA vs standard antibiotic therapy and risk of 30-day mortality in patients hospitalized for pneumonia. JAMA Intern Med 2020; 180 (04) 552-560
    CrossrefPubMedSearch in Google Scholar
  • 9 Aliberti S, Di Pasquale M, Zanaboni AM. et al. Stratifying risk factors for multidrug-resistant pathogens in hospitalized patients coming from the community with pneumonia. Clin Infect Dis 2012; 54 (04) 470-478
    CrossrefPubMedSearch in Google Scholar
  • 10 Restrepo MI, Babu BL, Reyes LF. et al; GLIMP. Burden and risk factors for Pseudomonas aeruginosa community-acquired pneumonia: a multinational point prevalence study of hospitalised patients. Eur Respir J 2018; 52 (02) 1701190
    CrossrefPubMedSearch in Google Scholar
  • 11 Villafuerte D, Aliberti S, Soni NJ. et al; GLIMP Investigators. Prevalence and risk factors for Enterobacteriaceae in patients hospitalized with community-acquired pneumonia. Respirology 2020; 25 (05) 543-551
    CrossrefPubMedSearch in Google Scholar
  • 12 Self WH, Wunderink RG, Williams DJ. et al. Staphylococcus aureus community-acquired pneumonia: prevalence, clinical characteristics, and outcomes. Clin Infect Dis 2016; 63 (03) 300-309
    CrossrefPubMedSearch in Google Scholar
  • 13 Gross AE, Van Schooneveld TC, Olsen KM. et al. Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia. Antimicrob Agents Chemother 2014; 58 (09) 5262-5268
    CrossrefPubMedSearch in Google Scholar
  • 14 Ma HM, Ip M, Woo J. et al. Risk factors for drug-resistant bacterial pneumonia in older patients hospitalized with pneumonia in a Chinese population. QJM 2013; 106 (09) 823-829
    CrossrefPubMedSearch in Google Scholar
  • 15 Metersky ML, Frei CR, Mortensen EM. Predictors of Pseudomonas and methicillin-resistant Staphylococcus aureus in hospitalized patients with healthcare-associated pneumonia. Respirology 2016; 21 (01) 157-163
    CrossrefPubMedSearch in Google Scholar
  • 16 Shorr AF, Myers DE, Huang DB, Nathanson BH, Emons MF, Kollef MH. A risk score for identifying methicillin-resistant Staphylococcus aureus in patients presenting to the hospital with pneumonia. BMC Infect Dis 2013; 13 (01) 268
    CrossrefPubMedSearch in Google Scholar
  • 17 Parente DM, Cunha CB, Mylonakis E, Timbrook TT. The clinical utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA pneumonia: a diagnostic meta-analysis with antimicrobial stewardship implications. Clin Infect Dis 2018; 67 (01) 1-7
    CrossrefPubMedSearch in Google Scholar
  • 18 Metlay JP, Waterer GW, Long AC. et al. Diagnosis and treatment of adults with community-acquired pneumonia. An Official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200 (07) e45-e67
    CrossrefPubMedSearch in Google Scholar
  • 19 American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171 (04) 388-416
    CrossrefPubMedSearch in Google Scholar
  • 20 Ewig S, Welte T, Torres A. Is healthcare-associated pneumonia a distinct entity needing specific therapy?. Curr Opin Infect Dis 2012; 25 (02) 166-175
    CrossrefPubMedSearch in Google Scholar
  • 21 Falcone M, Russo A, Giannella M. et al. Individualizing risk of multidrug-resistant pathogens in community-onset pneumonia. PLoS One 2015; 10 (04) e0119528
    CrossrefPubMedSearch in Google Scholar
  • 22 Kalil AC, Metersky ML, Klompas M. et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63 (05) e61-e111
    CrossrefPubMedSearch in Google Scholar
  • 23 Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med 2008; 168 (20) 2205-2210
    CrossrefPubMedSearch in Google Scholar
  • 24 Shorr AF, Zilberberg MD, Reichley R. et al. Validation of a clinical score for assessing the risk of resistant pathogens in patients with pneumonia presenting to the emergency department. Clin Infect Dis 2012; 54 (02) 193-198
    CrossrefPubMedSearch in Google Scholar
  • 25 Aliberti S, Cilloniz C, Chalmers JD. et al. Multidrug-resistant pathogens in hospitalised patients coming from the community with pneumonia: a European perspective. Thorax 2013; 68 (11) 997-999
    CrossrefPubMedSearch in Google Scholar
  • 26 Shindo Y, Ito R, Kobayashi D. et al. Risk factors for drug-resistant pathogens in community-acquired and healthcare-associated pneumonia. Am J Respir Crit Care Med 2013; 188 (08) 985-995
    CrossrefPubMedSearch in Google Scholar
  • 27 Self WH, Wunderink RG, Williams DJ, Barrett TW, Baughman AH, Grijalva CG. Comparison of clinical prediction models for resistant bacteria in community-onset pneumonia. Acad Emerg Med 2015; 22 (06) 730-740
    CrossrefPubMedSearch in Google Scholar
  • 28 Prina E, Ranzani OT, Polverino E. et al. Risk factors associated with potentially antibiotic-resistant pathogens in community-acquired pneumonia. Ann Am Thorac Soc 2015; 12 (02) 153-160
    CrossrefPubMedSearch in Google Scholar
  • 29 Ceccato A, Mendez R, Ewig S. et al. Validation of a prediction score for drug-resistant microorganisms in community-acquired pneumonia. Ann Am Thorac Soc 2021; 18 (02) 257-265
    CrossrefPubMedSearch in Google Scholar
  • 30 Falcone M, Tiseo G, Menichetti F. Community-acquired pneumonia owing to multidrug-resistant pathogens: a step toward an early identification. Ann Am Thorac Soc 2021; 18 (02) 211-213
    CrossrefPubMedSearch in Google Scholar
  • 31 Webb BJ, Dascomb K, Stenehjem E. et al. Derivation and multicenter validation of the drug resistance in pneumonia clinical prediction score. Antimicrob Agents Chemother 2016; 60 (05) 2652-2663
    CrossrefPubMedSearch in Google Scholar
  • 32 Dean NC, Vines CG, Carr JR. et al. A pragmatic, stepped-wedge, cluster-controlled clinical trial of real-time pneumonia clinical decision support. Am J Respir Crit Care Med 2022; 205 (11) 1330-1336
    CrossrefPubMedSearch in Google Scholar
  • 33 Madaras-Kelly KJ, Remington RE, Fan VS, Sloan KL. Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia. J Hosp Med 2012; 7 (03) 195-202
    CrossrefPubMedSearch in Google Scholar
  • 34 Amati F, Bindo F, Stainer A. et al. Identify drug-resistant pathogens in patients with community-acquired pneumonia. Adv Respir Med 2023; 91 (03) 224-238
    CrossrefPubMedSearch in Google Scholar
  • 35 Wang Y, Liang X, Jiang Y. et al. Novel fast pathogen diagnosis method for severe pneumonia patients in the intensive care unit: randomized clinical trial. eLife 2022; 11: e79014
    CrossrefPubMedSearch in Google Scholar
  • 36 Darie AM, Khanna N, Jahn K. et al. Fast multiplex bacterial PCR of bronchoalveolar lavage for antibiotic stewardship in hospitalised patients with pneumonia at risk of Gram-negative bacterial infection (Flagship II): a multicentre, randomised controlled trial. Lancet Respir Med 2022; 10 (09) 877-887
    CrossrefPubMedSearch in Google Scholar
  • 37 Monard C, Pehlivan J, Auger G. et al; ADAPT study group. Multicenter evaluation of a syndromic rapid multiplex PCR test for early adaptation of antimicrobial therapy in adult patients with pneumonia. Crit Care 2020; 24 (01) 434
    CrossrefPubMedSearch in Google Scholar
  • 38 Buchan BW, Windham S, Balada-Llasat JM. et al. Practical comparison of the BioFire FilmArray pneumonia panel to routine diagnostic methods and potential impact on antimicrobial stewardship in adult hospitalized patients with lower respiratory tract infections. J Clin Microbiol 2020; 58 (07) e00135-20
    CrossrefPubMedSearch in Google Scholar
  • 39 Voiriot G, Fartoukh M, Durand-Zaleski I. et al; MULTI-CAP study group. Combined use of a broad-panel respiratory multiplex PCR and procalcitonin to reduce duration of antibiotics exposure in patients with severe community-acquired pneumonia (MULTI-CAP): a multicentre, parallel-group, open-label, individual randomised trial conducted in French intensive care units. BMJ Open 2021; 11 (08) e048187
    CrossrefPubMedSearch in Google Scholar
  • 40 Martin-Loeches I, Torres A, Nagavci B. et al. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med 2023; 49 (06) 615-632
    CrossrefPubMedSearch in Google Scholar
  • 41 Lin T, Tu X, Zhao J. et al. Microbiological diagnostic performance of metagenomic next-generation sequencing compared with conventional culture for patients with community-acquired pneumonia. Front Cell Infect Microbiol 2023; 13: 1136588
    CrossrefPubMedSearch in Google Scholar
  • 42 Corrales-Medina VF, van Walraven C. Guideline-concordant antibiotic therapy for the hospital treatment of community-acquired pneumonia and 1-year all-cause and cardiovascular mortality in older adult patients surviving to discharge. Chest 2023; 163 (06) 1380-1389
    CrossrefPubMedSearch in Google Scholar
  • 43 Kollef MH, Betthauser KD. New antibiotics for community-acquired pneumonia. Curr Opin Infect Dis 2019; 32 (02) 169-175
    CrossrefPubMedSearch in Google Scholar
  • 44 Zhong NS, Sun T, Zhuo C. et al. Ceftaroline fosamil versus ceftriaxone for the treatment of Asian patients with community-acquired pneumonia: a randomised, controlled, double-blind, phase 3, non-inferiority with nested superiority trial. Lancet Infect Dis 2015; 15 (02) 161-171
    CrossrefPubMedSearch in Google Scholar
  • 45 File Jr TM, Low DE, Eckburg PB. et al; FOCUS 1 investigators. FOCUS 1: a randomized, double-blinded, multicentre, Phase III trial of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in community-acquired pneumonia. J Antimicrob Chemother 2011; 66 (Suppl. 03) iii19-iii32
    PubMedSearch in Google Scholar
  • 46 Low DE, File Jr TM, Eckburg PB. et al; FOCUS 2 investigators. FOCUS 2: a randomized, double-blinded, multicentre, Phase III trial of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in community-acquired pneumonia. J Antimicrob Chemother 2011; 66 (Suppl. 03) iii33-iii44
    CrossrefPubMedSearch in Google Scholar
  • 47 Nicholson SC, Welte T, File Jr TM. et al. A randomised, double-blind trial comparing ceftobiprole medocaril with ceftriaxone with or without linezolid for the treatment of patients with community-acquired pneumonia requiring hospitalisation. Int J Antimicrob Agents 2012; 39 (03) 240-246
    CrossrefPubMedSearch in Google Scholar
  • 48 McCurdy S, Keedy K, Lawrence L. et al. Efficacy of delafloxacin versus moxifloxacin against bacterial respiratory pathogens in adults with Community-Acquired Bacterial Pneumonia (CABP): microbiology results from the delafloxacin phase 3 CABP trial. Antimicrob Agents Chemother 2020; 64 (03) e01949-19
    CrossrefPubMedSearch in Google Scholar
  • 49 Gómez-Zorrilla S, Sendra E, Horcajada JP. A profile of delafloxacin in the treatment of adults with community-acquired bacterial pneumonia. Expert Rev Clin Pharmacol 2022; 15 (06) 671-688
    CrossrefPubMedSearch in Google Scholar
  • 50 Schreiber MP, Chan CM, Shorr AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia?. Chest 2010; 137 (06) 1283-1288
    CrossrefPubMedSearch in Google Scholar
  • 51 Park SC, Kang YA, Park BH. et al. Poor prediction of potentially drug-resistant pathogens using current criteria of health care-associated pneumonia. Respir Med 2012; 106 (09) 1311-1319
    CrossrefPubMedSearch in Google Scholar
  • 52 Park SC, Kim EY, Kang YA. et al. Validation of a scoring tool to predict drug-resistant pathogens in hospitalised pneumonia patients. Int J Tuberc Lung Dis 2013; 17 (05) 704-709
    CrossrefPubMedSearch in Google Scholar
  • 53 Ma HM, Ip M, Woo J, Hui DS. Development and validation of a clinical risk score for predicting drug-resistant bacterial pneumonia in older Chinese patients. Respirology 2014; 19 (04) 549-555
    CrossrefPubMedSearch in Google Scholar
  • 54 Wang PH, Wang HC, Cheng SL, Chang HT, Laio CH. Selection of empirical antibiotics for health care-associated pneumonia via integration of pneumonia severity index and risk factors of drug-resistant pathogens. J Formos Med Assoc 2016; 115 (05) 356-363
    CrossrefPubMedSearch in Google Scholar
  • 55 Rothberg MB, Haessler S, Deshpande A. et al. Derivation and validation of a risk assessment model for drug-resistant pathogens in hospitalized patients with community-acquired pneumonia. . [published online ahead of print, 2022 Sep 29] Infect Control Hosp Epidemiol 2023; 44 (07) 1143-1150
    CrossrefPubMedSearch in Google Scholar