https://www.CABPCounts.com - CABP experts discuss clinical failure in community-acquired bacterial pneumonia, what it looks like, and how it can affect treatment outcomes. Read more:
Michael Rybak, PharmD, MPH, Wayne State University, Detroit, MI – Well, regarding clinical failure and community-acquired bacterial pneumonia, in terms of definitions, clinical failure is really the failure of the patient to respond in the predictable timeframe that we normally would be accustomed to.
Steve Vacalis, DO, Family Practice Medicine, Charlotte, NC – Clinical failure could be extending the therapy, going to the hospital or seeing a specialist like an infectious disease to get another opinion based on why this patient hasn't achieved the goals we set forth for that person.
Stephen Brunton, Primary Care Respiratory Group, Charlotte, NC – For me, typically what we see is patients just not getting better. They'll call back after a week or two and say, you know, “I'm still not 100%,” that’s a situation where I think about changing the antibiotic or something else is going on.
Michael Rybak, PharmD, MPH, Wayne State University, Detroit, MI – There may be multiple reasons why a patient may not quickly respond. But I think one definition of failure is the lack of response to the, what you believe to be the appropriate antibiotic for that particular patient. So resistance is definitely a cause of clinical failure.
Teena Chopra, MD, MPH, FSHEA, FIDSA, Wayne State University, Detroit, MI – Resistance is definitely a cause of clinical failure. Resistance like macrolide resistance in the community is increasing. I'm talking about community-acquired pneumonia, the most common cause is Strep pneumo, and macrolide resistance to strep pneumo is as high as 30 to 50 percent. So, that can be a real cause of clinical failure as well.
Stephen Brunton, Primary Care Respiratory Group, Charlotte, NC – Once the patient is deteriorating, I think you know the alarms go off and realize that it may be that we had the wrong antibiotic or it may be there's something else going on and this is where we really require help or admit to the hospital.
Jennifer Hanrahan, DO, MetroHealth Medical Center, Cleveland, OH – So typically one of the first steps is, aside from looking for complications, to broaden antibiotic coverage. And so patients get exposed quite often to, you know, a variety of antibiotics.
Charles Dela Cruz, MD, PhD, Yale University School of Medicine, New Haven, CT – Well, oftentimes some of the patients who come into our ICU come in with worsening respiratory status. Some of them require mechanical ventilation. And failure means these patients have been treated with antibiotics as an outpatient or even as an inpatient in regular floors and for some reason they come up to the ICU. Level of care has to be stepped up because their clinical course deteriorates.
Lionell Mandell, MD, FRCPC, McMaster University Medical School, Hamilton, Ontario, Canada – I think it's important whether they don't improve or certainly if they start deteriorating that it's really important to re-assess why this is happening and typically we approach it as sort of a - the classic triad of the host, bug, and the drug.
Gregory Volturo, MD, FACEP, University of Massachusetts Medical School, Worcester, MA – I think whether it’s a primary care physician or an emergency physician, we often don’t see our own failures, our own clinical failures. We’ll place them on an antibiotic and say, in the community setting, after a week, the patient will come back and they’re still not doing better; they may be prescribed another course of antibiotic, if it’s a mild to moderate disease. And the patient might get better even if there’s potential resistance. So, it’s harder to recognize resistance in the community than truly in the hospital setting.
Michael Rybak, PharmD, MPH, Wayne State University, Detroit, MI – Clinicians may not have the opportunity to follow up with their patients. And that patient may actually wind up in another clinician’s office. So they may bounce from one office to another before they’re actually get response to therapy or maybe they’ll even be admitted to the hospital.
Hien Nguyen, MD, MAS, University of California, Davis Health System, Sacramento, CA – There’s really a fractured nature in healthcare. From the primary care office to the ED to the hospital, and so I would say at least in our practice from a hospitalist standpoint, very rarely do you see a patient in the ER to admission to discharge. We're always working in shifts and we're almost always not seeing that patient from one moment to the next and so to judge clinical failure, you sort of have to see that sort of trend across time, I guess.
Charles Dela Cruz, MD, PhD, Yale University School of Medicine, New Haven, CT – I think, you know, I think clinical failure in CAP is an important issue because I think more and more, this is a topic that is not well studied. So, it is an ongoing real challenge.