Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations.

PURPOSE: Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. METHODS: This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. RESULTS: Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. CONCLUSIONS: In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

Regulation of sodium and water excretions by neural renorenal reflexes in the cat.

The reduction in sodium and water excretion observed in the right kidney when the left kidney is subjected to transient denervation, is entirely abolished by bilateral section of the dorsal roots from T9 to L4, whereas section of the left dorsal roots only, at the same spinal level, does not affect the contralateral renal response to left renal nerve cooling. The possibility that the bilateral dorsal roots section abolished the response of the right kidney because the afferent fibres from the left kidney travel in the right dorsal roots was explored in the present study. Experiments were performed in anaesthetized cats in which reversible denervation of the left kidney was done by cooling of left renal nerves (for 10 min) after cutting the right dorsal roots from T9 to L4. Cooling of left renal nerves caused a large increase in sodium and water excretion from the left kidney and a prompt decrease in sodium and water excretion from the right kidney. During the cooling period arterial pressure did not change and glomerular filtration rate slightly increased in the left kidney only. The results obtained in this group of animals were not significantly different from those previously observed in sham-operated cats or in cats with section of left dorsal roots only. As the contralateral antidiuretic and antinatriuretic response to renal denervation survives dorsal root section on either side but is prevented by bilateral section, this demonstrates that the inhibitory renal afferent fibres responsible for this renorenal reflex are distributed bilaterally to spinal dorsal roots.