Daily Respiratory Research Analysis
Three impactful respiratory studies highlight practice-changing insights: 1) influenza antivirals are underused and delayed in high-risk adults, especially older patients, in urgent care/emergency settings; 2) initial broad anti-pseudomonal therapy for low–drug-resistant-risk community-acquired pneumonia is linked to higher mortality and costs; 3) real-world N-acetylcysteine use in bronchiectasis reduces exacerbations, hospitalizations, sputum burden, and Pseudomonas aeruginosa isolation.
Summary
Three impactful respiratory studies highlight practice-changing insights: 1) influenza antivirals are underused and delayed in high-risk adults, especially older patients, in urgent care/emergency settings; 2) initial broad anti-pseudomonal therapy for low–drug-resistant-risk community-acquired pneumonia is linked to higher mortality and costs; 3) real-world N-acetylcysteine use in bronchiectasis reduces exacerbations, hospitalizations, sputum burden, and Pseudomonas aeruginosa isolation.
Research Themes
- Antiviral stewardship and timely therapy in influenza
- Antibiotic stewardship in community-acquired pneumonia
- Real-world mucolytic therapy effectiveness in bronchiectasis
Selected Articles
1. Patterns in Prescribing and Dispensing Influenza Antivirals Among Adults With Influenza Presenting to Urgent Care and Emergency Department Settings: VISION Network, 2023-2024.
In a 10,700-encounter, multi-system analysis, only 58% of molecular test–positive high-risk adults received antivirals, with two-thirds prescribed same-day. Older adults (≥65 years) had significantly lower odds of same-day prescribing and dispensing, revealing critical gaps in timely influenza treatment.
Impact: Identifies system-level delays and underuse of antivirals among those most likely to benefit, directly informing quality improvement for influenza seasons.
Clinical Implications: Implement protocols to ensure same-day testing-to-treatment, prioritize older adults for prompt prescribing/dispensing, and monitor site-level performance to increase antiviral uptake.
Key Findings
- Among 5,231 molecular-positive encounters, 58% received antiviral prescriptions and 67% were same-day.
- Of 3,050 prescriptions, 80% were dispensed, with 65% dispensed same-day.
- Adults ≥65 years had lower odds of same-day prescribing (OR 0.57) and dispensing (OR 0.58) versus ages 18–49.
Methodological Strengths
- Large, multi-system dataset with standardized molecular confirmation of influenza
- Adjusted analyses accounting for demographics and clinical risk factors
Limitations
- Retrospective cross-sectional design limits causal inference
- Generalizability may be limited to urgent care/ED settings within integrated systems
Future Directions: Evaluate targeted interventions (e.g., test-to-treat pathways, standing orders, pharmacist-led dispensing) to improve same-day antiviral initiation in older adults.
BACKGROUND: We describe prescribing and dispensing patterns of influenza antivirals among patients with laboratory-confirmed influenza within US urgent care and emergency department settings. METHODS: A retrospective cross-sectional study was conducted for encounters from 4 large, integrated health systems participating in the VIrtual Sars-cov-2, Influenza, and Other respiratory viruses Network (VISION) of adult patients presenting with acute respiratory illness to urgent care or emergency departments and with positive influenza virus test results during the 2023-2024 influenza season. The analysis was restricted to adult patients at higher risk of influenza complications based on presence of underlying medical conditions, older age, pregnancy, and severe obesity. We calculated proportions and odds of prescribed and dispensed antivirals by demographic and clinical characteristics. RESULTS: A total of 10 700 patient encounters were eligible for analysis. Among encounters with a positive standard molecular influenza test result (n = 5231), 58% (range across sites: 47%-64%) were prescribed antivirals, with 67% of prescribing occurring on the encounter date. Among those prescribed antivirals (n = 3050), 80% (range across sites: 75%-91%) had them dispensed, with 65% of dispensing occurring on the prescription date. Encounters among persons aged ≥65 years had lower odds of same-day prescribing (.57; 95% CI: .42-.78) and lower odds of same-day dispensing (.58; 95% CI: .36-.94) compared with those aged 18-49 years. CONCLUSIONS: Gaps in antiviral treatment within urgent care and emergency department settings remain for patients at higher risk of influenza complications, notably among older adults. Strategies to improve earlier initiation of antiviral treatment may help reduce the risk of influenza-associated complications.
2. Effects of Broad-Spectrum Antimicrobials on Patients with Community-Acquired Pneumonia with Low Risk for Drug-Resistant Pathogens: Historical Cohort Study in Japan.
In 15,617 low-DRP-risk CAP inpatients, initial anti-pseudomonal β-lactams were associated with higher 30-day mortality (IPTW-adjusted OR 1.77) and higher costs compared with non–anti-pseudomonal regimens. Findings support narrower empiric therapy when DRP risk is low.
Impact: Provides robust stewardship evidence that broad anti-pseudomonal coverage harms low-risk CAP patients, with clear mortality and cost signals.
Clinical Implications: Avoid routine anti-pseudomonal β-lactams in CAP without high DRP risk; implement risk stratification and stewardship pathways to guide narrower empiric therapy.
Key Findings
- Among 15,617 CAP inpatients at low DRP risk, broad anti-pseudomonal β-lactams had higher 30-day mortality (10.6% vs 5.3%).
- IPTW-adjusted odds of 30-day mortality were 1.77 (95% CI 1.52–2.06) with broad-spectrum regimens.
- Mean inpatient costs were higher in the broad-spectrum group (USD 6,139 vs 5,184).
Methodological Strengths
- Large nationwide claims cohort with explicit exclusion of high DRP risk
- Use of inverse probability of treatment weighting to reduce confounding
Limitations
- Claims-based definitions may misclassify severity and DRP risk
- Residual confounding and indication bias cannot be fully excluded
Future Directions: Prospective studies using DRP-risk tools to validate narrower empiric pathways and assess safety, LOS, and antibiotic resistance outcomes.
INTRODUCTION: Broad-spectrum antimicrobials are commonly administered for community-acquired pneumonia (CAP); however, unnecessary administration may cause adverse events and poor outcomes. This study aimed to understand the impact of broad-spectrum anti-pseudomonal β-lactam use on clinical outcomes and healthcare resource utilization (HCRU) in inpatients with CAP and a low risk of drug-resistant pathogens (DRPs). METHODS: This historical cohort study reviewed Japan's hospital claims database (January to December of 2018) and included inpatients aged ≥ 20 years who received intravenous antimicrobial therapy for CAP. Those with high DRP risk were excluded. According to the initial antimicrobial regimen, patients were divided into broad-spectrum (anti-pseudomonal β-lactam therapy) and narrow-spectrum (non-anti-pseudomonal β-lactam therapy) groups. This study evaluated 30-day hospital mortality as a primary outcome using inverse probability of treatment weighting (IPTW) to adjust for differences between both groups and HCRU as an exploratory analysis. RESULTS: A total of 15,617 patients were analyzed (2627 in the broad-spectrum group and 12,990 in the narrow-spectrum group). In the broad-spectrum group, the 30-day mortality rate was 10.6%, which was higher than that in the narrow-spectrum group (5.3%). Furthermore, it was associated with an increased 30-day mortality compared with the narrow-spectrum group after IPTW (adjusted odds ratio, 1.77; 95% confidence interval, 1.52-2.06; p < 0.001). The mean inpatient cost was USD 6139 and USD 5184 for the broad- and narrow-spectrum groups, respectively. CONCLUSIONS: The initial use of anti-pseudomonal β-lactams for CAP with low DRP risk is associated with poor outcomes, including death and high HCRU. Thus, initial antimicrobials should be judiciously selected for CAP management.
3. Effect of N-Acetylcysteine on Bronchiectasis in a Real-life Study. Data From the Spanish RIBRON Registry.
Across 2,461 bronchiectasis patients in a multicenter registry, N-acetylcysteine (mostly 600 mg/day) reduced exacerbations (27%), hospitalizations (17%), sputum volume (~60%), and P. aeruginosa isolation (12%) versus nonuse, with good tolerability. A 1,200 mg/day dose provided only modest additional benefit.
Impact: Provides real-world, multicenter evidence supporting NAC as an adjunct to reduce clinically meaningful outcomes in bronchiectasis.
Clinical Implications: Consider chronic NAC (600 mg/day) in stable bronchiectasis to reduce exacerbations and sputum burden; monitor for potential benefits on P. aeruginosa colonization.
Key Findings
- NAC reduced exacerbations by 27% and hospitalizations by 17% versus nonuse after ANCOVA adjustment.
- Sputum volume decreased by 59.7% and Pseudomonas aeruginosa infection by 12% with NAC.
- A 1,200 mg/day dose provided only modest additional exacerbation reduction compared with 600 mg/day; both doses were well tolerated.
Methodological Strengths
- Large, multicenter ambispective registry with pre/post comparisons
- Adjusted analyses (ANCOVA) accounting for baseline and covariates
Limitations
- Nonrandomized design with potential confounding by indication
- Dose assignment and adherence not randomized; residual bias possible
Future Directions: Randomized trials comparing NAC doses and durations, and evaluations of microbiologic endpoints and quality of life.
INTRODUCTION: There is scarce information about the most used mucolytic drug in bronchiectasis N-acetylcysteine (N-AC). Our objective was to analyze the effect of N-AC with respect to some outcomes in bronchiectasis. METHODS: Ambispective, longitudinal, observational, multi-center (43 centers) study of a cohort of 2461 adult patients diagnosed with bronchiectasis. Those patients treated in a stable situation with at least 600mg/d of N-AC (368; 15%) for at least 6 months were compared with patients not receiving this treatment. The variables analyzed and compared were those available two years before and after treatment. ANCOVA analysis was used to analyze the effect of N-AC as the inter-group difference of the basal intra-group difference for each variable, adjusted for relevant covariables. RESULTS: The N-AC group showed a full adjusted improvement of 27% in exacerbations, 17% in hospitalizations, and 31% in total exacerbation rates compared with the no-N-AC group. Moreover, a decrease in the volume of sputum production of 59.7% was observed as well as a decrease of 12% of patients with bronchial infection by Pseudomonas aeruginosa (PA). The use of 1200mg/d (n=116) resulted in only a mild, albeit significative improvement in the exacerbation rate compared with the use of 600mg/d (-11% in absolute number). Both doses were well tolerated. CONCLUSION: N-AC (in most cases at a dose of 600mg/d) is safe and effective and sufficient to reduce both the number of exacerbations and hospitalizations and the purulence and volume of sputum, as well as the isolation rate of PA in patients with bronchiectasis.