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Methicillin-resistenta Staphylococcus aureus (MRSA) som bär på genen mecA, har förekommit och spridit sig över hela världen, främst i sjukhusmiljö, och orsakat utbrott av vårdrelaterade (så kallade nosokomiala) infektioner. Dessa infektioner kan inte behandlas med stafylokock-penicilliner och MRSA-bakterierna är ofta resistenta även mot flera andra grupper av antibiotika vilket medför att infektionerna ofta är påtagligt svårbehandlade. Under senare år har emellertid allt fler fall beskrivits av samhällsförvärvad MRSA infektion, det vill säga uppträdande av MRSA hos personer som tidigare ej har haft kontakt med sjukhusvård eller behandlats med antibiotika. Det har länge varit oklart om de samhällsförvärvade MRSA [community-acquired (CA-MRSA)] representerar spridning av bakterier från sjukhusmiljön ut till samhället eller om dessa MRSA är spontant uppträdande. Många av dessa stammar har dessutom visat sig bära på sjukdomsrelaterade gener som vanligen inte återfinns hos S. aureus, t.ex. Panton Valentine leukocidin (PVL) som associeras med hudinfektioner och allvarlig lunginflammation med hög dödlighet hos unga och annars friska individer. Denna avhandling beskriver den molekylära epidemiologin hos MRSA med fokus på samhällsförvärvade MRSA som utgjorde mer än hälften av samtliga fall av MRSA i Örebro län och som dessutom ofta producerade PVL toxinet, vars funktion vidare analyserades i detalj. Undersökning av ursprung och släktskap hos samtliga MRSA som isolerats i Örebro län, samt karaktärisering av det genetiskt element som kallas staphylococcal cassette chromosome mec (SCCmec) vilket innehåller genen mecA och ibland även andra resistensgener, visade att CA-MRSA inte är relaterade till de nosokomiala MRSA, och att dessa har uppstått oberoende av varandra. Flertalet MRSA visade sig dessutom bära på SCCmec, och resistensmekanismer, som tidigare inte beskrivits. Troligen har dessa MRSA uppstått genom ett genetiskt utbyte av SCCmec mellan methicillin-resistenta koagulas-negativa stafylokocker (MR-KNS), som utgör huvudparten av normalfloran på huden, och methicillin-känsliga S. aureus som därvid erhåller genen mecA och resistensmekanismer mot samtliga stafylokockantibiotika. I den här avhandlingen framläggs bevis för att ett sådant genetiskt utbyte har skett på Barnkliniken på Universitetssjukhuset i Örebro i slutet på 1990-talet, vilket resulterade i uppkomsten av en ny klon av MRSA som därefter orsakade ett allvarligt utbrott. Kartläggning av DNA-sekvensen hos flertalet unika SCCmec från svenska MRSA gav dessutom en bättre förståelse för hur resistens uppkommer och sprider sig, samt mekanismerna bakom detta. Dessa nya kunskaper kan bidra till en förbättrad diagnostik av MRSA. Detta är framför allt av stor betydelse eftersom nya effektiva kloner av MRSA verkar kunna uppstå ute i samhället med potential att orsaka svårbehandlade infektioner men även att sprida sig bland den friska befolkningen. / Material and methods - During a period of 14 years, around 2000 patients with head injuries were admitted to the emergency ward at Lindesberg County Hospital and Örebro Medical Centre Hospital. Six hundred subjects suffered from skull fracture and/or brain contusion and diagnosis was established using a computed tomography scan (CT). The degree of initial brain injury was estimated using the Swedish Reaction Level Scale (RLS). Sixty-six subjects were investigated with pure tone audiometry in close proximity to the trauma, and this gave an opportunity to study the issue of progress. The investigation took place two to 14 years after trauma, and the results were compared to matched control groups. A battery of different audiological methods was used to investigate peripheral and central auditory function, and a specially designed acoustic environmental room was also utilized. Cognition was investigated using a computer-based test-battery, text information process system (TIPS). Self-assessed hearing, cognition and quality of life were explored using different questionnaires. Results - A high percentage of peripheral and central auditory impairments and also cognitive shortcomings were demonstrated. Progress of SNHL was a common finding, and fracture, high age at trauma and large initial hearing loss predicted progress. Antibody-mediated autoimmunity as a mechanism behind posttraumatic progress of SNHL or clear evidence for sympathetic cochleolabyrinthitis could not be demonstrated. Binaural auditory deficits could be demonstrated when tested in a realistic acoustic environment. Tinnitus, vertigo and memory shortcomings proved to be common sequelae, even in a long-term perspectiveCognitive shortcomings were found in several of these well-rehabilitated subjects.On a group level, there was a good correlation between self-assessments and audiometric results, even if some individuals had a tendency to over- or underestimate their abilities. Conclusion - Auditory and cognitive long-term sequelae of CHI are a common finding even in well-rehabilitated and socially well-functioning subjects, as are vertigo and tinnitus. Vertigo and tinnitus are also common sequelae after CHI, therefore a basic audiovestibular investigation after CHI is recommended, at least in selected cases.Early awareness of the risk for hearing and cognitive sequelae after CHI could lead to measurements taken to prevent tension-related symptoms.Early detection of HI offers an opportunity to try immunosuppressive treatment in cases with a large initial SNHL.

Thematic Paper (M.C.T.M. (Tropical Pediatrics))--Mahidol University, 2005.

Thematic Paper (M.C.T.M. (Tropical Pediatrics))--Mahidol University, 2005.

O objetivo principal dessa tese foi avaliar se o tratamento com ceftriaxona e um macrolídeo leva a melhores desfechos quando comparada a monoterapia com ceftriaxona em pacientes hospitalizados com HIV/AIDS e pneumonia adquirida na comunidade (PAC). 227 adultos com HIV hospitalizados por uma suspeita de PAC foram randomizados numa proporção 1:1 para receber um dos dois regimes, ceftriaxona mais macrolídeo ou ceftriaxona mais placebo. Houve 2 exclusões após a randomização, um paciente retirou consentimento para uso de seus dados e outro paciente já havia sido incluído previamente no estudo, perfazendo um total de 225 pacientes analisados (112 receberam ceftriaxona mais placebo e 113 receberam ceftriaxona mais macrolídeo). Os pacientes tinham HIV há um longo tempo (período mediano de 10 anos) e a maioria não fazia uso regular de terapia antirretroviral. Somente 32/202 pacientes (16%) tinham carga viral menor que 50 cópias/mL e 146/202 (72%) tinham contagem de linfócitos T CD4+ menor que 200 células/mm³. A frequência do desfecho primário, letalidade durante a internação, não foi estatisticamente distinta entre os regimes estudados: 12/112 (11%) pacientes que receberam ceftriaxona mais placebo e 17/113 (15%) que receberam ceftriaxona mais macrolídeo foram a óbito durante a hospitalização (HR: 1.22, 95% CI: 0.57-2.59). Não foram encontradas diferenças entre os regimes para os desfechos secundários: letalidade em 14 dias (RR: 2.38, 95% CI: 0.87-6.53), uso de drogas vasoativas (OR: 1.18, 95% CI: 0.60-2.29) e ventilação mecânica (OR: 1.24, 95% CI: 0.64- 2.40). A etiologia das infecções pulmonares adquiridas na comunidade nesses pacientes com infecção pelo HIV também foi estudada e determinada prospectivamente. Essa investigação também buscou analisar a contribuição de diferentes métodos diagnósticos e o impacto de diferentes abordagens de investigação microbiológica. Além disso, os achados microbiológicos foram analisados levando em consideração a contagem de linfócitos T CD4+, gravidade da doença e a situação da vacina pneumocócica. 224 pacientes foram submetidos a investigação microbiológica estendida e 143 (64%) tiveram uma etiologia determinada. Por outro lado, a investigação microbiológica de rotina foi capaz de determinar o agente etiológico em 92 (41%) pacientes. Métodos baseados na reação em cadeia da polimerase foram essenciais para o diagnóstico de bactérias atípicas e vírus, além de melhorar a detecção de Pneumocystis jirovecii. Entre os 143 pacientes com uma etiologia determinada, Pneumocystis jirovecii foi o principal agente, detectado em 52 (36%) casos, seguido pelo Mycobacterium tuberculosis responsável por 28 (20%) casos. Streptococcus pneumoniae e Rhinovírus foram diagnosticados em 22 (15%) casos cada e Influenza em 15 (10%) casos. Entre as bactérias atípicas, Mycoplasma pneumoniae foi responsável por 12 (8%) e Chlamydophila pneumoniae por 7 (5%) casos. Infecções mistas ocorreram em 48 casos (34%). Streptococcus pneumoniae foi associado com maiores escores de gravidade, sem associação com o estado vacinal. A análise de agentes etiológicos baseada na contagem de linfócitos T CD4+ demonstrou que a etiologia da pneumonia nos pacientes que estavam gravemente imunossuprimidos (CD4+ < 200 células/mm³) foi similar aos que não estavam. Pneumocystis jirovecii foi o único agente mais frequente no primeiro grupo, um achado esperado levando em consideração os critérios diagnósticos empregados / The main purpose of this thesis was to evaluate if treatment with ceftriaxone and a macrolide improved patient outcome when compared with monotherapy with ceftriaxone in hospitalized patients with HIV/AIDS with community acquired pneumonia (CAP). 227 adult patients with HIV hospitalized due to suspected CAP were randomized to receive one of two regimens, ceftriaxone plus macrolide or ceftriaxone plus placebo, at a 1:1 proportion. We had 2 exclusions after randomization, one patient who withdrew consent for data inclusion and use and one that had previously been included, leaving a total of 225 patients to analyse (112 received ceftriaxone plus placebo and 113 received ceftriaxone plus macrolide). Patients had prolonged HIV infection, the median period was twelve years, and most of them did not make regular use of antiretroviral therapy. Only 32/202 patients (16%) had viral load below 50 copies/mL and 146/202 (72%) had a CD4+ T cell count below 200 cells/mm³. The frequency of the primary outcome, in-hospital mortality, was not statistically different between the studied regimens: 12/112 (11%) patients who received ceftriaxone plus placebo and 17/113 (15%) who received ceftriaxone plus macrolide died during hospitalization (HR: 1.22, 95% CI: 0.57-2.59). We did not find differences between the regimens for the secondary outcomes: mortality within 14 days (RR: 2.38, 95% CI: 0.87-6.53), need for vasoactive drug (OR: 1.18, 95% CI: 0.60-2.29) or mechanical ventilation (OR: 1.24, 95% CI: 0.64-2.40). The etiology of community-acquired pulmonary infections in these hospitalized patients with HIV was also studied and determined prospectively. This investigation also aimed to analyze the contribution of different diagnostic methods as well of the impact of different approaches to microbiological evaluation and to evaluate the microbiological findings in relation to the CD4+ T cell count, the severity of disease and pneumococcal vaccine status. 224 patients underwent the extended microbiological investigation of which 143 (64%) had an etiology determined. On the other hand, the microbiological routine investigation was able to determine the etiological agents in 92 (41%) patients. Polymerase chain reaction-based methods were essential for the diagnosis of atypical bacteria and viruses, besides contributing to ameliorate Pneumocystis jirovecii detection. Among the 143 patients with a determined etiology, Pneumocystis jirovecii was the main agent, detected in 52 (36%) cases and followed by Mycobacterium tuberculosis accounting for 28 (20%) cases. Streptococcus pneumoniae and Rhinovirus were diagnosed in 22 (15%) cases each and Influenza in 15 (10%) cases. Among atypical bacteria, Mycoplasma pneumoniae was responsible for 12 (8%) and Chlamydophila pneumoniae for 7 (5%) cases. Mixed infections occurred in 48 cases (34%). Streptococcus pneumoniae was associated with higher severity scores and not associated with vaccine status. Performing an analysis of causative agents based on CD4+ T cell count, we found that the etiology of pneumonia in those severely immunosuppressed (CD4+ < 200 cells/mm³) was similar to those who were not. Pneumocystis jirovecii is the only agent more frequent in the former group, an expected finding considering our diagnostic criteria

Orientadores: Patrícia Moriel, Carlos Emílio Levy / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T14:28:55Z (GMT). No. of bitstreams: 1 Mattos_KarenPradoHerzer_M.pdf: 1543498 bytes, checksum: 9d1f9328148bdfe74a6e65854c319426 (MD5) Previous issue date: 2014 / Resumo: As Infecções de Trato Urinário (ITUs) são definidas como colonizações microbianas com invasão tecidual de qualquer parte do trato urinário, desde a uretra até os rins, considerada a doença infecciosa extra intestinal de origem comunitária mais comum em todo mundo. As ITUs em sua maioria são causadas por bactérias Gram-negativas, sendo a Escherichia coli o micro-organismo invasor mais comum, isolado em cerca de 80% a 90% das infecções agudas de origem comunitária. Neste início de terceiro milênio, a resistência bacteriana é um dos desafios globais de saúde pública a ser enfrentado e sabe-se que, a intensidade de exposição ao antimicrobiano é um importante parâmetro relacionado à seleção e à manutenção de bactérias resistentes. Em 2010 o Brasil vivia uma situação na qual estavam sendo observados vários focos de infecções hospitalares causadas por micro-organismos multirresistentes como a Klebsiella pneumoniae produtoras de carbapenemase (KPC). Em função do preocupante cenário, em 2010 foi implantada a Resolução da Diretoria Colegiada (RDC) nº 44 da Agência Nacional de Vigilância Sanitária (ANVISA) que possui, dentre outros objetivos, a diminuição da resistência bacteriana aos antimicrobianos. Objetivo: Estudar o perfil de resistência de bactérias Gram-negativas relacionadas às ITUs de origem comunitária e analisar a influência da legislação atuante no controle de venda de antimicrobianos. Métodos: População de pacientes de demanda espontânea aos hospitais da Universidade Estadual de Campinas entre 2009 e 2013 com hipótese-diagnóstica de ITU de origem comunitária, de ambos os sexos, independente de raça e idade. As amostras de urina dos pacientes foram encaminhadas ao Laboratório de Microbiologia Clínica da instituição e foram incluídas no estudo as uroculturas com resultado positivo para os agentes etiológicos Escherichia coli, Klebsiella pneumoniae e Proteus mirabilis. Os antimicrobianos foram agrupados em 5 classes: Aminoglicosídeos, Fluorquinolonas, Sulfonamidas, Beta-lactâmicos e Nitrofurano . Foi realizada análise estatística descritiva e o nível de significância adotado foi de 5%. Resultados e discussão: Os dados demográficos demonstraram prevalência média de 75% de ITU's em mulheres. A idade média dos casos de ITU foi de 40 ± 1,8 anos. A E. coli foi o patógeno mais frequente (83%) nos exames de urocultura para casos de ITU. O relatório estatístico não apontou diferenças significantes entre a variação dos percentuais de resistência bacteriana para E. coli e P. mirabilis, além de não apontar uma tendência linear. Apenas a K. pneumoniae apresentou resultado estatístico significante na análise geral quando foi observado aumento das taxas de resistência e tendência linear crescente. A E. coli apresentou queda do percentual de resistência bacteriana e tendência linear decrescente com relação às fluorquinolonas. Estudo de 2013 da Universidade de São Paulo analisou o consumo extra hospitalar de antimicrobianos e observou queda de 7% do consumo geral, além de queda de 28% da venda de norfloxacino, o que suporta nossos resultados. Conclusão: Sugere-se que a RDC nº 44/2010 influenciou na queda das taxas de resistência bacteriana entre a classe das fluorquinolonas, principalmente o ciprofloxacino, para ITU¿s de origem comunitária / Abstract: Introduction: Community-acquired urinary tract infections (UTIs) are extra intestinal infectious diseases, causing microbial colonization and tissue invasion in the urinary tract. Gram-negative bacteria, especially Escherichia coli, are the most common invasive microorganisms causing UTIs; they are isolated in 80%¿90% of acute infections of community origin. Bacterial resistance is currently a global public health challenge. The intensity of bacterial exposure to antimicrobials is an important parameter affecting the selection and maintenance of resistant bacteria. In 2010, Brazil witnessed several outbreaks of nosocomial infections caused by multidrug-resistant microorganisms such as Klebsiella pneumoniae carbapenemase (KPC). Collegiate Board Resolution (CBR) no. 44 was introduced by the National Health Surveillance Agency with the goal of reducing bacterial resistance to antimicrobials. Objectives: To study the resistance profile of gram-negative bacteria causing community-acquired UTIs and to analyze the influence of the legislation promoting active control of the sale of antimicrobials. Methods: Patients of different gender, ethnicity, and age, admitted at the State University of Campinas Hospital between 2009 and 2013, with a diagnosis of suspected community-acquired UTI were included in the study Patients with urine cultures positive for Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis were included in the study. The antimicrobial classes used were aminoglycosides, fluoroquinolones, sulfonamides, beta-lactams, and nitrofuran. Descriptive statistical analysis was performed, and the level of significance was set at 5%. Results and Discussion: Demographic data showed the average prevalence of UTIs among women to be 75%. The average age of the affected individuals was 40 ± 1.8 years. E. coli was the most common pathogen (83%) detected in urine culture tests for UTI cases. The percentage of variation of bacterial resistance was not significant between E. coli and P. mirabilis and did not indicate a linear trend. Only K. pneumoniae showed a statistically significant result in the overall analysis, showing increasing rates of resistance and an increasing linear trend. E. coli demonstrated a decrease in the percentage of bacterial resistance and a decreasing linear trend in fluoroquinolone resistance. The 2013 study from the University of Sao Paulo discussed the extra-hospital antimicrobial consumption, and observed a 7% decline in overall consumption and a 28% decline in the sale of norfloxacin, which supports our results. Conclusion: It is suggested that CBR nº 44/2010 influenced the decline in the rate of bacterial resistance towards fluoroquinolones, especially ciprofloxacinin community-acquired UTIs / Mestrado / Ciencias Biomedicas / Mestra em Ciências Médicas

Staphylococcus aureus est l’une des causes majeures des infections communautaires et nosocomiales. Ce germe est responsable des infections aiguës et chroniques dont la plupart sont dues à sa capacité à adhérer sur les implants médicaux et à former un biofilm. D’après le Center for Disease Control and Prevention (CDC), 65% des infections bactériennes sont dues à la présence des biofilms. En outre, les infections associées aux biofilms constituent un problème majeur en clinique et sont la cause de l’augmentation de la mortalité et du coût de traitement. <p>Chez S. aureus, la formation du biofilm se déroule en deux phases principales: la première phase est l’attachement initial des cellules sur une surface, et la seconde est la multiplication et la formation d’une communauté structurée, mature et multicouche des cellules bactériennes. A l’intérieur du biofilm, les bactéries développent plusieurs types d’interactions et accroissent leur résistance aux agents antimicrobiens et aux défenses immunitaires de l’hôte, ce qui constitue un véritable problème de santé publique.<p>Les objectifs de ce travail étaient: (1) de caractériser des souches cliniques de S. aureus sensibles et résistantes à la méticilline (SASM et SARM) par une analyse phénotypique et génotypique; (2) d’étudier la répercussion des propriétés de membranes sur l’adhésion et la formation du biofilm; (3) de rechercher un moyen pour la prévention de l’adhésion et de la formation d’un biofilm sur une surface abiotique.<p>Deux souches de référence et 12 souches cliniques de S. aureus (4 SARM et 8 SASM) collectées à Kinshasa ont été caractérisées par la résistance aux antibiotiques, par le typage d’une région X du gène spa codant pour la protéine A de S. aureus et par la détermination des propriétés de la surface cellulaire. L’adhésion à une surface et la formation du biofilm ont été respectivement étudiées par la méthode de Biofilm Ring Test® (BFRT®) et par celle de coloration au cristal violet. Ces deux méthodes ont été utilisées pour l’évaluation de l’activité de l’acide éthylèneglycol tétraacétique (EGTA) sur l’adhésion et la formation du biofilm.<p>L’amplification par PCR (Polymerase Chain Reaction) d’un fragment du gène mecA a confirmé l’appartenance des souches étudiées au phénotype SARM ou SASM. L’analyse par PCR des répétitions présentes dans la séquence codante de la protéine A de S. aureus (spa typing) a permis d’identifier 7 types spa pour toutes les souches SARM et SASM2 dont un nouveau type spa t10715.<p>Les résultats du test MATS (Microbial Adhesion to Solvents) ont montré que les souches de S. aureus sensibles et résistantes à la méticilline possédaient des propriétés membranaires différentes susceptibles de modifier l’adhésion ou la formation d’un biofilm. Les souches sensibles à la méticilline avaient une paroi plus hydrophobe que celle de souches résistantes dont la paroi était acide, acceptrice d’électrons. <p>Les études sur l’interaction entre des souches cliniques de S. aureus et des surfaces abiotiques ont montré que les souches SARM adhéraient moins vite à une surface et formaient moins de biofilms que les souches SASM. <p>Les études de l’activité de l’EGTA, un chélateur des cations divalents, ont montré que ce dernier inhibait l’adhésion de souches SARM à une surface abiotique comme un tube de cathéter et empêchait la formation d’un biofilm par toutes les souches sensibles et résistantes à la méticilline. Cette action inhibitrice sur la formation du biofilm était réversible en présence d’un cation divalent (magnésium, calcium ou manganèse). <p>L’ensemble des données obtenues sur l’adhésion et la formation du biofilm par la méthode de BFRT® et par celle de coloration au cristal violet ont montré que le BFRT® était la méthode de choix dans les études de l’adhésion initiale des souches de S. aureus sur une surface abiotique. Le BFRT® pourrait être utilisée dans le screening rapide de produits contre l’adhésion bactérienne à la surface des implants médicaux à base de polystyrène ou de silicone.<p> / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

There are few data on mortality after discharge with community-acquired pneumonia (CAP). Therefore, we evaluated risk factors for 30-day post-discharge mortality after CAP. We included all patients of the prospective multi-national CAPNETZ study between 2002 and 2018 with (1) hospitalized CAP, (2) survival until discharge, and (3) complete follow-up data. The study endpoint was death within 30 days after discharge. We evaluated risk factors including demographics, comorbidities, admission CAP severity, and laboratory values and treatment-related factors in uni- and multivariable analyses. A total of 126 (1.6%) of 7882 included patients died until day 30 after discharge, corresponding to 26% of all 476 deaths. After multivariable analysis, we identified 10 independent risk factors: higher age, lower BMI, presence of diabetes mellitus, chronic renal or chronic neurological disease (other than cerebrovascular diseases), low body temperature or higher thrombocytes on admission, extended length of hospitalization, oxygen therapy during hospitalization, and post-obstructive pneumonia. By addition these factors, we calculated a risk score with an AUC of 0.831 (95%CI 0.822–0.839, p < 0.001) for prediction of post-discharge mortality. Early post-discharge deaths account for ¼ of all CAP-associated deaths and are associated with patient- and CAP-severity-related risk factors. Additional studies are necessary to replicate our findings in independent cohorts. Study registration: NCT 02139163.

Sepsis is the systemic inflammatory response to an infection. Severe sepsis with multi organ failure is one of the commonest causes of admission to intensive care units, and is associated with poor early and late outcomes. The pathophysiology of sepsis is complex, and poorly understood. This is reflected in the limited and contentious treatment options for sepsis. Genetic factors have been shown to be associated with the risk of and subsequent outcomes from infection. However, clear associations with bacterial sepsis are rare, and even when associations are present their functional effects are often unknown. Gene expression signatures in sepsis are investigated in this project using serial samples obtained from patients admitted to intensive care units with community-acquired pneumonia or faecal peritonitis. The evolving gene expression signatures that define the response to sepsis were identified with large changes seen in genes coding for ribosomal proteins RPS4Y1 and RPS26P54. The differences in the sepsis response between the two diagnostic classes were examined. The gene expression predictors of mortality in sepsis were determined and include genes from the class II MHC HLA-DRB4, HLA-DRB5 and the T cell differentiation protein MAL. The effects of important covariates on gene expression were investigated and their impact on survival related expression determined. The findings were confirmed in a validation cohort. A novel clustering of samples representing distinct inflammatory patterns in a clinically homogeneous population of sepsis patients was identified and related to differences in clinical behaviour. The biological relevance of the differentially expressed genes was ascertained by identifying enriched gene sets. The gene expression changes in sepsis were examined in the context of related clinically relevant immune phenomena: the sterile systemic inflammatory response in patients undergoing elective cardiac surgery and the phenomenon of endotoxin tolerance in PBMCs derived from healthy volunteers. The results highlight the complexities of clinical sepsis and identify hypotheses for future investigations.

The IDSA Community-Acquired Pneumonia (CAP) Guideline recommends ceftriaxone in combination with doxycycline as an alternative to combination therapy with ceftriaxone and azithromycin for non-intensive care unit (ICU) patients hospitalized with CAP. This is an attractive alternative regimen due to recent concerns of increased cardiovascular risk associated with azithromycin. The objective of this study was to compare the clinical outcomes of azithromycin and doxycycline each in combination with ceftriaxone for non-ICU Veterans hospitalized with CAP.