Optimizing Antimicrobial Stewardship in the Emergency Department.

Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.

Disseminated Protothecosis Due to Prototheca zopfii and Literature Review.

ABSTRACT: Prototheca species are achlorophyllic algae that are a rare cause of infection in humans. It most commonly causes localized cutaneous disease and rarely disseminated infection. Immunocompromised patients have the highest risk of disseminated protothecosis, with a higher mortality rate than localized cutaneous infections. At the species level, infections caused by Prototheca zopfii are reported less frequently than those caused by Prototheca wickerhamii. The diagnosis can be made using histopathology, culture, and molecular testing. There is no definitive evidence for an effective treatment, which currently consists of antifungals (primarily amphotericin B). With only a handful of cases of disseminated protothecosis reported worldwide that are caused by P. zopfii , we herein present an additional case of a postbone marrow transplant patient in the Midwest of the United States.

In vitro susceptibility of carbapenem resistant Enterobacterales to meropenem-vaborbactam and ceftazidime-avibactam at a single academic medical centre.

BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) are considered an urgent threat. Ceftazidime-avibactam and meropenem-vaborbactam contain ß-lactamase inhibitors active against CRE isolates including those that produce Klebsiella pneumoniae carbapenemases (KPC). METHODS: Retrospective chart review of CRE isolates from 1 January 2016 to 1 November 2018. Collected data includes a descriptive overview of measured MIC values, resistance mechanism via a polymerase chain reaction test (Xpert Carba-R, Cepheid, Sunnyvale CA), as well as clinical outcomes. RESULTS: Of 106 isolates reviewed, 86 isolates met the inclusion criteria from 85 individual subjects. The breakpoint:MIC ratio for ceftazidime-avibactam overall was 4, while for meropenem-vaborbactam this ratio was 32 (p < 0.0001). For KPC isolates, ceftazidime-avibactam MIC50/MIC90 in 2016, 2017, and 2018 were 2/4 mg/L (n = 32), 2/4 mg/L (n = 17), and 2/8 mg/L (n = 30), respectively. The meropenem-vaborbactam MIC50/MIC90, for KPC isolates in 2016, 2017, and 2018 were 0.06/0.125 mg/L (n = 32), 0.06/0.1 mg/L (n = 17), and 0.06/0.5 mg/L (n = 30), respectively. Microbiologic cure was 75% (n = 16) in ceftazidime-avibactam subjects and 58.3% (n = 12) in subjects treated with alternative agents (p = 0.43). The 14- and 30-day mortality was numerically higher in subjects treated with alternate agents when compared ceftazidime-avibactam 2/9 (22.2%) vs 3/17 (17.6%) (p = 1.00) and 4/9 (44.4%) vs 4/17 (28.6%) (p = 0.38), respectively. For ceftazidime-avibactam, 30-day mortality in 2016, 2017, and 2018 was 0/5 (0%), 0/2 (0%), and 4/10 (40%). CONCLUSION: Selective pressure from the use of ceftazidime-avibactam at our institution may be decreasing its utility as a first-line agent for CRE infections. Meropenem-vaborbactam maintained low MIC values and may be a promising treatment option for CRE.

Infectious Disease Consults of Pseudomonas aeruginosa Bloodstream Infection and Impact on Health Outcomes.

Background: Infectious diseases (ID) consultation improves health outcomes for certain infections but has not been well described for Pseudomonas aeruginosa (PA) bloodstream infection (BSI). Therefore, the goal of this study was to examine ID consultation of inpatients with PA BSI and factors impacting outcomes. Methods: This was a retrospective cohort study from January 1, 2012, to December 31, 2018, of adult hospitalized veterans with PA BSI and antibiotic treatment 2 days before through 5 days after the culture date. Multidrug-resistant (MDR) cultures were defined as cultures with resistance to at least 1 agent in ≥3 antimicrobial categories tested. Multivariable logistic regression models were fit to assess the impact of ID consults and adequate treatment on mortality. Results: A total of 3256 patients had PA BSI, of whom 367 (11.3%) were multidrug resistant (MDR). Most were male (97.5%), over 65 years old (71.2%), and White (70.9%). Nearly one-fourth (n = 784, 23.3%) died during hospitalization, and 870 (25.8%) died within 30 days of their culture. Adjusted models showed that ID consultation was associated with decreased in-hospital (odds ratio [OR], 0.47; 95% CI, 0.39-0.56) and 30-day mortality (OR, 0.51; 95% CI, 0.42-0.62). Conclusions: Consultation with ID physicians improves clinical outcomes such as in-hospital and 30-day mortality for patients with PA BSI. ID consultation provides value and should be considered for patients with PA BSI.

Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations.

Asymptomatic bacteriuria is a common clinical condition that often leads to unnecessary treatment. It has been shown that incidence of asymptomatic bacteriuria increases with age and are more prominent in women than men. In older women, the incidence of asymptomatic bacteriuria is recorded to be more than 15%. This number increased up to 50% for those who reside in long-term care facilities. In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections, and therefore, antibiotic treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes. In 2019, the Infectious Disease Society of America (IDSA) updated its asymptomatic bacteriuria management guidelines, which emphasized on the risks and benefits of treating the condition. Women who are pregnant should be screened for asymptomatic bacteriuria in the first trimester and treated, if positive. Individuals who are undergoing endoscopic urologic procedures should be screened and treated appropriately for asymptomatic bacteriuria as well. Treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and so on has not been found to improve clinical outcomes. Furthermore, unnecessary treatment is often associated with unwanted consequences including but not limited to increased antimicrobial resistance, Clostridioides difficile infection, and increased health care cost. As a result, multiple antibiotic stewardship programs around the US have implemented protocols to appropriately reduce unnecessary treatment of asymptomatic bacteriuria. It is important to appropriately screen and treat asymptomatic bacteriuria only when there is evidence of potential benefit.

Impact of a Procalcitonin-Based Protocol on Antibiotic Exposure and Costs in Critically Ill Patients.

To examine the impact before and after adoption of a procalcitonin-based protocol to guide sepsis management has on antibiotic use, care costs, and outcomes of critically ill patients. DESIGN: Before-after study. SETTING: ICU of an academic tertiary care center. PATIENTS: Adults over 18 years old admitted to the ICU from January 1, 2017, to January 31, 2020. INTERVENTIONS: In this before-after study, we compared the use of medications, outcomes, and overall cost before and after the introduction of a procalcitonin-based protocol for evaluation and treatment of sepsis. MEASUREMENTS AND MAIN RESULTS: The final study cohort consisted of 1,793 patients admitted to the ICU, 776 patients pre-procalcitonin and 1,017 patients in the post-procalcitonin period. Patients were not different in the pre-procalcitonin adoption period compared with post-procalcitonin adoption with regard to gender, age (62.0 vs 62.6), race, or comorbidities. Patients admitted during the post-procalcitonin adoption period were less likely to receive the examined broad-spectrum antibiotics (odds ratio, -0.58; CI, -0.99 to -0.17; p < 0.01) than patients during the pre-procalcitonin adoption period. The odds of inhospital death did not differ after procalcitonin adoption when compared with before (0.87; CI, 0.70-1.09; p = 0.234). Total charges for each admission were significantly less in the post-procalcitonin adoption period $3,834.99 compared with pre-procalcitonin adoption $4,429.47 (p < 0.05). Patients post-procalcitonin adoption incurred $1,127.18 per patient less in total charges (-1,127.18; CI, -2,014.74 to -239.62; p = 0.013) after controlling for relevant factors. CONCLUSIONS: In critically ill patients in a large U.S. tertiary care hospital, the adoption of a procalcitonin-based protocol for evaluation and treatment of sepsis may be associated with decreased antibiotic use and significant cost savings, with no change in mortality.

Lactobacillus rhamnosus Infection: A Single-center 4-year Descriptive Analysis.

INTRODUCTION: Lactobacillus rhamnosus is an anaerobic or facultative anaerobic Gram-positive rod that is commonly found in the human gastrointestinal tract and vaginal tract. Infections secondary to L. rhamnosus have not been well illustrated in the literature. The purpose of this study was to describe the clinical courses of patients with L. rhamnosus infection in our institution. MATERIALS AND METHODS: A retrospective chart review was performed on patients with the growth of L. rhamnosus or L. rhamnosus/casei from January 1, 2013, to December 31, 2017. RESULTS: Forty-seven patients had growth of L. rhamnosus or L. rhamnosus/casei. Of these, 35 patients were included in the study who received therapy. Twenty patients (57.1%) presented with leukocytosis, 17 (48.5%) with fever, and 15 (42.8%) with abdominal pain. Twenty-three (66.1%) had intra-abdominal infection, 8 (22.3%) were bacteremic, and 4 (11.4%) had mediastinitis. Thirty-three patients (94.3%) had a polymicrobial infection. Eighteen (51.4%) patients had disruption of the gastrointestinal tract, 14 (40.0%) had underlying malignancy, and 11 (31.4%) had prior antibiotic exposure. Twenty (57.1%) patients clinically improved after therapy. However, the overall mortality rate was 56.2%, all of whom died of unrelated causes. CONCLUSION: Lactobacilli are organisms thought to have low pathogenicity. Our study identified cases of L. rhamnosus infections in a population of patients with serious underlying medical conditions.

In Vitro Pharmacodynamic Analyses Help Guide the Treatment of Multidrug-Resistant Enterococcus faecium and Carbapenem-Resistant Enterobacter cloacae Bacteremia in a Liver Transplant Patient.

BACKGROUND: Infections due to multidrug-resistant pathogens are particularly deadly and difficult to treat in immunocompromised patients, where few data exist to guide optimal antimicrobial therapy. In the absence of adequate clinical data, in vitro pharmacokinetic (PK)/pharmacodynamic (PD) analyses can help to design treatment regimens that are bactericidal and may be clinically effective. METHODS: We report a case in which in vitro pharmacodynamic analyses were utilized to guide the treatment of complex, recurrent bacteremias due to vancomycin-, daptomycin-, and linezolid-resistant Enterococcus faecium and carbapenem-resistant Enterobacter cloacae complex in a liver transplant patient. RESULTS: Whole-genome sequencing revealed unique underlying resistance mechanisms and explained the rapid evolution of phenotypic resistance and complicated intrahost genomic dynamics observed in vivo. Performing this comprehensive genotypic and phenotypic testing and time-kill analyses, along with knowledge of institution and patient-specific factors, allowed us to use precision medicine to design a treatment regimen that maximized PK/PD. CONCLUSIONS: This work provides a motivating example of clinicians and scientists uniting to optimize care in the era of escalating antimicrobial resistance.

BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department.

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.

Mandibular blastomycosis: A case report and review of the literature.

INTRODUCTION: Blastomycosis is an endemic mycosis in the United States known to primarily cause pneumonia. However, dissemination to different organs including the musculoskeletal system has been described. CASE REPORT: We report a case of mandibular blastomycosis in a healthy patient with no evidence of lung involvement. A 28 year-old female presented with recurrent right mandibular osteomyelitis despite courses of antibiotics and surgical debridement. She eventually underwent right hemimandibulectomy. Budding yeasts visualized on Gomori Methenamine-Silver (GMS) and Periodic acid-Schiff (PAS) were morphologically consistent with Blastomyces dermatitidis, and intra-operative cultures showed growth of mold identified as B. dermatitidis by DNA probe. She was placed on a prolonged course of itraconazole with clinical improvement. We also reviewed the literature and found 5 cases of similar presentation which we briefly summarized in this present case report. CONCLUSION: Blastomycosis should be considered in patients with recurrent or persistent mandibular osteomyelitis even in immunocompetent individuals.