Daily Naltrexone Use Does Not Adversely Affect Physical, Cognitive or Marksmanship Performance in U.S. Army Soldiers.

INTRODUCTION: Considering the potential of weaponized opioids, evaluating how prophylactic countermeasures affect military-relevant performance is necessary. Naltrexone is a commercially available Food and Drug Administration-approved medication that blocks the effects of opioids with minimal side effects. However, the effects of naltrexone on the health and performance of non-substance abusing military personnel are not well described in the existing literature. METHODS: Active duty U.S. Army Soldiers (n = 16, mean ± SD, age: 23.1 ± 5.3 y) completed a series of physical, cognitive, and marksmanship tasks during a 4-day pretrial, a 7-day active trial, and a 4-day post-trial phase. During the active trial, participants were administered 50 mg of oral naltrexone daily. Physiological and biological processes were monitored with a daily review of systems, sleep monitoring, biochemistry, and hematology blood panels. RESULTS: Naltrexone did not negatively affect physical performance, cognitive functioning, marksmanship, or sleep duration (P > 0.05). Improvements were observed during the active trial compared to the pretrial phase in cognitive tasks measuring logical relations (P = 0.05), matching to sample (P = 0.04), math speed (P < 0.01), math percent correct (P = 0.04), and spatial processing (P < 0.01). Results from biochemistry and hematology blood panels remained within clinically normative ranges throughout all phases of the study. No participants were medically withdrawn; however, one participant voluntarily withdrew due to nausea and reduced appetite. CONCLUSIONS: Temporary (7-day) daily use of naltrexone was safe and did not negatively affect physical performance, cognitive functioning, marksmanship ability, or sleep in a healthy cohort of U.S. Army Soldiers.

Infectious Inequity: How the Gut Microbiome and Social Determinants of Health May Contribute to Clostridioides difficile Infection Among Racial and Ethnic Minorities.

Infectious diseases are a leading contributor to death in the United States, and racial differences in clinical outcomes have been increasingly reported. Clostridioides difficile infection (CDI) is a growing public health concern, as it causes nearly half a million infections per year and considerable excess hospital costs. Concurrent with other infectious diseases, recent literature denotes racial disparities in CDI incidence rates, mortality, and associated morbidity. Of note, investigations into CDI and causative factors suggest that inequities in health-related social needs and other social determinants of health (SDoH) may cause disruption to the gut microbiome, thereby contributing to the observed deleterious outcomes in racially and ethnically minoritized individuals. Despite these discoveries, there is limited literature that provides context for the recognized racial disparities in CDI, particularly the influence of structural and systemic barriers. Here, we synthesize the available literature describing racial inequities in CDI outcomes and discuss the interrelationship of SDoH on microbiome dysregulation. Finally, we provide actionable considerations for infectious diseases professionals to aid in narrowing CDI equity gaps.

Population based cohort to examine association between geospatial antibiotic factors and urinary tract infection outcomes.

INTRODUCTION: Urinary tract infections (UTIs) pose a significant health care burden. Outpatient antibiotic geospatial factors (eg, geographic prescribing and geographic resistance) may be associated with inpatient outcomes. This study examined the relationship between these factors, severe UTI, and hospitalization for severe UTI. METHODS: The first cohort included hospitalized, female, Medicare beneficiaries, aged >50 years. The primary outcome was severe UTI (defined as CSS diagnosis code of 159 with an APR-DRG severity of illness code of 3 or 4). The association between geospatial first-line prescribing (FLP) and severe UTI was assessed. The second cohort examined the association between these geospatial FLP and risk of hospitalization with severe UTI. Multivariable regression was used to produce adjusted odds ratios and adjusted risk ratios. RESULTS: In the first cohort (n = 14,474), low FLP was not associated with severe UTI (P = .87) in univariable analysis. In multivariable analysis, low FLP was associated with severe UTI was (aOR: 1.08 [95% CI 1.00, 1.16]). In the second cohort (n = 2,972,174), the admission rate was 47.0 and 49.8 per 10,000 (low FLP vs high FLP, respectively [P < .001]). The aRR for admission was 1.26 (95% CI 1.14, 1.39) in areas with low FLP. CONCLUSIONS: This study suggests that geospatial antibiotic factors may influence inpatient outcomes in women aged >50 with UTI. Further research is needed to corroborate our findings.

Associations Between Vancomycin Exposure and Acute Kidney Injury Within the Recommended Area Under the Curve Therapeutic Exposure Range Among Patients With Methicillin-Resistant Staphylococcus aureus Bloodstream Infections.

Among patients with methicillin-resistant Staphylococcus aureus bacteremia, vancomycin-associated acute kidney injury increased as a function of the day 2 area under the curve (AUC), even for daily AUCs within the recommended therapeutic range (400-600). Further data are needed to determine if daily AUCs <400 can be maintained without compromising efficacy.

Early clinical trial data and real-world assessment of COVID-19 vaccines: Insights from the Society of Infectious Diseases Pharmacists.

As of August 2021, there were three COVID-19 vaccines available in the United States for the prevention of coronavirus 2019 (COVID-19). The purpose of this narrative review is to examine the early experience from the Emergency Use Authorization (EUA) of BNT162b2 (Pfizer, Inc./BioNTech), mRNA-1273 (Moderna, Inc.), and Ad26.COV2.S (Johnson and Johnson/Janssen Global Services, LLC) through July 2021. The EUA data from the clinical trials have largely been corroborated by real-world effectiveness investigations post-authorization. These studies indicate that immunity is obtained within 2 weeks post-vaccination and may endure for 6 months. The immunity conferred by the vaccines may also be effective against SARS-CoV-2 variants of concern. Additionally, populations not included in the emergency use authorization studies may also benefit from vaccination. This look back at the initial clinical experience can be used by the global community to inform and develop COVID-19 vaccine programs.

Impact of Accelerate Pheno and BacT/Alert Virtuo on Clinical Processes and Outcomes in Patients with Sepsis and Concurrent Gram-Negative Bacteremia.

The Accelerate Pheno and BacT/Alert Virtuo systems may improve bacteremia management. Here, we evaluated the impact of both devices on outcomes in patients with sepsis and concurrent Gram-negative bacteremia. This quasiexperimental study included a retrospective preimplementation and a prospective postimplementation group. Patients ≥18 years old with Gram-negative bacteremia were included. Patients with neutropenia, pregnant patients, those who were transferred from an outside hospital with active bloodstream infections, and those with polymicrobial bacteremia were excluded. Blood culture incubation in the BacT/Alert 3D device and microdilution antimicrobial susceptibility testing from culture plate growth were used prior to implementation of the BacT/Alert Virtuo and Accelerate Pheno systems. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification directly from blood culture was used pre- and postimplementation. Time to Gram stain results, identification, susceptibility reporting, initiation of narrow-spectrum Gram-negative therapy at 72 h, 30-day inpatient mortality, sepsis resolution, and length of hospital stay were evaluated. A total of 116 patients were included (63 preimplementation, 53 postimplementation). Median times to Gram stain and susceptibility results were significantly shorter postimplementation (P < 0.001). The postimplementation group had an improved hazard ratio for narrow-spectrum Gram-negative therapy at 72 h (hazard ratio [HR], 2.685 [95% confidence interval {CI}, 1.348 to 5.349]), a reduced hazard ratio for 30-day inpatient mortality (adjusted HR [aHR], 0.150 [95% CI, 0.026 to 0.846]), and improved sepsis resolution (92.5% versus 77.8% [P = 0.030]). The length of hospital stay was unchanged after implementation. We conclude that implementation of the BacT/Alert Virtuo and Accelerate Pheno systems improved microbiology laboratory processes, antibiotic utilization processes, and clinical outcomes. These data support the use of rapid diagnostics in sepsis with concurrent Gram-negative bacteremia.

Antibiotic Prescribing in New York State Medicare Part B Beneficiaries Diagnosed With Cystitis Between 2016 and 2017.

BACKGROUND: Statewide tracking and reporting is an outpatient antimicrobial stewardship tool that may be useful for many stakeholders. However, to date, these evaluations have been limited. This study aimed to track and report outpatient antibiotic prescribing in Medicare Part B enrollees diagnosed with cystitis in the outpatient setting. METHODS: This was a retrospective, cohort study of Medicare Part B enrollees in New York State. Inclusion criteria include outpatient visit in 2016 or 2017, cystitis diagnosis code, and oral antibiotic prescription ≤3 days after diagnosis of cystitis. Antibiotics were categorized as first-line, oral ß-lactams, fluoroquinolones, or other per Infectious Diseases Society of America acute uncomplicated cystitis guidelines. Data were stratified by sex. Annual prescriptions proportions were compared using χ 2 test or Fisher's exact test as appropriate. RESULTS: A total of 50 658 prescriptions were included. For females' prescriptions, first line increased (41.5% vs 43.8%, P < .0001), oral ß-lactams increased (17.8% vs 20.5%, P < .0001), fluoroquinolones decreased (34.1% vs 29.1%, P < .0001), and other increased (6.5% vs 6.6%, P = .76) in 2017. For males' prescriptions, first line increased (25.2% vs 26.7%, P = .11), oral ß-lactams increased (23.1% vs 26.2%, P = .0003), fluoroquinolones decreased (44.0% vs 39.3%, P < .0001), and other remained unchanged (7.8% vs 7.8%, P = .92) in 2017. CONCLUSIONS: Guideline concordant therapy prescribing for cystitis increased among Medicare Part B beneficiaries in New York State between 2016 and 2017. However, there was still a high prevalence of fluoroquinolone prescribing. These data highlight the need for additional outpatient antimicrobial stewardship efforts in New York State.

Corrigendum to: Longitudinal, Nationwide, Cohort Study to Assess Incidence, Outcomes, and Costs Associated With Complicated Urinary Tract Infection.

[This corrects the article DOI: 10.1093/ofid/ofz446.].

Time to clinical response in sepsis associated with an algorithm for blood-culture pathogen identification using matrix-assisted laser desorption ionization time-of-flight mass spectroscopy.

PURPOSE: Antimicrobial stewardship programs (ASPs) can be aided by using rapid diagnostics (RDT). However, there are limited data evaluating the impact of ASPs and RDT on sepsis outcomes in the setting of the new Sepsis-3 guidelines. This study evaluates the impact of a low-resource method for ASPs with RDT on sepsis outcomes. METHODS: This was a prospective, quasi-experimental study with a retrospective double pretest. Patients ≥ 18 years old with sepsis and concurrent bacteremia or fungemia were included; patients who were pregnant, had polymicrobial septicemia or who were transferred from an outside hospital were excluded. In the first pretest (O1), polymerase chain reaction was used to identify Staphylococcal species from positive blood cultures, and traditional laboratory techniques were used to identify other species. Matrix-assisted laser desorption ionization time-of-flight mass spectroscopy and FilmArray were implemented in the second pretest (O2), and twice daily blood culture review was implemented in the posttest (O3). RESULTS: A total of 394 patients (157 in O1, 176 in O2, 61 in O3) were enrolled. Clinical response was 73.2%, 83.5%, and 88.5% in O1, O2, and O3, respectively, p = 0.013. By Cox regression, the O3 was associated with improved time to clinical response (hazard ratio, 1.388; 95% confidence interval, 1.004-1.919) as compared with O1. Mortality, hospital length of stay, and intensive care unit length of stay were unchanged between groups. CONCLUSION: Twice-daily blood culture review may be useful for implementing rapid diagnostics within low-resource ASPs. Further research is needed to identify the optimal method of blood culture follow-up within low-resource settings.

Antimicrobial Susceptibility Trends Observed in Urinary Pathogens Obtained From New York State.

International guidelines recommend using local susceptibility data to direct empiric therapy for acute uncomplicated cystitis. We evaluated outpatient urinary isolate susceptibility trends in New York State. Nitrofurantoin had the lowest resistance prevalence whereas trimethoprim-sulfamethoxazole and fluoroquinolones had higher prevalences. This study highlights the need for local outpatient antimicrobial stewardship programs.

Comparative incidence and excess risk of acute kidney injury in hospitalised patients receiving vancomycin and piperacillin/tazobactam in combination or as monotherapy.

Combination therapy with vancomycin and piperacillin/tazobactam (TZP) has been associated with increased risk of acute kidney injury (AKI) compared with monotherapy with either agent. This retrospective, matched cohort study was conducted to assess the comparative incidence of AKI due to combination therapy in patients receiving vancomycin and TZP in combination or as monotherapy. Patients aged ≥18 years admitted to Albany Medical Center (Albany, NY) between September 2013 and August 2014 who had received therapy for at least two consecutive days were included. Patients who were pregnant, neutropenic, had AKI on admission or with cystic fibrosis were excluded. Patients were matched on baseline risk of AKI. The main outcome of interest was AKI, defined as an increase in serum creatinine of ≥0.3 mg/L or ≥50% within 48 h. Secondary outcomes evaluated were length of hospital and ICU stay and inpatient mortality associated with AKI. The risk of AKI was 7.0%, 8.5% and 26.8% in the vancomycin monotherapy, TZP monotherapy and combination groups, respectively (P < 0.001). In the multivariate analysis, combination therapy was independently associated with an increased odds of AKI (adjusted odds ratio = 4.406, 95% confidence interval 1.472-13.188) compared with vancomycin monotherapy. The excess risk of combination therapy was 11.3%. In this matched cohort study, there was an increased incidence of AKI in patients receiving vancomycin and TZP combination therapy. Further research is needed to determine the individual strategies to best prevent inpatient AKI in patients receiving this combination therapy.

Pilot Study of a Bayesian Approach To Estimate Vancomycin Exposure in Obese Patients with Limited Pharmacokinetic Sampling.

This study evaluated the predictive performance of a Bayesian PK estimation method (ADAPT V) to estimate the 24-h vancomycin area under the curve (AUC) with limited pharmacokinetic (PK) sampling in adult obese patients receiving vancomycin for suspected or confirmed Gram-positive infections. This was an Albany Medical Center Institutional Review Board-approved prospective evaluation of 12 patients. Patients had a median (95% confidence interval) age of 61 years (39 to 71 years), a median creatinine clearance of 86 ml/min (75 to 120 ml/min), and a median body mass index of 45 kg/m2 (40 to 52 kg/m2). For each patient, five PK concentrations were measured, and four different vancomycin population PK models were used as Bayesian priors to estimate the vancomycin AUC (AUCFULL). Using each PK model as a prior, data-depleted PK subsets were used to estimate the 24-h AUC (i.e., peak and trough data [AUCPT], midpoint and trough data [AUCMT], and trough-only data [AUCT]). The 24-h AUC derived from the full data set (AUCFULL) was compared to the AUC derived from data-depleted subsets (AUCPT, AUCMT, and AUCT) for each model. For the four sets of analyses, AUCFULL estimates ranged from 437 to 489 mg·h/liter. The AUCPT provided the best approximation of the AUCFULL; AUCMT and AUCT tended to overestimate AUCFULL Further prospective studies are needed to evaluate the impact of AUC monitoring in clinical practice, but the findings from this study suggest that the vancomycin AUC can be estimated with good precision and accuracy with limited PK sampling using Bayesian PK estimation software.

Randomized Controlled Trial to Determine the Efficacy of Early Switch From Vancomycin to Vancomycin Alternatives as a Strategy to Prevent Nephrotoxicity in Patients With Multiple Risk Factors for Adverse Renal Outcomes (STOP-NT).

BACKGROUND: Use of alternative antimicrobials to vancomycin is a potential strategy to reduce acute kidney injury (AKI) in high-risk patients, but current data do not support widespread adoption of this practice. OBJECTIVE: To determine the efficacy of early switch to a nonnephrotoxic alternative for prevention of AKI in high-risk patients who receive vancomycin. METHODS: This was an IRB-approved, prospective randomized controlled trial in a single, tertiary care academic medical center. Patients initially prescribed vancomycin between October 2011 to April 2013 with at least 2 risk factors for AKI were included. Treatment randomization was stratified by indication for therapy. Patients were randomized to continuation of dose-optimized vancomycin or early switch to an alternative antimicrobial agent. The primary end point was nephrotoxicity by consensus guideline definition adjudicated by blinded review; the secondary end point was AKI network-defined AKI. RESULTS: A total of 103 patients were randomized; 100 were included in the modified intent-to-treat population, 51 in the vancomycin group and 49 in the alternative group. The incidence of nephrotoxicity was 6.1% in the alternative therapy arm and 9.8% in the vancomycin group ( P = 0.72). The incidence of AKI was 32.7% in the alternative therapy group and 31.4% in the vancomycin group ( P = 0.89). CONCLUSIONS: No significant difference in nephrotoxicity or AKI was detected among patients treated with alternative antimicrobials compared with vancomycin. The use of alternative antimicrobial therapy instead of vancomycin solely for the purpose of preventing AKI in high-risk patients does not appear to be warranted.

Assessment of Time to Clinical Response in Patients with Sepsis Treated Before and After Implementation of a Matrix-Assisted Laser Desorption Ionization Time-of-Flight Blood Culture Identification Algorithm.

OBJECTIVE To evaluate time to clinical response before and after implementation of rapid blood culture identification technologies. DESIGN Before-and-after trial. SETTING Large, tertiary, urban, academic health-sciences center. PATIENTS Patients >18 years old with sepsis and concurrent bacteremia or fungemia were included in the study; patients who were pregnant, had polymicrobial septicemia, or were transferred from an outside hospital were excluded. INTERVENTION Prior to the intervention, polymerase chain reaction was used to identify Staphylococcus species from positive blood cultures, and traditional laboratory techniques were used to identify non-staphylococcal species. After the intervention, matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) assay and FilmArray were also used to identify additional species. During both periods, the antimicrobial stewardship team provided prospective audit and feedback for all patients on antibiotics. RESULTS A total of 219 patients were enrolled in the study: 115 patients prior to the intervention and 104 after the intervention. The median time to clinical response was statistically significantly shorter in the postintervention group than in the preintervention group (2 days vs 4 days, respectively; P=.002). By Cox regression, the implementation of MALDI-TOF and FilmArray was associated with shorter time to clinical response (hazard ratio [HR], 1.360; 95% confidence interval [CI], 1.018-1.816). After controlling for potential confounders, the study group was not independently associated with clinical response (adjusted HR, 1.279; 95% CI, 0.955-1.713). Mortality was numerically, but not statistically significantly, lower in the postintervention group than in the preintervention group (7.6% vs 11.4%; P=.342). CONCLUSIONS In the setting of an existing antimicrobial stewardship program, implementation of MALDI-TOF and FilmArray was associated with improved time to clinical response. Further research is needed to fully describe the effect of antimicrobial stewardship programs on time to clinical response. Infect Control Hosp Epidemiol 2016;37:916-923.

Evaluation of pharmacy generalists performing antimicrobial stewardship services.

PURPOSE: Improvements in medication use achieved by pharmacy generalists using a care bundle approach to antimicrobial stewardship are reported. METHODS: A six-month prospective, repeated-treatment, quasi-experimental study involving three month-long intervention periods and three month-long control periods was conducted in the setting of an existing antimicrobial stewardship program at a large hospital. The intervention involved prospective audit and feedback conducted by pharmacy generalists who were trained in an antimicrobial stewardship care bundle approach. During control months, a pharmacy generalist who was not trained in antimicrobial stewardship rounded with the multidisciplinary team and provided standard-of-care pharmacy services. The primary endpoint was compliance with a care bundle of four antimicrobial stewardship metrics: documentation of indication for therapy in the medical record, selection of empirical therapy according to institutional guidelines, documented performance of indicated culture testing, and deescalation of therapy when indicated. RESULTS: Two-hundred eighty-six patients were enrolled in the study: 124 in the intervention group and 162 in the control group. The cumulative rate of full compliance with all care bundle components during the six-month study was significantly greater during intervention months than during control months (68.5% versus 45.7%, p < 0.001). After adjusting for infection type, antimicrobial stewardship provided by an intervention-group pharmacist was associated with improved care bundle compliance (adjusted odds ratio, 2.70; p < 0.001). No significant differences in patient outcomes during intervention and control months were detected. CONCLUSION: Pharmacy generalists trained to comply with a systematic care bundle approach enhanced the quality of antimicrobial management.

Shifting trends in the incidence of Pseudomonas aeruginosa septicemia in hospitalized adults in the United States from 1996-2010.

BACKGROUND: Pseudomonas aeruginosa septicemia (PAS) is associated with high mortality rates and substantial resource utilization; however, the burden of PAS in the United States in recent years is unknown. METHODS: This was a retrospective analysis of the U.S. National Hospital Discharge Surveys from 1996-2010. Adult patients with an ICD-9-CM code for PAS (038.43) were included. Incidence, in-hospital mortality, and hospital length of stay (LOS) for PAS discharges were reported. Incidence was calculated as PAS discharges per 10,000 total adult discharges. RESULTS: Overall, 213,553 patients had a PAS discharge diagnosis during the study period. Patients had a median (interquartile range [IQR]) age of 69 (55-78) years and were predominately men (61%) and white (75%). PAS incidence declined from 6.5 per 10,000 in 1996 to 3.1 per 10,000 in 2001 and then increased to 6.5 per 10,000 in 2010. PAS incidence was highest in the Northeast (7.6 per 10,000) and lowest in the South (6.2 per 10,000). The overall mortality rate was 16%, but this ranged from 10%-26% over the study period. Median LOS was 10 (IQR, 6-19) days, and this varied over the study period (8-13 days). CONCLUSIONS: The incidence of PAS has increased among hospitalized adults in the United States since 2001, with little evidence of improvement in mortality or LOS.

Vancomycin-associated renal dysfunction: where are we now?

Vancomycin has been in clinical use for over 60 years, during which time renal toxicity has been well documented. Multiple risk factors and outcomes are associated with vancomycin-related nephrotoxicity. Risk factors include vancomycin exposure (trough levels 15 mg/L or higher, larger area under the curve, duration of therapy), host susceptibility to vancomycin (increased body weight, preexisting renal dysfunction, critical illness), and concurrent nephrotoxin therapy. Nephrotoxicity is associated with prolonged hospital stays, mortality, and the need for renal replacement therapy. To what degree vancomycin-associated nephrotoxicity exacerbates these adverse clinical outcomes remains unclear. This article reviews the current evidence on vancomycin-associated nephrotoxicity and explores future research directions with potential implications for improved patient safety.

Ceftaroline Fosamil for the Treatment of Community-Acquired Pneumonia: from FOCUS to CAPTURE.

Ceftaroline fosamil (ceftaroline hereafter) is the latest addition to the armamentarium for the treatment of patients with community-acquired pneumonia (CAP). It is currently approved by the Food and Drug Administration (FDA) for community-acquired bacterial pneumonia (CABP), which is a recent FDA indication that centers on individuals with documented bacterial pneumonias that arise in the community setting. The purpose of this review is to summarize and discuss the major findings from the Phase III CAP clinical trials as well as the clinical experience with ceftaroline among patients with CAP in the "Ceftaroline Assessment Program and Teflaro(®) Utilization Registry" (CAPTURE). In its two Phase III CAP trials, ceftaroline was compared to ceftriaxone among adults with radiographically confirmed CAP requiring hospitalization who were classified as Pneumonia Outcomes Research Team (PORT) risk class III or IV. Among patients with CAP, clinical success at test of cure was 84.3% vs 77.7% (difference 6.6%, 95% confidence interval [CI]: 1.6-11.8%) in those treated with ceftaroline and ceftriaxone, respectively, across the two Phase III clinical trials. Among patients with a culture-confirmed CABP, day 4 response rates were numerically higher, albeit non-significant, among patients that received ceftaroline vs. ceftriaxone (69.5% for ceftaroline vs. 59.4% for ceftriaxone, difference 10.1%, 95% CI, -0.6% to 20.6%). The efficacy of ceftaroline is supported by real-world observational data from CAPTURE for patients with both CAP and CABP. In addition, the CAPTURE program afforded an opportunity to assess the outcomes of patients who were excluded or limited in the original Phase III trials in a non-comparative fashion. These underrepresented patient populations with CAP included: patients that received prior antibiotics, patients in the ICU, patients with severe renal dysfunction, and those with methicillin-resistant Staphylococcus aureus (MRSA) isolated from respiratory or blood culture. As CAPTURE is a retrospective, non-comparator convenience sample registry, all the findings need to be interpreted with caution.

Impact of a Multidisciplinary Culture Follow-up Program of Antimicrobial Therapy in the Emergency Department.

INTRODUCTION: Antimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared. METHODS: A single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff. RESULTS: Over the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044). CONCLUSION: Implementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models.