A Post-Neurosurgical Infection due to KPC-Producing Klebsiella pneumoniae Treated with Meropenem-Vaborbactam: A Case Report.

This case report describes a patient with post-neurosurgical infection and bacteremia caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae. There is limited evidence to guide antibiotic treatment decisions for such infections. The patient was treated with meropenem-vaborbactam (MEV). MEV monotherapy was associated with bacteremia clearance.

Antibiotic prescribing patterns for adult urinary tract infections within emergency department and urgent care settings.

Urinary tract infections (UTI) are a common reason for emergency department (ED) and urgent care (UC) visits. Fluoroquinolones (FQ) are frequently prescribed for treatment of UTI in the outpatient setting; however, data evaluating prescribing patterns after FDA safety warnings is limited, especially in UC. The study goal was to investigate and compare antimicrobial prescribing for UTIs in a single-site ED and an off-site UC in an urban, academic health system. This retrospective study included patients presenting with a UTI to the ED or UC between January and June 2018. Those 18 years or older with uncomplicated, complicated UTI, or pyelonephritis were included. Exclusion criteria were catheter-related UTI, urinary tract abnormalities, immunocompromised, or hospitalization. Primary outcome was FQ prescribing rate for all UTI in the ED and UC. Secondary outcomes were rates of non-FQ prescribing, re-presentation, bug-drug mismatch, and treatment durations. 184 patients were included. FQ prescribing rate was similar in ED and UC (21.2% vs. 16.3%, p = 0.4). Non-FQs prescribed in ED and UC were nitrofurantoin (20.2% vs 53.6%), beta-lactams (46.1% vs 22.6%), and trimethoprim/sulfamethoxazole (12.5% vs. 5%). A longer than recommended duration was identified in 46.3% UC patients compared to 21.2% ED patients. Thirty-day re-presentation with persistent UTI symptoms occurred more frequently in the ED compared to UC (13.5% vs. 7.5%). Predictors of FQ prescribing on logistic regression were male, recurrent UTI, and malignancy. FQ prescribing rate for UTI treatment was low with no difference between ED and UC. Opportunity exists to improve treatment duration and antimicrobial choice.

Risk factors for readmission in patients discharged with outpatient parenteral antimicrobial therapy: a retrospective cohort study.

BACKGROUND: Outpatient parenteral antimicrobial therapy (OPAT) is a practical and effective way of delivering antimicrobial therapy, but may be associated with significant risk for hospital readmission. This study aimed to elucidate risk factors related to 30-day readmissions in patients who were discharged with OPAT at Mount Sinai Beth Israel (MSBI). METHODS: This IRB approved retrospective cohort study included patients who were at least 18 years or older, admitted to MSBI from August 2015 to March 2016, and discharged to receive OPAT. Patients with intravenous antibiotics prescribed for chronic suppression or planned readmission within 30 days were excluded. The main outcome was readmission to the hospital within 30 days from previous hospital discharge. Univariate and logistic regression analyses were performed to determine predictors of 30-day readmission. RESULTS: There were a total of 200 patients included in the analysis; the median age was 60 years, 65.5% were male, and the median Charlson score was 2. A total of 155 (78%) patients received a peripherally inserted central catheter (PICC); the remainder was discharged with a midline. The most common medications prescribed for OPAT included cephalosporins (41%), vancomycin (31%), carbapenems (23%), and penicillins (16%). A total of 42 patients (21%) were readmitted within 30 days after previous discharge. Discharge to a skilled nursing facility or subacute rehabilitation center was found to be an independent predictor of readmission on logistic regression analyses (p <  0.05). CONCLUSION: Readmissions are common in patients discharged with OPAT. Recognizing predictors of readmission may help determine strategies to optimize care.

Cefepime versus carbapenems for the treatment of urinary tract infections caused by extended-spectrum ß-lactamase-producing enterobacteriaceae.

The aim of this study was to evaluate the effectiveness of cefepime compared with carbapenems for the management of urinary tract infections (UTIs) caused by extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae. This was a single-centre, retrospective study among patients with a documented ESBL-producing Enterobacteriaceae UTI between 1 July 2014 and 31 January 2017. Adult patients who received either cefepime or a carbapenem for symptomatic UTI were included in the analysis. The primary endpoint was clinical failure, defined by persistence of initial UTI symptoms that required escalation of therapy. Secondary endpoints included microbiological failure and relapse within 30 days. Of a total of 106 patients included in the study, 17 received cefepime and 89 received a carbapenem. None of the patients in either group experienced clinical or microbiological failure. Relapse occurred in six patients in the carbapenem group and none in the cefepime group. In conclusion, cefepime was comparable with carbapenems in the treatment of UTIs caused by ESBL-producing Enterobacteriaceae. Its use as a carbapenem-sparing agent for this indication should be further explored.

Combination Therapy With Vancomycin and Ceftaroline for Refractory Methicillin-resistant Staphylococcus aureus Bacteremia: A Case Series.

PURPOSE: Although vancomycin has been the mainstay of therapy for methicillin-resistant Staphylococcus aureus (MRSA) infections, its effectiveness has been challenged. Combination therapy may be used for patients with persistent MRSA bacteremia refractory to initial therapy. Studies have reported in vitro synergy between vancomycin and ceftaroline; however, clinical experience with this therapy is limited. Here, we report our experience with 5 cases of vancomycin-refractory MRSA bacteremia treated with the combination of vancomycin and ceftaroline. METHODS: Between January 2014 and August 2016, 5 patients were identified who received vancomycin and ceftaroline combination therapy due to persistent bacteremia or deterioration of their clinical status on vancomycin alone (despite a vancomycin MIC within the susceptible range). FINDINGS: Five patients presented with MRSA bacteremia secondary to endocarditis (n = 2), epidural abscess (n = 2), or left iliopsoas abscess (n = 1). Four of the 5 patients experienced microbiologic cure, and 1 patient transitioned to palliative care. IMPLICATIONS: This case series serves to describe additional clinical experience with vancomycin and ceftaroline combination therapy. This combination may be considered when vancomycin monotherapy does not lead to microbiological and/or clinical improvement in patients with metastatic MRSA bacteremia. Additional studies are warranted to further define its role in salvage therapy for persistent MRSA bacteremia.

Survey of risk factors for osteoporosis and osteoprotective behaviors among patients with epilepsy.

The prevalence of risk factors for osteoporosis in persons with epilepsy, patients' awareness of their risk, and their engagement in osteoprotective behaviors were assessed in this study. Two hundred and sixty patients with epilepsy (F=51.5%, average age=42) completed a survey tool. Of 106 patients with a dual energy X-ray absorptiometry (DXA) result, 52% had low bone mineral density, and 11% had osteoporosis. The results suggest that the majority of patients with epilepsy do not engage in bone-protective behaviors. Those who have undergone a DXA scan may be more likely to take calcium and vitamin D supplementation compared with those who did not undergo a DXA scan, but they do not engage in other osteoprotective behaviors. Many patients did not accurately report their DXA results, indicating that better patient education is warranted.

Compliance With Institutional Antimicrobial Dosing Guidelines in Patients Receiving Continuous Venovenous Hemodialysis.

OBJECTIVE: Describe the rate of compliance with institutional antimicrobial dosing guidelines in patients on concomitant continuous venovenous hemodialysis (CVVHD). METHODS: This single-center retrospective chart review evaluated adult patients receiving concomitant intravenous antimicrobials and CVVHD for at least 24 hours over a 2-month period. RESULTS: A total of 42 patients, 76 antimicrobial courses, and 208 study days (24 hours of concomitant therapy) were evaluated. Overall, antimicrobials were dosed according to the institutional guidelines on 162 (78%) of 208 study days. All nonconcordant doses were below recommendations. The recommended dose was never received prior to antibiotic or CVVHD discontinuation in 22% of the cases. In cases where antimicrobials were initiated when the patient was already on CVVHD, 74% of the initial doses met guideline criteria. Pharmacist recommendation was associated with increased dosing compliance (94% vs 73% of study days, P = .001). During transition from CVVHD to intermittent hemodialysis (IHD), only 62% of antimicrobial doses were decreased by the first IHD day. CONCLUSIONS: Antimicrobial dosing in patients on CVVHD was below institutional guideline recommendations in many cases. Pharmacist recommendation was associated with compliance. Centers should evaluate their own compliance rate with institutional guideline recommendations for CVVHD and implement initiatives to improve dosing practices.