Changes in Streptococcus pneumoniae Susceptibility in Wisconsin: Implications for Clinical Treatment Decisions for Respiratory Infections.

Objective: In 2019, the American Thoracic Society and Infectious Diseases Society of America updated clinical practice guidelines for community-acquired pneumonia (CAP). In contrast to guidelines published in 2007, macrolide monotherapy for outpatients was made a conditional recommendation based on resistance levels. Local knowledge of current antimicrobial susceptibility is needed to guide management of CAP and other bacterial respiratory pathogens. The purpose of this study was to investigate antimicrobial susceptibility profiles and trending for Wisconsin Streptococcus pneumoniae isolates.Design: Multi-center laboratory surveillance, with testing at a central location utilizing standardized susceptibility testing protocols.Methods: Data published by the Wisconsin Department of Health Services (DHS) were augmented with data from the Surveillance of Wisconsin Organisms for Trends in Antimicrobial Resistance and Epidemiology (SWOTARE) program. Data were stratified by invasive or non-invasive sources, as well as DHS region and compared to data compiled from 2006-2010.Results: Susceptibility rates for ≥ 916 invasive S. pneumoniae assessed from 2016-2020 were greater than 91% for ceftriaxone, tetracycline, and fluoroquinolone agents and were generally higher than those from 354 non-invasive isolates. Low susceptibility rates were observed for invasive isolates of penicillin (78.7%) and erythromycin (64.8%) and were even lower for non-invasive isolates (73.8% and 59.9%, respectively). This erythromycin susceptibility rate was a significant reduction from that observed in 2006-2010 (80.4; P < 0.0002). 24.8% of isolates generated an erythromycin MIC ≥ 8 µg/mL. Statewide geographic variability was noted.Conclusions: Rates of S. pneumoniae susceptibility to parenteral penicillins and cephems, and oral tetracycline and fluoroquinolone agents, remain high throughout Wisconsin. However, low oral penicillin susceptibility rates, taken together with declining macrolide susceptibility rates, should cause clinicians to consider alternative treatment options for respiratory tract infections, especially with macrolides.

Surveillance of Fluoroquinolone Resistance in Wisconsin: Geographic Variation and Impact of Revised CLSI Breakpoints.

Objective: Many clinical microbiology laboratories procure antimicrobial susceptibility testing data using guidelines established by Clinical and Laboratory Standards Institute (CLSI). When necessary, CLSI revises interpretive breakpoints in efforts to improve clinical correlation, with two revisions relative to fluoroquinolone agents occurring in 2019. The purpose of this investigation was to determine the impact of fluoroquinolone breakpoint revisions on Wisconsin clinical isolates of Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa.Design: Multi-center laboratory surveillance, with testing at a single location utilizing standardized media and susceptibility testing protocols.Methods: From the Surveillance of Wisconsin Organisms for Trends in Antimicrobial Resistance and Epidemiology (SWOTARE) program, levofloxacin and ciprofloxacin minimum inhibitory concentration (MIC) values for 1911, 1521, and 1463 Wisconsin isolates of E. coli, P. mirabilis, and P. aeruginosa, respectively, were determined by broth microdilution testing. In separate data analyses, all MIC data were interpreted using CLSI breakpoints published prior to 2019, then secondarily by using CLSI breakpoints published since 2019 (which reflect lower breakpoints for both levofloxacin and ciprofloxacin resistance). Findings were further stratified by Wisconsin Department of Health Services region.Results: Up to 3.2% decreased statewide fluoroquinolone susceptibility was observed for E. coli isolates, while 5.1% and 6.3% decreases in levofloxacin susceptibility were noted for P. aeruginosa and P. mirabilis isolates, respectively, when revised breakpoints were applied. E. coli isolates from the Western region and P. mirabilis isolates from the Southeastern region demonstrated significant shifts toward decreased fluoroquinolone susceptibility upon application of revised breakpoints. Northern region P. mirabilis isolates exhibited consistently decreased fluoroquinolone susceptibility.Conclusions: Fluoroquinolone resistance has been underreported in Wisconsin as a whole, yet geographic variability continues to exist. Targeted annual surveillance is important to identify and monitor resistance trending. Compilations of SWOTARE surveillance data can be utilized to predict the impact of future CLSI interpretive breakpoint revisions in Wisconsin.

Implementation of telehealth antimicrobial stewardship through partnership of an academic medical center and a community hospital.

PURPOSE: Small community hospitals often lack the human, financial, and technological resources necessary to implement and maintain successful antimicrobial stewardship programs now required by national regulatory and accrediting bodies. Creative solutions are needed to address this problem. SUMMARY: A 3-stage, quasi-experimental study including patients receiving antibiotics for pneumonia, skin and soft tissue infections, and urinary tract infections at a community hospital in Wisconsin from June 2013 to December 2015 was conducted. Remote telehealth prospective audit and feedback, guideline and order set management, and staff education targeting pharmacists, nurses, and physicians were provided during the 7-month intervention phase; these services were then removed for the postintervention period. Antimicrobial utilization (days of therapy [DOT] per 1,000 patient-days), hospital length of stay, and readmission and 30-day mortality rates were assessed to determine the impact of telehealth services on these outcomes. During the preintervention (baseline), intervention, and postintervention periods, 1,037 patients received antibiotics for the targeted infectious disease conditions. Patient demographics and rates of infectious disease conditions were similar among the different periods. Telehealth antimicrobial stewardship reduced broad-spectrum antibiotic use, including use of imipenem (from 83 to 31 DOT, P < 0.001), levofloxacin (from 123 to 99 DOT, P < 0.001), and vancomycin (from 104 to 85 DOT, P < 0.001), compared to utilization during the baseline period; mean (SD) length of stay also decreased (from 4.6 [2.8] days to 4.2 [2.6] days, P = 0.02). After nonrenewal of telehealth stewardship, vancomycin and piperacillin/tazobactam usage returned to or exceeded baseline levels. CONCLUSION: The partnership between an academic medical center and a small community hospital improved antimicrobial utilization and clinical outcomes. Successful telehealth antimicrobial stewardship models should be explored further as a means to provide optimal patient care.

Antibiotic utilization variability among training services at an academic medical center: An observational study.

OBJECTIVE: Evaluate the difference in antibiotic prescribing between various levels of resident training or attending types. DESIGN: Observational, retrospective study. SETTING: Tertiary-care, academic medical center in Madison, Wisconsin. METHODS: We measured antibiotic utilization from January 1, 2016, through December 31, 2018, in our general medicine (GM) and hospitalist services. The GM1 service is staffed by outpatient internal medicine physicians, the GM2 service is staffed by geriatricians and hospitalists, and the GM3 service is staffed by only hospitalists. The GMA service is led by junior resident physicians, and the GMB service is led by senior resident physicians. We measured utilization using days of therapy (DOT) per 1,000 patient days (PD). In a secondary analysis based on antibiotic spectrum, we used average DOT per 1,000 PD. RESULTS: Teaching services prescribed more antibiotics than nonteaching services (671.6 vs 575.2 DOT per 1,000 PD; P < .0001). Junior resident-led services used more antibiotics than senior resident-led services (740.9 vs 510.0 DOT per 1,000 PD; P < .0001). Overall, antibiotic prescribing was numerically similar between various attending physician backgrounds. A secondary analysis showed that GM services prescribed more broad-spectrum, anti-MRSA, and anti-pseudomonal antibiotics than the hospitalist services. GM junior resident-led services prescribed more broad-spectrum, anti-MRSA, and antipseudomonal therapy compared to their senior counterparts. CONCLUSIONS: Antibiotics were prescribed at a significantly higher rate in services associated with trainees than those without. Services led by a junior resident physician prescribed antibiotics at a significantly higher rate than services led by a senior resident. Interventions to reduce unnecessary antibiotic exposure should be targeted toward resident physicians, especially junior trainees.

In vitro evaluation of meropenem-vaborbactam against clinical CRE isolates at a tertiary care center with low KPC-mediated carbapenem resistance.

The in vitro activity of meropenem-vaborbactam was examined against clinical carbapenem-resistant Enterobacteriaceae isolates collected over 3 years at our medical center. Only 3 KPC-producers were identified. Susceptibility to meropenem-vaborbactam was noted in 15/16 (94%) isolates (MIC90 2 mg/L) that were nonsusceptible to meropenem. Meropenem-vaborbactam may have utility at centers where non-KPC-producers are more frequent.

Daptomycin dosing based on ideal body weight versus actual body weight: comparison of clinical outcomes.

Daptomycin use at our institution changed to ideal body weight dosing based on a published analysis of pharmacokinetic-pharmacodynamic efficacy target attainment, bacterial ecology, and a desire to reduce drug toxicity. The current study compared outcomes between actual body weight and ideal body weight dosing of daptomycin before and after this intervention. In the evaluable group, 69 patients received doses based on actual body weight and 48 patients received doses based on ideal body weight. Patients were treated for documented Enterococcus species, Staphylococcus aureus, or coagulase-negative Staphylococcus infections, including bloodstream, intraabdominal, skin and soft tissue, urinary, and bone. There was no statistically significant difference in clinical success between the groups (88.9% for actual body weight compared to 89.1% for ideal body weight, P = 0.97). After we adjusted for gender, age, body mass index, concomitant 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, infection type, and organism type, clinical success rates remained similar between groups (adjusted odds ratio of 0.68 in favor of actual body weight, 95% confidence interval [CI] of 0.13 to 3.55). Microbiological outcomes, length of stay, mortality, and adverse effects were also similar between groups. Further studies are warranted to confirm that ideal body weight dosing provides similar outcomes to actual body weight dosing for all patients and types of infections and organisms.

The "epic" challenge of optimizing antimicrobial stewardship: the role of electronic medical records and technology.

Antimicrobial stewardship programs (ASPs) are established means for institutions to improve patient outcomes while reducing the emergence of resistant bacteria. With the increased adoption and evolution of electronic medical records (EMRs), there is a need to assimilate the tools of ASPs into EMRs, using decision support and feedback. Third-party software vendors provide the mainstay for integration of individual institutional EMR and ASP efforts. Epic is the leading implementer of EMR technology in the United States. A collaboration of physicians and pharmacists are working closely with Epic to provide a more comprehensive platform of ASP tools that may be institutionally individualized. We review the historical relationship between ASPs and the EMR, cite examples of Epic stewardship tools from 3 academic medical centers' ASPs, discuss limitations of these Epic tools, and conclude with the current process in evolution to integrate ASP tools and decision support capacities directly into Epic's EMR.

Can the antibiogram be used to assess microbiologic outcomes after antimicrobial stewardship interventions? A critical review of the literature.

Hospitals are implementing antimicrobial stewardship programs (ASPs) in response to national guidelines to improve the use and to extend the utility of antiinfective drugs. An often implied purpose of ASPs is to curb or reverse the emergence of resistant bacteria. Because antibiotic use causes antibiotic resistance, there is a natural tendency to link local measures of antibiotic use to local measures of bacterial resistance, and the hospital antibiogram is a readily available measure of resistance. We performed a literature review to identify published reports that used hospitalwide and unit-specific antibiograms to assess the relationship of ASP interventions to changes in resistance. Eight studies were identified and reviewed. The relationship between hospital antibiotic use and resistance is complex, and the existing literature has several limitations. Furthermore, the antibiogram itself is neither designed nor well suited to reflect changes in hospital antimicrobial drug use. The literature on the effectiveness of ASPs in reducing resistance continues to emerge, but at this time the antibiogram bears an inconsistent relationship with changes in hospital antibiotic use and cannot be recommended to reliably evaluate an ASP intervention. Interrupted time series analysis is a superior strategy to assess the effect of an ASP intervention on bacterial resistance, but it is not widely used because of its complexity and greater data requirements. Nevertheless, before ASP efforts can be convincingly demonstrated to have a favorable impact on resistance, a more sophisticated approach that links drug use to resistance should become a priority, at least for hospitals that have sufficient resources.

Community-acquired methicillin-resistant staphylococcus aureus: diagnosis and treatment update for plastic surgeons.

LEARNING OBJECTIVES: : After studying this article, the participant should be able to: 1. Identify risk factors associated with community-acquired methicillin-resistant Staphylococcus aureus. 2. Recognize the clinical presentation of patients with community-acquired methicillin-resistant S. aureus. 3. Understand the treatment and indications for decolonization of patients who have community-acquired methicillin-resistant S. aureus infections. SUMMARY: : Community-acquired methicillin-resistant Staphylococcus aureus has evolved over the past 10 years as a new health threat seen by plastic surgeons and is an increasing cause of soft-tissue infections. This pathogen has several distinct virulence factors and unique antimicrobial susceptibilities that distinguish methicillin-resistant S. aureus from traditional hospital-acquired methicillin-resistant S. aureus. This article reviews the epidemiology, risk factors, clinical presentation, and treatment of community-acquired methicillin-resistant S. aureus.

Community-associated methicillin-resistant Staphylococcus aureus: review of an emerging public health concern.

Methicillin-resistant Staphylococcus aureus (MRSA) traditionally has been recognized as a virulent pathogen affiliated with health care institutions. However, community-associated strains of MRSA (CA-MRSA) have emerged over the past several years in young, healthy patients without significant health care contact. These isolates carry a distinct molecular makeup and lack the multidrug resistance pattern harbored by health care strains. CA-MRSA predominantly induces skin and soft tissue infections, though the presence of unique virulence factors may cause potentially lethal necrotizing pneumonia and other invasive infections. In response to this growing public health concern, clinicians must learn to identify risk factors for CA-MRSA, treat infections with judicious use of antimicrobial agents, and facilitate prevention strategies to limit transmission.

Limited infection upon human exposure to a recombinant raccoon pox vaccine vector.

A laboratory accident resulted in human exposure to a recombinant raccoon poxvirus (RCN) developed as a vaccine vector for antigens of Yersinia pestis for protection of wild rodents (and other animals) against plague. Within 9 days, the patient developed a small blister that healed within 4 weeks. Raccoon poxvirus was cultured from the lesion, and the patient developed antibody to plague antigen (F1) and RCN. This is the first documented case of human exposure to RCN.

Plasmodium vivax malaria in spite of atovaquone/proguanil (malarone) prophylaxis.

A 70-year-old male scientist, who had returned 5 weeks earlier from Ethiopia, was admitted to the hospital with symptoms consistent with malaria. On physical examination, he had orthostatic hypotension. He was dehydrated and showed a mild clinical delirium. Abdominal examination revealed a possible spleen tip, and he had petechial lesions bilaterally below his knees. Laboratory data revealed his white blood cell count to be 4,500/mL, with 67% polymorphonuclear cells and 15% band forms. The hemoglobin level was 13.9 g/dL, and the platelet count was low, at 32,000/mL.

Sexually transmitted diseases in Wisconsin men.

Trends in reported sexually transmitted diseases in Wisconsin men mimic the trends in national reporting. Chlamydia trachomatis, Neiserria gonorrheae, and Herpes simplex virus are the most frequently reported conditions. Newer diagnostic techniques based on the amplification of DNA for Neiserria gonorrheae and Chlamydia trachomatis provide health care providers with a more reliable and rapid diagnosis. In the current health care environment, reporting of sexually transmitted diseases among men occurs at a lower frequency than among women. Screening programs for Wisconsin men outside of the traditional setting are few. The most common sexually transmitted diseases are reviewed, with emphasis on newer developments. New treatment guidelines have been issued by the Center for Disease Control and Prevention (2002). Wisconsin health care providers can assist in the appropriate reporting of sexually transmitted diseases to the Wisconsin Division of Public Health.

A randomized, double-blind, multicenter comparison of gatifloxacin versus ciprofloxacin in the treatment of complicated urinary tract infection and pyelonephritis.

BACKGROUND: Gatifloxacin is a fluoroquinolone antibiotic with a broad spectrum of in vitro and in vivo activity against the gram-negative and gram-positive pathogens frequently implicated in urinary tract infections (UTIs). OBJECTIVE: This study compared the clinical and bacteriologic efficacy and tolerability of gatifloxacin versus ciprofloxacin in adult patients with complicated UTIs or pyelonephritis. METHODS: In this double-blind, multicenter, randomized, comparative study, patients were treated with either gatifloxacin 400 mg once daily or ciprofloxacin 500 mg twice daily for 7 to 10 days. Bacteriologic eradication (by quantitative urine culture) and clinical efficacy rates were assessed at a test-of-cure visit (5 to 9 days and 4 to 11 days posttreatment, respectively) and at an extended follow-up visit (29-42 days and 25-50 days posttreatment, respectively). RESULTS: A total of 372 adults were randomized to treatment, 189 to gatifloxacin and 183 to ciprofloxacin. The most commonly isolated pretreatment pathogens (n = 292) were Escherichia coli (53%) and Klebsiella pneumoniae (13%). Pathogen eradication rates for complicated UTIs were 92% and 83% with gatifloxacin and ciprofloxacin, respectively (95% CI, -4.1% to 24.5%); for pyelonephritis, the respective rates were 92% and 85% (95% CI, -20% to 37%). Clinical response rates of >90% were observed in both treatment groups among patients with complicated UTIs as well as those with pyelonephritis. Sustained eradication rates were 76% (64/84) with gatifloxacin and 66% (52/79) with ciprofloxacin. Both drugs were well tolerated, with the most common adverse events in both treatment groups being nausea, dizziness, diarrhea, and vomiting. CONCLUSIONS: Gatifloxacin is comparable to ciprofloxacin based on clinical efficacy and bacteriologic eradication rates for the treatment of complicated UTIs or pyelonephri- tis and is associated with a low incidence of clinically significant adverse events.