What Stops Doctors Switching from Intravenous to Oral Antibiotics?

Aims To explore doctors' perceptions of the motivators and barriers to complying with intravenous to oral switch antibiotic guidelines in a Model 4 Irish hospital. Methods A cross-sectional study was carried out amongst doctors attending hospital-wide educational sessions in November 2018 via a validated paper-based survey post ethical approval. Data were independently analysed using SPSS. Results One hundred and seventy four doctors of all grades and a variety of specialties participated. Respondents felt they were aware of the local intravenous to oral switch criteria but expressed they required prompts to consider switching to oral agents when appropriate, inclusive of alert stickers in the Kardex and medical notes as well as reminders from nursing and pharmacy staff. Other interventions to assist with improved decision-making included further education to junior doctors on the benefits of an intravenous to oral switch, electronic prescribing, and better accessibility to laboratory results. Conclusion Results will assist in implementing quality improvement initiatives to increase the rate of guideline compliance.

Successful termination of sustained transmission of resident MRSA following extensive NICU refurbishment: an intervention study.

BACKGROUND: Neonatal sepsis is a leading cause of morbidity and mortality in neonatal units worldwide. Meticillin-resistant Staphylococcus aureus (MRSA) has become a leading causative pathogen. Many neonatal units experience endemic colonization and infection of their infants, which is often very challenging to successfully eradicate. AIM: To assess the impact of neonatal unit refurbishment and redesign on endemic MRSA colonization and infection. METHODS: A retrospective review was carried out over an eight-year period in a 14-cot, level 2-3 neonatal unit in University Hospital Galway, a large university teaching hospital in the West of Ireland. Surveillance, colonization, and infection data for a four-year period pre and four-year period post neonatal unit refurbishment are described. Clinical and microbiological data were collected on all MRSA-colonized and -infected infants between 2008 and 2015. Molecular typing data are available for MRSA isolates. An interrupted time-series design was used, with unit refurbishment as the intervention. FINDINGS: Our neonatal unit had a pattern of sustained transmission of endemic resident MRSA strains which we could not eradicate despite repeated standard infection control interventions. Complete unit refurbishment led to successful termination of sustained transmission of these strains. Colonization decreased and no infants were actively infected post refurbishment of the unit. CONCLUSION: We report successful termination of sustained transmission of endemic strains of MRSA from our neonatal unit following complete unit redesign and refurbishment.

Targeted de-escalation rounds may effectively and safely reduce meropenem use.

OBJECTIVE: Use of meropenem in our hospital has doubled in recent years. An audit in 2013 showed that although initiation of therapy with meropenem was generally appropriate, therapy was rarely subsequently reviewed and de-escalated where appropriate. Therefore, a structured stewardship initiative focussed on meropenem de-escalation was developed. METHODS: A local guideline for review and de-escalation of meropenem was developed and approved by the Antimicrobial Stewardship Team. The guideline outlined clinical and microbiological criteria which when met should lead to recommendation for meropenem de-escalation. Implementation of the guideline was piloted for a period of 4 weeks by a consultant microbiologist and an antimicrobial pharmacist. Days of meropenem use and crude mortality in those in whom de-escalation was implemented were compared with those where de-escalation was not recommended or was recommended but not implemented. RESULTS: Thirty-three patients were reviewed. Overall, a recommendation to de-escalate from meropenem to a specified alternative antibiotic was made for 18 (55 %) patients. This advice was followed for 12 (36 %) patients. The median days of meropenem use in patients where meropenem was de-escalated was 4.5 days (range 2-19) compared with 14 days (range 6-84) where de-escalation was not recommended or the recommendation was not implemented. There was no statistically significant difference in crude mortality between patients de-escalated from meropenem and those where meropenem was continued. CONCLUSION: This pilot study suggests that targeted carbapenem de-escalation stewardship activity based on pre-determined criteria, while labour intensive, can effectively and safely reduce meropenem use in the acute hospital setting.

Transport of digested decontaminated sputum specimens to a central laboratory for testing for M. tuberculosis by Amplicor MTB test.

Rapid diagnosis of tuberculosis may improve management of infected patients and facilitate infection control procedures. The relatively slow growth rate of M. tuberculosis and the limited sensitivity and specificity of microscopy make rapid diagnosis difficult. Nucleic acid amplification techniques have been extensively studied for the detection of M. tuberculosis DNA and a number of commercial products for detection of M. tuberculosis nucleic acid in clinical specimens are now available. As performance of diagnostic PCR at central reference laboratories may be desirable, the impact of specimen transport on the performance of the Amplicor MTB PCR assay is of practical importance. We have assessed the performance of the Amplicor MTB PCR on specimens submitted and initially processed in laboratories in 3 cities and then transported to a single laboratory for PCR assay. The overall sensitivity of the PCR test was 97 per cent and the corrected specificity was 100 per cent. All of 23 culture positive specimens collected locally were PCR positive compared with 10 of 11 culture positive specimens transported from elsewhere. In this study transportation of digested decontaminated specimens to a central laboratory either frozen at -20 degrees, or overnight at room temperature had no apparent effect on the performance characteristic of the Amplicor MTB PCR assay.

A Mycobacterium malmoense-specific DNA probe from the 16S/23S rRNA intergenic spacer region.

Mycobacterium malmoense was first described in 1977. It is now recognized as an opportunistic human pathogen which can be difficult to identify using standard methods. M. malmoense may be underestimated as the causative agent of clinical disease because of the recognized difficulties in its primary cultivation and identification. In this study, the nucleotide sequence of the 16S/23S rRNA intergenic spacer region from five clinical isolates of M. malmoense has been determined, in order to develop a PCR-based DNA probe assay to facilitate the early identification of this organism. The DNA sequence generated was utilized to design an oligunucleotide probe that specifically hybridizes with M. malmoense. The ability of this DNA probe to detect geographically distinct M. malmoense isolates was investigated. The value of this DNA probe was realized by its ability to differentiate three isolates of the Mycobacterium avium complex, which had been misidentified as M. malmoense using conventional biochemical methods.

Evaluation of a PCR based method for identification of mycobacterial isolates.

In recent years an increasing number of mycobacterial species have been described as causing disease in humans. Identification of isolates to the species level is essential for evaluation of the significance of an isolate. Conventional methods for identification based on selective inhibitors of growth and biochemical reactions are slow. We have evaluated a novel method, PCR restriction enzyme pattern analysis (PRA), for identification of mycobacterial isolates. Fifty three cultures including a mixed culture of M. tuberculosis and M. avium and four mycobacterial cultures contaminated with rapidly growing organisms of other genera were studied. The method permits identification of most isolates within 1 to 2 days, including some contaminated cultures, and results were generally in accordance with those obtained by conventional methods.