Outcomes and Adverse Effects of Baricitinib Versus Tocilizumab in the Management of Severe COVID-19.

OBJECTIVES: The National Institutes of Health and Infectious Diseases Society of America guidelines recommend tocilizumab or baricitinib in the management of severe COVID-19. Despite clinical trials on the individual agents, there are no large-scale studies comparing the two agents to guide the selection of one versus the other. The purpose of this study was to compare the outcomes and adverse effects of baricitinib versus tocilizumab in the management of severe COVID-19. DESIGN: Retrospective, observational cohort study. SETTING: Eleven acute care hospitals in a large health system in Georgia. PATIENTS: Adult patients with severe COVID-19 who received at least one dose of either baricitinib or tocilizumab between June 2021 and October 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. The key secondary outcome was occurrence rate of adverse effects. A total of 956 patients were identified. The median age was 57 years, and 53% were of male sex. The median body mass index was 33.5, and more than 94% of the population was unvaccinated. Propensity score matching by baseline characteristics resulted in a total of 582 patients, 291 in each group. There was no difference in mortality between the two groups; however, the occurrence rate of adverse effects was significantly higher in the tocilizumab group compared with baricitinib: secondary infections (32% vs 22%; p < 0.01); thrombotic events (24% vs 16%; p < 0.01); and acute liver injury (8% vs 3%; p < 0.01). CONCLUSIONS: Our propensity score-matched, retrospective, observational study in patients hospitalized with severe COVID-19 showed no difference in mortality but significantly fewer adverse effects with baricitinib compared with tocilizumab. Our data suggest that baricitinib may be a better choice when treating patients with severe COVID-19, but additional prospective, randomized trials are needed to help clinicians choose the most optimal drug.

Education and coaching to optimise blood culture volumes: continuous quality improvement in microbiology.

The blood volume cultured in the detection of bacteraemia is a major variable in treating patients with systemic inflammatory response syndrome. The fact that drawing optimal volumes (8-10 mL) of blood for culture increases the sensitivity of the method is well established. This study aimed to optimise the mean blood volumes (mBVs) to that recommended level in a small rural hospital by implementing a continuous quality improvement programme in clinical microbiology. The education of phlebotomists, followed by monthly feedback and coaching sessions, can influence the blood volume drawn by phlebotomists and improve the sensitivity of blood cultures. Statistically significant increase (p<0.001) in both mBVs and median blood culture volumes occurred within 5 months compared with the baseline values obtained in the preceding 10 months. This quality improvement was sustained over 1 year. The mBVs inoculated into aerobic culture bottles met the manufacturer's instructions of a fill volume of 8 to 10 mL of blood per bottle and optimised the yield of isolation of organisms from blood cultures.

Dramatic effects of a new antimicrobial stewardship program in a rural community hospital.

BACKGROUND: New Joint Commission antimicrobial stewardship requirements took effect on January 1, 2017, promoted as a central strategy for coping with the emerging problems of antimicrobial resistance and Clostridium difficile infection. Our objective was to measure the effects of a new antimicrobial stewardship program (ASP) in a rural community hospital with no prior ASP, in the context of having a new infectious disease specialist on staff. METHODS: An ASP team was formed to implement a prospective audit with health care provider feedback and targeting 12 antimicrobial agents in a rural hospital in Georgia. An educational grand rounds lecture series was provided before implementation of the ASP to all prescribers. After implementation, algorithms to aid the selection of empirical antibiotics for specific infectious disease syndromes based on local antibiograms were provided to prescribers to improve this selection. Rates of C difficile infections, total targeted antimicrobial costs, and drug utilization rates were calculated for 1 year pre-ASP implementation (2013) and 1 year post-ASP implementation (October 2014-December 2015). RESULTS: The patient safety metric of C difficile infections decreased from 3.35 cases per 1,000 occupied bed days (OBDs) in 2013 to 1.35 cases per 1,000 OBDs in 2015. Total targeted antimicrobial costs decreased 50% from $16.93 per patient day in 2013 to $8.44 per patient day in 2015. Overall antimicrobial use decreased 10% from before the ASP initiative to 1 year after it. Annualized savings were $280,000 in 1 year, based on drug savings only. CONCLUSIONS: Judicious use of antimicrobials and resources can improve a patient safety metric and decrease costs dramatically in rural institutions where the average hospital census is <100 patients per day. The savings would allow the institutions to spend better while improving the use of antimicrobials.

Human Gongylonema pulchrum Infection: Esophageal Symptoms and Need for Prolonged Albendazole Therapy.

AbstractWe describe a case of human infection with Gongylonema pulchrum acquired in southeast Georgia. The patient presented with intermittent yet persistent nausea and vomiting for months. This case describes the need for extraction of worms on two occasions each followed by courses of albendazole treatment. Gongylonema pulchrum infections with high worm burden may relapse after extraction of the worm and a 3-day short course of albendazole therapy. Longer courses of albendazole may be indicated in selected circumstances.

A Case of Penicillin-Resistant Veillonella Prosthetic Joint Infection of the Knee.

Veillonella sp. and V. dispar are emerging pathogens. This is the third case of a monomicrobial Veillonella sp. prosthetic joint infection (PJI) among knees and hips; this is the second prosthetic knee infection described. The infection was treated with a 2-stage procedural approach combined with 6 weeks of ceftriaxone with excellent clinical response. There was no relapse in 2 years of follow-up care. This case exemplifies the importance of incubating anaerobic cultures for at least 7 days to grow some anaerobic pathogens.