Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative.

We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.

Case Series of Stillbirths Due to Syphilis in Edmonton, Alberta, Canada.

BACKGROUND: Data on the incidence and characteristics of stillbirths attributed to congenital syphilis were collected. METHODS: We extracted data on stillbirths in the Edmonton Zone on January 1, 2015, through June 30, 2021, born to persons diagnosed with infectious syphilis (primary, secondary, early latent, or early neurosyphilis) during pregnancy or at the time of delivery. RESULTS: Of 314 infants documented to be exposed to infectious syphilis during gestation, 16 (5.1%) were stillborn. Three of the 16 females with stillbirths were diagnosed with syphilis during pregnancy but not treated, 12 were diagnosed only at the time of stillbirth (1 of whom was treated early in pregnancy and presumably reinfected), and 1 had a stillbirth in the week after one dose of benzathine penicillin G. CONCLUSIONS: Stillbirths due to congenital syphilis were all due to failure to treat syphilis in pregnancy. Innovative strategies to prevent syphilis in the community and to reach those experiencing barriers to care are urgently required to not miss opportunities to diagnose and treat syphilis as early as possible during pregnancy.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018.

BACKGROUND: Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals. METHODS: Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd). RESULTS: Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd). CONCLUSIONS: This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Epidemiology, clinical features and outcomes of incident tuberculosis in children in Canada in 2013-2016: results of a national surveillance study.

PURPOSE: Childhood tuberculosis disease is difficult to diagnose and manage and is an under-recognised cause of morbidity and mortality. Reported data from Canada do not focus on childhood tuberculosis or capture key epidemiologic, clinical and microbiologic details. The purpose of this study was to assess demographics, presentation and clinical features of childhood tuberculosis in Canada. METHODS: We conducted prospective surveillance from 2013 to 2016 of over 2700 paediatricians plus vertical tuberculosis programmes for incident tuberculosis disease in children younger than 15 years in Canada using the Canadian Paediatric Surveillance Program (CPSP). RESULTS: In total, 200 cases are included in this study. Tuberculosis was intrathoracic in 183 patients of whom 86% had exclusively intrathoracic involvement. Central nervous system tuberculosis occurred in 16 cases (8%). Fifty-one per cent of cases were hospitalised and 11 (5.5%) admitted to an intensive care unit. Adverse drug reactions were reported in 9% of cases. The source case, most often a first-degree relative, was known in 73% of cases. Fifty-eight per cent of reported cases were Canadian-born Indigenous children. Estimated study rates of reported cases (per 100 000 children per year) were 1.2 overall, 8.6 for all Indigenous children and 54.3 for Inuit children. CONCLUSION: Childhood tuberculosis may cause significant morbidity and resource utilisation. Key geographies and groups have very high incidence rates. Elimination of childhood tuberculosis in Canada will require well-resourced community-based efforts that focus on these highest risk groups.

Pregnancy Among HIV-Serodiscordant Couples: Case Report of Vertical Transmission and Retrospective Case Series.

BACKGROUND: HIV transmission during pregnancy and breastfeeding among serodiscordant heterosexual couples represents an ongoing barrier to the elimination of vertical transmission of HIV-1 infection in Canada. OBJECTIVE: To report a case of vertical HIV transmission during breastfeeding and examine the prevalence of risk factors for HIV transmission in the pregnancy and postpartum periods among serodiscordant couples where the male partner is HIV positive and female partner HIV negative. METHODS: Case report and retrospective chart review of HIV-serodiscordant pregnant couples over an eight-year period in Edmonton, Canada. RESULTS: We report a case of maternal primary HIV infection during the postpartum period and vertical transmission to a nursing infant that went undetected until the infant presented with AIDS. We also report a series of 41 serodiscordant pregnant couples identified by our public health nurse between 2008 and 2016. Among HIV-infected male partners, 20 (49%) had a detectable viral load (VL) during their partner's pregnancy and during breastfeeding, with median peak VL 4,700 copies/mL (range 49-120,000) and 5,100 copies/mL (range 40-120,000) during pregnancy and breastfeeding, respectively. None of the female partners seroconverted during pregnancy, but three seroconverted at 1.8, 2.4, and 6.9 years after delivery. No vertical transmission occurred. CONCLUSION: Despite concerted attempts to minimize HIV transmission during pregnancy and breastfeeding in our well-resourced setting, residual transmission risk remains due to non-suppressed viral load within many HIV-serodiscordant pregnant couples.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study.

Objectives: An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. Design Setting Participants and Methods: In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Results: Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Conclusions: Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing-choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

Antimicrobial use among adult inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program: 2009 to 2016.

BACKGROUND: Antimicrobial resistance is a growing threat to the world's ability to prevent and treat infections. Links between quantitative antibiotic use and the emergence of bacterial resistance are well documented. This study presents benchmark antimicrobial use (AMU) rates for inpatient adult populations in acute-care hospitals across Canada. METHODS: In this retrospective surveillance study, acute-care adult hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) submitted annual AMU data on all systemic antimicrobials from 2009 to 2016. Information specific to intensive care units (ICUs) and non-ICU wards were available for 2014-2016. Data were analyzed using defined daily doses (DDD) per 1000 patient days (DDD/1000pd). RESULTS: Between 2009 and 2016, 16-18 CNISP adult hospitals participated each year and provided their AMU data (22 hospitals participated in ≥1 year of surveillance; 11 in all years). From 2009 to 2016, there was a significant reduction in use (12%) (from 654 to 573 DDD/1000pd, p = 0.03). Fluoroquinolones accounted for the majority of this decrease (47% reduction in combined oral and intravenous use, from 129 to 68 DDD/1000pd, p < 0.002). The top five antimicrobials used in 2016 were cefazolin (78 DDD/1000pd), piperacillin-tazobactam (53 DDD/1000pd), ceftriaxone (49 DDD/1000pd), vancomycin (combined oral and intravenous use was 44 DDD/1000pd; 7% of vancomycin use was oral), and ciprofloxacin (combined oral and intravenous use: 42 DDD/1000pd). Among the top 10 antimicrobials used in 2016, ciprofloxacin and metronidazole use decreased significantly between 2009 and 2016 by 46% (p = 0.002) and 26% (p = 0.002) respectively. Ceftriaxone (85% increase, p = 0.0008) and oral amoxicillin-clavulanate (140% increase, p < 0.0001) use increased significantly but contributed only a small component (8.6 and 5.0%, respectively) of overall use. CONCLUSIONS: This study represents the largest collection of dispensed antimicrobial use data among inpatients in Canada to date. Between 2009 and 2016, there was a significant 12% decrease in AMU, driven primarily by a 47% decrease in fluoroquinolone use. Modest absolute increases in parenteral ceftriaxone and oral amoxicillin-clavulanate use were noted but contributed a small amount of total AMU. Ongoing national surveillance is crucial for establishing benchmarks and antimicrobial stewardship guidelines.

Assessment of linezolid efficacy, safety and tolerability in the treatment of tuberculosis: A retrospective case review.

Linezolid is a potentially effective drug for the treatment of patients with drug-resistant tuberculosis. Among 13 patients treated for tuberculosis with linezolid in the present study, nine had treatment success and four remain on treatment. Adverse effects occurred in 11 (85%) patients, of whom three discontinued treatment because of adverse effects. The present study adds to the growing evidence supporting the efficacy of linezolid for tuberculosis, although treatment remains complicated by adverse effects.

Le linézolide est un médicament qui peut être efficace dans le traitement de patients atteints d'une tuberculose résistant aux médicaments. Dans la présente étude, chez 13 patients traités au linézolide contre la tuberculose, neuf ont vu leur traitement réussir et quatre sont toujours en traitement. Des effets indésirables se sont manifestés chez 11 (85 %) patients, dont trois ont arrêté le traitement pour cette raison. La présente étude s'ajoute aux données croissantes étayant l'efficacité du linézolide pour soigner la tuberculose, même si le traitement demeure compliqué par des effets indésirables.

Infections in children receiving extracorporeal life support.

OBJECTIVE: To describe risk factors for and the outcome of infections in children receiving extracorporeal life support (ECLS) and to determine the need for removal of foreign bodies with bloodstream infections (BSIs) in children receiving ECLS. DESIGN: Retrospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: Children receiving ECLS from May 1997 through May 2007. METHODS: For patients with documented infections, medical records were examined for demographic, clinical, and laboratory details. Patients with and without documented infections were compared with regard to demographic characteristics and ECLS course. RESULTS: One hundred seventeen patients underwent ECLS for a total of 878 days (median, 5.12 days). Thirty-five patients (29.9%) developed 55 infections, including 21 BSIs (38.2%), 20 urinary tract infections (36.4%), 6 ventilator-associated pneumonia episodes (10.9%), 2 viral infections (3.6%), and 6 miscellaneous infections (10.9%). The rates (in cases per 1,000 ECLS-days) were 23.9 for BSI, 22.8 for urinary tract infection, and 6.8 for ventilator-associated pneumonia. There were no significant differences in the demographic characteristics, indications for ECLS, or ECLS course between infected and uninfected patients, except for the median duration of ECLS (10.1 vs 3.8 days; P < .001). One death was attributed to infection. Resolution of BSI occurred without removal of foreign bodies in 18 (85.7%) of 21 children. CONCLUSIONS: Longer duration of ECLS was the only identified risk factor for infection. Mortality was not statistically significantly different between infected and uninfected patients. Most BSIs that occurred during ECLS cleared without removal of foreign bodies.