Evaluation of Serial Procalcitonin Levels for the Optimization of Antibiotic Use in Non-Critically Ill COVID-19 Patients.

BACKGROUND: Procalcitonin (PCT) has been used as a biomarker to guide antibiotic therapy in various patient populations. However, its role in optimizing antibiotic use in COVID-19 patients has not been well studied to date. Thus, we aimed to evaluate the use of serial PCT monitoring as an antimicrobial stewardship tool for COVID-19 patients. METHODS: This retrospective study included 240 COVID-19 patients who were admitted to a tertiary medical institution in Saudi Arabia between January 2020 and February 2022. Patients who received empiric antibiotic therapy for community-acquired pneumonia (CAP) and had serial procalcitonin levels were included. The patients were divided into two groups: the normal procalcitonin arm (PCT level < 0.5 ng/mL) and the elevated PCT arm (PCT level > 0.5 ng/mL). The primary and secondary outcomes were the effect of PCT monitoring on the duration of antibiotic exposure and the length of hospital stay, respectively. To measure the accuracy of PCT, the receiver-operating characteristic area under the curve (ROC-AUC) was determined. RESULTS: Among the included patients, 142 were in the normal procalcitonin arm (median PCT, 0.12 ng/mL), and 78 were in the elevated PCT arm (median PCT, 4.04 ng/mL). The baseline characteristics were similar between the two arms, except for the higher prevalence of kidney disease in the elevated PCT arm. There was no statistically significant difference in the duration of antibiotic exposure between the normal and elevated PCT arms (median duration: 7 days in both arms). However, the length of hospital stay was significantly shorter in the normal PCT arm (median stay, 9 days) than in the elevated PCT arm (median stay, 13 days; p = 0.028). The ROC-AUC value was 0.54 (95% CI: 0.503-0.595). CONCLUSIONS: Serial PCT monitoring did not lead to a reduction in the duration of antibiotic exposure in COVID-19 patients. However, it was associated with a shorter hospital stay. These findings suggest that PCT monitoring may be useful for optimizing antibiotic use and improving outcomes in COVID-19 patients. While PCT-guided algorithms have the potential to enable antibiotic stewardship, their role in the context of COVID-19 treatment requires further investigation.

Attitudes, Beliefs, and Behaviors of Topical Antibiotic Prescribing among Primary Care Providers in Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: The World Health Organization (WHO) estimates that 20-50% of antibiotics are misused in society. In addition to the development of antimicrobial resistance, topical antibiotics have been associated with adverse effects such as allergic contact dermatitis (ACD) and inadequate wound healing. This study investigated the appropriateness of topical antibiotic prescriptions among primary care providers in Saudi Arabia. METHODS: A cross-sectional survey was conducted among Saudi Arabian primary care providers (physicians (general, family, and internal medicine)) employed in governmental and non-governmental healthcare facilities (primary care centers and outpatient clinics). RESULTS: In total, 222 participants were included in the analysis. A total of 73% agreed that inappropriate topical antibiotic use puts patients at risk, and 43% reported antibiotic resistance in daily practice. Many respondents lacked knowledge of the proper indications for topical antibiotics, and 66.2% attributed this to a lack of updated knowledge, while 45% blamed inadequate supervision. CONCLUSION: Antibiotic prescription patterns deviated from the standards recommended by WHO. This calls for continuous review at all levels of healthcare, providing more physician education and ensuring that antibiotic therapy guidelines are easily accessible and effectively used to avoid the negative consequences of inappropriate antibiotic prescription.

Efficacy and Safety of Weight-based Dosing of Daptomycin in Obese Patients: A Systematic Review

Purpose: To provide a comprehensive review of daptomycin weight-based dosing methods for obese patients. Methods: PubMed, Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched through December 31, 2022. Studies relevant to daptomycin weight-based dosing methods in obese adult patients were included. Results: Sixteen studies were included, of which five were case reports and 11 were cohort studies. Obese patients were included in all case reports, of which one was pregnant. The infections improved after receiving a daptomycin dose based on actual body weight (ABW) in all cases. Seven studies demonstrated that ABW, ideal body weight (IBW), and adjusted body weight (AjBW)-based daptomycin dosing differed in terms of treatment success, microbiological clearance, and creatinine phosphokinase (CPK) elevation. However, AjBW was not statistically equivalent to ABW in all evaluated outcomes, except for treatment success. Three studies showed a higher area under the concentration-time curve (AUC) by 60% in obese patients, whereas two studies indicated a higher maximum plasma concentration (Cmax) of ~2 folds. One study demonstrated that obese patients had higher levels of total clearance and volume of distribution, whereas other pharmacokinetic parameters were comparable between obese and non-obese patients. Conclusion: While most of the available evidence reported daptomycin dosing based on actual or total body weight, a few other studies have reported the use of ideal or adjusted body weight. A significant elevation in CPK was observed when daptomycin was administered based on AdjBW, but not with ABW and IBW. Further research is required to determine the optimal daptomycin weight-based dosing method in obese patients (AU)

Microbiological trends and mortality risk factors of central line-associated bloodstream infections in an academic medical center 2015-2020.

BACKGROUND: Despite tremendous efforts to prevent central line-associated bloodstream infections, they still remain life-threatening complications among hospitalized patients with significant morbidity and mortality worldwide. The emerging antibiotic-resistant bacteria and other risk factors, including patient comorbidities, complicate patient management. METHODS: A single-center retrospective observational study was conducted at King Fahad Hospital of the University, Eastern Province, Saudi Arabia. Hospitalized patients with confirmed central line-associated bloodstream infections between January 2015 and December 2020 were included. The primary objectives were to investigate the trends in antibiotic susceptibility patterns of the causative agents, coexisting comorbid conditions, and other risk factors associated with mortality. RESULTS: A total of 214 patients with confirmed central line-associated bloodstream infections were included (CLABSI). The overall 30-day mortality rate was 33.6%. The infection rates per 1000 central line days for medical, surgical, and pediatric intensive care units were 4.97, 2.99, and 4.56 per 1000 CL days, respectively. The overall microbiological trends showed a predominance of Gram-negative agents, a steady increase of fungal CLABSI up to 24.0% in 2020, and a high prevalence of multidrug resistance up to 47% of bacterial CLABSI. In addition, the study indicates a significant negative surviving correlation with diabetes mellitus, cardiovascular disease, lung disease, chronic kidney disease, and the presence of ≥ 3 comorbidities (P < 0.05). CONCLUSION: The microbiological trends of the study population demonstrated a steady increase of CLABSI caused by Candida spp. with a predominance of Gram-negative pathogens. Stratifying the patients according to relevant mortality risk factors, including patient comorbidities, will help reduce CLABSI rates and improve patient outcomes.

Pharmacist-led education curriculum for fourth-year medical students: a single-center experience

Background: Doctors are usually challenged by the transition between theoretical basic science knowledge and actual clinical practice. Thus, a critical educational intervention is the early incorporation of pharmacists into the pharmacotherapy courses for undergraduate medical students from their college years and moving to the practice setting. Objective: We sought to determine if a pharmacist-led education course would improve medical students’ knowledge of general pharmacotherapy topics. Methods: All fourth-year female medical students were invited to enroll in the pharmacy practice curriculum between January and March 2022. The program was divided into three main domains: formal lectures, a hands-on prescription writing skills session, and on-site pharmacy practice sessions. The pharmacy practice session was divided into three sections: first section pharmacy practice, second section pharmacy innovation, and the third section clinical pharmacy. Those who completed the curriculum were requested to complete preand post-session assessments and curriculum evaluations. Results: One hundred fourteen medical students enrolled in the pharmacy practice module. One hundred eleven (97.4%) completed the pre-and post-course assessment. After completing the module, the medical students’ knowledge scores improved from pre- to post-course. A significant difference in the overall knowledge was observed between the pre-course and post-course scores (9.51 versus 16.04; p<0.001). The difference between the pre-course and post-course scores was also significant when comparing the knowledge per each part of the assessment, showing an average score of 2.78 versus 4.05 (p<0.001) for the first section; 3.39 versus 5.49 (p<0.001) for the second section; 3.34 versus 6.48 (p<0.001) for the third section. The program received overall positive feedback; the experience was rated overall as “Excellent” by 73% of the participants. (AU)

Assessment of knowledge, attitude, and practices of acute kidney injury incidence with co-administration of piperacillin/tazobactam and vancomycin among healthcare workers: A cross-sectional study.

Background: No studies have identified a link between acute kidney injury (AKI) incidence due to the co-administration of vancomycin and piperacillin/tazobactam (VPT) and healthcare providers' knowledge, attitudes, and practices. We aimed to (1) assess the knowledge, attitudes, and practices towards AKI due to VPT co-administration among healthcare providers in Saudi Arabia, and (2) examine the relationship between healthcare providers' knowledge and attitudes about AKI due to VPT co-administration and their practices. Methods: This cross-sectional study was conducted between February 2022 and April 2022. Healthcare providers, including physicians, pharmacists, and nurses, were included in the study population. The correlation coefficient assessed the relationship between knowledge, attitude, and practice. Spearman's rho was used as a test statistic. Results: Of the invited healthcare providers, 192 responded to the survey. A significant difference in knowledge was found among healthcare providers for two variables: the definition of AKI (p < 0.001) and appropriate management of AKI due to VPT (p = 0.002). Physicians were found to rely less on the most common causative organisms of infection to guide empirical antibiotic therapy (p < 0.001). In addition, physicians were less likely to switch piperacillin/tazobactam to cefepime or meropenem in combination with vancomycin with AKI incidence (p = 0.001). A positive attitude towards the perceived AKI risk with VPT was positively correlated with avoiding using VPT unless no alternatives were available (Rho = 0.336) and taking protective measures when using VPT (Rho = 0.461). Conclusion: Deviation has been observed in the knowledge, attitudes, and practices of AKI incidence with the co-administration of piperacillin/tazobactam and vancomycin among healthcare workers. Interventions at the organizational level are recommended to guide best practices.

Proof-of-Concept Study of Using Supervised Machine Learning Algorithms to Predict Self-Care and Glycemic Control in Type 1 Diabetes Patients on Insulin Pump Therapy.

OBJECTIVE: Using supervised machine learning algorithms (SMLAs), we built models to predict the probability of type 1 diabetes mellitus patients on insulin pump therapy for meeting insulin pump self-management behavioral (IPSMB) criteria and achieving good glycemic response within 6 months. METHODS: This was a single-center retrospective chart review of 100 adult type 1 diabetes mellitus patients on insulin pump therapy (≥6 months). Three SMLAs were deployed: multivariable logistic regression (LR), random forest (RF), and K-nearest neighbor (k-NN); validated using repeated three-fold cross-validation. Performance metrics included area under the curve-Receiver of characteristics for discrimination and Brier scores for calibration. RESULTS: Variables predictive of adherence with IPSMB criteria were baseline hemoglobin A1c, continuous glucose monitoring, and sex. The models had comparable discriminatory power (LR = 0.74; RF = 0.74; k-NN = 0.72), with the RF model showing better calibration (Brier = 0.151). Predictors of the good glycemic response included baseline hemoglobin A1c, entering carbohydrates, and following the recommended bolus dose, with models comparable in discriminatory power (LR = 0.81, RF = 0.80, k-NN = 0.78) but the RF model being better calibrated (Brier = 0.099). CONCLUSION: These proof-of-concept analyses demonstrate the feasibility of using SMLAs to develop clinically relevant predictive models of adherence with IPSMB criteria and glycemic control within 6 months. Subject to further study, nonlinear prediction models may perform better.

Efficacy of empiric macrolides versus fluoroquinolones in community-acquired pneumonia associated with atypical bacteria: A meta-analysis.

INTRODUCTION: It is unclear if one empiric regimen for community-acquired pneumonia (CAP) associated with atypical bacteria is superior to another. The objective of this meta-analysis was to compare fluoroquinolones to macrolides in the rates of clinical failure in CAP associated with atypical pathogens. METHODS: We searched PubMed and EMBASE databases for randomized controlled trials (RCTs) comparing the clinical efficacy of fluoroquinolones with macrolides for CAP associated with atypical bacteria. We estimated risk differences (RRs) with 95% confidence intervals (CIs) using random-effects models and assessed for heterogeneity (I2). RESULTS: Five RCTs met the inclusion criteria. No significant differences between macrolides and fluoroquinolones and were identified in rates of clinical failure in CAP associated with any atypical bacteria (RR = 1.57 [95% CI 0.73 to 3.38]; p = 0.251; I2 = 0%), Chlamydia pneumoniae (RR = 2.12 [95% CI 0.63 to 7.14]; p = 0.223; I2 = 0%), Mycoplasma pneumoniae (RR = 1.28 [95% CI 0.57 to 2.92]; p = 0.550; I2 = 0%), or Legionella pneumophila (RR = 0.24 [95% CI 0.02 to 2.86]; p = 0.256; I2 = 0%). CONCLUSIONS: This meta-analysis of RCTs found no significant differences between macrolides and fluoroquinolones in rates of clinical failure in CAP associated with atypical bacteria.

Exploring the perception and readiness of Pharmacists towards telepharmacy implementation; a cross sectional analysis.

Background: Amid the turbulent nature of the COVID-19 pandemic, telepharmacy has shifted the paradigm of patient care by leveraging digital medicine. Government mandated lockdowns and norms of social distancing have further underscored the need for telepharmacy. Many developed and developing countries implemented such initiatives where pharmacists have provided tele-pharmacy services via telecommunications. However, the implementation and utilization of tele-pharmacy services are quite negligible in resource limited settings due to financial and administrative constraints. This study was aimed to ascertain the perception and readiness of pharmacists working in various sectors of a resource limiting country. Methodology: A cross sectional study was carried out in all provinces of Pakistan to explore the perceptions of pharmacists towards telepharmacy implementation through a 35-items study instrument. The collected data was analyzed descriptively and scored accordingly. The chi-square test was used for inferential analysis on pharmacist's perception regarding implementation of tele-pharmacy with their demographics. Results: Of 380 pharmacists, the mean age is 27.67 ± 3.67 years with a preponderance of male pharmacists (n = 238, 62.6%). The pharmacists (n = 321, 84.5%) perceived that telepharmacy implementation improves patient's quality of life and decreases patients' visits (n = 291, 76.6%). Overall, pharmacists (n = 227, 59.7%) had negative perception towards benefits of telepharmacy implementation, but pharmacists had positive perception towards eligibility (n = 258, 67.9%), regulatory issues (n = 271, 71.3%) and telepharmacy during pandemic and beyond (n = 312, 82.1%). In chi-square testing gender (p = 0.03) and age (p = 0.03) had a significant association with perception regarding regulatory issues. Among perception regarding telepharmacy during COVID-19 pandemic and beyond age had a significant association (p = 0.03). Among perception regarding eligibility job location of pharmacists had significant association (p = 0.04). Conclusion: The majority of pharmacists had a positive perception regarding the eligibility of patients and regulatory issues/legal framework regarding the implementation of tele-pharmacy, as well as its use during the COVID-19 pandemic and beyond. The implementation of tele-pharmacy can play a major role in providing timely and better patient care to remote patient areas and may help in the prevention and treatment of different infectious diseases.

Assessing tobramycin levels and renal function following the implantation of CaSO4 beads impregnated with tobramycin: A prospective cohort study.

This study aimed to evaluate the risk of serum tobramycin concentrations exceeding therapeutic levels after administration of calcium sulfate (CaSO4) beads containing either 240 mg or 400 mg tobramycin and 1000 mg vancomycin. This single-center, prospective. This single-center, prospective study included included Piedmont Columbus, Regional orthopedic surgery patients. Following the implantation of tobramycin into CaSO4 beads, serially measured serum tobramycin concentrations were evaluated after 6, 12, 24, and 48 hours. In addition to that, serum tobramycin concentration was evaluated after 5 days. None of the patients who received 240 mg tobramycin-impregnated beads had a tobramycin level >2 µg/mL. Six hours after implantation, the tobramycin level in 2 out of 2 (100%) patients who received 400 mg of tobramycin-impregnated beads was >2 µg/mL. One day following the surgery, the median serum creatinine was 0.85 mg/dL, with an interquartile range of 0.73 to 1.04 mg/dL. No cases of acute kidney injury were observed. This cohort demonstrated that non-nephrotoxic serum tobramycin levels could be achieved in CaSO4 beads mixed with 240 mg or 400 mg of tobramycin.

Diffuse Alveolar Hemorrhage Associated With Severe Acute Respiratory Syndrome Coronavirus 2.

Diffuse alveolar hemorrhage (DAH) is a rare syndrome resulting from the accumulation of intra-alveolar red blood cells originating most often from the alveolar capillaries and, less frequently, from precapillary arterioles or postcapillary venules. The causes of DAH can be divided into infectious and noninfectious. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has not been previously identified in humans, and it is responsible for coronavirus disease-19 (COVID-19) infection. Here, we present a case of DAH that is believed to be a consequence of COVID-19 infection in a female patient with no known past medical history. The patient was found to be positive for perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA) and anti-glomerular basement membrane antibodies. The patient was diagnosed with ANCA-associated vasculitis with glomerulonephritis and was treated successfully with methylprednisolone 500 mg intravenous (IV) daily for three days, followed by rituximab 375 mg/m2 IV once weekly for four weeks. The long-term complications of COVID-19 are not entirely known and are still being investigated. The association between COVID-19 infection and DAH is not fully known. However, the inflammatory process of COVID-19 infection may have a role in vasculitis, leading to DAH.

Assessment of knowledge and attitude toward the new antibiotic dispensing law and its effect on antibiotic use in Saudi Arabia.

BACKGROUND: Antibiotics resistance is a serious problem around the world, which has been increasing in the last century due to misuse of antibiotics. Recently, Saudi Arabia enforced the Executive Regulations of Health Practice Law that prohibits dispensing antibiotics without prescription. AIM: (1) To assess the association between the knowledge and attitude toward the recent enforcement of the antibiotic restriction Law and the antibiotic use among Saudi population.(2) To assess the pattern of antibiotic use before and after the enforcement of the Law. METHOD: An online cross-sectional study was conducted among residents of Saudi Arabia. RESULTS: The study was carried out among 570 Saudi participants; the result shows no considerable difference before and after law enforcement in purchasing and use of antibiotics. During the six months before the law implementation, antibiotics were obtained by 42 (7%) through purchase from the pharmacy without a prescription, 23 (4%) through remains of previously used containers, and 7 (1%) through a relative or a friend; while during the six months after the law implementation it was 31 (5%), 22 (4%) and 7 (1%), respectively. Only 48% agreed that they always received advice from a doctor, nurse or pharmacist on how to use your antibiotics. 32% have no knowledge about antibiotic resistance or drug resistance or antibiotic-resistant bacteria. More than two third (75%) were aware of the recent enforcement of the law that prohibits dispensing antibiotics without prescription. Among the participants, 91 (16%), 285 (50%) and 194 (34%) were expressed negative, neutral and positive attitude towards the law, respectively. CONCLUSION: In spite of the recent enforcement of the Law, there is still misuse of antibiotics, which indicate need for educational programs and campaigns to improve the knowledge of the population.

Clinical cure with ceftriaxone versus ceftaroline or ceftobiprole in the treatment of staphylococcal pneumonia: a systematic review and meta-analysis.

Ceftriaxone is an empirical antibiotic commonly used to treat pneumonia. However, its use to treat infections caused by methicillin-susceptible Staphylococcus aureus (MSSA) is controversial given limited evidence of its clinical efficacy. The objective of this study was to compare the clinical efficacy of ceftriaxone with either ceftaroline or ceftobiprole in the treatment of pneumonia caused by MSSA. A systematic review and meta-analysis of randomised controlled trials (RCTs) comparing clinical cure in patients with pneumonia who received ceftriaxone versus those who received either ceftaroline or ceftobiprole was conducted. Patients who received ceftriaxone plus vancomycin were excluded. The PubMed, Embase and Cochrane Library databases as well as clinical trial registries were searched up to 8 June 2018. Risk differences (RDs) with 95% confidence intervals (CIs) were estimated using a random-effects model and assessing for heterogeneity (I2). A total of five RCTs met the inclusion criteria; four used ceftaroline and one used ceftobiprole. Four studies included adults and one included paediatric patients. The adult studies included non-intensive care unit patients with mild-to-moderate community-acquired pneumonia. Clinical cure was statistically lower with ceftriaxone (RD, -28.5%, 95% CI -53.5% to -3.4%; P = 0.026; I2 = 16.321%) than with ceftaroline or ceftobiprole. In conclusion, ceftriaxone use was associated with higher clinical failure of MSSA pneumonia compared with ceftaroline or ceftobiprole. This supports the notion that ceftriaxone is not an ideal agent for the treatment of MSSA infections and adds new evidence against its use for MSSA pneumonia.

Health Behaviors among Stroke Survivors in the United States: A Propensity Score-Matched Study.

GOAL: The American Heart Association/American Stroke Association has specific recommendations for secondary stroke prevention. The aim of this study was to compare health behaviors engagement between stroke survivors and propensity score-matched controls. METHODS: We conducted a retrospective, cross-sectional, matched case-control study using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. We included older adults aged 50 or older who participated in the 2015 BRFSS survey and completed the interview. Each case was matched to 3 controls (1:3) based on propensity scores to increase the power of the analyses. Stroke survivors were compared with controls on their physical activity, smoking, alcohol use, body mass index (BMI), last flu immunization, last physical checkup, last blood cholesterol check, heavy drinking, and vegetable and fruit consumption. We used binomial logistic regression to assess health behaviors among stroke survivors compared with controls. RESULTS: The final study sample consisted of 13,249 stroke survivors and 39,747 controls without stroke after propensity score matching. Multivariable analyses revealed that there were significant differences between stroke survivors and matched controls in terms of BMI, physical activity, smoking status, alcohol consumption, and vegetable and fruit consumption. For example, stroke survivors were 51% more likely to be smokers (adjusted odds ratio [AOR] 1.51, 95% confidence interval [CI], 1.32-1.73) and 14% less likely to consume alcohol (AOR .86, 95% CI .78-.95). CONCLUSION: Findings from our study indicate that compared with propensity score-matched controls, stroke survivors engage in poorer health behaviors with the exception of alcohol consumption.