Snapshots of ID Week 2022

Abstract

ID Week 2022 was, of course, our first in-person get-together in 3 years. Although all were masked, there was a sense of relief and normalcy, as old friendships were rekindled, and new friendships were made. We all got back to doing what we do best: teaching, learning, sharing new ideas, and inspiring one another. And our very own colleague Dr Anthony Fauci made a most welcome appearance. It is impossible to capture the depth and breadth of the meetings, but as always, we humbly try. (1) SESSION 175. IMPACT ON REDUCTION OF BLOOD CULTURE INCUBATION PERIOD FROM FIVE TO FOUR DAYS FROM LARGE TERTIARY CARE CENTER. PREMALKUMAR MP, PAGACZ M, TUMARINSON T, YOUSEFZADEH M, RIVERA C, RECINE M. Summary: Investigators at Mount Sinai Medical Center underwent a quality improvement initiative to look at whether reducing the standard blood culture incubation period from 5 to 4 days would have a clinically significant effect on patient care. They performed a retrospective chart review on all blood cultures (n = 120,360) from June 2017 to June 2020 and stratified all blood cultures based on positivity from day 1 to 5 and then reviewed the culture results from day 5 specifically to determine if these resulted in care changes. Overall positivity rate was 6.3% (n = 7558) during this time period. Approximately 94% of cultures were positive on day 1, an additional 4% on day 2, 2% more on day 3, 1% more on day 4, and less than 1% more on day 5. Of the isolates that were positive only on day 5, 12 were determined to be contaminants, 4 were repeat cultures already on appropriate therapy, and 8 had positive blood culture bottles but no growth on plates. None of these cases resulted in antibiotic changes on antibiotic chart review. Comments by Dr Stephen: Blood cultures are an important tool for infectious disease (ID) specialists, but the relatively long incubation takes up valuable laboratory space and time. If the standard holding time in automated systems can be safely reduced without affecting patient care, this will help reduce already significant burdens on the laboratory. In more than 7000 positive blood cultures, the investigators did not find a single case where a 4-day duration would have had a clinical impact on patient care. Prior data suggest that for the vast majority of organisms, growth is seen in the first 4 days with rare exceptions such as Aeromonas hydrophila, Gardnerella vaginalis, and Cutibacterium acnes (Hardy et al). Although this intervention seems like a promising way to reduce workload for the micro laboratory (Hardy DJ, Hulbert BB, Migneault PC. Time to detection of positive BacT/Alert blood cultures and lack of need for routine subculture of 5-to 7-day negative cultures. J Clin Microbiol 1992;30(10):2743–2745), its generalizability may depend on local microbiology patterns and epidemiology. (2) SESSION 734. EFFICACY OF SULBACTAM-DURLOBACTAM (SUL-DUR) VERSUS COLISTIN IN PATIENTS WITH EXTENSIVELY DRUG-RESISTANT (XDR) AND PAN-DRUG RESISTANT (PDR) ACINETOBACTER BAUMANNII-CALCOACETICUS COMPLEX (ABC) INFECTIONS. MILLER A, MCLEOD S, SHAPIRO AB, RANA, K, LEWIS D, POIRIER G, CHABAS D, ALTARAC D. Summary: Investigators of the ATTACK study funded by Entasis Therapeutics compared all-cause mortality and test of cure results in patients with carbapenem-resistant A. baumannii-calcoaceticus (CRABC) hospital-acquired pneumonia, vent-associated pneumonia, or bloodstream infections who received imipenem plus colistin versus imipenem plus SUL-DUR. All-cause mortality was 32.3% in the colistin group and 19% in the SUL-DUR arm (treatment difference of 13.2%; 95% confidence interval, −30 to 3.5). In addition, the clinical cure rate was higher in the SUL-DUR group at 61.9% compared with 40.3% in the colistin group. These improvements were seen in patients with XDR and PDR ABC infections as well. Overall, this suggested noninferiority of SUL-DUR compared with colistin for treatment of CRABC including XDR and PDR ABC. Comments by Dr Stephen: Treatment of CRABC infections is a challenge because of complex resistance patterns, limited antimicrobial options, and toxicities of available options, such as polymixins. Limitations of this study potentially include comparison to colistin when there are other novel agents being used for the treatment of ABC infections that may have less toxicities (Bassetti M, Echols R, Matsunaga Y, et al. Efficacy and safety of cefiderocol or best available therapy for the treatment of serious infections caused by carbapenem-resistant gram-negative bacteria (CREDIBLE-CR): a randomized, open-label, multicentre, pathogen-focused, descriptive, phase 3 trial. Lancet Infect Dis 2021;21(2):226–240). Sulbactam-durlobactam, however, is conceptually fascinating and specific to the known effect of sulbactam on ABC and if approved would represent a unique, specific therapy that appears to be noninferior to colistin, for this challenging-to-treat pathogen. (3) POSTER 2103. COMPARISON OF ANTIBIOGRAMS ACROSS SOLID ORGAN TRANSPLANT SERVICES WITHIN A MEDICAL CENTER. KIM A, MACDOUGALL C. Summary: The investigators hypothesized that antibiograms may differ in subpopulations of immunocompromised hosts. They conducted a single-center retrospective study to create a combined antibiogram of transplant patients and then proceeded to break the antibiogram down to specific organ transplants (heart, lung, liver, or kidney) to compare susceptibility patterns. The organisms compared were Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae. They found substantial differences in susceptibility patterns, such as a lower sensitivity of piperacillin-tazobactam to P. aeruginosa in heart and lung recipients relative to the other types of transplant patients. Escherichia coli also had a lower sensitivity to cefepime in lung, heart, and liver recipients but not in kidney transplants. The investigators concluded that there are significant differences in the susceptibility patterns among different types of solid organ recipients. This should be taken into account when choosing empiric therapy. Comments by Dr Alpizar-Rivas: With the continued rapid growth of organ transplantation, this type of study is important to better understand the differences between transplant recipients. Although transplant patients are all considered under the umbrella of “immunosuppressed hosts,” their individual characteristics may give them unique risks. Knowing that their sensitivity patterns are potentially different and taking this into account for empiric therapy may make a difference in the initial management of septic patients and their survival. The authors did not mention if there were differences other than the type of organ transplant that could account for the differences. For example, were different types of transplant patients segregated into different wards, were some groups exposed to different antibiotic regimens that potentially led to the differences in susceptibilities, or were some groups sicker than others? (4) PLENARY SESSION 279. CLOSING PLENARY: THE PANDEMIC AS A PORTAL: LOOKING TOWARDS THE FUTURE. MORSE M, BELL T. Summary: Drs Morse and Bell described how structural racism puts minority patients at increased risk from various diseases, as evidenced by how the COVID pandemic exacerbated disparities in access to health care. In the United States, between 2019 and 2021, the life expectancy drop in Latinx (4.7%) and African American patients (4.95%) was almost double that of White patients (2.67%). This difference in life expectancy among different ethnic groups, exacerbated by the pandemic, was not caused by biological differences, but instead was a result of long-standing inequities in access to health care. For example, as of June 2021, African Americans had the lowest vaccination rate against COVID. This has been attributed to a long history of the larger community targeting and distributing misinformation to the African American community. In response to the low vaccination rate, New York State took action by having Black race and Latin ethnicity be a risk factor that allowed for reallocation of monoclonal antibodies to these vulnerable populations. The New York State Public Health Corps also sought to invest in communities that were disproportionately impacted by COVID. Drs. Morse and Bell also recounted the recent attention given to the estimated glomerular filtration rate formula correction based on Black race. The modified formula for Blacks was based on the mistaken belief that Black people have higher muscle mass: similar reasoning had led to enslaving Blacks in the first place. Recent models have shown that the current practice based on this formula causes underdiagnosis of Black patients with kidney disease, thus delaying appropriate care. The faculty proposed building a system with unbiased public health leaders. To achieve this, pathways must be established, such as internships in advocacy groups or professional organizations, supported by grant funding. Academic institutions should integrate diversity, equity, and inclusion (DEI) into their core values, and extend DEI into clinical research. Ultimately, the most effective health care leaders must have emotional intelligence and the ability to listen and communicate with compassion and empathy, across age, social class, race, and gender identity. While ID physicians often display the qualities necessary to advance DEI, there is still much work to be done, as there continues to be underrepresentation of minorities in the ID academic hierarchy. Comments by Dr Alpizar-Rivas: Recently, I had a conversation with a friend who asked me why diversity is better. Although the question itself may sound inflammatory, having these hard conversations is key to finding solutions and improving the system. Diversity increases the pool of ideas, allows more voices to be heard, and enables more people to be recognized. I firmly believe that by improving the health care of everyone, regardless of race, gender, sexual orientation, ability, or any other characteristic, we can decrease the burden on the medical system and allow for better care for everyone. Furthermore, a healthier society is a more productive society, which benefits us all. (5) ORAL ABSTRACT 875. GUESS WHO'S BACK: THE RETURN OF SEASONAL RESPIRATORY VIRUSES IN THE STATE OF WISCONSIN AND ASSOCIATED CHANGES IN ANTIBIOTIC PRESCRIBING FOR RESPIRATORY COMPLAINTS. LEPAK A, TAYLOR L, SCHULZ L, HANSON E, TEMTE J. Summary: The authors collected data from more than 130 laboratories in Wisconsin regarding respiratory virus detection rate (percent of positive tests over all tests) for influenza, respiratory syncytial virus (RSV), seasonal coronaviruses, parainfluenza virus, enterovirus/rhinovirus, and human metapneumovirus between January 2015 and April 2022. They also utilized ambulatory antibiotic prescription data for respiratory complaints over the same period by querying the electronic medical record. Data showed that enterovirus/rhinovirus and seasonal coronavirus infections were detected at much lower levels, and other respiratory viruses were rarely detected. After April 2021, when loosening of mask mandates was enacted, respiratory virus detection rates increased for all viruses. Within a year of reversal of masking and other restrictions, most respiratory viruses had returned to their prepandemic levels of detection and seasonality (except influenza, which had a persistently lower detection rate, and RSV, which had an altered seasonality). Antibiotic prescriptions for respiratory symptoms were initially lower than baseline in the first year of the pandemic but have slowly increased since restrictions were loosened. The authors correlated the antibiotic prescription rates with respiratory virus detection rates (specifically non-RSV), using Mann-Whitney rank sum and Spearman correlation (0.71). The authors concluded that respiratory viruses have generally returned to prepandemic rate and seasonality, but antibiotic prescribing has overall remained lower than prepandemic rates, although still rising. Comments by Dr Pomakov: This presentation shows reassuring insight into the detection of respiratory viruses during the pandemic. Although suppositions and subjective experience likely suggest to many of us that all non-COVID respiratory viral illnesses were less prevalent during the masking mandates, seeing data to this effect is encouraging both for the positive effects of personal protective equipment and masking mandates as well as the prompt loss of protection from respiratory illnesses once mandates are removed. It is in fact a testament to the overall effectiveness of public policy during the pandemic. The correlation between the prevalence of respiratory viruses and numbers of scripts of antibiotics issued for respiratory symptoms is also encouraging. Increased patient and provider awareness of classic viral respiratory symptoms may have resulted in significant improvement in ability to delineate viral versus bacterial upper and lower respiratory tract illnesses. This mindfulness has the potential to aid in antimicrobial stewardship, especially in an era of rampant multidrug-resistant organisms. It would be interesting to further look into the data and assess whether positive home COVID testing had any influence on rates of prescription, as readily available ambulatory and home tests may have contributed to the diagnostic and treatment decision-making in those settings. Although the data show a decrease in prescriptions, it would be of interest to note reasons why patients with respiratory symptoms were specifically not given antibiotic prescriptions. (6) POSTER #1841. INCIDENCE AND PREDICTORS OF COMPLICATIONS IN GRAM NEGATIVE BLOODSTREAM INFECTION. MONDAL U, WARREN E, BOOKSTAVER PB, JUSTO J, ET AL. Summary: The incidence and risk factors of complications (such as metastatic infections) are not well defined in gram-negative bacteremia. This was a retrospective cohort study over a 3-year period, looking at complications of gram-negative bacteremia, including infective endocarditis, septic arthritis, osteomyelitis, spinal infections, deep-seated abscesses, and recurrent gram-negative bloodstream infection within 90 days of the initial episode. Seven hundred fifty-two patients were studied, of whom 13.9% experienced complications. Significant risk factors identified included nonurinary source, presence of prosthesis, persistent bacteremia, and blood culture positive for P. aeruginosa, Proteus mirabilis, or Serratia. Those with Serratia had a 39.7% incidence of complications. In contrast, the rate of complications from E. coli was only 8.7%. The authors conclude that stratification of patients based on the risk factors identified could help identify patients at high risk for metastatic infection, potentially identifying patients who might require further diagnostic workup. Comments by Dr Louie: A colleague of mine recently had a patient with Serratia bacteremia and ankle pain (it turned out to be a septic ankle). There was initially some pushback from the surgeon about washing out the ankle, but perhaps the above data could have helped support my colleague's view. (7) LATE BREAKER LB2303. SINGLE HIGH DOSE OF LIPOSOMAL AMPHOTERICIN B IN HIV/AIDS-RELATED DISSEMINATED HISTOPLASMOSIS: A RANDOMIZED TRIAL. PASQUALOTTO AC, GODOY C, LANA D, ET AL. Disseminated histoplasmosis has high mortality in HIV patients in developing countries. Conventional treatment is 2 to 6 weeks of amphotericin B, followed by maintenance therapy. This study was a prospective randomized phase II multicenter open-label trial in Brazil, whose aim was to examine the efficacy of a single high-dose amphotericin followed by maintenance itraconazole, to standard-of-care treatment. The study arms included a single 10-mg/kg dose of liposomal amphotericin B (L-AmB) versus a single 10 mg/kg L-AmB followed by 5 mg/kg L-AmB on day 3 versus 3 mg/kg L-AmB daily for 2 weeks. All were continued on 1 year of itraconazole following the induction regimen. Some exclusion criteria included central nervous system involvement, imminent death, and concomitant tuberculosis. The primary end point was clinical response, that is, resolution of fever and signs/symptoms attributable to histoplasmosis, on day 14. One hundred eighteen patients were randomized. Most patients had pulmonary and/or abdominal involvement. Clinical response on day 14 was as follows: arm 1: 89%, arm 2: 76%, and arm 3: 89%. There was no statistical significance in probability of survival at 300 days. Arm 1 had the least amount of kidney toxicity, although, surprisingly, arm 2 had more kidney toxicity than arm 3. The authors concluded that a single high dose of L-AMB was as safe and efficacious as a 2-week induction regimen and noted that a phase III trial is in the planning stages. Comments by Dr Louie: As we have recently learned about the efficacy of single-dose L-AmB followed by flucytosine and fluconazole in cryptococcal meningitis (Jarvis JN, Lawrence DS, Meya DB, Kagimu E, et al. Single-dose liposomal amphotericin B treatment for cryptococcal meningitis. N Engl J Med 2022;386:1109–1120), we look forward to more data supporting a similar practice in the case of disseminated histoplasmosis. Hopefully, simplified regimens will help stretch health care dollars further, especially in resource-poor countries.