Antimicrobial Recommendations Research Articles

P-1736. Examining the Impact of Eliminating a Transitions of Care Pharmacist Program on Antimicrobial Use

Abstract Background Antimicrobial stewardship interventions during transitions of care (TOC) have increased guideline concordant prescribing at hospital discharge. A TOC pharmacy program targeting discharging patients at the high risk for mortality was established at our community teaching hospital in 2016. A previous program analysis reported 14.4% of all pharmacist interventions made involved antimicrobials. The TOC pharmacy program was eliminated in 2022. The purpose of this study was to assess the impact of program elimination on appropriate and optimal antimicrobial prescribing. Methods This retrospective, single center, pre-post cohort study investigated the impact of the elimination of the TOC program on appropriate and optimal antimicrobial prescribing. Adult inpatients with the highest risk of 30-day mortality receiving an antimicrobial at discharge between September - November 2021 (TOC pharmacist program cohort) and September - November 2022 (post-TOC cohort) were included. Appropriate antimicrobial use was defined as prescribing of indication-based effective and safe therapy. Optimal prescribing was defined as adherence to institutional guideline-based antimicrobial stewardship recommendations. Results Six-hundred twenty-six patients were included with 313 patients in each cohort. Baseline characteristics between cohorts were generally similar with significant differences in the number of patients treated for community-acquired pneumonia (20.4% vs. 28.4%; P = 0.026) and bacteremias (11.5% vs. 5.1%; P = 0.004). There were no differences in appropriate (90.4% vs. 90.1%; P = 0.893), or optimal prescribing (80.8% vs. 78%; P = 0.374) between cohorts. There were no differences in incidence of non-optimal antimicrobial dosing (6.4% vs. 5.8%; P = 0.738), or non-optimal antimicrobial selection (1.3% vs. 2.9%; P = 0.161); however, the incidence of non-optimal duration decreased in the post-TOC cohort (22% vs. 15%; P = 0.024). Conclusion The elimination of the TOC pharmacy program did not impact appropriate or optimal antimicrobial prescribing. Relatively high appropriate and optimal prescribing were noted in both cohorts and additional ongoing stewardship interventions may have confounded results. Disclosures All Authors: No reported disclosures

P-1132. Patient Pre-Selection Improves Efficiency and Acceptability of Antimicrobial Audit-and-Feedback Rounds in a Neonatal Intensive Care Unit

Abstract Background Audit-and-Feedback Rounds (AFR) are an effective way of evaluating the appropriateness of antimicrobials in inpatient settings, but they are time- and resource-intensive. In our 52-bed tertiary care neonatal intensive care unit (NICU), AFR methodology was modified in that pharmacists would pre-select patients to be discussed, in order to focus on value-added discussions. This observational study describes the impact of this intervention on key AFR metrics.Figure 1.Percentage of NICU patients on systemic antimicrobials who were discussed at audit-and-feedback rounds, pre- and post-intervention. Methods Since October 2019, the NICU team and an Infectious Diseases (ID) physician met weekly to review all patients on systemic antimicrobials at the time of AFR. The ID physician assessed the appropriateness of antimicrobials and made recommendations to the team. Pharmacists prospectively collected data on the duration of AFR, reasons for inappropriate prescriptions, recommendations made, and adherence to recommendations 24 hours later. To improve efficiency, from September 2021 on, it was agreed that pharmacists would select out some patients from the discussion list as they were considered by default to be on appropriate therapy: those followed by the ID service; neonates on empiric ampicillin and an aminoglycoside for early-onset sepsis; and those on prophylactic antimicrobials if already reviewed once before.Figure 2.Percentage of antimicrobial stewardship recommendations accepted by NICU team, assessed 24 hours post-rounds. Results In the pre-intervention period (Oct 2019 - Oct 2020), 92% (n = 226) of patients on systemic antimicrobials were reviewed, and AFR lasted 27 minutes on average. Antimicrobial use was considered appropriate for 88% of patients and 75% (n=55) of recommendations were accepted by the NICU team. In the initial post-intervention period (Oct 2021- Oct 2022), 30 % (n = 101) of patients on antimicrobials were discussed at AFR (Figure 1), and usage was considered appropriate in 80% (n = 123). Between Oct 2022 and Oct 2023, mean duration of AFR had decreased to 13 minutes, and adherence to recommendations increased to 92% (n=36). Conclusion Patient pre-selection for AFR was associated with shorter rounds and increased uptake of recommendations by clinical teams. This method could be used to conduct AFR in other busy inpatient settings. Disclosures All Authors: No reported disclosures

P-2220. Real-World Utilization of a Multiplex Pneumonia PCR Panel on Antimicrobial Stewardship and Antibiotic Use

Abstract Background In October 2022 the Queen of the Valley Medical Center (QVMC) microbiology department implemented the Biofire® Pneumonia Pathogen Panel polymerase chain reaction (PCR) for identification of viral and bacterial pathogens along with resistance genes. This may aid in improved identification of pneumonia pathogens with a quicker turnaround time. In contrast, respiratory cultures take multiple days to return with both the organism and antibiotic susceptibility, which delays the time to achieving targeted therapy. Methods This was a retrospective cohort study from October 2022 to April 2023. Patients were included if they were admitted to QVMC and had a positive pneumonia PCR. Patients were excluded if they were receiving antibiotics for an indication other than pneumonia, if they did not receive antibiotics, or if they were discharged, transferred or died prior to the PCR result. The primary outcome was if the patient achieved targeted therapy. Secondary outcomes included time to targeted therapy, actions performed based on the results, and correlation between respiratory culture results and PCR. Results Fifty-nine patients were included for analysis. Most patients had a diagnosis of CAP (n = 43, 72%), vs. HAP (n = 8, 14%), and VAP (n = 8, 14%). Targeted therapy was achieved in 41 patients (70%). Seven (12%) of these patients had empiric therapy which was also targeted therapy. The mean time from PCR collection to the start of targeted therapy was 23.11 hours. For patients who had respiratory cultures collected, the mean time to final identification with susceptibilities was 40.6 hours. Therefore, targeted therapy was achieved at least 17 hours sooner than if de-escalation or escalation was solely dependent upon respiratory culture results. There were 47 antimicrobial stewardship recommendations documented, and 31 (66%) were accepted by providers. Forty-four patients (75%) also had respiratory cultures collected, and only 19 (43%) had organism growth. Conclusion Utilizing multiplex PCR technology for patients with pneumonia can be useful for antimicrobial stewardship programs by providing higher rates of pathogen identification and resistance data compared to respiratory culture alone. This allows for improved time to targeted therapy. Disclosures All Authors: No reported disclosures

P-1801. Optimizing Antimicrobial Therapy in Gram-Negative Bloodstream Infections: Insights from a Pharmacist-Driven Intervention Leveraging Molecular Rapid Diagnostic Testing

Abstract Background Molecular rapid diagnostic tests (mRDT) expedite pathogen and antimicrobial resistance gene detection in bloodstream infections (BSI), facilitating the prompt initiation of targeted therapy. However, mRDT has the greatest benefit to patients and public health when integrated with antimicrobial stewardship. This study describes a pharmacist-driven mRDT antimicrobial stewardship intervention in Gram-negative BSI, its associated outcomes and its applicability to public health partners.Table 1.Patient demographics, infection and management characteristics. Methods At an urban medical center in Detroit, Michigan, USA, trained pharmacists received an alert page for positive mRDT results. Subsequently, they conducted chart review and provided antimicrobial recommendations to the medical team per site protocol. This is a retrospective, descriptive analysis of patients ≥ 18 years old with Gram-negative BSI who received a pharmacist intervention from 5/2023-4/2024. Patient characteristics and intervention outcomes, including time to pharmacist review and recommendation type, are described.Table 2.Pharmacist intervention and clinical outcomes. Results Sixty-six patients were included; mean (SD) age was 63 (16) years and patients were predominantly Black (68.2%). The most common primary infection source was urinary (40.9%). Escherichia coli and Klebsiella pneumoniae were most frequently identified in blood culture; 31.8% of isolates possessed CTX-M. Pharmacists reviewed mRDT results at a median (IQR) of 20 (6-97) minutes post-alert. There was no difference in time to effective therapy when mRDT alerts occurred afterhours vs. daytime hours (9 [IQR 0-22] vs. 17 [IQR 0-20] hours, p = 0.66). Sixteen patients were on ineffective empiric therapy; a pharmacist successfully adjusted therapy in 13 of these patients; two patients did not have a resistance marker identified on the initial mRDT report and the pharmacist recommendation was rejected in one patient. Twenty-two patients received empiric anti-Pseudomonal therapy who could have potentially been de-escalated upon mRDT result.Figure 1.Pharmacist workflow for mRDT alert. Conclusion Pharmacists facilitated the attainment of effective therapy in those with Gram-negative BSI with mRDT resistance marker detection. Opportunities for de-escalation highlight the potential for pharmacists to further impact patient care and public health broadly through antimicrobial stewardship.Figure 2.Institutional Gram-negative therapy protocol. Disclosures Kaylee E. Caniff, PharmD, BCIDP, T2Biosystems: Honoraria Michael J. Rybak, PharmD, PhD, MPH, Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Advisor/Consultant|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Grant/Research Support|Abbvie, Melinta, Sionogi, Merck, T2Biosystems: Speaker

P-1696. Antibiotic consumption and resistance among admitted patients with urinary tract infection in the Philippines: Results from a longitudinal Global Point Prevalence Survey

Abstract Background Urinary Tract Infection (UTI) is a common diagnosis among hospitalized patients for which Escherichia coli (E.coli) is the most common etiologic agent. Recently, increasing antimicrobial resistance of E. coli to common antibiotics has been reported in the Philippines. We describe the prevalence of antimicrobial use for UTI in Philippine hospitals from 2017-2022 and compare this with the antimicrobial resistance pattern of urinary E. coli generated by the Department of Health, Antimicrobial Resistance Surveillance Program. Methods Since 2017, the Philippines has been conducting point prevalence surveys (PPS) on antimicrobial consumption using the standardized and validated methodology of the Global-PPS. All admitted patients on antimicrobials at 8 AM on the day of the survey were included. Type of infections and their corresponding antimicrobial prescriptions were recorded. Results Data were collected in 62 hospitals in the Philippines. Overall, three percent (N= 2242; 3.3%) of patients admitted in Philippine hospitals on the day of the PPS were treated with antimicrobials for UTI (lower UTI: 1,8%, upper UTI:1.5%). Ceftriaxone, cefuroxime, piperacillin-tazobactam, ciprofloxacin and meropenem were the top five antibiotics used (table 1), all of which are classified under the WATCH list of the WHO AWaRe classification. Seventy-seven percent of all antibiotics were prescribed empirically. Based on the antimicrobial surveillance data of the Department of Health, the resistance rates of E. coli to these antibiotics were high with on average more than 40% resistance to cefuroxime, ceftriaxone and ciprofloxacin (figure 1). Conclusion There is an opportunity to strengthen hospital antimicrobial stewardship programs, with particular emphasis on pre-authorization and audit and feedback strategies. Consideration may be given to placing ceftriaxone, cefuroxime, and ciprofloxacin under restricted categories requiring approval by the AMS clinician prior to empiric use. Importantly, local antibiograms should be reviewed on a regular basis and should be used as a basis for empiric antimicrobial recommendations in hospitals. Repeated point prevalence surveys are needed to measure the impact of interventions implemented by hospital AMS committees. Disclosures All Authors: No reported disclosures

Prevention and Treatment of Cancer-Related Infections, Version 3.2024, NCCN Clinical Practice Guidelines in Oncology.

There is an increased risk of infection in patients with cancer that results in higher morbidity and mortality. Several risk factors can predispose these patients to infectious complications. Some such factors include immunocompromised states like neutropenia, allogeneic hematopoietic cell transplantation, and graft-versus-host disease, while others include immunosuppressive agents like corticosteroids, purine analogs, monoclonal antibodies, and other emerging cancer therapeutics like CAR T-cell therapy. The NCCN Guidelines for the Prevention and Treatment of Cancer-Related Infections address infection concerns that may be observed in these immunocompromised populations and characterize the major pathogens to which patients with cancer are susceptible, with a focus on the prevention, diagnosis, and treatment of major common and opportunistic infections. This paper highlights 2 recently updated sections of the guidelines, namely, infection concerns related to CAR T-cell therapy and antimicrobial prophylaxis recommendations, including vaccination, in patients at high-risk for infections.

A review of antimicrobial stability testing guidance for outpatient parenteral antimicrobial therapy programmes: is it time for global harmonization of testing frameworks?

Antimicrobial stability is an important consideration for treatment planning and service delivery in outpatient parenteral antimicrobial therapy (OPAT) programmes. Regulation of stability assessment varies by region, and conflicting guidance and standards exist. This leads to disparity of equity in access and limits availability of certain antimicrobials for managing infections in the outpatient setting. This review discusses the degree to which the international regulatory bodies have reached consensus on the regulation of antimicrobial stability testing, specifically for OPAT, and describes the variation in antimicrobial recommendations across regulatory bodies. The three major findings in this review are (i) variation in antimicrobial stability testing guidance, particularly in relation to temperature; (ii) lack of regulatory guidance, specifically in that some regions did not have OPAT guidelines; and (iii) only the UK's NHS has provided non-regulatory OPAT-specific advice on antimicrobial stability testing. In conclusion, harmonization of antimicrobial stability testing to form a global OPAT-specific regulatory framework, particularly considering 'areas of variation' amongst current guidance, is required. We call for the development of a global OPAT antimicrobial stability testing framework with consensus from accepted antimicrobial stability criteria, expert opinion and pharmacopoeial best practice.

Assessing Illinois companion animal veterinarians' antimicrobial prescription practices and the factors that influence their decisions when treating bacterial infections in dogs and cats.

Judicious antimicrobial use in companion animal practice is critical for maintaining the effectiveness of antimicrobial agents against bacterial infections and reducing the selection of antimicrobial-resistant bacteria. This study aimed to provide insights into companion animal veterinarians' antimicrobial treatment recommendations for common bacterial infections in dogs and cats and describe the factors influencing their prescription choices. An online survey using QualtricsXM® software was administered between September and November 2022 to companion animal veterinarians who were Illinois State Veterinary Medical Association members. Descriptive and text analyses were conducted to assess the participants' responses. A total of 78 surveys were included in the analysis. Skin infections were ranked as the most common bacterial infections for which veterinarians prescribed antimicrobial agents, followed by ear, urinary tract, respiratory, and enteric infections. The severity of clinical symptoms and the results of bacterial culture and susceptibility tests were the most influential factors for veterinarians when making antimicrobial prescription choices. Veterinarians were aware of the current antimicrobial prescription guideline recommendations when prescribing antimicrobials empirically to nine hypothetical scenarios of bacterial infections. According to the results of the text analysis that assessed veterinarians' responses to an open-ended question, regarding their challenges when prescribing antimicrobial agents, the pairwise correlation of word frequencies within each response showed the highest correlations between the words 'owner' and 'compliance', 'administration' and 'route', 'cost' and 'culture', and 'patients' and 'acceptance'. The study results can support animal health stakeholders in the development of antimicrobial stewardship programmes to promote appropriate antimicrobial use and limit the emergence of antimicrobial resistance.

Survey of Infectious Diseases and Infection Prevention Practitioners on Diversity, Equity, and Inclusion Experiences

Background: Incorporating diversity, equity, inclusion, and justice into healthcare ensures equitable opportunity to achieve optimal health. Infectious diseases, antimicrobial stewardship, and infection prevention teams rely on consultative recommendations to improve patient care which may be influenced by implicit and explicit biases of the recipient treatment teams. Little is known about how race, ethnicity, and other characteristics impact stewardship and infection control recommendations. Methods: A survey of infectious diseases, antimicrobial stewardship, and infection prevention practitioners was developed through the Society of Healthcare Epidemiology of America (SHEA) Antimicrobial Stewardship Committee. The survey was sent electronically to members of the SHEA Research Network and was promoted to attendees of two sessions at IDWeek 2022 and SHEA Spring 2023. Survey questions included demographics, awareness of (and participation in) unconscious bias and microaggression training at their institutions, antibiotic prescribing bias observations, and perceptions of how race, ethnicity, and other characteristics have influenced participants' antimicrobial stewardship and infection prevention recommendations. Descriptive statistics were performed using SAS V.9.4 . Results: Among 175 survey respondents, 75% (n=129) were White, 16% (n=27) were Asian, 4% (n=7) were Black, 85% (n=150) were non-Hispanic, 5% (n=8) were Hispanic, and 3% (n=5) reported ethnicity as multiethnic. 76% of respondents identified as female, and 2% as non-binary or gender-fluid. 29% of respondents had a medical degree, 12% had a nursing degree, 7% had a pharmacy degree, and 52% had a degree listed as other (7% had a PhD, 23% had an MPH/MSPH degree, and 15% had an MS degree). 65% and 49% of respondents had participated in unconscious bias and microaggression training, respectively. 18% (n=22) of White respondents, 43% (n=3) of Black respondents, and 30% (n=8) of Asian respondents reported witnessing antimicrobial prescribing influenced by race, ethnicity, or other characteristics. 17% and 15% of respondents felt that their antimicrobial stewardship and infection prevention recommendations, respectively, had not been accepted due to their race, ethnicity, gender identity, or other personal identifiers. Conclusion: This survey showed demographic characteristics of professionals working in infectious diseases and their perceptions of how certain aspects of their identity have influenced their recommendations. Differences between racial groups were observed in how frequently respondents witnessed inequities in antimicrobial prescribing, and many respondents felt their recommendations had not been accepted due to their identity. A limitation of this analysis is that few Black individuals completed the survey, which makes comparisons by race difficult; however, the respondents were consistent with SHEA membership demographics.

Get Smart in Healthcare to Preserve the Power of Antimicrobials: Antimicrobial Stewardship

Antimicrobial resistance is one of the alarming health hazard to mankind. Unnecessary antibiotic usage leads to drug resistance, predisposes to opportunistic infections in immunodeficient and unnecessary economical loss to patient. This manuscript compiles & describes how crucial is Antimicrobial stewardship programs recommendations, strategies and implementation. Awareness and execution of institutional stewardship programs leads to better patient management, halt development of drug resistance and spread of resistant strains. This review is undertaken with an aim to discuss the development of an effective antimicrobial stewardship program and the key components and operating principles, and execution of these programs at healthcare facilities.

A Low-Cost Protocol Using the Adjunctive Action of Povidone-Iodine Irrigations and Sodium Hypochlorite Rinsing Solution in Step 2 of Periodontal Therapy for Patients with Stage III-IV Periodontitis: A Single-Blind, Randomized Controlled Trial.

In severe stages of periodontitis, conventional periodontal therapy and maintenance care are usually insufficient due to the viral and bacterial etiology; thus, a mechanical approach alone may not be sufficient to eliminate a substantial portion of subgingival pathogens, especially in deep periodontal sites. Background and Objectives: This single-blind, randomized clinical trial aimed to compare the clinical and microbiological efficacy of a low-cost protocol using povidone-iodine and sodium hypochlorite formulations as adjuncts to non-surgical therapy for patients with stage IV periodontitis when compared with chlorhexidine, the most commonly employed substance to date for antimicrobial regimens in periodontal therapy. Materials and Methods: Forty-five patients were randomly divided into two groups: control (subgingival instrumentation, chlorhexidine-assisted) and test (antiviral medication, subgingival instrumentation with povidone-iodine, sodium hypochlorite rinsing solution, and antibiotics). Clinical measurements and microbiological analyses were performed at baseline and after three months. Results: After three months, notable differences were found in the bacterial detection scores for Porphyromonas gingivalis (a significant reduction in detection frequency was observed in the test compared to the control (p = 0.021)), and there were significant reductions in detection in the test group for Tannerella forsythia and Treponema denticola, showing undetectable levels (p < 0.0001 for both). In the test group, the pocket probing depth median value was reduced significantly (p = 0.0005); similarly, bleeding on probing showed a marked decrease (p < 0.0001). However, changes in clinical attachment loss and full-mouth plaque score were not statistically significant. Conclusions: Using the proposed protocol, substantial improvements in clinical and microbiological parameters were obtained when compared with the current antimicrobial recommendations.

Antimicrobial susceptibility patterns of aerobic bacteria isolated from canine urinary samples in South East Queensland, 2013 to 2018.

Urinary tract infections are a common diagnosis in dogs presenting to veterinary practice. Veterinarians often treat suspected infections empirically, either in the absence of culture and susceptibility testing results or whilst waiting for them. This study aimed to identify the bacteria most frequently isolated from canine urinary samples and their antimicrobial susceptibility patterns in South East Queensland (SEQ) to help guide responsible empirical antimicrobial prescription by the veterinary community in this geographical location. Cumulative antibiograms were generated from the results of 1284 culture-positive urinary samples in SEQ, obtained from a commercial veterinary laboratory over a 5-year period. Escherichia coli was the most commonly isolated bacterial species (43%), followed by Staphylococcus spp. (23%), Proteus spp. (21%) and Enterococcus spp. (10%). Of the six most common isolates, 97% had susceptibility to at least one low-importance antimicrobial. Susceptibility to the low-importance and first-line antimicrobial recommendation, amoxicillin, was 81% for E. coli and 24% for Staphylococcus spp. Susceptibility of both E. coli and Staphylococcus spp. to medium-importance and commonly recommended empirical antimicrobials, trimethoprim sulphonamides and amoxicillin-clavulanic acid was ≥85% and >92% for high-importance antimicrobials enrofloxacin and ceftiofur. Of the E. coli and Staphylococcus spp. isolates, 8.8% and 4%, respectively, were considered multidrug resistant. There was no increase in resistance to antimicrobials detected over the study period. Susceptibilities suggest low- and medium-importance antimicrobials remain acceptable first-line empirical treatments. However, this should be continually assessed and updated using local surveillance data.

Updated antimicrobial dosing recommendations for obese patients.

The prevalence of obesity has increased considerably in the last few decades. Pathophysiological changes in obese patients lead to pharmacokinetic (PK) and pharmacodynamic (PD) alterations that can condition the correct exposure to antimicrobials if standard dosages are used. Inadequate dosing in obese patients can lead to toxicity or therapeutic failure. In recent years, additional antimicrobial PK/PD data, extended infusion strategies, and studies in critically ill patients have made it possible to obtain data to provide a better dosage in obese patients. Despite this, it is usually difficult to find information on drug dosing in this population, which is sometimes contradictory. This is a comprehensive review of the dosing of different types of antimicrobials (antibiotics, antifungals, antivirals, and antituberculosis drugs) in obese patients, where the literature on PK and possible dosing strategies in obese adults was critically assessed.

Antimicrobial dosing recommendations during continuous renal replacement therapy: different databases, different doses

Meticulous antimicrobial management is essential among critically ill patients with acute kidney injury, particularly if renal replacement therapy is needed. Many factors affect drug removal in patients undergoing continuous renal replacement therapy CRRT. In this study, we aimed to compare current databases that are frequently used to adjust CRRT dosages of antimicrobial drugs with the gold standard. The dosage recommendations from various databases for antimicrobial drugs eliminated by CRRT were investigated. The book ‘Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys’ was chosen as the gold standard. There were variations in the databases. Micromedex, UpToDate, and Sanford had similar rates to the gold standard of 45%, 35%, and 30%, respectively. The Micromedex database shows the most similar results to the gold standard source. In addition, a consensus was reached as a result of the expert panel meetings established to discuss the different antimicrobial dose recommendations of the databases.

Adherence to stewardship recommendations for antibiotic discontinuation reduces antibiotic-associated adverse drug events.

Inappropriate antibiotic use may lead to increased adverse drug events (ADEs). This study assessed whether an antimicrobial stewardship recommendation to discontinue antibiotics in patients with low likelihood for bacterial infection reduced antibiotic duration and antibiotic-associated ADEs. At a 4-hospital system, hospitalized adult patients receiving empiric antibiotics for suspected infection were identified between May 2, 2016 and June 30, 2018. For those patients who were deemed unlikely to have a bacterial infection, a note was left by an infectious diseases physician recommending antibiotic discontinuation. Patient cases were considered "adherent" to recommendations if antibiotics were discontinued within 48 hours of the note and "non-adherent" to recommendations if antibiotics were continued beyond this. Duration of antibiotics and potential antibiotic-associated ADEs were collected retrospectively. Attribution of the adverse event to the antibiotic was decided upon by the investigators. The incidence of ADEs and duration of antibiotics between the adherent and non-adherent groups were compared. Of 253 patients deemed unlikely to have a bacterial infection, 114 (45%) treatment teams stopped antibiotics within 48 hours of the recommendation, and 139 (55%) continued antibiotics. The total number of ADEs was significantly higher in the non-adherent group compared to the adherent group (34 ADEs vs 9 ADEs, P = .001). The median number of total prescribed antibiotic days was higher in the non-adherent group than in the adherent group (5 days vs 1 day, P < .001). This study demonstrates that stewardship programs may prevent ADEs by recommending antibiotic discontinuation in patients with low suspicion for bacterial infection.

Pattern of organisms causing central nervous system shunt related infections and their antibiotic susceptibility profile in a tertiary care setup

Background: Central nervous system (CNS) shunt-associated infections pose a significant threat, necessitating an in-depth understanding of the frequency and antimicrobial sensitivity patterns of the implicated pathogens. This research aimed to ascertain the frequency and antimicrobial sensitivity patterns of pathogens isolated from central nervous system shunt associated infections. Material and Methods: This cross-sectional study was conducted from April to September 2020 at the Neurosurgical department of Combined Military Hospital, Rawalpindi, and the Department of Microbiology, Armed Forces Institute of Pathology. 95 cerebrospinal fluid samples obtained through direct aspiration. The study employed standard microbiological techniques for pathogen isolation, identification, and antimicrobial susceptibility testing following CLSI guidelines 2019. Results: Pathogens isolated from central nervous system shunt associated infections included Staphylococcus spp. (29.47%), Escherichia coli (16.84%), Acinetobacter baumannii (13.68%), Klebsiella pneumoniae (10.53%), Pseudomonas spp. (8.42%), Enterococcus spp. (7.37%), Morganella morganii, Enterobacter cloacae, and Candida spp. (2.11% each), Stenotrophomonas maltophila (1.05%), and mixed infections. Among Gram-negative pathogens, 95% were susceptible to Polymixin B, 93% to Meropenem, and 55% to Cefepime. All Gram-positive organisms were sensitive to Vancomycin and Linezolid (100%). Conclusion: Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa were prevalent Gram-negative rods in infections related to CNS shunts, with Staphylococcus spp. following. Gram-negative bacteria exhibited sensitivity to Polymixin B, Meropenem, and Cefepime, while Gram-positive organisms were responsive to Vancomycin and Linezolid. The significant occurrence of Gram-negative rods emphasizes their consideration in empirical antimicrobial therapy recommendations for minimizing death and disability. Keywords: Shunt-associated infections of central nervous system, Antibiotic sensitivity, Gram Negative Rods, Meropenem

Infectious complications among CD19 CAR-T cell therapy recipients: A single-center experience.

CD19 chimeric antigen receptor (CAR)-T cell therapy has emerged as an effective treatment in those with refractory or relapsed lymphoma. CD19 CAR-T cell therapy can cause direct and indirect toxic adverse effects and increased risk for infection. Infectious complications and optimal antimicrobial prophylaxis strategies are an ongoing area of investigation. A single-center retrospective cohort study was conducted to review recipients of CD19 CAR-T cell therapy between April 2018 and December 2020. Patient characteristics and clinical outcomes were extracted from the electronic health records. Infectious complications were identified in 18/50 (36%) recipients with 31 episodes of infection. The median time to infection was 225 days (range 0-614). Bacterial infections were most common with bloodstream infection followed by sinusitis and skin and soft tissue infection. Eight viral infections were identified, most being respiratory viral illnesses. Two fungal infections were identified: Pneumocystis jirovecii pneumonia (PJP) and disseminated fusariosis. Seventeen infections (54.8%) were classified as severe: leading to death, requiring hospitalization, need for empiric intravenous antibiotics, or significant alteration in hospital course. No characteristics were found to be statistically significant risks for infection, although a trend toward significance was seen in prior autologous stem cell transplant recipients (p = .12) and those with recurrent neutropenia (p = .14). Three patients (6%) died from infection. Infections were common after CD19 CAR-T cell therapy and occurred beyond the first year. Further multicenter studies are needed to define infectious risks and optimize antimicrobial prophylaxis recommendations in recipients of CD19 CAR-T cell therapy.

Antimicrobial Prophylaxis in Lymphoma by Chemotherapy Regimen

Treatment of lymphomas involves a wide variety of chemotherapy, immunotherapy, and targeted-agents tailored to disease biology and patient characteristics. Each of these regimens carry their own risk of opportunistic infections in an immunocompromised population. In addition to the treatment associated immunosuppression, lymphoma itself is immunosuppressive. Lymphoma associated immunosuppression is secondary to increased production of abnormal lymphocytes resulting in decreased production of normally functioning lymphocytes. Additionally, lymphoma cells induce both humoral and cellular immunosuppression through effects on numerous cytokines, T-cells, myeloid-derived suppressor cells, and macrophages. Clinical trials, patient co-morbidities, and institutional preferences all play a role in determining the preferred antimicrobial prophylaxis. While there is a paucity of data on systematic reviews and guidelines for standardized chemotherapy regimens in lymphoma patients, the efficacy and recommendations for antimicrobial prophylaxis in specific chemotherapy regimens for lymphoma has not been fully reviewed. According to the National Comprehensive Cancer Network, lymphoma is generally regarded as an ‘intermediate risk’ cancer with regards to overall infection risk. This results in discordance between research data and clinical practice. This is reiterated in the SIGNIFICANT trial which reported that while guidelines previously advised against fluoroquinolone prophylaxis in lymphoma and solid cancers, a survey of 3,600 physicians revealed that 45% routinely used fluoroquinolone prophylaxis despite these recommendations. This review article analyzes numerous research studies with summarization of findings and antimicrobial prophylaxis recommendations based on specific lymphoma chemotherapy regimens. With regards to each specific chemotherapy regimen assessed, indications for antibacterial, anti-viral, anti-fungal, and Pneumocystis jiroveci pneumonia (PJP) prophylaxis were determined for each regimen. The degree of immunosuppression and the necessary prophylaxis varies across different regimens and lymphoma subgroups; and thus, an individualized approach is necessary to optimize the supportive care during lymphoma treatment.

Yoğun Bakım Hastalarında Antimikrobiyal İlaç Dozajlarının Uygunluğunun Değerlendirilmesi

The purpose of this study was to investigate the factors that required dose adjustments of antimicrobial drugs in intensive care unit (ICU) patients and to identify the drugs that required the most dose adjustments.&#x0D; The 26-bed reanimation ICU of a university-affiliated hospital hosted this study from September to December 2022. Two clinical pharmacists on duty examined patients' antimicrobial drug dosages daily. The acceptance status of the recommendations and the patients' demographic information were recorded.&#x0D; The study involved 133 ICU patients, and antimicrobial drug recommendations were made for 48 patients, 31 (64.6%) of whom were male. The median (IQR) age of the 48 patients was 67 (54–77). The number of recommendations was 94, and all of them were accepted by the physician. The recommendation rates according to the causes were: inappropriate dosages based on renal functions (71.3%), presence of continuous renal replacement therapy (11.7%), indication (10.6%), body weight (4.3%), and loading dose (2.1%).&#x0D; The top 3 drugs for which recommendations were made the most were colistin (21.3%), meropenem (18.1%), and piperacillin-tazobactam (12.8%). The most troublesome drug was colistin, which is frequently used to treat Acinetobacter pneumonia. Clinical pharmacist and physician collaboration may help rationalize ICU antimicrobial drug use.

Demonstrating the importance of local culture and susceptibility data: antibiograms from dogs at a veterinary tertiary care center.

To create antibiograms for commonly cultured organisms in a small animal tertiary care hospital following Clinical and Laboratory Standards Institute guidelines and to compare these local resistance patterns to published first-tier antimicrobial recommendations. Urine (n = 429), respiratory (41), and skin (75) isolates cultured from dogs between January 1, 2019, and December 31, 2020, at the Tufts University Foster Hospital for Small Animals. MIC and susceptibility interpretations were recorded for multiple sites for 2 years. Sites with greater than 30 isolates for at least 1 organism were included. Urinary, respiratory, and skin antibiograms were created using Clinical and Laboratory Standards Institute breakpoints and guidelines. Urinary Escherichia coli had a higher susceptibility percentage for amoxicillin-clavulanate (80% [221/275]) than amoxicillin alone (64% [175/275]). Respiratory E coli were greater than 80% susceptible to only 2 antimicrobials (imipenem, amikacin). Of skin Staphylococcus pseudintermedius isolates, 40% (30/75) were methicillin-resistant and frequently also displayed resistance to non-beta lactam antimicrobials. Susceptibility to recommended first-line antimicrobials varied and was greatest for gram-negative urinary isolates and lowest for methicillin-resistant S pseudintermedius skin isolates and respiratory E coli. Local antibiogram creation identified frequent resistance that may preclude the use of guideline-recommended first-line therapy. High levels of resistance identified in methicillin-resistant S pseudintermedius isolates supports growing concern for methicillin-resistant staphylococci in veterinary patients. This project highlights the need for population-specific resistance profiles to be used in conjunction with national guidelines.