Community-acquired Intra-abdominal Infections Research Articles

Comparative phenotypic and genotypic analysis of community-acquired and hospital-acquired intra-abdominal infections among liver transplanted patients.

During liver transplantation, both hospital-acquired (HA) and community-acquired (CA) intra-abdominal infections (IAIs) are involved causing life-threatening diseases. Therefore, comparative studies of aerobic and facultative anaerobic HA-IAIs and CA-IAIs after liver transplantation surgery are necessary. The species of detected isolates (310) from intra-abdominal fluid were identified and classified into hospital-acquired intra-abdominal infections (HA-IAIs) and community-acquired intra-abdominal infections (CA-IAIs). Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter baumannii were the most commonly detected species. The resistant phenotypes were commonly detected among the HA-IAIs; however, the virulent phenotypes were the predominant strains of CA-IAIs. Regrettably, the resistance profiles were shocking, indicating the inefficacy of monotherapy in treating these isolates. Therefore, we confirmed the use of empirical combination therapies of amikacin and meropenem for treating all IAIs (FICI≤0.5). Unfortunately, the high diversity and low clonality of all identified HA and CA-IAIs were announced with D-value in the range of 0.992-1. This diversity proves that there are infinite numbers of infection sources inside and outside healthcare centers.

Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study.

Optimal management of community-acquired intra-abdominal infections (IAI) requires timely surgical source control and adequate anti-infective treatment. To describe the initial management of community-acquired IAI admitted to the emergency department and assess the association between the length of time to either diagnosis or therapeutic procedures and patient outcomes. A prospective, multicentre, observational study. Thirteen teaching hospitals in France between April 2018 and February 2019. Two hundred and five patients aged at least 18 years diagnosed with community-acquired IAI. The primary outcome was hospital length of stay. The secondary outcome was hospital mortality. Patients had a mean age of 56 (± 21) years and a median [interquartile] SAPS II of 26 [17 to 34]. Among the study cohort, 18% were postoperatively transferred to intensive care unit and 7% had died by day 28. Median [IQR] time to imaging, antibiotic therapy and surgery were 4 [2 to 6], 7.5 [4 to 12.5] and 9 [5.5 to 17] hours, respectively. The length of time to surgical source control [0.99, 95% confidence interval (CI), 0.98 to 0.99], SOFA greater than 2 [0.36 (95% CI, 0.26 to 0.651)], age greater than 60 years [0.65 (95% CI, 0.45 to 0.94)], generalized peritonitis [0.7 (95% CI, 0.56 to 0.89)] and laparotomy surgery [0.657 (95% CI, 0.42 to 0.78)] were associated with longer hospital length of stay. The duration of time to surgical source control [1.02 (95% CI, 1.01 to 1.04)], generalized peritonitis [2.41 (95% CI, 1.27 to 4.61)], and SOFA score greater than 2 [6.14 (95% CI, 1.40 to 26.88)] were identified as independent risk factors for 28-day mortality. This multicentre observational study revealed that the time to surgical source control, patient severity and generalized peritonitis were identified as independent risk factors for increased hospital LOS and mortality in community-acquired IAI. Organisational strategies to reduce the time to surgical management of intra-abdominal infections should be further evaluated. ClinicalTrials.gov on 1 April 2018, NCT03544203.

Principles of Empirical and Therapeutic Antimicrobial Therapy

The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition, specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy, and recommended antibiotics for necrotizing soft tissue infections. This review contains 6 tables and 56 references

Principles of Empirical and Therapeutic Antimicrobial Therapy

The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition, specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy, and recommended antibiotics for necrotizing soft tissue infections. This review contains 6 tables and 56 references

Principles of Empirical and Therapeutic Antimicrobial Therapy

The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition, specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy, and recommended antibiotics for necrotizing soft tissue infections. This review contains 6 tables and 56 references

695. Antipseudomonal Versus Narrow-spectrum Agents for the Treatment of Community-onset Intra-abdominal Infections

BackgroundAntipseudomonal antibiotic regiments are often used to treat community-acquired intra-abdominal infections (CA-IAI) despite common causative pathogens being susceptible to more narrow-spectrum agents. The purpose of this study was to compare post-infection complications in adult patients treated for CA-IAI with antipseudomonal or narrow-spectrum regimensMethodsThis retrospective cohort study included patients ≥18 years admitted for CA-IAI treated with antibiotics between January 1, 2013, and December 31, 2019. Patients who had bacteremia or peritonitis were excluded. The primary objective of this study was to compare post-infection complications within 90 days between patients treated empirically with antipseudomonal versus narrow-spectrum regimens. Post-infection complication was defined as post-operative infection, recurrence of diverticulitis, or mortality. Secondary objectives were to compare infection and treatment characteristics along with patient outcomes. Sub-group analyses were planned to compare outcomes of patients with low-risk and high-risk CA-IAI and patients who required surgical intervention versus who were medically managedResultsA total of 350 patients were included: Antipseudomonal, n=204; Narrow-spectrum, n=146. There were no differences in 90-day post-infection complications between groups (Antipseudomonal 15.1% vs Narrow-spectrum 11.3%, p=0.296). Additionally, no differences were observed in hospital LOS, 90-day readmission, C. difficile, or mortality. Patients treated with Antipseudomonal regimens received longer durations of therapy (median 11 days [IQR 8-14] vs 9 days [IQR 5-12], p< 0.001). No differences were observed in 90-day post-infection complications for patient with low-risk (Antipseudomonal 15% vs Narrow-spectrum 9.6%, p=0.154) or high-risk CA-IAI (Antipseudomonal 15.8% vs Narrow-spectrum 22.2%, p=0.588), or those who were surgically (Antipseudomonal 8.5% vs Narrow-spectrum 9.2%, p=0.877) or medically managed (Antipseudomonal 17.5% vs Narrow-spectrum 13.1%, p=0.463). ConclusionPost-infection complication rates were similar among patients treated with antipseudomonal and narrow-spectrum antibiotics. Antipseudomonal therapy is likely unnecessary for most patients with CA-IAIDisclosures Lisa E. Dumkow, PharmD, BCIDP, Nothing to disclose

121. Evaluation of Multifaceted Antimicrobial Stewardship in Optimizing Antimicrobial Usage in Intraabdominal Infection at a Community Hospital

BackgroundTreatment of intraabdominal infections (IAI) commonly involves broad spectrum antimicrobials based on the severity and etiology of infections as well as the underlying medical conditions. However, the overuse of broad-spectrum agents has driven selection for Gram-negative and -positive resistance, as well as collateral consequences such as Clostridioides difficile colitis. We sought to evaluate the utilization of a pharmacy-driven multifaceted antimicrobial stewardship (AMS) intervention to optimize empiric antimicrobial therapy by risk stratification among IAI patients and reduce the number of antibiotic treatment days.MethodsThis is a single-center case observation study in hospitalized adult IAI patients on antimicrobial therapy from Dec 2019-Feb 2020 compared to patients from Dec 2020-Feb 2021 after initiation of AMS with daily prospective audit and feedback. The composite primary outcome is reduction of antibiotic treatment days and de-escalation from broad spectrum antibiotics (fluoroquinolones, piperacillin/tazobactam, and carbapenems) to cephalosporins. ResultsWe identified 40 patients each in the baseline (pre-AMS group) and post-AMS group via electronic medical record. Baseline characteristics were well-matched between groups. The majority of patients were diagnosed with community-acquired IAIs such as appendicitis, diverticulitis, and cholecystitis. Fluoroquinolone use as empiric therapy was significantly lower in the post-AMS group vs. pre-AMS group (2.5% vs. 25%, p< 0.001), while non-Pseudomonas cephalosporin use was increased (25% post-AMS vs. 0% pre-AMS, p< 0.001). Oral fluoroquinolone use at discharge was significantly decreased in the post-AMS group (p< 0.001). Antibiotic treatment days remained unchanged. There was no statistical difference between the two groups in 30-day mortality, 30-day readmission, relapse, and C. difficile colitis.ConclusionA multifaceted antimicrobial therapy intervention successfully reduced the use of fluoroquinolones in patients with community-acquired IAI during hospitalization and discharge. No differences in mortality, readmission, or relapse rates were observed.Disclosures All Authors: No reported disclosures

Antipseudomonal Versus Narrow-Spectrum Agents for the Treatment of Community-Onset Intra-abdominal Infections.

BackgroundAntipseudomonal antibiotics are often used to treat community-acquired intra-abdominal infections (CA-IAIs) despite common causative pathogens being susceptible to more narrow-spectrum agents. The purpose of this study was to compare treatment-associated complications in adult patients treated for CA-IAI with antipseudomonal versus narrow-spectrum regimens.MethodsThis retrospective cohort study included patients >18 years admitted for CA-IAI treated with antibiotics. The primary objective of this study was to compare 90-day treatment-associated complications between patients treated empirically with antipseudomonal versus narrow-spectrum regimens. Secondary objectives were to compare infection and treatment characteristics along with patient outcomes. Subgroup analyses were planned to compare outcomes of patients with low-risk and high-risk CA-IAIs and patients requiring surgical intervention versus medically managed.ResultsA total of 350 patients were included: antipseudomonal, n=204; narrow spectrum, n=146. There were no differences in 90-day treatment-associated complications between groups (antipseudomonal 15.1% vs narrow spectrum 11.3%, P=.296). In addition, no differences were observed in hospital length of stay, 90-day readmission, Clostridiodes difficile, or mortality. In multivariate logistic regression, treatment with a narrow-spectrum regimen (odds ratio [OR], 0.75; 95% confidence interval, 0.39–1.45) was not independently associated with the primary outcome. No differences were observed in 90-day treatment-associated complications for (1) patients with low-risk (antipseudomonal 15% vs narrow spectrum 9.6%, P=.154) or high-risk CA-IAI (antipseudomonal 15.8% vs narrow spectrum 22.2%, P=.588) or (2) those who were surgically (antipseudomonal 8.5% vs narrow spectrum 9.2%, P=.877) or medically managed (antipseudomonal 23.1 vs narrow spectrum 14.5, P=.178).ConclusionsTreatment-associated complications were similar among patients treated with antipseudomonal and narrow-spectrum antibiotics. Antipseudomonal therapy is likely unnecessary for most patients with CA-IAI.

Antimicrobial Resistance and Molecular Patterns in Community-acquired Complicated Intra-abdominal Infections: A Multicentric Study

Antimicrobial Resistance and Molecular Patterns in Community-acquired Complicated Intra-abdominal Infections: A Multicentric Study

An Evaluation of Treatment Patterns and Associated Outcomes Among Adult Hospitalized Patients With Lower-Risk Community-Acquired Complicated Intra-abdominal Infections: How Often Are Expert Guidelines Followed?

BackgroundExpert guidelines discourage use of antipseudomonal β-lactams and fluoroquinolones in lower-risk patients with community-acquired complicated intra-abdominal infection (CA cIAI). Compliance with these recommendations across US hospitals is unclear. This study sought to determine treatment patterns and associated outcomes among adult hospitalized lower-risk patients with CA cIAI.MethodsA study using data from the Premier Healthcare Database (10/2015–12/2017) was performed. Inclusion criteria: age ≥18 years; hospitalized; had a cIAI at admission; and received antibiotics within the first 4 hospital days. Patients were excluded if they were high risk, were transferred from another health care facility, had a recent hospital admission, or received dialysis within 30 days of admission. Empiric antibiotic treatment patterns and associated outcomes were quantified.ResultsOverall, 46 722 (66%) patients with cIAIs met the lower-risk CA IAI study criteria. Among lower-risk CA IAI patients, the mean (SD) age was 53.4 (18.2) years, and 71% had a Charlson Comorbidity Index score of 0. The most common diagnosis was acute appendicitis with peritonitis (59.7%). Among lower-risk CA IAI patients, 54% received piperacillin/tazobactam, 20% received a fluoroquinolone (FQ), 11% received ceftriaxone, and 7% received ampicillin/sulbactam. Overall, the median hospital length of stay was 4 days and median costs were $12 345 USD. Nearly 90% of patients were discharged home, and <1% died. Outcomes were similar across all empiric treatments received.ConclusionsOveruse of antipseudomonal β-lactams and fluoroquinolones was commonplace among lower-risk CA IAI patients. These findings can serve as the basis for an antimicrobial stewardship initiative in hospitals aspiring to reduce the use of broad-spectrum antibiotics.

Clinical and Microbiological Characteristics of Patients with Complicated Intra-abdominal Infections in Intensive Care Unit.

In order to investigate the clinical and microbiological characteristics of patients with complicated intra-abdominal infections (cIAIs) in intensive care unit (ICU), the clinical data of 612 cIAIs patients from January 2016 to December 2018 were retrospectively collected. Clinical characteristics, distribution of pathogens and drug resistance were statistically analyzed. It was found that patients with community-acquired intra-abdominal infections (CA-IAIs) made up a majority of cIAIs patients. The positive rate of abdominal drainage fluid culture was 55.56%. Gramnegative bacteria accounted for the majority, the most commonly isolated bacteria of which were Escherichia coli (20.96%), Klebsiella pneumoniae (10.20%) and Pseudomonas aeruginosa (5.57%). The most commonly isolated gram-positive bacteria were Enterococcus (16.88%) and Methicillin-resistant staphylococcus aureus (MRSA, 3.90%). Enterobacter isolates showed high resistance rate to most cephalosporins and low resistance rate to piperacillin/tazobactam and carbapenems. Extended spectrum beta-lactamase (ESBL) screen positive isolates from CA-IAIs patients showed an increasing trend in past three years. Enterococcus and MRSA showed high resistance rate to clindamycin, quinolone, erythromycin and tetracycline, while they showed high sensitivity rate to linezolid, tegacycline, teicoplanin and vancomycin. Our results indicate that isolated bacteria from abdominal drainage fluid show high resistance rates to commonly used antibiotics in ICU patients with cIAIs. The curative effects on diseases should be monitored continuously when antibiotics are used. Meanwhile, we should always keep eyes on drug-resistant bacteria, especially when the treatment efficacy is not good.

Antibiotic Resistance in Community-Acquired Intra-Abdominal Infections: Diabetes Mellitus as a Risk Factor.

Background: Antimicrobial drug resistance in community-acquired (CA) infections is a growing problem. Knowing the local epidemiology is essential to design empirical antibiotic therapy. Therefore, we conducted this study to evaluate the resistance patterns of microorganisms isolated from surgical samples of community-acquired intra-abdominal infections (IAIs) and to determine the factors associated with resistance. Methods: We analyzed retrospectively the records of patients treated from January 2015 to June 2017 who had IAIs with positives aerobic cultures performed in the first 72 hours after admission. Surgical site infections, abdominal wall procedures, peritoneal dialysis catheters, and patients with admissions in the prior month were excluded. To identify the factors associated with resistance, we considered the resistance to the regimen recommended at our institution, ampicillin/sulbactam (AMS) plus ciprofloxacin (CIP). Results: There were 119 patients with 133 isolates, 59% women, and mean age 54 years. The main sources of infection were appendicitis (38%) and cholecystitis (20%), with 64 patients presenting a complicated IAI (cIAI), defined by the presence of peritonitis (55%). Resistance in Enterobacteriaceae was AMS 32% (6.4% intermediate resistance), CIP 31%, cefotaxime 9%, piperacillin/tazobactam (PTZ) 3%, trimethoprim/sulfamethoxazole 32%, gentamicin 9.5%, and amikacin 2%. Considering all patients, resistance to AMS + CIP was 16.8%. Factors associated with resistant to this regimen was, by univariable and multivariable analysis, the presence of diabetes mellitus (odds ratio [OR] 3.6; 95% confidence interval [CI] 1.1-11.6; p = 0.03). Female gender (OR 2.7; CI 0.9-8.4; p = 0.08) and complicated IAI (OR 2.0; CI 0.7-5.4; p = 0.17) were associated with resistance but did not reach statistical significance. Conclusion: High resistance to CIP and AMS was observed. Although the combination of AMS + CIP offers coverage for 84% of patients, PTZ should be considered as an option for patients with severe infections or diabetes mellitus. Finding factors associated with antibiotic resistance could help to select empirical therapy for CA IAIs better.

Susceptibilities of Gram-negative bacilli from hospital- and community-acquired intra-abdominal and urinary tract infections: a 2016-2017 update of the Chinese SMART study.

Objectives: To update the epidemiology and susceptibility of hospital-acquired (HA) and community-acquired (CA), as well as intensive care unit (ICU) vs non-ICU-derived intra-abdominal infection (IAI) and urinary tract infection (UTI) pathogens in Chinese hospitals.Methods: A total of 2,546 Gram-negative isolates from IAIs and 1,947 isolates from UTIs collected in 16 hospitals and 7 regions of China from 2016 to 2017 were analyzed.Results: E. coli and K. pneumoniae were the most common pathogens identified in HA (40.7%, 21.9%) and CA (49.2%, 21.3%) IAIs and in HA (59.0%, 17.3%) and CA (64.3%, 12.7%) UTIs, respectively. The overall rates of extended-spectrum β-lactamase (ESBL)-positive strains were 48.2% for E. coli and 26.4% for K. pneumoniae. The rates of ESBL-positive E. coli and K. pneumoniae strains were significantly higher in HA than in CA IAIs (51.7% vs 42.4%, P=0.016 and 22.0% vs 20.6%, P<0.001). IAI E. coli ESBL-producing isolates were most susceptible to IPM (97.2%) and AMK (93.9%), and UTI-associated E. coli ESBL-producers were 94.74% susceptible to amikacin (AMK), 97.02% to imipenem (IPM), and 91.4% to ertapenem (ETP). IAI K. pneumoniae ESBL-producing isolates were most susceptible to AMK (84.43%) and IPM (82.79%), and UTI-associated K. pneumoniae ESBL-producers were 88.39% susceptible to AMK, 87.5% to IPM, and 82.14% to ETP. Overall, percentages of susceptible strains to ETP, IPM, AMK, and Piperacillin-Tazobactam (TZP) were in the range of 82.0% to 96.4%, to 5 cephalosporins in the range of 31.4%-69.6% and to 2 fluoroquinolones in the range of 37.8%-45.5% for E. coli and 65.5%-90.7%, 37.7%-75.3%, and 43.9%-73.2% for K. pneumoniae, respectively.Conclusion: E. coli and K. pneumoniae continued to be the main pathogens in Chinese UTIs and IAIs with high ESBL-positive rates between 2016 and 2017. Carbapenem- or amikacin-based therapies were the most effective to combat IAI and UTI pathogens.

Antimicrobial susceptibilities of specific syndromes created with organ-specific weighted incidence antibiograms (OSWIA) in patients with intra-abdominal infections

BackgroundThe aim was to evaluate the value of organ-specific weighted incidence antibiogram (OSWIA) percentages for bacterial susceptibilities of Gram-negative bacteria (GNB) collected from intra-abdominal infections (IAIs) during SMART 2010–2014.MethodsWe retrospectively calculated the OSWIA percentages that would have been adequately covered by 12 common antimicrobials based on the bacterial compositions found in the appendix, peritoneum, colon, liver, gall bladder and pancreas.ResultsThe ESBL positive rates were 65.7% for Escherichia coli, 36.2% for Klebsiella pneumoniae, 42.9% for Proteus mirabilis and 33.1% for Klebsiella oxytoca. Escherichia coli were mainly found in the appendix (76.8%), but less so in the liver (32.4%). Klebsiella pneumoniae constituted 45.2% of the total liver pathogenic bacteria and 15.2–20.8% were found in 4 other organs, except the colon and appendix (< 10%). The percentages of Pseudomonas aeruginosa infections were higher in the gall bladder, intra-abdominal abscesses, pancreas and colon (10.2–13.2%) and least (5.4%) in the appendix. The susceptibilities of hospital acquired (HA) and community acquired (CA) IAI isolates from appendix, gall bladder and liver showed ≥80% susceptibilities to amikacin (AMK), imipenem (IPM), piperacillin-tazobactam (TZP) and ertapenem (ETP), while the susceptibility of isolates in abscesses and peritoneal fluid showed ≥80% susceptibility only to amikacin (AMK) and imipenem (IPM). In colon CA IAI isolates susceptibilities did not reach 80% for AMK and ETP, and in pancreatic IAIs susceptibilities of HA GNBs did not reach 80% to AMK, TZP and ETP, and CA GNBs to IMP and ETP. In addition, besides circa 80% susceptibility of HA and CA IAI isolates from appendix to cefoxitin (FOX), IAI isolates from all other organs had susceptibilities between 7.6 and 67.9% to all cephalosporins tested, 28.3–75.2% to fluoroquinolones and 7.6–51.0% to ampicillin-sulbactam (SAM), whether they were obtained from CA or HA infections.ConclusionThe calculated OSWIA susceptibilities were specific for different organs in abdominal infections.

Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections

PurposeIt is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI). MethodsA retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP. Results320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). ConclusionThe presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.

Shortened Courses of Antibiotics for Bacterial Infections: A Systematic Review of Randomized Controlled Trials

Commonly prescribed durations of therapy for many, if not most, bacterial infections are not evidence-based. Misunderstandings by clinicians and patients alike influence perspectives on antibiotic use, including duration of therapy and its role in antibiotic resistance. To demonstrate that shorter durations of antibiotic therapy are as efficacious as longer durations for many infections, a systematic review was undertaken of English-language articles by using PubMed to identify articles for inclusion. Additionally, infection-specific guidelines were identified for review of recommendations. Search terms included specific infection types, randomized controlled trial (RCT), duration of therapy, treatment duration, short course, and long course. Only RCTs of single-agent antibiotic therapy for the treatment of bacterial infections in adults were included. Independent data extraction of articles was conducted by two authors by using predefined guidance for article inclusion. In total, 23 RCTs met our criteria for inclusion. All trials compared single-agent antibiotics for a short and long antibiotic course in six common infections: community-acquired pneumonia, ventilator-associated pneumonia, intraabdominal infections, skin and soft tissue infections, uncomplicated cystitis, and complicated cystitis or pyelonephritis. Clinicians can decrease net antibiotic use by recommending shorter courses where evidence supports them. Antimicrobial stewardship programs that systematically address treatment duration may significantly affect institutional antibiotic use without negatively affecting patient care.

PIN41 - Cost-Effectiveness Evaluation of Ertapenem in the Treatment of Adult Patients with Community-Acquired Complicated Intraabdominal Infection

To evaluate the cost-effectiveness of ertapenem versus piperaciliin/tazobactam and ceftriaxone/metronidazole in the treatment of patients with community-acquired complicated intraabdominal infections (IAI) in Colombia. For the cost-effectiveness analysis a previous published model that simulates the natural history of the disease, was adapted to Colombia setting. A systematic review of literature was done to extract the clinical data of safety and effectiveness for ertapenem in the prevention of complications and other health outcomes associated with IAI. The susceptibility profile of the different pathogens was described from Colombia SMART data, and clinical efficacy was adjusted by the distribution of pathogens in Colombia. Cost data were obtained from a database of a Colombian insurer and official lists for drugs prices. The economic evaluation was performed under the third payer perspective. A probabilistic sensitivity analysis was done using a Montecarlo simulation with 1,000 iterations, furthermore, an univariate sensitivity analysis was estimated by a tornado diagram. The effectiveness obtained after the adjustment (proportion of IAI cases successfully treated) was 89% for ertapenem, 73.6% for piperacilin/tazobactam, and 86% for ceftriaxone/metronidazole. In the cost-effectiveness evaluation, the cost generated to treat of a patient with IAI with ertapenem was COP $9,310,566 while with piperacilin/tazobactam was of COP $10,085,603 and with ceftriaxone/metronidazol COP$ $9,444,063. It is estimated that gaining 15.7% and 3.4% additional effectiveness units (clinical success case) costs COP$775,037 and COP$133,497 less with ertapenem, compared to piperacilin/tazobactam y ceftriaxone/metronidazole, repectively. In Colombia, IAI treatment with ertapenem is cost saving when compared with piperaciclin/tazobactam and ceftriaxone/metronidazole.

Impact of an Emergency Medicine Pharmacist on Appropriate Empiric Antibiotic Prescribing for Community-Acquired Pneumonia and Intra-Abdominal Infections

BackgroundAntibiotics are the second most common drug class prescribed in the Emergency Department (ED); therefore, it is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMP) play an important role in ASP by working with providers to choose the most appropriate antimicrobial agent, dose, and duration. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and community-acquired intra-abdominal infections (CA-IAI).MethodsA retrospective cohort study was conducted evaluating adult patients admitted with a diagnosis of CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in a new ASP (2014) vs. established ASP (2016). Secondary outcomes included in-hospital mortality and hospital-acquired Clostridium difficileinfection (CDI).Results320 patients were included in the study (EMP n = 185; no-EMP n = 135). Empiric antibiotic selection was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, P = 0.001). Guideline-concordant empiric prescribing occurred more often when an EMP was present in the subgroup of CAP patients (95% vs. 79% P = 0.005) as well as in the subgroup of CA-IAI patients (62% vs. 44% P = 0.025). Overall guideline-concordant prescribing significantly increased between the new ASP and established ASP (60% vs. 82.5%, P < 0.001) and was more likely when an EMP was present (new ASP: 68.3% vs. 45.8%, P = 0.005; established ASP: 90.5% vs. 73.7%, P = 0.005). Patients receiving guideline-concordant antibiotics in the ED were continued on appropriate therapy on admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (P < 0.001). The presence of an EMP did not impact hospital-acquired CDI (1.1% vs. 1.5%, P = 1.0) or in-hospital mortality (4.3% vs. 1.5%, P = 0.2).ConclusionThe presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI. This impact was demonstrated in both a new and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.Disclosures All authors: No reported disclosures.

Metabolite Profiles in Sepsis: Developing Prognostic Tools Based on the Type of Infection.

Currently used biomarkers insufficiently discriminate between patients with systemic inflammatory response syndrome of non-infectious origin and sepsis. The aim of this study was to identify surrogate markers that distinguish between systemic inflammatory response syndrome and sepsis as well as the underlying type of infection by targeted metabolomics. Retrospective analysis. Six sites of the Hellenic Sepsis Study Group and at Jena University Hospital. A total of 406 patients were analyzed: 66 fulfilling criteria for diagnosis of systemic inflammatory response syndrome, 100 for community-acquired pneumonia, 112 for urinary tract infection, 83 for intra-abdominal infection and 45 for bloodstream infection. Patients were divided into test cohort (n = 268) and confirmation cohort (n = 138). A total of 186 metabolites were determined by liquid chromatography tandem mass spectrometry. Serum concentrations of most acylcarnitines, glycerophospholipids and sphingolipids were altered in sepsis compared to systemic inflammatory response syndrome. A regression model combining the sphingolipid SM C22:3 and the glycerophospholipid lysoPCaC24:0 was discovered for sepsis diagnosis with a sensitivity of 84.1% and specificity of 85.7%. Furthermore, specific metabolites could be used for the discrimination of different types of infection. The glycerophospholipid lysoPCaC26:1 identified patients with community-acquired pneumonia in sepsis or severe sepsis/septic shock. Within severe sepsis/septic shock, patients with bloodstream infection could be discriminated by a decrease of acetylornithine. Changes of metabolites between sepsis and severe sepsis/septic shock also varied according to the underlying type of infection, showing that putrescine, lysoPCaC18:0 and SM C16:1 are associated with unfavorable outcome in community-acquired pneumonia, intra-abdominal infections and bloodstream infections, respectively. Using a metabolomics approach, single metabolites are identified that allow a good, albeit at about 14% false positive rate of sepsis diagnosis. Additionally, metabolites might be also useful for differentiation and prognosis according to the type of underlying infection. However, confirmation of the findings in ongoing studies is mandatory before they can be applied in the development of novel diagnostic tools for the management of sepsis.

Clinical and microbiological characteristics of complicated intra-abdominal infection in Colombia: a multicenter study

Complicated community-acquired intra-abdominal infections (CA-cIAI) are a common cause of acute abdomen. To identify the clinical and microbiology profile of CA-cIAI in four Colombian hospitals. This is a prospective, descriptive study, between 08-2012 and 09-2014, including patients with CA-cIAI > 15 years. Data collected included: socio-demographic, clinical, diagnosis, and isolates of the first culture obtained aseptically during surgery with antimicrobial susceptibility. 192 patients were included, 62% men, median age 47.3 years. Co-morbidities were present in 38.4%, 13% had been hospitalized in the previous year 13%, and 9.4% had received antibiotics in the last 6 months; 44.3% were admitted for appendicitis, 17.7% for peritonitis and 16.7% for bowel perforation. CA-cIAI were assessed as moderate in 64.1% of the cases and were treated with ampicillin/sulbactam (SAM) and ertapenem. In 70.8% of cases a bacteria was isolated: 65.1% were gramnegative rods (80.0% Escherichia coli, 44.8% of them susceptible to pipercillin/tazobactam, 65.7% to SAM; 11.2 % were K.pneumoniae, 85% was susceptible for SAM; 16.7% were grampositive cocci (28.1% Streptococci viridans group). The median hospital stay was 7 days and 15.1% died. E. coli, K. pneumoniae and S. viridans were the main organisms to consider in an empiric therapy for CA-cIAI and it is important to know the local epidemiology in order to choose the right antibiotic.