Infectious Diseases Consultation Research Articles

Optimizing Patient Care through Analysis of HIV-1 Genotyping: Insights into Test Ordering Strategies, Clinical Relevance, and Implications for Managing Drug Resistance

Abstract Background Antiretroviral resistance can lead to treatment failure and disease progression, especially in HIV patients. HIV-1 sequencing/genotyping tests (e.g., GenoSure) can be ordered by clinicians to detect HIV drug resistance (HIVDR). Here, we investigated our institution’s ordering practices, clinical relevance, and rates of HIVDR. Methods A total of 94 patients positive for HIV-1 between 01/2019-08/2021 were included (n=46 pre-COVID-19 prior to 03/11/2020; n=48 post-COVID-19). Patients’ charts were reviewed for demographics, laboratory results, clinical presentation, and antiviral management. Student t-test and Fisher exact test were used for statistical analyses. Results HIV-1 genotyping was ordered most by Medicine (67%), Surgery, (7%), Emergency medicine (6%), Neurology and Obstetrics & Gynecology (5% each). Only 70% of patients with GenoSure ordered and sent out had sufficient viral loads for genotyping. Among the patients with insufficient viral loads, the GenoSure test was most ordered by Medicine (68%), Surgery (9%) and Ob/Gyn (9%) departments. Our HIV patient population was predominantly male (70%) and had a mean age of 49 years (range: 25 to 90 years). Lower viral loads (1.8x105 vs. 3.4x105 copies/mL, p=0.05), CD4 counts (174 vs. 196 cells/mcL, p=0.7), CD8 counts (555 vs. 800 cells/mcL, p=0.04), and higher CD4/CD8 ratio (0.312 vs. 0.266, p=0.57) were seen in our post-COVID-19 patients. The overall prevalence of HIVDR was 20%. There was a 9% increase in HIVDR, predominantly in non-nucleotide reverse transcriptase inhibitors (NNRTI), after the COVID-19 pandemic. For example, higher resistance was documented for antiviral drugs Efavirenz (16%), Nevirapine (16%), and Rilpivirine (13%). Increased prevalence of mutations in G190A, K101, K103, and E138 positions which confer resistance to NNRTIs was seen. The GenoSure test results helped optimize antiviral therapy in 47.8% (42/88) of total cases, with an increase of 12.5% in patients from post-COVID-19 era. Infectious disease consultations led to more actionable changes (16% increase) and ordering of the updated version of the GenoSure test that includes integrase inhibitors (20% increase, p=0.005). Conclusion We have implemented stringent clinical criteria including pathologist approval and changed our electronic health record ordering system to ensure GenoSure is appropriately ordered. Diagnostic stewardship of sequencing tests needs to be implemented to ensure actionable clinical changes in the right patient population and to control testing costs. Additionally, our findings revealed increased HIVDR in our patient population post-COVID-19. Continued surveillance and collaboration with antimicrobial stewardship are critical to managing HIVDR and improving patient outcomes, particularly given the significant strain that the COVID-19 pandemic has placed on our healthcare system.

Determining the Prognostic Value of Complete Blood Count Subgroup Parameters in Staphylococcus aureus Bacteremia.

Serum cytokine alterations are associated with increased Staphylococcus aureus bacteremia (SAB) mortality. Unfortunately, clinical use of these cytokines is uncommon due to limited availability and high cost. Complete blood count (CBC) with differential reflects the host immune response, and CBC subgroup parameters may have prognostic value in SAB. We sought to determine the association between CBC subgroup parameters on the day of index blood culture and 30-day all-cause mortality in SAB patients. We conducted a retrospective study of adult SAB patients with infectious diseases consultation to evaluate the discriminatory capacity of CBC subgroup parameters in predicting SAB mortality. Clinical and microbiological data were collected, including severity of illness and CBC subgroup parameters, on the day of index blood culture. The primary outcome was 30-day all-cause mortality. A multivariable logistic regression model was used to determine the association between patient-level variables and mortality. A total of 119 patients were included. The overall 30-day all-cause mortality rate was 10.1%. The median neutrophil-to-lymphocyte count ratio (NLCR) among survivors was 13.6 vs 23.2 among non-survivors (p = .007). Median lymphocyte count among survivors was 0.9 x 103 cells/μL vs 0.6 x 103 cells/μL among non-survivors (p = .031). Median platelet count was higher among survivors than non-survivors (239 x 103 cells/μL vs 171 x 103 cells/μL, respectively; p = .018). All other CBC subgroup parameters were similar between the two groups. Known SAB mortality predictors, including age, were also associated with increased mortality. Lower lymphocyte count was independently associated with increased mortality (adjusted odds ratio [aOR] 0.236, 95% confidence interval [CI] 0.064-0.872), as was higher PITT bacteremia score (aOR 2.439, 95% CI 1.565-3.803). CBC subgroup parameters may have prognostic value in SAB. Additional study is warranted to further ascertain the prognostic value of these readily available laboratory values.

Infectious Diseases Fellowship Training in Caring for People Who Use Drugs: A National Assessment of an Emerging Training Need.

Infectious complications of substance use are increasingly encountered in infectious diseases (ID) clinical care. In this study, we surveyed ID fellows in the United States to assess training experiences, clinical practices, and perspectives in caring for people who use drugs (PWUD). An 18-item survey was distributed to ID fellows via email and social media platforms. Four focus groups were conducted with a subset of participants to elucidate themes in fellowship experiences and training needs. Among 196 survey respondents (estimated 24% response rate), all reported caring for PWUD in ID fellowship. Forty-nine percent received some formal fellowship-based didactics around care of PWUD, and 64% worked with faculty seen as advocates for PWUD. Integrated care practices for PWUD were infrequently employed: 50% offered risk reduction counseling, and 33% discussed medications for opioid use disorders, naloxone, or HIV preexposure prophylaxis. Risk reduction counseling was felt to be "extremely" within scope of ID practice (69%), although comfort level with this skill was low; fellows' likelihood of offering counseling was significantly associated with their comfort (P ≤ .0001). Common themes in caring for PWUD included an expanded role for ID consultants, a lack of formalized training, and benefits of developing dedicated opportunities in this field. ID fellows frequently care for PWUD but may have gaps in knowledge or comfort that affect care practices. Increased fellowship training in the care of PWUD has potential to improve clinical practices and support growing interest in this field among current and prospective ID fellows.

Screening Potential Cornea Donors for Signs of Sepsis

Purpose: This study sought to expand upon previous works to explore correlations between cornea donor characteristics and incidence of sepsis/donor ineligibility. Methods: The medical records of 837 potential cornea donors with signs of possible sepsis from 2 Eye Bank Association of America–accredited eye banks between 2009 and 2022 were reviewed by an infectious disease clinician consultant for US Food and Drug Administration-designated signs of sepsis. Data and machine learning analysis were performed to explore relationships between different donor features and donor eligibility. Results: A review of the potential cornea donor records revealed that the presence of a greater number of signs of sepsis was not associated with a higher probability of donor ineligibility (P = 0.45). The only single sign of sepsis that was associated with a higher likelihood of donor ineligibility determination was positive blood cultures (P < 0.001). Finally, if the patient's length of hospitalization was less than 24 hours, these potential donors were more likely to be deemed ineligible for cornea donation (P < 0.001). Machine learning analysis revealed length of hospitalization to be the most importantly weighted factor in determining donor eligibility. Conclusions: Based on our analysis of hundreds of medical records over more than a decade, the data suggest that potential cornea donors who 1) have a positive blood culture or 2) have a length of stay of less than 24 hours may be reasonably deemed likely not eligible for donation and not all forwarded to infectious disease consultants or their respective medical director. The results of this study call for further exploration with the collection of larger sample sizes and more representative populations of cornea donors to pursue potential protocols with respect to determining cornea donor eligibility.

Routine Infectious Diseases Consultations on a Pediatric Cardiac Unit to Improve Positive Blood Culture Management.

Bacteremia can be life-threatening, and highly medicalized patients, such as those with complex congenital heart disease, are at high risk. Infectious diseases (ID) consultation is associated with improved outcomes in bacteremia. We noted an opportunity for improvement in management of positive blood cultures in our cardiac care unit (CCU). We completed a quality improvement project that included a single plan-do-study-act cycle consisting of a policy of routine ID consultation for all positive blood cultures events in the CCU. Our outcome measure of interest was percentage of appropriately managed blood culture events, the process measure was percentage of blood culture events for which the ID service was formally consulted, and the balancing measure was number of individual patients for whom the ID service was formally consulted. Appropriate antimicrobial management was determined via chart review by an ID physician. Data were analyzed via run chart and simple statistics. Following the intervention, the rate of appropriately managed positive blood culture events increased from a baseline of 86% to 98%, and the rate of ID consultation for these events increased from 75% to 98%. A shift was noted in run charts for both the outcome and process measures. There was an increase in patients for whom the ID service was consulted throughout the entire study period. We successfully implemented mandatory ID consultations in a CCU to increase proportion of appropriately managed blood cultures. While this intervention cannot be universally applied, others may find it useful in selected scenarios.

Multimorbidity in people living with HIV and cancer in Mexico.

The proportion of older people living with HIV (PLWH) has increased. Non-communicable diseases occur earlier in PLWH than in the general population. The goal of this study was to estimate the prevalence of comorbidities in PLWH and cancer in a tertiary referral center in Mexico City. In this retrospective study, we included PLWH > 40 years with a history of cancer, coming to Instituto Nacional de Cancerologia from 2010 through 2019. All patients needed to be on antiretrovirals for at least six months. Data collected included cancer type, comorbidities, frequency of polypharmacy, FRAX score and 10-year cardiovascular risk. Patients were evaluated for depression with the Beck Inventory Depression-II Scale. Variables associated to multimorbidity (2 or more comorbidities) were evaluated. Of 125 patients, 69% had at least one comorbidity; 32% had ≥ 2. Common comorbidities were dyslipidemia (54%), hypertension (19%), obesity (14%) and Diabetes (12%). In patients ≥ 50 years, 29 (62%) already undergone a densitometry and 9 (31%) had osteoporosis; 56 depression questionnaires were used: 30% had mild-to-severe depression. Being ≥ 50 years was associated with multimorbidity (aOR 2.57 (1.18-5.58), p = 0.017). A high prevalence of multimorbidity and poor screening of bone disease and mental health is reported in patients with PLWH and cancer. A holistic approach to the PLWH in the Infectious Diseases consultation is needed to improve the detection and management of non-communicable diseases, to go beyond viral suppression and towards an improved quality of life.

Multimorbidity in people living with HIV and cancer in Mexico.

The proportion of older people living with HIV (PLWH) has increased. Non-communicable diseases occur earlier in PLWH than in the general population. The goal of this study was to estimate the prevalence of comorbidities in PLWH and cancer in a tertiary referral center in Mexico City. In this retrospective study, we included PLWH > 40 years with a history of cancer, coming to Instituto Nacional de Cancerologia from 2010 through 2019. All patients needed to be on antiretrovirals for at least six months. Data collected included cancer type, comorbidities, frequency of polypharmacy, FRAX score and 10-year cardiovascular risk. Patients were evaluated for depression with the Beck Inventory Depression-II Scale. Variables associated to multimorbidity (2 or more comorbidities) were evaluated. Of 125 patients, 69% had at least one comorbidity; 32% had ≥ 2. Common comorbidities were dyslipidemia (54%), hypertension (19%), obesity (14%) and Diabetes (12%). In patients ≥ 50 years, 29 (62%) already undergone a densitometry and 9 (31%) had osteoporosis; 56 depression questionnaires were used: 30% had mild-to-severe depression. Being ≥ 50 years was associated with multimorbidity (aOR 2.57 (1.18-5.58), p = 0.017). A high prevalence of multimorbidity and poor screening of bone disease and mental health is reported in patients with PLWH and cancer. A holistic approach to the PLWH in the Infectious Diseases consultation is needed to improve the detection and management of non-communicable diseases, to go beyond viral suppression and towards an improved quality of life.

A Digital Approach to Improve Infection Screening Among Solid Organ Transplant Candidates.

Pretransplantinfection screening (IS) of potential organ recipientsis essential to optimal outcome of solid organ transplantation (SOT). A pre-post study was performed during 2020-2023 to investigate the impact of the STREAM (Solid organ TRansplant stEwArdship and Multidisciplinary approach) intervention to improve IS in SOT. The intervention, performed in 2022, included the implementation of IS through educational meetings, local guidelines, and the availability of a digital screening tool. The objective of the study was the assessment of IS completion, including a list of 17 laboratory tests and the investigation of vaccination status. The reduction of unnecessary tests was also analyzed. The test of proportions and a multilevel multivariate Poisson regression model were used to compare IS completion before and after STREAM. infectious diseases (ID) consultation and urgent evaluation were investigated as predictors of IS completion. A total of 171 patients were enrolled, including liver (44%), heart (32%), and kidney (24%) transplant candidates. Mean age was 56 ± 11 years, and most patients (77%) were males. Ninety-five (56%) patients were included before the intervention and 76 (44%) after STREAM. IS completion increased after STREAM (IRR 1.41, p < 0.001) with significant improvement recorded for seven (39%) IS items. Unnecessary tests decreased by 43% after the intervention. ID consultation (IRR 1.13, p = 0.02) and urgent evaluation (p = 0.68, p < 0.001) were predictors of IS improvement. STREAM was successful in improving IS completion. Further research is needed to investigate the impact of this intervention on posttransplant infections.

Impact and Safety of Diagnostic Stewardship to Improve Urine Culture Testing Among Patients with Indwelling Urinary Catheters

Background: Indiscriminate urine culturing of patients with indwelling urinary catheters may lead to overdiagnosis of urinary tract infections, resulting in unnecessary antibiotic treatment and inaccurate reporting of catheter-associated urinary tract infections (CAUTIs) as a hospital quality metric. We evaluated the impact of a computerized diagnostic stewardship intervention to improve urine culture testing among patients with indwelling urinary catheters. Methods: We performed a single-center retrospective observational study at Rush University Medical Center from April 2018 – July 2023. In February 2021, we implemented a computerized clinical decision support tool to promote adherence to our internal urine culture guidelines for patients with indwelling urinary catheters. Providers were required to select one guideline criteria: 1) neutropenia, 2) kidney transplant, 3) recent urologic procedure, 4) urinary tract obstruction; or if none of the criteria were met, then an infectious diseases consultation was required for approval. We compared facility-wide CAUTI rate per 10,000 catheter days and standardized infection ratio (SIR) during baseline and intervention periods using ecologic models, controlling for time and for monthly Covid-19 hospitalizations. In the intervention period, we evaluated how providers responded to the intervention. Potential harm was defined as collection of a urine culture within 7 days of the intervention that resulted in a change in clinical management. Results: In unadjusted models, CAUTI rate decreased from 12.5 to 7.6 per 10,000 catheter days (p=0.04) and SIR decreased from 0.77 to 0.49 (p=0.09) during baseline vs intervention periods. In adjusted models, the CAUTI rate decreased from 6.9 to 5.5 per 10,000 catheter days (p=0.60) (Figure 1) and SIR decreased from 0.41 to 0.35 (p=0.65) during baseline vs intervention periods. Urine catheter standard utilization ratio (SUR) did not change (p=0.36). There were 598 patient encounters with ≥1 intervention. Selecting the first intervention for each encounter, 284 (47.5%) urine cultures met our guidelines for testing and 314 (52.5%) were averted (Figure 2). Of these, only 3 ( &lt; 1 %) had a urine culture collected in the subsequent 7 days that resulted in change in clinical management. Conclusion: We observed a trend of decreased CAUTIs over time, but effect of our diagnostic stewardship intervention was difficult to assess due to healthcare disruption caused by Covid-19. Adverse outcomes were rare among patients who had a urine culture averted. A computerized clinical decision support tool may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures in patients with indwelling urinary catheters.

Infectious Diseases Consultation Reduces Antibiotic Duration for Uncomplicated Gram-Negative Bacteremia

Background: Unlike Staphylococcus aureus bacteremia, the impact of ID consultation for gram negative bacteremia (GNB) has not been well studied. Recent literature has supported shorter courses of antibiotics in adults with uncomplicated GNB. We examined duration of therapy for adult patients with uncomplicated GNB over a period of time during which ID consultation for GNB was made mandatory. Method: NorthShore University HealthSystem is a 4 hospital, 828 bed hospital system located in the northern suburbs of Chicago. Data were collected retrospectively from 1/1/2018 through 12/31/2021 for patients 18 years or older hospitalized with an uncomplicated bloodstream infection due to Escherichia coli, Klebsiella species or Proteus species. This study was approved by the Institutional Review Board. All sources of infection were included. Days of effective antibiotic therapy were extracted manually by two pharmacists and an infectious diseases physician. During the study period, two major changes occurred: 1) the Physician Practice Council of NorthShore University Healthsystem voted in favor of a mandatory ID consultation for GNB and 2) the ID division developed a treatment algorithm for GNB management with an emphasis on shorter antibiotic duration in uncomplicated cases. This study was divided into three time periods: Pre-ID consultation – 1/1/2018 – 8/31/2019; Transition – 9/1/2019 – 5/31/2020 (after mandatory ID consultation, before ID division consensus achieved); Post-ID Consensus – 6/1/2020 – 12/31/21. Primary outcome was duration of antibiotic therapy. Secondary outcomes included in-hospital all-cause mortality and 30 day readmission. Continuous variables were described using median and interquartile range, and categorical data using frequency and prevalence. Kruskal-Wallis rank sum test for continuous and χ2 for categorical variables was used to verify similarity among the pre-ID consultation, transition and post-ID consensus periods. The analysis was performed using Python. Result: 1026 patients were included in the study. Pathogens included 773 E. coli (75.4%), 193 Klebsiella species (18.8%) and 60 Proteus species (5.9%). Length of stay, 30 day readmission and in-hospital mortality were not statistically significantly different when comparing pre-ID consultation and post-ID consensus time periods. Total duration of therapy was statistically significantly shorter in the post-ID consensus period (p &lt; 0.001). Conclusion: Mandatory ID consultation and development of an ID consensus approach can shorten antibiotic duration in uncomplicated GNB. Further analysis will explore timing of transition to oral therapy and syndromic differences.

Evaluating the Clinical Impact of Species-Level Identification in Coagulase-Negative Staphylococci Positive Blood Cultures

Background: Coagulase-negative staphylococci (CoNS) are often considered contaminants when isolated from blood cultures. While criteria exist to distinguish true bacteremia from contamination (Table 1), clinical judgement is often necessary. Clinical microbiology laboratories have traditionally identified CoNS to the species level only if present in multiple cultures. There have been concerns that blood cultures positive for rare or less familiar CoNS species might be misinterpreted as true bacteremia. Tufts Medical Center (TMC) clinical microbiology laboratory started reporting all CoNS to the species level in January 2023. We studied the impact of species-level identification of CoNS on clinically relevant outcomes following this change. Methods: The study evaluated inpatients at TMC aged ≥ 18 years with CoNS isolated from blood cultures between July 2022 and June 2023. The primary outcome was the difference in anti-staphylococcal antibiotic utilization between the pre- and post-intervention groups. Secondary outcomes included differences in true bacteremia diagnosis, length of hospital stay, and mortality between the two groups. We also compared the performance of Souvenir’s criteria with clinical judgement at distinguishing contamination from true bacteremia. A total of 100 patients were included in the pre- and post-intervention groups to detect an estimated effect size of 15% with a power of 81%. Results: Most patients were male, White, and English speaking (Table 2). No differences were found between the two groups in terms of infectious disease consultation frequency, blood culture collection department, or the presence of central venous catheters (Table 2). Staphylococcus epidermidis was the predominant CoNS in the post-intervention group. Blood cultures were repeated before and after starting antibiotics in 24% and 74% (pre-intervention) and 18% and 84% (post-intervention) of cases, respectively. Anti-staphylococcus antibiotic use was the same in both groups (82%). The median antibiotic therapy duration was 4.5 days pre- vs 3 days post-intervention (p =0.39). There were no differences in hospital length of stay or mortality between the two groups (Table 3). The clinical diagnosis of true bacteremia was established in 28% of cases in the pre- vs 25% in the post-intervention group (p= 0.63). Compared to clinical judgement, Souvenir’s true bacteremia criteria demonstrated a sensitivity of 80.3%, negative PV of 91.9%, and positive PV of 55.2%. Conclusions: Species-level identification of CoNS positive blood cultures did not impact antibiotic utilization, diagnosis of true bacteremia, length of hospital stay, or mortality. Further studies with larger cohorts and prospective designs are needed to validate these findings and assess the long-term implications in patients.

Quantitative analysis of the impact of infectious disease physicians on patients in the emergency department fast-track parenteral antibiotics program

IntroductionThe outpatient parenteral antibiotic therapy (OPAT) program of Vancouver General Hospital (VGH) was supervised by emergency physicians (EPs) until 2017 when infectious disease (ID) physicians began assisting in management. We designed a retrospective study to determine whether ID involvement led to improved outcomes.MethodsThis study analyzes the impact of ID involvement by comparing the mean days patients spent on OPAT with ID involvement versus EPs alone through a retrospective chart review. Secondary research objectives were to compare patient care decisions, e.g., antibiotic choice, tests ordered, and final diagnosis.ResultsThere was no difference between the mean number of days on OPAT between physician types. Compared to historic patterns, patients seen in OPAT after increased ID consultation spent an average of 0.5 fewer days in the program. However, when grouped by the first day of ID assessment, the average total days in OPAT was closely aligned with the day of first ID assessment, implying that ID frequently discharged patients close to initial assessment. Patients seen by ID were less likely to return within one month of discharge compared to those not seen by ID. Secondary findings include ID physicians prescribing a greater range of antibiotics, providing more varied final diagnoses, prescribing antibiotics less frequently, as well as ordering more cultures, diagnostic imaging and specialist consults.DiscussionThe findings of this study support the hypothesis that ID involvement in OPAT programs leads to changes in care that may have beneficial outcomes for patients and the healthcare system.

Importance of Source Control in the Subgroup of Intra-Abdominal Infections for Septic Shock Patients: Analysis of 390 Cases.

This study aimed to evaluate the epidemiology of septic shock (SS) associated with intraabdominal infections (IAI) as well as associated mortality and efficacy of early source control in a tertiary-care educational hospital. Patients who had SS with IAI and consulted by Infectious Diseases consultants between December 2013 and October 2022 during night shifts in our centre were analyzed retrospectively. A total number of 390 patients were included. Overall, 30-day mortality was 42.5% on day 3, while day 14 and 30 mortality rates were 63.3% and 71.3%, respectively. Source control by surgical or percutaneous operation was performed in 123 of 390 cases (31.5%), and the mortality rate was significantly lower in cases that were performed source control at any time during SS (65/123-52.8% vs 213/267-79.8%, p<0.001). In 44 of 123 cases (35.7%), source control was performed during the first 12 hours, and mortality was significantly lower in this group versus others (24/44-54.5% vs 254/346-73.4%, p=0.009). On the other hand, female gender (p<0.001, odds ratio(OR)= 2.943, 95%CI=1.714-5.054), diabetes mellitus (p= 0.014, OR=2.284, 95%CI=1.179-4.424), carbapenem-resistant Gram-negative etiology (p=0.011, OR=4.386, 95%CI=1.398-13.759), SOFA≥10 (p<0.001, OR=3.036, 95%CI=1.802-5.114), lactate >3 mg/dl (p<0.001, OR=2.764, 95%CI=1.562-4.891) and lack of source control (p=0.001, OR=2.796, 95%CI=1.523-5.133) were significantly associated with 30-day mortality in logistic regression analysis. Source control has a vital importance in terms of mortality rates for IAI-related septic shock patients. Our study underscores the need for additional research, as the present analysis indicates that early source control does not manifest as a protective factor in logistic regression.

Predictors of mortality of Pseudomonas aeruginosa bacteraemia and the role of infectious diseases consultation and source control; a retrospective cohort study.

To determine predictors of mortality among patients with Pseudomonas aeruginosa bacteraemia. Retrospective study. This study conducted at the Lausanne University Hospital, Switzerland included adult patients with P. aeruginosa bacteraemia from 2015 to 2021. During the study period, 278 episodes of P. aeruginosa bacteraemia were included. Twenty (7%) isolates were multidrug-resistant. The most common type of infection was low respiratory tract infection (58 episodes; 21%). Sepsis was present in the majority of episodes (152; 55%). Infectious diseases consultation within 48h of bacteraemia onset was performed in 203 (73%) episodes. Appropriate antimicrobial treatment was administered within 48h in 257 (92%) episodes. For most episodes (145; 52%), source control was considered necessary, with 93 (64%) of them undergoing such interventions within 48h. The 14-day mortality was 15% (42 episodes). The Cox multivariable regression model showed that 14-day mortality was associated with sepsis (P 0.002; aHR 6.58, CI 1.95-22.16), and lower respiratory tract infection (P < 0.001; aHR 4.63, CI 1.78-12.06). Conversely, interventions performed within 48h of bacteraemia onset, such as infectious diseases consultation (P 0.036; HR 0.51, CI 0.27-0.96), and source control (P 0.009; aHR 0.17, CI 0.47-0.64) were associated with improved outcome. Our findings underscore the pivotal role of early infectious diseases consultation in recommending source control interventions and guiding antimicrobial treatment for patients with P. aeruginosa bacteraemia.

Beyond Infection: Mortality and End-of-Life Care Associated with Infectious Disease Consultation in an Academic Health System.

Infectious diseases (ID) physicians are increasingly faced with the challenge of caring for patients with terminal illnesses or incurable infections. This was a retrospective cohort of all patients with an ID consult within an academic health system 1/1/2014 - 12/31/2023, including community, general, and transplant ID consult services. There were 60,820 inpatient ID consults (17,235 community, 29,999 general, and 13,586 transplant) involving 37,848 unique patients. The number of consults increased by 94% and the rate rose from 5.0 to 9.9 consults per 100 inpatients (p<0.001). In total, 7.5% of patients receiving an ID consult died during admission, and 1,006 (2.6%) of patients were discharged to hospice. In-hospital mortality was 5.2% for community ID, 7.8% for general ID, and 10.7% for transplant ID patients (p<0.001). Six-month mortality was 9% for all non-obstetric admissions, , vs. 19% for community ID, 20.9% for general ID, and 22.3% for transplant ID.In total 2,866 (7.6%) of all patients receiving ID consultation also received palliative care consultation during the same hospitalization. The index ID consult preceded any palliative consult in the majority (69.5%) of cases. 16.3% of patients had a do-not-resuscitate order during the index hospitalization. 12.2% of all patients with a do-not-resuscitate order had this placed on the same day as the ID consult. Patients receiving ID consultation were increasingly complex and more likely to die soon after consultation. These results provide a framework for ID clinicians to consider their role in end-of-life care.

ChatGPT as a Novel Consultant in Infectious Diseases and Clinical Microbiology: Correspondence.

ChatGPT as a Novel Consultant in Infectious Diseases and Clinical Microbiology: Correspondence.

Time to antibiotic administration in patients undergoing HSCT with neutropenic fever.

e19501 Background: Cytotoxic chemotherapy for hematologic malignancies may adversely affect myelopoiesis, resulting in profound neutropenia that predisposes patients to severe infections. Patients undergoing hematopoietic stem cell transplantation (HSCT) are at particularly increased risk. Neutropenia is defined by an absolute neutrophil count (ANC) &lt;500 cells/μL per complete blood count with differential. Neutropenic fever is a critical event with one-time temperature ≥101ºF or ≥100.4ºF sustained over one hour. Current standard-of-care is to initiate broad-spectrum antibacterial therapy within 30-60 minutes of presentation. MetroHealth Medical Center in Cleveland, Ohio launched a new Blood and Marrow Transplant program in 2023 in the state-of-the-art Glick Center. This retrospective study explores time to blood culture draw and initiation of antibiotics in HSCT patients with neutropenic fever. Methods: The MetroHealth HSCT database was used to identify hematologic malignancy patients status-post HSCT treated in the Blood and Marrow Transplant program. Tumor type and staging, chemo history, and infection prophylaxis (PPx) were recorded from chart review. Neutropenic fever episodes were identified by review of vitals history. Time to blood culture draw and antibiotic administration was then calculated from the medication administration record (MAR). Results: N = 11 hematologic malignancy patients status-post HSCT and chemotherapy were identified in the MetroHealth database. 8 presented with multiple myeloma (RISS stage II – IV), 2 with Hodgkin lymphoma, and 1 with mantle cell non-Hodgkin lymphoma. All patients were on Valtrex or acyclovir PPx, 10 on levofloxacin PPx, and 9 on fluconazole PPx. 6 of 11 patients had one documented episode of neutropenic fever each. ANC levels ranged from unidentifiable to 420 cells/μL. Half of the episodes saw blood culture draw within 1 hour and initiation of antibiotics in 60-90 minutes. The other 3 episodes saw culture draw at 2:13, 3:09, and 10:10 hours from fever and antibiotic administration at 12:00, 2:53, and 10:23 hours, respectively. Infectious disease (ID) specialists were consulted in each of the latter 3 cases. Conclusions: No patient at MetroHealth with neutropenic fever has seen appropriate initiation of antimicrobials within 30 to 60 minutes of presentation. Hypotheses for this delay include improper chart documentation, nurse training (delay in physician notification), and provider comfort (antimicrobials deferred to day team, ID consults). The latter is of particular concern given incidents of &gt;10 hour delay to antibiotic initiation. Fortunately, there have not been any severe morbidity or mortality outcomes yet. Next steps are to deploy a quality improvement initiative to increase speed to fever identification, blood culture draw, and empiric antimicrobial delivery.

Staphylococcus aureus bacteraemia cases at Helen Joseph Hospital.

Staphylococcus aureus bacteraemia (SAB) is associated with a high mortality. Data on SAB cases in South Africa (SA) are limited. This study aimed to establish the demographic profile, risk factors and complications of patients with SAB in a tertiary inpatient setting. We conducted a retrospective record review of inpatients above the age of 13 with SAB from October 2015 to November 2022 at Helen Jospeh Hospital (HJH) in Gauteng, SA. A total of 126 patients with SAB were reviewed. The case fatality ratio among these patients was 20.6% (95% confidence interval [CI]: 13.9-28.8); this was similar for methicillin-sensitive S. aureus and methicillin-resistant S. aureus (p = 0.154). Almost half (49.2%) were community acquired, and these were chiefly associated with skin and soft tissue infections (45.2%), while most healthcare-associated community-acquired infections (18.3%) and nosocomial-related infections (32.5%) were associated with short-term venous catheterisation (40.6%). The most common risk factors for acquiring a SAB were prior hospitalisation in the last 90 days (27.8%), the presence of an invasive device (26.2%) and receipt of haemodialysis (15.1%). Having hypertension (adjusted odds ratio: 5.55 [95% CI: 1.31-23.55]) and being recently hospitalised (adjusted odds ratio: 11.88 [95% CI: 1.84-26.99]) were associated with statistically significant increased odds of death. SAB-associated all-cause mortality remains high in a middle-income tertiary hospital setting, albeit with a case fatality ratio comparable to that seen in high-income countries. Our study suggests that acceptable outcomes are achievable in tertiary middle-income settings provided there is access to resources including infectious diseases consultation, echocardiograms and basic infection control practices.

Association Between Infectious Diseases Consultation and Mortality in Hospitalized Patients With Gram-negative Bloodstream Infection: A Retrospective Population-wide Cohort Study.

Data supporting routine infectious diseases (ID) consultation in gram-negative bloodstream infection (GN-BSI) are limited. We evaluated the association between ID consultation and mortality in patients with GN-BSI in a retrospective population-wide cohort study in Ontario using linked health administrative databases. Hospitalized adult patients with GN-BSI between April 2017 and December 2021 were included. The primary outcome was time to all-cause mortality censored at 30 days, analyzed using a mixed effects Cox proportional hazards model with hospital as a random effect. ID consultation 1-10 days after the first positive blood culture was treated as a time-varying exposure. Of 30 159 patients with GN-BSI across 53 hospitals, 11 013 (36.5%) received ID consultation. Median prevalence of ID consultation for patients with GN-BSI across hospitals was 35.0% with wide variability (range 2.7%-76.1%, interquartile range 19.6%-41.1%). In total, 1041 (9.5%) patients who received ID consultation died within 30 days, compared to 1797 (9.4%) patients without ID consultation. In the fully adjusted multivariable model, ID consultation was associated with mortality benefit (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] .77-.88, P < .0001; translating to absolute risk reduction of -3.8% or number needed to treat [NNT] of 27). Exploratory subgroup analyses of the primary outcome showed that ID consultation could have greater benefit in patients with high-risk features (nosocomial infection, polymicrobial or non-Enterobacterales infection, antimicrobial resistance, or non-urinary tract source). Early ID consultation was associated with reduced mortality in patients with GN-BSI. If resources permit, routine ID consultation for this patient population should be considered to improve patient outcomes.

Launch of Board Certification in Pediatric Infectious Diseases in Japan.

To cultivate specialists in pediatric infectious diseases (ID) in Japan, the Japanese Society for Pediatric Infectious Diseases initiated board certification for pediatric ID in 2017. Previously, in 2014, we had formed a committee for board certification in pediatric ID and discussed the fundamentals of the board certification system, including the goals, requirements for designated training institutions, provisional certification of pediatric ID specialists and eligibility for and content of the board certification examination. After approval from 31 programs, the pediatric ID programs started in 2017 with 8 fellows in 7 programs. The first 6 graduates received board certification in 2020. To date, 61 pediatricians have been board certified as pediatric ID specialists. In parallel, we introduced board certification for pediatricians who work mainly in primary care settings and have a special interest in pediatric ID. This system has certified 338 pediatricians. During and after the development of the programs, we achieved substantial progress in highlighting the pivotal role of pediatric ID specialists, including the establishment and maintenance of antimicrobial stewardship programs, pediatric ID consultations and introduction of viral diagnosis by polymerase chain reaction at institutions. However, several issues need to be addressed, including the establishment of independent pediatric ID departments in institutions, payment of consultation fees, program site visits, maintenance of certification and cultivation of physician-scientists. These challenges will be the focus of future efforts.