Evidence Of Bacterial Infection Research Articles

E-cigarettes: What evidence links vaping to acute lung injury and respiratory failure?

On September 18, 2019, the Middlesex-London Health-Unit (London, Canada) reported that a previously healthy, high-school student who had vaped nicotine daily, required hospitalization for life-support and had recovered. A week later, another single case was reported in Montreal, Quebec. These Canadian cases followed published cases of e-cigarette lung toxicity including a recent cluster of 53 patients in Illinois and Wisconsin and a 5 patient-cluster in North Carolina, both published on September 6, 2019. As of October 2019, there have been 26 deaths and 1,299 cases of lung injury linked to e-cigarettes. These reports have created widespread concern among clinicians and the public, creating a need to understand what we know at this point, with the caveat being that there is no clear understanding of the causes of vaping-related lung-toxicity. Most patients were previously healthy teenagers or young-adults with progressive dyspnea, hypoxemia, nausea and tachypnea with no evidence of bacterial infection while reporting recent e-cigarette use with nicotine and/or tetrahydrocannabinol. Chest computed-tomography findings included hypersensitivity-pneumonitis, diffuse alveolar hemorrhage, consolidation and ground-glass opacities. Most patients were treated with corticosteroids and symptoms resolved so that hospital discharge and community-based care could be undertaken. There have been no reports of long-term follow-up in survivors.

Case report: palmar herpetic whitlow and forearm lymphangitis in a 10-year-old female

BackgroundHerpetic whitlow is a viral infection caused by the herpes simplex virus (HSV) types 1 or 2, and occurs in the pediatric population primarily on the fingers and toes due to autoinoculation from oral secretions. Because of this cited prevalence, other locations of herpetic whitlow may go unrecognized.Case presentationWe present an atypical presentation of palmar herpetic whitlow with delayed recognition and associated viral lymphangitis. The patient presented as a transfer from an outside hospital with a progressive, three-day history of a suspected left hand abscess preceded by left hand pain and itching. She was initially evaluated by Orthopedic Surgery, who described an erythematous, edematous, tender, left palmar abscess with associated erythematous streaking up her forearm. The lesion was surgically managed with an incision and drainage. Wound cultures were obtained during which “minimal drainage” was noted. After admission to the General Pediatrics Hospital service, the lesion was noted to appear vesicular and subsequently obtained PCR samples were positive for HSV type 1, confirming her diagnosis of herpetic whitlow. Although she remained afebrile with negative wound cultures throughout her hospitalization, a secondary bacterial infection could not be conclusively excluded due to the accompanying lymphangitis. Thus, she was discharged with oral antibiotics and anticipatory guidance of potential recurrence of palmar lesions.ConclusionsHerpetic whitlow should be included in the differential diagnosis of palmar lesions that appear vesicular or abscess-like to ensure appropriate treatment. Additionally, these palmar lesions may present with associated lymphangitis without evidence of bacterial infection.

Multi-organ failure induced by Nivolumab in the context of allo-stem cell transplantation

BackgroundImmune checkpoint inhibitors have radically changed the landscape of anti-tumor therapies in several malignancies. However the adverse events associated with immune checkpoint blockade in combination with other treatments remains to be thoroughly documented. Here we report the case of a 33-year-old male with classical Hodgkin lymphoma who was successfully treated for lymphoma but experienced serious and eventually fatal multisystem organ failure following nivolumab administration and allogeneic stem cell transplantation.Case presentationThe patient was diagnosed with stage IIIa nodular sclerosing Hodgkin lymphoma. Originally treated by chemotherapy and autologous stem cell transplantation, he subsequently received two allogeneic stem cell transplants from matched and haplo-identical siblings upon successive disease recurrences. Nivolumab treatment was administered prior to the second allograft, after which complete remission of lymphoma was achieved (year 10), as evidenced by clinical and radiographic examination. However within the next 3 months, the patient went on to develop a constellation of symptoms affecting multiple organs, including acute pneumonia with no evidence of bacterial infection, widespread cutaneous eruptions on trunk and lower limbs, mucosal ulcerations, myositis, diarrhea and colitis. Further complications included hepatic cytolysis, acute renal failure, pancreatitis, as well as complete heart block. Some of these injuries being suggestive of graft-versus-host disease, the patient was administered immunosuppressive therapy (mycophenolate, steroids and polyvalent immunoglobulins), but died shortly afterwards. Tissue biopsies revealed extensive lymphocytic infiltration (mostly CD3 + T cells) in skin, liver, and most peculiarly in muscles, including the myocardium. Massive lymphoid-histiocytic infiltration of muscle fibers was accompanied by acute necrotizing myositis and endomysial inflammation.ConclusionsMulti-organ failure represents a rare but potentially fatal outcome of immune checkpoint blockade in patients receiving allogeneic stem cell grafts. Nivolumab may induce atypical immune-mediated tissue inflammation and damage, such as the extensive muscular polymyositis described here in a patient with Hodgkin lymphoma. Nivolumab might also worsen GVHD symptoms in the context of allogeneic stem cell transplantation. Irrespective of the actual pathological mechanisms, clinicians should be alerted to these fatal drug-related toxicities.

Impact of donor with evidence of bacterial infections on deceased donor liver transplantation: a retrospective observational cohort study in Taiwan

ObjectiveThe shortage of available donor organs is an unsolvable concern leading to an expansion in the donor criteria for organ transplantation. Here, we describe our experience and assess the outcomes...

Association between aseptic meningitis and jolt accentuation of headache in adults

The purpose of this study was to elucidate the association between aseptic meningitis and jolt accentuation of headache (JAH) in adults. 87 patients with meningeal irritation (age; 35.6 ± 13.3 years old, 45 males) who were admitted to our hospital from 1st August 2013 to 31st August 2018 were included. The diagnosis was determined according to the following criteria:, aseptic meningitis was defined as cerebrospinal fluids (CSF) pleocytosis with no evidence of bacterial infection, fungal infection or carcinomatous findings; meningism was defined as the absence of CSF pleocytosis. None of these patients had consciousness disturbance and focal neurological abnormalities. The blood and CSF data were reviewed for analysis. 61 patients were in aseptic meningitis group, 26 patients were in meningism group. Multiple logistic regression analysis showed older age (OR 1.059, 95% Confidence interval (CI) 1.012-1.108, P = 0.013), lower CRP (OR 0.803, 95%CI 0.697-0.925, P = 0.002) and absence of JAH (OR 0.048, 95%CI 0.004-0.554, P = 0.015) were significantly associated with aseptic meningitis. The sensitivity and specificity of JAH in aseptic meningitis were 68.9%, 3.8%.

Appropriateness of antimicrobial therapy for culture-proven blood stream infections

INTRODUCTION: Blood stream infections (BSIs) are responsible for significant morbidity and mortality. Numerous studies have pointed to the importance of early and prompt institution of empirical antimicrobial therapy in reducing morbidity and mortality in BSI. The antibiotic spectrum must be narrowed as soon as possible, considering the clinical condition of the patient, the pathogens identified in cultures and the sensitivity profile obtained from the antibiogram. When no evidence of bacterial infection is present, antibiotic therapy must be suspended. However, it is often observed that the clinician does not adhere to the guideline and continues with the same empirical treatment.MATERIALS AND METHODS: The study was conducted at Department of Microbiology, in a tertiary care hospital from April 2017 to September 2017. Two hundred patients with microbiologically documented BSIs were included in the study. They were followed up to find the appropriateness of change in empirical treatment carried out according to culture sensitivity report, and antimicrobial consumption was also calculated.RESULTS: We observed that there was an increased use of antipseudomonal penicillins plus beta-lactamase inhibitors, amikacin and carbapenems which was due to higher prevalence of multidrug-resistant Gram-negative bacilli among blood culture isolated. We also found that in most of the patients, the empirical treatment was inappropriately modified at day four after availability of culture reports, i.e., inappropriately escalated or de-escalated or continued while there was no indication to do so.CONCLUSION: Treatment inappropriate group was associated with higher treatment failure as compared to treatment appropriate group. Studies of the other factors associated with inappropriate treatment such as changes in resistance patterns, antimicrobial-related adverse effect and of the long-term clinical outcomes are warranted.

719. The Respiratory Pathogen Panel and Antibiotic Utilization in the Emergency Department

BackgroundThe multiplex polymerase chain reaction respiratory pathogen panel (RPP) is used frequently in emergency departments (EDs) for the rapid identification of viruses and atypical bacteria of the respiratory tract. Its clinical value is unclear, as numerous studies have demonstrated that its use has a limited impact on antibiotic prescribing. We aimed to describe the relationship between RPP results and antibiotic prescribing rates for ED patients in our large academic medical center.MethodsWe retrospectively analyzed the charts of 1,061 patients aged 18–90 who were treated and released from two EDs from January 1, 2015 to January 31, 2018 and underwent RPP testing. Patients with evidence of bacterial infection were excluded based on RPP detection of atypical bacteria and microbiological analysis of blood, urine, wound, and sputum specimens. The results of the RPP and the rates of subsequent respiratory pathogen-directed antibiotic prescribing (including ED and outpatient pharmacy orders) were compared.ResultsAntibiotic prescription rates were 21.5% in patients who tested negative for any respiratory virus, compared with 14.5% in patients who tested positive (OR 0.70, P < 0.01). When positive RPPs were subdivided based on virus type (influenza and non-influenza) and compared with negative RPPs, only influenza-detection was associated with a significant reduction in antibiotic prescriptions (Table 1).ConclusionIn our study population, the presence of a respiratory virus detected by the RPP was correlated with a significant decrease in antibiotic prescribing. This effect was largely driven by influenza detection. This demonstrates that at our institution, the RPP may have a role in reducing unnecessary antibiotic utilization, but providers need further guidance in the interpretation of non-influenza respiratory virus positivity.Table 1. Antibiotic Prescription Rates by RPP Result, Subdivided by Virus Type RPP Result N No. of Patients Given Antibiotics Odds Ratio (95% CI) P-value Negative 628135 (21.5%)Reference Positive 43363 (14.5%)0.70 (0.56–0.88)<0.01 Influenza*16920 (11.8%)0.49 (0.30–0.81)<0.01 Non-influenza virus(es)26443 (16.3%)0.71 (0.49–1.04) 0.08*Includes RPPs that were positive for multiple viruses if influenza was present.Disclosures All authors: No reported disclosures.

1805. Impact of Antimicrobial Stewardship Interventions Using Rapid Molecular Testing on the Appropriate Use of Antiviral Therapy and Reduction of Unnecessary Antibiotic Therapy for Patients Admitted With Acute Influenza

BackgroundRapid molecular tests combined with Antimicrobial Stewardship Program (ASP) interventions have provided opportunities to optimize patient outcomes and reduce unnecessary antimicrobial use. Our institution currently uses an FDA approved influenza/respiratory syncytial virus polymerase chain reaction (PCR) assay and multiplex respiratory panel. In addition, our institution commonly utilizes procalcitonin (PCT) levels. The ASP at Summa Health System – Akron Campus (SHS-AC) routinely recommends use of these rapid diagnostic tests to assist with antimicrobial and antiviral usage, including the discontinuation of antibiotics in influenza positive patients in the absence of a concurrent bacterial infection.MethodsA retrospective review of all ASP interventions on influenza positive patients at SHS-AC was performed from December 2017 to March 2018. The ASP reviewed all patients on broad-spectrum antibiotics >48 hours and all influenza positive patients without Infectious Disease consultation. The appropriateness of antimicrobial and antiviral therapy was assessed, including assessment of culture and PCR results, PCT levels, indication of therapy, and renal function. For patients with a positive influenza PCR and low PCT without evidence of bacterial infection, the recommendation was to discontinue antibacterial use. Data collected included: intervention type, acceptance rate, PCT levels, and influenza subtype.ResultsTwo hundred thirty-three total recommendations were made by the ASP on influenza positive patients, with a 96.6% acceptance rate. Interventions included the following: obtain PCT level (54/233), de-escalate or stop antibiotics based on culture, PCR, and PCT results (116/233), obtain influenza or respiratory PCR (8/233), initiate oseltamivir (37/233), and other (18/233).ConclusionASP intervention combined with PCT levels and PCR results contributed to the reduction of unnecessary antibiotic use, and the initiation of oseltamivir therapy in influenza-positive patients.Disclosures T. File, BioMerieux: Scientific Advisor, Consulting fee. Curetis: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Merck: Scientific Advisor, Consulting fee. MotifBio: Scientific Advisor, Consulting fee. Nabriva: Investigator and Scientific Advisor, Consulting fee and Research grant. Pfizer: Scientific Advisor, Consulting fee. Paratek: Scientific Advisor, Consulting fee.

Implementation of a Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: the Optimizing Antibiotic Strategies in Sepsis (OASIS) II Study.

Biomarkers can facilitate safe antibiotic discontinuation in critically ill patients without bacterial infection. We tested the ability of a biomarker-based algorithm to reduce excess antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) without bacterial infections (uninfected) in our pediatric intensive care unit (PICU). The algorithm suggested that PICU clinicians stop antibiotics if (1) C-reactive protein <4 mg/dL and procalcitonin <1 ng/mL at SIRS onset and (2) no evidence of bacterial infection by exam/testing by 48 hours. We evaluated excess broad-spectrum antibiotic use, defined as administration on days 3-9 after SIRS onset in uninfected children. Incidence rate ratios (IRRs) compared unadjusted excess length of therapy (LOT) in the 34 months before (Period 1) and 12 months after (Period 2) implementation of this algorithm, stratified by biomarker values. Segmented linear regression evaluated excess LOT among all uninfected episodes over time and between the periods. We identified 457 eligible SIRS episodes without bacterial infection, 333 in Period 1 and 124 in Period 2. When both biomarkers were below the algorithm's cut-points (n = 48 Period 1, n = 31 Period 2), unadjusted excess LOT was lower in Period 2 (IRR, 0.53; 95% confidence interval, 0.30-0.93). Among all 457 uninfected episodes, there were no significant differences in LOT (coefficient 0.9, P = .99) between the periods on segmented regression. Implementation of a biomarker-based algorithm did not decrease overall antibiotic exposure among all uninfected patients in our PICU, although exposures were reduced in the subset of SIRS episodes where biomarkers were low.

BEVACIZUMAB-INDUCED ATYPICAL ENCEPHALOPATHY

SESSION TITLE: Medical Student/Resident Pharmacotherapeutics SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Posterior reversible encephalopathy syndrome (PRES) manifests as edema in the white matter of the posterior regions of the cerebral hemispheres. PRES has been mostly associated with acute hypertensive encephalopathy along with variety of other causes. We are presenting a case of unusual PRES CASE PRESENTATION: A 43-year-old man with a past medical history of grade III anaplastic astrocytoma of the brainstem presented to the emergency department due to acute changes in mental status and fever. Seven months prior to presentation, bevacizumab (Avastin) was started. On admission BP of 203/124 mmHg, HR of 139/min and temperature of 103°F were found. The patient’s Glasgow coma scale was 10. His complete blood count and complete metabolic panel were unremarkable. Procalcitonin was elevated at 2.46 ng/mL. CT head without contrast indicated evidence of old tumor but no hemorrhage or mass effect. CSF showed mild elevation of protein but no cells. Magnetic resonance imaging of the brain exhibited signal abnormalities in the cerebellum and occipital lobes compatible with PRES. There was no evidence of infection by microbiological data. Once the patient’s hypertension was controlled, his mental status quickly improved and he had a full recovery after rehabilitation. DISCUSSION: Bevacizumab (Avastin) is a recombinant humanized monoclonal antibody that binds to vascular endothelial growth factor (VEGF) to prevent association with endothelial receptors. Bevacizumab (Avastin) inhibits angiogenesis and microvascular growth to subsequently slow down the growth of all tissues, including malignant tissues. The incidence of hypertension with bevacizumab (Avastin) therapy is estimated range from 8 to 67%. PRES has been reported with an incidence of <0.5% in clinical studies and the onset was anywhere from 16 hours to 1 year of initiation of Bevacizumab therapy.[1] A literature review from 2015 reported 21 cases of bevacizumab-induced PRES, 20 of which had complete recovery following withdrawal of medication along with strict BP control.[2] The concomitant occurrence of fever and PRES in the absence of infection has been identified in previous case reports,[3] however, fever along with elevated procalcitonin in the setting of PRES, without any evidence of bacterial infection, has never been documented. CONCLUSIONS: Hypertension and PRES are potential adverse effects of Bevacizumab therapy. Patients taking Bevacizumab require strict monitoring and control of their blood pressure. Although the combination of fever, altered mental status and elevated procalcitonin should alert physicians to infectious process potentially in the central nervous system, PRES should not be missed especially in patients receiving Bevacizumab. Reference #1: Product Information: AVASTIN(R) intravenous injection, bevacizumab intravenous injection. Genentech Inc (per manufacturer), South San Francisco, CA, 2016. Reference #2: Eryılmaz MK, Mutlu H, Salim DK, Musri FY, Coşkun HŞ. Fatal posterior reversible leukoencephalopathy syndrome associated coma induced by bevacizumab in metastatic colorectal cancer and review of literature. J Oncol Pharm Pract. 2016;22(6):806-810. Reference #3: Xie C, Jones VT. Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review. Oncol Lett. 2016;11(2):1512-1516. DISCLOSURES: No relevant relationships by Bhavinkumar Dalal, source=Web Response No relevant relationships by Ahmad Said, source=Web Response

誤嚥性肺炎の治療方針決定におけるプロカルシトニンの有用性(Procalcitonin utility for diagnosis and treatment of aspiration pneumonia)

要旨【目的】誤嚥性肺炎に対するプロカルシトニン（procalcitonin: PCT）の有用性を検討した。【対象】聖マリアンナ医科大学病院，東京ベイ・浦安市川医療センターの救急外来から誤嚥性肺炎で入院した成人患者で入院当日（第0病日）と第1病日のPCTがともに0.25ng/mL未満の場合は抗菌薬を投与せず，いずれかで0.25ng/mL以上の場合，抗菌薬を開始した。第4，7，10病日のPCT値の0.25ng/mL未満またはピーク値の10%未満への低下，あるいは担当医の判断で抗菌薬を終了した。【結果】患者は60人（男性26人），年齢中央値82歳［四分位範囲（interquartile range: IQR）71–89］，pneumonia severity index（PSI）は109.5（IQR 94–127）であった。第0，1病日のPCTがともに0.25ng/mL未満の14人（23.3%）は抗菌薬なしで全例治癒退院した。残り46人（76.7%）のうち1人を除く45人に抗菌薬が投与された。PCT値で抗菌薬を終了した患者が11人（24.4%），医師判断で抗菌薬を終了した患者が34人（75.6%），投与期間はそれぞれ7日（IQR 5.5–8），6.5日（IQR 5–7）で有意差は認めなかった。【結語】誤嚥性肺炎患者では入院初期のPCT陰性維持を根拠に安全に抗菌薬投与を制限できる可能性がある。

Monofocal Chronic Nonbacterial Osteomyelitis in the Mandible Accompanied With Mucocutaneous Disease.

Chronic nonbacterial osteomyelitis (CNO) is a bone disease with nonbacteria osteitis of unknown etiology. Symptoms, including pain, swelling, fever, etc, always result in misdiagnosis and wrong therapy. This study aims to introduce the clinical features and the therapy of patients with CNO accompanied with mucocutaneous disease. The authors retrospectively reviewed the patients who presented to our hospital from 2000 to 2016, the final sample including 3 patients with CNO accompanied with mucocutaneous disease, who presented repeated severe pain of bone, swelling, tenderness, and fever during attack stage with no evidence of bacterial infections. One patient underwent surgery, and all of them took the therapy of nonsteroidal anti-inflammatory drugs and immunosuppressive agents. There was no significant effect after taken surgery, but good results with drugs. The study suggested us that medical therapy sometimes better than surgery in CNO accompanied with mucocutaneous disease.

The first evidence of osteomyelitis in a sauropod dinosaur

Osteomyelitis is reported for the first time in a sauropod dinosaur. The material (MCS-PV 183) comes from the Anacleto Formation (Campanian, Late Cretaceous), at the Cinco Saltos locality, Rio Negro Province, Argentina. The specimen consists of 16 mid and mid-distal caudal vertebrae of a titanosaur sauropod. Evidence of bacterial infection is preserved in all of these vertebrae. The main anomalies are as follows: irregular ‘microbubbly’ texture of bone surfaces produced by periosteal reactive bone, abscesses on the rims of the anterior articular surfaces of two centra, numerous pits on centra anterior articulation surfaces, erosions on the anterior articulation of the vertebral centra, a vertical groove in posterior articular face of all the centra and disruption of the prezygapophysis and postzygapophysis (mainly the articular face) from the vertebra 19 and beyond. The last anomaly is increasingly pronounced in more distal elements of the series. Thin sections reveal that the anomalous cortical tissue is composed of avascular and highly fibrous bone matrix. The fibres of the bone matrix are organized into thick bundles oriented in different directions. Both morphological and histological abnormalities in the MCS-PV 183 specimen are pathognomonic for osteomyelitis.

No evidence of parthenogenesis‐inducing bacteria involved in Thripoctenus javae thelytoky: an unusual finding in Chalcidoidea

AbstractAll Hymenoptera have a haplodiploid mode of sex determination. Although most species reproduce by arrhenotokous parthenogenesis, there are many thelytokous species, in which unfertilized eggs develop into diploid females. Thelytoky can be genetic or due to microbial infection. In the large Chalcidoidea superfamily, thelytokous parthenogenesis is almost always associated with infection of endosymbionts of the genera Wolbachia, Cardinium, and Rickettsia. Thripoctenus javae (Girault) (Hymenoptera: Eulophidae) is a larval parasitoid of the greenhouse thrips Heliothrips haemorrhoidalis (Bouché) (Thysanoptera: Thripidae), an important worldwide pest. Both the host and its parasitoid reproduce by thelytokous parthenogenesis. The main goal of this study was to test whether endosymbiotic bacteria, either those known to induce thelytokous parthenogenesis or other sex‐manipulators, are responsible for thelytoky of two geographically distinct populations of T. javae. We used sequencing of ribosomal ITS2 and 28S‐D2 and mitochondrial COI genes to molecularly characterize the two populations, antibiotic and heat treatments, and FISH of ovaries, for thelytoky studies. It was impossible to revert thelytokous individuals back to sexual reproduction and no evidence of bacterial infection was found in parthenogenetic T. javae females. This makes T. javae the second chalcidoid in which thelytokous reproduction appears not to be associated with the presence of bacterial endosymbionts.

Individuals hospitalized with acute mania have increased exposure to antimicrobial medications.

We have preciously documented that many individuals with acute mania have immune activation. However, the sources of immune activation have not been identified. We investigated whether individuals hospitalized with acute mania have evidence of bacterial infections as determined by the prescription of systemic antimicrobial agents. We assessed the recent prescription of systemic antimicrobial medications and the site of presumed bacterial infection in 234 individuals hospitalized for acute mania in either an inpatient unit or a day hospital. We also assessed individuals hospitalized for other psychiatric disorders (n=368) and controls (n=555). We employed logistic regression models to compare the rates of antibiotic prescription in individuals with the different diagnoses, employing demographic variables as covariates. We found that individuals hospitalized with acute mania had a substantially increased rate of recent antimicrobial prescription, defined as exposure within three days of ascertainment (adjusted odds ratio=5.5, 95% confidence interval: 2.2-14.1, P<.0002). Overall, a total of 18 of the 234 (7.7%) individuals hospitalized for acute mania were prescribed antibiotics as opposed to seven of 555 (1.3%) controls. The prescription of antibiotics was associated with being on an inpatient unit as opposed to being in the day hospital, and having increased mania symptom severity but not with other clinical ratings, demographic variables, or psychiatric medications. Hospitalization for other psychiatric disorders was not associated with the recent prescription of antimicrobial medications. The urinary tract was the most common site of infection in women, while the respiratory tract and mucosal surfaces were the most common sites in men. Individuals hospitalized with acute mania have a markedly increased rate of bacterial infections, as evidenced by the recent prescription of antimicrobial agents. The prevention and effective treatment of bacterial infections may be important interventions for the management of individuals with mania.

Prospective antimicrobial audit and feedback did not decrease case fatality: Experiences from a hospital in northern Taiwan.

Although a prospective antimicrobial audit and feedback is an effective strategy in an antibiotic stewardship program, previous researchers have not adequately demonstrated a successful impact on patient outcomes. In this study, the causes of fatalities associated with a prospective antimicrobial audit and feedback were analyzed. Between June and September 2014, applications for 16 target parenteral formulas (including ceftriaxone, ceftazidime, cefepime, piperacillin/tazobactam, vancomycin, teicoplanin, ertapenem, imipenem/cilastatin, meropenem, levofloxacin, moxifloxacin, ciprofloxacin, tigecycline, linezolid, daptomycin, and amikacin), which were not approved by infectious diseases (ID) specialists, were followed up until patients were either discharged or passed away. Of the 292 cases studied, 193 (66%) were male, with a mean age (standard deviation) of 65.5 (19.3) years. There were five reasons for rejection, including dosage adjustments (37%), no evidence of bacterial infection (28.8%), modifications according to antimicrobial susceptibility (18.8%), target pathogens not being covered (7.2%), and redundant therapy (4.1%). Multiple logistic regression analysis demonstrated that an age greater than 75 years (odds ratio [OR]: 2.58; 95% confidence interval [CI]: 1.32-5.50; p = 0.005) was associated with significant mortality, while urinary tract (OR: 0.26; 95% CI: 0.09-0.70; p = 0.013) and soft tissue/bone infections (OR: 0.18; 95% CI: 0.05-0.61; p = 0.006) were associated with survival. Adjustments according to ID physicians' recommendations were not statistically significant (OR: 0.53; 95% CI: 0.27-1.06; p = 0.074). Antimicrobial adjustments according to ID physicians' recommendations showed only marginally preventative effects against fatalities.

Serum procalcitonin level in chronic hemodialytic patients with no evidence of bacterial infection

The baseline levels of serum procalcitonin (PCT) have not been determined in patients with end-stage renal disease needing renal replacement therapy. The purpose of the present study is to verify the reference range of PCT and parameters affecting its value in patients receiving chronic hemodialysis. A total of 125 dialytic patients who had no obvious clinical signs of systemic infection were included in this prospective observational study. The PCT level was measured, and its relationships to other clinical and laboratory parameters were evaluated. The baseline PCT levels of 82 male and 43 female patients were evaluated. Mean baseline PCT level was 0.24 ± 0.22 ng/ml. Sixteen (12.8 %) patients showed elevated PCT (>0.3 ng/ml) and C-reactive protein (CRP) (>0.3 mg/dl), and 11 (8.8 %) patients showed only abnormal PCT. In 9 patients (7.2 %), PCT levels exceeded 0.5 ng/ml, which is a common cutoff point for sepsis although they had no clinical signs of systemic bacterial infection. The PCT level was statistically correlated with the duration of chronic dialysis, urine volume per day, dialysis time, the serum CRP, β2-microglobulin levels, and normalized dialysis dose. Most dialysis patients had PCT levels within the reference range of non-dialytic individuals. However, a not negligible number of patients had higher PCT levels than the upper limit of healthy individuals, despite there being no sign of infection. Impairment of renal function and hemodialytic status may affect PCT level.

Antibiotic Utilization and Opportunities for Stewardship Among Hospitalized Patients With Influenza Respiratory Tract Infection.

Hospitalized influenza patients are often treated with antibiotics empirically while awaiting final diagnosis. The goal of this study was to describe the inappropriate continuation of antibiotics for influenza respiratory tract infections (RTIs). We retrospectively studied adults admitted to our institution over 2 respiratory flu seasons with positive influenza RTIs. Inappropriate antibiotic duration (IAD) was defined as antibiotic use for >24 hours after a positive influenza test in patients presenting with <72 hours of RTI symptoms and with no other indications of bacterial infection. During the study period, 322 patients included in this study were admitted for influenza RTI. Respiratory cultures were ordered for 50 of these patients (15.5%) and 71 patients (22%) had a positive chest x-ray, but antibiotics were prescribed to 211 patients (65.5%) on admission. Antibiotics were inappropriately continued in 73 patients (34.5%). Patients receiving IAD had a longer length of stay (LOS) (median, 6 days; range, 4-9 days) compared with those whose antibiotics were discontinued appropriately (median, 5 days; range, 3-8 days) and those who were not treated with antibiotics (median, 4 days; range, 3-6 days; P<.001). However, mortality was similar among these 3 groups: 3 patients (4.1%) from the IAD cohort died; 6 patients (4.3%) from the group with an appropriate antibiotic duration died; and 2 patients [1.8%] from the group given no antibiotics died (P=.510). The 30-day readmission rates were similar as well: 9 patients (12.3%) from the IAD group were readmitted within 30 days; 21 patients (15.2%) from the group with appropriate antibiotic duration were readmitted; and 11 patients (9.9%) from the group given no antibiotics were readmitted (P=.455). Total hospital costs were greater in patients treated with IAD ($10,645; range, $6,485-$18,035) compared with the group treated with appropriate antibiotic duration ($7,479; range, $4,866-$12,922) and the group given no antibiotics $5,961 (range, $4,711-$9,575). Thus, the hospital experienced a median loss in net hospital revenue of $2,076 per IAD patient compared with a patient for which antibiotic duration was appropriate. The majority of patients with influenza RTI received antibiotics on admission, and 34.5% were inappropriately continued on antibiotics without evidence of bacterial infection, which led to increased LOS, loss of net revenue, and no improvement in outcome. Thus, stewardship initiatives aimed at this population are warranted.

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value.

The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine. A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments. A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.

Ketamine*

Ketamine*