Infectious Diseases Consultation Research Articles

Impact of Infectious Disease Consultation on S. aureus Bacteremia Mortality

Objective: This study evaluated the impact of a hospital policy requiring infectious disease (ID) consultation and follow-up from an antimicrobial stewardship (AMS) pharmacist-driven team on S. aureus Bacteremia (SAB) patient mortality and improved clinical outcomes. Methods: This retrospective study included adult inpatients with SAB from 1 August 2016 to 30 May 2018 (pre-policy) and June 1 2018 to 29 February 2020 (post-policy). The primary outcome variable was in-hospital mortality, and secondary outcomes were 30-day readmission rate, acute kidney injury (AKI) at discharge, stay length, and adherence to evidence-based treatment. Results: The final sample included 435 patients for analysis. Management by non-ID physicians was associated with an 8.1 increased likelihood of mortality while hospitalized (CI 95%, 3.701–17.569). Overall mortality was reduced from 11% (n = 25) pre-policy to 6% (n = 13) after policy implementation (p = 0.07). Patients with antibiotics managed by non-ID physicians were 3 times more likely to be readmitted within 30 days. Those with a history of being immunocompromised (64% vs. 36%), or cardiovascular disease (56% vs. 44%), and patients whose providers followed guidelines (23% vs. 7%) were more likely to be discharged with AKI. Policy implementation reduced non-consultant cases from 11% to 0%. Conclusion: A policy of mandatory ID consultation with pharmacist-driven AMS review to ensure compliance can improve patient mortality, 30-day readmission rates, and clinical outcomes.

Effect of Automated Telephone Infectious Disease Consultations to Nonacademic Hospitals on 30-Day Mortality Among Patients With Staphylococcus aureus Bacteremia

Staphylococcus aureus bacteremia (SAB) is a common and potentially severe infectious disease (ID). Retrospective studies and derived meta-analyses suggest that bedside infectious disease consultation (IDC) for SAB is associated with improved survival; however, such IDCs might not always be possible because of the lack of ID specialists, particularly at nonacademic hospitals. To investigate whether unsolicited telephone IDCs (triggered by an automated blood stream infection reporting system) to nonacademic hospitals improved 30-day all-cause mortality in patients with SAB. This patient-blinded, multicenter, interventional, cluster randomized, controlled, crossover clinical trial was conducted in 21 rural, nonacademic hospitals in Thuringia, Germany. From July 1, 2016, to December 31, 2018, 1029 blood culture reports were assessed for eligibility. A total of 386 patients were enrolled, whereas 643 patients were not enrolled for the following reasons: death before enrollment (n = 59); palliative care (n = 41); recurrence of SAB (n = 9); discharge from the hospital before enrollment (n = 77); age younger than 18 years (n = 5); duplicate report from a single patient (n = 26); late report (n = 17); blood culture reported during the washout phase (n = 48); and no signed informed consent for other or unknown reasons (n = 361). During the ID intervention phase, ID specialists from Jena University Hospital provided unsolicited telephone IDCs to physicians treating patients with SAB. During the control phase, patients were treated according to local standards. Crossover was performed after including 15 patients or, at the latest, 1 year after the first patient was included. Thirty-day all-cause mortality. A total of 386 patients (median [IQR] age, 75 [63-82] years; 261 [67.6%] male) were included, with 177 randomized to the IDC group and 209 to the control group. The 30-day all-cause mortality rate did not differ between the IDC and control groups (relative risk reduction [RRR], 0.12; 95% CI, -2.17 to 0.76; P = .81). No evidence was found of a difference in secondary outcomes, including 90-day mortality (RRR, 0.17; 95% CI, -0.59 to 0.57; P = .62), 90-day recurrence (RRR, 0.10; 95% CI, -2.51 to 0.89; P = .89), and hospital readmission (RRR, 0.04; 95% CI, -0.63 to 0.48; P = .90). Exploratory evidence suggested that indicators of quality of care were potentially realized more often in the IDC group than in the control group (relative quality improvement, 0.16; 95% CI, 0.08-0.26; P = .01). In this cluster randomized clinical trial, unsolicited telephone IDC, although potentially enhancing quality of care, did not improve 30-day all-cause mortality in patients with SAB. drks.de Identifier: DRKS00010135.

Impact of a bloodstream infection stewardship program in hospitalized patients

Bloodstream infections (BSIs) in hospitalized patients represent sentinel events requiring timely and responsive antimicrobial prescribing. These infections represent an attractive but seldom-evaluated stewardship opportunity. Retrospective pre-post study design, with review of patient charts 18 months before and after initiation of a hospital Bloodstream Infection Stewardship Program (BSISP). Pre-intervention, the ward and attending physician were notified of all positive blood cultures. Post-intervention, an infectious disease (ID) pharmacist collaborating with an ID consultant was also notified. Two hundred twenty-six eligible BSIs were identified pre-intervention and 195 post-intervention. The urinary tract was the most common source of infection; most common bloodstream isolates were Escherichia coli, Staphylococcus aureus, beta-hemolytic streptococci, and Klebsiella pneumoniae; 71.7% of infections were community acquired. Empiric therapy was not given in 17.3% of cases and inadequate in 16.4% of patients. Therapy was altered on the basis of Gram stain results ('directed therapy') in 54.6% of episodes and was inadequate in 3.5%. Compared to pre-intervention, the post-intervention cohort received directed therapy on average 4.36 hours earlier (p = 0.003), was more likely to receive appropriate definitive therapy (99.0% post versus 79.1% pre, p <0.001), stepped down to oral therapy earlier (6.0 versus 8.0 days, p = 0.031), and received fewer directed prescriptions (214 per 100 cases post versus 260 per 100 cases pre; p = 0.001), including fewer prescriptions of quinolones and clindamycin. A BSISP could be an effective strategy for improving antimicrobial prescribing in hospitalized patients with a BSI.

Real-world Antimicrobial Stewardship Experience in a Large Academic Medical Center: Using Statistical and Machine Learning Approaches to Identify Intervention "Hotspots" in an Antibiotic Audit and Feedback Program.

BackgroundProspective audit with feedback (PAF) is an impactful strategy for antimicrobial stewardship program (ASP) activities. However, because PAF requires reviewing large numbers of antimicrobial orders on a case-by-case basis, PAF programs are highly resource intensive. The current study aimed to identify predictors of ASP intervention (ie, feedback) and to build models to identify orders that can be safely bypassed from review, to make PAF programs more efficient.MethodsWe performed a retrospective cross-sectional study of inpatient antimicrobial orders reviewed by the University of Maryland Medical Center’s PAF program between 2017 and 2019. We evaluated the relationship between antimicrobial and patient characteristics with ASP intervention using multivariable logistic regression models. Separately, we built prediction models for ASP intervention using statistical and machine learning approaches and evaluated performance on held-out data.ResultsAcross 17 503 PAF reviews, 4219 (24%) resulted in intervention. In adjusted analyses, a clinical pharmacist on the ordering unit or receipt of an infectious disease consult were associated with 17% and 56% lower intervention odds, respectively (adjusted odds ratios [aORs], 0.83 and 0.44; P ≤ .001 for both). Fluoroquinolones had the highest adjusted intervention odds (aOR, 3.22 [95% confidence interval, 2.63–3.96]). A machine learning classifier (C-statistic 0.76) reduced reviews by 49% while achieving 78% sensitivity. A “workflow simplified” regression model that restricted to antimicrobial class and clinical indication variables, 2 strong machine learning–identified predictors, reduced reviews by one-third while achieving 81% sensitivity.ConclusionsPrediction models substantially reduced PAF review caseloads while maintaining high sensitivities. Our results and approach may offer a blueprint for other ASPs.

Towards a complete cycle of care: a multidisciplinary pathway to improve outcomes in complex abdominal wall hernia repair.

The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes. A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre-optimization pathways were then compared with a recent Delphi consensus statement. Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre-optimization and plan the definitive repair. These pre-optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well-defined referral criteria, perioperative high-risk management with pre-optimization, surgical planning, postoperative care and follow-up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness. CAWH MDT can provide comprehensive, patient-centred care with improved postoperative outcomes. CQR are important to better evaluate long-term outcomes and ensure rigorous quality control.

My patient needs home IV antibiotics–Now what? Assessing OPAT involvement at a Veterans’ Affairs hospital

Background: Outpatient parenteral antimicrobial therapy (OPAT) involves the administration of intravenous antimicrobial therapy outside the hospital. The literature suggests that inpatient providers are often unaware of OPAT programs and may not engage this multidisciplinary group in a timely fashion, leading to potentially inappropriate OPAT use. However, few studies have directly addressed this issue. We characterized current practices for coordinating OPAT and assessed provider understanding of OPAT services. We also conducted an exploratory analysis of placement of a peripherally inserted central catheter (PICC) consultation prior to an infectious disease (ID) consultation as a proxy for potentially avoidable OPAT use. Methods: This study was conducted between September and December 2021 at the Ann Arbor VA Healthcare System. All charts (n = 212) in which a consultation for a PICC was placed between January and September 2021 were reviewed, including free-text data entered by patient teams and inpatient progress notes in the days leading up to and following PICC consultation. Additionally, inpatient providers were surveyed using an online format regarding knowledge, utilization, and perceptions of OPAT. Results: Of the 212 charts reviewed, 108 patient encounters resulted in PICC placement; 80 (74.1%) were placed for the indication of home IV antibiotics. Of these, 3 (4.0%) had the PICC consult placed prior to the ID consultation. Of the 104 PICC consultations that were cancelled, 9 (8.7%) were cancelled because the ID staff did not recommend home IV antibiotics. Other reasons for cancellation included alternative device placement, duplicate order, referral to interventional radiology, failure to meet criteria, or unsuccessful placement. Of the 285 inpatient providers sent the electronic survey, 121 (46.9%) completed at least some portion. Overall, 17 respondents (14.0%) were familiar with the acronym OPAT; however, only 10 were able to expand the acronym correctly. Of the 118 respondents asked about their familiarity with the OPAT program at the local institution, 98 (83.1%) were not familiar at all or were only slightly familiar with the program. In contrast, 7 respondents (6.0%) were very or extremely familiar with the OPAT program. Conclusions: Further education and structural interventions are necessary to improve inpatient providers’ awareness and early engagement of local OPAT programs to ensure appropriate OPAT use. An educational intervention with an informative flowchart diagramming the steps for engaging the OPAT team could raise awareness and improve engagement when potential OPAT needs are identified (Fig. 1).Funding: NoneDisclosures: None

Increasing Pediatric Infectious Diseases Consultation Rates for Staphylococcus aureus Bacteremia.

Introduction:Staphylococcus aureus bacteremia (SAB) in children is associated with significant mortality and morbidity, including recurrent bacteremia. Infectious disease consultation (IDC) improves SAB outcomes in adult patients. However, increasing IDC and impact for pediatric patients with SAB is not well described.Methods:This quality improvement project aimed to increase IDC for SAB events at a quaternary pediatric medical center. First, we evaluated the local practices regarding pediatric SAB and engaged stakeholders (July 2018–August 2020). We added an advisory comment supporting IDC for SAB to all blood culture results in September 2020. Using statistical process control charts, we monitored the number of SAB events with IDC before a SAB event without IDC. Finally, we evaluated SAB recurrences before and after initiating the advisory comment.Results:In the baseline period, 30 of 49 (61%) SAB events received an IDC with a mean of 1.4 SAB events with IDC before a SAB event without IDC. Postintervention, 22 of 23 (96%) SAB events received IDC with a mean of 14 events with IDC before 1 event without IDC. The SAB recurrence rate was 8%, with 6 events in 4 children; none of the index cases resulting in recurrence received an IDC (P = 0.0002), and all occurred before any intervention.Conclusions:An electronic advisory comment supporting IDC for SAB significantly increased the rate of pediatric IDC with no further SAB recurrence episodes following intervention. This low-resource intervention may be considered in other pediatric centers to optimize SAB management.

Impact of an anti-infective screening and monitoring protocol together with infectious disease consultation in preventing infective adverse events in patients treated with anti-CD20/CD52 agents for multiple sclerosis

BackgroundMonoclonal antibodies have been a milestone in the treatment of multiple sclerosis (MS). Infective complications have been observed in patients on agents targeting lymphoid cells’ surface antigens, namely anti-CD52 (alemtuzumab) and anti-CD20 agents (ocrelizumab and rituximab). Despite increasing emerging data, there is no standardized consensus regarding pre-treatment testing, vaccinations, and patient education before and during MS therapy or optimal infection-control strategies. MethodsWe led a retrospective/prospective real-life study to evaluate the effectiveness of a program of screening and prophylaxis for infective adverse events in patients with multiple sclerosis and related disorders treated with drugs directed against CD20/52 antigens. All patients referring to the MS Clinical Care and Research Center, University of Naples “Federico II”, who started on alemtuzumab, ocrelizumab or rituximab (off-label use) from 1 November 2015 to 30 June 2019 were recruited. From the 1st of February 2018 patients underwent a microbiological screening and were evaluated by an infectious disease specialist (IDs) before monoclonal antibodies infusion to rule out active infections. We evaluated incidence of infective complications and predictors before (retrospectively)and after (prospectively) the introduction of the above-mentioned anti-infective program. ResultsWe enrolled 275 patients, 104 retrospectively (pre-intervention group, PRE) and 171 prospectively (post-intervention group, POST). In PRE group, most patients were treated with alemtuzumab (58% vs 32%, p < 0.001), were more frequently DMT naïve (48% vs 36%, p = 0.044) or had received fingolimod in the past (48% vs 28%, p = 0.044) and the follow-up period was longer than in POST group (750 vs 191 days, p < 0.001). In POST group, patients were older (median age 47 vs 42 years, p = 0.030) and mostly received OCR (54% vs 14%, p < 0.001). Lymphopenia at baseline was significantly more commonly observed in PRE arm (47% vs 8%, p < 0.001). A total of 39 patients (38%) in PRE arm and 42 patients (25% in POST) group experienced one or more infections (p = 0.022); severe infections were significantly more common in PRE patients (23% vs 14%, p = 0.022). Our anti-infective program was associated with a lower IAE incidence both at univariate and multivariate analysis (aHR of infective events in PRE group: 3.652 [CI: 9.03-94.19], p < 0.001). Moreover, DMT naïve patients significantly experienced fewer infective complications (aHR: 0.470, [CI: 1.02-2.55], p = 0.040). ConclusionsA risk mitigation program including infectious disease consultation and standardized screening and prophylactic protocols was effective in reducing infective adverse events in patients receiving anti CD20/CD52 agents for MS.

Impact of Infectious Diseases Consultation on the Outcome of Patients With Enterococcal Bacteremia: A Systematic Literature Review and Meta-analysis.

BackgroundEnterococcal bacteremia carries significant mortality. While multiple studies have evaluated the impact of infectious disease consultation (IDC) on this condition, these studies were limited by the low numbers of patients enrolled. This systemic literature review and meta-analysis was conducted to determine whether IDC is associated with a mortality benefit among patients with enterococcal bacteremia.MethodsWe performed a systematic literature search using 5 databases for studies evaluating IDC among patients with enterococcal bacteremia. We conducted a meta-analysis to assess whether IDC was associated with reduced mortality. Random-effects models were used to calculate pooled odds ratios (pORs). Heterogeneity was evaluated using I2 estimation and the Cochran's Q statistic test.ResultsThe systematic literature review revealed 6496 reports, from which 18 studies were evaluated in the literature review and 16 studies in the meta-analysis. When all studies were pooled, the association between IDC and mortality was not statistically significant with a pOR of 0.81 (95% CI, 0.61–1.08) and substantial heterogeneity (I2 = 58%). When the studies were limited to those reporting multivariate analysis including IDC, there was a significant protective effect of IDC (pOR, 0.40; 95% CI, 0.24–0.68) without heterogeneity (I2 = 0%). Some studies also showed additional benefits to IDC, including appropriate antibiotic therapy and improved diagnostic use.ConclusionsIDC was associated with 60% lower odds of mortality when patients were well-matched, potentially through improvement in the care of patients with enterococcal bacteremia. IDC should be considered part of routine care for patients with enterococcal bacteremia.

The Expanding Role of the Infectious Disease Expert in the Context of the MS Centre.

Introduction: The complexity of the MS patient’s management is constantly growing. Consequently, the MS care unit requires a multidisciplinary approach, including an infectious disease specialist to minimise the risk of infectious complications related both to the disease and DMTs. Materials and methods: We retrospectively evaluated the infectious disease consultations performed from 2015 to 2019 in our MS centre. Results: We identified 107 patients with at least one infectious disease consultation out of 1088 patients. We found a progressive increase in the number of consultations from 2015 to 2019. Nearly half of the consultations were requested at the time of starting MS treatment. The most frequent requests were represented by chronic or acute infections. The most prevalent infectious agents were Herpesviridae and Mycobacterium tuberculosis. Antibiotic or antiviral treatment and prophylactic treatment or vaccination represented together the most frequent outcomes of the consultations. Finally, a treatment delay was significantly associated with the advice of a prophylactic treatment or of a vaccination. Conclusion: There is an increasing awareness of the potential infectious complications of MS and of exposure to DMTs. The interaction between the MS neurologist and infectious disease specialist is fundamental to minimise the infectious risk related to the disease and to the DMTs, with a progressive shift from complication management to a broader prevention workup at the time of MS diagnosis, including both vaccination and prophylactic treatments.

707 Invasive Non-Candida Fungal Infections in Acute Burns: A 13-Year Review of a Single Institution

IntroductionBurn patients have higher infection rates due to loss of the protective skin barrier. The past decade shows increased rates of burn infection with atypical invasive fungal organisms. After a recent trend of life-threatening atypical fungal burn infections at our hospital, we conducted this study to further characterize this.MethodsWe identified patients admitted to our burn center from January 2008 to June 2021, who developed fungal non-Candida burn infections while admitted. We gathered demographic data, burn injury details, surgical treatment course, and fungal and bacterial infection data. Descriptive statistics were used to characterize the data and identify trends.ResultsWe identified 37 acute burn patients with atypical invasive fungal infections. Of these, 28 were infected with 1 species, and 9 were infected with multiple fungi.Non-Candida fungi included Aspergillus (20), Fusarium (8), Mucor (6), and 11 other species. Three fungi were resistant to antifungals including amphotericin B. Other organisms included Candida (18), Enterococcus (13), Pseudomonas (9), and 19 other species. On average, patients were infected with 5 bacteria, had 13 antibacterial resistances, and required 6.5 antibacterials. There was one case of total-drug-resistant Pseudomonas aeruginosa. Every patient required Infectious Disease consultation. Eight patients became bacteremic and 1 became fungemic.The average burn surface area was 35%. All patients required excisional treatment, with an average of 7 excisions, 7 coverage procedures, and 3.5 other procedures; 44% of patients required amputations for infection control. The most common complications were graft loss (39%), ventilator-associated pneumonia (28%), and death (28%). The median length of stay was 40 days (IQR = 89) for survivors and 28 days (IQR = 14) for nonsurvivors. All fatalities were from overwhelming polymicrobial infection. The average modified Baux score was 73 (± 28) for survivors and 102 (± 38) for nonsurvivors. All nonsurvivors had clean wounds without penetrating trauma.ConclusionsBurn patients with atypical invasive fungal infections have severe polymicrobial infections and extreme antibiotic resistance. Patients may require, or fail, treatment with last-line antibiotic therapy and amputation. Early Infectious Disease consultation and aggressive treatment is critical. Further research may elucidate risk factors and ideal treatment patterns.

Evaluation of an Infectious Diseases Elective for Early Clinical Medical Students on Their Internal Medicine Clerkship.

BackgroundEarly medical subspecialty training is an emerging trend in medical education. These electives are still rare for Early Clinical Medical Students (ECMS). We describe the introduction of an Infectious Disease (ID) inpatient consult rotation elective for ECMS.MethodsIn addition to seeing patients and rounding with the inpatient ID consult team, we created a supplemental curriculum to provide added support for ECMS that included a checklist of clinical skills learning objectives, self-directed, publicly available mini-lectures on ID topics, and an ID Coach who provided directed and personalized tutoring for students. We surveyed ECMS, ID fellows and attendings on service, and ID Coaches to evaluate the acceptability, feasibility, and effectiveness of this rotation and curriculum.ResultsThe majority of ECMS reported that the rotation was a useful educational experience and that the ID Coach was one of the most valuable aspects of the rotation. The majority of ID fellows and attendings reported that working with ECMS improved their job satisfaction and well-being.ConclusionsThis multifaceted approach to early medical subspecialty training was valuable for ECMS, ID fellows, and faculty. Ongoing improvements in this curriculum will provide a useful tool for medical education.

A five-year retrospective descriptive study on the clinical characteristics and outcomes of candidaemia at a tertiary hospital in South Africa

ObjectivesTo describe the clinical features, microbiological profiles and outcome of patients with candidaemia at a tertiary hospital in South Africa. MethodsA retrospective study of blood cultures isolating Candida species at Tygerberg Hospital from 2014 to 2019. ResultsWe identified 108 patients with candidaemia. The most frequent species cultured were Candida albicans (51; 47.2%) followed by C glabrata (32; 29.6%), C parapsilosis (11; 10.2%), then C tropicalis (5; 4.6%). No treatment was given in 31 patients (28.7%), of whom 22 (71%) demised. Few patients were screened for complications. Of 14 screened by ophthalmoscopy, none had complications of ophthalmitis, 1 of 23 who underwent echocardiography had infective endocarditis, and 1 of 3 screened had hepatosplenic abscess. Case fatality rate was 59 of 108 (55%). Multivariable logistic regression for predictors of mortality showed that patients with diabetes mellitus were twice as likely to die from candidaemia (odds ratio (OR) 2.43; P=0.079). Failure to consult with Infectious Diseases increased the likelihood of mortality 3 times (OR 2.99; P=0.041). ConclusionsThe all-cause mortality of patients with candidaemia was high. Many patients did not have follow up on blood cultures performed, were not screened for complications, nor had antifungal treatment. The study highlighted the role of Infectious Diseases consultation for candidaemia.

Improving Antibiotic Stewardship for Inpatients with Reported Beta-Lactam Allergies and Limited Access to Penicillin Skin Testing.

Penicillin allergy is commonly reported, but true allergy is rare. Inpatients with reported beta-lactam allergy are often treated with alternative antibiotics. Penicillin skin testing (PST) is not universally available for inpatients. We designed a four-phase quality improvement project aimed to increase the percentage of inpatients on medical services with reported beta-lactam allergy who safely receive beta-lactam antibiotics at two hospitals with limited access to PST. First, we updated our hospital guideline to allow for cephalosporin graded challenge without antecedent PST. Second, we educated physicians, physician assistants, and nurses about the new guideline and beta-lactam allergy classification and management. Third, we designed a pocket card to reinforce the education. Last, we used antimicrobial stewardship software to screen our daily census to identify opportunities to improve management of patients with reported beta-lactam allergies. We observed a 29.2% increase in the percentage of patients who received beta-lactam antibiotics (excluding carbapenems) among those with reported beta-lactam allergy, from 42.2% (470/1,115) at baseline to 54.5% (379/696), p < 0.001, during the project period. There was a decrease in the use of alternative antibiotics, no change in hospital-onset Clostridioides difficile cases, and no increase in the number of infectious disease or allergy consults. The number of graded challenges increased during the project period, without any anaphylaxis events. A multiphase quality improvement project aimed to improve management of beta-lactam allergies and access to graded challenges led to an increase in beta-lactam utilization without an increase in anaphylaxis, even with limited access to PST.

P13 Development of a consult and antimicrobial stewardship service in Manchester Foundation Trust

ObjectivesTo prospectively audit the first year of the North Manchester infectious diseases AMS and Consult service June 2020 to June 2021 to: (i) characterize the number of patients who had antibiotic treatment narrowed, duration reduced and/or switch to oral options; (ii) assess documentation of indication and duration of antibiotic prescriptions; (iii) determine whether or not the appropriate microbiological specimens have been performed and with the lab; (iv) identify the impact on antibiotic consumption measured in defined daily dose (DDDs); and (v) establish whether base teams act on the advice given by the Consult/AMS team (data over a 6 week period).MethodsOn weekdays an electronic prescribing list of all patients prescribed piperacillin/tazobactam, meropenem and ciprofloxacin was generated, and the consults team performed either a bedside or notes review. Data was collected prospectively on 730 patients on which infection was treated, which specialty managed the patient, microbiology samples sent, duration and indication of treatment documentation, and advice given by consults team. Data was then collected over a further 6 weeks looking at whether the base specialty carried out the advice of the AMS team.ResultsThe main indication for broad spectrum antibiotic use was urinary tract infection (151/720) and hospital acquired pneumonia (104/720). Poor documentation of antimicrobial indication and duration was observed across all specialties (277/720). Just over 50% of appropriate microbiology samples were sent (422/726). For 42% of cases (311/730), colleagues were advised to stop or reduce antibiotic duration. In 30% of cases (220/730), narrowing of antibiotic spectrum was advised. Thirty percent (219/730) were advised on IV to oral switch. There was a modest reduction in antimicrobial consumption in some specialties comparing the year prior to the introduction of the service 2019–20 to 2020–21; 17.4% reduction respiratory (7810/9137), 0.2% increase in medicine (272698/267351) and 2.1% surgery (68722/67309). In 81 patients reviewed to look at outcomes over 6 weeks, 88% of Consult/AMS team advice was actioned by the lead specialties involved in the patients’ care.Conclusions(i) There is a substantial need for an AMS service within the hospital. (ii) Outcome data shows the ward teams engage with the service and most follow advice. (iii) The service contributed to limiting inappropriate prescribing during the COVID-19 pandemic. There was a modest rise in hospital-wide consumption. (iv) The AMS service needs to be available to provide patient equity across Manchester Foundation Trust, fostering a city-wide AMS strategy that encompasses education, guidelines, audit and quality improvement.

The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals’ knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September–October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: ‘Knowledge’; ‘Social/professional role and identity’; ‘Social influences’; ‘Memory, attention and decision processes’; ‘Beliefs about consequences’; ‘Environmental contexts and resources’. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

Clinico-Pathological Correlations of Poststreptococcal Glomerulonephritis

Abstract Postinfectious glomerulonephritis is associated with bacterial, viral, fungal, and parasitic infectious agents and histologically appears most often as acute diffuse endocapillary or proliferative glomerulonephritis secondary infection with: group A streptococcus, streptococcus viridans, staphilococus aureus, diploccocus pneumoniae, Brucella melitensis, Salmonella typhi, Yershinia enterocolitica, Plasmodium falciparum, meningococcus, Mycoplasma, Klebsiella, varicella, variola, mumps. Less commonly, it appears as diffuse crescentic glomerulonephritis and a lot of infectious causes are incriminated like: streptococcus, legionella, varicella, Treponema pallidum or as focal crescentic glomerulonephritis: streptococcus A. It rarely appears as mesangiocapillary glomerulonephritis secondary infection with: streptococcus viridans, hepatitis C virus; diffuse or focal mesangial proliferative glomerulonephritis: hepatitis B virus, salmonella, adenovirus, influenza virus, salmonella; focal segmental, necrotizing and sclerosing glomerulonephritis: bacterial endocarditis; membranous glomerulonephritis: hepatitis B virus, syphilis, filarial, Mycobacterium, plasmodium falciparum; focal proliferative: Mycoplasma; mesangiolytic glomerulonephritis :Echo virus. Poststreptococcal glomerulonephritis (PSGN) is caused by prior infection with specific nephritogenic strains of group A beta-hemolytic streptococcus. The clinical presentation of PSGN varies from asymptomatic, microscopic hematuria to the full-blown acute nephritic syndrome, characterized by red to brown urine, proteinuria (which can reach the nephrotic range), edema, hypertension, and acute kidney injury. The prognosis is generally favorable, especially in children, but in some cases, the long-term prognosis is not benign. Managing a case of PSGN requires cooperation between internists, nephrologists, infectious disease consultants, pharmacists, and nursing staff, functioning as an interprofessional team, to provide excellent care for their patients.

Editorial introductions.

Editorial introductions.

Trends in Antimicrobial Allergies in Patients Seen in Infectious Disease Consultation During Selected Periods 2007–2016

Background Antimicrobial allergies and adverse reactions limit patient treatment options. “Antibiotic allergy” labeling drives broader, more toxic, and/or parenteral therapy. Published allergy data may be decades old over which time antibiotic usage has changed with newer agents introduced and greater use of several older ones. Some patient allergy designations are inaccurate; many are not true hypersensitivity. Electronic health records (EHRs) promote collection of allergy information but could inflate numbers as data are repetitively elicited and recorded. Objectives This study measured antimicrobial allergy prevalence in hospitalized adults and determined how EHR implementation affected data. Methods Retrospective chart reviews were conducted on 750+ adults seen in community teaching hospital infectious diseases consultation during each of three 6-month periods in 2007–2008, 2011–2012, and 2015–2016. Dates correspond to pre-EHR, after nursing data entry started, and after physician order entry and full electronic recordkeeping. Total antibiotic and nonantibiotic allergies were compiled and factors in recording these tracked. Results Penicillin (20.5%–22%), cephalosporin (8%–10.2%), sulfa (12%–14.1%), and fluoroquinolone (5.4%–8.9%) allergy frequencies were high. Antibiotic allergy rates were stable from 2007–2008 to 2015–2016 due to most repetitive listings being made “inactive.” However, median total drug allergies rose from 0 to 1 per patient (P &lt; 0.01) and multiple drug intolerance (&gt;3 unrelated drugs) increased. Conclusions Overall allergy rates for several antimicrobials were high but stable over study period; nonantibiotic allergies rose. Multidisciplinary allergy documentation is crucial in accurate data collection. Antibiotic-allergic and multiple drug intolerant patients are a good focus for prospective allergy education and “delabeling” programs.

Effects of infectious disease consultation and antimicrobial stewardship program at a Japanese cancer center: An interrupted time-series analysis.

In cancer patients, appropriate diagnosis and management of infection are frequently challenging owing to subtle or atypical presentation. We investigated the effectiveness of infectious disease (ID) consultations and the Antimicrobial Stewardship Program (ASP) in a Japanese cancer center. This 36-month-period, single-institution, interrupted time series analysis was retrospectively conducted during April 1, 2018-March 31, 2021, to evaluate a two-phase intervention: Phase 1 (notification of antimicrobials by the infection control team) and Phase 2 (establishing an ID consultation service and implementing ASP). Among 32,202 patients hospitalized, 22,096 and 10,106 hospitalizations occurred at baseline and during intervention period, respectively. The Antimicrobial Stewardship Team (AST) provided feedback on specific broad-spectrum antimicrobials in 913 instances (347 appropriate [38%]; 566 inappropriate [62%]), and 440 ID consultations were completed, with a 75% overall acceptance rate for AST suggestions. In Phase 2, monthly carbapenem days of therapy (CAR-DOT) decreased significantly, and narrow-spectrum antibiotic usage increased significantly in both trend and level; monthly DOT of antipseudomonal agents decreased significantly in trend. The results of these analyses of antimicrobial use are consistent with the DOT-based data based on antimicrobial use density (AUD). The total number of inpatient specimens increased significantly; the trend of multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus infections decreased, without changes in the incidence of other resistant organisms, all-cause in-hospital mortality, and length of stay. Actual and adjusted CAR purchase costs per patient-day decreased without significant changes in the actual and adjusted purchase cost per patient-day for all intravenous antimicrobials. Combining ID consultation and ASP reduced carbapenem use without negative patient outcomes. Their implementation could facilitate establishment of safe cancer treatment facilities in Japan and improve prognosis in cancer patients.