Infectious Diseases Consultation Research Articles

1947. Educational Impact of a Hybrid Infectious Diseases Rotation for Internal Medicine Residents

BackgroundTraditional infectious diseases (ID) rotations for internal medicine (IM) residents focus on inpatient consultation, potentially skewing trainees’ perspectives on ID. We report our experience with a hybrid inpatient–outpatient ID rotation which provides broader ID clinical exposure and an effective venue for educational innovation.MethodsWe included all IM residents completing an assigned ID rotation in the UT Southwestern IM residency since July 2013. From July 2013 to June 2017, a 4-week ambulatory ID (Amb ID) rotation, consisting of general and subspecialty ID clinics and weekly teaching sessions focused on ID board review, was offered in parallel to traditional inpatient ID consult rotations. From July 2017 to present, all assigned residents complete up to a 4-week ID hybrid rotation, consisting of 2 weeks of ambulatory ID and 2 weeks of inpatient ID consults, with all residents receiving weekly teaching sessions; in some cases, the 4 weeks were not completed sequentially. Data were collected on resident numbers and training level, quantitative and qualitative course evaluations, and program in-training examination scores in ID content areas.ResultsFrom July 2013 to June 2019, IM residents completed a total of 626 ID rotations, an average of 104 per year (Table 1). A sample ID hybrid schedule is shown in Table 2. Overall resident satisfaction with the ID hybrid rotation was 4.7 (std. dev. 0.7) on a 5-point Likert scale. This rotation has consistently been among the highest rated rotations by residents. In-training examination ID scores increased significantly with creation of the Amb ID rotation in 2013 and further increased since 2017 with creation of the ID hybrid, in which both inpatient and ambulatory residents receive the weekly teaching sessions (Figure 1). Pilot educational innovations through this rotation include an online web-based antibiotic stewardship curriculum (2014–2015) and a mobile app-based ID board review platform utilizing spaced interval learning (2018–2019).ConclusionA hybrid inpatient–outpatient ID rotation for IM residents has proven to be a highly effective platform for ID education and curriculum innovation at our institution. This concept could be exported to other institutions and increase IM resident interest and breadth of clinical exposure in ID. DisclosuresAnk E. Nijhawan, MD, MPH, Gilead Sciences, Inc.: Research Grant.

Appropriateness of antimicrobial prescribing in a Swiss tertiary care hospital: a repeated point prevalence survey.

Inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance and adverse events. Antimicrobial stewardship programmes may both optimise treatment of infections and reduce antimicrobial resistance but are implemented in only a minority of Swiss hospitals. In addition, data on prescribing patterns and quality are scarce. We conducted a repeated point prevalence survey to evaluate the quality of antimicrobial prescribing in a single tertiary care centre. Antimicrobial use was audited twice (summer 2017 and winter 2018) among all patients admitted to the University Hospital Basel, Switzerland. Data were collected from the electronic health record. Appropriateness of antimicrobial use was evaluated according to previously published rules and local national guidelines. We evaluated 1112 patients of whom 378 (34%) received 548 prescriptions in total (30% for prophylaxis). Penicillins with β-lactamase inhibitors were most commonly used (30%), followed by cotrimoxazole (12%) and ceftriaxone (7%). Intravenous administration was chosen in 56% of patients. Prior to antimicrobial therapy, blood cultures were collected in 69% of patients. Overall, 182 (33%) prescriptions were not appropriate; reasons included lack of indication (11%), incorrect dosing (7%), delay in intravenous to oral switch (9%) or non-adherence to local guidelines (15%). A minority of patients received antimicrobials despite documented allergies (2%). Almost 38% of empirical prescriptions were inappropriate, compared with only 19% of prophylactic and 20% of targeted prescriptions. Penicillins with β-lactamase inhibitors and cephalosporins were most commonly involved in inappropriate prescribing (>50%) followed by carbapenems (30%), narrow-spectrum penicillins (17%) and cotrimoxazole (6%), with oral administration being involved less frequently than intravenous administration (15 vs 37%). Infectious diseases consultation and presence of immunosuppression were associated with reduced odds (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.21–0.70 and OR 0.31, 95% CI 0.17–0.54, respectively) of inappropriate prescription in the per-patient multivariable analysis, whereas being admitted to a surgical or intensive care unit was associated with increased odds (OR 1.83 and 5.67) compared with a medical unit. Almost one third of prescriptions were inappropriate in our tertiary care centre despite local guidelines and an on-demand infectious diseases consultation service. Our results underscore the need for expanding current antimicrobial stewardship efforts, including national initiatives such as stewardship and prescribing guidelines, repeated surveys and identification of areas for improvement including timely intravenous to oral switches in order to reduce the consequences of inappropriate prescribing and of multidrug resistant organisms.

Early Infectious Disease Consultation Is Associated With Lower Mortality in Patients With Severe Sepsis or Septic Shock Who Complete the 3-Hour Sepsis Treatment Bundle.

ObjectiveSevere sepsis and septic shock (SS/SS) treatment bundles reduce mortality, and early infectious diseases (ID) consultation also improves patient outcomes. We retrospectively examined whether early ID consultation further improves outcomes in Emergency Department (ED) patients with SS/SS who complete the sepsis bundle.MethodWe included 248 adult ED patients with SS/SS who completed the 3-hour bundle. Patients with ID consultation within 12 hours of ED triage (n = 111; early ID) were compared with patients who received standard care (n = 137) for in-hospital mortality, 30-day readmission, length of hospital stay (LOS), and antibiotic management. A competing risk survival analysis model compared risks of in-hospital mortality and discharge alive between groups.ResultsIn-hospital mortality was lower in the early ID group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25–0.89; P = .02). There was no significant difference in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived. A trend toward shorter time to antibiotic de-escalation in the early ID group (log-rank test P = .07) was observed. Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36–1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11–2.23; P-value .01) after adjustment.ConclusionsAmong patients receiving the SS/SS bundle, early ID consultation was associated with a 40% risk reduction for in-hospital mortality. The impact of team-based care and de-escalation on SS/SS outcomes warrants further study.

Endophthalmitis Related With Infectious Uveitis: Clinic, Diagnosis, Treatment

Metastatic endogenous endophthalmitis is a rare but serious ocular infection by seeding of bacteria or fungi into the eye from a source elsewhere in the body. Studies suggest that endogenous endophthalmitis accounts for 2 to 8% of all endophthalmitis. In North America and Europa, the most identified causative bacteria are Staphylococcus aureus and Streptococcus pneumonia, while in East Asia, Klebsiella pneumonia is chiefly responsible. Among fungal etiologies; Candida albicans is the most common yeast, and Aspergillus is the most common mold. Major risk factors are immunocompromised states (for example, chronic corticosteroid use, malignancy, end-stage liver / renal disease, organ transplant, diabetes mellitus), intravenous drug use and indwelling catheter. A key diagnostic finding is the presence of white infiltrate originating in the choroid and sometimes erupting in the vitreous cavity. The fundus may be obscured because of vitreous haze or vitritis. Patients' presentation and history are important in diagnosis. Depending on the suspected primary locus of infection, blood, urine, and other cultures are done. Also, a vitreous tap must be obtained. Hospitalization, infectious disease consultation, systemic therapy with antibiotics or antifungals should be started. Then, aggressive intravitreal antibiotic therapy, with or without pars plana vitrectomy, should be added to the regiment Early diagnosis is crucial because of delay of treatment is the factor most associated with poor visual prognosis.

EOSINOPHILIA AND DYSPNEA: NOT ALWAYS AN ASTHMA EXACERBATION

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Eosinophilia is a common laboratory finding in patients diagnosed with asthma, however combined with dyspnea and a chronic cough, other diagnoses can be overlooked.. Chronic eosinophilic pneumonia is characterized by a chronic and progressive course similar to worsening asthma with the addition of specific pathologic findings. Here we present a case of a patient with known asthma who presented with progressively worsening cough, shortness of breath and eosinophilia. CASE PRESENTATION: A 46-year-old male with a history of asthma presented to the emergency department (ED) with worsening shortness of breath at both rest and exertion for two months. The patient had associated wheezing, thick yellow sputum and rhinorrhea. At presentation he also noted a two-week history of night sweats with a ten pound weight loss. Prior to presentation the patient underwent a chest x-ray and was treated for two weeks with antibiotics. for presumed pneumonia. The patient then underwent a repeat chest x-ray and was subsequently referred for chest CT. In the ED the patient was noted to have leukocytosis of 34 K/uL with 23.2 K/uL eosinophils (68.2%) Chest X-Ray demonstrated patchy air-space opacities with a predominantly mid to upper lung zone distribution. The patient was started on methylprednisolone, ceftriaxone, and azithromycin for community acquired pneumonia and was seen by the pulmonary and infectious disease consultants. The patient was tested for angiotensin converting enzyme, P-ANCA, Aspergillus, HIV, and tuberculosis, all of which were negative. The patient clinically improved and antibiotic therapy was discontinued. Three days after admission a repeat CXR, showed improved bilateral pulmonary parenchymal abnormalities. The patient’s eosinophilia resolved within three days and the patient continued to clinically improve with a tapering course of steroid therapy. DISCUSSION: Chronic eosinophilic pneumonia (CEP)is characterized by chronic and progressive clinical features and specific pathological findings. The onset of CEP is generally insidious, either subacute or chronic. Accordingly, the symptoms often appear several months before the diagnosis is made. The diagnosis of CEP is based on the association of respiratory symptoms, alveolar or blood eosinophilia, a non-segmental pulmonary infiltration with peripheral predominance involving mainly the upper lobes on chest imaging and the exclusion of other eosinophilic lung diseases. Corticosteroid treatment results in rapid resolution of symptoms, radiologic opacities and peripheral eosinophilia as occurred in our case. CONCLUSIONS: This case demonstrates the need for physicians to broaden their differential diagnoses when considering the etiology of eosinophilia in patients with a history of asthma. Reference #1: https://www.uptodate.com/contents/chronic-eosinophilic-pneumonia?search=chronic%20eosinophilic%20pneumonia&source=search_result&selectedTitle=1∼37&usage_type=default&display_rank=1 DISCLOSURES: No relevant relationships by Jang Chadha, source=Web Response No relevant relationships by Yelenis Fuertes Yanes, source=Web Response No relevant relationships by Nida Hameedi, source=Web Response

2744 A Scary Case of Gastroenteritis

INTRODUCTION: Gas in the gastric venous system or the portal venous system is a critical finding and can be from a life threatening abdominal catastrophe as well as from benign conditions. CASE DESCRIPTION/METHODS: A 52 year old gentleman presented with nausea, vomiting and diarrhea for 2 days. He had multiple episodes of non bloody diarrhea for past two days and had an episode of vigorous non bilious/ non bloody vomiting. No fevers, chills or weight loss was reported. His medical history included diabetes mellitus type 2, hypertension, obstructive sleep apnea, depression and anxiety. On admission, his vitals were stable. The physical examination was completely benign. His laboratory data revealed mild leukocytosis of 13.3. Lactate was normal. There was no anemia or microcytosis. A CT scan of his abdomen was done which revealed gas in the gastric veins and the peri-gastric veins, which was very concerning. Urgent Surgical consultation was placed. The patient was admitted to step down unit and conservative management with hydration, anti emetics and supportive care was initiated. In the next 4 hours, the patient started feeling better and became asymptomatic. The CT of the abdomen was repeated. The entire patient care team was on high alert for a possible abdominal catastrophe/ischemia and need for emergent surgery. The repeat CT scan was done 6 hours later which revealed linear lucencies within the peripheral aspect of the left lobe of the liver, consistent with gas within the portal venous system. Urgent Infectious Disease consultation was called and piperacillin-tazobactam was initiated. At this time, the patient was asymptomatic, his vitals were stable, the lactate remained normal and the leukocytosis had resolved in the repeat laboratory analysis. Close monitoring was continued. The next day, the patient remained in the stable and asymptomatic. A third repeat CT scan of the abdomen revealed complete resolution of all the gas in the gastric and the portal venous system. The diet and activity were advanced gradually and the patient was discharged the same day. DISCUSSION: It is important to recognize that there are many benign causes of gastric venous gas and portal venous gas such as gastroenteritis. We believe that the mechanical trauma of retching and vigorous vomiting may have lead to this finding.

Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study

Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections. In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management. Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p<0·0001). In the model with inverse weighting by the propensity score, infectious disease consultation was associated with a hazard ratio of 0·81 (95% CI 0·73-0·91; p<0·0001) for mortality. In the consultation group, median duration of antifungal therapy was longer (18 [IQR 14-35] vs 14 [6-20] days; p<0·0001) and central-line removal (587 [76%] of 776 vs 538 [59%] of 915; p<0·0001), echocardiography use (442 [57%] of 776 vs 305 [33%] of 915; p<0·0001), and ophthalmological examination (412 [53%] of 776 vs 160 [17%] of 915; p<0·0001) were more frequently done. Fewer patients in the infectious disease consultation group were not treated (13 [2%] of 776 vs 128 [14%] of 915; p<0·0001). Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection. Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

Infectious disease consultation lowers candidaemia mortality

Infectious disease consultation lowers candidaemia mortality

Learning Experiences Within Infectious Diseases Pharmacy Residency Programs in the United States: A Cross-Sectional Survey.

BackgroundPharmacists with residency training in infectious diseases (ID) optimize antimicrobial therapy outcomes in patients and support antimicrobial stewardship (AS) programs. Although most ID residencies are accredited and assessed by certain standards, the degree to which these programs are similar is not known.MethodsA 19-item, cross-sectional, multicentered, electronic survey was distributed via e-mail to pharmacy residency program directors (RPDs) of all 101 second-year postgraduate (PGY-2) ID residency programs in the United States.ResultsSurvey responses were collected from 71 RPDs (70.3%); 64.8% were associated with an academic medical center and 97.2% focused primarily in adult ID. Rotations in the microbiology laboratory, adult AS, and adult ID consult were required in 98.6% of residency programs. Only 28.2% of responding programs required pediatric AS and pediatric ID consult rotations. Programs at academic medical centers were more likely to offer immunocompromised host ID consult (P = .003), pediatric ID consult (P = .006), and hospital epidemiology (P = .047) rotations but less frequently offered outpatient AS (P = .003), viral hepatitis clinics (P = .001), and travel medicine clinics (P = .007) rotations compared to programs at nonacademic medical centers. Residents were frequently involved in AS committees (97.2%), pharmacokinetic dosing of antimicrobials (83.1%), precepting pharmacy trainees (80.3%), and performing research projects (91.5%).ConclusionsThe PGY-2 ID pharmacy residency programs demonstrated consistency in required adult ID consult, antimicrobial management activities, committee service, and teaching and research opportunities. Pediatric experiences were less common. The PGY-2 ID residency programs prepare pharmacists to become antimicrobial stewards for adult patients.

Impact of a Telehealth-Based Antimicrobial Stewardship Program in a Community Hospital Health System.

Data on antimicrobial stewardship programs (ASPs) facilitated via telehealth in the community hospital setting are limited. A telehealth-based ASP was implemented in 2 community hospitals (285 and 176 beds). Local pharmacists without residency or prior antimicrobial stewardship training were trained to conduct prospective audit and feedback. For approximately 60 minutes 3 times weekly at the 285-bed hospital and 2 times weekly at the 176-bed hospital, infectious diseases (ID) physicians remotely reviewed patients on broad-spectrum antibiotics and those admitted with lower respiratory tract infections and skin and soft tissue infections with local pharmacists. Recommendations for ASP interventions made by ID physicians were relayed to primary teams and tracked by local pharmacists. Antimicrobial utilization was collected in days of therapy (DOT) per 1000 patient-days (PD) for a 12-month baseline and 6-month intervention period, and analyzed with segmented linear regression analysis. Local ID consultations were tracked and antimicrobial cost savings were estimated. During the 6-month intervention period, 1419 recommendations were made, of which 1262 (88.9%) were accepted. Compared to the baseline period, broad-spectrum antibiotic utilization decreased by 24.4% (342.1 vs 258.7 DOT/1000 PD; P < .001) during the intervention period. ID consultations increased by 40.2% (15.4 consultations per 1000 PD vs 21.5 consultations per 1000 PD; P = .001). Estimated annualized savings on antimicrobial expenditures were $142 629.83. An intense ASP model, facilitated in the community hospital setting via telehealth, led to reduced broad-spectrum antimicrobial utilization, increased ID consultations, and reduced antimicrobial expenditures.

Infectious diseases pre-transplant evaluation improves vaccination rates for liver transplant candidates.

Immunization rates in pre-liver transplant patients have been historically below rates for immunocompetent patients. At Cleveland Clinic, an infectious diseases (ID) consult is required for all patients during the liver transplant evaluation and may beneficially impact vaccination rates. The goal of this study was to evaluate pre-transplant vaccination rates in pre-liver transplant candidates. This single-center, retrospective chart review included adults transplanted between January 1, 2013, and December 31, 2016. Prior to transplant, rates of vaccination and/or documented seropositivity were 35% for hepatitis B vaccine, 92% for hepatitis A vaccine, 57% for pneumococcal conjugate vaccine, 62% for pneumococcal polysaccharide vaccine, and 77% for influenza vaccine. Vaccination rates were higher than to previously reported. Rates were also higher for several vaccines compared to transplant candidates for other organs without ID consult. With ongoing ID consult requirements for liver transplant candidates, combined with standardization of vaccine recommendations via technology, and increased multi-disciplinary collaboration, vaccination rates should improve further.

Use of antibiotics among end-of-life hospitalized patients with advanced directives: Status examination and association with infectious disease consultation and physician burnout

Overuse of antibiotics in end-of-life patients with advanced directives increases bacterial resistance and causes morbidity and mortality. Consultations with infectious disease (ID) physicians and burnout, which can affect antibiotic days of therapy (DOT) prescribed by physicians, have not been examined so far. To assess antibiotic use by physicians in end-of-life (EOL) patients with advanced directives and to investigate the association between ID consultations, physician burnout, and antibiotic DOT in those patients. A descriptive correlational study. Acute-care and post-acute-care hospitals. The study included 213 physicians and 932 their hospitalized patients in the last 2 weeks of life. We distributed questionnaires and analyzed the data collected regarding ID consultation, EOL antibiotics prescription with and without an advanced directive, and physician burnout to 278 physicians, and 213 were completed (response rate 76%). Of the 932 deaths, 435 of 664 (>50%) were EOL patients with advanced directives. Of these patients, 74% received antibiotics, 29.9% had bacterial resistance cultures, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues and had significantly fewer consultations with ID physicians in EOL patients with advanced directives (mean rate, 0.27) than those without advanced directives (mean rate, 0.47). ID physicians reported significantly higher emotional exhaustion levels (mean rate, 29) than other medical specialties (mean rate, 19.2). Antibiotic DOT was significantly higher when patients had ID consultations (mean rate, 21.6) than in patients who did not (mean rate, 16.2). In post-acute-care hospitals and/or geriatric wards, antibiotic DOT was significantly higher than in other types of hospitals and/or wards. Depersonalization level was negatively related to antibiotic DOT (P < .05). Antibiotics are overused in EOL patients with advanced directives. ID physician burnout and impact of ID consultation should be further assessed.

Development of Daptomycin Susceptibility Breakpoints for Enterococcus faecium and Revision of the Breakpoints for Other Enterococcal Species by the Clinical and Laboratory Standards Institute.

Daptomycin is one of the few treatment options for infections caused by enterococci that are resistant to ampicillin and vancomycin, such as vancomycin-resistant Enterococcus faecium. The emergence and clinical significance of daptomycin-resistant enterococci and evolving microbiologic, pharmacokinetic-pharmacodynamic, and clinical data indicated that the pre-2019 Clinical and Laboratory Standards Institute (CLSI) susceptible-only breakpoint of ≤4 μg/mL for daptomycin and enterococci was no longer appropriate. After analyzing data that are outlined in this article, the CLSI Subcommittee on Antimicrobial Susceptibility Testing established new breakpoints for daptomycin and enterococci. For E. faecium, a susceptible dose-dependent (SDD) breakpoint of ≤4 μg/mL was established based on an increased dosage of 8-12 mg/kg/day (≥8 μg/mL-resistant). CLSI suggests infectious diseases consultation to guide daptomycin use for the SDD category. For Enterococcus faecalis and other enterococcal species, revised breakpoints of ≤2 μg/mL-susceptible, 4 μg/mL-intermediate, and ≥8 μg/mL-resistant were established based on a standard dosage of 6 mg/kg/day.

Perspectives of United States-based Infectious Diseases Physicians on Outpatient Parenteral Antimicrobial Therapy Practice.

BackgroundAlthough outpatient parenteral antimicrobial therapy (OPAT) is generally considered safe, patients are at risk for complications and thus require close monitoring. The purpose of this study is to determine how OPAT programs are structured and how United States–based infectious diseases (ID) physicians perceive barriers to safe OPAT care.MethodsWe queried members of the Emerging Infections Network (EIN) between November and December 2018 about practice patterns and barriers to providing OPAT.ResultsA total of 672 members of the EIN (50%) responded to the survey. Seventy-five percent of respondents were actively involved in OPAT, although only 37% of respondents reported that ID consultation was mandatory for OPAT. The most common location for OPAT care was at home with home health support, followed by post–acute care facilities. Outpatient and inpatient ID physicians were identified as being responsible for monitoring laboratory results (73% and 54% of respondents, respectively), but only 36% had a formal OPAT program. The majority of respondents reported a lack of support in data analysis (80%), information technology (66%), financial assistance (65%), and administrative assistance (60%). The perceived amount of support did not differ significantly across employment models. Inability to access laboratory results in a timely manner, lack of leadership awareness of OPAT value, and failure to communicate with other providers administering OPAT were reported as the most challenging aspects of OPAT care.ConclusionsID providers were highly involved in OPAT, but only one-third of respondents had a dedicated OPAT program. Lack of financial and institutional support were perceived as significant barriers to providing safe OPAT care.

Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit.

Study Design:Single-center prospective cohort.Objectives:To evaluate a multidisciplinary led, structured protocol for reducing surgical site infections (SSIs) in pediatric scoliosis surgery.Methods:Following a spike to 8.6% in local annual infection rate, a multidisciplinary team was convened to identify interventions. The team consisted of spinal surgeons, infectious diseases consultants, physiotherapists, specialist nurses, and theatre managers. A protocol was initiated, including preoperative skin decontamination; standardized operative site prepreparation; betadine-soaked swabs sutured to wound edges; blood loss minimization; 3 L0.9% saline pulsed-lavage; defined protocol of glove changes; antibiotic regime of preoperative gentamicin, intraoperative subfascial vancomycin powder, 48-hour cefuroxime; and intraoperative normothermia. A 4-year audit was initiated of all patients aged ≤18 years undergoing corrective spinal deformity surgery. Institutional board review was not required.Results:Between January 1, 2014 and January 1, 2018, 414 operations were performed on 355 patients: male:female = 1:2.2, mean age 13.7 years (range 2.5-17.9), 233 idiopathic (mean operated vertebral levels 12), 122 neuromuscular (mean operated vertebral levels 14), 66 growing rod procedures, 41 multistage procedures. The mean number of operated vertebral levels both overall and in infected cases was 13 (range 2-17). Nine SSIs occurred in 8 patients at 3 months (4 neuromuscular), resulting in an overall SSI per operation of 2.2%.Conclusion:A multidisciplinary approach with standardized measures significantly reduced SSIs in the unit’s pediatric scoliosis surgery.

Development of quality indicators for the management of Staphylococcus aureus bacteraemia.

Background Staphylococcus aureus bacteraemia (SAB) is a serious and often fatal infectious disease. The quality of management of SAB is modifiable and can thus affect the outcome. Quality indicators (QIs) can be used to measure the quality of care of the various aspects of SAB management in hospitals, enabling professionals to identify targets for improvement and stimulating them to take action.ObjectivesTo develop QIs for the management of hospitalized patients with SAB.MethodsA RAND-modified Delphi procedure was used to develop a set of QIs for the management of SAB in hospitalized patients. First, available QIs for the management of SAB were extracted from the literature published since 1 January 2000 (MEDLINE and Embase databases). Thereafter, an international multidisciplinary expert panel appraised these QIs during two questionnaire rounds with an intervening face-to-face meeting.ResultsThe literature search resulted in a list of 39 potential QIs. After appraisal by 30 medical specialists, 25 QIs describing recommended care at patient level were selected. These QIs defined appropriate follow-up blood cultures (n=2), echocardiography (n=6), source control (n=4), antibiotic therapy (n=7), antibiotic dose adjustment (n=2), intravenous-to-oral switch (n=2), infectious disease consultation (n=1) and medical discharge report (n=1).ConclusionsA set of 25 QIs for the management of SAB for hospitalized patients was developed by using a RAND-modified Delphi procedure among international experts. These QIs can measure the quality of various aspects of SAB management. This information can be fed back to the relevant stakeholders in order to identify improvement targets and optimize care.

Cryptococcus neoformans infection in Human Immunodeficiency Virus (HIV)-infected and HIV-uninfected patients at an inner-city tertiary care hospital in the Bronx.

Cryptococcus neoformans causes life-threatening meningoencephalitis. Human immunodeficiency virus (HIV) infection is the most significant predisposing condition, but persons with other immunodeficiency states as well as phenotypically normal persons develop cryptococcosis. We retrospectively reviewed medical records of all patients with a diagnosis of cryptococcosis between 2005 and 2017 at our inner-city medical center in the Bronx, an epicenter of AIDS in New York City, and analyzed demographic data, clinical manifestations, laboratory findings, treatment, and mortality for these patients. In sum, 63% of the cases over this 12-year period occurred in HIV-infected patients. And 61% of the HIV-infected patients were non-adherent with antiretroviral therapy, 10% were newly diagnosed with AIDS, and 4% had unmasking cryptococcus-associated immune reconstitution inflammatory syndrome. The majority were Hispanic or black in ethnicity/race. HIV-uninfected patients (47/126) were older (P < .0001), and the majority had an immunocompromising condition. They were less likely to have a headache (P = .0004) or fever (P = .03), had prolonged time to diagnosis (P = .04), higher cerebrospinal fluid (CSF) glucose levels (P = .001), less CSF culture positivity (P = .03), and a higher 30-day mortality (P = .03). Cases in HIV-uninfected patients were often unsuspected during their initial evaluation, leading to a delay in infectious diseases consultation, which was associated with mortality (P = .03). Our study indicates that HIV infection remains the most important predisposing factor for cryptococcosis despite availability of antiretroviral therapy and highlights potential missed opportunities for earlier diagnosis and differences in clinical and prognostic factors between HIV-infected and HIV-uninfected patients.

Antimicrobial stewardship by academic detailing improves antimicrobial prescribing in solid organ transplant patients

We implemented twice-weekly academic detailing rounds in 2015 as an antimicrobial stewardship (AMS) intervention in solid organ transplant (SOT) patients, led by an AMS pharmacist and a transplant infectious diseases physician. They reviewed SOT patients' antimicrobials and made recommendations to prescribers on antimicrobial regimens, diagnostics investigations, and appropriate referrals for transplant infectious diseases consultation. To determine the impact of the intervention, we adjudicated antimicrobials prescriptions using established AMS principles, and compared the proportion of AMS-concordance regimens pre-intervention (2013) with post-intervention (2016) via 4-point-prevalence surveys conducted in each period. All admitted SOT patients who were receiving antimicrobial treatment on survey days were included. Primary outcome was the percentage of antimicrobial regimen adjudicated as AMS concordant. Secondary outcomes were percentage of AMS concordance in patients consulted by transplant infectious diseases; categories of AMS discordance; antimicrobial consumption in defined daily dose/100 patient-days (DDD/100PD); antimicrobial cost in CAD$/PD; and C. difficile infections. Balancing measures were length of stay, 30-day readmission, and in-hospital mortality. We compared outcomes using χ2 test or t-test; significant difference was defined as p < 0.05. Pre-intervention surveys included 139 patients, post-intervention, 179 patients, with 62.3% vs. 56.6% receiving antimicrobials, respectively (p = 0.27). AMS concordance increased from 69% (60/87) to 83.7% (93/111), p = 0.01. Not tailoring antimicrobials was the most common discordance category. AMS concordance under transplant infectious diseases was 82.5% (33/40) pre-intervention vs. 76.6% (36/47) post-intervention, p = 0.5. Antimicrobial consumption increased by 15.3% (140.9 vs.162.4 DDD/100PD, p = 0.001). Antimicrobial cost, C. difficile infection rates and balancing measures remained stable. Academic detailing increased appropriate antimicrobial use in SOT patients without untoward effects.

Clinical impact of an antimicrobial stewardship program on high-risk pediatric patients

To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients. Retrospective cohort study. Free-standing pediatric hospital. This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams. The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment. The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P &lt; .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure. ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.

Clinical impact of an educational antimicrobial stewardship program associated with infectious diseases consultation targeting patients with cancer: Results of a 9-year quasi-experimental study with an interrupted time-series analysis

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. However, their effectiveness or safety in immunocompromised hosts needs to be proved. An ecologic quasi-experimental study was performed from January 2009 to June 2017 in the Oncology department of a tertiary-care hospital. A stable program of Infectious Diseases consultation (IDC) already existed at this unit, and an educational ASP was added in 2011. Its main intervention consisted of face-to-face educational interviews. Antibiotic consumption was assessed through quarterly Defined Daily Doses (DDD) per 100 occupied bed-days. Mortality was evaluated in patients with bloodstream infections through the quarterly incidence density per 1000 admissions, and the annual mortality rates at 7 and 30-days. Time-trends were analysed through segmented-regression analysis, and the impact of the ASP was assessed through before-after interrupted time-series analysis. Mortality significantly decreased throughout the study period (-13.3% annual reduction for 7-day mortality rate, p<0.01; -8.1% annual reduction for 30-day mortality, p = 0.03), parallel to a reduction in antibiotic consumption (quarterly reduction -0.4%, p = 0.01), especially for broader-spectrum antibiotics. The before-after study settled a significant inflexion point on the ASP implementation for the reduction of antibiotic consumption (change in level 0.95 DDD, p = 0.71; change in slope -1.98 DDD per quarter, p<0.01). The decreasing trend for mortality before the ASP also continued after its implementation. The combination of an ASP with IDC improved antibiotic use among patients with cancer, and was accompanied by a reduction of mortality of bacteraemic infections. Implementation of the ASP was necessary to effectively change antibiotic use.