Infectious Disease Team Research Articles

Collective Intelligence and Skills Mobilization: The Key of the Outbreak in Trois-Rivières

In July 2017, 7 cases of Legionnaires' Disease (LD) were declared to the Public Health Department. This was unusually high considering the region has an annual average of 5 declarations of LD. Also, address of residence of cases indicated they lived in a 7 km radius from each other. This spacio-temporal aggregate prompted an outbreak investigation.The infectious disease team questioned patients and family. Questionnaire revealed that all of them spent time outside, in Trois-Rivières (TR), Québec, Canada. As well, a few patients had everyday activities that were almost exclusively in the downtown area.At the beginning of the investigation, the environmental health team rapidly validated cooling tower’s (CT) microbiological water quality. They were under the intervention threshold prescribed by the provincial regulations. Concomitantly, other potential sources of a Legionella were investigated in regards to their outbreak potential.The epidemiological survey highlighted the information on the temporal distribution of this outbreak (critical period between July 4th and 17th) and the concentration of patient's displacements in the city center of TR, confirming spatial distribution, which made it possible to refine environmental investigation. Therefore, culture results of a CT in this area were scrutinized in detail and irregularities were found. This CT had the results of recurrent interfering flora. Thus, the CT was resampled and results showed contamination at 630 000 CFU/l (under the current health standard of 1 000 000 CFU/l). Subsequently, the CT was closed.Ultimately, the Legionella strain found in respiratory specimen of the patients was a genotypic match to the one cultured from the CT and had never been documented in Quebec before.Major surveys require the participation of multiple skills from different horizons and use collective intelligence. This outbreak illustrates the complementary of the epidemiological and environmental investigations.

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department: Viale P, Tedeschi S, Schudeller L, et al. Clin Infect Dis 2017;65:1253-1259

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department: Viale P, Tedeschi S, Schudeller L, et al. Clin Infect Dis 2017;65:1253-1259

Effectiveness of kidney transplantation in HIV-infected recipients under combination antiretroviral therapy: a single-cohort experience (Brescia, Northern Italy).

Kidney transplantation was recently introduced for the treatment of end stage renal disease (ESRD) in HIV-infected patients. We report the results of the first 28 procedures at our centre. A retrospective study was conducted on HIV-infected patients evaluated for kidney transplantation between January 2005 and October 2016. Patients were selected and monitored by the kidney transplantation and infectious diseases teams, according to the national protocol. 60 patients were evaluated; 32 entered the list and 28 were transplanted. Median CD4+count was 337cell/μL at transplantation and 399 cell/μL 12months thereafter. HIV RNA was undetectable at transplantation in 27/28 patients and became undetectable within 24weeks in the only patient starting antiretroviral combination therapy (cART) after surgery. Four patients experienced virological failure, but reached again undetectability after cART regimen change. At last available point of follow-up (median 126.1weeks), HIV RNA was undetectable in all patients. Three patients experienced AIDS-defining events. We observed a cumulative number of 19 acute rejections in 16 patients (median time from transplantation to first rejection 5.2weeks). Survival rate was 82.1%. To avoid pharmacokinetics (PK) interactions, cART regimen was changed from a protease inhibitor (PI)/non-nucleoside reverse transcriptase inhibitor (NNRTI)-based to an integrase inhibitor (InSTI)-based regimen in 11/20 alive patients with functioning graft. Kidney transplantation appears to be safe in HIV-infected patients carefully selected. As previously reported, we observed a high incidence of acute rejection. We expect that the recent implementation of the immunosuppressive protocols will allow a better immunologic control. Moreover, the introduction of InSTI permits a better strategy of cART, with lower incidence of PK interactions with immunosuppressive drugs.

Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department.

The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026). Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

Corrigendum: Human antibody repertoire after VSV-Ebola vaccination identifies novel targets and virus-neutralizing IgM antibodies.

Nat. Med.; 10.1038/nm.4201; corrected online 15 November 2016 In the version of this article initially published online, the authors omitted acknowledging a funding agency and researchers for providing the pseudovirion neutralization assay data. The acknowledgments section has been revised to state,“We thank the US Army Medical Research Institute of Infectious Diseases team, including S.

Morbidity among the Israeli Defense Force response team during Nepal, post-earthquake mission, 2015.

On 25 April 2015, a 7.8-magnitude earthquake struck Nepal. Soon after, the Israel Defense Force (IDF) dispatched a rapid-response team and opened a tertiary field hospital in Kathmandu. There is limited data regarding the spectrum of diseases among rescue teams to disease-stricken areas. The aim of this study was to assess the morbidity among the field-hospital staff during the mission. The rescue team was deployed for a 2-week mission in Kathmandu. Pre-travel vaccinations were given prior to departure. The field-hospital was self-equipped including food and drinking water supply with a self-serving kitchen, yet had a shortage of running water. A Public Healthcare and Infectious-Diseases team was present and active during the entire mission. A survey assessing the morbidities and risk-factors throughout the mission was performed at the last day. One hundred thirty-seven (69%) team members completed the questionnaire. Medical complaints were recorded in 87 of them (64%). The most common symptoms were gastrointestinal (GI) (53% of all responders, 84% of the 87 with symptoms). Respiratory symptoms were recorded in 16% and fever in only 8%. There was no significant difference in the rate or spectrum of morbidity between the medical and the non-medical staff. The Israeli field hospital was a stand-alone facility, yet 53% of its' staff suffered from GI complaints. Prevention of morbidity and specifically of GI complaints upon arrival to a disaster-stricken area in a developing country is difficult. Medical teams in such missions should be acquainted with treating GI complaints.

Assessment of Knowledge, Attitudes, and Practices (KAP) of Providers Towards Internal Reporting of Antimicrobial Use

BackgroundSurveillance of antimicrobials is important to ensure appropriate practices. National mandatory reporting of antimicrobial utilization (AU) is anticipated. As feedback drives change, we surveyed providers to gain input on their perceptions about attribution, barriers to feedback, and preferences on AU feedback.MethodsA 20-question, IRB-approved survey was emailed to providers who prescribe antimicrobials at Vanderbilt University Hospital. Demographics, methods of and barriers to feedback, and case scenarios addressing attribution upon admission from the emergency department (ED), transfer between inpatient teams and consultant interactions were collected. Levels of concern were rated on a scale of 1 to 5 regarding barriers. Participants were stratified by service line. Chi-square and Fisher’s exact test for categorical variables and analysis of variance for intergroup mean differences were conducted.ResultsA total of 211 (27.5%) of 766 providers completed the survey. Upon admission, 83% of providers attributed to the ED team that ordered the antimicrobial with no between group differences, P = 0.21. After ICU transfer and broadening of therapy, 91% attributed to the ICU team that changed therapy, P = 0.39 between groups. After a new ICU team came on service, 73.9% attribute the antibiotic changed the day prior to the new team, P = 0.98. A significant difference was seen in the consult scenario of attribution to Infectious Disease (ID) team (critical care 50%, ED 43.5%, ID 37.5%, other medicine specialties 60.2%, and surgery 77.8%, P = 0.01). Providers wanted reporting to be based on service (62%) and to be notified via email (73%) as opposed to an online dashboard (36%). Levels of concern on following another provider’s recommendations varied (ED 3.1 vs. ID 2.3, P < 0.001 across all groups) as well as unaccounted patient severity (ED 4.4 vs. Surgery 2.8, P < 0.001 across all groups). Services also differed in likelihood to change practice based on feedback (ED 3.8 vs. Medicine 3.2, P = 0.047 across all groups).ConclusionThere is a general agreement on attribution throughout a hospitalization with varying levels of concern between services regarding feedback of utilization data. This is important to take into consideration prior to implementation of feedback distribution to providers.Disclosures T. Lines, National Institutes of Health: Investigator, Clinical and Translational Science Award grant obtained only to provide survey participants with $5 incentive in completing the survey

Impact of An Electronic “Antibiotic Time Out” on Provider Prescribing Patterns

BackgroundCurrent antibiotic stewardship guidelines suggest the use of an antibiotic time-out (ATO) 48–72 hours after antibiotic initiation to encourage review of empiric regimens once additional diagnostic information is available; however, the recommendation is based on low-quality evidence. Our objective was to retrospectively evaluate the impact of an electronic ATO alert within the EPIC™ electronic health record on provider prescribing patterns after implementation.MethodsThe ATO alerts were instituted in January 2017 and were triggered when an inpatient received Vancomycin (VAN), Piperacillin/Tazobactam (PT), Ceftriaxone (CEF), or a combination of them for >72 hours. We used an EPIC™ benchside report to identify ATO alerts between January and April 2017 and systematically reviewed charts from the last week of each month to identify de-escalation opportunities (DEO). Pediatric, bone marrow transplant, orthopedic, and cystic fibrosis patients were excluded. The primary outcome was de-escalation within 12 hours of the alert, defined as narrowing of spectrum or discontinuation of antibiotics.ResultsWe identified 805 alerts among 209 patients; 87 patients were excluded from analysis. Among 122 included patients, a median of 3 alerts were triggered per patient (470 in total). DEO was identified in 34.7% of alerts; de-escalation events (DEE) occurred in 34.3% of DEO. Table 1 lists alerts, DEO, and DEE by antibiotic. PT was the most frequently de-escalated antibiotic (46.4% [26/56] of DEE). De-escalation occurred more frequently among patients either actively followed (P < 0.01) or receiving new consultations by Infectious Disease (P = 0.04).Table 1.De-escalation opportunities and events by antibioticAntibioticAlerts(n = 470)De-escalation opportunities(n = 163)De-escalation events(n = 56)VAN130 (27.6%)23 (14.1%)8 (14.3%)PT137 (29.1%)66 (40.5%)26 (46.4%)CEF123 (26.2%)9 (5.5%)6 (10.7%)VAN/PT65 (13.8%)62 (38.0%)15 (26.8%)VAN/CEF15 (3.2%)3 (1.8%)1 (1.8%)ConclusionAn electronic ATO alert triggered only on the basis of drug and duration lacked specificity in identifying opportunities for antibiotic de-escalation. De-escalation occurred significantly more frequently with Infectious Disease team involvement. Additional study is required to identify how to best support de-escalation efforts.Disclosures J. S. Lewis II, Merck & Co.: Consultant, Consulting fee. J. C. McGregor, Merck & Co.: Grant Investigator, Research grant.

Identifying complexity in infectious diseases inpatient settings: An observation study

BackgroundUnderstanding complexity in healthcare has the potential to reduce decision and treatment uncertainty. Therefore, identifying both patient and task complexity may offer better task allocation and design recommendation for next-generation health information technology system design. ObjectiveTo identify specific complexity-contributing factors in the infectious disease domain and the relationship with the complexity perceived by clinicians. MethodWe observed and audio recorded clinical rounds of three infectious disease teams. Thirty cases were observed for a period of four consecutive days. Transcripts were coded based on clinical complexity-contributing factors from the clinical complexity model. Ratings of complexity on day 1 for each case were collected. We then used statistical methods to identify complexity-contributing factors in relationship to perceived complexity of clinicians. ResultsA factor analysis (principal component extraction with varimax rotation) of specific items revealed three factors (eigenvalues>2.0) explaining 47% of total variance, namely task interaction and goals (10 items, 26%, Cronbach’s Alpha=0.87), urgency and acuity (6 items, 11%, Cronbach’s Alpha=0.67), and psychosocial behavior (4 items, 10%, Cronbach’s alpha=0.55). A linear regression analysis showed no statistically significant association between complexity perceived by the physicians and objective complexity, which was measured from coded transcripts by three clinicians (Multiple R-squared=0.13, p=0.61). There were no physician effects on the rating of perceived complexity. ConclusionTask complexity contributes significantly to overall complexity in the infectious diseases domain. The different complexity-contributing factors found in this study can guide health information technology system designers and researchers for intuitive design. Thus, decision support tools can help reduce the specific complexity-contributing factors. Future studies aimed at understanding clinical domain-specific complexity-contributing factors can ultimately improve task allocation and design for intuitive clinical reasoning.

Oral Versus Parenteral Antibiotics for Osteoarticular Infections: You PICC.

A previously healthy 8-year-old girl presented to the emergency department with right hip pain and inability to bear weight on the right lower extremity. She had been afebrile at home, although was receiving ibuprofen for pain. Inflammatory markers were elevated, including a C-reactive protein (CRP) of 76.4 mg/L and an erythrocyte sedimentation rate of 40 mm per hour. A radiograph of the pelvis did not show any obvious joint effusion. Given the concern for septic hip, orthopedics was consulted and she was taken to the operating room for aspiration of her right hip joint. Aspiration showed cloudy yellow fluid with a white blood cell count >85 000. Orthopedics proceeded with incision and drainage and she was admitted for parenteral antibiotics. She was empirically started on cefazolin. The broth from her hip culture grew coagulase-negative Staphylococcus species, but the fluid culture was negative, and this was presumed to be a contaminant. The orthopedic and infectious disease teams made a joint decision to treat empirically with cefazolin for a total of 4 weeks for presumed septic hip. A peripherally inserted central catheter (PICC) was placed on hospital day 3 and she was discharged on hospital day 4. At the time of discharge, the patient had no hip pain, was afebrile, able to bear weight, and had a CRP of 8.8 mg/L. Four days after discharge, the patient presented to the emergency department with pain, erythema, and swelling above the site of her PICC line. A duplex ultrasound of the arm showed a deep vein thrombus. Her PICC line was removed and she was started on enoxaparin for 3 months. She was discharged on oral high-dose cephalexin. Total duration of treatment was 16 days; antibiotics were then discontinued based on a normal clinical examination and inflammatory markers. This case illustrates the harm that can …

Automated Allergy and Infectious Disease Pharmacy Consult to Limit the Use of Aztreonam in Patients with Reported Beta-Lactam Allergy

True IgE mediated hypersensitivity and severe delayed reactions due to penicillin are relatively uncommon, even in patients with reported beta-lactam allergy. Inpatients with reported beta-lactam allergies frequently receive alternative antibiotics which are often less appropriate and more expensive than patients without a reported penicillin allergy. The University of Washington Medical Center (UWMC) is a tertiary/quaternary care center with a significant number of inpatients with reported beta-lactam allergies. Given the high number of such patients admitted to UWMC, starting in June 2014 all inpatients prescribed IV aztreonam generated an automated alert; depending on the allergy history, either the Allergy/Immunology and/or Infectious Disease team on call reviewed the patient records and consulted after discussion with the primary inpatient service. This retrospective review evaluates all patients who received this intervention from June 2014 to June 2015. Of the 98 patients with aztreonam orders, 75 had documented beta-lactam allergies. Of these patients, 26 were successfully challenged to an alternative beta-lactam, 12 underwent skin testing and challenge, and 1 underwent desensitization. In total, 41/75 patients on aztreonam had therapy altered to a preferable therapy after evaluation. Additionally, 20/75 patients had penicillin allergy removed from their records after consultation and another 18/75 were amended to tolerate cephalosporins. No adverse events related to testing or challenges were reported. The use of an automated allergy/infectious disease consult was able to significantly impact the care of inpatients with reported beta-lactam allergies, reduce the use of aztreonam in the inpatient setting, and prevent unnecessary use of alternate antibiotics.

Clinical Complexity in Medicine: A Measurement Model of Task and Patient Complexity.

Complexity in medicine needs to be reduced to simple components in a way that is comprehensible to researchers and clinicians. Few studies in the current literature propose a measurement model that addresses both task and patient complexity in medicine. The objective of this paper is to develop an integrated approach to understand and measure clinical complexity by incorporating both task and patient complexity components focusing on the infectious disease domain. The measurement model was adapted and modified for the healthcare domain. Three clinical infectious disease teams were observed, audio-recorded and transcribed. Each team included an infectious diseases expert, one infectious diseases fellow, one physician assistant and one pharmacy resident fellow. The transcripts were parsed and the authors independently coded complexity attributes. This baseline measurement model of clinical complexity was modified in an initial set of coding processes and further validated in a consensus-based iterative process that included several meetings and email discussions by three clinical experts from diverse backgrounds from the Department of Biomedical Informatics at the University of Utah. Inter-rater reliability was calculated using Cohen's kappa. The proposed clinical complexity model consists of two separate components. The first is a clinical task complexity model with 13 clinical complexity-contributing factors and 7 dimensions. The second is the patient complexity model with 11 complexity-contributing factors and 5 dimensions. The measurement model for complexity encompassing both task and patient complexity will be a valuable resource for future researchers and industry to measure and understand complexity in healthcare.

Impact of Infectious Diseases Team Consultation Upon Antimicrobial Use, Length of Stay and Mortality in an Adult Intensive Care Unit

Impact of Infectious Diseases Team Consultation Upon Antimicrobial Use, Length of Stay and Mortality in an Adult Intensive Care Unit

First case report of usefulness of 18F-FDG PET/CT in diagnosing typhlitis (an oncological emergency)

Methods A 35-year-old lady was admitted with febrile neutropenia complaining of shortness of breath, productive cough and chest tightness. Having been diagnosed with acute myeloid leukaemia nine months ago, her disease had relapsed soon after allogeneic stem cell transplant from matched donor. A few diagnostic CECTs during her hospital stay showed findings in chest only confirmed to be due to invasive fungal and viral infections. Following some improvement, she was prescribed palliative subcutaneous cytarabine. The patient developed backache and neck pain with no findings on MRI. Due to continued fever and sepsis despite maximum treatment, PET/CT was requested by infectious disease team.

Impact of Infectious Diseases Team Consultation on Antimicrobial Use, Length of Stay and Mortality

Infectious disease (ID) clinicians and multidisciplinary teams may have a beneficial impact on patient outcomes. This study was conducted to determine the impact of dedicated ID team rounding in an adult noncardiac intensive care unit (ICU) on antimicrobial costs, length of stay and mortality. The authors instituted dedicated ICU ID team rounds at a large tertiary care hospital ICU ("intervention"), with the ID team conducting rounds in the ICU every weekday. The authors compared the cost of antimicrobial agents, total hospital and ICU length of stay and inpatient mortality for the 6-month period before and after institution of these rounds between those seen versus those not seen by the ID team. Among 386 patients analyzed, 206 were admitted in the preintervention and 180 in the postintervention period. Among those seen by the ID team, there was an 18% decrease in total antimicrobial cost (P < 0.0001), 40% decrease in ICU length of stay (P = 0.1), 33% decrease in overall hospital length of stay (P = 0.03) and 34% decrease in mortality (0.04) from preintervention to postintervention period. Among those not seen by ID, there was a 39% decrease in cost among those not seen by ID (P < 0.0001), but length of ICU or hospital stay and mortality were not significantly different. Institution of dedicated ID team rounding in the ICU leads to substantial decreases in antimicrobial costs, hospital length of stay and inpatient mortality among those patients seen by the team.

Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome.

IntroductionThe increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.ObjectivesTo evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.MethodsA pre (2003) and post-intervention (2005–6) retrospective study was undertaken.InterventionCohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.ResultsThe number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.ConclusionCohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.

Lower antibiotic costs attributable to clinical microbiology rounds

ObjectiveAt our institution, our microbiologist, pharmacist, and infectious disease (ID) team meet to discuss ID patients, and this meeting is referred to as microbiology rounds. We hypothesized that our microbiology rounds reduce antibiotic costs. The study involved a review of 80 patients with an ID consultation order at each of the 3 hospitals: hospital A (HA) (only HA has microbiology rounds), hospital B (HB), and hospital C (HC). Of this population, we included patients with a positive blood culture. Thirty-six patients who met the above criteria were included in the study. The average antibiotic cost/patient/day at HA, HB, and HC were $66.0, $123, and $109, respectively. Also, we found that change in antibiotics was appropriate when compared to the final microbiology results in 90%, 44%, and 40% of the time at HA, HB, and HC, respectively. Herein, we found an association between conducting microbiology rounds and reduction of antibiotic cost.

Medication Safety

Medication Safety

Providing nursing care to Ebola patients on the national stage: The National Institutes of Health experience

Providing nursing care to Ebola patients on the national stage: The National Institutes of Health experience

Implementation of a multidisciplinary infectious diseases team in a tertiary hospital within an Antimicrobial Stewardship Program

Background:In January 2011, as part of an antimicrobial stewardship program the Antimicrobial Management Team (AMT) at the Ghent University Hospital initiated a multidisciplinary Infectious Diseases Team (MIT) consisting of infectious diseases physicians, clinical microbiologists, and clinical pharmacists. The aim of this study is to describe the type and acceptance rate of recommendations provided by the MIT.Method:Prospective, observational study in a tertiary care, university teaching hospital with 1062 beds in non-consecutive hospitalized adult patients, excluding intensive care units and paediatrics.Results:The MIT communicated 432 recommendations in 87 days observed. Of the 293 patients for whom a recommendation was made, the median age was 57 years (range: 16–91 years) and 169 (57·7%) were male. Skin or soft tissue infections (14%), respiratory tract infections (13%), infections without known focus (11%), abdominal infections (11%), and bone infections (8%) were most common. Recommendations were made to perform additional clinical investigation(s) [N = 137 (27%)], to adjust the dose of an antimicrobial drug [N = 42 (8%)], to stop an antimicrobial drug [N = 104 (21%)], to switch from a parenteral to an oral drug [N = 39 (8%)] or to initiate an antimicrobial drug [N = 178 (36%)], with an acceptance rate of 73·0%, 83·3%, 81·7%, 76·9%, and 84·0%, respectively.Conclusions:The MIT formulated about five recommendations a day primarily focusing on pharmacotherapy, but also on clinical investigations. In both fields, a high acceptance rate was observed.